Ngan Phoon Fong

Risk perception and impact of severe acute respiratory syndrome (SARS) on work and personal lives of healthcare workers in Singapore : What can we learn?

Introduction:Healthcare workers (HCWs) were at the frontline during the battle against Severe Acute Respiratory Syndrome (SARS). Understanding their fears and anxieties may hold lessons for handling future outbreaks, including acts of bioterrorism. Method:We measured risk perception and impact on personal and work life of 15,025 HCWs from 9 major healthcare institutions during the SARS epidemic in Singapore using a self-administered questionnaire and Impact of Events Scale and analyzed the results with bivariate and multivariate statistics. Results:From 10,511 valid questionnaires (70% response), we found that although the majority (76%) perceived a great personal risk of falling ill with SARS, they (69.5%) also accepted the risk as part of their job. Clinical staff (doctors and nurses), staff in daily contact with SARS patients, and staff from SARS-affected institutions expressed significantly higher levels of anxiety. More than half reported increased work stress (56%) and work load (53%). Many experienced social stigmatization (49%) and ostracism by family members (31%), but most (77%) felt appreciated by society. Most felt that the personal protective measures implemented were effective (96%) and that the institutional policies and protocols were clear (93%) and timely (90%). Conclusion:During epidemics, healthcare institutions have a duty to protect HCWs and help them cope with their personal fears and the very stressful work situation. Singapores experience shows that simple protective measures based on sound epidemiological principles, when implemented in a timely manner, go a long way to reassure HCWs.

Comorbid cognitive impairment and depression is a significant predictor of poor outcomes in hip fracture rehabilitation

BACKGROUND The effects of depression and cognitive impairment on hip fracture rehabilitation outcomes are not well established. We aimed to evaluate the associations of depressive symptoms and cognitive impairment (individually and combined) with ambulatory, living activities and quality of life outcomes in hip fracture rehabilitation patients. METHODS A cohort of 146 patients were assessed on depressive symptoms (Geriatric Depression Scale, GDS > or = 5), cognitive impairment (Mini-mental State Examination, MMSE < or = 23), and other variables at baseline, and on ambulatory status, Modified Barthel Index (MBI), and SF-12 PCS and MCS quality of life on follow ups at discharge, 6 months and 12 months post fracture. RESULTS In these patients (mean age 70.8 years, SD 10.8), 7.5% had depressive symptoms alone, 28.8% had cognitive impairment alone, 50% had both, and 13.7% had neither (reference). Ambulatory status showed improvement over time in all mood and cognition groups ((beta = 0.008, P = 0.0001). Patients who had cognitive impairment alone (beta = -0.060, P = 0.001) and patients who had combined cognitive impairment with depressive symptoms beta = -0.62, P = 0.0003), showed significantly less improvement in ambulatory status than reference patients. In the latter group, the relative differences in ambulatory scores from the reference group were disproportionately greater over time (beta = -0.003, SE = 0.001, P = 0.021). Patients with combined depressive symptoms and cognitive impairment also showed a significantly lower MBI score, (beta = -10.92, SE = 4.01, P = 0.007) and SF-12 MCS (beta = -8.35, SE = 2.37, P = 0.0006). Mood and cognition status did not significantly predict mortality during the follow-up. CONCLUSION Depression and cognitive impairment comorbidity is common in hip fracture rehabilitation patients and significantly predicts poor functional and quality of life outcomes.

Prevalence and risk factors of depression in the elderly nursing home residents in Singapore

Objectives: Depression is a common health problem in elderly nursing home (NH) residents and is often under-recognized and under-treated. This study aimed to determine the prevalence rates of depression and identify the risk factors associated with depression in the elderly NH population in Singapore. Methods: A sample of 375 residents in six NHs in Singapore, aged 55 years and above, was assessed with the Structural Clinical Interview (SCID), based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. The association of demographic, functional and health-related characteristics with depression was examined using multivariate logistic regression analyses. Results: Overall point prevalence for depression in the elderly NH residents was found to be 21.1% (95% confidence intervals (CI): 17.1%–25.6%). The prevalence rate for minor depression in the elderly NH residents was 14.4% (95% CI: 11.1%–18.5%) and 6.7% (95% CI: 4.5%–9.8%) for major depression. Significant risk factors that were found to be associated with depression were length of stay for more than 2 years, known history of depression, pain, and no or lack of social contact. Conclusion: The prevalence rates for depression were high among NH residents in Singapore. More attention is needed to care for the psychosocial needs of elderly NH residents in Singapore.

The synergistic effect of functional status and comorbidity burden on mortality: a 16-year survival analysis.

Objectives The relationship between disability and comorbidity on mortality is widely perceived as additive in clinical models of frailty. Design National data were retrospectively extracted from medical records of community hospital. Data Sources There were of 12,804 acutely-disabled patients admitted for inpatient rehabilitation in Singapore rehabilitation community hospitals from 1996 through 2005 were followed up for death till 31 December 2011. Outcome Measure Cox proportional-hazards regression to assess the interaction of comorbidity and disability at discharge on all-cause mortality. Results During a median follow-up of 10.9 years, there were 8,565 deaths (66.9%). The mean age was 73.0 (standard deviation: 11.5) years. Independent risk factors of mortality were higher comorbidity (p<0.001), severity of disability at discharge (p<0.001), being widowed (adjusted hazard ratio [aHR]: 1.38, 95% confidence interval [CI]:1.25–1.53), low socioeconomic status (aHR:1.40, 95%CI:1.29–1.53), discharge to nursing home (aHR:1.14, 95%CI:1.05–1.22) and re-admission into acute care (aHR:1.54, 95%CI:1.45–1.65). In the main effects model, those with high comorbidity had an aHR = 2.41 (95%CI:2.13–2.72) whereas those with total disability had an aHR = 2.28 (95%CI:2.12–2.46). In the interaction model, synergistic interaction existed between comorbidity and disability (p<0.001) where those with high comorbidity and total disability had much higher aHR = 6.57 (95%CI:5.15–8.37). Conclusions Patients with greater comorbidity and disability at discharge, discharge to nursing home or re-admission into acute care, lower socioeconomic status and being widowed had higher mortality risk. Our results identified predictive variables of mortality that map well onto the frailty cascade model. Increasing comorbidity and disability interacted synergistically to increase mortality risk.

Colorectal Cancer Screening The Effectiveness of Education on Its Barriers and Acceptability

To assess the awareness and acceptability of colorectal cancer (CRC) screening in noncompliant Singaporeans and to determine if their barriers can be overcome by education. A questionnaire developed from thematic analysis of open-ended interviews with 72 subjects was administered to 580 residents in a local high-rise housing estate. Participants aware of CRC screening were assessed for barriers and acceptability of CRC screening. All participants were subsequently educated about CRC screening and reassessed for barriers and acceptance. Those keen for fecal occult blood testing (FOBT) were offered FOBT kits and followed up. CRC screening awareness was poor. Having no symptoms was the most common barrier. More barriers to FOBT than to colonoscopy were reduced with education. After education, acceptability toward FOBT increased but rejection rates rose even higher. FOBT is probably Singapore’s most acceptable screening modality. Education is limited by barriers, which need to be overcome by alternative measures.

Factors Associated with Nursing Home Placement of All Patients Admitted for Inpatient Rehabilitation in Singapore Community Hospitals from 1996 to 2005: A Disease Stratified Analysis

Objectives To (1) identify social and rehabilitation predictors of nursing home placement, (2) investigate the association between effectiveness and efficiency in rehabilitation and nursing home placement of patients admitted for inpatient rehabilitation from 1996 to 2005 by disease in Singapore. Design National data were retrospectively extracted from medical records of community hospital. Data Sources There were 12,506 first admissions for rehabilitation in four community hospitals. Of which, 8,594 (90.3%) patients were discharged home and 924 (9.7%) patients were discharged to a nursing home. Other discharge destinations such as sheltered home (n = 37), other community hospital (n = 31), death in community hospital (n = 12), acute hospital (n = 1,182) and discharge against doctor’s advice (n = 24) were excluded. Outcome Measure Nursing home placement. Results Those who were discharged to nursing home had 33% lower median rehabilitation effectiveness and 29% lower median rehabilitation efficiency compared to those who were discharged to nursing homes. Patients discharged to nursing homes were significantly older (mean age: 77 vs. 73 years), had lower mean Bathel Index scores (40 vs. 48), a longer median length of stay (40 vs. 33 days) and a longer time to rehabilitation (19 vs. 15 days), had a higher proportion without a caregiver (28 vs. 7%), being single (21 vs. 7%) and had dementia (23 vs. 10%). Patients admitted for lower limb amputation or falls had an increased odds of being discharged to a nursing home by 175% (p<0.001) and 65% (p = 0.043) respectively compared to stroke patients. Conclusions In our study, the odds of nursing home placement was found to be increased in Chinese, males, single or widowed or separated/divorced, patients in high subsidy wards for hospital care, patients with dementia, without caregivers, lower functional scores at admission, lower rehabilitation effectiveness or efficiency at discharge and primary diagnosis groups such as fractures, lower limb amputation and falls in comparison to strokes.

Rehabilitation Outcomes After Inpatient Rehabilitation for Lower Extremity Amputations in Patients With Diabetes

OBJECTIVE To identify factors associated with functional gain, discharge destination, and long-term survival after inpatient rehabilitation in patients with lower extremity amputation and diabetes. DESIGN Retrospective medical records review. SETTING All community hospitals. PARTICIPANTS Patients with diabetes (N=256) admitted for inpatient rehabilitation after lower extremity amputation. INTERVENTIONS Not applicable. MAIN OUTCOMES MEASURES Absolute functional gain (AFG) using the Shah-modified Barthel Index, discharge destination, and long-term survival for each patient. RESULTS Length of stay (B=.15; 95% confidence interval [CI], .08-.21; P<.001) and admission functional status (B=-.09; 95% CI, -.18 to -.01; P=.032) were significantly associated with AFG. Availability of caregiver (foreign domestic worker: odds ratio [OR], 16.39; 95% CI, 4.65-57.78; P<.001; child: OR, 3.82; 95% CI, 1.31-11.12; P=.014; spouse: OR, 2.82; 95% CI, 1.07-7.46; P=.037 vs none), Charlson Comorbidity Index of 1 (OR, 4.32; 95% CI, 1.34-13.93; P=.014 vs ≥4), and younger age (OR, .96; 95% CI, .93-.99; P=.02) were significantly associated with being discharged home. Admission functional status (hazard ratio [HR], .98; 95% CI, .97-.99; P<.001), AFG (HR, .99; 95% CI, 0.97-1.00; P=.058), Charlson Comorbidity Index (1 vs ≥4: HR, .42; 95% CI, .24-.77; P=.004), ischemic heart disease (HR, 2.25; 95% CI, 1.27-4.00; P=.006), discharge destination (other vs home: HR, 1.82; 95% CI, 1.02-3.23; P=.041), age (HR, 1.02; 95% CI, 1.00-1.03; P=.082), and ethnicity (Malay vs Chinese: HR, .37; 95% CI, .16-.87; P=.022) predicted survival postamputation. CONCLUSIONS Admission functional status predicted both functional gain during rehabilitation and survival in these patients. We also found ethnic differences in outcomes, with Malays having better survival after amputation. Lastly, there appears to be greater reliance on foreign domestic workers as caregivers, with patients with foreign domestic workers as their primary caregiver having the highest odds of being discharged home.

Using peer review to distribute group work marks equitably between medical students

BackgroundAlthough peer assessment has been used for evaluating performance of medical students and practicing doctors, it has not been studied as a method to distribute a common group work mark equitably to medical students working in large groups where tutors cannot observe all students constantly.MethodsThe authors developed and evaluated a mathematical formulation whereby a common group mark could be distributed among group members using peer assessment of individual contributions to group work, maintaining inter-group variation in group work scores. This was motivated by community health projects undertaken by large groups of year four medical students at the National University of Singapore, and the new and old formulations are presented via application to 263 students in seven groups of 36 to 40 during the academic year 2012/2013.ResultsThis novel formulation produced a less clustered mark distribution that rewarded students who contributed more to their team. Although collusion among some members to form a voting alliance and ‘personal vendettas’ were potential problems, the former was not detected and the latter had little impact on the overall grade a student received when working in a large group. The majority of students thought the new formulation was fairer.ConclusionsThe new formulation is easy to implement and arguably awards grades more equitably in modules where group work is a major component.

Caregivers: Do They Make a Difference to Patient Recovery in Subacute Stroke?

OBJECTIVE To evaluate the relationship between caregiver nature and availability, and rehabilitation outcomes in subacute stroke. DESIGN Retrospective cohort study. SETTING Four community rehabilitation hospitals. PARTICIPANTS Patients with subacute, first-time stroke (N=4042; 48.5% men; mean age ± SD, 70.12±10.4y; 51.5% women; mean age ± SD, 72.54 ±10.0y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehabilitation effectiveness, defined as the percentage of potential improvement eventually achieved with rehabilitation; and rehabilitation efficiency, defined as the rate of functional improvement during rehabilitation. RESULTS In our cohort, 96.7% had available caregiver(s), of which 42.0% were primarily supported by foreign domestic workers (FDWs), 25.9% by spouses, 19.3% by first-degree relatives, 7.8% by other relatives, and 5.1% by other caregivers. Using quantile regression, we found that having a caregiver was independently associated with rehabilitation efficiency (β=-3.83; 95% confidence interval [CI], -6.99 to -0.66; P=.018). The relationship between caregiver availability and rehabilitation effectiveness was modified by patient sex in that the negative association was significantly greater in men (β=-22.81; 95% CI, -32.70 to -12.94; P<.001) than women (β=-5.64; 95% CI, -14.72 to 3.44; P=.223). Having a FDW as a caregiver compared with a spousal caregiver was negatively associated with rehabilitation effectiveness (β=-3.95; 95% CI, -6.94 to -0.95; P=.01) and rehabilitation efficiency (β=-1.83; 95% CI, -3.14 to -0.53; P=.006). The number of potential caregivers was only significantly associated with rehabilitation effectiveness at the bivariate level (P=.006). CONCLUSIONS Caregiver identity, and possibly availability, appears to negatively affect rehabilitation outcomes in subacute stroke. A better understanding of these relationships has potential implications on clinical practice and policy directions.

Is there an Association Between Caregiver Factors and Rehabilitation Outcomes in Stroke

Research Objectives: To evaluate the relationship between caregiver factors and rehabilitation outcomes in subacute stroke patients. Design: Retrospective cohort study. Setting: Four subacute inpatient rehabilitation units in Singapore. Participants: 4042 subacute stroke patients. Interventions: Not applicable. Main Outcome Measure(s): (i) Rehabilitation effectiveness (REs), defined as the percentage of potential improvement achieved with rehabilitation; and (ii) rehabilitation efficiency (REy), defined as the rate of functional improvement during rehabilitation. Results: Among stroke survivors undergoing inpatient rehabilitation, 96.73% had potential caregivers, of which 41.97%were supported by foreign domestic workers (FDWs), 25.86% by spouses and 19.28% by first-degree relatives. At a bivariate level, caregiver availability and caregiver identity was significantly associated with REs and REy (all p<0.05), whilst the number of caregivers was only significantly associated with REs (pZ0.006). After adjusting for identified confounders using quantile regression, having a caregiver was associated with poorer REy (-3.83, 95% CI -6.99 to -0.66, pZ0.018). We found a significant interactive effect between gender and caregiver availability with respect to REs. Though REs is lower in general amongst those with caregivers, the difference was significantly greater among males (-22.81, 95% CI -32.70 to -12.94, p<0.001). In terms of caregiver identity, having a FDWas a caregiver was associated with poorer REs (-3.95, 95% CI -6.94 to -0.95, pZ0.01) and REy (-1.83, 95%CI -3.14 to -0.53, pZ0.006) when compared to spousal caregivers. Interestingly, having non-relative, unpaid caregivers was associated with better REs (8.36, 95% CI 1.89 to 14.83, pZ0.011). Conclusions: Caregiver availability and identity appears to be associated with rehabilitation outcomes. A better understanding of these relationships has potential implications on current and future clinical practice andpolicy directions.