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SINGHEALTH CENTRE FOR HEALTH SERVICES RESARCH ANNUAL REPORT 2008/2009

ENDURING INSIGHTS, EMPOWERING SOLUTIONS

The SingHealth Centre for Health Services Research (CHSR) conducts outcomes research and health technology assessments and uses these findings to provide up-to-date analysis and leading edge thinking on important healthcare policy and practice issues. We work closely with clinicians, administrators and healthcare organizations as well as industry and other partners to provide pragmatic and insightful healthcare solutions. This collaborative approach ensures that solutions are both effective and efficient; yielding high-quality research that guides subsequent interventions that are cost-effective and practical. For more information, visit http://www.singhealth.com.sg/Research/HealthServicesResearch/AboutUs/Pages/Home.aspx.

Centre of Health Services Research Annual Report 08/09

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Enduring Insights, Empowering Solutions

TABLE OF CONTENTS Director’s Message 2 Activities Research: 3 Health Technology Assessment 4 Outcomes Research 6 Systems Design 8 Education: 10 Seminars and Workshops 11

Temasek Foundation-SingHealth Training-of-Trainers Initiative to Enhance Health Care and Hospital Management in North India 13

Community Outreach 17 Internship Programme 18 Behind The Stethoscope Book Launch 19 Other Activities 19 The Team 20 Acknowledgements 28 Annexes 29 Publications 30 Conference Presentations 31

Grants and Commissioned Work 33


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DIRECTOR’S MESSAGE

Dear friends, It has been another busy year for the Centre and on behalf of the team, I would like to express our

gratitude for your support over the year, especially in the successful hosting (together with Ministry of

Health and National Healthcare Group) of the HTAi international meeting, the first time this

international gathering had been held in Asia. The last year saw a shift in the orientation of the

Centre away from internally oriented health services research (HSR) to guide SingHealth

management decision making, moving instead towards a more academic stance emphasizing grants

and academic publications.

In this respect, we have been fortunate to have some modest success, winning the Best Poster

(Allied Health) at the 18th Singapore General Hospital Annual Scientific Meeting with another 2

submissions short-listed for the Best Oral Presentation in Nursing and Allied Health. 2009 marked

the beginning of dedicated competitive funding for HSR commencing with the SingHealth Foundation

grant call and working with partners from the various SingHealth institutions, managed to secure 4

awards to further our research efforts. We also were awarded grants from the Arts for Health

program and SAPI (Singapore Association for Pharmaceutical Industries). Nationally, the inaugural

Ministry of Health HSR grant call will open at the end of the year and we intend to work closely with

partners within SingHealth and Duke-NUS to ensure strong representation.

The relationship with Duke-NUS has deepened further with multiple alliances forged for research

projects of mutual interest. 4 of our Centre staff have also assumed adjunct appointments with the

Duke-NUS. Moving ahead, we envisage an ever-increasing partnership in both research and

educational outreach.

The Centre has maintained its focus on education to promote awareness of health services research,

actively conducting workshops and seminars locally. We are gratified that our efforts have been

recognized in the form of a substantial grant from the Temasek Foundation to offer training in North

India and we hope this will mark the beginnings of international forays together with Duke-NUS and

further opportunities to contribute back to society both locally and internationally.

Finally, on a more personal note, I would like to thank all of you, friends, supporters and believers in

the value of health services research in improving patient care for the unstinting support since the

Centre’s inception in 2006. It is time to pass on the baton and I am gratified that Dr Chow Wai Leng,

who has grown with the Centre since its early days, has stepped up to the plate. I am confident that

under her leadership, the Centre will soar to new heights.

Yours Sincerely,

Dr. Jeremy Lim


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Research

Activities


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HEALTH TECHNOLOGY ASSESSMENT

At SingHealth, Health Technology Assessment (HTA)

provides a framework for making decisions based on a

comprehensive overview of new technologies and the

evaluation of their consequences in the health service. The

term ‘Technologies’ here encompasses all methods used to promote health, prevent and treat

disease and improve rehabilitation or long term care. These could range from the state of the art

robotic surgery, the latest chemotherapy, to programmes that promote responsible antibiotic

prescribing behaviour among physicians.

HTA assesses the effectiveness, appropriateness and cost of each technology by asking four

fundamental questions: Does the technology work? Who does it benefit? At what cost? And how

does it compare with alternatives? (UK National Health Service R & D Health Technology

Assessment Programme 2003).

Through HTA, the Centre supports the procurement and service development decision-making

process of our clinicians and management. Our analysis demonstrates how a multitude of

factors, including clinical effectiveness, disease burden, organizational strategic priorities, and

impact on quality and delivery of care, could potentially influence the allocation of healthcare

resources.

The Centre supports the review of applications by SingHealth Institutions to the Ministry of

Health (MOH) Health Services Development Program (HSDP) and Reinvestment Fund (RF).

A handbook on HTA has also been made available to healthcare practitioners from SingHealth

Institutions. The handbook provides a good introduction to the topic, the process of conducting a

HTA, as well as useful resources available.

In June 2009, our team, together with colleagues from Ministry of Health

and National Healthcare Group, hosted the 6th Annual Meeting of Health

Technology Assessment International in Singapore. This was the first time

the meeting was held in Asia and it presented a rare opportunity for

SingHealth clinicians to be exposed to a top-level meeting in health

technology assessment.

The conference was a resounding success, with over 700 attendances from more than 30

countries. The conference was well attended by SingHealth representatives with the delegates

expressing that they could now better appreciate the relevance and importance of Health

Technology Assessment in their work and in evidence-based management.


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Economic Evaluations in Healthcare

Health policy and practice is a large and complex area. It benefits from a range of perspectives,

including that of economics. Economic analyses are increasingly being integrated in decision-

making processes by policy-makers, administrators and practitioners around the world. In

Australia and Canada, guidelines have been proposed for the pharmaceutical industry on the

preparation of economic analyses to be included in submissions to the government committee

deciding on the reimbursement of pharmaceuticals.

Finite resources are available to provide healthcare for given populations. Each time we choose

to utilize resources to meet one need, the opportunity to use the resources to address another

need is passed over. This often mandates choices; rationing and prioritization are inevitable.

In the midst of scarce resources and competing demands, economic evaluations serve as a

useful decision-making tool. Economic helps to answer questions such as “Is this intervention

worth pursuing compared with other available options with these same resources?”. More

formally, an economic evaluation is a comparative analysis of alternative courses of actions in

terms of both their costs and consequences.

The SingHealth CHSR is building up capabilities in the field of healthcare economics, especially

in conducting economic evaluations. the Centre has since embarked on several economics-

related projects, including evaluations of HBOT, insulin glargine and endobronchial ultrasound.

In April 2009, the Singapore Association of Pharmaceutical Industries had commissioned our

Centre to conduct a research study on Developments in National Pharmaceutical Pricing,

Coverage and Reimbursement Policies. This ongoing study will examine the policies on access,

funding and financing of drugs across eight countries; a major study component is devoted to

examining how pharmaco-economics is being employed as an assessment tool by national

authorities in evaluating which drugs should qualify for government subsidies.


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OUTCOMES RESEARCH

Outcomes research examines whether patients have

benefited from the medical care provided. Rigorous measures

of outcomes are therefore crucial in the evaluation of different

treatments, procedures and programmes in order to ensure

safety and efficacy in patient care. These outcome measures

eventually serve as evidence in making evidence based and informed decisions by the

clinicians as well as patients.

Outcomes research should be used for the following:

1. To make informed decisions

Outcomes research provides both clinicians and patients with evidence on benefits, risks

and treatment efficacy for decision-making. It also provides information on management that

is needed to improve the quality and value of care.

2. To improve the knowledge base of medicine

Outcomes research, by providing evidence on the outcomes of clinical treatment, is an

important component of Evidence Based Medicine (EBM).

Our centre has been involved in many projects and studies that center around outcomes

research. We have collaborated with healthcare professionals from different specialties, such

as, Orthopedics, Endocrinology, Geriatric Medicine, Renal Medicine as well as Psychiatry just to

name a few.

(i) A validation of KDQOL-SFTM

We conducted a cross section survey of 1180 patients with kidney disease on haemodialysis in

order to determine reliability and validity of Kidney Disease Quality Of Life Short Form (KDQOL-

SFTM) scoring in haemodialysis in Singapore. The survey was administered at 22 National

Kidney Foundation, Singapore (NKF) haemodialysis centres. The psychometric properties of the

KDQOL–SFTM, resulting from this first-time administration of the instrument to Singapore

population were suitable. The result supports administering KDQOL –SFTM in studies with

haemodialysis patients in Singapore. The research was presented as a poster at the 18th SGH

Annual Scientific Meeting and was awarded the top poster prize in the Allied Health Category.


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(ii) Healthcare Workers’ Health Related Quality of Life

We performed an anonymous self-administered survey on 574 healthcare workers (HCW) from

a large tertiary hospital in Singapore. The objective of the study was to explore the health-

related quality of life (HRQOL) among HCW groups and to assess the level of job satisfaction

on their work environment engagement. We found that HCW have a lower health-related quality

of life compared to their normative values. Doctors reported higher quality of life scores than

nurses and AHP. While HCWs report low levels of job satisfaction. We identified creating career

development opportunities and improving working relationships with subordinates were the most

important areas identified to enhance job satisfaction. This was presented at the 18th SGH ASM

and was short-listed for the best presentation award for the Allied Health Category

(iii) Evaluation of the Coordination of Care Pilot Programme

In Feb 2009, the Centre embarked on a project at the KK Women’s and Children’s Hospital, to

evaluate the Coordination of Care Pilot Programme (CCP) that was being implemented by the

Ambulatory Geriatric Services (AGS), for all elderly female inpatients above 65 years old.

Under the CCP, a geriatric nurse will conduct a general mental and physical health assessment

for all elderly female inpatients; the geriatric nurse also assists with discharge instructions and

post-discharge plans. Patients whose medical conditions warrant consultations with

Geriatricians can be referred to the AGS. In consultation with the AGS, the Centre had

designed a three-part framework to assess how the CCP contributes to identifying patient

needs, improving the coordination and continuity of care received, and in enhancing patient

satisfaction.

In the year ahead, the Centre looks forward to further opportunities to support clinical and

hospital management departments in conducting evaluations of programmes or interventions.


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SYSTEM DESIGN

Healthcare systems are inherently complex due to the

presence of many constituent elements that usually have

intricate relationships among them. Thus, it is crucial to apply

a holistic multi-faceted approach in evaluation of the

healthcare systems where in-depth analysis of underlying

system structures and comprehensive account of all processes, incentives, controls,

interventions and their relationships are required. Over the last one year, the Centre have

completed several projects in this domain and they can be broadly categorized into two main

areas as follows.

a) Process Simulation & Optimization Modeling

Simulation is an imitation of the operation of a real system over time with account of process

interactions and relationships among the entities within the system. It has been employed widely

to either understand the behavior of a system of interest or evaluate various interventional

measures that potentially may improve system operations. In contrast, optimization model is a

mathematical representation of a problem of interest and the model’s solution is a good (if not

optimal) solution to the problem. Essentially, optimization modeling offers a systematic and

scientific framework of addressing a problem where the latter is mathematically formulated

before it is solved either by established or custom-designed solution algorithms.

(i) Evaluation of Outpatient Cycle Time Reduction Strategies at Department of Diagnostic

Radiology (SGH)

Together with SGH Department of Diagnostic

Radiology (DDR), we evaluated the possible causes

of long cycle time experienced by outpatients who

visited DRR. To aid this evaluation study in

identification of possible effective waiting time

reduction interventions, we used simulation software

to develop a discrete event simulation model to

represent the patient flow in DDR with account of

patients’ interaction with receptionists, registration counter staff, and radiographers. After the

aforementioned model was statistically validated with the actual system, we went on to use it to

perform several “what-if” analyses where we made changes to the original configuration (e.g.

upgrade of X-ray machine), process flow (e.g. re-allocation of patients among procedure rooms)

and evaluated their respective potential impact on the cycle times of patients without affecting

the real patients. Through this simulation modeling based approach, we were able to make

several recommendations to DDR on specific measures, which DDR had subsequently found to

be indeed effective in reducing the patient cycle times.

"Your team [CHSR] was of great help and encouragement to us. Data was collected in a detailed and systematic method. The analysis and results presented to us were remarkable."

Ms Toh Hong Guan, Manager, Department of Diagnostic

Radiology (SGH)


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(ii) Evaluation of Outpatient Waiting Time Reduction Strategies at SGH A&E

In collaboration with SGH Department of Emergency Medicine (DEM) and School of Mechanical

and Aerospace Engineering in Nanyang Technological University (NTU), we evaluated the

possible causes of long waiting time experienced by outpatients who visited SGH Accident and

Emergency (A&E). Using a simulation software (Arena), a discrete event simulation model was

developed to represent the patient flows in SGH A&E which differ based on the medical

conditions of arriving patients. After the aforementioned model was statistically validated with

the actual system, “what-if” analysis was performed where several waiting time reduction

strategies pertinent to manpower redeployment were evaluated.

(iii) Doctor Rostering Decision Support Tool (SGH A&E)

This was a project that was undertaken concurrently with the preceding one in collaboration with

SGH Department of Emergency Medicine (DEM) and School of Mechanical and Aerospace

Engineering in Nanyang Technological University (NTU) where an automated Excel-based

decision-support tool was developed to aid DEM in rostering of doctors. Essentially, the new

tool framework entails development of an optimization model with account of relevant A&E

operational requirements imposed by DEM and a monthly roster can be generated within a few

mouse clicks.

b) System Thinking

In Peter Senge’s book, The Fifth Discipline: The Art and Practice of the Learning Organization,

‘systems thinking’ is introduced as a conceptual framework based on system dynamics: It

disciplines us in seeing and understanding patterns – looking beyond events, to deeper

“structures” that control events, and discovering the leverage that lies hidden in these

structures. The essence of the discipline lies in a shift of mind to (1) see interrelationships rather

than linear cause effect chains, and (2) see processes of change rather than snapshots.

The Centre had employed systems thinking in a smoking cessation project to understand

underlying issues in smoker’s motivation to quit. By conducting focus group discussions with

smokers and non-smokers with 10 to 12 people in each group (age 21 to 65 years), we tried to

trace the events that led to the start of smoking behavior/habit, how was their life shaped and

what was driving smokers to smoke despite being aware of health problems. Essentially we

tried to detect the causes that acted as trigger points in one’s life. With the systems framework,

we managed to successfully identify interventions that had been ignored or were not obvious.


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Education Activities

Education

Activities


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The Panel comprising of Mr. Edwin Tong, Dr. Benjamin Yim, Prof Alastair Campbell, A/Prof Chin Jing Jih & Dr. Tan Chi Chiu taking questions from the floor

SEMINARS & WORKSHOPS

In addition to our health services research mandate, the Centre has an extensive educational

outreach program where seminars and workshops are organized to impart knowledge, stimulate

discussion about current healthcare issues and challenges.

Health Economics Modeling Course

We co-organized a Health Economics Modeling Course with the Ministry of Health (MOH) in

January this year to raise the level of awareness of health economics among the clinicians and

health services research community in Singapore. There was good feedback from the

participants and there are plans to organize similar workshops on a regular basis to increase

awareness and encourage the application of economic evaluation by clinicians and the

healthcare community moving forward. Prof Åke Blomqvist will be conducting a second

workshop in Aug 2009.

Professional Self-Regulation - Is It Still Relevant Today?

We worked with the NUS Medical Society to organize a Forum on the importance of

professional self-regulation among doctors. The

panel, discussed the overview of professional

self-regulation among doctors as well as the

perspectives of different stakeholders on self-

regulation, including the SMC, SMA, the legal

profession and the aesthetic medicine doctor.

Other issues addressed in the forum were the

significance of “whistle-blowing” in Singapore

and the involvement of laypersons in the

regulating committees.

Speed: Motor Sports & Medicine

In line with Science.08, we worked together with Dr. Mark Leong, a Trauma Specialist, SGH’s

Life Support Training Centre to conduct a seminar on motorsports and medicine. Participants

were given an overview of injuries associated with motor sports and road-traffic accidents and a

behind-the-scenes peek into SingHealth’s medical support for the F1 night races.

Total Quality Management (TQM) as a break through to chronic managerial constraints in

Health Facilities and community-based programs

Professor Yujiro Handa from the Japan International Cooperation Agency (JICA) presented on

the effectiveness of implementing TQM techiniques to help reduce waste and improve staff

morale and productivity in even the most resource-challenge settings. He also provided a

glimpse of the community work the JICA conducted in Africa and real-life stories of how the

application of the TQM techniques effected real change in the communities he worked with.


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Landmark Studies In Public Health

Dr. Jeremy Lim was invited by MOH to conduct a talk on some of the accomplishments

achieved by public health physicians, which have had a profound impact on the health of the

community at large, such as the eradication of smallpox. He also touched upon four seminal

public health studies, which include Tobacco Control, Injury Prevention Cardiovascular Disease

Prevention and Healthcare Financing.

Music Therapy Seminar

Ms. Patsy Tan, Ms. Melaine Kwan and Ms. Ng Wang Feng, music therapists from KKH and

SGH conducted a seminar giving an overview of music therapy; its application, effectiveness

and the research conducted on it. They also shared personal stories on how they used music

therapy to touch their patients’ lives.

Singapore Medical Education Research Forums (SMERFs)

The Centre, in collaboration with the Medical Education Department of Duke-NUS have

organised a number of research forums for

SingHealth faculty to learn and discuss new

programs for education and pedagogy and

serve as a platform for interested faculty to

present research ideas and findings. Subjects

covered include an overview of Medical

Education Research, standardized patients,

the practical considerations of starting a

medical education research project and the

medical residents’ view of medical education

research.

Involving patients and the public in clinical research

A joint effort by the Centre, SingHealth Corporate Communications and the National Medical

Research Council, this panel discussion led by Dr. Edwin Low (Director, NMRC), A/P Chong

Siow Ann (Senior Consultant Psychiatrist, IMH),

Ms. Tan Huang Shuo Mei (Director, Corporate

Communications, SingHealth) and Ms. Bec Hanley

(Co-director, Twocan Associates, UK) talked about

the importance of engaging patients and the

community at large in clinical research and different

strategies of engagement. Ms. Hanley, whose

organization promotes on the involvement of people

who use services in health care and health

research also shared on the work done by her in

the UK and Australia.

"It has been a great pleasure working with the CHSR team. Their familiarity with the healthcare system is a major plus-point which provided invaluable insights for the project we were working on."

Ms Yeo Wen Qing,

External Affairs & Communications Manager

NMRC, MOH

Faculty from SingHealth and Duke-NUS attending the SMERF on Standarised Patients


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TEMASEK FOUNDATION-SINGHEALTH TRAINING-OF-

TRAINERS INITIATIVE TO ENHANCE HEALTH CARE AND

HOSPITAL MANAGEMENT IN NORTH INDIA

SingHealth CHSR was awarded funding by Temasek Foundation to conduct a Training-of-

Trainers Initiative to Enhance Health care and Hospital Management in North India. The

objective of this initiative is to enhance the management of health care and hospital services in

North India through building capability and capacity of health care and hospital administrators,

managers and clinicians in rational, evidence-based decision-making in health care policy and

practice.

This initiative involves a partnership between Temasek Foundation, SingHealth and The

Catholic Health Association of India.

The program was inaugurated on the 23rd of May 2009. Albeit a small, informal inauguration

ceremony, there was great interest among the local media. Various local newspapers reported

on the event.

The first workshop on strategic leadership in health care and the first part of the training-of-

trainers workshop was held in Chandigarh, India from the 23rd till 26th of May 2009.

A simple ceremony took place after the speeches. The governor, superintendent and project directors took turns to light a lamp, which symbolized the start of the initiative, with blessings from the Goddess of Wisdom.

The inauguration was graced by H.E. Gen. (Retd.) S.F. Rodrigues, Governor of Punjab and Chief Administrator of Chandigarh.


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First Workshop on Strategic Leadership in Health Care

Participants of the first workshop on strategic leadership in health care were mostly from the

Government Medical College and Hospital (GMCH), and Post Graduate Medical Institute of

Education and Research (PGIMER), Chandigarh. There was immense interest to learn from the

faculty, as exemplified by an overwhelming attendance despite the workshop being held on a

Saturday. A total of 34 leaders attended the workshop.

Punjab Kesari “Health Care Services in the 3 cities should be strengthened: Rodrigues”

Dainik Bhaskar “Doctors from Singapore here to impart knowledge and skills”

Media Coverage of the Inauguration of the Training of Trainers Initiative in India

Amar Ujala “Standard of health care services in Chandigarh to be on par with Singapore”


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The topics covered in the workshop include an overview of the Singapore health care system,

the healthcare system and challenges in India, evidence-based management and health

technology assessment.

First Training-of-Trainers (TOT) Workshop (India Leg)

Similarly, participants of the first part of the TOT workshop showed keen interest and narrated

that concepts learnt during the workshop would be useful to their organization. The first part of

the TOT workshop in India covered the topics of evidence-based medicine, critical appraisal of

medical literature, systematic reviews and meta-analyses, health technology assessment,

health economics and modeling methods in health care. There were 31 participants at the

workshop and full attendance was achieved in all three days.

At the end of the three days, participants were given the chance to evaluate the workshop. On

the average, participants rated the workshop a high score of 54 out of a maximum of 60.

First Training-of-Trainers (TOT) Workshop (Singapore Leg)

The second part of the TOT workshop was held in Singapore from the 17th till 20th of June 2009.

All sessions were held at the premises within SingHealth Outram Campus. Faculty members

comprised of staff from SingHealth and Duke-National University of Singapore.

During the four-day workshop, participants had

the chance to further consolidate their learning

and interact with health care professionals who

have had the experience and expertise in

dealing with similar challenges and areas of

improvements that the participants had

identified for their own institutions.

Prof David Matchar conducted the Health Economics Segment of the Workshop

A Participant addressing a panel of managers in SGH on Hospital Operations

Participants working on a HTA case study in one of their breakout sessions.


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When asked to evaluate the usefulness of the workshop, participants in general found the

sessions to be very useful, giving an average score of 8 out of 10. Participants also commented

that the workshop was well organized and provided them with invaluable experience which they

would like to share with their colleagues back in their own institutions.

Upon the participants’ return to India, our program director and manager in India kept close

contacts with the participants in order to facilitate the use of what they have learnt to tackle

challenges in their own institutions. Participants were asked to come up with actions plans that

detailed (i) the current status of the problem they wish to solve; (ii) what they envisage

happening in one year’s time; (iii) targets for each quarter of the year and (iv) a pilot of their

action plan in the last quarter.


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Community

Outreach Activities


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INTERNSHIP PROGRAMME

We also provide internship opportunities (both short term and medium term) for both local and

international students and actively work with Singapore schools to teach students through service

learning projects the methods and techniques used in health services research. Care is taken to

match the interests expressed by the student to the projects they are involved in. Students are

also encouraged to work on projects of their own and to present their findings at conferences or

publish their work in peer-review journals. In particular, the Centre has a partnership with

Meridian Junior College to provide short term internships for the Outstanding Student Volunteer

Attachment Program (OSVAP) over the month of December and longer term internships of six

months for Junior College Graduates. In 2008, the Centre was awarded a Friends of Meridian

award in 2008.

Research Associates

Local

Himani Pruthi Aggarwal Doctoral candidate, National University of Singapore, Dept of Economics

Ang Chia Yuen Undergraduate, National University of Singapore, Dept of Economics

Yap Wei Qing Undergraduate, Nanyang Technological University

Imran Rafie Undergraduate, Nanyang Technological University

Evelyn Wong Recent graduate of Hwa Chong Junior College

Ng Wen Yan Recent graduate of Hwa Chong Junior College

Cherish Goh Recent graduate of Meridian Junior College

Low Sie Hui Recent graduate of Meridian Junior College

Charis Seow Recent graduate of Meridian Junior College

Ng Han Xian Student of Meridian Junior College

Amelin Foo Student of Meridian Junior College

Jamie Ding Student of Nanyang Junior College

Melissa Teo Student of Nanyang Junior College

Lin Xuan Yi Student of Nanyang Junior College

International

Huang Chia Yin Graduate student, I-Shou University, Republic of China]

Lee Yu Chia Graduate student, I-Shou University, Republic of China]

Veronica Alexandrakis Recent graduate, University of Applied Sciences Cologne, Germany

" We enjoyed this opportunity to intern at CHSR on the whole and hope that many more of our juniors who are interested in healthcare will be given to chance to go through the same intensive but challenging programme."

Ms. Charis Seow


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The Panel Comprising of Dr. Jeremy Lim, Prof Tan Cheng Lim, Dr. Lee Suan Yew, Minister Khaw Boon Wan, Prof Foo Keong Tatt & Prof Ranga Krishnan

The Finnish Delegation taking a walking tour of Outram Campus

Behind The Stethoscope Book Launch

In addition to the talks and seminars organized, the Centre working together with SingHealth

Quality Management, the SingHealth Academy and SingHealth Group Communications brought

together a number of like-minded doctors to write about their personal journeys and reflections

in a bid to capture the art, values and ethos of the profession. The book was launched on 10

Sep 2008 with a forum attended by 300 members titled “Heart to Heart: Conversations on the

meaning of Medicine” with

Minister of Health, Mr. Khaw

Boon Wan as the Guest of

Honor. He was joined by a panel

of prominent and well respected

doctors accomplished in their

respective fields, namely

Professor Foo Keong Tatt,

Emeritus Consultant at

Singapore General Hospital,

Professor Tan Cheng Lim,

Emeritus Consultant at KK

Women’s and Children’s

Hospital, Professor Ranga

Krishnan, Dean of Duke-NUS Graduate Medical School, and Dr Lee Suan Yew, General

Practitioner at SY Lee Clinic, to discuss the importance of the preserving the ethos of the

medical professions and the type of qualities and chracteristiscs which all doctors should

possess.

Other Activites Hosting of International Delegates

Singapore’s world-class health indices, coupled with a relatively low GDP expenditure

compared to other developed countries,

have generated much interest in our

healthcare system internationally. We have

had the privilege to be approached by

several international delegates to share

with them on Singapore’s healthcare

system. We have hosted several

delegations from Finland, South Korea,

Macau and Holland who visited Singapore

to better understand Singapore’s health

system. In the process, we have also had the opportunity to learn more about the best practices

from the other health systems through our discussions with the delegates.


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The Team


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THE TEAM

A surgeon by training, Jeremy now oversees research and education in the cluster and

concurrently leads the SingHealth Centre for Health Services Research. He has written and

lectured widely on health policy and maintains a professional and personal interest in the

provision of public healthcare services for lower socio-economic groups.

Jeremy is also active in the community and is Vice-Chairman of the Pasir Ris Elias Community

Club and formerly council member of the Northeast Community Development Council. He also

serves on the Executive Committee of the Fulbright Association of Singapore and sits on the

College Advisory Committee of Meridian Junior College. Jeremy contributes a monthly column

on topical health policy issues to the SMA News, the publication of the Singapore Medical

Association and reviews healthcare policy and management submissions to many local and

international journals.

Jeremy completed the Masters of Public Health program at the Johns Hopkins School of Public

Health on the Fulbright program. He was inducted into the Delta Omega Honor Society (top

10% of the graduating cohort) and was also honored by the school with the ‘Outstanding

Service Award’ for services rendered as President of the school’s JB Grant International Health

Society.

Dr Jeremy Lim Fung Yen MBBS, MPH, MRCS (Edin), MMed (Surg) Director, Education and Research Director, SingHealth Centre for Health Services Research (CHSR)


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Wai Leng has been actively involved in Health Services Research in SingHealth, Centre for

Health Services Research (CHSR) while concurrently holding the position of Senior Manager in

the Department of Quality Management in Singapore General Hospital (SGH) since August 2007.

Wai Leng’s work in the SingHealth CHSR and SGH are mainly related to healthcare delivery

processes and quality management in healthcare.

She is the Principal Investigator (PI) of an ongoing study funded by SingHealth Foundation on

evaluating recontamination of the hospital environment by methicillin-resistant staphylococcus

aureus (MRSA) after decontamination with adjubctive titanium dioxide environment coating. The

study is now in its 3rd year and nearing successful completion.

At the same time, Wai Leng has keen interest in studies relating to chronic disease management.

She has won a merit award for her oral presentation on Renal Shared Care For Early Chronic

Kidney Disease Patients - Challenges And Opportunities at WONCA World Conference 2007.

She is also a collaborator in 2 other studies on diabetes management that has been presented at

the recent JAMA-NUHS conference 2008.

She is the co-author of a paper entitled “Treatment of refractory Salmonella enteritidis meningitis

With intraventricular gentamicin – a case report”, published in the Singapore Paediatric Journal in

2002.

She is a medical doctor by training and has worked in the various public health institutions in

Singapore as a medical officer before joining the team. She obtained her MBBS degree from the

National University of Singapore and also has a Graduate Diploma in Family Medicine

(Singapore).

Dr Chow Wai Leng MBBS (Singapore), GDFM (Singapore) Assistant Director, CHSR


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Ang Shin Yuh MBA (Health Care Mgt), Adv Diploma in Nursing (Medical/Surgical), BSc (Hons) Nursing Studies Policy Analyst, CHSR

Shin Yuh joined the Centre with research interests in Operations Research, Health Technology

Assessment and knowledge-based organizations.

Prior to secondment to HSR, Shin Yuh has worked at various inpatient settings in Singapore

General Hospital with her last appointment being an Acting Nurse Clinician in a general surgery

ward. She was awarded the CEO's Best Clinical Nurse (1st runner up) in 2005. In 1998, Shin

Yuh was awarded a Public Service Commission Scholarship to pursue nursing studies at King's

College, London. She subsequently graduated with a Bachelor of Science (Hons). After working

as a nurse for a year, she then pursued and completed an Advanced Diploma in Nursing

(Medical/Surgical) in 2004. She then took up the Alice Lee Institute of Advanced Nursing

Scholarship in 2006 to do her MBA (health care management) at the National University of

Singapore.

Veena has over 20 years of research experience and over 8 years of teaching experience. Her

main research experience is in epidemiology, social science and market research. She uses

multidisciplinary techniques such as statistical techniques (multivariate analysis including

various regression models, exploratory and confirmatory factor analysis, correspondence

analysis, survival analysis, cluster & discriminant analysis, repeated measures), process

modeling, qualitative analysis and systems thinking.

Veena first joined the Centre in July 2006. She took up her first full time job with the National

Kidney Foundation, Singapore (NKFS) as Senior Biostatistician in 2000 before joining the

Health Promotion Board in 2006 as a Manager (Research and Evaluation). During her time in

NKF, Veena handled one of the largest health screening data sets including data on all the

dialysis patients in Singapore. Veena obtained her PhD in social science in 1994 and is

currently an Adjunct Assistant Professor at Duke-NUS Graduate Medical School.

Veena has published several papers in peer-reviewed journals such as Nephrology Journal,

Hong Kong Journal of Gerontology, Asia Pacific Journal of Social Work, Asia Pacific Journal of

Public Health and Ann Acad Med Singapore. Veena was a ranked Table tennis player during

her young days in India.

Dr Veena Joshi MSc. (Biometry), PhD (Psychology) Research Fellow, CHSR


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" Working here for the past 2 years has been both very challenging and intellectually stimulating, but it was given me a much deeper understanding of how healthcare in Singapore functions"

Dr. Tin Aung Soe

"I find it very rewarding when the work we do is implemented and used on the ground"

Mr. Oh Hong Choon

Hong Choon is an engineering graduate with extensive research experience in domains of

chemical supply chain network design, production-distribution planning & scheduling, maritime

logistics optimization, and optimization under uncertainty. He joined Centre for Health Services

Research in December 2008 and he hopes to apply and broaden his research experience in the

area of optimization, and contribute to healthcare research in fields where operations research

is relevant.

Hong Choon graduated with B.Eng (Chemical Engineering) and M.Eng from the National

University of Singapore in 1998 and 2000 respectively. Upon graduation, he joined Hewlett

Packard Singapore (Private) Limited as a product engineer where he supported the quality

control process within the inkjet manufacturing division.

After gaining 3 years of engineering experience, he

decided to return to the academia in 2003 by working as

a research fellow at the National University of Singapore

while pursing his doctorate on part-time basis.

Tin has been with the Centre of Health Services Research since July 2007. He is currently

working in the area of health related outcomes research. His main focus is on the evaluation of

chronic disease management in different settings.

Tin has worked in Yangon General Hospital for 2 years and

subsequently became the team leader of Leprosy control for 4 years.

He has a fair amount of experience participating in communicable

disease control programs in a developing country. In 2006, he was

awarded a Masters of Medicine in Public Health from the National

University of Singapore Yong Loo Lin School of Medicine. His

interests are primarily on communicable diseases. In his dissertation,

he determined the prevalence and risk factors contributing to the

delay in treatment of leprosy patients. Tin graduated with a MBBS degree from Myanmar.

Oh Hong Choon BSc (Hons) Chemical Engineering, MSc Engineering Policy Analyst, CHSR

Dr Tin Aung Soe MBBS (Myanmar), MMedSc Public Health (Myanmar), MMed Public Health (Singapore) Policy Analyst, CHSR


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Shao Chuen’s research interests are in patient expectations & consumer behavior, patient

motivation and international medicine models. He is also at present an Adjunct Research Fellow

at the Medical Education Department in the Duke-NUS Graduate Medical School.

He was working on service operations improvement projects in SGH prior to joining CHSR in

2008. He was an Administrative Fellow in Durham Regional Hospital in the Duke University

Health System and a research associate for the Washington University Infectious Diseases

Clinic prior to joining SGH. He has a BSc in Biomedical Engineering as well as a Masters in

Health Administration from Washington University in St Louis.

Kiki is currently coordinating a research study examining the attitudes and behaviour towards

kidney donation by the patients and the general public. At the same time, she has been working

on international comparisons of health systems, of which the latest being a research study on

national pharmaceutical reimbursement policies. Kiki’s main interest is the Singaporean

healthcare system as a whole: whether it concerns the healthcare structure, healthcare

expenditure and healthcare financing or the positioning of healthcare as a sector within

Singapore.

Kiki has seven years of work experience in Europe, mainly in the Netherlands. After starting her

career with a private equity investor as a Business Analyst, she then worked over five years in

organizational design as a senior consultant, mainly for clients in the healthcare sector. She has

advised the Ministry of Health in the Netherlands, healthcare insurers and organizations for

elderly care on healthcare policy, management and organizational structures.

Kiki has a Master of Science in Civil Engineering from Delft Technical University in the

Netherlands (2000). She pursued part of her studies in Paris, France at the Grand Ecole des

Ponts et Chaussees (1997).

Tong Shao Chuen BSc (Engineering), MHA Policy Analyst, CHSR

Kiki Van der Erf MSc (Civil Engineering) Policy Analyst, CHSR


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Vivian completed a Master’s degree in Information Studies from Nanyang Technological

University (NTU) and was a recipient of NTU Research Scholarship. She also obtained a

Bachelor of Computer Science from Wuhan University, China.

As a former member of HP Labs, Vivian contributed to the design and development of the

Shared Services Platform. Prior to HP, she was the Head of Product Development at

DecisionWare, a computer simulation company based in National University of Singapore.

Pavitar is a part-time Research Associate. Her interests are in multi-disciplinary qualitative work

involving literature, language, health communication and chronic disease. She is drawn to the

use of narrative analysis as a means of understanding the concerns of the chronically ill.

She worked at the Singapore Broadcasting Corporation as a Researcher/Producer previously.

She is now undertaking a part-time PhD in Health Research with the Institute of Health

Research at Lancaster University, UK, and her research topic is "Living with Inflammatory Bowel

Disease: Coping Mechanisms in a Singaporean Population". Pavitar graduated at the top of her

class for the BA (English) final exams at the University of Malaya, Kuala Lumpur and

subsequently pursued an MA in Linguistics at the University of Leeds, UK.

Pavitar Kaur Gill MA (Leeds) Research Associate, CHSR

Vivian Wang Wei MAsc Analyst, CHSR


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"The staff at the Centre for Health Services Research has been wonderful in providing research support for the kidney transplant program at SGH. At the moment, they are the driving force behind one of the largest scale survey to examine attitudes of patients and the public towards organ donation in Singapore. Without their professionalism and commitment, I doubt we could have made so much progress within a short period of time and I look forward to the findings would like to personally acknowledge Wai Leng, Kiki, Veena and Shirley for their assistance."

Dr. Terence Kee, Consultant,

Department of Renal Medicine (SGH)

Carol facilitates the administrative tasks in our fast-paced environment. She enjoys the vibrant

environment at the Centre. She looks forward to the many learning and career development

opportunities offered by the Centre.

Shirley coordinates and trains Silver Connection nurses for the many health surveys undertaken

by the Centre. She enjoys learning from the young and the old and is excited to contribute to the

many projects to help the sick.

Carol Tan Yin Yin Administrative Assistant, CHSR

Shirley Lim Hwee Hua Administrative Assistant, CHSR


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ACKNOWLEDGEMENTS

The CHSR team is grateful to have received ample trust, goodwill and support over the past

year from our project sponsors, partners and stakeholders. Thank you for having faith in the

work that we do.

Building on this foundation, we will continue furthering the cause of health services research as

a vital instrument in the ongoing efforts to further improve the quality and delivery of

healthcare.

PARTNERS AND COLLABORATORS (Not including SingHealth institutions)

Duke-Singapore Graduate Medical School

Glaxo Smith Kline Pte Ltd, Singapore

Meridian Junior College

Ministry of Foreign Affairs, Singapore

Ministry of Health, Singapore

National Medical Research Council

National Healthcare Group Corporate Office

National University of Singapore

Nanyang Junior College

Nanyang Technological University

Pfizer Pte Ltd, Singapore

Singapore Chinese Girls School

Singapore Management University

Singapore Association of Pharmaceutical Industries

Temasek Foundation


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Annexes


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PUBLICATIONS

Bridging the Gap between Primary and Specialist Care: Formidable Challenges Ahead, Ann Acad Med Singapore 2008;37:89-90, Koh G, Jeremy Lim Public Perceptions of Healthcare in Singapore, Ann Acad Med Singapore 2008;37:91-5, Veena Joshi, Jeremy Lim Consequences of Right Siting of Endocrinology Patients – A Financial and Workload Simulation, Ann Acad Med Singapore 2008;37:109-13, Tan DMH, Lee AL, Jeremy Lim Patient Advocacy and its role in Singapore, SGH Proceedings (Vol 17, Number 1, 2008), Soon G, Jeremy Lim Is the journal impact factor a valid indicator of scientific value? Singapore Med J 2009; 50(6):1-3, Oh Hong Choon, Jeremy Lim Health Equity and healthcare Equity – Eight themes from an Island State, American Scientific publishers, LA, USA (Feb.2009), Sanyal S, Pettigrew S, Ghista DN, Ong BC, Jeremy Lim; in Distributed Diagnosis and Home Healthcare, eds. Acharya UR, Tamura T, Ng EYK, Suri JS, Lim CM Submitted For Publication Assessing the Efficiency of Operating Rooms – What to Measure and Why? Oh Hong Choon, Tong Shao Chuen, Phua Tien Beng Jeremy Lim Health Insurance in Singapore – Who is not included and why? Veena Joshi, Jeremy Lim Public Perceptions of the Factors that Constitute a Good Healthcare System Veena Joshi, Jeremy Lim Smoking Cessation: Barriers, Motivators and the role of Physicians, A Survey of Physicians and Patients Veena Joshi, Virabhav Suchin, Jeremy Lim Advance Medical Directive in Primary Care Setting: Who Will Sign? Siew Chee Weng, Rukshini Puvanendran, Kwek Hwei Min, Veena Joshi Economic Analysis of Endobronchial Ultrasound (EBUS) as a Tool in the Diagnosis and Staging of Lung Cancer in Singapore Ang Shin Yuh, Mariko Koh, Rachel Tan, Jeremy Lim Appropriateness of Referrals for Specialist Diabetes Care Tin Aung Soe, Wee Shiou Liang, Goh Su-Yen, Darren Tan, Chow Wai Leng, Daphne Khoo, Jeremy Lim


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CONFERENCE PRESENTATIONS Jun 2009 2009 Health Technology Assessment International (HTAi)

Rapid HTA: Can Automated Breast Ultrasound replace Hand-Held Ultrasound as an adjunct to Mammography? by Ang Shin Yuh, Tan SM, Jeremy Lim

Treatment of poorly controlled type 2 diabetes (T2DM) patients with insulin glargine – An economic analysis by Chow Wai Leng, Goh SY, Ying WS, Ng BKH, Jeremy Lim

Music Therapy May Benefit Autistic Children but need larger RCTs by Kiki Van der Erf Saskia, Low YS, Tan PLP, Jeremy Lim

Mini-HTA: The Use of Myocardial Perfusion Imaging (MPI) in the diagnosis of cardiac pathology in patients presenting with chest pain in the Emergency Department by Tin Aung Soe, Chow JH, Lim SH, Jeremy Lim

Mini HTA: Enhancement of detection of colorectal polyps and dysplasia using Endoscopic Tri-Modal Imaging (ETMI) by Tin Aung Soe, Thia KTT, Jeremy Lim

Is ‘Super-Oxidized’ Water Effective as an Antiseptic in Wound Care? by Ang Shin Yuh, Jeremy Lim

Mini- HTA: Focused Assessment with Sonography for Trauma (FAST) by Tong Shao Chuen, Oh Jen Jen, Jeremy Lim

Apr 2009 SGH 18th Annual Scientific Meeting

The "Expectations Regarding Aging (ERA-12)" Instrument Can Be Used Among Middle-Aged Singaporeans by Veena Joshi, Malhotra R, Østbye T, Wong TK,Swan TS, Jeremy Lim

Validation of KDQOL-SFTM: A Dialysis Targeted Health Measure in Singapore (Awarded Best Poster for the Allied Health Category) by Veena Joshi, Seow YY, Thumboo J, Lee AL, Jeremy Lim

Retrospective Study of Discharges Within 24 and 48 Hours of Patients Admitted from Department of Emergency Medicine by Ang Shin Yuh, Tin Aung Soe, Lim SH, Ong MEH

Economic Analysis of Endobronchial Ultrasound (EBUS) as a Tool in the Diagnosis and Staging of Lung Cancer in Singapore by Ang Shin Yuh, Tan RWY, Koh MS, Jeremy Lim

Evaluating The Effectiveness Of The Nurse Specialist’s Role In The Care Of Patients With Inflammatory Bowel Disease (Short-listed for the Best Oral Paper in the Nursing Category) by Pavitar Kaur Gill, Ang Shin Yuh, Jeremy Lim Healthcare Workers In Singapore Have Lower Health-Related Quality of Life Scores compared to the General Population (Short-listed for the Best Oral Paper in the Allied Health Category) by Tin Aung Soe, Darren Tan, Jeremy Lim


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Mar 2009 2nd Asia Pacific IBD Scientific Meeting

Understanding the Psychosocial and Emotional Needs of Younger Patients with IBD: A Literature Review by Pavitar Kaur Gill, Jeremy Lim

Feb 2009 Society of Emergency Medicine Singapore 10th Annual Scientific Meeting

(Pilot Study) Retrospective Study of Discharges Within 24 and 48 Hours of Patients Admitted from Department of Emergency Medicine by Ang Shin Yuh, Tin Aung Soe, Lim Swee Han, Marcus Ong

Sep 2008 Third Singapore Public Health and Occupational Medicine Conference

Estimating Demand for Proton Beam Therapy (PBT) in Singapore by Ang Shin Yuh, Low YS, CHUA DHL

Expectations Towards Healthcare Financing of Retirees: Focus Group Discussion by Tong Shao Chuen, Yeo MHM, Chen YR, Tan DMH

Clustering Inpatients: Satisfied Patients Vs Dissatisfied Patients by Tong Shao Chuen, Low YS, Yeo MHM

Two Year Outcomes of Total Hip Replacement Surgery by Chen YR, Yeo MHM, Yeo W, Chong HC, Lo NN, Yeo SJ, Yang KY, Low YS, Jeremy Lim

Assessing The Safety of Singapore Homes with Resident Elderly by Yeo MHM, Chen YR, Chong AKY, Cheong JPW, Mohamed Yusoff M, Abdul Aziz NAZB, Binte Nasron LI, Jeremy Lim

Review of Proton Beam Therapy in Cancer Treatment by Ang Shin Yuh, Chua DHL, Low YS, Jeremy Lim

Boys Are Four Times More Likely to be Overweight Than Girls by Veena Joshi, Cheong JC, Chua ZH, Jeremy Lim

Estimating Health-Related Quality of Life in Singapore: Normative Values for the English and Chinese SF-36 Health Survey: Calculator to obtain SF-36 Scores for Local Population by Yeo MHM, Low YS, Thumboo J, Jeremy Lim

Aug 2008 AMEE 2008

Imparting Corporate Skills to Clinicians - A Service-learning Model by Jeremy Lim, Darren Tan

JAMA-NUHS CME Conference 2008

Appropriateness of Referrals for Specialist Diabetes Care by Tin Aung Soe, Chow Wai Leng, Wee SL, Tan MHD, Khoo HCD, Goh SY, Jeremy Lim

Adherence of Clinical Practice Guidlines in a Specialist Diabetes Care Setting by Tin Aung Soe, Chow Wai Leng, Wee SL, Tan MHD, Khoo HCD, Jeremy Lim


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GRANTS & COMMISSIONED WORK

Title of Grants/ Commissioned Work Funding Agencies

Advancing Clinical Scientific Research with Mathematical Modeling

A*STAR Biomedical Research Council (BMRC)

Conduct of a Baseline Survey on Patients' Perceptions of Clinical Trials

Ministry of Health - National Medical Research Council (NMRC)

Research Study on Developments in National Pharmaceutical Pricing, Coverage and Reimbursement Policies

Singapore Association of Pharmaceutical Industries (SAPI)

Evaluating recontamination of the hospital environment by Methicillin-Resistant Staphylococcus Aureus (MRSA) after Decontamination with adjunctive Titanium Dioxide environmental coating

SingHealth Foundation

Evaluating the magnitude of and factors associated with inappropriate patient stay in an acute care hospital


Health-related quality of life (QOL) of different healthcare professional groups within SGH and it's association with their employee engagement levels


Environmental Effects of Patient Isolation (Arts For Health)


A Retrospective Study of Cervical Cancer and Pre-Cancer Incidences - Mapping the Disease Characteristics, Patient Profiles and Corresponding Treatment costs in a Singaporean Patient Population


Antibiotic Prescribing Behaviour Among Primary Care Physicians


Quality of life of breast cancer patients and their partners SingHealth Foundation

Understanding the Educational Needs of Caregivers of Stroke Survivors in Acute-care setting in Singapore


Temasek Foundation - Singapore Health Services Pte Ltd Training of Trainers Initiative to enhance Health care & hospital management in North India

Temasek Foundation

singhealth centre for health services resarch …davejunia.com/chsr/files/ar_0809.pdf ·...

Documents