The association between chronic sinonasal inflammation and nasopharyngeal carcinoma - A systematic review and meta-analysis.

PURPOSE: There has been mounting evidence that inflammation is a key risk factor towards the development of certain cancers. Past studies have shown associations between nasopharyngeal carcinoma (NPC) and sinonasal tract inflammation. We aim to conduct a review and meta-analysis on the association between NPC and chronic sinus inflammation. MATERIALS AND METHODS: We conducted a meta-analysis, searching 4 international databases from 1 January 1973 to 28 March 2022 for studies reporting on sinonasal inflammation and NPC in adult patients (>18 years old). We included cohort, case-control or cross-sectional studies. These studies must examine the association between a prior history of sinonasal inflammation and the risk of developing NPC. The outcome is the incidence of NPC in patients who had prior sinonasal inflammation. RESULTS: 8 studies (8245 NPC; 1,036,087 non-NPC) were included. The overall odds ratio (OR) of patients having NPC after reporting sinonasal inflammation was 1.81 (95 % CI 1.73-1.89). Of note, chronic rhinosinusitis (CRS) (OR of 1.78 (95 %-CI: 1.68-1.90)) was more closely associated with an increased risk of NPC, as compared to allergic rhinitis (AR) (OR of 1.60 (95 %-CI: 1.52-1.68)). CONCLUSION: Chronic sinonasal inflammation is significantly associated with NPC in this systemic review and meta-analysis. The true cause-effect relationship and the potential effects of targeted screening need to be explored thoroughly with large scale prospective studies.

Instrument selection for the ASAS core outcome set for axial spondyloarthritis.

OBJECTIVES: To define the instruments for the Assessment of SpondyloArthritis international Society-Outcomes Measures in Rheumatology (ASAS-OMERACT) core domain set for axial spondyloarthritis (axSpA). METHODS: An international working group representing key stakeholders selected the core outcome instruments following a predefined process: (1) identifying candidate instruments using a systematic literature review; (2) reducing the list of candidate instruments by the working group, (3) assessing the instruments' psychometric properties following OMERACT filter 2.2, (4) selection of the core instruments by the working group and (5) voting and endorsement by ASAS. RESULTS: The updated core set for axSpA includes seven instruments for the domains that are mandatory for all trials: Ankylosing Spondylitis Disease Activity Score and Numerical Rate Scale (NRS) patient global assessment of disease activity, NRS total back pain, average NRS of duration and severity of morning stiffness, NRS fatigue, Bath Ankylosing Spondylitis Function Index and ASAS Health Index. There are 9 additional instruments considered mandatory for disease-modifying antirheumatic drugs (DMARDs) trials: MRI activity Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joints and SPARCC spine, uveitis, inflammatory bowel disease and psoriasis assessed as recommended by ASAS, 44 swollen joint count, Maastricht Ankylosing Spondylitis Enthesitis Score, dactylitis count and modified Stoke Ankylosing Spondylitis Spinal Score. The imaging outcomes are considered mandatory to be included in at least one trial for a drug tested for properties of DMARD. Furthermore, 11 additional instruments were also endorsed by ASAS, which can be used in axSpA trials on top of the core instruments. CONCLUSIONS: The selection of the instruments for the ASAS-OMERACT core domain set completes the update of the core outcome set for axSpA, which should be used in all trials.

Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials.

BACKGROUND: Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient's recovery. OBJECTIVES: We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures. METHODS: We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non-English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included "good quality" RCTs with Jadad score ≥ 3 for data extraction and synthesis. RESULTS: Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported. CONCLUSIONS: The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.

Role of Caregivers in Remote Management of Patients With Type 2 Diabetes Mellitus: Systematic Review of Literature.

BACKGROUND: With the growing use of remote monitoring technologies in the management of patients with type 2 diabetes mellitus (T2DM), caregivers are becoming important resources that can be tapped into to improve patient care. OBJECTIVE: This review aims to summarize the role of caregivers in the remote monitoring of patients with T2DM. METHODS: We performed a systematic review in MEDLINE, Embase, Scopus, PsycINFO, and Web of Science up to 2022. Studies that evaluated the role of caregivers in remote management of adult patients with T2DM were included. Outcomes such as diabetes control, adherence to medication, quality of life, frequency of home glucose monitoring, and health care use were evaluated. RESULTS: Of the 1198 identified citations, 11 articles were included. The majority of studies were conducted in North America (7/11, 64%) and South America (2/11, 18%). The main types of caregivers studied were family or friends (10/11, 91%), while the most common remote monitoring modalities evaluated were interactive voice response (5/11, 45%) and phone consultations (4/11, 36%). With regard to diabetes control, 3 of 6 studies showed improvement in diabetes-related laboratory parameters. A total of 2 studies showed improvements in patients' medication adherence rates and frequency of home glucose monitoring. Studies that evaluated patients' quality of life showed mixed evidence. In 1 study, increased hospitalization rates were noted in the intervention group. CONCLUSIONS: Caregivers may play a role in improving clinical outcomes among patients with T2DM under remote monitoring. Studies on mobile health technologies are lacking to understand their impact on Asian populations and long-term patient outcomes.

Social Media Use Among Members of the Assessment of Spondyloarthritis International Society: Results of a Web-Based Survey.

BACKGROUND: The use of social media in health care may serve as a beneficial tool for education, information dissemination, telemedicine, research, networking, and communications. To better leverage the benefits of social media, it is imperative to understand the patterns of its use and potential barriers to its implementation in health care. A previous study in 2016 that investigated social media use among young clinical rheumatologists (≤45 years) and basic scientists showed that there was substantial social media use among them for social and professional reasons. However, there is a limited inquiry into social media use in different areas of rheumatology, such as spondyloarthritis. OBJECTIVE: We aimed to explore the motivations, barriers, and patterns of social media use among an international group of experts in spondyloarthritis. METHODS: We distributed a web-based survey via email from March 2021 to June 2021 to 198 members of the Assessment of Spondyloarthritis International Society. It contained 24 questions about demographic characteristics, patterns of current social media use, and perceptions of utility. Univariable and multivariable logistic regression analyses were performed to identify the characteristics associated with use trends. RESULTS: The response rate was 78.8% (156/198). Of these, 93.6% (146/156) of participants used at least one social media platform. Apart from internet-based shopping and entertainment, the use of social media for clinical updates (odds ratio [OR] 6.25, 95% CI 2.43-16.03) and research updates (OR 3.45, 95% CI 1.35-8.78) were associated with higher social media consumption. Among the respondents, 66% (103/156) used social media in a work-related manner. The use of social media for new web-based resources (OR 6.55, 95% CI 2.01-21.37), interaction with international colleagues (OR 4.66, 95% CI 1.21-17.90), and establishing a web-based presence (OR 4.05, 95% CI 1.25-13.13) were associated with higher levels of consumption for work-related purposes. Time investment, confidentiality concerns, and security concerns were the top 3 challenges to a wider adoption of social media. CONCLUSIONS: Most respondents (103/156, 66%) use social media in a work-related manner. Professional development, establishing a web-based presence, and international collaboration were associated with higher use. Challenges to social media adoption should be addressed to maximize its benefits.

Validity and Reliability of the European Foot and Ankle Society (EFAS) Score in Patients With Hallux Valgus in Singapore.

The European Foot and Ankle Society score is a popular tool for monitoring treatment outcomes of foot or ankle conditions. However, few studies have assessed its psychometric properties in patients with hallux valgus. We aimed to validate the European Foot and Ankle Society score in patients with hallux valgus in Singapore. This is a cohort study of 121 patients with operatively managed hallux valgus from a tertiary referral hospital, evaluated preoperatively and at 6 months postoperatively with the primary endpoint of restoring patients to premorbid status. Internal consistency was assessed via Cronbach's alpha. Construct validity was assessed through 7 a priori hypotheses by correlating the European Foot and Ankle Society score with other patient-reported outcomes measures. Structural validity was assessed via Confirmatory Factor Analysis, whereby a good fit was indicated when Comparative Fit Index >0.95, Tucker-Lewis Index >0.95, Root Mean Square Error of Approximation <0.06, and Standardized Root Mean Residuals <0.08. Among our subjects, the European Foot and Ankle Society score demonstrated reliability, reflected by a good internal consistency (Cronbach's alpha = 0.773). Six out of the 7 a priori hypotheses were fulfilled, indicating both convergent and divergent construct validity. Structural validity was confirmed with our European Foot and Ankle Society score model which showed good fit for a 1-factor structure (Confirmatory Factor Analysis = 0.998, Tucker-Lewis Index = 0.996, Root Mean Square Error of Approximation = 0.025 [90% CI: 0-0.111], Standardized Root Mean Residuals = 0.027). In conclusion, the European Foot and Ankle Society score was validated for monitoring treatment outcomes of patients with hallux valgus in Singapore.

Elucidating the role of a positive family history in differentiating between axial and peripheral spondyloarthritis: an ancillary analysis of the ASAS-PerSpA study.

OBJECTIVES: Positive family history (PFH) of spondyloarthritis (SpA) is important in the diagnosis of SpA. However, the contribution of a PFH in differentiating the two SpA subtypes (axial and peripheral spondyloarthritis (pSpA)), in particular the importance of second-degree relative (SDR) has not been well-studied. We aimed to investigate whether PFH of radiographic axial spondyloarthritis (r-axSpA), psoriasis, uveitis, reactive arthritis and inflammatory bowel disease in first-degree relative (FDR) and second-degree relative (SDR) contributes to differentiation between axSpA and pSpA using the data from a multinational cohort study. METHODS: The ASAS-PerSpA study dataset was used to assess the effects of a PFH on differentiating between axSpA and pSpA via generalised structural equation modelling. Model building using backward selection was performed to obtain a final model. Direct, indirect and total effects of the path analysis were calculated. RESULTS: A total of 3803 patients were included: 2458 axSpA and 1345 pSpA patients. FDR (OR: 3.75, 95% CI: 2.86-4.91, p<0.001) and SDR (OR: 4.58, 95% CI: 3.19-6.59, p<0.001) with r-axSpA were positively associated while FDR (OR: 0.262, 95% CI: 0.207-0.331, p<0.001) and SDR (OR: 0.305, 95% CI: 0.221-0.420, p<0.001) with psoriasis were negatively associated with differentiating patients with axSpA from pSpA. CONCLUSIONS: The presence of r-axSpA and psoriasis in FDR or SDR are useful in differentiating axSpA from pSpA. SDR with r-axSpA may contribute greater towards the differentiation than FDR. Clinicians should consider taking an extensive family history of SpA and their subtypes to better differentiate the subtypes within the SpA spectrum.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks.

OBJECTIVE: To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups. METHODS: We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data. RESULTS: We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups. CONCLUSION: Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence. PROTOCOL REGISTRATION: PROSPERO Identifier: CRD42020181316.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review.

BACKGROUND: Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients. METHODS: The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed. RESULTS: Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients' race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies. CONCLUSIONS: Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Measurement Properties of Patient-Reported Outcome Measures for Diabetes: Systematic Review.

BACKGROUND: The management of diabetes is complex. There is growing recognition of the use of patient-reported outcome measures (PROMs) as a standardized method of obtaining an outlook on patients' functional status and well-being. However, no systematic reviews have summarized the studies that investigate the measurement properties of diabetes PROMs. OBJECTIVE: Our aims were to conduct a systematic review of studies investigating the measurement properties of diabetes PROMs by evaluating the methodological quality and overall level of evidence of these PROMs and to categorize them based on the outcome measures assessed. METHODS: This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the Embase, PubMed, and PsychINFO databases. The PROMs were evaluated with the COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) guidelines. RESULTS: A total of 363 articles evaluating the measurement properties of PROMs for diabetes in the adult population were identified, of which 238 unique PROMs from 248 studies reported in 209 articles were validated in the type 2 diabetes population. PROMs with at least a moderate level of evidence for ≥5 of 9 measurement properties include the Chinese version of the Personal Diabetes Questionnaire (C-PDQ), Diabetes Self-Management Instrument Short Form (DSMI-20), and Insulin Treatment Appraisal Scale in Hong Kong primary care patients (C-ITAS-HK), of which the C-PDQ has a "sufficient (+)" rating for >4 measurement properties. A total of 43 PROMs meet the COSMIN guidelines for recommendation for use. CONCLUSIONS: This study identified and synthesized evidence for the measurement properties of 238 unique PROMs for patients with type 2 diabetes and categorized the PROMs according to their outcome measures. These findings may assist clinicians and researchers in selecting appropriate high-quality PROMs for clinical practice and research. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020180978; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020180978.

Developing item banks to measure three important domains of health-related quality of life (HRQOL) in Singapore.

OBJECTIVES: To develop separate item banks for three health domains of health-related quality of life (HRQOL) ranked as important by Singaporeans - physical functioning, social relationships, and positive mindset. METHODS: We adapted the Patient Reported Outcomes Measurement Information System Qualitative Item Review protocol, with input and endorsement from laymen and experts from various relevant fields. Items were generated from 3 sources: 1) thematic analysis of focus groups and in-depth interviews for framework (n = 134 participants) and item(n = 52 participants) development, 2) instruments identified from a literature search (PubMed) of studies that developed or validated a HRQOL instrument among adults in Singapore, 3) a priori identified instruments of particular relevance. Items from these three sources were "binned" and "winnowed" by two independent reviewers, blinded to the source of the items, who harmonized their selections to generate a list of candidate items (each item representing a subdomain). Panels with lay and expert representation, convened separately for each domain, reviewed the face and content validity of these candidate items and provided inputs for item revision. The revised items were further refined in cognitive interviews. RESULTS: Items from our qualitative studies (51 physical functioning, 44 social relationships, and 38 positive mindset), the literature review (36 instruments from 161 citations), and three a priori identified instruments, underwent binning, winnowing, expert panel review, and cognitive interview. This resulted in 160 candidate items (61 physical functioning, 51 social relationships, and 48 positive mindset). CONCLUSIONS: We developed item banks for three important health domains in Singapore using inputs from potential end-users and the published literature. The next steps are to calibrate the item banks, develop computerized adaptive tests (CATs) using the calibrated items, and evaluate the validity of test scores when these item banks are administered adaptively.

Calibration of a physical functioning item bank for measurement of health-related quality of life in Singapore.

PURPOSE: We aimed to develop and calibrate an item bank to measure physical function (PF) in Singapore, a multi-ethnic city in Southeast Asia. METHODS: We recruited participants from community and hospital settings stratified for age and gender, with and without medical conditions to administer candidate pool of 61-items derived from the people's perspectives. We calibrated their responses using Samejima's graded response model of item response theory (IRT), including model assumptions, model fit, differential item functioning (DIF), and concurrent and known-groups validity. RESULTS: 496 participants (50% male; 41% above 50 years old; 33.3% Chinese, 32.7% Malay and 34.1% Indian; 35% without chronic illness) were included in the calibration of item bank. 6 items were excluded due to mis-fit and local dependence. Redundancies in the response level was collapsed and re-scoring, while preserving the 5-level response structure. We found the final 55-item PF bank had adequate fit to IRT assumptions of unidimensionality, local independence and monotonicity. Items generally showed discernible ceiling effects with latent scores between - 3.5 to + 1.5. We found no DIF with gender, ethnicity or education. The PF scores correlated in the hypothesized direction with self-reported global health (Spearman's rho = - 0.35, 95% confidence intervals - 0.43 to - 0.27) and discriminated between groups stratified by age, gender and medical conditions. CONCLUSION: The 55-item Singapore PF item bank provides an adequate tool for measuring the lower end of PF, with greatest potential utility in healthcare settings where restoration to normal physical functioning is the goal of intervention.

Prevalence and variables associated with fatigue in psoriatic arthritis: a cross-sectional study.

OBJECTIVE: To describe the prevalence of and evaluate the factors associated with fatigue patients with psoriatic arthritis (PsA) in an Asian population. METHODS: We used baseline data from a registry of patients with PsA attending an outpatient clinic of a tertiary hospital in Singapore. Demographic data and disease characteristics were evaluated. Fatigue was assessed by question one of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI-F) and the vitality domain of the Medical Outcome Survey, Short-Form 36 (SF-36 VT). We evaluated clusters of variables, and individual variables in association with fatigue. RESULTS: We included 131 patients (50.4% men, 63.4% Chinese, median PsA duration 21.0 months) with completed data for fatigue. Forty-five patients (34%) experienced severe fatigue (defined by BASDAI-F > 5/10). We used principal component analysis and identified five clusters of variables that explained 62.9% of the variance of all factors. Of these, disease activity and impact, and disease chronicity were significantly associated with BASDAI-F and SF-36 VT. In multivariable analyses, back pain, peripheral joint pain and patient global assessment were associated with BASDAI-F, whereas peripheral joint pain and mental health were associated with SF-36 VT. CONCLUSION: PsA-associated fatigue is prevalent in this Asian PsA cohort and is associated with disease activity, impact and chronicity.

Development of an Item Bank to Measure Medication Adherence: Systematic Review.

BACKGROUND: Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer-adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress. OBJECTIVE: We aim to develop an item bank to measure general medication adherence. METHODS: Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected ("binned" and "winnowed") according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group. RESULTS: A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence). CONCLUSIONS: We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

Measurement Properties of Existing Patient-Reported Outcome Measures on Medication Adherence: Systematic Review.

BACKGROUND: Medication adherence is essential for improving the health outcomes of patients. Various patient-reported outcome measures (PROMs) have been developed to measure medication adherence in patients. However, no study has summarized the psychometric properties of these PROMs to guide selection for use in clinical practice or research. OBJECTIVE: This study aims to evaluate the quality of the PROMs used to measure medication adherence. METHODS: This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. The PROMs were then evaluated based on the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. RESULTS: A total of 121 unique medication adherence PROMs from 214 studies were identified. Hypotheses testing for construct validity and internal consistency were the most frequently assessed measurement properties. PROMs with at least a moderate level of evidence for ≥5 measurement properties include the Adherence Starts with Knowledge 20, Compliance Questionnaire-Rheumatology, General Medication Adherence Scale, Hill-Bone Scale, Immunosuppressant Therapy Barrier Scale, Medication Adherence Reasons Scale (MAR-Scale) revised, 5-item Medication Adherence Rating Scale (MARS-5), 9-item MARS (MARS-9), 4-item Morisky Medication Adherence Scale (MMAS-4), 8-item MMAS (MMAS-8), Self-efficacy for Appropriate Medication Adherence Scale, Satisfaction with Iron Chelation Therapy, Test of Adherence to Inhalers, and questionnaire by Voils. The MAR-Scale revised, MMAS-4, and MMAS-8 have been administered electronically. CONCLUSIONS: This study identified 121 PROMs for medication adherence and provided synthesized evidence for the measurement properties of these PROMs. The findings from this study may assist clinicians and researchers in selecting suitable PROMs to assess medication adherence.

Identifying optimal indicators and purposes of population segmentation through engagement of key stakeholders: a qualitative study.

BACKGROUND: Various population segmentation tools have been developed to inform the design of interventions that improve population health. However, there has been little consensus on the core indicators and purposes of population segmentation. The existing frameworks were further limited by their applicability in different practice settings involving stakeholders at all levels. The aim of this study was to generate a comprehensive set of indicators and purposes of population segmentation based on the experience and perspectives of key stakeholders involved in population health. METHODS: We conducted in-depth semi-structured interviews using purposive sampling with key stakeholders (e.g. government officials, healthcare professionals, social service providers, researchers) involved in population health at three distinct levels (micro, meso, macro) in Singapore. The interviews were audio-recorded and transcribed verbatim. Thematic content analysis was undertaken using NVivo 12. RESULTS: A total of 25 interviews were conducted. Eight core indicators (demographic characteristics, economic characteristics, behavioural characteristics, disease state, functional status, organisation of care, psychosocial factors and service needs of patients) and 21 sub-indicators were identified. Age and financial status were commonly stated as important indicators that could potentially be used for population segmentation across three levels of participants. Six intended purposes for population segmentation included improving health outcomes, planning for resource allocation, optimising healthcare utilisation, enhancing psychosocial and behavioural outcomes, strengthening preventive efforts and driving policy changes. There was consensus that planning for resource allocation and improving health outcomes were considered two of the most important purposes for population segmentation. CONCLUSIONS: Our findings shed light on the need for a more person-centric population segmentation framework that incorporates upstream and holistic indicators to be able to measure population health outcomes and to plan for appropriate resource allocation. Core elements of the framework may apply to other healthcare settings and systems responsible for improving population health. TRIAL REGISTRATION: The study was approved by the SingHealth Institutional Review Board (CIRB Reference number: 2017/2597).

Assessment of medical professionalism using the Professionalism Mini Evaluation Exercise (P-MEX) in a multi-ethnic society: a Delphi study.

BACKGROUND: The importance of medical professionalism and its assessment has been well documented in the literature. However, there is currently no culturally-adapted tool to assess medical professionalism in Singapore. This study sets out to find consensus on relevance of the items from the Professionalism Mini Evaluation Exercise (P-MEX) for assessing medical professionalism in Singapore. METHODS: A two-round Delphi survey was completed by an expert panel consisting of program directors, associate designated institutional officials, and designated institutional official (n = 15) from residency programs in Singapore. Round 1 comprised of 23 items from the P-MEX rated on a 5-point scale (1 = Definitely include, 2 = Possibly include, 3 = Neutral, 4 = Possibly exclude, 5 = Definitely exclude). In round 2, the experts received feedback from the previous round, and were asked to re-rate the items which did not achieve consensus in the previous round. The threshold for consensus in the study was defined as 70% or greater agreement among experts. RESULTS: Completed questionnaires for both rounds were received from all 15 experts. In round 1, 18 items (78%) achieved consensus to be included. In round 2, 1 (4%) item achieved consensus to be included. However, none of the remaining items achieved consensus to be removed, and they exhibited stability in responses. A list of 19 items covering four domains of medical professionalism (Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills) was obtained during the two-rounds of Delphi survey. CONCLUSIONS: Nineteen items in the P-MEX had garnered consensus and is suitable for assessing medical professionalism in Singapore. The findings of this study can provide guidance for faculty and institutions who want to assess medical professionalism of their medical trainees.

Assessment of medical professionalism: preliminary results of a qualitative study.

BACKGROUND: The importance of medical professionalism has been well documented in the literature. Cultural background affects the constituents of professionalism. However, few studies have explored the domains of medical professionalism in an Asian context. We aim to describe the views and experiences of both patients and faculty on medical professionalism in an urban Asian city state. METHODS: Data for this qualitative study were collected through focus group discussions (FGDs) with patients and in-depth interviews (IDIs) with faculty members. The IDIs and FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted by two independent coders using a priori framework derived from Professionalism Mini Evaluation Exercise (P-MEX). Sociodemographic data of faculty members and patients were obtained through brief questionnaires. RESULTS: A total of 31 patients (58.1% male, all had visited healthcare facilities within the past year) and 26 faculty members (42.3% male, 38.5% from medical disciplines, median years as faculty is 11) participated in this study. The results supported the four domains of medical professionalism - Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills. Two new sub-domains which emerged from data were (1) communicated effectively with patient and (2) demonstrated collegiality. CONCLUSIONS: The domains of professionalism in Singapore were similar to previous studies. This study allows a better understanding of medical professionalism to enhance the assessment and ultimately, the teaching of medical professionalism in an urban multi-ethnic Asian city.

A collaborative approach in patient education for diabetes foot and wound care: A pragmatic randomised controlled trial.

Foot care education is an important strategy in reducing lower limb complications. There is evidence that contemporary communication approaches can improve patient education outcomes. To inform the potential of such methods in diabetic foot education, we trialled a collaborative approach in patient education counselling in a podiatry clinic. We conducted a single-blind pragmatic randomised controlled trial on 52 diabetes patients who had an active foot ulcer. Participants were randomised to either collaborative education or traditional didactic education. Outcomes on knowledge and self-care behaviours were collected via a pre and post study questionnaire (max score: 75). The study ended at 12 weeks or when the wound healed prior. 42 (80.7%) participants completed the study. The collaborative patient education group had a significant increase in score post-study (38.8 ± 8.5) compared to pre-study (32.8 ± 6.9; P < .001). The control group had no significant increase in score post study. The difference in scores between groups had a moderate effect size (d = 0.54). The use of a collaborative approach in patient education was able to produce significantly greater increase in knowledge retention and self-care behaviours, without the need for additional consultation time in a podiatry clinic.

Development and calibration of a novel social relationship item bank to measure health-related quality of life (HRQoL) in Singapore.

BACKGROUND: Social relationships (SR) is an important domain of health-related quality of life. We developed and calibrated a novel item bank to measure SR in Singapore, a multi-ethnic city in Southeast Asia. METHODS: We developed an initial candidate pool of 51 items from focus groups, individual in-depth interviews and existing instruments that had been developed and/or validated for use in Singapore. We administered all items in English to a multi-stage sample of subjects, stratified for age and gender, with and without medical conditions, recruited from community and hospital settings. We calibrated their responses using Samejima's Graded Response Model (SGRM). We evaluated a final 30-item bank with respect to Item Response Theory (IRT) model assumptions, model fit, differential item functioning (DIF), and concurrent and known-groups validity. RESULTS: Among 503 participants (47.7% male, 41.4% above 50 years old, 34.0% Chinese, 33.6% Malay and 32.4% Indian), bi-factor model analyses supported essential unidimensionality: explained common variance of the general factor was 0.805 and omega hierarchical was 0.98. Local independence was deemed acceptable: the average absolute residual correlations were < 0.06 and 1.8% of the total item-pair residuals were flagged for local dependence. The overall SGRM model fit was adequate (p = 0.146). Five items exhibited DIF with respect to age, ethnicity and education, but were retained without modification of scores because they measured important aspects of SR. The SR scores correlated in the hypothesized direction with a self-reported measure of global health (Spearman's rho = - 0.28, p < 0.001). CONCLUSION: The 30-item SR item bank has shown acceptable psychometric properties. Future studies to evaluate the validity of SR scores when items are administered adaptively are needed.