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Objectives To evaluate cost-effectiveness of a novel screening strategy using a microRNA (miRNA) blood test as a screen, followed by endoscopy for diagnosis confirmation in a 3-yearly population screening program for gastric cancer. Methods A Markov cohort model has been developed in Microsoft Excel 2016 for the population identified to be at intermediate risk (Singaporean men, aged 50-75 years with Chinese ethnicity). The interventions compared were (1) initial screening using miRNA test followed by endoscopy for test-positive individuals and a 3-yearly follow-up screening for test-negative individuals (proposed strategy), and (2) no screening with gastric cancer being diagnosed clinically (current practice). The model was evaluated for 25 years with a healthcare perspective and accounted for test characteristics, compliance, disease progression, cancer recurrence, costs, utilities, and mortality. The outcomes measured included incremental cost-effectiveness ratios, cancer stage at diagnosis, and thresholds for significant variables. Results The miRNA-based screening was found to be cost-effective with an incremental cost-effectiveness ratio of $40 971/quality-adjusted life-year. Key drivers included test costs, test accuracy, cancer incidence, and recurrence risk. Threshold analysis highlights the need for high accuracy of miRNA tests (threshold sensitivity: 68%; threshold specificity: 77%). A perfect compliance to screening would double the cancer diagnosis in early stages compared to the current practice. Probabilistic sensitivity analysis reported the miRNA-based screening to be cost-effective in >95% of iterations for a willingness to pay of $70 000/quality-adjusted life-year (approximately equivalent to 1 gross domestic product/capita) Conclusions The miRNA-based screening intervention was found to be cost-effective and is expected to contribute immensely in early diagnosis of cancer by improving screening compliance.

The Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) is a preconception, longitudinal cohort study that aims to study the effects of nutrition, lifestyle, and maternal mood prior to and during pregnancy on the epigenome of the offspring and clinically important outcomes including duration of gestation, fetal growth, metabolic and neural phenotypes in the offspring. Between February 2015 and October 2017, the S-PRESTO study recruited 1039 Chinese, Malay or Indian (or any combinations thereof) women aged 18 to 45 years and who intended to get pregnant and deliver in Singapore, resulting in 1032 unique participants and 373 children born in the cohort. The participants were followed up for 3 visits during the preconception phase and censored at 12 months of follow up if pregnancy was not achieved (N=557 censored). Women who successfully conceived (N=475) were characterised at gestational weeks 6-8, 11-13, 18-21, 24-26, 27-28 and 34-36. Follow up of their index offspring (N=373 singletons) is on-going at birth, 1, 3 and 6 weeks, 3, 6, 12, 18, 24 and 36 months and beyond. Women are also being followed up post-delivery. Data is collected via interviewer-administered questionnaires, metabolic imaging (magnetic resonance imaging), standardized anthropometric measurements and collection of diverse specimens, i.e. blood, urine, buccal smear, stool, skin tapes, epithelial swabs at numerous timepoints. S-PRESTO has extensive repeated phenotypic data collected which include genetic and epigenetic sampling from preconception which is unique in mother-offspring epidemiological cohorts This enables prospective assessment of a wide array of potential determinants of future health outcomes in women from preconception to post-delivery and in their offspring across the earliest development from embryonic stages into early childhood. In addition the S-PRESTO study, draws from the three major Asian ethnic groups that represent 50% of the global population, increasing the relevance of its findings to global efforts to address non-communicable diseases.

To identify how monetary incentives affect influenza vaccination uptake rate using a randomized control experiment and to subsequently design an optimal incentive program in Singapore, a high-income country with a market-based healthcare system.4000 people aged ≥65 were randomly assigned to 4 treatment groups (1000 each) and were offered a monetary incentive (in shopping vouchers) if they chose to participate. The baseline group was invited to complete a questionnaire with incentives of 10 Singapore dollars (SGD; where 1 SGD ≈ 0.73 USD), whereas the other three groups were invited to complete the questionnaire and be vaccinated against influenza at their own cost of around 32 SGD, in return for incentives of 10, 20, or 30 SGD.Increasing the total incentive for vaccination and reporting from 10 to 20 SGD increased participation in vaccination from 4.5% to 7.5% (P.001). Increasing the total incentive from 20 to 30 SGD increased the participation rate to 9.2%, but this was not statistically significantly different from a 20-SGD incentive. The group of nonworking elderly were more sensitive to changes in incentives than those who worked. In addition to working status, the effects of increasing incentives on influenza vaccination rates differed by ethnicity, socio-economic status, household size, and a measure of social resilience. There were no significant differential effects by age group, gender, or education, however. The cost of the program per completed vaccination under a 20-SGD incentive is 36.80 SGD, which was the lowest among the three intervention arms. For a hypothetical population-level financial incentive program to promote influenza vaccination among the elderly, accounting for transmission dynamics, an incentive between 10 and 20 SGD minimizes the cost per completed vaccination from both governmental and health system perspectives.Appropriate monetary incentives can boost influenza vaccination rates. Increasing monetary incentives for vaccination from 10 to 20 SGD can improve the influenza vaccination uptake rate, but further increasing the monetary incentive to 30 SGD results in no additional gains. A partial incentive may therefore be considered to improve vaccination coverage in this high-risk group.

Background To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs. Methods Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases. Results Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers. Conclusion This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs. Electronic supplementary material The online version of this article (10.1186/s12913-019-3980-x) contains supplementary material, which is available to authorized users.

Introduction : Frequent admitters FA, defined as patients with three or more inpatient acute hospital admissions within one year, account for about 27% of episodes and incur high healthcare costs. National University Health System Regional Health System NUHS-RHS Integrated Interventions and Care Extension NICE, launched in 2014, targeted FA with the aim of reducing avoidable hospital utilisation. NICE patients were assigned a case manager who customised their care plan based on holistic needs assessment. NICE provided post-discharge home visits and/or phone calls to monitor patients’ progress, appropriate referrals to community health and social services, and consolidated care under one team. We retrospectively evaluated NICE’s effect on reducing utilisation over 1-year post-enrolment: all-cause admissions ADM, emergency admissions EM, emergency department visits ED, specialist outpatient clinic visits SOC, and total inpatient length of stay LOS. Methods : NICE patients enrolled between June 2014 to December 2015 were grouped as cases n=668. Unenrolled patients who were FA during the same period were designated as potential controls n=5,714, taking their third admission date during this period as proxy date of enrolment. Propensity score matching was conducted with the following: gender, race, age, residential housing type, number of comorbidities at enrolment, date of enrolment and pre-enrolment utilisation 1-year prior. This resulted in 604 matched case-control pairs. As the variance of each measure of utilisation is greater than its mean, negative binomial regression was used to model post-enrolment utilisation, adjusting for log-transformed pre-enrolment levels and matching propensity score, with an offset term to account for potential mortality during follow-up. We report incidence rate ratios IRR of cases to controls, with 95% confidence intervals 95%CI. Results : Cases unadjusted mean=6.7 had significantly fewer post-enrolment SOC than controls unadjusted mean=8.6, IRR=0.86 95%CI: 0.77-0.97. No statistically significant differences were observed for post-enrolment ADM, EM, ED, and LOS. Discussion : The results suggest that NICE provided adequate post-discharge follow-up care that patients would otherwise seek from SOC, thus potentially decreasing patients’ time and cost burden. For a significant proportion of patients in both groups, post-enrolment ADM, EM, ED, and LOS may have regressed to a low mean following an acute period of high admissions, resulting in floor effects which limit any further reductions in a 1-year period. Conclusion : NICE had an impact in reducing patients’ SOC post-discharge. Lessons Learned : The higher than expected variability in the utilisation patterns suggest FA are a heterogeneous group, and stratification could allow for more targeted interventions that better cater to care needs. Limitations : Patients were not randomised into cases and controls, but inherent bias from confounding factors was mitigated with matching. Different patient profiles and needs possibly also led to implementation inconsistencies. Suggestions for Future Research : Future research could stratify FA into subgroups and explore programme effects in reducing readmissions within patient subsets over a longer follow-up period. Targeted interventions for various subsets could be tested and inform future iterations of such programmes. Cost-benefit analysis should be conducted to determine if the savings from reduced SOC that are attributable to NICE outweighs the cost to run the programme.

Background The lack of seasonality in influenza epidemics in the tropics makes the application of well-established temperate zone national vaccination plans challenging. Objectives We developed an individual-based simulation model to study optimal vaccination scheduling and assess cost-effectiveness of these vaccination schedules in scenarios of no influenza seasonality and the seasonality regimes of Singapore, Taipei, and Tokyo. Methods The simulation models heterogeneities in human contact networks, levels of protective antibodies following infection, the effectiveness of the influenza vaccine, and seasonality. Using a no intervention baseline, we consider 3 alternative vaccination strategies: (1) annual vaccination for a percentage of the elderly, (2) biannual vaccination for a percentage of the elderly, and (3) annual vaccination for all elderly and a fraction of the remaining population. We considered 5 vaccination uptake rates for each strategy and modeled the estimated costs, quality-adjusted life years, and incremental cost-effectiveness ratios (ICERs), indicating the cost-effectiveness of each scenario. Results In Singapore, annual vaccination for a proportion of elderly is largely cost-effective. However, with fixed uptake rates, partial biannual vaccination for the elderly yields a higher ICER than partial annual vaccination for the elderly, resulting in a cost-ineffective ICER. The most optimal strategy is the total vaccination of all the elderly and a proportion of individuals from other age groups, which results in a cost-saving ICER. This finding is consistent across different seasonality regimes. Conclusions Tropical countries like Singapore can have comparably cost-effective vaccination strategies as found in countries with winter epidemics. The vaccination of all the elderly and a proportion of other age groups is the most cost-effective strategy, supporting the need for an extensive national influenza vaccination program.

Background Drug resistance is a growing challenge to tuberculosis (TB) control worldwide, but particularly salient to countries such as Myanmar, where the health system is fragmented across the public and private sector. A recent systematic review has identified a critical lack of evidence for local policymaking, particularly in relation to drivers of drug-resistance that could be the target of preventative efforts. To address this gap from a health systems perspective, our study investigates the healthcare-seeking behavior and preferences of recently diagnosed patients with drug-resistant tuberculosis (DR-TB), focusing on the use of private versus public healthcare providers. Methods The study was conducted in ten townships across Yangon with high DR-TB burden. Patients newly-diagnosed with DR-TB by GeneXpert were enrolled, and data on healthcare-seeking behavior and socio-economic characteristics were collected from patient records and interviews. A descriptive analysis of healthcare-seeking behavior was followed by the investigation of relationships between socio-economic factors and type of provider visited upon first feeling unwell, through univariate logistic regressions. Results Of 202 participants, only 8% reported first seeking care at public facilities, while 88% reported seeking care at private facilities upon first feeling unwell. Participants aged 25–34 (Odds Ratio = 0.33 [0.12–0.95]) and males (Odds Ratio = 0.39 [0.20–0.75]) were less likely to visit a private clinic or hospital than those aged 18–24 and females, respectively. In contrast, participants with higher income were more likely to utilize private providers. Prior to DR-TB diagnosis, 86% of participants took medications from private providers. After DR-TB diagnosis, only 7% of participants continued to take medications from private providers. Conclusion In urban Myanmar, most patients shifted to being managed exclusively in the public sector after being formally diagnosed with DR-TB. However, since the vast majority of DR-TB patients first visited private providers in the period leading to diagnosis, related issues such as unregulated quality of care, potential delays to diagnosis, and lack of care continuity may greatly influence the emergence of drug-resistance. A greater understanding of the health system and these healthcare-seeking behaviors may simultaneously strengthen TB control programmes and reduce government and out-of-pocket expenditures on the management of DR-TB.

Aim Medication non‐adherence influences outcomes of therapies for chronic diseases. Allopurinol is a cornerstone therapy for patients with gout; however, non‐adherence to allopurinol is prevalent in Singapore and limits its effectiveness. Between 2008‐2010, an adherence‐enhancing program was implemented at the rheumatology division of a public tertiary hospital. The cost‐effectiveness of this program has not been fully evaluated. With healthcare resources being finite, the value of investing in adherence‐enhancing interventions should be ascertained. This study aims to evaluate the cost‐effectiveness of this adherence‐enhancing program to inform optimal resource allocation toward better gout management. Method Adopting a real‐world data approach, we utilized patient clinical and financial records generated in their course of routine care. Intervention and control groups were identified in a standing database and matched on nine risk factors through propensity score matching. Cost and effect data were followed through 1‐2 years. A decision tree was developed in TreeAge using a societal perspective. Deterministic and probabilistic sensitivity analyses were performed to assess parameter uncertainty. Results At an assumed willingness‐to‐pay threshold of $50 000 USD ($70 000 SGD) per quality‐adjusted life year (QALY), the intervention had an 85% probability of being cost‐effective compared to routine care. The incremental cost‐effectiveness ratio was $12 866 USD per QALY for the base case and ranged from $4 139 to $21 593 USD per QALY in sensitivity analyses. Conclusion The intervention is cost‐effective in the short‐term, although its long‐term cost‐effectiveness remains to be evaluated.

In line with the recent adoption of the Sustainable Development Goals, global health has grown increasingly relevant in Southeast Asia (SEA), with the proliferation of new actors and growing interest in global health issues. In SEA, Singapore has emerged as a developed nation with the capabilities and resources to be a powerful force of change for progress in global health. The aim of this paper is to explore the perceptions of global health actors in SEA on Singapore’s role and contributions to the global health landscape. Twenty-five semi-structured interviews were conducted with participants from the SEA region with global health expertise and experience. Key-informants were recruited from a range of international and local health institutions across public and private sectors. Thematic analysis was conducted to identify emergent themes. Findings suggest that Singapore is perceived as being successful in achieving the Millennium Development Goals (MDGs), in its progress in healthcare and in its ability to exercise good governance. Obstacles that hampered Singapore’s ability to do more in global health were linked to its pragmatic priorities focusing on domestic health. The findings suggest a myriad of ways in which Singapore can expand its role in health globally by leveraging the strength of its academic institutions, good structures of governance, and influence in the region. Such efforts are perceived to yield practical benefits in bolstering Singapore’s security, economy and foreign relations, while enabling the state to contribute towards more charitable goals in reducing the global burden of disease. Drawing on our findings and supporting literature, a more comprehensive multidisciplinary research project examining Singapore’s existing global health footprint in various sectors and its potential to contribute more in global health could be beneficial.

BACKGROUND: In Singapore, as diabetes is an increasingly important public health issue, the cost-effectiveness of pursuing lifestyle modification programs and/or alternative prevention strategies is of critical importance for policymakers. While the US Diabetes Prevention Program (DPP) compared weight loss through lifestyle modification with oral treatment of diabetes drug metformin to prevent/delay the onset of type 2 diabetes in pre-diabetic subjects, no data on either the actual or potential cost effectiveness of such a program is available for East or South-east Asian populations. This study estimates the 3-year cost-effectiveness of lifestyle modification and metformin among pre-diabetic subjects from a Singapore health system and societal perspective. METHODOLOGY: Cost effectiveness was analysed from 2010-2012 using a decision-based model to estimate the rates of getting diabetes, healthcare costs and health-related quality of life. Cost per quality-adjusted life year (QALY) was estimated using costs relevant to the time horizon of the study from Singapore. All costs are expressed in 2012 US dollars. PRINCIPAL FINDINGS: The total economic cost for non-diabetic subjects from the societal perspective was US$25,867, US$28,108 and US$26,177 for placebo, lifestyle modification and metformin intervention respectively. For diabetic patients, the total economic cost from the societal perspective was US$32,921, US$35,163 and US$33,232 for placebo, lifestyle modification and metformin intervention respectively. Lifestyle modification relative to placebo is likely to be associated with an incremental cost per QALY gained at US$36,663 while that of metformin intervention is likely to be US$6,367 from a societal perspective. CONCLUSION: Based on adaptation of the DPP data to local conditions, both lifestyle modification and metformin intervention are likely to be cost-effective and worth implementing in Singapore to prevent or delay the onset of type 2 diabetes. However, the cost of lifestyle modification from the societal perspective would have to be reduced in order to match the cost-effectiveness of metformin intervention.

BackgroundIn 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home.Methodology/principal findingsWe conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed "not necessary" by a household decision maker. Among the poorest women, "not necessary" was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended.ConclusionsIn developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.