Assessment of Hypertension Complications and Health Service Use 5 Years After Implementation of a Multicomponent Intervention.

Importance: There is a lack of information regarding the impact of implementing a protocol-driven, team-based, multicomponent intervention in public primary care settings on hypertension-related complications and health care burden over the long term. Objective: To compare hypertension-related complications and health service use at 5 years among patients managed with Risk Assessment and Management Program for Hypertension (RAMP-HT) vs usual care. Design, Setting, and Participants: In this population-based prospective matched cohort study, patients were followed up until the date of all-cause mortality, an outcome event, or last follow-up appointment before October 2017, whichever occurred first. Participants included 212 707 adults with uncomplicated hypertension managed at 73 public general outpatient clinics in Hong Kong between 2011 and 2013. RAMP-HT participants were matched to patients receiving usual care using propensity score fine stratification weightings. Statistical analysis was conducted from January 2019 to March 2023. Interventions: Nurse-led risk assessment linked to electronic action reminder system, nurse intervention, and specialist consultation (as necessary), in addition to usual care. Main Outcomes and Measures: Hypertension-related complications (cardiovascular diseases, end-stage kidney disease), all-cause mortality, public health service use (overnight hospitalization, attendances at accident and emergency department, specialist outpatient clinic, and general outpatient clinic). Results: A total of 108 045 RAMP-HT participants (mean [SD] age: 66.3 [12.3] years; 62 277 [57.6%] female) and 104 662 patients receiving usual care (mean [SD] age 66.3 [13.5] years; 60 497 [57.8%] female) were included. After a median (IQR) follow-up of 5.4 (4.5-5.8) years, RAMP-HT participants had 8.0% absolute risk reduction in cardiovascular diseases, 1.6% absolute risk reduction in end-stage kidney disease, and 10.0% absolute risk reduction in all-cause mortality. After adjusting for baseline covariates, the RAMP-HT group was associated with lower risk of cardiovascular diseases (hazard ratio [HR], 0.62; 95% CI, 0.61-0.64), end-stage kidney disease (HR, 0.54; 95% CI, 0.50-0.59), and all-cause mortality (HR, 0.52; 95% CI, 0.50-0.54) compared with the usual care group. The number needed to treat to prevent 1 cardiovascular disease event, end-stage kidney disease, and all-cause mortality was 16, 106, and 17, respectively. RAMP-HT participants had lower hospital-based health service use (incidence rate ratios ranging from 0.60 to 0.87) but more general outpatient clinic attendances (IRR, 1.06; 95% CI, 1.06-1.06) compared with usual care patients. Conclusions and Relevance: In this prospective matched cohort study involving 212 707 primary care patients with hypertension, participation in RAMP-HT was associated with statistically significant reductions in all-cause mortality, hypertension-related complications, and hospital-based health service use after 5 years.

Family Facilitators of, Barriers to and Strategies for Healthy Eating among Chinese Adolescents: Qualitative Interviews with Parent-Adolescent Dyads.

Healthy eating is vital in preventing obesity and long-term non-communicable diseases. This study explores potential family facilitators of, barriers to and strategies for healthy eating among adolescents in Chinese families to guide the development of effective interventions in the future. Parent-adolescent dyads were purposively sampled by age, gender, fruit and vegetable intake and household income. Key family factors were identified by thematic analysis. Fourteen themes under five domains were identified: family health with (1) illness experienced in the family; parental knowledge of (2) dietary recommendations, (3) the preparation of healthy food and (4) healthy food choice; parental attitudes towards (5) the importance of healthy eating and (6) the priority of family health; socioeconomic factors of (7) time concerns and (8) cost concerns; and food parenting practices in (9) nutritional education, (10) role modeling, (11) food provision, (12) child involvement, (13) parental supervision and (14) the cultivation of food preference. Useful strategies included incorporating healthy ingredients in adolescents' favorite recipes and providing a variety of fruit and vegetables at home. There is a need to empower parents with practical nutrition knowledge, to be more authoritative in food parenting practices, to discuss healthy eating with children and to acquire practical skills related to time- and cost-saving healthy cooking.

Lifetime cost-effectiveness analysis of first-line dialysis modalities for patients with end-stage renal disease under peritoneal dialysis first policy.

BACKGROUND: This study aimed to determine the lifetime cost-effectiveness of first-line dialysis modalities for end-stage renal disease (ESRD) patients under the "Peritoneal Dialysis First" policy. METHODS: Lifetime cost-effectiveness analyses from both healthcare provider and societal perspectives were performed using Markov modelling by simulating at age 60. Empirical data on costs and health utility scores collected from our studies were combined with published data on health state transitions and survival data to estimate the lifetime cost, quality-adjusted life-years (QALYs) and cost-effectiveness of three competing dialysis modalities: peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD. RESULTS: For cost-effectiveness analysis over a lifetime horizon from the perspective of healthcare provider, hospital-based HD group (lifetime cost USD$142,389; 6.58 QALYs) was dominated by the PD group (USD$76,915; 7.13 QALYs). Home-based HD had the highest effectiveness (8.37 QALYs) but with higher cost (USD$97,917) than the PD group. The incremental cost-effectiveness ratio (ICER) was USD$16,934 per QALY gained for home-based HD over PD. From the societal perspective, the results were similar and the ICER was USD$1195 per QALY gained for home-based HD over PD. Both ICERs fell within the acceptable thresholds. Changes in model parameters via sensitivity analyses had a minimal impact on ICER values. CONCLUSIONS: This study assessed the cost-effectiveness of dialysis modalities and service delivery models for ESRD patients under "Peritoneal Dialysis First" policy. For both healthcare provider and societal perspectives, PD as first-line dialysis modality was cost-saving relative to hospital-based HD, supporting the existing PD First or favoured policy. When compared with PD, Nocturnal home Home-based HD was considered a cost-effective first-line dialysis modality for ESRD patients.

Direct medical costs in the preceding, event and subsequent years of a first severe hypoglycaemia episode requiring hospitalization: A population-based cohort study.

AIMS: We aimed to estimate the use of healthcare services and the direct medical costs accrued by patients with diabetes mellitus (DM) during the year of the first severe hypoglycaemia (SH) event, as well as during the years before and after the event year. MATERIALS AND METHODS: We analysed a population-based, retrospective cohort including all adults with DM managed in the primary care setting from the Hong Kong Hospital Authority between 2006 and 2013. DM patients for whom SH was first recorded during the designated period were identified and matched to a control group of patients who had not experienced an SH event using the propensity score method. Direct medical costs in the years before, during and after the first SH event were determined by totalling the costs of health services utilized within respective years. RESULTS: After matching, a total of 22 694 DM patients were divided into the first recorded-SH group (n = 11 347) and the non-SH control group (n = 11 347). Patients for whom SH was first recorded, on average, made 7.85 outpatient clinic visits, made 1.89 emergency visits and spent 17.75 nights hospitalized during the event year. Mean direct medical costs during the event year were 11 751 US$, more than 2-fold that during the preceding year (4846 US$; P < 0.001) and subsequent years (4198-4700 US$; P < 0.001) and was 4.5 times that 2 years before the event (2481 US$; P < 0.001). Incremental costs of SH patients vs matched controls during the event year and the preceding year were 10 873 US$ (P < 0.001) and 3974 US$ (P < 0.001), respectively. CONCLUSIONS: SH is associated with excessive hospital admission rates and direct medical costs during the event year and, in particular, during the year before as compared to patients who had not experienced an SH event.

Direct and indirect costs of end-stage renal disease patients in the first and second years after initiation of nocturnal home haemodialysis, hospital haemodialysis and peritoneal dialysis.

PURPOSE: To estimate the direct and indirect costs of end-stage renal disease (ESRD) patients in the first and second years of initiating peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD. METHODS: A cost analysis was performed to estimate the annual costs of PD, hospital-based HD and nocturnal home HD for ESRD patients from both the health service provider's and societal perspectives. Empirical data on healthcare resource use, patients' out-of-pocket costs, time spent on transportation and dialysis by ESRD patients and time spent by caregivers were analysed. All costs were expressed in Hong Kong year 2017 dollars. RESULTS: Analysis was based on 402 ESRD patients on maintenance dialysis (PD: 189; hospital-based HD: 170; and nocturnal home HD: 43). From the perspective of the healthcare provider, hospital-based HD had the highest total annual direct medical costs in the initial year (mean ± SD) (hospital-based HD = $400 057 ± 62 822; PD = $118 467 ± 15 559; nocturnal home HD = $223 358 ± 18 055; P < 0.001) and second year (hospital-based HD = $360 924 ± 63 014; PD = $80 796 ± 15 820; nocturnal home HD = $87 028 ± 9059; P < 0.001). From the societal perspective, hospital-based HD had the highest total annual costs in the initial year (hospital-based HD = $452 151 ± 73 327; PD = $189 191 ± 61 735; nocturnal home HD = $242 038 ± 28 281; P < 0.001) and second year (hospital-based HD = $413 017 ± 73 501; PD = $151 520 ± 60 353; nocturnal home HD = $105 708 ± 23 853; P < 0.001). CONCLUSIONS: This study quantified the economic burden of ESRD patients, and assessed the annual healthcare and societal costs in the initial and second years of PD, hospital-based HD and nocturnal home HD in Hong Kong. From both perspectives, PD is cost-saving relative to hospital-based HD and nocturnal home HD, except that nocturnal home HD has the lowest cost in the second year of treatment from the societal perspective. Results from this cost analysis facilitate economic evaluation in Hong Kong for health services and management targeted at ESRD patients.

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

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.

Effects of health-related quality of life on health service utilisation in patients with colorectal neoplasms.

This study was to assess the impact of HRQOL on health service utilisation using four different count data models. The HRQOL was measured using the Short-Form Six-Dimension instrument and the functional assessment of cancer therapy-colorectal whereas health service utilisation was measured by the number of monthly clinical consultations and the number of monthly hospitalisation. Different count data models (Poisson's regression, negative binomial regression, zero-inflated Poisson's regression and zero-inflated negative binomial regression) were used to assess the association between HRQOL and health service utilisation. A performance comparison was made between the models. Goodness-of-fit statistics (the Pearson's chi-squared test statistic, the Akaike and Bayesian information criteria) were used to determine the best-fitting model. The negative binomial model performed the best in assessing the association between HRQOL measures and health service utilisation in patients with colorectal neoplasm and thus recommended. Physical well-being of patients was negatively and significantly associated with the monthly rate of health service utilisation after controlling for patient demographics. Both physical and function well-beings of patients were negatively and significantly associated with the number of monthly hospitalisations. If the data for the condition-specific FACT-C are not available, SF-6D showed a very strong negative relationship with health service utilisation. Such models can be used to guide the allocation of clinical resources and funding for the care of colorectal cancer patients.

SF-6D population norms for the Hong Kong Chinese general population.

PURPOSE: To estimate population norms for the SF-6D health preference (utility) scores derived from the MOS SF-36 version 1 (SF-36v1), SF-36 version 2 (SF-36v2), and (SF-12v2) health surveys collected from a representative adult sample in Hong Kong, and to assess differences in SF-6D scores across sociodemographic subgroups. METHODS: A random telephone survey of 2410 Chinese adults was conducted. All respondents completed questionnaires on sociodemographics and presence of chronic diseases (hypertension, diabetes, chronic rheumatism, chronic lung diseases, stroke, and mental illness), and the short-form 36-item health survey (SF-36) version 1, and selected items of the SF-36v2 that were different from those of SF-36v1. Responses of short-form 12-item health survey (SF-12) were extracted from responses of the SF-36 items. SF-6D health utility scores were derived from SF-36 version 1 (SF-6DSF-36v1), SF-36 version 2 (SF-6DSF-36v2), and SF-12 version 2 (SF-6DSF-12v2) using Hong Kong SF-6D value set. RESULTS: Population norms of SF-6DSF-36v1, SF-6DSF-36v2, and SF-6DSF-12v2 for the Hong Kong Chinese were 0.7947 (± 0.0048), 0.7862 (± 0.0049), and 0.8147 (± 0.0050), respectively. Three SF-6D scores were highly correlated (0.861-0.954), and had a high degree of reliability and absolute agreement. Males had higher health utility scores (SF-6DSF-36v1: 0.0025; SF-6DSF-36v2: 0.025; SF-6DSF-12v2: 0.018) but reported less problems in all the dimensions than women. Respondents with a higher number of chronic diseases had lower SF-6D scores. Among all respondents with one or more chronic diseases, those with hypertension scored the highest whereby those with mental illness scored the least. CONCLUSIONS: The SF-6D utility scores derived from different SF-36 or SF-12 health surveys were different. The population norms based on these three health surveys enable the normative comparisons of health utility scores from specific population or patient groups, and provide estimates of age-gender adjusted health utility scores for health economic evaluations.

Direct medical costs of diabetes mellitus in the year of mortality and year preceding the year of mortality.

AIM: To report the health resource use and estimate the direct medical costs among patients with diabetes mellitus (DM) in the year of mortality and the year preceding the year of mortality. MATERIALS AND METHODS: We analysed data from a population-based, retrospective cohort study including all adults with a DM diagnosis in Hong Kong between 2009 and 2013, and who died between January 1, 2010 and December 31, 2013. The annual direct medical costs in the year of mortality and the year preceding the year of mortality were determined by summing the costs of health services utilized within the respective year. The costs were analysed by gender, the presence of comorbidities, diabetic complications and primary cause of death. RESULTS: A total of 10 649 patients met the eligibility criteria for analysis. On average, the direct medical costs in the year of death were 1.947 times higher than those in the year before death. Men and women with DM incurred similar costs in the year preceding the year of mortality and in the mortality year. Patients with any diabetic complications incurred greater costs in the year of mortality and the year before mortality than those without. CONCLUSIONS: This analysis provides new evidence on incorporating additional direct medical costs in the mortality year, and refining the structure of total cost estimates for use in costing and cost-effectiveness analyses of interventions for DM.

Cost-effectiveness analysis of vaccinations and decision makings on vaccination programmes in Hong Kong: A systematic review.

OBJECTIVES: To describe and systematically review the modelling and reporting of cost-effectiveness analysis of vaccination in Hong Kong, and to identify areas for quality enhancement in future cost-effectiveness analyses. METHODS: We conducted a comprehensive and systematic review of cost-effectiveness studies related to vaccination and government immunisation programmes in Hong Kong published from 1990 to 2015, through database search of Pubmed, Web of Science, Embase, and OVID Medline. Methodological quality of selected studies was assessed using Consolidated Health Economic Evaluation Reporting Standards checklist (CHEERS). Decision making of vaccination was obtained from Scientific Committee on Vaccine Preventable Diseases (SCVPD) and Department of Health in Hong Kong. RESULTS: Nine eligible studies reporting twelve comparative cost-effectiveness comparisons of vaccination programme for influenza (n=2), pneumococcal disease (n=3), influenza plus pneumococcal disease (n=1), chickenpox (n=2), Haemophilus influenzae b (n=1), hepatitis A (n=1), cervical cancer (n=1) and rotavirus (n=1) were identified. Ten comparisons (83.3%) calculated the incremental cost-effectiveness ratio (ICER) of a vaccination strategy versus status quo as outcomes in terms of cost in USD per life-years, cost per quality-adjusted life-years, or cost per disability-adjusted life-years. Among those 10 comparisons in base-case scenario, 4 evaluated interventions were cost-saving relative to status quo while the ICER estimates in 3 of the 6 remaining comparisons were far below commonly accepted threshold and WHO willingness-to-pay threshold, suggestive of very cost-effective. Seven studies were of good quality based on the CHEERS checklist; one was of moderate quality; and one was of excellent quality. The common methodological problems were characterisation of heterogeneity and reporting of study parameters. CONCLUSIONS: There was a paucity of cost-effectiveness models evaluating vaccination targeted to the Hong Kong population. All evaluated vaccinations and immunisation interventions in Hong Kong, except for Haemophilus influenzae b, hepatitis A and HPV vaccinations, were considered either cost-saving or very cost-effective when compared to status quo.

Bridging the Gaps Between Patients and Primary Care in China: A Nationwide Representative Survey.

PURPOSE: China introduced a national policy of developing primary care in 2009, establishing 8,669 community health centers (CHCs) by 2014 that employed more than 300,000 staff. These facilities have been underused, however, because of public mistrust of physicians and overreliance on specialist care. METHODS: We selected a stratified random sample of CHCs throughout China based on geographic distribution and urban-suburban ratios between September and December 2015. Two questionnaires, 1 for lead clinicians and 1 for primary care practitioners (PCPs), asked about the demographics of the clinic and its clinical and educational activities. Responses were obtained from 158 lead clinicians in CHCs and 3,580 PCPs (response rates of 84% and 86%, respectively). RESULTS: CHCs employed a median of 8 physicians and 13 nurses, but only one-half of physicians were registered as PCPs, and few nurses had training specifically for primary care. Although virtually all clinics were equipped with stethoscopes (98%) and sphygmomanometers (97%), only 43% had ophthalmoscopes and 64% had facilities for gynecologic examination. Clinical care was selectively skewed toward certain chronic diseases. Physicians saw a median of 12.5 patients per day. Multivariate analysis showed that more patients were seen daily by physicians in CHCs organized by private hospitals and those having pharmacists and nurses. CONCLUSIONS: Our survey confirms China's success in establishing a large, mostly young primary care workforce and providing ongoing professional training. Facilities are basic, however, with few clinics providing the comprehensive primary care required for a wide range of common physical and mental conditions. Use of CHCs by patients remains low.

Systematic review on the cost-effectiveness of self-management education programme for type 2 diabetes mellitus.

OBJECTIVES: A review of cost-effectiveness studies on self-management education programmes for Type 2 diabetes mellitus. METHODS: Cochrane, PubMed and PsycINFO databases were searched for papers published from January 2003 through September 2015. Further hand searching using the reference lists of included papers was carried out. RESULTS: In total, 777 papers were identified and 12 papers were finally included. We found eight programmes whose effectiveness analyses were based on randomised controlled trials and whose costs were comprehensively estimated from the stated perspective. Among these eight, four studies showed a cost per unit reduction in clinical risk factors (HbA1c or BMI) of US$491 to US$7723 or cost per glycaemic symptom day avoided of US$39. In three studies the cost per QALY gained, as estimated from a life-time model, was less than US$50,000. However, one study found the programme was not cost-effective despite a gain in QALYs at the one-year follow up. CONCLUSION: A small number of cost-effectiveness studies were identified with only eight of sufficiently good quality. The cost of a self-management education programme achieving reduction in clinical risk factors seems to be modest and is likely to be cost-effective in the long-term.

Five-year cost-effectiveness of the Patient Empowerment Programme (PEP) for type 2 diabetes mellitus in primary care.

This study evaluated the short-term cost-effectiveness of the Patient Empowerment Programme (PEP) for diabetes mellitus (DM) in Hong Kong. Propensity score matching was used to select a matched group of PEP and non-PEP subjects. A societal perspective was adopted to estimate the cost of PEP. Outcome measures were the cumulative incidence of all-cause mortality and diabetic complication over a 5-year follow-up period and the number needed to treat (NNT) to avoid 1 event. The incremental cost-effectiveness ratio (ICER) of cost per event avoided was calculated using the PEP cost per subject multiplied by the NNT. The PEP cost per subject from the societal perspective was US$247. There was a significantly lower cumulative incidence of all-cause mortality (2.9% vs 4.6%, P < .001), any DM complication (9.5% vs 10.8%, P = .001) and CVD events (6.8% vs 7.6%, P = .018), in the PEP group. The costs per death from any cause, DM complication or case of CVD avoided were US$14 465, US$19 617 and US$30 796, respectively. The extra amount allocated to managing PEP was small and it appears cost-effective in the short-term as an addition to RAMP.

Effects of risk assessment and management programme for hypertension on clinical outcomes and cardiovascular disease risks after 12 months: a population-based matched cohort study.

OBJECTIVES: This study evaluated the effectiveness of a structured multidisciplinary risk assessment and management programme for patients with hypertension (RAMP-HT) who were managed in public primary care clinics but had suboptimal blood pressure (BP) control in improving BP, LDL-cholesterol (LDL-C) and predicted 10-year cardiovascular disease (CVD) risk after 12 months of intervention. METHODS: A total of 10 262 hypertension patients with suboptimal BP despite treatment, aged less than 80 years and without existing CVD were enrolled in RAMP-HT between October 2011 and March 2012 from public general out-patient clinics in Hong Kong. Their clinical outcomes and predicted 10-year CVD risk were compared with a matched cohort of hypertension patients who were receiving usual care in general out-patient clinics without any RAMP-HT intervention by propensity score matching. Multivariable linear and logistic regressions were used to determine the independent effectiveness of RAMP-HT after adjusting for potential confounding variables. RESULTS: Compared with the usual care group after 12 months, significantly greater proportions of RAMP-HT participants achieved target BP (i.e. BP < 140/90 mmHg) (OR = 1.18, P < 0.01) and LDL-C levels (i.e. <3.4 mmol/l for patients with CVD risk ≤20% or <2.6 mmol/l for CVD risk >20%) (OR = 1.13, P < 0.01). RAMP-HT participants also had significantly greater reduction in predicted 10-year CVD risk by 0.44% (coefficient = -0.44, P < 0.01). CONCLUSION: The structured multidisciplinary RAMP-HT was more effective than usual care in achieving target BP, LDL-C and reducing predicted 10-year CVD risk in public primary care patients with suboptimal hypertension control after 12 months of intervention. A long-term follow-up should be conducted to confirm whether the improvement in clinical outcomes can be translated into actual reductions in CVD complications and mortalities and whether such approach is cost-effective.

Possible Impact of Incremental Cost-Effectiveness Ratio (ICER) on Decision Making for Cancer Screening in Hong Kong: A Systematic Review.

OBJECTIVES: The aim of this paper was to critically review the literature on the cost effectiveness of cancer screening interventions, and examine the incremental cost-effectiveness ratios (ICERs) that may influence government recommendations on cancer screening strategies and funding for mass implementation in the Hong Kong healthcare system. METHODS: We conducted a literature review of cost-effectiveness studies in the Hong Kong population related to cancer screening published up to 2015, through a hand search and database search of PubMed, Web of Science, Embase, and OVID Medline. Binary data on the government's decisions were obtained from the Cancer Expert Working Group, Department of Health. Mixed-effect logistic regression analysis was used to examine the impact of ICERs on decision making. Using Youden's index, an optimal ICER threshold value for positive decisions was examined by area under receiver operating characteristic curve (AUC). RESULTS: Eight studies reporting 30 cost-effectiveness pairwise comparisons of population-based cancer screening were identified. Most studies reported an ICER for a cancer screening strategy versus a comparator with outcomes in terms of cost per life-years (55.6 %), or cost per quality-adjusted life-years (55.6 %). Among comparisons with a mean ICER of US$102,931 (range 800-715,137), the increase in ICER value by 1000 was associated with decreased odds (odds ratio 0.990, 0.981-0.999; p = 0.033) of a positive recommendation. An optimal ICER value of US$61,600 per effectiveness unit yielded a high sensitivity of 90 % and specificity of 85 % for a positive recommendation. A lower ICER threshold value of below US$8044 per effectiveness unit was detected for a positive funding decision. CONCLUSIONS: Linking published evidence to Government recommendations and practice on cancer screening, ICERs influence decisions on the adoption of health technologies in Hong Kong. The potential ICER threshold for recommendation in Hong Kong may be higher than those of developed countries.

Evaluation of the quality of care of a haemodialysis public-private partnership programme for patients with end-stage renal disease.

BACKGROUND: Haemodialysis (HD) is one of the life-saving options for patients with end stage renal disease but demand for this treatment exceeds capacity in publicly funded hospitals. One novel approach to addressing this problem is through a shared-care model whereby government hospitals partner with qualified private HD service providers to increase the accessibility of HD for needy patients. The aim of this study is to evaluate and enhance the quality of care (QOC) provided in such a shared-care programme in Hong Kong, the Haemodialysis Public-Private Partnership Programme (HD-PPP). METHODS/DESIGN: This is a longitudinal study based on Action Learning and Audit Spiral methodologies to measure the achievement of pre-set target standards for the HD-PPP programme over three evaluation cycles. The QOC evaluation framework is comprised of structure, process and outcome criteria with target standards in each domain developed from review of the evidence and in close collaboration with the HD-PPP working group. During each evaluation cycle, coordinators of each study site complete a questionnaire to determine adherence with structural criteria of care. Process and clinical outcomes, such as adverse events and dialysis adequacy, are extracted from the patient records of consenting study participants while face-to-face interviews are conducted to ascertain patient-reported outcomes such as self-efficacy and health-related quality of life. DISCUSSION: The study relies on the successful implementation of partnership-based action research to develop an evidence-based and pragmatic framework for evaluation of quality of care in an iterative fashion, and to use it to identify possible areas of quality enhancements in a shared-care programme for HD patients. The approach we take in this study emphasizes partnership and engagement with the clinical and administrative programme team, a robust but flexible evaluation framework, direct observation and the potential to realize positive change. The experience will be useful to inform the process of coordinating research studies involving multiple stakeholders and results will help to guide service planning and policy decision making. TRIAL REGISTRATION: US Clinical Trial Registry NCT02307903.

Cost-Effectiveness of a Short Message Service Intervention to Prevent Type 2 Diabetes from Impaired Glucose Tolerance.

Aims. To investigate the costs and cost-effectiveness of a short message service (SMS) intervention to prevent the onset of type 2 diabetes mellitus (T2DM) in subjects with impaired glucose tolerance (IGT). Methods. A Markov model was developed to simulate the cost and effectiveness outcomes of the SMS intervention and usual clinical practice from the health provider's perspective. The direct programme costs and the two-year SMS intervention costs were evaluated in subjects with IGT. All costs were expressed in 2011 US dollars. The incremental cost-effectiveness ratio was calculated as cost per T2DM onset prevented, cost per life year gained, and cost per quality adjusted life year (QALY) gained. Results. Within the two-year trial period, the net intervention cost of the SMS group was $42.03 per subject. The SMS intervention managed to reduce 5.05% onset of diabetes, resulting in saving $118.39 per subject over two years. In the lifetime model, the SMS intervention dominated the control by gaining an additional 0.071 QALY and saving $1020.35 per person. The SMS intervention remained dominant in all sensitivity analyses. Conclusions. The SMS intervention for IGT subjects had the superiority of lower monetary cost and a considerable improvement in preventing or delaying the T2DM onset. This trial is registered with ClinicalTrials.gov NCT01556880.

Simple non-laboratory- and laboratory-based risk assessment algorithms and nomogram for detecting undiagnosed diabetes mellitus.

BACKGROUND: The aim of the present study was to develop a simple nomogram that can be used to predict the risk of diabetes mellitus (DM) in the asymptomatic non-diabetic subjects based on non-laboratory- and laboratory-based risk algorithms. METHODS: Anthropometric data, plasma fasting glucose, full lipid profile, exercise habits, and family history of DM were collected from Chinese non-diabetic subjects aged 18-70 years. Logistic regression analysis was performed on a random sample of 2518 subjects to construct non-laboratory- and laboratory-based risk assessment algorithms for detection of undiagnosed DM; both algorithms were validated on data of the remaining sample (n = 839). The Hosmer-Lemeshow test and area under the receiver operating characteristic (ROC) curve (AUC) were used to assess the calibration and discrimination of the DM risk algorithms. RESULTS: Of 3357 subjects recruited, 271 (8.1%) had undiagnosed DM defined by fasting glucose ≥7.0 mmol/L or 2-h post-load plasma glucose ≥11.1 mmol/L after an oral glucose tolerance test. The non-laboratory-based risk algorithm, with scores ranging from 0 to 33, included age, body mass index, family history of DM, regular exercise, and uncontrolled blood pressure; the laboratory-based risk algorithm, with scores ranging from 0 to 37, added triglyceride level to the risk factors. Both algorithms demonstrated acceptable calibration (Hosmer-Lemeshow test: P = 0.229 and P = 0.483) and discrimination (AUC 0.709 and 0.711) for detection of undiagnosed DM. CONCLUSION: A simple-to-use nomogram for detecting undiagnosed DM has been developed using validated non-laboratory-based and laboratory-based risk algorithms.

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

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.

Cost-effectiveness simulation and analysis of colorectal cancer screening in Hong Kong Chinese population: comparison amongst colonoscopy, guaiac and immunologic fecal occult blood testing.

BACKGROUND: The aim of this study was to evaluate the cost-effectiveness of CRC screening strategies from the healthcare service provider perspective based on Chinese population. METHODS: A Markov model was constructed to compare the cost-effectiveness of recommended screening strategies including annual/biennial guaiac fecal occult blood testing (G-FOBT), annual/biennial immunologic FOBT (I-FOBT), and colonoscopy every 10 years in Chinese aged 50 year over a 25-year period. External validity of model was tested against data retrieved from published randomized controlled trials of G-FOBT. Recourse use data collected from Chinese subjects among staging of colorectal neoplasm were combined with published unit cost data ($USD in 2009 price values) to estimate a stage-specific cost per patient. Quality-adjusted life-years (QALYs) were quantified based on the stage duration and SF-6D preference-based value of each stage. The cost-effectiveness outcome was the incremental cost-effectiveness ratio (ICER) represented by costs per life-years (LY) and costs per QALYs gained. RESULTS: In base-case scenario, the non-dominated strategies were annual and biennial I-FOBT. Compared with no screening, the ICER presented $20,542/LYs and $3155/QALYs gained for annual I-FOBT, and $19,838/LYs gained and $2976/QALYs gained for biennial I-FOBT. The optimal screening strategy was annual I-FOBT that attained the highest ICER at the threshold of $50,000 per LYs or QALYs gained. CONCLUSION: The Markov model informed the health policymakers that I-FOBT every year may be the most effective and cost-effective CRC screening strategy among recommended screening strategies, depending on the willingness-to-pay of mass screening for Chinese population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02038283.