Primary Care In Singapore Research Articles

Primary care in Singapore: an occupational therapy perspective

Primary care in Singapore: an occupational therapy perspective

Deprescribing in Primary Care in Singapore: Barriers and Facilitators.

OBJECTIVES: To describe the prevalence of potentially inappropriate medications (PIMs) in older patients (65 years of age and older) in three selected polyclinics (PCs) and gather the perceptions of the health care providers in these PCs on the barriers and facilitators of deprescribing in their practice. To analyze the patients' age, number of active chronic diseases, and number of medicines, and investigate if they could influence the presence of PIMs. DESIGN: The study has two separate parts: The first part is a retrospective cross-sectional data collection of prescriptions; the second part is a prospective cross-sectional analysis of questionnaires by health care providers. SETTING: The study is in an institutional primary care setting. PATIENTS, PARTICIPANTS: Prescriptions were from 210 randomly selected patients 65 years of age or older with at least five long-term medications, who had attended the PCs over a selected 10-day period. Health care providers from the PCs were surveyed via an anonymous questionnaire. RESULTS: The prevalence of PIMs is 44% of the prescriptions. The most prevalent PIM is "long-term proton pump inhibitor (PPI) without documented indication" at 45.7%. The number of active chronic diseases and total number of medications are associated with prevalence of PIMs. Facilitators and barriers of deprescribing highlighted are motivation and goals of the health care providers, knowledge, lack of time for deprescribing, and communication between specialists and primary care providers. CONCLUSION: PPI is a feasible drug class to start deprescribing in primary care. Knowing the barriers and facilitators would set the impetus for future work to make deprescribing more widespread and acceptable for primary care in Singapore.

Deprescribing in Primary Care in Singapore: Barriers and Facilitators.

OBJECTIVES: To describe the prevalence of potentially inappropriate medications (PIMs) in older patients (65 years of age and older) in three selected polyclinics (PCs) and gather the perceptions of the health care providers in these PCs on the barriers and facilitators of deprescribing in their practice. To analyze the patients' age, number of active chronic diseases, and number of medicines, and investigate if they could influence the presence of PIMs. DESIGN: The study has two separate parts: The first part is a retrospective cross-sectional data collection of prescriptions; the second part is a prospective cross-sectional analysis of questionnaires by health care providers. SETTING: The study is in an institutional primary care setting. PATIENTS, PARTICIPANTS: Prescriptions were from 210 randomly selected patients 65 years of age or older with at least five long-term medications, who had attended the PCs over a selected 10-day period. Health care providers from the PCs were surveyed via an anonymous questionnaire. RESULTS: The prevalence of PIMs is 44% of the prescriptions. The most prevalent PIM is "long-term proton pump inhibitor (PPI) without documented indication" at 45.7%. The number of active chronic diseases and total number of medications are associated with prevalence of PIMs. Facilitators and barriers of deprescribing highlighted are motivation and goals of the health care providers, knowledge, lack of time for deprescribing, and communication between specialists and primary care providers. CONCLUSION: PPI is a feasible drug class to start deprescribing in primary care. Knowing the barriers and facilitators would set the impetus for future work to make deprescribing more widespread and acceptable for primary care in Singapore.

Tackling dementia together with primary care in Singapore

Tackling dementia together with primary care in Singapore

Serum folate predicts muscle strength: a pilot cross-sectional study of the association between serum vitamin levels and muscle strength and gait measures in patients >65 years old with diabetes mellitus in a primary care setting

BackgroundOld age and diabetes mellitus are risk factors for vitamin deficiencies, weakness and falls.Deficiencies of vitamin D, and possibly vitamin B12 and folate (which are associated with hyperhomocysteinaemia), contribute to sarcopenia. Determination of the physical effects of vitamin deficiencies in specific groups of people can help to guide public health policy with regard to vitamin supplementation.MethodsA pilot cross-sectional study was conducted to determine the association of levels of vitamin D, vitamin B12, folate and homocysteine with muscle strength, gait and fall history in 56 patients >65 years old with diabetes mellitus in primary care in Singapore.Hand-grip and leg-quadriceps strength measures were obtained and divided by body mass index (BMI).The timed up-and-go and Tinetti tests were used to measure gait. A history of “at least one fall in the preceding year” was obtained.ResultsVitamin B12 deficiency (<150 pmol/l) was present in 43 % of patients, folate deficiency (<13.5 mmol/l) in 20 %, hyperhomocysteinaemia (≥15.0 μmol/l) in 52 % and vitamin D deficiency (<49.9 nmol/l) in 25 %.Levels of vitamin D, vitamin B12 and homocysteine did not significantly predict muscle strength in regression analyses.Folate (B = 0.010, P < 0.01) and gender (B = 0.356, P < 0.001) predicted average grip strength corrected for BMI (F(2,53) = 17.74, P < 0.001, R 2 = 0.40)Folate (B = 0.011, P < 0.05) and gender (B = 0.367, P < 0.001) also predicted average leg quadriceps strength corrected for BMI (F(2,53) = 9.79, P < 0.001, R 2 = 0.27).Average leg strength and average leg strength corrected for BMI were both negatively associated with the risk of having fallen in the preceding year (odds ratio (OR) = 0.89, 95 % CI 0.80–0.98, P < 0.05 and OR = 0.12, 95 % CI 0.02–0.92, P < 0.05, respectively).ConclusionsThe prevalence of vitamin deficiency was very high in our sample of patients >65 years old with diabetes mellitus. Folate levels were significantly correlated with grip and leg strength (with correction for BMI). Leg strength was positively correlated with gait measures and negatively correlated with a history of falls. The role of folate in muscle weakness and falls warrants further study.

The impact of direct observed therapy on daily living activities, quality of life and socioeconomic burden on patients with tuberculosis in primary care in Singapore

Introduction: The prevalence of tuberculosis (TB) is rising in Singapore. The affected patients are provided with free directly observed therapy (DOT) at local polyclinics. The impact of DOT on their daily living activities (DLA) and quality of life (QOL) may affect their treatment adherence. The study aimed to evaluate the effect of DOT on the DLA and QOL of patients with TB and to quantify their socioeconomic burden. Material and methods: This questionnaire survey recruited adult multi-ethnic Asian patients with TB who were on DOT at nine local polyclinics. The questionnaire collected data on their demographic characteristics and DLA, anti-TB medications, the validated WHOQOL-BREF instrument, and socioeconomic costs. The associations between DOT and independent variables were tested using Student’s t-test and ANOVA. Results: The 356 patients recruited comprised 63% males with mean age of 43 years; 73% of them were employed, 73% reported increased travel time (mean 41 minutes/DOT visit) and DOT-related cost (mean S$260–S$389 for 6–9 months’ treatment); 47% indicated reduced participation in social functions and 45% felt that DOT had caused disruptions to their work, especially among younger patients. The WHOQOL-BREF scores were 13.3/20 “Physical Health”, 12.6/20 “Psychological”, 13.4/20 “Social Relationships” and 12.3/20 “Environment” domains, respectively. Some 52% of them rated their QOL as “good” or “very good”, 47% reported satisfaction with their health but 74% experienced negative feelings such as despair, anxiety and depression. Conclusion: The DOT affected patients’ DLA, QOL and increased their socioeconomic burden, which should be addressed by appropriate mitigating measures in the community.

Primary healthcare system and practice characteristics in Singapore

It is crucial to adapt and improve the (primary) health care systems of countries to prepare for future patient profiles and their related needs. The main aim of this study was to acquire a comprehensive overview of the perceptions of primary care experts in Singapore about the state of primary care in Singapore, and to compare this with the state of primary care in other countries. Notwithstanding ranked 2nd in terms of efficiency of health care, Singapore is facing significant health care challenges. Emails were sent to 85 experts, where they were asked to rate Singapore’s primary care system based on nine internationally adopted health system characteristics and six practice characteristics (response rate = 29%). The primary care system in Singapore received an average of 10.9 out of 30 possible points. Lowest ratings were given to: earnings of primary care physicians compared to specialists, requirement for 24 hr accessibility of primary care services, standard of family medicine in academic departments, reflection of community served by practices in patient lists, and the access to specialists without needing to be referred by primary care physicians. Singapore was categorized as a ‘low’ primary care country according to the experts.

PAIR UP for primary care excellence: perspectives from a primary healthcare provider in Singapore

Singapore is facing an increasing noncommunicable disease burden due to its ageing population. Singapore's primary healthcare services, provided by both polyclinic physicians and private general practitioners, are available to the public at differential fees for service. The resultant disproportionate patient loads lead to dissatisfaction for both healthcare providers and consumers. This article describes the 'PAIR UP' approach as a potential endeavour to facilitate primary care physicians (PCPs) in public and private sectors to collaborate to deliver enhanced primary care in Singapore. PAIR UP is an acronym referring to Policy, Academic development, Integration of healthcare information system, Research in primary care, Utility and safety evaluation, and Practice transformation. The current healthcare landscape is favourable to test out this multipronged approach. PCPs in both sectors can ride on it and work together synergistically to provide quality primary care in Singapore.

Impact of cigarette smoking on symptoms and quality of life of adults with asthma managed in public primary care clinics in Singapore: a questionnaire study

Cigarette smoking aggravates asthma exacerbations, yet some patients with asthma continue to smoke. To compare the quality of life of adult smokers and non-smokers with asthma. Asthma Quality of Life (AQLQ) questionnaires were administered to adult patients with asthma managed in primary care in Singapore. The survey also included data of their asthma status including symptom profiles. Independent two-sample t-test, ANCOVA model, χ2 test and ordinal logistic regression were used to compare the mean domain scores and the effect of smoking on nocturnal symptoms and awakening, respectively. 357 adult asthma patients (183 non-smokers and 174 smokers) were recruited. Smokers were mainly male (p<0.001), single (p=0.008), and younger (mean age 30 years) (p=0.007). They were more affected by nocturnal cough and wheezing (p=0.016). After adjustment for age, gender, and asthma medications, the mean scores of the AQLQ 'symptoms' and 'emotional function' domains of smokers were 0.41 (95% CI 0.10 to 0.72) and 0.50 (95% CI 0.16 to 0.84) points lower than for non-smokers, with no statistical differences in the 'activity limitations' and 'exposure to environmental stimuli' domains. Adult patients with asthma who smoke are more affected by nocturnal symptoms, with lower 'emotional function' scores in the AQLQ.

A Qualitative Study of Parental Use of the Written Asthma Action Plan for Their Children in Primary Care in Singapore

A symptom-based written asthma action plan (WAAP) was introduced to both adult and pediatric patients as part of the evidence-based local clinical practice guidelines to educate patients in asthma self-management in Singapore in 1998. This article aimed to explore the issues pertaining to the parental use of the WAAP for their children with asthma. A qualitative method using focus group discussions was used to gather qualitative data from parents of children with asthma who are on review at primary care clinics in Singapore. Qualitative data analysis based on grounded theory was carried out to identify emergent themes. Parents expressed difficulty in differentiating asthma-related symptoms from early symptoms of an upper-respiratory tract infection. Because of the failure to recognize cough as an asthma-related symptom, they focused more on symptomatic treatment of cough. They often relied on their own assessment of their children’s asthma status and sought medical consultation soon after onset of the children’s symptoms, rather than adjusting their inhaled medication. This deviated from the WAAP given by their physician. Their threshold to consult a doctor was thus variable, reflecting their confidence in self-management of their children’s asthma condition. Factors that hinder the implementation of the WAAP for children included difficulty in symptom recognition, parental focus on symptomatic treatment, and confidence issues in using the tool.

Treat-to-target approach in managing modifiable risk factors of patients with coronary heart disease in primary care in Singapore: what are the issues?

BackgroundThe key management strategy for established coronary heart disease (CHD) patients is to control the underlying risk factors. Further complications will be reduced when these risk factors are treated-to-target (TTT) as recommended by clinical practice guidelines. These targets include blood pressure (BP) lower than 130/80 mm Hg and LDL-cholesterol of less than 2.6 mmol/L and for those with type 2 diabetes mellitus (DM), HBA1c less than 7%. This article aimed to explore the issues affecting this approach from both the patients' and primary care physicians' (PCP) perspectives.MethodsThe study involved triangulation of research methods to determine the findings. Part A: focus group discussions to collect qualitative data from patients with CHD and from PCPs who were managing them in primary care. Part B: A subsequent questionnaire survey to determine the extent of their awareness of treatment targets for modifiable risk factors.ResultsCHD patients had variable awareness of the modifiable risk factors for CHD due to poor concordance between the PCPs' approach in managing the CHD patients and the latter's reception of information. 46% of participants knew their targets of BP control correctly; 11% of them were correct in stating their target for LDL-cholesterol control. Amongst these participants with DM (n = 146), 27% of them were correct in indicating their target of diabetic control.ConclusionsCommunication and practice barriers exist which hinder the treat-to-target approach in mitigating the risk factors for CHD patients. Incorporating this approach in routine clinical practice by PCPs has greater potential to achieve treatment targets for patients.