Title:

Cohort Study to Investigate the Outcomes of Patients with Hypertension and/or Diabetes Mellitus and the Effectiveness and Cost-effectiveness of Structured Multi-disciplinary Intervention Programmes

Principal Investigator:

Cindy Lk Lam

Co-Investigators:

Julie Y Chen, Weng-Yee Chin, Esther Yt Yu, Carlos KH Wong, Emily TY Tes, Eric YT Wan, David VK Chao, Wendy WS Tsui, Tony Ha

Objectives:

To evaluate the long-term effectiveness and cost-effectiveness of Risk Assessment and Management Programmes (RAMP) and other primary care services such as Patient Support Call Centre (PSCC) on the reduction of complications and deaths for primary care patients with hypertension (HT) or diabetes mellitus (DM) in Hong Kong.

Design:

Population-based cohort study

Setting:

Hospital Authority (HA) primary care clinics in Hong Kong

Participants:

All patients aged ≥ 18 years with DM or HT managed in HA primary care clinics between 2006 and 2021

Main outcome measures:

(1) Incidence of DM/HT complications and all-cause mortality
(2) Public health service utilization including out-patient clinics, Accident and Emergency service and overnight hospitalization
(3) Incremental cost-effectiveness ratio per complication or all-cause death avoided, and per QALY gained by RAMP or PSCC

Methods:

A naturalistic cohort study with maximum follow up of 10 years and retrospective extraction of data from the HA clinical management system (CMS) database. The outcomes of propensity score matched cohorts who have and have not participated in the respective programme will be compared. Multivariable Cox proportional hazards regression and Poisson/negative binomial regression will be conducted to evaluate the effect of RAMP, PSCC and other primary care services on the risk of complications, death and service utilization rates. Empirical costs and effectiveness data observed during the study period will be applied to calculate cost-effectiveness from the provider’s perspective.

Significance:

The findings can inform health policy and optimize service delivery to make care for patients with HT or DM more effective and efficient.

Title:

The Development and Validation of a DM and Pre-DM Risk Predication Function for Case Finding in Primary Care in Hong Kong

Principal Investigator:

Cindy Lk Lam

Co-Investigators:

Dr. David Chao, Department of Family Medicine & Primary Health Care, United Christian Hospital; Dr. Welchie Ko, Family Medicine and Primary Healthcare Department, Queen Mary Hospital; Prof. Kathryn Tan, Department of Medicine, HKU; Dr. Dovey Dong, Dr. Emily Tse, Dr. Carlos Wong, Dr. Weng Yee Chin, Dr. Laura Bedford, Department of Family Medicine and Primary Care, HKU

Background:

Diabetes Mellitus (DM) can lead to serious complications and premature mortality but it is often undiagnosed. Identifying individuals at risk of DM and pre-diabetes (pre-DM) can enable early intervention to prevent or delaying disease progression. Non-laboratory based risk prediction models for DM and pre-DM can facilitate cost-effective case finding in primary care.

Objectives:

The study objectives are to develop two DM and pre-DM risk prediction models one by regression and machine learning methods and to validate them among in Chinese adults in primary care in Hong Kong.

Design Setting Participants:

A cross-sectional study on data from the Hong Kong Population Health Survey (PHS) 2014/15 was used to develop DM/Pre-DM risk prediction models; and a prospective external validation study of the two models was carried out among Chinese patients presenting to primary care in Hong Kong .

Main outcome measures:

The primary outcome is the sensitivity of the models in detecting DM and pre-DM. Secondary outcomes include area under the receiver operating characteristic curve (AUC-ROC), specificity, positive predictive value (PPV) and negative predictive value (NPV) of the models.

Methods:

Data of 1857 Chinese adults without self-reported DM was extracted from the PHS 2014/15 to develop the DM and Pre-DM risk prediction models using logistic regression (LR) and machine learning (ML) methods, respectively. 919 Chinese adults without any known history of DM or Pre-DM gave from public and private primary care clinics in Hong Kong gave consent and participated in the study. Each participant completed a questionnaire on relevant risk factors and blood tests on Oral Glucose Tolerance Test (OGTT) and haemoglobin A1C (HbA1c) on recruitment and at 12 months if the baseline tests were normal.

Significance:

The prediction models incorporated modifiable lifestyle factors and are specific to primary care Chinese patients. They can identify high-risk individuals for further blood tests cost-effectively.

Output Results and Potential applications :

The ML and LR prediction models showed good external validity with a sensitivity of detecting DM and Pre-DM of 0.72 and 0.70, respectively, at the optimal cut-off threshold. A simplified scoring algorithm derived from LR model has a sensitivity of 0.77 at the cut-off score of ≥16/41. The algorithm could serve as an easy-to-use initial screening tool at the point of care to facilitate case finding of DM and pre-DM in busy primary care.

Output:

Prevalence of Diagnosis by ICPC-2 in Primary Care in Hong Kong 2021-22

Top 10 Diagnoses stratified by system in ICPC-2

Title:

The psychometric properties of a modified Patient Enablement Instrument (PEI-2) as a tool for serial measurements of health enablement

Principal Investigator:

Cindy Lk Lam

Co-Investigators:

Laura E Bedford, Maegan HY Yeung, Carlos KH Wong Ivan CH Au, Emily TY Tse, Cindy WY Yim, Esther YT Yu

Background:

Patient-centered and holistic primary care is conducive to patient empowerment, whereby patients are motivated to gain greater control over decisions affecting their health. A core tenet of empowerment is enablement, which refers to self-perceived ability to understand and cope with illnesses and health issues. The Patient Enablement Instrument (PEI) is a commonly used measure of enablement in a primary care setting. It is a transitional measure, such that the respondent reports their perceived level of change in enablement when compared to their recalled status before the consultation. However, a key problem with transitional scales is that respondents are not always able to accurately recall their baseline state, an issue that will become more pertinent if administering the measure long after a consultation or intervention. A modified version, the PEI-2, has therefore been developed to measure enablement at a given time-point without comparison to a recalled baseline.

Objectives:

The aim of this study is to evaluate the validity, reliability, responsiveness and sensitivity of the PEI-2.

Methods:

The PEI-2 was modified from the Chinese (HK) PEI to assess enablement over four weeks in a prospective cohort study nested within a community support programme (TFES) in Hong Kong. Baseline and 12-24 follow up data of 360 participants who have completed the PEI-2 will be extracted from the cohort study data base. A sample of 60 subjects will also be recruited to complete the PEI-2 in a two week test-retest study. Construct validity will be assessed by factor-analysis and convergent validity by Spearman’s correlations with health-related quality of life and depressive symptoms. Internal reliability will be assessed using Cronbach’s alpha. Test-retest reliability will be assessed by intraclass correlation, responsiveness by 12-24 month change in PEI-2 score, and sensitivity by differences in change of PEI-2 score between TFES participants and a control group.

Significance and application:

It is hoped that the results will support the application of the PEI-2 as a measure of person-centered care in cross-sectional as well as longitudinal studies. If is that the PEI-2 can track changes in health enablement over time without the need to compare to a recalled baseline state, then this will make it a promising tool for cohort and intervention studies. Indeed, given that “measurement is the first step that leads to control and eventually to improvement” (H. James Harrington), the PEI-2 could contribute to the long-term advancement of primary care practice.

Title:

Association of variability in hemoglobin A1c with cardiovascular diseases and mortality in Chinese patients with type 2 diabetes mellitus — A retrospective population-based cohort study.

Wan E.Y.F, Fung C.S.C., Wong C.H.K., Chin W.Y, Lam C.L.K.

Aims:

This study aimed to investigate the association between variability in HbA1c and incidence of cardiovascular disease (CVD) event and mortality among Chinese primary care patients with Type 2 diabetes mellitus (T2DM).

Methods:

A retrospective cohort study was conducted on 91,866 T2DM patients aged ≥ 18 years without any history of CVD. Variability in HbA1c, was measured by standard deviation (SD), associated with the risks of CVD and all-cause mortality were evaluated using Cox proportional hazards regression analysis by age groups ( 65 and ≥ 65 years old)." to "Variability in HbA1c was measured by standard deviation (SD) The association between Variability in HbA1c and the incidence of CVD and all-cause mortality were evaluated using Cox proportional hazards regression analysis by age groups ( 65 and ≥ 65 years old).

Results:

Over a median follow-up of 58.5 months, our study identified a positive linear relationship between variability in HbA1c and incidence of CVD and all-cause mortality in the younger and older groups. For every 1-SD increase in HbA1c, the risk of CVD events in the older group only increased by 15.2% (95% CI: 1.026–1.293), and the risks of all-cause mortality in both age groups increased by 49.5% (95% CI: 1.154–1.936) and 77.8% (95% CI: 1.563–2.024), respectively.

Conclusions:

The HbA1c variability independently of the mean HbA1c level may provide additional valuable information as a potential predictor for the development of CVD and all-cause mortality in diabetic patients, particularly for the elderly patients.

Title:

5-year effectiveness of the Multi-disciplinary Risk Assessment and Management Programme for primary care patients with Type 2 Diabetes Mellitus‎ (RAMP-DM) on DM-related complications and health service utilizations – A Population-based and Propensity-matched Cohort Study.

Eric Yuk Fai Wan, Colman Siu Cheung Fung, Fang Fang Jiao, Esther Yee Tak Yu, Weng Yee Chin, Daniel Yee Tak Fong, Carlos King Ho Wong, Anca Ka Chun Chan, Karina Hiu Yen Chan, Ruby Lai Ping Kwok and Cindy Lo Kuen Lam

Objective:

To evaluate the 5-year effectiveness of a multidisciplinary Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes.

Research Design and Methods:

A 5-year prospective cohort study was conducted with 121,584 Chinese primary care patients with type 2 DM who were recruited between August 2009 and June 2011. Missing data were dealt with multiple imputations. After excluding patients with prior diabetes mellitus (DM)-related complications and one-to-one propensity score matching on all patient characteristics, 26,718 RAMP-DM participants and 26,718 matched usual care patients were followed up for a median time of 4.5 years. The effect of RAMP-DM on nine DM-related complications and all-cause mortality were evaluated using Cox regressions. The first incidence for each event was used for all models. Health service use was analyzed using negative binomial regressions. Subgroup analyses on different patient characteristics were performed.

Results:

The cumulative incidence of all events (DM-related complications and all-cause mortality) was 23.2% in the RAMP-DM group and 43.6% in the usual care group. RAMP-DM led to significantly greater reductions in cardiovascular disease (CVD) risk by 56.6% (95% CI 54.5, 58.6), microvascular complications by 11.9% (95% CI 7.0, 16.6), mortality by 66.1% (95% CI 64.3, 67.9), specialist attendance by 35.0% (95% CI 33.6, 36.4), emergency attendance by 41.2% (95% CI 39.8, 42.5), and hospitalizations by 58.5% (95% CI 57.2, 59.7). Patients with low baseline CVD risks benefitted the most from RAMP-DM, which decreased CVD and mortality risk by 60.4% (95% CI 51.8, 67.5) and 83.6% (95% CI 79.3, 87.0), respectively.

Conclusions:

This naturalistic study highlighted the importance of early optimal DM control and risk factor management by risk stratification and multidisciplinary, protocol-driven, chronic disease model care to delay disease progression and prevent complications.

https://doi.org/10.2337/dc17-0426

Title:

5-year effectiveness of the Multi-disciplinary Risk Assessment and Management Programme for primary care patients with Type 2 Diabetes Mellitus‎ (RAMP-DM) on DM-related complications and health service utilizations – A Population-based and Propensity-matched Cohort Study.

Fang Fang Jiao, Colman Siu Cheung Fung, Eric Yuk Fai Wan, Anca Ka Chun Chan, Sarah Morag McGhee, Ruby Lai Ping Kwok, Cindy Lo Kuen Lam

Objective:

To estimate the cost-effectiveness of the multidisciplinary Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes in comparison with usual primary care in a cohort with 5 years’ follow-up.

Research Design and Methods:

We conducted a prospective cohort study among 17,140 propensity score–matched participants in RAMP-DM and those under usual primary care. The effectiveness measures were cumulative incidences of complications and all-cause mortality over 5 years. In a bottom-up approach, we estimated the program costs of RAMP-DM and health service utilization from the public health service provider’s perspective. The RAMP-DM program costs included the setup costs, ongoing intervention costs, and central administrative costs. We calculated the incremental cost-effectiveness ratio by dividing the incremental costs by the incremental effectiveness of the RAMP-DM group compared with those of the usual-care group.

Results:

There were significantly lower cumulative incidences of individual on any complications (15.34% vs. 28.65%, P < 0.001) and all-cause mortality (7.96% vs. 21.35%, P < 0.001) in the RAMP-DM group compared with the usual-care group. The mean program cost of RAMP-DM was 157 U.S. dollars (range 66–209) per participant over 5 years. The costs of health service utilization among participants in RAMP-DM group was 7,451 USD less than that of the usual-care group, resulting in a net savings of 7,294 USD per individual.

Conclusions:

RAMP-DM added to usual primary care was a cost-saving intervention in managing diabetes in patients over 5 years. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.

https://doi.org/10.2337/dc17-1149

Title:

Effect of Achieved Systolic Blood Pressure on Cardiovascular Outcomes in Patients with Type 2 Diabetes Mellitus - A Population-based Retrospective Cohort Study.

Eric Y.F. Wan, Esther Y.T. Yu, Weng-Yee Chin, Colman S.C. Fung, Daniel Y.T. Fong, Edmond P.H. Choi, Anca KC Chan, Cindy LK Lam

Objective:

The objective of this study was to compare the incidence of cardiovascular disease (CVD) among patients with type 2 diabetes mellitus (T2DM) with treated hypertension who achieved systolic blood pressures (SBPs) of <120, <130, and <140 mmHg after an increase in their antihypertensive regimen.

Research Design and Methods:

A retrospective cohort study was conducted on 28,014 primary care adult patients with T2DM with no prior diagnosis of CVD and who achieved SBP readings <140 mmHg after an increase in the number of antihypertensive medications prescribed. Using an extension of propensity score matching, a total of 2,079, 10,851, and 15,084 matched patients with achieved SBP measurements of <120, <130, and <140 mmHg were identified. The association between achieved SBP and incident CVD were evaluated using Cox regressions. Subgroup analyses were conducted by stratifying patients’ baseline characteristics.

Results:

Over a median follow-up period of 4.8 years, the incidence of CVD in patients with achieved SBP measures of <120, <130, and <140 mmHg were 318 (15.3%; incidence rate [IR] 34.3/1,000 person-years [PY]), 992 (9.1%; IR 20.4/1,000 PY), and 1,635 (10.8%; IR 21.4/1,000 PY). Achieved SBP <120 mmHg was associated with a higher risk of CVD compared with achieved SBP <130 mmHg (hazard ratio [HR] 1.75 [95% CI 1.53, 2.00]) and achieved SBP <140 mmHg (HR 1.67 [95% CI 1.46, 1.90]). There was a significant reduction in CVD risk in patients <65 years (HR 0.81 [95% CI 0.69, 0.96]) but no difference for other patients, including patients ≥65 years, who achieved SBP <130 mmHg when compared with the group that achieved SBP <140 mmHg.

Conclusions:

Our findings support a SBP treatment target of 140 mmHg and suspect no risk reduction attenuation on CVD for lower SBP targets (<120 or <130 mmHg) for most patients with uncomplicated T2DM. A randomized control trial is still needed to confirm these findings.

https://doi.org/10.2337/dc17-2443

Title:

Intensification with dipeptidyl peptidase-4 inhibitor, insulin, or thiazolidinediones and risks of all-cause mortality, cardiovascular diseases, and severe hypoglycemia in patients on metformin-sulfonylurea dual therapy: A retrospective cohort study

Carlos K H Wong, Kenneth K C Man, Margaret Shi, Esther W Chan, Chu Wa Ho, Emily T Y Tse, Ian C K Wong, Cindy L K Lam

Background:

Although patients with type 2 diabetes mellitus (T2DM) may fail to achieve adequate hemoglobin A1c (HbA1c) control despite metformin-sulfonylurea (Met-SU) dual therapy, a third-line glucose-lowering medication-including dipeptidyl peptidase-4 inhibitor (DPP4i), insulin, or thiazolidinedione (TZD)-can be added to achieve this. However, treatment effects of intensification with the medications on the risk of severe hypoglycemia (SH), cardiovascular disease (CVD), and all-cause mortality are uncertain. Study aim was to compare the risks of all-cause mortality, CVD, and SH among patients with T2DM on Met-SU dual therapy intensified with DPP4i, insulin, or TZD.

Methods and Findings:

We analyzed a retrospective cohort data of 17,293 patients with T2DM who were free from CVD and on Met-SU dual therapy and who were intensified with DPP4i (n = 8,248), insulin (n = 6,395), or TZD (n = 2,650) from 2006 to 2017. Propensity-score weighting was used to balance out baseline covariates across groups. Hazard ratios (HRs) for all-cause mortality, CVD, and SH were assessed using Cox proportional hazard models. Mean age of all patients was 58.56 ± 11.41 years. All baseline covariates achieved a balance across the 3 groups. Over a mean follow-up period of 34 months with 49,299 person-years, cumulative incidences of all-cause mortality, SH, and CVD were 0.061, 0.119, and 0.074, respectively. Patients intensified with insulin had higher risk of all-cause mortality (HR = 2.648, 95% confidence interval [CI] 2.367-2.963, p < 0.001; 2.352, 95% CI 2.123-2.605, p < 0.001) than those intensified with TZD and DPP4i, respectively. Insulin users had the greatest risk of SH (HR = 1.198, 95% CI 1.071-1.340, p = 0.002; 1.496, 95% CI 1.342-1.668, p < 0.001) compared with TZD and DPP4i users, respectively. Comparing between TZDs and DPP4i, TZDs were associated with a higher risk of SH (HR = 1.249, 95% CI 1.099-1.419, p < 0.001) but not all-cause mortality (HR = 0.888, 95% CI 0.776-1.016, p = 0.084) or CVD (HR = 1.005, 95% CI 0.915-1.104, p = 0.925). Limitations of this study included the lack of data regarding lifestyle, drug adherence, time-varying factors, patients' motivation, and cost considerations. A limited duration of patients intensifying with TZD might also weaken the strength of study results.

Conclusion:

Our results indicated that, for patients with T2DM who are on Met-SU dual therapy, the addition of DPP4i was a preferred third-line medication among 3 options, with the lowest risks of mortality and SH and posing no increased risk for CVD events when compared to insulin and TZD. Intensification with insulin had the greatest risk of mortality and SH events.

https://pubmed.ncbi.nlm.nih.gov/31877127/

Title:

Development of a Cardiovascular Diseases Risk Prediction Model and Tools for Chinese Patients with Type 2 Diabetes Mellitus – A Population-based Retrospective Cohort Study.

Eric Y.F. Wan, Daniel Y.T. Fong, Colman S.C. Fung, Esther Y.T. Yu, Weng-Yee Chin, Anca K.C. Chan, Cindy L.K. Lam

Aims:

Evidence-based cardiovascular diseases (CVD) risk prediction models and tools specific for Chinese patients with type 2 diabetes mellitus (T2DM) are currently unavailable. This study aimed to develop and validate a CVD risk predict.

Methods:

A retrospective cohort study was conducted with 137 935 Chinese patients aged 18 to 79 years with T2DM and without prior history of CVD, who had received public primary care services between January 1, 2010 and December 31, 2010. Using the derivation cohort over a median follow-up of 5 years, the interaction effect between predictors and age were derived using Cox proportional hazards regression with a forward stepwise approach. Harrell's C statistic and calibration plot were used on the validation cohort to assess the discrimination and calibration of the models. The web calculator and chart were developed based on the developed models.

Results:

For both genders, predictors for higher risk of CVD were older age, smoking, longer diabetes duration, usage of anti-hypertensive drug and insulin, higher body mass index, haemoglobin A1c (HbA1c), systolic and diastolic blood pressure, a total cholesterol to high-density lipoprotein-cholesterol (TC/HDL-C) ratio and urine albumin to creatinine ratio, and lower estimated glomerular filtration rate. Interaction factors with age demonstrated a greater weighting of TC/HDL-C ratio in both younger females and males, and smoking status and HbA1c in younger males.

Conclusions:

The developed models, translated into a web calculator and color-coded chart, served as evidence-based visual aids that facilitate clinicians to estimate quickly the 5-year CVD risk for Chinese T2DM patients and to guide intervention.

https://doi.org/10.1111/dom.13066

Title:

Long-term cost-effectiveness of a Patient Empowerment Programme for type 2 diabetes mellitus in primary care.

Lian J, McGhee SM, So C, Chau J, Wong CKH, Wong WCW, Lam CLK.

Aim:

To evaluate the long-term cost-effectiveness of a Patient Empowerment Programme (PEP) for type 2 diabetes mellitus (DM) in primary care.

Materials and Methods:

PEP participants were subjects with type 2 DM who enrolled into PEP in addition to enrolment in the Risk Assessment and Management Programme for DM (RAMP-DM) at primary care level. The comparison group was subjects who only enrolled into RAMP-DM without participating in PEP (non-PEP). A cost-effectiveness analysis was conducted using a patient-level simulation model (with fixed-time increments) from a societal perspective. We incorporated the empirical data from a matched cohort of PEP and non-PEP groups to simulate lifetime costs and outcomes for subjects with DM with or without PEP. Incremental cost-effectiveness ratios (ICER) in terms of cost per quality adjusted life year (QALY) gained were calculated. Probabilistic sensitivity analysis was conducted with results presented as a cost-effectiveness acceptability curve.

Results:

With an assumption that the PEP effect would last for 5 years as shown by the empirical data, the incremental cost per subject was US $197 and the incremental QALYs gained were 0.06 per subject, which resulted in an ICER of US $3290 per QALY gained compared with no PEP across the lifetime. Probabilistic sensitivity analysis showed 66% likelihood that PEP is cost-effective compared with non-PEP when willingness-to-pay for a QALY is ≥US $46 153 (based on per capita GDP 2017).

Conclusions:

Based on this carefully measured cost of PEP and its potentially large benefits, PEP could be highly cost-effective from a societal perspective as an adjunct intervention for patients with DM.

https://doi.org/10.1111/dom.13485

Title:

Patients' coping behaviors to unavailability of essential medicines in primary care in developed urban China

Dan Wu, Tai Pong Lam, Kwok Fai Lam, Kai Sing Sun, Xu Dong Zhou

Background:

China rolled out the national essential medicines policy (NEMP) in primary care in 2009 and led to some unintended consequences including unavailability of essential medicines. This study examined patients’ coping behaviors to these unintended consequences of NEMP as well as the potential impact on primary care system development in Hangzhou, a developed city of China.

Methods:

We conducted qualitative interviews and surveys with service users, primary care physicians (PCPs), and specialists in tertiary hospitals. Qualitative findings informed the design of the survey questionnaires. Main outcomes included patients’ coping behaviors after the NEMP implementation, as well as providers’ perceptions of NEMP’s impact on primary care development. Thematic analysis of the qualitative data and descriptive analysis of the survey data were conducted.

Results:

Unintended effects of NEMP included frequent unavailability of certain essential drugs, leading to patient flow from primary care to hospital outpatient clinics for drug refills, difficulties in the provision of continuing care in primary care, as well as compromised patient trust in PCPs. In total, 1248 service users completed the questionnaires. A total of 132 (10.6%) were aged 60 years or above. Among 153 (57.7%) of the 265 who had some chronic condition(s) and needed long-term medication treatment, 60.1% went to hospitals for refills. Four-hundred sixty PCPs and 651 specialists were recruited. Among 404 PCPs who were aware of the NEMP policy implementation in their facility, 169 (41.8%) reported that there was often a shortage of drugs at their facilities and 44 (10.9%) reported always. Moreover, 68.6% of these PCPs thought that the NEMP could not meet their patients’ needs. Further, 44.2% (220/498) of specialists who were aware of the NEMP policy in primary care reported that they often heard patients complaining about the policy. In total, 53.1% of PCPs and 42.4% of specialists disagreed that NEMP helped direct patient flow to community-based care.

Conclusion:

NEMP’s unintended effects undermined patients’ utilization of primary care in a developed city in China and led to unnecessary hospital visits. Countermeasures are needed to mitigate the negative impacts of NEMP on the primary care system.

https://www.ijhpm.com/article_3749.html

Title:

The effect of timing of incentive payments on response rates for cohort study telephone interviews in primary care setting with cost-minimization analysis.

Weng-Yee Chin, Edmond PH Choi, Cindy LK Lam

Background:

The effect of timing of incentive payments on the response rate of telephone surveys is unknown. This study examined whether up-front or delayed incentive payments were associated with higher response rates for participation in a telephone interview administered longitudinal cohort study amongst primary care patients with lower urinary tract symptoms, and to compare the costs between the two timing methods.

Methods:

This study was conducted as part of a naturalistic observation study on the health-related quality of life and health outcomes of Chinese primary care patients with lower urinary tract symptoms. The incentive payment was in the form of a supermarket gift voucher to the value of HD$50 (US$6.50) and could be used in lieu of cash at a major supermarket chain.720 subjects with lower urinary tract symptoms were randomly assigned into two groups. One group was offered an incentive of supermarket cash voucher at time of recruitment (‘up-front’ payment). The other group was told that the voucher would be sent to them after the complete of their 1-year follow-up telephone interview (‘delayed’ payment). Primary outcomes were the baseline and 1-year follow-up telephone survey response rates.

Results:

There was no statistical difference in response rates at baseline (p-value = 0.938) or at the 1-year follow-up (p-value = 0.751) between groups. Cost per completed subject interviews for the up-front payment method was USD16.64, whilst cost for the delayed payment was USD 13.85.

Conclusions:

It appears the timing of incentive payments does not affect response rates for telephone interview surveys conducted on primary care patients in Hong Kong at baseline or at 1-year follow-up. Delayed incentive payments can reduce the overall cost per successful case.

Trial registration

ClinicalTrials.gov Identifier: NCT02307929 Registered 28 August 2013.

http://www.biomedcentral.com/1471-2288/15/79

Title:

Seasonal influenza vaccine uptake among Chinese in Hong Kong: barriers, enablers and vaccination rates.

Sun KS, Lam TP, Kwok KW, Lam KF, Wu D, Ho PL.

Background:

Low influenza vaccination rates were observed in Asian countries including China. This study investigated the updated seasonal influenza vaccination rates among Chinese in Hong Kong, and the barriers and enablers to vaccination.

Methods:

Eight focus groups were conducted among the Chinese general public, followed by a telephone survey between March and April 2018 with 2,452 respondents (response rate 41.4%).

Results:

Of the survey respondents, 29.1% had received influenza vaccine in the past 12 months. A majority of them agreed with 'enhancing immunity' (94.4%) and 'feeling safer' (92.3%) as their reasons for vaccination, followed by the belief on 'quicker recovery' if they had influenza (69.5%), and free/subsidized vaccine (53.8%). Among respondents who had not received influenza vaccine, 71.2% 'believed in the strength of their own immunity' and 65.6% perceived 'low-risk of getting influenza'. Less than half were 'worried about side-effects' and 'effectiveness'. The groups aged 65-74 and 75 or above had vaccination rates of 49.1% and 69.9%, respectively, in contrast to 13.9% for the group aged 18-64. A rate of 37.9% for children was reported by the 442 respondents having children.

Conclusion:

The high uptake of vaccines among the children and elderly suggests the positive impact of the subsidy and outreach programs. However, young and middle-aged adults tend to believe in the strength of their own immunity and underestimate the infection risk. Public education should emphasize that inactivated vaccines such as influenza vaccines work by means of the viral antigens stimulating the host's immune system toward the major types of seasonal influenza.

https://www.tandfonline.com/doi/abs/10.1080/21645515.2019.1709351

Title:

Challenges to healthcare reform in China: profit-oriented medical practices, patients' choice of care and guanxi culture in Zhejiang province.

Dan Wu, Tai Pong Lam, Kwok Fai Lam, Xu Dong Zhou, Kai Sing Sun

Abstract:

Doctors’ profit-oriented practices in public institutions were widespread in China. Two major targets of the healthcare reform launched in 2009 were to curb the profit-making practices in public institutions and to encourage the citizens to use primary care. After 6 years, the status of profit-orientation of public institutions remains unknown. Compared with hospitals, there is no trend of increasing use of primary care. Our study aimed to explore the status of profit-orientation of public institutions and patients’ utilization preference. The impacts of guanxi (personal relationship) on patients’ utilization of healthcare and doctors’ practices were also explored. From September 2014 to September 2015, we conducted focus group and individual interviews, followed by a survey with doctors (n = 1111) in Hangzhou, Zhejiang province. Thematic analysis, independent t-test and Fisher’s exact test were conducted to analyse the data. This study found that 36.8% of survey respondents needed to consider making profits for their institutions, especially the hospital specialists. A total of 38.5% and 40.7% thought that their practices led to patients’ worries of unnecessary drugs and tests, respectively. Doctors attributed their profit-oriented practices to institutions’ agenda setting, poor salary and an organizational bonus system. Their awareness of breaching medical ethics created a guilt feeling and frustration. Nearly 65.0% reported patients’ preference for hospital-based care even for minor conditions and 76.2% if the patient was a child. Ineffective gate-keeping mechanism, weak primary care and mistrust in community-based care were major reasons. More specialists than primary care practitioners (41.0 vs 21.5%, P < 0.001) said that patients would use guanxi to gain better services and 64.5% of doctors reported better dedication when patients were somehow connected. In conclusion, profit-orientated practice widely exists in public institutions. Patients generally prefer hospital-based services. Guanxi, which affects both patients’ and doctors’ practices, is more often used to access hospital-based services.

https://academic.oup.com/heapol/article/32/9/1241/4035771

Title:

Public views towards community health and hospital-based outpatient services and their utilization in Zhejiang, China: a mixed methods study.

Dan Wu, Tai Pong Lam, Kwok Fai Lam, Xu Dong Zhou, Kai Sing Sun

Objective:

China is engaged in promoting community health services (CHS) nationwide. This study examines the public’s views towards CHS and their utilisation of community-based and hospital-based outpatient services.

Design

A mixed methods study using qualitative interviews and a cross-sectional survey.

Study setting and participants:

The study was conducted among the public between September 2014 and September 2015 in Zhejiang province, China. Six focus groups and 13 individuals were interviewed. The questionnaire was completed by 1248 respondents (response rate: 83%).

Primary outcome measures:

Utilisation of community-based and hospital-based outpatient services.

Results:

Functions of CHS perceived by the public included provision of minor illness management, coordination, drug dispensing, follow-up care and patient education. However, many also showed a distrust in primary care providers’ (PCPs) competence for confirming the initial diagnosis and management plan. As coordinators, PCPs’ integrity was challenged, and PCPs were thought to be potential ‘tuo er’ (cunning agents who tried to lead patients to some notorious hospitals to make money). Survey results showed that 800 (64.1%) respondents visited hospital-based clinics and 688 (55.1%) visited CHS at least once in the past year. Compared with the uninsured group, those covered by Urban Resident Medical Insurance (adjusted OR (AOR)=1.95, 95% CI 1.24 to 3.07) and Urban Employee Medical Insurance (AOR=2.59, 95% CI 1.59 to 4.24) were more likely to use hospital-based services. Respondents who had a chronic condition were more likely than their counterparts to use both hospital-based services (AOR=1.72, 95% CI 1.18 to 2.49) and CHS (AOR=1.66, 95% CI 1.19 to 2.32). Income levels were positively associated with the likelihood of visiting hospital-based clinics (AOR=1.67, 95% CI 1.15 to 2.42) but negatively associated with the likelihood of using CHS (AOR=0.68, 95% CI 0.48 to 0.96).

Conclusion:

Demand of hospital-based outpatient services is much higher than the community-based outpatient services. Policy reformers need to take further actions to address the public distrust in PCPs to facilitate their gatekeeping role. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

http://dx.doi.org/10.1136/bmjopen-2017-017611

Title:

Doctor, by the way, I have more bowel opening these days… Does it matter?

Tse ETY

Introduction:

Amongst the elderly, constipation is the leading bowel habit problem faced by family physicians. However, when an elderly patient mentions the contrary, ‘I’ve more bowel movement recently’, would that set your alarm bells ringing? Method: Case report A 79-year old woman attended regular general outpatient clinic (GOPC) follow up in March 2019. Her chronic diseases were stable. Towards the end of the consultation, she casually mentioned to the doctor, ‘I have more bowel opening in the past few months. Does it matter?’ She reported having several bowel movements in the morning with tenesmus. Yet, no per-rectal bleeding nor other red flags. Per-rectal examination, however, revealed an irregular circumferential nodularity with contact bleeding. She was referred immediately to the colorectal specialist. Her haemoglobin was normal but Carcinoembryonic Ag (CEA) elevated. Colonoscopy showed a circumferential tumor at 1cm from anal verge extending 1.5cm into the rectum. Biopsy confirmed adenocarcinoma. CT showed no distant metastasis. MRI showed levator ani muscle and lower vagina wall involvement. Curative neoadjuvant CTRT followed by surgery was recommended.

Output:

The patient and her family accepted the suggestions and proceeded accordingly. Discussion: Colorectal cancer is the commonest cancer in Hong Kong. 1 It accounted for 17.3% of all new cancer cases in 2016. The incidence rate for both sexes was on an upward trend between 1983 and 2016. However, many elderly patients are unaware of the significance of bowel habit changes and may not put it high on their consultation agenda especially when they have many co-morbidities. Family physicians play a crucial role in being vigilant against the disease

Conclusion:

Family physicians should be alerted to the possibility of colorectal cancer even when seemingly trivial bowel concerns are raised by patients.

https://hub.hku.hk/handle/10722/279948

Title:

Introducing family medicine in a pluralistic health care system: how patients and doctors see it.

Wun YT, Lam TP, Lam KF, Goldberg D, Li DK, Yip KC.

Background:

The health care systems in many countries are focused on specialist care. In those countries that have recently changed to a primary care-based system, some doctors and patients were dissatisfied with the change.

Objective:

To explore the opinions of the general public and the doctors on the change to a family medicine (FM)-based health care system.

Methods:

Qualitative study with focus groups of doctors working in different practice settings. Quantitative study with questionnaires sent to all doctors registered in Hong Kong and a telephone survey targeting the general public aged ≥18.

Results:

Doctors in the focus groups generally supported a FM-based health care system. They were concerned that there were not enough family doctors for such a system and the patients' current free choice of any doctor for primary care would impede its success. Thousand six hundred and forty-seven adults took part in the telephone survey (response rate 67.6%) and 2310 doctors (22.8%) responded to the questionnaire. Nearly 95% of the general public respondents agreed to the FM system though only 66.3% of them had ever heard of the term family doctor. About 65% of the doctors supported this system but only 33% agreed that the system would work. The specialist-doctors were less supportive of mandatory referral than the non-specialists, while the public was equally divided on this issue.

Conclusion:

The public accepts the FM-based system but needs education on the benefits of primary health care. Direct access to the specialist would be the greatest barrier. Government involvements are essential for the reform.

https://doi.org/10.1093/fampra/cmq064

Title:

Ten-year risk prediction models of complications and mortality of Chinese patients with diabetes mellitus in primary care in Hong Kong: a study protocol

Period:

2017-2019

Principal Investigator:

Cindy LK Lam

Co-Investigators:

Eric Yuk Fai Wan. Esther Yee Tak Yu, Weng Yee Chin, Colman Siu Cheung Fung, Ruby Lai Ping Kwok, David Vai Kiong Chao, King Hong Chan, Eric Ming-Tung Hui, Wendy Wing Sze Tsui, Kathryn Choon Beng Tan, Daniel Yee Tak Fong

Introduction:

Introduction Diabetes mellitus (DM) is a major disease burden worldwide because it is associated with disabling and lethal complications. DM complication risk assessment and stratification is key to cost-effective management and tertiary prevention for patients with diabetes in primary care. Existing risk prediction functions were found to be inaccurate in Chinese patients with diabetes in primary care. This study aims to develop 10-year risk prediction models for total cardiovascular diseases (CVD) and all-cause mortality among Chinese patients with DM in primary care.

Methods and analysis:

A 10-year cohort study on a population-based primary care cohort of Chinese patients with diabetes, who were receiving care in the Hospital Authority General Outpatient Clinic on or before 1 January 2008, were identified from the clinical management system database of the Hospital Authority. All patients with complete baseline risk factors will be included and followed from 1 January 2008 to 31 December 2017 for the development and validation of prediction models. The analyses will be carried out separately for men and women. Two-thirds of subjects will be randomly selected as the training sample for model development. Cox regressions will be used to develop 10-year risk prediction models of total CVD and all-cause mortality. The validity of models will be tested on the remaining one-third of subjects by Harrell’s C-statistics and calibration plot. Risk prediction models for diabetic complications specific to Chinese patients in primary care will enable accurate risk stratification, prioritisation of resources and more cost-effective interventions for patients with DM in primary care.

Ethics and dissemination:

The study was approved by the Institutional Review Board of the University of Hong Kong—the Hospital Authority Hong Kong West Cluster (reference number: UW 15–258).

Trial registration number:

NCT03299010; Pre-results.

Project title:

Knowledge, attitudes and practices of medical interns towards antibiotic use and resistance in Hong Kong – a mixed methods study

Principal Investigator:

Lam TP

Co-Investigators:

KF Lam, PL Ho

Period:

2018-2019

Fund source:

Seed Fund for Basic Research, awarded: HKD$63,460.

Abstract:

Inappropriate antibiotic prescribing practices predispose to resistance emergence. Despite the inclusion of the topic in medical school curricula worldwide, it is uncertain whether newly graduated medical interns have confidence in proper antibiotic prescription. The effectiveness of the teaching in medical school, antibiotics stewardship program and prescription guidelines for practicing doctors is also uncertain. This study aims to explore the antibiotic prescribing behaviours of the medical interns in Hong Kong and their barriers/enablers to appropriate antibiotic prescription in the hospitals.

Title:

In-depth cost-effectiveness study of Multidisciplinary Risk Factor Assessment and Management Programme (RAMP) of the HA

Principal Investigator:

Esther YT Yu

Co-Investigators:

Colman SC Fung, William CW Wong, Weng-Yee Chin, Julie Y Chen, Daisy Dai, Eva LH Tsui, Daniel YT Fong, Cindy LK Lam

Period:

2016-2018

Fund source:

Health and Medical Research Fund, (HMRF 13142471, HKD 1,199,964, 1 August 2016)

Aim and objectives:

The aim of this study is to evaluate the cost-effectiveness of the Hospital Authority’s (HA) risk factor assessment and management programme (RAMP) for patients with diabetes and/or hypertension in general outpatient clinics (GOPCs). The objectives are 1) to obtain data on outcomes from the accompanying studies on quality of care and to translate this into measures of benefit for a cost-effectiveness analysis (CEA)2) to obtain cost information for each relevant part of the programmes, ideally marginal cost information i.e. the cost of dealing with one extra patient under RAMP 3) to estimate cost-effectiveness using a variety of outcome measures 4) to model cost-effectiveness over the longer term and program expansion to identify cost-drivers and areas of uncertainty 5) to perform a value of perfect information (VPI) analysis to determine the worth of collecting further information to assist in determining cost-effectiveness 6) to collate all information into a robust model which can test variations in assumptions and parameters and aid decision-making about long term cost-effectiveness.

Methods:

Each participating clinic will complete a structured evaluation questionnaire and the data of all patients who have enrolled in the RAMP programme will be included in the evaluation. Age, sex and disease severity matched control patients (n=1300) who have not been enrolled into the RAMP programme will act as controls.A further 130 RAMP participants and 130 non-RAMP participants will be followed up by telephone to evaluate the effect of each programme on quality of life (QOL). Clinical indicators and data on public health care utilization will be retrieved from the HA clinical medical system (CMS). The primary health-related outcomes are the proportion of participants who received the criterion process of care, the proportion who achieve appropriate clinical outcomes (e.g. for diabetes the proportion with HbA1c level <7%), changes in complication risk status which can then be translated to likely changes in numbers of bad outcomes (e.g. stroke, heart attack, renal failure, blindness) over the longer term and the QOL information (translated to a utility score). Main cost items: The viewpoint for the CEA will be the provider/HA viewpoint and one of the main measures of cost from this viewpoint will be the costs of extra staff to deliver the multi-disciplinary RAMP programme. Costing these services will ideally require observational studies of health care delivery in both RAMP and non-RAMP settings. It is proposed that these would be done at the end of the first year and again at the end of the third year of operation when procedures may have become more streamlined and efficient. Any changes in health care utilization will be determined by comparing the data from the HA clinical medical system on public service utilization (inpatient and outpatient, including Accident and Emergency services) for the RAMP and non-RAMP participants. A number of other data sets will be required for appropriate modeling of costs and benefits. These will include estimation of future patient numbers, life table data to estimate life years saved and QALYs gained by the patients, clinical data from the HA clinical management system to characterize patient risk and changes in this. Some of this data will be collected longitudinally. Both cost and outcome data will be compiled and initial simple measures of cost and outcome will be generated. These data will be used to develop a cost-effectiveness model which will be updated with the longitudinal information and will be used to estimate relative cost-effectiveness of RAMP taking into account uncertainties and missing data which will be tested in sensitivity analysis, potential cost drivers, costs per outcome over varying time periods, acceptability curves, parameters most likely to affect cost-effectiveness and the amount worth spending on obtaining further information (VPI analysis), budget impact for the HA in different cost categories (staffing, organizational costs) and for patients under various assumptions of the future development of the service.

Result:

The cost-effectiveness of the RAMP programme will be determined as well as the cost-drivers and potential for future cost-effectiveness. The results of this study will provide important information on continuing expanding or otherwise operating the RAMP programmes.

Project title:

A pilot study on the enablers and barriers of the general public in Hong Kong to comply with toilet hygiene measures.

Principal Investigator:

Lam TP

Co-Investigators:

Dan Wu, Hoi Yan Chan, Kwok Fai Lam, Xu Dong Zhou, Jia Yao Xu, Kai Sing Sun and Pak Leung Ho

Period:

2016-2017

Background:

Public toilets are a common transmission vector of infectious diseases due to environmental contamination. Research on Chinese people’s hygiene practices in public lavatories are lacking. This study examined Chinese people’s hygiene practices in public lavatories in Hong Kong.

Methods:

We conducted qualitative interviews and a self-administered questionnaire survey with local residents from June 2016 to April 2018. Four focus group discussions and three individual interviews informed the design of the questionnaire. We recruited interviewees and survey respondents via social service centers. The interviews and questionnaire focused on the public’s daily practices and hygiene behaviors in public toilets. Content analysis of qualitative data was conducted. Multivariable logistic regressions were used to examine the association between age and toilet hygiene behaviors.

Results:

Our qualitative component revealed a range of handwashing practices, from not washing at all, washing without soap, to washing for a longer time than instructions. Other toilet use practices were identified, such as not covering toilet lid before flushing and stepping on toilet seats due to dirtiness, and spitting into toilet bowls or hand basin.

Totally, 300 respondents completed the questionnaire. Among them, 212 (70.9%) were female and 246 (86.1%) were aged 65 or below. More than two thirds always washed hands with soap (68.7%) and dried hands with paper towels (68.4%). Up to 16.2% reported stepping on toilet seats and 43.9% never covered the toilet lid before flushing. Over one fourth (26.4%) spit into squat toilets/ toilet bowl. Regression analyses showed that the elderly group were less likely to report stepping on toilet seats (adjusted odds ratio, AOR=0.17, 95%CI 0.03–0.88), flushing with the toilet lid closed (AOR=0.40, 0.16–0.96), but more likely to spit into squat toilets/ toilet bowl (AOR=4.20, 1.50–11.74).

Conclusions:

Hong Kong Chinese’s compliance to hygiene practices in public toilets is suboptimal. Stepping on toilet seat is a unique Chinese practice due to the dirtiness of toilet seats. Spitting practices may increase the risk of airborne infectious diseases and need improvement. Measures are needed to improve toilet hygiene behaviors, including public education campaigns and keeping toilet environment clean.

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-8014-4

Title:

Extended Evaluation of Quality Of Care of Chronic Disease Management Programmes and Public-Private Partnership Programmes of the Hospital Authority

Period:

2017-2019

Principal Investigator:

Cindy LK Lam

Co-Investigators:

William CW Wong, Weng-Yee Chin, Julie Y Chen, Colman SC Fung, Daisy Dai, Eva LH Tsui, Daniel YT Fong, Esther YT Yu.

Objective:

A portfolio of studies to evaluate the long-term quality of care (QOC) chronic disease management and private-public partnership programmes of the Hospital Authority.

Design, Setting and Subjects:

A portfolio of studies will be carried out to to evaluate the QOC of the Multidisciplinary Risk Factor Assessment and Management Programme (RAMP) of the General Outpatient clinics, the Patient Empowerment Programme (PEP), the public-private Shared-care Programme (SCP) for diabetes mellitus, the Nurse and Allied Health Clinics Programme (NAHC), and the Haemodialysis Public-Private Partnership Programme (HD-PPP).

Subjects:

All subjects who have been recruited into the respective programme since January, 2010 will be included for evaluation of QOC. A random sample of an equal number and up to 1300 non-participant controls will be recruited for comparison in change in outcomes for the RAMP, SCP, HD-PPP and PEP to evaluate the impact of the programmes. A random sample of 130 participants and 130 non-participant (controls) in each of RAMP, SCP, HD-PPP and PEP will be recruited per HA cluster for evaluation of patient reported outcomes.

Methods:

The evaluation on QOC of each programme will adopt the Action Learning & Audit Spiral Methodologies. An evaluation framework on structure, processes and outcomes of care will be applied to each study programme. Relevant baseline and prospective clinical data will be extracted from the HA database, and patient reported outcomes will be assessed by longitudinal telephone surveys. Three cycles of evaluation on the standards achieved in each quality criterion against the target standards will be carried out. Deficiencies will be identified and actions for improvement will be planned after each evaluation.

Main:

Outcome Measures and Data Analysis: The primary outcomes are the proportion of participants who have received the planned process of care, and achieved the target outcomes (e.g. HbA1c<7%, being empowered), and the 5-year predicted cardiovascular risk (applicable to RAMP, PEP and SCP). Within-subject improvement in outcomes from baseline at 12, 24, 36 and 48 months will be analysed by paired t test for continuous outcomes and McNemar test for binary outcomes. Differences in outcomes between groups will be tested by ANOVA or Chi-squared tests. Multiple regressions will be used to indentify factors that are associated with quality of care or effectiveness.

Results and potential applications:

The results will assure the QOC and establish evidence on the effectiveness of each programme in enhancing the health for patients with chronic diseases. The standards of good practice can be established for different programmes. The data on the outcomes and effectiveness in cardiovascular risk reduction will be used in the concurrent cost-effectiveness studies. The results can inform health policies and resources allocation.

Title:

To Determine Prevalence and Contextual Risk Factors of Sexually Transmitted Infections in Hong Kong

Principal Investigator:

William CW Wong

Co-Investigators:

WCW Wong, YL Yim, TN Leung, H Lynn, DC Ling

Introduction:

Sexually transmitted infections (STIs) remain a major public health problem in Hong Kong. Sex workers are reservoirs and vectors for the transmission of STIs in the community. To formulate prevention strategies, the prevalence and risk factors of STIs among asymptomatic female sex workers (FSW) should be determined. In Hong Kong, STI (including HIV) testing, treatment, and other medical services are available for free to local residents, but non-Hong Kong residents are charged a minimum fee of HK$1400. These high fees deter many non-local FSWs from seeking proper treatment, and may result in the potential spread of STIs to their clients and families.1 An outreach well-women clinic for FSWs in Hong Kong was established by the non-governmental organisation—Ziteng—in February 2004. In the clinic, Pap smears, STI (including HIV) screening, and basic physical examinations were provided for free to all FSWs. We aimed to report on the prevalence and risk factors of STIs (including HIV) among FSWs in Hong Kong.

Methods:

This study was conducted from October 2005 to September 2007. A total of 511 FSWs aged 18 to 55 years were recruited in the clinic of Ziteng between December 2005 and April 2007. It coordinated the screening service including Pap smears and venipunctures for STI (including HIV) testing, provided health education and ensured continuity of care through re-tests and follow-up interviews, conducted outreach and screening services at places where FSWs work. A team of two to three volunteer doctors worked in the clinic to provide medical counselling and care 2 to 3 hours a day, twice monthly. The subjects remained anonymous and their identification documents were not checked to ensure privacy and confidentiality. They had a face-to-face interview with a doctor or nurse, and HIV pre-test counselling and an opportunistic health education were given. They also underwent a physical examination, Pap smear, and blood tests for detection of gonorrhoea, chlamydia, hepatitis B, syphilis, and HIV infections. Demographics (age, place of origin, and marital status), lifestyle (smoking, drinking, and exercise habits), and sexual behaviour (use of condoms, number of sexual partners, and vaginal douching) were recorded using a multifaceted self-report questionnaire. After 2 to 4 weeks, the results of these examinations were explained to the patients. If the results were positive, follow-up medical care was arranged and treatment was given based on the Department of Health’s STI management guidelines (except for HIV). Follow-up services (prescriptions and referrals) were provided.

Results:

A total of 503 FSWs were classified into three groups according to their place of origin: 97 (19.3%) were local; 361 (71.8%) were new immigrants; and 45 (8.9%) were non-local illegal migrants on a temporary visitor visa (Table 1). Non-local FSWs were younger and less likely to be smoker, whereas local FSWs were less likely to be married and more likely to be smokers. New immigrant and non-local FSWs were more likely to have single child. The prevalence of STI among these FSWs was 43 (8.5%) for hepatitis B surface antigens, 9 (1.8%) for syphilis, 9 (1.8%) for gonorrhoea, 23 (4.6%) for chlamydia, and 1 (0.2%) for HIV infection. Of these FSWs, 55 (10.9%) worked on the street, 361 (71.8%) in a single-woman brothel, 81 (16.1%) in a sauna or massage parlour, and 6 (1.2%) in a karaoke club or for an agency (Table 2). The street was the most popular place for non-local FSWs (91.1%), whereas single-woman brothels were the most popular place for locals (72.2% of FSWs born in HK and 79.8% of new immigrants). About 57.6% of the FSWs had worked for <1 year. The average number of clients per day was 5.0; new immigrant FSWs received most clients per day. Twenty (4.0%) of the FSWs had ≥2 regular sexual partners (Table 2); 97.5% and 77.0% of the FSWs reported to have always used condoms when they had vaginal sex and oral sex with their clients, respectively. However, only 23.0% insisted on using condoms when they had sex with their partners. In addition, 56.1% of them performed regular vaginal douching with over-the-counter medicines or water. About 89.5% of FSWs had gynaecological examinations in the past and 70.6% had undergone a cervical smear, with non-local FSWs being significantly less likely to do so. Around 13.1% of FSWs had a history of STIs; new immigrant FSWs were least likely to contract STIs.

Project title:

Early detection of dementia: The knowledge and attitudes of primary care physicians in Hong Kong

Principal Investigator:

Tai Pong Lam

Co-Investigators:

Cheuk Wing Leung, Kwai Wing Wong, Vai Kiong David Chao

Period:

2013-2014

Background:

Dementia affects people worldwide and its prevalence is growing. Early detection of dementia by primary care physicians can be beneficial; thus, their knowledge and attitudes about this issue are important.

Objective:

To assess primary care physicians’ knowledge and attitudes about the early detection of dementia in Hong Kong.

Methods:

This was a mixed methods (qualitative and quantitative) study. Four focus groups with a purposive sample of 31 primary care physicians were interviewed, and a questionnaire-survey was completed and returned by 437 primary care physicians.

Results:

Participants all agreed that the early detection of dementia would benefit patients and primary care physicians should be capable of making such diagnoses. Confidence in making an early diagnosis varied; physicians tended to overlook symptoms in the early stages. All agreed that more training is needed at the post-graduate level of medical education.

Conclusions:

Participants had positive attitudes towards early detection of dementia; however, their confidence and ability to make an early diagnosis varied.

https://doi.org/10.1177/1471301218788133

Title:

Study on "Morbidity and management patterns of community-based primary health care services in Hong Kong"

Principal Investigator:

Yvonne C. Y. LO

Co-Investigators:

Y Y C Lo , C L K Lam, S W Mercer, D Y T Fong, A Lee, T P Lam, R Lee, B Chiu, J Tang, B Chui, D Chao, A Lam, K Chan

Introduction:

Population ageing and changes in the socioeconomic structure affect the disease pattern. Chronic diseases and psychological illnesses are major health care burdens in the 21st century.1 Primary care doctors are taking care of an increasing load of patients with chronic illness.2 This study aimed to explore the patterns of diseases and their management presenting to primary care doctors in Hong Kong, and whether different funding methods had an effect on these patterns.

Methods:

This study was conducted from June 2007 to February 2009. Primary care doctors from both private and public sectors were invited to take part. Patient demographics, payment method, diagnosis, nature of the illness (acute, chronic, preventive or administrative), and management (prescription, investigation, referral, and preventive activities) were recorded using standardised forms for patients presenting from July 2007 to June 2008. Diagnoses were coded using the International Classication of Primary Care (ICPC-2) developed by the World Organization of Family Doctors.3 Doctor demographics, type and years of practice, training, and postgraduate qualications were recorded on a separate form. Patient morbidity and management patterns were presented as percentage distribution. Multivariate regression analyses were performed to examine the relationship between payment method and nature of illness, investigation and referral patterns, and practice sectors and management pattern, with adjustment of confounding factors such as patient and doctor demographics, the nature of illness, the number of years the doctor in general practice, training in family medicine, and postgraduate qualication. All estimates were accompanied with a 95% condence interval. A P value of <0.05 was considered statistically signicant.

Results:

A total of 109 doctors (of whom 67 had family medicine training) participated in the survey. They recorded 52 337 patient encounters and 69 973 health problems. As the public sector was over-represented, the cross-sectional data was weighted to simulate the private and public primary care service utilisation ratio, as reported by the general population study on service utilisation patterns in Hong Kong in 2007-08.4

Title:

Study on "Utilization Pattern of Primary Health Care Services in Hong Kong - Does Having a Family Doctor Make Any Difference?

Principal Investigator:

Cindy L. K. Lam

Co-Investigators:

CLK Lam, GM Leung, SW Mercer, DYT Fong, A Lee, TP Lam, YYC Lo

Introduction:

Primary care should be a gate-keeper for secondary health services to prevent illness, improve health, enable coping with illness, and satisfy needs. The family doctor model has been proposed by the government as a solution for the rising demand for quality primary health care services for the ageing population in Hong Kong. This study aimed to explore the utilisation rates and patterns of various primary health care services, and the process and outcomes of primary care consultations in Hong Kong, and whether having a family doctor makes any difference. The objectives were to determine the rates and patterns of utilisation of different primary health care services, the process (including non-drug managements) and patient self-reported outcomes (enablement, change in health, and satisfaction) following primary care consultations, and any difference in the care for people with and without a regular family doctor.

Methods:

This study was conducted from June 2007 to November 2008. It was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster. A cross-sectional general population random telephone survey was carried out in two phases, first from September to October 2007, and second from March to April 2008 to cover the Summer and Winter seasons, respectively. A structured questionnaire was administered on the presence and type of regular primary care doctor, illness episodes, and medical service utilisations, process and outcome of consultations, health status, and sociodemographics. Longitudinal studies on 319 subjects with a diary on all illness episodes and consultations for 12 weeks were carried out to cross-validate the cross-sectional results. A total of 5174 eligible households were contacted, and 3148 (61%) subjects (1616 and 1532 in the first and second phases, respectively) completed the crosssectional survey. Of these, 708 agreed to the longitudinal study and 327 returned the diaries (self-completion), and 319 subjects had complete cross-sectional and longitudinal data for the final analysis. Subjects were classified by whether they had (1) a regular family doctor (RFD), defined as a doctor whom one would consult for all types of health problems; (2) a regular primary care doctor, defined as a doctor whom one would first consult when one needed to, who was not a family doctor (RnFD); or (3) no regular primary care doctor (NRD). Monthly medical service utilisation rate was calculated by the number of consultations over a period of 4 weeks. Patient selfreported outcomes of the consultation was measured by the Patient Enablement Instrument (PEI) score,1 perceived improvement in health and satisfaction. The rates of non-drug managements such as explanation of illness and advice on selfcare were measured. The mean monthly illness and consultation rates were calculated and weighted on the 2007 Hong Kong general population age-sex distribution to estimate the populationbased illness and consultation rates. Multivariate regressions were used to identify factors associated with different primary care doctor choices, and to test the effects of having a RFD on the various outcomes, with adjustment of confounding factors including sociodemographics, health status, lifestyle and chronic morbidity. Utilisation rates were compared across three groups by a Poisson regression model with seasonality entered as a covariate. Regression analysis was carried out on the longitudinal data to determine whether any adjustment factor for the estimation of the illness and service utilisation rates was needed and to cross-validate the results of the cross-sectional data. All estimates were accompanied with a 95% confidence interval (CI) and a P value of <0.05 was considered statistically significant.

Results:

Choice of primary health care doctors A total of 1969 (63%) subjects said that they had a regular primary care doctor, whereas 1157 (37%) did not. Among those with regular doctors, 1150 said their regular doctors were family doctors. Multivariate logistic regressions found that younger age, currently married, white-collar work, higher household monthly income, having a chronic disease, need of long-term medication and regular exercise were independent factors associated with having a regular primary care doctor. There was little difference in characteristics between the RFD and RnFD groups, except that the former were more likely to have regular exercise and better general health. The RFD group was less likely to smoke (18%) or drink (37%), but more likely to have regular exercise (68%) than the RnFD and NRD groups. Overall, 44% of the subjects said they would consult their primary care doctors for preventive care, with a higher proportion (53%) in the RFD group than the others (42% and 37%, respectively). Over 80% of the RFD and RnFD groups who were aged ≥30 years had their blood pressure checked in the last year, which was higher than the 70% in the NRD group. About 74 to 77% of ever-married women in the regular primary care doctor groups had cervical smears within the last 3 years, but only 61% of the NRD did so. About 47% of the people would consult their primary care doctors for their chronic disease follow-up, with a higher proportion in the RFD (50%) than RnFD (46%) and NRD (45%) groups.