Kidney specialist Tazeen Hasan Jafar is troubled. She keeps seeing patients with hypertension and poorly controlled blood pressure. While these ailments may not seem serious on their own, many of Jafar’s patients also suffer from kidney disease and heart failure.

This phenomenon is by no means a coincidence.

“The elevation in blood pressure damages blood vessels in the body, increasing the stiffness of the large arteries leading to the heart, brain and kidneys,” explained Jafar. “In the long run, this affects organ function, which can result in damage,” she added.

It is a fate that Jafar, a professor with Duke-NUS’ Health Services and Systems Research (HSSR) Programme hopes to help patients avoid.

“When patients fall sick with heart attacks or kidney failure, they require expensive treatment such as bypass surgeries or lifelong dialysis."

Prof Tazeen Jafar

Interventions that can be avoided.

“We tend to invest our resources in urgency, spending a huge amount of money often when it’s too late,” observed Professor Nicholas Graves, deputy director of the HSSR Programme. “A more strategic way would be to aggressively intervene earlier in life.”

That could involve encouraging people to make healthier lifestyle changes, through patient education and health promotion programmes. “As the saying goes, an ounce of prevention is worth a pound of cure,” stressed Graves, who is also deputy director of the SingHealth Duke-NUS Health Services Research Institute.

That is precisely what the Singapore government’s Healthier SG initiative hopes to bring about.

“The idea is to have population health under the coordination of a primary care provider,” explained Graves’ colleague David Matchar, a fellow professor with the HSSR Programme at Duke-NUS. 

“It’s about making sure that people are getting their care earlier in the trajectory, so they don't have to make it to the hospital, slowing the progress of their conditions rather than waiting until they develop serious health complications. And you can slow those things down by giving them good primary care.”

 
Moving towards a model focused on primary care

Translating this approach to Singapore’s health systems will require not only that primary care is integrated with all other services in the health system but for healthcare providers such as family physicians to lead the care, ensuring that the patient’s needs are met—what Matchar terms as “enhanced primary care”.

To get their buy-in, it is key to develop workflows that are simple and not stressful, with a support system in place for providers.

But there are also other considerations.

As both a physician and health services researcher, Matchar is aware that understanding what patients and family physicians think about this model is important.

Together with his colleague, Assistant Professor Semra Ozdemir, he surveyed more than 700 patients and 242 physicians.

“For the doctors, what seemed attractive to them was having more time with patients and having fewer patients per day,” said Matchar, who is also director of the Centre for Clinical Health Policy Research at the Duke Global Health Institute.

“I think a lot of them may be feeling quite time-pressured, and if they could reduce the number of patients they see under these enhanced practices, that would make them happier and more likely to move into these kinds of practices,” he added.

That could entail having a non-physician provider associated with the practice to take some pressure off the primary care provider’s time, so that more of their time could be spent with the patient, suggests Matchar.

And what do patients think?

“For patients, cost was the most important factor. The second important factor for them was the services available in a clinic—in particular, the kind of services they can expect to receive. It was really important for patients to be able to do as many tests as they could in one place,” said Ozdemir, who is also an assistant professor with Duke-NUS’ Lien Centre for Palliative Care.

With this data, Matchar hopes to fine-tune his models so that he can obtain better estimates of the manpower and system requirements, which could yield valuable insights for health policies further down the road.

Professor David Matchar sharing his team’s work on a proposed model for an enhanced primary care system at the Enhanced Primary Care symposium earlier this year// Credit: Duke-NUS’ HSSR Programme

 
Keeping pressures under control

While Matchar and others are looking at how to best overhaul the whole primary care system, Jafar and Graves are fighting for the same outcome but with a more specific focus. For Jafar, this means tackling hypertension, a chronic disease that is on the rise worldwide and that is the source of many of her patients’ kidney complications.

“Our research data has shown that cardiovascular mortality from poorly controlled blood pressure seems to be going up,” said Jafar, who is passionate about developing low-cost interventions that benefit whole societies.

Determined to prevent the situation from worsening, she teamed up with Clinical Associate Professor Tan Ngiap Chuan, director of research at SingHealth Polyclinics to understand the barriers and enablers in helping patients maintain optimal blood pressure.

Known as the SingHypertension trial, the study followed patients with uncontrolled blood pressure for two years at designated polyclinics.

Leveraging on the existing infrastructure, the team rapidly implemented the intervention study by focusing on several key areas. “We trained the polyclinic doctors in stratifying patients based on their cardiovascular risk level, and nurses in motivational conversations to counsel patients,” explained Jafar.

Patients, who were enrolled in the study, were prescribed a single two-in-one pill to help control their blood pressure and received telephone-based follow-ups by trained nurses.

“What we saw at the end of two years was a clinically meaningful reduction in blood pressure in the intervention clinics. There was a reduction in cardiovascular risk, and a lot of other positive outcomes, such as an improved quality of life,” noted Jafar.

“The SingHypertension intervention concurrently addressed several barriers faced by patients, physicians and health systems in attaining optimal blood pressure control,” said Tan, who is also Vice-Chair for Research at the SingHealth-Duke NUS Family Medicine Academic Clinical Programme in a press release issued on 1 July.

“We also received very good feedback from the people involved. The patients appreciated it and the nurses were happy—they felt that they were really making a difference. In fact, there were actually more nurses who wanted to do this and I think that speaks volumes,” added Jafar.

Clinical Associate Professor Tan Ngiap Chuan during a consultation with a patient // Credit: SingHealth Polyclinics
 

Professor Tazeen Jafar and Clinical Assoc Prof Tan with the physicians and nurses at a site initiation meeting for the SingHypertension trial at the Pasir-Ris Polyclinic // Credit: Tazeen Jafar
 

In Graves’ opinion, studies like these are important: “It’s a very powerful way of trying to understand how you can make a change, and why sometimes you fail to make a change.”

Like Jafar, his interest lies in looking at ways in which health services can be organised to benefit patients, given resources are scarce. “We’re always thinking about efficiency—how to get the most health returns with the resources we have,” he explained, which is why he is so concerned about finding services that are good value for money while steering away from treatments that are not cost-effective.

“We’ve demonstrated that percutaneous coronary interventions are not cost-effective for patients with stable heart disease. But hundreds of millions are spent every year in many settings on that,” said Graves.

A percutaneous coronary intervention is an interventional procedure to open clogged heart arteries in patients.

He believes funders and policy makers should incentivise a shift in practice with the released resources diverted to cost-effective alternatives such as improving uptake and adherence to cardiac rehabilitation programmes.

“These programmes are very good value for money,” he said. “Once we have the evidence and a model in place, we can move towards implementation.

 
“We have to do it now”

For these researchers moving the needle towards better population health, even small shifts can mean a big difference. “When you’re doing it for the masses, the impact is huge,” added Jafar.

“And we have to do it now,” stressed Matchar, who saw the value of having a primary care doctor oversee all services in his own practise at the Duke-affiliated veterans’ affairs hospital.

“After the health system transitioned to having an accountable primary care doctor with appropriate staff and IT support, I had an eye on all my patients. Other doctors and community service providers always knew to contact me—which is something like what Singapore is hoping to do with the Healthier SG initiative,” said Matchar, who had several hundred relatively complex patients under his care at one time.

“It worked really well. In fact, I think it actually reduced inpatient services to the extent that they closed wards,” he recalled. “That really has coloured my experience, and I feel that kind of holistic approach does make a difference.”

Having more clinicians like Matchar and Jafar involved in population health research could also accelerate change said Graves: “[As clinicians], they understand the issues and often they understand the solutions. Empowering them to lead change is something we also need to be thinking about.”

And in the near future, precision medicine may also come into play. “Genetic information about our population could enable people to receive proper therapy at the earliest possible point in their lives to avoid significant health problems,” said Matchar, who also consults with PRECISE, an initiative involved in optimising the use of genetic testing in clinical practice in Singapore.

“Ultimately, what we’re trying to do is to reduce the progression to worse health states and keep people in the healthier state. Basically, let’s all just be healthy until our last day."

Prof David Matchar