Temporal trends in quality of primary care for patients with type 2 diabetes mellitus: A population-based retrospective cohort study after implementation of a quality improvement initiative.

BACKGROUND: This study examined whether temporal trends exist in treatment of patients with type 2 diabetes (T2D) and quality of diabetes care after implementation of quality improvement initiative in primary care setting. METHODS: We conducted a population-based retrospective cohort study of 202,284 patients with T2D who were routinely managed in primary care clinics. We examined the change over time and the variability between clinics in quality of care from Hospital Authority administrative data over a 5-year period (2009-2013) and used multilevel logistic regression to adjust for patient and clinic characteristics. Observational period was partitioned in 5 calendar years. Ten quality-of-care criteria were selected: adherence to 7 process of care criteria (HbA1c test, renal function test, full lipid profile, urine protein analysis, retinal screening, lipid-lowering agent prescriptions among patients with hypercholesterolaemia, and angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescriptions among patients with microalbuminuria) and 3 outcome of care criteria (HbA1c  ≤ 7%, BP ≤ 130/80 mmHg, and LDL-C ≤ 2.6 mmol/L). Variability of standards between clinics was assessed by using intracluster correlation coefficients. RESULTS: Characteristics of patients with T2D managed in primary care changed substantially during the observational period, with increasing age and usage of insulin and longer duration of diabetes but improved metabolic profiles (all P trend < .001). Performance rates of the 7 process and 3 clinical outcomes of care criteria increased remarkably over time (all P trend < .001). Variations in retinal screening delivery between clinics were considerable, albeit decreasing over time. CONCLUSIONS: Coinciding with implementation of quality improvement initiative, quality of diabetes care improved significantly in the past 5 years, in part attributable to benefits of integrated multidisciplinary diabetes management.

Quality of care and volume for patients with diabetes mellitus in the primary care setting: A population based retrospective cohort study.

AIMS: To examine the association of patient volume with quality of diabetes care in the primary care setting. METHODS: We analyzed population-based data from Hospital Authority administrative database using a Hong Kong representative sample of 187,031 diabetic patients managed in 74 primary care general outpatient clinics between 04/2011 and 03/2012. We assessed the associations between annual clinic-based patient volume and quality of care in terms of adherence to care criteria of process (HbA1c test, renal function test, full lipid profile, urine protein analysis, diabetic retinopathy screening, and appropriate drug prescription) and clinical outcomes (HbA1c⩽7%, BP⩽130/80mmHg, LDL-C⩽2.6mmol/L) of care criteria, with and without adjustment for patient and clinic characteristics. RESULTS: Patient volume was associated with three of seven process of care criteria; however, when compared to clinics in higher volume quartiles, those in lowest-volume quartile had more odds of HbA1c test (odds ratios (OR): 0.781, 0.655 and 0.646 for quartile from 2 to 4, respectively), renal function test (OR: 0.357, 0.367 and 0.590 for quartile from 2 to 4, respectively), and full lipid profile test (OR: 0.508, 0.612 and 0.793 for quartile from 2 to 4, respectively). There was no significant association between patient volume and the standards of achieving of HbA1c, BP and LDL-C outcome targets. CONCLUSIONS: Disparities in volume and quality of diabetes care were observed in public primary care setting. Lower patient volumes at clinic level were associated with greater adherence to three process criteria but a volume-outcome association was not present.

Main predictors in health-related quality of life in Chinese patients with type 2 diabetes mellitus.

PURPOSE: This study aimed to identify the predictors of decline in health-related quality of life (HRQOL) in Chinese patients with type 2 diabetes mellitus (T2DM). METHODS: A prospective longitudinal observational study was conducted on 1826 Chinese T2DM patients managed in public primary care setting. HRQOL was measured at baseline, 1 and 2 years by the Short Form-12 Health Survey version 2 (SF-12v2) and Chinese (HK) Short Form-6 Dimensions (SF-6D). Linear mixed effect models with forward stepwise method were performed to select the factors associated with SF-12v2 physical (PCS) and mental component summary (MCS) scores and SF-6D value. RESULTS: Over a 2-year observation period, the HRQOL (PCS: -0.626; MCS: -1.869; and SF-6D: -0.017 per year) scores decreased significantly with time. Female, unmarried, current smoker, no regular exercise, obesity, comorbid hypertension, chronic kidney disease (CKD) or cardiovascular disease (CVD) and insulin use were predictors of one or more poorer HRQOL scores after 12 or 24 months. Older age had a negative impact on PCS score and SF-6D value, but had a positive impact on MCS score. CONCLUSIONS: The HRQOL of Chinese T2DM patients under primary care declined significantly over time. Obesity, smoking and no regular exercise were found to be modifiable risk factors of the decline in HRQOL in T2DM, which strengthened the importance of these lifestyle changes in diabetes care. More attention should be given to T2DM patients who are female, older, unmarried, or on anti-hypertensive drugs or insulin, or have comorbid hypertension, CKD or CVD in minimizing the negative impact of illness on their life.

Validity and reliability of the 19-item Audit of Diabetes-Dependent Quality of Life (ADDQoL-19) questionnaire in Chinese patients with type 2 diabetes mellitus in primary care.

BACKGROUND: This study aimed to determine the psychometric properties of the 19-item Audit of Diabetes-Dependent Quality of Life (ADDQoL-19) in Chinese patients with type 2 diabetes mellitus (T2DM) in primary care setting. METHODS: The ADDQoL-19 and SF-12v2 were administered to 386 Chinese patients with T2DM in public primary outpatient clinic in Hong Kong. Internal consistency reliability was determined by Cronbach's alpha, whereas construct validity was assessed by the Spearman's correlations between the scores of the ADDQoL-19 and SF-12v2. Independent t tests were used in known-group comparisons to identify the differences in the ADDQoL-19 scores between respondents with different duration of diabetes, treatment modalities, body mass index and glycemic control. RESULTS: The ADDQoL-19 had a moderate to weak correlation with SF-12v2 in convergent validity but with statistically significant results in known-group comparisons. Good internal consistency was generated with an acceptable value of 0.81, which was comparable to original English version. Construct validity was proven except the convergent validity is found to be weak with the generic SF-12v2, which was similar to the results in prior psychometric studies. CONCLUSIONS: Despite weak convergent validity, the ADDQoL-19 was found to have a satisfactory psychometric property, especially known-group comparisons and internal consistency reliability in the primary care setting.

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

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

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

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

The Association of Types of Training and Practice Settings with Doctors' Empathy and Patient Enablement among Patients with Chronic Illness in Hong Kong.

BACKGROUND: The increase in non-communicable disease (NCD) is becoming a global health problem and there is an increasing need for primary care doctors to look after these patients although whether family doctors are adequately trained and prepared is unknown. OBJECTIVE: This study aimed to determine if doctors with family medicine (FM) training are associated with enhanced empathy in consultation and enablement for patients with chronic illness as compared to doctors with internal medicine training or without any postgraduate training in different clinic settings. METHODS: This was a cross-sectional questionnaire survey using the validated Chinese version of the Consultation and Relational Empathy (CARE) Measure as well as Patient Enablement Instrument (PEI) for evaluation of quality and outcome of care. 14 doctors from hospital specialist clinics (7 with family medicine training, and 7 with internal medicine training) and 13 doctors from primary care clinics (7 with family medicine training, and 6 without specialist training) were recruited. In total, they consulted 823 patients with chronic illness. The CARE Measure and PEI scores were compared amongst doctors in these clinics with different training background: family medicine training, internal medicine training and those without specialist training. Generalized estimation equation (GEE) was used to account for cluster effects of patients nested with doctors. RESULTS: Within similar clinic settings, FM trained doctors had higher CARE score than doctors with no FM training. In hospital clinics, the difference of the mean CARE score for doctors who had family medicine training (39.2, SD = 7.04) and internal medicine training (35.5, SD = 8.92) was statistically significant after adjusting for consultation time and gender of the patient. In the community care clinics, the mean CARE score for doctors with family medicine training and those without specialist training were 32.1 (SD = 7.95) and 29.2 (SD = 7.43) respectively, but the difference was not found to be significant. For PEI, patients receiving care from doctors in the hospital clinics scored significantly higher than those in the community clinics, but there was no significant difference in PEI between patients receiving care from doctors with different training backgrounds within similar clinic setting. CONCLUSION: Family medicine training was associated with higher patient perceived empathy for chronic illness patients in the hospital clinics. Patient enablement appeared to be associated with clinic settings but not doctors' training background. Training in family medicine and a clinic environment that enables more patient doctor time might help in enhancing doctors' empathy and enablement for chronic illness patients.

Assessing medical student empathy in a family medicine clinical test: validity of the CARE measure.

INTRODUCTION: The Consultation and Relational Empathy (CARE) measure developed and validated in primary care settings and used for general practitioner appraisal is a 10-item instrument used by patients to assess doctors' empathy. The aim of this study is to investigate the validity of the CARE measure in assessing medical students' empathy during a formative family medicine clinical test. METHOD: All 158 final-year medical students were assessed by trained simulated patients (SPs) - who completed the CARE measure, the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE), and a global rating score to assess students' empathy and history-taking ability. RESULTS: Exploratory and confirmatory factor analysis identified a unidimensional structure. The CARE measure strongly correlated with both convergent measures: global rating (ρ=0.79 and <0.001) and JSPPPE (ρ=0.77 and <0.001) and weakly correlated with the divergent measure: history-taking score (ρ=0.28 and <0.001). Internal consistency was excellent (Cronbach's α=0.94). CONCLUSION: The CARE measure had strong construct and internal reliability in a formative, undergraduate family medicine examination. Its role in higher stakes examinations and other educational settings should be explored.

Having a family doctor was associated with lower utilization of hospital-based health services.

BACKGROUND: Primary care in the United States and most countries in Asia are provided by a variety of doctors. However, effectiveness of such diversified primary care in gate-keeping secondary medical services is unknown. This study aimed to evaluate health services utilization rates of hospital emergency and admission services among people who used different primary care doctors in Hong Kong. METHOD: This study was a population-based cross-sectional telephone survey using structured questionnaire on health services utilization rates and pattern in Hong Kong in 2007 to 2008. Information on the choice of primary care doctors, utilization rates and patterns of primary care service were collected. Poisson and logistic regression analyses were used to explore any differences in service utilization rates and patterns among people using different types of primary care doctors. RESULTS: Out of 3148 subjects who completed the survey, 1896 (60.2%) had regular primary care doctors, of whom 1150 (60.7%) regarded their regular doctors as their family doctors (RFD). 1157 (36.8%) of them did not use any regular doctors (NRD). Only 4.3% of the RFD group (vs 7.8% of other regular doctors (ORD) and 9.6% of NRD) visited emergency service and only 1.7% (vs 3.6% of ORD and 4.0% of NRD) were admitted to hospital for their last episode of illness. Regression analyses controlling for sociodemographics and health status confirmed that respondents having RFD were less likely to use emergency service than people who had NRD (OR 0.479) or ORD (OR 0.624) or being admitted to hospital (OR 0.458 vs NRD and 0.514 vs ORD) for their last episode of illness. CONCLUSION: Primary care is the most effective in gate-keeping secondary care among people with regular family doctors. People without any regular primary care doctor were more likely to use emergency service as primary care. The findings supported a family doctor-led primary care model. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov ID: NCT01422031.

The associations of body mass index with physical and mental aspects of health-related quality of life in Chinese patients with type 2 diabetes mellitus: results from a cross-sectional survey.

BACKGROUND: This study aimed to determine the associations of various clinical factors with generic health-related quality of life (HRQOL) scores among Hong Kong Chinese patients with type 2 diabetes mellitus (T2DM) in the outpatient primary care setting using the short-form 12 (SF-12). METHODS: A cross-sectional survey of 488 Chinese adults with T2DM recruited from a primary care outpatient clinic was conducted from May to August 2008. Data on the standard Chinese (HK) SF-12 Health Survey and patients' socio-demographics were collected from face-to-face interviews. Glycaemic control, body mass index (BMI), chronic co-morbidities, diabetic complications and treatment modalities were determined for each patient through medical records. Associations of socio-demographic and clinical factors with physical component summary (PCS-12) and mental component summary scores (MCS-12) were evaluated using multiple linear regression. RESULTS: The socio-demographic correlates of PCS-12 and MCS-12 were age, gender and BMI. After adjustment for socio-demographic variables, the BMI was negatively associated with PCS-12 but positively associated with MCS-12. The presence of diabetic complications was associated with lower PCS-12 (regression coefficient:-3.0 points, p < 0.05) while being on insulin treatment was associated with lower MCS-12 (regression coefficient:-5.8 points, p < 0.05). In contrast, glycaemic control, duration of T2DM and treatment with oral hypoglycaemic drugs were not significantly associated with PCS-12 or MCS-12. CONCLUSIONS: Among T2DM subjects in the primary care setting, impairments in the physical aspect of HRQOL were evident in subjects who were obese or had diabetic complications whereas defects in the mental aspect of HRQOL were observed in patients with lower BMI or receiving insulin injections.

A short message service (SMS) intervention to prevent diabetes in Chinese professional drivers with pre-diabetes: a pilot single-blinded randomized controlled trial.

AIM: To determine the efficacy of delivering short-message service (SMS) to provide diabetes-related information in reducing the risk of developing diabetes in Chinese professional drivers with pre-diabetes. METHODS: A pilot single-blinded randomized controlled trial was conducted in Hong Kong between 05/2009 and 04/2012. Professional drivers with impaired glucose tolerance (IGT) were randomly allocated to either a SMS group receiving messages comprising knowledge and lifestyle modification on diabetes or to a control group with usual care. Primary outcomes were the incidence rate of diabetes mellitus over 12 and 24 months period. RESULTS: Fifty-four, out of 104 professional drivers recruited, were randomly allocated to intervention group. Fewer subjects developed diabetes at 12 months in intervention group (5.56%) compared to control group (16.00%). Relative risk (RR) of diabetes onset was 0.35 (95%CI: 0.10­1.24) and the number needed to treat (NNT) for preventing one diabetes was 9.57. At 24 months, RR increased to 0.62 (95%CI: 0.24­1.61) with a NNT of 10.58. Logistic regression showed a significant odds ratio of 0.04 (P = 0.021) for intervention group compared to control group at 12-month follow-up for completers and a non-significant odds ratio of 0.34 (P = 0.303) at 24-month follow-up. CONCLUSIONS: The SMS program proved to have potential to reduce the risk of developing diabetes at 12 months but additional measures should be integrated to prevent or delay disease progression.

Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients.

BACKGROUND: Type 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework. METHOD/DESIGN: For evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework.Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to monitor quality of life, patient enablement, global rating of change in health and private health service utilization at baseline, 6, 12, 36 and 60 months. DISCUSSION: The quality of care and effectiveness of the RAMP in enhancing the health for patients with type 2 diabetes will be determined. Possible areas for quality enhancement will be identified and standards of good practice can be established. The information will be useful in guiding service planning and policy decision making.

The impact of work nature, lifestyle, and obesity on health-related quality of life in Chinese professional drivers.

OBJECTIVE: To assess the association of work nature, lifestyle and obesity with health-related quality of life (HRQOL) in professional drivers. METHODS: A total of 3376 Chinese professional drivers aged 18 to 70 years were recruited to assess the HRQOL by SF-12 summary scores (Physical Component Summary [PCS]; Mental Component Summary [MCS]), and collect data for work nature, lifestyle, and body mass index. Factors associated with HRQOL were examined by multiphase regression analyses. RESULTS: Professional drivers reported poorer physical and mental HRQOL than the general population. Shift work and lorry driving had significant negative effect on HRQOL. Obesity was associated with lower PCS but higher MCS. CONCLUSIONS: HRQOL of professional drivers tended to be low, especially among lorry drivers and shift drivers. Health intervention programs should promote regular exercise, healthy eating, no smoking, and weight control, which are modifiable factors improving HRQOL.

The Chinese-version of the CARE measure reliably differentiates between doctors in primary care: a cross-sectional study in Hong Kong.

BACKGROUND: The Consultation and Relational Empathy (CARE) Measure is a widely used patient-rated experience measure which has recently been translated into Chinese and has undergone preliminary qualitative and quantitative validation. The objective of this study was to determine the reliability of the Chinese-version of the CARE Measure in reliably differentiating between doctors in a primary care setting in Hong Kong METHODS: Data were collected from 984 primary care patients attending 20 doctors with differing levels of training in family medicine in 5 public clinics in Hong Kong. The acceptability of the Chinese-CARE measure to patients was assessed. The reliability of the measure in discriminating effectively between doctors was analysed by Generalisability-theory (G-Theory) RESULTS: The items in the Chinese-CARE measure were regarded as important by patients and there were few 'not applicable' responses. The measure showed high internal reliability (coefficient 0.95) and effectively differentiated between doctors with only 15-20 patient ratings per doctor (inter-rater reliability > 0.8). Doctors' mean CARE measure scores varied widely, ranging from 24.1 to 45.9 (maximum possible score 50) with a mean of 34.6. CARE Measure scores were positively correlated with level of training in family medicine (Spearman's rho 0.493, p < 0.05). CONCLUSION: These data demonstrate the acceptability, feasibility and reliability of using the Chinese-CARE Measure in primary care in Hong Kong to differentiate between doctors interpersonal competencies. Training in family medicine appears to enhance these key interpersonal skills.

Using illness scripts to teach clinical reasoning skills to medical students.

BACKGROUND AND OBJECTIVES: Most medical students learn clinical reasoning skills informally during clinical rotations that have varying quality of supervision. We conducted a randomized controlled trial to determine if a workshop that uses "illness scripts" could improve students' clinical reasoning skills when making diagnoses of patients portrayed in written scenarios. METHODS: In 2007--2008, 53 fourth-year medical students were randomly assigned to either a family medicine (intervention) or psychiatry (control) clerkship at The Chinese University of Hong Kong. Students in the intervention group participated in a 3-hour workshop on clinical reasoning that used illness scripts. The workshop was conducted with small-group teaching using a Web-based set of clinical reasoning problems, individualized feedback, and demonstration of tutors' reasoning aloud. The effectiveness of the intervention was assessed using the Diagnostic Thinking Inventory (DTI) and the measurement of individual students' performance in solving clinical reasoning problems (CRP). RESULTS: The post-intervention overall DTI scores between groups were similar (mean difference 0, 95% confidence interval [CI]= -7.4 to 7.4). However, the total scores on the CRP assessment were 14% (95% CI=8% to 21%) higher in the intervention group than in controls. CONCLUSION: A workshop on illness scripts may have some benefit for improving diagnostic performance in clinical reasoning problems.

Reliability and validity of the Chinese version of the CARE Measure in a primary care setting in Hong Kong.

BACKGROUND: The Consultation and Relational Empathy (CARE) Measure is a validated patient-rated measure of consultation quality in the UK. OBJECTIVES: To provide preliminary evidence of the reliability and validity of a Chinese version of the CARE Measure in a primary care setting in Hong Kong. METHODS: Following translation, back-translation and pilot testing, a Chinese version of the CARE Measure was developed and tested on 253 unselected primary care patients in Hong Kong. RESULTS: The Chinese-CARE Measure was regarded by patients as being relevant to their consultations, with on average only 5.5% of patients rating the items as not important (range 3.6-10.2% for individual items), suggesting high acceptability and face validity. This was also supported by the relatively low number of 'not applicable' responses recorded for the measure (average 8.2%, range 0.4-21.7% for individual items). Internal reliability was high (Cronbach's alpha 0.962) and was reduced by the removal of any of the 10 items, and homogeneity was indicated by high corrected item-total correlations (0.786-0.876). Factor analysis showed a single solution for the Chinese-CARE Measure items with high item loadings (0.821-0.891). Construct validity was further supported by significant hypothesized relationships with other variables (patient enablement and patient satisfaction). Consultation length and continuity of care were independent predictors of Chinese-CARE Measure score in stepwise multiple regression analysis but together explained <10% of variation in CARE score. CONCLUSION: These preliminary data support the reliability and validity of the Chinese version of the CARE Measure in primary care in Hong Kong.

Familial and extramarital relations among truck drivers crossing the Hong Kong-China border.

The current study investigated potential associations between working conditions of truck drivers crossing the Hong Kong-China border, family relationships, extramarital affairs, and the attitudes that these male drivers held toward extramarital relationships. A cross-sectional survey of 193 male cross-border truck drivers from Hong Kong was conducted in 2004 using a 47-item multi-faceted questionnaire. No statistical significance was found between family relationship and many work parameters. However, extramarital relationships were related to poor marital relationships. Further study may help to nourish information and opinions regarding the interaction between the job nature and the family relationship.

A qualitative study of patients' views on quality of primary care consultations in Hong Kong and comparison with the UK CARE Measure.

BACKGROUND: Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population. METHODS: Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1-3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7-10). RESULTS: Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs). CONCLUSION: These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required.