Medication compliance in Singaporean patients with Alzheimer's disease.

INTRODUCTION: Singapore has a rapidly ageing population and an increasing prevalence of Alzheimer's disease (AD). Compliance to AD medications is associated with treatment effectiveness. We investigated compliance to acetylcholinesterase inhibitors (AChEIs) and N-methyl-D-aspartate (NMDA) receptor antagonist and treatment persistence among patients seen at the General Memory Clinic of National University Hospital, Singapore. We also identified the reasons for non-compliance. METHODS: Patients seen at the General Memory Clinic between 1 January 2013 and 31 December 2014, who were prescribed AChEIs and NMDA receptor antagonist, were included in this retrospective cohort study. Non-compliance to medications was indirectly measured by failure to renew prescription within 60 days of the last day of medication supplied by the previous prescription. The reasons for non-compliance were identified. RESULTS: A total of 144 patients were included. At one year, 107 patients were compliant to AD medications, while 37 patients were non-compliant. Around 60% of the non-compliant patients discontinued the use of AD medications within the first six months, and the mean persistent treatment period among this group of patients was 10.3 ± 3.5 months. The main reason for non-compliance was patients' and caregivers' perception that memory loss was of lower priority than other coexisting illnesses. Other reasons for non-compliance included side effects of medications (18.9%), perceived ineffectiveness of treatment (16.2%), inability to attend clinic (5.4%) and high cost of medications (2.7%). CONCLUSION: Our findings suggest that the reasons for medication non-compliance can be identified early. Better compliance may be achieved through a multidisciplinary approach to patient education.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors.

BACKGROUND: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors. METHODS: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke. RESULTS: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter. CONCLUSION: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke.

BACKGROUND AND PURPOSE: Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke. MATERIALS AND METHODS: Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively. RESULTS: Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes. CONCLUSIONS: Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

Singapore ministry of health clinical practice guidelines on stroke and transient ischemic attacks.

The primary aim of these guidelines is to assist individual clinicians, hospital departments, and hospital administrators to produce local protocols for the: • assessment, investigation and immediate management of individuals with a transient ischemic attack or acute stroke (other than sub-arachnoid hemorrhage), and • secondary prevention and risk factor management following a transient ischemic attack or acute stroke. The secondary aim of these guidelines is to suggest methods for implementation and clinical audit. The workgroup preparing these guidelines was formed by the Ministry of Health, Singapore. It comprised healthcare workers from relevant specialties, family medicine, nursing, occupational therapy, and a lay patient advocate. The Scottish Intercollegiate Guidelines Network's Clinical Practice Guidelines on the Management of Patients with Stroke were reviewed, updated, and modified to meet local needs. The final guidelines are made up of evidence-based recommendations covering the following areas - assessment, investigation, immediate management, secondary prevention, rehabilitation, and implications for service delivery. The guidelines were sent to professional organizations for comments and endorsements. The final version was circulated to all medical practitioners in Singapore. It is hoped that the guidelines will improve the care of patients with stroke and transient ischemic attack. Clinical quality improvement measures are proposed.

Burden of stroke in Indonesia.

Stroke is the leading cause of death among Indonesians above five years of age, comprising 15.4% of all deaths, age-gender-standardised death rate 99/100 000, and age-gender-standardised disability-adjusted life years lost 685/100 000. Stroke prevalence is 0.0017% in rural Indonesia, 0.022% in urban Indonesia, 0.5% among urban Jakarta adults, and 0.8% overall. Frequent risk factors include hypertension, smoking and hypercholesterolaemia. The mean age of stroke patients is 58.8 years. Subarachnoid haemorrhage is found in 1.4% of patients, intracerebral haemorrhage in 18.5%, and ischaemic stroke in 42.9%. Only city hospitals have neurology, neurosurgery and neuroimaging services. Indonesia has 40 stroke units. Commonly used medications for stroke are easily available. Hospital-based rehabilitative services are available in large hospitals. Traditional medicine is widely practiced. Efforts to combat stroke include education, more stroke units and rehabilitative services especially in the rural areas.

Burden of stroke in Singapore.

Stroke is Singapore's fourth leading cause of death, with a crude death rate of 40.4/100 000 in 2006, a prevalence of 3.65% and an incidence of 1.8/1000, and is among the top 10 causes of hospitalization. Approximately one-quarter of strokes are hemorrhagic. Hospital care for acute stroke costs about US$5000. Subsidized healthcare is widely available for primary level and hospital care, as are rehabilitative services. A national stroke support group has been established. With our rapidly aging population, coupled with the high prevalence of stroke risk factors in the community, the burden of stroke is expected to increase dramatically in the years to come, posing challenges to the healthcare system and society. A national disease management plan incorporating high-quality clinical care coupled with research would be essential.

Hospital costs for stroke care in Singapore.

We performed this prospective study to determine the cost of care for acute stroke patients admitted to hospital. Stroke was subtyped into subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), nonlacunar infarct (NLC), lacunar infarct (LAC) and transient ischemic attack (TIA). Cost of care was computed for the various services the patient received. At the time of the study, US$ 1 = S$1. 50. 426 patients were studied. Mean length of stay (LOS) was 17 days. Mean cost/discharge was S$7,547. Ward charges accounted for 38.2%, radiology 14.5%, doctors' fees 10.3%, drugs 8.4%, therapy 7.3%. Cost was highly correlated with LOS, r(2) = 0.73. Mean cost/discharge was SAH S$28,539, IPH S$14,398, NLC S$7,476, LAC S$3,517, TIA S$1,962. Initial hospitalization cost for stroke is highly correlated with LOS. The bulk of cost is attributable to ward stay. Cost/discharge is highest with SAH, and in descending order IPH, NLC, LAC, TIA.