SABA prescriptions and asthma management practices in Singapore: results from a cross-sectional, observational SABINA III study.

OBJECTIVES: To evaluate asthma characteristics and treatment patterns, including short-acting ß2-agonist (SABA) prescriptions, in primary and specialist care in the Singapore cohort of the SABA use IN Asthma (SABINA III) study. DESIGN: Cross-sectional, observational study. SETTING: Multicentre study conducted at five sites across Singapore. METHODS: In patients with asthma (aged ≥12 years), data on demographics, disease characteristics and asthma treatment prescriptions were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by 2017 Global Initiative for Asthma recommendations) and practice type (primary/specialist care). RESULTS: Of the 205 patients analysed (mean (SD) age, 53.6 (16.8) years; female, 62%), 55.9% were enrolled by specialists and 44.1% by primary care physicians. Most study patients (80.5%) had moderate-to-severe asthma (86.0% in specialist care and 74.4% in primary care). In the 12 months before study enrolment, 18.0% of patients experienced ≥1 severe exacerbation. Asthma was well or partly controlled in 78.0% of patients. Overall, 17.1% of all patients were overprescribed SABA (≥3 SABA canisters/year) in the preceding 12 months, and overprescription was greater in specialist versus primary care (26.3% vs 5.6%). Only 2.9% of patients were prescribed SABA monotherapy, while 41.0% received SABA in addition to maintenance therapy. Among the latter, 40.5% were overprescribed SABA. Overall, a higher percentage of patients prescribed ≥3 SABA canisters (vs 0-2 SABA canisters) were assessed as having uncontrolled asthma during the study visit (42.9% vs 17.6%). Maintenance therapy in the form of inhaled corticosteroids (ICS) or ICS/long-acting ß2 agonist fixed-dose combinations were prescribed to 14.1% and 84.9% of patients, respectively, in the 12 months before enrolment. CONCLUSIONS: In this Singapore cohort, ~17% of all patients and more than 40% of patients prescribed SABA in addition to maintenance therapy were overprescribed SABA. These findings emphasise the need to align clinical practices with the latest evidence-based treatment recommendations. TRIAL REGISTRATION: NCT03857178.

Breaking the vicious circle-the Asthma Referral Identifier (ReferID) tool.

Asthma is associated with a significant burden of disease, especially for patients with severe or uncontrolled asthma. Many patients with severe asthma still receive treatment in primary care settings and despite the availability of effective options, inadequate asthma treatment remains a concern, particularly the use of systemic corticosteroids to treat exacerbations and severe asthma. Around the world, many patients are stuck in a vicious circle of misdiagnosis, undertreatment, and poor understanding of disease severity and management. In this manuscript, we describe the development of The Asthma Referral Identifier (ReferID) tool, a simple, 4-item questionnaire that healthcare providers can use to help identify patients with uncontrolled and/or potentially severe asthma. ReferID was developed specifically for use in primary care clinics in low- and middle-income countries and other clinics, where the optimisation of asthma assessments and treatment recommended for countries with well-established healthcare systems, are not possible. ReferID was developed through an informal collaborative process involving international asthma experts as well as general practitioners, nurses, and specialists throughout the Asia Pacific, Latin America and Middle East regions, in conjunction with current evidence and treatment guidelines. In collaboration with local and regional partners around the world, the developers have adapted ReferID and translated it into 21 languages, and implementation is ongoing in 30 countries. ReferID has the potential to help break the vicious circle, improving disease outcomes and health-related quality of life for patients with asthma.

General practitioners' views on retaining Singapore's primary care doctors: a cross-sectional survey and qualitative analysis.

BACKGROUND: To support its ageing population and the increasing need for chronic care in the community, Singapore needs to boost the number of doctors in its primary care workforce. To better understand how to improve doctor retention and build a more robust primary care system, we conducted a cross-sectional survey with doctors in general practice and family medicine to explore their career satisfaction, their career plans, factors related to their plans to leave, and their view on retaining GPs in primary care. METHODS: An anonymous online survey was distributed to general practitioners working in the public and private sectors. The survey contained questions on career satisfaction, career plans in the next 5 years, and factors important for retaining doctors in primary care. In addition, there were open-ended questions for respondents to elaborate on retention initiatives and other factors that may improve engagement among primary care doctors. Quantitative data was analyzed with descriptive statistics, principal component analysis, χ2 tests, t-tests, and Pearson's correlations; qualitative data was analyzed thematically. RESULTS: The survey was attempted by 355 general practitioners and completed in full by 303. The respondents were most satisfied with rapport with patients and their current professional role; they were least satisfied with the amount of paperwork and the status of general practice in society. In terms of their career plans in the next 5 years, 49/341 (14.4%) of the respondents plan to leave general practice permanently, 43/341 (12.6%) plan to take a career break, and 175/341 (51.3%) plan to reduce their clinical hours. Higher remuneration, recognizing general practice and family medicine as a medical specialty, and reducing the litigious pressures on medical practice were rated as the most important factors for retaining primary care. Free-text responses also revealed a growing dissatisfaction with the Third-Party Administrators that manage insurance arrangements. CONCLUSION: While the proportion of doctors who intend to leave is smaller than that reported in overseas studies, our findings highlight an urgent need for targeted interventions to engage and retain primary care doctors. Increasing recognition and support for general practitioners and their professional practice may contribute to strengthening community care for the ageing population.

Managing asthma in the COVID-19 pandemic and current recommendations from professional bodies: a review.

OBJECTIVE: To provide a summary of the management of asthma in the current COVID-19 pandemic by examining and comparing the recommendations from various professional bodies. DATA SOURCES AND STUDY SELECTION: Websites of known respiratory professional bodies were searched for COVID-19 guidance related to asthma. Subject matter experts were also consulted for useful resources. Resources that were targeted at healthcare professionals were included, while those targeting patients and the general public were excluded. RESULTS: There is currently little data to suggest that asthma protects from or increases the risk of COVID-19, nor is there any data to support strong recommendations for or against specific asthma treatments. Physicians should continue to manage asthma according to existing accepted asthma guidelines and recommendations. All prescribed medications, especially inhaled corticosteroids, should be continued, and, where indicated, oral corticosteroids and biologic therapies should still be used. Nebulizers and spirometry should be avoided where possible to reduce the risk of viral transmission. A detailed history should be taken to differentiate asthma exacerbations from COVID-19. CONCLUSION: Understanding similarities and differences among the recommendations of the various professional bodies will aid in medical decision-making in managing asthma in the COVID-19 pandemic. Health professionals should also consider the individual needs, preferences and values of their patients and the unique characteristics of their local healthcare systems.

A descriptive study of the effect of a disciplinary proceeding decision on medical practitioners' practice behaviour in the context of providing a hydrocortisone and lignocaine injection.

INTRODUCTION: We conducted a descriptive study to evaluate any changes in practice behaviour regarding the provision of hydrocortisone and lignocaine (H&L) injections among doctors and how an H&L injection is priced following a disciplinary proceeding decision. A doctor had been fined SGD 100,000 for failing to obtain informed consent before an H&L injection. METHODS: We performed a survey shortly after the disciplinary decision to ascertain: (a) the category of the respondent; (b) whether the respondent provided H&L injections and how much he charged before the decision; and (c) after the decision. All members of the Singapore Medical Association and College of Family Physicians Singapore are doctors and were invited to participate. RESULTS: 1,927 doctors responded to the survey. Prior to the decision, 804 doctors did not perform H&L injections; this increased by 20.4% to 968 after the decision. The number of doctors who gave H&L injections decreased by 164 (14.6%), from the previous 1,123. Pre-decision, doctors who determined their own price for H&L injections charged a median pricing ≤ SGD 100. Post-decision, the median charge rose to > SGD 100 to SGD 200. At higher price bands, the number of doctors who charged > SGD 1,000 increased eight-fold, from eight to 65. CONCLUSION: The study demonstrated how a disciplinary decision can affect practice behaviour, and specifically how doctors may choose to not offer a service, an example of defensive medicine through avoidance behaviour. It also showed how prices for a service can rise following such a decision, which demonstrates the concept of negative general deterrence in sentencing.

Asthma in Asia: Physician perspectives on control, inhaler use and patient communications.

OBJECTIVE: We examined the physician perspectives on asthma management in Asia. METHODS: An online/face-to-face, questionnaire-based survey of respiratory specialists and primary care physicians from eight Asian countries/region was carried out. The survey explored asthma control, inhaler selection, technique and use; physician-patient communications and asthma education. Inclusion criteria were >50% of practice time spent on direct patient care; and treated >30 patients with asthma per month, of which >60% were aged >12 years. RESULTS: REALISE Asia (Phase 2) involved 375 physicians with average 15.9(±6.8) years of clinical experience. 89.1% of physicians reporting use of guidelines estimated that 53.2% of their patients have well-controlled (GINA-defined) asthma. Top consideration for inhaler choice was asthma severity (82.4%) and lowest, socio-economic status (32.5%). Then 54.7% of physicians checked their patients' inhaler techniques during consultations but 28.2(±19.1)% of patients were using their inhalers incorrectly; 21.1-57.9% of physicians could spot improper inhaler techniques in video demonstrations. And 79.6% of physicians believed combination inhalers could increase adherence because of convenience (53.7%), efficacy (52.7%) and usability (18.9%). Initial and follow-up consultations took 16.8(±8.4) and 9.2(±5.3) minutes, respectively. Most (85.1%) physicians used verbal conversations and least (24.5%), video demonstrations of inhaler use; 56.8% agreed that patient attitudes influenced their treatment approach. CONCLUSION: Physicians and patients have different views of 'well-controlled' asthma. Although physicians informed patients about asthma and inhaler usage, they overestimated actual usage and patients' knowledge was sub-optimal. Physician-patient interactions can be augmented with understanding of patient attitudes, visual aids and ancillary support to perform physical demonstrations to improve treatment outcomes.

Time for a new language for asthma control: results from REALISE Asia.

PURPOSE: Asthma is a global health problem, and asthma prevalence in Asia is increasing. The REcognise Asthma and LInk to Symptoms and Experience Asia study assessed patients' perception of asthma control and attitudes toward treatment in an accessible, real-life adult Asian population. PATIENTS AND METHODS: An online survey of 2,467 patients with asthma from eight Asian countries/regions, aged 18-50 years, showed greater than or equal to two prescriptions in previous 2 years and access to social media. Patients were asked about their asthma symptoms, exacerbations and treatment type, views and perceptions of asthma control, attitudes toward asthma management, and sources of asthma information. RESULTS: Patients had a mean age of 34.2 (±7.4) years and were diagnosed with asthma for 12.5 (±9.7) years. Half had the Global Initiative for Asthma-defined uncontrolled asthma. During the previous year, 38% of patients visited the emergency department, 33% were hospitalized, and 73% had greater than or equal to one course of oral corticosteroids. About 90% of patients felt that their asthma was under control, 82% considered their condition as not serious, and 59% were concerned about their condition. In all, 66% of patients viewed asthma control as managing attacks and 24% saw it as an absence of or minimal symptoms. About 14% of patients who correctly identified their controller inhalers had controlled asthma compared to 6% who could not. CONCLUSION: Patients consistently overestimated their level of asthma control contrary to what their symptoms suggest. They perceived control as management of exacerbations, reflective of a crisis-oriented mind-set. Interventions can leverage on patients' trust in health care providers and desire for self-management via a new language to generate a paradigm shift toward symptom control and preventive care.

Integrating rheumatology care in the community: can shared care work?

INTRODUCTION: Singapore's rapidly ageing population and chronic disease burden at public hospital specialist clinics herald a silver tsunami. In Singapore, "right siting" aims to manage stable chronic disease in primary care at a lower cost. To improve the quality of rheumatology care, we created shared care between rheumatologist and family physician to reduce hospital visits. METHODS: Clinical practice improvement methodology was used to structure shared care of stable patients between hospital rheumatologists and eleven community family physicians; one ran a hospital clinic. A case manager coordinated the workflow. RESULTS: About 220 patients entered shared care over 29 months. Patients without hospital subsidies (private patients) and private family physicians independently predicted successful shared care, defined as one cycle of alternating care. DISCUSSION: Our shared care model incorporated a case manager, systematic workflows, patient selection criteria, willing family physician partners and rheumatologists in the absence of organizational integration. Health care affordability impacts successful shared care. Government subsidy hindered right siting to private primary care. CONCLUSIONS: Financing systems in Singapore, at health policy level, must allow transfer of hospital subsidies to primary care, both private and public, to make it more affordable than hospital care. Structural integration will create a seamless continuum between hospital and primary care.