Towards Better Patient-Centred Care

Issue 54
Jul 2025

ALL IN THE FAMILY

By Assistant Professor Goh Lay Hoon, Research Director, Dr Laurie Goldsmith and Dr Stephanie van der Lubbe, Senior Research Fellows and Dr Anna Szücs, Research Fellow, National University Health System, Department of Family Medicine

In the evolving landscape of primary care, there is a growing emphasis on placing the patient at the centre of healthcare delivery. At the National University Health System (NUHS) Department of Family Medicine, our research emphasises patient-centredness through multiple approaches, assessing patients’ presentations and needs both quantitatively and qualitatively.

We highlight here three different approaches aiming at: 1) increasing the precision and individualisation of the measurement of quality of care using routinely collected data, 2) understanding the experiences of patients in relation to mental healthcare with the help of their General Practitioners (GPs), and 3) creating a repository of patient experiences for a wide range of conditions to support self-care, research, training of health professionals, and health policy analysis.

Singapore is the
15^th
country to join the international patient voice initiative “Database of Individual Patients’ Experiences”

A better way of evaluating guideline concordance

One of our key data-driven projects is the development of a patient-centred model for evaluating concordance with guidelines in chronic disease management. Traditional scoring models often rely on a binary framework, marking the patient as “concordant” if a required test is completed within a given time frame and “not concordant” otherwise. While effective for evaluating clinical performance and cohort averages, this approach may not provide accurate individual scores, as it does not consider the care trajectory of the individual patient. Our new model takes a more personalised approach by incorporating additional information about the patient’s care history, including a longer time frame and the regularity of care. By offering a refined concordance score that more accurately reflects individual care patterns, this new concordance score equips clinicians with a tool to tailor their interventions and care strategies more effectively, ultimately supporting improved health outcomes.

To date, we have disseminated our findings at the NUHS Scientific and Innovation Summit 2024, the WONCA Asia Pacific Conference 2024, and the National University Polyclinics-DFM Research Forum.

Helping GPs manage late-life depression in older patients

Approaching patients’ clinical presentations from a different angle, we conducted qualitative interviews with private GPs about how they encountered late-life depression. This condition is often considered challenging to diagnose and manage in primary care, despite representing a growing public health issue in Singapore and elsewhere. Through the eyes of the GPs, we were able to explore how older patients tended to manifest their mental suffering and what the barriers to and facilitators of their favourable clinical evolution were. GPs also highlighted persisting gaps as well as useful resources in the current mental healthcare system, which can inform ongoing reforms under Healthier SG. We are currently working on contrasting these local findings with results from elsewhere in the world through two systematic reviews focusing on knowledge and help-seeking behaviours in the context of late-life depression. These projects pave the way towards a better integration of late-life depression care into primary care by enabling a more holistic approach, taking into account both age-related and cultural specificities of depressed older adults in Singapore.

Together, these research efforts underscore the Department of Family Medicine’s commitment to a future with a high degree of patient-centred care. Through leveraging these various forms of research, we aim to better understand patients, tailoring primary care delivery to their needs and improving their concordance and health outcomes.

International patient voice database

Additionally, we are proud to be part of an international patient voice initiative called the Database of Individual Patients’ Experiences (DIPEx)¹. Under our leadership, Singapore is the 15^th country to join this international collaborative, which conducts high-quality research on patient experiences and disseminates research findings on publicly accessible websites, in addition to scientific conferences and peer-reviewed publications. Each health condition studied in each country uses narrative interviews with patients with a wide range of backgrounds to document detailed information on every aspect of the patient’s journey. The country-specific websites are then used to share the details of the local patient journey through topic summaries and approximately 250 video, audio, and written excerpts from the interviews. DIPEx International websites are visited by around 8.5 million unique visitors a year and have been used to support patients and caregivers about illness and care, as well as clinicians in their training and policymakers in assessing how patient needs are met. Our first DIPEx projects include documenting patients’ journeys with colorectal cancer and recurrent urinary tract infections. We will continue to expand the health conditions we study in DIPEx Singapore over time.

Click here to read the team’s latest research.

https://dipexinternational.org.