Browsing by Author "Koh, Gerald Choon-Huat"

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    ItemOpen Access
    Can acute clinical outcomes predict health-related quality of life after stroke: a one-year prospective study of stroke survivors.
    (Health and quality of life outcomes, 2018-11-21) Yeoh, Yen Shing; Koh, Gerald Choon-Huat; Tan, Chuen Seng; Lee, Kim En; Tu, Tian Ming; Singh, Rajinder; Chang, Hui Meng; De Silva, Deidre A; Ng, Yee Sien; Ang, Yan Hoon; Yap, Philip; Chew, Effie; Merchant, Reshma Aziz; Yeo, Tseng Tsai; Chou, Ning; Venketasubramanian, N; Young, Sherry H; Hoenig, Helen; Matchar, David Bruce; Luo, Nan

    Background

    Health-related quality of life (HRQoL) is a key metric to understand the impact of stroke from patients' perspective. Yet HRQoL is not readily measured in clinical practice. This study aims to investigate the extent to which clinical outcomes during admission predict HRQoL at 3 months and 1 year post-stroke.

    Methods

    Stroke patients admitted to five tertiary hospitals in Singapore were assessed with Shah-modified Barthel Index (Shah-mBI), National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Mini-Mental State Examination (MMSE), and Frontal Assessment Battery (FAB) before discharge, and the EQ-5D questionnaire at 3 months and 12 months post-stroke. Association of clinical measures with the EQ index at both time points was examined using multiple linear regression models. Forward stepwise selection was applied and consistently significant clinical measures were analyzed for their association with individual dimensions of EQ-5D in multiple logistic regressions.

    Results

    All five clinical measures at baseline were significant predictors of the EQ index at 3 months and 12 months, except that MMSE was not significantly associated with the EQ index at 12 months. NIHSS (3-month standardized β = - 0.111; 12-month standardized β = - 0.109) and mRS (3-month standardized β = - 0.122; 12-month standardized β = - 0.080) were shown to have a larger effect size than other measures. The contribution of NIHSS and mRS as significant predictors of HRQoL was mostly explained by their association with the mobility, self-care, and usual activities dimensions of EQ-5D.

    Conclusions

    HRQoL at 3 months and 12 months post-stroke can be predicted by clinical outcomes in the acute phase. NIHSS and mRS are better predictors than BI, MMSE, and FAB.
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    ItemOpen Access
    Can caregivers report their care recipients' post-stroke hospitalizations and outpatient visits accurately? Findings of an Asian prospective stroke cohort.
    (BMC health services research, 2018-10-25) Tyagi, Shilpa; Koh, Gerald Choon-Huat; Luo, Nan; Tan, Kelvin Bryan; Hoenig, Helen; Matchar, David B; Yoong, Joanne; Finkelstein, Eric A; Lee, Kim En; Venketasubramanian, N; Menon, Edward; Chan, Kin Ming; De Silva, Deidre Anne; Yap, Philip; Tan, Boon Yeow; Chew, Effie; Young, Sherry H; Ng, Yee Sien; Tu, Tian Ming; Ang, Yan Hoon; Kong, Keng He; Singh, Rajinder; Merchant, Reshma A; Chang, Hui Meng; Yeo, Tseng Tsai; Ning, Chou; Cheong, Angela; Ng, Yu Li; Tan, Chuen Seng

    Background

    Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors' HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients.

    Methods

    A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types.

    Results

    We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%.

    Conclusions

    The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.
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    ItemOpen Access
    Dyadic approach to supervised community rehabilitation participation in an Asian setting post-stroke: exploring the role of caregiver and patient characteristics in a prospective cohort study.
    (BMJ open, 2020-04-23) Tyagi, Shilpa; Koh, Gerald Choon-Huat; Luo, Nan; Tan, Kelvin Bryan; Hoenig, Helen; Matchar, David Bruce; Yoong, Joanne; Chan, Angelique; Lee, Kim En; Venketasubramanian, Narayanaswamy; Menon, Edward; Chan, Kin Ming; De Silva, Deidre Anne; Yap, Philip; Tan, Boon Yeow; Chew, Effie; Young, Sherry H; Ng, Yee Sien; Tu, Tian Ming; Ang, Yan Hoon; Kong, Keng He; Singh, Rajinder; Merchant, Reshma A; Chang, Hui Meng; Yeo, Tseng Tsai; Ning, Chou; Cheong, Angela; Tan, Chuen Seng

    Objective

    To study the association of caregiver factors and stroke survivor factors with supervised community rehabilitation (SCR) participation over the first 3 months and subsequent 3 to 12 months post-stroke in an Asian setting.

    Design

    Prospective cohort study.

    Setting

    Community setting.

    Participants

    We recruited stroke survivors and their caregivers into our yearlong cohort. Caregiver and stroke survivor variables were collected over 3-monthly intervals. We performed logistic regression with the outcome variable being SCR participation post-stroke.

    Outcome measures

    SCR participation over the first 3 months and subsequent 3 to 12 months post-stroke RESULTS: 251 stroke survivor-caregiver dyads were available for the current analysis. The mean age of caregivers was 50.1 years, with the majority being female, married and co-residing with the stroke survivor. There were 61%, 28%, 4% and 7% of spousal, adult-child, sibling and other caregivers. The odds of SCR participation decreased by about 15% for every unit increase in caregiver-reported stroke survivor's disruptive behaviour score (OR: 0.845; 95% CI: 0.769 to 0.929). For every 1-unit increase in the caregiver's positive management strategy score, the odds of using SCR service increased by about 4% (OR: 1.039; 95% CI: 1.011 to 1.068).

    Conclusion

    We established that SCR participation is jointly determined by both caregiver and stroke survivor factors, with factors varying over the early and late post-stroke period. Our results support the adoption of a dyadic or more inclusive approach for studying the utilisation of community rehabilitation services, giving due consideration to both the stroke survivors and their caregivers. Adopting a stroke survivor-caregiver dyadic approach in practice settings should include promotion of positive care management strategies, comprehensive caregiving training including both physical and behavioural dimensions, active engagement of caregivers in rehabilitation journey and conducting regular caregiver needs assessments in the community.
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    ItemOpen Access
    Examining the Influence of Social Interactions and Community Resources on Caregivers' Burden in Stroke Settings: A Prospective Cohort Study.
    (International journal of environmental research and public health, 2021-11-23) Koh, Yen Sin; Koh, Gerald Choon-Huat; Matchar, David Bruce; Hong, Song-Iee; Tai, Bee Choo
    Since the introduction of the integrated care model, understanding how social interactions and community resources can alleviate caregivers' burden is vital to minimizing negative patients' outcomes. This study (n = 214) examined the associations between these factors and caregivers' burden in stroke settings. It used 3-month and 1-year post-stroke data collected from five tertiary hospitals. Subjective and objective caregivers' burdens were measured using Zarit burden interview and Oberst caregiving burden scale respectively. The independent variables examined were quality of care relationship, care management strategies for managing patients' behaviour, family caregiving conflict, formal service usage and assistance to the caregiver. Significant associations were determined using mixed effect modified Poisson regressions. For both types of burden, the scores were slightly higher at 3 months as compared to 1 year. Poorer care-relationship (relative risk: 0.81, 95% confidence interval (CI): 0.70-0.94) and adopting positive care management strategies (relative risk: 1.05, 95% CI: 1.02-1.07) were independently associated with a high subjective burden. Providing assistance to caregivers (relative risk: 2.45, 95% CI: 1.72-3.29) and adopting positive care management strategies (relative risk: 1.03, 95% CI: 1.02-1.04) were independently associated with a high objective burden. Adopting positive care management strategies at 3 months had a significant indirect effect (standardised β: 0.11, 95% CI: 0.01 to 0.20) on high objective burden at one year. Healthcare providers should be aware that excessive care management strategies and assistance from family members may add to caregivers' burden.
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    ItemOpen Access
    Health-related quality of life loss associated with first-time stroke.
    (PloS one, 2019-01-28) Yeoh, Yen Shing; Koh, Gerald Choon-Huat; Tan, Chuen Seng; Tu, Tian Ming; Singh, Rajinder; Chang, Hui Meng; De Silva, Deidre A; Ng, Yee Sien; Ang, Yan Hoon; Yap, Philip; Chew, Effie; Merchant, Reshma A; Yeo, Tseng Tsai; Chou, Ning; Venketasubramanian, N; Lee, Kim En; Young, Sherry H; Hoenig, Helen; Matchar, David Bruce; Luo, Nan
    OBJECTIVES:This study aimed to quantify health-related quality of life (HRQoL) loss associated with first episode of stroke by comparing patient-reported HRQoL before and after stroke onset. The impact of stroke in local population was also evaluated by comparing the pre- and post-stroke HRQoL with that of the general population. METHODS:The HRQoL of stroke survivors was assessed with the EQ-5D-3L index score at recruitment, for recalled pre-stroke HRQoL, and at 3 and 12 month post-stroke. Change in HRQoL from pre-stroke to 3 and 12 month was self-reported by 285 and 238 patients, respectively. Mean EQ index score at each time point (baseline: 464 patients; 3 month post-stroke: 306 patients; 12 month post-stroke: 258 patients) was compared with published population norms for EQ-5D-3L. RESULTS:There was a significant decrease in HRQoL at 3 (0.25) and 12 month (0.09) post-stroke when compared to the retrospectively recalled patients' mean pre-stroke HRQoL level (0.87). The reduction at 3 month was associated with the reduction in all EQ-5D-3L health dimensions; reductions remaining at 12 month were limited to dimensions of mobility, self-care, usual activities, and anxiety/depression. Stroke patients had a lower mean EQ index than the general population by 0.07 points pre-stroke (0.87 vs. 0.94), 0.33 points at 3 month (0.61 vs. 0.94) and 0.18 points at 12 month (0.76 vs. 0.94) post-stroke. CONCLUSIONS:Stroke has a substantial impact on HRQoL in Singapore, especially in the first three months post-stroke. Compared to the general population, stroke survivors have lower HRQoL even before stroke onset. This pre-stroke deficit in HRQoL should be taken into account when quantifying health burden of stroke or setting goals for stroke rehabilitation.
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    ItemOpen Access
    Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors.
    (BMC health services research, 2018-11-22) Tyagi, Shilpa; Koh, Gerald Choon-Huat; Nan, Luo; Tan, Kelvin Bryan; Hoenig, Helen; Matchar, David B; Yoong, Joanne; Finkelstein, Eric A; Lee, Kim En; Venketasubramanian, N; Menon, Edward; Chan, Kin Ming; De Silva, Deidre Anne; Yap, Philip; Tan, Boon Yeow; Chew, Effie; Young, Sherry H; Ng, Yee Sien; Tu, Tian Ming; Ang, Yan Hoon; Kong, Keng Hee; Singh, Rajinder; Merchant, Reshma A; Chang, Hui Meng; Yeo, Tseng Tsai; Ning, Chou; Cheong, Angela; Ng, Yu Li; Tan, Chuen Seng

    Background

    It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.

    Methods

    Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.

    Results

    Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.

    Conclusion

    Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.
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    Multicomponent interventions for enhancing primary care: a systematic review.
    (The British journal of general practice : the journal of the Royal College of General Practitioners, 2021-01) Jimenez, Geronimo; Matchar, David; Koh, Gerald Choon-Huat; Car, Josip

    Background

    Many countries have implemented interventions to enhance primary care to strengthen their health systems. These programmes vary widely in features included and their impact on outcomes.

    Aim

    To identify multiple-feature interventions aimed at enhancing primary care and their effects on measures of system success - that is, population health, healthcare costs and utilisation, patient satisfaction, and provider satisfaction (quadruple-aim outcomes).

    Design and setting

    Systematic review and narrative synthesis.

    Method

    Electronic, manual, and grey-literature searches were performed for articles describing multicomponent primary care interventions, providing details of their innovation features, relationship to the '4Cs' (first contact, comprehensiveness, coordination, and continuity), and impact on quadruple-aim outcomes. After abstract and full-text screening, articles were selected and their quality appraised. Results were synthesised in a narrative form.

    Results

    From 37 included articles, most interventions aimed to improve access, enhance incentives for providers, provide team-based care, and introduce technologies. The most consistent improvements related to increased primary care visits and screening/preventive services, and improved patient and provider satisfaction; mixed results were found for hospital admissions, emergency department visits, and expenditures. The available data were not sufficient to link interventions, achievement of the 4Cs, and outcomes.

    Conclusion

    Most analysed interventions improved some aspects of primary care while, simultaneously, producing non-statistically significant impacts, depending on the features of the interventions, the measured outcome(s), and the populations being studied. A critical research gap was revealed, namely, in terms of which intervention features to enhance primary care (alone or in combination) produce the most consistent benefits.
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    ItemOpen Access
    Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore.
    (BMC family practice, 2021-04-14) Tyagi, Shilpa; Koh, Gerald Choon-Huat; Luo, Nan; Tan, Kelvin Bryan; Hoenig, Helen; Matchar, David B; Yoong, Joanne; Chan, Angelique; Lee, Kim En; Venketasubramanian, N; Menon, Edward; Chan, Kin Ming; De Silva, Deidre Anne; Yap, Philip; Tan, Boon Yeow; Chew, Effie; Young, Sherry H; Ng, Yee Sien; Tu, Tian Ming; Ang, Yan Hoon; Kong, Keng He; Singh, Rajinder; Merchant, Reshma A; Chang, Hui Meng; Yeo, Tseng Tsai; Ning, Chou; Cheong, Angela; Ng, Yu Li; Tan, Chuen Seng

    Background

    Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke.

    Method

    Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0-3 months (early) and 4-12 months (late) post-stroke.

    Results

    For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits.

    Conclusion

    We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.
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    ItemOpen Access
    The associations between caregivers' psychosocial characteristics and caregivers' depressive symptoms in stroke settings: a cohort study.
    (BMC psychology, 2022-05-09) Koh, Yen Sin; Subramaniam, Mythily; Matchar, David Bruce; Hong, Song-Iee; Koh, Gerald Choon-Huat

    Background

    Studies have found that caregivers can influence stroke survivors' outcomes, such as mortality. It is thus pertinent to identify significant factors associated with caregivers' outcomes. The study objective was to examine the associations between caregivers' psychosocial characteristics and caregivers' depressive symptoms.

    Methods

    The analysis obtained three-month and one-year post-stroke data from the Singapore Stroke Study, which was collected from hospital settings. Caregivers' depressive symptoms were assessed via the Center for Epidemiologic Studies Depression instrument. Psychosocial characteristics of caregivers included subjective burden (Zarit Burden Interview), quality of care-relationship (a modified 3-item scale from the University of Southern California Longitudinal Study of Three-Generation Families) and expressive social support (an 8-item scale from Pearlin et al.). Mixed effect Tobit regressions were used to examine the associations between these study variables.

    Results

    A total of 214 caregivers of stroke patients hospitalized were included in the final analysis. Most caregivers were Chinese women with secondary school education, unemployed and married to the patients. Caregivers' subjective burden was positively associated with their depressive symptoms (Partial regression coefficient: 0.18, 95% CI 0.11-0.24). Quality of care-relationship (Partial regression coefficient: - 0.35, 95% CI - 0.63 to - 0.06) and expressive social support (partial regression coefficient: - 0.28, 95% CI - 0.37 to - 0.19) were negatively associated with caregivers' depressive symptoms. Caregivers' depressive symptoms were higher at three-month post-stroke than one-year post-stroke (Partial regression coefficient: - 1.00, 95% CI - 1.80 to - 0.20).

    Conclusion

    The study identified subjective burden, quality of care-relationship and expressive social support as significantly associated with caregivers' depressive symptoms. Caregivers' communication skills may also play a role in reducing caregivers' depressive symptoms.