{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,6]],"date-time":"2026-11-06T03:02:53Z","timestamp":1793934173913,"version":"4.8.0"},"reference-count":61,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2022,10,11]],"date-time":"2022-10-11T00:00:00Z","timestamp":1665446400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001348","name":"Agency for Science, Technology and Research","doi-asserted-by":"crossref","award":["H19\/01\/a0\/023"],"award-info":[{"award-number":["H19\/01\/a0\/023"]}],"id":[{"id":"10.13039\/501100001348","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Diabetes mellitus (DM) is a growing global health problem. In Singapore, the prevalence of Type 2 DM is rising, but comprehensive information about trends in DM-related complications is lacking.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Objectives<\/jats:title>\n<jats:p>We utilized the Singapore Health Services (SingHealth) diabetes registry (SDR) to assess trends in DM micro and macro-vascular complications at the population level, explore factors influencing these trends.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Methods<\/jats:title>\n<jats:p>We studied trends for ten DM-related complications: ischemic heart disease (IHD), acute myocardial infarction (AMI), peripheral arterial disease (PAD) and strokes, diabetic eye complications, nephropathy, neuropathy, diabetic foot, major and minor lower extremity amputation (LEA). The complications were determined through clinical coding in hospital (inpatient and outpatient) and primary care settings within the SingHealth cluster. We described event rates for the complications in 4 age-bands. Joinpoint regression was used to identify significant changes in trends.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Results<\/jats:title>\n<jats:p>Among 222,705 patients studied between 2013 and 2020. 48.6% were female, 70.7% Chinese, 14.7% Malay and 10.6% Indian with a mean (SD) age varying between 64.6 (12.5) years in 2013 and 65.7 (13.2) years in 2020. We observed an increase in event rates in IHD, PAD, stroke, diabetic eye complications nephropathy, and neuropathy. Joinpoints was observed for IHD and PAD between 2016 to 2018, with subsequent plateauing of event rates. Major and minor LEA event rates decreased through the study period.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec005\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>We found that DM and its complications represent an important challenge for healthcare in Singapore. Improvements in the trends of DM macrovascular complications were observed. However, trends in DM microvascular complications remain a cause for concern.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0275920","type":"journal-article","created":{"date-parts":[[2022,10,11]],"date-time":"2022-10-11T17:24:58Z","timestamp":1665509098000},"page":"e0275920","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":28,"title":["Trends in diabetes-related complications in Singapore, 2013\u20132020: A registry-based study"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4518-0477","authenticated-orcid":true,"given":"Joshua Kuan","family":"Tan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nur Nasyitah Mohamed","family":"Salim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gek Hsiang","family":"Lim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7591-3141","authenticated-orcid":true,"given":"Sing Yi","family":"Chia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Thumboo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yong Mong","family":"Bee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,10,11]]},"reference":[{"key":"pone.0275920.ref001","unstructured":"Ministry of Health Singapore. Disease Burden. [cited 26 Feb 2022]. https:\/\/www.moh.gov.sg\/resources-statistics\/singapore-health-facts\/disease-burden"},{"key":"pone.0275920.ref002","unstructured":"International Diabetes Federation. Singapore diabetes report 2000\u20132045. 2021 [cited 26 Feb 2022]. https:\/\/www.diabetesatlas.org\/data\/en\/country\/179\/sg.html"},{"key":"pone.0275920.ref003","first-page":"1012","article-title":"Ethnic and gender specific life expectancies of the Singapore population, 1965 to 2009\u2014Converging, or diverging?","author":"RBT Lim","year":"2013","journal-title":"BMC Public Health. BioMed Central"},{"key":"pone.0275920.ref004","first-page":"213","volume":"356","author":"P Hossain","year":"2009","journal-title":"Obesity and Diabetes in the Developing World\u2014A Growing Challenge"},{"key":"pone.0275920.ref005","article-title":"Microvascular and Macrovascular Complications of Diabetes","volume":"26","author":"MJ Fowler","year":"2008","journal-title":"Clin Diabetes \u2022"},{"key":"pone.0275920.ref006","unstructured":"Epidemiology & Disease Control Division, Ministry of Health SI for HM and E. The Burden of Disease in Singapore, 1990\u20132017: An overview of the Global Burden of Disease Study 2017 results. IHME; 2019."},{"key":"pone.0275920.ref007","unstructured":"Institute for Health Metrics and Evaluation (IHME). GBD Compare. Seattle, WA; [cited 18 Mar 2022]. https:\/\/gbd2017.healthdata.org\/gbd-compare\/"},{"key":"pone.0275920.ref008","article-title":"Projected burden of type 2 diabetes mellitus-related complications in Singapore until 2050: A Bayesian evidence synthesis","volume":"8","author":"KW Tan","year":"2020","journal-title":"BMJ Open Diabetes Res Care"},{"key":"pone.0275920.ref009","first-page":"1","article-title":"Current and future economic burden of diabetes among working-age adults in Asia: Conservative estimates for Singapore from 2010\u20132050 Chronic Disease epidemiology","volume":"16","author":"ME Png","year":"2016","journal-title":"BMC Public Health"},{"key":"pone.0275920.ref010","unstructured":"Ministry of Health Singapore. Speech By Minister For Health, Mr Gan Kim Yong, At The Moh Committee Of Supply Debate 2016. [cited 26 Feb 2022]. https:\/\/www.moh.gov.sg\/news-highlights\/details\/speech-by-minister-for-health-mr-gan-kim-yong-at-the-moh-committee-of-supply-debate-2016"},{"key":"pone.0275920.ref011","unstructured":"Region WHOE. Registries and information systems for diabetes care in the WHO European Region: preliminary findings for consultation 125."},{"key":"pone.0275920.ref012","first-page":"958","volume":"7","author":"RA Gabbay","year":"2005","journal-title":"Critical Features for a Successful Implementation of a Diabetes Registry"},{"key":"pone.0275920.ref013","doi-asserted-by":"crossref","first-page":"S7","DOI":"10.2337\/dc19-S001","article-title":"1. Improving care and promoting health in populations: Standards of medical care in diabetesd2019","volume":"42","author":"D Care","year":"2019","journal-title":"Diabetes Care"},{"key":"pone.0275920.ref014","doi-asserted-by":"crossref","first-page":"1","DOI":"10.5334\/ijic.5177","article-title":"Population health management in diabetes care: Combining clinical audit, risk stratification, and multidisciplinary virtual clinics in a community setting to improve diabetes care in a geographically defined population. an integrated diabetes care pilot i","volume":"20","author":"O Kozlowska","year":"2020","journal-title":"Int J Integr Care"},{"key":"pone.0275920.ref015","doi-asserted-by":"crossref","first-page":"215","DOI":"10.2147\/CLEP.S300663","article-title":"Establishment of the SingHealth Diabetes Registry","volume":"13","author":"DYZ Lim","year":"2021","journal-title":"Clin Epidemiol"},{"key":"pone.0275920.ref016","first-page":"1","article-title":"KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease","volume":"3","author":"Kidney Disease Improving Global Outcomes","year":"2013","journal-title":"Kidney Int Suppl"},{"key":"pone.0275920.ref017","first-page":"58","article-title":"Making Sense of Chronic Kidney Disease in Primary Care\u2013Identification, Evaluation and Monitoring","volume":"47","author":"YT Chua","year":"2021","journal-title":"Singapore Fam Physician"},{"key":"pone.0275920.ref018","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1007\/s00125-018-4711-2","article-title":"Global trends in diabetes complications: a review of current evidence","volume":"62","author":"JL Harding","year":"2019","journal-title":"Diabetologia"},{"key":"pone.0275920.ref019","first-page":"1","article-title":"ICD-10 coding algorithms for defining comorbidities of acute myocardial infarction","volume":"6","author":"L So","year":"2006","journal-title":"BMC Health Serv Res"},{"key":"pone.0275920.ref020","doi-asserted-by":"crossref","first-page":"1130","DOI":"10.1097\/01.mlr.0000182534.19832.83","article-title":"Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data","volume":"43","author":"H Quan","year":"2005","journal-title":"Med Care"},{"key":"pone.0275920.ref021","doi-asserted-by":"crossref","first-page":"311","DOI":"10.2147\/CLEP.S197474","article-title":"Can diabetic polyneuropathy and foot ulcers in patients with type 2 diabetes be accurately identified based on ICD-10 hospital diagnoses and drug prescriptions?","volume":"11","author":"DH Christensen","year":"2019","journal-title":"Clin Epidemiol"},{"key":"pone.0275920.ref022","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1371\/journal.pone.0215649","article-title":"Hospital burden of coronary artery disease: Trends of myocardial infarction and\/or percutaneous coronary interventions in France 2009\u20132014","volume":"14","author":"J Pinaire","year":"2019","journal-title":"PLoS One"},{"key":"pone.0275920.ref023","unstructured":"Singapore M of H. Table of Surgical Procedures. Singapore; 2021 Feb. https:\/\/www.moh.gov.sg\/docs\/librariesprovider5\/medisave\/table-of-surgical-procedures-(1-feb-2021).pdf"},{"key":"pone.0275920.ref024","unstructured":"Ministry of Health Singapore. Diabetes Mellitus: MOH Clinical Practice Guidelines 1\/2014. Ministry of Health, Singapore. 2014. https:\/\/www.moh.gov.sg\/content\/dam\/moh_web\/HPP\/Doctors\/cpg_medical\/current\/2014\/diabetes_mellitus\/cpg_Diabetes Mellitus Booklet\u2014Jul 2014.pdf"},{"key":"pone.0275920.ref025","unstructured":"National Committee for Quality Assurance. Comprehensive Diabetes Care. [cited 18 Mar 2022]. https:\/\/www.ncqa.org\/hedis\/measures\/comprehensive-diabetes-care\/"},{"key":"pone.0275920.ref026","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1002\/(SICI)1097-0258(20000215)19:3<335::AID-SIM336>3.0.CO;2-Z","article-title":"Permutation tests for joinpoint regression with applications to cancer rates","volume":"19","author":"HJ Kim","year":"2000","journal-title":"Stat Med"},{"key":"pone.0275920.ref027","first-page":"1","article-title":"Trends in diabetes-related complications in Hong Kong, 2001\u20132016: A retrospective cohort study","volume":"19","author":"H Wu","year":"2020","journal-title":"Cardiovasc Diabetol"},{"key":"pone.0275920.ref028","unstructured":"National Cancer Institute. APC\/AAPC\/Tau Confidence Intervals\u2014Joinpoint Help System. [cited 25 Mar 2022]. https:\/\/surveillance.cancer.gov\/help\/joinpoint\/setting-parameters\/method-and-parameters-tab\/apc-aapc-tau-confidence-intervals"},{"key":"pone.0275920.ref029","volume-title":"Stata Statistical Software: Release 14","author":"StataCorp","year":"2015"},{"key":"pone.0275920.ref030","unstructured":"Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute. Joinpoint Regression Program."},{"key":"pone.0275920.ref031","unstructured":"Ministry of Trade and Industry\u2014Department of Statistics. Singapore Residents By Age Group, Ethnic Group And Gender, End June, Annual-Data. 2020 [cited 28 Feb 2022]. https:\/\/data.gov.sg\/dataset\/resident-population-by-ethnicity-gender-and-age-group"},{"key":"pone.0275920.ref032","doi-asserted-by":"crossref","first-page":"975","DOI":"10.1016\/j.mayocp.2020.07.037","article-title":"Adherence to Chronic Kidney Disease Screening Guidelines Among Patients With Type 2 Diabetes in a US Administrative Claims Database","volume":"96","author":"K Folkerts","year":"2021","journal-title":"Mayo Clin Proc"},{"key":"pone.0275920.ref033","unstructured":"Centers for Disease Control and Prevention. Diabetes Report Card 2019. 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The Burden of Disease in Singapore, 1990\u20132017: An overview of the Global Burden of Disease Study 2017 results. 2019."},{"key":"pone.0275920.ref036","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/S1098-3597(05)80066-3","article-title":"A constellation of complications:The metabolic syndrome","volume":"7","author":"SM Grundy","year":"2005","journal-title":"Clin Cornerstone"},{"key":"pone.0275920.ref037","doi-asserted-by":"crossref","first-page":"2231","DOI":"10.2337\/dc20-2439","article-title":"Historical hba1c values may explain the type 2 diabetes legacy effect: Ukpds 88","volume":"44","author":"M Lind","year":"2021","journal-title":"Diabetes Care"},{"key":"pone.0275920.ref038","doi-asserted-by":"crossref","first-page":"120","DOI":"10.4093\/dmj.2020.0175","article-title":"Trends in Cardiovascular Complications and Mortality among Patients with Diabetes in South Korea","volume":"45","author":"JH Park","year":"2021","journal-title":"Diabetes Metab J"},{"key":"pone.0275920.ref039","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1371\/journal.pone.0259157","article-title":"Trends in cardiovascular risk factors and treatment goals in patients with diabetes in Singapore-analysis of the SingHealth Diabetes Registry","volume":"16","author":"L Feng","year":"2021","journal-title":"PLoS One"},{"key":"pone.0275920.ref040","doi-asserted-by":"crossref","first-page":"e000012","DOI":"10.1136\/bmjdrc-2013-000012","article-title":"Forecasting the burden of type 2 diabetes in Singapore using a demographic epidemiological model of Singapore","volume":"2","author":"TP Phan","year":"2014","journal-title":"BMJ Open Diabetes Res Care"},{"key":"pone.0275920.ref041","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1111\/jebm.12318","article-title":"Temporal trends in optimal diabetic care and complications of elderly type 2 diabetes patients in Thailand: A nationwide study","volume":"12","author":"W Kaewput","year":"2019","journal-title":"J Evid Based Med"},{"key":"pone.0275920.ref042","doi-asserted-by":"crossref","first-page":"1514","DOI":"10.1056\/NEJMoa1310799","article-title":"Changes in Diabetes-Related Complications in the United States, 1990\u20132010","volume":"370","author":"EW Gregg","year":"2014","journal-title":"N Engl J Med"},{"key":"pone.0275920.ref043","doi-asserted-by":"crossref","first-page":"1867","DOI":"10.1001\/jama.2019.3471","article-title":"Resurgence in Diabetes-Related Complications","volume":"321","author":"EW Gregg","year":"2019","journal-title":"JAMA\u2014J Am Med Assoc"},{"key":"pone.0275920.ref044","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1016\/j.ejvs.2021.09.041","article-title":"National Rates of Lower Extremity Amputation in People With and Without Diabetes in a Multi-Ethnic Asian Population: a Ten Year Study in Singapore","volume":"63","author":"T Riandini","year":"2022","journal-title":"Eur J Vasc Endovasc Surg"},{"key":"pone.0275920.ref045","doi-asserted-by":"crossref","first-page":"2689","DOI":"10.1007\/s00125-020-05278-2","article-title":"Secular trends in rates of hospitalisation for lower extremity amputation and 1 year mortality in people with diabetes in Hong Kong, 2001\u20132016: a retrospective cohort study","volume":"63","author":"H Wu","year":"2020","journal-title":"Diabetologia"},{"key":"pone.0275920.ref046","unstructured":"Ministry of Health Singapore. 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Lim","year":"2017","journal-title":"Glob Policy"},{"key":"pone.0275920.ref058","unstructured":"Ministry of Health Singapore. 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