Browsing by Author "Finkelstein, Eric Andrew"

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Background:

Interferon Gamma Release Assays (IGRAs) have proven to be potential replacement of tuberculin skin test (TST) in screening and diagnosing tuberculosis as shown by previous health economic studies. Given that these studies all center on pulmonary tuberculosis, we sought to examine the cost-effectiveness of IGRAs, specifically QFT-IT, as a diagnostic test for intraocular tuberculosis among uveitis patients in Singapore.

Method:

A decision tree was constructed to evaluate the cost-effectiveness of the QFT-IT for diagnosing intraocular tuberculosis among uveitis patients over a 30-year horizon. The input data were based on a cohort of 102 patients who presented with symptoms of uveitis and underwent relevant treatment and follow-up visits from 2009 to 2010 at Singapore National Eye Center (SNEC). By calculating their incremental cost-effectiveness ratio, we compared the cost-effectiveness of three strategies: TST alone, QFT-IT alone and TST followed by QFT-IT as a confirmatory test.

Results:

Our results show that in cost terms alone, QFT-IT alone strategy is the most expensive one (889 SGD per person), followed by TST alone (850 SGD per person) and finally the dual strategy (789 SGD per person). While examining effectiveness alone, TST alone strategy is the most effective one that helps gain 17.4923 quality-adjusted life years (QALYs) followed by QFT-IT alone and the dual strategy. Using the conventional willingness to pay of 50,000 USD/QALY (63000 SGD/QALY), having an incremental cost-effectiveness ratio of 1644 SGD/QALY demonstrates that TST alone strategy is the best choice to screen ocular TB in Singapore.

Conclusion:

Given the local ocular tuberculosis prevalence and key assumptions made in the analysis model, the TST alone strategy is recommended to diagnose intraocular TB among uveitis patients in Singapore.

Introduction: A wide of range of physician roles in palliative care have been recognized by doctors in many countries. However, while the demand for palliative care keeps increasing in Singapore, there is a lack of understanding of Singaporean physicians' perceptions on their roles in palliative care. Assessment on the perceived relative importance of these physician roles is also needed for a thorough understanding of physicians' views on palliative care.

Method: Nine physician roles were evaluated through twelve best-worst tasks. The worst counts were subtracted from best counts to develop a B-W score for each physician role. Paired model and marginal model were adopted to obtain an estimation of the coefficient of each role through conditional logit regression. Covariate-adjusted latent class cluster analysis was performed to investigate the heterogeneity among physicians and explore what physician characteristics are associated differences in perception patterns.

Results: "Treating pain and physical symptoms" (1), "discussing end-of-life care preferences with patients" (2) rank top two, while "extending the patient's life as long as possible (8) and "withholding diagnosis if asked by family members" (9) are at the bottom regarding their perceived relative importance by respondents. The largest discrepancies regarding physicians' perceptions lie in "addressing patients' psychological needs", "addressing patients' spiritual needs" and "extending life as long as possible." Clinical grade and palliative care training status are found to have statistically significant association (P<0.05) with different patterns of perceptions among physicians.

Conclusion: Singaporean physicians attach high importance to treating pains and symptoms, and value communicating with patients about treatment preferences based on effective information exchange. Respondents generally tend to focus more on patients' overall quality of life than just extending patients' life. Experience (reflected by clinical grade) and palliative care training may influence physicians' perceptions on their roles in palliative care.

Objective: To examine the quality of articles that claim cost savings resulting from chronic disease interventions. The interventions are limited to behavioral interventions, including worksite wellness programs, weight and disease management programs, and community-based programs. Methods: Published articles were identified from a database search. Included articles were published between January 1990 and December 2016, described a positive return on investment of behavioral interventions for chronic disease. A single reviewer, following specific criteria, assessed research quality using the Quality of Health Economic Studies (QHES) instrument. Results: Of 1990 retrieved articles, 19 met study inclusion criteria. No study we reviewed has sufficient quality to be considered evidentiary. Conclusions: Economic evaluations yield positive ROI on chronic disease behavioral interventions have limited methodological quality and their results should be interpreted with caution.

Pain and depressive symptoms are prevalent in cancer patients with previous studies showing that pain increases the risk of depressive symptoms among cancer patients. Though researchers have identified gender differences in the association between pain and depression in healthy pediatric populations in the U.S., little research has been conducted about the same association with cancer patients or in Singapore.

In this study, we aim to first assess the proportion of advanced cancer patients in Singapore presenting to the National Cancer Center Singapore (NCCS) and Singapore General Hospital (SGH) during 2016 – 2017, who have pain conditions as well as the proportion of the patients with depressive symptoms. We are also interested to evaluate whether the positive association between pain and depressive symptoms previously identified in cancer patients holds in advanced cancer patients approaching their end of lives. Finally, we aim to test the moderating effect of gender on the association between pain and depressive symptoms in this special population.

Our sample comprised 377 outpatient advanced cancer patients recruited from the National Cancer Center Singapore (NCCS) and Singapore General Hospital (SGH) during 2016 - 2017. We administrated Brief Pain Inventory (BPI)- Short form for pain assessment, and Hospital Anxiety and Depression Scale (HADS)- Depression Subscale for depressive symptoms. In multivariate analysis, we used Negative Binomial (NB) regression to estimate the association between pain severity / pain interference and depressive symptoms, and the moderating effect of gender in these associations, while controlling for age, education level, and ethnicity.

We found that 74.40% patients had pain conditions, and 6.20% of them had depressive symptoms. We have also identified a positive association between pain severity and depressive symptoms, as well as between pain interference and depressive

symptoms. We did not find evidence that gender moderates the association either between pain severity and depressive symptoms, or between pain interference and depressive symptoms.

The positive association between pain and depressive symptoms in advanced cancer patients suggests equal necessity to assess and treat pain as well as depression in palliative care settings because they often coexist. There is no strong evidence that physicians should tailor pain and depression management to male and female patients since no significant gender difference was observed in the association between pain and depressive symptoms.

Low work productivity has caused large indirect cost to many employers. Evidence shows that physical activity can improve health status, thus enhancing work productivity. In view of the benefits of physical activities, the World Health Organization (WHO) issued a guideline on age-specific physical activity standards in 2010. According to the guideline, two weekly physical activity standards (the WHO standard and the WHO additional standard) have been introduced in order to prevent non- communicable disease and relieve mental pressure.

In this study, the association between work productivity and physical activity has been explored. The work productivity is measured by presenteeism and absenteeism together. Presenteeism implies a situation where a mentally or physically sick employee attend to work despite a medical illness that makes their job performance sub-optimal. It is recorded as a self-reported percentage of work efficiency loss in the study. Absenteeism implies having work absence because of medical condition. It is recorded as whether participants have medical absence in the past week. 928 valid responses from Singapore full-time employees have been analyzed using logistic models.

Results show that participants who had not met the WHO additional standard are less likely to have medical absence (OR=2.51, P<0.05). The longer time spent on physical activity is associated with lower work productivity (OR=1.001, P<0.05). I also found that the more frequent individual keeps healthy lifestyle, the lower presenteeism and absenteeism one will have.

The findings could be explained by several reasons. First, physically active participants have higher chance of physical injuries, leading to medical absence from work. Secondly, participants who had met the WHO additional standard are more likely to have lower income. Because of the labor leisure tradeoff theory, people who have lower income are less incentivized to trade leisure time for work. Therefore, the participants who had met the WHO additional standard have a lower medical absence rate. Thirdly, findings show that frequent healthy lifestyle is associated with higher work productivity. However, People who had met the WHO additional standard are less likely to have a frequent healthy lifestyle due to the lower social and economic status they have. Therefore, even though they have longer time spent on physical activity, the work productivity is still lower. Lastly, because of the work ethics in Singapore, employees ask for medical absence only due to urgent and serious medication conditions and such urgent and serious medical conditions cannot be prevented by physical activities.

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