Age-specific associations between the number of co-morbidities, all-cause mortality and public direct medical costs in patients with type 2 diabetes: A retrospective cohort study.

AIM: To evaluate the association between the number of co-morbidities, all-cause mortality and public health system expenditure in patients with type 2 diabetes (T2D) across different age groups. MATERIALS AND METHODS: A retrospective observational study of T2D patients using electronic health records in Hong Kong was conducted. Patients were stratified by age (< 50, 50-64, 65-79, ≥ 80 years) and the number of co-morbidities (0, 1, 2, 3, ≥ 4), defined using the Charlson Comorbidity Index and prevalent chronic diseases identified in local surveys. The association between the number of co-morbidities, all-cause mortality and direct medical costs was examined using Cox proportional hazard regression and the gamma generalized linear model with log link function. RESULTS: A total of 262 212 T2D patients with a median follow-up of 10 years were included. Hypertension and dyslipidaemia were the most common co-morbidities in all age groups. After age stratification, cardiovascular diseases dominated the top pair of co-morbidities in the older age groups (65-79 and ≥ 80 years), while inflammatory and liver disease were predominant among younger individuals. Compared with co-morbidity-free T2D patients, the hazard ratios (95% CI) of death for patients aged younger than 50 and 80 years or older with two co-morbidities were 1.31 (1.08-1.59) and 1.25 (1.15-1.36), respectively, and increased to 3.08 (2.25-4.21) and 1.98 (1.82-2.16), respectively, as the number of co-morbidities increased to four or more. Similar trends were observed for medical costs. CONCLUSIONS: Age-specific co-morbidity patterns were observed for patients with T2D. A greater number of co-morbidities was associated with increased mortality and healthcare costs, with stronger relationships observed among younger patients.

Long-term spill-over impact of COVID-19 on health and healthcare of people with non-communicable diseases: a study protocol for a population-based cohort and health economic study.

INTRODUCTION: The COVID-19 pandemic has a significant spill-over effect on people with non-communicable diseases (NCDs) over the long term, beyond the direct effect of COVID-19 infection. Evaluating changes in health outcomes, health service use and costs can provide evidence to optimise care for people with NCDs during and after the pandemic, and to better prepare outbreak responses in the future. METHODS AND ANALYSIS: This is a population-based cohort study using electronic health records of the Hong Kong Hospital Authority (HA) CMS, economic modelling and serial cross-sectional surveys on health service use. This study includes people aged ≥18 years who have a documented diagnosis of diabetes mellitus, hypertension, cardiovascular disease, cancer, chronic respiratory disease or chronic kidney disease with at least one attendance at the HA hospital or clinic between 1 January 2010 and 31 December 2019, and without COVID-19 infection. Changes in all-cause mortality, disease-specific outcomes, and health services use rates and costs will be assessed between pre-COVID-19 and-post-COVID-19 pandemic or during each wave using an interrupted time series analysis. The long-term health economic impact of healthcare disruptions during the COVID-19 pandemic will be studied using microsimulation modelling. Multivariable Cox proportional hazards regression and Poisson/negative binomial regression will be used to evaluate the effect of different modes of supplementary care on health outcomes. ETHICS AND DISSEMINATION: The study was approved by the institutional review board of the University of Hong Kong, the HA Hong Kong West Cluster (reference number UW 21-297). The study findings will be disseminated through peer-reviewed publications and international conferences.

Ten-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Macrovascular and Microvascular Complications and All-Cause Mortality: A Population-Based Cohort Study.

OBJECTIVE: The Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) is a protocol-driven, risk-stratified, and individualized management program offered by a multidisciplinary team in addition to usual care for primary care patients with diabetes. This study aimed to evaluate the effectiveness of RAMP-DM for preventing complications and mortality over 10 years. RESEARCH DESIGN AND METHODS: A population-based, prospective cohort study of adult patients with type 2 diabetes managed in the Hong Kong public primary health care system between 2009 and 2010 was conducted. RAMP-DM participants and usual care patients were matched using one-to-one propensity score matching and followed for 10 years. Risks of macrovascular and microvascular complications and all-cause mortality were estimated by Cox proportional hazards regression. RESULTS: A total of 36,746 patients (18,373 in each group) were included after propensity score matching, with a median follow-up of 9.5 years and 306,802 person-years. RAMP-DM participants had significantly lower risks of macrovascular (hazard ratio [HR] 0.52, 95% CI 0.50-0.54) and microvascular (HR 0.68, 95% CI 0.64-0.72) complications and all-cause mortality (HR 0.45, 95% CI 0.43-0.47) than patients who received usual care only. However, the effect of RAMP-DM on macrovascular and microvascular complications attenuated after the 9th and 8th year of follow-up, respectively. RAMP-DM participants also showed better control of hemoglobin A1c, blood pressure, triglycerides, and BMI and a slower decline in renal function. CONCLUSIONS: Significant reductions in diabetes-related complications and all-cause mortality were observed among RAMP-DM participants over a 10-year follow-up, yet the effect of preventing complications attenuated after 8 years.

COVID-19 and Health-Related Quality of Life: A Community-Based Online Survey in Hong Kong.

The COVID-19 pandemic itself and related public health measurements have had substantial impacts on individual social lives and psychological and mental health, all to the detriment of health-related quality of life (HRQoL). There have been extensive studies investigating the mental health of people in different populations during the COVID-19 pandemic. However, few studies have explored the impact of COVID-19 and its association with HRQoL. To fill this research gap and provide further empirical evidence, this study examined the impact of COVID-19 on Hong Kong people and evaluated its association with HRQoL. A total of 500 participants were randomly recruited to complete an online questionnaire on their concerns related to COVID-19. This entailed responding to the World Health Organization Quality of Life-BREF instrument. Data were collected between 24 April and 3 May 2020. Independent t-tests and multiple linear regressions were used to examine the association between the impact of COVID-19 and HRQoL. Overall, 69.6% of participants were worried about contracting COVID-19, and 41.4% frequently suspected themselves of being infected. Furthermore, 29.0% were concerned by the lack of disinfectants. All of these findings were associated with poorer HRQoL in the physical and psychological health, social relationships, and environment domains. On the other hand, 47.4% of participants were concerned that they may lose their job because of the pandemic, while 39.4% were bothered by the insufficient supply of surgical masks. These two factors were associated with poorer HRQoL in the physical and psychological health and environment domains. The adverse impact of COVID-19 on individuals is multifactorial, affecting all aspects of HRQoL. In addition to enhancing anti-epidemic efforts, it is equally important to implement public health and social welfare measures, thereby diminishing the adverse impact of COVID-19 on overall well-being.

The Impact of Cardiovascular Disease and Chronic Kidney Disease on Life Expectancy and Direct Medical Cost in a 10-Year Diabetes Cohort Study.

OBJECTIVE: The relative effects of various cardiovascular diseases (CVDs) and varying severity of chronic kidney disease (CKD) on mortality risk, direct medical cost, and life expectancy in patients with diabetes are unclear. The aim of this study was to evaluate these associations. RESEARCH DESIGN AND METHODS: This was a retrospective cohort study that included 208,792 adults with diabetes stratified into 12 disease status groups with varying combinations of heart disease, stroke, moderate CKD (estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m2) and severe CKD (eGFR <30 mL/min/1.73 m2) in 2008-2010. The effect of risk of mortality, annual direct medical costs, and life expectancy were assessed using Cox regression, gamma generalized linear method with log-link function, and flexible parametric survival models. RESULTS: Over a median follow-up of 8.5 years (1.6 million patient-years), 50,154 deaths were recorded. Mortality risks for patients with only a single condition among heart disease, stroke, and moderate CKD were similar. The mortality risks were 1.75 times, 2.63 times, and 3.58 times greater for patients with one, two, and all three conditions (consisting of stroke, heart disease, and moderate CKD), compared with patients without these diseases, suggesting an independent and individually additive effect for any combination. A similar trend was observed in annual public health care costs with 2.91-, 3.90-, and 3.88-fold increased costs for patients with one, two, and three conditions, respectively. Increases in the number of conditions reduced life expectancy greatly, particularly in younger patients. Reduction in life expectancy for a 40-year-old with one, two, and three conditions was 20, 25, and 30 years for men and 25, 30, and 35 years, respectively, for women. A similar trend of greater magnitude was observed for severe CKD. CONCLUSIONS: The effects of heart diseases, stroke, CKD, and the combination of these conditions on all-cause mortality and direct medical costs are independent and cumulative. CKD, especially severe CKD, appears to have a particularly significant impact on life expectancy and direct medical costs in patients with diabetes. These findings support the importance of preventing both CVD and CKD in patients with diabetes.

Burden of CKD and Cardiovascular Disease on Life Expectancy and Health Service Utilization: a Cohort Study of Hong Kong Chinese Hypertensive Patients.

BACKGROUND: The relative effects of combinations of CKD, heart disease, and stroke on risk of mortality, direct medical costs, and life expectancy are unknown. METHODS: In a retrospective cohort study of 506,849 Chinese adults in Hong Kong with hypertension, we used Cox regressions to examine associations between all-cause mortality and combinations of moderate CKD (eGFR of 30-59 ml/min per 1.73 m2), severe CKD (eGFR of 15-29 ml/min per 1.73 m2), heart disease (coronary heart disease or heart failure), and stroke, and modeling to estimate annual public direct medical costs and life expectancy. RESULTS: Over a median follow-up of 5.8 years (2.73 million person-years), 55,666 deaths occurred. Having an increasing number of comorbidities was associated with incremental increases in mortality risk and medical costs and reductions in life expectancy. Compared with patients who had neither CKD nor cardiovascular disease, patients with one, two, or three conditions (heart disease, stroke, and moderate CKD) had relative risk of mortality increased by about 70%, 160%, and 290%, respectively; direct medical costs increased by about 70%, 160%, and 280%, respectively; and life expectancy at age 60 years decreased by about 5, 10, and 15 years, respectively. Burdens were higher with severe CKD. CONCLUSIONS: This study demonstrated extremely high mortality risk and medical cost increases for severe CKD, exceeding the combined effects from heart disease and stroke. Mortality risks and costs for moderate CKD, heart disease, and stroke were similar individually and roughly multiplicative for any combination. These findings suggest that to reduce mortality and health care costs in patients with hypertension, CKD prevention and intervention merits priority equal to that of cardiovascular disease.

Evaluation of the responsiveness of Short Form-12 Health Survey version 2 (SF-12v2) in Chinese patients with hypertension in primary care.

PURPOSE: There is limited evidence on the responsiveness of the Short Form-12 Health Survey version 2 (SF-12v2) in hypertensive patients. This study aimed to evaluate both the responsiveness of the SF-12 measures in Chinese hypertensive patients. METHODS: A prospective longitudinal study was conducted on hypertensive patients managed in public primary care clinics between 2012 and 2013. A total of 583 and 431 patients were surveyed and completed SF-12v2 at baseline and at 12-month follow-up interviews, respectively. Using global rating of change scale as an external anchor, the responsiveness was assessed by linear mixed effect models, multiple linear regression models, and receiver operating characteristic (ROC) curve analysis. RESULTS: SF-12v2 managed to detect negative changes among hypertensive patients in worsened general health group but failed to identify changes among hypertensive patients in improved general health group. Meanwhile, some domains of SF-12v2 detected a significant difference in difference between patients of worsened and stable/improved group and between patients of stable and improved group, but none of the domains and the summary scales reached the recommended standard of 0.7 in any comparisons in ROC analysis. CONCLUSIONS: The SF-12v2 was responsive to worsening of HRQOL but not to improvements in HRQOL among hypertensive patients. The overall responsiveness of SF-12v2 in hypertensive patients is unsatisfactory. Further studies are needed to identify HRQOL measures with good internal and external responsiveness for hypertensive patients.

Cost-effectiveness of a primary care multidisciplinary Risk Assessment and Management Program for patients with diabetes mellitus (RAMP-DM) over lifetime.

PURPOSE: The multidisciplinary Risk Assessment and Management Program for patients with diabetes mellitus (RAMP-DM) was found to be cost-saving in comparison with usual primary care over 5 years' follow-up. This study aimed to estimate the cost-effectiveness of RAMP-DM over lifetime. METHODS: We built a Discrete Event Simulation model to evaluate the cost-effectiveness of RAMP-DM over lifespan from public health service provider's perspective. Transition probabilities among disease states were extrapolated from a cohort of 17,140 propensity score matched participants in RAMP-DM and those under usual primary care over 5-year's follow-up. The mortality of patients with specific DM-related complications was estimated from a cohort of 206,238 patients with diabetes. Health preference and direct medical costs of DM patients referred to our previous studies among Chinese DM patients. RESULTS: RAMP-DM individuals gained 0.745 QALYs and cost US$1404 less than those under usual care. The probabilistic sensitivity analysis found that RAMP-DM had 86.0% chance of being cost-saving compared to usual care under the assumptions and estimates used in the model. The probability of RAMP-DM being cost-effective compared to usual care would be over 99%, when the willingness to pay threshold is HK$20,000 (US$ 2564) or higher. CONCLUSION: RAMP-DM added to usual primary care was cost-saving in managing people with diabetes over lifetime. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.

Five-Year Cost-effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM).

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.

Five-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Diabetes-Related Complications and Health Service Uses-A Population-Based and Propensity-Matched Cohort Study.

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.

Classification Rule for 5-year Cardiovascular Diseases Risk using decision tree in Primary Care Chinese Patients with Type 2 Diabetes Mellitus.

Cardiovascular disease(CVD) is the leading cause of mortality among patients with type 2 diabetes mellitus(T2DM), and a risk classification model for CVD among primary care diabetic patients is pivotal for risk-based interventions and patient information. This study developed a simple tool for a 5-year CVD risk prediction for primary care Chinese patients with T2DM. A retrospective cohort study was conducted on 137,935 primary care Chinese T2DM patients aged 18-79 years without history of CVD between 1 January 2010 and 31 December 2010. New events of CVD of the cohort over a median follow up of 5 years were extracted from the medical records. A classification rule of 5-year CVD risk was obtained from the derivation cohort and validated in the validation cohort. Significant risk factors included in decision tree were age, gender, smoking status, diagnosis duration, obesity, unsatisfactory control on haemoglobin A1c and cholesterol, albuminuria and stage of chronic kidney disease, which categorized patients into five 5-year CVD risk groups(<5%; 5-9%; 10-14%; 15-19% and ≥20%). Taking the group with the lowest CVD risk, the hazard ratios varied from 1.92(1.77,2.08) to 8.46(7.75,9.24). The present prediction model performed comparable discrimination and better calibration from the plot compared to other current existing models.

Effectiveness of a multidisciplinary risk assessment and management programme-diabetes mellitus (RAMP-DM) on patient-reported outcomes.

Little is known about how the patient-reported outcomes is influenced by multidisciplinary-risk-assessment-and-management-programme for patients with diabetes mellitus (RAMP-DM). This paper aims to evaluate the effectiveness of RAMP-DM on patient-reported outcomes. This was a prospective longitudinal study on 1039 diabetes mellitus patients (714/325 RAMP-DM/non-RAMP-DM) managed in primary care setting. 536 and 402 RAMP-DM participants, and 237 and 187 non-RAMP-DM participants were followed up at 12 and 24 months with completed survey, respectively. Patient-reported outcomes included health-related quality of life, change in global health condition and patient enablement measured by Short Form-12 Health Survey version-2 (SF-12v2), Global Rating Scale, Patient Enablement Instrument respectively. The effects of RAMP-DM on patient-reported outcomes were evaluated by mixed effect models. Subgroup analysis was performed by stratifying haemoglobin A1c (HbA1c) (optimal HbA1c < 7 % and suboptimal HbA1c ≥ 7 %). RAMP-DM with suboptimal HbA1c was associated with greater improvement in SF-12v2 physical component summary score at 12-month (coefficient:3.80; P-value < 0.05) and 24-month (coefficient:3.82;P-value < 0.05), more likely to feel more enabled at 12-month (odds ratio: 2.57; P-value < 0.05), and have improved in GRS at 24-month (odds ratio:4.05; P-value < 0.05) compared to non-RAMP-DM participants. However, there was no significant difference in patient-reported outcomes between RAMP-DM and non-RAMP-DM participants with optimal HbA1c. Participation in RAMP-DM is effective in improving physical component of HRQOL, Global Rating Scale and patient enablement among diabetes mellitus patients with suboptimal HbA1c, but not in those with optimal HbA1c. Patients with sub-optimal diabetes mellitus control should be the priority target population for RAMP-DM. This observational study design may have potential bias in the characteristics between groups, and randomized clinical trial is needed to confirm the results.

The 12-Month Incidence and Predictors of PHQ-9-Screened Depressive Symptoms in Chinese Primary Care Patients.

PURPOSE: Evidence regarding the onset of depressive symptoms in primary care is rarely available but can help inform policy development, service planning, and clinical decision making. The objective of this study was to estimate the 12-month cumulative incidence and predictors of a positive screen for depressive symptoms on the 9-item Patient Health Questionnare-9 (PHQ-9) among primary care patients with no history of physician-diagnosed depression. METHODS: We monitored a cohort of 2,929 adult primary care patients with no past history of physician-diagnosed depression and with baseline PHQ-9 scores of 9 or lower by telephone interview at 3, 6, and 12 months. A generalized linear mixed effects Poisson Model was used to explore factors associated with the incidence of PHQ-positive symptoms. RESULTS: The cumulative incidence of positive screening on the PHQ-9 over 12 months was 5.23% (95% CI, 3.83%-6.64%). Positive predictors included being female, coming from a lower-income household, being a smoker, having at least 2 comorbidities, having a family history of depression, and having consulted a physician at least twice in the past 4 weeks. Consulting a physician with qualifications in both family medicine and psychological medicine was a negative predictor. CONCLUSIONS: The cumulative incidence of PHQ-9-screened depressive symptoms in this study population was higher than those reported for depressive disorders in earlier systematic reviews. Groups who may warrant greater treatment attention include women, patients with multimorbidity, smokers, patients with recent high rates of medical consultations, and those who are from lower-income households or who have a family history of depression. Greater physician training may have a protective effect.

Evaluation of the quality of care of a multi-disciplinary Risk Factor Assessment and Management Programme for Hypertension (RAMP-HT).

BACKGROUND: There is some evidence to support a risk-stratified, multi-disciplinary approach to manage patients with hypertension in primary care. The aim of this study is to evaluate the quality of care (QOC) of a multi-disciplinary Risk Assessment and Management Programme for Hypertension (RAMP-HT) for hypertensive patients in busy government-funded primary care clinics in Hong Kong. The objectives are to develop an evidence-based, structured and comprehensive evaluation framework on quality of care, to enhance the QOC of the RAMP-HT through an audit spiral of two evaluation cycles and to determine the effectiveness of the programme in reducing cardiovascular disease (CVD) risk. METHOD/DESIGN: A longitudinal study is conducted using the Action Learning and Audit Spiral methodologies to measure whether pre-set target standards of care intended by the RAMP-HT are achieved. A structured evaluation framework on the quality of structure, process and outcomes of care has been developed based on the programme objectives and literature review in collaboration with the programme workgroup and health service providers. Each participating clinic is invited to complete a structure of care evaluation questionnaire in each evaluation cycle. The data of all patients who have enrolled into the RAMP-HT in the pre-defined evaluation periods are used for the evaluation of the process and outcomes of care in each evaluation cycle. For evaluation of the effectiveness of RAMP-HT, the primary outcomes including blood pressure (both systolic and diastolic), low-density lipoprotein cholesterol and estimated 10-year CVD risk of RAMP-HT participants are compared to those of hypertensive patients in usual care without RAMP-HT. DISCUSSION: The QOC and effectiveness of the RAMP-HT in improving clinical and patient-reported outcomes for patients with hypertension in normal primary care will be determined. Possible areas for quality enhancement and standards of good practice will be established to inform service planning and policy decision making.