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BACKGROUND Predicting early outbreaks and epidemics with artificial intelligence (AI) needs a standardized approach where human trust is explicitly characterized to be maximized. Data science or analytical methods were found useful in predicting health threats. Still, there lacks a systemic thinking of integrating data science and analytical methods to be a transparent and explainable design that human trust is characterized. OBJECTIVE We aimed to formulate a standardized input-analytics-output (i.e., three components) approach to predicting health threats like COVID-19. The approach should be built on a theoretical framework that humans can trust cognitively and emotionally. At the same time, each component was designed to maximize the information load, performance, transparency, and human trust. We aimed to illustrate the standardized approach to predicting Hong Kong’s early outbreaks and the later epidemic of COVID-19 as an example. METHODS We adopted the socio-ecological system (SES) as the theoretical framework to map the accumulated number and time-series data of outbreaks in residential buildings and their influencing factors into a hierarchical structure. Multiple sources of non-health data were analyzed and integrated into the SES hierarchies from the individual, household, to community levels. Analytics included the modeling based on deep neural networks (DNN) of the SES-informed structure, the cross-validations for flagging buildings of more infection risks, and the prospective validations for forecasting 3-, 7- and 14-day daily case increases of all studied buildings. RESULTS We found that the role of sociodemographics and residential environments in the early COVID-19 outbreaks (before the epidemic: 2020-01-23 to 2021-12-23) differed from those in the epidemic (2021-12-24 to 2022-05-21), after studying 345 residential buildings from three adjacent districts. Our DNN accurately classified the high-risk cluster in the epidemic (AUCs=0.99, 0.98, and 0.95). Its extracted Shapley values enabled accurate building-level outbreak forecasting between 2022-05-22 and 2022-07-23 (average AUC>0.95 in 7-day forecasting horizon). Residential environment factors played more significant roles than sociodemographics in the COVID-19 epidemic. Based on the identified influencing factors (e.g., work hours, monthly household income, number of households, number of non-working population and children, and floor plan, number of floors, flats, and corridors), implications on monitoring the early outbreaks and preventing its evolvement into epidemics were discussed. CONCLUSIONS We proposed a human-trust-driven AI design for predicting health threats and demonstrated its use and capability in flagging high-risk subjects with cross-sectional data and forecasting future outbreaks daily at the subject level. The standardized approach provided a systemic logic to design new AI and verify existing AI designs in predicting and understanding public-health threats like COVID-19. It also has excellent extensibility to integrate more data sources, flexibility to accommodate more complicated or uncomplicated modeling with low maintenance costs, and excellent generalizability to other medical research problems using SES or other theoretical frameworks.

Background The elderly healthcare voucher (EHCV) scheme is expected to lead to an increase in the number of elderly people selecting private primary healthcare services and reduce reliance on the public sector in Hong Kong. However, studies thus far have reported that this scheme has not received satisfactory responses. In this study, we examined changes in the ratio of visits between public and private doctors in primary care (to measure reliance on the public sector) for different strategic scenarios in the EHCV scheme. Methods Based on comments from an expert panel, a system dynamics model was formulated to simulate the impact of various enhanced strategies in the scheme: increasing voucher amounts, lowering the age eligibility, and designating vouchers for chronic conditions follow-up. Data and statistics for the model calibration were collected from various sources. Results The simulation results show that the current EHCV scheme is unable to reduce the utilization of public healthcare services, as well as the ratio of visits between public and private primary care among the local aging population. When comparing three different tested scenarios, even if the increase in the annual voucher amount could be maintained at the current pace or the age eligibility can be lowered to include those aged 60 years, the impact on shifts from public-to-private utilization were insignificant. The public-to-private ratio could only be marginally reduced from 0.74 to 0.64 in the first several years. Nevertheless, introducing a chronic disease-oriented voucher could result in a significant drop of 0.50 in the public-to-private ratio during the early implementation phase. However, the effect could not be maintained for an extended period. Conclusions Our findings will assist officials in improving the design of the EHCV scheme, within the wider context of promoting primary care among the elderly. We suggest that an additional chronic disease-oriented voucher can serve as an alternative strategy. The scheme must be redesigned to address more specific objectives or provide a separate voucher that promotes under-utilized healthcare services (e.g., preventive care), instead of services designed for unspecified reasons, which may lead to concerns regarding exploitation.

Background A residential care service voucher scheme has been introduced to expand the capacity and enhance choice of public-funded long-term care (LTC) in Hong Kong, enabling users to have greater choices over the types of LTC facilities. Older persons with communication problems have difficulties in understanding the care options available to them and expressing their preferences to care homes and daily service delivery, therefore hindering their ability to exercise control and choice. Thus, they may have different needs and preferences for the facilities than others due to their conditions. This study therefore aimed to investigate their preference for care homes in comparison with those without communication problems. Methods A discrete choice experiment was conducted to elicit preference for six attributes derived from prior studies. The family caregivers of a random sample of older voucher holders were invited to undertake face-to-face interview. Willingness-to-pay (WTP) for the attributes was estimated for those with or without communication problems separately. Results Two hundred eighty-three caregivers provided valid responses (74% response rate). Caregivers of those with communication problem preferred facilities operated by non-governmental organizations (WTP=HK$1777.4) and shorter travelling time (WTP=HK$1502.5 for Conclusions The reputation, greater space and staff, and proximity/familiarity of the facilities were important for those with communication problems. To help meet these preferences, the facilities could establish collaborations with local community-based service providers and build their own outreach team to familiarize themselves with older persons. Additionally, household income and informal support availability should be considered for care planning.

Using two early transmission chains in Hong Kong, the estimated R and k were 1.34 [95% credible interval (CrI): 0.94–2.19] and 0.33 (95%CrI: 0.17–0.62), respectively, inferring 20.3% (95%CrI: 12.7–29.6%) cases were responsible for 80% of the transmissions of the Omicron epidemic. Compared with Omicron BA.1, Omicron BA.2 had a greater superspreading potential.

Background Vouchers, which are demand-side subsidies to targeted groups, are a type of consumer-led near-cash social transfer for specified benefits that have been used in education, health and other sectors. To provide better access to residential care services and an additional choice for elderly people in need, a novel means-tested residential care service voucher has been introduced in Hong Kong for elderly people to purchase places in the private sector to enable consumer-directed care. The objectives of this paper are to analyze the perspectives of voucher users and their carers toward the voucher scheme and to identify key elements in the design that will contribute to meeting the scheme’s objectives. Methods An exploratory sequential mixed method design was adopted with initial explorative qualitative data collection of the perspectives of elderly people and their carers (Phase 1), which informed the design of the subsequent questionnaire survey (Phase 2). Thirty carers in 5 focus groups and 20 individual interviews with elderly people were conducted between April and May 2018. A total of 401 respondents (373 carers and 28 elderly people) completed the survey questionnaire. Findings from both phases were integrated both narratively and via a joint display. Results Five key themes summarized the features in two main elements of the design and implementation of the voucher scheme: awareness, meaning that inadequate knowledge and understanding of voucher schemes hinder participation; service needs and types, indicating that the urgent need for residential care services is the key reason for participation; shared responsibility, meaning that a high copayment level discourages participation; choice and flexibility, reflecting appreciation of the additional choices provided by voucher schemes although the availability of residential care beds limits choices; and service quality, indicating mixed perceptions of service quality and the impact of the voucher scheme. Voucher users believe that the voucher scheme is more helpful for relieving the financial burden (98.7%), reducing carers’ stress (97.0%) and reducing the waiting time for subsidized homes for elderly people (89.0%) than for increasing choice and flexibility (78.1%) and improving service quality (62.1%). Conclusions This study demonstrates how the design of a voucher scheme affects its take-up by targeted beneficiaries. When a voucher scheme is implemented in a long-term care system, it must consider the congruence with existing policies in long-term care provision and financing. The voucher scheme in Hong Kong has been able to generate the utilization of nonsubsidized places in homes for elderly people that were underutilized, but its effectiveness is limited by inadequate knowledge and understanding of the voucher scheme and the availability of residential care places. Giving the purchasing power and choice of providers to beneficiaries has the potential to enhance the quality of services, which will contribute to meeting the objectives. The study findings carry significant implications for long-term care policies and provide insights into the key features of the voucher scheme for residential care services and how to best design and implement a voucher scheme for elderly people in the context of policy objectives and a long-term care policy.

ImportanceFew studies have evaluated the waning of vaccine effectiveness against severe outcomes caused by SARS-CoV-2 Omicron infection. Hong Kong is providing inactivated and mRNA vaccines, but the population had limited protection from natural infections before the Omicron variant emerged.ObjectiveTo examine the change in vaccine effectiveness against hospitalization and mortality due to the Omicron variant over time.Design, Setting, and ParticipantsThis case-control study included adults with SARS-CoV-2 Omicron variant infection who died or were hospitalized in Hong Kong from January 1 to June 5, 2022 (ie, case participants), and adults with SARS-CoV-2 Omicron, sampled from the public health registry during the study period (ie, control participants), who were matched to case participants by propensity score.ExposuresVaccination status of the individuals.Main Outcomes and MeasuresEstimated vaccine effectiveness against death, death or hospitalization, and death among hospitalized patients. Vaccine effectiveness was calculated as 1 − adjusted odds ratio obtained by conditional logistic regression adjusted with covariates for each period following vaccination.ResultsThere were 32 823 case participants (25 546 [77.8%] ≥65 years; 16 930 [47.4%] female) and 131 328 control participants (100 041 [76.2%] ≥65 years; 66 625 [46.6%] female) in the sample analyzed for the death or hospitalization outcome. Vaccine effectiveness against death or hospitalization was maintained for at least 6 months after the second dose of both CoronaVac (74.0%; 95% CI, 71.8%-75.8%) and BNT162b2 (77.4%; 95% CI, 75.5%-79.0%) vaccines. Vaccine effectiveness against death in those aged 18 to 49 years was 86.4% (95% CI, 85.8%-87.0%) and 92.9% (95% CI, 92.6%-93.2%) for those receiving 2 doses of CoronaVac and BNT162b2, respectively, while for patients aged 80 years or older, it dropped to 61.4% (95% CI, 59.8%-63.2%) and 52.7% (95% CI, 50.2%-55.6%) for CoronaVac and BNT162b2, respectively. Nevertheless, overall vaccine effectiveness against death at 4 to 6 months after the third dose was greater than 90% for CoronaVac, BNT162b2, and the mixed vaccine schedule (eg, mixed vaccines: vaccine effectiveness, 92.2%; 95% CI, 89.2%-95.1%).Conclusions and RelevanceWhile vaccines were generally estimated to be effective against severe outcomes caused by SARS-CoV-2 Omicron infection, this analysis found that protection in older patients was more likely to wane 6 months after the second dose. Hence, a booster dose is recommended for older patients to restore immunity. This is especially critical in a setting like Hong Kong, where third-dose coverage is still insufficient among older residents.

Objective The measurement of patients’ experience is an important performance indicator of health care service quality. A reliable and validated instrument to elicit patients’ experience is an important step. This study aimed to develop a generic instrument to elicit patients’ experience in specialist outpatient clinic provision with a rigorous and systematic methodology. Design The instrument framework was developed according to findings of a literature review, patient focus group discussions, individual patient in-depth interviews and expert discussion. The framework was tested for psychometric performance with a cross-sectional telephone survey in terms of practicality, validity, reliability and responsiveness. Setting 26 Public specialist outpatient clinics in Hong Kong were selected. Participants Cantonese speaking patients aged 18 or above. Intervention(s): None. Main outcome measure(s): A validated generic patient experience questionnaire measuring Specialist Outpatient Service (SOPEQ). Results A proportional sample total of 513 patients from 26 specialist outpatient clinics were recruited, response rate of 56%. The findings indicated that the instrument is practicable and concise. A structure of nine dimensions with 47 items structure was confirmed based on exploratory factor analysis and content validity. These items showed satisfactory internal reliability consistency (α = 0.793) and test–retest reliability ranged from 0.618 to 0.829. Conclusions The SOPEQ was established with satisfactory psychometric properties. A valid and reliable measure to evaluate patients’ experience is an important step in providing valuable input from patients’ perspective for policy makers to improve patient-centred services. It also serves as a platform to engage patients and thereby, in improving health care quality and enhancing health outcomes.

Background Contact tracing and intensive testing programs are essential for controlling the spread of COVID-19. However, conventional contact tracing is resource intensive and may not result in the tracing of all cases due to recall bias and cases not knowing the identity of some close contacts. Few studies have reported the epidemiological features of cases not identified by contact tracing (“unlinked cases”) or described their potential roles in seeding community outbreaks. Objective For this study, we characterized the role of unlinked cases in the epidemic by comparing their epidemiological profile with the linked cases; we also estimated their transmission potential across different settings. Methods We obtained rapid surveillance data from the government, which contained the line listing of COVID-19 confirmed cases during the first three waves in Hong Kong. We compared the demographics, history of chronic illnesses, epidemiological characteristics, clinical characteristics, and outcomes of linked and unlinked cases. Transmission potentials in different settings were assessed by fitting a negative binomial distribution to the observed offspring distribution. Results Time interval from illness onset to hospital admission was longer among unlinked cases than linked cases (median 5.00 days versus 3.78 days; P Conclusions The unlinked cases were positively associated with time to hospital admission, severity of infection, and epidemic size—implying a need to design and implement digital tracing methods to complement current conventional testing and tracing. To minimize the risk of cluster transmissions from unlinked cases, digital tracing approaches should be effectively applied in high-risk socioeconomic settings, and risk assessments should be conducted to review and adjust the policies.

BACKGROUND Contact tracing and intensive testing programs are essential for controlling the spread of COVID-19. However, conventional contact tracing is resource intensive and may not result in the tracing of all cases due to recall bias and cases not knowing the identity of some close contacts. Few studies have reported the epidemiological features of cases not identified by contact tracing (“unlinked cases”) or described their potential roles in seeding community outbreaks. OBJECTIVE For this study, we characterized the role of unlinked cases in the epidemic by comparing their epidemiological profile with the linked cases; we also estimated their transmission potential across different settings. METHODS We obtained rapid surveillance data from the government, which contained the line listing of COVID-19 confirmed cases during the first three waves in Hong Kong. We compared the demographics, history of chronic illnesses, epidemiological characteristics, clinical characteristics, and outcomes of linked and unlinked cases. Transmission potentials in different settings were assessed by fitting a negative binomial distribution to the observed offspring distribution. RESULTS Time interval from illness onset to hospital admission was longer among unlinked cases than linked cases (median 5.00 days versus 3.78 days; PPP=.049). Cluster transmissions from the unlinked cases were most frequently identified in household settings, followed by eateries and workplaces, with the estimated probability of cluster transmissions being around 0.4 for households and 0.1-0.3 for the latter two settings. CONCLUSIONS The unlinked cases were positively associated with time to hospital admission, severity of infection, and epidemic size—implying a need to design and implement digital tracing methods to complement current conventional testing and tracing. To minimize the risk of cluster transmissions from unlinked cases, digital tracing approaches should be effectively applied in high-risk socioeconomic settings, and risk assessments should be conducted to review and adjust the policies.

While most countries in the Western Pacific Region (WPR) had similar trajectories of COVID-19 from January to May, their implementations of non-pharmaceutical interventions (NPIs) differed by transmission stages. To offer a better understanding for an implementation of multidisciplinary policies in COVID-19 control, we compared the impact of NPIs by assessing the transmissibility and severity of COVID-19 in different phases of the epidemic during the first five months in WPR. In this study, we estimated the piecewise instantaneous reproduction number (Rt) and the reporting delay-adjusted case-fatality ratio (dCFR) of COVID-19 in seven WPR jurisdictions: Hong Kong Special Administrative Region, Japan, Malaysia, Shanghai, Singapore, South Korea, and Taiwan. According to the results, implementing NPIs was associated with an apparent reduction of the piecewise Rt in two epidemic waves in general. However, large cluster outbreaks raised the piecewise Rt to a high level. We also observed relaxing the NPIs could result in an increase of Rt. The estimated dCFR ranged from 0.09% to 1.59% among the jurisdictions, except in Japan where an estimate of 5.31% might be due to low testing efforts. To conclude, in conjunction with border control measures to reduce influx of imported cases which might cause local outbreaks, other NPIs including social distancing measures along with case finding by rapid tests are also necessary to prevent potential large cluster outbreaks and transmissions from undetected cases. A comparatively lower CFR may reflect the health system capacity of these jurisdictions. In order to keep track of sustained disease transmission due to resumption of economic activities, a close monitoring of disease transmissibility is recommended in the relaxation phase. The report of transmission of SARS CoV-2 to pets in Hong Kong and to mink in farm outbreaks highlight for the control of COVID-19 and emerging infectious disease, the One Health approach is critical in understanding and accounting for how human, animals and environment health are intricately connected., Highlights • Multidisciplinary One Health policies to combat COVID-19 are required in WPR. • NPIs were associated with an apparent reduction in transmissibility of COVID-19. • However, some large cluster outbreaks raised the transmissibility to a high level. • We observed an increase in transmissibility when NPIs were partially lifted. • A lower case-fatality ratio in WPR may reflect the health system capacity.

Objective To assess public knowledge and expectations of the ways to assess doctors' competence to ensure patient safety. Design setting and participants Telephone survey of a random sample of 1000 non-institutionalized Hong Kong residents. Measures and results Only 5% of public were correct that doctors are not required to periodically be assessed, and 9% were correct that the doctors are not required to update knowledge and skills for renewing their license. These results echo international studies showing a low public knowledge of medical regulation. The public overwhelmingly felt a periodic assessment (92%) and requirements for continuous medical education (91%) were important processes for assuring doctors' competence. A high proportion of the public felt that lay representation in the Medical Council was insufficient. Conclusion There is a significant gap between public expectations and understanding of the existing medical regulation and the actual policies and practices. Despite a lack of public knowledge, the public thought it important to have an ongoing structured monitoring and assessment mechanism to assure doctors' competence. The public also expects a greater involvement in the regulatory processes as members of the Medical Council. There is a need to review and enhance the current regulatory system to meet public expectation and ensure accountability for the privilege and trust granted by the State in professional self-regulation. In the context of our complex health system, a thorough understanding on the dynamic interactions between different institutions and their complementary roles in a meta-regulatory framework is required in assuring patient safety.

Considering the ageing population in economically advanced regions across the world, measures are necessary to enhance the health of the older population as well as contain public healthcare spending. Hong Kong implements the Elderly Health Care Voucher Scheme (EHCVS), providing older people aged 65 or above an annual subsidy of visiting private healthcare service providers for chronic disease prevention and management. The services also aim at reallocating demand from the public to private sector as well as improve quality of services. This qualitative study explored the experiences of EHCVS recipients (n = 55, aged 61-94) with eight focus group interviews in Hong Kong in the year 2016. Convenience sampling was used. Research questions were: (1) Why do older people choose not to use EHCVS for preventive as well as disease management services among older people in Hong Kong? (2) What are the barriers to reallocating demand from the public to private sector? (3) In what ways did EHCVS improve the quality of primary care services for older people? Using a deductive and inductive approach, eight qualitative themes were identified. Findings suggested that the non-targeted services and inadequate knowledge on EHCVS deterred older people from using the vouchers for disease management and prevention. The relatively expensive private services, lack of trust in the private sector, low public clinic fees and good services quality of the public sector, together with inadequate private practitioners in the healthcare market were barriers that hinder demand reallocation. Nevertheless, the quality of primary care services had been improved after the implementation of EHCVS with shortened wait times and opportunities to discuss health-related issues with private practitioners. Findings were discussed with practice, policy and research implications.

PURPOSE. To characterize willingness to pay for private operations and preferred waiting time among patients awaiting cataract surgery in Hong Kong. METHODS. This was a cross-sectional survey. Subjects randomly selected from cataract surgical waiting lists in Hong Kong (n = 467) underwent a telephone interview based on a structured, validated questionnaire. Data were collected on private insurance coverage, preferred waiting time, amount willing to pay for surgery, and self-reported visual function and health status. RESULTS. Among 300 subjects completing the interview, 144 (48.2%) were 76 years of age or older, 177 (59%) were women, and mean time waiting for surgery was 17 +/- 15 months. Among 220 subjects (73.3%) willing to pay anything for surgery, the mean amount was US$552 +/- 443. With adjustment for age, education, and monthly household income, subjects willing to pay anything were less willing to wait 12 months for surgery (OR = 4.34; P = 0.002), more likely to know someone having had cataract surgery (OR = 2.20; P = 0.03), and more likely to use their own savings to pay for the surgery (OR = 2.21; P = 0.04). Subjects considering private cataract surgery, knowing people who have had cataract surgery, using nongovernment sources to pay for surgery, and having lower visual function were willing to pay more. CONCLUSIONS. Many patients wait significant periods for cataract surgery in Hong Kong, and are willing to pay substantial amounts for private operations. These results may have implications for other countries with cataract waiting lists. (Invest Ophthalmol Vis Sci. 2009; 50:3636-3642) DOI:10.1167/iovs.08-3025