Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: a systematic review

Background: Chronic Care Model (CCM) has been developed to improve patients' health care by restructuring health systems in a multidimensional manner. This systematic review aims to summarize and analyse programs specifically designed and conducted for the fulfilment of multiple CCM components. We have focused on programs targeting diabetes mellitus, hypertension and cardiovascular disease. Method and results: This review was based on a comprehensive literature search of articles in the PubMed database that reported clinical outcomes. We included a total of 25 eligible articles. Evidence of improvement in medical outcomes and the compliance of patients with medical treatment were reported in 18 and 14 studies, respectively. Two studies demonstrated a reduction of the medical burden in terms of health service utilization, and another two studies reported the effectiveness of the programs in reducing the risk of heart failure and other cardiovascular diseases. However, CCMs were still restricted by limited academic robustness and social constraints when they were implemented in primary care. Higher professional recognition, tighter system collaborations and increased financial support may be necessary to overcome the limitations of, and barriers to CCM implementation. Conclusion: This review has identified the benefits of implementing CCM, and recommended suggestions for the future development of CCM

Association between investigator-measured body-mass index and colorectal adenoma: a systematic review and meta-analysis of 168,201 subjects

The objective of this meta-analysis is to evaluate the odds of colorectal adenoma (CRA) in colorectal cancer screening participants with different body mass index (BMI) levels, and examine if this association was different according to gender and ethnicity. The EMBASE and MEDLINE were searched to enroll high quality observational studies that examined the association between investigator-measured BMI and colonoscopy-diagnosed CRA. Data were independently extracted by two reviewers. A random-effects meta-analysis was conducted to estimate the summary odds ratio (SOR) for the association between BMI and CRA. The Cochran’s Q statistic and I2 analyses were used to assess the heterogeneity. A total of 17 studies (168,201 subjects) were included. When compared with subjects having BMI < 25, individuals with BMI 25–30 had significantly higher risk of CRA (SOR 1.44, 95% CI 1.30–1.61; I2 = 43.0%). Subjects with BMI ≥ 30 had similarly higher risk of CRA (SOR 1.42, 95% CI 1.24–1.63; I2 = 18.5%). The heterogeneity was mild to moderate among studies. The associations were significantly higher than estimates by previous meta-analyses. There was no publication bias detected (Egger’s regression test, p = 0.584). Subgroup analysis showed that the magnitude of association was significantly higher in female than male subjects (SOR 1.43, 95% CI 1.30–1.58 vs. SOR 1.16, 95% CI 1.07–1.24; different among different ethnic groups (SOR 1.72, 1.44 and 0.88 in White, Asians and Africans, respectively) being insignificant in Africans; and no difference exists among different study designs. In summary, the risk conferred by BMI for CRA was significantly higher than that reported previously. These findings bear implications in CRA risk estimation

The effectiveness of dietary approaches to stop hypertension (DASH) counselling on estimated 10-year cardiovascular risk among patients with newly diagnosed grade 1 hypertension : a randomised clinical trial

The Dietary Approaches to Stop Hypertension (DASH) has been shown to lower blood pressure in the West. However, the real-life impact of DASH on reducing cardiovascular (CV) risk in routine clinical setting has not been studied. Methods A parallel-group, open-labelled, physician-blinded, randomised controlled trial was conducted in January–June 2013 and followed up for 6- and 12-months in primary care settings in Hong Kong. Patients newly diagnosed with grade 1 hypertension (aged 40–70 years) who had no concomitant medical conditions requiring dietary modifications were consecutively recruited. Subjects were randomised to standard education (usual care) (n = 275), or usual care plus dietitian-delivered DASH-based dietary counselling in a single one-to-one session (intervention) (n = 281). Primary outcomes were the changes in estimated 10-year CV risk. Results Outcome data were available for 504 (90.6%) and 485 (87.2%) patients at 6 and 12 months, respectively. There was no difference in the reduction of 10-year CV risk between the two groups at 6 months (−0.13%, 95% confidence interval [95% CI] −0.50% to 0.23%, p = 0.477) and 12 months (−0.08%, 95% CI −0.33% to 0.18%, p = 0.568). Multivariate regression analyses showed that male subjects, younger patients, current smokers, subjects with lower educational level, and those who dined out for main meals for ≥4 times in a typical week were significantly associated with no improvements in CV risk. Conclusions The findings may not support automatic referral of newly diagnosed grade 1 hypertensive patients for further one-to-one dietitian counselling on top of primary care physician's usual care. Patients with those risk factors identified should receive more clinical attention to reduce their CV risk

Medical students' attitude towards antibiotics misuse in Hong Kong

Background Antibiotics resistance is a major public health threat worldwide. Super bugs, for example, drug resistant tuberculosis or Staphylococcus aureus, are increasingly common in the communities. Hong Kong is one of the areas which have the highest antibiotics resistant strains prevalence rate in the world. Irrational use of antibiotics is an important contributing factor to the emergence of antibiotics resistance. Physician stewardship in the prescription of antibiotics is pivotal in the prevention of antibiotics resistance emergence. Medical students are going to be practicing doctors after graduation from medical school. But few studies had been conducted to investigate their knowledge and attitude towards antibiotics resistance and use, and relations with anticipated antibiotics prescription behaviour. Method 145 medical students at the University of Hong Kong were recruited in this study to complete a self-administered questionnaire. There were in total 14 questions in this questionnaire, covering 2 major themes 1.Self-report of current and past antibiotic use and behaviour; 2.Anticipated prescription behaviour of antibiotics upon graduation and practice in the future. Chi-square test was used to investigate the association between attitude and knowledge of antibiotics with their anticipated prescription behavior upon graduation and practice. Multivariable logistic regression model was used to adjust for potential confounders. Results 67.6 % of the participants hold the correct knowledge of the proper use of antibiotics. Compare with the participants who hold the wrong knowledge, they were to 0.18 times more likely to inappropriately prescribe antibiotics for non-complicated Upper respiratory tract infections (URTI). (OR: 0.18, 95 % CI: (0.08, 0.43); p <0.001). Respectively 33.6 % and 4.9% of all the participants perceived the severity of antibiotics resistance in Hong Kong as “Severe” and “Very severe “. Those who rated “Severe” or above were 0.37 times more likely to inappropriately prescribe antibiotics for non-complicated URTIs compared with the participants who rated “Neutral” or below. (OR: 0.37, 95 % CI: (0.15, 0.91); p = 0.03). Logistic regression model was employed to test the interaction effect. Result showed that clinical training significantly interacted with antibiotics knowledge (p < 0.01)and perceived severity of antibiotics resistance (p = 0.02) in their relations with inappropriate prescription for non-complicated URTIs. Conclusion For the medical students who have received clinical training, those who were more aware of the severity of antibiotics resistance in Hong Kong were less likely to inappropriately prescribe antibiotics for non-complicated URTI. For the medical students who have not received clinical training, correct knowledge of antibiotic use is associated with less inappropriate antibiotics prescription behaviour. These suggest that knowledge and attitude towards antibiotics resistance and use are important factors that may impact on physician stewardship in antibiotics use in the community.published_or_final_versionPublic HealthMasterMaster of Public Healt

International incidence and mortality trends of liver cancer: a global profile

We examined the global incidence and mortality rates of liver cancer, and evaluated the association between incidence/mortality and socioeconomic development (Human Development Index [HDI] and Gross Domestic Product [GDP]) using linear regression analysis. The average annual percent change (AAPC) of the trends was evaluated from join-point regression analysis. The global incidence of liver cancer varied widely by nine-fold, and was negatively correlated with HDI (men: r = -0.232, p = 0.003; women: r = -0.369, p &lt; 0.001) and GDP per capita (men: r = -0.164, p = 0.036; women: r = -0.212, p = 0.007). Its mortality showed a similarly negative correlation with both indices. The greatest incidence rise in men was observed in Poland (AAPC = 17.5, 95% C.I. = 5.6, 30.9) and Brazil (AAPC = 13.2, 95% C.I. = 5.9, 21.0), whereas Germany (AAPC = 6.6, 95% C.I = 2.0, 11.5) and Norway (AAPC = 6.5, 95% C.I. = 3.2, 10.0) had the greatest increase in women. The mortality rates paralleled the incidence rates in most countries. For mortality, Malta (AAPC = 11.5, 95% C.I. = 3.9, 19.8), Australia (AAPC = 6.8, 95% C.I. = 2.2, 11.5) and Norway (APCC = 5.6, 95% C.I. = 2.8, 8.5) reported the biggest increase among men; whilst Australia (AAPC = 13.4, 95% C.I. = 7.8, 19.4) and Singapore (AAPC = 7.7, 95% C.I. = 4.1, 11.5) showed the most prominent rise among women. These epidemiological data identified countries with potentially increasing trends of liver cancer for preventive actions

Approaching the hard-to-reach in organized colorectal cancer screening: an overview of individual, provider and system level coping strategies

Background: Despite the proven effectiveness of colorectal cancer (CRC) screening on reduction of CRC mortality, the uptake of CRC screening remains low. Participation rate is one of determinants for the success of organized population-based screening program. This review aims to identify those who are hard-to-reach, and summarize the strategies to increase their screening rate from individual, provider and system levels. Methods: A systematic search of electronic English databases was conducted on the factors and strategies of uptake in CRC screening for the hard-to-reach population up to May 2017. Discussion: The coverage rate and participation rate are two indexes to identify the hard-to-reach population in organized CRC screening program. However, the homeless, new immigrants, people with severe mental illness, the jail intimates, and people with characteristics including lower education levels and/or low socioeconomic status, living in rural/remote areas, without insurance, and racial minorities are usually recognized as hard-to-reach populations. For them, organized screening programs offer a better coverage, while novel invitation approaches for eligible individuals and multiple strategies from primary care physicians are still needed to enhance screening rates among subjects who are hard-to-reach. Suggestions implied the effectiveness of interventions at the system level, including linkages to general practice; use of decision making tools; enlisting supports from coalition; and the continuum from screening to diagnosis and treatment. Conclusion: Organized CRC screening offers a system access to approach the hard-to-reach populations. To increase their uptake, multiple and novel strategies from individual, provider and system levels should be applied. For policymakers, public healthcare providers and community stakeholders, it is a test to tailor their potential needs and increase their participation rates through continuous efforts to eliminate disparities and inequity in CRC screening service

The adoption of the Reference Framework for diabetes care among primary care physicians in primary care settings: a cross-sectional study

The prevalence of diabetes mellitus has been increasing both globally and locally. Primary care physicians (PCPs) are in a privileged position to provide first contact and continuing care for diabetic patients. A territory-wide Reference Framework for Diabetes Care for Adults has been released by the Hong Kong Primary Care Office in 2010, with the aim to further enhance evidence-based and high quality care for diabetes in the primary care setting through wide adoption of the Reference Framework. A valid questionnaire survey was conducted among PCPs to evaluate the levels of, and the factors associated with, their adoption of the Reference Framework. A total of 414 completed surveys were received with the response rate of 13.0%. The average adoption score was 3.29 (SD 0.51) out of 4. Approximately 70% of PCPs highly adopted the Reference Framework in their routine practice. Binary logistic regression analysis showed that the PCPs perceptions on the inclusion of sufficient local information (adjusted odds ratio [aOR]=4.748, 95%CI 1.597–14.115, P=0.005) and reduction of professional autonomy of PCPs (aOR=1.859, 95%CI 1.013–3.411, P=0.045) were more likely to influence their adoption level of the Reference Framework for diabetes care in daily practices. The overall level of guideline adoption was found to be relatively high among PCPs for adult diabetes in primary care settings. The adoption barriers identified in this study should be addressed in the continuous updating of the Reference Framework. Strategies need to be considered to enhance the guideline adoption and implementation capacity

The adoption of hypertension reference framework: An investigation among primary care physicians of Hong Kong.

BACKGROUND:The Hong Kong Government released a Reference Framework (RF-HT) for Hypertension Care for Adults in Primary Care Settings since 2010. No studies have evaluated its adoption by primary care physicians (PCPs) since its release. AIM:We aimed to evaluate the level of PCPs' adoption of the RF-HT and the potential barriers of its use in family practice. DESIGN AND SETTING:A cross-sectional study was conducted by a self-administered validated survey among all PCPs in Hong Kong through various means. METHODS:We assessed the level of and factors associated with its adoption by multivariate logistic regression modelling. RESULT:A total of 3,857 invitation episodes were sent to 2,297 PCPs in 2014-2015. We received 383 completed questionnaires. The average score of adoption was 3.43 out of 4.00, and 47.5% of PCPs highly adopted RF-HT in their daily consultations. Male practitioners (adjusted odds ratio [aOR] = 0.524, 95% CI = 0.290-0.948, p = 0.033) and PCPs of public sector (aOR = 0.524, 95% CI = 0.292-0.940, p = 0.030) were significantly less likely to adopt the RF-HT. PCPs with higher training completion or being academic fellow are more likely to adopt RF-HT than those who were "nil to basic training completion" (aOR = 0.479, 95% CI = 0.269-0.853, p = 0.012) or "higher trainee" (aOR = 0.302, 95% CI = 0.093-0.979, p = 0.046). Three most-supported suggestions on RF-HT improvement were simplification of RF-HT, provision of pocket version and promoting in patients. CONCLUSION:Among PCP respondents, the adoption level of the RF-HT was high. These findings also highlighted some factors associated with its adoption that could inform targeted interventions for enhancing its use in clinical practice