Sze Ling Chan

Introduction Around the time COVID-19 was declared a global pandemic, various restrictions and measures were implemented at all levels to limit disease spread and preserve healthcare capacity. Data are lacking in many low- and middle-income countries on how these measures impact healthcare utilisation and outcomes. This study aims to determine the impact of COVID-19 restrictions on volumes of the three emergency bellwether procedures in South and Southeast Asia.Methods This was an interrupted time series study of patients who underwent any of the three emergency bellwether procedures (caesarean section, laparotomy and open fracture fixation) from 1 January 2018 to 31 December 2021 at one of eight institutions in Singapore, Malaysia, Indonesia, India and Vietnam. We compared the weekly volumes, baseline characteristics and outcomes of each procedure across different time periods in each institution defined by different levels of COVID-19 restrictions using selected indicators from a city-level and hospital-level response index.Results Weekly volumes of emergency caesarean section decreased significantly in Guwahati Neurological Research Centre (GNRC) (p=1.62×10 −5) and Ulin General Hospital (UGH) (p<2.2×10−16) but increased in Adam Malik Hospital (AMH) (p=1.45×10−5). For laparotomies, volume increased in Singapore General Hospital (p=2.38×10−5) but decreased in Military Hospital 175 (p=6.30×10−7). The volume of open fracture fixations decreased in GNRC (p=3.08×10−8), AMH (p=1.68×10−6) and UGH (p=8.15×10−6).Conclusions COVID-19 restrictions on the city and hospital level were associated with a decrease in surgical volumes of the three bellwether procedures in some of the institutions. There was some suggestion of surgical capacity limitations in UGH and Military Hospital 175 during periods of more stringent COVID-19 restrictions.

Planning for a hospital is a complex and dynamic process, traditionally not informed by evidence. A systems thinking approach can be useful in informing hospital planning decisions. We derived insights from hospital executives and clinicians regarding the key drivers within the present hospital system that affect resource planning targets and leverage points for transformation in a new future hospital. We utilized a qualitative group model building (GMB) process conducted in one of the largest hospitals in Singapore to inform the development of a systems model for the planning of the new brownfield hospital. Participants included hospital executives supporting hospital planning, strategic management, health system planning, data management, and healthcare providers from clinical and allied health domains who were members of the hospital planning committee. Data were gathered through 10 GMB workshops from September 2023 to March 2024 and analysed using thematic analysis. A total of 20 participants attended the GMB workshops. Nine themes were identified across four hospital subsystems (Specialist Outpatient Clinic (SOC), emergency department (ED), inpatient, and surgeries & procedures (S&P)). Among these, five themes were linked to potential interventions to optimise hospital operations and patient care, including right-siting of patients (e.g., primary care, community, telehealth) and improving pre- and post-surgical care to reduce length of stay (LOS). Across this dynamic system, the most critical leverage point identified was the reduction of avoidable demand on acute hospital services through efficient patient right-siting and strengthened care transitions, which directly influences ED utilization and inpatient LOS. Four key drivers shaping hospital demand-supply dynamics were identified: ED utilization, extended inpatient LOS, the integration of technological advancements (particularly Artificial Intelligence (AI)), and the expansion of alternative care models. These insights directly culminated in a systems-level causal loop diagram that provided a foundation for identifying key leverage points to guide strategies aimed at better aligning hospital resources with patient demands while mitigating structural inefficiencies. We identified four key drivers and five potential strategies across four hospital sub-systems that could be leverage points for hospital redesign and transition to the future mode of operations.

Introduction: Surgical systems in Southeast Asia were already experiencing significant supply shortages before the COVID-19 pandemic, which further exacerbated these deficits. With the aim of identifying modifiable factors for improvement, our study benchmarks surgical system efficiencies of eight Southeast Asian Hospital and Health Systems’ (HHS) in combating COVID-19, with an analysis spanning three levels: country, city and HHS. Methods: Based on 18-month data (January 2020 to June 2021), we developed a two-stage frontier benchmarking approach that applies efficiency benchmarking techniques to evaluate how close organisations operate relative to an efficiency frontier (representing the maximum potential output achievable with a given set of inputs). Stage 1 involves data envelopment analysis, which yields monthly national efficiency scores for five countries based on country-level panel data. Stage 2 involves stochastic frontier analysis, followed by evaluating HHS-level efficiency with HHS-level data over 64 possible model configurations, adjusting for stage 1 national-level efficiency scores as well as city-level responses. Results: Among the 64 possible stage 2 model configurations, two model clusters comprising 36 plausible models demonstrated superior fit to the observed data, thereby providing robust insights through majority voting. Policy measures related to access control and workplace closure were positively associated with recovery rates. Elective surgery volumes showed a negative association and emergency surgery volumes a positive association with efficiency. Our analysis indicates lags of 0–1 month between input changes and effects on the surgical system. Conclusions: Insights from the benchmarking of HHS efficiencies will help inform surgical system policy and responses. Access control and workplace closure policies are associated with COVID-19 recovery rates. Emergency surgery volumes are associated with higher efficiency and elective surgery volumes with lower efficiency. System responses to policy measures can manifest with lags of up to a month. Considering insights from multiple plausible models makes these conclusions more robust.

Translation of evidence-based resuscitation practices into clinical settings remains slow and inconsistent, a gap that significantly impacts survival and neurological outcomes. Implementation science offers a structured approach to accelerate adoption by identifying context-specific barriers—such as dispatcher workload, team choreography, and resource constraints—and tailoring strategies to overcome them. This paper applies the Knowledge-to-Action (KTA) framework to resuscitation, emphasizing stakeholder engagement, iterative monitoring, and sustainability. We provide detailed guidance across key resuscitation settings, including dispatch-assisted cardiopulmonary resuscitation (DA-CPR), in-hospital code teams, and emergency medical services (EMS). The manuscript introduces a comprehensive outcomes framework encompassing implementation, service/system, and patient-level metrics, and illustrates practical application through case examples such as DA-CPR and real-time feedback devices. To enhance scientific utility, we also present a decision-oriented table for pilot testing, offering healthcare institutions a roadmap for sustainable integration of evidence-based resuscitation protocols.

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Objective: This study aimed to determine the association between diabetes mellitus (DM) medication use and glycaemic control. Design: This was a retrospective diabetes registry-based cohort study. Setting: Singapore. Participants: Patients aged 18 and above with incident DM in the SingHealth Diabetes Registry from 2013 to 2020 were included. The entire study period included a 1 year baseline period, a 1 year observation period and a 3 month outcome period. Outcome measures: Drug use was measured using the proportion of days covered (PDC), and the changes in glycated haemoglobin (HbA1c) between the outcome and baseline periods were assessed. The associations between baseline HbA1c and PDC ≥0.80 and between PDC and change in HbA1c were analysed using logistic regression and the Kruskal–Wallis test, respectively. Results: Of 184 646 unique patients in the registry from 2013 to 2020, 36 314 met the inclusion and exclusion criteria and were included in the analysis. The median PDC for any DM drug, oral DM drugs and insulin during the observation period was 20.3%, 16.8% and 0%, respectively. Those who had good glycaemic control at baseline were less likely to receive DM drugs and those with poor baseline glycaemic control or missing baseline HbA1c were more likely to be consistent users (PDC >80%) (p-16). Conclusion: The relationship between DM drug use and glycaemic control is complex and non-monotonic. Higher PDC for any DM drug and oral DM drugs during the observation period was significantly associated with clinically relevant HbA1c improvements.

This study in Singapore analysed the incubation periods of the following SARS-CoV-2 variants: Wuhan-Hu-1, Delta, and Omicron. Three pandemic waves were examined: Wuhan-Hu-1 (January 2020–March 2021), Delta (May–October 2021), and Omicron (January–June 2022). Data from the SingHealth COVID-19 registry, covering patients from 23 January 2020 to 10 June 2022, were used to calculate incubation periods during the three time periods. The study found median incubation periods of 11 days for Wuhan-Hu-1, 3 days for Delta, and 3 days for Omicron (p-value: <0.001). This study highlighted the impact of different containment measures and the importance of robust EMR systems for tracking and managing infectious diseases. Key challenges included accurate contact tracing and IT infrastructure capabilities. The findings support the use of EMR data for future infectious disease preparedness in Singapore.

Purpose: This is a prospective study to investigate the clinical outcomes of using noncompliant balloons in lower limb angioplasty for chronic limb threatening ischemia (CLTI). Materials and Methods: This is a prospective single-center cohort study performed at a local tertiary hospital in Singapore. Consecutive patients who underwent lower limb angioplasty for CLTI using a noncompliant balloon catheter were enrolled if they were aged 40 years and above, presented with CLTI Rutherford grade 4 to 6, and had TASC C or D lesions in the lower limb vessels that were at least 100mm in length. Patient demographics, Rutherford grading, lesion characteristics, complications, and follow-up data were collected and analyzed. The primary outcomes were 30-day freedom from major adverse events, amputation-free survival (AFS) at 12 months, and freedom from clinically driven target lesion revascularization (cdTLR) at 12 months. Secondary outcomes included clinical success and target lesion primary patency (TLPP) at 12 months. Amputation-free survival, freedom from cdTLR, and TLPP were calculated by Kaplan-Meier analysis. Results: From May 2020 to December 2021, 50 patients (50 limbs) were enrolled. 43 (86%) patients had diabetes mellitus, while 12 patients (24%) had end-stage renal failure. 85 lesions were treated, including 59 (69.4%) below-the-knee (BTK) lesions. All the lesions were TASC C (n=45, 52.9%) or TASC D (n=40, 47.1%) lesions. Mean lesion length was 231.4±116.2mm. Technical success rate was 96.5%. No patients were lost to follow-up. Median follow-up duration was 282 days (IQR: 31-390 days). One patient died on day 26 due to an acute myocardial infarction. Two patients had groin hematomas postprocedure, both of which were treated conservatively. AFS, freedom from cdTLR, and TLPP at 12 months postprocedure was 70.0% (95% confidence interval [CI]: 58.4%-83.9%), 90.1% (95% CI: 83.4%-97.4%), and 61.1% (95% CI: 50.7%-73.6%), respectively. Conclusion: Early results have shown that the use of a high-pressure, noncompliant balloon is effective in lower limb angioplasty for CLTI in a highly challenging group of patients with a high prevalence of long BTK disease. Good vessel patency and limb salvage rates can be achieved, with a low complication rate. We await more long-term outcomes on vessel patency. Clinical Impact: There are many devices in the market for use in lower limb angioplasty. However, many of them come with an increased financial cost, procedural time and procedural difficulty. We report our prospective results with the exclusive use of a high pressure, non-compliant balloon, in a challening group of patients with a high prevalence of diabetes and end stage renal failure, achieving amputation free surival at 6 and 12 months post-procedure of 84.0% and 70.0% respectively. The use of non-compliant balloon is technically easy and does not add additional steps compared to a standard POBA procedure, thus limiting costs. We believe this article can be a push factor for clinicians to consider the use of these high pressure, non-compliant balloons in their patient care.