Publications by authors named "Joyce Yu-Chia Lee"

23 Publications

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Enhancing diabetes care with community pharmacist-involved collaborative care model: A multi-centre randomised controlled trial.

Diabetes Res Clin Pract 2022 Mar 5;185:109238. Epub 2022 Feb 5.

School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, USA. Electronic address:

Aim: To evaluate the clinical and humanistic outcomes of a community pharmacist-involved collaborative care model in diabetes management.

Methods: This was a parallel arm, open-label, multi-centre randomized controlled trial conducted over 6 months. Subjects with type 2 diabetes, HbA1c ≥ 7.0% (53 mmol/mol) and taking ≥ 5 medications were included. Participants were randomized into intervention (collaborative care) and control groups (physician-centric care). The intervention included medication therapy management and telephonic follow-up with visits to family physicians, nurses, and dietitians. Clinical outcomes included changes in HbA1c, systolic blood pressure (SBP), lipids, and hypoglycaemic incidences. Humanistic outcomes included self-care capabilities and quality of life. Linear mixed models were constructed. Intention-to-treat analyses, with sensitivity analyses, were conducted.

Results: A total of 264 participants were randomized (intervention: 131, control: 133). Significantly greater reduction in HbA1c was observed in the intervention group (intervention: -0.32% (-3.52 mmol/mol) vs. control: -0.06% (-0.66 mmol/mol), p = 0.038). Changes in SBP, lipids, and incidences of hypoglycaemia were not significant over 6 months between both groups. Significantly greater improvements in self-management (p < 0.001) and quality of life (p = 0.003) were observed within the intervention group.

Conclusion: Partnering community pharmacists in a collaborative care team improved glycaemic control, quality of life and self-care capabilities of patients with diabetes and polypharmacy.
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http://dx.doi.org/10.1016/j.diabres.2022.109238DOI Listing
March 2022

Long-term clinical and cost-effectiveness of collaborative care in people with uncontrolled type 2 diabetes mellitus and polypharmacy: A multicenter randomized controlled trial.

Prim Care Diabetes 2022 02 23;16(1):188-195. Epub 2021 Dec 23.

Department of Clinical Pharmacy Practice, University of California, Irvine, United States. Electronic address:

Aims: This study examined the effectiveness of a collaborative care model on clinical and humanistic outcomes, medical cost, productivity loss, and its cost-effectiveness in managing uncontrolled Type 2 Diabetes Mellitus (T2DM).

Methods: A randomized controlled study was conducted in two outpatient health institutions in Singapore. Patients aged above 21 years with HbA1c > 7% and polypharmacy were included. Eligible patients were randomized into the intervention (collaborative care) and control (usual care) arms.

Results: A total of 255 patients were included in the analysis. Compared to the control arm, the intervention arm achieved significantly greater glycated hemoglobin (HbA1c) reduction (mean difference: 0.25, 95%CI: [0.001, 0.50], p = 0.049) and quality-adjusted life year (QALY) (+0.011, 95%CI: [0.003, 0.019], p = 0.011) at 12 months. The costs per additional HbA1c and QALY improvements over one year were $40.52 and $920.91 respectively. Activity impairment was lower in the intervention group both at 6 months (12.7% vs 19.0%; p = 0.022) and at 12 months (6.7% vs 14.0%; p = 0.008).

Conclusions: The collaborative care model achieved earlier HbA1c reduction and reduced patients' activity impairment without decreasing work productivity or increasing medical costs. This intervention is cost-effective for improving glycemic control and quality of life in patients with T2DM.
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http://dx.doi.org/10.1016/j.pcd.2021.12.013DOI Listing
February 2022

Spinning the globe from west to east: A mixed-method study to examine the impact of pharmacists on immunization advocacy and delivery in Asia Pacific.

J Am Pharm Assoc (2003) 2021 Sep-Oct;61(5):605-613. Epub 2021 May 1.

Background: Global effort is key to prevent and control infections effectively. Whereas pharmacists' involvement in the immunization neighborhood, collaborative effort to meet immunization needs of the public, has reduced burden of vaccine-preventable diseases in Western countries, the impact of pharmacist-involved vaccination advocacy and delivery in Asia Pacific remains unclear.

Objective: To examine the evidence for impact of pharmacists on immunization advocacy and delivery in Asia Pacific and to assess Singaporean pharmacists' experience in becoming immunizing pharmacists through the American Pharmacists Association's Pharmacy-based Immunization certificate training program.

Methods: A mixed-method study consisted of systematic review and survey was conducted. The systematic review was conducted by searching PubMed and Cumulative Index to Nursing and Allied Health databases from inception to March 2021. Randomized controlled trials and observational studies related to pharmacist-involved immunization advocacy and training conducted in Asia Pacific were included. Eligible studies were appraised for quality using CONsolidated Standards of Reporting Trials (CONSORT) and STrengthening the Reporting of OBservational checklists. In addition, a 20-item Likert-scale survey evaluated the pharmacists' experience in becoming immunizing pharmacists in Singapore. Frequencies of each response to the survey items were analyzed.

Results: Six studies were eligible for inclusion; 2 assessing impact of pharmacist as immunizer, 3 reporting outcomes of pharmacist-involved vaccine advocacy, and 1 evaluating the structure of pharmacist immunization training. Although study quality was minimal, all studies echoed positive findings as a result of pharmacist-provided immunization advocacy and delivery. Of the 23 pharmacists completing the survey, 91.3% strongly agreed that quality training was important to become immunizing pharmacists.

Conclusion: Although limited in number, studies conducted in Asia Pacific reported increased vaccination rates when involving pharmacists. Coupled with the enthusiasm to be trained in immunization advocacy and delivery as elucidated by the Singaporean pharmacists, pharmacists in Asia Pacific should also be advocated for their role in the immunization neighborhood as part of the global effort against vaccine-preventable infectious diseases.
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http://dx.doi.org/10.1016/j.japh.2021.04.018DOI Listing
October 2021

Investigation on the association between diabetes distress and productivity among patients with uncontrolled type 2 diabetes mellitus in the primary healthcare institutions.

Prim Care Diabetes 2020 10 27;14(5):538-544. Epub 2020 Apr 27.

Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore; Department of Clinical Pharmacy Practice, University of California, Irvine, 101 Theory, suite 100, Irvine, CA 92697, United States. Electronic address:

Aims: To investigate associations between diabetes distress and productivity, and to identify the potential risk factors that could affect these particular associations.

Methods: This cross-sectional study was conducted in three outpatient healthcare institutions. Patients aged ≥21 years with uncontrolled T2DM and polypharmacy were included. The Problem Areas in Diabetes (PAID) measuring diabetes distress and Work Productivity and Activity Impairment General Health (WPAI-GH) measuring productivity were administered by trained interviewers.

Results: A total of 259 patients were analysed. Point prevalence of clinically severe diabetes distress, work productivity loss and life productivity loss were 7.7%, 45.0% and 35.1% respectively. Diabetes distress was positively associated with work productivity loss (p = 0.001) and life productivity loss (p < 0.001). Multiple linear regression analysis demonstrated that diabetes distress (p = 0.003), the total number of chronic medications (p = 0.012), insulin therapy (p = 0.027) and the presence of chronic kidney disease (p = 0.038) were significantly associated with work impairment. Diabetes distress (p = 0.001) and the presences of osteoarthritis (p = 0.039) were significantly associated with activity impairment.

Conclusion: Healthcare professionals should screen patients for diabetes distress to prevent productivity losses, especially in patients with polypharmacy and/or on insulin and with coexisting osteoarthritis or chronic kidney disease.
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http://dx.doi.org/10.1016/j.pcd.2020.04.004DOI Listing
October 2020

Efficacy and Safety of Use of the Fasting Algorithm for Singaporeans With Type 2 Diabetes (FAST) During Ramadan: A Prospective, Multicenter, Randomized Controlled Trial.

Ann Fam Med 2020 03;18(2):139-147

Department of Pharmacy, Faculty of Science, National University of Singapore

Purpose: We aimed to evaluate the efficacy and safety of use of the Fasting Algorithm for Singaporeans with Type 2 Diabetes (FAST) during Ramadan.

Methods: We performed a prospective, multicenter, randomized controlled trial. The inclusion criteria were age ≥21 years, baseline glycated hemoglobin (HbA) level ≤9.5%, and intention to fast for ≥10 days during Ramadan. Exclusion criteria included baseline estimated glomerular filtration rate <30 mL/min, diabetes-related hospitalization, and short-term corticosteroid therapy. Participants were randomized to intervention (use of FAST) or control (usual care without FAST) groups. Efficacy outcomes were HbA level and fasting blood glucose and postprandial glucose changes, and the safety outcome was incidence of major or minor hypoglycemia during the Ramadan period. Glycemic variability and diabetes distress were also investigated. Linear mixed models were constructed to assess changes.

Results: A total of 97 participants were randomized (intervention: n = 46, control: n = 51). The HbA improvement during Ramadan was 4 times greater in the intervention group (-0.4%) than in the control group (-0.1%) ( = .049). The mean fasting blood glucose level decreased in the intervention group (-3.6 mg/dL) and increased in the control group (+20.9 mg/dL) ( = .034). The mean postprandial glucose level showed greater improvement in the intervention group (-16.4 mg/dL) compared to the control group (-2.3 mg/dL). There were more minor hypoglycemic events based on self-monitered blood glucose readings in the control group (intervention: 4, control: 6; = .744). Glycemic variability was not significantly different between the 2 groups ( = .284). No between-group differences in diabetes distress were observed ( = .479).

Conclusions: Our findings emphasize the importance of efficacious, safe, and culturally tailored epistemic tools for diabetes management.
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http://dx.doi.org/10.1370/afm.2500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062498PMC
March 2020

Perception of electronic peer review of SOAP notes among pharmacy students enrolling in their first pharmacotherapeutics course.

Curr Pharm Teach Learn 2019 Dec 17;11(12):1259-1264. Epub 2019 Oct 17.

National University of Singapore, Department of Pharmacy, 18 Science Drive 4, Block S4A, Level 3, 117543, Singapore. Electronic address:

Introduction: This study aimed to assess the perception of electronic peer review of subjective, objective, assessment, plan (SOAP) notes performed by pharmacy students during their first pharmacotherapeutic course experience.

Methods: In this single-center, cross-sectional study, a questionnaire was administered to students who had undergone an electronic peer review process of a SOAP note. Four areas were assessed: baseline knowledge, development of therapeutic plans, attitudes and perceptions on peer assessment in enhancing SOAP note writing skills, and perceptions of factors that were/would have been helpful toward providing and/or receiving peer assessment.

Results: One hundred students completed and returned the survey (response rate 61.3%). Most students (93%) reported no prior exposure to writing SOAP notes prior to their participation. SOAP note writing was a valuable component of the module, with most students (97%) recognizing that SOAP note writing skills are important for their future practice as pharmacists. Students also acknowledged that activities in the module improved their abilities to develop (93%) and communicate (80%) patient-specific therapeutic plans in the form of SOAP notes.

Conclusions: Students were comfortable receiving an assessment of a SOAP note from a classmate, and most students indicated that their classmates could provide an honest assessment of their SOAP notes. The electronic peer review process allowed students to receive feedback on their work, and this learning strategy could be further extended to the education of other functional skills that are essential in pharmacy practice.
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http://dx.doi.org/10.1016/j.cptl.2019.09.005DOI Listing
December 2019

Impact of pharmaceutical care on mental well-being and perceived health among community-dwelling individuals with type 2 diabetes.

Qual Life Res 2019 Dec 29;28(12):3273-3279. Epub 2019 Jul 29.

Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, 18 Science Drive 4, Singapore, 117543, Singapore.

Purpose: Mental well-being among community-dwelling individuals with type 2 diabetes has not been well established. The primary objective was to evaluate the change in the mental well-being of individuals with diabetes. The secondary objective was to evaluate the association between changes in mental well-being and perceived health over 6 months, and any interacting factors in this association.

Methods: This was a prospective, multicenter study. Community-dwelling individuals aged ≥ 21 years with type 2 diabetes were invited to meet with community pharmacists monthly for 6 months. Individuals who were unable to converse independently were excluded. A 12-item General Health Questionnaire (GHQ), measuring mental well-being was administered at baseline, and after 3 and 6 months. Perception of health was measured using the visual analog scale (VAS) of the EuroQoL 5-Dimension tool. Linear mixed model was used to analyze the change in mean GHQ and VAS scores. Association between the changes in GHQ and VAS scores was determined, and moderation analysis was conducted to elucidate the interacting variables of this association.

Results: Ninety-six individuals (82.4%) were included for analysis. The mean age was 60.3 years with a baseline mean HbA1c of 7.6%. A mean GHQ score reduction of 1.36 (p = 0.022) was observed. This reduction of mean GHQ score was associated with the change in mean VAS score. Having a duration of diabetes diagnosis of < 3.2 years was identified as moderator of this association.

Conclusion: Effective integrated pharmaceutical care with individualized counseling on lifestyle management appeared to improve the mental health of community-dwelling individuals with diabetes on top of glycemic control.
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http://dx.doi.org/10.1007/s11136-019-02253-2DOI Listing
December 2019

Evaluating the impact of self-monitoring of blood glucose frequencies on glucose control in patients with type 2 diabetes who do not use insulin: A systematic review and meta-analysis.

Int J Clin Pract 2019 Jul 22;73(7):e13357. Epub 2019 May 22.

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore.

Aims: International diabetes guidelines have not established the frequencies of self-monitoring of blood glucose in patients with type 2 diabetes (T2D) who do not use insulin. The present study aimed to assess the impact of self-monitoring of blood glucose (SMBG) frequencies on the glucose control and other outcomes in non-insulin-treated patients with T2D.

Methods: A literature search was performed in four databases. Randomised controlled trials with ≥6-month follow-up duration that compared the impact of different frequencies of SMBG on glycated haemoglobin A1c (HbA1c) were included. Studies with abstract only or reported effects of SMBG as a secondary outcome were excluded.

Results: Of the 1557 studies identified, 12 RCTs with a total of 3350 patients were analysed. Overall, performing SMBG for 8 to 14 times per week was correlated with a better HbA1c control at 6 months (MD -0.46%, 95% CI -0.54 to -0.39) and 12 months (MD -0.20%, 95% CI -0.29 to -0.11). However, up to seven measurements of SMBG per week did not significantly affect glycaemic control. In addition, performing SMBG between 8 and 14 times per week was also associated with improved BMI (MD -0.46, 95% CI -0.84 to -0.08). When the results of SMBG were applied to adjust diabetes medication, a significant reduction in HbA1c levels was observed in the intervention arm compared to the control arm.

Conclusions: Eight to 14 measurements of SMBG per week were associated with an improved glycaemic control and a reduced BMI in patients with T2D not using insulin.
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http://dx.doi.org/10.1111/ijcp.13357DOI Listing
July 2019

Impact of Timing Between Insulin Administration and Meal Consumption on Glycemic Fluctuation and Outcomes in Hospitalized Patients With Type 2 Diabetes.

J Pharm Pract 2020 Aug 25;33(4):449-456. Epub 2018 Dec 25.

Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore.

Background: The effect of time interval from insulin injection to meal consumption ("insulin-meal") on glycemic fluctuation and outcomes is not well understood.

Objective: This study aims to investigate the impact of coordinated versus mismatched insulin-meal administration on glycemic fluctuation and outcomes among hospitalized patients with type 2 diabetes (T2D).

Methods: Hospitalized patients with T2D who received at least 1 dose of insulin as part of sliding scale regimen were included. Data such as capillary blood glucose values and insulin-meal time intervals were collected.

Results: A total of 215 patients with 840 insulin-meal encounters were eligible for the study. Compared to the insulin-meal mismatch group (n = 206), the coordinated insulin-meal administration group (n = 9) had lower mean glycemic fluctuation (6.5 [2.6] mmol/L vs 5.6 [2.5] mmol/L or 117 [47] mg/dL vs 100 [45] mg/dL). Encounters with the insulin-meal time interval of 30 to 45 minutes (n = 172) were associated with the lowest percentage of severe hyperglycemia occurrences (13%) as compared to encounters with time interval of 0 to 29 minutes (n = 280, 15%) and more than 45 minutes (n = 246, 16%).

Conclusion: Coordinated insulin-meal administration was associated with lower glycemic fluctuation among hospitalized patients with T2D.
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http://dx.doi.org/10.1177/0897190018818908DOI Listing
August 2020

Multidisciplinary collaborative care in the management of patients with uncontrolled diabetes: A systematic review and meta-analysis.

Int J Clin Pract 2019 Feb 29;73(2):e13288. Epub 2018 Nov 29.

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore City, Singapore.

Background: Diabetes is a chronic and complex disease that requires a multidisciplinary collaborative care approach.

Objective: The primary objective was to evaluate the clinical outcomes of patients with uncontrolled diabetes within a multidisciplinary collaborative care model. The secondary objective was to evaluate the humanistic and economic outcomes of this model of care.

Methods: A search using PubMed, SCOPUS, and CINAHL from 2007 to 2017 was conducted. Articles selected included randomised controlled studies on multidisciplinary collaborative care (defined as care provision by ≥ two different care providers) vs usual care (defined as standard care provided solely by physicians) for patients with uncontrolled diabetes. In addition, the eligible article had to report at least two of the three outcomes such as clinical (glycated haemoglobin [HbA1c], systolic blood pressure [SBP], low-density lipoprotein [LDL], and triglyceride [TG]), humanistic (patient-reported measures), and economic (healthcare costs and utilisations) outcomes. Parameters examined included study characteristics, care interventions, patient characteristics, and study outcomes. Primary outcomes using mean differences (MDs) with 95% confidence intervals (CIs) were analysed either by fixed- or random-effects models.

Results: A total of 16 studies were included in the review. Multidisciplinary collaborative care significantly improved HbA1c (MD = -0.55%, 95% CI = -0.65% to -0.45%, P < 0.001, I  = 35%) and SBP (MD = -4.89 mm Hg, 95% CI = -6.64 to -3.13 mm Hg, P < 0.001, I  = 46%) over 3-12 months. The humanistic outcomes in the multidisciplinary collaborative care model were either improved or maintained over time. In comparison to usual care, the healthcare costs and utilisations in the multidisciplinary collaborative care model were comparable without incurring excessive costs.

Conclusions: Multidisciplinary collaborative care appeared to positively impact on the clinical, humanistic, and economic outcomes of patients with uncontrolled diabetes.
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http://dx.doi.org/10.1111/ijcp.13288DOI Listing
February 2019

Risk factors and quality of life of patients with high diabetes-related distress in primary care: a cross-sectional, multicenter study.

Qual Life Res 2019 Feb 7;28(2):491-501. Epub 2018 Sep 7.

Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Singapore.

Purpose: This study aimed to examine risk factors and quality of life of patients with high diabetes-related distress (DRD) in primary care.

Methods: A cross-sectional, multicenter study was conducted in four primary healthcare institutions. Patients aged ≥ 21 years with T2DM were included; patients who were pregnant or unable to communicate independently were excluded from this study. The problem area in diabetes (PAID) measuring DRD, European quality of life-5 dimensions (EQ-5D), and audit of diabetes-dependent quality of life (ADDQoL) measuring quality of life were administered by trained research assistants.

Results: A total of 525 patients were eligible for this study. The mean PAID score was 26.90 ± 20.23, with 27.8% of patients reporting having high DRD (PAID score ≥ 40). Patients who were younger than 50 years (OR 4.577, 95% CI 1.977-10.600) and patients with HbA1c greater than 9% (OR 1.720, 95% CI 1.064-2.779) were at higher risk of having high DRD (p < 0.05). Patients with high DRD have a lower EQ-5D index value (B = - 0.141) and ADDQoL AWI (B = - 1.276) than patients with little/no DRD (p < 0.001).

Conclusion: High DRD was more common among younger patients and patients with poorer glycemic control. High DRD was associated with poorer quality of life and early screening and management of DRD is recommended.
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http://dx.doi.org/10.1007/s11136-018-1994-1DOI Listing
February 2019

Development of a Collaborative Algorithm for the Management of Type 2 Diabetes during Ramadan: An Anchor on Empowerment.

Diabetes Technol Ther 2018 10 6;20(10):698-703. Epub 2018 Sep 6.

1 Department of Pharmacy, National University of Singapore , Singapore, Singapore .

Empowerment plays significant roles in the complex management of type 2 diabetes. International guidelines have provided recommendations on management of Muslims who fast during Ramadan. However, there remains a lack of patient-centered epistemic tool to empower healthcare providers and patients in managing diabetes during Ramadan. This study discussed the development and evaluation of such tool. The collaborative algorithm was developed with reference to the nominal group technique by a board-certified clinical pharmacist and discussed with endocrinologists, nurses, and family physicians. The empowerment component of the algorithm was developed based on the Basic Psychological Needs Theory. The algorithm was evaluated through a randomized controlled trial. Glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and postprandial glucose (PPG) levels and safety profiles in terms of hypoglycemic events were assessed. The collaborative algorithm was developed with four components: screening, education, dose modification by healthcare provider, and dose adjustment by patient. A total of 62 individuals were recruited, with 30 and 32 randomized into the intervention and control groups, respectively. The mean age was 58.4 years, with majority being females (67.7%). There was a reduction in mean HbA1c from 7.9% ± 0.9% to 7.5% ± 0.8% (P < 0.001) in the intervention group, while no significant difference was observed in the control group (P = 0.270). FPG (P < 0.001) and PPG (P = 0.002) also improved significantly in the intervention group. There were no major hypoglycemic events and minor hypoglycemia comparable between both groups (P = 0.465). The collaborative algorithm incorporated empowerment and promoted shared decision-making in diabetes management, hence promoting safe and effective fasting.
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http://dx.doi.org/10.1089/dia.2018.0159DOI Listing
October 2018

Patients' perceptions of pharmacist-managed diabetes services in the ambulatory care and community settings within Singapore.

Int J Clin Pharm 2018 Apr 20;40(2):403-411. Epub 2018 Jan 20.

Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, Singapore, 117543, Republic of Singapore.

Background Qualitative evidence on patients' perceptions of pharmacist-managed diabetes services (PMDSs) is limited. Objective To explore patients' perceptions of PMDSs Setting Patients being cared for in the outpatient settings in Singapore. Methods This focus group included patients who were diagnosed with type 2 diabetes, spoke either English or Mandarin, attended PMDSs for at least 6 months in the ambulatory care or community settings, and were at least 21 years of age. Patients with cognitive impairments or mobility issues were excluded. Thematic analysis of transcribed audio recordings was undertaken. Main outcomes measure Patients' care experiences with PMDSs. Results A total of 26 patients from two outpatient ambulatory care clinics and three retail pharmacies were assembled into four focus groups based on the care setting. Four themes abstracted from focus group data illustrated patients' perspectives on PMDSs in fulfilling their health needs, delivery and quality of service, changes attributed to the service, and suggestions for improvement of service. The patients highlighted that PMDSs fulfilled their need for information on diabetes. They also felt comfortable speaking to the pharmacists about their health, and they appreciated the role of the pharmacists as healthcare professionals. Furthermore, the patients reported better diabetes-related self-empowerment via increased medication knowledge and lifestyle modification. Some of the patients noted that medication adherence and glycemic control had improved. Suggestions to improve PMDSs were minimal. Conclusions Overall, patients with type 2 diabetes had positive perceptions of PMDSs regardless of the care settings.
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http://dx.doi.org/10.1007/s11096-018-0591-2DOI Listing
April 2018

Incidence of thromboembolic and bleeding events in patients with newly diagnosed nonvalvular atrial fibrillation: An Asian multicenter retrospective cohort study in Singapore.

Clin Cardiol 2017 Dec 18;40(12):1218-1226. Epub 2017 Dec 18.

Department of Pharmacy, Khoo Teck Puat Hospital, Singapore.

Background: Real-world effectiveness and safety of antithrombotics in nonvalvular atrial fibrillation (NVAF) patients in Singapore has not been thoroughly studied.

Hypothesis: Users of various antithrombotics experience a significantly different risk of stroke and major bleed compared with warfarin users.

Methods: This multicenter retrospective cohort study included patients age ≥ 21 years newly diagnosed with NVAF between July 2012 and September 2015. Using electronic medical records, data on patients' demographics, antithrombotics prescribed, and CHA DS -VASc and HAS-BLED risk factors were collected. Patients were followed for 1 year from diagnosis for the primary effectiveness and safety endpoints of incident stroke or systemic embolism and major bleed, respectively. The secondary safety endpoint was overall bleed. Hazard ratios (HR) were determined from Cox regression.

Results: Of 743 patients included, 224 were on warfarin, 156 on direct oral anticoagulants (DOACs), 277 on single antiplatelet therapy (SAPT), 28 on dual antiplatelet therapy (DAPT), and 58 on no therapy. Mean age (±SD) was 68.7 ± 13.0 years. Compared with warfarin users, SAPT (adjusted [adj.] HR: 3.70, 95% confidence interval [CI]: 1.21-11.3) and DAPT users (adj. HR: 10.1, 95% CI: 1.51-67.2) were more likely to develop thromboembolic outcomes. Also, DOAC users (adj. HR: 0.304, 95% CI: 0.158-0.585), SAPT users (adj. HR: 0.142, 95% CI: 0.0680-0.295), and DAPT users (adj. HR: 0.112, 95% CI: 0.0146-0.857) were less likely to experience any bleed compared with warfarin users.

Conclusions: SAPT and DAPT are less effective than warfarin in NVAF patients. DOACs may be considered in view of lower risk of overall bleed.
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http://dx.doi.org/10.1002/clc.22811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6490354PMC
December 2017

Long-term Clinical and Cost Outcomes of a Pharmacist-managed Risk Factor Management Clinic in Singapore: An Observational Study.

Clin Ther 2017 Dec 1;39(12):2355-2365. Epub 2017 Nov 1.

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore; Department of Pharmacy, Tan Tock Seng Hospital, Singapore. Electronic address:

Purpose: Few studies have determined the benefits of pharmacist-run clinics within a tertiary institution, and specifically on their capability to improve clinical outcomes as well as reduce the cost of illness. This study was designed to investigate the effectiveness of a pharmacist-managed risk factor management clinic (RFMP) in an acute care setting through the comparison of clinical (improvement in glycosylated hemoglobin level) and cost outcomes with patients receiving usual care.

Methods: This single-center, observational study included patients aged ≥21 years old and diagnosed with type 2 diabetes mellitus (DM) who received care within the cardiology department of a tertiary institution between January 1, 2014, and December 31, 2015. The intervention group comprised patients who attended the RFMP for 3 to 6 months, and the usual-care group comprised patients who received standard cardiologist care. Univariate analysis and multiple linear regression were conducted to analyze the clinical and cost outcomes.

Findings: A total of 142 patients with DM (71 patients in the intervention group and 71 patients in the usual-care group) with similar baseline characteristics were included. After adjusting for differences in baseline systolic blood pressure and triglyceride levels, the mean reduction in glycosylated hemoglobin level at 6 months from baseline in the intervention group was significantly lower by 0.78% compared with the usual-care group. Patients in the usual-care group had a significantly higher risk of hospital admissions within the 12 months from baseline compared with the intervention group (odds ratio, 3.84 [95% CI, 1.17-12.57]; P = 0.026). Significantly lower mean annual direct medical costs were also observed in the intervention group (US $8667.03 [$17,416.20] vs US $56,665.02 [$127,250.10]; P = 0.001).

Implications: The pharmacist-managed RFMP exhibited improved clinical outcomes and reduced health care costs compared with usual care within a tertiary institute.
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http://dx.doi.org/10.1016/j.clinthera.2017.10.009DOI Listing
December 2017

Evaluation of the Diabetes, Multidisciplinary, Experiential (DIAMANTE) Program for Retail Pharmacists: A Mixed-Method Study.

J Contin Educ Health Prof 2017 ;37(2):116-122

Ms. Siaw: PhD candidate in the Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Republic of Singapore. Mr. Ang: Undergraduate Pharmacy Student, Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Republic of Singapore. Dr. Lee: Associate Professor and Clinical Pharmacist in Ambulatory Care and Domain Leader, Pharmacy Practice, Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Republic of Singapore.

Introduction: The Diabetes, Multidisciplinary, Experiential (DIAMANTE) program was established to enhance collaboration between retail pharmacists and the diabetes care team in the health institutions through interprofessional education. This article describes the program and reports on an evaluation of its impact on attitudes, knowledge, and confidence of the participants in managing diabetic patients.

Methods: This study utilized a mixed-method design with focus group (FG), exit assessment, and survey. Ten participants were approached to complete the 2-week DIAMANTE program with hands-on training from a multidisciplinary diabetes team. In addition to an exit assessment and a pre-post online survey to assess attitudes of participants toward diabetes care, diabetes knowledge, and confidence in managing diabetic patients, FG was used to obtain the qualitative feedback of pharmacists. Feedback of the preceptors related to the program and pharmacist performance was also sought through an online survey. Survey data and FGs were analyzed using Wilcoxon signed-rank test and thematic analysis, respectively.

Results: All participants completed the program successfully. The FGs revealed four themes: program design, participants' view on preceptors, participants' perceptions of program benefits, and program's outlook. Participants perceived the program content as comprehensive and relevant. With experiential learning, the pharmacists reported improved counseling skills and increased understanding of the roles of different healthcare members. Their knowledge and confidence in managing diabetic patients was improved (P = .008). All participants passed the exit assessment. In general, the preceptors were satisfied with the program design, assessment content, and participant performance.

Discussion: The overall view of DIAMANTE appeared positive. The program also improved knowledge and confidence of the participants in managing diabetic patients.
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http://dx.doi.org/10.1097/CEH.0000000000000157DOI Listing
April 2018

HbA1c variability in type 2 diabetes is associated with the occurrence of new-onset albuminuria within three years.

Diabetes Res Clin Pract 2017 Jun 14;128:32-39. Epub 2017 Feb 14.

Department of Pharmacy, National University of Singapore, Singapore. Electronic address:

Aims: To evaluate the association between HbA1c coefficient of variation (HbA1c-CV) and 3-year new-onset albuminuria risk.

Methods: A retrospective cohort study involving 716 normoalbuminuric type 2 diabetes patients was conducted between 2010 and 2014. HbA1c-CV was used to categorize patients into low, moderate or high variability groups. Multivariate logistic models were constructed and validated. Integrated discrimination (IDI) and net reclassification (NRI) improvement indices were used to quantify the added predictive value of HbA1c-CV.

Results: The mean age of our cohort was 56.1±12.9years with a baseline HbA1c of 8.3±1.3%. Over 3-years of follow-up, 35.2% (n=252) developed albuminuria. An incremental risk of albuminuria was observed with moderate (6.68-13.43%) and high (above 13.44%) HbA1c-CV categories demonstrating adjusted odds ratios of 1.63 (1.12-2.38) and 3.80 (2.10-6.97) for 3-year new-onset albuminuria, respectively. Including HbA1c-CV for 3-year new-onset albuminuria prediction improved model discrimination (IDI: 0.023, NRI: 0.293, p<0.05). The final model had a C-statistic of 0.760±0.018 on validation.

Conclusion: HbA1c-CV improves 3-year prediction of new-onset albuminuria. Together with mean HbA1c, baseline urine albumin-to-creatinine ratio and presence of hypertension, accurate 3-year new-onset albuminuria prediction may be possible.
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http://dx.doi.org/10.1016/j.diabres.2017.02.007DOI Listing
June 2017

Psychometric properties of the Chinese version of the Problem Areas in Diabetes scale (SG-PAID-C) among high-risk polypharmacy patients with uncontrolled type 2 diabetes in Singapore.

J Diabetes Investig 2017 Mar 31;8(2):235-242. Epub 2016 Aug 31.

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore.

Aims/introduction: Undetected diabetes distress is a cause of concern. However, the lack of a validated questionnaire is a barrier to screening for diabetes distress. The aim of the present study was to examine the validity and reliability of the Chinese version of the Problem Areas in Diabetes scale (SG-PAID-C), and its association with sociodemographic and clinical parameters in patients with type 2 diabetes.

Materials And Methods: This cross-sectional study was carried out in four outpatient healthcare institutions in Singapore. Chinese-speaking patients with uncontrolled type 2 diabetes, polypharmacy, and multiple comorbidities were administered the SG-PAID-C and European Quality of Life-5 Dimensions questionnaires as quality of life measures. The factorial construct, convergent validity and internal consistency of SG-PAID-C were evaluated.

Results: The exploratory factor analysis resulted in a three-factor structure of SG-PAID-C with subscales on emotional- and management-related problem (11 items), ability to cope with diabetes problem (3 items) and support-related problem (2 items). The findings also showed good model fit in the confirmatory factor analysis, and provided support for the construct and convergent validity of SG-PAID-C. Overall, the internal consistency of SG-PAID-C was good (Cronbach's alpha = 0.900). Sex and duration of diabetes were positively associated with the 16-item SG-PAID-C, whereas age and type of antidiabetic agents were inversely associated with the 16-item SG-PAID-C.

Conclusions: The 16-item SG-PAID-C is a valid and reliable instrument for use among patients with uncontrolled type 2 diabetes in Singapore. Future studies on its clinical utility should be carried out.
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http://dx.doi.org/10.1111/jdi.12556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334295PMC
March 2017

Direct medical cost of type 2 diabetes in singapore.

PLoS One 2015 27;10(3):e0122795. Epub 2015 Mar 27.

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore.

Due to the chronic nature of diabetes along with their complications, they have been recognised as a major health issue, which results in significant economic burden. This study aims to estimate the direct medical cost associated with type 2 diabetes mellitus (T2DM) in Singapore in 2010 and to examine both the relationship between demographic and clinical state variables with the total estimated expenditure. The National Healthcare Group (NHG) Chronic Disease Management System (CDMS) database was used to identify patients with T2DM in the year 2010. DM-attributable costs estimated included hospitalisations, accident and emergency (A&E) room visits, outpatient physician visits, medications, laboratory tests and allied health services. All charges and unit costs were provided by the NHG. A total of 500 patients with DM were identified for the analyses. The mean annual direct medical cost was found to be $2,034, of which 61% was accounted for by inpatient services, 35% by outpatient services, and 4% by A&E services. Independent determinants of total costs were DM treatments such as the use of insulin only (p<0.001) and the combination of both oral medications and insulin (p=0.047) as well as having complications such as cerebrovascular disease (p<0.001), cardiovascular disease (p=0.002), peripheral vascular disease (p=0.001), and nephropathy (p=0.041). In this study, the cost of DM treatments and DM-related complications were found to be strong determinants of costs. This finding suggests an imperative need to address the economic burden associated with diabetes with urgency and to reorganise resources required to improve healthcare costs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0122795PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4376523PMC
February 2016

Evaluating the Effect of Ramadan Fasting on Muslim Patients with Diabetes in relation to Use of Medication and Lifestyle Patterns: A Prospective Study.

Int J Endocrinol 2014 11;2014:308546. Epub 2014 Nov 11.

Department of Pharmacy, Faculty of Science, National University of Singapore, Block S4, 18 Science Drive 4, Singapore 117543.

Objectives. This study aimed to examine the effect of Ramadan fasting on HbA1c in Muslim patients with type 2 diabetes. The incidence of hypoglycemia and glycemic changes in relation to the adjustment of doses of antidiabetic agents, diet, and physical activity during Ramadan was also evaluated. Methods. This was a prospective study conducted in an outpatient endocrine clinic. A set of questionnaires was administered to Muslim patients with diabetes who fasted for ≥10 days. Those who were hospitalized for diabetic ketoacidosis or severe hypoglycemia a month prior to Ramadan or were given short-term corticosteroid therapy were excluded. The patients' responses and clinical outcomes from the clinic database were collected before, during, and after Ramadan. Results. A total of 153 participants completed the study. The mean HbA1c improved from 8.9% before Ramadan to 8.6% during Ramadan (P < 0.05). Although diet and physical activity did not contribute to changes in glycemia, a significant improvement in HbA1c was observed in patients who had adjustments made to their doses of antidiabetic agents during Ramadan (P < 0.001). In addition, their rate of hypoglycemia was minimal. Conclusions. Ramadan fasting appeared to improve glycemic control, especially in those whose doses of antidiabetic agents were adjusted during Ramadan.
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http://dx.doi.org/10.1155/2014/308546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244681PMC
December 2014

"Symptom-based insulin adjustment for glucose normalization" (SIGN) algorithm: a pilot study.

Diabetes Technol Ther 2012 Dec 4;14(12):1145-8. Epub 2012 Oct 4.

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore.

Background: Lack of self-monitoring of blood glucose (SMBG) records in actual practice settings continues to create therapeutic challenges for clinicians, especially in adjusting insulin therapy. In order to overcome this clinical obstacle, a "Symptom-based Insulin adjustment for Glucose Normalization" (SIGN) algorithm was developed to guide clinicians in caring for patients with uncontrolled type 2 diabetes who have few to no SMBG records. This study examined the clinical outcome and safety of the SIGN algorithm.

Subjects And Methods: Glycated hemoglobin (HbA1c), insulin usage, and insulin-related adverse effects of a total of 114 patients with uncontrolled type 2 diabetes who refused to use SMBG or performed SMBG once a day for less than three times per week were studied 3 months prior to the implementation of the algorithm and prospectively at every 3-month interval for a total of 6 months after the algorithm implementation. Patients with type 1 diabetes, nonadherence to diabetes medications, or who were not on insulin therapy at any time during the study period were excluded from this study.

Results: Mean HbA1c improved by 0.29% at 3 months (P = 0.015) and 0.41% at 6 months (P = 0.006) after algorithm implementation. A slight increase in HbA1c was observed when the algorithm was not implemented. There were no major hypoglycemic episodes. The number of minor hypoglycemic episodes was minimal with the majority of the cases due to irregular meal habits.

Conclusions: The SIGN algorithm appeared to offer a viable and safe approach when managing uncontrolled patients with type 2 diabetes who have few to no SMBG records.
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http://dx.doi.org/10.1089/dia.2012.0140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3521138PMC
December 2012

Development and validation of a general health literacy test in Singapore.

Health Promot Int 2012 Mar 5;27(1):45-51. Epub 2011 Apr 5.

Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore.

Due to the concern of equating correct pronunciation with comprehension and the differences in health care systems, existing health literacy (HL) instruments may not be appropriate for or applicable to English-speaking countries other than the USA. The purpose of this study was to develop and validate the Health Literacy Test for Singapore (HLTS), which is an adapted version of the Short-Test of Functional Health Literacy in Adults. Three hundred and two patients were interviewed and administered the HLTS, the Newest Vital Sign (NVS), a demographic questionnaire, and a knowledge test of chronic diseases. The convergent validity of HLTS was determined by examining the association between HLTS and NVS HL levels, whereas predictive validity was tested by examining the difference in knowledge of chronic conditions between the two HLTS HL (i.e. adequate and inadequate HL) groups. Bivariate correlation of HLTS HL levels with age and education was assessed to test a priori hypotheses that patients with inadequate HL were older and less educated. The results showed that HLTS displayed good internal reliability (Cronbach's alpha = 0.87). The correlation between HLTS and NVS was moderate (γ = 0.55; P = 0.005) and individuals with inadequate HL were older (P = 0.002) and less educated (P = 0.007). In addition, patients with adequate HL had a higher mean score on the chronic disease knowledge test (P = 0.036). In conclusion, the HLTS is a valid and reliable measure for assessing Singaporeans ability to read and comprehend health-related materials written in English.
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http://dx.doi.org/10.1093/heapro/dar020DOI Listing
March 2012

Development and implementation of signs- and symptoms-based insulin adjustment algorithm.

Am J Health Syst Pharm 2010 Sep;67(18):1503-6

Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore.

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http://dx.doi.org/10.2146/ajhp100032DOI Listing
September 2010
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