Economic Evaluation of an Enhanced Post-Discharge Home-Based Care Program for Stroke Survivors.

OBJECTIVES: To examine the cost-effectiveness of an enhanced postdischarge home-based care program for stroke survivors compared with usual care. METHODS: This was a trial-based economic evaluation study. One hundred and sixteen patients with ischemic stroke were recruited from neurology units in a Chinese hospital and randomized into intervention (n = 58) or usual care groups (n = 58). The intervention commenced with predischarge planning and transitioned to home follow-up postdischarge. Trained nurse case managers supported by an interdisciplinary team provided comprehensive assessment, individualized goal setting, and skill training to support home-based rehabilitation for intervention group participants. Standard care was provided to usual care group participants. Total cost and quality-adjusted life-years gained at 3-month (T1), 6-month (T2), and 12-month (T3) follow-ups were calculated. The incremental cost-effectiveness ratios between the groups were obtained. RESULTS: The intervention group showed a significant increase in utility compared with the usual care group at T1 (P = .003), T2 (P = .007), and T3 (P < .001). The average total QALY gain from baseline for the intervention group was higher than for the usual care group at all time points. The likelihood of being cost-effective ranged from 61.9% to 67.2% from the provider perspective, and from 59.7% to 66.8% from the societal perspective. CONCLUSIONS: The results showed that the intervention program was cost-effective with significantly higher quality-adjusted life-years for stroke survivors when compared with usual care. It provides economic evidence to support the development of home-based stroke rehabilitation program, especially in the low- and middle-income countries.

An evaluation of a community-based vision care programme for the elderly.

BACKGROUND: This study evaluated the real-world effectiveness and potential cost-effectiveness of a community-based vision care programme for the elderly population aged 60 years or above. METHODS: Data from a total of 8899 subjects participating in a community-based comprehensive vision care programme from 2015 to 2019 were analysed to evaluate the effectiveness of the programme in terms of the prevalence of distance visual impairment (VI), the change in the prevalence of distance VI after refractive error correction, and the types of ocular disorders suspected. Distance VI was defined as a) visual acuity (VA) worse than 6/18 in any eye (worse eye) and b) VA worse than 6/18 in the better eye. The cost-effectiveness from the funder's perspective was also estimated in terms of cost per distance VI avoided. RESULTS: Based on the presenting vision of the worse eye, the prevalence of distance VI was 39.1% (3482/8899, 95% CI: 38.1%-40.1%) and reduced to 13.8% (1227/8899, 95% CI: 13.1%-14.5%) based on best-corrected VA. Referenced to the presenting vision of the better eye, the prevalence of distance VI was 17.3% (1539/8899, 95% CI: 16.5%-18.1%) and decreased to 4.2% (373/8899, 95% CI: 3.8%-4.6%) with best optical correction. Uncorrected refractive error was the major cause of presenting distance VI. From the funder's perspective, the cost per distance VI case prevented was HK$1921 based on VA in the worse eye and HK$3715 based on the better eye. CONCLUSION: This community-based programme identified distance VI in the best eye of 17 out of every 100 subjects. With appropriate new or updated distance optical corrections, distance VI was reduced to about 4 in 100 subjects. Visual impairment in the elderly is common even in a relatively affluent city. A model of care which could minimise avoidable distance VI would bring benefits at individual and societal levels.

Barriers to preventive care utilization among Hong Kong community-dwelling older people and their views on using financial incentives to improve preventive care utilization.

BACKGROUND: Financial incentive is increasingly used as a mean to promote preventive care utilization (PCU), but the current Elderly Health Care Voucher Scheme (EHCVS) in Hong Kong is ineffective for encouraging PCU. OBJECTIVE: To explore the older people's barriers to PCU and their views on financial incentive, including EHCVS, for improving private PCU. DESIGN AND SETTING: Focus-group discussions were conducted in community elderly centres located in five districts of Hong Kong. PARTICIPANTS: Community-dwelling older people aged 60 years or above. RESULTS: Lack of understanding about preventive care and low awareness of the need for preventive care were key factors for the low motivation for PCU. Uncertainty over the level of service fee charged and concerns over service quality hindered the choice of using the private service providers under the current EHCVS. Financial incentives specific for preventive care services were thought to be cues to actions and guides for service promotion. However, some flexibility in service coverage and a set time limit of the financial incentives were preferred to accommodate individual needs. CONCLUSIONS: Apart from promoting knowledge of preventive care, official monitoring for service fee and quality is important for empowering older people to choose private service providers for preventive care. Financial incentives for preventive care services should be more specific to cue service promotion and uptake of preventive care while maintaining flexibility to accommodate individual needs. PATIENT OR PUBLIC CONTRIBUTION: Participants were recruited using purposive sampling with the coordination of community elderly centres. Data were analysed using thematic coding.

Effectiveness and Parental Acceptability of Social Networking Interventions for Promoting Seasonal Influenza Vaccination Among Young Children: Randomized Controlled Trial.

BACKGROUND: Seasonal influenza vaccination (SIV) coverage among young children remains low worldwide. Mobile social networking apps such as WhatsApp Messenger are promising tools for health interventions. OBJECTIVE: This was a preliminary study to test the effectiveness and parental acceptability of a social networking intervention that sends weekly vaccination reminders and encourages exchange of SIV-related views and experiences among mothers via WhatsApp discussion groups for promoting childhood SIV. The second objective was to examine the effect of introducing time pressure on mothers' decision making for childhood SIV for vaccination decision making. This was done using countdowns of the recommended vaccination timing. METHODS: Mothers of child(ren) aged 6 to 72 months were randomly allocated to control or to one of two social networking intervention groups receiving vaccination reminders with (SNI+TP) or without (SNI-TP) a time pressure component via WhatsApp discussion groups at a ratio of 5:2:2. All participants first completed a baseline assessment. Both the SNI-TP and SNI+TP groups subsequently received weekly vaccination reminders from October to December 2017 and participated in WhatsApp discussions about SIV moderated by a health professional. All participants completed a follow-up assessment from April to May 2018. RESULTS: A total of 84.9% (174/205), 71% (57/80), and 75% (60/80) who were allocated to the control, SNI-TP, and SNI+TP groups, respectively, completed the outcome assessment. The social networking intervention significantly promoted mothers' self-efficacy for taking children for SIV (SNI-TP: odds ratio [OR] 2.69 [1.07-6.79]; SNI+TP: OR 2.50 [1.13-5.55]), but did not result in significantly improved children's SIV uptake. Moreover, after adjusting for mothers' working status, introducing additional time pressure reduced the overall SIV uptake in children of working mothers (OR 0.27 [0.10-0.77]) but significantly increased the SIV uptake among children of mothers without a full-time job (OR 6.53 [1.87-22.82]). Most participants' WhatsApp posts were about sharing experience or views (226/434, 52.1%) of which 44.7% (101/226) were categorized as negative, such as their concerns over vaccine safety, side effects and effectiveness. Although participants shared predominantly negative experience or views about SIV at the beginning of the discussion, the moderator was able to encourage the discussion of more positive experience or views and more knowledge and information. Most intervention group participants indicated willingness to receive the same interventions (110/117, 94.0%) and recommend the interventions to other mothers (102/117, 87.2%) in future. CONCLUSIONS: Online information support can effectively promote mothers' self-efficacy for taking children for SIV but alone it may not sufficient to address maternal concerns over SIV to achieve a positive vaccination decision. However, the active involvement of health professionals in online discussions can shape positive discussions about vaccination. Time pressure on decision making interacts with maternal work status, facilitating vaccination uptake among mothers who may have more free time, but having the opposite effect among busier working mothers. TRIAL REGISTRATION: Hong Kong University Clinical Trials Registry HKUCTR-2250; https://tinyurl.com/vejv276.

Long-term cost-effectiveness of a Patient Empowerment Programme for type 2 diabetes mellitus in primary care.

AIM: To evaluate the long-term cost-effectiveness of a Patient Empowerment Programme (PEP) for type 2 diabetes mellitus (DM) in primary care. MATERIALS AND METHODS: PEP participants were subjects with type 2 DM who enrolled into PEP in addition to enrolment in the Risk Assessment and Management Programme for DM (RAMP-DM) at primary care level. The comparison group was subjects who only enrolled into RAMP-DM without participating in PEP (non-PEP). A cost-effectiveness analysis was conducted using a patient-level simulation model (with fixed-time increments) from a societal perspective. We incorporated the empirical data from a matched cohort of PEP and non-PEP groups to simulate lifetime costs and outcomes for subjects with DM with or without PEP. Incremental cost-effectiveness ratios (ICER) in terms of cost per quality adjusted life year (QALY) gained were calculated. Probabilistic sensitivity analysis was conducted with results presented as a cost-effectiveness acceptability curve. RESULTS: With an assumption that the PEP effect would last for 5 years as shown by the empirical data, the incremental cost per subject was US $197 and the incremental QALYs gained were 0.06 per subject, which resulted in an ICER of US $3290 per QALY gained compared with no PEP across the lifetime. Probabilistic sensitivity analysis showed 66% likelihood that PEP is cost-effective compared with non-PEP when willingness-to-pay for a QALY is ≥US $46 153 (based on per capita GDP 2017). CONCLUSIONS: Based on this carefully measured cost of PEP and its potentially large benefits, PEP could be highly cost-effective from a societal perspective as an adjunct intervention for patients with DM.

Five-year cost-effectiveness of the Patient Empowerment Programme (PEP) for type 2 diabetes mellitus in primary care.

This study evaluated the short-term cost-effectiveness of the Patient Empowerment Programme (PEP) for diabetes mellitus (DM) in Hong Kong. Propensity score matching was used to select a matched group of PEP and non-PEP subjects. A societal perspective was adopted to estimate the cost of PEP. Outcome measures were the cumulative incidence of all-cause mortality and diabetic complication over a 5-year follow-up period and the number needed to treat (NNT) to avoid 1 event. The incremental cost-effectiveness ratio (ICER) of cost per event avoided was calculated using the PEP cost per subject multiplied by the NNT. The PEP cost per subject from the societal perspective was US$247. There was a significantly lower cumulative incidence of all-cause mortality (2.9% vs 4.6%, P < .001), any DM complication (9.5% vs 10.8%, P = .001) and CVD events (6.8% vs 7.6%, P = .018), in the PEP group. The costs per death from any cause, DM complication or case of CVD avoided were US$14 465, US$19 617 and US$30 796, respectively. The extra amount allocated to managing PEP was small and it appears cost-effective in the short-term as an addition to RAMP.

Cost-Effectiveness of Screening for Intermediate Age-Related Macular Degeneration during Diabetic Retinopathy Screening.

PURPOSE: To determine whether screening for age-related macular degeneration (AMD) during a diabetic retinopathy (DR) screening program would be cost effective in Hong Kong. DESIGN: We compared and evaluated the impacts of screening, grading, and vitamin treatment for intermediate AMD compared with no screening using a Markov model. It was based on the natural history of AMD in a cohort with a mean age of 62 years, followed up until 100 years of age or death. PARTICIPANTS: Subjects attending a DR screening program were recruited. METHOD: A cost-effectiveness analysis was undertaken from a public provider perspective. It included grading for AMD using the photographs obtained for DR screening and treatment with vitamin therapy for those with intermediate AMD. The measures of effectiveness were obtained largely from a local study, but the transition probabilities and utility values were from overseas data. Costs were all from local sources. The main assumptions and estimates were tested in sensitivity analyses. MAIN OUTCOME MEASURES: The outcome was cost per quality-adjusted life year (QALY) gained. Both costs and benefits were discounted at 3%. All costs are reported in United States dollars ($). RESULTS: The cost per QALY gained through screening for AMD and vitamin treatment for appropriate cases was $12,712 after discounting. This would be considered highly cost effective based on the World Health Organization's threshold of willingness to pay (WTP) for a QALY, that is, less than the annual per capita gross domestic product of $29,889. Because of uncertainty regarding the utility value for those with advanced AMD, we also tested an extreme, conservative value for utility under which screening remained cost effective. One-way sensitivity analyses revealed that, besides utility values, the cost per QALY was most sensitive to the progression rate from intermediate to advanced AMD. The cost-effectiveness acceptability curve showed a WTP for a QALY of $29,000 or more has a more than 86% probability of being cost effective compared with no screening. CONCLUSIONS: Our analysis demonstrated that AMD screening carried out simultaneously with DR screening for patients with diabetes would be cost effective in a Hong Kong public healthcare setting.

Lifetime cost-effectiveness of myopia control intervention for the children population.

Background: Myopia is a common eye condition and projected to affect half of the global population by 2050. Controlling its progression during childhood may prevent associated ocular diseases in later life. Certain interventions retard myopia progression but their long-term costs and consequences are not well understood. We evaluated the cost-effectiveness of myopia control via an optical approach using the Defocus Incorporated Multiple Segments (DIMS) lens over a lifetime. Methods: We constructed an individual-based, state-transition model to simulate 1) the development and progression of myopia in childhood with and without control and 2) the impact of myopia on the development of four sight-threatening complications in adulthood. We compared strategies of myopia control with 100% uptake vs. no myopia control from the societal perspective to determine whether myopia control is value for money. Results: With myopia control, the cumulative prevalence of high myopia was relatively reduced by 44.7% (5.9 vs. 10.7%) and severe visual impairment by 19.2% (2.2 vs. 2.7%) compared to no myopia control. The lifetime cost per quality-adjusted life year gained was 26 407 US dollars (USD) and is considered cost-effective compared to the threshold recommended by the World Health Organization (WHO) of one times annual per capita gross domestic product (48 359 USD). Probabilistic sensitivity analysis showed that myopia control had an 87% likelihood of being cost-effective at the WHO threshold. Conclusions: Myopia control is cost-effective when provided to all eligible children. Further investigation is required to determine if it is cost-effective for the government to subsidise myopia control in order to maximise access.

To Determine the Risk-Based Screening Interval for Diabetic Retinopathy: Development and Validation of Risk Algorithm from a Retrospective Cohort Study.

Background: The optimal screening interval for diabetic retinopathy (DR) remains controversial. This study aimed to develop a risk algorithm to predict the individual risk of referable sight-threatening diabetic retinopathy (STDR) in a mainly Chinese population and to provide evidence for risk-based screening intervals. Methods: The retrospective cohort data from 117,418 subjects who received systematic DR screening in Hong Kong between 2010 and 2016 were included to develop and validate the risk algorithm using a parametric survival model. The risk algorithm can be used to predict the individual risk of STDR within a specific time interval, or the time to reach a specific risk margin and thus to allocate a screening interval. The calibration performance was assessed by comparing the cumulative STDR events versus predicted risk over 2 years, and discrimination by using receiver operative characteristics (ROC) curve. Results: Duration of diabetes, glycosylated hemoglobin, systolic blood pressure, presence of chronic kidney disease, diabetes medication, and age were included in the risk algorithm. The validation of prediction performance showed that there was no significant difference between predicted and observed STDR risks in males (5.6% vs. 5.1%, P=0.724) or females (4.8% vs. 4.6%, P=0.099). The area under the receiver operating characteristic curve was 0.80 (95% confidence interval [CI], 0.78 to 0.81) for males and 0.81 (95% CI, 0.79 to 0.83) for females. Conclusion: The risk algorithm has good prediction performance for referable STDR. Using a risk-based screening interval allows us to allocate screening visits disproportionally more to those at higher risk, while reducing the frequency of screening of lower risk people.

Barriers in older adults' decision-making process to use routine eye examinations in Hong Kong.

CLINICAL RELEVANCE: The decision to have a routine eye examination involves individual- and service-level judgement. A deeper understanding of patient access barriers and expectations could facilitate the design of better-aligned service models in optometric practice, improving the utilisation rate of an important facet of primary healthcare services. BACKGROUND: Routine eye examinations achieve several health objectives, including mitigation of sight-threatening risk factors. However, there are barriers to service uptake. Through the qualitative approach, a deeper understanding of these barriers can be realised and enhanced strategies designed to improve the uptake of the routine eye examination. A qualitative study was conducted to identify the factors influencing the decision-making process of older adults to use the routine eye examination service. METHODS: This study was guided by the grounded theory approach. Participants were purposively recruited from six community elderly centres. Semi-structured interviews were conducted with 25 community-dwelling adults aged 65 years or above in Hong Kong. Data were transcribed and constant comparison techniques were used for data analysis. RESULTS: Difficulty in prioritising and including the routine eye examination in the existing health service utilisation was the central theme associated with its lower use. Four sub-themes were identified to explain this phenomenon: (1) previous health care service utilisation as a reference for judging primary eye care; (2) low perceived primary eye care service needs; (3) low perceived self-efficacy on routine eye care utilisation; (4) service expectations. CONCLUSION: Multiple modifiable factors influence decision-making by older adults, suggesting that their routine eye care seeking behaviour might be altered through behaviour change intervention. The context in which services are delivered requires further study, with a focus on exploring the factors influencing service experience and its subsequent impact on regular eye care seeking behaviour.

Significant increase in astigmatism in children after study at home during the COVID-19 lockdown.

CLINICAL RELEVANCE: Evaluating changes in refractive astigmatism after 'study at home' during the COVID pandemic may shed light on the aetiology of refractive errors. BACKGROUND: To investigate whether there has been a change in the proportion of astigmatism among primary school children after the school closure period during the COVID-19 pandemic. METHODS: This observational study compared cross-sectional (2018: n = 112; 2020: n = 173) and longitudinal data (n = 38) collected from two vision screenings, one in 2018 and the other after the school closure period in 2020, in the same primary school for children aged 8-10 years. Non-cycloplegic refraction and axial length were measured using an open-field auto-refractometer and IOL Master, respectively. A questionnaire focusing on demographic information, near-work time, and outdoor activities was administered to parents of all participants. RESULTS: While there were no significant differences in age, gender, or monthly family income between the two cohorts, astigmatism proportion (Cyl ≥ 0.75 D) in 2020 was 1.5-fold higher than that in 2018 (49.1% vs. 33.9%). The median cylindrical power was significantly higher in 2020 in older children (9 or 10 years old). More importantly, the children participating in both vision screenings had cylindrical power and J0 astigmatism significantly increased by 0.35 ± 0.40 D and 0.21 ± 0.25 D, respectively. CONCLUSION: A significant increase in astigmatism (both proportion and magnitude) was found after the school closure period. Further studies are needed to investigate the origin of this increased astigmatism.

Individualised risk prediction model for new-onset, progression and regression of chronic kidney disease in a retrospective cohort of patients with type 2 diabetes under primary care in Hong Kong.

OBJECTIVES: This study is aimed to develop and validate a prediction model for multistate transitions across different stages of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus under primary care. SETTING: We retrieved the anonymised electronic health records of a population-based retrospective cohort in Hong Kong. PARTICIPANTS: A total of 26 197 patients were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: The new-onset, progression and regression of CKD were defined by the transitions of four stages that were classified by combining glomerular filtration rate and urine albumin-to-creatinine ratio. We applied a multiscale multistate Poisson regression model to estimate the rates of the stage transitions by integrating the baseline demographic characteristics, routine laboratory test results and clinical data from electronic health records. RESULTS: During the mean follow-up time of 1.8 years, there were 2632 patients newly diagnosed with CKD, 1746 progressed to the next stage and 1971 regressed into an earlier stage. The models achieved the best performance in predicting the new-onset and progression with the predictors of sex, age, body mass index, systolic blood pressure, diastolic blood pressure, serum creatinine, haemoglobin A1c, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides and drug prescriptions. CONCLUSIONS: This study demonstrated that individual risks of new-onset and progression of CKD can be predicted from the routine physical and laboratory test results. The individualised prediction curves developed from this study could potentially be applied to routine clinical practices, to facilitate clinical decision making, risk communications with patients and early interventions.

Risk factors of chronic kidney diseases in Chinese adults with type 2 diabetes.

In this study we conducted a cross sectional study to comprehensively evaluated the risk factors of chronic kidney disease (CKD) in a large sample of Chinese adults under primary care for type 2 diabetes mellitus (T2DM). We investigated the risk factors associated with the prevalence of CKD in adults with T2DM, who were enrolled in the Risk Factor Assessment and Management Programme for Patients with Diabetes Mellitus (RAMP-DM) of Hong Kong from July 2014 to June 2017. We collected the individual data of 31,574 subjects, with mean age of 63.0 (±10.8) years and mean DM duration of 7.4 (±6.4) years. Of them 9,386 (29.7%) had CKD and 7,452 (23.6%) had micro- or macro-albuminuria. After adjustment for multiple demographic and lifestyle confounders, we identified several modifiable risk factors associated with higher rate of CKD: obesity (OR = 1.54), current smoking (OR = 1.33), higher systolic blood pressure (OR = 1.01), dyslipidemia (OR = 1.32 and 0.61 for triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C)), hyperglycemia (OR = 1.11 for HbA1c), diabetic retinopathy (OR = 1.36 and 2.60 for non-sight and sight threatening retinopathy), and stroke (OR = 1.43). The risk factors of lower dialytic blood pressure and coronary heart disease were identified only in men, whereas peripheral arterial disease only in women. In conclusion, several modifiable and gender specific risk factors were significantly associated with higher prevalence of CKD in Chinese adults with T2DM. The high-risk populations identified in this study shall receive regular screening for renal functions to achieve better patient management in primary care settings.

Awareness of diabetic retinopathy and its association with attendance for systematic screening at the public primary care setting: a cross-sectional study in Hong Kong.

OBJECTIVE: To assess the association between awareness of diabetic retinopathy (DR) and actual attendance for DR screening. DESIGN: Cross-sectional study. SETTING: Two public general outpatient clinics. PARTICIPANTS: The subjects were people with diabetes mellitus (DM) who participated in a randomised controlled trial, set up in 2008, to test the impact of a copayment on attendance for DR screening. PRIMARY AND SECONDARY OUTCOME MEASURES: The subjects' awareness of DR was evaluated using a structured questionnaire conducted via a telephone interview. The attendance for screening was from the actual attendance data. Association between awareness and attendance for screening was determined using multivariate logistic regression model and was reported as ORs. RESULTS: A total of 2593 participants completed the questionnaire. A total of 42.9% (1113/2593) said they would worry if they had any vision loss and 79.6% (2063/2593) knew that DM could cause blindness. Only 17.5% (453/2593) knew that treatment was available for DR and 11.5% (297/2593) knew that early DR could be asymptomatic. The importance of having a regular eye examination was acknowledged by 75.7% (1964/2593), but 34% (881/2593) did not know how frequently their eyes should be examined. Worry about vision loss (OR=1.72, P<0.001), awareness of the importance of regular eye examination (OR=1.83, P=0.002) and awareness of the frequency of eye examinations ('every year' (OR=2.64, P<0.001) or 'every 6 months' (OR=3.27, P<0.001)) were the most significant factors associated with attendance. CONCLUSIONS: Deficits in knowledge of DR and screening were found among subjects with DM, and three awareness factors were associated with attendance for screening. These factors could be targeted for future interventions.