Malhotra R, Bautista MA, Müller AM, Aw Su, Koh GCH, Theng YL, Hoskins SJ, Wong CH, Miao C, Lim WS, Malhotra C, Chan A. Gerontologist.2018;1-11.
The juxtaposition of a young city-state showing relative maturity as a rapidly aging society suffuses the population aging narrative in Singapore and places the “little red dot” on the spotlight of international aging. We first describe population aging in Singapore, including the characteristic events that shaped this demographic transition. We then detail the health care and socioeconomic ramifications of the rapid and significant shift to an aging society, followed by an overview of the main aging research areas in Singapore, including selected population-based data sets and the main thrust of leading aging research centers/institutes. After presenting established aging policies and programs, we also discuss current and emerging policy issues surrounding population aging in Singapore. We aim to contribute to the international aging literature by describing Singapore’s position and extensive experience in managing the challenges and maximizing the potential of an aging population. We hope that similar graying populations in the region will find the material as a rich source of information and learning opportunities. Ultimately, we aspire to encourage transformative collaborations—locally, regionally, and internationally—and provide valuable insights for policy and practice.
Full article at: https://doi.org/10.1093/geront/gny160
Yang GMJ, Yoon S, Tan YY, Liaw K.. Am J Hosp Palliat Care.2018; 35(11):1433-1438.
Palliative care is associated with better outcomes in advanced cancer, but there is limited research comparing different models of palliative care delivery alongside oncology care. For inpatients with cancer, palliative care is mostly delivered through a consult service, primarily relying on oncologist-initiated referrals to a separate specialist palliative care team. In our hospital setting, we piloted a palliative care and oncology corounding model of care. To explore the views and experience of oncology and palliative care professionals on the corounding model compared to an inpatient consult service. A qualitative study nested within a pre–post study of the corounding model of care, with semistructured interviews using thematic analysis. Eleven doctors and nurses involved in the pilot corounding model were interviewed. Two main themes emerged: (1) the efficiency of care delivery and (2) quality of patient care. The theme on the efficiency of care delivery was related to access to palliative care input, team communications, and parallel workflow. The quality of patient care was described in terms of holistic approach to cancer care and rapport building with patients and their families. Most participants acknowledged positive aspects of the corounding model, yet some minor concerns were reported, such as disagreements between oncology and palliative care professionals. This study provides insights into the benefits and drawbacks of a corounding model of care for inpatients. The views of health-care professionals can be incorporated into the development of integrated oncology and palliative care models to improve care for patients with advanced cancer.
Zhuang Q, Yang GMJ, Neo SHS, Cheung YB. J Pain Symptom Manage.2018.
The prevalence and severity of dyspnea increases at the end of life. Many of these patients have difficulty in reporting their symptoms. Accurate surrogate measures are needed for appropriate assessment and treatment. The Respiratory Distress Observation Scale (RDOS) is proposed as a possible scale although more external validation is needed. We set out to validate the RDOS in the context of palliative care patients near the end of life. We prospectively studied 122 palliative care patients in a tertiary hospital in Singapore. Prior RDOS scale training was done using a standardised instructional video. Dyspnea was assessed by RDOS, Dypsnea Numerical Rating Scale (Dyspnea-NRS) and Dyspnea Categorical Scale (Dyspnea-Cat). Pain was assessed by Pain Numerical Rating Scale (Pain-NRS). We measured RDOS interrater reliability, convergent validity and divergent validity. We utilised Area under Receiver Operating Characteristics Curve Analysis (AUC) to examine the discriminant properties of RDOS using dyspnea self-report as benchmark. RDOS had good inter-rater reliability with an Intraclass Correlation (ICC) of 0.947 (95% CI 0.919-0.976). It showed moderate to strong correlation with Dyspnea-NRS (r=0.702) and Dyspnea-Cat (r=0.677) and negligible correlation to Pain-NRS (r=0.080). It showed good discriminant properties of identifying patients with moderate and severe dyspnea with AUC of 0.874 (95% CI 0.812-0.936). RDOS ≥ 4 predicted patients with moderate and severe dyspnea with a sensitivity of 76.6%, specificity of 86.2%, positive predictive value of 86.0% and negative predictive value of 76.9%. The RDOS shows promise and clinical utility as a observational dyspnea assessment tool. Further studies in uncommunicative patients are needed to determine clinical usefulness and generalizability of results.
Full article at: https://doi.org/10.1016/j.jpainsymman.2018.10.506
Malhotra C, Sim D, Jaufeerally FR, Finkelstein EA. BMJ Open.2018; 8(9):e021688.
To make informed choices about use of future invasive life-sustaining interventions (ILSI), patients with congestive heart failure (CHF) need to correctly understand the intent of their current treatments. However, healthcare providers may be wary of having these discussions due to fear of distressing patients. In this study, we assessed whether patients who understand their treatment intent are less willing to undergo ILSI and are indeed more psychologically distressed. As part of a cross-sectional survey conducted prior to randomising patients for a trial, we asked 282 patients with advanced CHF (New York Heart Association Class III and IV) whether they believe their existing treatments would cure their heart condition, their willingness to undergo ILSI and assessed their anxiety and depression using the Hospital Anxiety and Depression Scale. Approximately half of patients reported a willingness to undergo ILSI if needed. Only 22% knew that their current treatments were not curative. These patients were far less willing to undergo ILSI (OR 0.28, 95% CI 0.15 to 0.56) and were not at a greater risk of having clinically significant anxiety (OR 0.72, 0.34 to 1.54) and depression (OR 0.70, 0.33 to 1.47) compared with those who did not understand their current treatment intent. Improving patients’ understanding of the intent of their current treatments can help patients make informed choices about ILSI.
Full article at: http://dx.doi.org/10.1136/bmjopen-2018-021688
Malhotra C, Foo R, Singh R, Ozdemir S, Teo I, Sim D, Jaufeerally FR, Aung T, Yeo KK, Nadkarni N, Finkelstein EA. BMJ Open.2018;8(9):e022248.
Understanding the symptom and health expenditure burden among patients with advanced congestive heart failure (CHF) and their family caregivers is essential to reform policy and practice needed to provide quality care to these patients at affordable prices. The proposed cohort study titled Singapore Cohort of Patients with Advanced Heart Failure aims to describe trajectories of quality of life among patients and their primary informal caregivers, quantify healthcare utilisation and expenditures, assess changes in patient and caregiver awareness of and preferences for knowing diagnostic and prognostic information, awareness and utilisation of palliative care services, preferences for treatments and decision making, perceived quality of care, self-care, caregiver psychological distress and caregiver burden. This cohort study will recruit 250 patients with New York Heart Association Classification class III and IV CHF from inpatient wards at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are being surveyed every 4 months until patients’ death; caregivers are followed until 8 weeks postpatient death. Medical and billing records of patients are obtained and merged with patients’ survey data.
Full article at: https://bmjopen.bmj.com/content/8/9/e022248
Yang GMJ, Teo I, Neo SHS, Tan D, Cheung YB. Am J Hosp Palliat Care.2018; 35(8):1050-1056.
New models of care that are effective and feasible for widespread implementation need to be developed for the delivery of early palliative care to patients with advanced cancer. The objectives were to determine the feasibility and acceptability of the Enhancing Quality of Life in Patients (EQUIP) intervention, data completion rate of patient-reported outcome measures in the context of the EQUIP trial, and the estimated effect of the EQUIP intervention on quality of life and mood. In this pilot randomized phase II trial, eligible patients had newly diagnosed advanced lung cancer and an Eastern Cooperative Oncology Group performance status of 0, 1, or 2. Randomization was to the control group that received standard oncology care or to the intervention group where patients individually received the EQUIP intervention, comprising 4 face-to-face educational sessions with a nurse. A total of 69 patients were recruited. In the intervention group, 30 (85.7%) of 35 patients completed all 4 EQUIP sessions. All patients were satisfied with the topics shared and felt they were useful. However, there was no significant difference between intervention and control groups in terms of quality of life and mood at 12 weeks after baseline. This pilot study showed that nurse-directed face-to-face educational sessions were feasible and acceptable to patients with advanced lung cancer. However, there was no indication of benefit of the EQUIP intervention on quality of life and mood. This could be due in part to a low prevalence of targeted symptoms.
Full article at: https://doi.org/10.1177/1049909118756095
Finkelstein EA, Ozdemir S, Malhotra C, Jafar TH, Choong LHL, Gan SSW. Health Policy.2018; 122(8):915-921.
Despite literature suggesting conservative management (CM) is a viable option for elderly comorbid ESRD patients, the vast majority in Singapore receive dialysis. We hypothesized that the high demand for dialysis is driven by 1) lack of knowledge of CM and relative benefits for dialysis to CM, 2) adherence to physician recommendations which favour dialysis, and high subsidies for hemodialysis (HD). We tested these hypothesis via a survey including a discrete choice experiment (DCE), administered to 151 elderly pre-dialysis kidney patients and their family caregivers. Results are consistent with the hypotheses. 40% (95% Confidence Interval (CI) 32-48) of patients and 46% (CI 38-55) of caregivers reported not being aware of CM, and 43% (CI 35-51) of patients and 24% (CI 17-31) of caregivers could not provide information on expected survival for dialysis or CM. Yet, once aware of CM as an option, 54% of patients and 42% of caregivers chose CM. However, if their physician recommended dialysis, 49% (CI 40-58) of patients and 68% (CI 59-77) of caregivers switched their choice. Subsidies on HD further demand for CM by 6 percentage points. These results reveal that the high demand for dialysis is driven mostly by lack of awareness of CM as an option and by physician recommendations for dialysis over CM.
Full article at: https://doi.org/10.1016/j.healthpol.2018.06.008
Menon S, Kars MC, Malhotra C, Campbell AV, Delden JJM. Journal of Pain and Symptom Management.2018; 56(2):213-221.
Advance care planning (ACP) has been shown to improve end-of-life care, but it was developed in the U.S., and most research has been conducted in western communities. We aimed to study the attitudes and perceptions of patients with life-limiting illnesses, informal caregivers, doctors, nurses, and medical social workers regarding ACP in a multicultural family centric community. We conducted an explorative qualitative study, using focus groups and individual in-depth interviews. We used purposive sampling techniques to recruit 61 adults (15 doctors, 13 nurses, 5 medical social workers, 15 patients, and 13 caregivers) from multiple health care settings across the country. The participants are genuinely anxious about the implementation of ACP. They had positive and negative expectations of ACP. Many were confused about the legal framework for health care decision-making and expected ACP to be of limited value because family members, rather than the patient, were usually the key decision makers. A nuanced approach to ACP that considers the family network is required in multicultural family centric communities. Policies should be reconciled to create a more consistent message that respects patients, the family, and is legally coherent. Further research could focus on adaptations of ACP to promote its acceptance in such communities.
Full article at: https://doi.org/10.1016/j.jpainsymman.2018.05.007
Tan EGF, Teo I, Finkelstein EA, Chan CM. Nephrology. 2018.
In Singapore, most elderly end stage renal disease (ESRD) patients choose dialysis over palliative management. However, dialysis may not be the optimal treatment option given only moderate survival benefits and high costs and treatment burden compared to non-dialysis management. Elderly patients may therefore come to regret this decision. This study investigated (1) extent of patients’ decision regret after starting dialysis, and (2) potentially modifiable predictors of regret: satisfaction with chronic kidney disease education, decisional conflict, and decision‐making involvement. Cross-sectional study of 103 dialysis patients above 70 years old surveyed at Singapore General Hospital’s renal medicine clinics between March and June 2017. Participants reported their levels of decision regret on the Decision Regret Scale (DRS), retrospective decisional conflict on the Decisional Conflict Scale, information satisfaction, and decision-making involvement. 81% of participants reported no decision regret (DRS score <50), 11% ambivalence (DRS=50), and 8% regret (DRS>50). In individual DRS items, 19% felt dialysis had done them harm and 16% would not make the same decision again. In multivariable analyses, lower information satisfaction [b = -0.07 (95% CI: -0.13, -0.01)] and decisional conflict [b = 0.004 (95% CI: 0.002, 0.006)] were significantly associated with decision regret. Although majority of elderly dialysis patients were comfortable with their decision to start dialysis, a proportion was ambivalent or regretted this choice. Regret was more likely among those who experienced decisional conflict and/or expressed poorer information satisfaction. Healthcare professionals should recognize these risk factors and take steps to minimize chances of regret among this population subset.
Full article at: https://doi.org/10.1111/nep.13400
Teo I, Singh R, Malhotra C, Ozdemir S, Dent RA, Kumarakulasinghe NB, Yeo WL, Cheung YB, Malhotra R, Kanesvaran R, Yee ACP, Chan N, Wu HY, Soh MC, Hum AYM, Yang GMJ, Soek PHN, Nadkarni N, Harding R, Finkelstein EA. BMC Cancer.2018;18:459.
Advanced cancer significantly impacts quality of life of patients and families as they cope with symptom burden, treatment decision-making, uncertainty and costs of treatment. In Singapore, information about the experiences of advanced cancer patients and families and the financial cost they incur for end-of-life care is lacking. Understanding of this information is needed to inform practice and policy to ensure continuity and affordability of care at the end of life. The primary objectives of the Cost of Medical Care of Patients with Advanced Serious Illness in Singapore (COMPASS) cohort study are to describe changes in quality of life and to quantify healthcare utilization and costs of patients with advanced cancer at the end of life. Secondary objectives are to investigate patient and caregiver preferences for diagnostic and prognostic information, preferences for end-of-life care, caregiver burden and perceived quality of care and to explore how these change as illness progresses and finally to measure bereavement adjustment. The purpose of this paper is to present the COMPASS protocol in order to promote scientific transparency. This cohort study recruits advanced cancer patients (n = 600) from outpatient medical oncology clinics at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are surveyed every 3 months until patients’ death; caregivers are followed until 6 months post patient death. Patient medical and billing records are obtained and merged with patient survey data. The treating medical oncologists of participating patients are surveyed to obtain their beliefs regarding care delivery for the patient. The study will allow combination of self-report, medical, and cost data from various sources to present a comprehensive picture of the end-of-life experience of advanced cancer patients in a unique Asian setting. This study is responsive to Singapore’s National Strategy for Palliative Care which aims to identify opportunities to meet the growing need for high quality care for Singapore’s aging population. Results will also be of interest to policy makers and researchers beyond Singapore who are interested to understand and improve the end-of-life experience of cancer patients.
Full article at: https://doi.org/10.1186/s12885-018-4356-z
Jafar TH, Tan NC, Allen JC, Finkelstein EA, Goh P, Moey P, Quah JHM, Hwang SW, Bahadin J, Thiagarajah AG, Chan J, Kang G, Koong A. Trials.2018;19(1):180.
Hypertension is a serious public health problem in Singapore and is associated with significant morbidity and mortality from cardiovascular disease (CVD) with considerable implications for health-care resources. The goal of this trial is to compare a multicomponent intervention (MCI) to usual care to evaluate the effectiveness and cost-effectiveness of the MCI for lowering blood pressure (BP) among adults with uncontrolled hypertension in Singapore primary-care clinics. The study is a cluster randomized trial in eight polyclinics in Singapore: four deliver a structured MCI and four deliver usual care. The components of the MCI are (1) an algorithm-driven antihypertensive treatment for all hypertensive individuals using single-pill combination (SPC) and lipid-lowering medication for high-risk hypertensive individuals (2) a motivational conversation for high-risk hypertensive individuals (3) telephone-based follow-ups of al hypertensive individuals by polyclinic nurses, and (4) discounts on SPC antihypertensive medications. The trial was conducted with 1000 individuals aged ≥ 40 years with uncontrolled hypertension (systolic BP ≥140 mmHg or diastolic BP≥90 mmHg, based on the mean of the last two or three measurements) in eight polyclinics in Singapore. The primary outcome is change in systolic BP from baseline to follow-up at 24 months post-randomization. The incremental cost of MCI per CVD disability adjusted life years (DALY) averted and quality adjusted life years (QALY) saved will be computed. The demonstration of an effective and cost-effective hypertension control program that is implementable in busy polyclinics would provide compelling evidence for upscaling the program across all primary-care centres in Singapore, and possibly other regional countries with a similar health-care structure.
Full article at: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-2559-x
Yang GMJ, Ng E, Lian S, Ong MEH. Proceedings of Singapore Healthcare.2018; 27(1):59-62.
For advanced cancer patients, an emergency department (ED) visit in the last week of life may result in aggressive care that is inappropriate and futile. The objective of this study is to explore the characteristics of advanced cancer patients who present to ED in the last week of life. Specifically, we describe the spectrum of presenting symptoms. This was a retrospective cross-sectional study of ED attendances in the Singapore General Hospital during a one-year period. The electronic medical record system was used to retrieve demographic data, characteristics of the ED visits and presenting complaints. A total of 145 patients with advanced cancer dying in hospital within seven days of an ED visit were included. Breathlessness was the most common reason for presenting to ED (85 patients, 58.62%), followed by pain (50 patients, 34.48%), generalised weakness or lethargy (39 patients, 26.90%) and decreased appetite or anorexia (35 patients, 24.14%). Strategies to improve end-of-life care can focus on pre-emptive management of breathlessness and pain. Community programmes can also help prepare families for symptoms like generalised weakness and appetite loss which may signal a progression of the disease. Supportive and palliative care interventions will need to be implemented in the ED setting to better manage the symptoms suffered by these advanced cancer patients.
Full article at: https://doi.org/10.1177/2010105817713024
Malhotra C, Kanesvaran R, Krishna L, Xiang L, Kumarakulasinghe NB, Tan SH, Tulsky JA, Pollak KI. Supportive Care in Cancer.2018;26(3):957-965.
Patients with advanced cancer and their caregivers experience many negative emotions. Empathic responses from oncologists can help alleviate their distress. We aimed to assess expressions of negative emotions among patients with advanced cancer and their caregivers and oncologists’ empathic responses during consultations in an Asian setting. We also assessed the association between oncologists’ expression of empathy and patients’ and caregivers’ perception of communication quality. We surveyed 100 patients with advanced cancer and their caregivers and audio recorded consultations with their oncologists. We coded expressions of negative emotions by patients and caregivers and oncologists’ empathic responses. We also surveyed participating oncologists (n = 30) about their confidence in expressing empathy and perceived communication behavior outcomes. About 52% of patients and 49% of caregivers expressed at least one negative emotion during the consultation, though 59% of patients and 48% of caregivers reported not wanting to discuss negative emotions. Oncologists responded empathically to 12% of patients’ negative emotions and 9% of caregivers’ negative emotions, despite 92% of them reporting confidence in expressing empathy. Oncologists’ expression of empathy did not vary significantly by patient, caregiver, or their own demographic characteristics. It also did not differ based on their confidence in expressing empathy and positive outcome expectations. When oncologists responded empathically just one time, patients perceived communication more favorably. In this Asian setting, patients and caregivers commonly expressed negative emotions. Oncologists’ expressed empathy infrequently, although when they were empathic, it was related to improved patient perception of communication quality.
Full article at: https://doi.org/10.1007/s00520-017-3916-0
Akyar I, Dionne-Odom JN, Yang GMJ, Bakitas MA. Asia-Pacific Journal of Oncology Nursing.2018; 5(1):33-39.
The field of palliative care is growing in acceptance and sophistication globally. No longer considered just for patients at end-of-life, palliative care is now being incorporated early in the disease trajectory. Despite professional guidelines supporting early palliative care, there are few models that have been created that can be translated into practice cross-culturally. In the United States, the Educate, Nurture, Advise, Before, Life Ends (ENABLE) early palliative care telehealth model has demonstrated effectiveness in improving quality of life, mood, symptom relief, and survival for patients with cancer and is now being tested in patients with heart failure. Family caregivers of patients who have received ENABLE concurrent with their care recipients have also demonstrated positive outcomes in quality of life and caregiver burden. Internationally, a number of investigators are culturally adapting ENABLE for patients and family caregivers. While some elements of ENABLE, such as symptom management and self-care, and the caregiving role are relevant cross-culturally, others have been built on Western principles of self-determination or represent concepts such as advance care planning which will require more cultural adaptation. In addition, ENABLE was initially an in-person approach that was converted to telehealth to accommodate a rural population-it will be important to understand cultural norms related to receiving care by phone or if an in-person approach will be more culturally acceptable. This paper describes efforts in Turkey and Singapore to culturally adapt the ENABLE early palliative care principles for their countries.
Full article at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5763436/
Yang GMJ, Kanesvaran R, Neo SHS, Yee ACP, Block SD, Cheung YB. Journal of Palliative Medicine.2018; 21(1):95-98.
Our aim was to obtain initial estimates of the effect of a palliative care and medical oncology co-rounding model on hospital length of stay, proportion of patients reviewed by specialist palliative care (SPC), and proportion of patients who were readmitted within 7 and 30 days of hospital discharge. Earlier timing of palliative care improves patient outcomes, but current consultative models of palliative care service delivery are not feasible for widespread implementation. We conducted a pilot pre–post intervention study of a palliative care and medical oncology co-rounding model of care in the inpatient hospital setting. All patients admitted under the care of an inpatient oncology team during the study period were included. Hospital length of stay, proportion of patients reviewed by SPC, and readmission data were retrieved from the electronic administrative database. There were 595 unique patients (352 in the “consultative” group and 243 in the “co-rounding” group). There was no significant difference in the proportion of patients who were reviewed by a SPC physician (consultative model 21.02% vs. co-rounding model 25.10%, p = 0.243). The hospital length of stay was shorter for the co-rounding group (median 3 days, interquartile range 2–7 days) compared with the consultative group (median 4 days, interquartile range 2–7 days) (p = 0.025). There was no significant difference in proportion of patients readmitted within 30 days of hospital discharge (consultative model 29.78% vs. co-rounding model 28.90%, p = 0.773). In our target population, the co-rounding model was associated with a shorter hospital length of stay.
Full article at: https://doi.org/10.1089/jpm.2017.0186
Ozdemir S, Finkelstein EA. Cognitive Bias: Journal of Clinical Oncology Cancer Informatics.2018. (Online first).
This narrative review presents theoretical and empirical evidence of common cognitive biases that are likely to influence treatment choices of patients with cancer and other illnesses. We present an overview of common cognitive biases that result from how and when information is presented to patients. We supplement these descriptions with cancer-specific examples or those from other health fields if no cancer-specific examples are available. The results provide compelling evidence that patient treatment choices are subconsciously influenced by both known and unknown biases. Shared decision making is ideal in theory, but in reality, it is fraught with risks resulting from cognitive biases and undue influence of even the best-intentioned physicians and family members. Efforts should be made to minimize these concerns and to help patients to make decisions that their future selves are least likely to regret.
Full article at: http://ascopubs.org/doi/abs/10.1200/CCI.18.00011
Vivat B, Young TE, Winstanley J, Arraras JI, Black K, Boyle F, Bredart A, Costantini A, Guo J, Irarrazaval ME, Kobayashi K, Kruizinga R, Navarro M, Omidvari S, Rohde GE, Serpentini S, Spry N, Van Laarhoven HWM, Yang GMJ, EORTC Quality of Life Group. European Journal of Cancer Care (England).2017; 26(6):e12697.
The EORTC Quality of Life Group has just completed the final phase (field-testing and validation) of an international project to develop a stand-alone measure of spiritual well-being (SWB) for palliative cancer patients. Participants (n = 451)-from 14 countries on four continents; 54% female; 188 Christian; 50 Muslim; 156 with no religion-completed a provisional 36-item measure of SWB plus the EORTC QLQ-C15-PAL (PAL), then took part in a structured debriefing interview. All items showed good score distribution across response categories. We assessed scale structure using principal component analysis and Rasch analysis, and explored construct validity, and convergent/divergent validity with the PAL. Twenty-two items in four scoring scales (Relationship with Self, Relationships with Others, Relationship with Someone or Something Greater, and Existential) explained 53% of the variance. The measure also includes a global SWB item and nine other items. Scores on the PAL global quality-of-life item and Emotional Functioning scale weakly-moderately correlated with scores on the global SWB item and two of the four SWB scales. This new validated 32-item SWB measure addresses a distinct aspect of quality-of-life, and is now available for use in research and clinical practice, with a role as both a measurement and an intervention tool.
Full article at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ecc.12697
Malhotra C, Ling X, Ozdemir S, Kanesvaran R, Chan N, Finkelstein EA. Psycho-Oncology.2017;26(10):1611-1617.
Applying prospect theory to end-of-life decision making, we hypothesize that community-dwelling older adults (CDOAs) will be relatively less inclined towards extending length over improving quality of life compared with patients. We also hypothesize that differences in relative inclination for length over quality of life between the 2 groups will decrease with advancing age. We tested these hypotheses by administering the quality-quantity questionnaire to 1067 CDOAs and 320 stage IV cancer patients and applying a linear regression model to assess whether relative inclination for length over quality of life, as estimated by the questionnaire, differed between CDOAs and patients after controlling for differences in sociodemographic characteristics. We also assessed the effect of interaction between age and participant status (CDOA compared to patient) on relative inclination for length over quality of life. Consistent with prospect theory, a lower proportion of CDOAs (26%) than patients (42%) were relatively more inclined towards length over quality of life. Results were significant even after adjusting for differences in sociodemographic (P < .01). With increasing age, the difference in relative inclination between CDOAs and patients increased (P = .01). Findings indicate that attitudes towards length and quality of life differ by life stage. This has implications for end-of-life care decisions made by CDOAs, such as purchasing health or disability insurance and signing advance directives or care plans.
Full article at: https://www.ncbi.nlm.nih.gov/pubmed/27943487
Yang GMJ, Tan YY, Cheung YB, et al. Palliative & Support Care.2017; 15(4):434-443.
Physicians and nurses do not assess spirituality routinely, even though spiritual care is a vital part of palliative care for patients with an advanced serious illness. The aim of our study was to determine whether a training program for healthcare professionals on spirituality and the taking of a spiritual history would result in improved patient quality of life (QoL) and spiritual well-being. This was a cluster-controlled trial of a spiritual care training program for palliative care doctors and nurses. Three of seven clinical teams (clusters) received the intervention, while the other four served as controls. Included patients were newly referred to the palliative care service, had an estimated survival of more than one month, and were aware of their diagnosis and prognosis. The primary outcome measure was the Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being (FACIT–Sp) patient-reported questionnaire, which patients completed at two timepoints. Total FACIT–Sp score includes the Functional Assessment of Cancer Therapy–General (FACT–G) questionnaire, which measures overall quality of life, as well as a spiritual well-being score. Some 144 patients completed the FACIT–Sp at both timepoints—74 in the control group and 70 in the intervention group. The change in overall quality of life, measured by change in FACT–G scores, was 3.89 points (95% confidence interval [CI 95%] = –0.42 to 8.19, p = 0.076) higher in the intervention group than in the control group. The difference between the intervention and control groups in terms of change in spiritual well-being was 0.32 (CI 95% = –2.23 to 2.88, p = 0.804). A brief spiritual care training program can possibly help bring about enhanced improvement of global patient QoL, but the effect on patients' spiritual well-being was not as evident in our participants. Further study with larger sample sizes is needed to allow for more definite conclusions to be drawn.
Full article at: https://doi.org/10.1017/S1478951516000894
Vedanthan R, Kamano JH, Lee H, Andama B, Bloomfield GS, DeLong AK, Edelman D, Finkelstein EA, Hogan JW, Horowitz CR, Manyara S, Menya D, Naanyu V, Pastakia SD, Valente TW, Wanyonyi CC, Fuster V. American Heart Journal.2017;188:175-185.
Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with >80% of CVD deaths occurring in low and middle income countries (LMICs). Diabetes mellitus and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with DM. There is a critical period now during which reducing CVD risk among individuals with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. Two promising strategies to improve health outcomes are group medical visits and microfinance.
This study tests whether group medical visits integrated into microfinance groups are effective and cost-effective in reducing CVD risk among individuals with diabetes or at increased risk for diabetes in western Kenya. An initial phase of qualitative inquiry will assess contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction. Subsequently, we will conduct a four-arm cluster randomized trial comparing: (1) usual clinical care, (2) usual clinical care plus microfinance groups only, (3) group medical visits only, and (4) group medical visits integrated into microfinance groups. The primary outcome measure will be 1-year change in systolic blood pressure, and a key secondary outcome measure is 1-year change in overall CVD risk as measured by the QRISK2 score. We will conduct mediation analysis to evaluate the influence of changes in social network characteristics on intervention outcomes, as well as moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of the interventions. Cost-effectiveness analysis will be conducted in terms of cost per unit change in systolic blood pressure, percent change in CVD risk score, and per disability-adjusted life year saved.
This study will provide evidence regarding effectiveness and cost-effectiveness of interventions to reduce CVD risk. We aim to produce generalizable methods and results that can provide a model for adoption in low-resource settings worldwide.
Full article at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491075/
Teo I, Cheung YB, Lim TYK, Namuduri RP, Long V, Tewani K. Psycho-Oncology.2017; 27(1):69-74.
Gynecologic cancer is associated with long-term effects that can be both physical and emotional. We examined symptom prevalence and body image disturbance in patients with gynecologic cancer and their association with quality of life. Predictors of clinically-relevant body image disturbance were examined.A sample of patients in Singapore (n = 104) was assessed for symptom prevalence, quality of life, and body image dissatisfaction. Clinical factors were extracted from medical records.
The most frequently reported symptoms were fatigue, abdominal bloatedness, weight gain, constipation, hot flashes, and pelvic pain. Approximately one quarter patients reported feeling less physically attractive and dissatisfied with their body. Ordinary least squares regression indicated that symptom prevalence alone predicted physical well-being, b = -1.09, P < .001, 95% CI, -1.45 to -0.73, and functional well-being, b = -0.88, P < .001, 95% CI, -1.32 to -0.45. Body image dissatisfaction alone significantly predicted emotional well-being, b = -0.21, P < .01, 95% CI, -0.35 to -0.06. Younger age was a significant risk factor for clinically-relevant score of body image distress, OR = 0.95 per year older, 95% CI, 0.92 to 0.99, P = .02.
Symptom prevalence and body image dissatisfaction were associated with different domains of quality of life. Emotional well-being of patients was better explained by body image, rather than extent of symptoms experienced. Patients who are younger appear particularly susceptible to body image disturbance.
Full article at: https://doi.org/10.1002/pon.4457
Finkelstein EA, Ozdemir S, Malhotra C, Jafar TH, Choong HL, Suhardjono J. Kidney International Reports.2017;2(2):212-218.
For elderly end-stage renal disease (ESRD) patients with multiple comorbidities, dialysis may offer little survival benefit compared to conservative management (CM). Yet, many elderly ESRD patients undergo dialysis, partly due to physicians’ recommendations regarding treatment choice. This study aims to elucidate the factors that influence these recommendations. We surveyed a convenience sample of physicians who attended the 9th Asian Forum of Chronic Kidney Disease Initiative conference. We used vignettes that vary by age and comorbidity status, and asked physicians to recommend dialysis or CM for a hypothetical patient with that profile and to predict survival with both treatment options. We also compared the physician’s recommendations to patients for what they would recommend for themselves if they were diagnosed with ESRD.
On average, physicians believed that dialysis extends life relative to CM. Yet, a large subset believed that CM confers greater survival. Estimates range from 17.3% (for a 65-year-old with diabetes and CHF) to 50% for patients with advanced cancer. Results further reveal high discordance regarding treatment recommendations. For a 65-year-old patient with diabetes, 62% recommended dialysis and 38% did not. For advanced cancer, the split was 25% and 75%. Physicians were far more likely to recommend dialysis for themselves than for their patients.
This study suggests that physicians would benefit from a greater understanding of survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. This would allow patients to make more informed decisions.
Full article at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678627/
Ng QX, Kuah TZL, Loo GJM, Ho WHH, Wagner NL, Sng JGK, Yang GMJ, Tai BC. Annals Academy of Medicine Singapore.2017; 46(3):84-90.
Advance care planning (ACP) is an important aspect of end-of-life care that has been shown to improve patient autonomy in decision-making and reduce stress for surviving family members. Given the rapidly ageing population in Singapore, a greater emphasis on end-of-life care planning is needed. This study therefore sought to examine the awareness and attitudes of the general Singaporean community towards participating in ACP, which are not known hitherto.
A 24-item interviewer-administered questionnaire was constructed and administered via door-to-door survey amongst community-dwelling residents living in Housing and Development Board (HDB) flats across Singapore, selected via a two-stage stratified random sampling. Of the 406 completed surveys, 14.4% of respondents had heard of ACP (n = 58), mostly through the media (67.9%), from family and friends (21.4%) and healthcare providers (21.4%). Only 26.8% of those who had previously heard of ACP knew how to begin an ACP discussion and 12.5% of them had a prior ACP discussion. After education, the majority of respondents were willing to begin an ACP discussion (n = 236, 60.1%). Being of an older age, having a life threatening illness, and having more knowledge about ACP were significant factors associated with willingness to have an ACP discussion. Barriers included perceiving oneself as still healthy and preferring the family to make decisions instead. There is a low awareness but high expressed willingness to engage in an ACP discussion amongst the Singaporean community. More efforts are needed to educate the public about ACP, engage the family unit and correct the present misconceptions.
Full article at: http://www.annals.edu.sg/pdf/46VolNo3Mar2017/MemberOnly/V46N3p84.pdf
Peh TY, Yang GMJ, Krishna LK, Yee ACP. Journal of Palliative Medicine.2017; 20(2):141-146.
Doctors report inadequate training and lack confidence in providing palliative care. Although palliative care training improves self-assessed competence, it is not known whether the duration of a palliative medicine (PM) posting affects the extent of improvement in confidence. The aim of this study was to determine whether the duration of a PM posting affects the extent of improvement in doctors' confidence in various aspects of palliative care.
This was a retrospective study analyzing doctors' self-rated competence level in different aspects of palliative care at the start and end of a PM posting. The change in scores was analyzed to determine the extent of improvement corresponding to the length of the posting. Seventy-one residents and medical officers participated in the study, which was conducted in a hospital-based palliative care consultative service. Participants reported low baseline self-rated competence in palliative care. A longer posting duration resulted in a greater improvement in the doctors' confidence across different domains of palliative care, particularly in end-of-life communication.
A one-month posting may suffice in training a doctor in basic end-of-life medical issues, but a longer posting duration results in a greater improvement in the doctors' confidence across different domains of palliative care, particularly in end-of-life communication. Trainee doctors in specialties that frequently deal with terminally ill patients should undertake a longer posting in PM to be further equipped with greater confidence to better care for these patients.
Full article at: https://doi.org/10.1089/jpm.2016.0293
Yang GMJ, Neo SHS, Lim SZZ, Krishna LK. Journal of Palliative Medicine.2016; 19(11):1156-1165.
Although the benefits of palliative care in the outpatient setting are well established, there has been little to support the employing of hospital palliative care services for inpatients with cancer. We conducted a systematic literature review to evaluate the effectiveness of palliative care for cancer patients in the acute inpatient hospital setting.
Two electronic databases—PubMed and CINAHL Plus—were searched for articles published between 1 January 2005 and 28 May 2015. The search was augmented by hand-searches of specific journals and by examining the reference lists of short-listed articles. Studies were included if they evaluated a hospital palliative care service for cancer patients. Data extracted included study design, patient population, study setting, composition of the team, nature of the intervention, outcomes measured, and main findings. No randomized controlled trials were found. There were 14 pre-post studies that evaluated patient outcomes, of which only 2 had a control group. We also reviewed a further seven studies that evaluated other aspects of the palliative care intervention. The studies were not robust enough to confirm the efficacy of hospital palliative care services for cancer patient outcomes. Nonetheless, published studies provide a glimpse into the wider benefits of palliative care interventions.
Data to support the benefit of palliative care interventions in the inpatient acute hospital setting are still lacking. Future studies should employ innovative strategies to further this field of research.
Full article at: https://www.liebertpub.com/doi/abs/10.1089/jpm.2016.0052
Lee, G.L., Teo, I., Kanesvaran, R. Health Communication. 2016; 33(4)
The article reports on a pilot study that examine the complexities of doctor-patient-family communication in an oncology setting in Singapore. Twenty consultations were audio-recorded and post consultation questionnaire was administered to patients and their accompanying person (AP) to examine their communication preferences. Patients and APs rated physician expertise and message content as highly important, supportive elements of the communication were rated as less important. Patients preferred information concerning their condition, while APs preferred information regarding treatment options. There was discordance between what was perceived by patients/AP and actual delivery, and within patient-AP dyads. Our findings elucidates some of the complexities in communication preferences in an Asian oncology context that can inform clinical practice
Full article at: www.researchgate.net/publication/311224631_The_Complexities_of_Doctor-Patient Family_Communication_in_an_Asian_Oncology_Setting_Concordance_and_Discordance_Among_Patient_Preferences_Family_Preferences_and_Perceived_and_Actual_Communication
Finkelstein EA, Malhotra C, Chay J, Ozdemir S, Chopra A, Kanesvaran R. Value in Health.2016; 19(6):788-794.
To examine the extent to which financial assistance, in the form of subsidies for life-extending treatments (LETs) or cash payouts, distorts the demand for end-of-life treatments.
A discrete choice experiment was administered to 290 patients with cancer in Singapore to elicit preferences for LETs and only palliative care (PC). Responses were fitted to a latent class conditional logistic regression model. We also quantified patients’ willingness to pay to avoid and willingness to accept a less effective LET or PC-only. We then simulated the effects of various LET subsidy and cash payout policies on treatment choices.
We identified three classes of patients according to their preferences. The first class (26.1% of the sample) had a strong preference for PC and were willing to give up life expectancy gains and even pay for receiving only PC. The second class (29.8% of the sample) had a strong preference for LETs and preferred to extend life regardless of cost or quality of life. The final class (44.1% of the sample) preferred LETs to PC, but actively traded off costs and length and quality of life when making end-of-life treatment choices. Policy simulations showed that LET subsidies increase demand for LETs at the expense of demand for PC, but an equivalent cash payout was not shown to distort demand.
Patients with cancer have heterogeneous end-of-life preferences. LET subsidies and cash payouts have differing effects on the use of LETs. Policymakers should be mindful of these differences when designing health care financing schemes for patients with life-limiting illnesses.
Full article at: https://www.sciencedirect.com/science/article/pii/S1098301516000620
Malhotra C, Do YK. Public Health Policy and Planning. 2016; 32(3): 314-319.
Improvement in overall responsiveness to people’s expectations is an important goal for any health system; socioeconomic equity in responsiveness is equally important. However, it is not known if socioeconomic disparities in responsiveness can be reduced through greater public health expenditure. This article assesses the relationship of the proportion of public health expenditure over total health expenditure (PPHE) with responsiveness for poorest individuals and the difference in responsiveness between the richest and poorest individuals. We used data from six responsiveness dimensions (prompt attention, dignity, choice, clarity of information, confidentiality and quality of basic amenities) of outpatient services from World Health Survey data from 63 countries. Hierarchical Ordered Probit (HOPIT) models assessed the probability of ‘very good’ responsiveness in each domain among the poorest and riches individuals for each country, correcting for reporting heterogeneity through vignettes. Linear regression models were then used to assess the association between predicted probabilities from HOPIT models and PPHE, adjusting for (log) Gross Domestic Product per capita. The study findings showed that higher PPHE was associated with a higher probability of ‘very good’ responsiveness for each domain among the poorest individuals, and with smaller pro-rich disparities in responsiveness between the richest and poorest individuals. In conclusion, increasing PPHE may improve the responsiveness of health services for the poorest individuals and reduce disparities in responsiveness between the richest and poorest individuals.
Full article at: https://academic.oup.com/heapol/article/32/3/314/2555440
Malhotra C, Bilger M, Liu J, Finkelstein EA. Asian Pac J Cancer Prev. 2016; 17(8):3887-3895.
In order to increase breast and cervical cancer screening uptake in Singapore, women’s perceived barriers to screening need to be identified and overcome. Using data from both focus groups and surveys, we aimed to assess perceived barriers and motivations for breast and cervical cancer screening. We conducted 8 focus groups with 64 women, using thematic analysis to identify overarching themes related to women’s attitudes towards screening. Based on recurring themes from focus groups, several hypotheses regarding potential barriers and motivations to screen were generated and tested through a national survey of 801 women aged 25-64. Focus group participants had misconceptions related to screening, believing that the procedures were painful. Cost was an issue, as well as efficacy and fatalism. By identifying barriers to and motivators for screening through a mixed-method design that has both nuance and external validity, this study offers valuable suggestions to policymakers to improve breast and cervical cancer screening uptake in Singapore.
Full article at: https://pdfs.semanticscholar.org/6006/f210c637032f4830e67ccf985d971aa4a47e.pdf
Malhotra C, Sim DKL, Jaufeerally F, Nadkarni N, Wong GCS, Tan BC, Ng CSH, Tho PL, Lim J, Chuang CYT, Fong FHM, Liu J, Finkelstein EA. Trials. 2016; 17(1):285.
Despite the promise and popularity of advance care planning, there is insufficient evidence that advance care planning helps patients to meet their end-of-life care preferences, especially in Asian settings. Thus, the proposed study aims to assess whether patients with advanced heart failure who are receiving advance care planning have a greater likelihood of receiving end-of-life care consistent with their preferences compared to patients receiving usual care. Secondary objectives are to compare differences in health care expenditures, quality of life, anxiety and depression, understanding of own illness, participation in decision-making and concordance with their caregiver’s preferences for end-of-life care, between patients with advanced heart failure receiving advance care planning and usual care.
This is a two-arm randomized controlled trial of advance care planning versus usual care (control) conducted at two institutions in Singapore. Two hundred and eighty-two patients with advanced heart failure (n=94 in the advance care planning arm; n = 188 in the control arm receiving usual care) will be recruited from these centers and followed for 1 year or until they die, whichever is earlier. Additionally, the study will include up to one caregiver per patient enrolled.
If advance care planning is proven to be effective, the results will help to promote its uptake among health care providers and patients both within Singapore and in other countries.
Full article at: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1414-1
Nguyen VH, Bose S, Finkelstein EA. BMC Nephrology. 2016; 17(1):45.
Sevelamer is an alternative to calcium carbonate for the treatment of hyperphosphatemia among non-dialysis dependent patients with chronic kidney disease (CKD). Although some studies show that it may reduce mortality and delay the onset of dialysis when compared to calcium carbonate, it is also significantly more expensive. Prior studies looking at the incremental cost-effectiveness of sevelamer versus calcium carbonate in pre-dialysis patients are based on data from a single clinical trial. The goal of our study is to use a wider range of clinical data to achieve a more contemporary and robust cost-effectiveness analysis. We used a Markov model to estimate the lifetime costs and quality-adjusted life years (QALYs) gained for treatment with sevelamer versus calcium carbonate. The model simulated transitions among three health states (CKD not requiring dialysis, end-stage renal disease, and death). Data on transition probabilities and utilities were obtained from the published literature. Costs were calculated from a third party payer perspective and included medication, hospitalization, and dialysis. Sensitivity analyses were also run to encompass a wide range of assumptions about the dose, costs, and effectiveness of sevelamer. Over a lifetime, the average cost per patient treated with sevelamer is S$180,724. The estimated cost for patients treated with calcium carbonate is S$152,988. A patient treated with sevelamer gains, on average, 6.34 QALYs relative to no treatment, whereas a patient taking calcium carbonate gains 5.81 QALYs. Therefore, sevelamer produces an incremental cost-effectiveness ratio (ICER) of S$51,756 per QALY gained relative to calcium carbonate.
Based on established benchmarks for cost-effectiveness, sevelamer is cost effective relative to calcium carbonate for the treatment of hyperphosphatemia among patients with chronic kidney disease initially not on dialysis.
Full article at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848865/
Flynn T, Bilger M, Malhotra C, Finkelstein EA. Pharmacoeconomics. 2016; 34(3):273-284.
Although efficient designs have sample size advantages for discrete choice experiments (DCEs), it has been hypothesised that they may result in biased estimates owing to some respondents using simplistic heuristics. The main objective was to provide a case study documenting that many respondents choose on the basis of a single attribute when exposed to highly efficient DCE designs but switch to a conventional multi-attribute decision rule when the design efficiency was lowered (resulting in less need to trade across all attributes). Additional objectives included comparisons of the sizes of the estimated coefficients and characterisation of heterogeneity, thus providing evidence of the magnitude of bias likely present in highly efficient designs.
Five hundred and twenty-five respondents participating in a wider end-of-life survey each answered two DCEs that varied in their design efficiency. The first was a Street and Burgess 100 % efficient Orthogonal Main Effects Plan design (27 in 8), using the top and bottom levels of all attributes. The second DCE comprised one eighth of the full Orthogonal Main Effects Plan in 32 pairs, (a 2 × 46). Linear probability models estimated every respondent’s complete utility function in DCE1. The number of respondents answering on the basis of one attribute level was noted, as was the proportion of these who then violated this rule in DCE2, the less efficient DCE. Latent class analyses were used to identify heterogeneity. Sixty per cent of respondents answered all eight tasks comprising DCE1 using a single attribute; most used the rule “choose cheapest end-of-life care plan”. However, when answering the four less efficient tasks in DCE2, one third of these (20 % overall) then traded across attributes at least once. Among those whose decision rule could not be described qualitatively, latent class models identified two classes; compared to class one, class two was more concerned with quality rather than cost of care and wished to die in an institution rather than at home. Higher efficiency was also associated with smaller regression coefficients, suggesting either weaker preferences or lower choice consistency (larger errors). This is the first within-subject study to investigate the association between DCE design efficiency and utility estimates. It found that a majority of people did not trade across attributes in the more efficient design but that one third of these then did trade in the less efficient design. More within-subject studies are required to establish how common this is. It may be that future DCEs should attempt to maximise some joint function of statistical and cognitive efficiency to maximise overall efficiency and minimise bias.
Full article at: https://link.springer.com/article/10.1007/s40273-015-0338-z
Teo I, Fronczyk KM, Guindani M, Vannucci M, Ulfers SS, Hanasono MM, Fingeret MC.. Head and Neck. 2016; 38(7):1035-42.
Patients with cancer undergoing head and neck reconstruction can experience significant distress from alterations in appearance and bodily functioning. We sought to delineate salient dimensions of body image concerns in this patient population preparing for reconstructive surgery. Participants completed self-report questionnaires evaluating numerous aspects of body image. We used Bayesian factor analysis modeling methods to identify latent factors emerging from the data.
We identified 2 latent factors: appearance distress and functional difficulties. The highest level of preoperative body image concerns were related to distress about appearance changes and its perceived social consequences. Appearance distress items displayed greater variability compared with functional difficulties. Appearance and functional changes to body image are important areas of concern for patients with head and neck cancer as they prepare for reconstructive surgery. Knowledge regarding specific body image issues can be used to guide psychosocial assessments and intervention to enhance patient care.
Full article at: https://onlinelibrary.wiley.com/doi/full/10.1002/hed.24415
Malhotra C, Wong GCS, Tan BC, Ng CSH, Lee NC, Lau CSL, Sim DKL, Finkelstein EA. Proceedings of Singapore Healthcare. 2016; 25(2):92-97.
Heart failure is a progressive and often incurable condition associated with a poor quality of life. The aim of this study was to understand the experiences and preferences regarding care, communication and decision-making among patients living with heart failure in Singapore. Five focus groups were conducted with 27 patients that had heart failure. The focus groups were audio-recorded and transcribed verbatim. Thematic analysis was used for analyzing transcripts. Six themes representing the experiences of patients with heart failure were identified. These were: 1) physical and psychological symptoms; 2) financial concerns; 3) uncertainty and lack of knowledge about disease; 4) difficulties in navigating the healthcare system; 5) end-of-life care concerns; and 6) fear of burdening family. The study highlights that health care services for patients with heart failure need to address the multifaceted impacts of the disease on patient’s lives. A focus on the provision of comprehensive health care services at the primary care level, training of health care providers in communication skills, involving patients and their families in decision making, and discussions about end-of-life care preferences and goals of care may help to improve care for patients with heart failure.
Full article at: https://journals.sagepub.com/doi/pdf/10.1177/2010105815624121
Luo N, Wang X, Ang M, Finkelstein EA, Aung T, Wong TY, Lamoureux E.. Value Health.2015;18(8):1037-1042.
Recently, a vision “bolt-on” EuroQol five-dimensional questionnaire (EQ-5D) was developed and tentative utility values (i.e., a “value set”) for this new descriptive system were estimated.To compare the discriminatory power of this bolt-on and standard utility-based EQ-5D health indices.
Cross-sectional data on the (3-level) vision bolt-on EQ-5D were collected through face-to-face interviews with 500 and 336 individuals with and without visual impairment, respectively. To assess the discriminatory power of the vision bolt-on index relative to the standard EQ-5D index developed in the vision bolt-on valuation study, 16 pairs of mutually exclusive subgroups of individuals defined by the individuals’ visual acuity and responses to the 14-item visual function questionnaire were compared pairwise. The absolute mean difference in the two index scores and the corresponding F statistic derived from the comparisons were used as measures of discriminatory power.
The absolute mean difference in the bolt-on index score was larger than that in the standard EQ-5D index score in 14 of the 16 comparisons. The bolt-on index score exhibited a larger F-statistic value than did the standard EQ-5D index score in all known-group comparisons, with the F-statistic ratio ranging from 0.415 to 0.770.The vision bolt-on EQ-5D appears to be more discriminative than the standard EQ-5D in measurement of vision problems. Future studies should investigate the extent to which the vision bolt-on item can increase the sensitivity of the EQ-5D to vision change in interventional studies.
Full article at: https://www.sciencedirect.com/science/article/pii/S1098301515020306
Chong JA, Quah YL, Yang GMJ, Menon S, Radha Krishna LK. BMJ Support Palliat Care.2015; 5(4):420-6.
The practice of patient autonomy within the prevailing bioethical framework in the West appears increasingly at odds with the prominent influence of the family in medical decision making in the Asian culture. The actual extent of involvement of patient versus the family in the decision making process for cancer management in clinical practice is largely unknown in Asia.
Aims (1) To describe patient and family involvement in healthcare decision making in actual practice, and to determine whether those practices are consistent with Singapore law; and (2) to act as a pilot for a larger prospective study examining the preferences of cancer patients on the decision making process, and the reasons for excluding patients from that process. A retrospective review of patients who died in an oncology ward in Singapore General Hospital from February to April 2011. Patient and family involvement in discussions on (1) disclosure of diagnosis, (2) initial treatment decisions and (3) initiation of a ‘maximum ward management’ order was evaluated by reviewing case notes completed by healthcare professionals. Data were collected for 55 patients. Involvement of patients and families at first disclosure of diagnosis was noted in 61% and 64% of cases, respectively. In 12% of cases, the family requested withholding of the diagnosis from the patient. 86% of patients were involved in the initial treatment decisions, and their family was involved in 65% of cases. Only 9% of the 32 alert patients were consulted in end of life decisions. Factors associated with lower patient involvement were advanced age and inability to speak English.
While most cancer patients are involved in the healthcare decision making process during the early phase, familial involvement gains prominence as the disease progresses.
Full article at: https://spcare.bmj.com/content/5/4/420
Flynn TN, Bilger M, Malhotra C, Finkelstein EA. PharmacoEconomics. 34(3):273-284.
Although efficient designs have sample size advantages for discrete choice experiments (DCEs), it has been hypothesised that they may result in biased estimates owing to some respondents using simplistic heuristics.The main objective was to provide a case study documenting that many respondents choose on the basis of a single attribute when exposed to highly efficient DCE designs but switch to a conventional multi-attribute decision rule when the design efficiency was lowered (resulting in less need to trade across all attributes). Additional objectives included comparisons of the sizes of the estimated coefficients and characterisation of heterogeneity, thus providing evidence of the magnitude of bias likely present in highly efficient designs. Five hundred and twenty-five respondents participating in a wider end-of-life survey each answered two DCEs that varied in their design efficiency. The first was a Street and Burgess 100 % efficient Orthogonal Main Effects Plan design (27 in 8), using the top and bottom levels of all attributes. The second DCE comprised one eighth of the full Orthogonal Main Effects Plan in 32 pairs, (a 2 × 46). Linear probability models estimated every respondent’s complete utility function in DCE1. The number of respondents answering on the basis of one attribute level was noted, as was the proportion of these who then violated this rule in DCE2, the less efficient DCE. Latent class analyses were used to identify heterogeneity. Sixty per cent of respondents answered all eight tasks comprising DCE1 using a single attribute; most used the rule “choose cheapest end-of-life care plan”. However, when answering the four less efficient tasks in DCE2, one third of these (20 % overall) then traded across attributes at least once. Among those whose decision rule could not be described qualitatively, latent class models identified two classes; compared to class one, class two was more concerned with quality rather than cost of care and wished to die in an institution rather than at home. Higher efficiency was also associated with smaller regression coefficients, suggesting either weaker preferences or lower choice consistency (larger errors).
This is the first within-subject study to investigate the association between DCE design efficiency and utility estimates. It found that a majority of people did not trade across attributes in the more efficient design but that one third of these then did trade in the less efficient design. More within-subject studies are required to establish how common this is. It may be that future DCEs should attempt to maximise some joint function of statistical and cognitive efficiency to maximise overall efficiency and minimise bias.
Finkelstein EA, Bilger M, Flynn T, Malhotra C. Health Policy.2015; 119(11):1482-1489.
Singapore is in the midst of several healthcare reforms in efforts to finance and deliver health services for a rapidly aging population. The primary focus of these reforms is to make healthcare services, including those at the end of life (EOL), affordable. Given the increasingly high health care costs at the EOL, policy makers need to consider how best to allocate resources. One strategy is to allocate resources based on the preferences of sub-populations most likely to be affected. This paper thus aims to quantify preferences for EOL care both among community dwelling older adults (CDOAs) and among patients with a life-limiting illness. A discrete choice experiment was administered to CDOAs and advanced cancer patients in Singapore and willingness to pay (WTP) for specific EOL improvements was estimated. We find that patients have a higher WTP for nearly all EOL attributes compared with CDOAs. We also show that, for both groups, moderate life extension is not the most important consideration; WTP for one additional life year is lower than common thresholds for cost-effectiveness. Irrespective of whose preference are considered, the results highlight the importance of pain management and supporting home deaths at the EOL, perhaps at the expense of public funding for costly but only marginally effective treatments.
Full article at: https://www.sciencedirect.com/science/article/pii/S0168851015002237
Malhotra C, Chan N, Zhou J, Dalager HB, Finkelstein EA. BMC Palliative Care.2015; 14(1):52.
There is high variability in end-of-life (EOL) treatments. Some of this could be due to differences in physician treatment recommendations, their knowledge/attitude regarding palliative care, and their perceived roles in treating patients with advanced serious illness (ASI). Thus, the objective of this paper was to identify potential variation in physician recommendations, their knowledge/attitude regarding palliative care and perceived roles in treating ASI patients. A cross-sectional survey consisting of vignettes describing patient characteristics that varied by age, expected survival, cognitive status and treatment costs and asked physicians whether they would recommend life-extending treatments for each scenario, was administered to 285 physicians who treat ASI patients in Singapore. Physicians were also assessed on their knowledge/attitude in palliative care. They were administered a best-worst scaling exercise requiring them to select their most and least important role as a physician caring for an ASI patient. There was a wide variation in physician recommendations for life-extending treatments for patients with similar profiles, which can partly be attributed to physician characteristics (years of experience and place of training). Only about one-fourth of the physicians answered all knowledge/attitude questions correctly. Statements assessing knowledge/attitude regarding pain management had the fewest correct responses. The most important perceived role regarding provision of EOL care concerned symptom management. Results suggest that variation in physician treatment recommendations may be partly related to their own characteristics, raising concerns regarding the EOL care being provided to patients. Efforts should be made to better understand this variation and to provide the physicians with additional training in key aspects of palliative care management.
Full article at: https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-015-0050-y
Teo I, Reece GP, Christie IC, Guindani M, Markey MK, Heinberg LJ, Crosby MA, Fingeret MC. Psycho-Oncology. 2015; 25(9):1106-1112.
The process of cancer-related breast reconstruction is typically multi-staged and can take months to years to complete, yet few studies have examined patient psychosocial well-being during the reconstruction process. We investigated the effects of reconstruction timing and reconstruction stage on body image and quality of life at specific time points during the breast reconstruction process. In this cross-sectional study, 216 patients were grouped into four reconstructive stages: pre-reconstruction, completed stage 1, completed stage 2, and final stages. Multiple regression analyses examined the roles of reconstruction timing (immediate vs delayed reconstruction) and reconstruction stage as well as their interaction in predicting body image and quality of life, controlling for patient age, BMI, type of reconstruction, chemotherapy, radiation therapy, and major complication(s). A difference in pattern of body image was observed across the reconstructive stages, with those receiving delayed reconstruction showing significant decrease in body image dissatisfaction compared with those with immediate reconstruction. At pre-reconstruction, patients awaiting delayed reconstruction reported significantly lower social well-being compared with those awaiting immediate reconstruction. Reconstruction stage predicted emotional well-being, with higher emotional well-being observed in those who had commenced reconstruction.
Timing and stage of reconstruction are important to consider when examining psychosocial outcomes of breast cancer patients undergoing reconstruction. Those waiting to initiate delayed reconstruction appear at particular risk for body image, emotional, and social distress. Our findings have implications for delivery of psychosocial treatment to maximize body image and quality of life of patients undergoing cancer-related breast reconstruction.
Full article at: https://onlinelibrary.wiley.com/doi/abs/10.1002/pon.3952
Lee CE, Tai IS, Yang GM, et al. Progress in Palliative Care.2015; 23(4):199-207.
Spirituality is essential and forms a critical factor in the way palliative care patients cope with their illnesses. It has been recognized as a major and important component of palliative care. There is little data in Singapore on the current state of spiritual care at the end of life. A retrospective case-notes audit of the current state of spirituality assessment was conducted in the home care as well as hospital in-patient setting. The case-notes audit was selected from patients who were seen by the palliative medicine teams between June and July 2013. A total of 108 home care patient case notes and 182 hospital in-patient case notes were analyzed during the period of this study. Only 24.1% of home care patients and 30.2% of hospital in-patients had spirituality assessments conducted, of which most patients (77.8%) had these assessments completed during the first initial clinical review. The common spiritual themes identified were fairly equally distributed among the 81 palliative care patients in whom a spirituality assessment was performed.
Our audit shows that less than one-third of patients have had a spiritual assessment conducted, similar to the results of other studies elsewhere. It is hoped that this spirituality assessment rate can be improved by putting in place a structured spiritual programme in future.
Full article at: https://www.tandfonline.com/doi/abs/10.1179/1743291X14Y.0000000116
Teo I, Fingeret MC, Liu J, Chang DW. Journal of Health Psychology. 2015; 21(12):2983-2993.
Breast cancer–related lymphedema is associated with numerous adverse outcomes. This study investigated the extent clinical factors, lymphedema symptoms, lymphedema-related appearance, and coping strategies predicted quality of life. Female patients who underwent microsurgical treatment for lymphedema (n = 54) participated. Lymphedema symptoms were associated with physical and functional well-being, but not emotional and social well-being. Clinical factors and lymphedema-related appearance were not significantly associated with quality of life. Compared to adaptive coping strategies, maladaptive coping strategies (e.g. denial, venting, self-blame) were more strongly associated with quality of life. This suggests psychosocial interventions aimed at modifying maladaptive coping behaviors can potentially improve quality of life for this patient population.
Full article at: https://journals.sagepub.com/doi/abs/10.1177/1359105315589801
Ozdemir, S. The Patient-Centered Outcomes Research.2015;8(3),247-55.
The objective of this article was to discuss potential benefits and drawbacks of using a time-to-think (TTT) approach in healthcare research. Implementing a TTT approach in a stated-preference survey study gives respondents the opportunity to reflect on their options before answering preference-elicitation questions. This article offers an evaluation of circumstances that are suited for implementing this approach, and highlights several remaining questions and problems that should be explored in future research.
Full article at: https://link.springer.com/article/10.1007/s40271-014-0084-x
Lai H, Choong CV, Fook-Chong S, Ng YY, Finkelstein EA, Haaland B, Goh ES, Leong BSH, Gan HN, Foo D, Tham LP, Charles R, Ong MEH, PAROS study group.. Resuscitation.2015; 89:155-161.
We aim to study if there has been an improvement in survival for Out-of-Hospital Cardiac Arrest (OHCA) in Singapore, the effects of various interventional strategies over the past 10 years, and identify strategies that contributed to improved survival. Rates of OHCA survival were compared between 2001–2004 and 2010–2012, using nationwide data for all OHCA presenting to EMS and public hospitals. A multivariate logistic regression model for survival to discharge was constructed to identify strategies with significant impact.
A total of 5453 cases were included, 2428 cases from 2001 to 2004 and 3025 cases from 2010 to 2012. There was significant improvement in Utstein (witnessed, shockable) survival to discharge from 2001–2004 (2.5%) to 2010–2012 (11.0%), adjusted odds ratio (OR) 9.6 [95% CI: 2.2–41.9]). Overall survival to discharge increased from 1.6% to 3.2% (adjusted OR 2.2 [1.5–3.3]). Bystander CPR rates increased from 19.7% to 22.4% (p = 0.02). The multivariate regression model (adjusted for important non-modifiable risk factors) showed that response time <8 min (OR 1.5 [1.0–2.3]), bystander AED (OR 5.8 [2.0–16.2]), and post-resuscitation hypothermia (OR 30.0 [11.5–78.0]) were significantly associated with survival to hospital discharge. Conversely, pre-hospital epinephrine (OR 0.6 [0.4–0.9]) was associated negatively with survival.
OHCA survival has improved in Singapore over the past 10 years. Improvement in response time, public AEDs and post-resuscitation hypothermia appear to have contributed to the increase in survival. Singapore's experience might suggest that developing EMS systems should focus on reducing times to basic life support, including bystander defibrillation and post-resuscitation care.
Full article at: https://www.sciencedirect.com/science/article/abs/pii/S0300957215000660
Malhotra C, Farooqui MA, Kanesvaran R, Bilger M, Finkelstein EA. Palliative Medicine. 2015; 29(9): 842-850.
Patients with advanced cancer often have to make difficult decisions, such as how much to spend on moderately life-extending treatments. This and other end-of-life decisions are also influenced by their informal caregivers. Understanding the relative value that patients and their caregivers place on various aspects of end-of-life care can help clinicians tailor treatments to best meet the preferences of their patients. To quantify willingness to pay of patients with advanced cancer and their caregivers to extend the patients’ life by 1 year and to compare this result to their willingness to pay for other end-of-life improvements. Cross-sectional survey using a discrete choice experiment. A total of 211 patients with stage IV cancer and their informal caregivers. The willingness to pay of patients to extend their life by 1-year (S$18,570; 95% confidence interval: S$6687–S$30,542) was not statistically different from their willingness to pay to avoid severe pain (S$22,199; S$11,648–S$32,450), to die at home (S$31,256; S$21,249–S$41,391), not be a burden on family and friends (S$4051; −S$3543 to S$11,568), or to receive a high-quality health-care experience (S$16,191; S$9266–S$23,037). Consistent with our hypothesis, caregivers had a greater willingness to pay than patients to extend life (S$61,368; S$37,030–S$86,210) and for most other end-of-life improvements.
Results highlight the importance of pain management, supporting home deaths, and addressing other end-of-life concerns, in addition to efforts to extend life. Differences in willingness to pay of patients and caregivers suggest the need for eliciting patient preferences during treatment decision making as opposed to relying on caregiver input.
Full article at: https://journals.sagepub.com/doi/abs/10.1177/0269216315578803
Malhotra R, Haaland BA, Chei CL, Chan A, Malhotra C , Matchar DB. Geriatrics & Gerontology International.2015; 15(3):372-380.
To determine the extent of interviewer error on the Short Portable Mental Status Questionnaire (SPMSQ), the association between interviewer-level variables and SPMSQ score, compare the prevalence of SPMSQ cognitive status categories before and after correction for interviewer error, and identify SPMSQ items prone to interviewer error. Data of 4542 older adults from a national survey in Singapore were utilized. Multilevel models, which adjusted for respondent-level variables known to be associated with cognitive status, were utilized to determine the intraclass correlation on the SPMSQ, association of interviewer-level variables (age, ethnicity, education and number of interviews carried out) with SPMSQ and identify SPMSQ items prone to interviewer error. The intraclass correlation, after adjusting for respondent-level variables, was 0.265. Interviewer educational status was associated with SPMSQ score. Correction for interviewer error resulted in an “improvement” in cognitive status of a substantial proportion of those initially classified as moderately or severely impaired. Two of the SPMSQ items, “Please count backward from 20 by 3” and “When were you born?” were particularly prone to interviewer error.
Investigators using the SPMSQ, and potentially, other instruments, for assessing cognitive function in surveys of older adults and using face-to-face interviews for data collection should be cognizant of the sensitivity of such instruments to interviewer error. Intensive training of interviewers to standardize instrument administration as well as assessment for interviewer error and its correction, using appropriate statistical models, such as multilevel models, is warranted.
Full article at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ggi.12331
Chua AC, DeSantis SM, Teo I, Fingeret MC. Body image: An international journal.2015; 13:33-37.
Breast cancer and its treatment can significantly affect a woman's body image. As such, it would be useful to understand the importance or value these patients place on their appearance. We evaluated the factor structure of the Appearance Schemas Inventory-Revised (ASI-R), a measure of body image investment, with a sample of 356 breast cancer patients undergoing mastectomy and breast reconstruction. Using confirmatory and exploratory factor analyses, we found that a three-factor model demonstrated an improvement in fit over the original two-factor structure of the ASI-R. These factors were named Appearance Self-Evaluation, Appearance Power/Control, and Appearance Standards and Behavior. The three aforementioned factors demonstrated acceptable internal consistency reliabilities. Our findings have implications for the use of the ASI-R in an oncology setting, specifically for breast cancer patients undergoing reconstruction.
Full article at: https://www.sciencedirect.com/science/article/abs/pii/S1740144514001764
Fingeret MC, Teo I, Goettsch K. Body image: Current Oncology Reports.2015;17(1): 422.
Increasing attention is being given to evaluating and treating body image difficulties of patients undergoing cancer treatment. Head and neck cancer significantly alters physical appearance and bodily functioning and therefore directly impacts body image. Research involving body image in head and neck cancer patients is growing, and this review considers published findings from 2013 to 2014. Primary attention is given to discussing recent advancements in body image assessment, qualitative studies, descriptive research, and psychosocial intervention studies relevant to body image. Limitations and necessary advancements in this field are noted, and a commentary is provided on the state of the current literature.
Full article at: https://link.springer.com/article/10.1007/s11912-014-0422-0