In Hong Kong, it is government policy that no one is denied adequate medical care due to a lack of means, making Hong Kong a proud provider of almost universal access to medical services. Nonetheless, these medical services provided by the Hospital Authority mostly involve specialist care that eventually dominates a 'treatment-based' patient care system and plays down preventive care. With a rapidly ageing population1 and escalating burden of chronic diseases, the impact of complicated disease is compounded by neglect of care for patients who are otherwise well but at an early stage of disease. This results in increasingly long waiting times for 'routine' specialist out-patient care.2

As evidenced by Hong Kong’s Domestic Health Accounts in 2019/20, only around 17% of the total public current health expenditure was spent on primary healthcare, with the remaining 83% spent on secondary and tertiary healthcare services.3 This implies that most individuals will not undergo individual health assessments because they are rarely able to obtain routine individualised preventive care advice from doctors about issues such as vaccination scheduling, cancer screening or chronic disease screening.4

Data from the Hong Kong Population Health Survey 2014/15 revealed that 54.1% and 47.5% of patients with diabetes mellitus (DM) and hypertension, respectively, were unaware of their condition prior to the health examination that formed part of the survey.5 Even worse, patients known to be pre-diabetic did not receive the care that may have prevented their progression to DM (an annual conversion rate of approximately 5-10%).6 7 With no alternative, public hospitals must care for these patients, with approximately 40 000 per year newly diagnosed and referred.8 The dilemma is how to tackle the challenge of maintaining public health with minimal intervention in a city where the number of patients with chronic disease is projected to reach 3 million by 2039.9

Currently, Hong Kong has an underdeveloped primary healthcare system with the private sector providing around 70% of all services.10 Compared with 11 developed countries, Hong Kong lacks a mature family doctor network, a core component of continuous care provision that can improve chronic disease management and prevention.11 The concept of 'family doctor for all' is one of the key visions of the Primary Healthcare Blueprint issued by the Government of the Hong Kong Special Administrative Region in December 2022. The plan is to formalise and link the Primary Care Directory and subsidised services, not only for Elderly Health Care Vouchers, vaccination and cancer screening but also chronic diseases, with matched family doctors.

In 2023, the Health Bureau will pilot the Chronic Disease Co-Care Scheme announced in the Policy Address 2022. The objective is to make use of the community network to improve (1) screening, (2) diagnosis of pre-diabetes, early DM and hypertension, and to (3) match patients with a family doctor listed in the Primary Care Directory. There is evidence that for individuals with early-stage or asymptomatic chronic disease, lifestyle modification and early medical intervention are essential.12 Therefore, the programme will coordinate and subsidise both local and professional support for patients to receive holistic care and lifestyle interventions from family doctors and District Health Centres. The proposed packages will encourage individuals to build a long-term relationship with a self-selected family doctor supported by a community coordinator.

A new statutory body to be established in 2024, the Primary Healthcare Commission, will develop district-based healthcare and drive the 'family doctor for all' policy in an attempt to shift the focus of patient care towards prevention by increasing public funding. Through coordination and networking, the future healthcare model will provide public access to screening, health planning, community care and individual advice/intervention by a family doctor. This will be achieved through: (1) consolidation of existing services provided by the Department of Health, (2) purchased private services, (3) enhanced training in family medicine, (4) coordination of community networks, and (5) better governance including bi-directional referrals between primary and secondary care. Setting up of clinical standards and performance monitoring will be core functions to build public confidence in the purchased or network services. The Primary Care Register for family doctors will be formalised and structured for the general public under a legal framework. Furthermore, through the Electronic Health Record Sharing System and the eHealth App, more initiatives rolled out via digital healthcare will increase connections and networks available within the community. With a mature family doctor system, more subsidised and convenient disease prevention programmes can be initiated to improve public health.

Hong Kong has a dual track medical system, but 'treatment-based' healthcare is not sustainable in the provision of quality care. The Primary Healthcare Blueprint aims to steer our future multidimensional development to include a prevention centric system. The reform requires the full support of our professionals who can share common goals in building trust between professionals and the community, as well as pursuing timely interventions for people of all ages within a strong primary healthcare system.

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

Both authors have declared no conflict of interest.

1. Census and Statistics Department, Hong Kong SAR Government. Hong Kong Population Projections 2020-2069, 2020 edition. Available from: https://www.censtatd.gov.hk/hkstat/sub/sp190.jsp?productCode=B1120015. Accessed 23 Dec 2022.

2. Hong Kong SAR Government press release. LCQ7: Specialist out-patient services of Hospital Authority. 21 July 2021. Available from: https://www.info.gov.hk/gia/general/202107/21/P2021072100563.htm. Accessed 23 Dec 2022.

3. Health Bureau, Hong Kong SAR Government. Hong Kong’s Domestic Health Accounts 2019/20. Available from: https://www.healthbureau.gov.hk/statistics/en/dha.htm. Accessed 23 Dec 2022.

4. Tam DY, Lo YY, Tsui W. Knowledge, practices and expectations of preventive care: a qualitative study of patients attending government general outpatient clinics in Hong Kong. BMC Fam Pract 2018;19:58. Crossref

5. Surveillance and Epidemiology Branch, Centre for Health Protection, Department of Health, Hong Kong SAR Government. Report of Population Health Survey 2014/15. 2017. Available from: https://www.chp.gov.hk/en/static/51256.html. Accessed 23 Dec 2022.

6. Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: a high-risk state for diabetes development. Lancet 2012;379:2279-90. Crossref

7. Li G, Zhang P, Wang J, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet 2008;371:1783-9. Crossref

8. Quality Assurance Sub-committee of Central Committee on Diabetic Service. Hospital Authority. Hospital Authority Diabetes Mellitus Care Report 2019/20. 2020. Available from: https://www.ha.org.hk/haho/ho/icp/HA_DM_Care_Report1920_en_txt.pdf. Accessed 23 Dec 2022.

9. Hospital Authority. Hospital Authority Strategic Plan 2022-2027. 2021. Available from: https://www.ha.org.hk/haho/ho/ap/HA_StrategicPlan2022-2027_Eng_211216_1.pdf. Accessed 27 Dec 2022.

10. Our Hong Kong Foundation. Strategic Purchasing: Enabling Health for All. Dec 2021. Available from: https://ourhkfoundation.org.hk/sites/default/files/media/pdf/20211214_OHKF_Health_Finance_Research_Report_E.pdf. Accessed 27 Dec 2022.

11. Wong SY, Zou D, Chung RY, et al. Regular source of care for the elderly: a cross-national comparative study of Hong Kong with 11 developed countries. J Am Med Dir Assoc 2017;18:807.e1-8. Crossref

12. Haw JS, Galaviz KI, Straus AN, et al. Long-term sustainability of diabetes prevention approaches: a systematic review and meta-analysis of randomized clinical trials. JAMA Intern Med 2017;177:1808-17. Crossref

Antimicrobial resistance (AMR) has been declared one of the top ten global public health threats facing humanity by the World Health Organization (WHO) in 2019.1 The WHO has estimated that, by 2050, the number of deaths attributed to AMR will be as high as 10 million each year, exceeding those caused by cancer (8.2 million).2 The coronavirus disease 2019 (COVID-19) pandemic has exacerbated the AMR situation globally. In 2020, the Centers for Disease Control and Prevention of the United States reported more cases of carbapenem-resistant Acinetobacter (increased by 78%), antifungal-resistant Candida auris (increased by 60%), and carbapenem-resistant Enterobacterales (increased by 35%) than in 2019, possibly due to more and sicker patients during the pandemic who required more frequent and longer use of catheters and ventilators, personal protective equipment and laboratory supply challenges, fewer healthcare staff, and longer lengths of stay.3 Outbreaks of multidrug-resistant organisms, including carbapenem-resistant Acinetobacter baumannii,4 5 C auris6 and Enterobacterales,7 as well as vancomycin-resistant Enterococcus,8 9 have been reported in healthcare facilities. In a systematic review that identified 17 outbreaks during the COVID-19 pandemic caused mainly by carbapenem-resistant Acinetobacter baumannii and C auris, inadequate personal protective equipment or hand hygiene adherence, personal protective equipment shortage, and high antibiotic use were the most commonly reported modifiable factors contributing to the outbreaks.10 In some countries, antimicrobial stewardship programmes in hospitals were adversely affected or even suspended.11 12 Hong Kong is not immune to these challenges, and substantial resource have been diverted to tackle the COVID-19 pandemic.

Despite these constraints, considerable progress has been made in Hong Kong, according to directives as described in the Hong Kong Strategy and Action Plan on Antimicrobial Resistance (2017-2022).13 The AMR Information System was established in October 2021 to collate, analyse, and report data from various departments of the Hong Kong SAR Government and the Hospital Authority. This system provides well-organised and transparent access to surveillance data on the human side covering AMR and antimicrobial use (AMU). Antimicrobial resistance and AMU involving food animals are also now included in a regular surveillance programme, and a long-term food surveillance system on AMR has been established. Enhanced regulatory measures against the illegal sale of antimicrobials, health promotional activities, and collaboration between healthcare providers and community partners to advocate appropriate use of antimicrobials have been effective. The percentage of total supply of antibiotics to community pharmacies gradually decreased from around 18.5% in 2016 to 5.6% in 2021. Under the Antibiotic Stewardship Programme in Primary Care initiative, new guidance notes and patient information sheets on seven common infections have been developed to drive appropriate antibiotic use by primary care doctors. Coupled with antimicrobial stewardship programmes implemented in hospitals, the proportion of the total antimicrobial supply classified as the “Access” group under WHO classification (ie, those showing lower resistance potential than antibiotics in the other groups) reached 61.9% in 2020 and 65.8% in 2021 in Hong Kong, above the 60% target set by the WHO. Data from the Hospital Authority in 2021 reflected that 94.5% use of two broad spectrum antibiotics, namely piperacillin/tazobactam and meropenem, were found to be appropriately used in medical, surgical and orthopaedic and traumatology specialty of acute hospitals.14

The Hong Kong SAR Government is also tackling AMR on other fronts. For animal health, a policy is being prepared for “veterinary prescription-only medication supply”.14 To reduce the incidence of infection, infection prevention and control training is in place, with over 30 000 attendances per year in the human health sector and 6000 in the food sector. The Department of Health has also been offering free seasonal influenza vaccination and pneumococcal vaccination to eligible target groups, which helps reduce potential complications from these diseases, such as secondary bacterial infections and AMU. Under the “One Health” framework, the Department of Health, the Agriculture, Fisheries and Conservation Department, and the Food and Environmental Hygiene Department have joined together to launch publicity activities to echo the annual World Antibiotic Awareness Week to promote proper use of antibiotics. To encourage research, AMR has been included as one of the thematic priorities in the open call for investigator-initiated projects under the Health and Medical Research Fund, and 33 related projects have been funded in the 2017 to 2020 round of open call applications.

Nevertheless, many challenges to further improve the AMR situation remain. A sustained high rate of methicillin-resistant Staphylococcus aureus bacteraemia was detected after 48 hours of admission in public hospitals in the past few years. Data reported to the Centre for Health Protection indicate that the number of cases of carbapenemase-producing Enterobacteriaceae discharged to residential care homes for the elderly has been doubled from 242 cases in 2019 to 526 cases in 2021. Since the first case of C auris, an emerging multidrug-resistant fungus, reported in Hong Kong in July 2019, more cases and outbreaks in public hospitals have been reported.15 16 Despite a reduction of AMU among community pharmacies and general practitioners in 2020 and 2021, it is possible for rebound of respiratory illnesses and resurge of AMU in these settings after relaxation of public health measures for COVID-19. Health promotion on AMR is still needed: in a survey of the general public, 54.0% of respondents mistakenly identified cold and flu as treatable with antibiotics.17 Moreover, comprehensive data on AMU and AMR among general practitioners are lacking. There is also limited scientific knowledge on the role of the environment in the evolution of AMR.

In his Policy Address on 19 October 2022, the Chief Executive of Hong Kong pledged to promulgate a new plan on AMR for the next 5 years. To tackle this public health threat and address challenges ahead, Hong Kong Strategy and Action Plan on Antimicrobial Resistance (2023-2027)14 adopts six key policy areas: strengthen knowledge through surveillance and research; optimise use of antimicrobials in humans and animals; reduce incidence of infection through effective sanitation, hygiene and prevention measures; improve awareness and understanding of AMR through effective communication, education and training; promote research on AMR; and strengthen partnerships and foster engagement of relevant stakeholders. Among the 21 objectives in the Action Plan, five are identified as priority interventions: surveillance and control of AMR in ready-to-eat food; strengthening regulation of record keeping for prescription-only antimicrobials in community pharmacies; enhancement of antimicrobial stewardship programme in public hospitals; a territory-wide decolonisation programme for multidrug-resistant organism in residential care homes for the elderly; and conducting regular surveys among the general public on AMR to inform strategies on health promotion.

The theme for the 2022 World Antibiotic Awareness Week (18-24 November) is “Contribute Together to Combat Antimicrobial Resistance!”. Antimicrobial resistance is everyone’s business. The Hong Kong Centre for Health Protection has a dedicated page (https://www.chp.gov.hk/en/features/47850.html) with the latest information on AMR for the general public and healthcare workers. With concerted effort from healthcare professionals and all other concerned parties, we can combat AMR together in the coming 5 years and beyond.

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

The author has declared no conflict of interest.

1. World Health Organization. Ten threats to global health in 2019. Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019. Accessed 22 Oct 2022.

2. World Health Organization. Factsheet: Antimicrobial resistance. July 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance. Accessed 22 Oct 2022.

3. Centers for Disease Control and Prevention. COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022. Available from: https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf. Accessed on 22 Oct 2022.

4. Shinohara DR, Dos Santos Saalfeld SM, Martinez HV, et al. Outbreak of endemic carbapenem-resistant Acinetobacter baumannii in a coronavirus disease 2019 (COVID-19)–specific intensive care unit. Infect Control Hosp Epidemiol 2022;43:815-7. Crossref

5. Perez S, Innes GK, Walters MS, et al. Increase in hospital-acquired carbapenem-resistant Acinetobacter baumannii infection and colonization in an acute care hospital during a surge in COVID-19 admissions—New Jersey, February– July 2020. MMWR Morb Mortal Wkly Rep 2020;69:1827-31. Crossref

6. Villanueva-Lozano H, de Treviño-Rangel RJ, González GM, et al. Outbreak of Candida auris infection in a COVID-19 hospital in Mexico. Clin Microbiol Infect 2021;27:813-6. Crossref

7. García-Meniño I, Forcelledo L, Rosete Y, García-Prieto E, Escudero D, Fernández J. Spread of OXA-48-producing Klebsiella pneumoniae among COVID-19-infected patients: the storm after the storm. J Infect Public Health 2021;14:50-2. Crossref

8. Kampmeier S, Tönnies H, Correa-Martinez CL, Mellmann A, Schwierzeck V. A nosocomial cluster of vancomycin resistant enterococci among COVID-19 patients in an intensive care unit. Antimicrob Resist Infect Control 2020;9:154.Crossref

9. Rathod SN, Bardowski L, Tse I, et al. Vancomycin-resistant Enterococcus (VRE) outbreak in a pre- and post-cardiothoracic transplant population: impact of discontinuing multidrug-resistant organism (MDRO) surveillance during the COVID-19 pandemic. Transpl Infect Dis 2022 Sep 28. Epub ahead of print. Crossref

10. Thoma R, Seneghini M, Seiffert SN, et al. The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of a carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature. Antimicrob Resist Infect Control 2022;11:12. Crossref

11. Comelli A, Genovese C, Lombardi A, et al; ASP Lomb Study Group. What is the impact of SARS-CoV-2 pandemic on antimicrobial stewardship programs (ASPs)? The results of a survey among a regional network of infectious disease centres. Antimicrob Resist Infect Control 2022;11:108. Crossref

12. Ashiru-Oredope D, Kerr F, Hughes S, et al. Assessing the impact of COVID-19 on antimicrobial stewardship activities/programs in the United Kingdom. Antibiotics (Basel) 2021;10:110. Crossref

13. Hong Kong SAR Government. Hong Kong Strategy and Action Plan on Antimicrobial Resistance 2017-2022. 2017. Available from: https://www.chp.gov.hk/files/pdf/amr_action_plan_eng.pdf. Accessed 22 Oct 2022.

14. Hong Kong SAR Government. Hong Kong Strategy and Action Plan on Antimicrobial Resistance 2023-2027. 2022. Available from: https://www.chp.gov.hk/files/pdf/amr_action_plan_eng_2023.pdf. Accessed 17 Nov 2022.

15. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Alert on the rise in Candida auris colonisation in Hong Kong (letter to doctors). Available from: https://www.chp.gov.hk/files/pdf/lti_c_auris_20201015_eng.pdf. Accessed 22 Oct 2022.

16. Hong Kong SAR Government press release. Update on cluster of Candida auris cases in Princess Margaret Hospital. Available from: https://www.info.gov.hk/gia/general/202205/30/P2022053000624.htm. Accessed 22 Oct 2022.

17. Centre for Health Protection, Department of Health, Hong Kong SAR Government. General public’s knowledge, attitude and practice survey on antimicrobial resistance 2016/17. Available from: https://www.chp.gov.hk/en/static/51310.html. Accessed 22 Oct 2022.

The consequences of population ageing are major concerns for most governments, particularly in economically developed countries and regions. This has been exacerbated by the ongoing coronavirus disease 2019 (COVID-19) pandemic. In Hong Kong, government officials, professionals, academics, community leaders, parents, family members, carers, teachers and frontline workers have been facing unpredictable and changeable situations arising from measures introduced to limit the number of COVID-19 cases and associated deaths. There has also been excess mortality among the older population, mostly residents of elderly homes, during the fifth wave of the outbreak in early 2022.1 In this issue of Hong Kong Medical Journal, Luk and Chan2 highlight that the measures intended to protect the elderly population may have had the unintended adverse effect of worsening frailty and sarcopenia. Policymakers and healthcare providers are often caught off guard no matter how much time, effort, and resources have been invested in planning and preparing for public health crises.

Ageing populations aggravate the demand on social and health services, and Hong Kong’s population—with one of the world’s longest life expectancies of 85.2 years—is no exception. Longevity naturally results in more age-related problems such as declining functional and intrinsic capacities, including frailty, that require care and attention by family members, carers, and healthcare providers.3 The Hong Kong population aged ≥65 years is predicted to increase from 16% in 2017 to 34% in 2066.4 Many older adults need regular and long-term care; most of them have at least one common chronic condition resulting from ageing. Older adults also consume 6 times more in-patient services than do younger patients, and this represents a continuing burden to the healthcare system, affecting its sustainability.5 6 The traditional model of public financing and delivery of acute-centric hospital-oriented care leads to significant and negative effects on accessibility, equity, and sustainability. In contrast, primary care effectively and efficiently provides better and more appropriate care to the residents in the best interests of the community.7

Complex health states commonly called geriatric syndromes are unavoidable in ageing and caused by a number of potentially concurrent bodily conditions like frailty, urinary incontinence, recurrent falls, mental impairment and pressure ulcers. Frailty is an emerging global health burden coming from the ageing populations. It is a syndrome arising from continuing changes and decline across multiple physiological systems of the immune, musculoskeletal and endocrine systems, often considered as minor and associated with fatigue, decreased muscle strength, and increase in dependence, falls, hospitalisation, mortality, and vulnerability to stressors as well as health costs. The affected older adults look shrinking, feel weak and exhausted, move slowly, resulting in low level of activity, cognitive impairment, slow gait, and poor balance. Thus, frailty is an important predictor and health indicator for the older adults. The prevalence increases with age and is found to be lower in the rural ageing population. Risk factors include multi-morbidity, polypharmacy, female gender, low socio-economic status and educational background, poor diet, and physical inactivity.8 9 About 10% of older adults are affected by frailty but they may maintain almost full daily life capacity. However, there is potential of severe long-term effects on the wellbeing of individuals.10 The affected older adults are less ready or able to recover from illnesses or injuries. This can have an obvious impact on the quality of daily living and life expectancy.11

As noted by Luk and Chan,2 frailty and sarcopenia are closely related syndromes in geriatrics. Ageing entails the catabolism of muscles resulting in sarcopenia and frailty, and these often overlap in clinical presentation. The loss of muscle mass and function in sarcopenia is usually related to ageing but can also be induced by starvation, malnutrition, or inactivity. In contrast, frailty is age-related multi-system impairment and loss of weight and energy, but is not limited specifically to the muscles. Gait speed and hand grip strength are employed as diagnostic measures for both frailty and sarcopenia. Treatments for both of these two conditions also overlap, including adequate protein and vitamin D supplementation, plus resistance exercise programmes, which may not be feasible for the old and frail.12 13

Lifestyle risk factors are potentially modifiable by specific interventions and preventive actions. The concept of frailty is increasingly being discussed in public health, and primary, acute and specialist care.9 However, frailty may be missed or ignored as a process of normal ageing.14 It is thus imperative to identify frailty routinely, as part of the comprehensive geriatric assessments in older adults, using validated simple-to-use screening tools.

In this issue of Hong Kong Medical Journal, Umehara et al15 developed prediction models for the prognosis of pre-frailty and frailty in older patients with heart failure, and evaluated their accuracy. They found that the patient’s condition at admission was predictive of pre-frailty and frailty, and that cardiac rehabilitation may help to improve frailty after cardiac intervention. These findings are consistent with a recent review by Ijaz et al,16 who found that tailored cardiac rehabilitation in patients with cardiac failure was associated with positive results on frailty. Those authors therefore proposed that active screening should be incorporated into a patient-centred model of cardiovascular practice in order to identify frail older adults who would benefit from frailty intervention, particularly after cardiovascular interventions.16 Such practices should be adopted in Hong Kong where cardiovascular diseases are prevalent and detection of early or pre-frailty will be beneficial to the older adults at higher risk.

Management of co-morbid conditions is essential when caring for frailty. Walking and simple body movements are considered useful in improving strength, thereby alleviating weakness, even for the very old.17 The author started learning sitting tai chi a year before and had found it very effective for relaxation, co-ordination and positive feeling. Treatment plans must be individualised to address the age, goals of care and expectations of the patient and their family. When indicated, palliative care and symptom control can be considered for frailer older people.14

Frailty is drawing more attention worldwide because of the increasing ageing populations. It is being better defined through consensus conferences, and research in ageing and the associated intrinsic capacity. Frailty is considered as partly preventable and thus early detection with screening tools is a critical step in routine geriatric assessment. Targeted interventions and management plans can then be initiated to allow the older adults to live a quality life with dignity, as part of the holistic and humanistic approaches in elderly care and services.18 19

The author contributed to the concept or design, drafting of the manuscript, and critical revision for important intellectual content. The author had full access to the data, 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.

1. Cheung PH, Chan CP, Jin DY. Lessons learned from the fifth wave of COVID-19 in Hong Kong in early 2022. Emerg Microbes Infect 2022;11:1072-8.Crossref

2. Luk JK, Chan DK. Frailty and sarcopenia—from theory to practice. Hong Kong Med J 2022;28:392-5.

3. Yu R, Leung J, Lum CM, et al. A comparison of health expectancies over 10 years: implications for elderly service needs in Hong Kong. Int J Public Health 2019;64:731-42. Crossref

4. Census and Statistics Department, Hong Kong SAR Government. Hong Kong Population Projections 2017-2066. Available from: https://www.statistics.gov.hk/pub/B1120015072017XXXXB0100.pdf. Accessed 20 Aug 2022.

5. Elderly Commission, Hong Kong SAR Government. Report on healthy ageing executive summary. Available from: https://www.elderlycommission.gov.hk/en/library/Ex-sum.htm#2. Accessed 20 Aug 2022.

6. Kwok CL, Lee CK, Lo WT, Yip PS. The contribution of ageing to hospitalisation days in Hong Kong: a decomposition analysis. Int J Health Policy Manag 2017;6:155-64. Crossref

7. Ng TK, Fong BY, Kwong CK. Transition of hospital acute-centric to long term care in an ageing population in Hong Kong—is it an issue of service gap? Asia Pac J Health Manag 2019;14:11-5. Crossref

8. Woo J, Zheng Z, Leung J, Chan P. Prevalence of frailty and contributory factors in three Chinese populations with different socioeconomic and healthcare characteristics. BMC Geriatr 2015;15:163. Crossref

9. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications for clinical practice and public health. Lancet 2019;394:1365-75. Crossref

10. Age UK. Understanding frailty. Available from: https://www.ageuk.org.uk/our-impact/policy-research/frailty-in-older-people/understanding-frailty/. Accessed 20 Aug 2022.

11. Royal College of Nursing. Frailty in older people. Available from: https://www.rcn.org.uk/clinical-topics/Older-people/Frailty. Accessed 20 Aug 2022.

12. Dodds R, Sayer AA. Sarcopenia and frailty: new challenges for clinical practice. Clin Med (Lond) 2016;16:455-8. Crossref

13. Cederholm T. Overlaps between frailty and sarcopenia definitions. Nestle Nutr Inst Workshop Ser 2015;83:65-9. Crossref

14. Allison R 2nd, Assadzandi S, Adelman M. Frailty: evaluation and management. Am Fam Physician 2021;103:219-26.

15. Umehara T, Katayama N, Kaneguchi A, Iwamoto Y, Tsunematsu M, Kakehashi M. Models to predict prognosis in older patients with heart failure complicated by pre-frailty and frailty: a pilot prospective cohort study. Hong Kong Med J 2022;28:356-66.Crossref

16. Ijaz N, Buta B, Xue Q, et al. Interventions for frailty among older adults with cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2022;79:482-503. Crossref

17. Johns Hopkins Medicine. Stay strong: four ways to beat the frailty risk. Available from: https://www.hopkinsmedicine.org/health/wellness-and-prevention/stay-strong-four-ways-to-beat-the-frailty-risk. Accessed 20 Aug 2022.

18. Kwak D, Thompson LV. Frailty: past, present, and future? Sports Med Health Sci 2021;3:1-10. Crossref

19. Law VT, Fong BY, editors. Ageing with Dignity in Hong Kong and Asia: Holistic and Humanistic Care. Singapore: Springer; 2022. Crossref

Primary care is an integrated model of care underpinned by the discipline of general practice (GP), aiming to optimise population health and reduce disparities across the population. The key attributes of primary care—first contact, continuity, coordination, comprehensiveness, and community orientation and family centeredness—enable a high-value service delivery to address the wider determinants of health.1 In recent years, primary care transformation has taken place across the globe. In Scotland, for example, ‘GP clusters’ have been introduced to provide a more holistic, values-based approach to health and social care integration. It aims to provide a mechanism for a focus on quality improvement to encourage primary care to adjust clinical foci to local aims and needs, alongside the expansion of multidisciplinary teams to address workload and population health inequalities.2 In Hong Kong, strategies to foster continuity of care have been developed, such as the Elderly Health Care Voucher Scheme to encourage a regular source of care best suited to people’s needs, the integration of the medical workforce in Community Health Centres, which is particularly important for patients with multiple healthcare needs, and the expansion of the Electronic Health Records Sharing System to enable smooth information transfer of patient records to achieve coordinated care.3 In mainland China, the ‘family doctor teams’ which are built on the national basic public health service package have been gradually translated into routine primary care practice.4 A typical team consists of one GP clinician and healthcare personnel including public health doctors, nurses, and if available and suitable, pharmacists and social workers. The teams are featured by a continuous relationship between service providers and service users, thereby enhancing the provision of a core set of preventive care including health assessment, health-promoting interventions, health advice, and when necessary, home visits. Health issues related to the efficiency of care, control of chronic diseases, and quality of services from users’ perspectives have gained increasing attention.5

In this issue of the Hong Kong Medical Journal, Shi et al6 explore the utilisation pattern of village clinics in rural areas and investigate the clinical competence of rural primary care providers through a survey study conducted in Southwestern China. Significant gaps were identified in service provision between ethnic groups, which may be explained by the suboptimal clinical competence of ethnic minority providers. The study carries implications for upscaling system-level inputs to enhance the clinical capacity of rural primary care personnel through government-level actions to ensure adequate in-service training and professional development in remote and deprived areas. It also provides impetus for developing integrated competency-based GP training systems for village clinicians, which could then be translated into improved accessibility to and process of primary care, thereby leading to sustainable health promotion and disease prevention.

Nevertheless, multisectoral efforts to strengthen capacity building in rural primary care would also require attention paid to address barriers to strong motivation and active commitment to the provision of care in rural practice given the possible existence of clinical inertia and workload-related factors. A recent multicentre study conducted among rural primary care physicians across four provinces in China demonstrated physician-level challenges to the attainment of the target frequency of follow-up care for hypertension and diabetes—the two most common long-term conditions in the community.7 Ethnic minorities, or those who live in rural areas of high socio-economic deprivation, tend to encounter greater physician-level barriers to optimal care such as inadequate healthcare capacity and limited availability of qualified professionals. This may be due to insufficient clinical resources and the physician’s inherent pursuit of advanced medical technology, higher remuneration, and better career prospect in more affluent areas. Meanwhile, individual-level barriers such as financial burden, lack of social support, fearful emotions, negative health beliefs, underestimation of concomitant risks, and unfavourable cultural preferences may also inhibit the routine utilisation of healthcare services in low-income areas. In real-world settings, longitudinal observations manifest difficulties in maintaining long-term improvement of clinical parameters in chronically ill patients in the absence of actively provided and continuous health education support.8 Previous investigations conducted in eastern, central, and western rural China have highlighted the importance of effective provider-patient communication, which is, however, relatively poor during clinical encounters in rural primary care practice.9 These barriers may act together, rather than in isolation, to hinder the personalisation and prioritisation of care, resulting in exacerbated health and social disparities in areas of high socio-economic deprivation.10

From the perspective of health services research, the physician-patient encounter is a reflection of the care process, which takes into account patient needs and health expectations. A recent multi-centre primary care assessment demonstrated significant associations between improvement in patients’ experiences and reduced treatment burden.4 Structural efforts to improve the process of care emphasise the need to strengthen capacity building within, with and around primary care multidisciplinary teams in joint decision-making and problem-solving.11 Such approaches carry the potential to enable a combination of care regimes based on effective health education to ensure patient engagement across the care continuum, leading to improved patient experiences and population health.12

International consensus has been reached on the contribution of high-quality primary care to better population health outcomes in a cost-effective manner. This offers improvements in health equity, greater efficiency in chronic disease management, avoidance of preventable hospitalisation and emergency room visits, and better quality of life. Nowadays, primary care plays a central role in delivering both patient-centred and population-oriented services for long-term conditions, for instance, the screening for diabetes.13 Of equal importance is eye health for those diagnosed with diabetes to prevent vision loss. Similarly, promoting and improving eye health also requires systematic actions to address a wide range of protective and risk factors at all stages of life, starting from as early as the preconception and prenatal stage, through infancy and early childhood to adolescence, and into adulthood and older age. To further this objective, the World Health Organization is calling for increased emphasis on reorienting the model of care towards an integrated, people-centred approach for eye health based on strong primary care.14

Local experiences have demonstrated the crucial role of well-trained primary care physicians in infectious disease control, performance measurement, and emergency response as an integral part of the surveillance system in dealing with outbreaks of severe acute respiratory syndrome (SARS), H1N1 influenza, and coronavirus disease 2019 (COVID-19).15 16 So-called ‘long covid’ poses additional challenges for delivering tailored health and educational services to children and families.17 In response to the ever-increasing healthcare need due to complex conditions and circumstances, more work is needed in the study of digital technologies for health, lifestyle management strategies from the perspective of complementary and alternative medicine,18 and research instruments that capture key attributes of primary care to monitor the extent to which equitable care is achieved.19 Meanwhile, endeavours to promote workforce wellbeing and prevent primary care practitioners from stress, burnout, and depression are of vital importance.20 Empirical evidence from studies on innovative models of service delivery in real-world settings would better inform policy decisions and prioritisations to meet the health aims and move the health system towards a more people-centred approach of service delivery over time in areas of different socio-economic status.

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

All authors have declared no conflict of interest.

1. World Health Organization and United Nations Children’s Fund (UNICEF). Operational Framework for Primary Health Care: Transforming Vision into Action. Geneva: World Health Organization; 2020.

2. Stewart E, Donaghy E, Guthrie B, et al. Transforming primary care in Scotland: a critical policy analysis. Br J Gen Pract 2022;72:292-4.Crossref

3. Ho MK. Strengthening primary care in Hong Kong: fostering continuity of care from a health system perspective. Hong Kong Med J 2020;26:543-5. Crossref

4. Hu XJ, Wang HH, Li YT, et al. Healthcare needs, experiences and treatment burden in primary care patients with multimorbidity: an evaluation of process of care from patients’ perspectives. Health Expect 2022;25:203-13. Crossref

5. Wong MC, Huang J, Xu W, et al. Research for health issues in mainland China—a growing need unaddressed. Hong Kong Med J 2020;26:4-5. Crossref

6. Shi Y, Song S, Peng L, et al. Utilisation of village clinics in Southwestern China: evidence from Yunnan Province. Hong Kong Med J 2022;28:306-14. Crossref

7. Wang Y, Hu XJ, Wang HH, et al. Follow-up care delivery in community-based hypertension and type 2 diabetes management: a multi-centre, survey study among rural primary care physicians in China. BMC Fam Pract 2021;22:224. Crossref

8. Hu XJ, Wu HF, Li YT, et al. Influence of health education on clinical parameters in type 2 diabetic subjects with and without hypertension: a longitudinal, comparative analysis in routine primary care settings. Diabetes Res Clin Pract 2020;170:108539. Crossref

9. Zhou Q, An Q, Wang N, et al. Communication skills of providers at primary healthcare facilities in rural China. Hong Kong Med J 2020;26:208-15. Crossref

10. Wang HH, Mercer SW. Understanding barriers to adherence to optimal treatment of elevated blood pressure and hypertension-insights from primary care. JAMA Netw Open 2021;4:e2138651. Crossref

11. Wang HH. Taking a multidisciplinary team approach to better healthcare outcomes for society. Hong Kong Med J 2020;26:551-2. Crossref

12. 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

13. Wong MC, Huang J, Kong AP. Diabetes screening revisited: issues related to implementation. Hong Kong Med J 2020;26:283-5. Crossref

14. World Health Organization. World Report on Vision. Geneva: World Health Organization; 2019.

15. Poon PK, Wong SY. Primary care doctors and the control of COVID-19. Hong Kong Med J 2021;27:86-7. Crossref

16. Yu EY, Leung WL, Wong SY, Liu KS, Wan EY; HKCFP Executive and Research Committee. How are family doctors serving the Hong Kong community during the COVID-19 outbreak? A survey of HKCFP members. Hong Kong Med J 2020;26:176-83. Crossref

17. Tse WW, Kwan MY. Impacts of the COVID-19 pandemic on the physical and mental health of children. Hong Kong Med J 2021;27:175-6. Crossref

18. Wang Y, Wu XY, Wang HH, et al. Body constitution and unhealthy lifestyles in a primary care population at high cardiovascular risk: new insights for health management. Int J Gen Med 2021;14:6991-7001. Crossref

19. Wang HH, Wong SY, Wong MC. Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences. QJM 2015;108:549-60. Crossref

20. Kwan KY, Chan LW, Cheng PW, Leung GK, Lau CS. Burnout and well-being in young doctors in Hong Kong: a territory-wide cross-sectional survey. Hong Kong Med J 2021;27:330-7. Crossref

Although coronavirus disease 2019 (COVID-19) is primarily a respiratory disease, cardiovascular complications are frequent in patients with COVID-19 and are associated with poor prognosis.1 Myocardial injury, defined as elevation of serum troponin level, is one of the most common extrapulmonary complications of COVID-19.2 The incidence of cardiac injury increases with severity of disease (62.9% in severe cases vs 17.9% in mild),2 and with age (4% <60 years vs 12.5% 60-74 years vs 31% ≥75 years in age).3 Elevated troponin levels are associated with increased intensive care unit admission and worse prognosis.4 5 As the COVID-19 pandemic evolves and variants emerge, a clear understanding regarding the short- and long-term effects of COVID-19 on the cardiovascular system and outcomes is urgently needed.

In this issue of Hong Kong Medical Journal, Lo et al6 review the literature on cardiac injury associated with COVID-19. This review is both timely and important for us to better understand the pathogenesis of cardiac injury and the implications for treatment. Most studies included in this review reported cardiovascular complications during the acute phase of infection; however, recent data have shown that COVID-19 can cause cardiovascular symptoms, such as shortness of breath and palpitations. These symptoms can last weeks or months after the infection has gone. This is sometimes called post-COVID-19 syndrome or “long COVID”.7 A recent study has shown that the risk and 1-year burden of cardiovascular disease, including cerebrovascular disorders, dysrhythmias, ischemic and non–ischaemic heart disease, pericarditis, myocarditis, heart failure, and thromboembolic disease in survivors of acute COVID-19 are substantial.7 Patients with severe COVID-19 who need to be admitted to hospital or intensive care unit are at higher risk; however, even people with mild disease who do not need hospitalisation are also at increased risk of cardiovascular diseases 6 months to 1 year later.7 There is still a lot to learn about the lasting effects COVID-19 has had on the heart. Among magnetic resonance imaging scans of patients who recovered from COVID-19, the majority (78/100) showed abnormal findings suggestive of ongoing inflammation and scarring on the heart muscle.8 The virus may leave behind lasting heart damage that needs monitoring in some patients.

Since the emergence of the new Omicron variant in November 2021, experts have been trying to learn more about this variant and the risks it poses in the long term. The Omicron variant is highly transmissible which might mean an increase in cases, leading to more hospitalisations, cardiovascular complications, and deaths. The long-term cardiovascular effects of this variant are less well understood and are yet be addressed.

Physicians should consider a history of COVID-19 as a cardiovascular disease risk. It is important to identify early signs or symptoms of heart disease in these people. Early detection, diagnosis, and treatment will be key to prevent downstream adverse cardiovascular consequences. There are a lot of knowledge gaps that need to be investigated in future research to gain a better understanding of long-term cardiovascular outcomes of patients with COVID-19. How best to identify, diagnose, and treat these patients is a critical area of future research. The long-term trajectory of cardiovascular diseases among patients with COVID-19 requires long-term cohort studies to guide clinical practice and inform public health policy. An important message is increased awareness of cardiovascular complications among patients with COVID-19 and having well-established follow-up strategies.

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

The authors have declared no conflict of interest.

1. Welty FK, Rajai N, Amangurbanova M. Comprehensive review of cardiovascular complications of coronavirus disease 2019 and beneficial treatments. Cardiol Rev 2022;30:145-57. Crossref

2. Li T, Lu L, Zhang W, et al. Clinical characteristics of 312 hospitalized older patients with COVID-19 in Wuhan, China. Arch Gerontol Geriatr 2020;91:104185. Crossref

3. Zhao M, Wang M, Zhang J, et al. Comparison of clinical characteristics and outcomes of patients with coronavirus disease 2019 at different ages. Aging (Albany NY) 2020;12:10070-86. Crossref

4. Lala A, Johnson KW, Januzzi JL, et al. Prevalence and impact of myocardial injury in patients hospitalized with COVID-19 infection. J Am Coll Cardiol 2020;76:533-46. Crossref

5. Ni W, Yang X, Liu J, et al. Acute myocardial injury at hospital admission is associated with all-cause mortality in COVID-19. J Am Coll Cardiol 2020;76:124-5. Crossref

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

7. Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nat Med 2022;28:583-90. Crossref

8. Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020;5:1265-73. Crossref