Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case-control study.

Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case-control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow-up (33% vs 76%, P < .001), decrease in 1-year minor amputation rate (14% vs 3%, P = .007), and decrease in 1-year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.

Effectiveness of Diabetes Foot Screening in Primary Care in Preventing Lower Extremity Amputations.

INTRODUCTION: The risk of lower extremity amputations (LEAs) in diabetics is 20 times higher than in non-diabetics. Clinical practice guidelines recommend that all diabetics should receive an annual foot examination to identify high-risk foot conditions. Despite this recommendation, there is little evidence in the literature to show its effectiveness in preventing LEA. This study aims to evaluate the effectiveness of diabetes foot screening in primary care in preventing LEA and to identify LEA risk factors. MATERIALS AND METHODS: This is a retrospective cohort study of diabetic patients who visited the National Healthcare Group Polyclinics for the first time from 1 January 2008 to 31 December 2012. The intervention of interest was foot screening performed at least once during 2 years of follow-up, and the outcome of interest was LEA (major and/or minor) performed during 2 years of follow-up. Patients who did foot screening (n=8150) were compared to a propensity score matched control group (n=8150) who did not do foot screening. Logistics regression was done to identify factors associated with LEA. RESULTS: Among those who underwent foot screening, there were 2 (0.02%) major amputations and 15 (0.18%) minor amputations compared with 42 (0.52%) and 52 (0.64%) among those who did not (P<0.001). CONCLUSION: Lack of diabetes foot screening, lower socioeconomic status, hip fracture, Malay ethnicity, chronic kidney disease, poorer glycaemic control, longer diabetes duration and male gender have been found to be associated with a higher risk of LEA.

Quality of care of patients with chronic kidney disease in national healthcare group polyclinics from 2007 to 2011.

INTRODUCTION: Chronic kidney disease (CKD) is a major public health problem where majority of patients are managed in the primary care. The major risk factors are advanced age, hypertension and diabetes mellitus, and risk factors control is paramount to prevent progression to CKD. The objective of the study is to describe the epidemiology and quality of care of patients with CKD stages 3 to 5 at National Healthcare Group Polyclinics (NHGP). MATERIALS AND METHODS: The study was carried out using data from National Healthcare Group (NHG) Renal Registry. Patients were included if they were identified to have CKD based on ICD-9-CM codes and laboratory results. RESULTS: Overall, the number of CKD patients increased more than 2 fold from 4734 in 2007 to 10,245 in 2011. In 2011, the majority belonged to stages 3A (39.6%) and 3B (37.6%), had hypertension (98.2%), dyslipidemia (97.2%) and diabetes mellitus (68.7%). From 2007 to 2011, among those with hypertension, the use of angiotensin converting enzyme (ACE) inhibitors and/ or angiotensin receptor blockers increased from 78.4% to 84.1%, and the percentage with good systolic blood pressure control (<130 mmHg) improved from 18.7% to 36.3%. Among those with dyslipidemia, the use of statins increased from 81% to 87.1%, and the percentage of patients with low density lipoproteins (LDL) <2.6 mmol/L increased from 40% to 54.7%. However, among those with diabetes mellitus, mean glycated haemoglobin (HBA1c) increased from 7.4% to 7.6%, and the percentage of patients with HBA1c ≤7.0% decreased from 44.5% to 39.4%. CONCLUSION: The number of CKD patients in NHGP has increased significantly from 2007 to 2011 at an average annual rate of 21.3%. Majority of patients the study conducted in 2011 were in stage 3A and stage 3B. Blood pressure and LDL control are encouraging but glycaemic control can be further improved.

Changing epidemiology of enteric fevers in Singapore.

INTRODUCTION: We studied the epidemiological trends of enteric fevers (typhoid and paratyphoid fever) in Singapore from 1990 to 2009 and carried out a review of the current prevention and control measures. MATERIALS AND METHODS: Epidemiological records of all reported enteric fevers maintained by the Communicable Diseases Division, Ministry of Health from 1990 to 2009 were analysed. RESULTS: A total of 2464 laboratory confirmed cases of enteric fevers (1699 cases of typhoid and 765 cases of paratyphoid) were reported. Of these, 75% were imported, mainly from India and Indonesia. There had been a significant fall in the mean annual incidence rate of indigenous enteric fevers from 4.3 per 100,000 population in 1990 to 0.26 per 100,000 population in 2009 (P <0.005) with a corresponding increase in the proportion of imported cases from 71% between 1990 and 1993 to 92% between 2006 and 2009 (P <0.0005). Imported cases involving foreign contract workers increased significantly from 12.8% between 1990 and 1993 to 40.4% between 2006 and 2009 (P <0.0005). CONCLUSION: Singapore has experienced a marked decline in the incidence of enteric fevers that is now comparable to that of other developed countries. Continued vigilance and proactive measures that address the changing epidemiology of enteric fevers in Singapore are necessary to sustain the milestone achieved in the past 2 decades.