Lee CF, Wee HL, Teo I, Lee GL, Thumboo J, Cheung YB, & Neo S. Journal of patient-reported outcomes.2021; 5(1):17.
Purpose: The 15- and 10-item short forms of the Singapore Caregiver Quality of Life Scale (SCQOLS-15 and SCQOLS-10) were recently developed as a quick assessment of caregiver quality of life. Reference values describing the distribution of the total and domain scores are available for the full-length version, but they are not yet available for the short forms. This study aimed to estimate the reference values for the short forms. Methods: Data from a cross-sectional survey of 612 family caregivers of patients with advanced cancer in Singapore were fitted in quantile regression models. Percentiles were estimated by regressing the short forms' scores on caregiver characteristics. Classification by the reference values for the short forms and the full-length version were compared and agreement was evaluated. Results: The caregiver's role in caring for the patient and the patient's performance status were associated with the percentiles of the total scores and most domain scores (each Bonferroni-adjusted p-value, PB, < 0.05). Higher-educated caregivers were categorized into higher percentiles according to the SCQOLS-15 and SCQOLS-10 total scores and the SCQOLS-15 Mental Well-being and Financial Well-being domain scores (each PB < 0.05). Ethnicity was associated with the SCQOLS-15 Physical Well-being and Experience & Meaning domains (each PB < 0.05). The percentiles for the short forms showed moderate to substantial agreement with those for the full-length version in terms of classifying caregivers into percentile intervals (quadratic-weighted Kappa = 0.72 to 0.92). Conclusion: Reference values for the SCQOLS-15 and SCQOLS-10 were estimated in relation to caregiver characteristics to facilitate interpretation of the short form scores.
Full article at: https://jpro.springeropen.com/articles/10.1186/s41687-021-00290-5
Malhotra C, Bundoc FG, Sim D, Jaufeerally FR, Finkelstein EA. Journal of the American Medical Directors Association.2021; 22(2): 349.e29-349.e34.
Patient preference for place of death is an important component of advance care planning (ACP). If patients’ preference for place of death changes over time, this questions the value of
their documented preference. We aimed to assess the extent and correlates of change in preference for place of death over time among patients with symptoms of advanced heart failure.
We conducted a secondary analysis of data from a randomized controlled trial of a formal ACP program vs usual care. We interviewed 282 patients aged 21 years old and above with heart failure and
New York Heart Association Classification III and IV symptoms in Singapore. Analytic sample included 200 patients interviewed at least twice. We assessed factors associated with patients’
preference for place of death (home/institution/no preference) and change in their preference for place of death from previous time point (change toward home death/toward an institutional
death/toward no preference/no change). These included patient demographics, quality of life (Kansas City Cardiomyopathy Questionnaire), and prognostic understanding. In our study, 66% of patients
with heart failure changed their preference for place of death at least once during the study period with no consistent pattern of change. Correct prognostic understanding at the time of survey
reduced the relative risk of change in preference for place of death to home (relative risk ratio 0.49, 95% confidence interval 0.32, 0.76), whereas a higher quality of life score was associated
with a lower relative risk of patients changing their preferred place of death to an institution (relative risk ratio 0.99, 95% confidence interval 0.97, 1.00) relative to no change in preference.
We provide evidence of instability in patients with heart failure preference for place of death, which suggests that ACP documents should be regularly re-evaluated.
Full article at: https://www.sciencedirect.com/science/article/abs/pii/S1525861020304345
Aloweni F, Ayre TC, Wong MHM, Tan HK, Teo I., Journal of Nursing and Patient Safety.2020; 1:001-009
Introduction: Nurses worldwide are facing hardships during the COVID-19 pandemic. Aims: To examine the impact of work environment, workplace support and individual-related factors on burnout
during the COVID-19 pandemic. Methods: This was an analytical cross-sectional study conducted in a hospital in Singapore that nursed confirmed and suspected COVID-19 patients between 12 March and
25 May 2020. An email invitation was sent to all nurses to participate in an online survey. Multivariable logistic regression analysis was conducted to examine associations between burnout and
work environment, workplace support and individual-related factors. Results: 855 nurses responded to the survey. Compared to nurses working in low-risk areas, nurses in high-risk areas had 1.6
times higher risk of burnout (95% CI: 1.072 – 2.454; p=0.022). Perceiving lack of teamwork (OR = 1.630, 95% CI: 1.067– 2.492, p=0.024), not feeling appreciated (OR = 14.811, 95% CI:
3.520 – 62.328, p.<0.001) and poor self-rated health (OR=0.348, 95% CI: 0.264-0.460, p<.001) were associated with burnout. Discussion: Nurses working in high-risk areas, such as wards
are designated for acute respiratory infections patients, are at higher risk of experiencing burnout. Implications for practice: Nurses in high-risk areas would benefit from interventions that
build physical health and esprit de corps to prevent burnout.
Full article at:
Malhotra C, Hazirah M, Tan LL, Malhotra R, Yap P, Balasundaram B, Tong KM, Pollak KI, PISCES Study Group. Journal of Pain and Symptom Management.2020. Published
Online First. doi: 10.1016/j.jpainsymman.2020.11.021
Context: Dementia involves suffering. Assessing the experience of suffering among persons with severe dementia is instrumental to delivering quality end-of-life care to them and their caregivers.
Objectives: We aimed to assess dimensions of suffering from the perspective of family caregivers and the resulting impact on their decisions for the care of persons with severe dementia. Methods:
Between July 2018 and February 2019, we conducted qualitative in-depth interviews with 27 family caregivers of community-dwelling persons with severe dementia with Functional Assessment Staging
Test staging 7. We asked caregivers if they perceived persons with severe dementia to be suffering and explored reasons for their perceptions. We analyzed data using principles of reflexive
thematic analysis. Results: We conceptualized five dimensions of suffering among persons with severe dementia from the perspective of their caregivers: 1) untreated physical or behavioral
symptoms, 2) emotional pain, 3) loss of agency, 4) loss of engagement with society, and 5) loss of personhood. Suffering among persons with severe dementia influences their caregivers' expression
of a wish for their death and caregivers’ decision regarding the use of life-prolonging interventions for them. Conclusion: Findings suggest that suffering among persons with severe dementia
can occur independent of physical symptoms and requires provision of person-centered care. The study adds to the understanding of end-of-life care in persons with severe dementia and their
Full article at:
Ng, C. Z., Cheung, Y. B., Koh, A., Teo, H. R., Mok, N., & Yang, G. M. BMJ supportive & palliative care.2020. Published Online First. doi:
Background: Compared with the current inpatient consultation model, a novel corounding model of care whereby palliative specialists round with oncology teams, increases healthcare collaboration
and may improve quality of care for inpatients. Whether this translates to better pain control for patients is unexplored. Objective: To determine whether the corounding model provides better pain
control compared with the consultation model for cancer inpatients. Methods: Cancer patients with moderate or severe pain severity during the admission were included in this observational study.
Pain severity was determined using electronic records. Improvement to mild or no pain by day 3 of identification of moderate or severe pain was defined as good pain control and proportion of
admissions achieving this was compared between models. Results: A total of 142 and 128 admissions admitted under the consult and corounding model, respectively, had moderate or severe pain. The
proportion of patients that achieved good pain control was 77.3% (99/128) and 71.8% (102/142) in the corounding and consult model, respectively. The difference in proportion of admissions
achieving good pain control was significantly higher in the corounding model after adjusting for differences in baseline characteristics (unadjusted OR, 1.34; 95% CI, 0.77 to 2.33; adjusted OR,
2.25; 95% CI, 1.19 to 4.26). Discussion: The odds of achieving good pain control was significantly better in the corounding model. However, the mechanism behind this is unexplored. This study can
serve as precedence for future studies evaluating the corounding model of care.
Full article at:
Doble B, Lau E, Malhotra C, Ozdemir S, Teo I, Finkelstein EA, APPROACH study group. Journal of psychosomatic research.2020. Published Online First. doi:
Objective: To understand the prevalence of behavioral and characterological self-blame and their associations with stated preferences for life-extension and the use of pain-relief medication in a
multi-country cohort of advanced cancer patients. Methods: The prevalence of self-blame and reasons participants attributed to their diagnosis was assessed in a sample of 968 advanced cancer
patients enrolled in one of five sites from four Asian countries of the multi-country cross-sectional survey titled APPROACH. Ordered probit and Firth logistic regressions were used to determine
associations between each type of self-blame and two treatment-related outcomes: participants' stated preference for life-extension and the use of pain-relief medication in the last 24 h. Results:
Behavioral and characterological self-blame were reported by 41% and 49% of the participants respectively, with only 19% and 2% of participants providing a logically consistent reason for the two
types of self-blame. We observed no statistically significant differences in stated preferences for life-extension for either type of self-blame and in the use of pain-relief medication for
participants reporting behavioral self-blame. However, participants reporting characterological self-blame were 9.7% (95% CI, 2.0% to 17.3%; p = 0.014) more likely to report using pain-relief
medication compared to participants not reporting characterological self-blame. Conclusions: A substantial proportion of patients report self-blame and those reporting characterological self-blame
appear more likely to use pain medication. Therefore, developing interventions aimed at reducing characterological self-blame might help patients receive only appropriate treatments as opposed to
treatments pursued in response to feelings of self-blame.
Full article at:
Finkelstein EA, Ozdemir S, Baid D. The Straits Times.2020; Opinion:21.
Evidence suggests that for herd immunity – the threshold at which the virus can no longer replicate in the population – to occur, roughly 70 per cent of the population would need to be
immune, either through vaccination or through prior exposure. Given the low Covid-19 exposure rate in Singapore, having a vaccination level below 70 per cent may not be successful in stopping the
spread of the disease, say the writers.
Full article at:
Cheung YB, Teo I, Lim WS, Hum A, Neo SHS, Yang GM, Tan G, Seow DC. Journal of Patient-Reported Outcomes.2020; 4:84.
Purpose: To develop and evaluate a measurement scale for multi-domain assessment of the quality of life of family caregivers of persons with dementia (PWD) in Singapore, a multi-ethic
society in South-East Asia where English is the lingua franca. Methods: Items from the Singapore Caregiver Quality of Life Scale (SCQOLS), which was originally developed in the context of advanced
cancers, were adopted as candidate items. Furthermore, a multi-disciplinary panel reviewed dementia-specific caregiver quality of life scales to identified items not covered in SCQOLS for
inclusion as candidate items. A pilot study of 31 family caregivers of PWD was conducted to solicit inputs on candidate items; 102 family caregivers of PWD were surveyed for evaluation of the
scale's measurement properties. Results: Factor analysis confirmed a 5-domain structure of the 63 candidate items. The Root Mean Square Error of Approximation was 0.056 and Comparative Fit Index
was 0.928. Convergent validity of the total and domain scores was demonstrated in terms of correlation with the Brief Assessment Scale for Caregivers and its sub-scales. The scores also showed an
expected pattern of correlation with hours spent on caregiving per week. Known-group validity was demonstrated by differences in mean scores between functional staging groups. Cronbach's alpha of
the total and domain scores ranged from 0.89 to 0.95. Test-retest reliability (intraclass correlation coefficient) ranged from 0.77 to 0.92. Conclusions: The Singapore Caregiver Quality of Life
Scale - Dementia (SCQOLS-D) is a quality of life measurement scale for family caregivers of persons with dementia that is valid and reliable.
Full article at: https://jpro.springeropen.com/articles/10.1186/s41687-020-00252-3
Malhotra C, Krishnan A, Yong JR, Teo I, Ozdemir S, Ning XH, Hapuarachchi T, Palat G, Bhatnagar S, Joad AK, Nguyen TM, Mon SW, Finkelstein EA.
International Journal for Equity in Health.2020; 19(1):158.
A systematic understanding of socio-economic inequalities in end-of-life (EOL) suffering among advanced cancer patients is required to inform efforts to reduce these inequalities as part of
Universal Health Coverage goals. To assess inequalities in multiple domains of EOL suffering among advanced cancer patients-physical, functional, psychological, social and spiritual-using two
socio-economic status (SES) indicators, education and perceived economic status of the household. Patients living in low economic status households/ with fewer years of education reported greater
suffering in several domains. We also found significant interaction effects between economic status of the household and years of education for all EOL suffering outcomes. Age significantly
moderated the association between economic status of the household and social suffering and between years of education and psychological, social and spiritual suffering. Results highlight that SES
inequalities in EOL suffering vary depending on the suffering domain, the SES indicator assessed and by patient age. Greater palliative care resources for patients with low SES may help reduce
Full article at: https://link.springer.com/article/10.1186/s12939-020-01274-5
Ozdemir S, Teo I, Bundoc FC, Malhotra C, Yeo KK, Sim DKL, Finkelstein EA. Patient Education and Counseling.2020; S0738-3991(20)30464-X.
We investigated the predictors of patient-experienced and preferred roles for decision making, and the association between patient-experienced role in decision making and patient outcomes among
congestive heart failure (HF) patients in a multi-ethnic Asian population. We surveyed 246 HF patients classified as New York Heart Association class 3/4. Multivariable regressions were used to
analyse the associations between patient-experienced roles and patient outcomes.
Patients who were male, attained higher education, and had a higher cognitive score were more likely to experience and prefer active roles in decision making. Younger patients and patients with
lower symptom burden were more likely, while married patients were less likely to prefer leading decision making. Patients with collaborative (family and/or physician) decision making reported
higher emotional well-being and sense of meaning/peace. Collaborative and patient-led decision making were associated with higher perceived control over illness. Those who were led by others or
made decisions alone reported lower quality of physician communication.
Collaborative decision making was associated with higher emotional well-being, sense of meaning/peace, and higher perceived control over illness among HF patients. Physicians should explain the
benefits of shared decision making and encourage patients to participate in treatment decisions.
Full article at: https://www.sciencedirect.com/science/article/abs/pii/S073839912030464X
Mon SW, Myint Z, Myint M, Win H, Zin T, Yang GM, Malhotra C, Teo I, Finkelstein EA, Ozdemir S. Asia-Pacific Journal of Clinical Oncology.2020. Published Online First.
To investigate prognostic awareness, preference for prognostic information, and perceived and preferred roles in decision making among patients with advanced cancer in Myanmar. A cross‐sectional
survey was administered at the Yangon General Hospital to stage 4 cancer patients who were at least 21 years old and aware of their cancer diagnosis. Patients were asked questions about their
prognosis, participation in treatment decisions, sociodemographic and clinical information. Data from 131 patients were analyzed using descriptive statistics and logistic regressions.
Only 15% of patients surveyed were aware that their cancer was advanced and only a quarter (26%) of patients knew that treatment intent was noncurative. The likelihood of treatment‐intent
awareness was higher among patients who were male, high income, and aware that they had advanced cancer. Roughly 60% of patients reported playing an active or collaborative role in treatment
decisions, with a strong preference (59%) for the latter. For the majority of patients (69%), perceived and preferred roles in decision making were the same. Sociodemographic characteristics did
not predict perceived and preferred roles in decision making.
This is the first effort to analyze prognostic awareness and decision‐making practices among advanced cancer patients in Myanmar. Patients had inadequate knowledge on their disease progression and
intent of treatment. Yet, the majority of them were keen to be involved in treatment decisions.
Full article at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ajco.13430
Malhotra C, Harding R, Teo I, Ozdemir S, Koh GCH, Neo P, Lee LH, Kanesvaran R, Finkelstein EA, COMPASS study group.
Supportive Care in Cancer.2020; 28(8):3781-3789.
To assess association of total pain and suffering (i.e. physical, psychological, social, and spiritual health outcomes) and perceived health care quality with financial difficulties among stage IV
solid malignancy patients. Using baseline data from the COMPASS cohort study, we assessed total pain and suffering including physical (physical and functional well-being, pain, symptom burden),
psychological (anxiety, depression, emotional well-being), social (social well-being), and spiritual (spiritual well-being, hope) outcomes and perceived health care quality (physician
communication, nursing care, and coordination/responsiveness). Financial difficulties were scored by assessing patient perception of the extent to which their resources were meeting expenses for
their treatments, daily living, and other obligations. We used multivariate linear/logistic regression to test association between financial difficulties and each patient-reported outcome.
Full article at: https://link.springer.com/article/10.1007%2Fs00520-019-05208-y
Chua GP, Pang GSY, Yee ACP, Neo PSH, Zhou S, Lim C, Wong YY, Qu DL, Pan FT, Yang GM. BMC Cancer.2020; 20(1):768.
The impact and consequences of cancer on the patients and their family caregivers (FCs) are closely intertwined. Caregivers’ burdens can be increased due to the patients’ unmet needs
and unresolved problems. Additionally, the caregivers’ unmet needs may adversely affect their own well-being and the patients’ health outcomes. This study aims to determine the
palliative care needs and the factors associated with these needs in patients with advanced solid cancer and their FCs. In a cross-sectional survey, 599 patients with advanced solid tumours and
599 FCs were recruited from the largest ambulatory cancer centre and the inpatient ward of the largest hospital in Singapore. Determinants of patients’ and FCs’ needs were assessed by
the Comprehensive Needs Assessment Tool (CNAT) and CNAT-C respectively. Clinical characteristics of patients were obtained from medical records.
Overall, the findings confirm that patients with advanced cancer and their FCs have many palliative care needs irrespective of their clinical settings. Initiatives and interventions for the
development of a comprehensive support system for both patients with advanced cancer and their FCs are warranted and can be derived from these findings.
Full article at: https://bmccancer.biomedcentral.com/articles/10.1186/s12885-020-07239-9
Ning X, Krishnan A, Li X, Liu Z, Li J, Dai X, Ozdemir S, Malhotra C, Finkelstein EA, Teo I. Journal of Supportive Care in Cancer.2020;
Patient-perceived quality of care has become an increasingly important index within the healthcare setting. We examined patient-reported overall quality of care and patient experiences in three
specific domains of care (physician communication, nursing care, and care coordination) in a sample of Chinese patients with advanced cancer. A cross-sectional study was conducted with stage IV
cancer patients (N=202) who were recruited from a public, tertiary hospital in Beijing. Study participants completed surveys administered by a research assistant. Multivariable regression analysis
was conducted to examine the extent to which patient demographic factors (age, gender, socioeconomic status), disease/treatment factors, and domain-specific care were associated with overall
quality of care.
A majority of patients with advanced cancer in this Chinese hospital reported positive overall quality of care. Physician communication and care coordination are potential areas to focus on to
improve patient-reported overall quality of care. Understanding perceptions of care quality will allow opportunities to improve delivery of healthcare.
Full article at: https://link.springer.com/article/10.1007/s00520-020-05559-x
Teo I, Tan YP, Finkelstein EA, Yang GM, Pan FT, Lew H, Tan E, Ong S, Cheung YB. Journal of Pain and Symptom Management.2020; S0885-3924(20)30530-3.
The primary aims of this study were to examine the feasibility and acceptability of a cognitive behavioral therapy (CBT)-based intervention to improve coping with the disease. The secondary aim is
to evaluate preliminary intervention efficacy. Patients with advanced colorectal cancer in Singapore (N = 60) were randomized to either receive a four-session CBT intervention immediately or be
waitlisted. Intervention feasibility (i.e., recruitment and intervention adherence) and acceptability (i.e., participant satisfaction and cultural sensitivity) were assessed. Changes in
psychological distress and self-efficacy were examined. The study successfully recruited the intended sample (mean age 61; 62% men). A proportion (12%) reported Hospital Anxiety and Depression
Scale scores indicative of distress at baseline. Most (88%) completed all sessions. Participants reported high rates of satisfaction (97%), helpfulness (96%), and cultural sensitivity (95%) of the
intervention. The intervention group did not show decrease in psychological distress; however, self-efficacy in cancer-related coping (information seeking: effect size [ES] = 0.64; 95% CI = 0.17,
0.85; coping with side effects: ES = 0.69; 95% CI = 0.33, 0.82; and maintaining positive attitude: ES = 0.45; 95% CI = 0.19, 0.79) increased in the intervention group compared with the waitlisted
The CBT-based intervention was feasible and acceptable to patients in Singapore. There is no sufficient evidence to warrant a larger trial in this sample with low baseline distress. Future work
should identify and target those who are most in need of support.
Full article at: https://www.sciencedirect.com/science/article/abs/pii/S0885392420305303
Zain Z, Mohamad H, Seow D, Hum AYM, Allen JC, Tong KM, Malhotra R, Balasundaram B, Malhotra C. Journal of the American Geriatrics Society.2020;
Evidence suggests that tube feeding persons with severe dementia (PWSDs) does not improve survival or quality of life, yet many continue to be tube fed. Reasons why caregivers choose to do so are
not entirely understood. To understand what shapes caregiver preference toward nasogastric (NG) tube feeding for community‐dwelling PWSDs we conducted a qualitative study that employed
semistructured interviews. Participants included primary informal caregivers of community‐dwelling persons diagnosed with dementia Functional Assessment Staging Test (FAST) stage 7 in Singapore.
Caregivers participated in qualitative in‐depth interviews during which their preferences toward NG tube feeding of PWSDs were explored. We used principles of reflexive thematic analysis to
compare caregivers who expressed a preference for NG tube feeding with those who did not prefer it.
We interviewed 27 caregivers of PWSDs. Most caregivers, 67% (n = 18), expressed a preference for tube feeding. We conceptualized four main themes describing what shapes caregiver
preference toward NG tube feeding: (1) willingness to use tube feeding to prolong life at the expense of suffering, (2) deference to healthcare provider's (HCP’s) recommendation, (3)
caregiver knowledge of alternatives to tube feeding, and (4) caregivers' internal and external conflicts.
Results from this study highlight the need for new inclusive approaches to shared decision‐making between HCPs and caregivers regarding tube feeding for community‐dwelling PWSDs.
Full article at: https://doi.org/10.1111/jgs.16641
Mon SW, Ozdemir S, Zu WWM, Win H, Maw MM, Win KC, Thant KZ, Teo I, Krishnan A, Goh CR, Finkelstein EA, Malhotra C.
Asia-Pacific Journal of Clinical Oncolgy.2020: 10.1111/ajco.13371.
Access to palliative care services is essential for attaining universal health coverage for patients with a terminal cancer. Despite this, many patients with advanced cancer in low‐income
countries, such as Myanmar, suffer at the end of life (EOL) due to little or no access to palliative care. However, actual evidence on EOL experiences of cancer patients in Myanmar is lacking.
This paper aims to describe various dimensions of EOL experiences among patients with an advanced cancer from the largest public hospital in Myanmar. We surveyed 195 patients with stage IV cancer
seeking care from outpatient oncology clinics to assess their quality of life, pain severity, pain medications taken, quality of communication with doctors, nursing care and health care
coordination, and desire to end life sooner. We assessed socioeconomic status (SES) differences in each patient outcome using separate multivariate linear/logistic regressions.
Forty‐one percent of the patients in our sample reported that they wish their life would end sooner. Low SES cancer patients had significantly worse quality of life, reported poor health care
coordination and were more likely to report severe pain compared to high SES cancer patients visiting the same hospital.
To improve quality of life and pain management and to reduce EOL distress among patients with advanced cancer, there is a pressing need to develop and invest in hospital and community‐level
palliative care services in Myanmar.
Full article at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ajco.13373
Malhotra C, Vishwanath P, Yong JR, Truls O, Seow D, Yap P, Tan LL, Tham WY, Vaingankar J, Foo J, Tan BY, Tong KM, Ng WC, Allen JC, Malhotra R, Tan WM, Wee SL, Ng LL, Goveas R,
Mok V, Sim A, Ng WF, Wong HK, Balasundaram B, Tan RQ, Ong PS, Cheong CY, Yee A, Tiong C, Hum A, Lee A & Finkelstein EA. Journal of Alzheimer’s Disease.2020; 75(2):403-416.
Although many persons with severe dementia (PWSDs) are cared for at home by their family caregivers, few studies have assessed end of life (EOL) care experiences of PWSDs. We present the protocol
for the PISCES study (Panel study Investigating Status of Cognitively impaired Elderly in Singapore) which aims to describe the clinical course, health care utilization, and expenditures for
community-dwelling PWSDs; and perceived burden, coping, resilience, anticipatory and prolonged grief among their caregivers. This ongoing multi-centre prospective longitudinal study is recruiting
primary informal caregivers of 250 PWSDs from major restructured public hospitals, community hospitals, home care foundations, and hospices in Singapore. Caregivers are surveyed every four months
for two years or until the PWSD passes away and then at eight weeks and then six months post-death to assess the bereavement of the caregiver. Survey questionnaires included validated tools to
assess PWSDs’ quality of life, suffering, behaviors, functional status, resource utilization; and caregiver’s satisfaction with care, awareness of prognosis, care preferences,
resilience, coping, perceived burden, distress, positive aspects of caregiving, anticipatory grief and bereavement adjustment.
Full article at:
Cheung YB, Neo S, Yang GM, Teo I, Lee GL, Qu D, Koh A, Thumboo J, Wee HL. Journal of Patient-Reported Outcomes.2020; 4(1):34.
The Singapore Caregiver Quality of Life Scale (SCQOLS) was recently developed and validated in two languages - English and Chinese. The total and domain scores are scaled to range from 0 to 100.
However, the scale is not at the interval-ratio level of measurement. To facilitate interpretation, we established the percentiles of the scale’s total and domain scores among family
caregivers of patients with advanced cancers and demonstrate the effect size in terms of differences in relation to caregiver and patient characteristics. Methods: Data were drawn from a
cross-sectional survey of family caregivers of patients with stage III or IV solid cancers in Singapore. Quantile regression was used to estimate the percentiles in relation to caregiver and
patient characteristics. Results: Participants in adjacent categories of patient’s performance status and caregiver’s having other family members to share caregiving duties differed by
3 to 5 points in median quality of life total score and most domain scores (each Bonferroni-adjusted P, P[B], < 0.05). Ethnicity was associated with the Physical Well-being and Experience &
Meaning domain scores (each P[B] < 0.05), with variable direction and magnitude. Education was associated with Mental Well-being and Financial Well-being (each P[B] < 0.05). Equations and
examples for calculation of the percentiles are provided. Conclusion: Percentiles and effect size estimates are provided to facilitate interpretation of the SCQOLS.
Full article at: https://doi.org/10.1186/s41687-020-00201-0
Zhuang Q, Lau ZY, Ong WS, Yang GM, Tan KB, Ong M, Wong TH. PLoS One.2020; 15(4):e0232219.
Factors associated with place of death inform policies with respect to allocating end-of-life care resources and tailoring supportive measures. To determine factors associated with non-hospital
deaths among cancer patients. Retrospective cohort study of cancer decedents, examining factors associated with non-hospital deaths using multinomial logistic regression with hospital deaths as
the reference category. Cancer patients (n = 15254) in Singapore who died during the study period from January 1, 2012 till December 31, 2105 at home, acute hospital, long-term care (LTC) or
hospice were included.
We found key sociodemographic and clinical factors associated with non-hospital deaths in cancer patients. More can be done to enable patients to die in the community and with dignity rather than
in a hospital.
Full article at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232219
Yang GM, Neo SHS, Teo I, Lee GL, Thumboo J, Chia J, Lau A, Koh A, Qu D, Che WW, Wee HL, Glajchen M, Cheung YB. Journal of Patient Experience.2020;
Multilingual outcome measures are used so that research studies are more generalizable across language contexts. To determine the score equivalence of the English and Chinese versions of Brief
Assessment Scale for Caregivers (BASC) in Singapore. Caregivers of patients with advanced cancer completed the BASC in either English or Chinese. Multivariable linear regression analysis was used
to compare the mean BASC total and factor scores between the 2 language versions, with adjustment for possible confounding variables. Equivalence was declared if the 90% confidence interval of the
mean scores fell entirely within an equivalence zone of ±0.5 standard deviation. There were 521 ethnic Chinese participants, of whom 214 answered the English version and 307 answered the
Chinese version. The BASC total and factor scores met the criteria for equivalence. Cronbach α coefficients were similar and exploratory factor analysis showed similar 2-factor structures
for both language versions. The English and Chinese versions of the BASC were found to be equivalent in terms of similar adjusted mean scores, Cronbach α, and factor structures.
Full article at: https://journals.sagepub.com/doi/full/10.1177/2374373519836477
Chowdhury AR, Kanesvaran R, Tan KW, Pollak K, Malhotra C. Asia-Pacific Journal of Clinical Oncology.2020; 16(1):86-87.
The advent of new cancer therapies has improved prognosis but increased patients’ financial burden. American Society of Clinical Oncology thus recommends that oncologists discuss treatment
costs during consultations, but many cancer patients report never having these discussions. An objective assessment of actual patient‐oncologist consultations is, however, rare, especially in
Asia. To address this gap, we aimed to describe the prevalence and content of cost discussions during cancer consultations using audio recorded consultations. We used data from Singapore, where
out‐of‐pocket health expenditure is one of the highest among developed economies in the world.
We used audio recorded consultations from two studies. The first study (August‐September 2011) involved 20 cancer patients attending an initial oncology consultation, while the second (March
2015‐January 2016) involved 100 Stage IV cancer patients in an initial or follow‐up consultation. Of the 120 consultations, 53 (44%) involved cost discussions and were analyzed further for their
content. These 53 patients were on average 58 (SD: 13) years of age, 55% were females, and 66% were more than primary school educated. More than a third had two or more instances of cost
discussion. In 66% of the consultations, cost discussions were initiated by oncologist and in no case did the oncologist avoid discussing finances. Cost affected patient's choice of treatment in
17% consultations, and in 15% of the consultations oncologist even recommended a treatment based on cost. Patients requested financial aid in 17% and oncologists recommended it in 23% of the
consultations. Employment concerns were discussed in more than a quarter of the consultations. We observed only one instance of emotional response by patients/caregiver to treatment costs. We did
not observe any discordance between patient and caregiver regarding financial issues.
Full article at: https://onlinelibrary.wiley.com/doi/full/10.1111/ajco.13237
Vilardaga JCP, Winger JG, Teo I, Owen L, Sutton L, Keefe FJ, Somers TJ. Journal of Pain and Symptom Management.2020; 59(2):270-278.
The aim of the present study was to assess the feasibility and acceptability of telephone implementation of Engage, a novel brief combined Coping Skills Training and Acceptance and Commitment
Therapy protocol, for reducing symptoms and increasing quality of life in community patients with advanced cancer. Adult patients with advanced cancer receiving care in the community received
Engage, four 60-minute manualized telephone sessions delivered by a trained psychotherapist and completed pretreatment and post-treatment assessments. Engage was feasible, achieving 100% accrual
(N = 24) of a heterogeneous sample of patients with advanced cancer, with good retention (88% completed). Acceptability was demonstrated via satisfaction (mean 29 of 32; SD 2), engagement (95%
attendance), and use of skills. Engage, our brief novel combined Coping Skills and Acceptance and Commitment Therapy intervention, demonstrated initial feasibility and acceptability when delivered
over the telephone and increased access for community clinic patients with advanced cancer.
Full article at: https://www.sciencedirect.com/science/article/pii/S0885392419305251
Malhotra C, Kanesvaran R, Kumarakulasinghe NB, Tan SH, Xiang L, Tulsky JA, Pollak KI. Health Expectations.2020; 23(1):220-228.
Patient involvement in treatment decisions is recommended in clinician-patient encounters. Little is known about how oncologists engage patients in shared decision making in non-Western countries.
We assessed the prevalence of shared decision making among Singaporean oncologists and analysed how they discussed prognosis. We audio-recorded 100 consultations between advanced cancer patients
and their oncologists. We developed a coding system to assess oncologist encouragement of patient participation in decision making and disclosure of an explicit prognosis. We assessed patient and
oncologist characteristics that predicted these behaviours.
Forty-one consultations involved treatment discussions. Oncologists almost always listed more than one treatment option (90%). They also checked patient understanding (34%), discussed pros and
cons (34%) and addressed uncertainty (29%). Oncologists discussed prognosis mostly qualitatively (34%) rather than explicitly (17%). They were more likely to give an explicit prognosis when
patients/caregivers asked questions related to prognosis.
Oncologists in our sample engaged their patients in decision making. They have areas in which they can improve to involve patients at a deeper level to ensure shared decision making. Findings will
be used to develop an intervention targeting oncologists and patients to promote patient involvement in decision making.
Full article at: https://onlinelibrary.wiley.com/doi/epdf/10.1111/hex.12994
Malhotra C, Hu M, Malhotra R, Sim D, Jaufeerally FR, Bundoc FG, Finkelstein EA. Journal of General Internal Medicine.2020; 35(7):2010-2016.
Efforts to improve quality of end-of-life (EOL) care are increasingly focussed on eliciting patients’ EOL preferences through advance care planning (ACP). However, if patients’ EOL
preference changes over time and their ACP documents are not updated, these documents may no longer be valid at the time EOL decisions are made. To assess extent and correlates of changes in
stated preference for aggressive EOL care over time. Two hundred eighty-two patients with heart failure (HF) and New York Heart Association Classification III and IV symptoms were recruited and
interviewed every 4 months for up to 2 years to assess their preference for EOL care. Analytic sample included 200 patients interviewed at least twice. Nearly two thirds (64%) of patients changed
their preferred type of EOL care at least once. Proportion of patients changing their stated preference for type of EOL care increased with time and the change was not unidirectional. Patients who
understood their prognosis correctly were less likely to change their preference from non-aggressive to aggressive EOL care or to prefer aggressive EOL care. On the other hand, patient-surrogate
discussion of care preference was associated with a higher likelihood of change in patient preference from aggressive EOL care to non-aggressive EOL care.
The study provides evidence of instability in HF patients stated EOL care preference. This undermines the value of an ACP document recorded months before EOL decisions are made unless a strategy
exists for easily updating this preference.
Full article at: https://link.springer.com/article/10.1007%2Fs11606-020-05740-2
Cheung YB, Neo S, Yang GM, Lee GL, Teo I, Koh A, Thumboo J, Wee HL. Journal of Clinical Epidemiology.2020; 121:101-108.
The Singapore Caregiver Quality of Life Scale (SCQOLS) comprises five domains and 51 items in total. This study aimed to develop and evaluate short forms of SCQOLS. Data were collected from 612
family caregivers of patients with advanced cancers in Singapore. Exploratory factor analysis and best subset regression were used to identify candidate items for each domain. The short forms were
evaluated for measurement properties. Inclusion of at least two items per domain in the short form gave correlation coefficients of at least 0.8 with the corresponding domain scores in the
full-length version. The short forms and full-length version had similar correlation coefficients with Negative Personal Impact and Positive Personal Impact measures. Two of the five domains of
the 10-item version had Cronbach’s alpha ≤0.50 and test-retest reliability ≤0.65. A 15-item version of the scale with two to four items per domain performed satisfactorily in all
A 15-item short form of the SCQOLS (SCQOLS-15) is valid and reliable for the assessment of the overall and domain-specific quality of life of family caregivers. A 10-item short form (SCQOLS-10)
may serve as a quick, valid and reliable assessment of the overall level of quality of life.
Full article at: https://www.sciencedirect.com/science/article/pii/S0895435619304329
Malhotra C, Sim D, Jaufeerally FR, Hu M, Nadkarni N, Ng CSH, Wong G, Tan BC, Lim JF, Chuang CY, Finkelstein EA. Journal of Cardiac Failure.2020;
There is no evidence on effectiveness of advance care planning (ACP) among patients with heart failure (HF). We examined the effect of an ACP program in facilitating end of life (EOL) care
consistent with the preferences of patients with HF (primary aim), and on their decisional conflict, discussion with surrogates, illness understanding, anxiety, depression, and quality of life
(secondary aims). We randomized 282 patients with HF to receive ACP (n=93) or usual care (control arm, n=189). Primary outcomes were assessed among deceased (n=89) and secondary outcomes from
baseline and 6 follow-ups conducted every 4 months. Deceased patients in the ACP arm were no more likely than those in control arm to have wishes followed for EOL treatments (ACP: 35%, Control:
44%; P= .47), or place of death (ACP: 52%, Control: 51%; P = .1.00). A higher proportion in the ACP arm had wishes followed for cardiopulmonary resuscitation (ACP: 83%, Control: 62%; P = .12). At
first follow-up, patients with ACP had lower decisional conflict (β = −10.8, P< .01) and were more likely to discuss preferences with surrogates (β = 1.3, P = .04). ACP did not
influence other outcomes.
This trial did not confirm that our ACP program was effective in facilitating EOL care consistent with patient preferences. The program led to short-term improvements in the decision-making.
Full article at: https://www.sciencedirect.com/science/article/abs/pii/S1071916419314940
Teo I, Vilardaga JP, Tan YP, Winger J, Cheung YB, Yang GMJ, Finkelstein EA, Shelby RA, Kamal AH, Kimmick G, Somers TJ. Psycho-oncology.2020;
Advanced breast cancer patients around the world experience high symptom burden (i.e., distress, pain, and fatigue) and are in need of psychosocial interventions that target symptom management.
This study examined the feasibility, acceptability, and engagement of a psychosocial intervention that uses cognitive‐behavioral strategies along with mindfulness and values‐based activity to
enhance patients' ability to manage symptoms of advanced disease in a cross‐cultural setting (United States and Singapore). Pre‐treatment to post‐treatment outcomes for distress, pain, and fatigue
were compared between intervention recipients and waitlisted controls.
A pilot randomized controlled trial included women with advanced breast cancer (N = 85) that were recruited in the United States and Singapore. Participants either received the four-session
intervention or be put on waitlist. Descriptive statistics and effect size of symptom change were calculated. The psychosocial intervention was found to be feasible as indicated through successful
trial accrual, low study attrition (15%), and high intervention adherence (77% completed all sessions). Acceptability (i.e., program satisfaction and cultural sensitivity) and engagement to the
study intervention (i.e., practice of skills taught) were also high. Anxiety, depression, and fatigue scores remained stable or improved among intervention participants while the same symptoms
worsened in the control group. In general, effect sizes are larger in the US sample compared with the Singapore sample.
The cognitive‐behavioral, mindfulness, and values‐based intervention is feasible, acceptable, and engaging for advanced breast cancer patients in a cross‐cultural setting and has potential for
efficacy. Further larger‐scaled study of intervention efficacy is warranted.
Full article at: https://onlinelibrary.wiley.com/doi/full/10.1002/pon.5275
Cheung YB, Neo SHS, Teo I, Yang GM, Lee GL, Thumboo J, Chia JWK, Koh ARX, Qu DLM, Che WWL, Lau A, Wee HL. Health and Quality of Life Outcomes.2019; 17(1):35.
The quality of life of family caregivers of patients with advanced cancers is an important concern in oncology care. Yet, there are few suitable measurement scales available for use in Asia. The
study aims to develop and evaluate a locally derived measurement scale in English and Chinese to assess the quality of life of family caregivers of patients with advanced cancers in Singapore.
Full article at: https://link.springer.com/article/10.1186/s12955-019-1108-y
Ozdemir S, Jafar TH, Choong LHL, Finkelstein EA. BMC Nephrology.2019; 20(1):73.
Elderly end stage kidney patients face a decision concerning whether or not to initiate dialysis. In Asia, this decision is highly influenced by family caregivers. The objective of this paper was
to understand patients’ experience with and preferences for family involvement in treatment decisions, and via a series of hypothetical vignettes, to identify whether there was discordance
in treatment preferences between patients and their caregivers, and how any potential conflicts were reconciled.
Full article at: https://link.springer.com/article/10.1186/s12882-019-1259-4
Yang GM, Pang GSY, Lee GL, Neo PSH, Wong YY, Qu DL, Cheung YB. Progress in Palliative Care.2019; 27(3):103-108.
The 41-item Comprehensive Needs Assessment Tool for Cancer Caregivers (CNAT-C) is an English language survey for needs assessment developed and validated in South Korean cancer caregivers. The
objective of this study was to validate both the English and a translated Chinese version of the CNAT-C in cancer caregivers in Singapore. This was a cross-sectional survey where cancer caregivers
completed the CNAT-C and World Health Organisation Quality-of-life BREF (WHOQOL-BREF) in English or Chinese. Cronbach’s alpha was used to measure internal consistency. Convergent validity
was assessed using Pearson correlation coefficients between CNAT-C scores and WHOQOL-BREF domains. For known groups validity, independent samples t-test was used to compare CNAT-C scores based on
Karnofsky performance status. In summary, there was low to moderate convergent validity with the WHOQOL-BREF for both the English and translated Chinese versions. However, both language versions
of CNAT-C showed good internal consistency and good known groups validity according to performance status, and both language versions of the CNAT-C can be used to assess the level of unmet needs
for cancer caregivers in the Singapore context.
Full article at:
Yang GM, Pang GS, Lee GL, Neo PSH, Wong YY, Qu DL, Cheung YB. Indian Journal of Palliative Care.2019; 25(3):374-378.
The 59-item Comprehensive Needs Assessment Tool (CNAT) for cancer patients is an English language survey developed in South Korea. The objective of this study was to validate the English version
of CNAT in advanced cancer patients in Singapore.
Full article at: https://pubmed.ncbi.nlm.nih.gov/31413451/
Teo I, Krishnan A, Lee GL. Psycho-Oncology.2019; 28(7):1394-1407.
Psychosocial care for advanced cancer encompasses a wide range of interventions that help patients make life‐changing decisions, manage debilitating symptoms, confront impending mortality, and
improve other patient outcomes. Psychosocial care is becoming increasingly available to advanced cancer patients; however, an overview of the various types of interventions is lacking. The
objective of this review was to summarise the current and growing body of research in psychosocial interventions for advanced cancer patients without focusing solely on intervention effectiveness.
Thus, we did not exclude studies based on methodological quality. The aim was to provide a synthesis of evidence from studies with robust results together with preliminary findings to obtain a
broad snapshot of the field.
Full article at: https://onlinelibrary.wiley.com/doi/full/10.1002/pon.5103
Neo SHS, Yang GM, Kanesvaran R, Cheung YB. Journal of Pain and Symptom Management.2019; 58(5):878-885.
Family satisfaction with care is an important quality indicator in palliative care. This study aimed to translate and validate the 10-item Family Satisfaction with End-of-Life Care (FAMCARE) tool.
Family caregivers of patients with advanced cancer were recruited. FAMCARE was translated from English to Chinese using a forward and backward translation process. Chinese-speaking caregivers were
interviewed with the preliminary Chinese FAMCARE, and phrasing was edited to ensure clarity of the items. Subsequently, a baseline and follow-up survey in English and the finalized Chinese version
were performed to assess psychometric properties.
Cronbach's alpha (α) and intraclass correlation coefficient were used for internal consistency and test-retest reliability, respectively. Validity was assessed with Spearman's correlation
coefficient (r). The Comprehensive Needs Assessment Tool-Caregiver (CNAT-C) and a one-item assessment by caregivers regarding “good-care” acted as a validity criterion. Pooled analysis
of both languages and language-specific analyses were performed. FAMCARE showed good reliability and validity.
Full article at: https://doi.org/10.1016/j.jpainsymman.2019.07.018
Chan A, Saito Y, Matchar DB, Ostbye T, Malhotra C, Ang S, Ma S, Malhotra R. International Journal of Epidemiology.2019; 48(6):1750-1751.
Singapore is one of the world’s most rapidly ageing countries. The proportion of the population aged ≥60 years (hereafter, elderly), 19.7% in the year 2017, is expected to reach
40% by 2050. This increase is primarily driven by declining fertility rates and increasing life expectancy. In addition, the number of elderly Singaporeans living alone or only with an unrelated
elderly person has been increasing in recent years, in turn raising concerns regarding their social isolation and associated health risks. Given the emphasis on filial piety and the
elderly’s reliance on intergenerational transfers in Asian societies, understanding the profile of familial support and living arrangements of the elderly within the Singapore context has
wide-ranging implications for health and social policy.
Full article at: https://academic.oup.com/ije/article-abstract/48/6/1750/5543461
Rohde GE, Young T, Winstanley J, Arraras JI, Black K, Boyle F, Bredart A, Constantini A, Guo J, Irarrazaval ME, Kobayashi K, Kruizinga R, Navarro M, Omidvari S, Serpentini S, Spry N, van
Laarhoven H, Yang GM, Vivat B. European Journal of Cancer Care.2019; 28(6):e13145.
The EORTC QOL Group has recently completed the cross‐cultural development and validation of a standalone measure of spiritual well‐being (SWB) for cancer patients receiving palliative care: the
EORTC QLQ‐SWB32. The measure includes four scales: Relationships with Others, Relationship with Self, Relationship with Someone or Something Greater, and Existential, plus a Global‐SWB item. This
paper reports on further research investigating relationships between sex, age and SWB for patients receiving palliative care for cancer—adjusting for other socio‐demographic, clinical and
function variables, including WHO performance status and EORTC QLQ‐C15‐PAL emotional and physical function score. The findings suggest that it might be beneficial if healthcare providers seeking
to address patients’ spiritual needs pay particular attention to male patients, younger patients, and those with poor emotional functioning.
Full article at: https://onlinelibrary.wiley.com/doi/full/10.1111/ecc.13145
Han E, Haldane V, Koh JJK, Quek RYC, Ozdemir S, Finkelstein EA, Jafar TH, Choong HL, Gan S, Lim LWW, Shiraz F, Legido-Quigley H. Health Expectations.2019;
End‐stage renal disease (ESRD) is increasing both globally and in Asia. Singapore has the fifth highest incidence of ESRD worldwide, a trend that is predicted to rise. Older patients with ESRD are
faced with a choice of haemodialysis, peritoneal dialysis or conservative management, all of which have their risks and benefits. This study seeks to explore perspectives on decision making
amongst older (≥70) Singaporean ESRD patients and their caregivers to undergo (or not to undergo) dialysis. While some patients believed that they had made an independent treatment decision,
others reported feeling like they had no choice in the matter or that they were strongly persuaded by their doctors and/or family members to undergo dialysis. Patients reported decision‐making
factors including loss of autonomy in daily life, financial burden (on themselves or on their families), caregiving burden, alternative medicine, symptoms, and disease progression. Caregivers also
reported concerns about financial and caregiving burden. This study has identified several factors that should be considered in the design and implementation of decision aids to help older ESRD
patients in Singapore make informed treatment decisions, including patients' and caregivers' decision‐making factors as well as the relational dynamics between patients, caregivers and doctors.
Full article at: https://onlinelibrary.wiley.com/doi/full/10.1111/hex.12943
Han E, Shiraz F, Haldane V, Koh JJK, Quek RYC, Ozdemir S, Finkelstein EA, Jafar TH, Choong HL, Gan S, Lim LWW, Legido-Quigley H. BMC Public Health.2019; 19(1):1107.
As the incidence and prevalence rates of end stage renal disease (ESRD) rise globally, a disproptionate increase has been observed in the elderly population. Singapore has the fifth highest
incidence of treated ESRD worldwide, with the upward trend of ESRD being most apparent among those aged 70 years and older. Although it is well-documented that ESRD patients suffer an impaired
quality of life compared to the general population, there is limited research focusing on the unique experiences and needs of elderly ESRD patients in Asian populations. To address the knowledge
gap, this study seeks to explore the impact of ESRD and dialysis on the quality of life of elderly ESRD patients in Singapore and examine the coping strategies utilised by these patients.
Full article at: https://link.springer.com/article/10.1186/s12889-019-7433-6
Ozdemir S, Malhotra C, Teo I, Yang GM, Kanesvaran R, YEE ACP, Finkelstein EA. Annals Academy of Medicine, Singapore.2019; 48(8):241-246.
We investigated the awareness of palliative care (PC) services in advanced cancer patients and their family caregivers and whether negative perceptions was a possible barrier to PC utilisation in
Singapore. Patients with stage 4 solid cancer and their caregivers were interviewed between July 2016 and March 2018 at outpatient clinics located in the medical oncology departments of 2 major
public hospitals in Singapore. Patients and caregivers were asked whether they were aware of PC services, how they first learned about them, who first recommended PC to the patient, whether the
patient had received PC, and reasons for not receiving PC. Awareness of PC was lower in patients compared to caregivers (43% vs 53%). The odds of being aware in patients was higher if they had
higher education and higher income. Compared to patients, more caregivers reported that a healthcare provider recommended PC to the patient. Furthermore, 7% of patients and 15% of caregivers
reported that the patient received PC. The most common reasons for not receiving PC reported by patients and caregivers (respectively), were that the patient was still receiving treatment (68 %
and 78%), it is not time for PC (76% and 59%) and PC would not be of help (18% and 19%). Our findings suggest that efforts should be made to increase awareness of PC and promote its acceptance in
cancer patients and their family caregivers in Singapore.
Full article at: http://www.annals.edu.sg/pdf/48VolNo8Aug2019/V48N8p241.pdf
Jacob J, Palat G, Verghese NR, Chandran P, Rapelli V, Kumari S, Malhotra C, Teo I, Finkelstein EA, Ozdemir S. BMC Palliative Care.2019;18(1):94.
Patients with advanced cancer often experience poor health-related quality-of-life (HRQoL) due to cancer and treatment-related side-effects. With India’s palliative care landscape in its
infancy, there is a concern that advanced cancer patients, especially individuals who are from disadvantaged populations experience poor HRQoL outcomes. We aim to assess HRQoL of advanced cancer
patients in terms of general well-being (physical, functional, emotional, and social/ family well-being), pain experiences, psychological state, and spiritual well-being, and determine the
relationship between belonging to a disadvantaged or minority backgrounds, identified in this paper as financially distressed, female, lower years of education, lower social/family support,
minority religions, and Non-General Castes, would be associated with worse HRQoL outcomes compared to those who are not from a disadvantaged group.
Full article at: https://link.springer.com/article/10.1186/s12904-019-0465-y
Lim H, Chua TE, Malhotra R, Allen J, Teo I, Chern BSM, Tan KH, Chen H. General Hospital Psychiatry.2019; 61:26-33.
The present study sought to determine the longitudinal trajectories of antenatal depression and examine their associations with birth outcomes. 926 healthy women with uncomplicated singleton
pregnancies within 14 weeks of gestation participated in this prospective cohort study. Women completed a sociodemographic and medical questionnaire and the locally-validated Edinburgh Postnatal
Depression Scale (EPDS) in their first, second, and third trimesters, and prior to parturition. Gestational age and neonatal weight, length, and head circumference were recorded at birth.
Group-based trajectory modelling characterized trajectories of antenatal depression. Four distinct non-fluctuating trajectories of depressive symptoms were identified, with 9% women suffering from
probable clinical depression throughout the pregnancy. Women in this persistently-moderate depression trajectory delivered 2.48 days earlier than in other trajectories; a one-point increase in
EPDS scores was associated with an adjusted reduction of 5.82 g in birthweight. Although meaningful trajectories were identified, no clinically relevant associations between persistently-moderate
depressive symptoms with neonatal outcomes were found. The stability of these trajectories, however, suggests the importance of screening for depressive symptoms early in pregnancy to identify
women who may benefit from greater formal and informal support.
Full article at: https://www.sciencedirect.com/science/article/pii/S0163834319302002
Teo I, Baid D, Ozdemir S, Malhotra C, Singh R, Harding R, Malhotra R, Yang GM, Neo SHS, Cheung YB, Neo PSH, Kanesvaran R, Kumarakulasinghe NB, Lee LH, Koh G,
Finkelstein EA, COMPASS study group. BMJ Supportive & Palliative Care.2019. Published Online First. doi.org/10.1136/bmjspcare-2019-001979.
Family caregivers of patients with advanced cancer have been reported to provide long hours of care and be at risk for poor psychological outcomes. Although research has focused on the nature of
caregiving burden, little attention has been paid to identifying protective factors that improve caregiver psychological outcomes. We examined the relationship between caregivers’ time spent
caregiving and the following psychological outcomes: anxiety, depression and caregiving esteem. Subsequently, we explored the main and moderating effects of caregiver-perceived self-competency and
sense of meaning on caregiver psychological outcomes.
Cross-sectional analysis was conducted using the baseline data from an ongoing cohort study. Family caregivers of advanced cancer patients (n=287) were recruited from two tertiary hospitals in
Singapore. Time spent caregiving was not significantly associated with caregiver anxiety, depression or caregiving esteem. However, significant main effects of self-competency on anxiety and
caregiving esteem; and sense of meaning on anxiety, depression and caregiving esteem were observed. Moderator analyses further indicated that self-competency attenuated the positive relationship
between time spent caregiving and anxiety, while sense of meaning attenuated the negative relationship between time spent caregiving and caregiving esteem. Our findings suggest that screening
caregivers for distress is an important part of care, and that supportive interventions for caregivers should aim to enhance their perceived caregiving competencies and the ability to make meaning
of their caregiving role.
Full article at: https://spcare.bmj.com/content/early/2019/12/05/bmjspcare-2019-001979.long
Malhotra C, Rajasekaran T, Kanesvaran R, Yee A, Bundoc FG, Singh R, Tulsky JA, Pollak KI. Journal of Oncology Practice.2019; 16(2):e190-e200.
High-quality end-of-life cancer care requires oncologists to communicate effectively and patients/caregivers to be participatory. However, most communication interventions target either but not
both. We aimed to pilot a potentially disseminable combined oncologist-patient/caregiver intervention to improve oncologist empathic responses, discussions of prognosis and goals of care, and
patient/caregiver participation. We assessed its feasibility, acceptability, and preliminary efficacy. Between June 2018 and January 2019, we conducted a pilot 2-arm cluster trial in Singapore,
randomly assigning 10 oncologists in a 1:1 ratio to receive the combined intervention or usual care. Intervention arm oncologists received online communication skills training, and their patients
received a brief prompt sheet before consultations. We audio recorded consultations with 60 patients with stage IV solid malignancy and analyzed 30 in the postintervention phase. The study was not
powered for statistical significance. All oncologists completed the online training within an average of 4.5 weeks; 73% of the patients selected at least 1 question in the prompt sheet. Compared
with the control arm, intervention arm oncologists had more empathic responses in total (relative risk [RR], 1.66) and for every patient/caregiver negative emotion (RR, 2.01). Their consultations
were more likely to involve discussions of prognosis (RR, 3.00) and goals of care, and their patients were more likely to ask a prognosis-related question.
The combined oncologist-patient/caregiver intervention is feasible and acceptable and has the potential to improve communication within consultations.
Full article at: https://ascopubs.org/doi/full/10.1200/JOP.19.00412
Teo I, Cheng GHL, Tewani K. Annals Academy of Medicine, Singapore.2019; 48(12):396-402.
Few studies in Asia have examined the association among depressive symptoms, relationship satisfaction, sexual dysfunction and emotional expressiveness. Examining the role of emotional
expressiveness in the context of depression and relationships is important as it can be a point for therapeutic intervention. Guided by the Marital Discord Model of Depression and based on data
from partnered women in Singapore (n = 193), we conducted a path analysis to examine the mediating role of relationship satisfaction and sexual dysfunction in the link between difficulty in
emotional expression and depressive symptoms. Controlling for age and health, lower relationship satisfaction, higher sexual dysfunction and greater difficulty in emotional expression were
associated with increased depressive symptoms. Relationship satisfaction partially mediated the association between emotional expressiveness and depressive symptoms. The findings suggest the
importance of effective communication in mitigating relationship – and self-distress.
Full article at: http://www.annals.edu.sg/pdf/48VolNo12Dec2019/V48N12p396.pdf
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/
Ozdemir S, Finkelstein EA. Cognitive Bias: Journal of Clinical Oncology Cancer Informatics.2018; 2:1-10
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
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
Full article at: https://doi.org/10.1089/jpm.2017.0186
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
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:
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:
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;
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
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:
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..
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