Primary care physicians' perspectives on the identification and management of postnatal mental health problems.

BACKGROUND: Postnatal mental health problems (PMHPs) are prevalent and negatively affect mothers, children, and society. International and local guidelines recommend that Singapore primary care physicians (PCP) screen, assess, and manage mothers with PMHPs. However, little is known about their experiences and views. METHODS: We conducted semi-structured interviews with 14 PCPs in Singapore. Interview questions elicited perspectives on the identification and management of mothers with PMHPs. The interview guide was developed from a conceptual framework incorporating the knowledge-attitudes-practices, self-efficacy, and socio-ecological models. Interviews were audio-recorded and transcribed. Thematic analysis was used to identify emergent themes. RESULTS: Singapore PCPs viewed themselves as key providers of first-contact care to mothers with PMHPs. They believed mothers preferred them to alternative providers because of greater accessibility and trust. In detection, they were vigilant in identifying at-risk mothers and favoured clinical intuition over screening tools. PCPs were confident in diagnosing common PMHPs and believed that mothers not meeting diagnostic criteria must be readily recognized and supported. In managing PMHPs, PCPs expressed varying confidence in prescribing antidepressants, which were viewed as second-line to supportive counselling and psychoeducation. Impeding physician factors, constraining practice characteristics and health system limitations were barriers. Looking forward, PCPs aspired to leverage technology and multidisciplinary teams to provide comprehensive, team-based care for the mother-child dyad. CONCLUSION: Singapore PCPs are key in identifying and managing mothers with PMHPs. To fully harness their potential in providing comprehensive care, PCPs need greater multidisciplinary support and technological solutions that promote remote disclosure and enhanced preparation for their role.

Personalised care and support planning in Singapore: qualitative interviews with people living with diabetes.

BACKGROUND: Personalised care and support planning (CSP) is a person-centred approach for the care of people living with long-term conditions. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) adapts the Year of Care Partnerships (YOCP) approach to CSP in the UK for people living with diabetes at Singapore polyclinics. Polyclinics are multi-storey primary care hubs that provide affordable, multidisciplinary, comprehensive, and high-throughput public health care for the multi-ethnic, multilingual Singapore population. AIM: To explore the experience of PACE-D-enrolled people living with diabetes with personalised CSP at Singapore polyclinics. DESIGN & SETTING: Qualitative interviews of people living with diabetes who experienced personalised CSP at National University Polyclinics (NUP) in Singapore between July 2020 and November 2021. METHOD: PACE-D-enrolled people living with diabetes who experienced personalised CSP were purposively sampled. In-depth semi-structured interviews were recorded, transcribed, and analysed using Braun and Clarke's reflexive thematic analysis. RESULTS: Fifty-two patients participated in the study. Four main themes were identified. Theme 1 was the importance of the care-planning letter. Patients reported that the CPL prompted reflection and patient preparation for CSP conversations. Theme 2 was the role of the programme coordinator. PACE-D programme coordinators amplified self-management by playing advocate and confidant beyond administrative duties. Theme 3 was the value of the personalised CSP conversation. CSP providers were perceived as partners in care, with more time to listen compared with usual consultations. Patient engagement was affected by language confidence. Theme 4 was agency in self-management. With adequate time and support, patients increased in confidence and agency both in CSP engagement and diabetes self-management. CONCLUSION: While language confidence may affect patient engagement, personalised CSP shows promise for strengthening patient engagement and self-management among people living with diabetes at Singapore polyclinics.

Patient perspectives of diabetes care in primary care networks in Singapore: a mixed-methods study.

BACKGROUND: Type 2 diabetes (T2D) remains an important chronic condition worldwide requiring integrated patient-centred care as advocated by the Chronic Care Model (CCM). The Primary Care Networks (PCNs) in Singapore organise general practitioners (GPs) with nurses and care coordinators to deliver team-based care for patients with chronic conditions. This study examined the quality of care in the PCNs as defined by the CCM from the patients' perspective. METHODS: This study followed a cross-sectional convergent mixed-method design with T2D patients across three PCN types (GP-led, Group, and Cluster). The Patient Assessment of Chronic Illness Care (PACIC, range 1-5) was completed by a convenience sample of 343 patients. Multivariate linear regression was performed to estimate the associations between patient and service characteristics and PACIC summary score. Twenty-four participants were purposively recruited for interviews on the experienced care until thematic saturation was reached. Quantitative and qualitative data were collected concurrently and independently. Integration occurred during study design and data analysis using the CCM as guidance. Quantitative and qualitative results were compared side-by-side in a joint comparison table to develop key concepts supported by themes, subthemes, and patients' quotes. RESULTS: The PACIC mean summary score of 3.21 for 343 patients evidenced that some have received CCM consistent care in the PCNs. Being younger and spending more time with the GP were associated with higher PACIC summary scores. PACIC summary scores did not differ across PCN types. The 24 patients interviewed in the qualitative study reported receiving team-based care, nurse services, good continuity of care, as well as patient-centred care, convenient access, and affordable care. Key concepts showed that integrated care consistent with the CCM was sometimes received by patients in the PCNs. Patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling were sometimes received by patients, while follow-up/coordination was generally not received. CONCLUSIONS: Patients with T2D from the Singapore Primary Care Networks received integrated care consistent with the Chronic Care Model, particularly in patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling. Follow-up/coordination needed improvement to ensure higher quality of diabetes care.

Antibiotic treatment failure of uncomplicated urinary tract infections in primary care.

BACKGROUND: Higher resistance rates of > 20% have been noted in Enterobacteriaceae urinary isolates towards ciprofloxacin and co-trimoxazole (C + C) in Singapore, compared with amoxicillin-clavulanate and nitrofurantoin (AC + N). This study examined if treatment failure varied between different antibiotics, given different resistant rates, for uncomplicated urinary tract infections (UTIs) managed in primary care. We also aimed to identify gaps for improvement in diagnosis, investigations, and management. METHODS: A retrospective cohort study was conducted from 2019 to 2021 on female patients aged 18-50 with uncomplicated UTIs at 6 primary care clinics in Singapore. ORENUC classification was used to exclude complicated UTIs. Patients with uncomplicated UTIs empirically treated with amoxicillin-clavulanate, nitrofurantoin, ciprofloxacin or co-trimoxazole were followed-up for 28 days. Treatment failure was defined as re-attendance for symptoms and antibiotic re-prescription, or hospitalisation for UTI complications. After 2:1 propensity score matching in each group, modified Poisson regression and Cox proportional hazard regression accounting for matched data were used to determine risk and time to treatment failure. RESULTS: 3194 of 4253 (75.1%) UTIs seen were uncomplicated, of which only 26% were diagnosed clinically. Urine cultures were conducted for 1094 (34.3%) uncomplicated UTIs, of which only 410 (37.5%) had bacterial growth. The most common organism found to cause uncomplicated UTIs was Escherichia coli (64.6%), with 92.6% and 99.4% of isolates sensitive to amoxicillin-clavulanate and nitrofurantoin respectively. Treatment failure occurred in 146 patients (4.57%). Among 1894 patients treated with AC + N matched to 947 patients treated with C + C, patients treated with C + C were 50% more likely to fail treatment (RR 1.49, 95% CI 1.10-2.01), with significantly higher risk of experiencing shorter time to failure (HR 1.61, 95% CI 1.12-2.33), compared to patients treated with AC + N. CONCLUSION: Treatment failure rate was lower for antibiotics with lower reported resistance rates (AC + N). We recommend treating uncomplicated UTIs in Singapore with amoxicillin-clavulanate or nitrofurantoin, based on current local antibiograms. Diagnosis, investigations and management of UTIs remained sub-optimal. Future studies should be based on updating antibiograms, highlighting its importance in guideline development.

Utilization of Nurse-Administered Screening, Brief Intervention, and Referral to Treatment in a Brief Psychiatric Inpatient Unit.

BACKGROUND: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been established as an effective screening tool for providing interventions for patients with risky substance use. OBJECTIVES: The objectives of this project were to train and coach staff nurses in the use of SBIRT, offer SBIRT to all admissions of a brief psychiatric inpatient unit, and decrease readmission rates. DESIGN: Using the Iowa Model for Implementing Evidence-Based Practices, SBIRT was implemented on the unit. Data were collected on the frequency of patients offered SBIRT and readmission rates. RESULTS: Fifty-nine percent of all admissions were offered SBIRT. The average readmission rates decreased by 18.3% for the first 2 months of implementation and by 67.5% for Days 16-31 postdischarge. CONCLUSIONS: SBIRT is an effective tool for nurses on psychiatric units to address substance use and to decrease readmission rates.

Concordance of self-reporting of diabetes compared with medical records: A comparative study using polyclinic data in Singapore.

INTRODUCTION: Studies of concordance between patients' self-report of diseases and a criterion standard (e.g. chart review) are usually conducted in epidemiological studies to evaluate the agreement of self-reported data for use in public health research. To our knowledge, there are no published studies on concordance for highly prevalent chronic diseases such as diabetes and pre-diabetes. The aims of this study were to evaluate the concordance between patients' self-report and their medical records of diabetes and pre-diabetes diagnoses, and to identify factors associated with diabetes concordance. METHOD: A cross-sectional, interviewer-administered survey was conducted on patients with chronic diseases after obtaining written consent to assess their medical notes. Interviewers were blinded to the participants' profiles. Concordance was evaluated using Cohen's kappa (κ). A multivariable logistic regression model was used to identify factors associated with diabetes concordance. RESULTS: There was substantial agreement between self-reported and medical records of diabetes diagnoses (κ=0.76) and fair agreement for pre-diabetes diagnoses (κ=0.36). The logistic regression model suggested that non-Chinese patients had higher odds of diabetes concordance than Chinese patients (odds ratio [OR]=4.10, 95% confidence interval [CI] 1.19-14.13, P=0.03). Patients with 3 or more chronic diseases (i.e. multimorbidity) had lower odds of diabetes concordance than patients without multimorbidity (OR=0.21, 95% CI 0.09-0.48, P<0.001). CONCLUSION: Diabetes concordance was substantial, supporting the use of self-report of diabetes by patients with chronic diseases in the primary care setting for future research. Pre-diabetes concordance was fair and may have important clinical implications. Further studies to explore and improve health literacy and patient-physician communication are needed.

Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis.

BACKGROUND: Mixed evidence exists regarding the effectiveness of the Chronic Care Model (CCM) with patient outcomes. The aim of this review is to examine the effectiveness of CCM interventions on hemoglobin A1c (HbA1c), systolic BP (SBP), diastolic BP (DBP), LDL cholesterol and body mass index (BMI) among primary care adults with type 2 diabetes. METHODS: PubMed, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, Scopus and Web of Science were searched from January 1990 to June 2021 for randomized controlled trials (RCTs) comparing CCM interventions against usual care among adults with type 2 diabetes mellitus in primary care with HbA1c, SBP, DBP, LDL cholesterol and BMI as outcomes. An abbreviated search was performed from 2021 to April 2022. This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for data extraction and Cochrane risk of bias assessment. Two reviewers independently extracted the data. Meta-analysis was performed using Review Manager software. Heterogeneity was evaluated using χ2 and I2 test statistics. Overall effects were evaluated using Z statistic. RESULTS: A total of 17 studies involving 16485 patients were identified. Most studies had low risks of bias. Meta-analysis of all 17 studies revealed that CCM interventions significantly decreased HbA1c levels compared to usual care, with a mean difference (MD) of -0.21%, 95% CI -0.30, -0.13; Z = 5.07, p<0.00001. Larger effects were experienced among adults with baseline HbA1c ≥8% (MD -0.36%, 95% CI -0.51, -0.21; Z = 5.05, p<0.00001) and when four or more CCM elements were present in the interventions (MD -0.25%, 95% CI -0.35, -0.15; Z = 4.85, p<0.00001). Interventions with CCM decreased SBP (MD -2.93 mmHg, 95% CI -4.46, -1.40, Z = 3.75, p=0.0002) and DBP (MD -1.35 mmHg, 95% CI -2.05, -0.65, Z = 3.79, p=0.0002) compared to usual care but there was no impact on LDL cholesterol levels or BMI. CONCLUSIONS: CCM interventions, compared to usual care, improve glycaemic control among adults with type 2 diabetes in primary care, with greater reductions when the mean baseline HbA1c is ≥8% and with interventions containing four or more CCM elements. SYSTEMATIC REVIEW REGISTRATION: PROSPERO  CRD42021273959.

COVID-19 vaccine acceptance and hesitancy among primary healthcare workers in Singapore.

BACKGROUND: Factors affecting COVID-19 vaccine acceptance and hesitancy among primary healthcare workers (HCW) remain poorly understood. This study aims to identify factors associated with vaccine acceptance and hesitancy among HCW. METHODS: A multi-centre online cross-sectional survey was performed across 6 primary care clinics from May to June 2021, after completion of staff vaccination exercise. Demographics, profession, years working in healthcare, residential status, presence of chronic medical conditions, self-perceived risk of acquiring COVID-19 and previous influenza vaccination were collected. HCW who accepted vaccine were then asked to rank their top 5 reasons for vaccine acceptance; HCW who were vaccine hesitant had to complete the 15-item 5C scale on psychological antecedents of vaccination. RESULTS: Five hundred fifty seven out of 1182 eligible HCW responded (47.1%). Twenty nine were excluded due to contraindications. Among 528 respondents, vaccine acceptance rate was 94.9% (n = 501). There were no statistically significant differences in COVID-19 vaccine acceptance between sex, age, ethnicity, profession, number of years in healthcare, living alone, presence of chronic diseases, self-perceived risk or previous influenza vaccination. The top 3 reasons for COVID-19 vaccine acceptance ranked by 501 HCW were to protect their family and friends, protect themselves from COVID-19 and due to high risk of acquiring COVID-19 because of their jobs. HCW with suspected or confirmed COVID-19 exposure were 3.4 times more likely to rank 'high risk at work' as one of the top reasons for vaccine acceptance (χ2 = 41.9, p < 0.001, OR = 3.38, 95%C.I. 2.32-4.93). High mean scores of 'Calculation' (5.79) and low scores for 'Constraint' (2.85) for 5C components among vaccine hesitant HCW (n = 27) highlighted that accessibility was not a concern; HCW took time to weigh vaccine benefits and consequences. CONCLUSION: COVID-19 vaccine hesitancy is a minute issue among Singapore primary HCW, having achieved close to 95% acceptance rate. COVID-19 exposure risk influences vaccine acceptance; time is required for HCW to weigh benefits against the risks. Future studies can focus on settings with higher hesitancy rates, and acceptance of booster vaccinations with the emergence of delta and omicron variants.

Nephrologist referrals of older patients with chronic kidney disease in Singapore: a cross-sectional study.

BACKGROUND: Chronic kidney disease (CKD) is common in the older population. By 2035, approximately one-quarter of Singapore residents are expected to have CKD. Many of these patients are not referred to nephrologists. AIM: To compare the characteristics of older patients (aged ≥65 years) with CKD stage ≥3B in the referral and non-referral groups. DESIGN & SETTINGS: A cross-sectional study in the primary care organisation National University Polyclinics (NUP), Singapore. METHOD: Retrospective data were extracted from the electronic health records of patients with CKD (aged ≥65 years) with CKD stage ≥3B. RESULTS: From 1 January-31 December 2018, a total of 1536 patients aged ≥65 years were diagnosed with CKD stage ≥3B (non-referral group = 1179 versus referral group = 357). The mean patient age in the non-referral group (78.4 years) was older than that in the referral group (75.9 years) (P<0.001). Indian older patients were referred more compared with their Chinese counterparts (P = 0.008). The non-referral group was prescribed significantly less fibrate, statins, insulin, sulfonylureas, dipeptidyl peptidase-4 (DPP4) inhibitors, and antiplatelet than the referral group (P<0.05), but only the difference in fibrates remained significant on subsequent multivariate analysis. CONCLUSION: This study demonstrates that there is a considerable number of older patients with CKD exclusively managed in the primary care setting (n = 1179) and that referrals primarily depend on demographic factors, namely age and ethnic group, rather than medical determinants of CKD severity or case complexity.

COVID-19 Vaccine Booster Hesitancy among Healthcare Workers: A Retrospective Observational Study in Singapore.

BACKGROUND: COVID-19 booster uptake remained poor among healthcare workers (HCW) despite evidence of improved immunity against Delta and Omicron variants. While most studies used a questionnaire to assess hesitancy, this study aimed to identify factors affecting booster hesitancy by examining actual vaccine uptake across time. METHOD: COVID-19 vaccination database records among HCW working at seven Singaporean public primary care clinics between January to December 2021 were extracted, with sex, profession, place of practice, vaccination type, and dates. Time to booster was calculated from the date of vaccination minus date of eligibility. Chi-square test was used to compare the relationship between first dose and booster hesitancy, Kaplan-Meier method and log-rank test were adopted to evaluate differences in cumulative booster uptake. Multivariate Cox regression was used to investigate predictors for timely booster vaccination. Vaccination rate was charted across time and corroborated with media releases pertaining to legislative changes. RESULTS: A total of 877 of 891 (98.9%) primary care HCW were fully vaccinated, 73.8% of eligible HCW had taken the booster. HCW were less booster hesitant [median 16 (5-31.3) days] compared to the first dose [median 39 (13-119.3) days]. First dose-hesitant HCW were more likely to be booster hesitant (OR = 3.66, 95%CI 2.61-5.14). Adjusting for sex, workplace, and time to first dose, ancillary (HR = 1.53, 95%CI 1.03-2.28), medical (HR = 1.8, 95%CI 1.18-2.74), and nursing (HR = 1.8, 95%CI 1.18-2.37) received boosters earlier compared with administrative staff. No temporal relationship was observed between booster uptake, legislative changes, and COVID-19 infection numbers. CONCLUSION: Vaccine hesitancy among HCW had improved from first dose to booster, with timely booster vaccination among medical and nursing staff. Tailored education, risk messaging, and strategic legislation might help to reduce delayed booster vaccination.

A Tale of 3 Asian Cities: How is Primary Care Responding to COVID-19 in Hong Kong, Singapore, and Beijing.

Hong Kong, Singapore, and Beijing have some of the highest numbers of international arrivals and densest living spaces globally, yet these cities have reported low numbers of deaths amid the coronavirus disease 2019 (COVID-19) outbreak. Primary care has played different roles in each of the health systems in combatting the pandemic. Both Hong Kong and Singapore have a 2-tiered health system with the majority of primary care provided in the private sector. The primary care system in Beijing consists of community health facilities, township health centers, and village clinics. The role of primary care in Hong Kong includes using the public primary care clinics as part of an enhanced surveillance program together with accident and emergency departments, as well as triaging patients with suspected infection to hospitals. Singapore's response to COVID-19 has included close cooperation between redeveloped polyclinics and private and public health preparedness clinics to provide screening with swab tests for suspected cases in the primary care setting. Beijing's unique response has consisted of using online platforms for general practitioners to facilitate monitoring among community residents, as well as public health education and a mobilized pharmacy refill program to reduce risk of transmission. Established challenges, however, include shortages of personal protective equipment and the heavy workload for health care staff. Regardless, all 3 cities have demonstrated enhanced preparedness since experiencing the severe acute respiratory syndrome epidemic, and the responses of their primary care systems therefore may offer learning points for other countries during the COVID-19 pandemic.

How does multimorbidity affect middle-aged adults? A cross-sectional survey in the Singapore primary healthcare setting.

BACKGROUND: Multimorbidity is of increasing prevalence and importance. It has been associated with poorer health-related quality of life (HrQoL) especially in the elderly population. Despite substantial multimorbidity in the middle-aged population, defined as those aged between 40-64 years old, there is a paucity of research investigating the impact of multimorbidity in this population. This study aimed to investigate the association between multimorbidity and HrQoL in the middle-aged primary care population in Singapore. METHODS: A cross-sectional study was conducted at a primary care centre in Singapore. Interviewer-administered questionnaires were used to collect data regarding the participants' sociodemographic characteristics, chronic conditions, and HrQoL, as measured by the EuroQol five dimensions 3-levels questionnaire (EQ5D). We defined multimorbidity as the presence of three or more conditions, out of a list of 14 chronic conditions. The associations between multimorbidity and the components of the EQ5D were assessed using multivariable regression analyses. RESULTS: The study included 297 participants, aged 40-64 years, of which 124 (41.7%) had multimorbidity. After adjusting for sociodemographic factors, participants with multimorbidity had significantly lower EQ5D UI, (ß-coefficient - 0.064 (C.I -0.125, - 0.003), p = 0.04), but not significantly lower EQ5D VAS, (ß-coefficient - 0.045 (C.I 0.102, 0.012), p = 0.12). Additionally, participants with multimorbidity had higher odds (OR = 2.41, p = 0.01) of reporting problems due to pain/discomfort. CONCLUSION: Multimorbidity was not significantly associated with the overall health state, as measured by the EQ5D VAS, in middle-aged primary care patients. However, it was associated with the EQ5D UI which is a composite measure of five specific domains of HrQoL. Specifically, there was a statistically significant association between multimorbidity and the pain domain. Further studies are required to understand the relationship between multimorbidity and pain to enable physicians to better manage pain and HrQoL in this population.

The Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) protocol: a non-randomised controlled trial of personalised care and support planning for persons living with diabetes.

BACKGROUND: Personalised care and support planning (CSP) has been shown to improve diabetes outcomes, patient experience and provider morale in the care of persons living with diabetes. However, this has not been confirmed in controlled studies. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) is a pragmatic controlled trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in the public primary care setting in Singapore. METHODS: Teamlet-empanelled patients with diabetes at four polyclinics are recruited for this study. Participants who attend either of the two Intervention clinics are sent their investigation results in a care planning letter (CPL) to prepare them for the CSP conversation. This conversation is facilitated by a trained CSP practitioner who engages them in discussion of concerns, goals and action plans, and documents their plans for subsequent review. Participants in the two Control clinics will receive standard diabetes care. Participants will complete two or more CSP conversations (Intervention) or regular consultations (Control) at the annual review visits within the 18 months of the study. The sample size is calculated at 1620 participants, with glycated haemoglobin (HbA1c) as the primary outcome measure. Secondary outcome measures include patient activation (as measured by PAM-13) and changes in healthcare utilisation and cost. DISCUSSION: This study is a pragmatic trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in a real world setting. It promises to provide insights with regard to the implementation of this model of care in Singapore and the region. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04288362. Retrospectively registered on 28 February 2020.