Singapore Healthcare System Research Articles

Current status of the early childhood developmental intervention ecosystem in Singapore

Childhood developmental-behavioural issues and disabilities have been identified as the major challenges in child health and to the national healthcare system in Singapore. Dealing with these morbidities requires new and innovative approaches that go far beyond hospital-based care into the community, with structured integration of medical services with education, and social and community support, including a strong collaborative partnership with parents and caregivers. A unique child development programme has evolved in Singapore over the last 30 years. Its main objectives are early identification and treatment of children with developmental and behavioural problems so as to correct developmental dysfunctions, minimise the impact of a child’s disability or prevailing risk factors, strengthen families and establish the foundations for subsequent development. This paper aimed to provide an update of the current ecosystem, along with a review of the fast-changing landscape in recent years.

A review of implementation frameworks to operationalize health technology assessment recommendations for medical technologies in the Singapore setting.

Methodologies of health technology assessment (HTA) for medical technologies are well established; yet, operational frameworks that enable appropriate uptake of HTA recommendations into routine clinical practice are lacking. This review aims to identify the key themes needed to guide the planning and implementation of HTA subsidy decisions for medical technologies such as diagnostics, medical devices, and services and to monitor their impact on a complex multipayer healthcare system like Singapore. A literature search of implementation frameworks was conducted up to 20 December 2020 and was documented in a flow diagram. A thematic analysis of the evidence base was performed using the Braun and Clark approach to identify key themes, from which an implementation framework suitable for Singapore's healthcare system could be developed. The searches yielded forty-four articles for review, from which twenty themes were identified. The top ten themes constituted the key themes of implementation essential for local adaptation and were categorized into five domains: implementation strategy, organizational support, stakeholder engagement, information dissemination, and implementation outcomes and evaluation. These domains provide operational guidance to methodically identify gaps to facilitate sustainable implementation of HTA-informed medical technology subsidy decisions. A robust and adaptable implementation of HTA-informed subsidy decisions is crucial to optimize its intended impact of improving patient outcomes per dollar spent. The key themes of an implementation framework should capture the important aspects of organizational feasibility to ensure successful adoption in a complex multipayer healthcare system like Singapore.

Neurology of COVID-19 in Singapore

PurposeTo describe the spectrum of COVID-19 neurology in Singapore. MethodWe prospectively studied all microbiologically-confirmed COVID-19 patients in Singapore, who were referred for any neurological complaint within three months of COVID-19 onset. Neurological diagnoses and relationship to COVID-19 was made by consensus guided by contemporaneous literature, refined using recent case definitions. Results47,572 patients (median age 34 years, 98% males) were diagnosed with COVID-19 in Singapore between 19 March to 19 July 2020. We identified 90 patients (median age 38, 98.9% males) with neurological disorders; 39 with varying certainty of relationship to COVID-19 categorised as: i) Central nervous system syndromes-4 acute disseminated encephalomyelitis (ADEM) and encephalitis, ii) Cerebrovascular disorders-19 acute ischaemic stroke and transient ischaemic attack (AIS/TIA), 4 cerebral venous thrombosis (CVT), 2 intracerebral haemorrhage, iii) Peripheral nervous system-7 mono/polyneuropathies, and a novel group, iv) Autonomic nervous system-4 limited dysautonomic syndromes. Fifty-one other patients had pre/co-existent neurological conditions unrelated to COVID-19. Encephalitis/ADEM is delayed, occurring in critical COVID-19, while CVT and dysautonomia occurred relatively early, and largely in mild infections. AIS/TIA was variable in onset, occurring in patients with differing COVID-19 severity; remarkably 63.2% were asymptomatic. CVT was more frequent than expected and occurred in mild/asymptomatic patients. There were no neurological complications in all 81 paediatric COVID-19 cases. ConclusionCOVID-19 neurology has a wide spectrum of dysimmune-thrombotic disorders. We encountered relatively few neurological complications, probably because our outbreak involved largely young men with mild/asymptomatic COVID-19. It is also widely perceived that the pandemic did not unduly affect the Singapore healthcare system.

Cost-Effectiveness of Transcatheter Aortic Valve Implantation in Intermediate and Low Risk Severe Aortic Stenosis Patients in Singapore

Singapore has the world's second most efficient healthcare system while costing less than 5% GDP. It remains unclear whether transcatheter aortic valve implantation (TAVI) is cost-effective for treating intermediate-low risk severe aortic stenosis (AS) patients in a highly efficient healthcare system. A two-phase economic model combining decision tree and Markov model was developed to assess the costs, effectiveness, and the incremental cost-effectiveness ratio (ICER) of transfemoral (TF) TAVI versus surgical aortic valve replacement (SAVR) in intermediate-low risk patients over an 8-year time horizon. Mortality and complications rates were based on PARTNER 2 trial cohort A and Singapore life table. Costs were mainly retrieved from Singapore National University Health System database. Health utility data were obtained from Singapore population based on the EuroQol-5D (EQ-5D). A variety of sensitivity analyses were conducted. In base case scenario, the incremental effectiveness of TF-TAVI versus SAVR was 0.19 QALYs. The ICER of TF-TAVI was S$33,833/QALY. When time horizon was reduced to 5 years, the ICER was S$60,825/QALY; when event rates from the propensity analysis was used, the ICER was S$21,732/QALY and S$44,598/QALY over 8-year and 5-year time horizons, respectively. At a willingness to pay threshold of S$73,167/QALY, TF-TAVI had a 98.19% probability of being cost-effective after 100,000 simulations. The model was the most sensitive to the costs of TF-TAVI procedure. TF-TAVI is a highly cost-effective option compared to SAVR for intermediate-low risk severe AS patients from a Singapore healthcare system perspective. Increased procedure experience, reduction in device cost, and technology advance may have further increased the cost-effectiveness of TF-TAVI per scenario analysis.

Pandemics and Their Impact on Medical Training: Lessons From Singapore

The ongoing coronavirus disease 2019 (COVID-19) crisis has hit Singapore hard. As of February 25, 2020, Singapore had the fourth highest number of confirmed COVID-19 infections outside of China, only trailing behind South Korea, Italy, and Japan. This has had reverberating effects on Singapore’s health care system, and has, consequently, also affected medical education all the way from the undergraduate to the postgraduate level. While efforts are underway to contain disease spread and transmission, the authors believe that this is an opportune time to examine and reflect on the impact that medical crises like COVID-19 can have on medical training and education and to evaluate “business continuity plans” to ensure quality medical education even in the face of constant disruptions from pandemic outbreaks. Medical training is as important a mandate as patient care and service. The authors believe that even in trying times like this, rich and precious lessons can be sought and taught, which will immensely benefit medical students and residents—the health care leaders of tomorrow. In this Perspective, the authors discuss the various ways in which the COVID-19 crisis has affected medical instruction in Singapore and explore pertinent practical and creative solutions for the continuity of medical training in these trying times, drawing on their previous experience with the Severe Acute Respiratory Syndrome outbreak in 2003 as well as the current ongoing COVID-19 crisis.

Electroconvulsive therapy during a highly contagious respiratory pandemic-A framework during COVID-19.

Necessary procedures during the COVID-19 pandemic include electroconvulsive therapy (ECT). Providing ECT has been considered an essential service during COVID-19 in the Singapore healthcare system, not least to contribute to disease control within a society in part due to the nature of the ECT patient population. There is limited evidence-based scientific information available regarding a procedural framework for ECT during a respiratory pandemic, when much attention in the healthcare system is focused on different areas of clinical care. This article attempts to describe such a framework for ECT procedures acknowledging limited solid scientific evidence at this time and being mindful of future changes to these suggestions as testing, immunization, and treatment options develop. This approach can be adopted in whole or in part to assist practitioners to protect the patient and themselves during the procedure.

Acute medical unit: experience from a tertiary healthcare institution in Singapore.

Singapore's healthcare system is under strain from the rising demands of an increasing and ageing population, resulting in delayed specialist care for patients presenting to the emergency department and requiring admission. Acute assessment units have been developed elsewhere but are not well established in local healthcare. Our institution extended our acute medical team to form an acute medical unit (AMU), in which focused internist-led teams are stationed on site to rapidly assess and re-triage patients. All patients (excluding those with very complex conditions) are admitted to the AMU and managed by internists who provide holistic, patient-centric care with better ownership, improved efficiency and less fragmentation. Patients can receive timely access to medical interventions and stable patients can benefit from early supported discharge, anchored by the nursing, allied health and transitional care teams. Given the ageing patient population with multiple comorbidities, this integrated model with exceptional outcomes is highly suitable for Singapore.

PMD101 - COST-EFFECTIVENESS OF TRANSFEMORAL TRANSCATHETER AORTIC VALVE REPLACEMENT VERSUS SURGICAL AORTIC VALVE REPLACEMENT IN INTERMEDIATE-LOW RISK PATIENTS WITH SEVERE AORTIC STENOSIS IN SINGAPORE

Transcatheter aortic valve replacement (TAVR) has been mainly advised for inoperable and high surgical risk patients for treating severe aortic stenosis (AS). We conducted cost-effectiveness analysis on TAVR compared with common practice, surgical AVR (SAVR), in intermediate-low risk patients with severe AS in Singapore. Due to transfemoral (TF) access being dominant in Singapore, TF-TAVR was used in current analysis. A two-phase economic model combining decision tree and Markov model was developed to assess the incremental cost-effectiveness (ICER) of TF-TAVR versus SAVR over18-year horizon from Singapore healthcare system perspective. Event rates of mortality and complications were estimated from the Placement of Aortic Transcatheter Valves (PARTNER) 2 RCT cohort A and Singapore life table. Cost data were retrieved from the National University Heart Centre database. Health utilities were obtained from Singapore population norm based on EQ-5D. Scenario analyses were conducted using shorter horizon and event rates from PARTNER 2 S3 propensity analysis that used newer TAVR systems. Both one-way and probabilistic sensitivity analyses were performed. In base case scenario, the incremental effectiveness of TAVR versus SAVR is 0.30 QALYs. The ICER of TF-TAVR is S$21,062/QALY. In scenario analysis, where horizon was reduced to 10 years, ICER of TF-TAVR is S$27,060/QALY; where event rates from PARTNER 2 S3 propensity analysis was used, ICER of TF-TAVR is S$16,843/QALY and S$21,378/QALY over 18-year and 10-year horizon, respectively. At a willingness to pay threshold of S$65,000/QALY, TF-TAVR, compared with SAVR, has 99.87% probability of been cost-effective after 10,000 simulations. The model is the most sensitive to cost of TF-TAVI procedure, followed by cost of SAVR procedure. TF-TAVR seems to be a highly cost-effective option compared to SAVR for intermediate-low surgical risk patients with severe AS in Singapore. Increased procedure experience and/or technology advance may have further increased the cost-effectiveness of TF-TAVR per scenario analysis.

Excess Hospitalization Expenses Attributable to Type 2 Diabetes Mellitus in Singapore

ObjectivesTo estimate the excess hospitalization expenses attributable to type 2 diabetes mellitus (T2DM) in a high-income Asian country from the health system perspective and the patient perspective. MethodsElectronic medical records from a tertiary academic hospital in Singapore from 2012 to 2013 were used to create propensity score–matched cohorts with and without T2DM on the basis of their entry characteristics. A two-part model was then used to control for remaining differences between the cohorts. Excess cost due to diabetes was defined as the difference in hospital expenses between a patient with diabetes and a matched patient without diabetes. As part of the sensitivity analysis, a two-part model without matching and different matching algorithms were used to obtain the range of hospitalization expenses attributable to patients with T2DM. Balance of covariates after matching was investigated. All costs were presented in 2013 US dollars. ResultsMean adjusted excess hospital expense of one hospital visit attributable to diabetes was approximately $1007 and $113 from the health system perspective and the patient perspective, respectively. For the cohort of patients with T2DM in Singapore, this amounts to a total average expenditure of $117 million and $13 million from the health system perspective and the patient perspective, respectively. ConclusionsHospitalization expenses from diabetes result in a significant cost to the health care system in Singapore. Nevertheless, the excess burden of hospitalization on patients is mitigated significantly by cost sharing, which may reduce financial incentives to avert admissions through preventative care, which is largely out-of-pocket.

Family Medicine Clinic: a case study of a hospital-family medicine practice redesign to improve chronic disease care in the community in Singapore.

Singapore's health care system is strained by the health care needs of a rapidly aging population. The unprecedented collaboration between a public hospital and a private family practice to set up the Family Medicine Clinic (FMC) to co-manage patients with chronic disease is an example of efforts to shift care to the community. To explore patients' initial experience of shared chronic disease care in a private family practice setting. In this exploratory case study, we surveyed 330 patients with stable chronic diseases and interviewed 10 complex care patients and their caregivers. Most patients were willing to transfer their care from the hospital to a FMC and satisfied with the care received. Patients reported enhanced access at FMC and appreciated the improvement in care continuity and care coordination across settings. Patients with complex care needs felt engaged with their case manager even though they did not understand case management. Despite the favourable assessment of FMC, patients sought care from other health care providers and a third of patients would leave if the subsidy for their care at FMC was removed. Families and caregivers felt that their needs could be better addressed and that FMC could play a role. To ensure that patients' initial positive experience translates to a long-term relationship with FMC, providers should move beyond providing improved access to care. It is necessary to help patients understand the comparative advantage of community-based care and its contribution to long-term health outcomes. Providers should also elicit patients' desires and expectations when designing future models of care. At a policy level, higher cost of private primary care should be addressed.

Evolution, Revolution, Devolution and Volution of Singapore's Healthcare System

Over the years, Singapore’s healthcare system has evolved from the British colonial welfare healthcare system in the 1900s to today’s current Regional Healthcare Systems (RHS) and an upcoming reform into 3 clusters. The revolution of healthcare was evident after Singapore gained independence in 1965. It moved from a welfare, centralized healthcare system comprising of only one General Hospital to a decentralized network of 26 satellite hospitals/clinics whose main aim was to provide basic healthcare for its people and also eliminate infectious diseases like smallpox and measles. The move away from welfare state was to shift the costs of healthcare burden from the government to the people. In 2000, evolution of Singapore’s healthcare system began. Public healthcare institutions were organised into 2 healthcare clusters which further evolved into 6 regional healthcare clusters. purpose of restructuring the healthcare system into Regional Healthcare Systems (RHS) was to cater to the people’s needs in a more localised manner, enhance and strengthen integrated care across the care continuum in view of the challenges posed by increasing demands of healthcare needed by the greying population. The RHS framework comprised of general practitioners (GPs) restructured hospitals (RHs), community hospitals (CHs), nursing homes (NHs) and home care providers within each region. The process of restructuring the hospitals also sees a devolution of power from the government to the hospital, giving them autonomy to make decisions. The purpose of this is to ensure high standards and quality of care by competing against each other in a free market setting. In 2017, the government decided that a 3-cluster healthcare system (Volution of healthcare) would better optimise resources and capabilities to provide more comprehensive and patient-centered care to meet Singaporeans’ evolving needs. The convolution of Singapore healthcare’s system is responsive and adaptive to the changing needs of the population. Singapore’s healthcare system has been changing to better cater to the needs of the population. From providing basic healthcare in the 1960s to providing better integrated care to meet the needs of the ageing population and increased chronic burden through the 2-cluster system then the 6 RHS to better localised healthcare within the regions and to the upcoming 3-cluster healthcare system to better optimise and focus our resources to inch closer to our aim of providing accessible, affordable and quality health care.

Association between asthma control and asthma cost: Results from a longitudinal study in a primary care setting.

Asthma control can be assessed with the Asthma Control Test (ACT) and a score of 20 or higher indicates good asthma control. Patients pay for their consultation and treatment in the fee-for-service primary healthcare system in Singapore. We hypothesized that achieving asthma control would result in lower asthma costs through reduced acute exacerbations, fewer physician consultations and lower lost productivity. The study compared the healthcare costs of patients who achieved asthma control and those with suboptimal asthma control based on ACT scores. Factors influencing asthma control and healthcare expenditure over time were also examined. A total of 736 patients were enrolled into an asthma care programme in two polyclinics during 2008 and 2013. Direct costs of asthma management were derived from the frequency of polyclinic consultations, medication costs and hospitalization. Indirect costs were estimated from lost workdays due to exacerbations. The generalized estimating equation (GEE) approach was used to longitudinally model the factors associated with total healthcare expenditure. Patients with asthma control spent S$48 (US$36) more per doctor visit on asthma drugs (P < 0.01) but incurred S$65 (US$48) less per doctor visit in total costs (P < 0.01) than those with suboptimal asthma control. The savings from achieving asthma control for obese patients were greater than for normal-weight patients (S$42 or the equivalent of US$31; P < 0.05). Optimal asthma control was associated with reduced healthcare costs. An effective treatment regimen should also consider other modifiable factors such as weight control to achieve asthma control and eventually reduce asthma costs.

ISQUA16-1201PATIENT-PROVIDER DISCONNECT: A QUALITATIVE EXPLORATION OF UNDERSTANDING AND PERCEPTIONS TO CARE INTEGRATION IN SINGAPORE

Integrated care has been well-recognized as a solution to improve quality of care and quality of life for patients with complex, long-term problems cutting across multiple services, providers, and settings. As Singapore's healthcare system increasingly adopts integrated models of care, it is unclear if providers, patients and caregivers share adequate and similar understanding of such development. This study aims primarily to assess understanding and perception of care integration among various key healthcare stakeholders (providers, patients, caregivers, administrators) in Singapore. Secondary objectives were to identify challenges and expectations in implementing …

Modelling the cost-effectiveness of pharmacist-managed anticoagulation service for older adults with atrial fibrillation in Singapore

Background Oral anticoagulation with warfarin is the cornerstone therapy in atrial fibrillation (AF) for stroke prevention. Multi-disciplinary anticoagulation management services have been shown to be cost-effective in the United States, Hong Kong and Thailand, but the findings are not readily generalizable to Singapore's healthcare system. Objective This study aimed to evaluate the cost-effectiveness of pharmacist-managed anticoagulation clinic (ACC) compared with usual care (UC) for the management of older adults with AF receiving oral anticoagulation with warfarin. Setting Pharmacist-managed ACC in an academic medical centre. Method A Markov model with 3-month cycle length and 30-year time horizon compared costs and quality-adjusted life-years (QALYs) of ACC and UC from the patient's and healthcare provider's perspectives. Four pathways based on time in therapeutic range (TTR) were: ACC TTR<70%, ACC TTR≥70%, UC TTR<70% and UC TTR≥70%. A hypothetical cohort of 70-year-old Singaporean AF patients receiving warfarin was utilised. Local data from national disease registries, patient surveys and hospital databases were used. When local data was not available, published studies on Asian populations were utilized when available. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to account for uncertainties. Costs and QALYs were discounted annually by 3%. Main outcome measure Costs and QALYs of ACC and UC. Results Pharmacist-managed ACC was found to dominate UC in all comparisons. It improved effectiveness by 0.19 and 0.13 QALYs at TTR<70% and TTR≥70% respectively compared with UC. From the patient's perspective, ACC reduced costs by SG$1222.67 (€1110.24) for TTR<70% and SG$1008.16 (€915.46) for TTR≥70%. Similar trends were observed from the healthcare provider's perspective, with ACC reducing costs by SG$1444.79 (€1311.94) for TTR<70% and SG$1269.17 (€1152.46) for TTR≥70% compared with UC. The results were robust to variations of the parameters over their plausible ranges in one-way sensitivity analyses. Probabilistic sensitivity analyses demonstrated that ACC was cost-effective more than 79% of the time from both perspectives at a willingness-to-pay threshold of SG$69,050 (€62,701) per QALY. Conclusion Pharmacist-managed ACC is more effective and less costly compared with UC regardless of the quality of anticoagulation therapy. The findings support the current body of evidence demonstrating the cost-effectiveness of ACC.

Determining the cost-effectiveness of endoscopic surveillance for gastric cancer in patients with precancerous lesions.

To identify the optimal strategy for gastric cancer (GC) prevention by evaluating the cost-effectiveness of esophagogastroduodenoscopy (EGD)-based preventive strategies. We conducted a model-based cost-effectiveness analysis. Adopting a healthcare payer's perspective, Markov models simulated the clinical experience of the target population (Singaporean Chinese 50-69 years old) undergoing endoscopic screening, endoscopic surveillance and usual care of do-nothing. The screening strategy examined the cohort every alternate year whereas the surveillance strategy provided annual EGD only to people with precancerous lesions. For each strategy, discounted lifetime costs ($) and quality adjusted life years (QALY) were estimated and compared to generate incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analysis was conducted to identify influential parameters and quantify the impact of model uncertainties. Annual EGD surveillance with an ICER of $34200/QALY was deemed cost-effective for GC prevention within the Singapore healthcare system. To inform implementation, the models identified six influential factors and their respective thresholds, namely discount rate (<4.20%), age of starting surveillance (>51.6 years), proportion of program cost in delivering endoscopy (<65%), cost of follow-up EGD (<$484), utility of stage 1 GC patients (>0.72) and odds ratio of GC for high-risk subjects (>3.93). The likelihood that surveillance is the most cost-effective strategy is 69.5% accounting for model uncertainties. Endoscopic surveillance of gastric premalignancies can be a cost-effective strategy for GC prevention. Its implementation requires careful assessment on factors influencing the actual cost-effectiveness.

Long-term Cost-effectiveness of Statin Treatment for Primary Prevention of Cardiovascular Disease in the Elderly.

This study aimed to evaluate the cost-effectiveness of statins for primary prevention of stroke and myocardial infarction (MI) in the elderly in Singapore. A Markov model was developed to investigate the lifetime costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) of statin treatment in those aged 65 years and older without a history of stroke or MI from the perspective of Singapore's healthcare system, using elderly-specific clinical data and local costs from hospital databases. A lifetime horizon was used and all costs and health outcomes were discounted at 3% annually. In the base-case analysis, statin treatment prevented an additional four strokes and eight MIs among 1,000 "healthy" elderly individuals compared with no treatment. Statin treatment resulted in a QALY gain of 0.26 and additional costs of SGD 11,314 per person, yielding an ICER of SGD 43,925 (USD 33,495) per QALY gained. The results were sensitive to statin effectiveness, particularly statins' effect on all-cause mortality, and cost of statin medication. Probabilistic sensitivity analysis demonstrated that the probability of statin treatment being cost-effective was 72% at a willingness-to-pay threshold of SGD 65,000 (USD 49,546) per QALY gained. Shortening the time horizon from lifetime to 10 years (simulating limited life expectancy) considerably increased the ICER to SGD 291,313 (USD 167,171) per QALY. Female gender and younger age were also associated with higher ICERs owing to a lower baseline risk of cardiovascular disease (CVD) and higher costs to manage events in these subgroups. Statin treatment for the primary prevention of CVD in the elderly was cost-effective. However, treatment warrants re-evaluation when the prognosis of the individual is considered less than ten years; other goals may take precedence over CVD prevention.

Reducing hypersensitivity reactions with HLA-B*5701 genotyping before abacavir prescription: clinically useful but is it cost-effective in Singapore?

Abacavir (ABC) is one of the more affordable antiretroviral drugs used for controlling HIV. Although with similar efficacy to current first-line drugs, its limited usage in Singapore can be attributed to its possible side effect of adverse hypersensitivity reactions (HSRs). HLA-B*5701 genotyping is a clinically relevant procedure for avoiding abacavir-induced HSRs. As patients who do not carry the risk allele are unlikely to develop HSRs, a simple rule can be developed to allow abacavir prescription for patients who are B*5701 negative. Here, we carry out a cost-effectiveness analysis of HLA-B*5701 genotyping before abacavir prescription in the context of the Singapore healthcare system, which caters predominantly to Han Chinese, Southeast-asian Malays, and South-asian Indians. In addition, we aim to identify the most cost-effective treatment regimen for HIV patients. A decision tree model was developed in TreeAge. The model considers medical treatment and genotyping costs, genotyping test characteristics, the prevalence of the risk allele, reduction in the quality of life, and increased expenditure due to side effects and other factors, evaluating independently over early-stage and late-stage HIV patients segmented by drug contraindications. The study indicates that genotyping is not cost-effective for any ethnicity irrespective of the disease stage, except for Indian patients with early-stage HIV who are contraindicated to tenofovir. Abacavir (as first-line) without genotyping is the cheapest and most cost-effective treatment for all ethnicities except for early-stage Indian HIV patients contraindicated to tenofovir. The HLA-B*5701 frequency, the mortality rate from abacavir-induced HSRs, and genotyping costs are among the major factors influencing the cost-effectiveness.

Towards universal health coverage: the national health insurance in Singapore

This paper investigates the factors resulting in Singapore's health insurance coverage expansion through MediShield Life. A questionnaire-based survey is used to identify these factors. It is found that the Singaporean Government is rolling out MediShield Life to enhance coverage, but it remains to be seen whether this will alleviate the health insurance cost burden for Singaporeans. In practice, MediShield has not provided adequate coverage owing to exclusions of people bearing congenital or chronic illnesses, the elderly, and those who cannot afford private health insurance; MediShield Life aims at addressing these issues. The social implications are that although Singapore's healthcare system has been recognised as world-class, the healthcare services there are not perceived by citizens to be affordable; MediShield Life attempts to alleviate this concern. This paper provides a discussion about the affordability vs. coverage of Singapore's national health insurance, optimal balance between public and private health insurance, gaps and necessary reforms.

Measurement of Integrated Care on the level of Regional Health System in Singapore

In response to the rapidly aging population of Singapore and the increasing demands on healthcare, the Singapore healthcare system was reorganized into six regional health systems (RHS) according to geographic locations to provide a better integrated health system. In each of the RHS, an acute hospital works closely with the community hospital, nursing homes, homecare providers, general practitioners and polyclinics to deliver seamless and holistic care to patients. However, even with an increasing awareness of the needs to better integrate the health system, there is no universal definition and method of integrated care. Furthermore, the recent initiative of RHS has not been evaluated. Therefore, this study aims to (i) explore the concept of integrated care in the Singapore context (ii) validate an integrated care measure developed by Valentijn et a.l (iii) measure the nature and degree of integrated care within and across the RHS and (iv) provide recommendations to improve integrated care in Singapore. Focus group discussions will be conducted to gather opinions from healthcare users of the RHS about the concept of integrated care. Healthcare professionals from the RHS will be surveyed for validation of the integrated care instrument and measurement of the level of integrated care of the RHS. The degree of integrated care of the RHS will then be compared to the international community and recommendations will be made based on the triangulation of data collected from the healthcare users and professionals. Results of this study which will be presented during the conference will provide insights on the degree of integrated care within and across the RHS to provide recommendations for improvements of the RHS. Data collected from this study can also be used as a baseline reference for prospective follow up.

Cost-effectiveness of dabigatran and rivaroxaban compared with warfarin for stroke prevention in patients with atrial fibrillation.

This study aimed to evaluate the cost-effectiveness of dabigatran and rivaroxaban compared with warfarin for the prevention of stroke in patients with atrial fibrillation (AF) in Singapore. A Markov model was constructed to compare the lifetime costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) of dabigatran 110 and 150 mg, rivaroxaban 20 mg and adjusted-dose warfarin from the perspective of the Singapore healthcare system, using clinical data from published studies, utilities from a patient-reported survey and costs from hospital databases. The target population was a hypothetical cohort of 65-year-old AF patients with no contraindications to anticoagulation. In the base-case analysis, the QALYs were 8.75 with warfarin, 8.73 with dabigatran 110 mg, 8.82 with dabigatran 150 mg, and 9.33 with rivaroxaban. The costs were Singapore dollar (SG$) 34,648 for warfarin, SG$54,919 for dabigatran 110 mg, SG$50,484 for dabigatran 150 mg and SG$51,975 for rivaroxaban. The ICER of rivaroxaban versus warfarin was SG$29,697 (US$26,727) per QALY. Rivaroxaban and warfarin had extended dominance over the high-dose dabigatran. The low-dose dabigatran was dominated by warfarin. Deterministic sensitivity analyses showed that the ICER of rivaroxaban versus warfarin was sensitive to cost of rivaroxaban and utilities for rivaroxaban and warfarin. Probability sensitivity analysis demonstrated that the probability of rivaroxaban being the optimal choice was 97.8% and 99.5% at a willingness-to-pay threshold of SG$65,000 (US$58,500) and SG$130,000 (US$117,000) per QALY, respectively. Rivaroxaban may be a cost-effective alternative to warfarin for the prevention of stroke in patients with AF in Singapore.