A latent profile analysis on patient empowerment programme in a Hong Kong primary care setting.

OBJECTIVE: This study identified the profiles of subgroups of type 2 diabetic (T2DM) patients of the Patient Empowerment Programme (PEP) by different levels of benefits gained in diabetic self-management behaviors, self-efficacy, and health literacy. METHODS: This study adopted a non-experimental repeated-measures design on T2DM patients who joined PEP, using structured questionnaires. Latent profile analysis (LPA) was used to identify patterns of participants' change on the outcome measures. RESULTS: Findings of LPA revealed that participants who were older, unemployed, weaker in diabetic self-management, and having a higher self-perception in personal disease risk were more likely to join the empowerment sessions and gained more benefits from the program. Participants with lower impairment in energy function and lower autonomy in personal health care showed more improvement in the outcomes. CONCLUSION: The study identified significant factors associated with patients' participation on and benefits gained from a service delivery model integrating health education and patient empowerment in a primary care setting. PRACTICE IMPLICATION: Findings from this study shed light on strategies to improve the PEP design in order to meet the needs of individuals with different health-related profiles.

Declining Trends of Cardiovascular-Renal Complications and Mortality in Type 2 Diabetes: The Hong Kong Diabetes Database.

OBJECTIVE: Nationwide studies on secular trends of diabetes complications are not available in Asia. We examined changes in risk factor control and incidence of complications from diabetes and death in a large longitudinal cohort of Chinese adults with type 2 diabetes in Hong Kong. RESEARCH DESIGN AND METHODS: Between 1 January 2000 and 31 December 2012, 338,908 Chinese adults with type 2 diabetes underwent metabolic and complication assessment in 16 diabetes centers operated by Hong Kong Hospital Authority that provided care to a large majority of diagnosed patients. Patients were followed for incident acute myocardial infarction (AMI), stroke, end-stage renal disease (ESRD), and death until 31 December 2012. Risk factor levels between enrollment periods were compared. Incidence of clinical events, stratified by diabetes duration, was examined over time. RESULTS: Incidence of complications from diabetes and death declined over the observation period in patients at varying disease duration. Among the high-risk group with diabetes for at least 15 years, crude incidence of AMI decreased from 8.7 to 5.8, stroke from 13.5 to 10.1, ESRD from 25.8 to 22.5, and death from 29.0 to 26.6 per 1,000 person-year between the periods 2000 to 2002 and 2010 to 2012. Improvements in levels of metabolic risk factors were detected. Proportion of patients achieving HbA1c <7.0% (53 mmol/mol) was increased from 32.9 to 50.0%, blood pressure ≤130/80 mmHg from 24.7 to 30.7%, and LDL cholesterol <2.6 mmol/L from 25.8 to 38.1%. CONCLUSIONS: From this territory-wide Hong Kong Diabetes Database, we observed decreases in incidence of cardiovascular-renal complications and death and corresponding improvements in risk factor control over a 13-year period.

Evaluation of patient-reported outcomes data in structured diabetes education intervention: 2-year follow-up data of patient empowerment programme.

To examine the effects of a structured group-based education programme, patient empowerment programme (PEP), compared with usual care on 2-year changes in patient-reported outcomes (PRO) in patients with diabetes mellitus (DM). A prospective observational study of 715 patients (PEP/non-PEP: 390/325) was conducted to complete the baseline PRO survey and followed up for 2 years. Health-related quality of life (HRQOL) was measured using the short-form 12 at baseline and annually at two follow-up assessments, which yielded physical and mental component summary and SF-6D preference-based scores. Perceived control over diabetes and general health status were measured using the patient enablement instrument (PEI) and global rating scale (GRS) at follow-ups. When compared with non-PEP, PEP participants significantly reported improvement in health condition (GRS score > 0; 24.55 % vs 10.16 %; odds ratio = 2.502; P = 0.018) in 2 years and enabled the self-perceived control over diabetes (PEI score > 0; 72.20 % vs 38.40 %; odds ratio = 3.25; P < 0.001) in 1-year follow-up but no sustained effects in year 2 (52.65 % vs 39.04 %; odds ratio = 1.366; P = 0.265). There were no significant differences between PEP and non-PEP groups in the changes in quality of life scores (all P > 0.05) at 1 year. Although HRQOL scores deteriorated over 2-year period in both groups, PEP participants reported similar changes in HRQOL scores to that of non-PEP. PEP for DM patients preserved self-perceived disease control and health condition, whereas PEP participants perceived their HRQOL similar to that of non-PEP participants. Findings of PRO should be considered alongside clinical outcomes when evaluating the overall benefits of PEP.

Evaluation of the quality of care of a haemodialysis public-private partnership programme for patients with end-stage renal disease.

BACKGROUND: Haemodialysis (HD) is one of the life-saving options for patients with end stage renal disease but demand for this treatment exceeds capacity in publicly funded hospitals. One novel approach to addressing this problem is through a shared-care model whereby government hospitals partner with qualified private HD service providers to increase the accessibility of HD for needy patients. The aim of this study is to evaluate and enhance the quality of care (QOC) provided in such a shared-care programme in Hong Kong, the Haemodialysis Public-Private Partnership Programme (HD-PPP). METHODS/DESIGN: This is a longitudinal study based on Action Learning and Audit Spiral methodologies to measure the achievement of pre-set target standards for the HD-PPP programme over three evaluation cycles. The QOC evaluation framework is comprised of structure, process and outcome criteria with target standards in each domain developed from review of the evidence and in close collaboration with the HD-PPP working group. During each evaluation cycle, coordinators of each study site complete a questionnaire to determine adherence with structural criteria of care. Process and clinical outcomes, such as adverse events and dialysis adequacy, are extracted from the patient records of consenting study participants while face-to-face interviews are conducted to ascertain patient-reported outcomes such as self-efficacy and health-related quality of life. DISCUSSION: The study relies on the successful implementation of partnership-based action research to develop an evidence-based and pragmatic framework for evaluation of quality of care in an iterative fashion, and to use it to identify possible areas of quality enhancements in a shared-care programme for HD patients. The approach we take in this study emphasizes partnership and engagement with the clinical and administrative programme team, a robust but flexible evaluation framework, direct observation and the potential to realize positive change. The experience will be useful to inform the process of coordinating research studies involving multiple stakeholders and results will help to guide service planning and policy decision making. TRIAL REGISTRATION: US Clinical Trial Registry NCT02307903.

Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP).

Patient Empowerment Programme (PEP) in primary care was effective in preventing diabetes-related complications in patients with diabetes. Nevertheless, the effect of PEP on glycaemic control, weight control, and complications was unclear in obese type 2 diabetic patients. We aimed to assess whether PEP reduced all-cause mortality, first macrovascular and microvascular disease events. A cohort of 6372 obese type 2 diabetic patients without prior occurrence of macrovascular or microvascular disease events on or before baseline study recruitment date was linked to the administrative database from 2008 to 2013. Non-PEP participants were matched one-to-one with the PEP participants using propensity score method with respect to their baseline covariates. Cox proportional hazard regressions were performed to estimate the associations of the PEP intervention with the occurrence of first macrovascular or microvascular disease events and death from any cause, controlling for demographic and clinical characteristics. During a median 31.5 months of follow-up, 350 (PEP/non-PEP: 151/199) patients suffered from a first macrovascular or microvascular disease event while 95 patients (PEP/non-PEP: 34/61) died from any cause. After adjusting for confounding variables, PEP participants had lower incidence rates of all-cause mortality [hazard ratio (HR): 0.589, 95 % confidence interval (CI) 0.380-0.915, P = 0.018] and first macrovascular or microvascular disease events (HR: 0.782, 95 % CI 0.632-0.968, P = 0.024) than those with PEP. Enrolment to PEP was an effective approach in reducing all-cause mortality and first macrovascular or microvascular disease events in obese patients with type 2 diabetes.

Increased number of structured diabetes education attendance was not associated with the improvement in patient-reported health-related quality of life: results from Patient Empowerment Programme (PEP).

AIMS: To assess the effect of a structured education intervention, Patient Empowerment Programme (PEP) patient-reported health-related quality of life (HRQOL) among type 2 diabetes mellitus (T2DM) patients, and if positive effect is confirmed, to further explore any association between frequency of sessions attendance and HRQOL. METHODS: A total of 298 T2DM patients were recruited when they attended the first session of PEP, between March and September 2010, and were followed over a one-year period from baseline. HRQOL data were assessed using Short Form-12 Health Survey version 2 (SF-12) and Short Form-6 Dimension (SF-6D) at baseline and one-year follow-up. Individuals' anthropometric and biomedical data were extracted from an administrative database in Hong Kong. Unadjusted and adjusted analyses of linear regression models were performed to examine the impact of PEP session attendance on the change in the HRQOL scores, accounting for the socio-demographic and clinical characteristics at baseline. RESULTS: Of the 298 eligible patients, 257 (86.2%) participated in the baseline assessment and 179 (60.1%) patients completed the follow-up assessment, respectively. Overall, PEP resulted in a significant improvement in SF-12 bodily pain and role emotional subscales and SF-6D utility scores. These positive changes were not associated with the level of participation as shown in both unadjusted and adjusted analyses. CONCLUSIONS: The PEP made significant improvement in bodily pain, role emotional and overall aspects of HRQOL. Higher number of session attendance was not associated with improvement in HRQOL in primary care real-world setting. Key Messages ● Participants with type 2 diabetes mellitus who participated in structured diabetes education programme made significant improvement in bodily pain and role emotional subscales and SF-6D scores. ● There was no association between the number of sessions attended and any aspect of HRQOL.

Framework and components for effective discharge planning system: a Delphi methodology.

BACKGROUND: To reduce avoidable hospital readmissions, effective discharge planning and appropriate post discharge support care are key requirements. This study is a 3-staged process to develop, pretest and pilot a framework for an effective discharge planning system in Hong Kong. This paper reports on the methodology of Delphi approach and findings of the second stage on pre-testing the framework developed so as to validate and attest to its applicability and practicability in which consensus was sought on the key components of discharge planning. METHODS: Delphi methodology was adopted to engage a group of experienced healthcare professionals to rate and discuss the framework and components of an effective discharge planning. The framework was consisted 36 statements under 5 major themes: initial screening, discharge planning process, coordination of discharge, implementation of discharge, and post discharge follow-up. Each statement was rated independently based on 3 aspects including clarity, validity and applicability on a 5-point Likert-scale. Statement with 75% or above of participants scoring 4-5 on all 3 aspects would be included in the discharge planning framework. For those statements not reaching 75% of consensus in any one of the aspect, it would be revised or discarded following the group discussion, and be re-rated in another round. RESULTS: A total of 24 participants participated in the consensus-building process. In round one rating, consensus was achieved in 25 out of 36 statements. Among those 11 statements not reaching consensus, the major concern was related to the "applicability" of the statements. The participants expressed a lack of manpower, skills and time in particular during weekends and long holidays in carrying out assessment and care plans within 24 h after admission. There were also timeliness and availability issue in providing transportation and necessary equipment to the patients. To make the statements more applicable, the wordings of some of the statements were revised to provide greater flexibility. Due to the lack of a statement in clarifying the role of the members of the healthcare professional team, one additional statement on the role and responsibility of the multidisciplinary team members was added. The first theme on "initial screening" was further revised to "initial screening and assessment" to better reflect the first stage of discharge planning process. After two rounds of rating process, all the 36 statements and the newly added statement reached consensus CONCLUSIONS: A structured, systematic and coordinated system of hospital discharge system is required to facilitate the discharge process to ensure a smooth patient transition from the hospital to the community and improve patient health outcome in both clinical and social aspect. The findings of this paper provide a reference framework helping policymakers and hospital managers to facilitate the development of a coherent and systematized discharge planning process. Adopting a Delphi approach also demonstrates the values of the method as a pre-test (before the clinical run) of the components and requirements of a discharge planning system taking into account of the local context and system constraints, which would lead to improvements to its applicability and practicability. To confirm the applicability and practicability of this consensus framework for discharge planning system, the third stage of process of development of the discharge planning framework is to apply and pilot the framework in a hospital setting to evaluate its feasibility, applicability and impact in hospital including satisfaction from both the perspectives of staff and patients.

Utility of a preoperative assessment clinic in a tertiary care hospital.

OBJECTIVES: To assess the utilisation rate of a preoperative assessment clinic and its impact on length of stay and discharge destinations. DESIGN: Retrospective case series with internal comparisons. SETTING: A tertiary hospital in Hong Kong. PATIENTS: All medical records of elective surgical admissions to a hospital in Hong Kong from April to June 2008 were retrieved. Medical records of patients who did not attend the preoperative assessment clinic were further reviewed by surgeons to assess if the patients could have been referred to the clinic. MAIN OUTCOME MEASURES: Total length of stay, preoperative and postoperative length of stay, and the discharge destinations of the patients attending and not attending the clinic were compared. RESULTS. In all, 640 patients underwent elective operations, of whom 22 (3%) patients were seen in the preoperative assessment clinic. In patients who had a major operation, the mean (standard deviation) total length of stays for clinic attenders and non-attenders were: 5.2 (3.6) versus 13.2 (18.8) days (P<0.001). The respective figures for preoperative and postoperative length of stay were: 1.3 (2.3) versus 4.5 (8.9) days (P=0.001), and 3.9 (2.9) versus 8.7 (14.5) days (P<0.001). For patients who had an intermediate operation, the respective mean (standard deviation) length of hospital stays were 2.4 (2.0) versus 7.3 (13.9) days (P=0.002) and the figures for postoperative length of stays were 1.3 (0.5) versus 4.5 (9.3) days (P=0.001). Surgeons had classified 108 (17%) of the cases as possible preoperative assessment clinic users. Among the latter, 71 (66%) had no special reason to stay in the hospital. The discharge destination was not associated with the use of preoperative assessment clinic for patients having major (Chi squared=0.18, P=0.912) or intermediate (Chi squared=0.34, P=0.468) operations. CONCLUSION: Successful implementation of preoperative assessment clinic service requires close collaboration between surgeons, anaesthetists, clinicians, and also the re-engineering of health service delivery.

Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) accounts for around 4% of all public hospital annual admissions in Hong Kong. By year 2020, COPD will be ranked fifth among the conditions with the highest burden to the society. This study identifies admission and unplanned readmission of COPD patients, factors affecting unplanned readmission, and estimates its cost burden on the public healthcare system in Hong Kong. METHODS: This is a retrospective study analyzing COPD admissions to all public hospitals in Hong Kong. All admission episodes to acute medical wards with the principal diagnosis of COPD (ICD-9:490-492, 494-496) from January 2006 to December 2007 were captured. Unplanned readmission was defined as an admission which followed a previous admission within 30 days. RESULTS: In 2006 and 2007, 65497 (8.0%) of episodes from medical wards were identified as COPD admissions, and among these, 15882 (24.2%) were unplanned readmissions. The mean age of COPD patients was 76.81 ± 9.59 years and 77% were male. Unplanned readmission was significantly associated with male gender, receiving public assistance and living in nursing homes while no association was found with the Charlson comorbidity index. Patients who were readmitted unplanned had a significant longer acute length of stay (ß = 0.3894, P < 0.001) after adjustment for other covariates. CONCLUSIONS: Unplanned readmission of COPD patients has a huge impact on the public healthcare system. A systematic approach in programme provision and a good discharge planning process targeting on COPD patients who are at high risk of unplanned readmission are essential.

The Chinese-version of the CARE measure reliably differentiates between doctors in primary care: a cross-sectional study in Hong Kong.

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.

Unplanned readmission rates, length of hospital stay, mortality, and medical costs of ten common medical conditions: a retrospective analysis of Hong Kong hospital data.

BACKGROUND: Studies on readmissions attributed to particular medical conditions, especially heart failure, have generally not addressed the factors associated with readmissions and the implications for health outcomes and costs. This study aimed to investigate the factors associated with 30-day unplanned readmission for 10 common conditions and to determine the cost implications. METHODS: This population-based retrospective cohort study included patients admitted to all public hospitals in Hong Kong in 2007. The sample consisted of 337,694 hospitalizations in Internal Medicine. The disease-specific risk-adjusted odd ratio (OR), length of stay (LOS), mortality and attributable medical costs for the year were examined for unplanned readmissions for 10 medical conditions, namely malignant neoplasms, heart diseases, cerebrovascular diseases, pneumonia, injury and poisoning, nephritis and nephrosis, diabetes mellitus, chronic liver disease and cirrhosis, septicaemia, and aortic aneurysm. RESULTS: The overall unplanned readmission rate was 16.7%. Chronic liver disease and cirrhosis had the highest OR (1.62, 95% confidence interval (CI) 1.39-1.87). Patients with cerebrovascular disease had the longest LOS, with mean acute and rehabilitation stays of 6.9 and 3.0 days, respectively. Malignant neoplasms had the highest mortality rate (30.8%) followed by aortic aneurysm and pneumonia. The attributed medical cost of readmission was highest for heart disease (US$3 199 418, 95% CI US$2 579 443-803 393). CONCLUSIONS: Our findings showed variations in readmission rates and mortality for different medical conditions which may suggest differences in the quality of care provided for various medical conditions. In-hospital care, comprehensive discharge planning, and post-discharge community support for patients need to be reviewed to improve the quality of care and patient health outcomes.

Patient self-management and pharmacist-led patient self-management in Hong Kong: a focus group study from different healthcare professionals' perspectives.

BACKGROUND: Patient self-management is a key approach to manage non-communicable diseases. A pharmacist-led approach in patient self-management means collaborative care between pharmacists and patients. However, the development of both patient self-management and role of pharmacists is limited in Hong Kong. The objectives of this study are to understand the perspectives of physicians, pharmacists, traditional Chinese medicine (TCM) practitioners, and dispensers on self-management of patients with chronic conditions, in addition to exploring the possibilities of developing pharmacist-led patient self-management in Hong Kong. METHODS: Participants were invited through the University as well as professional networks. Fifty-one participants comprised of physicians, pharmacists, TCM practitioners and dispensers participated in homogenous focus group discussions. Perspectives in patient self-management and pharmacist-led patient self-management were discussed. The discussions were audio recorded, transcribed and analysed accordingly. RESULTS: The majority of the participants were in support of patients with stable chronic diseases engaging in self-management. Medication compliance, monitoring of disease parameters and complications, lifestyle modification and identifying situations to seek help from health professionals were generally agreed to be covered in patient self-management. All pharmacists believed that they had extended roles in addition to drug management but the other three professionals believed that pharmacists were drug experts only and could only play an assisting role. Physicians, TCM practitioners, and dispensers were concerned that pharmacist-led patient self-management could be hindered, due to unfamiliarity with the pharmacy profession, the perception of insufficient training in disease management, and lack of trust of patients. CONCLUSIONS: An effective chronic disease management model should involve patients in stable condition to participate in self-management in order to prevent health deterioration and to save healthcare costs. The role of pharmacists should not be limited to drugs and should be extended in the primary healthcare system. Pharmacist-led patient self-management could be developed gradually with the support of government by enhancing pharmacists' responsibilities in health services and developing public-private partnership with community pharmacists. Developing facilitating measures to enhance the implementation of the pharmacist-led approach should also be considered, such as allowing pharmacists to access electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines.

Perspective from health professionals on delivery of sub-acute care in Hong Kong: a qualitative study in a health system.

OBJECTIVES: The perception and understanding of health professionals of the role of sub-acute care in the health system will have an impact on the potential effectiveness in preventing unnecessary hospitalization. This study aims to explore the perceived role and quality of sub-acute care services in the context of Hong Kong from the perspective of health service providers and to identify barriers to effectiveness. METHODS: Seven focus groups were conducted and the discussion was led by a guide covering three main areas: definition/component/role of sub-acute, difficulties in the sub-acute care services provision, and suggestion for further improvement in the provision of sub-acute care. RESULTS: The participants highlighted the positive role of sub-acute to promote patient's health and quality of life so as to reduce unnecessary hospitalization. The potential barriers in the sub-acute care identified were interrelated and focused mainly on systemic issues including lack of service coordination, specialist input and resources. The participants also suggested a number of practical ways to improve the quality of sub-acute care services. CONCLUSIONS: The findings showed a need for further improvement in the process of sub-acute care by developing operation guideline and re-evaluating the allocation of resources to support the sub-acute care provision.

Transition care for adolescents and families with chronic illnesses.

OBJECTIVES: To explore the attitudes of adolescents and parents toward transition care and to identify factors and barriers associated with transition decision. METHODS: The study was conducted at a pediatric out-patient clinic using a self-administered questionnaire to evaluate the perspective of adolescent chronic patients on transition care for common chronic diseases. Despite its importance as emphasized in medical literature, transition care for adolescent patients with chronic illnesses is under-developed in Hong Kong. RESULTS: A total of 137 adolescents aged 16-19 years, and 67 parents completed the survey; 85.3% of adolescents and 82.5% of parents were willing to transfer to adult care. "Adolescent's perception of his/her own responsibility towards chronic illness" was positively associated with willingness to transfer to adult care (OR = 3.84; 95% CI, 1.41-10.45; p = .008), whereas "Detailed explanation by doctors" encouraged transition decision for adolescents (OR = 12.20; 95% CI, 1.22-122.33; p = .033). "Do not want to change" was the only significant barrier for transition for both adolescents (OR = .08; 95% CI, .01-.50; p = .007) and parents (OR = .07; 95% CI, .02-.36; p = .001). However, less than 10% of subjects had ever received any transition information from doctors or other healthcare workers. CONCLUSIONS: This is the first study in Asia region evaluating attitudes of adolescents and parents on transition care. The majority of adolescents and parents accept transition care from pediatrics to adult service, but only a small proportion has ever received transition information from doctors. Our findings should be useful to healthcare providers in planning transition care programmes for adolescent patients with chronic illnesses.

Avoidable readmission in Hong Kong--system, clinician, patient or social factor?

BACKGROUND: Studies that identify reasons for readmissions are gaining importance in the light of the changing demographics worldwide which has led to greater demand for hospital beds. It is essential to profile the prevalence of avoidable readmissions and understand its drivers so as to develop possible interventions for reducing readmissions that are preventable. The aim of this study is to identify the magnitude of avoidable readmissions, its contributing factors and costs in Hong Kong. METHODS: This was a retrospective analysis of 332,453 inpatient admissions in the Medical specialty in public hospital system in Hong Kong in year 2007. A stratified random sample of patients with unplanned readmission within 30 days after discharge was selected for medical record reviews. Eight physicians reviewed patients' medical records and classified whether a readmission was avoidable according to an assessment checklist. The results were correlated with hospital inpatient data. RESULTS: It was found that 40.8% of the 603 unplanned readmissions were judged avoidable by the reviewers. Avoidable readmissions were due to: clinician factor (42.3%) including low threshold for admission and premature discharge etc.; patient factor (including medical and health factor) (41.9%) such as relapse or progress of previous complaint, and compliance problems etc., followed by system factor (14.6%) including inadequate discharge planning, inadequate palliative care/terminal care, etc., and social factor (1.2%) such as carer system, lack of support and community services. After adjusting for patients' age, gender, principal diagnosis at previous discharge and readmission hospitals, the risk factors for avoidable readmissions in the total population i.e. all acute care admissions irrespective of whether there was a readmission or not, included patients with a longer length of stay, and with higher number of hospitalizations and attendance in public outpatient clinics and Accident and Emergency departments in the past 12 months. In the analysis of only unplanned readmissions, it was found that the concordance of the principal diagnosis for admission and readmission, and shorter time period between discharge and readmission were associated with avoidable readmissions. CONCLUSIONS: Our study found that almost half of the readmissions could have been prevented. They had been mainly due to clinician and patient factors, in particular, both of which were intimately related to clinical management and patient care. These readmissions could be prevented by a system of ongoing clinical review to examine the clinical practice/decision for discharge, and improving clinical care and enhancing patient knowledge of the early warning signs for relapse. The importance of adequate and appropriate ambulatory care to support the patients in the community was also a key finding to reduce avoidable readmissions. Education on patient self-management should also be enhanced to minimize the patient factors with regard to avoidable readmission. Our findings thus provide important insights into the development of an effective discharge planning system which should place patients and carers as the primacy focus of care by engaging them along with the healthcare professionals in the whole discharge planning process.

Measuring and preventing potentially avoidable hospital readmissions: a review of the literature.

OBJECTIVE: To review literature identifying key components for measuring avoidable readmissions, their prevalence, risk factors, and interventions that can reduce potentially avoidable readmissions. DATA SOURCES AND EXTRACTION: Literature search using Medline, PubMed and the Cochrane Library up to June 2010, using the terms "avoidable", "preventable", "unplanned", "unnecessary", "readmission", and "rehospitalization". STUDY SELECTION: A total of 48 original papers and review articles were selected for inclusion in this review. DATA SYNTHESIS: Although hospital readmission seemed to be a term commonly used as an outcome indicator in many studies, it is difficult to make valid comparison of results from different studies. This is because the definitions of terms, methods of data collection, and approaches to data analysis differ greatly. The following criteria for studying hospital readmissions have been recommended: (a) identify hospital admissions and define relevant terms, (b) establish a clinical diagnosis for a readmission; (c) establish the purpose for a readmission, (d) set a discharge-to-readmission timeframe, and (e) identify the sources of information for assessing readmissions. Studies to identify avoidable readmissions usually involve medical records and chart reviews by clinicians using the classification scheme developed by the authors. The proportion of all readmissions assessed as preventable varies from 9 to 59% depending on the population of patients studied, duration of follow-up, type and methodology of the study and case-mix-related factors. A number of studies classified risk factors for readmission into four categories: patient, social, clinical, and system factors. Home-based interventions, intensive education/counselling, multidisciplinary care approaches, and telephone follow-up were the main types of interventions to address potentially avoidable readmissions. CONCLUSIONS: A standard instrument to identify avoidable readmission is important in enabling valid comparisons within the system and at different timelines, so as to permit robust evaluation of interventions. The assessment of preventable risk factors for readmissions also provides a basis for designing and implementing intervention programmes.

Association of SRD5A2 variants and serum androstane-3alpha,17beta-diol glucuronide concentration in Chinese elderly men.

BACKGROUND: Results of recent studies have demonstrated that genetic variants of the enzyme steroid 5α reductase type II (SRD5A2) are associated with serum concentrations of major androgen metabolites such as conjugates of androstane-3α,17ß-diol-glucuronide (3α-diol-G). However, this association was not consistently found among different ethnic groups. Thus, we aimed to determine whether the association with SRD5A2 genetic variations exists in a cohort of healthy Chinese elderly men, by examining 2 metabolite conjugates: androstane-3α,l7ß-diol-3-glucuronide (3α-diol-3G) and androstane-3α,17ß-diol-17-glucuronide (3α-diol-17G). METHODS: We used GC-MS and LC-MS to measure serum sex steroid concentrations, including testosterone and dihydrotestosterone, and 3α-diol-3G and 3α-diol-17G in 1182 Chinese elderly men age 65 and older. Genotyping of the 3 SRD5A2 tagSNPs [rs3731586, rs12470143, and rs523349 (V89L)] was performed by using melting-temperature-shift allele-specific PCR. RESULTS: The well-described SRD5A2 missense variant rs523349 (V89L) was modestly associated with the 3α-diol-17G concentration (P = 0.040). On the other hand, SNP rs12470143 was found to be significantly correlated with 3α-diol-3G concentration (P = 0.021). Results of haplotype analysis suggested that the presence of an A-C-G haplotype leads to an increased 3α-diol-3G concentration, a finding consistent with results of single SNP analysis. CONCLUSIONS: The genetic variation of SRD5A2 is associated with circulating 3α-diol-3G and 3α-diol-17G concentrations in Chinese elderly men. In addition, we showed that SRD5A2 haplotypic association, rather than a single SNP alone, might be a better predictor of the 3α-diol-G concentration. Thus, the effect of either the haplotype itself or of other ungenotyped SNPs in linkage disequilibrium with the haplotype is responsible for the interindividual variation of 3α-diol-G.

Association of genetic variations in aromatase gene with serum estrogen and estrogen/testosterone ratio in Chinese elderly men.

BACKGROUND: Single nucleotide polymorphism (SNP) rs2470152 of the gene CYP19A1 is associated with serum estradiol (E2) levels in Caucasian men. However, it remains to be verified if rs2470152 is the sole determinant accounting for the association. We determined whether 2 CYP19A1 SNPs tagging different haploblocks (rs2470152 and rs2899470) are associated with sex steroid levels in Chinese men. METHOD: Serum sex steroid level including E2, estrone (E1) and testosterone (T), of 1402 Chinese men aged > or = 65 years were analyzed. Genotyping of the two CYP19A1 SNPs was performed using Tm-shift allele-specific PCR. RESULTS: SNP rs2899470 was significantly associated with serum E2, E1 levels and E2/T ratio (p<0.001). However, SNP rs2470152 was only modestly associated with E2/T ratio (p=0.023). Analysis of haplotype showed a significant association between C-G, T-T haplotype with serum E2/T ratio (p=0.019 and p=1 x 10(-5), respectively). Similarly, E2 levels was also associated the T-T and T-G haplotypes (p=1 x 10(-5)). CONCLUSION: The genetic variation of CYP19A1 was associated with circulating estrogen levels in Chinese elderly men. In addition, it revealed that haplotype of rs2899470 and rs2470152, rather than rs2899470 alone, was a better indicator for the serum E2/T ratio and E2 levels.

Sex-specific effect of Pirin gene on bone mineral density in a cohort of 4000 Chinese.

BACKGROUND: Osteoporosis is a common condition among elderly. Genetic mapping studies repeatedly located the distal short arms of X-chromosome as the quantitative trait loci (QTL) for BMD in mice. Fine mapping of a syntenic segment on Xp22 in a Caucasian female population suggested a moderate association between lumbar spine (LS) BMD and 2 intronic SNPs in the Pirin (PIR) gene, which encodes an iron-binding nuclear protein. This study aimed to examine genetic variations in the PIR gene by a comprehensive tagging method and its sex-specific effects on BMD and osteoporotic risk. METHODS: Two thousand men and 2000 women aged 65 or above were recruited from the community. BMDs at the LS, femoral neck, total hip and whole body were measured and followed up at 4-year. Genotyping was performed for tagSNPs of PIR gene including adjacent regions, and the PIR haplotypes were inferred using PHASE program. RESULTS: Analysis by linear regression showed a significant association between SNP rs5935970 and LS-BMD, while haplotype T-T-A was significantly associated with BMD of all measured sites. However, none of such associations were found in men. Linear Mixed Model also confirmed the same sex-specific and site-specific effect for longitudinal BMD changes. CONCLUSION: In addition to confirming the association between BMDs and the PIR gene, we also revealed that this finding is sex-specific, possibly due to an X-linked effect. This study demonstrated the importance of considering sex and genetic interactions in studies of disease predisposition and complex traits.