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Background: Primary care patients, especially those with an older age, are one of the most vulnerable populations for post-COVID-19 symptoms. Identifying predictors of post-COVID symptoms can help identify high-risk individuals for preventive care., Methods: Out of 977 primary care patients aged 55 years or above with comorbid physical and psychosocial conditions in a prospective cohort in Hong Kong, 207 patients infected in the previous 5-24 weeks were included. The three most common post-COVID-19 symptoms (breathlessness, fatigue, cognitive difficulty), which lasted beyond the 4-week acute infection period, were assessed using items from the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS), together with other self-reported symptoms. Multivariable analyses were conducted to identify predictors of post-acute and long COVID-19 symptoms (5-24 weeks after infection)., Results: The 207 participants had a mean age of 70.8 ± 5.7 years, 76.3% were female, and 78.7% had ≥2 chronic conditions. In total, 81.2% reported at least one post-COVID symptom (mean: 1.9 ± 1.3); 60.9, 56.5 and 30.0% reported fatigue, cognitive difficulty, and breathlessness respectively; 46.1% reported at least one other new symptom (such as other respiratory-related symptoms (14.0%), insomnia or poor sleep quality (14.0%), and ear/nose/throat symptoms (e.g., sore throat) (10.1%), etc.). Depression predicted post-COVID-19 fatigue. The female sex predicted cognitive difficulty. Receiving fewer vaccine doses (2 doses vs. 3 doses) was associated with breathlessness. Anxiety predicted a higher overall symptom severity level of the three common symptoms., Conclusion: Depression, the female sex, and fewer vaccine doses predicted post-COVID symptoms. Promoting vaccination and providing intervention to those at high-risk for post-COVID symptoms are warranted., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Zhang, Chung, Chan, Xu, Zhou, Tam, Lee, Sit, Mercer and Wong.)

Background: The COVID-19 pandemic has impacted the psychological health and health service utilisation of older adults with multimorbidity, who are particularly vulnerable., Aim: To describe changes in loneliness, mental health problems, and attendance to scheduled medical care before and after the onset of the COVID-19 pandemic., Design and Setting: Telephone survey on a pre-existing cohort of older adults with multimorbidity in primary care., Method: Mental health and health service utilisation outcomes were compared with the outcomes before the onset of the COVID-19 outbreak in Hong Kong using paired t -tests, Wilcoxon's signed-rank test, and McNemar's test. Loneliness was measured by the De Jong Gierveld Loneliness Scale. The secondary outcomes (anxiety, depression, and insomnia) were measured by the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder tool, and the Insomnia Severity Index. Appointments attendance data were extracted from a computerised medical record system. Sociodemographic factors associated with outcome changes were examined by linear regression and generalised estimating equations., Results: Data were collected from 583 older (≥60 years) adults. There were significant increases in loneliness, anxiety, and insomnia, after the onset of the COVID-19 outbreak. Missed medical appointments over a 3-month period increased from 16.5% 1 year ago to 22.0% after the onset of the outbreak. In adjusted analysis, being female, living alone, and having >4 chronic conditions were independently associated with increased loneliness. Females were more likely to have increased anxiety and insomnia., Conclusion: Psychosocial health of older patients with multimorbidity markedly deteriorated and missed medical appointments substantially increased after the COVID-19 outbreak., (©The Authors.)

Purpose: This is an ongoing prospective cohort aiming to examine the biopsychosocial health profiles and predictors of health outcomes of older patients with multimorbidity in primary care in Hong Kong., Participants: From April 2016 to October 2017, 1077 patients aged 60+ years with at least two chronic diseases were recruited in four public primary care clinics in the New Territories East Region of Hong Kong., Findings to Date: After weighting, the patients had 4.1 (1.8) chronic conditions and 2.5 (1.9) medications on average; 37% forgot taking medication sometimes; 71% rated their health as fair or poor; 17% were frail; 73% reported one (21%) or two or more (52%) body pain areas; 62% were overweight/obese; 23% reported chewing difficulty, 18% reported incontinence; 36% had current stage 1/2 hypertension; 38% had handgrip strength below the cut-off; 10% screened positive in sarcopenia; 17% had mild or severer cognitive impairment; 17% had mild to severe depression; 16% had mild to severe anxiety; 50% had subthreshold to severe insomnia; 28% indicated being lonely; 12% needed help in at least one out of the five daily functions and the EuroQoL-5-Dimensions-5-Level index score was 0.81 (0.20) and its Visual Analogue Scale (VAS) score was 67.6 (14.6). In the past 12 months, 17% were hospitalised, 92% attended general outpatient clinics, 70% attended specialist outpatient clinics and 10% used elderly daycare centre services, the median out-of-pocket health cost was HK$1000 (US$150). Female and male patients showed significant differences in many biopsychosocial health aspects., Future Plans: With assessments and clinical data, the cohort can be used for understanding longitudinal trajectories of biopsychosocial health profiles of Chinese older patients with multimorbidity in primary care. We are also initially planning cohort studies on factors associated with various health outcomes, as well as quality of life and healthcare use., Cohort Registration Number: ChiCTR-OIC-16008477., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Previous research has suggested a differential short-term effect of multimorbidity on hospitalization by age, with younger groups affected more. This study compares the nine-year hospitalization pattern by age and multimorbidity status in a retrospective cohort of discharged in-patients, who represent a high-need portion of the population., Methods: We examined routine clinical records of all patients aged 45+ years with chronic conditions discharged from public general hospitals in 2005 in Hong Kong. Patterns of annual frequencies of hospital admissions and number of hospitalized days over nine years (2005-2014) were compared by multimorbidity status (1, 2, 3+ conditions) and age group (45-64, 65-74, 75+)., Results: Among 121,188 included patients, 33.9% had 2+ conditions and 12.3% had 3+. Hospitalization patterns varied by age and multimorbidity status. For those having only 1 condition, annual number of admissions was similar by age, but older patients had more hospitalized days (4.40 days per person-year for the 45-64 group versus 10.29 for the 75+ group in the 5th year). For those with 3+ conditions, younger patients had more admissions (4.39 admissions per person-year for the 45-64 group versus 1.87 for the 75+ group in the 5th year) but similar number of hospitalized days with older patients. Interaction analysis showed effect of multimorbidity on hospitalization was stronger in younger groups (P < 0.05)., Conclusion: Middle-aged discharged in-patients with multimorbidity are admitted more often than their older counterparts and have similar total hospitalized days per year. Further research is needed to investigate chronic care needs of younger people with multimorbidity., (Copyright © 2018 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Using data collected from 25,780 Hong Kong citizens in a household survey, this study aimed to investigate the association between having regular source of primary care and hospitalization amongst people with and without multimorbidity (two or more chronic conditions). Potential interaction effects of regular primary care with multimorbidity were also examined. Results revealed a significant association between having regular source of primary care from General Practitioners and reduced hospitalization amongst respondents with multimorbidity (RR = 0.772; 95% CI = 0.667-0.894), adjusting for other potential confounding factors (i.e., socio-demographic factors and medical insurance and benefits). In contrast, having regular Specialist care was significantly associated with increased risk of hospitalization among both people with multimorbidity (RR = 1.619; 95% CI = 1.256-2.087) and without multimorbidity (RR = 1.981; 95% CI = 1.246-3.149), adjusting for potential confounders. A dose-response relationship between the number of chronic diseases and hospitalization was also observed, regardless of whether participants had regular source of primary care or not; relative risks and predicted probabilities for hospitalization were generally greater for those without regular source of primary care. Further studies are warranted to explore the role of healthcare system, informatics, organizational and practice-related factors on healthcare and functional outcomes.

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.

Associations of multimorbidity and income with hospital admission were investigated in population samples from 3 widely differing health care systems: Scotland (n = 36,921), China (n = 162,464), and Hong Kong (n = 29,187). Multimorbidity increased odds of admissions in all 3 settings. In Scotland, poorer people were more likely to be admitted (adjusted odds ratio [aOR] = 1.62; 95% CI, 1.41-1.86 for the lowest income group vs the highest), whereas China showed the opposite (aOR = 0.58; 95% CI, 0.56-0.60). In Hong Kong, poorer people were more likely to be admitted to public hospitals (aOR = 1.68; 95% CI, 1.36-2.07), but less likely to be admitted to private ones (aOR = 0.18; 95% CI, 0.13-0.25). Strategies to improve equitable health care should consider the impact of socioeconomic deprivation on the use of health care resources, particularly among populations with prevalent multimorbidity., (© 2015 Annals of Family Medicine, Inc.)

Background: Caregivers of people with chronic conditions are more likely than non-caregivers to have depression and emotional problems. Few studies have examined the effectiveness of mindfulness-based stress reduction (MBSR) in improving their mental well-being., Methods: Caregivers of persons with chronic conditions who scored 7 or above in the Caregiver Strain Index were randomly assigned to the 8-week MBSR group (n = 70) or the self-help control group (n = 71). Validated instruments were used to assess the changes in depressive and anxiety symptoms, quality of life, self-efficacy, self-compassion and mindfulness. Assessments were conducted at baseline, post-intervention and at the 3-month follow-up., Results: Compared to the participants in the control group, participants in the MBSR group had a significantly greater decrease in depressive symptoms at post-intervention and at 3 months post-intervention (p < 0.01). The improvement in state anxiety symptoms was significantly greater among participants in the MBSR group than those of the control group at post-intervention (p = 0.007), although this difference was not statistically significant at 3 months post-intervention (p = 0.084). There was also a statistically significant larger increase in self-efficacy (controlling negative thoughts; p = 0.041) and mindfulness (p = 0.001) among participants in the MBSR group at the 3-month follow-up compared to the participants in the control group. No statistically significant group effects (MBSR vs. control) were found in perceived stress, quality of life or self-compassion., Conclusions: MBSR appears to be a feasible and acceptable intervention to improve mental health among family caregivers with significant care burden, although further studies that include an active control group are needed to make the findings more conclusive.

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.

Background: Antibiotics overuse is common and is the major cause of antibiotic resistance. Rational use of antibiotics by GPs is essential as most health problems are exclusively dealt within primary care. Postgraduate family medicine (FM) training has become established in various countries over the last few decades but little is known about the effect of FM training on antibiotic prescribing., Objective: To determine whether GPs with FM training prescribe less antibiotics than those without training., Methods: GPs working in a pluralistic primary health care system took part in the 2007-08 primary care morbidity and management survey in Hong Kong and collected information of all consecutive patient encounters during predetermined weeks of data collection. Characteristics of GPs, training status, patient morbidity and antibiotic prescribing pattern were compared using multivariate regression analyses., Results: One hundred and nine GPs, of whom 67 had FM training, participated in the study and recorded 69 973 health problems. The overall antibiotic prescribing rate was 8.5% and that of GPs with FM training was 5.4% compared with the 13.3% among those without. Multivariate logistic regression showed that GPs with FM training were less likely to prescribe antibiotics (odds ratio 0.68, P < 0.05). They had lower antibiotic prescribing rates when managing upper respiratory tract infections, acute bronchitis and cough but higher in treating infective conjunctivitis and acute laryngitis., Conclusions: Postgraduate FM training in Hong Kong is associated with significantly lower antibiotic prescribing rates. This supports the importance of FM training in rationalizing the use of antibiotics in Hong Kong.

Background: The Patient Enablement Instrument (PEI) was developed to measure patients' enablement, which is an indicator of the effectiveness of a primary care consultation; however, to date, the PEI has not been tested in Asian populations., Objectives: The purpose of this study is to test the acceptability, validity, reliability and other psychometric properties of a Chinese [Hong Kong (HK)] translation of the PEI in Chinese patients in Hong Kong and whether these properties would be affected by different timing of administration., Methods: A Chinese (HK) translation of the PEI was developed by iterative forward-backward translations and the content validity was assessed by a cognitive debriefing interview with 10 Chinese patients. It was then administered to 152 adult patients attending a government-funded primary care clinic in Hong Kong both immediately after the consultation and 2-3 weeks later by telephone. Internal construct validity was assessed by item-scale correlations and factor analysis, test-retest reliability was assessed by intraclass correlation (ICC) and sensitivity was assessed by known group comparison., Results: The Chinese (HK) PEI was semantically equivalent to the original PEI for all items. Acceptability of the PEI was high with 83.1% response and 100% completion rates. Statistical analyses showed no difference between test and retest means as well as good reproducibility (ICC 0.75). Internal reliability determined by Cronbach's alpha was >0.8 irrespective of timing of administration. Scale construct validity was confirmed by strong (r>0.4) item-scale correlations and resumed to a one-factor hypothesized structure. PEI scores were significantly higher in younger patients supporting sensitivity. There was no significant difference in the psychometric properties or scores between the assessment results from immediately after and 2-weeks post-consultation., Conclusions: A Chinese (HK) translation of the PEI equivalent to the original is now available for application to Chinese populations. Pilot testing supported its acceptability, validity, reliability and sensitivity. Further studies to confirm its construct validity and responsiveness will help to establish the Chinese (HK) PEI as an outcome measure of the effectiveness of primary care consultations in Chinese patients.

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.

Background: Despite Hong Kong government's official commitment to the development of traditional Chinese medicine (TCM) over the last ten years, there appears to have been limited progress in public sector initiated career development and postgraduate training (PGT) for public university trained TCM practitioners. Instead, the private TCM sector is expected to play a major role in nurturing the next generation of TCM practitioners. In the present study we evaluated TCM graduates' perspectives on their career prospects and their views regarding PGT., Method: Three focus group discussions with 19 local TCM graduates who had worked full time in a clinical setting for fewer than 5 years., Results: Graduates were generally uncertain about how to develop their career pathways in Hong Kong with few postgraduate development opportunities; because of this some were planning to leave the profession altogether. Despite their expressed needs, they were dissatisfied with the current quality of local PGT and suggested various ways for improvement including supervised practice-based learning, competency-based training, and accreditation of training with trainee involvement in design and evaluation. In addition they identified educational needs beyond TCM, in particular a better understanding of western medicine and team working so that primary care provision might be more integrated in the future., Conclusion: TCM graduates in Hong Kong feel let down by the lack of public PGT opportunities which is hindering career development. To develop a new generation of TCM practitioners with the capacity to provide quality and comprehensive care, a stronger role for the government, including sufficient public funding, in promoting TCM graduates' careers and training development is suggested. Recent British and Australian experiences in prevocational western medicine training reform may serve as a source of references when relevant program for TCM graduates is planned in the future.

Background: Increasing use is being made of routinely collected electronic patient data in health services research. The aim of the present study was to evaluate the potential usefulness of a comprehensive database used routinely in the public healthcare system in Hong Kong, using antihypertensive drug prescriptions in primary care as an example., Methods: Data on antihypertensive drug prescriptions were retrieved from the electronic Clinical Management System (e-CMS) of all primary care clinics run by the Health Authority (HA) in the New Territory East (NTE) cluster of Hong Kong between January 2004 and June 2007. Information was also retrieved on patients' demographic and socioeconomic characteristics, visit type (new or follow-up), and relevant diseases (International Classification of Primary Care, ICPC codes)., Results: 1,096,282 visit episodes were accessed, representing 93,450 patients. Patients' demographic and socio-economic details were recorded in all cases. Prescription details for anti-hypertensive drugs were missing in only 18 patients (0.02%). However, ICPC-code was missing for 36,409 patients (39%). Significant independent predictors of whether disease codes were applied included patient age > or = 70 years (OR 2.18), female gender (OR 1.20), district of residence (range of ORs in more rural districts; 0.32-0.41), type of clinic (OR in Family Medicine Specialist Clinics; 1.45) and type of visit (OR follow-up visit; 2.39). In the 57,041 patients with an ICPC-code, uncomplicated hypertension (ICPC K86) was recorded in 45,859 patients (82.1%). The characteristics of these patients were very similar to those of the non-coded group, suggesting that most non-coded patients on antihypertensive drugs are likely to have uncomplicated hypertension., Conclusion: The e-CMS database of the HA in Hong Kong varies in quality in terms of recorded information. Potential future health services research using demographic and prescription information is highly feasible but for disease-specific research dependant on ICPC codes some caution is warranted. In the case of uncomplicated hypertension, future research on pharmaco-epidemiology (such as prescription patterns) and clinical issues (such as side-effects of medications on metabolic parameters) seems feasible given the large size of the data set and the comparability of coded and non-coded patients.

Background: There has been an increasing prevalence of both depression and chronic medical conditions globally but the relationship between depression and multi-morbidity is not well understood. The aim of the present study was to investigate the relationship between depression, multi-morbidity (number of chronic medical conditions, and measures of socioeconomic standing (SES) in an elderly Hong Kong population., Methods: Cross sectional study. Information on clinically relevant depressive symptoms, measured by the Geriatric Depression Scale (GDS), and demographic and chronic medical conditions were collected using standardized questionnaires. Information collected on SES included educational status (ES), maximum ever income (MEI), and self-perceived social standing in local community (SES-COM) and in Hong Kong generally (SES-HK). Analysis was conducted using multiple logistic regression, Results: Depression rates were similar in men and women (GDS caseness 8.1% vs 8.4%). Multi-morbidity of chronic medical conditions was common (40% of men and 46% of women had three or more). In the overall sample, the prevalence of depression was associated with the number of chronic medical conditions (OR 1.27; CI: 1.16-1.39). In addition, SES-HK and SES-COM were significant independent variables., Conclusion: In this elderly Hong Kong population, depression prevalence rose markedly with number of chronic medical conditions and SES-HK and SES-COM.