Drug non-adherence and associated risk factors among Chinese geriatric patients in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:284-92 | Number 4, August 2007
ORIGINAL ARTICLE
Drug non-adherence and associated risk factors among Chinese geriatric patients in Hong Kong
PW Lam, CM Lum, MF Leung
Specialty Outpatient Department, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVES. To study the prevalence of drug non-adherence among Chinese elderly people and its associated risk factors.
 
DESIGN. Cross-sectional survey.
 
SETTING. Medical and Geriatrics specialist out-patient clinic in a regional hospital.
 
PATIENTS. Elderly patients (≥5 years) with chronic diseases requiring regular medications were selected by systematic sampling.
 
MAIN OUTCOME MEASURES. Drug non-adherence; potential risk factors studied include patients' factors, availability of assistance, and prescription factors.
 
RESULTS. Two hundred and nine elders participated with 84% response rate. Estimated mean prevalence rate of drug non-adherence was 37% (standard deviation, 7%). The risk factors for drug non-adherence were: (1) self-perceived adverse drug effects (odds ratio=2.5; 95% confidence interval, 1.2-5.2; P=0.017); (2) use of respiratory drugs (2.7; 1.0-7.5; P=0.048); (3) complicated drug regimens (7.4; 3.2-16.9; P<0.001); and (4) necessity to cut tablets (4.8; 2.1-10.7; P<0.001). Presence of caregiver/community nursing services assistance to pack medication (odds ratio=0.2; 95% confidence interval, 0.1-0.5; P=0.001), and the use of medication boxes (0.5; 0.3-1.0; P=0.050) were found to be the protective factors against drug non-adherence.
 
CONCLUSIONS. Drug non-adherence is an important concern in patient management. Medication regimen should be simplified as far as possible, in particular to avoid cutting pills or use of different dosage at different timing. Patients receiving drugs for respiratory diseases should be the first target group for intervention. Patients should be encouraged to voice out their perceived adverse drug effects.
 
Key words: Aged; Chinese; Patient compliance; Prescriptions, drug; Risk factors
 
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Intussusception trends in Hong Kong children

ABSTRACT
Hong Kong Med J 2007;13:279-83 | Number 4, August 2007
ORIGINAL ARTICLE
Intussusception trends in Hong Kong children
Hong Kong Intussusception Study Group
 
 
OBJECTIVES. To assess trends in intussusception and to validate the coding in Hong Kong's computerised discharge information system.
 
DESIGN. Case notes were reviewed for all children under the age of 5 years who had a discharge diagnosis indicating intussusception or a procedure indicating reduction of intussusception during the 6-year period 1 July 1997 through 30 June 2003.
 
RESULTS. Intussusception rates for infants under 1 year of age (108/100 000) and under 5 years of age (38/100 000) were slightly higher than previous estimates (78-100/100 000 and 27-32/100 000, respectively) that used passive discharge data alone.
 
CONCLUSIONS. Hong Kong's passive computer data systems could be used to monitor rates of intussusception after the introduction of new rotavirus vaccines, provided readmissions, inter-hospital transfers, and hospital follow-ups for the same episode are taken into account.
 
Key words: Child, preschool; Infant; Intussusception; Population surveillance; Rotavirus
 
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Endovascular coiling versus neurosurgical clipping for ruptured intracranial aneurysms: significant benefits in clinical outcome and reduced consumption of hospital resources in Hong Kong Chinese patients

ABSTRACT
Hong Kong Med J 2007;13:271-8 | Number 4, August 2007
ORIGINAL ARTICLE
Endovascular coiling versus neurosurgical clipping for ruptured intracranial aneurysms: significant benefits in clinical outcome and reduced consumption of hospital resources in Hong Kong Chinese patients
Simon CH Yu, George KC Wong, Jeffrey KT Wong, WS Poon
Department of Diagnostic Radiology and Organ Imaging, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. Using specific selection criteria to determine whether endovascular coiling as compared to neurosurgical clipping is associated with significant benefits, in terms of 1-year clinical outcomes and consumption of hospital resources, for the treatment of ruptured intracranial aneurysms in Hong Kong Chinese patients.
 
DESIGN. Retrospective study.
 
SETTING. University teaching hospital, Hong Kong.
 
PATIENTS. Records of outcomes of 169 consecutive Chinese patients, who were treated with endovascular coiling (n=80) or surgical clipping (n=89), were reviewed. All patients were followed up clinically for a mean of 55 (standard deviation, 201) months and radiologically with sequential digital subtraction angiography at 6 and 18 months after treatment.
 
RESULTS. The mean ages of patients were 56 (standard deviation, 13) years for the coiling group, and 57 (standard deviation, 13) years for the clipping group (P=0.575). The median aneurysm size was 4 mm in both groups (P=0.898). The severity of subarachnoid haemorrhage in the two groups did not differ (P=0.619). The rate of death or permanent disability leading to dependency (Glasgow Outcome Scale, 1-3) at 1 year was significantly lower in the coiling group (12/80, 15%) as compared to the clipping group (30/89, 34%) [P=0.005], resulting in a risk reduction of 19% (95% confidence interval, 6-32%). There were significantly more frequent admissions into the intensive care unit in the clipping group (P<0.001); the median duration of intensive care unit stay was 2 days (vs 0 days in the coiling group). The incidence of subsequent treatment procedures for residual or recurrent aneurysm was more common in the coiling group (13/80 vs 3/89; P=0.004).
 
CONCLUSION. Endovascular coiling as compared to neurosurgical clipping for treatment of patients with ruptured intracranial aneurysms is associated with significant benefits in terms of a reduced need for intensive care unit admissions and better general clinical outcomes in Hong Kong Chinese patients.
 
Key words: Aneurysm, ruptured; Cerebral arteries; Embolization, therapeutic; Intracranial aneurysm; Treatment outcome
 
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Intercostal nerve blockade for cancer pain: effectiveness and selection of patients

ABSTRACT
Hong Kong Med J 2007;13:266-70 | Number 4, August 2007
ORIGINAL ARTICLE
Intercostal nerve blockade for cancer pain: effectiveness and selection of patients
Frank CS Wong, TW Lee, KK Yuen, SH Lo, WK Sze, Stewart Y Tung
Department of Clinical Oncology, Tuen Mun Hospital, Tuen Mun, Hong Kong
 
 
OBJECTIVES. To review treatment results of intercostal nerve blockade at our centre and those reported in the literature, and to determine which patients benefit most from this procedure.
 
DESIGN. Retrospective study.
 
SETTING. Regional palliative care centre in a regional hospital in Hong Kong.
 
PATIENTS. Oncology patients who had intercostal nerve blockade at Tuen Mun Hospital from 1995 to 2005 were divided into three groups: (1) those who appeared not to tolerate opioids; (2) those deemed to have inadequate pain control, despite high doses of analgesics; and (3) those referred to avoid early use of high-dose opioids and tolerance.
 
MAIN OUTCOME MEASURES. The effectiveness and complications of intercostal nerve blockade, and the extent of benefit derived from intercostal nerve blockade in different patient groups.
 
RESULTS. This study found that 80% of the 25 patients noted optimal local pain control and 56% experienced reduction in analgesic use after intercostal nerve blockade. About 32% did not notice recurrence of the targeted pain till the end of their lives. None of the patients developed pneumothorax. Most benefit from intercostal nerve blocks were derived by group 2 patients, 90% of whom obtained optimal local pain control (P=0.23) and enjoyed a significant reduction in analgesics use (P=0.019), and in 40% their target pain was controlled till the end of life. Only about one third of group 3 patients had subsequent reduction in use of analgesics, mainly because they had co-existing pain other than at the target selected for treatment. Half (50%) of group 1 patients achieved optimal pain control.
 
CONCLUSION. Our treatment results from intercostal nerve blockade are comparable to those reported in the literature. The procedure is safe if closely monitored. Good selection of cases is important for optimising the therapeutic gain. The largest benefit is obtained in patients who have inadequate pain control after high-dose morphine.
 
Key words: Anesthesia, local; Intercostal nerves; Nerve block; Pain clinics; Palliative care
 
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Characteristics, management process, and outcome of patients suffering in-hospital cardiopulmonary arrests in a teaching hospital in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:258-65 | Number 4, August 2007
ORIGINAL ARTICLE
Characteristics, management process, and outcome of patients suffering in-hospital cardiopulmonary arrests in a teaching hospital in Hong Kong
HY Yap, Thomas ST Li, KS Tan, YS Cheung, PT Chui, Philip KN Lam, Desmond WL Lam, YF Tong, MC Chu, PN Leung, Gavin M Joynt
Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. To examine the demographics, process indicators of adult in-hospital cardiopulmonary arrest resuscitation, and outcomes in a teaching hospital in Hong Kong.
 
DESIGN. Retrospective study.
 
SETTING. A university-affiliated tertiary referral hospital with 997 acute adult beds in Hong Kong.
 
PATIENTS. Those who suffered a cardiopulmonary resuscitation event, as documented in retrieved records of all in-patients during the inclusive period January 2002 to December 2005.
 
RESULTS. There were 531 resuscitation events; the mean (standard deviation) age of the corresponding patients was 70.7 (15.4) years. Most (83%) occurred in non-monitored areas and most (97%) were cardiopulmonary arrests. The predominant initial rhythm was asystole (52%); only 8% of patients had ventricular tachycardia/fibrillation. All the resuscitations were initiated by on-site first responders. The median times from collapse to arrival of the resuscitation team, to defibrillation, to administration of adrenaline, and to intubation were: 5 (interquartile range, 2-6) minutes, 5 (1-7) minutes, 5 (3-10) minutes, and 9 (5-13) minutes, respectively. The overall hospital survival (discharge) rate was 5%. The survival rate was higher among patients in monitored areas (9 vs 4%, P=0.046), among patients with isolated respiratory arrests (61 vs 3%, P<0.001), primary ventricular tachycardia/fibrillation arrests (13 vs 4%, P<0.001), shorter interval times from collapse to medication (1.5 vs 5 min, P=0.013), and longer interval times to intubation (12 vs 8 min, P=0.013).
 
CONCLUSION. Hospital survival after in-hospital cardiopulmonary arrests was poor. Possible strategies to improve survival include shorten time interval to defibrillation, and provision of more monitored beds.
 
Key words: Cardiopulmonary resuscitation; Emergency Service, hospital; Heart arrest; Survival rate; Treatment outcome
 
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Delayed presentation and treatment of newly diagnosed pulmonary tuberculosis patients in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:221-7 | Number 3, June 2007
ORIGINAL ARTICLE
Delayed presentation and treatment of newly diagnosed pulmonary tuberculosis patients in Hong Kong
Eric CC Leung, CC Leung, CM Tam
TB and Chest Service, Centre of Health Protection, Department of Health, Hong Kong
 
 
OBJECTIVE. To measure patients' and providers' delays in the presentation and treatment of newly diagnosed pulmonary tuberculosis.
 
DESIGN. Retrospective study using structured questionnaires.
 
SETTING. Tuberculosis and Chest Service, Centre of Health Protection, Department of Health.
 
PARTICIPANTS. Tuberculosis patients notified to the Department of Health, selected by systematic sampling of all notifications in the first 2 weeks of every even month in the year 2004.
 
MAIN OUTCOME MEASURES. Health-seeking behaviour of pulmonary tuberculosis patients, including respective demographic, clinical, and disease factors.
 
RESULTS. Of a total of 6262 notified tuberculosis patients in 2004, 1662 (26.5%) were recruited into the study; of these, 42.6% first presented to private doctors, and 57.4% to the public sector. The diagnosis of tuberculosis was made in 13.7% of these patients by the former and 86.3% by the latter. The median patient delay (elapsed time from symptoms to medical consultation) and provider delay (elapsed time from medical consultation to treatment) were both 20 days; 25th to 75th percentiles being 7-37 and 6-55 days, respectively. Longer patient delay was associated with positive sputum smear and culture, and more extensive radiological disease. On multiple regression analysis, unemployment independently predicted longer patient delay, while haemoptysis predicted shorter patient and total delay. Patients older than 60 years, with no initial sputum and chest X-ray examination predicted longer provider and total delays.
 
CONCLUSIONS. Our patient and provider delays compared favourably with those of other countries, and very likely reflect easy service access. Adverse social factors and non-specific presentations prolong patient delay, whilst older age and unavailable bacteriological/radiological evidence delay diagnosis and treatment.
 
Key words: Diagnosis; Time factors; Tuberculosis, pulmonary
 
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Adulteration of over-the-counter slimming products with pharmaceutical analogue - an emerging threat

ABSTRACT
Hong Kong Med J 2007;13:216-20 | Number 3, June 2007
ORIGINAL ARTICLE
Adulteration of over-the-counter slimming products with pharmaceutical analogue - an emerging threat
YP Yuen, CK Lai, WT Poon, SW Ng, Albert YW Chan, Tony WL Mak
Department of Pathology, Princess Margaret Hospital, Laichikok, Kowloon, Hong Kong
 
 
OBJECTIVES. To review pharmaceutical analogue adulteration of nonprescription slimming products.
 
DESIGN. Retrospective study.
 
SETTING. Tertiary referral centre for toxicology analysis, Hong Kong.
 
PATIENTS. All patients known to have been hospitalised after taking slimming products adulterated with pharmaceutical analogues from September 2004 to December 2006.
 
MAIN OUTCOME MEASURES. Age, reasons for hospital admission, major biochemical findings, and toxicology analysis results of the offending slimming products.
 
RESULTS. N-nitrosofenfluramine, an analogue of fenfluramine with hepatotoxic effect, was found in two slimming products. Three patients were hospitalised after taking these slimming products, one of whom developed liver failure treated by liver transplantation. Another slimming product was found to contain N-desmethyl-sibutramine, an analogue of sibutramine. A patient with an unremarkable medical history developed acute psychosis after taking the latter product for 1 week.
 
CONCLUSIONS. Analogues, created by modifying the chemical structures of pharmaceuticals, are used as adulterants in non-prescription slimming products, in an attempt to evade regulatory inspection. The imperceptible use of these analogues is very dangerous because they have not been tested formally for efficacy and safety. In view of the potential harm to the public, more effective and proactive measures are required to guard against the illicit use of pharmaceutical analogues. There is also a need for increased awareness among the public and the medical professionals about this emerging threat.
 
Key words: Anti-obesity agents; Fenfluramine; Liver failure, acute; Weight loss
 
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A questionnaire survey on patients' attitudes towards epidural analgesia in labour

ABSTRACT
Hong Kong Med J 2007;13:208-15 | Number 3, June 2007
ORIGINAL ARTICLE
A questionnaire survey on patients' attitudes towards epidural analgesia in labour
William WK To
Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVES. To evaluate patient attitudes about epidural services in labour and correlate them with patient options and actual usage of epidural analgesia.
 
DESIGN. Questionnaire survey.
 
SETTING. Eight Hospital Authority obstetrics units.
 
PARTICIPANTS. A cohort of new antenatal patients and a cohort of postnatal in-patients over 1 calendar month.
 
MAIN OUTCOME MEASURES. Antenatal patient awareness of epidural services and attitudes towards epidural analgesia during labour; the actual usage of such analgesia and the reported experience of postnatal patients.
 
RESULTS. A total of 2109 and 2851 patients completed the antenatal and postnatal survey, respectively. The former revealed that only 47% of patients had been exposed to the concept of epidural analgesia in labour, and only 13% opted for such analgesia. In the postnatal cohort, the overall epidural analgesia rate was 10%, although 19% had actually requested it. Patients who received epidural analgesia in labour were more likely to consider their experience as favourable (85%) compared to those who went through labour without such analgesia (26%) [P<0.001]. There was no significant improvement in knowledge about epidural analgesia among postnatal as compared to antenatal patients. The main reasons generally ascribed by patients for not being able to obtain an epidural service despite it being requested, were related to limited resources.
 
CONCLUSION. The results showed poor general awareness of pregnant women about the proper role of epidural analgesia in labour, leading to a low patient demand for such services. Despite the low prevailing request rate for epidural analgesia in labour, there appears to be a lack of adequate resources to meet the demand.
 
Key words: Analgesia, epidural; Labor, obstetric; Patient satisfaction
 
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Universal antenatal human immunodeficiency virus (HIV) testing programme is cost-effective despite a low HIV prevalence in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:199-207 | Number 3, June 2007
ORIGINAL ARTICLE
Universal antenatal human immunodeficiency virus (HIV) testing programme is cost-effective despite a low HIV prevalence in Hong Kong
PM Lee, KH Wong
Red Ribbon Centre, Public Health Services Branch, Centre for Health Protection, Department of Health, Hong Kong
 
 
OBJECTIVE. To evaluate the cost-effectiveness of universal antenatal human immunodeficiency virus (HIV) testing in Hong Kong.
 
DESIGN. Cost-effectiveness analysis from the health care provider's perspective.
 
SETTING. Public antenatal clinics in Hong Kong.
 
PARTICIPANTS. All pregnant women who gave birth in Hong Kong during the inclusive period 1 September 2001 and 31 December 2004.
 
MAIN OUTCOME MEASURES. The primary endpoints were (i) the cost per HIV infection avoided and (ii) the cost per life-year gained.
 
RESULTS. From 2001 to 2004, a total of 160 878 deliveries were recorded in Hong Kong; and 75% of the corresponding women had HIV-testing before delivery. In all, 28 women tested HIV-positive and gave birth to 15 babies, one of which was HIV-positive. The mother of the infected baby presented late in labour, without her HIV status being diagnosed and thus missed the opportunity for prompt intervention. Assuming a natural transmission rate of 25%, it was estimated that six out of seven anticipated HIV infections among the newborns had been avoided. The cost for implementation of the programme for the first 3 years was HKD12 227 988. Hence, the average costs per HIV infection averted and per discounted life-year gained were HKD2 037 998 and HKD79 099, respectively. Sensitivity analysis showed that both the coverage and the loss-to-follow-up rate were the major determinants of the cost-effectiveness of the universal antenatal testing programme in Hong Kong.
 
CONCLUSION. The universal antenatal testing programme in Hong Kong is largely efficient. In view of the low prevalence of HIV infection, high rates of HIV testing and uptake of antiretroviral prophylaxis are crucial to the success of the programme.
 
Key words: Cost-benefit analysis; Disease transmission, vertical; HIV infections; Mass screening; Quality-adjusted life years
 
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Clinicopathological correlates in a cohort of Hong Kong breast cancer patients presenting with screen-detected or symptomatic disease

ABSTRACT
Hong Kong Med J 2007;13:194-8 | Number 3, June 2007
ORIGINAL ARTICLE
Clinicopathological correlates in a cohort of Hong Kong breast cancer patients presenting with screen-detected or symptomatic disease
Amy W Leung, Joyce Mak, Polly SY Cheung, Richard J Epstein
Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
 
 
OBJECTIVES. To examine the differences in breast cancer presentation by analysing our recent experience in the diagnosis and management of breast cancer patients.
 
DESIGN. Retrospective study.
 
SETTING. Private hospital, Hong Kong.
 
PATIENTS. Consecutive patients (702 in all) referred to the hospital with newly diagnosed breast cancer over the 5-year period from 2001 to 2006.
 
MAIN OUTCOME MEASURES. Methods of detection; tumour size, lymph node involvement, and surgical treatment modalities.
 
RESULTS. Over 80% of these patients presented following self-discovery of a breast mass, whereas routine mammography accounted for only 8%. Screen-detected tumours were smaller than self-discovered tumours (2.02 vs 2.35 cm, P<0.03), and mastectomy rates were lower in mammogram-screened patients than in self-discovered disease (35% vs 50%; P=0.03). In addition, self-detected tumours were significantly more likely to be associated with lymph node involvement than screen-detected tumours (38% vs 20%; P=0.007), confirming a prognostic difference. These uncontrolled data should not be interpreted as proving either the efficacy or the cost-effectiveness of breast screening.
 
CONCLUSION. The findings suggest a disturbingly low utilisation of mammography in Hong Kong patients, and raise the possibility of a more proactive public health approach to promote such screening for susceptible target groups.
 
Key words: Breast neoplasms; Breast selfexamination; Mammography; Mass screening; Mastectomy, segmental
 
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