Background: Across health systems globally, transforming hospital-centric care toward strong, integrated primary care (PC) remains an elusive goal. Despite wide consensus on PC’s value, policymakers lack tools to anticipate how large-scale reforms will interact with population aging, workforce constraints, and financing models. Objective: To develop a model of the impact of enhanced primary care provision on Singapore’s healthcare system, illustrating its application to targeted vs. broad rollout. Methods: We developed a System Dynamics–based policy laboratory—the Enhancing Primary Care (EPC) Model—to simulate the long-term impact of strengthening PC within Singapore’s ongoing Healthier SG reform. Using national administrative data, longitudinal survey results, discrete choice experiments of patient and provider preferences, and structured expert elicitation, the model estimated interactions among population health states, service use, costs, satisfaction, and productivity under multiple enhanced primary care rollout scenarios. Results: Simulations indicated that strengthening PC yields modest but sustained gains in population health and satisfaction, reductions of 7–16% in tertiary care utilization, and approximately 2% growth in national productivity by 2060, relative to historical trends. Targeting enhanced care solely to complex patients improved survival but raised average costs, whereas broad enrolment achieved higher societal benefit through prevention and continuity effects. Conclusions: Preliminary insights suggest that rebalancing the Singapore health system to enhance the role and reach of primary care could achieve meaningful benefits to the health of the population, all forms of service utilization, and the general economy. The EPC model is tailored to the information needs of policy makers and is premised on the understanding that these needs will evolve with time. Beyond Singapore, the framework offers a transferable approach for governments seeking to rebalance their health systems through primary care reform.

Introduction:A Cardiology Integrated Chronic Care (ICC) clinic was established at a polyclinic through collaboration between a tertiary hospital and a polyclinic. This novel model in Singapore prompted a study exploring explore how stakeholders conceptualise and operationalise integration when implementing the clinic in primary care, aiming to understand if common cardiology conditions can be anchored in primary care. Methods:Nine semi-structured interviews were conducted with a cardiologist, intervention's director, family physician, polyclinic head, coordinators and advanced practice nurse. Twelve documents -including implementation monitoring reports, steering committee reports and meeting minutes - were analysed using Singer and colleagues' conceptual model of integration types. Results:Co-located consultation rooms, direct access investigations and remote consultations between healthcare providers promoted structural integration. Interpersonal integration was fostered through teamwork. Functional integration was accomplished via comprehensive care management protocols and training. Low patient numbers reduced polyclinic revenue but positively impacted care efficiency. Provider satisfaction remained high, with participants gaining knowledge and confidence in managing cases. Conclusion:The clinic demonstrated operational integration but may lack a broader healthcare system perspective. For sustainable larger-scale evolution, economic and policy scrutiny is needed focusing on operational feasibility and outcomes, given low patient volume constraints affecting financial viability and scalability potential.

​BackgroundUniversal genetic testing (GT) has been proposed as a public health strategy to reduce Lynch syndrome (LS)-related cancer burden, but lacks economic validation in Singapore. We aimed to identify the most cost-effective LS diagnostic strategy and assess its budget impact.Methods We conducted cost-utility analyses from Singapore's healthcare system perspective with a lifetime horizon, targeting three populations and their first-degree relatives (FDRs): newly diagnosed colorectal (CRC), endometrial cancer (EC) patients, and cancer-unaffected individuals aged 30 years. Strategies included reflex testing, upfront GT, family history (FH)-guided testing, and no testing. Willingness-to-pay (WTP) threshold was $75,000/quality-adjusted life-year (QALY). Uncertainty was assessed deterministically and probabilistically.FindingsFor CRC patients, immunohistochemistry (IHC)-guided GT was the most cost-effective strategy (ICER: $45,959/QALY versus no testing). Upfront GT exceeded the WTP threshold (ICER: $129,808/QALY versus IHC-guided GT) unless LS prevalence is ≥4.10%. For EC patients, Upfront GT was the optimal strategy (ICER: $19,131/QALY versus the next best strategy), demonstrating 66.68% probability of cost-effectiveness. In the cancer-unaffected population, FH-guided testing exhibited decision uncertainty, compared to no testing (45.44% versus. 54.50% probability), but achieved cost-effectiveness by extending cascade testing to second-degree relatives. Cost-effectiveness was highly sensitive to surveillance adherence, cascade testing uptake, and LS prevalence. Implementing optimal strategies for CRC and EC patients, including their FDRs requires $0.50 million annually.InterpretationIHC-guided triage is cost-effective in CRC patients, whereas upfront GT is preferred for EC patients. Implementation efforts should prioritise improving cascade testing uptake, a critical driver of program value.Funding National Research Foundation, Singapore.

Falls are a major cause of injury and loss of independence among older adults, making prevention a critical priority for healthy aging. Early detection of fall risk through screening can enable timely interventions that reduce these adverse out-comes. Traditional clinical methods, such as using the history of falls and simple questionnaire-based screening, provide a quick and low-cost means of assessment but often have poor predictive accuracy and fail in presence of missing information. To support cost-effective screening and intervention, there is a need for tools that can accurately assess fall-risk in presence of missing information with better accuracy than cur-rent approaches. In this study, we developed a k-Nearest Neighbors (kNN) model that predicts whether an older adult will experience at least one fall within 12 months after baseline assessment, while simultaneously imputing missing data. Using data from 2,291 community-dwelling older adults in Singapore and 317 features spanning gait, cognition, physical activity, and comorbidities, our model achieved an AUC = 0.62 and F1 = 0.40, a significant improvement over the current clinical standard based solely on fall history (AUC ≈ 0.50). This model offers a more cost-effective screening tool for large-scale community deployment and highlights the feasibility of light-weight, imputation-aware models for practical fall-risk screening in aging populations.

In recent years, the growing demand for cost-effective rehabilitation after stroke has motivated the development of novel technologies to support high-intensity rehabilitation. However, available knowledge on the economic benefits of stroke technology-assisted rehabilitation (TAR) is relatively scarce and fragmented. Therefore, this scoping review aimed to review evidence on the economic benefits of TAR in laboratory, clinical, and home settings, as well as the methodologies used to evaluate these outcomes. A systematic search of four electronic bibliographic databases and two additional grey literature/ economic evidence sources (until 03 June 2026) identified 6469 records. Following predefined inclusion and exclusion criteria, 44 records were considered for further analysis. Additionally, 21 records were identified through a citation search. In total, 65 articles reporting TAR-related costs were included, but only a few of these studies reported cost analyses (mostly cost comparisons). Firstly, of the 38 studies conducted in laboratory settings, only one reported a formal TAR-related cost analysis. Secondly, out of 16 studies reporting costs, 11 studies performed cost analysis for TAR in clinical settings. Of these, the majority (six) estimated TAR to be equally effective or even superior (one) and cheaper than conventional therapy (CT) in the clinic, but only when TAR enabled the therapist to treat several stroke survivors in parallel. This was captured using the relative therapist-to-patient ratio (rT/P), indicating that staffing and supervision models were more important than device cost. Lastly, seven of 13 studies conducted TAR-related cost analysis in a home setting. Three studies suggested that TAR may be economically beneficial compared with CT in the clinic. Empirical findings suggest that TAR may generate cost savings compared to CT in the clinic, particularly when rT/P is < 0.5. However, the current evidence is sparse, with limited comparability and generalisability due to heterogeneous TAR modalities, comparators and cost-calculation methods. Not applicable.

Objectives To evaluate the association between asthma-related emergency department (ED) visits and weather, air quality, monsoons, haze and cultural festivals in Singapore.Design Retrospective cohort study.Setting A public healthcare cluster that covers 20% of the nation’s adult asthma population.Participants 2617 adult patients accounting for 5337 asthma ED visits between 2016 and 2024.Primary and secondary outcome measures Temperature, rainfall, wet bulb temperature (WBT), wind speed and Pollution Standards Index (PSI) were correlated with asthma ED counts at 0–7 day lags. Associations between ED visits and monsoons, transboundary haze and cultural festivals were evaluated using one-way analysis of variance. Weekly seasonal ARIMA models with exogenous regressors were fitted, incorporating PSI as a covariate and adjusting for demographic, clinical and socioeconomic factors.Results Asthma ED visits were positively correlated with PSI (lag 0: r=0.142; 95% CI 0.107 to 0.178) and inversely correlated with rainfall (lag 3: r=−0.062; 95% CI −0.099 to –0.026) and WBT (lag 1: r=−0.067; 95% CI −0.104 to −0.031). Wind speed (lag 2: r=−0.049; 95% CI −0.086 to –0.013) and ambient temperature (lag 6: r=−0.045; 95% CI −0.081 to –0.008) showed weaker inverse associations. Mean PSI was higher during haze (82.67 vs 51.46, p<0.001) and festival periods (53.42 vs 51.57, p=0.001). Mean ED visits fell across successive haze events (2.60 in 2016, 2.36 in 2019, 1.46 in 2023) but peaked during the Northeast monsoons despite lower PSI, indicating weather influences beyond ambient pollution.Conclusions PSI–ED association peaked on the same day of exposure but was no longer significant after adjusting for demographic and clinical factors. Pollution-linked festivals, transboundary haze and the Northeast monsoon were associated with increased asthma ED visits

Background: Countries are implementing interventions to reduce avoidable hospital readmissions. However, evaluating such interventions are potentially complex. These interventions can cause unintended consequences, and they are among the most common causes of the intervention’s failure. The objective of this study was to identify the unintended consequences from implementing a pilot case management team to reduce avoidable hospital readmissions at a tertiary hospital in Singapore. Methods: We conducted five in-depth semi-structured interviews with stakeholders who were involved in the planning, development, and implementation of the intervention in addition to analysing 12 intervention documents. Deductive thematic analysis using Rogers’ diffusion of innovation theory was conducted. Results: Data analysis generated seven subthemes: ineffective targeting of patient population, fund constraints, lack of patient ownership, limited post discharge follow up, comprehensive care approaches, role overlap and patient confusion. The absence of a readmission risk assessment tool resulted in care plan needs assessments being conducted for all admitted patients, rather than targeting those who would benefit most. This broad approach overwhelmed care coordination efforts. The initial plan to form a specialised intervention team responsible for care plan needs assessments could not be fully established due to funding constraints. As a result, the intervention team functioned more as a consulting service, providing recommendations to the primary team, which retained decision-making authority. Overlapping roles with existing case managers caused patient confusion, prompting the intervention team to step back and support care plan needs assessment remotely. Conclusion: Overall, results suggest that intervention team recognised a problem and participated in the intervention. This became the foundation for implementing change. However, the unintended consequences undermined the intervention from achieving its objectives and as a result the intervention was stopped. Decision-makers should pay attention to these unintended consequences to inform effective implementation and refine future interventions.

INTRODUCTION:Implementing falls prevention programmes in the community presents numerous challenges. We sought to understand the dynamics between the determinants influencing implementation to develop a common conceptual model describing the complexities of implementing falls prevention programmes in Singapore. METHODS:A full-day group model building workshop with a series of structured activities was organised with 31 multidisciplinary stakeholders. Stakeholders who attended include healthcare professionals of different specialities (i.e. geriatrics, rehabilitation medicine, physiotherapy, nursing), community-based voluntary welfare organisations, researchers and policymakers. RESULTS:A causal loop diagram was developed to illustrate the determinants influencing implementation of community-based fall prevention programmes. It revealed factors driving key implementation and service outcomes in supply and demand of such programmes. Determinants of these outcomes were synthesised into four themes: (i) structural factors affecting the management and resource allocation for community-based falls prevention programmes, (ii) participation in programmes affected by older adults' willingness and ability to participate, (iii) perceived value as a composite of costs and benefits, and (iv) social support and exercise self-efficacy motivating long-term adherence. Furthermore, in our analysis of feedback relationships, two organisational behaviours were identified: unsustainable growth due to resource constraints (Limits to Growth) and tensions between executing symptomatic or fundamental solutions (Eroding Goals). Stakeholders also explored strategies for effective implementation. CONCLUSIONS:A conceptual model describing the dynamics of implementing community-based fall prevention programmes was developed. This informed the formulation of a National Falls Prevention Framework, a priority action step for the effective implementation of these programmes in Singapore.

Asthma inhalers are significant contributors of greenhouse gas emissions. However, less is known about the potentially avoidable carbon footprint i.e. medication wastage and oversupply. We aimed to analyse dispensing patterns and carbon footprints of asthma inhalers, quantify medication wastage, and identify determinants of medication oversupply. We reviewed the asthma-related dispensation records from 2015 to 2019, in an anonymised, cluster-wide repository linking electronic medical, pharmacy and administrative records, containing patient and visit details on demographics, comorbidities, GINA step, and site of care. Medication wastage, a visit-level measure, was defined as the number of inhalers dispensed in excess of the quantity required during each refill interval. Medication oversupply, a patient-level aggregated measure defined by medication possession ratio (MPR) > 1.2, where MPR equals total dispensed days (summed across all maintenance inhalers) divided by the follow-up period. All analyses were performed using R Studio. 205,337 inhaler units were dispensed over the study period, contributing an estimated 1,541,591 kgCO2e. The most frequently prescribed inhalers were SABA MDIs (79,007 units; 38.5

OBJECTIVES:Understanding older adults' health beliefs regarding falls is important for the design of participant-centric programs. Although there is evidence on older adults' perceptions toward falls and falls prevention, there is insufficient understanding of older adults' adaptive responses to cope with falls. In addition, these perceptions are understudied within the context of Asia for the development of programs in Asia. METHODS:In-depth interviews were conducted with 30 community-dwelling older adults (aged 60 and older) in Singapore. The Health Belief Model, adapted to falls and falls prevention, helped guide interviews. RESULTS:Our findings uncovered a discordance between perceived susceptibility to falls and actual physical ability, influencing the actions toward falls prevention. Adaptive responses to falls were encapsulated as the concept "being careful" in this context. This manifested in two groups: those who monitor their physical health due to perceived high risk and those who only manage external hazards due to perceived low risk. In addition, we examined cues to actions: caregiver and clinician support, managing chronic pain, and prioritizing social roles; and discussed their implications for future program development. The findings also highlighted the importance of engaging family and caregivers in falls prevention efforts, a strategy that resonates deeply across Asian sociocultural contexts. DISCUSSION:Falls prevention practices should integrate tailored education and behavioral strategies based on older adults' perceived susceptibility to falls. In Asian contexts and other cultures with a strong focus on family, caregiver-supported interventions in addition to personalized interventions should also be optimized to encourage participation and sustain adherence.

PURPOSE:The prevalence and economic burden of asthma across the public healthcare landscape in Singapore is substantial, where the asthma patient journey often transitions between primary care (PC) and specialty care (SC) settings. PATIENTS AND METHODS:This study used the SingHealth COPD and Asthma Data Mart, a repository of clinical and administrative data from patients with asthma or chronic obstructive pulmonary disease, to collect real-time, real-world data across a range of demographics, disease severities and treatment pathways. RESULTS:Key differences were identified among patients treated in PC, SC, or both (PC/SC). There were more patients of Chinese ethnicity and ex-smokers among those treated in SC versus PC or PC/SC. Patients in SC also had a lower mean Asthma Control Test score (17.93 [standard deviation: 4.92]) versus the other groups (PC: 20.32 [4.37], p < 0.001; PC/SC: 19.65 [4.55], p < 0.001). More patients used low-dose inhaled corticosteroids in the PC (76.95 %) than SC group (60.1 %). Patients treated in PC/SC were older and had more frequent emergency department visits (0.54 [1.17] vs PC: 0.04 [0.16], p < 0.001; SC: 0.35 [0.92], p < 0.001) and exacerbations per patient/year (2.31 [3.37] vs PC: 1.48 [2.56], p < 0.001; SC: 0.96 [2.67], p < 0.001), and higher proportions had comorbidities versus PC or SC. Overall, nearly half of patients had uncontrolled asthma, 58.88 % of whom were in the PC group. CONCLUSION:Findings of this study provide greater understanding of the asthma public healthcare landscape in Singapore, allowing for the identification of current gaps in care, particularly for high-risk groups that may benefit from optimised treatment.

Limited diagnostic testing for drug-resistant TB (DR-TB) may lead to high rates of misdiagnosis and undertreatment. Current diagnostic tests focus only on detection of rifampicin-resistant TB (RR-TB). This study aims to determine the impact of improved diagnostic testing for a wider range of drug resistance on DR-TB outcomes in high-burden TB settings, using the Philippines and Thailand as case studies. A dynamic compartmental model was designed to simulate population level TB transmission, accounting for acquired drug resistance from treatment failure of drug susceptible TB. Three scenarios were analyzed: (1) Use of GeneXpert MTB/RIF on all presumptive TB cases (Status Quo); (2) GeneXpert MTB/RIF + GeneXpert XDR, (3) GeneXpert MTB/RIF + targeted Next Generation Sequencing (tNGS). Scenarios were modelled over a 10-year period, from 2025 to 2034. Compared to the status quo, Scenario 2 results in a fourfold increase in annual DR-TB cases diagnosed in the Philippines and a fivefold increase in Thailand. DR-TB treatment failure decreases by 20

Inhaled corticosteroid (ICS) is the mainstay therapy for asthma, but general adherence is low. There is a paucity of real-world inhaler prescribing and adherence data from Asia and at the population level. To address these gaps, we performed a real-world data analysis of inhaler prescribing pattern and adherence in a multi-ethnic Asian asthma cohort and evaluated the association with asthma outcomes. We performed a retrospective analysis of adult asthma patients (aged ≥18 years) treated in the primary and specialist care settings in Singapore between 2015 to 2019. Medication adherence was measured using the medication possession ratio (MPR), and categorised into good adherence (MPR 0.75-1.2), poor adherence (MPR 0.75) or medication oversupply (MPR > 1.2). All statistical analyses were performed using R Studio. 8023 patients, mean age 57 years, were evaluated between 2015 and 2019. Most patients were receiving primary care (70.4%) and on GINA step 1-3 therapies (78.2%). ICS-long-acting beta-2 agonist (ICS-LABA) users increased over the years especially in the primary care, from 33% to 52%. Correspondingly, inpatient admission and ED visit rates decreased over the years. Between 2015 and 2019, the proportion of patients with poor adherence decreased from 12.8% to 10.5% (for ICS) and from 30.0% to 26.8% (for ICS-LABA) respectively. Factors associated with poor adherence included minority ethnic groups (Odds ratio of MPR 0.75-1.2: 0.73-0.93; compared to Chinese), presence of COPD (OR 0.75, 95% CI 0.59-0.96) and GINA step 4 treatment ladder (OR 0.71, 95% CI 0.61-0.85). Factors associated with good adherence were male gender (OR 1.14, 95% CI 1.01-1.28), single site of care (OR 1.22 for primary care and OR 1.76 for specialist care), GINA step 2 treatment ladder (OR 1.28, 95% CI 1.08-1.50). Good adherence was also associated with less frequent inpatient admission (OR 0.91, 95% CI 0.84-0.98), greater SABA overdispensing (OR 1.66, 95% CI 1.47-1.87) and oral corticosteroids use (OR 1.10, 95% CI 1.05-1.14). Inhaled corticosteroid (ICS) adherence has improved generally, however, poor adherence was observed for patients receiving asthma care in both primary and specialist care, and those from the minority ethnicities.

BACKGROUND:Falls and fall-related injuries among older adults in Singapore are a serious health problem that require early intervention. In previous research, exercise interventions have been effective in improving functional outcomes and reducing falls for a broad group of older adults. However, results from multi-domain, multi-component falls prevention programs for high fall risk older adults in the community remain equivocal. One reason for these results is that there is significant heterogeneity in falls risk factors amongst high falls risk older adults which makes tailoring multicomponent interventions complex. The objective of the trial is to evaluate the effectiveness of an enhanced version of the predecessor program, SAFE. The Steps to Avoid Falls in the Elderly-a TECHnology enhanced intervention (SAFE-TECH) is designed for older adults in the community who are at high risk of falls, with candidate selection and program tailoring based on gait variables derived from wearable sensors and various questionnaire-based features. METHODS:SAFE-TECH is a 12-month randomized controlled trial involving 400 older adults at high risk of falling, who are randomly allocated to an intervention or control group in a 1:1 ratio. Participants will be assessed at baseline, 3rd-month and 12th-month for functional status, physical performance, cognitive status, quality of life, and medical history. Monthly phone calls will assess fall status, healthcare utilization, physical activity, and exercise self-efficacy. Participants in the intervention group will undergo a tailored, multi-domain, multi-component falls prevention program. The active intervention phase will last for 12-weeks with exercises focusing on strength, balance, coordination, flexibility, and aerobic endurance; and weekly educational sessions on falls risk with personalized feedback based on participant's falls risk assessments and environmental checklist. DISCUSSIONS:SAFE-TECH seeks to evaluate enhanced existing falls prevention programs by addressing the heterogeneity of falls risk through rapid assessments and personalisation of exercise and education components while maintaining the efficiency of the group setting. Our findings will inform practical efforts to reduce falls and falls-related injuries among community-dwelling older adults. TRIAL REGISTRATION:ClinicalTrials.gov. CLINICAL TRIAL NUMBER:NCT06102954|| 22-10-2023.

Purpose:Patients with asthma in Singapore often have complex patient journeys, with diagnosis and management across various primary and speciality care settings. Real-world population health data is needed to identify care gaps and inform policies. Patients and Methods:This retrospective, longitudinal cohort study assessed real-world data from adults (aged ≥18 years) with asthma in the SingHealth Chronic Obstructive Pulmonary Disease and Asthma Data Mart, an integrated database of electronic medical records of patients who attended primary and/or speciality care clinics in the SingHealth Regional Health System 01/01/2015-12/31/2020. Patients were indexed by first asthma diagnosis and categorized into cohorts of index year. Patient characteristics, asthma management and outcomes were described during baseline (1-year pre-index) and follow-up periods (1-year post-index). Results:Overall, 21,215 patients were included across 4 cohorts: 2016, N=12,947; 2017, N=3419; 2018, N=2816; 2019, N=2033. Most common baseline asthma medication changed from inhaled corticosteroids (ICS) alone in the 2016 cohort (32.8% [n=4252]) to ICS/long-acting β2-agonist in the 2019 cohort (33.3% [n=677]). Asthma symptom control (mean [SD] Asthma Control Test scores) improved from 2016 to 2019 during baseline (18.38 [4.93] vs 19.87 [4.56]; p<0.001) and follow-up (18.34 [4.23] vs 21.07 [3.51]; p<0.001). Mean (standard deviation [SD]) number of exacerbations per patient during follow-up decreased from 2016 to 2019 (1.91 [3.11] vs 0.89 [2.07]; p<0.001). Mean (SD) number of emergency department visits per patient during follow-up decreased from 0.21 (0.75) in 2016 to 0.17-0.18 (0.60-0.65; p<0.001) between 2017 and 2019. Conclusion:Health status at first asthma diagnosis improved for each succeeding cohort from 2016 to 2019, along with improvements in patient management and outcomes. This reflects greater awareness of the condition and improved use of medication and referrals in recent years, suggesting policy changes and their implementation, including promotion of disease awareness and adoption of guideline recommendations, may improve asthma outcomes in Singapore.

Background and Objectives:Falls among older adults are a significant health problem globally. Studies of multicomponent fall prevention programs in randomized controlled trials demonstrate effectiveness in reducing falls; however, the translation of research into the community remains challenging. Although there is an increasing interest to understand the factors contributing to implementation barriers, the dynamic relationships between factors are less well examined. Furthermore, evidence on implementation barriers from Asia is lacking as most of these studies originate from the West. As such, this study aims to engage stakeholders in uncovering the factors that facilitate or inhibit implementing community-based fall prevention programs in Singapore, with a focus on the interrelationship between those factors.Research Design and Methods:Health care professionals familiar with fall prevention programs were invited to discuss the enablers and challenges to the implementation. This effort was facilitated using a systems modeling methodology of Group Model Building (GMB) to share ideas and create a common conceptual model of the challenges. The GMB employs various engagement techniques to draw on the experiences and perceptions of all stakeholders involved.Results:This process led to the development of a Causal Loop Diagram (CLD), a qualitative conceptual model of the dynamic relationships between the barriers and facilitators of implementing fall prevention programs. Results from the CLD show that implementation is influenced by two main drivers: health care provider factors that influenced referrals, and patient factors that influenced referral acceptance and long-term adherence. Key leverage points for potential interventions were identified as well.Discussion and Implications:The overall recommendation emphasized closer coordination and collaboration across providers to ensure sustainable and effective community-based fall prevention programs. This has to be supported by a national effort, involving a multidisciplinary stakeholder advisory group. These findings generated would be promising to guide future approaches to fall prevention.

Background: Little is known about the caregiving time of different types of caregivers in Singapore or its monetary value. We quantified the caregiving time of primary informal, secondary informal, and migrant domestic worker (MDW) caregivers of older adults and estimated the monetary value of caregiving time of primary and secondary informal caregivers. Methods: 278 primary informal caregivers reported the time provided by themselves, secondary informal caregivers and MDW caregivers in a typical week helping their care-recipients, aged >= 75 years, with activities of daily living (ADLs), instrumental ADLs, healthcare and social care use, other needs, and supervision of MDW caregivers. We estimated monetary value using the proxy good method. Results: On average, primary and secondary informal caregivers provided 33.0 (annual monetary value: S $15,959) and 8.4 (annual monetary value: S$4,062) caregiving hours/week. MDW caregivers provided even more - 42.0 h/week. Care-recipients received 60.5 h of care/week on average. Nationally, the monetary value of informal caregiving time for Singaporeans aged >= 75 years requiring human assistance was about S$1.28 billion. Conclusion: This study highlights the substantial time commitment of informal and MDW caregivers. Our estimates of the monetary value of informal caregiving time can inform economic evaluations of care models for older adults and policies for supporting informal caregivers, particularly in societies that rely heavily on informal care.

Background Health-related quality of life (HRQoL) measures are predictors of adverse health outcomes in older adults. Studies have demonstrated cross-sectional associations between HRQoL measures and blood-based biochemical markers. Acylcarnitines (ACs) are a class of metabolites generated in the mitochondria and are predictive of multiple geriatric syndromes. Changes in ACs reflect alterations in central carbon metabolic pathways. However, the prospective relationship between plasma ACs and declining HRQoL has not been examined. This study aimed to investigate both cross-sectional and longitudinal associations of baseline ACs with baseline and declining EuroQol-5 Dimension/EuroQol Visual Analogue Scale (EQ-5D/EQ-VAS) in community-dwelling older adults. Methods One hundred and twenty community-dwelling older adults with EQ-5D/EQ-VAS measurements at baseline and follow-up were included. We quantified ACs at baseline using targeted plasma metabolomics profiling. Multivariate regressions were performed to examine cross-sectional and longitudinal associations between the measures. Results Cross-sectionally, ACs showed no significant associations with either EQ-5D index or EQ-VAS scores. Longitudinally, multiple baseline short-chain ACs were significantly and inversely associated with declining EQ-5D index score, explaining up to 8.5% of variance in the decline. Conclusions Within a cohort of community-dwelling older adults who had high HRQoL at baseline, we showed that higher levels of short-chain ACs are longitudinally associated with declining HRQoL. These findings reveal a novel association between central carbon metabolic pathways and declining HRQoL. Notably, dysregulation in mitochondrial central carbon metabolism could be detected prior to clinically important decline in HRQoL, providing the first evidence of objective biomarkers as novel predictors to monitor HRQoL in nonpharmacological interventions and epidemiology.