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BackgroundContrasting the well-described effects of early intervention (EI) services for youth-onset psychosis, the potential benefits of the intervention for adult-onset psychosis are uncertain. This paper aims to examine the effectiveness of EI on functioning and symptomatic improvement in adult-onset psychosis, and the optimal duration of the intervention.Methods360 psychosis patients aged 26–55 years were randomized to receive either standard care (SC, n = 120), or case management for two (2-year EI, n = 120) or 4 years (4-year EI, n = 120) in a 4-year rater-masked, parallel-group, superiority, randomized controlled trial of treatment effectiveness (Clinicaltrials.gov: NCT00919620). Primary (i.e. social and occupational functioning) and secondary outcomes (i.e. positive and negative symptoms, and quality of life) were assessed at baseline, 6-month, and yearly for 4 years.ResultsCompared with SC, patients with 4-year EI had better Role Functioning Scale (RFS) immediate [interaction estimate = 0.008, 95% confidence interval (CI) = 0.001–0.014, p = 0.02] and extended social network (interaction estimate = 0.011, 95% CI = 0.004–0.018, p = 0.003) scores. Specifically, these improvements were observed in the first 2 years. Compared with the 2-year EI group, the 4-year EI group had better RFS total (p = 0.01), immediate (p = 0.01), and extended social network (p = 0.05) scores at the fourth year. Meanwhile, the 4-year (p = 0.02) and 2-year EI (p = 0.004) group had less severe symptoms than the SC group at the first year.ConclusionsSpecialized EI treatment for psychosis patients aged 26–55 should be provided for at least the initial 2 years of illness. Further treatment up to 4 years confers little benefits in this age range over the course of the study.

Aims/Introduction To examine the impact of different levels of financial incentive in terms of fee subsidization on diabetic retinopathy screening in the private primary care setting in Hong Kong. Materials and Methods All general practitioners working in the private sector and registered in two electronic public databases were invited to participate. Consecutive patients with diabetes mellitus were then recruited by the participating practitioners. The recruited participants were randomly allocated to one of three screening groups with different fee levels (HK$0, HK$150 [US$19], HK$300 [US$39]) in a randomized controlled trial. Screening uptake and severity of diabetic retinopathy detected were compared. Results Out of 1,688 eligible practitioners, 105 participated and invited 402 patients, with 239 initially agreeing to participate (59.5%). After randomization, 78, 75 and 76 participants in the HK$0, HK$150 and HK$300 fee groups, respectively, reconfirmed their participation and were offered screening at the relevant fee. The uptake of screening was 79.5% (62/78), 81.3% (61/75) and 63.2% (48/76), in the HK$0, HK$150 and HK$300 groups, respectively (P, A half subsidized diabetic retinopathy screening service appears to be sustainable, with comparable uptake to full subsidization, including those with high diabetic retinopathy risk, while using less medical expenditure.

Introduction: The care needed at end of life can go beyond what services can offer. This is where volunteers can make a difference, however the nature of their support can vary. Dodd et al. [1] recognised two types of input: ‘being there’ and ‘doing for’. Similarly, Burbeck et al. [2] examined the volunteer role and found three themes; the distinctness, characteristics and experience of the role. Here, a volunteer can be mediating between patients and staff, sometimes acting as a surrogate family member. Such complexity requires further study and more detailed information about the impact on care recipients, and the volunteers themselves, would greatly assist the training and development of volunteers as well as decisions on how to maximise the use of volunteers to achieve the most benefit. Compassionate Isle of Man (IOM) has been developing the role of volunteers as Palliative Care Companions in the community. This evaluation aims to capture the impact and experience of volunteers and care recipients and examine the explicit and implicit needs for palliative care that they address. This paper will report on the pilot of the methods and initial findings.Aims: To use capability measures, qualitative and other data to identify the implicit and explicit needs for volunteer support, the short-term impact(s) on care recipients and volunteers and the implications for the training of volunteers. Methods: A prospective study will enrol care recipients and their carers at the outset of Compassionate IOM support. Baseline data will include stated needs as well as the ICEpop CAPability (ICECAP) measures [3] and interviews. Data collection will be repeated at 6 and 12 weeks and will include specially designed questionnaires and interviews to elicit perceptions of impact, satisfaction and details of the support experience. This information will be set within a cost-benefit framework to quantify the extent to which declared and undeclared needs are met, at what cost and with what benefits to care recipients and volunteers. The initial pilot study will test the methods and include at least 10 care recipients, their main carers and the related volunteers.Conclusion and implications: This pilot study will form the basis for a longer-term study which will provide essential information on the potential scope of volunteer support and their place in the overall service delivery of palliative care in the community.References1. Dodd S, Hill M, Ockenden N, Algorta GP, Payne S, Preston N, et al. ‘Being with’ or ‘doing for’? How the role of an end-of-life volunteer befriender can impact patient wellveing: interviews from a multiple qualitative case study (ELSA). Supportive Care in Cancer 2018;26(9):3163-3172. doi: https://doi.org/10.1007/s00520-018-4169-22. Burbeck R, Candy B, Low J, Rees R. Understanding the role of the volunteer in specialist palliative care: a systematic review and thematic synthesis of qualitative studies. BMC Palliative Care 2014;13(3):1-12. doi:https://doi.org/10.1186/1472-684X-13-33. University of Birmingham. ICECAP capability measures [webpage on the Internet]. [cited 2021 30 Nov]. Available from: https://www.birmingham.ac.uk/research/activity/mds/projects/haps/he/icecap/index.aspx

PurposePalliative care requires integration between services, organisations and the community. A series of community engagement programmes, named “Listening Events”, were conducted across the Isle of Man. The aim was to involve the community in the development of Hospice strategy by sharing their views on the future of palliative and end of life care.Design/methodology/approachThree Listening Event programmes were conducted in community settings, secondary schools and the Isle of Man’s University College. The investigators facilitated discussions on current knowledge of Hospice services, what would matter to people should they need to use these, and how Hospice could best serve the community in the future. Participants and investigators noted thoughts and comments. Data were analysed using thematic analysis.FindingsIn total, 899 people participated from across the community. Main themes surrounded effective care, person-centred care and integrated care. Most themes agreed across the three programmes, despite some nuances.Originality/valueThe results were used as an evidence base from which Hospice Isle of Man’s new strategy was derived in order to ensure that it aligned with the community’s needs. By initiating conversations and discussions in the community, the Listening Events may have also increased understanding about hospice care.

PurposeThis case study aims to understand the experience of care from a patient/carer perspective and to describe how the method can be replicated to address gaps in evidence relating to integrated person-centred care.Design/methodology/approachThe case study was constructed using data extracted from personal diaries and medical records kept by a person with a complex condition, correspondence with family from the last 18 months of life and interviews with the carer and long-term conditions coordinator. The number of professionals or teams involved in providing care from statutory services, the third sector, and private providers were counted to understand the ecosystem of care. The number of contacts was plotted by provider and purpose of care. The type of care and hours of respite were estimated. A protocol was developed to assess the feasibility of replicating the data and analyses used.FindingsThere were 35 care providers from the public, private and the third sector, demonstrating that only the patient or carer can identify the ecosystem of care. The majority of care was for respite and on average, the carer provided four hours of care per every respite care hour. The method was replicated successfully.Research limitations/implicationsThe case study formed the basis of a workshop that brought together health care professionals from the public services and the third sector. The discussion led to the identification of gaps and areas where greater coordination between providers would benefit patients.Originality/valueThe case study method combines contemporaneous patient and carer sources of data and health service activity to create a detailed account of care at the end of life. The approach addresses gaps in person-centred evidence for the development and evaluation of integrated palliative and end-of-life care.

Background In response to the COVID-19 pandemic, the hospice moved to digital approaches. Whilst tele-rehabilitation has shown benefits for various chronic health conditions (Bhatt, Patel, Anderson, et al., 2019; Zanaboni, Hoaas, Lien, et al., 2017; Hwang, Bruning, Morris, et al., 2017), there is a gap in the literature on telehealth interventions for palliative rehabilitation. Aim To evaluate digital delivery of a palliative rehabilitation programme and obtain perceptions of users and staff. Methods All members of the Fatigue and Breathlessness (FAB) follow-on group (n=19) were invited to complete a questionnaire on the experience of transitioning to Zoom sessions. Descriptive statistics were produced using the statistical software package, Stata (Version 15; StataCorp, 2017). Qualitative data were analysed using an inductive thematic analysis framework (Braun & Clarke, 2006). Three members of the rehabilitation team were interviewed about encountered benefits and challenges. Results Thirteen members completed the questionnaire (68%) and all were positive about the transformed sessions. Eight respondents (62%) felt that the Zoom sessions were ‘no different’ or ‘better’ than in-person sessions. No adverse events were reported. Themes from open-ended comments included patient-level effects such as maintained exercise and social contact when in isolation and removed travel requirements. At the service level, there was improved access but technological challenges. Most respondents (9, 69%) suggested keeping the option of Zoom for flexibility and 46% (6) wanted both staff-led and self-led elements. The rehabilitation team felt their rapid response and team working enabled efficient transition to Zoom. This included risk assessments, particularly for those living alone. With help, users quickly learned and the virtual delivery provided opportunities to try new activities. At times, staff found the ‘silent audience’ challenging. The rehabilitation team felt the approach may only work with groups with existing rapport. Conclusions The hospice rehabilitation team now provide concurrent sessions at home via Zoom and in the hospice. These access options provide choice, appear to be acceptable and offer flexibility around changing condition status and personal factors.

Background Measuring patient outcomes is necessary to assess the impact of care and identify areas for improvement (Etkind, Daveson, Kwok, et al., 2015; Marshall, Haywood, Fitzpatrick, 2006). It is therefore vital that staff are confident and comfortable using outcome measures. Hospice adopted three of the Outcome Assessment and Complexity Collaborative (OACC) (Witt, Murtagh, de Wolf-Linder, et al.) measures in July 2019: the Phase of Illness, Australia-modified Karnofsky Performance Status (AKPS) and Integrated Palliative care Outcome Scale (IPOS). In July 2020, Hospice investigated clinicians’ perceptions of the measures. Aim To understand clinicians use and views of the OACC measures, any problems and suggestions for improvement. Methods A survey was distributed to clinicians (n=42). Descriptive statistics were calculated using the statistical packages R and RStudio (Version 4.1.0 for Windows). Qualitative data were analysed using a thematic analysis framework (Braun & Clarke, 2006). Results Twenty-nine clinicians (response rate 69%) had used one of the three measures at least once. Twenty-five (93%), 22 (85%) and 24 (92%) stated that they use IPOS, AKPS and Phase of Illness some or all of the time, respectively. Moreover, 24 (83%), 23 (79%) and 21 (72%) clinicians felt confident appropriately using IPOS, AKPS and Phase of Illness, respectively. Respondents identified the measures as a helpful resource for person-centred assessment and monitoring. They can help open up dialogue and increase rapport between patient and clinician, and provide a ‘common language’ between clinicians. However, they felt the measures added little to a clinical assessment, particularly for Allied Health Professionals (AHPs), and an apparent focus on physical health limited holistic assessment. Respondents recommended increased application of OACC measures at handover. For AHPs, other outcome measures might be considered. Some wanted feedback on outcomes and more training on use of the measures. Conclusions In a palliative care setting, benefits were witnessed mainly in patient assessment but less in the application of outcomes. Further staff training and application of outcomes may be beneficial.

Background Rotavirus is a common cause of severe gastroenteritis in young children in Hong Kong (HK) with a high economic burden. This study aimed to evaluate the cost-effectiveness of introducing rotavirus vaccination into the HK Government’s Childhood Immunisation Programme (CIP) and to include the potential protective effect of the vaccine against seizures. Methods A decision-support model was customised to estimate the potential impact, cost-effectiveness and benefit-risk of rotavirus vaccination in children below 5 years over the period 2020–2029 in HK. Two doses of Rotarix® and three doses of RotaTeq® were each compared to no vaccination. Rotavirus treatment costs were calculated from a governmental health sector perspective (i.e., costs of public sector treatment) and an overall health sector perspective (both governmental and patient, i.e., costs of public sector treatment, private sector treatment, transport and diapers). We ran probabilistic and deterministic uncertainty analyses. Results Introduction of rotavirus vaccination in HK could prevent 49,000 (95% uncertainty interval: ~44,000–54,000) hospitalisations of rotavirus gastroenteritis and seizures and result in ~50 (95% uncertainty interval: ~25–85) intussusception hospitalisations, over the period 2020–2029 (a benefit-risk ratio of ~1000:1), compared to a scenario with no public or private sector vaccine use. The discounted vaccination cost would be US$51–57 million over the period 2020–2029 based on per-course prices of US$72 (Rotarix®) or US$78 (RotaTeq®), but this would be offset by discounted treatment cost savings of US$70 million (government) and US$127 million (governmental and patient health sector). There was a greater than 94% probability that the vaccine could be cost-saving irrespective of the vaccine product or perspective considered. All deterministic ‘what-if’ scenarios were cost-saving from an overall health sector perspective (governmental and patient). Conclusions Rotavirus vaccination is likely to be cost-saving and have a favourable benefit-risk profile in HK. Based on the assumptions made, our analysis supports its introduction into CIP.

The multidisciplinary Risk Assessment and Management Program for patients with diabetes mellitus (RAMP-DM) was found to be cost-saving in comparison with usual primary care over 5 years’ follow-up. This study aimed to estimate the cost-effectiveness of RAMP-DM over lifetime. We built a Discrete Event Simulation model to evaluate the cost-effectiveness of RAMP-DM over lifespan from public health service provider’s perspective. Transition probabilities among disease states were extrapolated from a cohort of 17,140 propensity score matched participants in RAMP-DM and those under usual primary care over 5-year’s follow-up. The mortality of patients with specific DM-related complications was estimated from a cohort of 206,238 patients with diabetes. Health preference and direct medical costs of DM patients referred to our previous studies among Chinese DM patients. RAMP-DM individuals gained 0.745 QALYs and cost US$1404 less than those under usual care. The probabilistic sensitivity analysis found that RAMP-DM had 86.0% chance of being cost-saving compared to usual care under the assumptions and estimates used in the model. The probability of RAMP-DM being cost-effective compared to usual care would be over 99%, when the willingness to pay threshold is HK$20,000 (US$ 2564) or higher. RAMP-DM added to usual primary care was cost-saving in managing people with diabetes over lifetime. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.

OBJECTIVE To estimate the cost-effectiveness of the multidisciplinary Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes in comparison with usual primary care in a cohort with 5 years’ follow-up. RESEARCH DESIGN AND METHODS We conducted a prospective cohort study among 17,140 propensity score–matched participants in RAMP-DM and those under usual primary care. The effectiveness measures were cumulative incidences of complications and all-cause mortality over 5 years. In a bottom-up approach, we estimated the program costs of RAMP-DM and health service utilization from the public health service provider’s perspective. The RAMP-DM program costs included the setup costs, ongoing intervention costs, and central administrative costs. We calculated the incremental cost-effectiveness ratio by dividing the incremental costs by the incremental effectiveness of the RAMP-DM group compared with those of the usual-care group. RESULTS There were significantly lower cumulative incidences of individual on any complications (15.34% vs. 28.65%, P < 0.001) and all-cause mortality (7.96% vs. 21.35%, P < 0.001) in the RAMP-DM group compared with the usual-care group. The mean program cost of RAMP-DM was 157 U.S. dollars (range 66–209) per participant over 5 years. The costs of health service utilization among participants in RAMP-DM group was 7,451 USD less than that of the usual-care group, resulting in a net savings of 7,294 USD per individual. CONCLUSIONS RAMP-DM added to usual primary care was a cost-saving intervention in managing diabetes in patients over 5 years. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.

Aim To develop models to estimate the direct medical costs associated with diabetes-related complicationsin the event year and in subsequent years. Methods The public direct medical costs associated with 13 diabetes-related complications were estimated among a cohort of 128 353 people with diabetes over 5 years. Private direct medical costs were estimated from a cross-sectional survey among 1825 people with diabetes. We used panel data regression with fixed effects to investigate the impact of each complication on direct medical costs in the event year and subsequent years, adjusting for age and co-existing complications. Results The expected annual public direct medical cost for the baseline case was US$1,521 (95% CI 1,518 to 1,525) or a 65-year-old person with diabetes without complications. A new lower limb ulcer was associated with the biggest increase, with a multiplier of 9.38 (95% CI 8.49 to 10.37). New end-stage renal disease and stroke increased the annual medical cost by 5.23 (95% CI 4.70 to 5.82) and 5.94 (95% CI 5.79 to 6.10) times, respectively. History of acute myocardial infarction, congestive heart failure, stroke, end-stage renal disease and lower limb ulcer increased the cost by 2–3 times. The expected annual private direct medical cost of the baseline case was US$187 (95% CI 135 to 258) for a 65-year-old man without complications. Heart disease, stroke, sight-threatening diabetic retinopathy and end-stage renal disease increased the private medical costs by 1.5 to 2.5 times. Conclusions Wide variations in direct medical cost in event year and subsequent years across different major complications were observed. Input of these data would be essential for economic evaluations of diabetes management programmes. This article is protected by copyright. All rights reserved.

This study evaluated the short-term cost-effectiveness of the Patient Empowerment Programme (PEP) for diabetes mellitus (DM) in Hong Kong. Propensity score matching was used to select a matched group of PEP and non-PEP subjects. A societal perspective was adopted to estimate the cost of PEP. Outcome measures were the cumulative incidence of all-cause mortality and diabetic complication over a 5-year follow-up period and the number needed to treat (NNT) to avoid 1 event. The incremental cost-effectiveness ratio (ICER) of cost per event avoided was calculated using the PEP cost per subject multiplied by the NNT. The PEP cost per subject from the societal perspective was US$247. There was a significantly lower cumulative incidence of all-cause mortality (2.9% vs 4.6%, P < .001), any DM complication (9.5% vs 10.8%, P = .001) and CVD events (6.8% vs 7.6%, P = .018), in the PEP group. The costs per death from any cause, DM complication or case of CVD avoided were US$14 465, US$19 617 and US$30 796, respectively. The extra amount allocated to managing PEP was small and it appears cost-effective in the short-term as an addition to RAMP.

To evaluate the effectiveness of the multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) in reducing the risks of microvascular complications.This prospective cohort study was conducted with 29,670 propensity-score-matched RAMP-DM participants and diabetes patients under the usual primary care (14,835 in each group). Study endpoints were the first occurrence of any diabetic microvascular complications, non-proliferative diabetic retinopathy/preproliferative diabetic retinopathy (NPDR/prePDR), sight-threatening diabetic retinopathy (STDR) or blindness, nephropathy, end-stage renal disease (ESRD), neuropathy and lower-limb ulcers or amputation. Log-rank tests and multivariable Cox proportional-hazards regressions were employed to estimate between-group differences in incidences of study endpoints.After a median follow-up of 36 months with41,000 person-years in each group, RAMP-DM participants had a lower incidence of microvascular complications (760 vs 935; adjusted hazard ratio [HR]: 0.73; 95% confidence interval [CI]: 0.66-0.81; P0.001) and lower incidences of all specific microvascular complications except neuropathy (adjusted HR: 0.94; 95% CI: 0.61-1.45; P=0.778). Adjusted HRs for the RAMP-DM vs control group for ESRD, STDR or blindness, and lower-limb ulcers or amputation were 0.40 (95% CI: 0.24-0.69; P0.001), 0.55 (95% CI: 0.39-0.78; P=0.001) and 0.49 (95% CI: 0.30-0.80; P=0.005), respectively.The RAMP-DM intervention was associated with lower incidences of all microvascular complications except neuropathy over a 3-year follow-up. These encouraging results constitute evidence that structured risk assessment and risk-stratified management provided by a multidisciplinary team is effective for reducing microvascular complications in diabetes patients.NCT02034695, www.ClinicalTrials.gov.

Background Hospice Isle of Man’s aim is to provide access to those who could benefit regardless of diagnosis. The hospice began offering services to non-cancer patients in 2016. Little is known about how many could benefit or the extent of the hospice’s involvement by disease category. The Isle of Man is not included in Hospice UK’s PopNAT. Aims To estimate the number of persons who could have potentially benefited from palliative and end-of-life care. To understand differences in hospice involvement by disease category. Methods The Isle of Man Registry maintains weekly Excel sheets with death certificate data. We extracted variables of interest for the period between 1 January 2013 to 31 December 2018. We created a variable for palliative need based on cause of death where there was any mention of cancer, Alzheimer’s/dementia, organ failure or a neurodegenerative condition. Using hospice records, we identified persons who received hospice care for the years 2016–2018. We estimated unmet need by comparing hospice involvement and presence of a condition likely to benefit from palliative care and compared hospice involvement by palliative disease category. Results There were 5,005 deaths between 2013 and 2018, representing 1% of the population per year. Prior to 2016, the hospice cared for 30% of persons who died. By 2018, 39% had hospice care representing a 21% increase from 2016. Of all deaths between 2013 and 2018, 30% had a palliative condition and hospice care. An additional 34% had a palliative condition but no hospice care. The hospice was involved in 88% of all cancer cases but only in a quarter or less of cases with organ failure (28%), neurodegenerative conditions (26%), or Alzheimer’s/dementia (16%). Conclusions Since 2016, more persons received hospice care. However, persons with non-cancer conditions who could benefit remained under-represented compared to those with cancer. Future studies are needed to understand the factors contributing to this difference.

Background Hospice UK is promoting ECHO™ (Extension of Community Healthcare Outcomes) to democratise specialist skills and increase confidence of staff in palliative and end-of-life care. Hospice Isle of Man is reaching the end of the first year of Project ECHO™ with local nursing homes. Aim To carry out a formative evaluation of project ECHO™ at the end of its first year of operation and prepare for a summative evaluation at the end of five years. Methods The logic model identifies resources and inputs, activities, outputs, short and longer-term outcomes. Inputs, activities and outputs come from routinely collected data and short-term outcomes from a mix of ad-hoc quantitative data from surveys and qualitative data from interviews. For longer-term outcomes we have 1) set up a data collection exercise to obtain feedback from all of those experiencing bereavement, 2) identified sources of data on place of care at the end-of-life with the aim of determining whether experiences change over the period of Project ECHO™’s operation. Results We are currently conducting the formative evaluation with nursing homes using the quantitative data described in the first three categories of the logic model. We are also carrying out qualitative interviews with those who participated in the first year of Project ECHO™. We trialled a validated questionnaire (Grande et al. End-of-life skills survey) on end-of life skills and confidence which will be a required part of enrolment for those who join further ECHO™s and will map to our Island skills framework. Feedback is positive and Project ECHO™ will continue in nursing homes with further ECHO™s including residential homes and other community providers. Conclusion With the formative evaluation we are learning lessons about how best to deliver Project ECHO™ in nursing homes and extend it to other sites. We have set up measures which we hope will shed light on longer-term outcomes.

Background Isle of Man (IOM) is a crown dependency with 83,000 residents. To provide an evidence-base for the strategy on person-centred, palliative and end of life care, Hospice Isle of Man carried out a needs assessment. Typically this involves quantitative and qualitative data describing services and identifying gaps. Many data sources used for this purpose in the UK (e.g. Hospice UK’s PopNAT) are not available in the IOM so we compensated by extensive engagement with those working in relevant services and organisations as well as the public. Aim To carry out a needs assessment on palliative and end of life care. Methods Population demographics and weekly death data were processed to enable predictions of need for palliative and end of life care. Interviews were carried out with over 60 representatives of services and organisations involved in care for those with life limiting conditions, in elderly care, end of life or bereavement support. The questions were: ‘What works well?’, ‘What does not work well?’, ‘What are the gaps?’ and ‘What might be solutions?’ in palliative and end of life care. Adult members of the public, schoolchildren and college students were asked what would matter to them if using Hospice services to ensure a focus on person-centred care. Results We discovered that the hospice was probably reaching around half of those who could benefit but users were very positive about it. Passion for Island services, but frustration with aspects of the system, was identified among professionals and some disjointedness among third sector groups. The majority of the data are currently being analysed and will be presented at Hospice UK’s 2019 conference. Conclusion Expert views of those working in the services and charities, supplemented by person-centred perceptions of the public and available data are shedding necessary light on the Island’s needs for palliative and end of life care. (Support provided by Manx Lottery Trust)

Electronic cigarettes (e-cigarettes) have gained popularity rapidly in the Western world but data in the East are scarce. We examined the awareness and ever use of e-cigarettes, and reasons for e-cigarette use in a probability sample of adults in Hong Kong.Cross-sectional data were collected in 2014 from Chinese adults aged 15-65 in Hong Kong (819 never smokers, 800 former smokers, 800 current smokers) via computer-assisted telephone interviews (response rate: 73.8%). Analysis was limited to a subset of 809 respondents (i.e., 357 never smokers, 269 former smokers, 183 current smokers) who were randomly selected to answer questions on e-cigarettes. Chi-square analyses compared e-cigarette awareness and ever use by gender, age, education, and cigarette smoking status. Multivariable logistic regression examined if e-cigarette awareness was associated with demographic variables and cigarette smoking status.75.4% of adults had heard of e-cigarettes, and 2.3% reported having used e-cigarettes. Greater awareness was associated with male gender and higher education. Ever use of e-cigarettes was higher among males (3.6%, p=.03), younger adults (aged 15-29, 5.2%, p=.002), and current cigarette smokers (11.8%, p.001). Common reasons for using e-cigarettes were curiosity (47.4%), the stylish product design (25.8%), and quitting smoking (13.6%).Awareness of e-cigarettes was widespread in Hong Kong. Although the use of e-cigarettes was low, its relation with younger age and current smoking is of concern. Health surveillance of e-cigarette use is needed. Interventions should target young adults and cigarette smokers, and address the marketing messages, especially the effect of e-cigarettes on smoking cessation.

Background The integrated care concept is being implemented world-wide but is often considered setting-specific. Small islands are one of these settings which face particular issues. Hospice Isle of Man is taking a measured approach, from which we hope that others might be able to benefit. Aim To develop a strategy for integrated palliative and end of life care on a small island. Methods Create connections and networks to support the planning, implementation and evaluation stages of the work Identify, via a needs assessment, what works, what gaps need filled and what matters to the population and professionals Identify particular issues facing small islands and ensure that any recommendations for change lead to solutions which are sustainable in the longer term. Results to date Hospice Isle of Man formed relationships with the International Foundation for Integrated Care (IFIC) and IFIC Scotland who facilitated two face-to-face stakeholder meetings in 2017 and 2018. Using an example of a patient journey, areas that could be improved were identified. As a result, Hospice Isle of Man, public health care providers and charities meet bi-monthly to discuss the progress of the needs assessment and consider how to work more closely together. Engagement activities for the needs assessment have included members of the public, patients and carers, schoolchildren, community groups, public and private health care providers, nursing home staff and residents with their families. Conclusions Many of the issues encountered are similar to those in other settings and proximity does not always lead to closeness although personal connections are an advantage. There is some consistency so far in the views of participants that we aim for the right care, in the right place at the right time, although the small island setting presents some unique challenges.

Background To deliver person-centred integrated end of life care, providers need to understand the experience of patients and carers. Real-time experience may differ from retrospective accounts of experience which may have implications for initiatives to improve care. Aims To explore the benefits of using a combination of prospective and retrospective data collection methods from multiple sources to understand the experience of care of a patient and carer. Methods The carer of a patient with progressive supranuclear palsy was approached six months after death for an interview. Using personal diaries, we extracted data on face-to-face contacts with Department of Health and Social Care (DHSC), charities and private care providers for the last 18 months of life. Numbers of contacts were plotted by month and sector. A timeline from pre-diagnosis to after death was created using details provided by the carer and verified by correspondence generated at the time of care. Results In the last 18 months of life, the patient received care from 25 DHSC providers, four charities, six private providers, plus family and friends. The patient had an average of 24±8 encounters per month. DHSC activity declined in April, September and December (1st 12 months). The main providers of care in the last months of life were from the voluntary and private sector. The carer developed a system for organising documentation, appointments, medications and outside services. The carer reported that the long-term conditions coordinator was invaluable for coordinating DHSC care. However, the carer remained the overall coordinator. Correspondence was critical in constructing an accurate and unbiased timeline. The results surprised the carer when compared to their recollection of events. Conclusions A combined approach to data collection is a promising method to capture user experience to inform service design and delivery. Further cases studies in different conditions are planned.

Background Hospice Isle of Man (IoM) is celebrating its 35th anniversary. To thank the community and to inform the next five-year strategy, the hospice conducted a series of community listening events with the theme of ‘What matters to you, matters to us’. Aims To understand what the public knew about Hospice and learn about their experience; to find out what matters most when confronted with end of life; and to ask how the hospice can best serve the IoM. Methods Hospice staff approached members of the public at supermarkets and community events at seven locations. Events took place between January and February 2018 during business hours. Demographic data were collected on age and sex. Interviewers recorded responses that were analysed using thematic analysis according to the aims. Results A total of 278 persons from a population of 83 000 provided comments. The majority were female (63%) and over 55 (68%), 32% had used services, and 74% had general awareness of hospice. Respondents were aware of specialist skills and services and/or were supporters. However, only 5% knew about the range of services and there were misconceptions about who the hospice serves. Others preferred ‘not to think about it’ or felt there was ‘one way out’. Overall, experience with Hospice was positive and many felt it was ‘for families’. What mattered to people included: kind, compassionate and effective care, emotional support, person-centred care, equity, the environment, open access, good communication, honesty and helping others talk about death. Hospice can best serve by making services available ‘to all who need it’, ensure sustainability, by supporting families, friends/co-workers, schools and by improving transparency of its accounts. Conclusions Hospice needs to raise awareness of its services. Hospice care is valued and needs to be provided at the right time and place for all who need it.

Background There is a welcome and appropriate movement, encouraged by Hospice UK, towards increasing the role of research in palliative and end of life care. Aim To enable Hospice Isle of Man to reposition as a Research Active Hospice. Methods A survey was undertaken to ascertain the current level of research interest and awareness in Hospice Isle of Man. Results to date The survey was completed by 25 staff and 45 volunteers. The majority (88%) of clinical staff had some research training but most had no recent opportunity to engage in research; over 70% agreed that research added value to their daily work but only 40% were confident in their critical appraisal skills. As a result further training e.g. in critical appraisal skills within journal clubs is being initiated. Amongst the volunteers 22% were identified to have research skills but very few were actively engaged in research. These volunteers will be invited to participate in future projects. Funding from the Scholl Foundation and the Manx Lottery Trust has enabled research staff to be recruited and has facilitated protected time for some clinical staff to participate in research with peer support and skill sharing in, for example, developing outcome measurements, appropriate analyses and interpretation of data and considering how the value of routine data can be improved. Initial uncertainty about the role of research and researchers is gradually being replaced with appreciation of their support in enhancing research awareness and activity among staff. Conclusion Hospice Isle of Man had a low level of research activity however a step-change has been achieved by utilising existing skills and interests of the clinical staff. Key drivers were obtaining funding for protected research time for key clinical staff and employing experienced researchers to support and complement the clinical staff to develop an active research culture.

Aim To evaluate the long-term cost-effectiveness of a Patient Empowerment Programme (PEP) for type 2 diabetes mellitus (DM) in primary care. Materials and methods PEP participants were subjects with type 2 DM who enrolled into PEP in addition to enrolment in the Risk Assessment and Management Programme for DM (RAMP-DM) at primary care level. The comparison group was subjects who only enrolled into RAMP-DM without participating in PEP (non-PEP). A cost-effectiveness analysis was conducted using a patient-level simulation model (with fixed-time increments) from a societal perspective. We incorporated the empirical data from a matched cohort of PEP and non-PEP groups to simulate lifetime costs and outcomes for subjects with DM with or without PEP. Incremental cost-effectiveness ratios (ICER) in terms of cost per quality adjusted life year (QALY) gained were calculated. Probabilistic sensitivity analysis was conducted with results presented as a cost-effectiveness acceptability curve. Results With an assumption that the PEP effect would last for 5 years as shown by the empirical data, the incremental cost per subject was US $197 and the incremental QALYs gained were 0.06 per subject, which resulted in an ICER of US $3290 per QALY gained compared with no PEP across the lifetime. Probabilistic sensitivity analysis showed 66% likelihood that PEP is cost-effective compared with non-PEP when willingness-to-pay for a QALY is ≥US $46 153 (based on per capita GDP 2017). Conclusions Based on this carefully measured cost of PEP and its potentially large benefits, PEP could be highly cost-effective from a societal perspective as an adjunct intervention for patients with DM.

Objectives To examine trends in deaths for conditions associated with secondhand smoke exposure over the years prior to and following the implementation of a smoke-free policy in Hong Kong. Design Time-series study. Setting Death registration data from Hong Kong Special Administrative Region (SAR) Government Census and Statistics Department. Participants All deaths registered from 1 January 2001 to 31 December 2011. Main outcome measures Deaths for conditions associated with passive smoking include cardiovascular disease (CVD), respiratory disease and other causes. Results There was a decline in the annual proportional change for ischaemic heart disease (IHD), acute myocardial infarction (AMI) and CVD mortality in the year after the intervention for all ages and those aged 65 years or older. There were also clear declines in the cool season peaks for these three conditions in the first postintervention year. There was a further drop in the cool season peak for AMI among all ages in the year after the exemptions ceased. No declines in annual proportional change or changes in seasonal peaks of mortality were found for any of the control conditions. Conclusions The findings in this study add to the evidence base, as summarised in the Surgeon General9s report, extending the impact of effective smoke-free legislation to those aged 65 years or older and to cerebrovascular events in younger age groups. They also reinforced the need for comprehensive, enforced and effective smoke-free laws if the full extent of the health gains are to be achieved.

Purpose To determine the prevalence of diabetic retinopathy (DR), sight threatening DR (STDR), visual impairment and other eye diseases in a systematic DR screening programme among primary care Chinese patients with diabetes mellitus (DM) in Hong Kong. Methods Screening for DR was provided to all subjects with DM in public primary care using digital fundus photography according to the English national screening programme. STDR was defined as preproliferative DR (R2), proliferative DR (R3) and/or maculopathy (M1). The presence of other eye diseases was noted. Visual impairment was classified as none (visual acuity in the better eye of 6/18 or better), mild (6/18 to >6/60) and severe (6/60 or worse). Results Of 174 532 subjects screened, most had never been screened before. The prevalence of DR was 39.0% (95% CI 38.8% to 39.2%) and STDR 9.8% (95% CI 9.7% to 9.9%). The most common DR status was R1 (35.7%), followed by M1 (8.6%), R2 (3.0%) and R3 (0.3%). The prevalence of mild and severe visual impairment was 4.2% and 1.3%, respectively. Subjects with STDR had a higher prevalence (9.8%) of visual impairment than those without (3.5%). Conclusions DR was prevalent in this population and one in 10 had STDR. This suggests the need for systematic screening to ensure timely referral to an ophthalmologist for monitoring and/or treatment.

Introduction A large proportion of patients diagnosed with diabetic maculopathy using fundus photography and hence referred to specialist clinics following the current screening guidelines adopted in Hong Kong and United Kingdom are found to be false-positive, implying that they did not have macular oedema. This study aimed to evaluate the false-positive rate of diabetic maculopathy screening using the objective optical coherence tomography scan. Methods This was a cross-sectional observational study. Consecutive diabetic patients from the Hong Kong West Cluster Diabetic Retinopathy Screening Programme with fundus photographs graded R1M1 were recruited between October 2011 and June 2013. Spectral-domain optical coherence tomography imaging was performed. Central macular thickness of ≥300 μm and/or the presence of optical coherence tomography signs of diabetic macular oedema were used to define the presence of diabetic macular oedema. Patients with conditions other than diabetes that might affect macular thickness were excluded. The mean central macular thickness in various subgroups of R1M1 patients was calculated and the proportion of subjects with central macular thickness of ≥300 μm was used to assess the false-positive rate of this screening strategy. Results A total of 491 patients were recruited during the study period. Of the 352 who were eligible for analysis, 44.0%, 17.0%, and 38.9% were graded as M1 due to the presence of foveal 'haemorrhages', 'exudates', or 'haemorrhages and exudates', respectively. The mean (±standard deviation) central macular thickness was 265.1±55.4 μm. Only 13.4% (95% confidence interval, 9.8%-17.0%) of eyes had a central macular thickness of ≥300 μm, and 42.9% (95% confidence interval, 37.7%-48.1%) of eyes had at least one optical coherence tomography sign of diabetic macular oedema. For patients with retinal haemorrhages only, 9.0% (95% confidence interval, 4.5%-13.5%) had a central macular thickness of ≥300 μm; 23.2% (95% confidence interval, 16.6%-29.9%) had at least one optical coherence tomography sign of diabetic macular oedema. The false-positive rate of the current screening strategy for diabetic macular oedema was 86.6%. Conclusion The high false-positive rate of the current diabetic macular oedema screening adopted by the United Kingdom and Hong Kong may lead to unnecessary psychological stress for patients and place a financial burden on the health care system. A better way of screening is urgently needed. Performing additional spectral-domain optical coherence tomography scans on selected patients fulfils this need.

Objectives To determine the preference of mothers in Hong Kong and their willingness to pay (WTP) for human papillomavirus (HPV) vaccination for their daughters. Method A discrete choice experiment survey with a two-alternative study design was developed. Data were collected from pediatric specialist outpatient clinics from 482 mothers with daughters aged between 8 and 17 years. Preferences of the four attributes of HPV vaccines (protection against cervical cancer, protection duration, side effects, and out-of-pocket costs) were evaluated. The marginal and overall WTP were estimated using multinomial logistic regression. A subgroup analysis was conducted to explore the impact of socioeconomic factors on mothers' WTP. Results Side effects, protection against cervical cancer, protection duration, and out-of-pocket cost determined the decision to receive or not receive the vaccine. All attributes had a statistically significant effect on the preference of and the WTP for the vaccine. Maximum WTP for ideal vaccines (i.e., 100% protection, lifetime protection duration, and 0% side effects) was HK$8976 (US $1129). The estimated WTP for vaccines currently available was HK$1620 (US $208), lower than the current market price. Among those who had a monthly household income of more than HK$100,000 (US $12,821), the WTP for vaccines currently offered was higher than the market price. Conclusions This study provides new data on how features of the HPV vaccine are viewed and valued by mothers by determining their perception of ideal or improved and current vaccine technologies. These findings could contribute to future policies on the improvement of HPV vaccine and be useful for the immunization service in Hong Kong.

Background: home visits and telephone calls are two often used approaches in transitional care, but their differential economic effects are unknown. Objective: to examine the differential economic benefits of home visits with telephone calls and telephone calls only in transitional discharge support. Design: cost-effectiveness analysis conducted alongside a randomised controlled trial (RCT). Participants: patients discharged from medical units randomly assigned to control (control, N = 210), home visits with calls (home, N = 196) and calls only (call, N = 204). Methods: cost-effectiveness analyses were conducted from the societal perspective comparing monetary benefits and quality-adjusted life years (QALYs) gained. Results: the home arm was less costly but less effective at 28 days and was dominating (less costly and more effective) at 84 days. The call arm was dominating at both 28 and 84 days. The incremental QALY for the home arm was −0.0002/0.0008 (28/84 days), and the call arm was 0.0022/0.0104 (28/84 days). When the three groups were compared, the call arm had a higher probability being cost-effective at 84 days but not at 28 days (home: 53%, call: 35% (28 days) versus home: 22%, call: 73% (84 days)) measuring against the NICE threshold of £20,000. Conclusion: the original RCT showed that the bundled intervention involving home visits and calls was more effective than calls only in the reduction of hospital readmissions. This study adds a cost perspective to inform policymakers that both home visits and calls only are cost-effective for transitional care support, but calls only have a higher chance of being cost-effective for a sustained period after intervention.

Objectives There is interest in the extent to which valuations of health may differ between different countries and cultures, but few studies have compared preference values of health states obtained in different countries. The present study applies a nonparametric model to estimate and compare two HK and UK standard gamble values for six-dimensional health state short form (derived from short-form 36 health survey) (SF-6D) health states using Bayesian methods. Methods The data set is the HK and UK SF-6D valuation studies in which two samples of 197 and 249 states defined by the SF-6D were valued by representative samples of the HK and UK general populations, respectively, both using the standard gamble technique. We estimated a function applicable across both countries that explicitly accounts for the differences between them, and is estimated using the data from both countries. Results The results suggest that differences in SF-6D health state valuations between the UK and HK general populations are potentially important. In particular, the valuations of Hong Kong were meaningfully higher than those of the United Kingdom for most of the selected SF-6D health states. The magnitude of these country-specific differences in health state valuation depended, however, in a complex way on the levels of individual dimensions. Conclusions The new Bayesian nonparametric method is a powerful approach for analyzing data from multiple nationalities or ethnic groups to understand the differences between them and potentially to estimate the underlying utility functions more efficiently.

BACKGROUND Reduction in smoking prevalence does not necessarily reduce the costs of smoking as evidence shows in developed countries. We provide up-to-date estimates for direct and indirect costs attributable to smoking in Hong Kong in 2011 and compare with our 1998 estimates. METHODS We took a societal perspective to include lives and life years lost, health care costs and time lost from work in the costing. We followed guidelines on estimating costs of active smoking for those aged 35 years or above (35+) and costs due to second-hand smoking (SHS) exposure for 35+, infants aged 12 months and under and children aged 15 and below. All costs are in US dollars. RESULTS We estimated that 6154 deaths among 35+ in Hong Kong in 2011 were attributable to active smoking, an increase of 10% from 1998. Besides, 672 deaths were attributable to SHS exposure, that is, 10% of the total 6826 smoking-attributable deaths. The estimate of productive life lost due to deaths from active smoking by those aged under 65 years in 2011 was $166 million, an increase of about 4% over the estimate in 1998. Our conservative estimate of the annual tobacco-related disease cost in 2011 was $716 million which accounted for 0.3% of GDP. If we added the value of attributable lives lost, the annual cost would be $4.7 billion. CONCLUSION Despite the reduction in smoking prevalence, smoking-attributable disease still imposes a substantial economic burden on Hong Kong society. These findings support more stringent and effective tobacco control legislation, policies, and measures. IMPLICATIONS Current evidence shows reduction in smoking prevalence does not necessarily reduce the economic costs of smoking. Most studies in developed countries employed a societal perspective, including costs of productivity loss and indirect costs, but not all studies estimated costs associated with second-hand smoking (SHS). The present study estimated the total costs of smoking in Hong Kong including direct and indirect costs attributable to active smoking and to SHS exposure. Our study confirms the pattern of smoking epidemic in developed countries, forewarns the increasing economic burdens from tobacco, and provides East Asian countries with a prediction of their own future costs.

The purpose of this study was to determine the reliability of detecting age-related macular degeneration (AMD) during screening for diabetic retinopathy (DR). This prospective study included 2,003 subjects with diabetes mellitus who underwent photographic screening for DR. The reliability of detecting AMD lesions was tested by interobserver and intraobserver agreement, and the sensitivity and specificity of diagnosing AMD at different grades of severity were tested using the consensus grading of a group as the reference standard. DR affected 24.7 % of the subjects. The age-standardized prevalence of early AMD was 17.9 %, and late AMD was 0.1 %. The interobserver and intraobserver agreement for grading AMD was substantial (k = 0.72 and 0.71 respectively, p

Aim The aim of the present study was to investigate the preference and willingness-to-pay (WTP) of older Chinese adults for community end-of-life care in a nursing home rather than a hospital. Methods A total of 1540 older Chinese adults from 140 nursing homes were interviewed. Four hypothetical questions were asked to explore their preferences for end-of-life care. Using a discrete choice approach, specific questions explored acceptable trade-offs between three attributes: availability of doctors onsite, attitude of the care staff and additional cost of care per month. Results Approximately 35% of respondents preferred end-of-life care in the nursing home, whereas 23% of them would consider it in a better nursing home. A good attitude of staff was the most important attribute of the care site. Respondents were willing to pay an extra cost of US$5 (HK$39) per month for more coverage of doctor's time, and US$49 (HK$379) for a better attitude of staff in the nursing home. The marginal WTP for both more coverage of doctor's time and better attitude of staff amounted to US$54 (HK$418). Respondents on government subsidy valued the cost attribute more highly, as expected, validating the hypothesis that those respondents would be less willing to pay an additional cost for end-of-life care. Conclusions Older Chinese adults living in nursing homes are willing to pay an additional fee for community end-of-life care services in nursing homes. Both the availability of the doctor and attitudes of nursing home staff are important, with the most important attribute being the staff attitudes. Geriatr Gerontol Int 2013; 14: 273–284.

Aim Psychotic disorders incur substantial long-term burdens to patients and society. Early intervention (EI) during the initial years of psychotic disorders can improve long-term outcome. In Hong Kong, a pilot EI programme (EASY, Early Assessment Service for Young people with psychosis) had been set up since 2001 to serve clients under 25 years of age. Although EASY has been effective in improving outcome, consolidation of early psychosis work requires further development. Methods The present paper describes a new EI development which targets adult patients with psychosis in Hong Kong. The Jockey Club Early Psychosis (JCEP) project was launched in 2009. Expanding the service to patients above 25 years old, JCEP aims to deliver a territory-wide specialized EI service to adult-onset psychosis patients, to promote public awareness on early psychosis, and to research on the optimal intervention model and duration for early psychosis in a 4-year randomized controlled trial (RCT). Participants were randomly assigned to receive either 4 years of EI service, 2 years of EI service, or 4 years of standard care. Their symptoms, neurocognitive functions, psychosocial well-being and health economics were regularly assessed. Results To date, 360 patients were recruited into the RCT, and 740 patients were recruited in a 2-year naturalistic study. Prospective, longitudinal follow-up assessments of these patients are still underway. Conclusions JCEP is the first EI project to provide adult early psychosis service in Chinese population. Future data would help to address the optimal duration of EI and its cost-effectiveness. This would also assist regional and international mental health development.

Background/aims This was a cross-sectional survey to find the prevalence of visual impairment and eye diseases among adults with Down syndrome (DS) in Hong Kong. Methods 91 DS patients over the age of 30 were recruited through the Hong Kong Down Syndrome Association. Each patient was provided with a complete ophthalmological assessment including best corrected visual acuity, refraction, slit lamp and fundus examination. Results In our sample, 56.6% had normal vision to mild vision impairment, 33.7% and 7.2% had moderate and severe vision impairment, respectively, and 2.4% were blind. The mean presenting distant LogMAR visual acuity was 0.66 (Snellen equivalent 20/90), and the best corrected LogMAR visual acuity was 0.48 (Snellen equivalent 20/60). Significant refractive errors were found in 86.3% of the eyes, with spherical equivalent corrections ranging from −23.25D to +3.00D. Myopia and astigmatism were prevalent and found in 59.3% and 72.7% of the eyes, respectively. Blepharitis and chalazion were found in 44% of the eyes, while corneal problems were present in 27.5%. There were low incidences of infective keratitis (0.5%), keratoconus (0.5%) and Brushfield spots (1.1%). Cataracts were found in 72.2% of the eyes; 26.1% were congenital and 44.9% were age-related. Fundal abnormalities were present in 49.5% of the eyes. Conclusions There is a high prevalence of vision impairment among Chinese DS adults. Uncorrected refractive errors, high myopia and cataracts are the main visually debilitating ophthalmological abnormalities. Vision may be improved through the simple use of glasses and early treatment of age-related cataracts.

Objectives A review of cost-effectiveness studies on self-management education programmes for Type 2 diabetes mellitus. Methods Cochrane, PubMed and PsycINFO databases were searched for papers published from January 2003 through September 2015. Further hand searching using the reference lists of included papers was carried out. Results In total, 777 papers were identified and 12 papers were finally included. We found eight programmes whose effectiveness analyses were based on randomised controlled trials and whose costs were comprehensively estimated from the stated perspective. Among these eight, four studies showed a cost per unit reduction in clinical risk factors (HbA1c or BMI) of US$491 to US$7723 or cost per glycaemic symptom day avoided of US$39. In three studies the cost per QALY gained, as estimated from a life-time model, was less than US$50,000. However, one study found the programme was not cost-effective despite a gain in QALYs at the one-year follow up. Conclusion A small number of cost-effectiveness studies were identified with only eight of sufficiently good quality. The cost of a self-management education programme achieving reduction in clinical risk factors seems to be modest and is likely to be cost-effective in the long-term.

Diabetes mellitus has become a global epidemic. It causes significant macrovascular complications such as coronary artery disease, peripheral artery disease, and stroke; as well as microvascular complications such as retinopathy, nephropathy, and neuropathy. Diabetic retinopathy is known to be the leading cause of blindness in the working-age population and may be asymptomatic until vision loss occurs. Screening for diabetic retinopathy has been shown to reduce blindness by timely detection and effective laser treatment. Diabetic retinopathy screening is being done worldwide either as a national screening programme or hospital-based project or as a community-based screening programme. In this article, we review different methods of screening including grading used to detect the severity of sight-threatening retinopathy and the newer screening methods. This review also includes the method of systematic screening being carried out in Hong Kong, a system that has helped to identify diabetic retinopathy among all attendees in public primary care clinics using a Hong Kong-wide public patients' database.

We analysed retinal nerve fibre layer (RNFL) defects in eyes with normal circumpapillary RNFL (cpRNFL) thickness using posterior pole asymmetry analysis (PPAA) and investigated the parameters of Bruch membrane opening (BMO) and neural canals using enhanced depth imaging spectral domain optical coherence tomography (EDI-SDOCT). A total of 112 preperimetric glaucomatous eyes of 92 patients were examined to obtain cpRNFL thickness using SD-OCT. Posterior pole asymmetry analysis (PPAA) and central cross-sectional images of the optic nerve head (ONH) were obtained using EDI-SDOCT. Minimal and horizontal distances between the BMO and ONH surfaces (BMOM, BMOH) and the terminal of retinal pigment epithelium (RPE) and ONH surfaces (RPEM, RPEH) were measured. The distribution of the absolute black cells in PPAA was more concentrated in eyes with “U”-shaped neural canals (p

Objectives To map Functional Assessment of Cancer Therapy-General (FACT-G) and Functional Assessment of Cancer Therapy-Colorectal (FACT-C) subscale scores onto six-dimensional health state short form (derived from short form 36 health survey) (SF-6D) preference-based values in patients with colorectal neoplasm, with and without adjustment for clinical and demographic characteristics. These results can then be applied to studies that have used FACT-G or FACT-C to predict SF-6D utility values to inform economic evaluation. Methods Ordinary least square regressions were estimated mapping FACT-G and FACT-C onto SF-6D by using cross-sectional data of 537 Chinese subjects with different stages of colorectal neoplasm. Mapping functions for SF-6D preference-based values were developed separately for FACT-G and FACT-C in four sequential models for addition of variables: 1) main-effect terms, 2) squared terms, 3) interaction terms, and 4) clinical and demographic variables. Predictive performance in each model was assessed by the R 2 , adjusted R 2 , predicted R 2 , information criteria (Akaike information criteria and Bayesian information criteria), the root mean square error, the mean absolute error, and the proportions of absolute error within the threshold of 0.05 and 0.10. Results Models including FACT variables and clinical and demographic variables had the best predictive performance measured by using R 2 (FACT-G: 59.98%; FACT-C: 60.43%), root mean square error (FACT-G: 0.086; FACT-C: 0.084), and mean absolute error (FACT-G: 0.065; FACT-C: 0.065). The FACT-C–based mapping function had better predictive ability than did the FACT-G–based mapping function. Conclusions Models mapping FACT-G and FACT-C onto SF-6D reached an acceptable degree of precision. Mapping from the condition-specific measure (FACT-C) had better performance than did mapping from the general cancer measure (FACT-G). These mapping functions can be applied to FACT-G or FACT-C data sets to estimate SF-6D utility values for economic evaluation of medical interventions for patients with colorectal neoplasm. Further research assessing model performance in independent data sets and non-Chinese populations are encouraged.

Objectives To estimate the direct medical cost of colorectal neoplasia (CRN) from newly diagnosed to the completion of the tumour-specific treatment in the initial year of disease across stages and tumour primary sites. Methods Only direct medical costs from the perspective of the health care service provider were incorporated in the cost analysis (in 2009 USD) using a bottom-up approach. Tumour-specific treatments of surgery, chemotherapy and radiotherapy data in the initial year of disease were identified from the 401 CRN adult patients by a review of their medical records. Service utilization for diagnosis, staging, pre-operative assessment and post-operative follow-up consultations was estimated from the recommendations of established surveillance and clinical practice guidelines. Results Direct medical cost for the care of a newly diagnosed CRN was ranging from $1941 for low-risk polyp to $45 115 for stage IV colorectal cancer in the initial year of care. Costs of care showed a gradient increase from $1748 for low-risk colonic polyps to $42 899 for stage IV colon cancer, and from $2232 for low-risk rectal polyps to $48 453 for stage IV rectal cancers. Diagnostic/pre-operative assessment and treatment accounted for most of total costs of colorectal polyp (58.9–76.7%) and cancer (60.8–85.2%) care. Conclusion The results provided stage and site-specific estimations of the direct medical costs of CRN in a Chinese population that can assist policy decision making and facilitate health care service planning and cost-effectiveness evaluations.

Background The effects of workplace second-hand smoke (SHS) on lung function remain uncertain because of a lack of objective measures for SHS exposures. Objective To determine whether an exposure–response association exists between lung function and two different markers of SHS based on indoor fine particulate (PM 2.5 ) and urinary cotinine levels in non-smoking catering workers. Design A cross-sectional study during a 1.5-year exemption of licensed catering premises from smoke-free legislation. Participants 186 non-smoking catering workers aged 18–65 years in Hong Kong were recruited. A declared non-smoking status was accepted in workers with exhaled breath carbon monoxide levels Main outcome measures Lung function measures of forced expiratory volume in 1s (FEV 1 in litres), forced vital capacity (FVC in litres) and forced expiratory flow as 25–75% of FVC (FEF 25–75 in l/s) were recorded. Results Indoor fine particulate (PM 2.5 ) concentrations were 4.4 times as high in smoking premises (267.9 μg/m 3 ) than in non-smoking premises (60.3 μg/m 3 ) and were strongly associated with the probability of permitted smoking (R 2 =0.99). Smoking was the dominant source of particulates (R 2 =0.66). Compared with workers exposed to the lowest indoor PM 2.5 stratum ( 3 ), lung function was lower in the three higher PM 2.5 strata (25–75, 75–175, >175 μg/m 3 ) with FEV 1 −0.072 (95% CI −0.123 to −0.021), −0.078 (95% CI –0.132 to −0.024), −0.101 (95% CI −0.187 to −0.014); FEF 25–75 −0.368 (95% CI −0.660 to −0.077), −0.489 (95% CI −0.799 to −0.179), −0.597 (95% CI −0.943 to −0.251); and FEV 1 /FVC (%) −2.9 (95% CI −4.8 to −1.0), −3.2 (95% CI −5.1 to −1.4) and −4.4 (95% CI −7.4 to −1.3), respectively. Urinary cotinine was associated positively with indoor PM 2.5 but negatively with lung function. Consistently lower values for lung function per unit increase of indoor PM 2.5 were found. Conclusion Lung function is inversely associated with workplace SHS. Workplace exemptions and delays in implementing smoke-free policies and current moves to relax legislation are a major threat to the health of workers.

INTRODUCTION Smoke-free workplace legislation often exempts certain venues. Do smoking (exempted) and nonsmoking (nonexempted) catering premises' workers in Hong Kong report different perceptions of risk from and reactions to nearby smoking as well as actual exposure to secondhand smoke (SHS)? METHODS In a cross-sectional survey of 204 nonsmoking catering workers, those from 67 premises where smoking is allowed were compared with workers from 36 nonsmoking premises in Hong Kong on measures of perceptions of risk and behavioral responses to self-reported SHS exposure, plus independent exposure assessment using urinary cotinine. RESULTS Self-reported workplace SHS exposure prevalence was 57% (95% CI = 49%-65%) in premises prohibiting and 100% (95% CI = 92%-100%) in premises permitting smoking (p < .001). Workers in smoking-permitted premises perceived workplace air quality as poorer (odds ratio [OR] = 9.3, 95% CI = 4.2-20.9) with higher associated risks (OR = 3.7, 95% CI = 1.6-8.6) than workers in smoking-prohibited premises. Workers in smoking-prohibited premises were more bothered by (OR = 0.2, 95% CI = 0.1-0.5) and took more protective action to avoid SHS (OR = 0.2, 95% CI = 0.1-0.4) than workers in smoking-permitted premises. Nonwork exposure was negatively associated with being always bothered by nearby smoking (OR = 0.3, 95% CI = 0.1-0.9), discouraging nearby smoking (OR = 0.5, 95% CI = 0.2-1.1), and discouraging home smoking (OR = 0.4, 95% CI = 0.2-0.9). Urinary cotinine levels were inversely related to workers' avoidance behavior but positively related to their perceived exposure-related risks. CONCLUSIONS Different workplace smoking restrictions predicted actual SHS exposure, exposure-related risk perception, and protective behaviors. Workers from smoking-permitted premises perceived greater SHS exposure-related risks but were more tolerant of these than workers in smoking-prohibited premises. This tolerance might indirectly increase both work and nonwork exposures.

We conducted a health impact assessment of the government's proposed new air quality objectives (AQO) in Hong Kong, a high pollution environment. We based this on the World Health Organization (WHO) 2005 Air Quality Guidelines (AQG) and used a lognormal probability density function to model possible changes in annual mean pollutant levels resulting from the new AQO. All of the proposed short-term AQO were based on WHO interim targets (IT) or AQG, but allowed additional exceedances of these single limit values. Compliance with these short-term AQO may reduce (18-30%) the current annual mean concentrations but the distribution proportions exceeding the annual or annualized AQG remain high (83-100%). For SO2, the proposed 24-hr AQO of 125 μg m -3 , with 3 days exceedances, cannot ensure reduction of the current annual mean but may legally permit an increase of the pollutant concentration distribution. If the proposed legal limits of AQO are fully exploited by polluters, we estimated the annual number of avoidable deaths at 1860, and avoidable health care events at 5.2 million doctor visits and 92745 hospital bed-days with a total annual community cost of US$2.6 billion. The proposed AQO may only reduce the current air pollution health impacts by 17% but could achieve 41% reduction if additional exceedances were not permitted. An epidemiologic approach should be adopted to assess external costs arising from modifications of WHOAQG and support accountability in air quality management. This analysis of the WHOAQG in a high pollution setting demonstrates problems arising from the absence of annual limits for some pollutants and the discordance between the short-term and annual AQG, suggesting that revisions based on a lognormal probability model should be considered.

The Isle of Man is a small island of 83,000 residents situated in the Irish Sea. The Island is a self-governing Crown Dependency of the United Kingdom. Due to its geographic isolation, the Island provides a unique opportunity to re-design and co-create a model of care that incorporates private, public, third sector and community elements. Financially strained health services recognise that sustainability depends on integration across sectors in the community. Hospice Isle of Man, the only specialist provider of end of life care on the Island, is working with the Department of Health and Social Care and the Council of Voluntary Organisations to develop the Isle of Man’s Integrated Palliative and End of Life Care Strategy. The World Health Organization and the Worldwide Palliative Care Alliance have underscored the need for palliative care to be based on individual needs rather than on disease-specific diagnoses or prognosis Connor and Sepulveda, 2014. In order to provide the right care, at the right time, in the right place, the Island-wide strategy requires a population-based approach and methods to match patients and services based on needs. Early stakeholder engagement facilitated through a workshop held on December 7th, 2017 with members of the health services including primary care, mental health, social health, third sector and carers identified the need for earlier identification of patients at the end of life in order to provide the most appropriate services. It was recognised that patient networks and resources must be taken into account in order for gaps to be adequately identified and to meet patient needs. Patient journey case studies with different diagnoses identified needs across the spectrum of care – including the third sector and patient networks. Age-based segmentation fails to recognize the contribution and potential capacity of those who would otherwise be considered “dependent” in traditional demographic analyses. Cross-sector integration of care raises additional questions and challenges. Who leads the process? What does person-centred care look like with cross-sector involvement? Who can function as a “key worker”? How will fragmented services organise? How do charitable organisations balance mission and goals with the requirements of an integrated network? What trade-offs are stakeholders willing to make? By combining findings obtained through focus groups, patient and carer journeys and cross-sector workshops we identify the non-medical determinants of need for community end of life support and propose strategies to meet them. These findings will form the basis for initiatives that will be piloted and evaluated prior to Island-wide implementation.

Objective To assess the association between awareness of diabetic retinopathy (DR) and actual attendance for DR screening. Design Cross-sectional study. Setting Two public general outpatient clinics. Participants The subjects were people with diabetes mellitus (DM) who participated in a randomised controlled trial, set up in 2008, to test the impact of a copayment on attendance for DR screening. Primary and secondary outcome measures The subjects’ awareness of DR was evaluated using a structured questionnaire conducted via a telephone interview. The attendance for screening was from the actual attendance data. Association between awareness and attendance for screening was determined using multivariate logistic regression model and was reported as ORs. Results A total of 2593 participants completed the questionnaire. A total of 42.9% (1113/2593) said they would worry if they had any vision loss and 79.6% (2063/2593) knew that DM could cause blindness. Only 17.5% (453/2593) knew that treatment was available for DR and 11.5% (297/2593) knew that early DR could be asymptomatic. The importance of having a regular eye examination was acknowledged by 75.7% (1964/2593), but 34% (881/2593) did not know how frequently their eyes should be examined. Worry about vision loss (OR=1.72, P

Background: Second hand smoke (SHS) exposure is a modifiable cause of ill health. Despite the smoking ban in public places introduced in Hong Kong in 2007, infants and children continue to be exposed within the home. Aims: To determine the critical windows of SHS exposure and the duration of its impact on serious infectious morbidity in the first 8 years of life. Methods: The Hong Kong children of 1997 birth cohort is a prospective, population based study of 8327 children comprising 88% of all births in April and May 1997, of whom 7402 (89%) were followed up until their 8th birthday in 2005. We used multivariable Cox regression to assess the relation between post-natal SHS exposure and risk of first admission to public hospitals (together accounting for >95% total bed-days overall) for respiratory, other and all infections from birth to 8.0 years of age, for all individuals and for vulnerable sub-groups. Results: Overall, household SHS exposure within 3 metres in early life was associated with a higher risk of admission for infectious illness up until 8 years of age (HR 1.14, 95% CI 1.00 to 1.31), after adjustment for sex, birth-weight, gestational age, feeding method, maternal age, highest parental education and proxies of preferred service sector. The association was strongest in the first 6 months of life (HR 1.45, 95% CI 1.15 to 1.83). In vulnerable sub-groups such as premature babies, the association held through to 8 years old (HR 2.00, 95% CI 1.08 to 3.72). Infants exposed to SHS in the first 3 months of life were most vulnerable to infectious causes of hospitalisation. Conclusion: Household SHS exposure in early infancy increases severe infectious morbidity requiring hospital admission. Reducing SHS exposure in infants and particularly in more vulnerable infants will lower the bed-days burden due to infectious causes.

Most dietary recommendations are based on studies of limited power and do not adequately reflect the current knowledge base, particularly with regard to effects of diet on clinical outcomes, the most important endpoint from the patients' perspective. In this review we discusses the current state of dietary research, and present a summary of the evidence upon which to base dietary recommendations and guidelines for atherosclerotic vascular disease prevention. We also highlight the complexity and limitations of interpreting current diet-based epidemiological studies in isolation.

Summary Objective The metabolic syndrome has been associated with increased mortality in some Caucasian populations, but data in Asian populations are not available. We present data describing the association of the metabolic syndrome with mortality. Methods The impact of the US National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) metabolic syndrome guidelines definition (using Asian central obesity criteria) on mortality was examined using Cox regression analyses in a population-based cohort (n = 2863) of Chinese subjects. Results The cohort was followed up for a mean duration of 8·45 years, a total of 24 101 person-years, with 89 deaths (33·7% of vascular origin). Compared to those without any component of the metabolic syndrome, following adjustment for age, socioeconomic status and a range of lifestyle habits, those with the metabolic syndrome had increased risk of both all-cause [hazard ratio (HR) 2·02, 95% confidence interval (CI) 1·02–4·00, P for trend = 0·037] and vascular disease (HR 6·39, 95% CI 1·40–29·2, P