Population Segmentation Based on Healthcare Needs: Validation of a Brief Clinician-Administered Tool.

BACKGROUND: As populations age with increasingly complex chronic conditions, segmenting populations into clinically meaningful categories of healthcare and related service needs can provide healthcare planners with crucial information to optimally meet needs. However, while conventional approaches typically involve electronic medical records (EMRs), such records do not always capture information reliably or accurately. OBJECTIVE: We describe the inter-rater reliability and predictive validity of a clinician-administered tool, the Simple Segmentation Tool (SST) for categorizing older individuals into one of six Global Impression (GI) segments and eight complicating factors (CFs) indicative of healthcare and related social needs. DESIGN: Observational study ( ClinicalTrials.gov , number NCT02663037). PARTICIPANTS: Patients aged 55 years and above. MAIN MEASURES: Emergency department (ED) subjects (between May and June 2016) had baseline SST assessment by two physicians and a nurse concurrently seeing the same individual. General medical (GM) ward subjects (February 2017) had a SST assessment by their principal physician. Adverse events (ED visits, hospitalizations, and mortality over 90 days from baseline) were determined by a blinded reviewer. Inter-rater reliability was measured using Cohen's kappa. Predictive validity was evaluated using Cox hazard ratios based on time to first adverse event. KEY RESULTS: Cohen's kappa between physician-physician, service physician-nurse, and physician-nurse pairs for GI were 0.60, 0.71, and 0.68, respectively. Cox analyses demonstrated significant predictive validity of GI and CFs for adverse outcomes. CONCLUSIONS: With modest training, clinicians can complete a brief instrument to segment their patient into clinically meaningful categories of healthcare and related service needs. This approach can complement and overcome current limitations of EMR-based instruments, particularly with respect to whole-patient care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02663037.

COVID-19 pandemic unmasking cardiovascular risk factors and non-communicable diseases among migrant workers: a cross-sectional study in Singapore.

OBJECTIVES: This study aims to report the prevalence of cardiovascular risk factors (CVRFs) and other non-communicable diseases among migrant workers in Singapore admitted for COVID-19 infection, to highlight disease burden and the need for changes in health screening and healthcare delivery in this unique population. SETTING: The study was conducted in the largest tertiary hospital in Singapore. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: 883 migrant workers who had mild or asymptomatic COVID-19 infection admitted to three isolation wards between 6 April 2020 and 31 May 2020 were included in this study. OUTCOME MEASURES: The outcome measures were the prevalence of pre-existing and newly diagnosed comorbid conditions and the prevalence of CVRFs-diabetes mellitus, hypertension and hyperlipidaemia-and non-communicable diseases at the time of discharge. The OR of having specific CVRFs depending on country of origin was generated via multivariate logistic regression analysis. RESULTS: The median age of our study population was 45 years. 17.0% had pre-existing conditions and 25.9% received new diagnoses. Of the new diagnoses, 15.7% were acute medical conditions and 84.3% chronic medical conditions. The prevalence of CVRFs was higher in Southeast Asian and South Asian migrant workers compared with Chinese. The prevalence of non-communicable diseases on discharge was highest among Southeast Asians (49.4%). CONCLUSIONS: The COVID-19 outbreak in a large number of migrant workers in Singapore unmasked a significant disease burden among them, increasing stakeholders' interests in their welfare. Moving forward, system-level changes are necessary to deliver healthcare sustainably and effect improvements in migrant workers' health.

Respiratory surveillance wards as a strategy to reduce nosocomial transmission of COVID-19 through early detection: The experience of a tertiary-care hospital in Singapore.

OBJECTIVES: Patients with COVID-19 may present with respiratory syndromes indistinguishable from those caused by common viruses. Early isolation and containment is challenging. Although screening all patients with respiratory symptoms for COVID-19 has been recommended, the practicality of such an effort has yet to be assessed. METHODS: Over a 6-week period during a SARS-CoV-2 outbreak, our institution introduced a "respiratory surveillance ward" (RSW) to segregate all patients with respiratory symptoms in designated areas, where appropriate personal protective equipment (PPE) could be utilized until SARS-CoV-2 testing was done. Patients could be transferred when SARS-CoV-2 tests were negative on 2 consecutive occasions, 24 hours apart. RESULTS: Over the study period, 1,178 patients were admitted to the RSWs. The mean length-of-stay (LOS) was 1.89 days (SD, 1.23). Among confirmed cases of pneumonia admitted to the RSW, 5 of 310 patients (1.61%) tested positive for SARS-CoV-2. This finding was comparable to the pickup rate from our isolation ward. In total, 126 HCWs were potentially exposed to these cases; however, only 3 (2.38%) required quarantine because most used appropriate PPE. In addition, 13 inpatients overlapped with the index cases during their stay in the RSW; of these 13 exposed inpatients, 1 patient subsequently developed COVID-19 after exposure. No patient-HCW transmission was detected despite intensive surveillance. CONCLUSIONS: Our institution successfully utilized the strategy of an RSW over a 6-week period to contain a cluster of COVID-19 cases and to prevent patient-HCW transmission. However, this method was resource-intensive in terms of testing and bed capacity.

Clarithromycin and Glipizide Drug-drug Interaction Leading to Refractory Hypoglycemia.

A 70-year-old end-stage renal disease patient was admitted for refractory hypoglycemia secondary to drug-drug interaction between clarithromycin and glipizide. We discussed the mechanism of antimicrobial and sulfonylurea interactions as well as the importance of understanding these interactions in the primary care setting to reduce medication-related hospitalizations.

Misled by the Air: Pneumocephalus.

Pneumocephalus, the presence of air within the cranium, commonly suggests a breach in the meningeal layer or an intracranial infection by a gas-producing organism. Trauma is the most common cause of pneumocephalus, followed by cranial surgery. Other causes include infection and intracranial neoplasm. An 87-year-old man was conveyed to the emergency department after being found to be drowsy by his helper. He was noted to have a new onset right-sided hemiparesis. Past medical history was significant for hypertension, stage 5 chronic kidney disease, cerebrovascular accident, pacemaker insertion for sick sinus syndrome, transurethral resection of the prostate for benign prostatic hyperplasia, and pulmonary tuberculosis. Computed tomography (CT) of the brain revealed pneumocephalus with air within the dural venous sinuses. A facial bone CT that was performed to look for a fracture demonstrated a minimally displaced fracture of the lateral wall of the right maxillary sinus. There was an acute left middle cerebral artery territory infarct with a hemorrhagic conversion. Despite medical treatment, the patient demised one month after the initial presentation. Pneumocephalus is an uncommon finding, even in trauma. In the event that the clinical presentation cannot be explained by the mere presence of air within the cranium, another diagnosis ought to be sought. The delay in finding an alternative diagnosis and its management can be disastrous or even fatal.

Chyluria in non-filarial endemic areas: an internist's perspective.

A 60-year-old Chinese woman presented with intermittent, painless, gross haematuria and subsequently complained of persistent milky urine. The diagnosis of chyluria was confirmed after cystoscopy demonstrated ureteric milky fluid discharge which had elevated levels of triglycerides. The patient did not travel to filarial endemic areas and her serum circulating filarial antigen was negative. Intravenous pyelography with CT of the abdomen did not reveal any masses or obstruction. It was determined that her chyluria was non-parasitic in origin and her symptoms improved with a low fat, high-protein diet. However, her chyluria recurred 1 year later, resulting in hypoalbuminaemia and proteinuria. Her symptoms resolved and her albumin levels normalised with adherence to dietary modifications.