Evaluation of the quality of care of a multi-disciplinary Risk Factor Assessment and Management Programme for Hypertension (RAMP-HT)

Background: There is some evidence to support a risk-stratified, multi-disciplinary approach to manage patients with hypertension in primary care. The aim of this study is to evaluate the quality of care (QOC) of a multi-disciplinary Risk Assessment and Management Programme for Hypertension (RAMP-HT) for hypertensive patients in busy government-funded primary care clinics in Hong Kong. The objectives are to develop an evidence-based, structured and comprehensive evaluation framework on quality of care, to enhance the QOC of the RAMP-HT through an audit spiral of two evaluation cycles and to determine the effectiveness of the programme in reducing cardiovascular disease (CVD) risk. Method/Design: A longitudinal study is conducted using the Action Learning and Audit Spiral methodologies to measure whether pre-set target standards of care intended by the RAMP-HT are achieved. A structured evaluation framework on the quality of structure, process and outcomes of care has been developed based on the programme objectives and literature review in collaboration with the programme workgroup and health service providers. Each participating clinic is invited to complete a structure of care evaluation questionnaire in each evaluation cycle. The data of all patients who have enrolled into the RAMP-HT in the pre-defined evaluation periods are used for the evaluation of the process and outcomes of care in each evaluation cycle. For evaluation of the effectiveness of RAMP-HT, the primary outcomes including blood pressure (both systolic and diastolic), low-density lipoprotein cholesterol and estimated 10-year CVD risk of RAMP-HT participants are compared to those of hypertensive patients in usual care without RAMP-HT. Discussion: The QOC and effectiveness of the RAMP-HT in improving clinical and patient-reported outcomes for patients with hypertension in normal primary care will be determined. Possible areas for quality enhancement and standards of good practice will be established to inform service planning and policy decision making.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

Effects of risk assessment and management programme for hypertension on clinical outcomes and cardiovascular disease risks after 12 months: a population-based matched cohort study

Objectives: This study evaluated the effectiveness of a structured multidisciplinary risk assessment and management programme for patients with hypertension (RAMP-HT) who were managed in public primary care clinics but had suboptimal blood pressure (BP) control in improving BP, LDL-cholesterol (LDL-C) and predicted 10-year cardiovascular disease (CVD) risk after 12 months of intervention. Methods: A total of 10 262 hypertension patients with suboptimal BP despite treatment, aged less than 80 years and without existing CVD were enrolled in RAMP-HT between October 2011 and March 2012 from public general out-patient clinics in Hong Kong. Their clinical outcomes and predicted 10-year CVD risk were compared with a matched cohort of hypertension patients who were receiving usual care in general out-patient clinics without any RAMP-HT intervention by propensity score matching. Multivariable linear and logistic regressions were used to determine the independent effectiveness of RAMP-HT after adjusting for potential confounding variables. Results: Compared with the usual care group after 12 months, significantly greater proportions of RAMP-HT participants achieved target BP (i.e. BP 20%) (OR = 1.13, P < 0.01). RAMP-HT participants also had significantly greater reduction in predicted 10-year CVD risk by 0.44% (coefficient = -0.44, P < 0.01). Conclusion: The structured multidisciplinary RAMP-HT was more effective than usual care in achieving target BP, LDL-C and reducing predicted 10-year CVD risk in public primary care patients with suboptimal hypertension control after 12 months of intervention. A long-term follow-up should be conducted to confirm whether the improvement in clinical outcomes can be translated into actual reductions in CVD complications and mortalities and whether such approach is cost-effective.published_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

Five-year change of clinical and complications profile of diabetic patients under the primary health care service across Hong Kong

Conference Theme: Stay Caring, Go Excelling in Primary CareFree Paper Competition - Poster Presentation 12 (abstract)INTRODUCTION The number of Diabetic patients receiving primary care of the Hospital Authority (HA) GOPC rose from 150,157(2009) to 173,015(2013). This study aims to review the recent 5-year changes in epidemiology of diabetic patients. METHOD A cross-sectional study was conducted with information of all diabetic patients under care of HA GOPC retrieved at 2009 and 2013 from HA Clinical Management System. Descriptive statistics were used to show patient’s socio-demographic, clinical parameters, drug usage and major complications. The characteristics comparison between 2009 and 2013 were evaluated by independent t-test for continuous parameters and chi-square for categorical parameters. RESULTS Annual checking of key clinical parameters and data completion rate had been improved significantly. There were significant increases in proportions of patients achieving target HbA1c, SBP, DBP, LDL-C, TG, and HDL-C (p<0.001). Levels of HbA1c, blood pressure (SBP, DBP), LDL-cholesterol (LDL), triglycerides (TG), and BMI dropped significantly from 7.2% to 7.0%, 137.1mmHg to 131.1mmHg, 75.6mmHg to 72.8mmHg, 3.1mmol/L to 2.5mmol/L, 1.7mmol/L to 1.4mmol/L, and 25.7kg/m2 to 25.4kg/m2, respectively. More patients (1.6% raised to 4.0%) used insulin in addition to their oral anti-diabetic drugs for their management, and a significant boost (from 9.0% to 55.7%) on statin use. Prevalence of major DM complications, including cardiovascular diseases (CVD), sight-threatening diabetic retinopathy (STDR), and end-stage renal disease (ESRD) showed significant increase of 0.4% to 2.5%. DISCUSSION Improvement in coverage of annual checking of key clinical parameters and patients’ achievement to target values may be attributed by the regular monitoring and early intervention, including use of appropriate medications, after the launch of the territory-wide Risk Assessment and Management Programme (Diabetes Mellitus) since 2009, with its coverage raised from 3.1% (2009) to 81.9% (2013)

Hypertension control and treatment in Hong Kong: a cross sectional study

Free Paper Competition – Abstracts of Poster Presentation: Poster Presentation 36INTRODUCTION Hypertension (HT) is the leading risk factor for global disease burden, and control of blood pressure (BP) is one of the most cost-effective methods to reduce premature cardiovascular morbidities and mortalities. This study aimed to review the control and treatment of HT patients in the public primary care setting in Hong Kong. METHOD Cross-sectional retrospective study on anonymous clinical data of HT patients without diabetes managed in public primary care clinics of the Hospital Authority in 1 July 2012 – 30 June 2013 was conducted. Descriptive statistics were used to analyze the clinical profile and management pattern of the primary care hypertension population. The last available BP reading of each case by the end of study period was used for analysis. RESULTS 205,745 HT patients were included in this study; mean age was 68.5 years and 57.6% were female. Overall, 73.6% HT patients achieved optimal BP control (140/90mmHg. Concerning HT management, 2.2% patients were managed by lifestyle intervention alone; approximately half of the patients required two or more anti-hypertensive medications. Calcium channel blocker was the most common anti-hypertensive drug used, and calcium channel blocker plus β-blocker was the most popular drug combination. DISCUSSION The standard of BP control among HT patients in HK public primary care is comparable with those achieved in developed countries such as the UK and USA. While this finding is reassuring, the significant proportion of patients with uncontrolled BP, especially those who had already developed complication(s), deserves our attention. A greater effort should be put into optimization of their management in order to attain the ultimate management goal – reduction of cardiovascular disease burden

Clinical benefits of the Multi-disciplinary Risk Assessment and Management Programme-Hypertension (RAMP-HT) for patients with Hypertension in GOPCs - the First Year Experience

Oral Presentation 1.5Conference Theme: With the Patients, For the Patients: Achieving Health Equity in Primary CareIntroduction: Since October 2011, the Hospital Authority (HA) has introduced the Risk Assessment and Management Programme (RAMP) for patients with hypertension (HT) managed in the public primary care setting. The programme aimed to improve cardiovascular outcomes for hypertensive patients through risk assessment, risk stratification and risk-guided management by a multi-disciplinary effort. This study evaluated the clinical benefits of RAMP-HT at 12-month. Method: Evaluation involved 5 clusters under HA that had launched RAMP-HT since Oct 2011. A sampling of 13,155 hypertensive patients aged ≤80, without existing cardiovascular diseases and with suboptimal blood pressure (i.e. systolic blood pressure (SBP) >140mmHg or diastolic blood pressure (DBP) >90mmHg) who were enrolled into RAMP-HT for more than one year was compared to 33,172 non-RAMP-HT participants on clinical outcomes including SBP, low-density lipoprotein cholesterol (LDL-C) and the estimated 10-year cardiovascular disease (CVD) risk using Framingham risk scores equation to reveal the net benefit of RAMP-HT. Multivariate linear regressions were used to identify the net effectiveness of RAMP-HT by adjusting the potential confounding variables. Results: There was a reduction in mean SBP, LDL-C and estimated 10-year cardiovascular risk in both the RAMP-HT participants and hypertensive patients receiving usual care from general-out-patient-clinics (GOPCs) at 12 months. The RAMP-HT participants had greater reduction in LDL-C (coef. = -0.02, P-value = 0.04) and estimated 10-years CVD risk (coef. = -0.45, P-value < 0.01) compared to the usual care group, and the difference was statistically significant. RAMP-HT participants also had a greater reduction in SBP than the usual care group, however the difference did not reach statistical significance. Discussion: For hypertensive patients aged ≤80 with suboptimal blood pressure control but without existing cardiovascular complications, the multi-disciplinary RAMP-HT was shown to confer additional clinical benefits over usual care at GOPCs in terms of a greater reduction of estimated 10-year CVD risk and LDL-C at 12 months. A more comprehensive and longer-term evaluation of the effectiveness of RAMP-HT should be performed to better illustrate the true clinical impact of such programme

Incidence and Risk Factors for Cardiovascular Disease in Diabetic patients in Hong Kong

Free Paper Competition - Poster Presentation 22 (abstract)Conference Theme: Stay Caring, Go Excelling in Primary CareINTRODUCTION Cardiovascular Disease (CVD) is the major cause of morbidity and mortality in patients with diabetes mellitus (DM). The study aimed to calculate the 5-year incidence and identify risk factors for developing CVD in Chinese diabetic patients. METHOD A retrospective cohort study was conducted on 119,276 Chinese adult diabetic patients without CVD history and receiving care in the Hospital Authority primary care clinics on or before 1 January 2009. They were followed up until 31 December 2013. Multiple imputation was used to deal with the missing data. Risk factors including socio-demographics and clinical parameters associated with the incidence of CVD were examined using Cox Proportional Hazard regression. Sensitivity analysis was conducted by using the cohort with complete case. RESULTS Five-year incidence rate (1,000 person-years) of first CVD event (n=9,753) among diabetic patients was 17.6. Risk factors associated with CVD were age (Hazard ratio (HR):1.073), male (HR:1.310), smoker (HR:1.219), longer duration of DM (HR:1.014), insulin used (HR:1.425), higher stage of Chronic Kidney Disease (e.g. stage 5 vs stage 1 HR:4.430) and higher clinical parameters including body mass index (HR:1.022), systolic blood pressure (HR:1.002), total cholesterol to HDL cholesterol ratio (HR:1.056) and Urine Albumin/Creatinine ratio (HR:1.001). All of these risk factors were statistically significant (p <0.05). Sensitivity analysis showed the similar results except insulin use, hemoglobin A1c(HbA1c), systolic blood pressure and Triglyceride. DISCUSSION Identification of CVD-related risk factors and early intervention play a crucial role in preventing CVD complications in diabetic patients. HbA1c, which reflects the control of DM, was not found to be a significant risk factor from this study. Further study is needed to explore the effect of controlling of HbA1c on CVD risk

Effectiveness of the Multi-disciplinary Risk Assessment and Management Programme (RAMP) on patients with Diabetic Mellitus – the First Year Experience

Oral PresentationConference Theme: Innovations in Primary CareINTRODUCTION: This study aimed to reveal the post 12-month effectiveness of the Multi-disciplinary Risk Assessment and Management Programme (RAMP) on diabetic patients. METHOD: Evaluation involved eleven clinics from four clusters of the Hospital Authority which had started RAMP before June 2010. A random sampling of 1248 patients enrolled into RAMP for more than one year was compared to age-sex, and disease-severity matched non-RAMP controls on clinical outcomes including HbA1c, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C), and the estimated 10-year cardiovascular disease (CVD) risk using Framingham risk scores equation to reveal the net benefit of RAMP. Independent t-test and Chi-square tests were used for comparison of continuous data and proportions, respectively. RESULTS: Both RAMP and non-RAMP patients showed a reduction in mean HbA1c, blood pressure, and LDL-C; and an increase in proportions of patients achieving target control of HbA1c ≤ 7%, BP ≤ 130/80 mmHg, and LDL-C ≤ 2.6 mmol/L). RAMP group did not show a significant net reduction in HbA1c compared to non-RAMP group but did show a significant net reduction of 2.61 (1.49) mmHg in SBP (DBP), and LDL-C of 0.17 mmol/L. RAMP reduce 10-year CVD risk by 4.66%, which significantly overwhelmed the 2.46% in control group by 2.2%. DISCUSSION: RAMP helped diabetic patients to improve their control of blood glucose, blood pressure, cholesterol level, and reduce their 10-year CVD risk. Significant extra reduction in 10-year CVD risk without net HbA1c reduction supported that the goal of management of diabetic patients should not limited to HbA1c only