Eric Finkelstein

Background and objectivesAdvanced cancer patients’ understanding of their illness is key for making informed treatment decisions. Despite the known importance of patients’ awareness of their disease prognosis, it is debatable whether this awareness is positively, negatively, or not associated with clinical and psychological outcomes among patients with advanced cancer. This paper aims to determine the prevalence of and factors associated with prognostic awareness and its association with quality of life (QoL), spiritual well-being, pain control, and psychological distress in patients with advanced cancer in Indonesia.MethodsThis cross-sectional questionnaire-based survey was part of a multicountry study titled “Asian Patient Perspectives Regarding Oncology Awareness, Care and Health (APPROACH).” Patients were asked what they knew about their cancer and treatment. QoL and spiritual well-being were …

ObjectivesTo determine the measurement properties of PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS), a parent-reported measure of Quality of Care for seriously ill children across care settings and illness trajectories.Study Design and SettingParents self-administered baseline and 2-week follow-up surveys online. Exploratory Factor Analysis was used to determine PRECIOUS’s factor structure and select items. Internal consistency was evaluated with Cronbach’s α, test-retest reliability with intraclass correlation coefficients, and convergent validity with Spearman’s correlations between PRECIOUS scales and subscales of Measure of Processes of Care and Quality of Children’s Palliative Care Instrument.ResultsOf 152 parents [108 (71%) mothers, 44 (29%) fathers] who completed the baseline survey, 123 (81%) completed follow-up. Exploratory Factor Analysis grouped PRECIOUS …

Background The SingHypertension primary care clinic intervention, which consisted of clinician training in hypertension management, subsidized single‐pill combination medications, nurse‐delivered motivational conversations and telephone follow‐ups, improved blood pressure control and cardiovascular disease (CVD) risk scores relative to usual care among patients with uncontrolled hypertension in Singapore. This study quantified the incremental cost‐effectiveness, in terms of incremental cost per unit reduction disability‐adjusted life years, of SingHypertension relative to usual care for patients with hypertension from the health system perspective. Methods and Results We developed a Markov model to simulate CVD events and associated outcomes for a hypothetical cohort of patients over a 10‐year period. Costs were measured in US dollars, and effectiveness was measured in disability‐adjusted life years …

BackgroundFor patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care.MethodsParticipants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework’s decisional-needs manual was …

The prevalence of obesity and its associated comorbidities continues to rise in the United States. Populations who are uninsured and from racial and ethnic minority groups continue to be disproportionately affected. These populations also experience fewer clinically meaningful outcomes in most weight loss trials. Weight gain prevention presents a useful strategy for individuals who experience barriers to weight loss. Given the often-limited weight management resources available to patients in primary care settings serving vulnerable patients, evaluating interventions with pragmatic designs may help inform the design of comprehensive obesity care delivered in primary care. To evaluate the effectiveness of Balance, a two-arm 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention, delivered to patients receiving primary care within Federally qualified community health centers (FQHCs). Balance was a two-arm 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention delivered to individuals who had a body mass index (BMI) of 25-40 kg/m2, spoke English or Spanish, and were receiving primary care within a network of FQHCs in North Carolina. The Balance intervention was designed to encourage behavioral changes that result in a slight energy deficit. Intervention participants received: tailored goal setting and tracking, skills training, self-monitoring, and responsive health coaching from registered dietitians. Weight was measured at regular primary care visits and documented in the electronic health record. We compared the percentage of≤ 3% weight gain in each arm …

Background: Cancer is the third leading cause of death in Kenya. Yet, little is known about prognostic awareness and preferences for prognostic information.Aim: To assess the prevalence of prognostic awareness and preference for prognostic information among advanced cancer patients in Kenya.Setting: Outpatient medical oncology and palliative care clinics and inpatient medical and surgical wards of Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya.Methods: The authors surveyed 207 adults with advanced solid cancers. The survey comprised validated measures developed for a multi-site study of end-of-life care in advanced cancer patients. Outcome variables included prognostic awareness and preference for prognostic information.Results: More than one-third of participants (36%) were unaware of their prognosis and most (67%) preferred not to receive prognostic information. Increased age (OR= 1.04, 95% CI: 1.02, 1.07) and education level (OR: 1.18, CI: 1.08, 1.30) were associated with a higher likelihood of preference to receive prognostic information, while increased symptom burden (OR= 0.94, CI: 0.90, 0.99) and higher perceived household income levels (lower-middle vs low: OR= 0.19; CI: 0.09, 0.44; and upper middle-or high vs low: OR= 0.22, CI: 0.09, 0.56) were associated with lower odds of preferring prognostic information.Conclusion: Results reveal low levels of prognostic awareness and little interest in receiving prognostic information among advanced cancer patients in Kenya.Contribution: Given the important role of prognostic awareness in providing patient-centred care, efforts to educate patients in Kenya on …

Background The prevalence of obesity and its associated comorbidities continue to rise in the United States. Populations who are uninsured and from racial and ethnic minority groups continue to be disproportionately affected. These populations also experience fewer clinically meaningful outcomes in most weight loss trials. Weight gain prevention presents a useful strategy for individuals who experience barriers to weight loss. Given the often-limited weight management resources available to patients in primary care settings serving vulnerable patients, evaluating interventions with pragmatic designs may help inform the design of comprehensive obesity care delivered in primary care. Objective This study aims to evaluate the effectiveness of Balance, a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention, delivered to patients receiving primary care within federally qualified community health centers. Methods Balance was a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention delivered to individuals who had a BMI of 25-40 kg/m2, spoke English or Spanish, and were receiving primary care within a network of federally qualified community health centers in North Carolina. The Balance intervention was designed to encourage behavioral changes that result in a slight energy deficit. Intervention participants received tailored goal setting and tracking, skills training, self-monitoring, and responsive health coaching from registered dietitians. Weight was measured at regular primary care visits and …

Discrete Choice Experiments (DCEs) are widely employed survey-based methods to assess preferences for healthcare services and products. While they offer an experimental way to represent health-related decisions, the stylized representation of scenarios in DCEs may overlook contextual factors that could influence decision-making. The aim of this paper was to evaluate the predictive validity of preferences elicited through a DCE in decisions likely influenced by a hot-cold empathy gap, and compare it to another commonly used method, a direct-elicitation question. We focused on preferences for pain-relief modalities, especially for an epidural during childbirth - a context where direct-elicitation questions have shown a preference for or intention to have a natural birth (representing the “cold” state), yet individuals often opt for an epidural during labor (representing the “hot” state). Leveraging a unique dataset …

Aims Frailty increases healthcare utilization and costs for patients with heart failure but is challenging to assess in clinical settings. Hand grip strength (GS) is a single‐item measure of frailty yet lacks evidence as a potential screening tool to identify patients at risk of higher unplanned events and related healthcare costs. We examined the association of baseline and longitudinal GS measurements with healthcare utilization and costs among patients with advanced heart failure. Methods and results Between July 2017 and April 2019, we enrolled 251 patients with symptoms of advanced heart failure (New York Heart Association class III or IV) in a prospective cohort study in Singapore. We measured GS at baseline and every 4 months for 2 years and linked patients' survey data with their medical and billing records. We categorized patients as having weak GS if their GS measurement was below the 5th percentile of the …

BackgroundThe Diabetic Retinopathy Extended Screening Study (DRESS) aims to develop and validate a new DR/diabetic macular edema (DME) risk stratification model in patients with Type 2 diabetes (DM) to identify low-risk groups who can be safely assigned to biennial or triennial screening intervals. We describe the study methodology, participants’ baseline characteristics, and preliminary DR progression rates at the first annual follow-up.MethodsDRESS is a 3-year ongoing longitudinal study of patients with T2DM and no or mild non-proliferative DR (NPDR, non-referable) who underwent teleophthalmic screening under the Singapore integrated Diabetic Retinopathy Programme (SiDRP) at four SingHealth Polyclinics. Patients with referable DR/DME (> mild NPDR) or ungradable fundus images were excluded. Sociodemographic, lifestyle, medical and clinical information was obtained from medical records …

In our study 1 published in The Lancet Regional Health—Southeast Asia, we used a cluster randomised trial design to evaluate the effectiveness of a financial incentive intervention for increasing purchase of fruits and vegetables in a rural context in southern India. In this Correspondence, we reply to the concerns raised by Krishnan and colleagues. 2 While our methodology has numerous advantages, we concur with Krishnan and colleagues 2 that its primary aim is not to understand ‘how’an intervention works or ‘which factors’ influence its effectiveness. To address these aims, we conducted a process evaluation in parallel which will be published shortly.Krishnan and colleagues 2 raise an interesting point about the potential role of different household decisionmaking models in the success of the intervention. Our in-depth interviews with people implementing and receiving the subsidies confirm that the recipients …

Pooling data from different subgroups offers advantages of shrinking standard errors and simplifying characterization of the data structure. The ability to pool data also facilitates meta-analysis to evaluate consensus among multiple studies and to inform benefit transfer to new choice settings. Testing for poolability requires accounting for differences in response variance or scale among subgroups. This is commonly done by assuming a single scale factor within each subgroup of interest. This assumption may not hold for many subgroups, especially when task non-attendance is present. We use data from a prior DCE study to show that task non-attendance, and by extension the assumption of a single scale factor across subgroups, can lead to inaccurate conclusions when determining poolability. To address this concern, we propose a latent-class/random-parameters Logit (LCRP) model specification that …

BackgroundParent-reported experience measures are part of pediatric Quality of Care (QoC) assessments. However, existing measures were not developed for use across multiple healthcare settings or throughout the illness trajectory of seriously ill children. Formative work involving in-depth interviews with parents of children with serious illnesses generated 66 draft items describing key QoC processes. Our present aim is to develop a comprehensive parent-reported experience measure of QoC for children with serious illnesses and evaluate its content validity and feasibility.MethodsFor evaluating content validity, we conducted a three-round Delphi expert panel review with 24 multi-disciplinary experts. Next, we pre-tested the items and instructions with 12 parents via cognitive interviews to refine clarity and understandability. Finally, we pilot-tested the full measure with 30 parents using self-administered online …

ImportanceUnderstanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences.ObjectivesTo investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient’s life and the associations of the goals of care with patient-caregiver characteristics.Design, Setting, and ParticipantsThis prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient’s death or February 28, 2022. Data from the last 2 years of the patients’ lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore.Main Outcomes and MeasuresGoals of care were examined via the tradeoffs between life extension and symptom management and between life …

Introduction Physical inactivity is a risk factor for obesity and non-communicable diseases. Despite myriad health and non-health benefits resulting from physical activity (PA), most individuals do not meet PA recommendations. Providing an incentive for meeting activity goals may increase activity levels. Classical economists argue that cash is the best incentive. Behavioral economists have posited that hedonic (pleasurable) incentives (e.g., massages, restaurant meals) may be superior to cash when incentives are offered over multiple time periods. To date, no studies have directly compared the effectiveness of cash versus hedonic incentives in promoting PA across multiple time periods. Methods We conducted a two-arm, parallel, 4-month randomized controlled trial with healthy adults in Singapore where participants were randomized to either cash or hedonic incentives. Participants could earn up to SGD50 (≈USD37) in cash or hedonic incentives each month they met the study’s step target of 10,000 steps daily on at least 20/25 days out of the first 28 days of a month. The primary objective was to compare the mean proportion of months that participants met the step target between the two arms. Results By month 4, participants in the cash (N = 154) and hedonic incentive (N = 156) arms increased their mean daily steps by 870 (p < 0.001) and 1,000 steps (p < 0.001), respectively. The mean proportion of months the step target was achieved was 90.53 and 88.34 for participants in the cash and hedonic incentive arms respectively, but differences across arms were small and not statistically significant for this or any outcome assessed …

BackgroundSpecialist palliative care is often provided late in the patient’s disease trajectory in response to uncontrolled symptoms. Shifting from this reactionary illness-stress paradigm to a proactive health-wellness approach, the ENABLE (Educate, Nurture, Advise, Before Life Ends) telehealth model aims to enhance the coping, stress and symptom management, self-care, and advance care planning skills of patients with advanced cancers and their caregivers. The ENABLE model has been culturally adapted to Singapore (ENABLE-SG) and pilot-tested. A hybrid type 1 effectiveness-implementation design will be used to evaluate the effectiveness of ENABLE-SG while collecting real-world implementation data.MethodsThis single-centre, assessor-blind, wait-list (immediately vs. 6 months) randomized controlled trial will recruit 300 adult patients within 60 days of an advanced cancer diagnosis and their family …

Introduction Among those with advanced illness, higher levels of hope may offer physiological benefits. Yet, greater levels of hope may also encourage aggressive treatments. Therefore, higher levels of hope may lead to greater healthcare utilization, higher expenditure, and longer survival. We test these hypotheses among patients with advanced cancer. Methods A secondary data analysis from a cross-sectional survey of 195 advanced cancer patients with high mortality risk linked to subsequent healthcare utilization (outpatient, day surgeries, non-emergency admissions), health expenditures, and death records. The survey collected data on hope, measured generally by the Herth Hope Index (HHI) and more narrowly by two questions on illness-related hope. Generalized linear regression and Cox models were used to test our hypotheses. Results 142 (78%) survey participants died during the period of analysis, with close to half (46%) doing so within a year of the survey. Contrary to expectation, HHI scores did not have a significant association with healthcare utilization, expenditure or survival. Yet, illness-related hope, defined as those who expected to live at least 2 years, as opposed to the likely prognosis of 1 year or less as determined by the primary treating oncologist, had 6.6 more planned hospital encounters (95% CI 0.90 to 12.30) in the 12-months following the survey and 41% lower mortality risk (hazard ratio: 0.59, 95% CI 0.36 to 0.99) compared to those who were less optimistic. Secondary analysis among decedents showed that patients who believed that the primary intent of their treatment is curative, had higher total expenditure (S …

Objective The study aim was to review the economic evaluation literature of commercially available and effective nonsurgical weight‐loss interventions to investigate whether there is evidence to support claims of cost‐effectiveness (i.e., good value for money) or cost savings (i.e., a positive return on investment). Methods Relevant databases were systematically reviewed to identify economic evaluations of commercially available weight‐loss products and services shown to result in clinically significant weight loss. Five weight‐loss medications (orlistat, liraglutide, naltrexone‐bupropion, semaglutide, and phentermine‐topiramate), two meal replacement programs (Jenny Craig, Optifast), and one behavioral intervention (Weight Watchers [WW]) that met inclusion criteria were identified. After screening, 32 relevant comparisons of cost‐effectiveness or cost savings across 20 studies were identified. Results Ten of …

ObjectiveTo longitudinally examine caregiver-reported treatment decision-making roles and to investigate the associations of these roles with caregiver burden, caregiving esteem, caregiver anxiety, and depression.Methods281 caregivers of patients with stage IV solid cancers were recruited from outpatient clinics in Singapore. Caregivers were eligible if they were aged ≥21 y, primary informal caregiver, and involved in treatment decision making. We used 3 y of longitudinal data. The decision-making roles were grouped into 4 categories: no family involvement, patient/physician-led, joint, and family-led/alone decision making. Mixed-effects linear regressions were used to assess associations between decision-making roles and caregiver outcomes.ResultsOn average, 72% of caregivers reported family involvement in decision making. Compared with baseline, a higher proportion of caregivers at the 36-mo follow …

Background Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are leading causes of disability and premature mortality. At a global level, over 300 million people are estimated to suffer from major depressive disorders, equivalent to 4· 4% of the world’s population. Pandemic era stressors have increased rates for depression and anxiety by upwards of 25%. The goal of this study is to estimate the prevalence and economic burden of depression and anxiety symptoms in Singapore after the peak of the COVID-19 pandemic. Methods An existing web panel was queried between April 2022 and June 2022. Adult participants aged> 21 years old who screened positive for depression and anxiety symptoms based on the Patient Health Questionnaire-4 (PHQ-4) Screener were eligible for participation. Prevalence estimates were quantified by dividing the number of respondents who screened positive …