The Hong Kong eldercare and healthcare system faces a high burden from osteoporosis and hip fragility fractures. The prevalence of osteoporosis in people aged ≥50 years in Hong Kong has been measured as high as 37% in some studies.1 A study of 4000 community-dwelling older people in Hong Kong found that 7% of men and 11% of women had ≥1 incident of major osteoporotic fracture over 9.9 and 8.8 years of follow-up, respectively.2 The number of patients admitted for hip fracture surgery increased from 3678 in 2000 to an estimated 6300 in 2020,3 a 71.3% increase over 20 years. Although the risk of geriatric hip fracture in Hong Kong is declining slightly, this is outweighed by the growing elderly population.3 The life expectancy in Hong Kong (81.9 years for men; 87.6 years for women) is among the highest in the world,4 5 and projections suggest that by 2036, 31.1% of the population will be aged ≥65 years.6 Without intervention, the ageing of the population is predicted to result in a considerable increase in the incidence of fragility fracture, with estimates for hip fractures rising to more than 14 500 in 2040.3

Direct costs per hip fracture to Hong Kong public hospitals have been estimated at HK$81 120 (2017 data by Su et al7). This equates to an annual estimated cost of HK$511 million for the territory’s Hospital Authority. Although no estimates of indirect costs are available for Hong Kong, Taiwanese data from 2016 suggest they are likely to be substantial. Estimated annual indirect costs in Taiwan are HK$13 728, HK$3744, or HK$9687 per patient if discharged to a nursing home, foreign-paid home care, or domestic-paid home care, respectively.8 A Hong Kong study found that 23% of patients with hip fractures who had previously been living at home were discharged to residential care homes for the elderly.9

Follow-up care after hip fracture in Hong Kong is suboptimal, with low usage of bone-enhancing medication with poor follow-up rates.9 In a territory-wide retrospective study, only 8.2% of patients were prescribed anti-osteoporotic medication during the year after hip fracture.10 Among patients with primary hip fractures, 6% had fracture complications, and 4% had secondary fracture(s) within 12 months.9 The post-discharge mortality rate was also high: 17.3% died within 1 year of hip surgery versus 1.6% of age-matched controls.9

Local data on other major types of osteoporotic fractures are scarce. In the Hong Kong Osteoporosis Study (HKOS),11 the incidence of vertebral fracture was 194 per 100 000 person-years in men and 508 per 100 000 person-years women aged ≥50 years.12 In 2013, in Hong Kong, the prevalence of vertebral fracture was 17% in men and 30% in women aged 70 to 79 years.13 Many vertebral fractures do not require immediate medical attention, making their impact difficult to study,13 but international data suggest they are associated with substantial morbidity, possibly contributing to increased mortality.14

European and North American studies have demonstrated that dual-energy X-ray absorptiometry (DXA) screening followed by osteoporosis treatment in older people can substantially reduce hip fracture rates by 25% to 50% in ≤5 years and is cost-effective.15 16 17 Therefore, many fractures and associated complications, including secondary fractures and mortality, could be prevented by routine osteoporosis screening in older people and timely treatment initiation in at-risk individuals.

The rising burden of fragility hip fractures demands a response. Based on existing studies from Hong Kong and abroad, we believe that reducing this burden is achievable. Here, we provide clear, practical, evidence-based recommendations on how to reduce hip fracture rates in Hong Kong with the goal of reducing incidence by 6.8% annually, thereby curbing rising incidence.

Roundtable meetings of experts reviewing hip fracture burden in Hong Kong were held in October and December 2018 and June 2019. Tactics to relieve the primary fracture burden were discussed, and a consensus on a rigorous approach to screening, prevention, and treatment was formed.

The calculated predictive performance and simulated effects of our proposed strategies used a similar population to that used by Su et al18 in the Mr OS and Ms OS Hong Kong Cohort Study, employing the same statistical model and simulation analysis methods. Simulated analysis of the cohort was based on DXA scans of the hip and spine performed on men aged ≥70 years and women aged ≥65 years, without pre-selection, followed by treatment if the Fracture Risk Assessment Tool (FRAX; including bone mineral density [BMD]) score was ≥3%.18

The number needed to DXA scan and number needed to treat (NNT) were calculated using data derived from the same simulated analysis as that performed by Su et al.18 The present epidemiological analysis assumes that only 50% of eligible patients agree to undergo the DXA scan and engage in follow-up steps.

Better awareness of osteoporosis screening and treatment among healthcare providers is urgently needed, as is public financial support for evidence-based tools that can reduce this problem. Discussions resulted in the formulation of three evidence-based recommendations.

We propose that the lower age limits for screening of women and men be set to 65 and 70 years, respectively, based on a 2017 study showing that the average age of fragility fracture in Hong Kong was 82.1 years.9 From ages 65 to 69 years to 70 to 74 years, the annual incidence of hip fracture rose exponentially from 156.0 to 364.4 per 100 000 person-years in women and 102.6 to 212.2 per 100 000 person-years in men.19 The incidence continued to double in every subsequent 5-year period.19 Our proposed age thresholds align with those specified in international guidelines and reflect the differing ages at which the prevalence of reduced bone mass increases in men and women.15 20

A prospective cohort study of almost 4000 men and women aged ≥65 years in Hong Kong estimated the effectiveness of hip fracture prevention strategies using DXA.18 Based on the calculation method used in this study, we recommend a strategy of universal DXA measurement and treating patients with FRAX (including BMD measurement) risk ≥3%. The FRAX threshold of 3% was selected because our statistical analysis suggests that this prevents the greatest number of hip fractures while maintaining acceptable NNT. Furthermore, this threshold aligns with current local and international treatment guidelines,13 and a United States study found that this threshold was cost-effective.21

With our strategy, we found that one hip fracture can be prevented for every 111 men (aged ≥70 years) DXA scanned, with 54 subsequently treated; or for every 111 women (aged ≥65 years) DXA scanned, with 73 subsequently treated (Table 1). Using the projected older population of 1.16 million,6 and assuming that only 50% of the target population would be scanned, we could prevent 5234 hip fractures over the next 10 years.

To put the number of hip fractures prevented into context, we considered the projected number of hip fractures and the estimated growth rate. The estimated number of hip fractures in 2020 according to Man et al3 was 6300. If we apply the 4.3% estimated annual growth of the older population to this figure,6 by 2029, we would expect 9167 hip fractures in Hong Kong. Assuming the same 4.3% estimated annual increase also applies to the number of fractures prevented each year,6 we expect to prevent 431 hip fractures in 2020, and 627 in 2029. Based on these calculations, we estimate that by DXA screening and treating 581 000 men and women, the incidence of hip fracture could be reduced by approximately 6.8% (Table 1). As the estimated growth of the older population is 4.3% each year,6 an 6.8% annual hip fracture reduction rate would outweigh the annual increase in hip fracture cases among elderly patients due to population growth.

We selected DXA for screening because reduced hip BMD in the femoral neck measured by DXA is widely used in treatment guidelines to define osteoporosis and set drug-treatment thresholds.22 Hip BMD is strongly associated with hip fracture risk in both men and women23: its association with fragility fracture is stronger than that of spine BMD in Hong Kong Chinese people.24 25 Dual-energy X-ray absorptiometry is cheaper than magnetic resonance imaging (each DXA session cost approximately HK$500 in Hong Kong in 2018)7; it is non-invasive, and uses less irradiation than computed tomography.26 Local guidelines do not recommend the use of quantitative ultrasound for monitoring or treatment of osteoporosis, and currently consider the evidence for peripheral DXA to be insufficient.13

This recommendation is supported by health economics studies. Screening strategies based on DXA are more cost-effective in individuals aged ≥65 years than in younger people because hip fracture is rare in the latter.15 American and European studies have shown that screening strategies, including DXA screening, are cost-effective for prevention of hip fracture in elderly men and women.15 27 A recent Hong Kong study that modelled screening strategies found that DXA-based approaches, including universal DXA with or without pre-screening, were more cost-effective than no screening.7 In women aged ≥65 years and men aged ≥70 years, the incremental effectiveness gained by universal DXA screening versus no screening incurred no additional cost, which is well below the widely acceptable willingness to pay (US$50 000 per quality-adjusted life year).7 A modelling analysis using North American data found that universal densitometry and treatment with alendronate was highly cost-effective for women aged ≥65 years, and it was cost-saving for ambulatory women aged ≥85 years.28 The International Society for Clinical Densitometry recommends DXA assessment for all women and men aged ≥65 and ≥70 years, respectively.29 While the United States Preventative Services Task Force recommends screening in women aged ≥65 years and in younger postmenopausal women with elevated risk, it makes no recommendation for men because of insufficient evidence.22 In Hong Kong, however, the analysis of Su et al,18 which is based on extensive local data, suggested that strategies using DXA, including universal screening, can potentially be cost-effective for fracture prevention in both men and women at the age thresholds we propose. Other countries such as Australia, Malaysia, Japan, and Singapore also wholly or partially fund universal DXA screening for older people.30 31 32 33

Scanning alone would only be impactful if followed up by a treatment plan. We recommend using FRAX to guide treatment because it calculates the 10-year fracture risk from a patient’s age, body mass index, and risk-factor profile (fracture history, family history, tobacco or alcohol use, use of oral glucocorticoids, and presence of rheumatoid arthritis).34 It can be used with or without BMD data; it is the most widely adopted fracture risk assessment tool, and FRAX has been extensively validated and adapted to local populations, including that of Hong Kong.34 35

The FRAX risk thresholds are widely used to guide intervention in local and international osteoporosis treatment guidelines.13 36 The 2019 European guidelines recommend country-specific use of FRAX to assess risk in postmenopausal women, including BMD in intermediate-risk individuals.34 An example of a successful real-world fragility fracture-reducing intervention incorporating FRAX has been documented.37 A United Kingdom trial used a questionnaire incorporating FRAX to promote DXA screening in women aged 70 to 85 years, leading to a 28% hip fracture reduction over 5 years.37

We suggest 3 years as the duration of antiresorptive treatment based on local studies of alendronate, which showed increases in BMD of 5% to 6% at the lumbar spine and 3% to 4% at the hip after 1 year of treatment in postmenopausal women with osteoporosis.38 39 Local guidelines recommend 5 years of initial therapy with oral bisphosphonates but acknowledge that no consensus exists regarding the optimal treatment duration.13 We believe that 3 years of duration offers an appropriate balance of efficacy and cost. Additional financial support for longer-term therapy may become feasible when our recommendations begin demonstrating effectiveness in fragility fracture reduction, with improved compliance, during the first 3 years.

Current osteoporosis treatments are appropriate for addressing the hip fracture burden in Hong Kong (Table 213). The efficacy and safety of locally approved antiresorptive therapies have been extensively validated in numerous clinical trials in men and postmenopausal women, including long-term studies.40 41 42 Cost-effectiveness analyses support their use for fracture prevention, with gains in quality-adjusted life years for patients and incremental cost-effectiveness ratios well within acceptability thresholds (vs no treatment).7 21 A meta-analysis of eight studies of four agents found that antiresorptive therapy for osteoporosis led to significant mortality-rate reductions.43 Recently, a study in Hong Kong showed that real-world use of bisphosphonates among hip fracture patients may protect against cardiovascular diseases.10 Adverse event (AE) imbalances suggesting cardioprotective effects were also observed in a randomised trial of zoledronate in 2000 women with osteopenia in New Zealand.44 Bisphosphonates are easily accessible in Hong Kong, and many patients with osteoporosis could feasibly be treated in primary care.13 Our analysis found that, with universal DXA scanning of men aged ≥70 years and women aged ≥65 years, a treatment threshold of FRAX (with BMD) risk ≥3% for hip fracture yields a NNT of 54 for men and 73 for women to prevent one fracture.

In line with local treatment guidelines, we recommend lifestyle measures, including a balanced diet rich in calcium and vitamin D, regular exercise, avoidance of smoking or excessive alcohol intake, and adequate sunlight exposure, as a universal approach to prevention and non-pharmacological management of osteoporosis.13 Vitamin D supplementation should be given alongside antiresorptive medications, and calcium supplementation is recommended for those unable to achieve adequate levels through diet alone.13 This is particularly pertinent in Hong Kong, where dietary vitamin D intake is generally low and the prevalence of vitamin D insufficiency or deficiency has been observed to be high.45 A Cochrane systematic review found that exercise has a small but significant effect on BMD in postmenopausal women with osteoporosis.46 People with osteoporosis and high hip fracture risk should be treated with antiresorptive drugs combined with calcium or vitamin D and physical exercise.

Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) are well-known AEs of antiresorptive therapies.13 47 However, the absolute risk of ONJ with the administration of antiresorptive therapy in patients with osteoporosis patients is low, and the risk-benefit balance is highly favourable.48 49 Risk-minimising precautions against ONJ, including close attention to good dental hygiene during treatment and endodontic (rather than surgical) corrective procedures, have already been incorporated into local guidelines.13

Poor adherence is a challenge for long-term use of oral bisphosphonates in osteoporosis.50 51 One study showed persistence declining to <50% over 2 years.51 Factors associated with poor adherence include advanced age, fear of AEs, and inadequate education.52 Improving patient education,53 using antiresorptive therapies with longer dosing intervals,54 and managing AEs appropriately may help to improve adherence.55

For screening and follow-up treatment programmes to be worthwhile, assessing the cost-benefit ratio is important. The estimated costs of Recommendation 1 (universal DXA screening in men aged ≥70 years and women aged ≥65 years) in 10 years are shown in Table 3.25

We assumed that 3 years of generic alendronate plus calcium and vitamin D supplementation would be given for treatment, costing approximately HK$2500 (accounting for inflation; Table 325). We chose alendronate because it is currently the lowest-priced generic antiresorptive; patients may self-fund other options should they prefer. For instance, denosumab may be an option, particularly for patients with high fracture risk, poor adherence, contraindications, or intolerance to bisphosphonates.13 49 The incidence of ONJ in bisphosphonate-treated patients with osteoporosis in Hong Kong appears to be low (73.53 per 100 000 person-years of oral treatment), and the reported cases were in patients with readily modifiable risk factors.56 Estimates for the incidence of AFF in Hong Kong are not available, but data from abroad suggest that AFF is also very rare (13.6 per 100 000 patient-years at 2.0-3.9 years of bisphosphonate use).57 On this basis, we have not included the costs associated with ONJ and AFF in our calculations, as the associated cost is likely to be low.

The total cost of Recommendations 1 and 2 is HK$1155 million in 10 years (Table 325). In terms of benefits, we estimate that our proposals will prevent 5234 hip fractures over 10 years; if the estimated direct cost per hip fracture is HK$81 120 (2017),7 this would save the healthcare system HK$425 million in 10 years, with further savings from reduced outpatient and indirect costs. Additionally, elderly people and their families would avoid costs associated with institutional care. Based on 6300 hip fractures in Hong Kong in 2020,3 fracture reduction of 6.8%, the proportion of all patients with hip fractures discharged to institutional care (17%),9 and local institutional care costs (HK$120 000 annually for 5 years), we estimate that the savings from reduced institutional care needs would be HK$534 million in 10 years. Therefore, the total cost savings would be HK$959 million over 10 years; it should be noted, though, that this estimation is conservative and has not taken into account the year-on-year increase in hip fracture rate or inflation. Although the prevention of hip fractures alone may not reduce the institutional care cost for all patients, it would still likely be associated with substantial cost savings for the majority of patients. A full cost-effectiveness analysis of our proposal has not been performed, but the above cost-savings calculation has not included other fragility fractures, indirect healthcare cost savings (eg, transportation, costs associated with work productivity in family members), and inflation. Therefore, we believe that our recommendations are potentially cost-effective.

Because of ageing of muscles and declining balance control, older adults are more likely to experience falls than their younger counterparts.58 Fall history is a risk factor for subsequent falls59 60 61 and an independent predictor of fracture in older men and women.62 Recently, a hip fracture prediction score (HKOS score) was developed and validated for older adults aged ≥80 years in Hong Kong, and fall history is one of the risk factors included.63

Older people who have a history of falling should therefore be offered a comprehensive fall risk assessment. We also recommend DXA screening in these high-risk individuals. Although a history of falling is a good reason for fall risk and DXA assessments, these assessments should not be confined to those with a history of falling. Guidelines from the American Geriatrics Society/British Geriatrics Society recommend annual screening of all community-dwelling older people aged ≥65 years for falls and risk of falling.64

A meta-analysis of 159 trials in over 79 000 community-dwelling patients, including diverse fall-risk reduction strategies, concluded that home or group-based exercise programmes, including Tai Chi and home modifications, can reduce fall risk and fall-related fracture.65 In a study of elderly Hong Kong patients with a history of falling, a single risk assessment and home modification visit by an occupational therapist resulted in a reduced fall prevalence in the following 12 months compared with controls (13.7% vs 20.4%, P=0.03).66

Table 413 summarises the key elements of our recommendations, including treatment thresholds specified by local guidelines. Osteoporosis and fall risk assessment can be managed in the primary care setting, especially in Hong Kong, where access to DXA screening is excellent.

To promote DXA screening, Shepstone et al37 showed that a self-completed questionnaire capturing FRAX risk factors was effective at alerting older women to their fracture risk, resulting in a 28% reduction in hip fracture incidence in 5 years. On the basis of local prospective data, we demonstrated that combining a short questionnaire for sarcopenia (SARC-F) and the FRAX questionnaire could identify >75% of older people who suffered an incident hip fracture within 10 years.18 Furthermore, the well-calibrated HKOS score may accurately identify the oldest old (≥80 years) who are at high hip fracture risk.63

The high primary hip fracture burden in Hong Kong can be reduced with an evidence-based screening programme. High-risk patients identified by our proposed screening can be effectively managed using well-established and affordable therapies within the primary care field. Our proposals are supported by extensive evidence: similar programmes have shown efficacy, both in Hong Kong and abroad.

We propose that the Hong Kong government provide public funding support for a universal DXA screening programme for all men aged ≥70 years and women aged ≥65 years. Patients with a history of falling must receive systematic fracture-risk evaluations; patients with high fracture risk identified through these measures should be treated with antiresorptive agents and receive appropriate multidisciplinary follow-up.

We recommend a multidisciplinary effort including colleagues in general practice, orthopaedics, geriatric medicine, etc, to improve awareness of already available screening tools and effective treatment options for osteoporosis. If properly implemented and supported, we believe that our goal of a 7% annual reduction in hip fracture incidence in Hong Kong can be achieved, helping to offset the annual increase in the elderly population. Adoption of our proposals will shift government spending from post-fracture management to proactive osteoporosis management and fracture prevention. If our proposals are adopted, the estimated HK$1 billion that would be spent in 10 years on post-fracture management will instead be spent on improved osteoporosis management and fracture prevention for tens of thousands of patients. Furthermore, preventing fractures would also preserve the quality of life of many patients and their families. Achieving better control of hip fracture burden will be challenging, but it is well within our reach.

All authors contributed to the literature review and recommendations, critically revised the manuscript for important intellectual content, approved the final version for publication, and take responsibility for its accuracy and integrity.

This publication is funded by a supportive grant from Amgen Asia Holding Limited to the Hong Kong Osteoporosis Foundation (HKOF) and the Osteoporosis Society of Hong Kong (OSHK) Consensus Group on Prevention of Fractures in Older People. All authors declare that they have no additional conflicts of interest.

Editorial support for this manuscript was provided by Magdalene Chu and Dr Alister Smith of MIMS Hong Kong, funded by the Hong Kong Osteoporosis Foundation.

This publication is funded by a supportive grant from Amgen Asia Holding Limited to the Hong Kong Osteoporosis Foundation (HKOF) and the Osteoporosis Society of Hong Kong (OSHK) Consensus Group on Prevention of Fractures in Older People.

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60. Wu TY, Chie WC, Yang RS, Kuo KL, Wong WK, Liaw CK. Risk factors for single and recurrent falls: a prospective study of falls in community dwelling seniors without cognitive impairment. Prev Med 2013;57:511-7. Crossref

61. Woo J, Leung J, Wong S, Kwok T, Lee J, Lynn H. Development of a simple scoring tool in the primary care setting for prediction of recurrent falls in men and women aged 65 years and over living in the community. J Clin Nurs 2009;18:1038-48. Crossref

62. Harvey NC, Odén A, Orwoll E, et al. Falls predict fractures independently of FRAX probability: a meta-analysis of the osteoporotic fractures in men (MrOS) study. J Bone Miner Res 2018;33:510-6. Crossref

63. Lam MT, Sing CW, Li GH, Kung AW, Tan KC, Cheung CL. Development and validation of a risk score to predict the first hip fracture in the oldest old: a retrospective cohort study. J Gerontol A Biol Sci Med Sci 2020;75:980-6. Crossref

64. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148-57. Crossref

65. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;(9):CD007146. Crossref

66. Chu MM, Fong KN, Lit AC, et al. An occupational therapy fall reduction home visit program for community-dwelling older adults in Hong Kong after an emergency department visit for a fall. J Am Geriatr Soc 2017;65:364-72. Crossref

Clinical simulation training has become more widely practised in local hospitals and academic healthcare institutions in the past decade, with a wide range of training modalities, from part-task simulator to full-body manikin and from single skill training to interprofessional team-based training.

The Nethersole Clinical Simulation Training Centre is a hospital-based training centre which has advocated high-fidelity multidisciplinary team training for hospital staff since its establishment in 2012 in Pamela Youde Nethersole Eastern Hospital. From 2008, the emergency department of the hospital was one of the centres for teaching emergency medicine specialty clerkship medical students from one of the medical schools in Hong Kong. In 2017, the emergency department collaborated with the Nethersole Clinical Simulation Training Centre in an initiative to design a high-fidelity simulation training session for medical students.

In the past, medical students in local medical school did not have much high-fidelity simulation training because medical schools did not have high-fidelity training facilities. Furthermore, it was conventionally believed that high-fidelity simulation training is more beneficial for expert-level learners and that low-fidelity training was more suitable for beginners, because the sophisticated context in the high-fidelity environment might potentially jeopardise learning objectives by creating excessive cognitive burden.1 2 3 Medical students, owing to their low clinical exposure, were regarded as beginners.

However, a recent study suggested that once medical students have learnt some basic skills, high-fidelity simulation training might benefit learners through psychological immersion, despite the extra cognitive burden.4 Therefore, we decided to trial high-fidelity simulation training for final-year medical students, who have already completed most of their academic studies and have acquired some basic practical skills.

The prototype of the simulation training course was started in 2017 and at that time we mainly evaluated the “reaction” phase of the learners which is the basic level of outcome evaluation according to Kirkpatrick’s model (Fig). The feedback from the students was very positive and they welcomed the course very much.5 Encouraged by this, we revised the course material in 2018 with written intended learning outcomes. In the present study, we evaluate “learning”, which is a level higher in the Kirkpatrick’s model.

The aim of the present study was to evaluate the learning outcomes of a high-fidelity simulation training course for final-year medical students.

This was a qualitative study by a survey in English. The contents were checked against SRQR reporting guideline (Standards for Reporting Qualitative Research 2016 version).

The training course was conducted in the Nethersole Clinical Simulation Training Centre that has a simulation training suite with isolated simulation rooms and a debriefing room. The simulation rooms are equipped with ceiling-mounted cameras for video-assisted debriefing. The simulation room used was prepared to resemble the environment of a resuscitation room in the emergency department with a full-body high-fidelity manikin.

The training course consisted of a brief introduction followed by four short case scenarios in a 3-hour session. In the introduction, students were briefed about course structure, learning objectives, and clinical simulation rules and underwent a short simulation laboratory familiarisation session. A group of seven to eight students further divided into two subgroups played the four scenarios in turn. While one subgroup was doing the scenario, the other subgroup observed from the debriefing room via the audio-visual system. The instructor wore a nurse uniform and acted as an experienced nurse in the scenarios, which included no real-time coaching. In the four scenarios all the patients presented with acute or even life-threatening conditions that need prompt treatment. Such a design simulated the high psychological fidelity of real life. Participants had to treat the patients on their own with no guidance from the instructor. A debriefing session was carried out immediately after each scenario.

A cohort of student participants in 2018 were selected by convenience sampling and they were asked to complete an evaluation form immediately after the session. The evaluation form invited the students to offer free text only with no rating scale. They could write up to three perceived learning outcomes, up to three reflections after the course and any extra comments or suggestions about the course. There was no space to enter the name of the students, so the data collection was completely anonymous.

The findings in the evaluation form were processed through thematic analysis shortly after each course and compared with the intended learning outcomes of the course (Table 1). The intended learning outcomes were designed to include both clinical learning outcomes and teamwork learning outcomes such as briefing, debriefing, communication, situation awareness, and leadership. The clinical learning outcomes, owing to their diversity were further divided into three separate categories (general approach to critical patients, use of investigations and resuscitation skills) while all the teamwork-related learning outcomes are grouped under one category. The written learning outcomes were first coded under these intended learning outcomes. Items not fitted under the intended learning outcomes were considered new findings. These new findings were further processed newly identified themes. The results of thematic analysis were checked serially by the authors for quality assurance. Consensus on new themes after further literature review was made between authors on items that could not be categorised under the intended learning outcomes.

Data saturation was attained after 20 sessions with 149 evaluation forms collected (data saturation is a point when no new theme was found by thematic analysis after analysing the responses after several courses). The response rate was 100% and more than 99% (148 out of 149) of the returned forms were complete, despite the voluntary nature of data collection.

The intended learning outcomes are listed in Table 1. From the contents of the evaluation form, all of the intended learning outcomes were well received by the respondents, as reflected by the responses shown in Table 1.

In addition to the intended learning outcomes, we discovered a large number of learning points or reflections that cannot be categorised under our pre-planned learning objectives. These additional unexpected learning points were processed by thematic analysis under new headings as listed in Table 2.

Respondents were also given the opportunity to make open comments or suggestions about the course. Some of the responses are listed in Table 3.

The original intention of course evaluation questionnaire was to evaluate the learning objectives as perceived by students. The results suggest that our intended learning outcomes were well received by our students. A number of learning outcomes were revealed that did not fall into our intended learning outcomes by thematic analysis. Additional literature review revealed that these unexpected outcomes match some gaps identified in the transition between undergraduate medical education and postgraduate practice.

In our training course, high fidelity was thought to be an important element to achieve the learning outcomes, including the unexpected ones. Fidelity is commonly defined as “the level of realism present to the learners during a simulation training”.3 4 Conventionally, it is believed that higher fidelity leads to more efficient learning.6

However, fidelity is not a single-dimensional concept and there are different components of fidelity described in the literature using different terminology. For simplicity, we consider the definition of fidelity described by Feinstein and Cannon, in which fidelity of simulation has physical and functional aspects.3 Physical fidelity includes the environmental, visual, and spatial components, such as the design of the simulation room, the performance of manikin, and the settings of various instruments. Functional fidelity is a dynamic interaction between the participants and their task, including information, stimuli, and responses of learners. Other simulation educators have used the terms “conceptual”, “experiential”, “emotional” or more commonly “psychological” fidelity to describe the same or similar concepts,2 7 but further discussion is beyond the scope of the present study.

High-fidelity simulation training was not always regarded as superior to lower-fidelity training. Besides the issue of cost, early studies in the last century in various disciplines (such as civil and military aviation) failed to show better learning outcomes after high physical fidelity training.3 8 9 10 This might be because the high physical fidelity training over-stimulated novice learners and resulted in cognitive overload that jeopardised the intended learning objectives.11 Such findings supported the conventional belief that low fidelity is better for beginners and high fidelity is for expert learners. Medical students are regarded as novice learners and have little or no working experience. These conventional beliefs lead to the conclusion that it is unreasonable and not cost-effective to expose medical students to high physical fidelity simulation training. However, this overlooks the importance of functional or psychological fidelity. In recent years, studies have suggested that functional or psychological fidelity is important in enhancing learning.7 12 13 14 15 In addition to simulating real-world functioning, high psychological fidelity also creates a stressful environment, increasing student arousal level and facilitating learning and performance. Therefore, in our training course, in addition to the relatively high physical fidelity provided by the well-equipped simulation training room and sophisticated manikin, we further enhanced functional or psychological fidelity by the following interventions:

A short briefing session before the scenario emphasised behavioural authenticity (such as doing real chest compression and discharging full energy for defibrillation) and psychological immersion. This is equivalent to a fiction contract to suspend disbelief described in clinical simulation training literature.15 16

All participants and the instructor wore clinical attire, including white coats and nurse uniforms that simulated real staffing in an emergency department.

The instructor behaved as a helpful nurse and talked in a submissive manner while occasionally offered hints with limited scientific knowledge out of past experiences.

The instructor might immediately remind or even criticise participants who demonstrated non-immersive clinical behaviour such as laughing, suboptimal chest compression, or non-participative gesture.

Stress level was enhanced by the absence of real-time coaching in critical clinical conditions. Students were made to solve challenges and overcome difficulties or uncertainty by themselves with a deteriorating patient in front of them.

All of these measures enhanced functional fidelity by providing a realistic working environment and imposed psychological immersion for the participants.

A further remark on the term “fidelity” is that physical and psychological fidelity are not mutually exclusive nor competitive, but are actually complementary to each other.17 18 19 20 For example, a high-fidelity manikin who can talk or moan can enhance psychological stimuli for the participants.

Some of the learning outcomes of the course are closely related to psychological fidelity, namely teamwork, working under stress, identifying one’s own weakness, acute patient management, and situation awareness. In the written responses under these headings, we could see interaction, flow of information, stress, and self-reflection.

Although not the original objective of this study, we found that the unexpected learning outcomes of this study echoed some of the identified gaps between transitions from undergraduate medical education to early postgraduate medical practice in the literature. In the medical education literature there have been calls worldwide for reform of undergraduate medical curricula, to address gaps identified in undergraduate medical education that adversely affect medical interns in their early practice.21 22 23 24 25 These gaps include working under stress, working on call, uncertainties, helplessness, workload, difficulties prescribing medication, and managing acutely ill patients, and similar gaps have been identified in medical educations programmes across the world.

Newly graduated interns perceive their work to be stressful and have feelings of being underprepared.23 24 25 Educators have suggested that undergraduate curricula should prepare medical students to deal with expected stress, such as facing uncertainty, knowing one’s limitations, and asserting one’s right for support.21 26 27 These wordings or identified gaps were found in the perceived learning outcomes of our course. In the literature, interns have indicated that they could not predict their shortcomings in their undergraduate study until they were in clinical practice. Furthermore, it was also suggested that undergraduate medical education should include more on communication skills and emotional involvement.21 28 29 Again these aspects match the perceived learning outcomes of our course.

More work-related training should be put in the final year of medical school, particularly for dealing with acutely ill patients and prescribing medication.30 31 32 Studies have shown that despite curriculum reform, management of acute problems has remained an unclosed gap.30 33 34 Work-related training with acutely ill patients is difficult to achieve because such patients are not always readily available even if medical students do a period of assistant internship. This is a likely reason that curriculum reform and workplace placements during their final year closed some gaps but not others.20 21 The opportunities for students to experience real acute care are limited, making it difficult to build expertise through repetitive practice.35 36 Furthermore, there is always an ethical consideration of whether to allow students to treat acutely ill patients.37

The learning outcomes of our study suggest that high-fidelity simulation training can be a solution to the gaps identified. High-fidelity simulation training can create a lot of scenarios with acutely ill patients in a short period of time, to create an environment in which students can make mistakes and learn from these mistakes without harming real patients. This idea is supported by the literature, which demonstrates simulation training is better than other forms of instruction method such as didactic or problem-based learning and should serve as an adjunct to other instruction methods.2 38 39 This point is particularly important because interns or junior doctors are the first medical responders called to attend acutely deteriorating patient in a ward and their suboptimal management might put patients at risk or delay appropriate treatment.21 29 The General Medical Council of the United Kingdom also recommends the use of simulation technology in medical school.22

The limitations of this study include that data were collected from only one medical school, the current curriculum was not discussed, the cohort included students at different times in their final year, and most (but not all) students were recruited before formal clinical placement.

There are gaps between undergraduate medical education and transition to postgraduate clinical practice which could be eliminated through reform of undergraduate medical school curricula. The application of psychologically immersive high-fidelity simulation training for medical students is likely to be a helpful strategy to enhance their preparedness. Such training should emphasise management of acutely ill patients.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity. YF Choi wrote the article. All authors contributed to the concept of study, acquisition and analysis of data, and critical revision for important intellectual content.

As an editor of the journal, TW Wong was not involved in the peer review process. The other author has disclosed no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

No real patients were involved in this study and no personal data was collected from the participants. Verbal consent was obtained from all participants in the introduction session of the course; participation was non-compulsory. The study was approved by the hospital ethics committee (Ref HKECREC-2019-013).

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2. Maran NJ, Glavin RJ. Low- to high- fidelity simulation—a continuum of medical education? Med Educ 2003;37(Suppl 1):22-8. Crossref

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4. Mills BW, Carter OB, Rudd CJ, Claxton LA, Ross NP, Strobel NA. Effects of low- versus high-fidelity simulations on the cognitive burden and performance of entry-level paramedicine students: a mixed-methods comparison trial using eye-tracking, continuous heart rate, difficulty rating scales, video observation and interviews. Simul Healthc 2016;11:10-8. Crossref

5. Choi YF, Wong TW. High fidelity simulation training for medical students in emergency medicine specialty clerkship. Proceedings of the 9th Asia Medical Education Symposium cum Frontiers in Medical and Healthcare Science Education 2017. OP2.

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7. Diederich E, Mahnken JD, Rigler SK, Williamson TL, Tarver S, Sharpe MR. The effect of model fidelity on learning outcomes of a simulation-based education program for central venous catheter insertion. Simul Healthc 2015;10:360-7. Crossref

8. Matsumoto ED, Hamstra SJ, Radomski SC, Cusimano MD. The effect of bench model fidelity on endourological skill: a randomized controlled trial. J Urol 2002;167:1243-7. Crossref

9. Chandra DB, Savoldelli GL, Joo HS, Weiss ID, Nail VN. Fiberoptic oral intubation: the effect of model fidelity on training for transfer to patient care. Anesthesiology 2008;109:1007-13. Crossref

10. Grober ED, Hamstra SJ, Wanzel KR, et al. The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg 2004;240:374-81. Crossref

11. Martin EL, Waag WL. Contributions of platform motion to simulator training effectiveness: Study I—basic contact. 39. Brooks Air Force Base, Texas Air Force Human Resources Laboratory; 1978. Crossref

12. Bland AJ, Topping A, Tobbell J. Time to unravel the conceptual confusion of authenticity and fidelity and their contribution to learning within simulation-based nursing education. A discussion paper. Nurse Educ Today 2014;24:1112-8. Crossref

13. Chetwood JD, Grag P, Burton K. High-fidelity realistic acute medical simulation and SBAR training at a tertiary hospital in Blantyre, Malawi. Simul Healthc 2018;13:139-45. Crossref

14. Rudolph JW, Simon R, Reamer DB. Which reality matters? Questions on the path to high engagement in healthcare simulation. Simul Healthc 2007;2:161-3. Crossref

15. Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA. Reconsidering fidelity in simulation-based training. Acad Med 2014;89:387-92. Crossref

16. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc 2014;9:339-49. Crossref

17. Kozlowski SW, DeShon RP. A psychological fidelity approach to simulation-based training: theory, research and principles. In: Elliott LR, Coovert MD, Schiflett SG, editors. Scaled Worlds: Development, Validation and Applications. New York: Ashgate Publishing; 2017.

18. Oser RL, Cannon-Bowers J, Sala E, Dwyer DJ. Enhancing human performance in technology-rich environments: Guidelines for scenario-based training. Hum Tach Interact Complex Sys 1999;9:175-202.

19. Beaubien JM, Baker DP. The use of simulation for training teamwork skill in health care: how low can we go? Qual Saf Health Care 2004;13 Suppl 1:i51-6. Crossref

20. Tun JK, Alinier G, Tang J, Kneebone RL. Redefining simulation fidelity in healthcare education. Simul Gaming 2015;46:159-74. Crossref

21. Bernnan N, Corrigan O, Allard J, et al. The transition from medical student to junior doctor: today’s experiences of tomorrow’s doctors. Med Educ 2010;44:449-58. Crossref

22. General Medical Council. Tomorrow’s Doctors. London: GMC; 2009.

23. Teo A. The current state of medical education in Japan: a system under reform. Med Educ 2007;41:302-8. Crossref

24. Segouin C, Jouquan J, Hodges B, et al. Country report: medical education in France. Med Educ 2007;41:295-301. Crossref

25. Ochsmann EB, Zier U, Drexler H, Schmid K. Well prepared for work? Junior doctors’ self-assessment after medical education. BMC Med Educ 2011;11:99. Crossref

26. Miles S, Kellett J, Leinster SJ. Medical graduates’ preparedness to practice: a comparison of undergraduate medical school training. BMC Med Educ 2017;17:33. Crossref

27. Lempp H, Cochrane M, Seabrook M, Rees J. Impact of educational preparation on medical students in transition from final year to PRHO year: a qualitative evaluation of final-year training following the introduction of new year 5 curriculum in a London medical school. Med Teach 2004;26:276-8. Crossref

28. Watmough S, Garden A, Taylor D. Pre-registration house officers’ views on studying under a reformed medical curriculum in the UK. Med Educ 2006;40:893-9. Crossref

29. O’Neill PA, Jones A, Willis SC, McArdle PJ. Does a new undergraduate curriculum based on Tomorrow’s Doctors prepare house officers better for their first post? A qualitative study of the views of pre-registration house officers using critical incidents. Med Educ 2003;37:1100-8. Crossref

30. Illing JC, Peile E, Morrison J, et al. How prepared are medical graduate to begin practice? A comparison of three diverse UK medical school. London: General Medical Council; 2008.

31. Smith CM, Perkins GD, Bullock I, Bion JF. Undergraduate training in the care of the acutely ill patient: a literature review. Intensive Care Med 2007;33:901-7. Crossref

32. Jensen ML, Hesselfeldt R, Rasmussen MB, et al. Newly graduated doctors’ competence in managing cardiopulmonary arrests assessed using a standardized Advanced Life Support (ALS) assessment. Resuscitation 2008;77:63-8. Crossref

33. Bosch J, Maaz A, Hitzblech T, Holzhausen Y, Peters H. Medical students’ preparedness for professional activities in early clerkship. BMC Med Educ 2017;17:140. Crossref

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37. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med 2003;78:783-8. Crossref

38. Beal MD, Kinnear J, Anderson CR, Martin TD, Wamboldt R, Hooper L. The effectiveness of medical simulation in teaching medical students critical care medicine: A systemic review and meta-analysis. Simul Healthc 2017;12:104-16. Crossref

39. McCoy CE, Menchine M, Anderson C, Kollen R, Langdorf MI, Lotfipour S. Prospective randomized crossover study of simulation vs didactics for teaching medical students the assessment and management of critically ill patients. J Emerg Med 2011;40:448-55. Crossref

Osteoporosis is a socio-economic threat, and with the ageing population, the disease has grown into a global epidemic. The lifetime fracture risk in patients with osteoporosis can reach 40%, and the most common fracture regions are the hip, distal radius, and spine.1 In Hong Kong, the number of fragility fractures is on the rise, and hospital budgets are increasing. Currently, around 6000 hip fractures occur annually in Hong Kong, and these numbers are projected to double by 2050.2 A recent study showed that the number of hip fractures in Asia will increase from 1 124 060 in 2018 to 2 563 488 in 2050, a 2.28-fold increase.3 It is also expected that 50% of hip fractures will occur in Asia, with the majority in China.4

According to the Osteoporosis Society of Hong Kong, 95% of direct costs of osteoporosis are incurred for acute management and rehabilitation of the fracture.5 Annual hospital expenditures for hip fractures in Hong Kong amount to approximately US$52 million and rising.6

The occurrence of fragility fractures is strongly associated with significant morbidity and mortality. Mortality after a hip fracture is around 5% to 10% after 1 month, and one-third of patients die by 1 year.7 At least 10% of patients have care issues, and most have residual disability and pain. Many studies have also shown that mortality after vertebral compression fractures is almost as high as that after hip fractures.8 More importantly, after the occurrence of the first fracture, prompt measures and initiatives should be taken for secondary prevention to decrease healthcare costs.

The single most predictive factor of a fragility fracture is the presence of a previous fracture. The relative risk is approximately 2-fold higher to sustain a hip or vertebral fracture after a prior fragility fracture. The risk of vertebral fracture is 4-fold higher for patients with prior vertebral fractures than for those without.9 The increased relative risk is not constant with time or age, as imminent fractures occur shortly after the initial one.10 A previous large-scale prospective cohort study in Australia showed that absolute repeat fracture risk persists up to 10 years and that 40% to 60% of surviving patients experience a subsequent fracture. However, 41% of refractures in women and 52% of refractures in men occur within the first 2 years.11 Effective recommendations should be made to treat these patients punctually for secondary prevention of fractures and ultimately decrease healthcare costs in Hong Kong.

This guideline serves to provide recommendations about identifying patients with risk of imminent fracture. Prompt management with the incorporation of fracture liaison services (FLS) based on a review of the current literature is provided.

The PubMed database (date last accessed: 28 October 2018) was searched. The keywords used for the search criteria were “fragility fracture” and “Hong Kong” and “manage*”. Seven studies were retrieved in the initial search. From these results, four studies related to the management of fragility fractures in Hong Kong were included.12 13 14 15 The remaining studies were unrelated and excluded. The key pitfalls in the current management of patients with fragility fractures in Hong Kong are the lack of FLS (10%-25% in public hospitals), low prescription rates for osteoporosis on discharge (23% of hip fracture cases), inadequate referral rates for rehabilitation (22% of hip fracture cases), and low follow-up attendance (35.1% of hip fracture cases at 1 year). It is therefore important to raise awareness about imminent fractures and FLS to further improve the current management situation.

Currently, there is a large treatment gap between osteoporotic fractures and secondary prevention. According to the International Osteoporosis Foundation (IOF), only 10% to 25% of public hospitals in Hong Kong have FLS.6 Furthermore, a study of six hospitals in Hong Kong located in different clusters showed that only 23% of patients were prescribed anti-osteoporotic medications postoperatively for hip fractures.15 Another study showed that 33% of anti-osteoporotic medications that were prescribed were given 6 months after discharge.14 Routine preoperative orthogeriatric co-management for hip fractures was given in only 3.5% of cases.15 A previous study had already established certain outcomes, showing a shorter length of stay, shorter time to surgery, lower in-hospital mortality, and lower hospital cost of US$170 224 annually with implementation of an orthogeriatric intervention for hip fracture patients in Hong Kong.16 Currently, there is poor coordination among different subspecialties in delivery of post-fragility fracture care. There is also low follow-up attendance after discharge: 74.8% at 3 months and 35.1% at 1 year.15 Internal surveys showed only 22% of patients are referred for rehabilitation, with inadequate fall prevention programmes provided.

As the number of patients with osteoporosis continues to grow, regular follow-up is crucial, as long-term monitoring for chronic disease is required. Currently, fewer than five public hospitals have dedicated osteoporosis clinics for care of these patients. More importantly, many patients are seen at various subspecialty clinics, including general medicine, orthopaedics, endocrinology, and geriatrics, causing the standard of care to be suboptimal.

There are currently seven dual-energy X-ray absorptiometry (DXA) scanning facilities in the public setting in Hong Kong. The average waiting time for a DXA scan is 1 to 6 years, depending on location. The long waiting time places the patient at high risk of imminent fractures occurring within 2 years of the initial fracture.

According to the Asian Federation of Osteoporosis Societies Call-To-Action Committee, osteoporosis should be made a national health priority.17 It is also important to raise public awareness, have educational programmes for health professionals, and ultimately prevent secondary fractures. The current evidence suggests that a structured service delivery model (ie, an FLS) is therefore essential to improve the care of our patients. There is certainly a pressing need for further resource allocation to the prevention of secondary fractures to decrease healthcare costs, patient morbidity, and mortality.

Imminent fractures, or fractures occurring within 2 years of the initial fracture, should be identified promptly to receive anti-osteoporotic treatment and fall prevention programmes.10 18 Prompt multidisciplinary assessment should be employed, and patients should undergo thorough evaluation to prevent imminent fractures. It is well documented that the cause of imminent fractures may be the increase of frailty during hospital admission.18 Immobility due to pain and disability causes an increased loss of cortical and trabecular bone.

The Reykjavik Study fracture registrar from Iceland showed that the risk of a major osteoporotic fracture after a previous one was 2.7-fold higher compared with the general population risk at 1 year, and this risk elevation decreases to 1.4-fold at 10 years.10 The risk of a second major osteoporotic fracture also increases by 4% for each year of age. As the absolute risk is 6.1% for subsequent fractures at 1 year, the implementation of global fracture prevention strategies to prevent imminent fractures is crucial.10 The concept of a recent fracture as a more predictive risk factor than fracture history is important for future health policies.10 19 Therefore, the window of opportunity to treat imminent fractures is best taken advantage of by FLS, as it provides a holistic approach and treats osteoporosis from a public health perspective.20

Fracture liaison services are coordinated services that identify patients with fragility fractures, assess and treat their bone health, make referrals for rehabilitation, and aim to prevent secondary fractures.21

Most patients do not receive appropriate bone health assessment and treatment. In fact, only 9% to 50% of patients in the US, the UK, and Canada proceed with these assessments after a fragility fracture.21 International FLS guidelines in the US including initiatives by specialty groups, such as the American Orthopedics Association “Own the Bone” campaign, have been established to target these patients during the imminent fracture time interval.22 In a US nationwide study of 273 330 patients with index fractures, imminent fractures were common in the 1 year following hip, shoulder or wrist fractures. Therefore, national strategies to minimise further impairment have been urged, as subsequent fractures cause significant morbidity and loss of quality of life. However, many hospitals worldwide still lack this model of care.23 24

A recent meta-analysis of 74 controlled studies showed that FLS programmes improved outcomes, with significant increases in bone mineral density assessment (48.0% vs 23.5%), treatment initiation (38.0% vs 17.2%) and adherence (57.0% vs 34.1%), and reductions in re-fracture incidence (6.4% vs 13.4%) and mortality (10.4% vs 15.8%).25 In Taiwan, 22 FLS programmes have already been established, of which 11 are accredited by the IOF.26 Taiwan has some of the best FLS coverage in the Asia-Pacific region. Randomised controlled trials are being conducted to assess outcomes in Taiwan.26 Other countries that have adopted FLS programmes include Japan, where it has been proven to be cost-effective. A recent study in Japan showed an additional lifetime cost of US$3396 per person for an additional 0.118 quality-adjusted life year (QALY), resulting in an incremental cost-effectiveness ratio of US$28 880 per QALY gained.27 Furthermore, a systematic review has also shown that FLS per the IOF Best Practice Standards conducted in Canada, Australia, the US, the UK, Japan, and Sweden were all found to be cost-effective in comparison with usual or no treatment, regardless of programme intensity or country.24 The costs per QALY ranged from US$3023 to US$28 800 in Japan and from US$14 513 to US$112 877 in the US. Several studies have also shown that FLS was cost-saving, which further reinforces that these services should be widely adopted and introduced.24 Fracture liaison services could effectively bridge the gap between the patient and prevention of imminent fractures.

There are several published models to create an effective model of FLS care. Many hospitals have adopted the recommendations of the IOF Capture the Fracture Campaign, which consist of 13 Best Practice Standards.28 The recent FLS consensus meeting in the Asia-Pacific Region endorsed by the IOF, the Asian Federation of Osteoporosis Societies, and the Asia Pacific Osteoporosis Foundation reinforced that there is still a wide gap in terms of fragility fractures and secondary prevention.12

Therefore, it is essential to establish FLS in Hong Kong (Fig). One essential element is a dedicated coordinator, often a nurse,29 who provides proactive recruitment of patients aged ≥50 years with new fragility fractures or vertebral fractures. All patients should be evaluated for future fracture risk within 3 months. In addition to DXA scanning, the cause of osteoporosis should also be recognised, and blood tests including serum calcium, phosphate, creatinine, and 25-hydroxyvitamin D should be performed to look for secondary osteoporosis. All patients with osteoporosis should be treated promptly with anti-osteoporotic medications and reviewed regularly during follow-up. Fall risk and health and lifestyle risk factors should be evaluated accordingly. A dedicated database with long-term management should be established for these patients.

The implementation of an FLS model would play a major role in improving patient outcomes to prevent imminent fractures. It is important to have policymaker and stakeholder engagement to achieve successful and widespread uptake of FLS in our community.

In Hong Kong, only 23% of hip patients discharged are prescribed with anti-osteoporotic medications, excluding calcium and vitamin D supplements.15 An FLS model would be important to coordinate and improve on osteoporosis medication initiation and adherence and improve follow-up.30 Bisphosphonates are most commonly prescribed and are currently considered first-line drugs for treatment of osteoporosis.5 The Agency for Healthcare Research and Quality published a systematic review showing alendronate, risedronate, zoledronic acid, denosumab and teriparatide to be effective at reducing fractures.31 This further shows the importance of early treatment to prevent imminent fractures. A meta-analysis of 10 studies of five anti-osteoporotic agents (risedronate, alendronate, strontium ranelate, zoledronic acid, and denosumab) also showed an 11% reduction in mortality with treatment for established fragility fractures. Mortality reduction was highest in patients who were frail and older.32 The Table summarises a selection of anti-osteoporotic drugs.

Currently, the prescription of combination treatment has a low quality of evidence, except for the addition of teriparatide to on-going denosumab, which produces a large increase in bone mineral density compared with monotherapy.33 The use of bisphosphonates following teriparatide has been shown to produce an additional bone mineral density increase in both the hip and spine.33 34 Sequential anabolic drugs followed by anti-remodelling agents may therefore become the standard to treat imminent fractures in the future.35

However, poor compliance with bisphosphonates is a major issue worldwide.18 Additional measures to tackle this problem are essential to ensure successful patient care during the period of imminent fractures.

A systematic review has shown that 50% of all patients prescribed oral bisphosphonates stop treatment within 1 year.18 36 Although patients receiving weekly instead of daily oral bisphosphonates had higher compliance at 1 year, the overall treatment rate was still below the required standard for optimal fracture prevention.37 A meta-analysis of 15 articles describing 171 063 patients revealed a 46% increase of fracture risk in non-compliant patients compared with compliant patients.38 Adherence to bisphosphonates has become a major problem leading to subsequent fractures, morbidity, and mortality.

International guidelines to improve adherence have been recommended. A systematic review showed that periodic follow-up interaction between patients and health professionals improved adherence and persistence.39 A review of 20 studies showed the importance of simplification of the dosing regimen.40 The Denosumab Adherence Preference Satisfaction study, a 24-month randomised, crossover comparison with alendronate in postmenopausal women, showed less frequent non-adherence with denosumab, which was injected every 6 months.41 Of the 250 women who enrolled, at 1 year and 2 years, 88.1% and 92.5% adhered to denosumab, whereas only 76.6% and 63.5% adhered to alendronate, respectively. Furthermore, of the 198 subjects who expressed treatment preference, 92.4% favoured injections over oral therapy.41 A US study consisting of 10 863 patients with newly initiated osteoporosis treatment showed that at 12 months of treatment, persistence varied from 28.9% to 35.1% for oral bisphosphonate users, 59.1% for teriparatide, and 68.3% for denosumab.42 Although there has been no comparison between denosumab and zoledronic acid, recent reviews have shown that adherence to and patient preference for zoledronic acid were greater compared with that for oral bisphosphonates.43 This further reinforces that patients prefer less frequent dosing and that switching from oral to injection therapy may improve compliance.44

Prescribing anti-osteoporotic drugs that have higher compliance is an important consideration for clinicians, especially during the first 2 years, when imminent fracture risk is high.

Numerous studies have concluded that among elderly people, fall prevention is as important as treating osteoporosis.45 It is estimated that fall prevention reduces the number of fractures by over 50%. Fracture liaison services models have recommended assessment of fall risk, which is essential to prevent imminent fractures. Early referral for physiotherapy and exercise-based intervention (including multi-component exercises with strength, endurance, and balance training) reduces the rate and risk of falling.46 Balance training is also an important component of fall prevention for patients with fragility fractures during rehabilitation. Tai chi has been shown to significantly reduce fall risk and rate.47

A recent systematic review and meta-analysis showed that vibration therapy reduced fall rate and may prevent fractures by reducing falls.48 Vibration therapy provides a non-invasive, cyclic mechanical stimulation that has been shown to improve quadriceps muscle strength, balancing, and movement velocity.49 Incorporating the device into multidisciplinary rehabilitation programmes for elderly patients with hip fractures has also been shown to be effective.13 The FLS programme is able to integrate fall risk assessments with adequate information and treatment for patients to prevent further falls and fractures, especially during the imminent fracture period.

Sarcopenia is an age-related decline in muscle bulk and strength, which is strongly associated with frailty.50 According to the practical definition and consensus for age-related sarcopenia in 2010 by the European Working Group on Sarcopenia in Older People and in 2014 by the Asian Working Group for Sarcopenia, low muscle mass and low muscle function or low physical performance are the criteria for diagnosis.51 52

Sarcopenia leads to falls, disability, and increased mortality. More importantly, a recent multi-centre cross-sectional study showed that 37% of subjects with hip fractures were diagnosed with sarcopenia.53 Several studies have shown that osteoporosis is closely related to sarcopenia.54 A study of 2400 Japanese women also showed sarcopenia was highly associated with osteopenia (present in 16.8% of cases) and osteoporosis (in 20.4%).55

A local study showed that the prevalence of sarcopenia was 73.6% in men and 67.7% in women with geriatric hip fractures.56 This prevalence is much higher than that in community-dwelling elderly people, and therefore, the health status of muscle tissue should be investigated during hospitalisation.51 A global evaluation of nutritional status is required in addition to early mobilisation of patients. Resistance exercises and supplements including vitamin D should be recommended to strengthen muscle and hence reduce falls.57 58 Studies have also shown that nutrition is important for sarcopenia and that protein intake of 1.0 to 1.2 g/kg per day is recommended for older adults.59 Dietary protein increases insulin-like growth factor, which has anabolic effects on bone and muscle. Furthermore, calcium absorption is increased, having positive effects on bone health.59 Awareness and understanding of the condition are crucial for better care and quality of life for elderly patients.

Once an official FLS programme is established in Hong Kong based on the 13 best practice standards, serial workshops should be hosted to promote FLS expansion by a panel of local experts.26 Experts should be invited as clinical instructors and coordinators to share experiences. New programmes can also share challenges and interim progress for discussion. Furthermore, osteoporosis treatment promotion events can be held at each participating hospital to allow close interactions between healthcare providers and patients. After successful implementation, accreditation by the IOF can be achieved based on assessment of the practice guidelines.60

Fracture liaison service models should be adopted in hospitals for secondary prevention of fractures, particularly imminent fractures. Fracture liaison services can improve patient outcomes and decrease healthcare costs. With the current lack of resources and pitfalls in fragility fracture management in Hong Kong, major changes and engagement with stakeholders are crucial to achieve successful and widespread uptake of FLS to tackle the undertreatment of osteoporosis.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Concept and design of study: All authors.
Acquisition of data: RMY Wong, SKH Chow, WH Cheung.
Drafting of the manuscript: RMY Wong, SW Law, WH Cheung.
Critical revision for important intellectual content: KB Lee, SKH Chow.

All authors have disclosed no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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5. OSHK Task Group for Formulation of 2013 OSHK Guideline for Clinical Management of Postmenopausal Osteoporosis in Hong Kong; Ip TP, Cheung SK, Cheung TC, et al. The Osteoporosis Society of Hong Kong (OSHK): 2013 OSHK guideline for clinical management of postmenopausal osteoporosis in Hong Kong. Hong Kong Med J 2013;19 Suppl 2:1-40.

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12. Chan DD, Chang LY, Akesson KE, et al. Consensus on best practice standards for Fracture Liaison Service in the Asia-Pacific region. Arch Osteoporos 2018;13:59. Crossref

13. Cheung WH, Shen WY, Dai DL, et al. Evaluation of a multidisciplinary rehabilitation programme for elderly patients with hip fracture: a prospective cohort study. J Rehabil Med 2018;50:285-91. Crossref

14. Kung AW, Fan T, Xu L, et al. Factors influencing diagnosis and treatment of osteoporosis after a fragility fracture among postmenopausal women in Asian countries: a retrospective study. BMC Womens Health 2013;13:7. Crossref

15. Leung KS, Yuen WF, Ngai WK, et al. How well are we managing fragility hip fractures? A narrative report on the review with the attempt to set up a Fragility Fracture Registry in Hong Kong. Hong Kong Med 2017;23:264-71. Crossref

16. Ho WW, Dai DL, Liu KW, et al. To investigate the effect and cost-effectiveness of implementing an orthogeriatric intervention for elderly patients with acute hip fracture: the experience in Hong Kong. J Am Geriatr Soc 2009;57:2153-4. Crossref

17. Yeap SS, Jaisamrarn U, Park YS, Takeuchi Y, Xia W, AFOS Call-To-Action Committee. The Asian Federation of Osteoporosis Societies’ call to action to improve the undertreatment of osteoporosis in Asia. Osteoporos Sarcopenia 2017;3:161-3. Crossref

18. Roux C, Briot K. Imminent fracture risk. Osteoporos Int 2017;28:1765-9. Crossref

19. O’Hanlon CE, Parthan A, Kruse M, et al. A model for assessing the clinical and economic benefits of bone-forming agents for reducing fractures in postmenopausal women at high, near-term risk of osteoporotic fracture. Clin Ther 2017;39:1276-90. Crossref

20. Noordin S, Allana S, Masri BA. Establishing a hospital based fracture liaison service to prevent secondary insufficiency fractures. Int J Surg 2018;54(Pt B):328-32. Crossref

21. Walters S, Khan T, Ong T, Sahota O. Fracture liaison services: improving outcomes for patients with osteoporosis. Clin Interv Aging 2017;12:117-27. Crossref

22. Bynum JP, Bell JE, Cantu RV, et al. Second fractures among older adults in the year following hip, shoulder, or wrist fracture. Osteoporosis Int 2016;27:2207-15. Crossref

23. Huntjens KM, van Geel TA, van den Bergh JP, et al. Fracture liaison service: impact on subsequent nonvertebral fracture incidence and mortality. J Bone Joint Surg Am 2014;96:e29. Crossref

24. Wu CH, Kao IJ, Hung WC, et al. Economic impact and cost-effectiveness of fracture liaison services: a systematic review of the literature. Osteoporos Int 2018;29:1227-42. Crossref

25. Wu CH, Tu ST, Chang YF, et al. Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systematic literature review and meta-analysis. Bone 2018;111:92-100. Crossref

26. Chang LY, Tsai KS, Peng JK, et al. The development of Taiwan Fracture Liaison Service network. Osteoporos Sarcopenia 2018;4:47-52. Crossref

27. Moriwaki K, Noto S. Economic evaluation of osteoporosis liaison service for secondary fracture prevention in postmenopausal osteoporosis patients with previous hip fracture in Japan. Osteoporos Int 2017;28:621-32. Crossref

28. Akesson K, Marsh D, Mitchell PJ, et al. Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporos Int 2013;24:2135-52. Crossref

29. Ganda K, Puech M, Chen JS, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 2013;24:393-406. Crossref

30. Yates CJ, Chauchard MA, Liew D, Bucknill A, Wark JD. Bridging the osteoporosis treatment gap: performance and cost-effectiveness of a fracture liaison service. J Clin Densitom 2015;18:150-6. Crossref

31. Levis S, Theodore G. Summary of AHRQ’s comparative effectiveness review of treatment to prevent fractures in men and women with low bone density or osteoporosis: update of the 2007 report. J Manag Care Pharm 2012;18(4 Suppl B):S1-15. Crossref

32. Bolland MJ, Grey AB, Gamble GD, Reid IR. Effect of osteoporosis treatment on mortality: a meta-analysis. J Clin Endocrinol Metab 2010;95:1174-81. Crossref

33. McClung MR. Using osteoporosis therapies in combination. Curr Osteoporos Rep 2017;15:343-52. Crossref

34. Black DM, Bilezikian JP, Ensrud KE, et al. One year of alendronate after one year of parathyroid hormone (1-84) for osteoporosis. N Engl J Med 2005;353:555-65. Crossref

35. Cosman F, Nieves JW, Dempster DW. Treatment sequence matters: anabolic and antiresorptive therapy for osteoporosis. J Bone Miner Res 2017;32:198-202. Crossref

36. Maraka S, Kennel KA. Bisphosphonates for the prevention and treatment of osteoporosis. BMJ 2015;351:h3783. Crossref

37. Rabenda V, Mertens R, Fabri V, et al. Adherence to bisphosphonates therapy and hip fracture risk in osteoporotic women. Osteoporos Int 2008;19:811-8. Crossref

38. Imaz I, Zegarra P, González-Enríquez J, Rubio B, Alcazar R, Amate JM. Poor bisphosphonate adherence for treatment of osteoporosis increases fracture risk: systematic review and meta-analysis. Osteoporos Int 2010;21:1943-51. Crossref

39. Gleeson T, Iversen MD, Avorn J, et al. Interventions to improve adherence and persistence with osteoporosis medications: a systematic literature review. Osteoporos Int 2009;20:2127-34. Crossref

40. Hiligsmann M, Salas M, Hughes DA, et al. Interventions to improve osteoporosis medication adherence and persistence: a systematic review and literature appraisal by the ISPOR Medication Adherence & Persistence Special Interest Group. Osteoporos Int 2013;24:2907-18. Crossref

41. Freemantle N, Satram-Hoang S, Tang ET, et al. Final results of the DAPS (Denosumab Adherence Preference Satisfaction) study: a 24-month, randomized, crossover comparison with alendronate in postmenopausal women. Osteoporos Int 2012;23:317-26. Crossref

42. Cheng LI, Durden E, Limone B, et al. Persistence and compliance with osteoporosis therapies among women in a commercially insured population in the United States. J Manag Care Spec Pharm 2015;21:824-33, 833a. Crossref

43. Lozano MJ, Sánchez-Fidalgo S. Adherence and preference of intravenous zoledronic acid for osteoporosis versus other bisphosphonates. Eur J Hosp Pharm 2019;26:4-9. Crossref

44. Dalle Carbonare L, Zanatta M, Gasparetto A, Valenti MT. Safety and tolerability of zoledronic acid and other bisphosphonates in osteoporosis management. Drug Healthc Patient Saf 2010;2:121-37. Crossref

45. Jarvinen TL, Sievänen H, Khan KM, Heinonen A, Kannus P. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 2008;336:124-6. Crossref

46. Vieira ER, Palmer RC, Chaves PH. Prevention of falls in older people living in the community. BMJ 2016;353:i1419. Crossref

47. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;(9):CD007146. Crossref

48. Jepsen DB, Thomsen K, Hansen S, Jørgensen NR, Masud T, Ryg J. Effect of whole-body vibration exercise in preventing falls and fractures: a systematic review and meta-analysis. BMJ Open 2017;7:e018342. Crossref

49. Leung KS, Li CY, Tse YK, et al. Effects of 18-month low-magnitude high-frequency vibration on fall rate and fracture risks in 710 community elderly—a cluster-randomized controlled trial. Osteoporos Int 2014;25:1785-95. Crossref

50. Hong W, Cheng Q, Zhu X, et al. Prevalence of sarcopenia and its relationship with sites of fragility fractures in elderly Chinese men and women. PloS One 2015;10:e0138102. Crossref

51. Tarantino U, Piccirilli E, Fantini M, Baldi J, Gasbarra E, Bei R. Sarcopenia and fragility fractures: molecular and clinical evidence of the bone-muscle interaction. J Bone Joint Surg Am 2015;97:429-37. Crossref

52. Chen LK, Liu LK, Woo J, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc 2014;15:95-101. Crossref

53. Steihaug OM, Gjesdal CG, Bogen B, Kristoffersen MH, Lien G, Ranhoff AH. Sarcopenia in patients with hip fracture: a multicenter cross-sectional study. PloS One 2017;12:e0184780. Crossref

54. Tarantino U, Baldi J, Scimeca M, et al. The role of sarcopenia with and without fracture. Injury 2016;47 Suppl 4:S3-10. Crossref

55. Miyakoshi N, Hongo M, Mizutani Y, Shimada Y. Prevalence of sarcopenia in Japanese women with osteopenia and osteoporosis. J Bone Miner Metab 2013;31:556-61. Crossref

56. Ho AW, Lee MM, Chan EW, et al. Prevalence of pre-sarcopenia and sarcopenia in Hong Kong Chinese geriatric patients with hip fracture and its correlation with different factors. Hong Kong Med J 2016;22:23-9. Crossref

57. Roth SM, Ferrell RF, Hurley BF. Strength training for the prevention and treatment of sarcopenia. J Nutr Health Aging 2000;4:143-55.

58. Mithal A, Bonjour JP, Boonen S, et al. Impact of nutrition on muscle mass, strength, and performance in older adults. Osteoporos Int 2013;24:1555-66. Crossref

59. Gaffney-Stomberg E, Insogna KL, Rodriguez NR, Kerstetter JE. Increasing dietary protein requirements in elderly people for optimal muscle and bone health. J Am Geriatr Soc 2009;57:1073-9. Crossref

60. International Osteoporosis Foundation. Does your fracture liaison service deserve gold-star recognition? 2014. Available from: https://www.iofbonehealth.org/news/does-your-fracture-liaison-service-deserve-gold-star-recognition. Accessed 1 Jul 2018.

Out-of-hospital cardiac arrest (OHCA) and sudden cardiac death (SCD) are significant healthcare challenges and public health burdens worldwide.1 It has been estimated that around half of cardiovascular mortalities present as SCD.2 Premature death may be caused by OHCA and SCD, particularly in cases involving children, adolescents, and young adults. The burden of premature death due to OHCA is on the magnitude of millions of years of potential life lost, and this is the third leading cause of years of potential life lost following cancer and heart disease.1

In Hong Kong, more than 5000 OHCA cases with attempted resuscitation occur annually.3 The incidence rate of OHCA in 2012 was reported to be 72 per 100 000 population. Although the incidence is low, the prognosis of OHCA is generally poor. Worldwide, the survival rate of OHCA is 2% to 11%.4 In Hong Kong, a 2017 territory-wide study reported a survival rate of 2.3% and a neurologically favourable survival rate of 1.5%.3 Reported survival rates of OHCA in other parts of the world are heterogeneous, with 0.5%-8.5% reported in Asian countries,5 8.5% in the US,6 and 10.3% in Europe.7 The survival rate of OHCA in Hong Kong is low compared with other cities or countries.

To maximise the effectiveness of any efforts to improve OHCA outcomes, a well-organised territory-wide survival enhancement campaign covering public, prehospital, and in-hospital resuscitative care for OHCA would be optimal.8 9 In the public dimension, fostering public awareness, enhancement of rate of good-quality bystander cardiopulmonary resuscitation (CPR),10 and a territory-wide public access defibrillation programme11 have been the main pillars of enhancement of survival of OHCA. In Hong Kong, there have been investigations on the availability and accessibility of defibrillators in the community.12 13 However, an organised public access programme is still lacking. In terms of prehospital and in-hospital measures, shorter response times of emergency medical systems, post-resuscitation targeted temperature management, and comprehensive post-cardiac arrest care have proven to be effective measures to improve survival.8 14 A previous systematic review based mainly on observational data and small-scale trials suggested that prehospital epinephrine produced no improvement in rate of survival to hospital discharge.15 A recently published large-scale trial demonstrated that epinephrine increased the rate of survival to hospital discharge while increasing the rate of severe neurological injury in survivors.16

Interpretation and comparison of survival rates of OHCA between cities is complicated by various factors, including variation in reporting mechanisms, reporting definitions, and prehospital care models, particularly the practice of prehospital termination of resuscitation at arrest scenes. The International Liaison Committee on Resuscitation has defined a standardised style of resuscitation outcome reports with definitions of parameters.17 The Utstein-style guidelines provide a standardised and harmonised framework for comparison and benchmarking of emergency medical services (EMS) systems.17 18 More importantly, epidemiological data on cardiac arrest provide insight about local systems for management of cardiac arrest and provide feedback to influence change in systems for enhancing survival. In 2010, the American Heart Association (AHA) recognised and reinforced the importance of data collection about OHCA and the establishment of cardiac arrest registries. The AHA identified and defined the essential core elements of a high-quality resuscitation system: measurement, benchmarking, and providing feedback for change. Experts have recommended that OHCA events become reportable events.19 In the last decade, there have been worldwide efforts to establish regional cardiac arrest registries in various cities and countries, including Japan, Singapore, South Korea, Sweden, and the United Kingdom. There have been collaborative registries in Asia (The Pan-Asian Resuscitation Outcomes Study), Europe (European Registry of Cardiac Arrest), the US (Cardiac Arrest Registry to Enhance Survival), and Australia, and New Zealand (Australian Resuscitation Outcomes Consortium epidemiological registry). As OHCA is an important public health burden, there is room for improvement in Hong Kong to enhance the survival rate of OHCA, and there is scientific support for strategies and measures to improve the outcomes of OHCA. What is missing in Hong Kong is a well-organised survival enhancement campaign, together with a territory-wide cardiac arrest registry. A cardiac arrest registry is a non-replaceable element of continuous surveillance, identification of weak points in the chain of survival, and evaluation of the effectiveness of newly implemented survival enhancement measures.

The outcomes and survival rate of OHCA depend on the chain of survival (Fig). The survival rate and outcomes of OHCA are not performance indicators of prehospital EMS or emergency departments. Instead, it is a composite indicator of community resilience and effectiveness of EMS, advanced life support, and resuscitation in emergency departments and post-arrest cardiac and intensive care. The concept of community resilience, which has been supported by many experts in resuscitation science, had been raised in recent years in management of conditions where every second counts, such as OHCA.20 Early recognition and appropriate response by laypersons is the first and most critical step, including EMS activation, initiation of bystander CPR, and public access defibrillation. If these initial steps of recognition and resuscitation are not performed well, profound hypoxic-ischaemic insult to the brain and other major organs is likely. No matter how hard the subsequent steps in the chain of survival are, and regardless of the sophistication of advanced and post-arrest care, the chance of survival and neurological integrity would be limited. Without a registry, the resilience of Hong Kong and the efficiency of its emergency healthcare system remain unclear.

The OHCA registry is a means of surveillance. The US Cardiac Arrest Registry to Enhance Survival (CARES) generates reports with trend analysis regularly. Any major changes in outcomes are identified, with corresponding investigation and rectification of any gaps. During audits, weak points of care in the chain of survival can be identified, which would provide invaluable information for the planning of a survival enhancement campaign. The AHA has recommended a complete audit cycle of (1) measurement by a cardiac arrest registry; (2) benchmarking; and (3) feedback and change. With the OHCA data, one could identify the weakest link in the chain of survival. Targeted survival enhancement measures can then be designed and implemented. For example, a local cardiac arrest registry at the accident and emergency department of Tuen Mun Hospital identified deficiencies in the availability and accessibility of publicly accessible defibrillators.12 With the implementation of survival enhancement measures, longitudinal data collected using the same collection methodology are required to evaluate their effectiveness.

Efficacy is the extent to which a treatment is capable of bringing about its intended effect under ideal circumstances. Most clinical trials nowadays have provided information on efficacy. However, the translation of the effects into clinical practice is not direct. Effectiveness is the extent to which a treatment achieves its intended effect in usual clinical settings in daily practice, which is addressed by studies with pragmatic design. Similar to numerous clinical conditions, most studies of OHCA evaluate efficacy instead of effectiveness. Effectiveness cannot be measured in controlled trials. The observational data in cardiac arrest registries constitute an important dimension to measure the effectiveness of survival enhancement measures. In the past decade, there have been numerous improvements in community engagement and prehospital and in-hospital care for OHCA in Hong Kong. Community measures include the Heart-safe School Project by the Hong Kong College of Cardiology,21 mass CPR training organised by the Resuscitation Council of Hong Kong,22 and the CPR training programme for secondary school students and domestic helpers by the Emergency Medicine Unit of the University of Hong Kong. Prehospital improvement measures have included universal application of external defibrillators, enhanced training of ambulance crews, widespread prehospital use of laryngeal mask airways, intravenous adrenaline, first dispatch firefighters, telephone CPR advice, and enhanced diversion policy for cardiopulmonary arrest. In-hospital innovations have included implementation of up-to-date advanced life support care guidelines, use of end-tidal capnography for CPR feedback, use of mechanical thumpers, extracorporeal CPR, and advancement in post-arrest intensive and cardiac care. So far, all reports of resuscitation outcomes of cardiac arrest in Hong Kong have been cross-sectional. There are no longitudinal data reporting survival trends. An OHCA registry provides insights into the effectiveness of these measures in terms of changes in survival. The Japanese Nationwide public access defibrillation programme, which employs the All-Japan Utstein Registry of the Fire and Disaster Management Agency, recorded that the rate of neurologically favourable survival rose from 1.6% to 4.3% in 5 years.11

The Pan-Asian Resuscitation Outcomes Study (PAROS) collaborative network23 was established in 2010 with a prospective multicentre registry of OHCA events across the Asia-Pacific region. It was supported by the Singapore Clinical Research Institute and followed the CARES method. With input from the US Centers for Disease Control and Prevention (CDC), the PAROS database is CARES-compatible. The Asian Emergency Medical Services Council adopted the PAROS registry as one of its core activities. The PAROS network has now grown into a consortium of nine participating regions and countries: Australia, Japan, South Korea, Malaysia, Singapore, Taiwan, Thailand, Turkey, and the United Arab Emirates. The registry includes a population base of over 89 million. Each participating country is responsible for administering its own data collection process, and all data are input via a secure shared internet data capture system with a harmonised database hosted by the Singapore Clinical Research Institute. The goals of the network are to provide benchmarking against established registries, to generate best practice protocols for EMS systems, and to impact community awareness of emergency resuscitative care.

In 2007, the European Resuscitation Council initiated a campaign for Europe-wide collaboration on a European registry to record and analyse cases of cardiac arrest. The European Resuscitation Council set up a steering committee in 2008 focusing on the development of the European Registry of Cardiac Arrest (EuReCa), and its objective is to create a central quality management tool.24 The EuReCa collects data about resuscitative events episodically. The EuReCa ONE, which included 27 European countries, gathered all resuscitative events in October 2014.7 For EuReCa TWO, which covers resuscitation events from 1 October 2017 to 31 December 2017, data collection was completed by April 2018 and publication of results is pending.

The CARES was funded by the US CDC, the Canadian Ontario Pre-hospital Advanced Life Support network, and the Resuscitation Outcomes Consortium of North America.25 Its governance is provided by the US CDC and the Emory University School of Medicine. It provides various platforms for input of standardised parameters about OHCA events by the participating states. The data sources include EMS providers, dispatch centres, and hospitals. The data are then merged into a single event representing a resuscitative episode. The registry provides a validated measurement tool with benchmarking capability for continuous quality improvement. It consolidates observations and conclusions from the collected data and publishes them in the form of a Morbidity and Mortality Report,6 and the scientific evidence is integrated into the AHA’s resuscitation guidelines. The CARES was developed as a low-cost, high-impact public health surveillance system to identify the weakest links in the chain of survival in participating states.

The Australian Resuscitation Outcome Consortium (Aus-ROC) was established as a National Health and Medical Research Council Centres of Research Excellence in 2011. Its objective is to increase research capacity and improve OHCA survival and outcomes. Six previously established cardiac arrest registries in Australia and two in New Zealand contributed the data to form the Aus-ROC epidemiological registry (Epistry) in 2014. The Epistry represents approximately 63% of the Australian population (23.5 million) and 100% of the New Zealand population (4.5 million). The Epistry is coordinated and located at the Aus-ROC administrative base in the School of Public Health and Preventive Medicine at Monash University in Australia. Participating ambulance service networks are responsible for the data collection and upload through a web-based engine. An Epistry Management Committee was established to serve as the governing agent. Annual benchmarking reports are generated from the Epistry’s data and provided to the ambulance services network and relevant bodies for continuous quality improvement.

Hong Kong is technically ready for the establishment of a territory-wide cardiac arrest registry. Clinical documentation in the prehospital and in-hospital settings would provide the basic technical infrastructure of the registry. Prehospital care for patients with cardiac arrest is provided almost exclusively by the ambulance service of the Fire Services Department, while the Government Flying Service and St John’s ambulance service play a supplementary role. The prehospital documentation is digitalised in the electronic Ambulance Journey Record, where the parameters about cardiac arrest patients are standardised and Utstein-compatible. Together with electronic hospital databases and the electronic Accident and Emergency System project of the Hospital Authority, merging and integration of prehospital and in-hospital databases would provide a feasible infrastructure and backbone of the cardiac arrest registry in Hong Kong.

The establishment of cardiac arrest registries may be quite different from other existing healthcare registries in Hong Kong, such as the Hong Kong Cancer Registry26 and the Hong Kong Renal Registry.27 The cardiac arrest registries involve various stakeholders including emergency medical dispatchers, EMS systems, and acute hospitals. The specialties of acute hospitals include emergency departments, and intensive care, paediatric, cardiology and medical units. Expert input from academic units and professional bodies such as the Hong Kong Academy of Medicine and its Colleges, the Resuscitation Council of Hong Kong, and universities is desirable.

Governance and a well-defined operational framework of the OHCA registry are mandatory for sustainability and assurance of data quality. Referring to the experience with collaborative registries in the US, Europe, Asia, Australia, and New Zealand, it is reasonable to set up a registry governing and management committee whose role is to oversee areas such as setup, maintenance, data quality control, data privacy and security, and data use and access. The registry committee might be led by government bodies such as the Food and Health Bureau or co-governed with academic bodies such as the Hong Kong College of Emergency Medicine or universities. All relevant stakeholders should be involved in the registry committee. One key enabler of a sustainable registry is personnel to maintain it. With the digitisation of documentation in prehospital and in-hospital records, the gap requiring manual data entry and manipulation has been dramatically narrowed in recent years.

Setting up an OHCA registry alone does not improve outcomes of patients with SCD. Survival enhancement campaigns and strategies, perhaps led by the government, are required. A cardiac arrest registry should be considered a starting point that provides data to evaluate the effectiveness of measures adopted in survival enhancement campaigns and strategies and to provide uniform benchmarking for quality measurement.

With the growing public health burden of OHCA, Hong Kong has an imminent need to establish a territory-wide cardiac arrest registry. It can provide guidance and insight about the effectiveness of survival enhancement measures. It also provides uniform benchmarking for continuous quality improvement by both prehospital and in-hospital service providers. Concerted efforts by various stakeholders from the government, the Hospital Authority, and academia are necessary to make the registry a reality.

All authors contributed to the content of the review article, drafting of the manuscript, and critical revision for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors declared no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Stecker EC, Reinier K, Marijon E, et al. Public health burden of sudden cardiac death in the United States. Circ Arrhythm Electrophysiol 2014;7:212-7. Crossref

2. Mehra R. Global public health problem of sudden cardiac death. J Electrocardiol 2007;40(6 Suppl):S118-22. Crossref

3. Fan KL, Leung LP, Siu YC. Out-of-hospital cardiac arrest in Hong Kong: a territory-wide study. Hong Kong Med J 2017;23:48-53. Crossref

4. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:1479-87. Crossref

5. Ong ME, Shin SD, De Souza NN, et al. Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS). Resuscitation 2015;96:100-8. Crossref

6. McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance—Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005-December 31, 2010. MMWR Surveill Summ 2011;60:1-19.

7. Gräsner JT, Lefering R, Koster RW, et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 2016;105:188-95. Crossref

8. Perkins GD, Lockey AS, de Belder MA, et al. National initiatives to improve outcomes from out-of-hospital cardiac arrest in England. Emerg Med J 2016;33:448-51. Crossref

9. Scottish Government. Scottish out-of-hospital cardiac arrest data linkage project: 2015/16-2016/17 results. Available from: https://www.gov.scot/publications/scottish-out-hospital-cardiac-arrest-data-linkage-project-2015-16/pages/4/. Accessed 30 Sep 2018.

10. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377-84. Crossref

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15. Atiksawedparit P, Rattanasiri S, McEvoy M, Graham CA, Sittichanbuncha Y, Thakkinstian A. Effects of prehospital adrenaline administration on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis. Crit Care 2014;18:463. Crossref

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Hypertension is an important cardiovascular risk factor and the commonest chronic disease in Hong Kong, with a prevalence of 27.7% among people aged ≥15 years.1 The Primary Care Office of the Department of Health first published the Hong Kong Reference Framework for Hypertension Care for Adults in Primary Care Settings (Reference Framework) in 2010.2 Drawing on international evidence of best practice, the Reference Framework provides an evidence-based reference to primary healthcare professionals in the identification and management of hypertension in Hong Kong. To ensure the Reference Framework reflects latest medical development and evidence, it is updated regularly with expert advice from the Advisory Group on Hong Kong Reference Framework for Care of Diabetes and Hypertension in Primary Care Settings (Advisory Group). The Advisory Group comprises representatives from academia, relevant Colleges of the Hong Kong Academy of Medicine, and professional organisations.

In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) released guideline recommendations using lower blood pressure (BP) values to define hypertension as systolic BP (SBP) ≥130 mm Hg and/or diastolic BP (DBP) ≥80 mm Hg.3 This recommendation is in contrast to the prevailing consensus of SBP ≥140 mm Hg and/or DBP ≥90 mm Hg adopted by the World Health Organization and other international guidelines.4 The BP goal of hypertensive therapy was also lowered to <130/80 mm Hg in the new ACC/AHA guideline.3 It is foreseeable that these new recommendations would arouse concern regarding the diagnosis and management of hypertension at individual patient care level, as well as issues related to disease labelling, changes in epidemiology, and the applicability of these recommendations to other populations. Even within the United States, the recommendations in this guideline were not unanimously agreed with among different authorities, and the application of these recommendations remains controversial.5 6 There is also little understanding of how these recommendations translate to non–United States populations, and there is currently no general consensus on the adoption of these recommendations in Hong Kong.

The aim of this study was to review the relevant literature, discuss the benefits and potential harms of setting lower BP values in the diagnosis and management of hypertension, and suggest updated recommendations on care for individuals with uncomplicated hypertension in the context of the primary care settings in Hong Kong.

Hypertension is a well-known modifiable risk factor for cardiovascular disease. It is associated with a number of adverse outcomes such as stroke, myocardial infarction, heart failure, peripheral artery disease, end-stage renal disease, and premature death.7 Meta-analyses of observational prospective studies suggested that people with SBP 120 to 139 mm Hg and/or DBP 80 to 89 mm Hg may also be at risk of cardiovascular events.8 9 10 11 12 13 14 15 16 17 For this group of people, it was observed that the higher the BP was, the higher the cardiovascular risk was, in general. However, the risk was less significant and less clearly established in Asians, except for the risk of stroke which was shown to be lower, similar to, or even higher than that for non-Asians from different meta-analyses. 8 9 10 11 12 13 14 15 16 17 The benefit of lowering BP to <140/90 mm Hg is well established. A meta-analysis showed that, when compared with treatment with a mean BP goal of 140/81 mm Hg, more intensive treatment with a lower mean BP goal of 133/76 mm Hg provided additional benefits on reducing the risk of major cardiovascular events, myocardial infarction, stroke, and albuminuria.18 However, although it was shown that treatment with a BP goal of <140/90 mm Hg lowered cardiovascular risk in general, further reductions in BP may further reduce the risk only of stroke.19 This relationship between BP values and the risk of stroke is also seen in the Chinese population. A study involving 17 720 Chinese uncomplicated hypertensive adults concluded that an SBP goal of 120 to 130 mm Hg resulted in the lowest risk of first stroke.20

Since the above findings were mostly from meta-analyses based on observational prospective studies, it may be worthwhile to have a brief discussion on the SPRINT21 trial and the ACCORD22 trial, which were the two major randomised controlled trials on lower BP goals. The participant characteristics were different in these two trials; SPRINT involved hypertensive patients with increased cardiovascular risk but no history of diabetes mellitus or stroke, whereas ACCORD included patients with type 2 diabetes mellitus.21 22 Both trials compared the clinical outcomes and adverse events in an intensive treatment group (SBP <120 mm Hg) and a standard treatment group (SBP <140 mm Hg). The results regarding the primary outcome were different in the two trials. The SPRINT trial concluded that the intensive BP-lowering treatment significantly lowered rates of heart failure, fatal major cardiovascular events, and all-cause mortality.21 In contrast, the ACCORD trial failed to demonstrate such cardiovascular benefits in the intensive treatment group. The ACCORD trial concluded that intensive BP-lowering treatment did not reduce the rate of the primary composite outcomes of fatal and non-fatal major cardiovascular events.22

There was concern regarding the use of unattended automated office BP in the SPRINT trial; automated office BP had not been used in any previous major randomised controlled trials (such as ACCORD) on BP-lowering treatment.23 When compared with conventional office BP measurement, automated office BP may result in lower BP values due to the absence of the white-coat effect. Therefore, it has been suggested that the BP values reported in SPRINT may actually correspond to conventional office SBPs of 130 to 140 mm Hg and 140 to 150 mm Hg in the more intensive and less intensive BP-lowering treatment groups, respectively.7 It is unclear if these findings can be extrapolated to hypertensive patients in Hong Kong.

In both SPRINT and ACCORD trials, significantly higher rates of adverse events were observed in patients treated with lower BP goals (ie, the intensive treatment group). In these groups, patients used a larger average number of antihypertensive medications than those in the standard treatment group. The recorded adverse events included hypotension, electrolyte abnormality, and acute kidney injury.21 22 Recent systemic reviews and meta-analyses have proposed that intensive BP-lowering treatment increases the risk of cardiovascular death without observable benefits; these studies have concluded that there is insufficient evidence to justify the lower BP goal.24 25 26 A large retrospective cohort study in Hong Kong, which involved around 100 000 Chinese patients with diabetes mellitus receiving primary care services, identified that the SBP range for the lowest risk of cardiovascular diseases and all-cause mortality was 130 to 134 mm Hg. In addition, a J-curve relationship between SBP and all outcomes of fatal and non-fatal cardiovascular diseases was observed, and patients with SBP <125 mm Hg were found to have significantly higher hazard ratio to all composite outcomes.27

Isolated systolic hypertension—an elevation in SBP but not DBP—is prevalent in older adults.28 29 Because interventions that lower SBP also reduce DBP, intensive SBP reduction in patients with isolated systolic hypertension may also result in lower values of DBP. Low DBP is associated with increased risk of target-organ hypoperfusion and cardiovascular events.28 29 30 For example, most ventricular myocardial perfusion occurs during diastole; therefore, a lower DBP could potentially lead to myocardial hypoperfusion and associated damage, especially in individuals with left ventricular hypertrophy or coronary artery disease.30 It has also been suggested that low DBP is associated with an increase in all-cause mortality.31

The Advisory Group regularly reviews the latest scientific evidence and recommendations from different professional organisations. The Advisory Group has noticed that there is currently inadequate evidence and lack of general consensus to support a change to the definition of hypertension in Hong Kong. Therefore, the Advisory Group agreed that the Reference Framework definition of hypertension should remain unchanged as a BP of ≥140/90 mm Hg.

Hypertensive patients are known to have a higher cardiovascular risk if they have other risk factors such as smoking, obesity, sedentary lifestyle, or elevated lipids or glucose; hence, a global risk approach should be included in assessing the cardiovascular risk of an individual patient.32 Although some evidence has suggested that a lower BP may provide greater benefit for patients with higher cardiovascular risk, there is also an increased risk of treatment noncompliance and serious adverse events from treatment if the BP is pushed too low, especially in older patients. It is, therefore, appropriate to determine the treatment goal on an individual basis after balancing the benefits and potential harms of having a lower BP goal in the context of that individual. Taking these into account, the Advisory Group endorses the approach of setting the BP goal with the consideration of age, underlying cardiovascular risk factors, and tolerability to treatment of the individual patient, instead of a single BP goal for all patients. This approach echoes the recommendation of recently published international guidelines.7 The Advisory Group recommends that the initial BP goal of therapy for individuals with uncomplicated hypertension should be <140/90 mm Hg; and for individuals who can tolerate it, the BP goal should be ≤130/80 mm Hg. A lower BP is advisable for young or overweight/obese patients, smokers, and patients with other cardiovascular risk factors.

Hypertension is an important cardiovascular risk factor and the commonest chronic disease in Hong Kong. Primary care physicians play an important role in the early diagnosis, prompt assessment and proper management of hypertension. The Reference Framework aims to provide updated evidence-based recommendations to support and influence the current practice of primary care physicians in Hong Kong, and to reduce the burden of long-term cardiovascular sequelae for hypertensive patients.

All authors have contributed to the concept or design of this study, acquisition of data, analysis or interpretation of data, drafting of the manuscript, and critical revision for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

We would like to thank the members of the Advisory Group for their invaluable contributions in the development and update of the Reference Framework.

As an editor of the journal, MCS Wong was not involved in the peer review process. All other authors have disclosed no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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