Retrospective evaluation of healthcare utilisation and mortality of two post-discharge care programmes in Singapore.

OBJECTIVE: To evaluate the impact on healthcare utilisation frequencies and charges, and mortality of a programme for frequent hospital utilisers and a programme for patients requiring high acuity post-discharge care as part of an integrated healthcare model. DESIGN: A retrospective quasi-experimental study without randomisation where patients who received post-discharge care interventions were matched 1:1 with unenrolled patients as controls. SETTING: The National University Health System (NUHS) Regional Health System (RHS), which was one of six RHS in Singapore, implemented the NUHS RHS Integrated Interventions and Care Extension (NICE) programme for frequent hospital utilisers and the NUHS Transitional Care Programme (NUHS TCP) for high acuity post-discharge care. The programmes were supported by the Ministry of Health in Singapore, which is a city-state nation located in Southeast Asia with a 5.6 million population. PARTICIPANTS: Linked healthcare administrative data, for the time period of January 2013 to December 2016, were extracted for patients enrolled in NICE (n=554) or NUHS TCP (n=270) from June 2014 to December 2015, and control patients. INTERVENTIONS: For both programmes, teams conducted follow-up home visits and phone calls to monitor and manage patients' post-discharge. PRIMARY OUTCOME MEASURES: One-year pre- and post-enrolment healthcare utilisation frequencies and charges of all-cause inpatient admissions, emergency admissions, emergency department attendances, specialist outpatient clinic (SOC) attendances, total inpatient length of stay and mortality rates were compared. RESULTS: Patients in NICE had lower mortality rate, but higher all-cause inpatient admission, emergency admission and emergency department attendance charges. Patients in NUHS TCP did not have lower mortality rate, but had higher emergency admission and SOC attendance charges. CONCLUSIONS: Both NICE and NUHS TCP had no improvements in 1 year healthcare utilisation across various setting and metrics. Singular interventions might not be as impactful in effecting utilisation without an overhauling transformation and restructuring of the hospital and healthcare system.

Realist evaluation of a complex integrated care programme: protocol for a mixed methods study.

INTRODUCTION: The lack of understanding of how complex integrated care programmes achieve their outcomes due to the lack of acceptable methods leads to difficulties in the development, implementation, adaptation and scaling up of similar interventions. In this study, we evaluate an integrated care network, the National University Health System (NUHS) Regional Health System (RHS), consisting of acute hospitals, step down care, primary care providers, social services and community partners using a theory-driven realist evaluation approach. This study aims to examine how and for whom the NUHS-RHS works to improve healthcare utilisations, outcomes, care experiences and reduce healthcare costs. By using a realist approach that balances the needs of context-specific evaluation with international comparability, this study carries the potential to address current research gaps. METHODS AND ANALYSIS: This evaluation will be conducted in three research phases: (1) development of initial programme theory (IPT) underlying the NUHS-RHS; (2) testing of programme theory using empirical data; and (3) refinement of IPT. IPT was elicited and developed through reviews of programme documents, informal discussions and in-depth interviews with relevant stakeholders. Then, a convergent parallel mixed method study will be conducted to assess context (C), mechanisms (M) and outcomes (O) to test the IPT. Findings will then be analysed according to the realist evaluation formula of CMO in which findings on the context, mechanisms will be used to explain the outcomes. Finally, based on findings gathered, IPT will be refined to highlight how to improve the NUHS-RHS by detailing what works (outcome), as well as how (mechanisms) and under what conditions (context). ETHICS AND DISSEMINATION: The National Healthcare Group, Singapore, Domain Specific Review Board reviewed and approved this study protocol. Study results will be published in international peer-reviewed journals and presented at conferences and internally to NUHS-RHS and Ministry of Health, Singapore.

Incipient Albuminuria in Persons with Newly Diagnosed Type 2 Diabetes Mellitus: A 5-Year Retrospective Cohort Study.

INTRODUCTION: This study aimed to determine the 5-year incidence of albuminuria among Asian persons with newly diagnosed type 2 diabetes mellitus (DM), and to identify the risk factors at diagnosis for progression to albuminuria. MATERIALS AND METHODS: A retrospective 5-year closed cohort study was conducted among 1016 persons aged ≥18 years old who were diagnosed with type 2 DM between 1 January 2007 and 31 December 2009 at primary care facilities in Singapore. The cumulative incidence of progression from normoalbuminuria to albuminuria-termed "progression"-was determined. The risk factors associated with progression were evaluated using multiple logistic regression analysis. RESULTS: A total of 541 (53.2%) participants were men. The mean (SD) onset age of type 2 DM was 54 (11) years. From diagnosis of type 2 DM, the 5-year cumulative incidence of progression was 17.3% and mean (SD) duration to progression was 2.88 (1.23) years. Higher onset age (OR 1.02; 95% CI, 1.00-1.04), history of hypertension (OR, 1.88; 95% CI, 1.32-2.70) and higher glycated haemoglobin (HbA1c) (OR, 1.17; 95% CI, 1.09-1.26) at diagnosis were associated with progression. In addition, being on angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) treatment at baseline modified the effect of hypertension on progression. CONCLUSION: This study highlighted the importance of early screening and treatment of diabetes as well as prevention of hypertension, which could potentially delay the onset of microalbuminuria in persons with type 2 DM. Persons on ACEI or ARB treatment should continue to be monitored regularly for progression to albuminuria.

Group B Streptococcus Serotype III Sequence Type 283 Bacteremia Associated with Consumption of Raw Fish, Singapore.

We conducted a retrospective study of 40 case-patients and 58 controls as part of a nationwide investigation of a group B Streptococcus outbreak in Singapore in 2015. Eating a Chinese-style raw fish dish (yusheng) was a major risk factor for bacteremia, particularly caused by serotype III sequence type 283.