Experiences of doctors working in Singapore's public primary healthcare clinics.

Despite providing 20 percent of primary healthcare and a larger proportion of care for patients with chronic conditions, little is documented about working in public primary healthcare clinics in Singapore. While previous studies of primary care physicians' occupational stress focused on burnout, this study explores broader personal, professional and organisational factors affecting their experiences. It examines factors influencing doctors working in such clinics to leave or remain in this setting, and the initiatives that would retain and encourage re-entry in the public sector. The study employs a qualitative approach involving semi-structured interviews with 22 doctors conducted between November 2018 and May 2019. These doctors had at least 1 year of experience working in a public primary healthcare clinic. Sixteen of them had left the public sector and six others remaining. Qualitative content analysis was used to interpret the data. The respondents shared three key less favourable themes of working in these clinics; heavy workload and long working hours, short consultation times, and a perceived lack of management's concern about doctors' welfare, and two key valuable experiences of working in this setting; continuity of care and opportunities for academic scholarly activity, including teaching and research. The findings suggest that to retain doctors in these clinics, change is needed at an organisational and structural level. Overall, this study bears important implications for health policy and planning, especially with regard to how the public healthcare system can strike a balance between meeting the demand for high-quality healthcare, and the professional needs of healthcare providers.

Assessment of Circumferential Angle Closure with Swept-Source Optical Coherence Tomography: a Community Based Study.

PURPOSE: To evaluate the diagnostic performance of swept-source optical coherence tomography (SS-OCT, CASIA SS-1000; Tomey Corporation, Nagoya, Japan) for angle closure detection, in comparison with gonioscopy, in a community setting. DESIGN: Reliability analysis. METHODS: A total of 2027 phakic subjects aged ≥50 years, with no previous history of glaucoma, laser (including peripheral iridotomy), intraocular surgery, or ocular trauma, were consecutively recruited from a community polyclinic in Singapore. Gonioscopy was performed by a single trained ophthalmologist. SS-OCT angle scans, which obtain radial scans for the entire circumference of the angle, were analyzed by a single examiner, masked to the subject's clinical details. On SS-OCT images, angle closure was defined as contact between the iris and any part of the angle wall anterior to the scleral spur. Different cutoff values of the degree of circumferential angle closure (≥35%, ≥50%, and ≥75%) were taken for analysis to assess SS-OCT performance in detecting angle closure. RESULTS: A total of 1857 subjects (91.6%) were included in the final analysis after excluding poor-quality SS-OCT scans. Almost 90% of the subjects were Chinese, with a mean age of 61.8 ± 6.7 years, and more than half were women (63.5%). The overall AUC of SS-OCT manual grading against gonioscopy was 0.84 (95% confidence interval, 0.81-0.88). The prevalence of angle closure on SS-OCT was 26.1% for the ≥35% definition, with an area under the curve of 0.80 (0.77-0.84), sensitivity of 82.5% (75.3%-88.4%), and specificity of 78.5% (76.5%-80.4%). The first-order agreement coefficient statistics for the 2-quadrant gonioscopic definition of angle-closure with corresponding ≥35%, ≥50%, and ≥75% angle closure definitions for SS-OCT were good at 0.89 (0.83-0.93), 0.88 (0.842-0.93), and 0.88 (0.831-0.99), respectively. CONCLUSIONS: In this large community-based study, SS-OCT exhibited moderate performance for angle closure detection compared to gonioscopy as the reference standard.

Determinants of poor sleep quality in elderly patients with diabetes mellitus, hyperlipidemia and hypertension in Singapore.

AimThe objective of this study was to assess determinants of poor sleep quality which is an under-diagnosed and under-treated problem in elderly patients with diabetes mellitus, hyperlipidemia and hypertension. BACKGROUND: Poor sleep quality is linked to decreased quality of life, increased morbidity and mortality. Poor sleep quality is common in the elderly population with associated cardiometabolic risk factors such as diabetes, hyperlipidemia and hypertension. METHODS: This is a cross-sectional study undertaken in the primary healthcare setting (Singhealth Polyclinics-Outram) in Singapore. Singaporeans aged 65 years and above who had at least one of the three cardiometabolic risk factors (diabetes, hypertension and hyperlipidemia) were identified. Responders' sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire and were divided into those with good quality sleep and those with poor quality sleep, based on the PSQI score. Information on demographics, co-morbidities and lifestyle practices were collected. Descriptive and multivariate analyses of determinants of poor sleep were determined.FindingsThere were 199 responders (response rate 88.1%). Nocturia (adjusted prevalence rate ratio 1.54, 95% confidence interval 1.06-2.26) was found to be associated with an increased risk of poor sleep quality in elderly patients with diabetes mellitus, hypertension and hyperlipidaemia. Nocturia, a prevalent problem in the Asian elderly population, has been found to be associated with poor sleep quality in our study. Hence, it is imperative to identify and treat patients with nocturia to improve sleep quality among them.

Health-related quality of life is associated with diabetic complications, but not with short-term diabetic control in primary care.

INTRODUCTION: Type 2 diabetes mellitus is of increasing healthcare concern worldwide, with incidence rising, complications leading to significant morbidity and mortality, posing strain on public healthcare funding. Health-related quality of life of diabetic patients is increasingly being recognised as "the ultimate goal of all health interventions". The aim of our study was to identify the quality of life predictors of diabetic patients in primary care. This study was conducted in 8 public primary care polyclinics from SingHealth Polyclinics. MATERIALS AND METHODS: We carried out a cross-sectional, questionnaire-based survey on 699 diabetic patients, administered by medical students on a systematic sample of patients during their routine visit. Multiple regression analysis was used to investigate the socio-demographic and clinical characteristics as predictors of quality of life, measured by the Short Form 36 Health Survey (SF-36) and the EQ-5D self-report questionnaire. RESULTS: Higher quality of life in diabetic patients is associated with younger age, male gender, employed status, higher educational level and exercise. Lower quality of life is associated with comorbidities and diabetic complications. Short-term glycaemic control as measured by HbA1c did not correlate with quality of life. Most interestingly, confidence in doctor and satisfaction in clinic were related to better quality of life. CONCLUSION: Health-related quality of life is adversely associated with symptomatic complications of diabetes mellitus, but not with short-term diabetic control. This suggests that the diabetic patient may not appreciate the impact of good diabetic control immediately on his or her health-related quality of life. More effort should be invested into patient education of the importance of glycaemic control to prevent these long-term complications.