'Improving smart medication management': an online expert discussion.

Medication safety continues to be a problem inside and outside the hospital, partly because new smart technologies can cause new drug-related challenges to prescribers and patients. Better integrated digital and information technology (IT) systems, improved education on prescribing for prescribers and greater patient-centred care that empowers patients to take control of their medications are all vital to safer and more effective prescribing. In July 2021, a roundtable discussion was held as a spin-off meeting of the International Forum on Quality and Safety in Health Care Europe 2021 to discuss challenges and future direction in smart medication management. This manuscript summarises the discussion focusing on the aspects of digital and IT systems, safe prescribing, improved communication and education, and drug adherence.

Is it Possible to Make Everyone Talk in the Same Language?

Speaking the same language is a vital pre-requisite in verbal communication. The same applies in sharing health information among medical professionals in rendering care to patients. The Hospital Authority of Hong Kong developed its own clinical vocabulary table (HACVT) for clinicians to document diagnoses and procedures directly in the Clinical Management System (CMS) since 1996. HACVT is referenced to international classifications and reference terminologies, with local terms added and is built according to the principles of terminology management [1]. This poster describes the process of data standardisation within the organisation in the past years to achieve data interoperability through different adoption methods of HACVT.

An Electronic Nursing Patient Care Plan Helps in Clinical Decision Support.

Information technology can help to improve health care delivery. The utilisation of informatics principle enhances the quality of nursing practices through improved communication, documentation and efficiency. The Nursing Profession constitutes 34% of the total workforce in the Hong Kong Hospital Authority (HA) and includes 21,000 nurses in 2012. To enhance the quality of care and patient safety in both hospitals and community care setting, it is essential that an integrated electronic decision support system for nurses is designed to track documentation and support care or service including observations, decisions, actions and outcomes throughout the care process at each point-of-care. The Patient Care Plan project was set up to achieve these objectives. The Project adheres to strict documentation information architecture to ensure data sharing is freely available. Preliminary results showed very promising improvement in clinical care.

Duration of initial antihypertensive prescription and medication adherence: a cohort study among 203,259 newly diagnosed hypertensive patients.

BACKGROUND: Optimal adherence with antihypertensive medications is crucial to prevent hypertension-related complications. This study evaluated whether the duration of initial antihypertensive prescription is associated with better medication adherence in a large sample of Chinese hypertensive patients. METHODS AND RESULTS: From a validated clinical database which consists of all patients in the public healthcare sector in Hong Kong, all patients on their first-ever antihypertensive agent from 2001 to 2005 (N=203,259) were included and followed-up for 12 months (and up to 5 years in separate analyses). The average age was 58.7 years (SD 17.3), and the overall rate of optimal adherence (as measured by having the Proportion of Days Covered≥0.80) was 32.4%. The proportion of patients whose initial prescriptions lasted for ≤6 days; 7-14 days; 15-28 days and ≥29 days was 23.7%, 24.3%, 15.1% and 37.0%, respectively. The corresponding proportion of optimal adherence was 18.1%, 20.1%, 31.0% and 50.3%. The binary logistic regression analysis showed that after controlling for age, sex, socioeconomic status, service type, drug class, and district of residence, those whose initial prescription was 7-14 days (adjusted odds ratio [AOR]=1.17, 95% C.I. 1.12-1.22); 15-28 days (AOR=1.90, 95% C.I. 1.82-1.99) and ≥29 days (AOR=4.13, 95% C.I. 3.96-4.31) were significantly more likely to be adherent than those who were prescribed for ≤6 days (all p<0.001). These findings remained significant in separate analyses where the period of follow-up was extended to 5 years. CONCLUSIONS: Shorter duration of first antihypertensive prescriptions was associated with poorer medication adherence, and this practice should be avoided if possible.

The incidence of cancer deaths among hypertensive patients in a large Chinese population: a cohort study.

Current evidence is mixed regarding the association between antihypertensive prescriptions and cancer mortality. We evaluated this association in a large Chinese hypertensive population. We followed for five years all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 in a public healthcare sector of Hong Kong. The association between antihypertensive drug class and cancer mortality was evaluated by Cox proportional hazard models with propensity score matching. Age, gender, socioeconomic status, service settings, district of residence, proportion of days covered reflecting medication adherence, and the number of comorbidities were adjusted. From 217,910 eligible patients, 9500 (4.4%) died from cancer within five years after their first-ever antihypertensive prescription. Most cancer deaths occurred in the digestive (38.9%) and respiratory system (30.4%); the breast (6.2%); and the lympho-hematopoietic tissues (5.3%). The proportion of patients who died from cancer was the highest in the calcium channel blocker (CCB) group (6.5%), followed by thiazide diuretics (4.4%), angiotensin converting enzyme inhibitors (4.2%) and ß-blockers (2.6%). When compared with ß-blockers, patients prescribed CCBs (Adjusted Hazard Ratio [AHR]=1.406, 95% C.I. 1.334-1.482, p<0.001) were more likely to die from cancer. Thiazide users were also more likely to suffer from cancer deaths (AHR=1.364, 95% C.I. 1.255-1.483, p<0.001), but became insignificant in stratified analysis. The association between cancer mortality and use of CCB, and perhaps thaizide, may alert physicians to the need for more meticulous and comprehensive care of these patients in clinical practice. We recommend prospective studies to evaluate cause-and-effect relationships of these associations.

Factors associated with multimorbidity and its link with poor blood pressure control among 223,286 hypertensive patients.

Multimorbidity has become the norm worldwide as populations age. It remains, however, infrequently researched. This study evaluated factors associated with multimorbidity in a predominantly Chinese hypertensive population. We included all adult patients prescribed their first antihypertensive agents in the entire public sector in Hong Kong from a validated database. Multimorbidity was defined as having one or more medical conditions (cardiovascular diseases; respiratory diseases; diabetes or impaired fasting glucose; renal disease) in addition to hypertension. We studied the prevalence of multimorbidity and performed multinomial regression analyses to evaluate factors independently associated with multimorbidity. 223,286 hypertensive patients (average age of 59.9 years, SD 17.6) were included. The prevalence of having 0, 1 and ≥ 2 additional conditions was 59.6%, 32.8% and 7.5%, respectively. The most common conditions were cardiovascular disease (24.2%) and diabetes (23.0%), followed by respiratory disorders (14.6%) and renal disease (10.9%). Older age (>50 years), male sex, lower household income, receipt of social security allowance and suboptimal blood pressure control (>140 mmHg or >90 mmHg; >130 mmHg or >80 mmHg for diabetes patients; AOR = 3.38-4.49) were significantly associated with multimorbidity. There exists a synergistic effect among these variables as older (≥ 70 years), male patients receiving security allowance had substantially higher prevalence of multimorbidity (19.9% vs 7.5% among all patients). Multimorbidity is very common in hypertensive patients and its prevalence increased markedly with the presence of risk factors identified in this study. Hypertensive patients with multimorbidities should receive more meticulous clinical care as their blood pressure control tends to be poorer.

Cardiovascular mortality in hypertensive patients newly prescribed perindopril vs. lisinopril: a 5-year cohort study of 15,622 Chinese subjects.

BACKGROUND: Perindopril and lisinopril are two common ACE inhibitors prescribed for management of hypertension. Few studies have evaluated their comparative effectiveness to reduce mortality. This study compared the all-cause and cardiovascular related mortality among patients newly prescribed ACE inhibitors. METHODS: All adult patients newly prescribed perindopril or lisinopril from 2001 to 2005 in all public clinics or hospitals in Hong Kong were retrospectively evaluated, and followed up until 2010. Patients prescribed the ACE inhibitors for less than a month were excluded. The all-cause mortality and cardiovascular-specific (i.e. coronary heart disease, heart failure and stroke) mortality were compared. Cox proportional hazard regression model was used to assess the mortality, controlling for age, sex, socioeconomic status, patient types, the presence of comorbidities, and medication adherence as measured by the proportion of days covered. An additional model using propensity scores was performed to minimize indication bias. RESULTS: A total of 15,622 patients were included in this study, in which 6910 were perindopril users and 8712 lisinopril users. The all-cause mortality (22.2% vs. 20.0%, p<0.005) and cardiovascular mortality (6.5% vs. 5.6%, p<0.005) were higher among lisinopril users than perindopril users. From regression analyses, lisinopril users were 1.09-fold (95% C.I. 1.01-1.16) and 1.18-fold (95% C.I. 1.02-1.35) more likely to die from any-cause and cardiovascular diseases, respectively. Age-stratified analysis showed that this significant difference was observed only among patients aged >70 years. The additional models controlled for propensity scores yielded comparable results. CONCLUSIONS: The long-term all-cause and cardiovascular related mortality rates of lisinopril users was significantly different from those of perindopril users. These findings showed that intra-class variation on mortality exists among ACE inhibitors among those aged 70 years or older. Future studies should consider a longer, large-scale randomized controlled trial to compare the effectiveness between different medications in the ACEI class, especially among the elderly.

The effectiveness of metoprolol versus atenolol on prevention of all-cause and cardiovascular mortality in a large Chinese population: a cohort study.

BACKGROUND: Existing trials almost exclusively used atenolol to represent the entire ß-blocker class, and it is unknown whether there are intra-class differences. We compared the incidence of all-cause and cardiovascular mortality, blood pressure (BP) control and adherence levels between patients newly prescribed atenolol vs. metoprolol tartrate. METHODS: This cohort study included all public, clinical settings in Hong Kong between 2001 and 2005, followed up till 2010. We compared outcomes between 22,479 new atenolol users and 29,972 new metoprolol tartrate users. Cox proportional hazard regression analysis was used to evaluate the difference in mortality between drugs. Binary logistic regression analyses were used to compare the BP control rates and adherence levels. RESULTS: 7.0% and 13.1% died of any causes among atenolol and metoprolol users, respectively (p<0.005). The incidence of cardiovascular mortality among atenolol users was lower than metoprolol users (1.4% vs. 3.7%, p<0.001). When compared with atenolol users, metoprolol users were 1.13-fold (95% C.I. 1.06-1.20) and 1.56-fold (95% C.I. 1.27-1.90), respectively, more likely to experience all-cause and cardiovascular mortality; less likely to be drug adherent (adjusted relative risk [aRR]: 0.95, 95% C.I. 0.90-0.99, p=0.013); and less likely to achieve optimal overall BP control (aRR 0.94, 95% C.I. 0.90-0.99, p=0.023) and diastolic BP control (aRR 0.86, 95% C.I. 0.77-0.97, p=0.013). CONCLUSIONS: These findings imply an intra-class difference for beta-blockers when used as first-line antihypertensive prescriptions in real-life clinical settings which inform future clinical guidelines. More outcome studies on the effectiveness of different subtypes within other major antihypertensive drug classes are warranted.

Exposure to air pollutants and mortality in hypertensive patients according to demography: a 10 year case-crossover study.

This study evaluated whether short term exposures to NO2, O3, particulate matter <10 mm in diameter (PM10) were associated with higher risk of mortality. A total of 223,287 hypertensive patients attended public health-care services and newly prescribed at least 1 antihypertensive agent were followed-up for up to 5 years. A time-stratified, bi-directional case-crossover design was adopted. For all-cause mortality, significant positive associations were observed for NO2 and PM10 at lag 0-3 days per 10 µg/m(3) increase in concentration (excess risks 1.187%-2.501%). Significant positive associations were found for O3 at lag 1 and 2 days and the excess risks were 1.654% and 1.207%, respectively. We found similarly positive associations between these pollutants and respiratory disease mortality. These results were significant among those aged ≥65 years and in cold seasons only. Older hypertensive patients are susceptible to all-cause and respiratory disease-specific deaths from these air pollutants in cold weather.

Predictors of the incidence of all-cause mortality and deaths due to diabetes and renal diseases among patients newly prescribed antihypertensive agents: a cohort study.

BACKGROUND: Randomized trials have shown that the major antihypertensive drug classes are similarly effective to reduce mortality, but whether these drug class difference exists in clinical practice has been scarcely explored. This study evaluated the association between antihypertensive drug class, all-cause mortality and deaths due to diabetes or renal disease in real-life clinical settings. METHODS: A clinical database in Hong Kong included all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 from the public healthcare sector. All patients were followed up for five years, and grouped according to the initial antihypertensive prescription. The associations between antihypertensive drug class, all-cause mortality or combined diabetes and renal mortality, respectively, were evaluated by Cox proportional hazard models. RESULTS: From 218,047 eligible patients, 33,288 (15.3%) died within five years after their first-ever antihypertensive prescription and among which 1055 patients (0.48%) died of diabetes or renal disease. After adjusted for age, gender, socioeconomic status, service settings, district of residence, medication adherence, and the number of comorbidities, each drug class was similarly likely to be associated with mortality due to diabetes or renal disease [Adjusted Hazard Ratios (AHR) ranged from 0.92 to 1.73, p=0.287-0.939] and all-cause mortality (AHR ranged from 0.83 to 1.02) except for beta-blockers (AHR=0.815, 95% C.I. 0.68-0.87, p=0.024) when ACEI was used as a reference group in propensity score-adjusted analysis. CONCLUSIONS: These findings provide real-life evidence reinforcing that any major antihypertensive drug class is suitable as a first-line agent for management of hypertension as recommended by international guidelines.

Antihypertensive prescriptions over a 10-year period in a large Chinese population.

BACKGROUND: International guidelines recommending antihypertensive prescriptions for the management of hypertension have been published in the past decade. Beta-blocker use was discouraged by a significant body of evidence and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) were found more effective among younger patients. This study aims to evaluate the trends in prescription profiles in a large Chinese population because patterns of antihypertensive agent dispensation represent important information for physicians and policymakers. METHODS: From clinical databases consisting of all patient records in the public health-care system of Hong Kong, we examined all antihypertensive prescriptions according to the drug classes (thiazide diuretics, alpha-blockers, beta-blockers, calcium channel blockers (CCBs), ACEIs, ARBs, fixed-dose combinations, and polytherapy (2, ≥3)) between 2001 and 2010. We retrieved >6.3 million prescription episodes for 223,287 patients. RESULTS: The average age of the patients was 59.9 years (SD = 17.6), and 54.8% were women. According to prescription episodes, the most commonly prescribed medications were beta-blockers (31.7%) and CCBs (29.2%), followed by ACEIs (13.9%), thiazide diuretics (5.0%), and alpha-blockers (4.5%). Between 2001 and 2010, the prescription proportions of beta-blockers decreased from 41.5% to 21.5%, whereas that of ARBs increased from 0.5% to 1.0% (P < 0.001, χ(2) test for trend). It was found that the decline of beta-blockers (71.0% to 35.4%) and increase in ARB prescriptions (0.4% to 1.0%) were particularly marked among younger subjects aged <55 years. CONCLUSIONS: These findings provided information on the prescription patterns of antihypertensive agents in a large Chinese population. It sets a future research direction to study the various reasons influencing these drug class-specific trends.

Initial antihypertensive prescription and switching: a 5 year cohort study from 250,851 patients.

PURPOSE: Adverse effects of antihypertensive therapy incur substantial cost. We evaluated whether any major classes of antihypertensive drugs were significantly associated with switching as a proxy measure of medication side effects in a large Chinese population in Hong Kong. METHODS: From a clinical database, all adult patients newly prescribed an antihypertensive mono-therapy in Hong Kong between the years 2001-2003 and 2005 were included. Those who paid only one visit, died or stayed in the cohort for <180 days after the prescription, or prescribed more than one antihypertensive agent were excluded. The factors associated with switching at 180 days were evaluated by multivariate regression analyses. Age, gender, payment status, service type, district of residence, drug class, systolic and diastolic blood pressure levels were predictor variables. RESULTS: From 250,851 subjects, 159,813 patients were eligible. A total of 6,163 (3.9%) switched their medications within 180 days. Patients prescribed thiazide diuretics had the highest switching rate (5.6%), followed by ACEIs (4.5%), CCBs (4.4%) and beta-blockers (3.2%). When compared with ACEIs, patients on thiazide diuretics were significantly more likely to be switchers (adjusted odds ratio [AOR] 1.49, 95% C.I. 1.31-1.69, p<0.001), whilst patients prescribed CCBs and beta-blockers were similarly likely to have switching. Following these patients up for 5 years showed that thiazide had the most marked increase in switching rate. CONCLUSIONS: The higher rates of switching among thiazide diuretics in this study might raise a probably greater incidence of their adverse effects in this Chinese population, yet other factors might also influence switching rates. Patients prescribed thiazide diuretics for longer term should be observed for their intolerability.

Medication adherence to first-line antihypertensive drug class in a large Chinese population.

PURPOSE: Suboptimal adherence to antihypertensive agents leads to adverse clinical outcomes. This study aims to evaluate the association between first-line antihypertensive drug class and medication adherence in a large Chinese population. METHODS: All patients prescribed ≥ one antihypertensive drug in 2001-2003 and 2005 who have paid at least two consecutive clinic visits in the public healthcare system of Hong Kong were included. We excluded patients who have followed-up in the clinics for ≤ 30 days. Interval-based Proportion of Days Covered (PDC) was used to assess medication adherence. All patients were followed-up for up to 5 years. Binary logistic regression analysis was used to evaluate the factors associated with optimal adherence, defined as PDC ≥ 80%. RESULTS: From 147,914 eligible patients, 69.2% were adherent to the antihypertensive prescriptions. When compared with angiotensin converting enzyme inhibitors (ACEIs), patients initially prescribed α-blockers (adjusted odds ratio [AOR]=0.234, 95% C.I. 0.215-0.256), ß-blockers (AOR=0.447, 95% C.I. 0.420, 0.477), thiazide diuretics (AOR=0.431 95% C.I. 0.399, 0.466) and calcium channel blockers (AOR=0.451, 95% C.I. 0.423, 0.481) were significantly less likely to be drug adherers. Angiotensin receptor blockers (ARBs) and fixed-dose combination therapies were similarly likely to be medication adherent. Older age, male gender, visits in general out-patient clinics, residence in urbanized regions, and the presence of comorbidity were positively associated with optimal drug adherence. CONCLUSION: Patients receiving initial prescriptions of ACEIs, ARB and combination therapy had more favorable adherence profiles than the other major antihypertensive classes in real-life clinical practice.

Drug adherence and the incidence of coronary heart disease- and stroke-specific mortality among 218,047 patients newly prescribed an antihypertensive medication: a five-year cohort study.

BACKGROUND: Randomized trials have shown that optimal adherence to antihypertensive agents could protect against cardiovascular diseases, but whether adherence reduces cardiovascular deaths in community settings has not been explored so fully. This study evaluates the association between antihypertensive adherence and cardiovascular (coronary heart disease and stroke) mortality in the primary care settings. METHODS: From a territory-wide database in Hong Kong, we included all patients who were prescribed their first-ever antihypertensive agents in the years between 2001 and 2005 from the public healthcare sector. All patients were followed up for five years, and assigned as having poor (Proportion of Days Covered [PDC]<40%), intermediate (40-79%), and high (≥ 80%) adherence to antihypertensive agents. The association between antihypertensive adherence and cardiovascular mortality was evaluated by using the Cox proportional hazard models. RESULTS: From a total of 218,047 eligible patients, 3825 patients (1.75%) died of cardiovascular disease within five years after having received their first-ever antihypertensive agents. The proportions of patients having poor, intermediate, and high medication adherence were 32.9%, 12.1%, and 55.0%, respectively. Higher adherence levels at PDC 40%-79% (HR=0.46, 95% C.I. 0.41-0.52, p<0.001) and ≥ 80% (HR=0.91, 95% C.I. 0.85-0.98, p=0.012) were significantly less likely to be associated with mortality than the poor adherence (PDC0.040) group. CONCLUSIONS: Better antihypertensive adherence was associated with lower cardiovascular mortality. This highlights the need to promote adherence through strategies which have been proved to be effective in clinical settings.

A territory-wide electronic health record--from concept to practicality: the Hong Kong experience.

In Hong Kong, a pilot project is being undertaken to implement a web-based electronic patient record system to allow integrated, real time patient based information to be shared in clinics, private and public hospitals. Such sharing aims to ensure that complete and accurate healthcare information is available to citizens' multiple points of care through a stable IT system. A challenge is to share this electronic information whilst ensuring privacy and security. Hong Kong has achieved its initial goals and pioneered in building a territory-wide electronic health record (EHR). This paper will outline the tasks involved, approach, method used and initial review of the pilot project. Barriers to implementation are discussed and critical success factors are identified.

Building a womb-to-tomb health record in Hong Kong--an application of information architecture.

The Hospital Authority developed the Information Architecture (IA) model in 2002 to support a fast, robust, flexible and accurate electronic patient record (ePR) to meet the high-tempo health care environment in Hong Kong. With several successful applications in sharing data that were created for the same patients in various systems, the IA model was further developed to extend the longitudinal ePR to include one's fetal data as entered in the mother's record. This paper describes how various IA elements: Section, View, Form, Group, Entity, Content, Document supports the building of a true womb-to-tomb ePR for the HA patients. The future focus of Information Architecture in the HA will include building a Information Architecture Management System and linking the ePR with other patient records in the community.

Structured data entry of clinical information for documentation and data collection.

Routine databases containing large amounts of clinical data represent a tremendous opportunity for the evaluation of health care practices and outcomes. However, data collected for administrative purposes has limitations in content, accuracy and completeness. Routine entry of clinical information directly into clinical information systems by care providers is one strategy to address this problem. We developed a structured data entry method, the Clinical Data Framework (CDF), which has been used to support the capture of clinical information by clinicians in the normal process of care delivery. A study of the CDF over a two month period showed that it improved the accuracy of completeness of data collection over a coding method which was based on selection of ICD-9-CM codes.

Independent association of rheumatoid factor and the HLA-DRB1 shared epitope with radiographic outcome in rheumatoid arthritis.

OBJECTIVE: Findings of a recent study suggested that HLA-DRB1 alleles encoding the rheumatoid arthritis (RA) "shared epitope" (SE) were not predictive of erosive damage at 2 years in patients with early inflammatory arthritis who were rheumatoid factor (RF) positive, but were predictive in those who were RF negative. The present study was undertaken to determine whether RF status was also important in the association between the SE and radiographic outcome in patients with longstanding RA. METHODS: The association between radiographic outcome, HLA-DRBI, and RF status was examined in 299 RA patients with established disease (5-30 years). Radiographic outcome was measured by scoring radiographs of the hands and feet using the standard radiographs of Larsen. HLA-DRB1 typing was performed using polymerase chain reaction methodology. Results were stratified by RF status and analyzed by multiple regression. RESULTS: An association between radiographic severity and the SE was found in RF-, but not RF+, patients. RF- patients carrying an SE allele had higher Larsen scores than RF- patients lacking the SE, although there was no association with SE dosage. The mean Larsen score was significantly higher in RF+ patients than in RF- patients, but there were no differences between RF+ patients with 0, 1, or 2 SE alleles. Multiple regression analysis confirmed independent associations of RF and SE positivity with radiographic outcome. No significant associations were found between RF and the SE, or RF and individual SE alleles. CONCLUSION: Our data indicate that RF and the SE are independently associated with radiographic outcome in RA. In RF+ patients with longstanding RA, there is no apparent association between the presence of the SE and radiographic damage. However, in RF-patients, although radiographic outcome is generally less severe, there is an association between severity and presence of the SE.

Medical informatics--the state of the art in the Hospital Authority.

Since its inception in 1990, the Hospital Authority (HA) has strongly supported the development and implementation of information systems both to improve the delivery of care and to make better information available to managers. This paper summarizes the progress to date and discusses current and future developments. Following the first two phases of the HA information technology strategy the basic infrastructural elements were laid in place. These included the foundation administrative and financial systems and databases; establishment of a wide area network linking all hospitals and clinics together; laboratory, radiology and pharmacy systems with access to results in the ward. A major push into clinical systems began in 1994 with the clinical management system (CMS), which established a clinical workstation for use in both ward and ambulatory settings. The CMS is now running at all major hospitals, and provides single logon access to almost all the electronically collected clinical data in the HA. The next phase of development is focussed on further support for clinical activities in the CMS. Key elements include the longitudinal electronic patient record (ePR), clinical order entry, generic support for clinical reports, broadening the scope to include allied health and the rehabilitative phase, clinical decision support, an improved clinical documentation framework, sharing of clinical information with other health care providers and a comprehensive data repository for analysis and reporting purposes.