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R R, Sangameshwar A, Tan YY, Teh Kim Jun K, Tham TY, Cheah Chang Chuen M. Approach to Abnormal Liver Biochemistries in the Primary Care Setting. Cureus 2024; 16:e56541. [PMID: 38646392 PMCID: PMC11026984 DOI: 10.7759/cureus.56541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Liver biochemistries are commonly ordered in the primary care setting, and they may return abnormal even in an asymptomatic patient. Primary care physicians need to have a systematic way of interpreting any derangement in these tests so that further investigations, referrals, and management can be arranged appropriately. This review dwells into patterns of liver biochemistry derangement, common aetiologies to consider, history and examinations that are required, initial investigations to order, and when to refer urgently to the emergency department.
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Affiliation(s)
- Rajesh R
- Gastroenterology and Hepatology, Singapore General Hospital, Singapore, SGP
| | | | - Yi Yuan Tan
- Gastroenterology and Hepatology, Singapore General Hospital, Singapore, SGP
| | - Kevin Teh Kim Jun
- Gastroenterology and Hepatology, Singapore General Hospital, Singapore, SGP
| | - Tat Yean Tham
- Family Medicine, Frontier Healthcare, Singapore, SGP
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Ang IYH, Ng SHX, Rahman N, Nurjono M, Tham TY, Toh SA, Wee HL. Right-Site Care Programme with a community-based family medicine clinic in Singapore: secondary data analysis of its impact on mortality and healthcare utilisation. BMJ Open 2019; 9:e030718. [PMID: 31892645 PMCID: PMC6955507 DOI: 10.1136/bmjopen-2019-030718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Stable patients with chronic conditions could be appropriately cared for at family medicine clinics (FMC) and discharged from hospital specialist outpatient clinics (SOCs). The Right-Site Care Programme with Frontier FMC emphasised care organised around patients in community rather than hospital-based providers, with one identifiable primary provider. This study evaluated impact of this programme on mortality and healthcare utilisation. DESIGN A retrospective study without randomisation using secondary data analysis of patients enrolled in the intervention matched 1:1 with unenrolled patients as controls. SETTING Programme was supported by the Ministry of Health in Singapore, a city-state nation in Southeast Asia with 5.6 million population. PARTICIPANTS Intervention group comprises patients enrolled from January to December 2014 (n=684) and control patients (n=684) with at least one SOC and no FMC attendance during same period. INTERVENTIONS Family physician in Frontier FMC managed patients in consultation with relevant specialist physicians or fully managed patients independently. Care teams in SOCs and FMC used a common electronic medical records system to facilitate care coordination and conducted regular multidisciplinary case conferences. PRIMARY OUTCOME MEASURES Deidentified linked healthcare administrative data for time period of January 2011 to December 2017 were extracted. Three-year postenrolment mortality rates and utilisation frequencies and charges for SOC, public primary care centres (polyclinic), emergency department attendances and emergency, non-day surgery inpatient and all-cause admissions were compared. RESULTS Intervention patients had lower mortality rate (HR=0.37, p<0.01). Among those with potential of postenrolment polyclinic attendance, intervention patients had lower frequencies (incidence rate ratio (IRR)=0.60, p<0.01) and charges (mean ratio (MR)=0.51, p<0.01). Among those with potential of postenrolment SOC attendance, intervention patients had higher frequencies (IRR=2.06, p<0.01) and charges (MR=1.86, p<0.01). CONCLUSIONS Intervention patients had better survival, probably because their chronic conditions were better managed with close monitoring, contributing to higher total outpatient attendance frequencies and charges.
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Affiliation(s)
- Ian Yi Han Ang
- Regional Health System Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Sheryl Hui-Xian Ng
- Regional Health System Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Nabilah Rahman
- Regional Health System Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Milawaty Nurjono
- Centre for Health Services and Policy Research (CHSPR), Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Tat Yean Tham
- Clinical Affairs Department, Frontier Healthcare Group, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sue-Anne Toh
- Regional Health System Office, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Singapore Population Health Improvement Centre (SPHERiC), National University Health System, Singapore, Singapore
| | - Hwee Lin Wee
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Faculty of Science, National University of Singapore, Singapore, Singapore
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Ho HJ, Tan YR, Cook AR, Koh G, Tham TY, Anwar E, Hui Chiang GS, Lwin MO, Chen MI. Increasing Influenza and Pneumococcal Vaccination Uptake in Seniors Using Point-of-Care Informational Interventions in Primary Care in Singapore: A Pragmatic, Cluster-Randomized Crossover Trial. Am J Public Health 2019; 109:1776-1783. [PMID: 31622142 DOI: 10.2105/ajph.2019.305328] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objectives. To evaluate the effectiveness of point-of-care informational interventions in general practitioner clinics to improve influenza and pneumococcal vaccination uptake among elderly patients.Methods. We conducted a pragmatic, cluster-randomized crossover trial in 22 private general practitioner clinics in Singapore, from November 2017 to July 2018. We included all patients aged 65 years or older. Clinics were assigned to a 3-month intervention (flyers and posters encouraging vaccination) plus 1-month washout period, and a 4-month control period (usual care). Primary outcomes were differences in vaccination uptake rates between periods. Secondary outcomes were identification of other factors associated with vaccination uptake.Results. A total of 4378 and 4459 patients were included in the intervention and control periods, respectively. Both influenza (5.9% vs 4.8%; P = .047) and pneumococcal (5.7% vs 3.7%; P = .001) vaccination uptake rates were higher during the intervention period compared with the control period. On multilevel logistic regression analysis, follow-up for hypertension, diabetes mellitus, hyperlipidemia, or any combination of the 3 was associated with uptake of both vaccines.Conclusions. Point-of-care informational interventions likely contributed to increased influenza and pneumococcal vaccination uptake. Patients on follow-up for hypertension, diabetes mellitus, hyperlipidemia, or any combination of the 3 were more likely to receive influenza and pneumococcal vaccination and should be actively engaged by physicians.Trial Registration. ClinicalTrials.gov Identifier: NCT03445117.
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Affiliation(s)
- Hanley J Ho
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - Yi-Roe Tan
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - Alex R Cook
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - Gerald Koh
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - Tat Yean Tham
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - Eve Anwar
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - Grace Shu Hui Chiang
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - May O Lwin
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | - Mark I Chen
- Hanley J. Ho is with the Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore. Yi-Roe Tan and Mark I. Chen are with the National Centre for Infectious Diseases, Singapore. Alex R. Cook and Gerald Koh are with the Saw Swee Hock School of Public Health, National University of Singapore, Singapore. Tat Yean Tham is with Frontier Healthcare Group, Singapore. Eve Anwar is with OneCare Medical Group Pte Ltd, Singapore. Grace Shu Hui Chiang is with the Department of Medicine, St Luke's Hospital, Singapore. May O. Lwin is with the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
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Abstract
A rapidly aging population along with the increasing burden of patients with chronic conditions in Asia requires efficient health systems with integrated care. Although some efforts to integrate primary care and hospital care in Asia are underway, overall care delivery remains fragmented and diverse, eg, in terms of medical electronic record sharing and availability, patient registries, and empowerment of primary health care providers to handle chronic illnesses. The primary care sector requires more robust and effective initiatives targeted at specific diseases, particularly chronic conditions such as diabetes, hypertension, depression, and dementia. This can be achieved through integrated care - a health care model of collaborative care provision. For successful implementation of integrated care policy, key stakeholders need a thorough understanding of the high-risk patient population and relevant resources to tackle the imminent population demographic shift due to the extremely rapid rate of increase in the aging population in Asia.
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Affiliation(s)
- Tat Yean Tham
- Clinical Affairs Department, Frontier Healthcare Group, Singapore
| | - Thuy Linh Tran
- Department of Pharmacy, National University of Singapore, Singapore
| | - Somjit Prueksaritanond
- Department of Community, Occupational and Family Medicine, Faculty of Medicine, Burapha University, Chonburi, Thailand
| | - Josefina S Isidro
- Department of Family and Community Medicine, University of the Philippines, Manila, Philippines
| | - Sajita Setia
- Transform Medical Communications, Wanganui, New Zealand
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Luo M, Poh Z, Koh G, Tham TY, Lau W, Toh SA, Chong CK, Low LL, Venkataraman K. Diabetes management in a Primary Care Network (PCN) of private general practitioners in Singapore: An observational study. Medicine (Baltimore) 2018; 97:e12929. [PMID: 30412099 PMCID: PMC6221669 DOI: 10.1097/md.0000000000012929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A Primary Care Network (PCN) is a virtual network of general practitioners (GPs), sharing common resources and common clinical governance framework for effective chronic disease management. In this study, we analyzed the frequency of assessment as well as control of HbA1c, blood pressure (BP), and low-density lipoprotein (LDL) over time among adult patients with diabetes managed by a group of private GPs under PCN.Data, including clinical measurements of HbA1c, BP, and LDL from 2012 to 2015, of 943 subjects at 9 GP clinics that piloted PCN in Singapore in 2012 was obtained from the chronic disease register for this analysis.The total number of PCN patients increased from 371 in 2012 to 911 in 2015. The average HbA1c decreased from 7.5% in 2012 to 7.3% in 2015, with a significant yearly improving trend of -0.11% (P < .001). The trends in change for systolic BP and LDL were not statistically significant during the same follow-up period. Regular assessment of HbA1c decreased from 80% in 2012 to 55% in 2015. Such decreases were also found in BP and LDL assessments. We also found that receiving government subsidies under a national scheme was a major determinant for maintaining regular assessment, with patients so covered 3 to 20 times more likely to have regular assessments.The PCN model can help improve care and clinical outcomes in adult patients with diabetes in the private primary care sector. Investing greater financial and human resources to augment service capacity and expanding subsidy coverage may be important to ensure the effectiveness, scalability, and sustainability of such a model of care.
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Affiliation(s)
- Miyang Luo
- Saw Swee Hock School of Public Health, National University of Singapore
| | | | - Gerald Koh
- Saw Swee Hock School of Public Health, National University of Singapore
| | - Tat Yean Tham
- Frontier Healthcare Group
- Yong Loo Lin School of Medicine, National University of Singapore
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Tai ES, Chia BL, Bastian AC, Chua T, Ho SCW, Koh TS, Low LP, Tey JS, Poh KK, Tan CE, Ting P, Tham TY, Toh SA, van Dam RM. Ministry of Health Clinical Practice Guidelines: Lipids. Singapore Med J 2017; 58:155-166. [PMID: 28361160 DOI: 10.11622/smedj.2017018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Lipids to provide doctors and patients in Singapore with evidence-based treatment for lipids. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on Lipids, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.
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Affiliation(s)
- E Shyong Tai
- Department of Endocrinology, University Medicine Cluster, National University Health System, National University Hospital, Singapore.
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Pan DST, Huang JH, Lee MHM, Yu Y, Chen MIC, Goh EH, Jiang L, Chong JWC, Leo YS, Lee TH, Wong CS, Loh VWK, Poh AZ, Tham TY, Wong WM, Lim FS. Knowledge, attitudes and practices towards antibiotic use in upper respiratory tract infections among patients seeking primary health care in Singapore. BMC Fam Pract 2016; 17:148. [PMID: 27809770 PMCID: PMC5094024 DOI: 10.1186/s12875-016-0547-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 10/21/2016] [Indexed: 11/10/2022]
Abstract
Background Patients’ expectations can influence antibiotic prescription by primary healthcare physicians. We assessed knowledge, attitude and practices towards antibiotic use for upper respiratory tract infections (URTIs), and whether knowledge is associated with increased expectations for antibiotics among patients visiting primary healthcare services in Singapore. Methods Data was collected through a cross-sectional interviewer-assisted survey of patients aged ≥21 years waiting to see primary healthcare practitioners for one or more symptoms suggestive of URTI (cough, sore throat, runny nose or blocked nose) for 7 days or less, covering the demographics, presenting symptoms, knowledge, attitudes, beliefs and practices of URTI and associated antibiotic use. Univariate and multivariate logistic regression was used to assess independent factors associated with patients’ expectations for antibiotics. Results Nine hundred fourteen out of 987 eligible patients consulting 35 doctors were recruited from 24 private sector primary care clinics in Singapore. A third (307/907) expected antibiotics, of which a substantial proportion would ask the doctor for antibiotics (121/304, 40 %) and/or see another doctor (31/304, 10 %) if antibiotics were not prescribed. The majority agreed “antibiotics are effective against viruses” (715/914, 78 %) and that “antibiotics cure URTI faster” (594/912, 65 %). Inappropriate antibiotic practices include “keeping antibiotics stock at home” (125/913, 12 %), “taking leftover antibiotics” (114/913, 14 %) and giving antibiotics to family members (62/913, 7 %). On multivariate regression, the following factors were independently associated with wanting antibiotics (odds ratio; 95 % confidence interval): Malay ethnicity (1.67; 1.00–2.79), living in private housing (1.69; 1.13–2.51), presence of sore throat (1.50; 1.07–2.10) or fever (1.46; 1.01–2.12), perception that illness is serious (1.70; 1.27–2.27), belief that antibiotics cure URTI faster (5.35; 3.76–7.62) and not knowing URTI resolves on its own (2.18; 1.08–2.06), while post-secondary education (0.67; 0.48–0.94) was inversely associated. Those with lower educational levels were significantly more likely to have multiple misconceptions about antibiotics. Conclusion Majority of patients seeking primary health care in Singapore are misinformed about the role of antibiotics in URTI. Agreeing with the statement that antibiotics cure URTI faster was most strongly associated with wanting antibiotics. Those with higher educational levels were less likely to want antibiotics, while those with lower educational levels more likely to have incorrect knowledge. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0547-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Darius Shaw Teng Pan
- Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, 119228, Singapore, Singapore
| | - Joyce Huixin Huang
- Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, 119228, Singapore, Singapore
| | - Magdalene Hui Min Lee
- Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, 119228, Singapore, Singapore
| | - Yue Yu
- Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, 119228, Singapore, Singapore
| | - Mark I-Cheng Chen
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, 12 Science Drive 2, 117549, Singapore, Singapore. .,Institute of Infectious Diseases & Epidemiology, Communicable Disease Centre, Tan Tock Seng Hospital, 308433, Singapore, Singapore.
| | - Ee Hui Goh
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, 12 Science Drive 2, 117549, Singapore, Singapore
| | - Lili Jiang
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, 12 Science Drive 2, 117549, Singapore, Singapore
| | - Joash Wen Chen Chong
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, 12 Science Drive 2, 117549, Singapore, Singapore
| | - Yee Sin Leo
- Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, 119228, Singapore, Singapore.,Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, 12 Science Drive 2, 117549, Singapore, Singapore.,Institute of Infectious Diseases & Epidemiology, Communicable Disease Centre, Tan Tock Seng Hospital, 308433, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nan Yang Technological University, 308232, Singapore, Singapore
| | - Tau Hong Lee
- Institute of Infectious Diseases & Epidemiology, Communicable Disease Centre, Tan Tock Seng Hospital, 308433, Singapore, Singapore
| | - Chia Siong Wong
- Institute of Infectious Diseases & Epidemiology, Communicable Disease Centre, Tan Tock Seng Hospital, 308433, Singapore, Singapore
| | - Victor Weng Keong Loh
- Division of Family Medicine, Department of Medicine, University Medicine Cluster, National University Hospital System, 119228, Singapore, Singapore
| | | | - Tat Yean Tham
- Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, 119228, Singapore, Singapore.,Division of Family Medicine, Department of Medicine, University Medicine Cluster, National University Hospital System, 119228, Singapore, Singapore.,Frontier Healthcare group, 400305, Singapore, Singapore
| | - Wei Mon Wong
- Division of Family Medicine, Department of Medicine, University Medicine Cluster, National University Hospital System, 119228, Singapore, Singapore.,Division of Primary Care, Raffles Medical Group, 188770, Singapore, Singapore.,Duke NUS Graduate Medical School, National University of Singapore, 169857, Singapore, Singapore
| | - Fong Seng Lim
- Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, 119228, Singapore, Singapore.,Division of Family Medicine, Department of Medicine, University Medicine Cluster, National University Hospital System, 119228, Singapore, Singapore
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