Exploring primary care physicians' challenges in using home blood pressure monitoring to manage hypertension in Singapore: a qualitative study

Objective

Hypertension guidelines recommend using home blood pressure (HBP) to diagnose, treat and monitor hypertension. This study aimed to explore the challenges primary care physicians (PCPs) face in using HBP to manage patients with hypertension.

Method

A qualitative study was conducted in 2022 at five primary care clinics in Singapore. An experienced qualitative researcher conducted individual in-depth interviews with 17 PCPs using a semi-structured interview guide. PCPs were purposively recruited based on their clinical roles and seniority until data saturation. The interviews were audio-recorded, transcribed verbatim and managed using NVivo qualitative data management software. Analysis was performed using thematic analysis.

Results

PCPs identified variations in patients' HBP monitoring practices and inconsistencies in recording them. Access to HBP records relied on patients bringing their records to the clinic visit. A lack of seamless transfer of HBP records to the EMR resulted in an inconsistency in documentation and additional workload for PCPs. PCPs struggled to interpret the HBP readings, especially when there were BP fluctuations; this made treatment decisions difficult.

Conclusion

Despite strong recommendations to use HBP to inform hypertension management, PCPs still faced challenges accessing and interpreting HBP readings; this makes clinical decision-making difficult. Future research should explore effective ways to enhance patient self-efficacy in HBP monitoring and support healthcare providers in documenting and interpreting HBP.

Epidemiology and risk factors associated with gout control among adult Asians: a real-world retrospective cohort study

Background

Gout is associated with significant morbidity and mortality, yet suboptimal gout control remains a problem globally. Identifying the risk factors associated with poor gout control among patients in primary care allows targeted interventions to improve their clinical management. This study aimed to determine the prevalence of poor gout control and its associated demographic and clinical factors among urbanized community-dwelling Asian patients.

Methods

This retrospective study was based on data extracted from the electronic medical records of 8 public primary care clinics in Singapore. Patients with a diagnostic code of gout who had 2 or more visits between 1st January 2018 and 31st December 2019 were included in the analysis. Data extracted included: demographics, anthropological measurements, comorbidities, serum uric acid levels and medication prescription. A patient is defined to have poor gout control if they suffer two or more acute gout attacks within a year. Chi-Squared test was used for categorical parameters. For continuous variables, univariate logistic regression analysis was first performed. Significant factors (p ≤ 0.1) were then included in the logistics regression model to account for confounders.

Results

A total of 7,970 patients and 24,624 visits were included in the analysis. The prevalence of poorly controlled gout was 28.2% (n = 2,244/7,970); only 46.3% of them (n = 1,039/2,244) were prescribed allopurinol and 13.4% (n = 301/2,244) were taking doses ≥300 mg. Using logistic regression, factors associated with poor gout control were: male gender [adjusted OR (AOR) =1.66, p < 0.001], Malay ethnicity (AOR = 1.27, p = 0.007), congestive heart failure (AOR = 1.64, p = 0.037). Patients prescribed allopurinol (AOR = 1.52, p < 0.001), NSAIDs (AOR = 2.76, p < 0.001) and corticosteroids (AOR = 2.83, p < 0.001) were more likely to have poorly-controlled gout.

Conclusion

Nearly 30% of patients had poor gout. Interventions should focus on male and Malay patients and those with congestive cardiac failure.

Intention to Vaccinate against COVID-19 in Adolescents: A Systematic Review

BACKGROUND

Multiple COVID-19 vaccines have been approved for use in adolescents; these vaccines play a critical role in limiting the transmission and impact of COVID-19. This systematic review aims to summarize the willingness of adolescents aged 10 to 19 years to receive the COVID-19 vaccination and the factors influencing their decision.

METHODS

A search of literature published between January 2018 and August 2022 was performed in Medline©, EMBASE©. and CINAHL© electronic databases. Studies published in English that assessed adolescents' intentions to receive the COVID-19 vaccine were included. Qualitative studies and those unrelated to the COVID-19 vaccine were excluded. The study was conducted based on the PRISMA guidelines.

RESULTS

Of the 1074 articles retrieved, 13 were included in the final review. Most studies were conducted in the US (n = 3) and China (n = 3). The pooled prevalence of COVID-19 vaccine acceptance among adolescents was 63% (95% CI: 52-73%). Factors influencing intent to vaccinate were divided into five categories: "Socio-demographic determinants"; "Communication about COVID-19 pandemic and vaccination"; "COVID-19 vaccine and related issues"; "COVID-19 infection and related issues" and "Other determinants". The enablers were sociodemographic factors including older age, higher education level, good health perception, and parental norms in terms of parental vaccination acceptance; perceived vaccine effectiveness and safety; a desire to protect themselves and others; recent vaccination; and anxiety. The barriers were concerns over vaccine effectiveness, safety, and long-term side effects; low perceived necessity and risk of infection; and needle phobia.

CONCLUSIONS

This review highlighted that adolescents' intent to vaccinate is driven by a desire to protect themselves and others. However, concerns over vaccine effectiveness, safety, and long-term side effects hinder COVID-19 vaccine uptake. To improve vaccination acceptance, policymakers should address adolescents' concerns via more targeted public health messaging, while schools should leverage peer norms to positively influence vaccination intent.

Awareness, Barriers and Concerns of Adolescents Toward the COVID-19 Vaccine: A Cross-Sectional Study in Singapore

Background

COVID-19 vaccination is a key public health measure to mitigate the crippling effects of the pandemic. COVID-19 vaccination began in adults and targeted adolescents at a later stage. However, medical decision-making on its uptake among the latter was unknown, which could be affected by their literacy and concerns about the vaccine. The study aimed to elucidate the awareness, concerns and barriers of adolescents toward the COVID-19 vaccine.

Methods

A cross-sectional online survey using a self-developed questionnaire was conducted between June to November 2021. The adolescent participants were students from institutes of post-secondary education who were recruited via convenience sampling. The data were collated from an officially approved electronic platform, audited and analyzed. Continuous and categorical variables were expressed as mean (standard deviation) and percentages, respectively.

Results

A total of 460 adolescents participated in the study (mean age: 16.99 ± 0.99; 73% female). Most of them (91.5%) were aware of the COVID-19 vaccines. The main barriers to vaccination were uncertainty about long-term health risks (38.6%) and vaccine efficacy (37.3%). Regarding the potential vaccine side effects, they were concerned about: anaphylactic shock (73.2%), low blood pressure (58.3%) and fast heartbeat (58.0%). Only 58% expressed willingness for repeated COVID-19 vaccination.

Conclusion

Despite high COVID-19 vaccine awareness, the adolescents were concerned about the potentially severe but rare side-effects. The study identified apprehension regarding vaccine efficacy and the potential long-term health impact as the main barriers to vaccination. Future studies should address these concerns to scale vaccination programs among adolescents.

Crisis management in the community mass recall of angiotensin II receptor blocker losartan due to nitrosamine impurities

Introduction

Angiotensin II Receptor Blockers (ARB) are widely utilized in the treatment of hypertension and nephropathy. In March 2019, a mass recall of selected brands of an ARB, losartan due to reported elevated levels of potentially carcinogenic nitrosamine impurities was implemented in a Singapore primary care institution.

Objective

To describe the crisis management of the mass losartan recall in a public primary healthcare institution in Singapore.

Methods

The crisis management framework was adapted from the Gonzalez-Herrero and Pratt model. This crisis was managed over three phases: identification of impending crisis based on risk reports by local health authorities, formation of a task force to develop turnaround strategies and measures, implementation and monitoring of the remedial measures. Data to plan and chart implementation was retrieved from the institution databases, including the Electronic Health Intelligence System for patient medical and prescription records, Outpatient Administrative System for reimbursement of medications and other expenditures incurred. An exigency scheme, Losartas® Review Service (LRS), was established to expedite the replacement of the affected medication with another ARB or another anti-hypertensive medication.

Results

SingHealth Polyclinics completed the recall of 29,794 (92.1%) patients within 14 weeks. The majority of the patients (76.2%) were attended to by doctors, while 16.5% and 7.3% were managed using the LRS and pharmacy respectively. The institution incurred a cost of SGD2,824,760 (estimated SGD95 per patient) to manage the crisis.

Conclusion

The successful implementation of a mass medication recall hinged on timely intervention, cross-departmental coordination, effective communication and judicious resource allocation.

The association between self-efficacy and self-care in essential hypertension: a systematic review

BACKGROUND

The successful management of hypertension requires sustained engagement in self-care behaviour such as adhering to medication regimens and diet. Bandura's Social Cognitive Theory suggests that self-efficacy is a major determinant of engagement in self-care behaviour. Self-efficacy refers to an individual's belief in their capacity to execute behaviours necessary to produce specific performance attainments. This systematic review of observational studies aims to summarise and evaluate the quality of evidence available to support the association between self-efficacy and engagement in self-care behaviour in hypertension.

METHODS

Searches were performed of the Pubmed, MEDLINE, CINAHL and OpenSIGLE databases from database inception to January 2020. Reference lists and individual journals were also hand searched. Observational studies in English quantifying self-efficacy and self-care behaviour in hypertensive adults were included. The quality of included articles was assessed with the National Institute of Health Quality Assessment Tool for observational studies.

RESULTS

The literature search identified 102 studies, of which 22 met the inclusion criteria for full-text review. There were 21 studies which reported that higher self-efficacy was associated with engagement in self-care behaviours including medication adherence (n = 9), physical activity (n = 2) and dietary changes (n = 1). Of these, 12 studies were rated as 'good' on the quality assessment tool and 10 were 'fair'. A common limitation in these studies was a lack of objectivity due to their reliance on self-reporting of engagement in self-care behaviour.

CONCLUSION

Our review suggests an association between self-efficacy and self-care. However, the evidence supporting this association is of low to medium quality and is limited by heterogeneity. Our findings suggest the need for further well-designed interventional studies to investigate this association.