Ethnic Differences and Trends in ST-Segment Elevation Myocardial Infarction Incidence and Mortality in a Multi-Ethnic Population.

INTRODUCTION: This study aimed to compare the incidence and mortality of ST-segment elevation myocardial infarction (STEMI) across the 3 main ethnic groups in Singapore, determine if there is any improvement in trends over the years and postulate the reasons underlying the ethnic disparity. MATERIALS AND METHODS: This study consisted of 16,983 consecutive STEMI patients who sought treatment from all public hospitals in Singapore from 2007 to 2014. RESULTS: Compared to the Chinese (58 per 100,000 population in 2014), higher STEMI incidence rate was consistently observed in the Malays (114 per 100,000 population) and Indians (126 per 100,000 population). While the incidence rate for the Chinese and Indians remained relatively stable over the years, the incidence rate for the Malays rose slightly. Relative to the Indians (30-day and 1-year all-cause mortality at 9% and 13%, respectively, in 2014), higher 30-day and 1-year all-cause mortality rates were observed in the Chinese (15% and 21%) and Malays (13% and 18%). Besides the Malays having higher adjusted 1-year all-cause mortality, all other ethnic disparities in 30-day and 1-year mortality risk were attenuated after adjusting for demographics, comorbidities and primary percutaneous coronary intervention. CONCLUSION: It is important to continuously evaluate the effectiveness of existing programmes and practices as the aetiology of STEMI evolves with time, and to strike a balance between prevention and management efforts as well as between improving the outcome of "poorer" and "better" STEMI survivors with finite resources.

Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore.

OBJECTIVES: This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits. METHODS: This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period. RESULTS: In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system. CONCLUSIONS: ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.