Development of an explicit tool assessing potentially inappropriate medication use in Hong Kong elder patients.

BACKGROUND: Potentially inappropriate medication (PIM) use has adverse effects on health, particularly in elder patients. Various country-specific explicit criteria have been developed to measure the appropriateness of prescribing worldwide. However, it is difficult to apply the criteria developed from other regions to measure and guide the local prescribing practice in Hong Kong. This study aims to develop a Hong Kong-specific PIM assessing tool from previously published criteria and validate this tool using the modified Delphi method. METHODS: A disease-oriented Hong Kong-specific preliminary PIM list was developed based on nine sets of reference criteria selected from a literature review. Any medication or medication class appeared in at least two sets of the reference criteria as well as its related medical conditions were selected as PIM candidates. After examining the availability of PIM candidates by the Hong Kong Hospital Authority drug formulary, the Hong Kong-specific preliminary PIM list was validated by a two-round of modified Delphi process. Eight experts from different specialties were invited to rate the degree of inappropriateness of each PIM candidate using a five-point Likert scale. The experts were also encouraged to propose therapeutic alternatives and new PIM candidates not covered by the preliminary PIM list. The PIM candidates that the expert panel didn't reach consensus on were excluded from the final Hong Kong-specific PIM list. RESULTS: After two rounds of the Delphi process, eight PIM candidates remained questionable and thus were excluded from the PIM list. The final Hong Kong-specific PIM list included a total of 164 statements applicable to older adults aged 65 years or above, among which 77 were under PIMs independent of diagnoses, and 87 were under PIMs considering specific medical conditions. CONCLUSIONS: The Hong Kong-specific PIM list can be used as a quality measure and an educational tool to improve the local prescribing quality. Further studies should validate its association with adverse health outcomes in clinical and research settings.

Barriers and Facilitators to Receiving the COVID-19 Vaccination and Development of Theoretically-Informed Implementation Strategies for the Public: Qualitative Study in Hong Kong.

OBJECTIVES: enhancing uptake of COVID-19 vaccines is an important tool for managing the pandemic. However, in Hong Kong, the COVID-19 vaccination rate in the general population was unsatisfactory during the early phase of the vaccination program. This two-part study aimed to (i) identify barriers and facilitators to receiving vaccinations, and (ii) develop theoretically-informed implementation strategies for promoting uptake. METHODS: in part 1, 45 Hong Kong residents who differed in their willingness to vaccinate (willing (n = 15), were unwilling (n = 15), and were hesitant (n = 15)), were interviewed individually in February 2021. They were invited to express their perceptions of receiving the COVID-19 vaccination. The theoretical domains framework (TDF) was applied to guide the interviews and analyses. Behavioral diagnoses from these findings were then used to develop theoretically-informed implementation strategies in part 2, composed of behavior change techniques (BCTs) informed by the established BCT taxonomy. RESULTS: in part 1, the five main barriers were (i) concerns on severe and long-term side effects; (ii) low confidence in the safety and effectiveness due to concerns of their accelerated development; (iii) unclear information on logistical arrangements of the vaccination program; (iv) insufficient data on safety and effectiveness; and (v) perceived low protection ability conferred by the vaccines. The five main facilitators included (i) healthcare professionals' recommendations; (ii) news from TV, radio, and newspapers as main sources of trustworthy information; (iii) vaccine-related health education delivered by healthcare professionals; (iv) expectations of resuming to a normal social life; and (v) perceived benefits outweighing risks of mild and short-term side effects. CONCLUSIONS: seven implementation strategies were developed in part 2 based on the results above, namely (i) providing trustworthy vaccine-related information and scaling up the promotion; (ii) encouraging healthcare professionals to recommend vaccinations; (iii) giving incentives; (iv) using social influence approaches; (v) allowing a selection of COVID-19 vaccine brands; (vi) increasing accessibility for vaccinations; and (vii) emphasizing social responsibility.

Quantifying the effect of government interventions and virus mutations on transmission advantage during COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has become a major public health threat. This study aims to evaluate the effect of virus mutation activities and policy interventions on COVID-19 transmissibility in Hong Kong. METHODS: In this study, we integrated the genetic activities of multiple proteins, and quantified the effect of government interventions and mutation activities against the time-varying effective reproduction number Rt. FINDINGS: We found a significantly positive relationship between Rt and mutation activities and a significantly negative relationship between Rt and government interventions. The results showed that the mutations that contributed most to the increase of Rt were from the spike, nucleocapsid and ORF1b genes. Policy of prohibition on group gathering was estimated to have the largest impact on mitigating virus transmissibility. The model explained 63.2% of the Rt variability with the R2. CONCLUSION: Our study provided a convenient framework to estimate the effect of genetic contribution and government interventions on pathogen transmissibility. We showed that the S, N and ORF1b protein had significant contribution to the increase of transmissibility of SARS-CoV-2 in Hong Kong, while restrictions of public gathering and suspension of face-to-face class are the most effective government interventions strategies.

Association of volunteer-administered home care with reduced emergency room visits and hospitalization among older adults with chronic conditions: A propensity-score-matched cohort study.

OBJECTIVES: The objective of this study was to examine the association of receiving care from a volunteer-administered outreach program with emergency room utilization and hospitalization among older people with chronic conditions in Hong Kong. METHODS: Volunteers consisting of retired healthcare professionals, university students, and openly recruited citizens received training to provide home care services to hospital-discharged older Chinese adults aged 65+ with chronic conditions who were identified as high-risk patients of hospital admission and referred by public healthcare providers. Several home visits were made to enhance the patients' self-care capacity. For comparison, a 4:1-propensity score matching based on age, sex, the month of discharge, length of stay for the index episode, and 14 common chronic conditions was conducted to select a comparison group from a territory-wide inpatient database. Poisson regression was used to compare emergency room utilization and the number of hospitalized days. RESULTS: In total, 775 patients were analyzed, including 155 home care recipients and 620 extracted from the inpatient database as a matched comparison with similar baseline characteristics. Regression analysis showed that home care recipients had 21% fewer overall emergency room visits [95% confidence interval (CI): 3%-35%], 22% fewer such visits which led to hospitalization (95% CI: 1%-39%) and 22% fewer overall hospitalized days (95% CI: 16%-28%). Nevertheless, the number of hospitalized days admitted through the emergency room was 10% higher among home care recipients (95% CI: 0%-20%). CONCLUSIONS: Volunteer-administered home care might be effective in reducing emergency room visits and non-acute hospitalization, as well as early detection of acute problems warranting tertiary care. Further randomized studies are needed to substantiate this finding.

Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals.

ABSTRACT: BACKGROUND: Studies have shown that effective discharge planning is one of the key factors related to the quality of inpatient care and unnecessary hospital readmission. The perception and understanding of hospital discharge by health professionals is important in developing effective discharge planning. The aims of this present study were to explore the perceived quality of current hospital discharge from the perspective of health service providers and to identify barriers to effective discharge planning in Hong Kong. METHODS: Focus groups interviews were conducted with different healthcare professionals who were currently responsible for coordinating the discharge planning process in the public hospitals. The discussion covered three main areas: current practice on hospital discharge, barriers to effective hospital discharge, and suggested structures and process for an effective discharge planning system. RESULTS: Participants highlighted that there was no standardized hospital-wide discharge planning and policy-driven approach in public health sector in Hong Kong. Potential barriers included lack of standardized policy-driven discharge planning program, and lack of communication and coordination among different health service providers and patients in both acute and sub-acute care provisions which were identified as mainly systemic issues. Improving the quality of hospital discharge was suggested, including a multidisciplinary approach with clearly identified roles among healthcare professionals. Enhancement of health professionals' communication skills and knowledge of patient psychosocial needs were also suggested. CONCLUSIONS: A systematic approach to develop the structure and key processes of the discharge planning system is critical in ensuring the quality of care and maximizing organization effectiveness. In this study, important views on barriers experienced in hospital discharge were provided. Suggestions for building a comprehensive, system-wide, and policy-driven discharge planning process with clearly identified staff roles were raised. Communication and coordination across various healthcare parties and provisions were also suggested to be a key focus.

Evaluation of the implementation of information system for postdischarge with the theoretical domains framework by healthcare professionals: a multistage design with qualitative inquiry and Delphi expert discussion protocol.

INTRODUCTION: Improving discharge information dissemination may improve patients' health literacy of self-care and health outcomes, avoid unnecessary healthcare utilisation, and reduce the healthcare cost. This study aims to use an implementation science theory guided approach to examine the beliefs and behaviours of healthcare professionals regarding postdischarge information summary (PDIS) implementation in a public inpatient setting. METHODS AND ANALYSIS: A multistage study design involving qualitative inquiry and Delphi expert discussion will be used to systematically explore the perceived barriers in the four implemented hospitals and enable the full implementation of the PDIS in geriatric and medical care. The theoretical domains framework (TDF), behavioural change wheel and realistic evaluation framework will be used to guide the investigation of implementation. This study consists of three steps: (1) identifying barriers and enablers from an implementation perspective using a TDF-informed interview guide; (2) devising theory-based implementation strategy packages to facilitate the adoption and enhancement of PDIS by performing a strategy mapping exercise and (3) developing an effective implementation strategy package for scaling up PDIS in other target hospitals as well as other specialities using the Delphi expert discussion. The goal of this multistage study design is to identify the perspectives from healthcare professionals towards the PDIS implementation and explore their barriers and facilitators of the process in the pilot phase. The invited healthcare professionals would share their daily experience on providing PDIS to patient in various study hospitals with similar ward setting. The implementation of discharge intervention in a study setting through different steps to aid in the exploration and development of the modified implementation strategies for the adoption and enhancement of PDIS in the discharge process. ETHICS AND DISSEMINATION: Ethics approval for the study was obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committees. Results of the study would be released as a report submitted to the Health and Medical Research Fund of Food and Health Bureau of the Hong Kong Government. The result would also be published in international peer-reviewed medical journals and presented in conferences. TRIAL REGISTRATION NUMBER: ChiCTR2000034382.

Prevalence and determinants of potentially inappropriate medication use in Hong Kong older patients: a cross-sectional study.

OBJECTIVES: To assess the prevalence of potentially inappropriate medication (PIM) use in Hong Kong older patients visiting general outpatient clinics (GOPCs) between 2006 and 2014 and to identify factors associated with PIM use among older adults visiting GOPCs in 2014. DESIGN: Cross-sectional study. SETTING: GOPC. PARTICIPANTS: Two study samples were constructed including a total of 844 910 patients aged 65 and above from 2006 to 2014 and a cohort of 489 301 older patients in 2014. MEASUREMENTS: Two subsets of the 2015 American Geriatrics Society Beers criteria-PIMs independent of diagnosis and PIMs due to drug-disease interactions-were used to estimate the prevalence of PIM use over 12 months. PIMs that were not included in the Hospital Authority drug formulary or with any specific restriction or exception in terms of indication, dose or therapy duration were excluded. Characteristics of PIM users and non-PIM users visiting GOPCs in 2014 were compared. Independent associations between patient variables and PIM use were assessed by stepwise multivariable logistic regression analysis. RESULTS: The 12-month period prevalence of PIM use decreased from 55.56% (95% CI 55.39% to 55.72%) in 2006 to 47.51% (95% CI 47.37% to 47.65%) in 2014. In the multivariable regression analysis, the strongest factor associated with PIM use was the number of different drugs prescribed (adjusted OR, AOR 23.01, 95% CI 22.36 to 23.67). Being female (AOR 0.89, 95% CI 0.85 to 0.87 for males vs females) and having a greater number of GOPC visits (AOR 1.83, 95% CI 1.78 to 1.88) as well as more than six diagnoses (AOR 1.43, 95% CI 1.36 to 1.52) were associated with PIM use. CONCLUSIONS: The overall prevalence of PIM use in older adults visiting GOPCs decreased from 2006 to 2014 in Hong Kong although the prevalence of PIM use was still high in 2014. Patients with female gender, a larger number of medications prescribed, more frequent visits to GOPCs, and more than six diagnoses were at higher risk for PIM use.

Effectiveness of nurse-led peri-discharge interventions for reducing 30-day hospital readmissions: Network meta-analysis.

BACKGROUND: Existing systematic reviews have compared the effectiveness of nurse-led peri-discharge interventions comprising different components with usual care on reducing all-cause 30-day hospital readmissions. However, conflicting results were reported. OBJECTIVE: We conducted a network meta-analysis to evaluate the comparative effectiveness of different nurse-led peri-discharge interventions, compared with usual care, for reducing all-cause 30-day hospital readmissions. DESIGN: Network meta-analysis. METHODS: A total of five international databases were searched for systematic reviews of randomized controlled trials. Additional searches for most updated randomized controlled trials published between 2014 to 2019 were conducted. Data from included randomized controlled trials were extracted for random-effect pairwise meta-analyses. Pooled risk ratios with 95% confidence interval were used to quantify impact of nurse-led peri-discharge interventions on all-cause 30-day hospital readmissions. Network meta-analysis was used to evaluate the comparative effectiveness of different interventions. RESULTS: From two systematic reviews and additional randomized controlled trial searches, 12 eligible randomized controlled trials (n=150,840) assessing 15 different nurse-led peri-discharge interventions were included. For reducing all-cause 30-day hospital readmissions, pairwise meta-analysis showed that there was no significant difference between nurse-led peri-discharge interventions and usual care (pooled risk ratios = 0.86, 95% confidence interval: 0.71-1.04, moderate quality of evidence). Network meta-analysis indicated no significant difference across different interventions despite variation in complexity. CONCLUSIONS: Our results indicated that nurse-led peri-discharge interventions were not significantly different from usual care for reducing all-cause 30-day hospital readmissions. Simpler nurse-led peri-discharge interventions are on par with more complex interventions in terms of effectiveness. Benefits of nurse-led peri-discharge interventions may vary across health system context. Therefore, careful consideration is required prior to implementation. REGISTRATION DETAILS: The protocol for this study has been registered in PROSPERO (Registration No. CRD42020186938). Tweetable abstract: This study suggested that nurse-led peri-discharge interventions do not differ from usual care for reducing all-cause 30-day hospital readmissions.

Characteristics and well-being of urban informal home care providers during COVID-19 pandemic: a population-based study.

OBJECTIVES: Globally, the COVID-19 pandemic has overwhelmed many healthcare systems, which has hampered access to routine clinical care during lockdowns. Informal home care, care provided by non-healthcare professionals, increases the community's healthcare capacity during pandemics. There is, however, limited research about the characteristics of informal home care providers and the challenges they face during such public health emergencies. DESIGN: A random, cross-sectional, population-based, RDD, telephone survey study was conducted to examine patterns of home care, characteristics of informal home care providers and the challenges experienced by these care providers during this pandemic. SETTING: Data were collected from 22 March to 1 April 2020 in Hong Kong, China. PARTICIPANTS: A population representative study sample of Chinese-speaking adults (n=765) was interviewed. PRIMARY AND SECONDARY OUTCOME MEASURES: The study examined the characteristics of informal home care providers and self-reported health requirements of those who needed care. The study also examined providers' self-perceived knowledge to provide routine home care as well as COVID-19 risk reduction care. Respondents were asked of their mental health status related to COVID-19. RESULTS: Of the respondents, 25.1% of 765 provided informal home care during the studied COVID-19 pandemic period. Among the informal home care providers, 18.4% of respondents took leave from school/work during the epidemic to provide care for the sick, fragile elderly and small children. Care providers tended to be younger aged, female and housewives. Approximately half of care providers reported additional mental strain and 37.2% reported of challenges in daily living during epidemic. Although most informal home care providers felt competent to provide routine care, 49.5% felt inadequately prepared to cope with the additional health risks of COVID-19. CONCLUSION: During public health emergencies, heavy reliance on informal home healthcare providers necessitates better understanding of their specific needs and increased government services to support informal home care.

Involvement in shared decision-making for patients in public specialist outpatient clinics in Hong Kong.

OBJECTIVE: This study is a preliminary exploration of the association between patient involvement in decision-making and patient socioeconomic characteristics and experience in specialist outpatient clinics (SOPCs) in Hong Kong. METHODS: Cross-sectional telephone interviews were conducted using the Specialist Outpatient Experience Questionnaire (SOPEQ) in 26 Hospital Authority public SOPCs in Hong Kong. The SOPEQ was designed by The School of Public Health and Primary Care at The Chinese University of Hong Kong, fully taking into account both literature review and the local context of the public specialist outpatient system in Hong Kong. A total of 22,525 eligible participants were recruited for the study. RESULTS: There were 13,966 valid responses. The results indicated that the patients who had more involvement in decision-making were younger (odds ratio [OR] =2.10; 95% CI 1.75, 2.53), more highly educated (OR =1.67; 95% CI 1.45, 1.93), less likely to be receiving a government allowance (OR =0.61; 95% CI 0.57, 0.65), and less likely to be in the new case group (OR =0.84; 95% CI 0.78, 0.92). Participants living with their families (OR =3.38; 95% CI 2.03, 5.63) or who were unemployed (OR =1.10; 95% CI 1.01, 1.21) had a more decisive role in the decision- making process. Those participants who had been more involved in decision-making and wanted to continue being more involved had greater levels of satisfaction (mean =7.94; P<0.001) and a better health status (OR =0.49; 95% CI 0.41, 0.58). CONCLUSION: Engaging patients in their health care management remains a challenge in improving patient-centered care. Our results suggest that patient engagement is associated with perceived health status and the experience of using a health service. Understanding patients' characteristics and roles facilitates the development of preferred styles in the decision-making model.