Public Preference for Off-Label Use of Drugs for Cancer Treatment and Relative Importance of Associated Adverse Events: A Discrete Choice Experiment and Best-Worst Scaling.

BACKGROUND AND OBJECTIVE: Patients may get more treatment options with off-label use of drugs while exposed to unknown risks of adverse events. Little is known about the public or demand-side perspective on off-label drug use, which is important to understand how to use off-label treatment and devise financial assistance. This study aimed to quantify public preference for off-label cancer treatment outcomes, process, and costs, and perceived importance of associated adverse events. METHODS: A discrete choice experiment and a best-worst scaling were conducted in Hong Kong in December 2022. Quota sampling was used to randomly select the study sample from a territory-wide panel of working-age adults. Preferences and willingness to pay (WTP) for treatment effectiveness, risk of adverse events, mode of drug administration, and availability of off-label treatment guidelines were estimated using a random parameter logit model and latent class model. The relative importance of different adverse events was elicited using Case 1 best-worst scaling. RESULTS: A total of 435 respondents provided valid responses. In the discrete choice experiment, the respondents indicated that extra overall survival as treatment effectiveness (WTP: HK$448,000/US$57,400 for 12-month vs 3-month extra survival) was the most important attribute for off-label drugs, followed by the risk of adverse events (WTP: HK$318,000/US$40,800 for 10% chance to have adverse event vs 55%), mode of drug administration (WTP: HK$42,000/US$5300 for oral intake vs injection), and availability of guidelines (WTP: HK$31,000/US$4000 for available versus not available). Four groups with distinct preferences were identified, including effectiveness oriented, off-label use refusal, oral intake oriented, and adverse event risk aversion. In the best-worse scaling, hypothyroidism, nausea/vomiting, and arthralgia/joint pain were the three most important adverse events based on the perceptions of respondents. Risk-averse respondents, who were identified from the discrete choice experiment, had different perceived importance of the adverse events compared with those with other preferences. CONCLUSIONS: Knowing the preference and WTP for cancer treatment-related characteristics from a societal perspective facilitates doctors' communications with patients on decision making and treatment goal-setting for off-label treatment, and enables devising financial assistance for related treatments. This study also provides important insight to inform evaluations of public acceptance and information dissemination in drug development as well as future economic evaluations.

Patient experience and satisfaction with shared decision-making: A cross-sectional study among outpatients.

OBJECTIVES: This study aimed to investigate how doctor-patient communication, trust in doctors impacted patients' experience and satisfaction in shared decision-making (SDM). METHODS: This study is based on the data from a cross-sectional survey (n = 12,401) conducted in 27 public specialist outpatient clinics in Hong Kong. RESULTS: The multivariable regression models revealed that doctors' better communication skills were associated with lower decision-making involvement (odd ratio, 0.75 [95 % CI, 0.88-0.94], P < .001) but higher satisfaction with involvement (odd ratio, 6.88 [95 % CI, 5.99-7.93], P < .001). Similarly, longer consultation durations were associated with reduced involvement in decision-making (odd ratio, 0.71 [95 % CI, 0.66-0.73], P < .001) but increased satisfaction with involvement (odd ratio, 1.91 [95 % CI, 1.80-2.04], P < .001). Trust in doctors significantly mediated these associations, except for the association between consultation duration and patients' satisfaction with decision-making involvement. CONCLUSION: Doctors' better communication skills and longer consultations might not necessarily increase patient involvement in SDM but correlated with increased satisfaction with involvement. Trust in doctors emerged as a mediator for participation and satisfaction in decision-making. PRACTICE IMPLICATIONS: Clinics should consider patients' preferences and capabilities when tailoring communication strategies about decision-making and optimizing patient satisfaction.

The risk of hospitalization associated with hot nights and excess nighttime heat in a subtropical metropolis: a time-series study in Hong Kong, 2000-2019.

Background: Recent studies showed increased mortality risks after hot nights, but their effect on hospitalizations, especially in vulnerable populations, remains under-studied. Methods: Daily hospitalization, meteorological (including hourly), and air pollution data were collected for the hot seasons (May-October) of 2000-19 in Hong Kong. We derived three hot-night metrics: HNday28 °C, daily minimum temperature ≥28 °C, the governmental definition of hot nights; HNe, hot night excess calculated by summing heat excess of hourly temperatures above 28 °C at night; and HNday90th, hot nights classified using the 90th percentile HNe (17.7 °C⋅h) as a cutoff. We fitted time-series regression with distributed lag nonlinear models to examine the associations of hot-night metrics with various hospitalizations. Findings: During the 3680 study days, 5,002,114 non-cancer non-external (NCNE) hospitalizations were recorded. Half (1874) of the days experienced excess nighttime heat (HNe>0) with a mean (SD) of 8.0 (6.8) °C⋅h; 499 and 187 hot nights were identified by HNday28 °C and HNday90th, respectively. Extreme HNe (99th percentile vs 0 °C⋅h) was significantly associated with increased NCNE hospitalizations over lag 0-4 days by 3.1% [95% confidence interval: 1.5%, 4.8%] overall, with enhanced effects in elderly (5.3% [3.2%, 7.4%]), low-SES individuals (5.3% [2.8%, 8.0%]), and circulatory admissions (3.4% [0.2%, 6.8%]). HNday90th, reflecting extreme HNe, better identified hazardous hot nights than the official HNday28 °C. Interpretation: Excessive nighttime heat is significantly associated with increased hospitalizations, particularly affecting the elderly and socioeconomically disadvantaged individuals. Nighttime heat intensity should be incorporated in defining hot nights with public health relevance. Funding: British Heart Foundation.

Invitation strategy of vaginal HPV self-sampling to improve participation in cervical cancer screening: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Human papillomavirus (HPV) self-sampling is recognized as a feasible option for enhancing screening for cervical cancer, particularly among hard-to-reach women. The magnitude of the effectiveness of screening participation under different invitation strategies was reported. This review seeks to compare the effectiveness of invitation strategies in increasing screening participation of HPV self-sampling across diverse study settings. METHODS: A systematic literature search was conducted in Embase, MEDLINE, and PubMed in April 2023. Articles were included if (1) their target participants were aged between 25 and 70 years; (2) participants in the intervention arm were randomized to receive HPV self-sampling devices through various invitation strategies; (3) participants in the control arm who either received invitations for cervical cancer screening other than HPV self-sampling or opportunistic screening as usual care; (4) studies that provided sufficient data on screening participation in HPV self-sampling as outcome measured. The study design of the included articles was limited to randomized controlled trials. RESULTS: A total of 15 articles were included in this review. Invitation strategies of disseminating HPV self-sampling devices included opt-out and opt-in. Meta-analysis revealed screening participation in the self-sampling group was significantly greater than control arm (OR 3.43, 95% CI 1.59-7.38), irrespective of the invitation strategy employed. Among invitation strategies, opt-out appeared to be more effective on increasing screening participation, compared to control and opt-in strategy (opt-out vs. control OR 3.91, 95% CI 1.82-8.42; opt-in vs. control OR 1.34, 95% CI 0.28-6.39). CONCLUSIONS: Opt-out strategy is more successful at improving screening participation compared to opt-in and routine invitation to cervical screening. It is therefore a promising way to improve participation in cervical cancer screening. The findings of this review provide important inputs to optimize strategies for inviting women to participate in vaginal HPV self-sampling across the study setting, thus improving participation in cervical cancer screening.

Risk Factors Associated With General and Abdominal Obesity Among South Asian Minorities in Hong Kong.

South Asians have become a sizable ethnic minority in Hong Kong with unique health and social needs often being overlooked. Elevated obesity risk among South Asians has been highlighted in high-income Western settings; however, relevant local evidence is scarce. This cross-sectional study aims to explore the obesity prevalence and related risk factors among South Asians in Hong Kong. Between June 2022 and February 2023, 535 South Asian adults were recruited via territory-wide health outreach services, and completed a survey and anthropometric measurements on height, weight, and waist circumference. In our female-dominated sample (84.1% female; mean age = 41.0 ± 12.3 years), the observed prevalence of general obesity (body mass index [BMI] ≥ 27.5 kg/m2 for South Asians) and abdominal obesity (waist-to-height ratio [WHtR] > 50%) were 60.2% and 89.4%, respectively. Results from multivariable linear regressions showed that mean BMI and WHtR were significantly higher among women and Pakistani individuals (and Nepalese individuals for BMI only) but lower among better educated and employed respondents. Apart from age, household size, and marital status as common risk factors, having a healthier diet and higher physical activity level were also associated with lower WHtR. Notably, the associations of female gender and Pakistani ethnicity were attenuated after adjustments for socioeconomic and lifestyle factors. In conclusion, there was a high prevalence of obesity in South Asian participants in this study. The identified risk and protective factors could inform targeted services and community-based weight management programs to mitigate obesity and its associated cardiometabolic risks in this fast-growing but vulnerable community.

The influence of written medication reminder on patient experience among older adult patients: a repeat cross-sectional study.

BACKGROUND: Older adult patients are particularly vulnerable to medication-related issues during the discharge process. To enhance medication discharge education and patient experience, a written medication reminder, incorporating crucial medication side effects and warning signs, was implemented in medicine wards. This study aimed to examine the influence of this reminder on patient experience and medication-taking behaviors among older adults in public healthcare settings. METHODS: Two separate rounds of cross-sectional surveys were conducted before and after the program implementation among different discharged patients in each round. The study enrolled older adult patients aged ≥ 65 or their caregivers discharged from the medical wards of four pilot public hospitals in Hong Kong. A structured questionnaire was administered via telephone within 14 days of the patient's discharge. The survey assessed patients' experience with the provided medication information during discharge, including the clarity, adequacy, and usefulness of the information, as well as their overall experience with inpatient services. The self-reported medication-taken behaviors, including adherence and side-effect encounters, were also measured. RESULTS: A total of 1,265 responses were collected before the implementation of the medication reminder, and 1,426 responses were obtained after the implementation. Pre/post-implementation survey comparison showed significant improvement in patient experience regarding the clarity of the provided medication information (7.93 ± 1.84 vs. 8.18 ± 1.69, P = 0.002), adequacy (7.92 ± 1.93 vs. 8.15 ± 1.76, P = 0.014), and usefulness (8.06 ± 1.80 vs. 8.26 ± 1.70, P = 0.017), significantly positive experience on the overall discharge information (ß coefficient, 0.43 [95%CI, 0.30 to 0.56]) and inpatient service (ß coefficient, 0.47 [95%CI, 0.32 to 0.61]). In addition, the side effects encounters were significantly lower in the post-implementation survey group (11.6% vs. 9.0%, P = 0.04) and no statistical difference was found in self-reported medication adherence between the two groups. CONCLUSIONS: The provision of written medication reminders on key medication risks effectively improved older adult patients' experience and reduced side effects without any unintended negative consequences. The findings can serve as a reference for similar settings seeking to enhance post-discharge care among older adult patients. Future studies could investigate the influence in other specialties and age groups and include clinical outcomes to test the program's effectiveness.

Age Differences in Electronic Mental Health Literacy: Qualitative Study.

BACKGROUND: Electronic mental health literacy (eMHL) is critical for accessing and effectively using digital mental health resources. However, there is a paucity of research on how eMHL varies across age groups. OBJECTIVE: This study aimed to investigate differences in eMHL among young, middle-aged, and older adults; provide insights into the needs, behaviors, and attitudes of different age groups in relation to digital mental health resources; and ultimately, inform the improvement of mental health services. METHODS: A qualitative investigation was conducted to examine the differences in eMHL across different age demographics in the Chinese population in 2023. The study sample comprised 3 distinct age groups: 18-34 years, 35-64 years, and 65 years and older. Participants were recruited through purposive sampling to ensure a diverse representation of the population. Data were collected through semistructured one-on-one interviews, which allowed for in-depth exploration of individual experiences and perceptions. The gathered data were subsequently subjected to rigorous thematic analysis to enable the identification and interpretation of recurring patterns and themes. RESULTS: The principal outcomes derived from these interviews were synthesized into 5 distinct dimensions: emotional needs, use of digital mental health resources, assessment of digital mental health information, engagement with social media to regulate emotions, and coping strategies. These dimensions were uniformly observed across the 3 age groups. CONCLUSIONS: We identified differences in knowledge, skills, and attitudes regarding the use of web-based information for managing mental health problems between the 3 age groups. The findings highlight the importance of age-specific strategies for improving eMHL.

Outcomes and Hospital Service Use Among Patients With COPD in a Nurse- and Allied Health-Led Clinic.

Importance: Multidisciplinary disease management efforts enable the improvement in lung function among patients with chronic obstructive pulmonary disease (COPD), but there is little evidence of its association with risks of adverse health outcomes and health care service use. Objective: To examine the association between the use of a nurse- and allied health-led primary care clinic for respiratory patients, namely the Nurse and Allied Health Clinic-Respiratory Care (NAHC-Respiratory), and their risks of mortality and morbidity and health care service use. Design, Setting, and Participants: This territory-wide, population-based, propensity-matched, retrospective cohort study used data from the electronic health records of all patients who used public health care services in Hong Kong, China, from January 1, 2010, to December 31, 2019. All patients with COPD treated in public outpatient clinics between January 1, 2010, and December 31, 2014, were included. Patients who attended NAHC-Respiratory and usual care only were propensity score-matched at a 1:2 ratio. Data analyses were conducted between August 2023 and April 2024. Exposure: Attendance at NAHC-Respiratory. Main Outcomes and Measures: All-cause and cause-specific mortality, incidence of COPD complications, and use of emergency department and inpatient services until the end of 2019 were compared between the NAHC-Respiratory and usual care participants using Cox proportional hazard regression, Poisson regression, and log-link gamma regression models after matching. Results: This study included 9048 eligible patients after matching, including 3093 in the exposure group (2814 [91.0%] men; mean [SD] age, 69.8 [9.5] years) and 5955 in the reference group (5431 [91.2%] men; mean [SD] age, 69.5 [11.7] years). Compared with patients in the usual care-only group (reference), patients in the exposure group had lower risks of all-cause mortality (hazard ratio [HR], 0.84; 95% CI, 0.78-0.90) as well as pneumonia-caused (HR, 0.85; 95% CI, 0.74-0.97), respiratory-caused (HR, 0.86; 95% CI, 0.77-0.96), and cardiovascular-caused (HR, 0.74; 95% CI, 0.59-0.93) mortality. Exposure was associated with reduced rates of emergency department visits (incidence rate ratio [IRR], 0.92; 95% CI, 0.86-0.98) and hospitalization through emergency department (IRR, 0.89; 95% CI, 0.83-0.95). Conclusions: In this cohort study, the use of a nurse- and allied health-led clinic in primary care settings was associated with reduced risks of mortality and use of hospital services among patients with COPD. These findings emphasize the important role of health care workers other than physicians in disease management in the primary care setting. The NAHC-Respiratory model and service components can be used to help improve primary care programs to benefit more patients with COPD.

Implementing the information system for older adult patients post-discharge self-management: a qualitative study.

BACKGROUND: Discharging older adult patients from the hospital poses risks due to their vulnerable conditions, complex instructions and limited health literacy. Insufficient information about medication side effects adds to patient concerns. To address this, a post-discharge information summary system was developed. While it has shown positive impacts, concerns exist regarding implementation fidelity. OBJECTIVE: This study employed a theory-driven approach to understand health providers' perspectives on effective implementation. METHOD: Individual semi-structured interviews were conducted via telephone with nurses, doctors and pharmacists from local public hospitals. All interviews were audio-recorded and transcribed verbatim. Theoretical Domains Framework (TDF) was applied for direct content analysis. Belief statements were generated by thematic synthesis under each of the TDF domains. RESULTS: A total of 98 participants were interviewed. Out of the 49 belief statements covering eight TDF domains, 19 were determined to be highly relevant to the implementation of the post-discharge information summary system. These TDF domains include knowledge, skills, social/professional role and identity, beliefs about consequences, intentions, memory, attention and decision processes, environmental context and resources and social influences. CONCLUSION: Our study contributes to the understanding of determinants in implementing discharge interventions for older adult patients' self-care. Our findings can inform tailored strategies for frontline staff, including aligning programme rationale with stakeholders, promoting staff engagement through co-creation, reinforcing positive programme outcomes and creating default settings. Future research should employ rigorous quantitative designs to examine the actual impact and relationships among these determinants.

Caregiver Employees' Mental Well-Being in Hong Kong.

BACKGROUND: The rapidly aging global population has increased the demand for caregivers. Many caregivers simultaneously engage in paid employment, and the dual role makes the needs of caregiver employees conceivably more remarkable. However, there is a gap in the literature about the specific needs of caregiver employees. METHOD: Caregiver employees (n = 1205) across Hong Kong caring for those ≥65 years were recruited for a cross-sectional face-to-face survey from December 2021 to January 2022, to evaluate mental well-being measured by the Short Warwick -Edinburgh Mental Well-being Scale. Univariate and multivariate analyses were conducted; significant variables (p < 0.05) were included in multiple linear regression, along with caregiver-friendly workplace policies' availability, to understand their association with their mental well-being. FINDINGS: The mean score of the Short Warwick-Edinburgh Mental Well-being Scale among caregiver employees in this study was 24.9, with 7.2% indicative of probable clinical depression and 10.0% possible mild depression. In addition, the current study showed that 30.2% of the caregiver employees felt distressed about the caregiving role. Among external factors, family support (measured by the Lubben Social Network Scale) and workplace culture (measured by the Marshall Supervision Subscale) positively correlated with mental well-being with regression coefficients of 0.252 (p < 0.001) and 0.482 (p < 0.001), respectively. In the fully adjusted model, a negative regression coefficient was observed for overall spillover (-0.050, p < 0.001) and Short Warwick-Edinburgh Mental Well-being Scale scores, while positive regression coefficients were observed for overall self-rate (0.041, p < 0.001), Lubben (0.124, p < 0.001), and corporate culture (0.365, p < 0.001). Better Short Warwick-Edinburgh Mental Well-being Scale scores were observed when caregiver-friendly workplace policies were clearly stated than when they were made on a case-by-case discretionary basis. CONCLUSIONS: Caregiver-friendly workplace policies may be critical to Hong Kong's sustainable future, both economically and socially, as they ensure a healthy and productive workforce to support an aging population.

Evaluating the impact of sugar-sweetened beverages tax on overweight, obesity, and type 2 diabetes in an affluent Asian setting: A willingness-to-pay survey and simulation analysis.

BACKGROUND: The potential health effects of taxing sugar-sweetened beverages (SSBs) has been insufficiently examined in Asian contexts. This study aimed to assess the impact of SSB taxation on the prevalence of obesity/overweight and type 2 diabetes mellitus (T2DM) in Hong Kong using a willingness-to-pay (WTP) survey and simulation analysis. METHODS: A random telephone survey was conducted with 1000 adults from May to June 2020. We used a contingent valuation approach to assess individuals' WTP for SSBs under four tax payment scenarios (5%, 10%, 40%, and 50% of the current market price). Based on the WTP, a simulation analysis was conducted to project changes in SSB purchase and associated reductions in the prevalence of obesity/overweight and T2DM over a 10-year simulation period. FINDINGS: When 5% and 10% taxation rates were introduced, approximately one-third of the population were unwilling to maintain their SSB purchase. Our simulation demonstrated a gradual decline in the prevalence of obesity/overweight and diabetes with a more pronounced decrease when higher taxation rates were introduced. 10% taxation resulted in a mean reduction of 1532.7 cases of overweight/obesity per 100 thousand population at the sixth year, while T2DM prevalence decreased by 267.1 (0.3%). CONCLUSIONS: This study underscores the effects of an SSB tax on purchase behaviors and health outcomes in an affluent Asia setting, with a more pronounced influence on adult population. These findings are expected to inform policymakers in making decisions regarding an effective and equitable tax rate on SSBs.

Effectiveness of a self-determination theory-based smoking cessation intervention plus instant messaging via mobile application for smokers with cancer: Protocol for a pragmatic randomized controlled trial.

BACKGROUND AND AIMS: Despite evidence that patients living with cancer who continue to smoke after diagnosis are at higher risk for all-cause mortality and reduced treatment efficacy, many cancer patients continue to smoke. This protocol is for a study to test the effectiveness of a self-determination theory-based intervention (quit immediately or progressively) plus instant messaging (WhatsApp or WeChat) to help smokers with cancer to quit smoking. DESIGN: This will be a multi-centre, two-arm (1:1), single-blind, pragmatic, individually randomized controlled trial. SETTING: Taking part will be specialist outpatient clinics in five major hospitals in different location-based clusters in Hong Kong. PARTICIPANTS: The sample will include 1448 Chinese smokers living with cancer attending medical follow-ups at outpatient clinics. INTERVENTIONS: The intervention group will receive brief advice (approximately 5-8 minutes) from research nurses in the outpatient clinics and then be invited to choose their own quit schedules (immediate or progressive). During the first 6-month follow-up period they will receive instant messaging with smoking cessation advice once per week for the first 3 months, and thereafter approximately once per month. They will also receive four videos, and those opting to quit progressively will receive a smoking reduction leaflet. The control group will also receive brief advice but be advised to quit immediately, and instant messaging with general health advice during the first 6-month follow-up period using the same schedule as the intervention group. Participants in both groups will receive smoking cessation leaflets. MEASUREMENTS: The primary outcome is biochemically validated smoking abstinence at 6 months, as confirmed by saliva cotinine level and carbon monoxide level in expired air. Secondary outcomes include biochemically validated smoking abstinence at 12 months, self-reported 7-day point prevalence of smoking abstinence at 6 and 12 months, self-reported ≥ 50% reduction of cigarette consumption at 6 and 12 months and quality of life at 6 and 12 months. All time-points for outcomes measures are set after randomization. COMMENTS: The results could inform research, policymaking and health-care professionals regarding smoking cessation for patients living with cancer, and therefore have important implications for clinical practice and health enhancement.

Social Support, Resilience, and Mental Health Among Three High-Risk Groups in Hong Kong: A Mediation Analysis.

Objectives: To compare the prevalence of anxiety/depression, resilience, and social support among nurses, foreign domestic helpers (FDHs), and residents living in subdivided units (SDUs), and to examine their associations in these high-risk groups in Hong Kong during Omicron waves. Methods: We recruited 1,014 nurses, 621 FDHs, and 651 SDU residents from December 2021 to May 2022 in this cross-sectional survey. The depression, anxiety, social support, and resilience levels were measured by the validated scales. The multivariate binary logistic regression and causal mediation analysis were applied to examine the associations. Results: We observed a prevalence of 17.7% in anxiety and 21.6% in depression which were the highest in SDU residents, followed by FDHs, and lowest in nurses. Social support was associated with increased resilience levels and decreased risks of anxiety/depression. The association of social support with mental disorders was partly mediated by resilience, accounting for 30.9% and 20.9% of the total effect of social support on anxiety and depression, respectively. Conclusion: Public health strategies should target improving social support and providing resilience-promoting interventions to help reduce mental disorders in vulnerable groups.

The EORTC QLU-C10D: the Hong Kong valuation study.

OBJECTIVE: The EORTC QLU-C10D is a new preference-based measure derived from the EORTC QLQ-C30. Country-specific value sets are required to support the cost-utility analysis of cancer-related interventions. This study aimed to generate an EORTC QLU-C10 value set for Hong Kong (HK). METHODS: A HK online panel was quota-sampled to achieve an adult general population sample representative by sex and age. Participants were invited to complete an online discrete choice experiment survey. Each participant was asked to complete 16 choice-pairs, randomly assigned from a total of 960 choice-pairs, each comprising two QLU-C10D health states and a duration attribute. Conditional and mixed logistic regression analyses were used to analyse the data. RESULTS: The analysis included data from 1041 respondents who had successfully completed the online survey. The distribution of sex did not differ from that of the general population, but a significant difference was found among age groups. A weighting analysis for non-representative variable (age) was used. Utility decrements were generally monotonic, with the largest decrements for physical functioning (- 0.308), role functioning (- 0.165), and pain (- 0.161). The mean QLU-C10D utility score of the participants was 0.804 (median = 0.838, worst to best = - 0.169 to 1). The value of the worst health state was - 0.223, which was sufficiently lower than 0 (being dead). CONCLUSIONS: This study established HK utility weights for the QLU-C10D, which can facilitate cost-utility analyses across cancer-related health programmes and technologies.

A scoping review of implementation science theories, models, and frameworks - an appraisal of purpose, characteristics, usability, applicability, and testability.

BACKGROUND: A proliferation of theories, models, and frameworks (TMFs) have been developed in the implementation science field to facilitate the implementation process. The basic features of these TMFs have been identified by several reviews. However, systematic appraisals on the quality of these TMFs are inadequate. To fill this gap, this study aimed to assess the usability, applicability, and testability of the current TMFs in a structured way. METHODS: A scoping review method was employed. Electronic databases were searched to locate English and Chinese articles published between January 2000 and April 2022. Search terms were specific to implementation science. Additionally, hand searches were administered to identify articles from related reviews. Purpose and characteristics such as the type of TMF, analytical level, and observation unit were extracted. Structured appraisal criteria were adapted from Birken et al.'s Theory Comparison and Selection Tool (T-CaST) to conduct an in-depth analysis of the TMFs' usability, applicability, and testability. RESULTS: A total of 143 TMFs were included in this analysis. Among them, the most common purpose was to identify barriers and facilitators. Most TMFs applied the descriptive method to summarize the included constructs or the prescriptive method to propose courses of implementation actions. TMFs were mainly mid-range theories built on existing conceptual frameworks or demonstrated grand theories. The usability of the TMFs needs to be improved in terms of the provision of conceptually matched strategies to barriers and facilitators and instructions on the TMFs usage. Regarding the applicability, little attention was paid to the constructs of macro-level context, stages of scale-up and sustainability, and implementation outcomes like feasibility, cost, and penetration. Also, fewer TMFs could propose recommended research and measurement methods to apply the TMFs. Lastly, explicit hypotheses or propositions were lacking in most of the TMFs, and empirical evidence was lacking to support the claimed mechanisms between framework elements in testability. CONCLUSIONS: Common limitations were found in the usability, application, and testability of the current TMFs. The findings of this review could provide insights for developers of TMFs for future theoretical advancements.

Thinking beyond the virus: perspective of patients on the quality of hospital care before and during the COVID-19 pandemic.

Objectives: The COVID-19 pandemic has a huge impact on the healthcare system and affects the normal delivery of routine healthcare services to hospitalized patients. This study aimed to examine the differences in patient experience of hospital service before and during COVID-19 among the discharged adult population. Methods: A territory-wide patient experience survey was conducted before and during COVID-19 (between October 2019 and April 2020) among patients discharged from the main acute and rehabilitation public hospitals in Hong Kong. A hierarchical ordinal logistic model was employed to examine the difference in multiple dimensions of patient experience, with adjustments of covariates. Results: In total, 9,800 participants were recruited. During the pandemic, there was a marginally significant increase in overall care rating (AOR: 1.12, 95% CI: 0.99-1.27), and an improvement in the timeliness of admission. However, significant reductions in patients' confidence in nurses were observed. Communication of information regarding medication side effects reduced significantly (AOR: 0.72, 95% CI: 0.64-0.82). Conclusion: The patients hospitalized during the pandemic reported worse responsiveness in communication in their patient journey than those admitted before the pandemic. These findings will help develop appropriate strategies to address patients' concerns in the new normal.

Emergency Department Use Across Income Groups Following an Increase in Cost-Sharing.

Importance: To encourage the appropriate utilization of emergency care, cost-sharing for emergency care was increased from HK$100 (US $12.8) to HK$180 (US $23.1) per visit in June 2017 in all public hospitals in Hong Kong. However, there are concerns that this increase could deter appropriate emergency department (ED) visits and be associated with income-related disparities. Objective: To examine changes in ED visits after the fee increase. Design, Setting, and Participants: This retrospective cohort study used administrative data from June 2015 to May 2019 from all public hospitals in Hong Kong. Participants included all Hong Kong residents aged 64 years and younger, categorized into low-income, middle-income, and high-income groups according to the median household income in their district of residence. Data analysis was performed from May to June 2023. Main Outcomes and Measures: The primary outcome was the ED visit rate per 100 000 people per month, categorized into 3 severity levels (emergency, urgent, and nonurgent). Secondary outcomes include general outpatient (GOP) visit rate, emergency admission rate, and in-hospital mortality rate per month at public hospitals. Segmented regression analyses were used to estimate changes in the level and slope of outcome variables before and after the fee increase. Results: This study included a total of 5 441 679 ED patients (2 606 332 male patients [47.9%]; 2 108 933 patients [38.5%] aged 45-64 years), with 2 930 662 patients (1 407 885 male patients [48.0%]; 1 111 804 patients [37.9%] aged 45-64 years) from the period before the fee increase. The fee increase was associated with an 8.0% (95% CI, 7.1%-9.0%) immediate reduction in ED visits after June 2017, including a 5.9% (95% CI, 3.3%-8.5%) reduction in urgent visits and an 8.9% (95% CI, 8.0%-9.8%) reduction in nonurgent visits. In addition, a 5.7% (95% CI, 4.7%-6.8%) reduction of emergency admissions was found, whereas no significant changes were observed in in-hospital mortality. Specifically, a statistically significant increase in GOP visits (4.1%; 95% CI, 0.9%-7.2%) was found within the low-income group, but this association became insignificant after controlling for the social security group, who were exempted from payment, as a control. Conclusions and Relevance: In this cohort study, the fee increase was not associated with changes in ED visits for emergency conditions, but there was a negative and significant association with both urgent and nonurgent conditions across all income groups. Considering the marginal increase in public GOP services, further study is warranted to examine strategies to protect low-income people from avoiding necessary care.

Association between ambient BTEX mixture and neurological hospitalizations: A multicity time-series study in Taiwan.

BACKGROUND: Benzene, toluene, ethylbenzene, and xylenes, collectively known as BTEX, are hazardous chemical mixtures, and their neurological health effects have not been thoroughly evaluated. We examined the association between BTEX exposure and neurological hospital admissions. METHODS: This was a multicity time-series study conducted in five major Taiwanese cities. Daily hospital admission records for diseases of the nervous system from January 1, 2016, to December 31, 2017, were collected from the National Health Insurance Research Database. Ambient BTEX and criteria pollutant concentrations and weather factors were collected from Photochemical Assessment Monitoring Stations. We applied a Poisson generalized additive model (GAM) and weighted quantile sum regression to calculate city-specific effect estimates for BTEX and conducted a random-effects meta-analysis to pool estimates. RESULTS: We recorded 68 neurological hospitalizations per day during the study period. The daily mean BTEX mixture concentrations were 22.5 µg/m3, ranging from 18.3 µg/m3 in Kaohsiung to 27.0 µg/m3 in Taichung, and toluene (13.6 µg/m3) and xylene (5.8 µg/m3) were the dominant chemicals. Neurological hospitalizations increased by an average of 1.6 % (95 % CI: 0.6-2.6 %) for every interquartile range (15.8 µg/m3) increase in BTEX at lag 0 estimated using a GAM model. A quartile increase in the weighted sum of BTEX exposure was associated with a 1.7 % (95 % CI: 0.6-2.8 %) increase in daily neurological hospitalizations. CONCLUSION: We found consistent acute adverse effects of BTEX on neurological hospitalizations in Taiwan, with toluene and xylene as the dominant chemicals. These findings aid the development of more targeted public health interventions.

Relative Validity of a Short Food Frequency Questionnaire for Disadvantaged Families in Hong Kong.

Individuals with lower socioeconomic status are more vulnerable in securing good nutritional quality. It was also found that people who had received a lower education level had greater difficulty in completing the conventional dietary assessment such as a food frequency questionnaire (FFQ). Previous studies have demonstrated the validity of a short FFQ in Hong Kong's pregnant women, but its validity among a wider community was still unknown. For the present study, we aimed to validate a short FFQ among disadvantaged communities in Hong Kong. Amongst 103 individuals participating in a dietary intervention programme, their dietary data were collected by FFQs and three-day dietary records. Relative validity was assessed by correlation analysis, cross-tabulation, one-sample t-test, and linear regression. In general, water and total energy intake had significant correlations (0.77 for crude water intake and 0.87 for crude total energy intake) between values reported by FFQ and dietary records, good agreement (both with over 50% of observations falling into the same quartile), and insignificant differences between assessment methods reported by one-sample t-test and linear regression. Meanwhile, several nutrients had good agreement in terms of the values reported by FFQ and dietary records, such as energy from total fat, carbohydrates, total fat, cholesterol, phosphorus, and potassium. The results of this study demonstrated that the short version FFQ could be a convenient assessment tool of multiple dietary behaviors, especially in total energy and water intakes.

Validation of the accident and emergency experience questionnaire: a cross-sectional survey.

BACKGROUND: Patient feedback is an important way for healthcare providers to understand patient experience and improve the quality of care effectively and facilitate patient-centered care in the healthcare system. This study aimed to suggest a validated instrument by evaluating the psychometric properties of the Accident and Emergency Experience Questionnaire (AEEQ) for measuring patient experience in the accident and emergency department (AED) service among the adult Chinese population. METHODS: Attendances aged 18 or above from all public hospitals with AEDs during 16-30 June 2016 were targeted and a cross-sectional telephone survey was conducted using AEEQ. Preliminary AEEQ consisted of 92 items, including 53 core evaluative items and 19 informative items, and the other 20 items covered socio-demographics, self-perceived health status, and free open-ended comments on AED service. Psychometric properties of the evaluative items were evaluated for practicability, content and structure validity, internal consistency, and test-retest reliability in this study. RESULTS: A total of 512 patients were recruited with a response rate of 54% and a mean age of 53.2 years old. The exploratory factor analysis suggested removing 7 items due to weak factor loadings and high cross-loading and then leaving 46 items grouped into 5 dimensions, which were care and treatment (14 items), environment and facilities (16 items), information on medication and danger signals (5 items), clinical investigation (3 items), and overall impression (8 items) to represent patient experience on AED service. The internal consistency and test-retest reliability were high with Cronbach's alpha coefficient and Spearman's correlation coefficient of the suggested scale of 0.845 and 0.838, respectively. CONCLUSION: The AEEQ is a valid and reliable instrument to evaluate the AED service which helps to build the engagement platform for promoting patient-centered care between patients and frontline healthcare professionals and improving healthcare quality in the future.