Editorial

EDITORIAL

Mind the gap in kidney care: translating what we know into what we do

Valerie A Luyckx, MD^{1,2,3 #}; Katherine R Tuttle, MD^{4,5 #}; Dina Abdellatif, MD^{6 †}; Ricardo Correa-Rotter, MD^{7 †}; Winston WS Fung, MBBChir (Cantab), FRCP (Lond)⁸; Agnès Haris, MD, PhD^{9 †}; LL Hsiao, MD^{2 †}; Makram Khalife, BA^{10 ‡}; Latha A Kumaraswami, BA^{11 †}; Fiona Loud, BA^{10 ‡}; Vasundhara Raghavan, BA^{10 ‡}; Stefanos Roumeliotis, MD¹²; Marianella Sierra, BA^{10 ‡}; Ifeoma Ulasi, MD^{13 †}; Bill Wang, BA^{10 ‡}; SF Lui, MD^{14 †}; Vassilios Liakopoulos, MD, PhD^{12 †}; Alessandro Balducci, MD^{15 †}; for the World Kidney Day Joint Steering Committee

¹ Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland

² Renal Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, United States

³ Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa

⁴ Providence Medical Research Center, Providence Inland Northwest Health, Spokane, United States

⁵ Nephrology Division, Department of Medicine, University of Washington, Seattle, United States

⁶ Department of Nephrology, Cairo University Hospital, Cairo, Egypt

⁷ Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico

⁸ Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China

⁹ Nephrology Department, Péterfy Hospital, Budapest, Hungary

¹⁰ International Society of Nephrology Patient Liaison Advisory Group

¹¹ Tamilnad Kidney Research Foundation, Chennai, India

¹² 2nd Department of Nephrology, AHEPA University Hospital Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece

¹³ Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria

¹⁴ Division of Health System, Policy and Management, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China

¹⁵ Italian Kidney Foundation, Rome, Italy

^# Equal contribution

^† Members of the World Kidney Day Joint Steering Committee

^‡ Patient representatives of the Patient Liaison Advisory Group of the International Society of Nephrology

Corresponding author: Dr Valerie A Luyckx (valerie.luyckx@uzh.ch)

Full paper in PDF

Abstract

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people worldwide with these conditions are diagnosed, and even fewer receive appropriate treatment. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among diagnosed patients, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative to initiate treatments early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximised, starting at the primary care level. Many systematic barriers exist, encompassing patient, clinician, health system, and societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

At least 1 in 10 people worldwide is living with a kidney disease.1 According to the Global Burden of Disease study, >3.1 million deaths were attributed to kidney dysfunction in 2019, making it the seventh leading risk factor for mortality worldwide (Fig 1 and online supplementary Fig).2 However, global mortality from all kidney diseases may actually range from 5 to 11 million per year if the mortality rate also includes estimated lives lost from acute kidney injury and lack of access to renal replacement therapy for kidney failure (KF), especially in lower-resource settings.3 These high global mortality rates reflect disparities in prevention, early detection, diagnosis, and treatment of chronic kidney disease (CKD).4 Mortality rates from CKD are especially high in some regions, particularly Central Latin America and Oceania (islands of the South Pacific Ocean), highlighting the need for urgent action.5

Figure 1. Top 10 global risk factors for mortality, all ages, 2019. Kidney dysfunction (defined as estimated glomerular filtration rate <60 mL/min per 1.73 m² or albumin-to-creatinine ratio ≥30 mg/g) was the seventh-highest global level 3 risk factor for death in 2019 (red). The three leading global risk factors for kidney diseases, including hypertension, diabetes, and overweight/obesity, are also leading global risk factors for mortality (green); therefore, holistic strategies are required to simultaneously address all risk factors. Rankings are based on millions of deaths attributed to each risk factor. Error bars depict confidence intervals. Global rankings of kidney dysfunction stratified by World Bank income category and sex are presented in online supplementary Figure. Data in this figure were obtained from the Global Burden of Disease Study2

Chronic kidney disease also represents a substantial global economic burden, with exponentially increasing costs as CKD progresses, due to the costs of dialysis and transplantation, as well as multiple co-morbidities and complications that accumulate over time.6 7 In the United States, Medicare fee-for-service spending for all beneficiaries with CKD was US$86.1 billion in 2021 (22.6% of total expenditures).8 Data from many lower-resource settings, where most healthcare spending comprises out-of-pocket costs, are absent. A recent study in Vietnam showed that the perpatient cost of CKD was higher than the gross domestic product per capita.7 In Australia, it has been estimated that early diagnosis and prevention of CKD could save the health system AU$10.2 billion over 20 years.9

Although there is regional variation in the causes of CKD, the risk factors with the highest population-attributable factors for age-standardised CKD-related disease-adjusted life years are hypertension (51.4%), a high fasting plasma glucose level (30.9%), and a high body mass index (26.5%).10 These risk factors are also leading risk factors for mortality worldwide (Fig 1). Only 40% and 60% of people with hypertension and diabetes, respectively, are aware of their diagnosis; considerably smaller proportions of these individuals are receiving treatment and reaching therapeutic targets.11 12 Moreover, at least 1 in 5 people with hypertension and 1 in 3 people with diabetes also have CKD.13

Most cases of CKD can be prevented through healthy lifestyles, prevention and management of risk factors, avoidance of acute kidney injury, optimisation of maternal and child health, mitigation of climate change, and efforts to address social and structural determinants of health.3 Nevertheless, the benefits of some of these measures may only be evident in future generations. Until then, early diagnosis and risk stratification create opportunities to introduce therapies that can slow, halt, or even reverse CKD.14 It is concerning that CKD awareness is particularly low among individuals with kidney dysfunction, such that approximately 80% to 95% of such patients worldwide are unaware of their diagnosis (Fig 2).15 16 17 18 19 20 Therefore, people are dying because of missed opportunities to detect CKD early and deliver optimal care.

Figure 2. Proportion of people with chronic kidney disease (CKD) who are aware of their diagnosis and receiving guideline-recommended care. The proportion of people with CKD who are aware of their diagnosis varies from 7% to 20% worldwide. Knowledge of CKD increases as CKD stage worsens. Among those with a diagnosis of CKD, the average proportion of patients receiving appropriate medication to delay CKD progression (renin-angiotensin-aldosterone system [RAS] inhibitors and sodium-glucose cotransporter 2 [SGLT2] inhibitors) is suboptimal, as are the average proportions of patients achieving target blood pressure, maintaining diabetes control, and receiving nutrition advice. Treatment targets depicted in the figure follow the 2012 Kidney Disease: Improving Global Outcomes guidelines.15 Most data are from higher-resource settings; the corresponding proportions are likely to be lower in lower-resource settings. Data represent the proportions of patients reaching blood pressure <130/80 mm Hg. Data compiled from previous studies15 16 17 18 19 20

Furthermore, CKD is a major risk factor for cardiovascular disease; during kidney disease progression, cardiovascular death and KF become competing risks.21 Indeed, data from the 2019 Global Burden of Disease Study showed that more deaths were caused by kidney dysfunction–related cardiovascular disease (1.7 million deaths) than by CKD itself (1.4 million deaths).2 Therefore, cardiovascular disease management should also be prioritised for people with CKD.

Gaps between knowledge and implementation in kidney care

Strategies to prevent and treat CKD have been established on the basis of strong evidence collected over the past three decades (Fig 3).19 22 Clinical practice guidelines for CKD are clear; however, adherence to these guidelines is suboptimal (Fig 2).15 19 20

Figure 3. Recommended optimal lifestyle and therapeutic management for chronic kidney disease (CKD) in people with diabetes. Illustration of a comprehensive and holistic approach to optimising kidney health in people with CKD. In addition to key lifestyle adjustments, attention to diabetes, blood pressure (BP), and cardiovascular risk factors is important for kidney care

Regardless of aetiology, management of major risk factors, particularly diabetes and hypertension, forms the basis of optimal care for people with CKD.19 23 In addition to lifestyle changes and risk factor control, the earliest pharmacological agents to demonstrate kidney protection were renin-angiotensin-aldosterone system inhibitors in the form of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers.14 19 Despite decades of knowledge that these medications have substantial protective effects on renal and cardiovascular function in people with CKD, real-world data from electronic health records show that their use remains low (Fig 2). For example, in the United States, ACEI and angiotensin receptor blocker utilisation rates ranging from 20% to 40% were reported ≥15 years after the most recent approval of these agents for patients with CKD and/or type 2 diabetes.24 Although more recent data show that prescribing rates in this population have improved to 70%, only 40% of such patients continue taking an ACEI or angiotensin receptor blocker for at least 90 days.20 These data indicate gaps in prescribing nephroprotective medication and continuity of care over time, potentially related to cost, lack of patient education, polypharmacy, and adverse effects.25

Although the initial enthusiasm for sodium-glucose cotransporter 2 (SGLT2) inhibitors focused on their benefits for diabetes and cardiovascular disease, unprecedented therapeutic benefits have also been observed regarding CKD. Relative risk reduction levels with SGLT2 inhibitors approach 40% for substantial decreases in estimated glomerular filtration rate, KF, and mortality among populations with several types of CKD, heart failure, or elevated cardiovascular disease risk.26 27 These decreases were observed in addition to benefits from standard-of-care risk factor management and renin-angiotensin-aldosterone system inhibitors. The risks of heart failure, cardiovascular death, and all-cause mortality were also reduced in patients with CKD during SGLT2 inhibitor treatment.26 The addition of SGLT2 inhibitors to renin-angiotensin-aldosterone system inhibitor–based treatment was able to delay the need for renal replacement therapy by several years, depending on the initial timing of combined treatment.28 Moreover, for every 1000 patients with CKD who received an SGLT2 inhibitor in addition to standard therapy, 83 deaths, 19 heart failure–related hospitalisations, 51 instances of dialysis initiation, and 39 episodes of acute renal function worsening were prevented.29

The persistent underuse of these and other guideline-recommended therapies involving SGLT2 inhibitors is concerning (Fig 2).20 24 In the CURE-CKD (Center for Kidney Disease Research, Education and Hope–CKD) Registry, only 5% and 6.3% of eligible patients with CKD and diabetes, respectively, continued to receive SGLT2 inhibitor and glucagon-like peptide-1 receptor agonist therapy at 90 days.18 Notably, a lack of commercial health insurance and the receipt of treatment in community-based (versus academic) institutions were associated with lower likelihoods of SGLT2 inhibitor, ACEI, or angiotensin receptor blocker prescriptions among patients with CKD and diabetes.20 In low- or middle-income countries (LMICs), the gap between evidence and implementation is even wider, considering the high cost and inconsistent availability of these medications, although generics are available.30 Such gaps in delivering optimal care for CKD are unacceptable.

In addition to SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists have been demonstrated to reduce the risks of CKD progression, KF, cardiovascular events, and mortality, when used in addition to standard-of-care treatment involving renin-angiotensin-aldosterone system inhibitors, among people with type 2 diabetes.31 There is a growing portfolio of promising therapeutic options, including glucagon-like peptide-1 receptor agonists (NCT03819153, NCT04865770), aldosterone synthase inhibitors (NCT05182840), and dual-to-triple incretins (online supplementary Table 1).26 32 Furthermore, there is clear evidence that in patients with CKD and/or type 2 diabetes, glucagon-like peptide-1 receptor agonists reduce cardiovascular events, constitute safe and effective glucose-lowering therapies, and aid in weight loss.32

Historically, it has taken an average of 17 years for new treatments to move from clinical evidence to routine practice.33 Considering that millions of people with CKD die each year, this waiting period is far too long.

Closing the ‘gap’ between what we know and what we do

Lack of policy and presence of global inequity

Health policy

Since the launch of the World Health Organization Global Action Plan for the prevention and control of non-communicable diseases (NCDs) in 2013, there has been global progress in the proportion of countries with a national NCD action plan and dedicated NCD units.34 However, CKD is incorporated into NCD strategies in approximately one-half of countries.4 Policies are required to integrate kidney care within essential health packages under universal health coverage (Fig 4).30 Multisectoral policies must also address social determinants of health, which are major amplifiers of CKD risk and severity that limit people’s opportunities to improve their health.3 A lack of investment in kidney health promotion, along with primary and secondary prevention of kidney diseases, hinders progress.14

Figure 4. Depiction of factors impacting the implementation of timely, high-quality kidney care

Health systems

Two major goals of universal health coverage are to achieve coverage for essential health services and to reduce financial hardship imposed by healthcare. However, universal health coverage alone is insufficient to ensure adequate access to kidney care.3 Health systems must be strengthened, and quality of care must be prioritised, because poor quality care contributes to more deaths than lack of access in low-resource settings.35 Quality care requires a well-trained healthcare workforce, sustainable availability of accurate diagnostics, reliable infrastructure, and medication supplies; it should be monitored through a continuous quality improvement process (Fig 4). Medication quality, especially in LMICs, may be an additional barrier to successful management of CKD.36 Regulation and monitoring of drug manufacturing and quality standards are important to ensure safe and effective therapies. Strategies to support regulation and quality assurance should be developed according to local circumstances and guidelines, as outlined elsewhere.37

The establishment of a credible case for CKD detection and management based on real-world data regarding risks, interventions, outcomes, and costs will help translate theoretical cost-effectiveness (currently established primarily in high-income countries with minimal data from other countries) into economic reality.30 38 Screening should include evaluation of risk factors for CKD; identification of family history; recognition of potential symptoms (usually advanced, such as fatigue, poor appetite, oedema, and itching); and measurements of blood pressure, serum creatinine, urine components (ie, urinalysis), and urine albumin/protein to creatinine ratio, as outlined in established guidelines.19 39 Early identification of CKD in primary care is expected to lower costs over time by reducing CKD complications and KF. Medications required for kidney care are already included in the World Health Organization Model List of Essential Medicines (Table 1). These medications should be provided at the national level under universal health coverage.40 Additionally, pharmaceutical companies should provide these medications at affordable prices.

Table 1. Essential medicines for patients with kidney disease

Challenges in primary care and clinical inertia

Healthcare professionals

The shortage of primary care professionals is exacerbated by inconsistent access to specialists and allied health professionals in both high-income countries and LMICs. It is essential to define roles and responsibilities for kidney care. Solutions may include multidisciplinary team care (primary care physicians, pharmacists, specialists, nurses, therapists, educators, nutritionists, and mental health professionals), well-established mechanisms for collaboration among all elements, and rapid communication technologies (both within health systems and among health professionals) to support care and decision-making.41 42 Brain drain in low-resource settings is a complex issue that must be addressed.

The mobilisation of community health workers yields cost-savings in infectious disease programmes within LMICs; it may facilitate early detection, diagnosis, and management of NCDs.43 Protocolised CKD management, possibly assisted by electronic decision-support systems, may be appropriate for interventions at the community level, with the integration of primary care physicians and aid from nephrologists and other professionals.44 45 For example, in some settings, pharmacists could identify people with diabetes or hypertension exhibiting CKD risk, based on their prescriptions, then offer on-site testing and referral as needed.46 Pharmacists could also provide medication reconciliation and advice regarding safety, effectiveness, and adherence. Social workers and pharmacists can help patients with medications to access suitable programmes.46

Clinical inertia

Clinical ‘inertia’, commonly regarded as a causative factor in low prescribing rates, has many facets (Fig 4).47 Many knowledge gaps regarding CKD exist among primary care physicians.48 Such gaps can be remedied with focused public and professional education. Additional factors include fear of adverse effects from medication, misaligned incentives within the health system, excessive workload, formulary restrictions, and clinician burnout.47 Furthermore, inconsistent recommendations in guidelines from different professional organisations may enhance confusion. A major barrier to optimal care is the time constraints imposed on individual clinicians. A typical primary care physician in the United States would require approximately 26.7 hours per day to implement guideline-recommended care for a panel of 2500 patients.49 Innovation is required to support guideline implementation, especially for primary care physicians who must follow multiple guidelines to meet the diverse needs of their patients. Electronic health records, reminders, team-based nudges, and decision-support tools offer potentially valuable assistance for quality kidney care in busy clinical practices.50 However, the additional time and effort involved in negotiating pre-authorisations or completing medication assistance programme requests, as well as the need for frequent monitoring of multiple medications, also hinder appropriate prescribing.25 Many primary care physicians only have a few minutes allocated for each patient because of institutional pressure or patient volume. The term ‘inertia’ can hardly be applied to clinicians working at this pace. The number of health professionals worldwide must increase.

Visits for patients with CKD are complex because multimorbidity is common. Such patients are often managed by multiple specialists, leading to fragmentation of care, lack of holistic oversight, and diffusion of responsibility for treatment. Single and combined outcomes analyses have shown that multidisciplinary care improves transition to renal replacement therapy and reduces mortality.51 Novel ‘combined clinic’ models with on-site collaboration and joint participation (eg, with nephrologists, cardiologists, and endocrinologists) may provide substantial benefits for patients in terms of reduced fragmentation of care, logistics, and cost savings.

Patient centeredness

Health literacy

Self-management is the most important aspect of kidney care. A patient’s ability to understand his/her health needs, make healthy choices, feel safe and respected in the health system, and obtain psychosocial support are important for promoting health decision-making (Fig 4). Good communication should begin with quality information and confirmation of ‘understanding’ by the patient (and family members, as applicable). Electronic apps and reminders can serve as useful tools that support patients by improving disease knowledge, promoting patient empowerment, and improving self-efficacy; however, a one-size-fits-all approach is unlikely to be successful.52 Important barriers include a lack of patient health information, poor communication, and mistrust, especially in the marginalised and minoritised communities where CKD is common.30 Patients may also be confused by contradictory recommendations among healthcare professionals, as well as conflicting messages in mainstream media. Innovative platforms that improve CKD-related communication between patients and clinicians represent a promising approach to promote optimal prescribing and adherence.53 54

Patient perspectives are essential when designing and testing health strategies to overcome barriers and promote equity. Collaborative care models must include patients, families, and community groups, as well as various types of healthcare professionals, health systems, government agencies, and payers.38 Advocacy organisations, local community groups, and peer navigators with trusted voices and relationships can serve as conduits for education while providing input regarding the development of patient tools and outreach programmes.55 Most importantly, patients must be the focus of their own care.

Medication cost and availability

In high-income countries, people without health insurance and people with high copays paradoxically pay the highest amounts for essential and non-essential nonessential medications.38 Across LMICs, kidney diseases represent the leading cause of catastrophic health expenditures due to reliance on out-of-pocket payments.56 In 18 countries, four cardiovascular disease medications frequently indicated in CKD (statins, ACEIs, aspirin, and β-blockers) had greater availability in private settings than in public settings; they were mostly unavailable in rural communities, and they were unaffordable for 25% of people in upper middle-income countries and 60% of people in low-income countries.57 Newer therapies may be prohibitively expensive worldwide, especially where generics are not yet available. In the United States, the retail price for a 1-month supply of an SGLT2 inhibitor or finerenone is approximately US$500 to $700; for glucagon-like peptide-1 receptor agonists, the retail price is approximately US$800 to $1200 per month.38 This reliance on out-of-pocket payments for vital, life-saving essential medications is unacceptable (Fig 4).

Special considerations

Not all kidney diseases are equal. Much of what has been discussed here applies to the most common forms of CKD (eg, diabetes-related and hypertension-related). Some incompletely understood forms of CKD have different risk profiles, including environmental exposures, genetic predisposition, and autoimmune or other systemic disorders. Highly specialised therapies may be required. Pharmaceutical companies should be responsible for ensuring that research studies include disease-representative participants with appropriate representation (eg, race, ethnicity, sex, and gender), that effective drugs are made available after studies, and that the balance between profits and prices is fair and transparent. Many novel therapies are offering new hope for various kidney diseases; once these therapies are approved, there must be no delay in extending benefits to all affected patients (online supplementary Table 1).

An important but often overlooked group consists of children with kidney diseases. This group is especially vulnerable in LMICs, where nephrology services and resources are limited; families must often decide whether to pay for one child’s treatment or support the rest of the family.58 Children with CKD also have a high risk of cardiovascular disease, even in high-income settings, and they require more attention to control risk factors and achieve treatment targets.59

Fostering innovation

Implementation science and knowledge translation

Considering that rigorous evidence-based treatments for CKD have been established, implementation must be optimised.60 Implementation research aims to identify effective solutions by understanding how evidence-based practices, often developed in high-income countries, can be integrated into care pathways in lower-resource settings. The management of CKD is suitable for implementation research: optimal therapeutic strategies are known, outcomes are easily measurable, and essential diagnostics and medications already are in place. Crucial components of such research are the identification of local patient preferences and elucidation of challenges. Ministries of health should commit to overcoming identified barriers and scaling up successful and sustainable programmes.

Polypills as an example of simple innovation

Polypills are attractive on multiple levels: fixed doses of several guideline-recommended medications are present within a single tablet (Table 1), the price is low, the pill burden is reduced, and the regimen is simple.61 Polypills can prevent cardiovascular disease and are cost-effective for patients with CKD.62 More studies are needed, but considering the alternatives of costly renal replacement therapy or premature death, it is likely that polypills will be a cost-effective approach for reducing CKD progression.

Harnessing digital technologies

The integration of telehealth and other types of remotely delivered care can improve efficiency and reduce costs.63 Electronic health records and registries can support monitoring of quality of care and identify gaps to guide implementation and improve outcomes within an evolving health system that is capable of learning. Artificial intelligence may also be harnessed to stratify risk, personalise medication prescribing, and facilitate adherence.64 The use of telenephrology for communication between primary care physicians and specialists may also be beneficial for patient care.65

Patient perspectives

Multiple methods can support the identification of patient preferences for CKD care, including interviews, focus groups, surveys, discrete choice experiments, structured tools, and simple conversations.66 67 Many of these methods are currently in the research phase. Clinical translation will require contextualisation and assessments of local and individual acceptability.

The journey of each person living with CKD is unique; however, common challenges and barriers exist. As examples of lived experiences, comments collected from patients about their medications and care are detailed in online supplementary Table 2. These voices must be heard and acknowledged to close gaps and improve the quality of kidney care worldwide.

Call to action

The current lack of progress in kidney care has been tolerated for far too long. New therapeutic advances offer real hope that many people with CKD can survive without developing KF. The evidence for clinical benefit is overwhelming and unequivocal. These patients cannot wait another 17 years for this evidence to be translated into clinical practice.33 It is time to ensure that all who are eligible for CKD treatment receive this care in an equitable manner.

Known barriers and global disparities in access to diagnosis and treatment must be urgently addressed (Fig 4). To achieve health equity for people with kidney diseases and those at risk of developing kidney diseases, we must raise awareness among policy makers, patients, and the general population; harness innovative strategies to support all cadres of healthcare workers; and balance profits with reasonable prices (Table 2). If we narrow the gap between what we know and what we do, kidney health will become a reality worldwide.

Table 2. Examples of strategies to improve implementation of appropriate chronic kidney disease care

Author contributions

All authors contributed equally to the conception, preparation, and drafting of the manuscript.

Conflicts of interest

VA Luyckx is chair of the Advocacy Working Group of the International Society of Nephrology and has no financial disclosures. KR Tuttle has received research grants from the National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases, National Heart, Lung, and Blood Institute, National Center for Advancing Translational Sciences, National Institute on Minority Health and Health Disparities, director’s office), the United States Centers for Disease Control and Prevention, and Travere Therapeutics; and consultancy fees from AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, and Novo Nordisk. She is also chair of the Diabetic Kidney Disease Collaborative for the American Society of Nephrology. R Correa-Rotter is a member of the Steering Committee for World Kidney Day, a member of the Diabetes Committee of the Latin American Society of Nephrology and Hypertension, and a member of the Latin American Regional Board of the International Society of Nephrology. He is also a member of the Steering Committees for the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial (AstraZeneca), the Study Of diabetic Nephropathy with AtRasentan (SONAR) [AbbVie], A Non-interventional Study Providing Insights Into the Use of Finerenone in a Routine Clinical Setting (FINE-REAL) [Bayer], and CKD-ASI (Boehringer Ingelheim). He has received research grants from AstraZeneca, GlaxoSmithKline, Roche, Boehringer Ingelheim, and Novo Nordisk, as well as speaker honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, and Amgen. All other authors have declared no competing interests.

Funding/support

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

Declaration

This article was published in Kidney International (Luyckx VA, Tuttle KR, Abdellatif D, et al. Mind the gap in kidney care: translating what we know into what we do. Kidney Int 2024;105:406-17. https://doi.org/10.1016/j.kint.2023.12.003), and was reprinted concurrently in several journals. The articles cover identical concepts and wording, but vary in minor stylistic and spelling changes, detail, and length of manuscript in keeping with each journal’s style. Any of these versions may be used in citing this article.

Supplementary material

The supplementary material was provided by the authors and some information may not have been peer-reviewed. Accepted supplementary material will be published as submitted by the authors, without any editing or formatting. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by the Hong Kong Academy of Medicine and the Hong Kong Medical Association. The Hong Kong Academy of Medicine and the Hong Kong Medical Association disclaim all liability and responsibility arising from any reliance placed on the content.

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27. Nuffield Department of Population Health Renal Studies Group; SGLT2 inhibitor Meta-Analysis Cardio-Renal Trialists' Consortium. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022;400:1788-801. Crossref

28. Fernández-Fernandez B, Sarafidis P, Soler MJ, Ortiz A. EMPA-KIDNEY: expanding the range of kidney protection by SGLT2 inhibitors. Clin Kidney J 2023;16:1187-98. Crossref

29. McEwan P, Boyce R, Sanchez JJ, et al. Extrapolated longer-term effects of the DAPA-CKD trial: a modelling analysis. Nephrol Dial Transplant 2023;38:1260-70. Crossref

30. Vanholder R, Annemans L, Braks M, et al. Inequities in kidney health and kidney care. Nat Rev Nephrol 2023;19:694-708. Crossref

31. Agarwal R, Filippatos G, Pitt B, et al. Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J 2022;43:474-84. Crossref

32. Tuttle KR, Bosch-Traberg H, Cherney DZ, et al. Post hoc analysis of SUSTAIN 6 and PIONEER 6 trials suggests that people with type 2 diabetes at high cardiovascular risk treated with semaglutide experience more stable kidney function compared with placebo. Kidney Int 2023;103:772-81. Crossref

33. Rubin R. It takes an average of 17 years for evidence to change practice—the burgeoning field of implementation science seeks to speed things up. JAMA 2023;329:1333-6. Crossref

34. World Health Organization. Mid-point evaluation of the implementation of the WHO global action plan for the prevention and control of noncommunicable diseases 2013-2020 (NCD-GAP). Volume 1: Report. 2020. Available from: https://cdn.who.int/media/docs/default-source/documents/about-us/evaluation/ncd-gap-final-report.pdf?sfvrsn=55b22b89_5&download=true. Accessed 18 Nov 2023.

35. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet 2018;392:2203-12. Crossref

36. Kingori P, Peeters Grietens K, Abimbola S, Ravinetto R. Uncertainties about the quality of medical products globally: lessons from multidisciplinary research. BMJ Glob Health 2023;6(Suppl 3):e012902. Crossref

37. Pan American Health Organization. Quality control of medicines. Available from: https://www.paho.org/en/topics/quality-control-medicines. Accessed 18 Nov 2023.

38. Tuttle KR, Wong L, St Peter W, et al. Moving from evidence to implementation of breakthrough therapies for diabetic kidney disease. Clin J Am Soc Nephrol 2022;17:1092-103. Crossref

39. Kalyesubula R, Conroy AL, Calice-Silva V, et al. Screening for kidney disease in low- and middle-income countries. Semin Nephrol 2022;42:151315. Crossref

40. Francis A, Abdul Hafidz MI, Ekrikpo UE, et al. Barriers to accessing essential medicines for kidney disease in low- and lower middle-income countries. Kidney Int 2022;102:969-73. Crossref

41. Rangaswami J, Tuttle K, Vaduganathan M. Cardio-renal-metabolic care models: toward achieving effective interdisciplinary care. Circ Cardiovasc Qual Outcomes 2020;13:e007264. Crossref

42. Neumiller JJ, Alicic RZ, Tuttle KR. Overcoming barriers to implementing new therapies for diabetic kidney disease: lessons learned. Adv Chronic Kidney Dis 2021;28:318-27. Crossref

43. Mishra SR, Neupane D, Preen D, Kallestrup P, Perry HB. Mitigation of non-communicable diseases in developing countries with community health workers. Global Health 2015;11:43. Crossref

44. Joshi R, John O, Jha V. The potential impact of public health interventions in preventing kidney disease. Semin Nephrol 2017;37:234-44. Crossref

45. Patel A, Praveen D, Maharani A, et al. Association of multifaceted mobile technology-enabled primary care intervention with cardiovascular disease risk management in rural Indonesia. JAMA Cardiol 2019;4:978-86. Crossref

46. Ardavani A, Curtis F, Khunti K, Wilkinson TJ. The effect of pharmacist-led interventions on the management and outcomes in chronic kidney disease (CKD): a systematic review and meta-analysis protocol. Health Sci Rep 2023;6:e1064. Crossref

47. Sherrod CF, Farr SL, Sauer AJ. Overcoming treatment inertia for patients with heart failure: how do we build systems that move us from rest to motion? Eur Heart J 2023;44:1970-2. Crossref

48. Ramakrishnan C, Tan NC, Yoon S, et al. Healthcare professionals’ perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics. BMC Health Serv Res 2022;22:560. Crossref

49. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the time needed to provide adult primary care. J Gen Intern Med 2023;38:147-55. Crossref

50. Peralta CA, Livaudais-Toman J, Stebbins M, et al. Electronic decision support for management of CKD in primary care: a pragmatic randomized trial. Am J Kidney Dis 2020;76:636-44. Crossref

51. Rios P, Sola L, Ferreiro A, et al. Adherence to multidisciplinary care in a prospective chronic kidney disease cohort is associated with better outcomes. PLoS One 2022;17:e0266617. Crossref

52. Stevenson JK, Campbell ZC, Webster AC, et al. eHealth interventions for people with chronic kidney disease. Cochrane Database Syst Rev 2019;8:CD012379. Crossref

53. Tuot DS, Crowley ST, Katz LA, et al. Usability testing of the kidney score platform to enhance communication about kidney disease in primary care settings: qualitative think-aloud study. JMIR Form Res 2022;6:e40001. Crossref

54. Verberne WR, Stiggelbout AM, Bos WJ, van Delden JJ. Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients. BMC Med Ethics 2022;23:47. Crossref

55. Taha A, Iman Y, Hingwala J, et al. Patient navigators for CKD and kidney failure: a systematic review. Kidney Med 2022;4:100540. Crossref

56. Essue BM, Laba TL, Knaul F, et al. Economic burden of chronic ill health and injuries for households in low- and middle-income countries. In: Jamison DT, Gelband H, Horton S, et al, editors. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd ed. The International Bank for Reconstruction and Development/The World Bank; 2017: 121-43. Crossref

57. Khatib R, McKee M, Shannon H, et al. Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet 2016;387:61-9. Crossref

58. Kamath N, Iyengar AA. Chronic kidney disease (CKD): an observational study of etiology, severity and burden of comorbidities. Indian J Pediatr 2017;84:822-5. Crossref

59. Cirillo L, Ravaglia F, Errichiello C, Anders HJ, Romagnani P, Becherucci F. Expectations in children with glomerular diseases from SGLT2 inhibitors. Pediatr Nephrol 2022;37:2997-3008. Crossref

60. Donohue JF, Elborn JS, Lansberg P, et al. Bridging the “know-do” gaps in five non-communicable diseases using a common framework driven by implementation science. J Healthc Leadersh 2023;15:103-19. Crossref

61. Population Health Research Institute. Polypills added to WHO essential medicines list. 2023. Available from: https://www.phri.ca/eml/". Accessed 18 Nov 2023.

62. Sepanlou SG, Mann JF, Joseph P, et al. Fixed-dose combination therapy for prevention of cardiovascular diseases in CKD: an individual participant data meta-analysis. Clin J Am Soc Nephrol 2023;18:1408-15. Crossref

63. Dev V, Mittal A, Joshi V, et al. Cost analysis of telemedicine use in paediatric nephrology–the LMIC perspective. Pediatr Nephrol 2024;39:193-201. Crossref

64. Musacchio N, Zilich R, Ponzani P, et al. Transparent machine learning suggests a key driver in the decision to start insulin therapy in individuals with type 2 diabetes. J Diabetes 2023;15:224-36. Crossref

65. Zuniga C, Riquelme C, Muller H, Vergara G, Astorga C, Espinoza M. Using telenephrology to improve access to nephrologist and global kidney management of CKD primary care patients. Kidney Int Rep 2020;5:920-3. Crossref

66. van der Horst DE, Hofstra N, van Uden-Kraan CF, et al. Shared decision making in health care visits for CKD: patients' decisional role preferences and experiences. Am J Kidney Dis 2023;82:677-86. Crossref

67. Hole B, Scanlon M, Tomson C. Shared decision making: a personal view from two kidney doctors and a patient. Clin Kidney J 2023;16(Suppl 1):i12-9. Crossref

Bridging the gap in the prevention of respiratory syncytial virus infection among older adults in Hong Kong

Hong Kong Med J 2024 Jun;30(3):196–9 | Epub 29 May 2024

https://doi.org/10.12809/hkmj245156

EDITORIAL

Bridging the gap in the prevention of respiratory syncytial virus infection among older adults in Hong Kong

Ivan FN Hung, MD (HK), FRCP (Lond)^1,2 Ada WC Lin, FHKAM (Medicine), FHKCCM³; Jane CK Chan, MD, PDipID⁴; Tony NH Chan, FHKAM (Medicine), FRCP (Edin)⁵; Philip Eng, MMed, FRCP (Lond)^6,7; Angus HY Lo, FHKAM (Medicine), FRCP (Edin)⁸; Martin CS Wong, MD, MPH^9,10; William KK Wong, FHKAM (Medicine), FRCP (Edin)⁵

¹ Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China

² Gleneagles Hospital Hong Kong, Hong Kong SAR, China

³ HKSH Medical Group, Hong Kong SAR, China

⁴ Hong Kong Chinese Medical Association, Hong Kong SAR, China

⁵ The Hong Kong Geriatrics Society, Hong Kong SAR, China

⁶ Mount Elizabeth Hospital, Singapore

⁷ National University of Singapore, Singapore

⁸ Premier Medical Centre, Hong Kong SAR, China

⁹ The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

¹⁰ Editor-in-Chief, Hong Kong Medical Journal

Corresponding author: Dr Ivan FN Hung (ivanhung@hku.hk)

Full paper in PDF

Respiratory syncytial virus (RSV) is an important pathogen that causes acute respiratory tract illness and exacerbations of chronic cardiopulmonary disease among adults.1 2 3 Although most RSV infections in adults are mild, advanced age, chronic cardiopulmonary disease, and immunocompromising conditions can predispose individuals to higher risks of morbidity and mortality.1 3 4 Respiratory syncytial virus will become an increasingly important threat to countries/regions with an ageing population, such as Hong Kong. In 2046, older persons are projected to constitute 36% of Hong Kong’s total population,5 underscoring the need to better understand the RSV disease burden to protect this vulnerable population.

Respiratory syncytial virus disease burden in older adults is substantial but often underestimated

Respiratory syncytial virus is a major cause of morbidity and mortality in older adults. In 2019, adults aged >70 years had the highest worldwide mortality rate of 34.5 per 100 000 individuals.5 Recent studies have shown that, in older adults, RSV causes more severe infections than influenza.6 7 Older patients hospitalised for RSV have longer hospital stays, higher risks of pneumonia and bacterial superinfection, a higher risk of intensive care unit admission, a greater likelihood of repeat hospitalisation, and higher in-hospital and 1-year mortality rates than older patients hospitalised for influenza.6 7

Respiratory syncytial virus infection imposes a substantial economic burden on older adults. In the United States, the national direct cost of RSV-related hospitalisations among adults aged ≥60 years was estimated to be US$1.5 to 4.0 billion in 2005.8 Furthermore, severe RSV can cause functional decline and insidious deterioration of respiratory health, along with high mortality, in frail older adults.9 10 11 12 Exacerbations of congestive heart failure and other chronic conditions can substantially contribute to disease burden among older adults.3 13

Changes in respiratory syncytial virus seasonality can hinder reduction of its disease burden

Respiratory syncytial virus circulation is seasonal, typically peaking between April and November in Hong Kong.14 An understanding of RSV seasonality can facilitate effective public health planning and resource allocation. However, disruptions in RSV seasonality could lead to off-season outbreaks that affect health system performance.14 For example, the implementation of infection control measures during the coronavirus disease 2019 pandemic and their subsequent relaxation has led to an atypical surge in RSV activity across many countries in the post–coronavirus disease 2019 era,15 16 17 highlighting the need for year-long disease surveillance.

Existing challenges that lead to the underestimation of respiratory syncytial virus burden in older adults

Respiratory syncytial virus infection is challenging to diagnose because of its non-specific clinical symptoms.14 18 Although rapid antigen diagnostic tests and nucleic acid amplification tests are important tools for RSV detection, their diagnostic accuracy in adults is generally poor due to the lower viral load in such patients, especially when upper respiratory tract specimens are used for testing.9 18 19 Therefore, clinicians must be aware of the limitations of current assays while supporting the development of more sensitive assays for adults.

Additionally, the testing rate among adult patients remains suboptimal,14 resulting in underdiagnosis of RSV infection. The absence of disease surveillance protocols and lack of systemic data collection mechanisms lead to further underestimation of the RSV disease burden in Hong Kong.14 Currently, RSV is not one of the statutory notifiable infectious diseases according to the Centre for Health Protection.14 A surveillance system that allows clinicians to submit data regarding positive RSV cases would be helpful in terms of monitoring its incidence and disease burden.

A safe and effective vaccine is needed to reduce respiratory syncytial virus disease burden

The current approach to managing RSV infection in adults focuses on supportive care.3 Whereas immunoprophylaxis with monoclonal antibodies is recommended for infants and young children, there are no clinical data supporting these treatments for high-risk adults.3 In the absence of guideline-directed management, some clinicians do not recommend RSV testing for adults with suspected acute lower respiratory tract infection (ALRTI). Considering the high RSV disease burden and lack of RSV-specific treatment, a safe and effective vaccine is urgently needed to prevent RSV-related severe illness among high-risk adults.

The quest for an effective RSV vaccine began in the 1960s and encountered multiple obstacles. The discovery of the RSV fusion (F) glycoprotein in its pre-F conformation has renewed interest in vaccine development. The RSV pre-F protein (RSVpreF) has emerged as an attractive candidate vaccine target because of its conserved neutralising epitope.20 21

The multinational phase III RENOIR trial (RSV Vaccine Efficacy Study in Older Adults Immunized against RSV Disease) showed that the bivalent RSVpreF vaccine had respective efficacy rates of 84.4% and 81.0% for preventing ALRTI and medically attended RSV-associated acute respiratory tract illness over two RSV seasons among immunocompetent adults aged ≥60 years.22 Importantly, the RSVpreF vaccine also demonstrated a favourable safety profile. A recent study showed that concomitant administration of RSVpreF and seasonal inactivated influenza vaccine elicited robust RSV serum-neutralising responses and appeared to have a favourable safety profile among adults aged 50 to 85 years,23 thereby supporting annual concomitant immunisation with seasonal inactivated influenza vaccine.

Based on the RENOIR trial, the United States Food and Drug Administration approved bivalent RSVpreF vaccine for use in adults aged ≥60 years.24 Subsequently (in June 2023), the United States Centers for Disease Control and Prevention’s Advisory Committee on Immunisation Practices voted to recommend that adults aged ≥60 years receive a single dose of RSV vaccine through a shared clinical decision-making process.24

Driving the successful implementation of respiratory syncytial virus vaccination in older adults

It is important to conduct a public awareness campaign that educates the general public about the risks of RSV infections among high-risk individuals, especially older adults. This campaign should address vaccine hesitancy by highlighting the safety and efficacy of vaccines against severe RSV while dispelling misconceptions about the safety of the vaccine.

Additionally, it is imperative to establish a continuous medical education programme focused on respiratory care for primary care physicians and other specialists who manage high-risk patients. This programme should cover the role of diagnostic testing in patients with suspected ALRTI to guide disease management (despite the absence of effective treatment) and vaccination against severe RSV in high-risk populations. Ideally, the programme should emphasise the public health benefits of RSV vaccination beyond reducing disease severity. Moreover, the programme should discuss strategies to encourage vaccination uptake among older adults with cognitive impairment and/or their family members.

Additional research to improve confidence in respiratory syncytial virus vaccination

Local epidemiological studies could help to define RSV prevalence in general and high-risk populations, quantify the RSV disease burden, and identify its impacts on public health and healthcare services. These data could also aid in defining target populations that would experience the greatest benefit from RSV vaccination. Furthermore, a local cost-effectiveness analysis based on local epidemiological data could help demonstrate the value of RSV vaccination in target populations. Research concerning the durability of protection conferred by an RSV vaccine in high-risk adults could guide appropriate dosing intervals and vaccination schedules. Additional efficacy and safety data concerning the co-administration of an RSV vaccine with other respiratory virus vaccines could support simplified immunisation schedules for adults.

Post-marketing studies could provide additional information regarding the real-world effectiveness and safety of an RSV vaccine in target populations, especially individuals with multimorbidity and immunocompromised conditions. Future real-world studies could also include assessments of vaccine effectiveness in reducing other clinical outcomes, such as the rates of RSV infection, hospitalisation, intensive care unit admission, ventilator use, and mortality.

Author contributions

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.

Conflicts of interest

IFN Hung is an advisory board member for Pfizer, GlaxoSmithKline, AstraZeneca, MSD, and Moderna. P Eng served as an advisory board member for Pfizer, GlaxoSmithKline, AstraZeneca, and Boehringer Ingelheim. MCS Wong is an honorary medical advisor for GenieBiome Ltd, BGI Health (HK) Company Limited, and Sunrise; an advisory committee member for Pfizer; an external expert for GlaxoSmithKline; and a member of the advisory board for AstraZeneca; he has also been paid consultancy fees for providing research advice. Other authors declare no conflicts of interest.

Funding/support

Funding for this study was provided by Pfizer Hong Kong. Editorial and medical writing support was provided by Weber Shandwick Health HK, funded by Pfizer Hong Kong. The funders had no role in study design, data collection/analysis/interpretation or manuscript preparation.

References

1. Belongia EA, King JP, Kieke BA, et al. Clinical features, severity, and incidence of RSV illness during 12 consecutive seasons in a community cohort of adults ≥60 years old. Open Forum Infect Dis 2018;5:ofy316. Crossref

2. Nam HH, Ison MG. Respiratory syncytial virus infection in adults. BMJ 2019;366:l5021. Crossref

3. Villanueva DH, Arcega V, Rao M. Review of respiratory syncytial virus infection among older adults and transplant recipients. Ther Adv Infect Dis 2022;9:20499361221091413. Crossref

4. Branche AR, Saiman L, Walsh EE, et al. Incidence of respiratory syncytial virus infection among hospitalised adults, 2017-2020. Clin Infect Dis 2022;74:1004-11. Crossref

5. Du Y, Yan R, Wu X, et al. Global burden and trends of respiratory syncytial virus infection across different age groups from 1990 to 2019: a systematic analysis of the Global Burden of Disease 2019 study. Int J Infect Dis 2023;135:70-6. Crossref

6. Ambrosch A, Luber D, Klawonn F, Kabesch M. Focusing on severe infections with the respiratory syncytial virus (RSV) in adults: risk factors, symptomatology and clinical course compared to influenza A/B and the original SARS-CoV-2 strain. J Clin Virol 2023;161:105399. Crossref

7. Ackerson B, Tseng HF, Sy LS, et al. Severe morbidity and mortality associated with respiratory syncytial virus versus influenza infection in hospitalised older adults. Clin Infect Dis 2019;69:197-203. Crossref

8. Grace M, Colosia A, Wolowacz S, Panozzo C, Ghaswalla P. Economic burden of respiratory syncytial virus infection in adults: a systematic literature review. J Med Econ 2023;26:742-59. Crossref

9. Coultas JA, Smyth R, Openshaw PJ. Respiratory syncytial virus (RSV): a scourge from infancy to old age. Thorax 2019;74:986-93. Crossref

10. Branche AR, Saiman L, Walsh EE, et al. Change in functional status associated with respiratory syncytial virus infection in hospitalized older adults. Influenza Other Respir Viruses 2022;16:1151-60. Crossref

11. Juhn YJ, Wi CI, Takahashi PY, et al. Incidence of respiratory syncytial virus infection in older adults before and during the COVID-19 pandemic. JAMA Netw Open 2023;6:e2250634. Crossref

12. Begley KM, Monto AS, Lamerato LE, et al. Prevalence and clinical outcomes of respiratory syncytial virus vs influenza in adults hospitalised with acute respiratory illness from a prospective multicentre study. Clin Infect Dis 2023;76:1980-8. Crossref

13. Kujawski SA, Whitaker M, Ritchey MD, et al. Rates of respiratory syncytial virus (RSV)-associated hospitalization among adults with congestive heart failure—United States, 2015-2017. PLoS One 2022;17:e0264890. Crossref

14. Chan WS, Yau SK, To MY, et al. The seasonality of respiratory viruses in a Hong Kong Hospital, 2014–2023. Viruses 2023;15:1820. Crossref

15. Eden JS, Sikazwe C, Xie R, et al. Off-season RSV epidemics in Australia after easing of COVID-19 restrictions. Nat Commun 2022;13:2884. Crossref

16. Bardsley M, Morbey RA, Hughes HE, et al. Epidemiology of respiratory syncytial virus in children younger than 5 years in England during the COVID-19 pandemic, measured by laboratory, clinical, and syndromic surveillance: a retrospective observational study. Lancet Infect Dis 2023;23:56-66. Crossref

17. Zheng Z, Warren JL, Artin I, Pitzer VE, Weinberger DM. Relative timing of respiratory syncytial virus epidemics in summer 2021 across the United States was similar to a typical winter season. Influenza Other Respir Viruses 2022;16:617-20. Crossref

18. Talbot HK, Falsey AR. The diagnosis of viral respiratory disease in older adults. Clin Infect Dis 2010;50:747-51. Crossref

19. Chartrand C, Tremblay N, Renaud C, Papenburg J. Diagnostic accuracy of rapid antigen detection tests for respiratory syncytial virus infection: systematic review and meta-analysis. J Clin Microbiol 2015;53:3738-49. Crossref

20. Mazur NI, Higgins D, Nunes MC, et al. The respiratory syncytial virus vaccine landscape: lessons from the graveyard and promising candidates. Lancet Infect Dis 2018;18:e295-311.

21. Melero JA, Mas V, McLellan JS. Structural, antigenic and immunogenic features of respiratory syncytial virus glycoproteins relevant for vaccine development. Vaccine 2017;35:461-8. Crossref

22. Walsh EE, Pérez Marc G, Zareba AM, et al. Efficacy and safety of a bivalent RSV prefusion F vaccine in older adults. N Engl J Med 2023;388:1465-77. Crossref

23. Falsey AR, Walsh EE, Scott DA, et al. Phase 1/2 randomised study of the immunogenicity, safety, and tolerability of a respiratory syncytial virus prefusion F vaccine in adults with concomitant inactivated influenza vaccine. J Infect Dis 2022;225:2056-66. Crossref

24. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunisation Practices– United States, 2023. MMWR Morb Mortal Wkly Rep 2023;72:793-801. Crossref

Informed consent: clarifying the post-Montgomery duty of care to discuss 'reasonable alternative treatment'

Hong Kong Med J 2024 Apr;30(2):88–9 | Epub 28 Mar 2024

https://doi.org/10.12809/hkmj245159

EDITORIAL

Informed consent: clarifying the post-Montgomery duty of care to discuss 'reasonable alternative treatment'

Gilberto KK Leung, FHKAM (Surgery), LLM

Department of Surgery, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China

Corresponding author: Prof Gilberto KK Leung (gilberto@hku.hk)

Full paper in PDF

Many doctors have become concerned and unsure about the standard of care required of them in obtaining informed consent following the United Kingdom Supreme Court decision in Montgomery v Lanarkshire Health Board ('Montgomery').1 This article aims to provide an update on the relevant common law positions, clarified helpfully by the same court in McCulloch v Forth Valley Health Board ('McCulloch') in July 2023.2

The case of Montgomery established that a doctor must 'take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.' It rejected the previous paternalistic approach to medical consent and introduced a legal standard that emphasises respect for a patient’s right to self-determination. The decision also gave rise to uncertainties about the meaning of 'reasonable alternative treatment' and the role of professional clinical judgement in determining it.3

Must a doctor discuss all possible treatment options with the patient, including those which the doctor considers to be inappropriate? Does it matter if the doctor’s decision not to discuss certain treatment options is, in fact, supported by expert witness opinion?

In McCulloch, a 39-year-old man was hospitalised with chest pain and suspected pericarditis. Echocardiogram findings were inconclusive. A cardiologist who subsequently saw the patient decided not to prescribe non-steroidal anti-inflammatory drugs (NSAIDs) because the patient was by then pain-free, and she did not discuss that treatment option with the patient. The patient died of cardiac tamponade secondary to idiopathic pericarditis and pericardial effusion a few days later.

The patient’s widow brought a claim, alleging that had the patient been informed of the option of NSAID, he would have taken it and would not have died. The cardiologist explained that she did not, in her professional judgement, regard NSAIDs as necessary or appropriate treatment when she assessed him; had he been in pain, she would have prescribed the medication. Expert witnesses agreed that NSAID could reduce pericardial effusion, but opinions were divided regarding its use in the absence of chest pain. The case eventually went to the Supreme Court, which found for the defendant cardiologist based on expert opinions in support of her practice, and took the opportunity to clarify that:

whether a treatment is a reasonable alternative is determined by applying the 'professional practice test', ie, whether the doctor has acted in accordance with a practice accepted as proper by a responsible body of medical opinion4;

a doctor is not negligent in failing to discuss a treatment option if the doctor’s opinion that the treatment is not reasonable is supported by a reasonable body of medical opinion;

the doctor is also not negligent in this regard even if the doctor is aware (or ought to be aware) that another reasonable body of opinion would consider that treatment option to be reasonable (and therefore warranting discussion with the patient);

once the doctor has applied the professional practice test and decided on a range of reasonable treatment options, the patient should be informed of all of those options; the doctor cannot simply discuss only the option(s) that the doctor prefers; and

the doctor must inform the patient of the respective advantages, disadvantages, and material risks associated with the treatment option(s) which the doctor considers reasonable.

McCulloch thus affirmed the pre-eminent role of professional clinical judgement in determining the reasonable treatment options for each patient, as well as the principle that the role of the court is not to substitute clinical expertise but to impose a duty of care to inform. The decision is consistent with Montgomery in that patients remain entitled to be adequately advised, albeit not on all possible alternative treatments, but on all reasonable ones in accordance with reasonable and responsible medical practice. This narrowing-down approach has the merits of reducing the risk of doctors bombarding patients with information and reducing the risk of putting doctors in a position of conflict by requiring them to discuss treatments which they do not find clinically appropriate. It is a significant clarification of the laws which should bring some relief to our professional peers.

The adoption of the 'professional practice test' means that a doctor can defend an omission to discuss certain treatment options only if his or her practice is supported by expert witness opinion (it will be recalled that the doctor’s omission to discuss the option of caesarean section in Montgomery was not supported by any reasonable body of medical opinion). Where expert opinions are divided, the court cannot prefer one opinion to another (and hence the ruling in McCulloch).4 However, the court may on rare occasions reject an opinion if it does not have a logical basis.5 The importance of quality expert witness opinion and proper training for expert witnesses cannot be overemphasised.

Another caveat is the continued and resolute requirement for doctors to discuss the material risks of medical treatment, defined in Montgomery as 'risks to which a reasonable person in the patient’s position would be likely to attach significance, or risks to which the doctor is or should reasonably be aware that the particular patient would be likely to attach significance.' Factors pointing to materiality may include: the odds and nature of the risk, the effect of its occurrence on the life of the patient, the importance to the patient of the benefits sought through the treatment, and the alternatives available and the risks associated with those alternatives.1

The broad definition of material risks can pose challenges to the doctor concerned as it necessitates an appreciation of the particular patient’s subjective values, beliefs, occupational needs, or even lifestyle and hobbies. It arguably opens up unforeseeable possibilities to support a claim, as suggested by a four-fold increase in consent-based claims in the United Kingdom during the post-Montgomery era.6 Doctors should therefore be mindful that obtaining informed consent is not a mere tick-box exercise, but a shared decision-making process involving personalised and bi-directional discussions.

Lastly, it is important to mention that McCulloch and Montgomery, both post-1997 Supreme Court decisions, are persuasive or highly persuasive, but not binding, in Hong Kong. Although Montgomery had already been applied in a local dental case, it is unclear whether McCulloch will receive the same judicial response.7 Similarly, the Medical Council of Hong Kong has incorporated the principles espoused in Montgomery into its professional guidance on medical consent.8 Whether McCulloch will be so treated remains to be seen; there is little doubt that it be welcome.

Author contributions

The author is solely responsible for drafting of the manuscript, approved the final version for publication, and takes responsibility for its accuracy and integrity.

Conflicts of interest

The author has declared no conflict of interest.

Funding/support

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

References

1. Montgomery v Lanarkshire Health Board [2015] UKSC 11

2. McCulloch v Forth Valley Health Board [2023] UKSC 26

3. Devaney S, Purshouse C, Cave E, Heywood R, Miola J, Reinach N. The far-reaching implications of Montgomery for risk disclosure in practice. J Patient Saf Risk Manag 2019;24:25-9. Crossref

4. Bolam v Friern Hospital Management Committee (1957) 1 WLR 582

5. Bolitho v City and Hackney Health Authority [1998] AC 232

6. Wald DS, Bestwick JP, Kelly P. The effect of the Montgomery judgment on settled claims against the National Health Service due to failure to inform before giving consent to treatment. QJM 2020;113:721-5. Crossref

7. Chan Siu Yim v Dr Cheung Sheung Kin [2017] DCPI 2358/2013

8. The Medical Council of Hong Kong. Newsletter: Implications of “Montgomery (Appellant) v Lanarkshire Health Board (Respondent)(Scotland)”. 2015;22. Available from: https://www.mchk.org.hk/files/newsletter22.pdf. Accessed 8 Mar 2024.

Call to action: bridging gaps in lipid management in Hong Kong

Hong Kong Med J 2024 Apr;30(2):90–3 | Epub 10 Apr 2024

https://doi.org/10.12809/hkmj245158

EDITORIAL

Call to action: bridging gaps in lipid management in Hong Kong

Bryan PY Yan, MD, FRCP¹; Kui Kai Lau, DPhil, FRCP²; Andrea OY Luk, MD, FRCP³; Martin CS Wong, MD, MPH^4,5

¹ Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China

² Division of Neurology, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China

³ Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China

⁴ The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

⁵ Editor-in-Chief, Hong Kong Medical Journal

Corresponding author: Dr Bryan PY Yan (bryan.yan@cuhk.edu.hk)

Full paper in PDF

Atherosclerotic cardiovascular disease in Hong Kong

Cardiovascular disease is the third leading cause of death in Hong Kong, contributing to 13% of all deaths in 2020.1 According to the Hong Kong Population Health Survey conducted between 2020 and 2022, the prevalence of high blood cholesterol among individuals aged 15 to 84 years in the Hong Kong general population increased from 8.4% in 2003/20042 to 51.9% in 2022.3 Low-density lipoprotein cholesterol (LDL-C) has been recognised as one of the most important modifiable risk factors for atherosclerotic cardiovascular disease (ASCVD).4 Accordingly, optimal LDL-C management is essential for reducing the incidence of and mortality from ASCVD. Despite the availability of effective and safe lipid-lowering therapies (LLTs) and guidelines for managing elevated LDL-C and other lipids, implementation remains a key challenge in clinical practice.

Advancements in lipid-lowering therapies

A lower LDL-C level is highly beneficial because of the direct correlation between the absolute reduction in LDL-C level and reduced cardiovascular risk, such that an incremental reduction in LDL-C level leads to a proportional reduction in the number of cardiovascular events.5 Statins are well-established as effective LLTs; this recognition has been extended to other non-statin therapies, including proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is), ezetimibe, bempedoic acid, evinacumab, and inclisiran.6 7 Clinical trials have demonstrated that PCSK9is effectively lower LDL-C levels, thereby surpassing previous recommendations (high risk: <2.6 mmol/dL; very high risk: <1.8 mmol/dL) to offer additional cardiovascular benefits to patients (particularly those with high or very high ASCVD risk) who failed to meet their target LDL-C goal despite maximally tolerated high-intensity statin therapy.6 8

Adapting the latest evidence into current guidelines

The European Society of Cardiology and European Atherosclerosis Society (ESC/EAS) revised their guidelines in 2019 to integrate recent evidence concerning ASCVD prevention.5 These updates include a more aggressive approach with new LDL-C targets across all cardiovascular risk categories, as well as recommendations for lipid-lowering strategies. Since these updates, other cardiology societies (Table)1 5 10 11 and medical associations12 13 have also begun to recommend achieving the lowest possible LDL-C levels, especially for patients with very high ASCVD risk.

Table. Target LDL-C goals established by various regional guidelines

The 2019 ESC/EAS guidelines recommend the following LDL-C targets for the prevention of ASCVD in very high- and high-risk patients: <1.4 mmol/L and <1.8 mmol/L (and 50% reduction from baseline), respectively.5 Consistent with these recommendations, the 2024 American Diabetes Association guidelines recommend that patients with diabetes aged 40 to 70 years receive moderate-intensity statins, and such patients with one or more ASCVD risk factors receive high-intensity statins, to achieve LDL-C level <1.8 mmol/L and ≥50% reduction from baseline.12 Statin therapy should also be considered for young adults aged 20 to 39 years, depending on their existing risk factors.12 The American Heart Association/American Stroke Association guidelines recommend a target LDL-C level of <1.8 mmol/L for patients who have experienced transient ischaemic attack/ischaemic stroke with atherosclerotic disease.13

If there is inadequate LDL-C reduction with maximally tolerated statins, the addition of non-statin options (eg, PCSK9is or ezetimibe) can be considered according to the extent of reduction required to reach the LDL-C goal.5 7 9 10 11 12 13

Low-density lipoprotein cholesterol target achievement remains challenging in Hong Kong

Low-density lipoprotein cholesterol management in Hong Kong has gradually improved, but considerable gaps in care persist. A territory-wide study conducted between 2016 and 2021 revealed poor achievement of LDL-C target goals among patients hospitalised for acute coronary syndrome.14 The study showed low rates of prescription for high-intensity statins (53%) and combination LLTs (1.3%-3.8%) at discharge; LLT and statin treatments were rarely intensified after discharge.14 Notably, approximately 22% of patients did not undergo follow-up lipid profile assessment after discharge.14 This lack of follow-up has been identified as an independent risk factor for all-cause death and cardiovascular-related death.14

A separate study involving over 700 000 patients revealed gross underutilisation of statins among patients with diabetes in Hong Kong, such that most of this population failed to meet LDL-C targets.15 Importantly, women and younger individuals were particularly undertreated, highlighting the need to address these age and sex disparities in lipid management.15 Consistent with current evidence,5 a large cohort of local patients with ischaemic stroke (with or without significant large artery atherosclerosis) demonstrated that the achievement of a target LDL level <1.8 mmol/L was associated with a reduced risk of subsequent major adverse cardiovascular events.16

Outdated recommendations in local settings can hinder optimal lipid management. As a result, physicians may fail to initiate appropriate LLT, prioritise regular monitoring, or provide appropriate follow-up care to assess treatment efficacy. Patients may not recognise the dangers of elevated LDL-C levels or understand the importance of lifestyle modification and medication adherence, leading to suboptimal outcomes.

Call to action: bridging gaps in lipid management

The International Atherosclerosis Society issued a call to action for improvements in lipid management, based on a multinational survey that involved 1758 physicians comprising cardiologists, endocrinologists, neurologists/stroke specialists, nephrologists, and general medicine practitioners from Japan, Germany, Colombia and the Philippines; the survey was designed to identify knowledge gaps in clinical practice.17 The results highlighted three major gaps in beliefs and behaviour across the four countries: (1) physicians lacked clear guidance concerning the management of higher-risk patients who may benefit from aggressive LLT; (2) although most physicians believed that they followed guideline recommendations, only half knew the LDL-C target for high-risk patients, and more than one-third had no opinion concerning the safety of low LDL-C levels; and (3) physicians were unsure of the potential effects of statins on cognitive, renal, and hepatic functions, as well as the increased risk of haemorrhagic stroke associated with low LDL-C levels.17 Taken together, these findings highlighted key areas for enhanced education and research efforts to bridge gaps in lipid management.17 Physicians’ limited familiarity with the rapidly changing guidelines hinders optimal LDL-C management.

The Hong Kong Cardiovascular Task Force published a consensus statement regarding ASCVD prevention in 2016, based on the 2011 ESC/EAS guidelines and the 2013 American Heart Association/American College of Cardiology guidelines.18 Although the consensus is valuable, it primarily constitutes expert opinion and lacks endorsement from any medical societies. Additionally, although various international societies have established guidelines for optimal lipid management, differences among these recommendations (eg, pharmacological treatment, lifestyle modification, and therapeutic targets) may lead to confusion and uncertainty among primary care physicians regarding the best approach.19

Efforts to bridge current gaps in lipid management in Hong Kong will require identifying local therapeutic limitations and barriers to optimising lipid management among physicians and patients. Based on knowledge of these issues, a consensus among local experts (ie, cardiologists, endocrinologists, neurologists, nephrologists, internists, general practitioners, nutritionists, and other healthcare specialists) can be achieved to provide practical recommendations that are consistent with international guidelines and adapted to local clinical practice.11 Considering the complexities and time involved in developing local guidelines, a practical course of action would involve local medical societies across various specialties collaborating to issue a joint statement that recommends the adoption of appropriate guidelines, thereby ensuring a more cohesive and unified approach to lipid management in Hong Kong.

Local recommendations should also address pertinent issues, such as greater adherence to established guidelines—specifically, by encouraging the prompt initiation and intensification of statin therapy in eligible patients. Because the overall ASCVD risk assessment is the basis for treatment decisions in patients with dyslipidaemia,5 7 9 appropriate tools—adapted to the local population—should be used in routine clinical practice to ensure that patients are adequately assessed and managed. Additionally, the benefits of long-term adherence to LLT should be consistently and effectively communicated to patients.

Author contributions

All authors contributed to the development of the manuscript, approved the final version for publication, and take full responsibility for its accuracy and integrity.

Conflicts of interest

KK Lau has received grants from the Croucher Foundation, Research Fund Secretariat of the Food and Health Bureau, Innovation and Technology Bureau, Research Grants Council, Amgen, Boehringer Ingelheim, Eisai, and Pfizer, as well as consultation fees from Amgen, Boehringer Ingelheim, Daiichi Sankyo, and Sanofi, all unrelated to the submitted work. AOY Luk has served as a member of advisory panels for Amgen, AstraZeneca, Boehringer Ingelheim, and Sanofi and has received research support from Amgen, Asia Diabetes Foundation, Bayer, Biogen, Boehringer Ingelheim, Lee’s Pharmaceutical, MSD, Novo Nordisk, Roche, Sanofi, Sugardown Ltd., and Takeda, unrelated to the submitted work. As editors of the journal, BPY Yan, KK Lau and MCS Wong were not involved in the peer review process.

Acknowledgement

Medical writing support was provided by Veronica Yap and Analyn Lizaso of Weber Shandwick Health HK.

Funding/support

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

References

1. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Heart diseases. Available from: https://www.chp.gov.hk/en/healthtopics/content/25/57.html. Accessed 23 Jan 2024.

2. Centre for Health Protection, Department of Health, Hong Kong SAR Government and Department of Community Medicine, University of Hong Kong. Population Health Survey 2003/2004. Available from: https://www.chp.gov.hk/files/pdf/report_on_population_health_survey_2003_2004_en.pdf. Accessed 23 Jan 2024.

3. Non-Communicable Disease Branch, Centre for Health Protection, Department of Health, Hong Kong SAR Government. Population Health Survey 2020-22 (Part II). Published April 2023. Available from: https://www.chp.gov.hk/files/pdf/dh_phs_2020-22_part_2_report_eng_rectified.pdf. Accessed 23 Jan 2024.

4. Borén J, Chapman MJ, Krauss RM, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J 2020;41:2313-30. Crossref

5. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020;41:111-88. Crossref

6. Furtado RH, Giugliano RP. What lessons have we learned and what remains to be clarified for PCSK9 inhibitors? A review of FOURIER and ODYSSEY outcomes trials. Cardiol Ther 2020;9:59-73. Crossref

7. Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2022 ACC Expert consensus decision pathway on the role of nonstatin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022;80:1366-418. Crossref

8. Catapano AL, Graham I, De Backer G, et al. 2016 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J 2016;37:2999-3058. Crossref

9. Koh N, Ference BA, Nicholls SJ, et al. Asian Pacific Society of Cardiology consensus recommendations on dyslipidaemia. Eur Cardiol 2021;16:e54. Crossref

10. Li JJ, Zhao SP, Zhao D, et al. 2023 Chinese guideline for lipid management. Front Pharmacol 2023;14:1190934. Crossref

11. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:e285-350. Crossref

12. American Diabetes Association Professional Practice Committee. 10. Cardiovascular disease and risk management: standards of care in diabetes—2024. Diabetes Care 2024;47(Suppl 1):S179-218. Crossref

13. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke 2021;52:e364-467. Crossref

14. Sun H, Lai A, Tan GM, Yan B. Therapeutic gaps in low-density lipoprotein cholesterol management have narrowed over time but remain wide: a Hong Kong–wide study of 40,141 acute coronary syndrome patients from 2016 to 2021. Presented at the European Society of Cardiology Congress 2023; 2023 Aug 25-28; Amsterdam: Netherlands. Crossref

15. Wu H, Lau ES, Yang A, et al. Trends in diabetes-related complications in Hong Kong, 2001-2016: a retrospective cohort study. Cardiovasc Diabetol 2020;19:60. Crossref

16. Lau KK, Chua BJ, Ng A, et al. Low-density lipoprotein cholesterol and risk of recurrent vascular events in Chinese patients with ischemic stroke with and without significant atherosclerosis. J Am Heart Assoc. 2021;10:e021855. Crossref

17. Barter PJ, Yamashita S, Laufs U, et al. Gaps in beliefs and practice in dyslipidaemia management in Japan, Germany, Colombia and the Philippines: insights from a web-based physician survey. Lipids Health Dis 2020;19:131. Crossref

18. Cheung BM, Cheng CH, Lau CP, et al. 2016 consensus statement on prevention of atherosclerotic cardiovascular disease in the Hong Kong population. Hong Kong Med J 2017;23:191-201. Crossref

19. Singh M, McEvoy JW, Khan SU, et al. Comparison of transatlantic approaches to lipid management: the AHA/ACC/Multisociety Guidelines vs the ESC/EAS Guidelines. Mayo Clin Proc 2020;95:998-1014. Crossref

COVID-19: emerging trends, healthcare practice, artificial intelligence–assisted decision support, and implications for service innovation

Hong Kong Med J 2024 Feb;30(1):7–9

https://doi.org/10.12809/hkmj245155

EDITORIAL

COVID-19: emerging trends, healthcare practice, artificial intelligence–assisted decision support, and implications for service innovation

Harry HX Wang, PhD^{1,2,3 #}; Yu-ting Li, MPH^{4 #}; Junjie Huang, PhD^1,5; Haifeng Zhang, MD⁶; Wenyong Huang, MD⁴; Martin CS Wong, MD, MPH^5,7,8,9,10

¹ Editors, Hong Kong Medical Journal

² School of Public Health, Sun Yat-Sen University, Guangzhou, China

³ Young Cadre Branch, Guangdong Primary Healthcare Association, Guangzhou, China

⁴ State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China

⁵ Centre for Health Education and Health Promotion, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

⁶ Department of Cardiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China

⁷ Editor-in-Chief, Hong Kong Medical Journal

⁸ School of Public Health, Fudan University, Shanghai, China

⁹ The Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

¹⁰ School of Public Health, Peking University, Beijing, China

^# Equal contribution

Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)

Full paper in PDF

According to the World Health Organization (WHO) global statistics as of early January 2024, >774 million confirmed cases of coronavirus disease 2019 (COVID-19) and >7 million deaths have been reported worldwide during the COVID-19 pandemic.1 At a global level, the COVID-19 pandemic has now evolved into a steady state of low-level transmission, with low numbers of reported COVID-19 cases and deaths. The trend has been maintained over the past 12 months, despite a slight increase in the number of reported cases during the most recent available 28-day period.1 Since the declaration of the Public Health Emergency of International Concern by the WHO in January 2020, the global pandemic has caused widespread and devastating economic and social turmoil, along with extensive disruptions and backlogs affecting health services in overburdened healthcare systems. In the early months of the pandemic, global attention focused on COVID-19 emergency response and control efforts, such as case identification, contact tracing, rapid diagnostic tests, and acute treatment. As understanding has improved regarding the COVID-19 pandemic and its effects, including post-acute sequelae of COVID-19 (ie, long COVID), on all aspects of healthcare,2 3 many countries have shifted their focus to the establishment of longer-term, dynamic, and sustained frameworks for health emergency preparedness, response, and resilience at national, regional, and global levels.

In the WHO Strategic Preparedness and Response Plan for 2023-2025,4 a new strategy consisting of five core components—(a) emergency coordination; (b) collaborative surveillance; (c) community protection; (d) safe and scalable care; and (e) access to countermeasures—has been proposed with a strong emphasis on the mobilisation of multisectoral partnerships for coordination, planning, financing, monitoring, and evaluation. Considering the potential for surges of new variants with greater severity or transmissibility,5 the updated WHO framework has been designed and positioned to maintain sufficient capacity, operational readiness, and system flexibility to scale up clinical care services and multidisciplinary team support. This approach builds on the response-driven pillars outlined between 2020 and 2022 to address the complex interactions of COVID-19 with an expanding range of emerging long-term conditions and circumstances.

Extensive research has been conducted regarding the effects of public health measures intended to reduce the risk of COVID-19 transmission.6 The COVID-19–driven changes and innovations in health practice have also been captured in past issues of the Hong Kong Medical Journal.7 In the Greater Bay Area, collaborative efforts between mainland medical staff and their Hospital Authority counterparts in a community treatment facility and large makeshift hospital to combat the fifth wave of the pandemic have highlighted the potential for cross-border connectivity and healthcare integration to benefit residents of Hong Kong and Macau.7 In addition to government- and provider-level support for the expansion of community-oriented and patient-centred healthcare services, there have been dramatic increases in the use and application of digital health technologies during the COVID-19 pandemic. Such innovations have also substantially impacted the manners in which clinical competencies are enhanced, patient education is delivered, performance parameters are evaluated, resilience-building environments are created, and health practices are strengthened. Studies have shown satisfactory perception and acceptance of telemedicine consultations among adults in Hong Kong; telemedicine users reported positive experiences regarding physician diagnosis, disease management, and resolution of barriers to healthcare delivery.8 9 Transformative health practices empowered by digital technologies, including (but not limited to) computerised decision support tools and clinical management systems, may help to address clinical inertia and workload-related factors, thereby facilitating efforts to improve physician motivation and satisfaction in the post-pandemic era.

The digital technology innovations also contributed to the understanding of the dynamic associations between regions with low average number of daily COVID-19 cases and early public awareness of WHO-recommended multiple preventive measures. This has been shown in an infodemiology study based on Google Trends data.10

The use of publicly available and aggregated data retrieved from internet searches could offer valuable insights into population-level behaviours and their links to the spread of COVID-19 across different time periods; these insights may support risk communications, community engagement, and response coordination.11 Post-pandemic cancer care delivery should be tailored to accommodate the diverse unmet needs of patient groups with different psychological phenotypes, as suggested by Hong Kong researchers who reported the use of psychometric analysis as a tool to identify patients with high risks of decline in physical, psychological, and dietary wellness.12

In parallel with the explosive spread of COVID-19 and the persistence of long COVID symptoms over the past 4 years, the development of artificial intelligence (AI) technology has advanced at an unprecedented pace worldwide. In preventive ophthalmology, there is evidence that community-based diabetic retinopathy screening via teleophthalmology, based on imaging examinations with low-cost devices and remote interpretation, can serve as an accurate and cost-effective alternative to conventional face-to-face examinations; it achieves similar clinical outcomes, broader population coverage, and timely referral to ophthalmologists, while maintaining high satisfaction rates.13 This approach could substantially enhance workflow efficiency across clinical settings and support clinical decision-making by determining triage thresholds and tailoring interventions using predictive analytics.

The use of telemedicine and AI has also received increasing attention; in particular, the integration of clinical, biological, and genetic data with long-term health outcomes will help to elucidate the bi-directional relationship between COVID-19 and the cardiovascular system.14 The 2023 updated position paper from the Italian Society of Cardiology and Working Group on Telecardiology and Informatics has highlighted the considerable potential of AI-assisted clinical prediction models in terms of enhancing cardiovascular illness screening, diagnosis, monitoring, and adverse event prevention.15 In both ambulatory and inpatient settings, health practice innovations such as telemedical care, mobile health applications, and personalised wearable biosensors play key roles in efforts to improve clinical decision-making, avoid unnecessary hospital admission, reduce time to treatment during cardiac emergencies, rationalise healthcare services, and promote home care.15

The evolution of COVID-19 demands sustained global commitment to building a well-prepared, responsive, and resilient future. This evolution also highlights the urgent need for research that addresses the legal, regulatory, ethical, and reliability challenges involved in transforming ‘big data’ and AI into innovative services that can be implemented in clinical and real-world settings. Important and open questions concerning the management of COVID-19—particularly in relation to its complex pathophysiology, risk factors, and effective treatments, as well as long-term vaccine safety and efficacy (and related issues)—continue to require multi-channel collection of standardised data supported by diverse, coordinated, and collaborative efforts from biomedical and research communities to inform practice and policy in the new digital era.

Author contributions

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

The authors have declared no conflicts of interest.

References

1. World Health Organization. COVID-19 epidemiological update—19 January 2024. Available from: https://www.who.int/publications/m/item/covid-19-epidemiological-update---19-january-2024. Accessed 5 Feb 2024.

2. Arsenault C, Gage A, Kim MK, et al. COVID-19 and resilience of healthcare systems in ten countries. Nat Med 2022;28:1314-24. Crossref

3. The Lancet Respiratory Medicine. Long COVID: confronting a growing public health crisis. Lancet Respir Med 2023;11:663. Crossref

4. World Health Organization. From Emergency Response to Long-Term COVID-19 Disease Management: Sustaining Gains Made during the COVID-19 Pandemic. Geneva: World Health Organization; 2023.

5. Jacobs JL, Haidar G, Mellors JW. COVID-19: challenges of viral variants. Annu Rev Med 2023;74:31-53. Crossref

6. Ayouni I, Maatoug J, Dhouib W, et al. Effective public health measures to mitigate the spread of COVID-19: a systematic review. BMC Public Health 2021;21:1015. Crossref

7. Pai PM, Fan JK, Wong WC, Deng XF, Xu XP, Lo CM. Promoting integrated healthcare for Hong Kong and Macau residents in the Greater Bay Area during the COVID-19 pandemic. Hong Kong Med J 2023;29:268-72. Crossref

8. Hung KK, Chan EY, Lo ES, Huang Z, Wu JC, Graham CA. User perceptions of COVID-19 telemedicine testing services, disease risk, and pandemic preparedness: findings from a private clinic in Hong Kong. Hong Kong Med J 2023;29:404-11. Crossref

9. Choi MC, Chu SH, Siu LL, et al. Telemedicine acceptance by older adults in Hong Kong during a hypothetical severe outbreak and after the COVID-19 pandemic: a cross-sectional cohort survey. Hong Kong Med J 2023;29:412-20. Crossref

10. Mok A, Mui OO, Tang KP, et al. Public awareness of preventive measures against COVID-19: an infodemiology study. Hong Kong Med J 2023;29:214-23. Crossref

11. Wang HH, Li YT, Wong MC. Leveraging the power of health communication: messaging matters not only in clinical practice but also in public health. Hong Kong Med J 2022;28:103-5. Crossref

12. Bao KK, Cheung KM, Chow JC, Leung CW, Wong KH. The real-world impact of the COVID-19 pandemic on patients with cancer: a multidisciplinary cross-sectional survey. Hong Kong Med J 2023;29:132-41. Crossref

13. Vujosevic S, Limoli C, Luzi L, Nucci P. Digital innovations for retinal care in diabetic retinopathy. Acta Diabetol 2022;59:1521-30. Crossref

14. Lo YS, Jok C, Tse HF. Cardiovascular complications of COVID-19. Hong Kong Med J 2022;28:249-56. Crossref

15. Brunetti ND, Curcio A, Nodari S, et al; Working Group on Telecardiology, Informatics of the Italian Society of Cardiology. The Italian Society of Cardiology and Working Group on Telecardiology and Informatics 2023 updated position paper on telemedicine and artificial intelligence in cardiovascular disease. J Cardiovasc Med (Hagerstown) 2023;24(Suppl 2):e168-77. Crossref

Forging a distinctive Chinese identity and pursuing global excellence: introducing the Chinese Medical Journal

Hong Kong Med J 2024 Feb;30(1):4–6 | Epub 28 Dec 2023

https://doi.org/10.12809/hkmj2311319

EDITORIAL

Forging a distinctive Chinese identity and pursuing global excellence: introducing the Chinese Medical Journal

Yuanyuan Ji, MMed¹; Xiuyuan Hao, MD²

¹ Deputy Managing Director, Chinese Medical Journal, Beijing, China

² Managing Director, Chinese Medical Journal, Beijing, China

Corresponding author: Dr Xiuyuan Hao (haoxiuyuan@163.com)

Full paper in PDF

Brief introduction

As a leading journal in the China Scientific Journal Excellence Action Plan, the Chinese Medical Journal (CMJ) has a 136-year publishing history. This journal was established in 1887 and is regarded as the official journal of the Chinese Medical Association. The CMJ covers all areas of medicine and is recognised as the most influential and authoritative journal in the field of medicine in China. Thus, it serves as an important window for medical exchanges between China and the world.

The CMJ is an international peer-reviewed and fully open access journal published semi-monthly in English. It has been indexed in many world-renowned databases, such as Web of Science, Scopus, PubMed, PubMed Central, MEDLINE, Directory of Open Access Journals, and Embase. As an English-language medical journal, the CMJ has the largest circulation in China, as well as exchange relationships with more than 100 countries and regions around the world. Academician Wang Chen, the Editor-in-Chief of the CMJ, is also the vice president of the Chinese Academy of Engineering and the president of both the Chinese Academy of Medical Sciences and Peking Union Medical College.

History of the journal

Considering the CMJ’s profound historical legacy, its editorial ambitions and roles have evolved alongside the sweeping changes of the times. From its inception in 1887 to the present day, developments in the CMJ have paralleled numerous monumental events that have shaped China and the wider world. The CMJ’s journey mirrors the ebbs and flows of history across four distinct eras: its founding by foreign missionaries (1887-1931), a period of Sino-foreign collaborations (1932-1941), the tumultuous years of World War II and its aftermath (1941-1949), and the transformative era following the birth of the People’s Republic of China (1949-present day).

In 1886, a group of missionary doctors in Shanghai came together to form the China Medical Missionary Association. By March of the following year, the Association had published the inaugural issue of The China Medical Missionary Journal, which is now considered the foundational volume of the CMJ, with John G Kerr as its first Editor-in-Chief. In 1907, the journal was rebranded to become The China Medical Journal. By January 1932, the journal had been amalgamated with the English-language section of the National Medical Journal of China and officially received the title of Chinese Medical Journal. In 1941, the outbreak of World War II led to the division of China into occupied zones and areas behind the front lines of its conflict with Japan. During this turbulent era, the CMJ was produced in three separate editions: Shanghai, Chengdu, and Washington, D.C. By December 1945, however, only the Shanghai edition remained and would continue until 1951. In that year, the CMJ’s editorial operations followed the Chinese Medical Association’s move to Beijing. With contributions from across the nation, the CMJ featured diverse content which attracted subscribers from 37 countries and regions.

Achievements in recent years

Since its inception 136 years ago, the CMJ has chronicled the progression of medical science in modern-day China and bore witness to dramatic changes in Chinese health care. The journal has emphasised the significant roles of contemporary medical techniques in fostering better health, reducing sickness, and extending the lifespan of Chinese people. Significant studies have been published during this time, including the ground-breaking 1957 study by Feifan Tang and colleagues concerning the pathogens responsible for trachoma, which represented a crucial contribution from China’s medical experts to the field of pathogenic microorganisms. The 1960s were particularly fertile years for medical research in China, with some studies recognised as world-leading. This status was highlighted in 1965 when the CMJ published Zhongwei Chen’s report of the first-ever successful reattachment of a severed finger, which asserted China’s position in the forefront of microsurgery globally. In addition, the esteemed Nobel Laureate in Medicine, Professor Youyou Tu, published two of her seminal papers in this respected journal in 1979 and 1999.

Promoting scientism

One of the CMJ’s critical roles is to foster scientism and facilitate scholarly studies. In 1915, Lien-teh Wu penned his aspirations for collaborative efforts between the Chinese Medical Association and the China Medical Missionary Association, with the aim of advancing national health through medical science. Fast forwarding to 1953, Naiquan Gong’s writings captured the strides made in health endeavours shortly after the emergence of a new China. Entering the new millennium, Linhua Tang’s 2000 retrospective highlighted half a century of triumphs in combating malaria. A notable development in 2020 was the journal’s publication of the pivotal 7th rendition of the guidelines for diagnosing and managing coronavirus disease 2019 (COVID-19), which supported scientific efforts to battle the worldwide health crisis. The following year marked an enlightening contribution from Longde Wang, a distinguished member of the Chinese Academy of Engineering, who detailed the substantial progress made since 2011 in the field of stroke prevention and control within China.1 This article received widespread recognition and was cited in various esteemed publications, such as the New England Journal of Medicine, Circulation, and Lancet Neurology.

Global perspective

During the outbreak of the COVID-19 pandemic in 2020, the CMJ swiftly and proactively orchestrated the compilation of studies from various prominent bodies, including the Institute of Pathogenic Microbiology at the Chinese Academy of Medical Sciences, Tongji Hospital at the Huazhong University of Science and Technology, and the Shanghai Public Health Clinical Center. This initiative was aimed at global dissemination of China’s insights and strategies for combating the pandemic. On 25 January 2020, the CMJ accepted its first research paper on COVID-19, entitled “Identification of a novel coronavirus causing severe pneumonia in human: A descriptive study.”2 This paper was expedited for online preview by 29 January, enhanced with informative graphics and videos, and concurrently distributed via social media platforms and EurekAlert! This publication played a pivotal role in delivering essential scientific evidence that helped to uncover the origin of the virus, understand its modes of transmission, and devise effective countermeasures for the pandemic.2

Embodying cultural confidence

The CMJ is committed to conveying China’s medical narratives by spotlighting key Chinese data, clinical trials of homegrown innovative medications, and innovative research at the forefront of international science. In the past 3 years, for instance, the CMJ has published six studies related to the world-leading China Kadoorie Biobank project, a cutting-edge, large-scale cohort involving the largest biobank within China, which contains over 500 000 samples. This extensive population cohort has significant implications for precision disease management, diagnostics, therapy, and pharmaceutical innovation. In 2023, the CMJ unveiled the findings of Phase III trials of anaprazole, the first proton pump inhibitor developed entirely in China. After its feature report in the CMJ, this ground-breaking treatment for duodenal ulcers received the green light for market entry in June 2023.3 In a report that made waves in 2020, the CMJ covered the first case worldwide of a patient with COVID-19 who received a lung transplant. This bold move highlighted China’s learning, resolve, and bravery in the global fight against the COVID-19 pandemic.4

Official journal of the Chinese Medical Association

As the official journal of the Chinese Medical Association, the CMJ is responsible for expressing the Association’s stance on various issues to medical societies worldwide. In March 2020, the CMJ featured an article authored by the Chinese Society of Organ Transplantation of Chinese Medical Association, “Development of the organ donation and transplantation system in China,”5 which informed an international audience about the development of organ donation and transplantation in China, dispelled misconceptions, and highlighted progress China has made in the field of organ transplantation.

Emphasising win-win cooperation

The CMJ has established a strong partnership for scholarly exchange with Archivos de Bronconeumología. In the 2022 edition of Archivos de Bronconeumología, a CMJ editorial board member, Professor Yongchang Sun, detailed the measures currently in place for managing chronic obstructive pulmonary disease in China, and Professor Luzhao Feng described China’s revised tactics for responding to the evolving COVID-19 crisis. As part of the exchange, the Editor-in-Chief of Archivos de Bronconeumología, Professor Miguel Angel Martinez-Garcia, contributed to the 2022 edition of the CMJ with his perspective on the complex relationship between bronchiectasis and COVID-19, titled “Bronchiectasis and COVID-19 infection: A two-way street.”6 This collaborative approach has significantly broadened the readership of the two entities and enhanced their cultural and intellectual interactions.

To the readers of Hong Kong Medical Journal

The CMJ focuses on publishing epidemiological data, review articles on hot topics, clinical studies with high levels of evidence, and translational medical research with the potential for clinical transformation. As the CMJ’s international influence continues to grow, its impact factor also steadily increases. According to the latest Journal Citation Report, the impact factor of the CMJ in 2022 was 6.1, which ranks the journal within the first quantile in the fields of General and Internal Medicine. As an international English-language medical journal, we look forward to establishing academic and journal exchange relationships with the Hong Kong Medical Journal to jointly promote the development of medicine and benefit the public.

Author contributions

Concept or design: Both authors.
Acquisition of data: Y Ji.
Analysis or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.

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.

Conflicts of interest

All authors have disclosed no conflicts of interest.

References

1. Chao BH, Tu WJ, Wang LD; Stroke Prevention Project Committee, National Health Commission of the People’s Republic of China. Initial establishment of a stroke management model in China: 10 years (2011-2020) of Stroke Prevention Project Committee, National Health Commission. Chin Med J (Engl) 2021;134:2418-20. Crossref

2. Ren LL, Wang YM, Wu ZQ, et al. Identification of a novel coronavirus causing severe pneumonia in human: a descriptive study. Chin Med J (Engl) 2020;133:1015-24. Crossref

3. Zhu H, Pan X, Zhang L, et al. Effect and safety of anaprazole in the treatment of duodenal ulcers: a randomized, rabeprazole-controlled, phase III non-inferiority study. Chin Med J (Engl) 2022;135:2941-9. Crossref

4. Chen JY, Qiao K, Liu F, et al. Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis. Chin Med J (Engl) 2020;133:1390-6. Crossref

5. Shi BY, Liu ZJ, Yu T. Development of the organ donation and transplantation system in China. Chin Med J (Engl) 2020;133:760-5. Crossref

6. Oscullo G, Gómez-Olivas JD, Beauperthuy T, et al. Bronchiectasis and COVID-19 infection: a two-way street. Chin Med J (Engl) 2022;135:2398-404. Crossref

The need for good practice guidelines for expert witnesses

Hong Kong Med J 2023 Dec;29(6):487–8 | Epub 7 Nov 2023

https://doi.org/10.12809/hkmj235153

EDITORIAL

The need for good practice guidelines for expert witnesses

Albert Lee, FHKAM (Family Medicine), LLM^1,2,3,4; Tracy Cheung, LLB, PCLL^4,5,6

¹ The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

² Board Governor and Education Committee, World Association for Medical Law

³ Education Committee, Australasian College of Legal Medicine, Australia

⁴ Visiting Lecturer, The University of Law, United Kingdom

⁵ Consultant Solicitor, Wanda Tong & Company, Hong Kong SAR, China

⁶ Lecturer, School of Law, City University of Hong Kong, Hong Kong SAR, China

Corresponding author: Dr Albert Lee (alee@cuhk.edu.hk)

Full paper in PDF

Disputes in the healthcare sector between patients, healthcare professionals, and providers involve technical medical issues. Therefore, expert witnesses are needed to assist legal representatives, judges, and tribunals with specialised knowledge to better understand patient care and management, the standard of care provided, and to determine the issues in dispute.1 Expert witnesses possess specialist knowledge, skills, experience, and training to provide expert opinions and testify in Court or before tribunals to assist in providing a better understanding of the factual and expert evidence and/or to determine the issues in dispute. Opinion evidence is generally not permitted to be given by factual witnesses. Expert witnesses assist the Court and tribunals by providing opinions to evaluate the factual and medical evidence and determine whether the standard of healthcare services was met or fell below the legal standard, leading to the alleged injuries and losses.

There have been a series of high-profile cases of gross negligence manslaughter in Hong Kong and the United Kingdom in recent years, which highlight the important role of expert witnesses in assisting in the administration of justice.2 If an expert witness provides an unsound or biased opinion to a party in a dispute, it could potentially lead to lengthy legal and disciplinary proceedings against a healthcare professional, which could otherwise be avoided.3 The purpose of a Medical Council Inquiry is to determine whether the conduct of the registered medical practitioner amounts to professional misconduct, rendering the registered medical practitioner unfit to practice and/or subject to disciplinary sanctions. Professional misconduct refers to misconduct in a professional respect and includes conduct which falls below the standards expected of members of the profession.4 5 The legal standard of care is set out in the English case of Bolam,6 where it held that a medical practitioner will not be negligent if s/he is acting in accordance with a practice accepted as proper by a responsible body of medical opinion, and the practice must be able to stand up to logical analysis.7 Who will qualify as a responsible body of medical opinion? It ought to be persons with knowledge, expertise, and training in the specific specialist area of practice as the subject medical practitioner.

A medical practitioner cannot rely on a so-called ‘reasonable doctor test’ for advice given to a patient in relation to informed consent issues. The Courts in some common law jurisdictions have increasingly adopted the principle of a ‘reasonable patient test’ as seen in the cases of Whitaker8 and Montgomery9. In this respect, an expert medical opinion is still necessary to determine standard of care issues. The Montgomery case requires a doctor to take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.”10 Expert opinion is still required to determine if there are and if so, what are the reasonable alternatives or variant treatments available to patient, and what a doctor should reasonably know and advise on the significant risk(s) for that patient. In the recent case of McCulloch,11 the Supreme Court of the United Kingdom unanimously agreed that the consideration of whether a treatment is a reasonable alternative should be an exercise of professional skill and judgement by a professional body of medical opinion.

Medico-legal reports by expert witnesses must meet the requirements of the legal process and are not merely medical reports prepared for clinical or treatment purposes. The integrity of expert witnesses is paramount and they should possess a unique skillset to provide an expert opinion with quality and substance, in addition to the specialist knowledge and skills in the relevant practice area. The primary role of the expert is to act independently and objectively in providing assistance to the court or tribunal in matters pertaining to the medical facts of the case. They are not a ‘hired gun’ for the instructing party. An expert report should include a clear articulation of all factual assumptions made and reasons for giving a particular opinion. These reasons must be supported by authoritative research.12

In Hong Kong, there is a demand for healthcare professionals to act as expert witnesses. However, there is a perceived reluctance to accept instructions to act in this capacity due to concerns over uncertainty of the contents and format of expert reports for legal and disciplinary proceedings, large volumes of documents to be considered, and time needed to attend to communications with instructing lawyers and preparation for appearance before the Medical Council and Court.13 The time-frame and lengthy legal proceedings, as well as fears over giving evidence in Court and before the Medical Council and being challenged during cross-examination by lawyers can be daunting.13 To address these issues, the Hong Kong Academy of Medicine (the Academy) provides an online training course for Fellows and practitioners who wish to become competent expert witnesses.14

In addition, the Academy has published the Best Practice Guidelines for Expert Witnesses in October 2023, which provides concise and comprehensive guidance to medical and dental practitioners who are partaking or considering to partake the role of an expert witness.15 The Guidelines provide a step-by-step approach to acting as an expert witness, beginning with practical guidance and a list of things to obtain upon receiving instructions. The Guidelines also include useful case studies illustrating how to assess suitability to act as an expert witness in specific clinical circumstances and address particular issues, for example, the difference between assessing the standard of care and causation of damage in law. Furthermore, the Guidelines provide practitioners with a better understanding of concepts such as standard of care, professional misconduct, and causation (the ‘but for’ test, the concept of the balance of probabilities, etc.) to formulate an expert medico-legal opinion. Since not all doctors and dentists are familiar with these concepts and required forms, a very useful appendix is included.15

The issues to be determined in various legal and disciplinary proceedings will differ, and so will the scope of expert reports. The Guidelines address disciplinary inquiry proceedings, Coroner’s Court proceedings, and civil litigation defence proceedings. Healthcare professionals can also be asked to act as expert witnesses in criminal proceedings, in civil claims where they are instructed by plaintiffs, or upon the instructions of the Director of Legal Aid. A table can be used to summarise different types of proceedings with guiding notes for the issues that expert witnesses need to pay attention to.

The Guidelines emphasise the duties of expert witnesses and stress the importance of being impartial and independent in formulating opinions. The potential liabilities are also highlighted. The Guidelines serve as a valuable resource for doctors and dentists, enabling them to act as competent expert witnesses and avoid potential pitfalls. Critical appraisal of fictitious expert reports can illustrate what constitutes a good or bad report and assist doctors and dentists in mastering the skills, style, and content of medico-legal opinion reporting.

Appearance in court or disciplinary inquiries can be stressful for expert witnesses. Observing actual proceedings, which are open to the public, can better prepare experts. Online demonstration videos can serve as useful resources.

There is a need for a larger pool of competent expert witnesses in Hong Kong, readily available to provide valuable input in different clinical disciplines and serve our community. The Guidelines are an invaluable resource that supports doctors and dentists in offering their services as expert witnesses.

Author contributions

Both authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

Both authors have declared no conflict of interest.

Funding/support

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

References

1. Donovan DF, Re-examining the legal expert in international arbitration (eleventh Kaplan Lecture, 15 November 2017). In: Hong Kong International Arbitration Centre, editor. International Arbitration: Issues, Perspectives and Practices. Netherlands: Kluwer Law International; 2019: Chapter 11.

2. Leung GK. Medical manslaughter in Hong Kong: what now? Hong Kong Med J 2023;29:4-5. Crossref

3. Lee A. Key elements of gross negligence manslaughter in the clinical setting. Hong Kong Med J 2023;29:99-101. Crossref

4. Chiu JS, Leung GK. Expert witnesses and areas of expertise. Hong Kong Med J 2022;28:4-5. Crossref

5. The Medical Council of Hong Kong. Code of professional conduct. 2016. Available from: www.mchk.org.hk/english/code/files/Code_of_Professional_Conduct_2016.pdf. Accessed 24 Sep 2023.

6. Bolam v Friern Health Management Committee [1957] 1 WLR 582 [2015] UKSC 11

7. Bolitho v City and Hackney Healthy Authority [1996] 4 All ER 771

8. Roger v Whitaker [1992] 175 C.L.R. 479 [HC] Australia

9. Montgomery v Lanarkshire Health Board [2015] AC 143 (Supreme Court (Scotland)), UK

10. Sokol DK. Update on the UK Law on consent. BMJ 2015;350:h1481. Crossref

11. McCulloch v Forth Valley Health Board [2023] UKSC 26

12. Beran RG. Legal medicine: how to prepare a report. Aus Fam Physician 2011;40:246-8.

13. Lee A. An Expert’s Perspective: Preparing for Court and Professional Issues. Medical Protection Society and Hong Kong Medical Association Medical Experts Training Workshop, September 24, 2017, Hong Kong.

14. Hong Kong Academy of Medicine. HKAM Training Course for Expert Witness. Available from: https://www.hkam.org.hk/en/events/hkam-training-course-expert-witnesses. Accessed 24 Sep 2023.

15. Professionalism and Ethics Committee of the Hong Kong Academy of Medicine. Best Practice Guidelines for Expert Witnesses. Available from: https://www.hkam.org.hk/en/news/best-practice-guidelines-expert-witnesses. Accessed 27 Oct 2023.

Data-driven service model to profile healthcare needs and optimise the operation of community-based care: A multi-source data analysis using predictive artificial intelligence

Hong Kong Med J 2023 Dec;29(6):484–6 | Epub 13 Dec 2023

https://doi.org/10.12809/hkmj235154

EDITORIAL

Data-driven service model to profile healthcare needs and optimise the operation of community-based care: a multi-source data analysis using predictive artificial intelligence

Eman Leung, PhD¹; Albert Lee, FHKAM (Family Medicine), MD^1,2,3; Hector Tsang, PhD²; Martin CS Wong, FHKAM (Family Medicine), MD^1,3

¹ The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

² Department of Rehabilitation Science, The Hong Kong Polytechnic University, Hong Kong SAR, China

³ Centre for Health Education and Health Promotion, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

Corresponding author: Dr Albert Lee (alee@cuhk.edu.hk)

Full paper in PDF

As the needs of our ageing population grow in intensity and diversity, there is a need to achieve precision in public health via data-driven profiling of population-level preventive care, while optimising medical and social services to address those needs. These initiatives will maximise population health and minimise health care costs. Nevertheless, population-level precision public health research is rare; its application to drive service planning and deployment at the population level is even rarer.1 Thus, with support from the Strategic Public Policy Research Funding Scheme managed by the Policy Innovation and Co-ordination Office of the Hong Kong SAR Government, we initiated a research programme to fill the gap in precision public health research and practice by triangulating data that represent population-level socioecology,2 such as personal-level clinical and functional data, relational-level data for individual households, community-level data regarding socio-demographic characteristics and physical living environments, data describing organisations that meet population-level needs, and data reflecting the impacts of governmental policy. We sought to identify individuals who can receive the greatest benefit from primary, secondary, and tertiary preventive care. The resulting profiles could inform population-level planning and allocation of the three tiers of preventive care programmes.

Nevertheless, our research objectives were confronted with challenges related to the following contextual factors: (1) the inherent biases and quality of real-world data extracted from medical services’ Electronic Health Records (EHRs) and social services’ record systems; (2) the fragmentation among services (and their respective databases) which are required to address needs arising from specific aspects of population-level socioecology, including the distinct medical and social needs that our siloed medical and social services seek to address; and (3) the coronavirus disease 2019 (COVID-19) pandemic and the associated social and public health measures which emerged shortly after project initiation and have persisted throughout its life cycle. To overcome these challenges, we adopted a multi-source analytical approach,3 whereby parallel and iterative analyses were performed across databases representing different socioecology aspects at the resident level. Specifically, an analytical profile developed in one database was applied to other databases with the goal of identifying research questions and facilitating the selection of corresponding features and analytics. The findings from multiple siloed databases could be triangulated to coherently address individual research objectives. In addition, where applicable, parameters extracted from siloed databases were integrated to model particular outcomes using our artificial intelligence (AI) algorithm, for which the input architecture was anthropomorphised4 according to spheres described in the socioecological prevention framework of the Centers for Disease Control and Prevention. This approach enabled structuring of the hierarchically interrelated input layers.

In the following text, we describe our multi-source analytical approach and emerging findings from our research programme. Although the academic outputs of our research programme are in various stages of peer review, this description of a data-driven process to formulate research questions and develop sampling frames for examination across siloed databases in the construction of a population-level coherent care profile may serve as an alternative approach for other researchers to consider when they face similar contextual challenges in population-level precision public health research.

For example, using the study populations’ EHRs (obtained via the Hospital Authority Data Collaboration Laboratory), we applied unsupervised and supervised machine learning algorithms in tandem to identify tertiary prevention needs and the service gaps that prevent those needs from being met in the study populations. Our analyses revealed that the highest rehospitalisation rates (>80%) and the shortest times between discharge and rehospitalisation occurred in sub-populations of patients who lacked specific ambulatory or postacute services. Nonetheless, these services were also available to patients who shared similar clinical and utilisation profiles but exhibited significantly lower rehospitalisation rates. Among the sub-populations with high rehospitalisation rates and low utilisation of rehospitalisation-mitigating post-discharge services, one had a typical profile (ie, population segment medoids) of patients aged 50 to 64 years with musculoskeletal pain–related disorders as primary diagnoses. These patients more frequently exhibited a history of multiple chronic illnesses and higher clinical complexity at index hospitalisation compared with other patients who had similar clinical and acute care utilisation profiles.

The profiling of sub-populations who fell through the service gaps and were rehospitalised at the highest rate enabled us to bring precision to tertiary prevention efforts and subsequently perform data-driven optimisation of population-level post-discharge service allocation, thereby minimising medical costs. Furthermore, the profile we constructed from EHRs could also be applied beyond medical settings to identify potential secondary prevention targets that may exacerbate the evolution of an underlying disease process, such that it interfered with quality of life among individuals who matched the EHR-based and machine-constructed profile, ultimately triggering health-seeking behaviour.

Thus, in a non-medical setting, we recruited residents of the study population aged 50 to 64 years who had musculoskeletal pain, according to community-based primary care clinicians. In addition to the residents’ socio-demographic characteristics, behavioural health, and co-morbid chronic illness statuses, clinicians also assessed anthropometric measures and biomarkers of metabolic dysfunction that are often direct or indirect precursors to the most common forms of chronic illnesses. These factors were included as predictive features in a random forest model for selection and risk-scoring of potential secondary prevention targets that could mitigate the exacerbation of pain symptoms. The model also included features representing various aspects of the residents’ living environments, which were separately parameterised and initially selected by our AI algorithm according to the following constraints: (1) they were sourced from multiple public domain datasets that belonged to governmental agencies such as the Census and Statistics Department, Housing Authority, Lands Department, Department of Health, and District Offices; (2) they were organised as layered input into a multi-headed hierarchical convolutional neural network, with an anthropomorphised architecture that captured the study population’s internal and external built environments and socio-demographic profiles; and (3) they were selected according to the statistical importances of their unique and combined contributions to residential building-level aggregates of general health based on census data and COVID-19 case counts from the Department of Health.

Finally, after parameterisation and selection in accordance with their degrees of importance to the population’s general health and COVID-19 susceptibility, features representing the built environments of the study district’s residential buildings were processed as follows: (1) they were entered into a random forest model together with the aforementioned individual-level measures to compare their respective importances in the onset of pain interference; and (2) they were scored according to their individual and combined adverse health effects, then assigned to individual residential buildings in the study district for optimised allocation of local primary prevention programmes.

Our analyses revealed that, although features representing residents’ socio-demographic characteristics and metabolic dysfunction had high importance with respect to the presence of pain interference in various residential quality of life domains, their feature importances were secondary to the importances of built-environment features, such as living area size, air quality, access to light, architecture conducive to social connectivity, and building age. In addition to scoring the risk of pain interference for individual residents, we scored the built environment of each building in public housing estates within the study district according to the likelihood that its residents would experience sufficient pain to interfere with their quality of life. This scoring approach can inform service planning in geospatially targeted secondary pain prevention programmes.

Patients with chronic obstructive pulmonary disease who exhibited high clinical complexity and multiple co-morbidities were another sub-population who typically exhibited high rehospitalisation rates and low utilisation of rehospitalisation-mitigating post-discharge services. This patient profile was used to guide the recruitment of study district residents outside of medical settings, enabling examination of the evolution of disease processes and hospitalisation trends among asymptomatic and symptomatic community residents. Together with the findings regarding musculoskeletal pain and health-related effects of the built environment, our work has provided the basis for a predictive AI platform that was commissioned by the Sham Shui Po District Office to support its social health surveillance and policy decision needs. Additionally, our work has been incorporated into an algorithm deployed at community diagnosis events hosted by the Sham Shui Po District Office and at events co-hosted by the Kwai Tsing Safe Community and Healthy City Association and the Kwai Tsing District Office.

Acknowledgement

The work described in the current editorial is made possible with the support of the Strategic Public Policy Research Funding Scheme (project No: S2019.A4.015.19S). The authors thank Dr Jingjing Guan's analytical leadership, Mr Sam Ching's data science management, Ms Olivia Lam's data analytics and visualisation, Ms Yilin He's data wrangling, and Ms Hilliary Yee's data collection. The authors are also deeply grateful for the partnertships of Health In Action and People Service Centre, who have granted us permission to analyse the data under their custodianship under strict confidentiality agreements that safeguard the anonymity of their clients while driving improvements in their respective services.

Author contributions

Concept or design: E Leung, A Lee, H Tsang.
Acquisition of data: E Leung.
Analysis or interpretation of data: E Leung, A Lee.
Drafting of the manuscript: E Leung, A Lee.
Critical revision of the manuscript for important intellectual content: All authors.

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.

Conflicts of interest

As editor and adviser of the journal, respectively, MCS Wong and E Leung were not involved in the peer review process. Other authors have disclosed no conflicts of interest.

Funding/support

This editorial is supported by the Strategic Public Policy Research Funding Scheme (project No.: S2019.A4.015.19S). The funder had no role in study design, data collection/analysis/interpretation or manuscript preparation.

References

1. Talias MA, Lamnisos D, Heraclides A. Data science and health economics in precision public health. Front Public Health 2022;10:960282. Crossref

2. Centers for Disease Control and Prevention and Health Resources and Services Administration. 2022. The social-ecological model: a framework for prevention. Available from: https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html. Accessed 8 Dec 2023.

3. Noi E, Rudolph A, Dodge S. Assessing COVID-induced changes in spatiotemporal structure of mobility in the United States in 2020: a multi-source analytical framework. Int J Geogr Inf Sci 2022;36:585-616. Crossref

4. Glikson E, Woolley AW. Human trust in artificial intelligence: review of empirical research. Acad Manag Ann 2020;14:627-60. Crossref

Modernising postgraduate medical education: evolving roles of The Hong Kong Jockey Club Innovative Learning Centre for Medicine in the Hong Kong Academy of Medicine

Hong Kong Med J 2023 Dec;29(6):480–3 | Epub 4 Dec 2023

https://doi.org/10.12809/hkmj2311178

EDITORIAL

Modernising postgraduate medical education: evolving roles of The Hong Kong Jockey Club Innovative Learning Centre for Medicine in the Hong Kong Academy of Medicine

PP Chen, FHKAM (Anaesthesiology); HY So, FHKAM (Anaesthesiology); Johnson ST Lo, MPA, MEM; Benny CP Cheng, FHKAM (Anaesthesiology)

The Hong Kong Jockey Club Innovative Learning Centre for Medicine, Hong Kong Academy of Medicine, Hong Kong SAR, China

Corresponding author: Dr Benny CP Cheng (ccp414@ha.org.hk)

Full paper in PDF

Introduction

The Hong Kong Jockey Club Innovative Learning Centre for Medicine (HKJCILCM) was established by the Hong Kong Academy of Medicine (HKAM) on 10 December 2013 as a state-of-the-art facility specifically focused on simulation-based learning (SBL). Since then, the HKJCILCM has evolved to become the education arm of the HKAM. Here, we review this evolution in celebration of the 10th anniversary of the HKJCILCM.

Establishment of the Centre

The publication of To Err is Human: Building a Safer Health System by the Institute of Medicine set forth the agenda to build a safer health system.1 The report concluded that the high rates of preventable medical errors were caused by faulty systems, processes, and conditions, rather than individual ‘bad apples’.1 Improvements to patient safety would require the design of a safer healthcare system; the establishment of this system would involve a paradigm shift in medical education.1

Simulation-based learning offers many advantages. It provides a safe environment for learners to practise and learn from their mistakes. Simulated tasks can be repeated and standardised; their difficulties can be controlled to match various levels of expertise among learners. Moreover, rare events can be practised without the delays involved in real-world encounters.2 However, until the early 2000s, the adoption of SBL was slow among HKAM Colleges, medical schools, nursing schools, and the Hospital Authority.

By 2010, there was increasing evidence regarding the effectiveness of SBL in enhancing quality healthcare and patient safety3; various authorities supported a greater role for SBL in medical education.4 5 6 7 Consistent with this trend, the HKAM published a position paper on postgraduate medical education in 2010, which recommended greater adoption of simulation in postgraduate medical training, along with the establishment of SBL centres.8 Under the leadership of the then President Dr Donald Kwok-tung Li, the Council of the HKAM decided in 2012 to establish a centre of excellence for innovative learning in medicine on the seventh floor of the HKAM Building. Through collaborations with simulation centres at Hospital Authority hospitals and medical schools, the HKJCILCM was intended to facilitate trainee instruction at HKAM Colleges, provide continuing education opportunities to Fellows and other healthcare professionals, and support research. It was established in December 2013 with a generous donation of HK$53.5 million from The Hong Kong Jockey Club Charities Trust.

To achieve the highest standards, the HKAM formed a partnership with the Center for Medical Simulation (CMS) in Boston of the United States that was led by Professor Jeffrey Cooper. The CMS team provided advice regarding development of the HKJCILCM, including its agenda, the promotion of simulation in medical education, assessments and research, faculty development, continuing medical education programmes, and scientific research collaborations. The HKAM’s partnership with the CMS remains strong and robust to this day.

Early years

During its early years, the HKJCILCM faced several challenges. Although the original objectives of the Centre had been established, its role among simulation training centres in Hong Kong was unclear. At times, the HKJCILCM was engaged in competition to attract trainers, and some training programmes overlapped. Also, in those years, access to the Centre by public transportation was difficult, and it was not a popular location for training activities.

Various measures were undertaken to address these challenges. The Centre was equipped with an array of training equipment, including partial-task trainers, advanced laparoscopic and endoscopic simulators, high-fidelity human patient simulators, as well as interactive virtual reality platforms (eg, XVR and Igloo [with 360° visualisation]), to enhance training scope and experience. The HKJCILCM team also supported and collaborated with the Academy’s Disaster Preparedness and Response Institute (a project concluded in October 2022), the Hospital Authority, The University of Hong Kong, The Chinese University of Hong Kong, City University of Hong Kong, and our Colleges to develop and implement training courses at the Centre. Fellows and trainees were encouraged to use the training equipment to practise individual clinical skills. Furthermore, the HKJCILCM established an internship programme for students in the Department of Biomedical Engineering at The Hong Kong Polytechnic University. The first intern was accepted into the programme in July 2017, further enhancing the Centre’s role in education and research.

Considering the shortage of qualified simulation trainers in Hong Kong, the HKJCILCM focused on faculty development from its inception. Initially, the Centre contracted with the CMS’s Institute of Medical Simulation to provide five ‘Simulation as a Teaching Tool’ Instructor Courses, and two Advanced Courses on Debriefing, over 5 years. However, high demand led to the completion of all seven courses within the first 2 years. In 2015, the HKJCILCM began to develop its own faculty development programme; the 4-day Comprehensive Simulation Educator Course (CSEC) was first conducted in June 2016. The CSEC was initially supervised and later endorsed by the CMS. In 2018, a 2-day Debriefing Skills for Simulation Instructors (DSSI) course was developed to provide debriefing skill training to simulation educators who may not be involved in the development of simulation curricula or design of simulated case scenarios. These faculty development initiatives have had a substantial impact, such that 542 trainers completed the CSEC and 354 trainers completed the DSSI course by September 2023. These alumni are now trainers in various healthcare professional education and training organisations in Hong Kong. Additionally, through an agreement with the Hospital Authority, the HKJCILCM established a 2-month full-time Visiting Scholar programme at the CMS. Ten scholars from the HKJCILCM have completed the programme since 2014.

Consolidation of early achievements

Since 2016, the HKJCILCM has provided access to its library collection of peer-reviewed journals and books. This resource was made available to all Fellows and trainees, allowing them to remain informed about SBL and medical education. Furthermore, arrangements were established whereby Colleges could borrow the HKJCILCM’s equipment for training and examination purposes outside of the HKJCILCM facility. The HKJCILCM also offered its medical simulation expertise to assist Colleges with the development of their own programmes. By leveraging the knowledge and experience of the HKJCILCM, Colleges were able to implement effective simulation-based programmes tailored to their particular specialty needs.

Over time, the role of the HKJCILCM became clearer. The main focus shifted to ensuring programme quality and standards, maintaining trainer competency, and providing guidance to our Colleges (and other institutions) regarding the use of SBL. A quality assurance structure was developed to ensure quality in all courses organised by the HKJCILCM; the structure was also intended to maintain trainer competency. In November 2017, the HKAM published its Position Statement on SBL, which provided guidance regarding the safe and effective use of SBL methods in postgraduate education and training for healthcare professionals.9

Subsequently, a certification programme for HKJCILCM’s Simulation Trainers was developed, along with a structured system for standards maintenance. After approval by the Council of the HKAM, the first cohort of HKJCILCM-Certified Simulation Trainers was approved in early 2019 for a 3-year cycle. By September 2023, 62 trainers were participating in the programme.

Evolution to greater heights

Since its inception, the HKJCILCM has been actively involved in medical education. In the early years, it regularly led organising efforts for the annual HKAM Medical Education Conference and other scientific meetings. Through a collaborative initiative with The University of Hong Kong–Shenzhen Hospital, the HKJCILCM organised a symposium and workshops regarding SBL in July 2019; these events were held in Shenzhen on the mainland and attracted considerable interest from participants across Guangdong Province. Subsequently, multiple doctors from Shenzhen joined the faculty development programme in Hong Kong to establish a group of local trainers.

Over the past decade, leaders at the HKAM have increasingly recognised the need to strengthen the Academy’s efforts to modernise postgraduate medical education. Considering its experience and success in promoting SBL, the HKJCILCM was regarded as the appropriate body to serve as the Academy’s educational arm. A strategic planning retreat was conducted in November 2020 to extensively discuss this vision. Based on a survey among the members of the HKAM Education Committee, three high-priority interrelated topics were identified as areas for development: competency-based medical education (CBME), workplace-based assessment (WBA), and e-learning.

The HKAM Position Paper on Postgraduate Medical Education, published in 2010, emphasised the need of transition from traditional process-oriented training to CBME.8 To accomplish this important transition, the following four strategies have been implemented10:

1. Engagement: Because CBME is a complex concept, conference speeches and presentations, as well as published articles, have been used to promote and clarify its importance, meaning, and implementation methods.

2. Redesign: It is important for Colleges to adjust their training and assessment standards and procedures to align with CBME principles. This process was streamlined at a strategic education and training workshop organised by the HKAM, which culminated in the publication of a position paper in 2023 that summarised recommendations from the discussion.11

3. Faculty development: Because the implementation of CBME requires trainers to learn modern teaching skills, faculty development is essential. The Workgroup on Faculty Development has been assembled with representatives from most Colleges, and resources have been provided to support this initiative. The Basic Medical Education Course, developed by the Hong Kong College of Emergency Medicine, has been evaluated and approved as a model training programme for faculty development. An intercollegiate curriculum for faculty development is currently in development.

4. Research: Because postgraduate medical education is a relatively new field with a limited academic footprint, there is a need to generate context-specific knowledge to guide the progress of the HKJCILCM. This research often involves qualitative methods with which our Fellows may have limited familiarity. Simulation approaches involving mentorship from experienced scholars are under consideration as initial steps towards project-based learning. An online course regarding qualitative research for medical education has been established as a learning resource.

Competency-based medical education requires fundamental changes in assessment methods, which highlight the need for various measures that include authentic tasks and direct observation in a clinical setting.12 As a component of the CBME approach, WBA has become crucial in efforts to evaluate performance and contribute to the education of trainee doctors. Our strategy at the HKJCILCM involves the development of a standard workshop, which could be tailored to the specific needs of our partner Colleges. We have already collaborated with several Colleges, including the Hong Kong College of Orthopaedic Surgeons, the Hong Kong College of Anaesthesiologists, Hong Kong College of Physicians, and the Hong Kong College of Otorhinolaryngologists, to provide workshops that focus on providing effective feedback to trainee doctors. However, Carless13 emphasised the requirement for feedback literacy to ensure effective feedback utilisation; we are addressing this aspect through a pilot workshop established in collaboration with the Hong Kong College of Otorhinolaryngologists.

Because of the coronavirus disease 2019 pandemic, members of the HKJCILCM have shifted towards e-learning as an alternative to traditional face-to-face teaching methods. Although our experience with e-learning has not been entirely satisfactory, we have identified unique benefits, including flexibility for learners and the ability to engage with topics at a self-selected pace. Moreover, the use of reusable e-learning materials has provided valuable time savings for trainers and trainee doctors, allowing them to focus on practical learning activities.

Members of the HKJCILCM have facilitated e-learning through three strategies. First, we established the eHKAM Learning Management System (LMS) Taskforce, consisting of representatives from all 15 Colleges, the HKJCILCM, and other relevant Departments of the HKAM, to conduct a systematic process of needs analysis, selection, vetting, and implementation of our LMS. The LMS of the HKAM has been operational since 2022. Second, we have developed and delivered the Learning Online Educator course, which is intended to equip our Fellows with the technological skills and educational expertise necessary to teach online. The educational framework is based on the community of inquiry model, whereby our participants are empowered to use e-learning as an instrument for adult learning through an inquiry process.14 Finally, our project team provides technical support to the Colleges’ programmes through mechanisms approved by the eHKAM LMS Taskforce.

Conclusion

Through its emphasis on the need to modernise medical education, the ground-breaking report To Err is Human: Building a Safer Health System initiated a major paradigm shift. To encourage this shift, the HKAM established the HKJCILCM, which initially focused on SBL development and more recently expanded to include CBME, WBA, and e-learning. This experience has provided a few important lessons. First, CBME is a constantly evolving approach intended to achieve better healthcare through effective medical education,15 and the role of the HKJCILCM will continue to adapt in response to new innovations. Second, we must focus on innovations in both technology and education. Although technologies such as simulation and e-learning are intriguing, we must remember that such technologies are intended to enhance education; their effective use requires a thorough understanding of educational theories. This principle has guided us in the development and implementation of the CSEC, the DSSI course, and the Learning Online Educator course.

Finally, efforts to transform educational practices can only be successful if all stakeholders participate. On behalf of the HKJCILCM, we would like to take this opportunity to express our deepest gratitude and appreciation to the following Fellows and partners for their generous contributions and unwavering support to the evolution and development of the HKJCILCM: Dr Donald KT Li, Prof CS Lau, Prof Gilberto KK Leung, Dr YF Chow, Prof Philip KT Li, Prof Paul BS Lai, Dr CC Lau, Dr HT Luk, Dr WK Tung, Dr Francis PT Mok, Prof NG Patil; Presidents of all HKAM Colleges; Convenors and Faculties of all HKJCILCM courses; members of all HKJCILCM Committees, Subcommittees and Working Groups; the Hong Kong Jockey Club Charities Trust; Center for Medical Simulation in Boston of the United States; Hospital Authority; The University of Hong Kong; The Chinese University of Hong Kong; The Hong Kong Polytechnic University; and The Hong Kong Society of Simulation for Healthcare. Your support, commitment, and invaluable insights have been crucial to our progress and success in the transformation of postgraduate medical education in Hong Kong.

Author contributions

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding/support

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

References

1. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academy Press; 2000.

2. So HY, Chen PP, Wong GK, Chan TT. Simulation in medical education. J R Coll Physicians Edinb 2019;49:52-7. Crossref

3. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011;306:978-88. Crossref

4. Aggarwal R, Mytton OT, Derbrew M, et al. Training and simulation for patient safety. Qual Saf Health Care 2010;19 Suppl 2:i34-43. Crossref

5. Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care 2009;18:424-8. Crossref

6. Khan K, Pattison T, Sherwood M. Simulation in medical education. Med Teach 2011;33:1-3. Crossref

7. Amin Z, Boulet JR, Cook DA, et al. Technology-enabled assessment of health professions education: consensus statement and recommendations from the Ottawa 2010 Conference. Med Teach 2011;33:364-9. Crossref

8. Postgraduate Medical Education Working Group, Hong Kong Academy of Medicine. Position Paper on Postgraduate Medical Education. October 2010. Available from: https://www.hkam.org.hk/sites/default/files/HKAM_position_paper.pdf. Accessed 14 Sep 2023.

9. Hong Kong Jockey Club Innovative Learning Centre for Medicine, Hong Kong Academy of Medicine. Position Statement on Simulation-based Learning. November 2017. Available from: https://www.hkam.org.hk/sites/default/files/Position%20Statement%20on%20Simulation-based%20learning%20(Formatted)%20-%20final.pdf. Accessed 14 Sep 2023.

10. So HY. Postgraduate medical education: see one, do one, teach one…and what else? Hong Kong Med J 2023;29:104. Crossref

11. So HY, Li PK, Lai PB, et al. Hong Kong Academy of Medicine position paper on postgraduate medical education 2023. Hong Kong Med J 2023;29:448-52. Crossref

12. Corracio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: from Flexner to competencies. Acad Med 2002;77:361-7. Crossref

13. Carless D. From teacher transmission of information to student feedback literacy: activating the learner role in feedback processes. Act Learn High Educa 2022;23:143-53. Crossref

14. Garrison DR. E-learning in the 21st century: a framework for research and practice. New York: Taylor & Francis Group; 2011.

15. Holmboes ES, Sherbino J, Englander R, Snell L, Frank JR; ICBME Collaborators. A call to action: the controversy of and rationale for competency-based medical education. Med Teach 2017;39:574-81. Crossref

Advances and opportunities in the new digital era of telemedicine, e-health, artificial intelligence, and beyond

Hong Kong Med J 2023 Oct;29(5):380–2

https://doi.org/10.12809/hkmj235152

EDITORIAL

Advances and opportunities in the new digital era of telemedicine, e-health, artificial intelligence, and beyond

Harry HX Wang, PhD^{1,2,3 #}; Yu-ting Li, MPH^{4 #}; Junjie Huang, PhD⁵; Wenyong Huang, MD⁴; Martin CS Wong, MD, MPH^5,6,7,8,9

¹ School of Public Health, Sun Yat-Sen University, Guangzhou, China

² Department of General Practice, The Second Hospital of Hebei Medical University, Shijiazhuang, China

³ Usher Institute, Deanery of Molecular, Genetic and Population Health Sciences, The University of Edinburgh, Scotland, United Kingdom

⁴ State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China

⁵ Centre for Health Education and Health Promotion, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China

⁶ Editor-in-Chief, Hong Kong Medical Journal

⁷ School of Public Health, Fudan University, Shanghai, China

⁸ The Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

⁹ School of Public Health, Peking University, Beijing, China

^# Equal contribution

Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)

Full paper in PDF

Over the past decade, there has been an explosion in the development and use of digital technologies in health and health-related areas. In 2018, the 71st World Health Assembly Resolution on Digital Health demonstrated collective recognition of the contributions of digital technologies to improving health, reducing health inequalities, and enhancing healthcare services in the context of achieving the Sustainable Development Goals laid down by the United Nations.1 The increasing popularity of digital tools, wearable devices, information systems, and electronic resources in clinical practices and health services has resulted in unique opportunities to reshape healthcare in response to diverse existing and emerging health system challenges. Furthermore, technological innovations have been evolving at an unprecedented scale, transforming the ways in which medicine is practised. This transformation has created a range of opportunities for telemedicine and mobile health to transform service delivery, and for advanced ‘big data’ and artificial intelligence approaches to enhance evidence-based decision support. At the global level, the World Health Organization established an e-health vision in its Global Strategy on Digital Health 2020-2025, with strategic objectives and an action framework to support countries in various development contexts when expanding the implementation of digital health technologies.2

In this issue of the Hong Kong Medical Journal, two original articles report survey findings regarding the perception and acceptance of telemedicine, a service which is rapidly expanding to overcome distance barriers in healthcare delivery.3 4 Hung et al3 analysed the experiences of individuals who used telemedicine during the coronavirus disease 2019 (COVID-19) pandemic in Hong Kong. They found a high level of satisfaction with telemedicine consultations; users felt that such consultations were useful in disease diagnosis and management. Choi et al4 explored the values, concerns, and expectations associated with telemedicine among Hong Kong adults aged ≥60 years in two hypothetical scenarios: during a severe outbreak while under government-imposed lockdown, and after the COVID-19 pandemic. The results of both studies supported the use of high-quality telemedicine as a novel approach to enhance clinical consultations and patient education, while emphasising the need for government- and provider-level support to promote and expand services.

There has been global recognition of the power that digital health technologies (eg, telemedicine) have to exchange information for disease diagnosis, treatment, and prevention. For example, the use of telemedicine technologies to educate patients and train community care providers is included in an innovative stepwise approach recommended by the World Kidney Day Steering Committee to improve service affordability and access for patients with kidney disease and their care partners in low-resource settings.5 The increasing access to digital resources and growing popularity of electronic health records have substantially supported patient self-education and public advocacy regarding kidney disease awareness and learning, thereby bridging gaps in kidney health education and literacy.6 Mobile messaging applications and social media platforms, characterised by multi-channel information dissemination and knowledge sharing, also play key roles in meeting the need for community empowerment and public engagement through digital health communications.7

In addition to the collaborative efforts of healthcare professionals and scientists to navigate challenges arising during the COVID-19 pandemic, digital health technologies have significantly contributed to the widespread adoption of the quick-response code–based contact tracing system in many countries. In particular, the LeaveHomeSafe mobile application in Hong Kong has enabled the public to more accurately record the date and time of entering and exiting various locations.8 There has been a remarkable increase in the use of artificial intelligence—a cutting-edge computing science innovation—to inform diagnosis, prognosis, treatment, and triage decisions across clinical settings. As summarised in a recent scoping review, 66 artificial intelligence products and tools have been used in the healthcare response to COVID-19, including pulmonary evaluations, assessments of infection risk, personalised care recommendations, triage decisions, patient deterioration monitoring, and predictions of disease severity.9 Another scoping review specifically examined the cost savings, performance in improving health outcomes, workflow efficiency in treatment and diagnosis, local feasibility, user friendliness, and reliability and trust associated with the implementation of artificial intelligence in low- and middle-income countries.10 Innovations such as clinical decision support systems, treatment planning and triage assistants, and health chatbots have demonstrated the potential to strengthen healthcare systems.10

Regarding the management of arterial hypertension, which is the most important contributor to the global burden of disease, the 2023 European Society of Hypertension Guidelines recommend the use of internet-based, interactive digital interventions in home blood pressure monitoring to enhance the digital storage and transfer of home blood pressure data, and to facilitate evaluation of those data by healthcare professionals.11 Remote clinical management programmes based on standardised home blood pressure monitoring supported by automatic transmission via mobile applications, along with collaborations involving multiple healthcare providers in the context of team-based care, could help reduce nonadherence to antihypertensive treatment. Meta-analyses have shown that virtual care for hypertension, mediated by telemonitoring and smartphone applications, provides benefits such as better patient education, greater blood pressure reduction, and improved cardiovascular outcomes.11 A scientific statement from the American Heart Association has affirmed the utility of telehealth in risk factor modification, medication adherence, and symptom monitoring during the management of various cardiovascular diseases.12

Ophthalmology is another branch of medicine that has closely embraced new models of care to improve patient-physician interactions through digital health innovations, such as multipurpose mobile applications, community-based teleconsultation units, and medical chatbots for improved case triage.13 Additionally, the screening and management of diabetic retinopathy—a major complication of diabetes mellitus and leading cause of preventable blindness worldwide—has been augmented by advances in healthcare digitisation and increasing emphasis on telehealth initiatives. In primary care and community settings, deep learning–based artificial intelligence for automated image-recognition, combined with telemedicine programmes based on low-cost devices and remote interpretation, would enable greater population coverage and facilitate timely referral to ophthalmic specialists for the management of vision-threatening conditions.14

Digital infrastructure can also play a central role in efforts to support and expand research capacity. As accurate and reliable sources of research data, electronic patient record systems have been extensively used in epidemiological investigations of clinical manifestations, radiological characteristics, laboratory results, and biomarkers.15 16 17 18 The use of electronic clinical management systems for patient screening and data collection to identify socio-economic factors, as well as health-protective and health-damaging behaviours associated with quality of life and health outcomes, was demonstrated in a study of childhood cancer survivors in Hong Kong.19

Despite potential risks and challenges related to oversight, regulations, data protection, and privacy—the focus of stepwise capacity-building efforts and mitigation strategies—digital health innovations have been implemented worldwide. Considering the rapid growth and development of digital health technologies, the use of telemedicine, e-health, and artificial intelligence as integral components of routine health service delivery is revolutionising medicine and health; the greatest impacts involve management of the increasingly complex conditions and circumstances encountered in primary care.20 These innovations and advancements will benefit medical education, clinical practice, and healthcare delivery, thereby ensuring service quality, accessibility, and affordability. In terms of effectiveness, acceptability, and feasibility, studies with rigorously designed methodologies in various contexts are needed to formulate evidence-based recommendations regarding the use of digital health technologies.

Author contributions

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

The authors have declared no conflicts of interest.

References

1. World Health Organization. WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: World Health Organization; 2019.

2. World Health Organization. Global strategy on digital health 2020-2025. Geneva: World Health Organization; 2021.

3. Hung KK, Chan EY, Lo ES, Huang Z, Wu JC, Graham CA. User perceptions of COVID-19 telemedicine testing services, disease risk, and pandemic preparedness: findings from a private clinic in Hong Kong. Hong Kong Med J 2023;29:404-11. Crossref

4. Choi MC, Chu SH, Siu LL, et al. Telemedicine acceptance by older adults in Hong Kong during a hypothetical severe outbreak and after the COVID-19 pandemic: a cross-sectional cohort survey. Hong Kong Med J 2023;29:412-20. Crossref

5. Kalantar-Zadeh K, Li PK, Tantisattamo E, et al. Living well with kidney disease by patient and care partner empowerment: kidney health for everyone everywhere. Hong Kong Med J 2021;27:97-8. Crossref

6. Langham RG, Kalantar-Zadeh K, Bonner A, et al. Kidney health for all: bridging the gap in kidney health education and literacy. Hong Kong Med J 2022;28:106.e1-8. Crossref

7. Wang HH, Li YT, Wong MC. Leveraging the power of health communication: messaging matters not only in clinical practice but also in public health. Hong Kong Med J 2022;28:103-5. Crossref

8. Li VW, Wan TT. COVID-19 control and preventive measures: a medico-legal analysis. Hong Kong Med J 2021;27:224-5. Crossref

9. Mann S, Berdahl CT, Baker L, Girosi F. Artificial intelligence applications used in the clinical response to COVID-19: a scoping review. PLOS Digit Health 2022;1:e0000132. Crossref

10. Ciecierski-Holmes T, Singh R, Axt M, Brenner S, Barteit S. Artificial intelligence for strengthening healthcare systems in low- and middle-income countries: a systematic scoping review. NPJ Digit Med 2022;5:162. Crossref

11. Mancia G, Kreutz R, Brunström M, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens 2023 Jun 21. Epub ahead of print.

12. Takahashi EA, Schwamm LH, Adeoye OM, et al. An overview of telehealth in the management of cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2022;146:e558-68. Crossref

13. Tham YC, Husain R, Teo KY, et al. New digital models of care in ophthalmology, during and beyond the COVID-19 pandemic. Br J Ophthalmol 2022;106:452-7. Crossref

14. Vujosevic S, Limoli C, Luzi L, Nucci P. Digital innovations for retinal care in diabetic retinopathy. Acta Diabetol 2022;59:1521-30. Crossref

15. Wang Y, Luo S, Zhou CS, et al. Clinical and radiological characteristics of COVID-19: a multicentre, retrospective, observational study. Hong Kong Med J 2021;27:7-17. Crossref

16. Baig NB, Chan JJ, Ho JC, et al. Paediatric glaucoma in Hong Kong: a multicentre retrospective analysis of epidemiology, presentation, clinical interventions, and outcomes. Hong Kong Med J 2021;27:18-26. Crossref

17. Tam EM, Kwan YK, Ng YY, Yam PW. Clinical course and mortality in older patients with COVID-19: a cluster-based study in Hong Kong. Hong Kong Med J 2022;28:215-22. Crossref

18. Kwok CC, Wong WH, Chan LL, et al. Effects of primary granulocyte-colony stimulating factor prophylaxis on neutropenic toxicity and chemotherapy dose delivery in Chinese patients with breast cancer who received adjuvant docetaxel plus cyclophosphamide chemotherapy: a retrospective cohort study. Hong Kong Med J 2022;28:438-46. Crossref

19. Cheung YT, Yang LS, Ma JC, et al. Health behaviour practices and expectations for a local cancer survivorship programme: a cross-sectional study of survivors of childhood cancer in Hong Kong. Hong Kong Med J 2022;28:33-44. Crossref

20. Wang HH, Li YT, Wong MC. Strengthening attributes of primary care to improve patients’ experiences and population health: from rural village clinics to urban health centres. Hong Kong Med J 2022;28:282-4. Crossref

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