Person-Centred Care in Diabetes: What Is It Based On and Does It Work?

@#Chronic diseases are now the top cause of death and disability around the world. This creates challenges for global health systems, which are mostly designed for acute care, requiring them to transform to optimise the health of patients living with chronic diseases. The Chronic Care Model provides the best evidence-based framework for optimising diabetes care delivery by modifying essential elements of the healthcare system to support person-centred care. In this article, we review the theoretical basis of person-centred care, with special focus on the Chronic Care Model, and describe the steps involved in performing person-centred care. We also discuss the evidence for the impact of person-centred care on chronic disease outcomes, self-management, as well as individual and healthcare professional (HCP) satisfaction.

High-sensitivity troponin T and long-term adverse cardiac events among patients presenting with suspected acute coronary syndrome in Singapore

INTRODUCTION@#Prognostic thresholds for 30-day major adverse cardiac events (MACE) have been studied for high-sensitivity troponin T (hsTnT) in patients with suspected acute coronary syndrome (ACS), but there is limited data on the prognostic performance of hsTnT for one-year MACE.@*METHODS@#We prospectively measured hsTnT (in ng/mL up to two decimal places) at 0, 2 and 7 hours for patients presenting with symptoms suggestive of ACS to our emergency department from March 2010 to April 2013. We assessed the prognostic performance of hsTnT cut-offs for 30-day and one-year MACE, and the utility of delta-hsTnT in predicting MACE.@*RESULTS@#Among 2,444 patients studied, 273 (11.2%) developed MACE (including index MACE) by 30 days and 359 (14.7%) patients developed MACE at one year. The suggested hsTnT cut-off for 30-day MACE was ≥ 10 ng/L at 0 hour (positive predictive value [PPV] 33.5%, negative predictive value [NPV] 94.5%) and 7 hours (PPV 37.3%, NPV 94.5%), and ≥ 20 ng/L at 2 hours (PPV 36.9%, NPV 96.9%). For one-year MACE, the suggested cut-off was also ≥ 10 ng/L at all readings. Plasma hsTnT ≥ 30 ng/L at any reading gave PPV > 54% and NPV > 93% for 30-day MACE. Absolute 0-2 hour and 2-7 hour delta-hsTnT ≥ 10 ng/L gave PPV > 50% for 30-day and one-year MACE.@*CONCLUSION@#Patients with 0-, 2- or 7-hour hsTnT ≥ 30 ng/L and 0-2 hour delta-hsTnT ≥ 10 ng/L had PPV > 50% for 30-day and one-year MACE, and should be investigated thoroughly.

Establishing validity of EQ-5D-3L (Tagalog) to measure health-related quality of life states among adult Filipinos (20-50 years old)

@#<p style="text-align: justify;"><b>OBJECTIVE: </b>To establish the validity of EQ-5D-3L in Tagalog language in assessing health-related quality of life states among adult Filipinos 20-50 years old.</p><p style="text-align: justify;"><b>METHODS:</b> A face-to-face cross-sectional community survey of apparently healthy adult Filipinos (20-50 years old) in Metro Manila and in 4 nearby provinces (Bulacan, Batangas, Quezon, Rizal) was conducted. Trained interviewers administered the Tagalog language versions of EuroQoL 5-Dimension 3 Levels (EQ-5D-3L), Short-Form 2 (SF-26V2®), and a socio-economic questionnaire. All questionnaires were pre-tested for cultural appropriateness. Concurrent validity (against the SF-36v2R®) and known group validity of the EQ-5D-3L were evaluated.</p><p style="text-align: justify;"><b>RESULTS:</b> Complete data from 3,056 participants were analyzed. Almost half of the participants reported perfect health on EQ-5D-3L and had higher scores on all SF-36v2® domains compared to those who reported some problems on EQ-5D-3L. Compared to participants who reported some problems on EQ-5D-3L mobility (or anxiety/depression), participants who reported no problem on EQ-5D-3L mobility (or anxiety/depression) reported lower SF-36v2® Physical Functioning (or Mental Health) scores (differences of 7.1 and 10 points, respectively) that were minimally important (i.e. exceeds 5 points). Participants with poorer self-reported health had considerably lower EQ-5D index scores (p < 0.05) irrespective of their socio-demographic characteristics.</p><p style="text-align: justify;"><b>CONCLUSION:</b> EQ-5D-3L (Tagalog) demonstrated construct and known groups validity among adult Filipinos (20-50 years old).</p>

Validation Of The Kessler's Psychological Distress Scale (K10 & K6) In A Malaysian Population

@#Objective: A quick assessment tool for screening individuals with depression or anxiety is pertinent in mental-health set up. This study aims to validate the K10 and the K6 to screen patients with non-specific psychological distress in a Malaysian population. Methods: Translation of the questionnaire was done from English to Malay. Face validity was conducted on patients, and a pilot study was performed to assess the reliability of the K10 questionnaire. Fieldwork was conducted to determine the reliability and validity of the K10 questionnaire based on convenience sampling of healthy individuals and patients diagnosed with psychiatric illness. Malay version for K10 was administered to healthy participants (group without psychological distress) and patients on psychiatric clinic follow up (psychological distress). Data collection was done between August 2016 and September 2016. Result: A total of 94 subjects were recruited in the study, of which 32 formed the case group. The Cronbach’s alpha coefficients for K10 were 0.837(control) and 0.885 (case), as for K6 were 0.716 (control) and 0.859 (case). The total score of the K10 and the K6 clearly differentiated between the control and case groups (p<0.001). The area under the curve for K10 and K6 were 0.84 with 95% CI (0.81, 0.96) and 0.86 with 95% CI (0.77, 0.94) respectively. For K10, at the optimal cut-off score of 17, the sensitivity and specificity were 84.4% and 75.3% respectively while for K6, at the optimal cut-off score of 11, the sensitivity and specificity were 78.1% and 75.8%, respectively. Conclusion: The Malay version of the K10 and the K6 are reliable and valid to be used for screening patients with non-specific psychological distress in a Malaysian population. Kessler psychological distress scale has minimal items and yet this Kessler psychological distress scales have minimal items and yet are an effective screening tool.

Ministry of Health Clinical Practice Guidelines: Lipids

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Lipids to provide doctors and patients in Singapore with evidence-based treatment for lipids. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on Lipids, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.

Validity of a Revised Short Form-12 Health Survey Version 2 in Different Ethnic Populations

<p><b>INTRODUCTION</b>The Short Form-12 version 2 (SF-12v2) is a shorter version of the Short Form-36 version 2 (SF-36v2) for assessing health-related quality of life. As the SF-12v2 could not be resolved into the physical- and mental-component summary score (PCS and MCS, respectively) in the general population of Singapore, this study aims to determine and validate the Singapore SF-12 version 2 (SG-12v2).</p><p><b>MATERIALS AND METHODS</b>The SG- 12v2 was generated using the same methodology as the SF-12v2. Bootstrap analysis was used to determine if the SG-12v2 were significantly different from the SF-12v2. Content validity was assessed using percentage of variance (R²) of the Singapore version of SF-36v2 PCS and MCS explained by the SG-12v2 items. Agreement between the SF-36v2 and the SG-12v2 was assessed using Bland-Altman diagrams. Criterion validity was demonstrated if effect size differences between SF-36v2 and SG-12v2 were small (Cohen's criteria). Known-group validity of SG-12v2 was reported for participants with and without chronic diseases.</p><p><b>RESULTS</b>Five items differed between the SG-12v2 and SF-12v2. Bootstrap analysis confirmed that SG-12v2 and SF-12v2 were significantly different. The SG12v2 explained 94% and 79% of the R² of the SF-36v2 PCS and MCS, respectively. Agreement was good and effect size differences were small (<0.3). Participants with chronic diseases reported lower SG-12v2 scores compared to participants without chronic diseases.</p><p><b>CONCLUSION</b>The SG-12v2 offers advantage over the SF-12v2 for use in the general population of Singapore. The SG-12v2 is a valid measure and will be particularly useful for large population health surveys in Singapore.</p>

Diabetes Health Profile-18 is Reliable, Valid and Sensitive in Singapore

<p><b>INTRODUCTION</b>The Diabetes Health Profile-18 (DHP-18) measures diabetes-related psychological well-being in patients with type 2 diabetes mellitus (T2DM). It includes 3 subscales: psychological distress (PD), barriers to activity and disinhibited eating. The psychometric properties of the DHP have not been evaluated in Asia. The aim of this study was to determine the psychometric properties of the DHP in multiethnic Singapore.</p><p><b>MATERIALS AND METHODS</b>Patients between the ages of 18 to 65 diagnosed with diabetes (either type 1 or type 2) for at least 1 year were recruited from a diabetes outpatient clinic in a tertiary hospital. They completed a set of self-administered questionnaires including sociodemographic information and the DHP. Validity of the DHP was evaluated using confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). Reliability was assessed with internal consistency and sensitivity was determined by effect size, associated with detecting a statistically significant and clinically important difference between various patient subgroups.</p><p><b>RESULTS</b>A total of 204 patients with mean age 45.4 (11.9) years, comprising 64% males and 50% Chinese, 27% Indian and 12% Malay were studied. In CFA, model fit was poor. Forced 3-factor EFA supported the original 3-factor structure of the DHP. Convergent and discriminant validity was demonstrated (100% scaling success). DHP was sensitive across majority of social demographic, clinical and social-functioning determinants (i.e., effect size >0.3). Cronbach's alpha exceeded 0.70 for all subscales. Ceiling effects were negligible but large floor effects were seen for the PD subscale (23%).</p><p><b>CONCLUSION</b>The DHP is valid, reliable and sensitive for measuring well-being in Asian patients with T2DM.</p>

Normative Data for the Singapore English and Chinese SF-36 Version 2 Health Survey

<p><b>INTRODUCTION</b>The aim of this study is to report normative data for the Short-Form 36 version 2 (SF-36v2) for assessing health-related quality of life, in the Singapore general population.</p><p><b>MATERIALS AND METHODS</b>Data for English and Chinese-speaking participants of the Singapore Prospective Study Programme were analysed. The SF-36v2 scores were norm-based with the English-speaking Singapore general population as reference and reported by age (in decades), gender and ethnicity as well as for the 5 most prevalent chronic medical conditions. Scores were reported separately for the English and Chinese language versions.</p><p><b>RESULTS</b>A total of 6151 English-speaking (61.5% Chinese and 19.2% Malay) and 1194 Chinese-speaking participants provided complete data. Mean (SD) age of all participants was 49.6 (12.58) years with 52.4% being women. In both languages, women reported lower scores than men on all scales. Among the chronic medical conditions, stroke had the largest impact on all English SF-36v2 scales and on 3 Chinese SF-36v2 scales (role-physical, general health and social functioning).</p><p><b>CONCLUSION</b>We have provided detailed normative data for the Singapore English and Chinese SF-36v2, which would be valuable in furthering HRQoL research in Singapore and possibly the region.</p>

Prevalence and control of hypercholesterolaemia as defined by NCEP-ATPIII guidelines and predictors of LDL-C goal attainment in a multi-ethnic Asian population

<p><b>INTRODUCTION</b>Few studies in Asia have assessed the burden of hypercholesterolaemia based on the global cardiovascular risk assessment. This study determines the burden of hypercholesterolaemia in an Asian population based on the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII) guidelines, and examines predictors of low-density lipoprotein cholesterol (LDL-C) goal attainment.</p><p><b>MATERIALS AND METHODS</b>Five thousand and eighty-three Chinese, Malays and Asian-Indians living in Singapore were assigned to coronary heart disease (CHD)-risk category based on the NCEP-ATPIII guidelines. Awareness, treatment and control of hypercholesterolaemia based on risk- specific LDL-C goal were determined, including the use of lipid-lowering therapy (LLT). Cox-regression models were used to identify predictors of LDL-C above goal among those who were aware and unaware of hypercholesterolaemia.</p><p><b>RESULTS</b>One thousand five hundred and sixty-eight (30.8%) participants were aware of hypercholesterolaemia and 877 (17.3%) were newly diagnosed (unaware). For those who were aware, 39.3% participants received LLT. Among those with 2 risk factors, only 59.7% attained LDL-C goal. The majority of them were taking statin monotherapy, and the median dose of statins was similar across all CHD risk categories. Among participants with 2 risk factors and not receiving LLT, 34.1% would require LLT. Malays or Asian-Indians, higher CHD risk category, increasing body mass index (BMI), current smoking and lower education status were associated with higher risk of LDL-C above goal. Being on LLT reduced the risk of having LDL-C above goal.</p><p><b>CONCLUSION</b>The burden of hypercholesterolaemia is high in this multi-ethnic population especially those in the higher CHD risk categories, and might be partly contributed by inadequate titration of statins therapy. Raising awareness of hypercholesterolaemia, appropriate LLT initiation and titration, weight management and smoking cessation may improve LDL-C goal attainment in this population.</p>

The relevance of the metabolic syndrome

<p><b>INTRODUCTION</b>To review the definitions of the metabolic syndrome according to various expert groups and assess their relevance to clinical practice.</p><p><b>MATERIALS AND METHODS</b>Medline searches were conducted to identify studies which addressed: (i) the utility of the metabolic syndrome compared to multivariable predictive functions for the identification of individuals at high risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), (ii) the importance and definition of obesity in the definition of the metabolic syndrome and (iii) the impact of lifestyle and pharmacological interventions designed to reduce the risk of cardiovascular disease in those with and without the metabolic syndrome.</p><p><b>RESULTS</b>Although inferior to multivariable risk scores in predicting T2DM and CVD, the metabolic syndrome represents a simple clinical tool, particularly for the prediction of T2DM. Obesity is not a critical component of the metabolic syndrome for identifying those at increased risk of CVD but may be important for predicting T2DM. If anything, pharmacological therapy, especially lipid lowering is as, if not more, effective in those with the metabolic syndrome than in those without.</p><p><b>CONCLUSIONS</b>Although the metabolic syndrome appears to have limited utility for the identification of individuals at increased risk of T2DM or CVD, the diagnosis of the metabolic syndrome presents an opportunity to rationalise health services to deliver coordinated care to those with metabolic syndrome.</p>

Lack of awareness amongst community patients with diabetes and diabetic retinopathy: the Singapore Malay eye study

<p><b>INTRODUCTION</b>We assessed awareness of diabetes and diabetic retinopathy in a Singaporean Malay population. We hypothesised that poor awareness is associated with poorer control of diabetic retinopathy risk factors (glycaemic and blood pressure levels) and suboptimal treatment with laser therapy.</p><p><b>MATERIALS AND METHODS</b>A population-based survey of 3280 (78.7% response rate) persons among Singaporean Malays aged between 40 and 80 years old. Diabetes was defined in persons with random glucose >or=11.1mmoL/L, use of diabetic medication, or a previous physician diagnosis. Diabetic retinopathy was graded from retinal photographs following the modified Airlie House classification. Patient awareness was assessed via structured interviews. Glycosylated haemoglobin was measured from venous blood.</p><p><b>RESULTS</b>Of the 3280 study participants, 768 had diabetes, of whom 13.2% (n = 101) were unaware of their diabetes status. Participants unaware of their diabetes status had significantly higher mean glycosylated haemoglobin (9.7% vs 8.2%, P <0.001), systolic blood pressure (160.0 mmHg vs 153.7 mmHg, P = 0.01) and diastolic blood pressure (83.5 mmHg vs 78.5 mmHg, P <0.001), compared to participants who were aware. Of the 272 (35.4%) participants detected to have diabetic retinopathy, 83.4% (n = 227) were unaware of having retinopathy. Of the 77 with vision-threatening retinopathy, laser treatment had been performed in only 55.6% of those unaware of having retinopathy.</p><p><b>CONCLUSION</b>In a sample of Malays with diabetes, high proportions were unaware of their disease. Unawareness was associated with poorer control of diabetic retinopathy risk factors. Only half of persons who were unaware that they had vision-threatening diabetic retinopathy had received laser treatment. These data highlight room for improvement in diabetic retinopathy prevention through better patient education and screening.</p>