Hwee Pin Phua

Objectives: Inappropriate antibiotic prescribing for acute upper respiratory tract infections (URTIs) is a significant problem in emergency departments (EDs) worldwide. In this study, we separately evaluated the effectiveness of physician feedback and patient education in reducing antibiotic prescribing for URTIs in the ED setting. Methods: We conducted a quasi-experimental study across four large adult EDs in Singapore from January 2021 to December 2023. After a baseline period (18 months), two EDs were randomly assigned to either implement physician feedback or patient education for six months (intervention period 1), and all EDs subsequently implemented both interventions in the next six months (intervention period 2). Hierarchical segmented logistic regression was used to assess the effectiveness of the interventions in reducing weekly antibiotic prescribing for URTIs. Results: In the two EDs that implemented physician feedback first, there was a significant decrease in the trend of weekly antibiotics prescribed (AOR 0.981 [95% CI (0.964, 0.998)]) compared to the last 6 months of the pre-intervention period. Adding patient education in the next phase (intervention period 2) did not further reduce the trend of weekly antibiotics prescribed. For the second group of two EDs that implemented patient education first, there was no significant reduction in the weekly antibiotic prescribing trend during intervention period 1. With the addition of physician feedback, a significant decline in the trend of weekly antibiotics prescribed was observed in intervention period 2 (AOR 0.921 [95% CI (0.903,0.940)]). Conclusions: Physician feedback alone can reduce antibiotic prescribing for URTIs in EDs. Further research is warranted to assess the effectiveness of patient education involving multi-modal educational channels co-created with patients.

Aims: This study aims to investigate the relationship between long‐term visit‐to‐visit within‐person HbA1c variability and hospitalisation outcomes in adults with type 2 diabetes (T2D). Methods: We conducted a cohort study at a tertiary hospital in Singapore involving people aged 21 to 101 years with T2D who had ≥3 HbA1c tests over 2 years. HbA1c variability was assessed using coefficient of variation (CV), variability independent of the mean (VIM) and HbA1c variability score (HVS). A 1‐year follow‐up was performed after the last HbA1c measurement to identify all‐cause and potentially avoidable hospitalisations (PAH), categorised as overall, acute, chronic and diabetes composites. Results: The study included 14 923 patients (mean age: 62.9 ± 12.9 years; 55% male). The median HbA1c variability was 8.6% CV (IQR: 5.1–14.3). Higher quartiles of HbA1c variability were associated with greater risks of PAH and all‐cause hospitalisations, independent of glycaemic control. Compared to Q1, for example, the risk ratios and 95% confidence intervals for diabetes‐related PAH based on HbA1c CV were as follows: Q2, 1.32 (0.93–1.88); Q3, 1.65 (1.18–2.31) and Q4, 2.16 (1.54–3.03). For all‐cause hospitalisations, they were as follows: Q2, 0.97 (0.90–1.05); Q3, 1.08 (1.00–1.17) and Q4, 1.16 (1.07–1.26). When stratified by glycaemic control, elevated risk of PAH persisted even in those with optimal glycaemic control. Consistent findings were observed using HbA1c VIM and HVS measures. Conclusions: In individuals receiving care at specialist outpatient clinics of a tertiary hospital, HbA1c variability is associated with a higher risk of PAH. Comprehensive diabetes management strategies addressing both glycaemic control and variability may offer benefits.

Immunosenescence (age-related immune dysfunction) and inflamm-aging contribute to suboptimal immune responses in older adults to standard-dose influenza vaccines, which may be exacerbated in those with metabolic co-morbidities. We sought to investigate metabolic factors/predictors of influenza vaccine immune response in an older adult (age ≥65 years) cohort in Singapore, where influenza typically circulates year-round. The primary outcome for the DYNAMIC prospective cohort study was haemagglutination-inhibition titer (HAI) response to each of the trivalent inactivated influenza vaccine strains at day 28 (D28) compared to baseline (D0), as assessed by seroconversion and D28/D0 log2 HAI fold rise. Baseline blood samples were tested for total Vitamin D (25-(OH) D) levels. We enrolled 234 participants in June–Dec 2017. Two hundred twenty completed all study visits. The median age was 71 [IQR 68–75] years, 67 (30.5%) had diabetes mellitus (DM), and the median BMI was 24.9 [IQR 22.2–27.8] kg/m². Median baseline totals 25-(OH) D was 29 [IQR: 21–29] ng/ml. Age, DM, obesity, and baseline 25-(OH) D were not associated with HAI fold rise in multivariable analysis. More recent prior influenza vaccination and higher baseline HAI titers were associated with lower HAI fold rise for influenza A/HK/H3N2. Physical activity was associated with a higher HAI fold rise for influenza A/HK/H3N2 in a dose-response relationship (p-test for trend = 0.015). Older adults with well-controlled metabolic co-morbidities retain HAI response to the influenza vaccine, and physical activity had a beneficial effect on immune response, particularly for influenza A/HK/H3N2.

Background and objective Little is known about the epidemiology and cost of bronchiectasis in Asia. This study describes the disease burden of bronchiectasis in Singapore. Methods A nationwide administrative dataset was used to identify hospitalisations with bronchiectasis as a diagnosis. Population statistics and medical encounter data were used to estimate the incidence, mortality, prevalence and direct medical costs associated with hospitalisation-requiring bronchiectasis. Results There were 420 incident hospitalised bronchiectasis patients in 2017, giving an incidence rate of 10.6/100 000. Age-standardised incidence declined on average by 2.7% per year between 2007 and 2017. Incidence rates increased strongly with age in both men and women. Tuberculosis was a secondary diagnosis in 37.5% of incident hospitalisations in 2007, but has declined sharply since then. Patient survival was considerably lower in both men (5-year Relative Survival Ratios (RSR) of 0.63 (95% CI, 0.59 to 0.66)) and women ((5-year RSR of 0.75 (95% CI, 0.72 to 0.78)). The point prevalence of bronchiectasis was 147.1/100,000 in 2017, and increased sharply with age, with more than 1% of people aged 75 years and older having bronchiectasis. Total first-year costs among incident bronchiectasis patients in 2016 varied widely, with an average of $7331 (standard deviation of $8863). About 10% of the patients admitted in 2016 had total first-year costs of more than $14 380. Conclusion Bronchiectasis is common and imposes a substantial burden on health care costs and survival rates of patients in Singapore.