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 ADDQoL (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-groups 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-groups 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-groups comparisons and internal consistency reliability in the primary care setting.postprin

Association of Hemoglobin A1c Levels With Cardiovascular Disease and Mortality in Chinese Patients With Diabetes

LettersAmong diabetic patients, hemoglobin A1c (HbA1c) is an important indicator of glycemic control and, together with blood pressure and cholesterol, is an indicator for risk of complications, including cardiovascular disease (CVD) and mortality. At present, there is no universal consensus on the optimal HbA1c level. Despite this, most international guidelines include a recommended HbA1c target range or level as a treatment goal. Several studies have identified a J-shaped curvilinear relationship between HbA1c and CVD incidence and all-cause mortality, but such a relationship has not yet been confirmed in a Chinese population. There are substantial differences in disease risks across racial and ethnic groups due to genetic and environmental factors including life-style and health behaviors, and thus, previous results from Western studies may not be transferable to a Chinese population. We sought to examine the association among mean HbA1c, CVD events, and mortality among Chinese primary care patients with type 2 diabetes mellitus (T2DM) in Hong Kong.postprin

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.published_or_final_versio

Primary hyperaldosteronism among Chinese hypertensive patients: how are we doing in a local district in Hong Kong

OBJECTIVES: To estimate the point prevalence of primary hyperaldosteronism in a government out-patient setting and to compare associated patient characteristics with those having essential hypertension. DESIGN: Case series with external comparison. SETTING: A single public hospital (Caritas Medical Centre) and all five associated general out-patient clinics in Sham Shui Po district in Hong Kong. PATIENTS: All patients with confirmed primary hyperaldosteronism and randomly selected patients with essential hypertension from a medical specialist clinic and general out-patient clinics, retrieved from a computer database for the period January 2007 to December 2008. MAIN OUTCOME MEASURES: Estimated point prevalence of primary hyperaldosteronism among hypertensive patients treated in the public sector of Sham Shui Po district. Patient age when hypertension was diagnosed, number of antihypertensive drugs used for treatment, and the presence of target organ damage in the patients with primary hyperaldosteronism and those with essential hypertension were compared. RESULTS: Among the 46 012 patients receiving antihypertensive treatment, 49 were confirmed to have primary hyperaldosteronism. The estimated point prevalence of primary hyperaldosteronism among these hypertensive patients was 0.106% only, which was far smaller than figures from other countries. When compared with the 147 patients with essential hypertension by multivariate analysis, those with primary hyperaldosteronism were: (1) associated with longer durations of hypertension (odds ratio=1.14; 95% confidence interval, 1.06-1.24) despite being younger at the time of study, (2) likely to be taking three or more antihypertensive drugs (odds ratio=2.51; 95% confidence interval, 1.59-3.95), and (3) more likely to have left ventricular hypertrophy (odds ratio=5.01; 95% confidence interval, 1.83-13.69). All primary hyperaldosteronism patients studied presented with hypokalaemia. The need for antihypertensive drugs was markedly reduced after adrenalectomy for adrenal adenoma. CONCLUSIONS: Primary hyperaldosteronism, which is potentially a surgically curable cause of hypertension, appeared to be underdiagnosed in our locality. Screening by aldosterone-renin ratio of high-risk individuals may help improve patient outcomes.published_or_final_versio

Effect of metformin monotherapy on cardiovascular diseases and mortality: a retrospective cohort study on Chinese type 2 diabetes mellitus patients

Background: Many factors influence whether the first-line oral anti-diabetic drug, metformin, should be initiated to a patient with type 2 diabetes mellitus (T2DM) early in the course of management in addition to lifestyle modifications. This study aims to evaluate the net effects of metformin monotherapy (MM) on the all-cause mortality and cardiovascular disease (CVD) events. Methods: A retrospective 5-year follow-up cohort study was conducted on Chinese adult patients with T2DM and without any CVD history under public primary care. Cox proportional hazard regressions were performed to compare the risk of all-cause mortality and CVD events (CHD, stroke, heart failure) between patients receiving lifestyle modifications plus MM (MM groups) and those with lifestyle modifications alone (control groups). Results: 3400 pairs of matched patients were compared. MM group had an incidence rate of 7.5 deaths and 11.3 CVD events per 1000 person-years during a median follow-up period of 62.5 months whereas control group had 11.1 deaths and 16.3 per 1000 person-years during a median follow-up period of 43.5–44.5 months. MM group showed a 29.5 and 30–35 % risk reduction of all-cause mortality and CVD events (except heart failure) than control group (P < 0.001). MM group was more prone to progress to chronic kidney disease but this was not statistically significant. Conclusions: Type 2 diabetic patients who were started on metformin monotherapy showed improvement in many of the clinical parameters and a reduction in all-cause mortality and CVD events than lifestyle modifications alone. If there is no contraindication and if tolerated, diabetic patients should be prescribed with metformin early in the course of the diabetic management to minimize their risk of having the cardiovascular events and mortality in the long run.published_or_final_versio

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 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.published_or_final_versio

Mothers’ health-related quality of life: Its relationship with children’s health-related quality of life and behavior in low-income families

Objective: To examine the association between mothers’ health-related quality of life (HRQOL) and their children’s HRQOL and behavior in low-income families. Methods: Mothers of 278 children aged 6‐12 years from low-income families were invited to complete the Child Health Questionnaire Parent Form 50 (CHQ-PF50) and the Strength and Difficulties Questionnaire (SDQ) for their children as well as the 12-item Short-Form Health Survey version 2 (SF-12v2) and the Patient Health Questionnaire-2 (PHQ-2). Multiple linear regressions with mother‐child pairs as the unit of analysis were performed to examine the associations between maternal and child variables with adjustment of mother- and child-level confounders. Results: Compared with the general population, low-income mothers had a lower mean SF-12v2 mental component summary score and their children also had lower mean CHQ-PF50 physical and psychosocial summary scores and SDQ total difficulties score. Children of mothers with SF-12v2 scores below the population mean of 50 had significantly worse CHQ-PF50 scores and higher SDQ total difficulties scores. The mother’s PHQ-2 depression status had no association with the child’s CHQ-PF50 scores. Conclusion: Our findings suggest that more attention should be paid to reducing the negative impact of health problems on mothers’ daily roles in childcare in low-income families.published_or_final_versio

Effects of the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) on biomedical outcomes, observed cardiovascular events and cardiovascular risks in primary care: a longitudinal comparative study

Background To assess whether the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) led to improvements in biomedical outcomes, observed cardiovascular events and predicted cardiovascular risks after 12-month intervention in the primary care setting. Methods A random sample of 1,248 people with diabetes enrolled to RAMP-DM for at least 12-months was selected and 1,248 people with diabetes under the usual primary care were matched by age, sex, and HbA1c level at baseline as the usual care group. Biomedical and cardiovascular outcomes were measured at baseline and at 12-month after the enrollment. Difference-in-differences approach was employed to measure the effect of RAMP-DM on the changes in biomedical outcomes, proportion of subjects reaching treatment targets, observed and predicted cardiovascular risks. Results Compared to the usual care group, RAMP-DM group had lower cardiovascular events incidence (1.21% vs 2.89%, P=0.003), and net decrease in HbA1c (-0.20%, P<0.01), SBP (-3.62 mmHg, P<0.01) and 10-year cardiovascular disease (CVD) risks (total CVD risk, -2.06%, P<0.01; coronary heart disease (CHD) risk, -1.43%, P<0.01; stroke risk, ?0.71%, P<0.01). The RAMP-DM subjects witnessed significant rises in the proportion of reaching treatment targets of HbA1c, and SBP/DBP. After adjusting for confounding variables, the significance remained for HbA1c, predicted CHD and stroke risks. Conclusions The RAMP-DM resulted in greater improvements in HbA1c and reduction in observed and predicted cardiovascular risks at 12-months follow-up, which indicated a risk-stratification multidisciplinary intervention was an effective strategy for managing Chinese people with diabetes in the primary care setting. Trial registryClinicalTrials.gov, NCT02034695published_or_final_versio

Effectiveness of the multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) for diabetic microvascular complications: A population-based cohort study

Aim: To evaluate the effectiveness of the multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) in reducing the risks of microvascular complications. Methods: This prospective cohort study was conducted with 29,670 propensity-score-matched RAMP-DM participants and diabetes patients under the usual primary care (14,835 in each group). Study endpoints were the first occurrence of any diabetic microvascular complications, non-proliferative diabetic retinopathy/preproliferative diabetic retinopathy (NPDR/prePDR), sight-threatening diabetic retinopathy (STDR) or blindness, nephropathy, end-stage renal disease (ESRD), neuropathy and lower-limb ulcers or amputation. Log-rank tests and multivariable Cox proportional-hazards regressions were employed to estimate between-group differences in incidences of study endpoints. Results: After a median follow-up of 36 months with>41,000 person-years in each group, RAMP-DM participants had a lower incidence of microvascular complications (760 vs 935; adjusted hazard ratio [HR]: 0.73; 95% confidence interval [CI]: 0.66-0.81; P<0.001) and lower incidences of all specific microvascular complications except neuropathy (adjusted HR: 0.94; 95% CI: 0.61-1.45; P=0.778). Adjusted HRs for the RAMP-DM vs control group for ESRD, STDR or blindness, and lower-limb ulcers or amputation were 0.40 (95% CI: 0.24-0.69; P<0.001), 0.55 (95% CI: 0.39-0.78; P=0.001) and 0.49 (95% CI: 0.30-0.80; P=0.005), respectively. Conclusion: The RAMP-DM intervention was associated with lower incidences of all microvascular complications except neuropathy over a 3-year follow-up. These encouraging results constitute evidence that structured risk assessment and risk-stratified management provided by a multidisciplinary team is effective for reducing microvascular complications in diabetes patients.postprin

Long-term effects of the multidisciplinary risk assessment and management program for patients with diabetes mellitus (RAMP-DM): a population-based cohort study

Background: Studies on the long-term effectiveness of multidisciplinary risk-stratification based management in Chinese population were rare. This study aimed to evaluate the effectiveness of a multidisciplinary risk assessment and management program for patients with diabetes mellitus (RAMP-DM) in reducing the risks of cardiovascular complications and all-cause mortality. Methods: A prospective cohort study was conducted in 18,188 propensity score matched RAMP-DM participants and subjects with diabetes under usual primary care (9,094 subjects in each group). The study endpoints were the first occurrence of coronary heart disease (CHD), stroke, heart failure (HF), total cardiovascular disease (CVD) and all-cause mortality. We constructed multivariable Cox proportional hazard regressions to estimate the association between the RAMP-DM intervention and the first occurrence of study endpoints. Results: The median follow-up period was 36 months. Three hundred and ninety-nine CVD events occurred in the RAMP-DM group, as compared with 608 in the control group [adjusted hazard ratio, 0.629; 95 % confidence interval (CI) 0.554–0.715; P < 0.001]. The total number of all-cause deaths in RAMP-DM group was less than half that of control group (202 vs 552, adjusted hazard ratio, 0.363; 95 % CI, 0.308–0.428; P < 0.001). The adjusted hazard ratios of the RAMP-DM group for CHD, stroke, and HF were 0.570 (95 % CI, 0.470–0.691; P < 0.001), 0.652 (95 % CI, 0.546–0.780; P < 0.001), and 0.598 (95 %CI, 0.446–0.802; P = 0.001), respectively. Conclusions: The RAMP-DM intervention was associated with lower incidences of individual and total cardiovascular complications, as well as all-cause mortality over 3 years follow-up. The encouraging results provided evidence to support that the structured risk-stratification management leading by a multidisciplinary clinical team was an effective approach to reduce future cardiovascular complications in people with diabetes.published_or_final_versio