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Value-Based Care of Hypertensive Patients in National University Polyclinics (NUP)

Case study


The National University Polyclinics (NUP) implemented value-driven outcomes (VDO) for hypertension in 2018. Hypertension is the second most common chronic condition seen in the polyclinics and is a risk factor for atherosclerotic cardiovascular disease and chronic kidney disease.


  • To use the value driven outcomes tool to identify care cost of managing patients with hypertension in our polyclinics.
  • To identify variability in clinical quality and care costs among the polyclinics to support value improvement initiatives.


We engaged family physicians at NUP with interest in hypertension management to be clinician leads for VDO hypertension. The VDO dashboard for hypertension was presented by a clinician lead at the quarterly clinic heads' meeting. Choa Chu Kang polyclinic was identified for improvement of value-based care.


Choa Chu Kang polyclinic carried out a value improvement initiative in 2019 on blood pressure (BP) control of the different patient groups in accordance to clinical practice guidelines. The initiative included doctor education and reminders of blood pressure (BP) targets, documentation of BP in the electronic medical records, and the use of home BP monitoring for patients.

Clinical Quality Index

CQI Breakdown (2017 to 2020)

The proportion of patients with hypertension achieving the recommended blood pressure targets improved for all four groups: from 73% to 84 in the <140/90 mmHg group, 55% to 63% (<140/80 mmHg group), 28% to 49% (<130/80 mmHg group) and 85% to 90% (<150/90 mmHg group)

CQI vs Cost (2017 to 2020) Hypertension

The annual cost of care increased from 5.5% on average per patient. There is an increase in CQI from 48% to 49% during the same period, and an apparent decrease in 2020 attributed to data interface issue for the BMI measurement care component.


The value-driven outcomes dashboard is a useful tool to identify and to support value improvement of patients with hypertension at Choa Chu Kang polyclinic. Our dashboard showed the changes in CQI vs Cost with the value improvement activities, and includes breakdown of CQI to individual process and outcome care components.

Team members
  • Dr Jonathan Phang, Deputy Director, Clinical Services, National University Polyclinics
  • Dr Keith Tsou, Director, Clinical Services, National University Polyclinics
  • Toh Chang Yang, Manager, Clinical Services, National University Polyclinics
  • Dr Richard Hui, Director, Regional Health System Office (Primary Care Partnership), National University Health System
  • Dr Hou Minsheng, Family Physician, Bukit Panjang Polyclinic
  • Dr Voo Yau Onn, Director, Quality, National University Polyclinics
  • Dr Justin Chong, Assistant Director, Quality, National University Polyclinics
  • Lee Jun Yue, Senior Assistant Manager, Quality, National University Polyclinics
  • Dr Kwan Yew Seng, Family Physician Senior Consultant, Pioneer Polyclinic
  1. Lee VS, Kawamoto K, Hess R, et al. Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality. JAMA. 2016;316(10):1061–1072. doi:10.1001/jama.2016.12226
  2. Ministry of Health Singapore Hypertension MOH Clinical Practice Guidelines (Nov 2017).
  3. Ministry of Health Singapore Chronic Disease Management Programme Handbook for Healthcare Professionals 2018 Latest Edition 2021.
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