Around 850 million people are currently affected by different types of kidney disorders.1 Up to one in 10 adults worldwide has chronic kidney disease (CKD), which is invariably irreversible and mostly progressive. The global burden of CKD is increasing, and CKD is projected to become the fifth most common cause of years of life lost globally by 2040.2 If CKD remains uncontrolled and if the affected person survives the ravages of cardiovascular and other complications of the disease, CKD progresses to end-stage renal disease (ESRD), where life cannot be sustained without dialysis therapy or kidney transplantation. Hence, CKD is a major cause of catastrophic health expenditure.3 The costs of dialysis and transplantation consume 2% to 3% of the annual healthcare budget in high-income countries, and spent on <0.03% of the total population of these countries.4

Importantly, however, kidney disease can be prevented and progression to ESRD can be delayed with appropriate access to basic diagnostics and early treatment including lifestyle modifications and nutritional interventions.4 5 6 7 8 Despite this, access to effective and sustainable kidney care remains highly inequitable across the world, and kidney disease a low health priority in many countries. Kidney disease is crucially missing from the international agenda for global health. Notably absent from the impact indicators for the Sustainable Development Goal Goal 3. Target 3.4: “By 2030, reduce by one third premature mortality from non-communicable diseases (NCDs) through prevention and treatment and promote mental health and well-being” and from the latest iteration of the United Nations Political Declaration on NCDs, kidney diseases urgently need to be given political attention, priority, and consideration.9 Current global political commitments on NCDs focus largely on four main diseases: cardiovascular disease (CVD), cancer, diabetes, and chronic respiratory diseases. Yet, it is estimated that 55% of the global NCD burden is attributed to diseases outside of this group.10 Furthermore, kidney disease frequently co-exists with one or more of the above four major NCDs, leading to worse health outcomes. Chronic kidney disease is a major risk factor for heart disease and cardiac death, as well as for infections such as tuberculosis, and is a major complication of other preventable and treatable conditions including diabetes, hypertension, human immunodeficiency virus, and hepatitis.4 5 6 7 As the Sustainable Development Goals and Universal Health Coverage agendas progress and provide a platform for raising awareness of NCD healthcare and monitoring needs, targeted action on kidney disease prevention should become integral to the global policy response.1 The global kidney health community calls for the recognition of kidney disease and effective identification and management of its risk factors as a key contributor to the global NCD burden and the implementation of an integrated and people-centred approach to care.

According to the expert definitions including the Centers for Disease Control and Prevention,11 the term “prevention” refers to activities that are typically categorised by the following three definitions: (1) primary prevention, which implies intervening before health effects occur in an effort to prevent the onset of illness or injury before the disease process begins; (2) secondary prevention, which suggests preventive measures that lead to early diagnosis and prompt treatment of a disease to prevent more severe problems developing and includes screening to identify diseases in the earliest stages; and (3) tertiary prevention, which indicates managing disease after it is well established in order to control disease progression and the emergence of more severe complications, which is often by means of targeted measures such as pharmacotherapy, rehabilitation, and screening for and management of complications. These definitions have an important bearing on the prevention and management of the CKD, and accurate identification of risk factors that cause CKD or lead to faster progression to renal failure as shown in the Figure are relevant in health policy decisions and health education and awareness related to CKD.12

The incidence and prevalence of CKD have been rising worldwide.13 This primary level of prevention requires awareness of modifiable CKD risk factors and efforts to focus healthcare resources on those patients who are at the highest risk of developing new onset or de novo CKD.

Measures to achieve effective primary prevention should focus on the two leading risk factors for CKD including diabetes mellitus and hypertension. Evidence suggests that an initial mechanism of injury is renal hyperfiltration with seemingly elevated glomerular filtration rate (GFR), above normal ranges. This is often the result of glomerular hypertension that is often seen in patients with obesity or diabetes mellitus, but it can also occur after high dietary protein intake.8 Other CKD risk factors include polycystic kidneys or other congenital or acquired structural anomalies of the kidney and urinary tracts, primary glomerulonephritis, exposure to nephrotoxic substances or medications (such as nonsteroidal anti-inflammatory drugs), having one single kidney, eg, solitary kidney after cancer nephrectomy, high dietary salt intake, inadequate hydration with recurrent volume depletion, heat stress, exposure to pesticides and heavy metals (as has been speculated as the main cause of Mesoamerican nephropathy), and possibly high protein intake in those at higher risk of CKD.8 Among non-modifiable risk factors are advancing age and genetic factors such as apolipoprotein 1 gene that is mostly encountered in those with sub-Saharan African ethnicity, especially among African Americans. Certain disease states may cause de novo CKD such as cardiovascular and atheroembolic diseases (also known as secondary cardiorenal syndrome) and liver diseases (hepatorenal syndrome). Some of the risk factors of CKD are shown in the Table.

Among measures to prevent the emergence of de novo CKD are screening efforts to identify and treat patients at high risk of CKD, especially those with diabetes mellitus and hypertension. Hence, targeting primordial risk factors of these two conditions including metabolic syndrome and overnutrition is relevant to primary CKD prevention as is correcting obesity.14 Promoting healthier lifestyle is an important means to that end including physical activity and healthier diet. The latter should be based on more plant-based foods with less meat, less sodium intake, more complex carbohydrates with higher fibre intake, and less saturated fat. In those with hypertension and diabetes, optimising blood pressure and glycaemic control has shown to be effective in preventing diabetic and hypertensive nephropathies. A recent expert panel suggested that patients with solitary kidney should avoid high protein intake >1 g/kg body weight per day.15 Obesity should be avoided, and weight reduction strategies should be considered.14

Evidence suggests that among patients with CKD, the vast majority have an early stage of the disease, ie, CKD stages 1 and 2 with microalbuminuria (30-300 mg/day) or CKD stage 3B (ie, estimated GFR between 45 and 60 mL/min/1.73 m²).16 In these patients with pre-existing disease, the secondary prevention of CKD has the highest priority. For these earlier stages of CKD, the main goal of kidney health education and clinical interventions is how to slow disease progression. Uncontrolled or poorly controlled hypertension is one of the most established risk factors for faster CKD progression. The underlying pathophysiology of faster CKD progression relates to ongoing damage to the kidney structure and loss of nephrons with worsening interstitial fibrosis as it happens with sustained hypertension. A target of blood pressure of <130/80 mmHg should be recommended.

The cornerstone of the pharmacotherapy in secondary prevention is the use of angiotensin pathway modulators, also known as renin-angiotensin- aldosterone system inhibitors. These drugs reduce both systemic blood pressure and intraglomerular pressure by opening efferent arterioles of the glomeruli, hence, leading to longevity of the remaining nephrons. Low-protein diet appears to have a synergistic effect on renin-angiotensin- aldosterone system inhibitor therapy.17 In terms of the potential effect of controlling glycaemic status and correcting obesity on the rate of CKD progression, there are mixed data. However, recent data suggest that a new class of antidiabetic medications known as sodium-glucose cotransporter-2 inhibitors can slow CKD progression, but this effect may not be related to glycaemic modulation of the medication. The CREDENCE study demonstrated that the risk of renal failure is significantly lower in the canagliflozin group than the placebo group.18 Another emerging antidiabetic agent in delaying kidney injury is the glucagon-like peptide-1 receptor agonist.19 A glycated haemoglobin level of <7% should be the goal. Whereas acute kidney injury (AKI) may or may not cause de novo CKD, AKI events that are superimposed on pre-existing CKD may accelerate disease progression.20 In particular, judicious use of nephrotoxic agents (such as iodine-based contrast, chemotherapeutic agents and immunomodulatory drugs) in patients with pre-existing CKD is imperative in order to prevent new AKI. A relatively recent case of successful secondary prevention that highlights the significance of implementing preventive strategies in CKD is the use of a vasopressin V2-receptor antagonists in autosomal dominant polycystic kidney disease.21

In patients with advanced CKD, management of uraemia and related co-morbid conditions such as anaemia, mineral and bone disorders, and CVD is of high priority, so that these patients can continue to achieve the highest longevity. These measures can be collectively referred to as tertiary prevention of CKD. In these patients, CVD burden is exceptionally high, especially if they have underlying diabetes or hypertension, while they often do not follow other traditional profile of cardiovascular risk such as obesity or hyperlipidaemia. Indeed, in these patients, a so-called reverse epidemiology exists, in which hyperlipidaemia and obesity appear to be protective at this advanced stage of CKD. This could be due to the overshadowing impact of the protein-energy wasting that happens more frequently with worsening uraemia and which is associated with weight loss and poor outcomes including CVD and death. Whereas many of these patients, if they survive ravages of protein-energy wasting and CVD, will eventually receive renal replacement therapy in form of dialysis therapy or kidney transplantation, a new trend is emerging to maintain them longer without dialysis by implementing conservative management of CKD. However, in some with additional co-morbidities such as metastatic cancers, palliative measures with supportive care can be considered.

The lack of awareness of CKD around the world is one of the reasons for late presentation of CKD in both developed and developing economies.22 23 24 The overall CKD awareness among the general population and even high cardiovascular risk groups across 12 low-income and middle-income countries (LMIC) was <10%.24

Given its asymptomatic nature, screening of CKD plays an important role in early detection. Consensus and positional statements have been published by the International Society of Nephrology,25 National Kidney Foundation,26 Kidney Disease Improving Global Outcomes,27 NICE Guidelines,28 and Asian Forum for Chronic Kidney Disease Initiatives.29 There was lack of trials to evaluate screening and monitoring of CKD.30 Currently, most will promote a targeted screening approach to early detection of CKD. Some of the major groups at risk for targeted screening include patients with diabetes; hypertension; patients with a family history of CKD; patients taking potentially nephrotoxic drugs, herbs, substances, or indigenous medicines; patients with a history of AKI; and patients aged >65 years.29 31 Chronic kidney disease can be detected with two simple tests: a urine test for the detection of proteinuria and a blood test to estimate the GFR.26 29

Given that currently a population screening for CKD is not recommended and it was claimed that it might add unintended harm to the general population being screened,30 there is no speciality society or preventive services group which recommends general screening.32 Low-to-middle-income countries are ill-equipped to deal with the devastating consequences of CKD, particularly the late stages of the disease. There are suggestions that screening should primarily include high-risk patients, but also extend to those with suboptimal levels of risk, eg, pre-diabetes and prehypertension.33

Universal screening of the general population would be time-consuming, expensive, and has been shown to be not cost-effective. Unless selectively directed towards high-risk groups, such as the case of unknown cause of CKD in disadvantaged populations,34 according to a cost-effectiveness analysis using a Markov decision analytic model, population-based dipstick screening for proteinuria has an unfavourable cost-effectiveness ratio.35 A more recent Korean study confirmed that their National Health Screening Program for CKD is more cost-effective for patients with diabetes or hypertension than the general population.36 From an economic perspective, screening CKD by detection of proteinuria was shown to be cost-effective in patients with hypertension or diabetes in a systematic review.37 The incidence of CKD, rate of progression, and effectiveness of drug therapy were major drivers of cost-effectiveness and thus CKD screening may be more cost-effective in populations with higher incidences of CKD, rapid rates of progression, and more effective drug therapy.

The approach towards CKD early detection will include the decision for frequency of screening, who should perform the screening and intervention after screening.23 Screening frequency for targeted patients should be yearly if no abnormality is detected on initial evaluation. This is in line with the Kidney Disease Improving Global Outcomes resolution that the frequency of testing should be according to the target group to be tested and generally needs not be more frequent than once per year.27 Who should perform the screening is always a question especially when the healthcare professional availability is a challenge in lower-income economies. Physicians, nurses, paramedical staff, and other trained healthcare professionals are eligible to do the screening tests. Intervention after screening is also important and patients detected to have CKD should be referred to primary care and general physicians with experience in management of kidney disease for follow-up. A management protocol should be provided to primary care and general physicians. Further referral to nephrologists for management will be based on the well-defined protocols.24 27 29

Given the close links between CKD and other NCDs, it is critical that CKD advocacy efforts be aligned with existing initiatives concerning diabetes, hypertension, and CVD, particularly in LMIC. Some countries and regions have successfully introduced CKD prevention strategies as part of their NCD programmes. As an example, in 2003, a kidney health promotion programme was introduced in Taiwan, with its key components including a ban on herbs containing aristolochic acid, public awareness campaigns, patient education, funding for CKD research, and the setting up of teams to provide integrated care.38 In Cuba, the Ministry of Public Health has implemented a national programme for the prevention of CKD. Since 1996 the programme has followed several steps: (1) analysis of the resources and health situation in the country; (2) epidemiological research to define the burden of CKD; and (3) continuing education for nephrologists, family doctors, and other health professionals. The main goal has been to bring nephrology care closer to the community through a regional redistribution of nephrology services and joint treatment of patients with CKD by primary healthcare physicians and nephrologists.39 The integration of CKD prevention into NCD programme has resulted in the reduction of renal and cardiovascular risks in the general population. Main outcomes have been the reduction in the prevalence of risk factors, such as low birth weight, smoking, and infectious diseases. There has been an increased rate of the diagnosis of diabetes and of glycaemic control, as well as an increased diagnosis of patients with hypertension, higher prescription use of renoprotective treatment with angiotensin-converting enzyme inhibitor, and higher rates of blood pressure control.40 Recently, the United States Department of Health and Human Services has introduced an ambitious programme to reduce the number of Americans developing ESRD by 25% by 2030. The programme, known as the Advancing American Kidney Health initiative, has set goals with metrics to measure its success; among them is to put more efforts to prevent, detect, and slow the progression of kidney disease, in part by addressing traditional risk factors such as diabetes and hypertension. To reduce the risk of kidney failure, the programme contemplates advancing public health surveillance and research to identify populations at risk and those in early stages of kidney disease, and to encourage adoption of evidence-based interventions to delay or stop progression to kidney failure.41 Ongoing programmes, such as the Special Diabetes Program for Indians, represent an important part of this approach by providing team-based care and care management. After implementation of that programme, the incidence of diabetes-related kidney failure among Indian populations decreased by over 40% between 2000 and 2015.42

Detection and prevention of CKD programmes require considerable resources both in terms of manpower and funds. Availability of such resources will depend primarily on the leadership of nephrologists.43 However, the number of nephrologists is not sufficient to provide renal care to the growing number of patients with CKD worldwide. It has been suggested that most cases of non-progressive CKD can be managed without referral to a nephrologist, and specialist referral can be reserved for patients with an estimated GFR <30 mL/min/1.73 m², rapidly declining kidney function, persistent proteinuria, or uncontrolled hypertension or diabetes.44 It has been demonstrated that with an educational intervention the clinical competence of family physicians increases, resulting in preserved renal function in diabetic patients with early renal disease.45 The practitioners who received the educational intervention used significantly more angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and statins than did practitioners who did not receive it. The results were similar to those found in patients treated by nephrologists.46 The role of primary healthcare professionals in the implementation of CKD prevention strategies in LMIC has been recently illustrated.47

The e-Learning has become an increasingly popular approach to medical education. Online learning programmes for NCD prevention and treatment, including CKD, have been successfully implemented in Mexico. By 2015, over 5000 health professionals (including non-nephrologists) had been trained using an electronic health education platform.48

The resources for nephrology care remain at critical levels in many parts of the world. Even in Western developed countries, nephrologists are frequently in short supply. In a selection of European countries with similar, predominantly public, healthcare systems, there was a substantial variation in the nephrology workforce. Countries such as Italy, Greece, and Spain reported the highest ratios, whereas countries such as Ireland, Turkey, and the United Kingdom had the lowest ratios.49 In the United States, the number of nephrologists per 1000 ESRD patients has declined from 18 in 1997 to 14 in 2010.50 The situation in the developing world is even worse. With the exception of Nigeria, Sudan, Kenya and South Africa, in many countries of sub-Saharan Africa there are <10 nephrologists. The number of nephrology nurses and dialysis technicians is also insufficient.51 In Latin America the average number of nephrologists is 13.4 per million population (pmp). However, there is unequal distribution between countries; those with <10 nephrologists pmp (Honduras, 2.1 pmp; Guatemala, 3.3 pmp; and Nicaragua, 4.6 pmp), and those >25 pmp (Cuba, 45.2 pmp; Uruguay, 44.2 pmp; and Argentina, 26.8 pmp).52

The causes of this shortage are multiple. Potential contributors to this variation include the increasing burden of CKD, erosion of nephrology practice scope by other specialists, lack of workforce planning in some countries relative to others, and the development of new care delivery models.50 A novel strategy has been the successful International Society of Nephrology’s Fellowship programme. Since its implementation in 1985, over 600 fellows from >83 LMIC have been trained. A significant number of fellowships were undertaken in selected developed centres within the fellow’s own region. In a recent survey, 85% of responding fellows were re-employed by their home institutions.53 54

Since 1994, a National Institute of Health consensus advocated for early medical intervention in predialysis patients. Owing to the complexity of care of CKD, it was recommended that patients should be referred to a multidisciplinary team consisting of nephrologist, dietitian, nurse, social worker, and health psychologist, with the aim to reduce predialysis and dialysis morbidity and mortality.55 In Mexico, a nurse-led protocol-driven multidisciplinary programme reported better preservation in estimated GFR and a trend in the improvement of quality of care of patients with CKD similar to those reported by other multidisciplinary clinic programmes in the developed world. Additionally, more patients started dialysis non-emergently, and some obtained a pre-emptive kidney transplant. For those unable to obtain dialysis or who choose not to, a palliative care programme is now being implemented.56 Care models supporting primary care providers or allied health workers achieved better effectiveness in slowing kidney function decline when compared to those providing speciality care. Future models should address region-specific causes of CKD, increase the quality of diagnostic capabilities, establish referral pathways, and provide better assessments of clinical effectiveness and cost-effectiveness.57

Whereas it is important to enhance the promotion and implementation of prevention of kidney disease and kidney failure among healthcare professionals, it is equally important to promote prevention with education programmes for those at risk of kidney disease and kidney failure, and with the general population at large. It is a stepwise process, from awareness, through engagement, participation, and empowerment, to partnership. As highlighted above, in general, the health literacy of the general population is low. Awareness and understanding of kidney disease are inadequate. Education is key to engaging patients with kidney disease. It is the path to self-management and patient-centred care. Narva et al58 found patient education is associated with better patient outcomes. Obstacles include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. New education approaches should be developed through research and quality improvement efforts. Schatell59 found that web-based kidney education is helpful in supporting patient self-management. The internet offers a wealth of resources on education. Understanding the types of internet sources that patients with CKD use today can help renal professionals to point patients in the right direction. It is important that reputable healthcare organisations, preferably at a national level, facilitate users to have easier access to health information on their websites (as shown in online supplementary Appendix). The mode of communication currently used by patients and the population at large is through the internet—websites, portals, and other social media, such as Facebook and Twitter. There are also free apps on popular mobile devices providing education on kidney disease. There is no shortage of information on the internet. The challenge is how to effectively push important healthcare information in a targeted manner, and to facilitate users seeking information in their efforts to pull relevant and reliable information from the internet. It is important that health information is relevant for the condition (primary, secondary or tertiary prevention), and offered at the right time to the right recipient. It is possible, with the use of information technology and informatics, to provide relevant and targeted information for patients at high risk, coupling the information based on diagnosis and drugs prescribed. Engagement of professional society resources and patient groups is a crucial step to promote community partnership and patient empowerment on prevention. Additional resources may be available from charitable and philanthropic organisations.

Given the urgency for increased education and awareness on the importance of the preventive measures, we suggest the following goals to redirect the focus on plans and actions:

1. Empowerment through health literacy in order to develop and support national campaigns that bring public awareness to prevention of kidney disease.
2. Population-based approaches to manage key known risks for kidney disease such as blood pressure control, and effective management of obesity and diabetes.
3. Implementation of the World Health Organization ‘Best Buys’ approach including screening of at-risk populations for CKD, universal access to essential diagnostics of early CKD, availability of affordable basic technologies and essential medicines and task shifting from doctors to frontline healthcare workers to more effectively target the progression of CKD and other secondary preventative approaches.

To that end, the motto “Kidney Health for Everyone, Everywhere” is more than a tagline or wishful thinking. It is a policy imperative which can be successfully achieved if policy-makers, nephrologists, and healthcare professionals place prevention and primary care for kidney disease within the context of their Universal Health Coverage programmes.

PKT Li and K Kalantar-Zadeh serve as the corresponding authors. All the authors contributed equally otherwise. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

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

This article was originally published in Kidney International, volume 97, pages 226-232, Copyright World Kidney Day Steering Committee (2020), and 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.

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51. Naicker S, Eastwood JB, Plange-Rhule J, Tutt RC. Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective. Clin Nephrol 2010;74 Suppl 1:S129-33. Crossref

52. Cusumano AM, Rosa-Diez GJ, Gonzalez-Bedat MC. Latin American Dialysis and Transplant Registry: Experience and contributions to end-stage renal disease epidemiology. World J Nephrol 2016;5:389-97. Crossref

53. Feehally J, Brusselmans A, Finkelstein FO, et al. Improving global health: measuring the success of capacity building outreach programs: a view from the International Society of Nephrology. Kidney Int Suppl (2011) 2016;6:42-51. Crossref

54. Harris DC, Dupuis S, Couser WG, Feehally J. Training nephrologists from developing countries: does it have a positive impact? Kidney Int Suppl (2011) 2012;2:275-8. Crossref

55. Morbidity and mortality of renal dialysis: an NIH consensus conference statement. Consensus Development Conference Panel. Ann Intern Med 1994;121:62-70. Crossref

56. Garcia-Garcia G, Martinez-Castellanos Y, Renoirte-Lopez K, et al. Multidisciplinary care for poor patients with chronic kidney disease in Mexico. Kidney Int Suppl (2011) 2013;3:178- 83. Crossref

57. Stanifer JW, Von Isenburg M, Chertow GM, Anand S. Chronic kidney disease care models in low- and middleincome countries: a systematic review. BMJ Glob Health 2018;3:e000728. Crossref

58. Narva AS, Norton JM, Boulware LE. Educating patients about CKD: the path to self-management and patient-centered care. Clin J Am Soc Nephrol 2016;11:694-703. Crossref

59. Schatell D. Web-based kidney education: supporting patient self-management. Semin Dial 2013;26:154-8. Crossref

Visual impairment in children is a common health issue in China, especially in rural areas where the use of spectacles is limited.1 Visual impairment is a barrier to academic learning among children of school age.2 Appropriate use of spectacles can reduce this barrier and motivate students academically. Although spectacles are a cost-effective and non-invasive remedy for visual impairment, their use is limited among school-age children in rural China.3 In addition to suboptimal ownership, undercorrection or poorly fitted spectacles also contribute to the poor academic performance of these children.4 Previous research has examined this topic among only elementary and lower secondary school students. Few studies have investigated the prevalence of visual impairment and spectacles ownership among upper secondary school students.

In this issue of Hong Kong Medical Journal, Zhao et al5 report the results of their survey of 5583 students of academic and vocational upper secondary schools in northwestern rural China. The authors examined the prevalence of visual impairment and spectacles ownership, as well as the factors associated with spectacles ownership. The authors assessed the participants in terms of visual acuity, spectacles ownership, and demographic characteristics. The overall prevalence of visual impairment was high (72%, 4026/5583) among the population. The prevalence of visual impairment (75% vs 58%) and spectacles ownership (75% vs 35%) was higher in students in academic upper secondary schools than in those in vocational upper secondary schools. The ownership of spectacles was associated with less visual impairment, male sex, residence in urban areas, and attendance at academic upper secondary school. The implication is that comprehensive vision measurements should be implemented to enhance visual care among rural schools in China. In addition to lifestyle modifications, early identification of visual impairment is important to reduce its disease burden. Health promotion programmes can be organised to provide accurate and high-quality spectacles to those in need. The cost-effectiveness of such interventions requires further investigation.

China unveiled a health reform plan in 2009, intending to provide affordable and equitable health care for all Chinese citizens by 2020.6 As a result, there was an increase in high-quality studies from China on various aspects of health science, including control on non-communicable disease, mental disorders, ageing population, maternal and child health, primary care, and health policy.7 However, the growing need for healthcare research into visual impairment in children and other health issues among the underprivileged in China remains unaddressed.

With continuous deepening and broadening engagement in health issues, China has made great strides in healthcare and health science. The quantity and use of data have increased greatly in the past 10 years, particularly in healthcare research.8 Data from the national identification system, the social insurance system, and other sources can now be linked and made available to health researchers. Big data from national surveys, observational studies, or large-scale multicentre studies present new opportunities to generate findings with implications for clinical practice and healthcare policy. Other national data sources, including the discharge summary of inpatients and the death registry, are also available for research purposes. Many health researchers have used these national datasets to evaluate the burden of non-communicable diseases.9 A centralised and integrated database for precision medicine is also under development. This platform may contain relevant demographic data and biological samples collected from a large cohort. The platform will facilitate research for investigators to conduct nationwide, multicentre studies to address specific health issues, and enable researchers to scale up interventions with evidence supported by cost-effectiveness analysis. Academic institutions in China are also pioneering data sharing programmes, including standardised and individual participant data for data harmonisation, performance of meta-analyses, generation of new cohorts, and validation of disease-based dataset.10 This progress enables China to identify and address the most important health issues more efficiently. The rapid development of health research in China might be attributable to several factors. China's economic development over the years has provided ample funding for conducting health-related original studies. In 2017, China's expenditure on research and development summed to 1.8 trillion RMB (US$260 billion), making it the second highest globally.7 Extensive international cooperation is another important contributing factor to the research development in China. Increasing numbers of Chinese researchers have joined different international, collaborative research networks. These exchange platforms and processes have provided opportunities for high-quality research to be conducted in China. Recently, promotion of the application of big data in health research is a national priority to improve healthcare in China.11

Despite the progress made, conducting health research in China remains challenging. As an interdisciplinary field, health research requires attention and efforts from experts in various disciplines, who should communicate and identify needs to facilitate health research. Electronic medical records such as administrative databases are currently primarily used for clinical practice rather than research. The accessibility and quality of the data has remained suboptimal. They contain mostly unstructured data and much missing information. Furthermore, use of individual electronic medical records has been limited by the incompatibility of systems between different hospitals.12 To tackle these issues, medical authorities, hospitals, and other stakeholders must agree on how to strengthen data exchange and compatibility between organisations. In terms of health topics, there are huge research gaps in the quality of health care, control of chronic diseases, efficiency in health delivery, control of medical expenditures, and public satisfaction to health services.13 To reduce the increasing public health burden induced by the ageing population, it is necessary to build a primary healthcare–based delivery system, to improve the quality of healthcare providers, and to educate the public on the importance of disease prevention and health maintenance.

Contrast-enhanced computed tomography plays an important role in emergency and intensive care units. Contrast media is one of the most commonly used agents. Its administration may potentially lead to acute kidney injury (AKI).1 However, it remains unknown whether intravenous contrast media may increase the risk of AKI in patients with sepsis.2 Sepsis is a major cause of admission to intensive care settings and hospital death, and is also a risk factor for AKI.3 4 Therefore, it is important to study the association between contrast media and the incidence of AKI in patients with sepsis.

In this issue of the Hong Kong Medical Journal, Hsu et al5 conducted a study on patients with sepsis who received computed tomography scans with or without contrast media at a tertiary referral centre. The results showed no difference between the two groups in the incidence of AKI, emergent dialysis, mortality, and hospital stay. They concluded that intravenous contrast administration in computed tomographic scans was not associated with increased risk of AKI in patients with sepsis. These findings justified the practice of administering contrast to patients with sepsis in emergency and intensive care settings. As was mentioned by the authors, there were limitations in the study. The study was conducted in only a single site, limiting its generalisability to other populations in different hospital settings. Secondly, a causal relationship could not be established as the analysis was performed by reviewing electronic health records. There may have been selection bias as the control group consisted of patients with older age, higher blood pressure, and poorer renal function. Missing data on lactate and initial serum creatinine had also decreased the statistical power to detect an association. Despite the application of propensity score matching other residual confounders may exist.

Although the above study reported negative results, the Journal accepted this important original study due to its significant clinical implications. Studies that have included negative or inconclusive results,6 7 or those that are mostly descriptive in nature,8 9 have been accepted by the Journal owing to their value and interest to readers in clinical practice or healthcare services. Studies with negative results are usually regarded less favourably in the scientific literature.10 Papers with statistically significant positive results are estimated to be 3 times more likely to be published than studies with negative results.11 In the past years, the proportion of studies with negative results published in scientific literature in most disciplines had been decreasing.12 This will bring forth some important issues, including publications bias.

Publication bias is introduced when the results of a study influence the decision on whether to disseminate them. Publishing only statistically significant findings influences the balance of evaluation and results in potential bias.13 Investigation on publication bias is a key topic in systematic review and meta-analysis. For instance, the funnel plot is a useful tool to test the existence of publication bias in meta-analysis.14 Since there is a preference for publishing studies with positive results, the overall scientific literature contains many more Type I errors (false positive) than Type II errors (false negative).15 This is harmful as the Type I errors may mislead researchers, physicians, and policymakers on evaluating the benefits of an intervention. Awareness of publication bias may deter investigators from submitting negative trials in the first place.

The preference for positive results also contributes to the phenomenon of hypothesising after the results are known (also known as HARKing).16 This happens when researchers review their study results and change their hypotheses without acknowledgement of this process. This commonly observed form of data misinterpretation may be caused by increasing competition in science among researchers. To identify positive results, researchers tend to focus on statistically significant positive results rather than negative ones. More seriously, there are some reports on scientific misconduct of falsifying the data among researchers.17

Not publishing studies with negative results can waste the time, money, and resources of not only those researchers but also of other researchers exploring similar lines of research. Consequently, this vicious circle results in personal discouragement and a significant waste of research resources that could have been allocated to other areas. Although finding that a treatment is ineffective may not be as interesting as positive results, it is a valuable result and worth sharing with the community, provided the study is properly designed and conducted. By doing this, it is unnecessary for other researchers to duplicate and they are less prone to study on the same research question. When healthcare resources are limited, it is important for policymakers to know which interventions are effective and which are not.

Additionally, it may indirectly increase the health risk for patients who are involved in a similar clinical trial using ineffective treatment. Publishing negative results may not only save resources for the participants but also help prevent previously observed adverse events from recurring, especially in the research of drug discovery. Participants offer informed consent for research under the circumstances of benefits outweighing harm to facilitate scientific development. These participants expose themselves to risk and trust the research team. It is a moral obligation for researchers to report and disseminate the results irrespective of the outcomes.

Many challenges discourage different contributors from publishing manuscripts with negative results. There is no doubt that many journal editors prefer to publish studies with positive results which are more interesting and will attract more citations. For journals, more citations can contribute to better reputation, higher quality submissions, and more advertising revenues. On the contrary, editors might take the opposite view since procedures or treatments proven ineffective by negative studies could lead to subsequent omission of their use.

From the perspective of researchers, they are also more likely to choose not to submit studies with negative results. However, the major reason for this is lack of time and priority rather than fear of rejection by the journals.13 They may turn to investigate other novel and promising research projects instead of writing up the results of a negative trial. Among the fields of hot research topics, there are many more options for them to study. With negative studies published, they may be reluctant to admit that they had selected the wrong hypothesis.

Other stakeholders, such as pharmaceutical companies or sponsors may also prefer not to disseminate negative findings. Clinical trials sponsored by industry are less likely to get published compared to studies initiated by the academia.18 For clinicians, it is relatively difficult to incorporate negative study findings into clinical practice owing to improper dissemination of such study findings; poorly designed decision tools for clinical use; and confusion caused by inconsistent study results, scepticism of new data, and information overload.19

The problem of unethical publication bias has led many academic organisations, including the International Committee of Medical Journal Editors (ICMJE),20 the World Health Organization,21 and the Committee on Publication Ethics (COPE)22 to implement relevant recommendations and guidelines that recommend journals require publishing the registration number of clinical trials and support disseminating the findings of previously unreported clinical trials.20 21 This is also supported by the Consolidated Standards of Reporting Trials Statement (CONSORT)23 guidelines and the Declaration of Helsinki.24 Some journals offer publication of trial protocols in advance of completion of the study, with an undertaking to publish the results irrespective of whether they are positive or negative.

Researchers have now formed an All Trials campaign to support reporting unpublished clinical studies owing to the observed irreproducibility of many published studies. The campaign endorses publication of negative findings to gather all data on the evaluation of interventions.25 Reviewers and editors should not bury studies investigating important research questions that fail to illustrate a treatment effect. Care should also be taken to differentiate true negative findings from low-quality studies, to ensure the results are not caused by chance. Some journals publish mainly negative findings, such as the Journal of Pharmaceutical Negative Results; however, others have already ceased publication, such as the Journal of Negative Results in BioMedicine. It is uncertain if such journals might produce bias, as publication of studies with negative findings is preferred. Standards for publishing are the study quality and statistical power regardless of the results, and appropriate study design in non-superiority and equivalence trials. The findings from well-conducted research can be trusted irrespective of proving or rejecting the null hypothesis.

We wish to emphasise that the Hong Kong Medical Journal is committed to publishing high-quality reports of research relevant to the journal’s scope for clinical practice, including those with negative results.26 A well-performed negative study is a positive contribution to science and clinical practice, and can contribute to the judicious use of healthcare resources. The relevance of research questions and the quality of the methodology are the important aspects we wish to evaluate. We suggest that research outcomes should be reported for articles irrespective of their statistical significance and they should comply with the reporting guidelines from relevant organisations or academic groups. It is also advised to report effect size and confidence intervals for all clinical outcomes. To conclude, researchers, reviewers, editors, readers, and sponsors need to be aware of the importance of negative findings and promote disseminating negative and positive results alike.

MCS Wong and JH Huang contributed to the drafting of the article; D Weller and R Jones reviewed and revised the article. All authors approved the final version for publication.

The authors have declared no conflicts of interest.

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

1. Pasternak JJ, Williamson EE. Clinical pharmacology, uses, and adverse reactions of iodinated contrast agents: a primer for the non-radiologist. Mayo Clinic 2012;87:390-402. Crossref

2. Hinson JS, Al Jalbout N, Ehmann MR, Klein EY. Acute kidney injury following contrast media administration in the septic patient: A retrospective propensity-matched analysis. J Crit Care 2019;51:111-6. Crossref

3. Poston JT, Koyner JL. Sepsis associated acute kidney injury. BMJ 2019;364:k4891. Crossref

4. Lam SM, Lau AC, Lam RP, Yan WW. Clinical management of sepsis. Hong Kong Med J 2017;23:296-305. Crossref

5. Hsu YC, Su HY, Sun CK, Liang CY, Chen TB, Hsu CW. Risk of post-contrast acute kidney injury in emergency department patients with sepsis. Hong Kong Med J 2019;25:429-37. Crossref

6. Lo W, Fung GP, Cheung PC. Factors associated with multi-disciplinary case conference outcomes in children admitted to a regional hospital in Hong Kong with suspected child abuse: a retrospective case series with internal comparison. Hong Kong Med J 2017;23:454-61. Crossref

7. Cheung TK, Cheng TC, Wong LY. Willingness for deceased organ donation under different legislative systems in Hong Kong: population-based cross-sectional survey. Hong Kong Med J 2018;24:119-27. Crossref

8. Chow JF, Yeung WS, Lee VC, Lau EY, Ho PC, Ng EH. Preimplantation genetic diagnosis and screening by array comparative genomic hybridisation: experience of more than 100 cases in a single centre. Hong Kong Med J 2017;23:129- 33. Crossref

9. Cheung MY, Ho AW, Wong SH. Post-fracture care gap: a retrospective population-based analysis of Hong Kong from 2009 to 2012. Hong Kong Med J 2018;24:579-83. Crossref

10. Duyx B, Urlings MJ, Swaen GM, Bouter LM, Zeegers MP. Scientific citations favor positive results: a systematic review and meta-analysis. J Clin Epidemiol 2017;88:92-101. Crossref

11. Dickersin K, Chan S, Chalmers TC, Sacks HS, Smith H Jr. Publication bias and clinical trials. Control Clin Trials 1987;8:343-53. Crossref

12. Fanelli D. Negative results are disappearing from most disciplines and countries. Scientometrics 2012;90:891-904. Crossref

13. Song F, Parekh S, Hooper L, et al. Dissemination and publication of research findings: an updated review of related biases. Health Technol Assess 2010;14:iii,ix-xi,1-193. Crossref

14. Sterne JA, Sutton AJ, Ioannidis JP, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ 2011;343:d4002. Crossref

15. Connor JT. Positive reasons for publishing negative findings. Am J Gastroenterol 2008;103:2181-3. Crossref

16. Kerr NL. HARKing: hypothesizing after the results are known. Pers Soc Psychol Rev 1998;2:196-217. Crossref

17. Rahman MS, Yoshida N, Tsuboi H, et al. The health consequences of falsified medicines—A study of the published literature. Trop Med Int Health 2018;23:1294-303. Crossref

18. Stefaniak JD, Lam TC, Sim NE, Al-Shahi Salman R, Breen DP. Discontinuation and non-publication of neurodegenerative disease trials: a cross-sectional analysis. Eur J Neurol 2017;24:1071-6. Crossref

19. Mitka M. Clinicians remain reluctant to allow negative findings to influence practice. JAMA 2012;308:1305-6. Crossref

20. International Committee of Medical Journal Editors. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals. Available from: http://www.icmje.org/recommendations/. Accessed 17 Nov 2019.

21. World Health Organization. Statement on Public Disclosure of Clinical Trial Results. Available from: http://www.who.int/ictrp/results/reporting/en/. Accessed 17 Nov 2019.

22. Committee on Publication Ethics. Code of conduct and best practice guidelines for journal editors. Available from: https://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf. Accessed 17 Nov 2019.

23. Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. Crossref

24. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013;310:2191-4. Crossref

25. AllTrials Campaign. All trials registered. All results reported. Available from: http://www.alltrials.net/wp-content/uploads/2013/09/What-does-all-trials-registered-and-reported-mean.pdf. Accessed 17 Nov 2019.

26. Wong MC. Exerting an impact on clinical practice— upholding quality, visibility, and timeliness of publications. Hong Kong Med J 2017;23:4-5.Crossref

Urological symptoms are very common and could present in a wide variety of forms.1 2 In this issue of Hong Kong Medical Journal, Cheng et al3 report on emergency attendances and hospitalisations for complications within 30 days after transrectal ultrasound-guided prostate (TRUS) biopsy in two hospitals in Hong Kong. The recorded complications tend to be those that are more severe and require emergency attendances or hospitalisations. Reported rates of sepsis are more accurate as they usually require hospital care. The reported rates of complications such as per rectal bleeding (0.4%) and gross haematuria (2.1%) were patients that required hospital care, and these are likely much lower than the actual rates. Reported rates of per rectal bleeding and gross haematuria in a systematic review were 11% to 40% and 28% to 64%, respectively.4 Although most complications subside within 1 to 2 weeks, there are some potential adverse events that patients should acknowledge. Another point to note is that about 50% of biopsies in this series had <10 biopsy cores taken and this might contribute to a lower complication rate.

Cheng et al3 should be complimented for the low sepsis rate (1.2% fever, 0.9% sepsis) after TRUS biopsy, when the rate can be up to 6% in some series. Transperineal prostate biopsy is an alternative that can achieve near zero sepsis rates, as reported in Caucasian men5 and in Chinese men.6 There is also no per rectal bleeding in transperineal biopsy. A ‘Trexit’ initiative to convert all prostate biopsies to transperineal under local anaesthesia has been rolled out in south-east London with the aim to achieve fewer infective complications.7 More and more prostate biopsies have been converted to transperineal biopsy in Hong Kong with the aim to eliminate septic complications after prostate biopsy.

In Chinese men with prostate-specific antigen (interquartile range, 5.5-12.6 ng/mL), the positive biopsy rate reported by Cheng et al is 19.8%.3 This is much lower than the reported rates of 26% to 47% in Caucasian series with prostate-specific antigen <10 ng/mL.8 This is a commonly reported phenomenon among Asian or Chinese men, and indicates that, if most biopsy decisions are based on prostate-specific antigen alone, Chinese or Asian men may undergo more unnecessary biopsies than do Caucasian men. This may raise the question of whether a risk-stratification approach to reduce unnecessary biopsies is more important than improving positive biopsy rates. Using simple and cost-effective tools like prostate cancer risk calculators or blood tests like the prostate health index could reduce unnecessary biopsies and in turn reduce biopsy complications.9 10 A multi-parametric magnetic resonance imaging scan of the prostate is also an important tool to improve diagnosis of significant prostate cancer, enable targeted biopsy, and reduce unnecessary biopsies.11 However, magnetic resonance imaging is more costly, not easily available in public healthcare setting, and there is a lack of reporting expertise. Furthermore, poorly reported magnetic resonance images with a lot of false positives might also increase unnecessary biopsies. Above all, the principle of primum non nocere (first, to do no harm) should be adhered to; in active surveillance among patients with low-risk prostate cancer, unnecessary biopsies should be avoided.12

Finally, using fluoroquinolone as a routine antibiotic prophylaxis for prostate biopsy has been challenged in recent years. Adverse effects of fluoroquinolone antibiotics include tendon ruptures or pain, muscle weakness, numbness or neuropathy, psychiatric adverse events, and life-threatening hypoglycaemia coma in patients with diabetes mellitus. The Food and Drug Administration in the United States issued a drug safety announcement on fluoroquinolones in 2018.13 The European Commission issued a legally binding decision in March 2019 on the restriction of use of fluoroquinolone antibiotics, including their use in prevention of recurrent urinary tract infection and in prophylaxis before urological procedures.14 This is supported by the European Association of Urology Infections guidelines committee, and fluoroquinolone is expected to be removed from the list of suggested prophylaxis before TRUS prostate biopsy in the next guideline update.

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.

The authors have disclosed no conflicts of interest.

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

1. Egan KB. The epidemiology of benign prostatic hyperplasia associated with lower urinary tract symptoms: Prevalence and incident rates. Urol Clin North Am 2016;43:289-97. Crossref

2. Chan SY, Ng CF, Lee KW, et al. Differences in cancer characteristics of Chinese patients with prostate cancer who present with different symptoms. Hong Kong Med J 2017;23:6-12. Crossref

3. Cheng KC, Lam WC, Chan HC, et al. Emergency attendances and hospitalisations for complications after transrectal ultrasound-guided prostate biopsies: a 5-year retrospective multicentre study. Hong Kong Med J 2019;25:349-55. Crossref

4. Loeb S, Vellekoop A, Ahmed HU, et al. Systematic review of complications of prostate biopsy. Eur Urol 2013;64:876-92. Crossref

5. Stefanova V, Buckley R, Flax S, et al. Transperineal prostate biopsies using local anesthesia: Experience with 1,287 patients. Prostate cancer detection rate, complications and patient tolerability. J Urol 2019;201:1121-6. Crossref

6. Lo KL, Chui KL, Leung CH, et al. Outcomes of transperineal and transrectal ultrasound-guided prostate biopsy. Hong Kong Med J 2019;25:209-15. Crossref

7. The Trexit initiative: transperineal prostate biopsies under local anaesthetic. Available from: nhsaccelerator.com/trexit-initiative-transperineal-prostate-biopsies-local-anaesthetic/. Accessed 24 Jun 2019.

8. Vickers AJ, Cronin AM, Roobol MJ, et al. The relationship between prostate-specific antigen and prostate cancer risk: the Prostate Biopsy Collaborative Group. Clin Cancer Res 2010;16:4374-81. Crossref

9. Chiu PK, Alberts AR, Venderbos LD, Bangma CH, Roobol MJ. Additional benefit of using a risk-based selection for prostate biopsy: an analysis of biopsy complications in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer. BJU Int 2017;120:394-400. Crossref

10. Ng CF, Chiu PK, Lam NY, Lam HC, Lee KW, Hou SS. The Prostate Health Index in predicting initial prostate biopsy outcomes in Asian men with prostate-specific antigen levels of 4-10 ng/mL. Int Urol Nephrol 2014;46:711-7. Crossref

11. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med 2018;378:1767-77. Crossref

12. Tsang CF, Tsu JH, Lai TC, et al. Pathological outcome for Chinese patients with low-risk prostate cancer eligible for active surveillance and undergoing radical prostatectomy: comparison of six different active surveillance protocols. Hong Kong Med J 2017;23:609-15. Crossref

13. FDA updates warnings for fluoroquinolone antibiotics on risks of mental health and low blood sugar adverse reactions. Available from: www.fda.gov/news-events/press-announcements/fda-updates-warnings-fluoroquinolone-antibiotics-risks-mental-health-and-low-blood-sugar-adverse. Accessed 24 Jun 2019.

14. European Medicine Agencies. EMA/175398/2019. 11 March 2019.

Out-of-hospital cardiac arrest (OHCA) is the most time-critical and challenging medical emergency. Patient survival depends on a “strong chain of survival” requiring the community, call centres, ambulances, and hospitals working together. Early cardiopulmonary resuscitation (CPR) and defibrillation are crucial for successful outcomes. Despite improvements in early intervention, improved surveillance, and increased public awareness in recent decades, the overall survival rate of OHCA remains low. According to the United States data in 2017, 10.4% of OHCA patients survived to hospital discharge.1 In Europe, 10.3% of OHCA patients survived for at least 30 days or to hospital discharge.2 A study published in 2017 found that the figure for Hong Kong was even lower: only 2.3% of OHCA patients survived for at least 30 days or to hospital discharge.3 Furthermore, knowledge of automatic external defibrillator use and first aid training among the general public in Hong Kong are also low.4

Researchers and medical practitioners have long searched for better interventions that may prevent cardiac arrest or reduce the number of deaths. Preventive measures such as screening for high-risk groups and using implantable cardioverter-defibrillators are effective in the prevention of cardiac arrest. However, these measures are costly and there are procedural and long-term risks, such as infection and device or lead malfunction, which limit their use and coverage.5 Therefore, OHCA remains a challenge and initiatives aimed at optimising the quality and outcome of resuscitation are important. The Resuscitation Academy of the United States6 has published numerous initiatives to improve OHCA survival, among which setting up a Cardiac Arrest Registry was considered as the first step for continuous quality improvement.

In 2015, the Institute of Medicine published a report titled Strategies to Improve Cardiac Arrest Survival: A Time to Act7 that emphasised the significance of establishing a National Cardiac Arrest Registry as the first recommendation out of eight. In this issue of the Hong Kong Medical Journal, Lui et al8 review OHCA registries worldwide and discuss the urgent need for a territory-wide registry for OHCA. They argue that setting up such a registry is a critical step to improve the outcomes of OHCA in Hong Kong as it enables data-driven assessment of the process and outcomes of OHCA management. Through ongoing and systematic collection of high-quality data, improvement efforts can be tracked, benchmarked, and refined.9 Data collected through an OHCA registry could enable high-quality research to identify areas for improvement that would strengthen the chain of survival.10 11 However, effective implementation can be challenging. The government plays a crucial role in assembling resources, infrastructure, and personnel that will be required to successfully establish, implement and sustain an OHCA registry. It may be practical to set up a government-led committee to govern and manage the registry. Emergency medical services personnel and healthcare workers would be ideally placed to oversee the overall operation of the registry and ensure consistent data contributions.

Data collected through an OHCA registry can be used for analysis and for planning improvements. In addition, these data can reveal controversial aspects of cardiac arrest. Also in this issue of the Hong Kong Medical Journal, So et al12 discuss the difficulties of making a declaration of medical futility and a decision on termination of resuscitation (TOR). The decision of TOR is difficult to make but it can help reduce futile medical care of OHCA patients.13

Despite researchers working hard to refine the guidelines for TOR best practice, the discussion over when to stop resuscitation remains controversial. Clinical judgement will always be critical in deciding TOR timing; however, surveillance data from an OHCA registry can provide more objective figures for medical researchers to analyse and establish better guidelines for TOR. It is extremely important that TOR guidelines are regularly updated with the latest surveillance data analysis and advances in medical technology.

An OHCA registry is a fundamental source of data for cardiac arrest and a cornerstone for understanding the current OHCA burden as well as for designing effective improvement plans. Potential roles for an OHCA registry extend far beyond epidemiological research, from deployment of resources to health economics, from the evaluation of bystander CPR to monitoring the OHCA outcomes, and from outcome improvement to the development of guidelines. Despite efforts by researchers and medical professionals to uphold the current standards, the survival rate of OHCA in Hong Kong remains very low. Hong Kong has already implemented successful policies on protection of rescuers and public access to defibrillators.14 15 Given the successful experiences from nearby countries such as Japan and Singapore that have introduced OHCA registries,16 17 18 it is of pressing need to establish such a territory-wide OHCA registry in Hong Kong.

The author contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has disclosed no conflicts of interest.

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

1. Cardiac Arrest Registry to Enhance Survival, United States. CARES Annual Report 2017. Available from: https://mycares.net/sitepages/uploads/2018/2017flipbook/index.html?page=26. Accessed 1 Apr 2019.

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

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

4. Fan KL, Leung LP, Poon HT, Chiu HY, Liu HL, Tang WY. Public knowledge of how to use an automatic external defibrillator in out-of-hospital cardiac arrest in Hong Kong. Hong Kong Med J 2016;22:582-8. Crossref

5. Marine JE, Russo AM. Primary prevention of sudden cardiac death in heart failure and cardiomyopathy. Available from: https://www.uptodate.com/contents/primary-prevention-of-sudden-cardiac-death-in-heart-failure-and-cardiomyopathy. Accessed 15 May 2019.

6. Resuscitation Academy, United States. 10 Steps for improving survival from cardiac arrest. 2010. Available from: http://www. resuscitationacademy.org/downloads/ebook/10_steps_2018.pdf. Accessed 1 Apr 2019.

7. Robert G, Margaret AM, Andrea MS. Strategies to Improve Cardiac Arrest Survival: A Time to Act. Board on Health Sciences Policy; Institute of Medicine, Washington (DC): National Academies Press (US); 2015.

8. Lui CT, Lau CL, Siu AY, Fan KL, Leung LP. Hong Kong needs a territory-wide registry for out-of-hospital cardiac arrest. Hong Kong Med J 2019;25:222-7.

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