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Wu Y, Wang DY, Zhao S, Wang MH, Wong ELY, Yeoh EK. Emergency Department Use Across Income Groups Following an Increase in Cost-Sharing. JAMA Netw Open 2023; 6:e2329577. [PMID: 37589972 PMCID: PMC10436128 DOI: 10.1001/jamanetworkopen.2023.29577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
Importance To encourage the appropriate utilization of emergency care, cost-sharing for emergency care was increased from HK$100 (US $12.8) to HK$180 (US $23.1) per visit in June 2017 in all public hospitals in Hong Kong. However, there are concerns that this increase could deter appropriate emergency department (ED) visits and be associated with income-related disparities. Objective To examine changes in ED visits after the fee increase. Design, Setting, and Participants This retrospective cohort study used administrative data from June 2015 to May 2019 from all public hospitals in Hong Kong. Participants included all Hong Kong residents aged 64 years and younger, categorized into low-income, middle-income, and high-income groups according to the median household income in their district of residence. Data analysis was performed from May to June 2023. Main Outcomes and Measures The primary outcome was the ED visit rate per 100 000 people per month, categorized into 3 severity levels (emergency, urgent, and nonurgent). Secondary outcomes include general outpatient (GOP) visit rate, emergency admission rate, and in-hospital mortality rate per month at public hospitals. Segmented regression analyses were used to estimate changes in the level and slope of outcome variables before and after the fee increase. Results This study included a total of 5 441 679 ED patients (2 606 332 male patients [47.9%]; 2 108 933 patients [38.5%] aged 45-64 years), with 2 930 662 patients (1 407 885 male patients [48.0%]; 1 111 804 patients [37.9%] aged 45-64 years) from the period before the fee increase. The fee increase was associated with an 8.0% (95% CI, 7.1%-9.0%) immediate reduction in ED visits after June 2017, including a 5.9% (95% CI, 3.3%-8.5%) reduction in urgent visits and an 8.9% (95% CI, 8.0%-9.8%) reduction in nonurgent visits. In addition, a 5.7% (95% CI, 4.7%-6.8%) reduction of emergency admissions was found, whereas no significant changes were observed in in-hospital mortality. Specifically, a statistically significant increase in GOP visits (4.1%; 95% CI, 0.9%-7.2%) was found within the low-income group, but this association became insignificant after controlling for the social security group, who were exempted from payment, as a control. Conclusions and Relevance In this cohort study, the fee increase was not associated with changes in ED visits for emergency conditions, but there was a negative and significant association with both urgent and nonurgent conditions across all income groups. Considering the marginal increase in public GOP services, further study is warranted to examine strategies to protect low-income people from avoiding necessary care.
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Affiliation(s)
- Yushan Wu
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Dorothy Yingxuan Wang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Shi Zhao
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Maggie Haitian Wang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Eliza Lai-yi Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Eng-kiong Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems and Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
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Penneau A. Do mobile hospital teams in residential aged care facilities increase health care efficiency: an evaluation of French residential care policy. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022:1-15. [PMID: 36131213 PMCID: PMC9492467 DOI: 10.1007/s10198-022-01522-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
CONTEXT Patients in residential aged care facilities (RACF) are frequently admitted to hospital since the RACF often lack adequate medical resources. Different economic agents, whose missions and funding may conflict, provide care for RACF residents: residential facility, primary care physicians, and hospital. In this article, I estimate the economic impact of employing a mobile hospital team (MHT) in RACF, which modifies the relationship between these three agents by providing care directly in RACF. METHOD A national, patient level database on RACF from 2014 to 2017 is used to calculate RACF outcome indicators. I analyse the difference between RACFs, that use MHT for the first time during the period (treatment group), and those that did not use MHT at all in the same period using a difference in difference (DID) model. RESULTS The MHT had a significant impact on health care quality in treated RACFs and reduced the number of patients transferred to hospital and the number of emergency department visits, and increased palliative care utilisation at the end-of-life, without increasing total hospital expenditure. CONCLUSION MHT appear improve care quality in RACFs by filling the gap in care needs including better end of life care, without increasing health expenditure. Given the high number of hospital transfers especially towards the end of life, securing the right level and mix of social and medical resources in RACFs is essential. Transferring some competencies of MHT teams to residential facilities may improve the quality of life of residents while improving allocative efficiency of public resources.
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Affiliation(s)
- Anne Penneau
- Institute for Research and Information in Health Economics (IRDES), 117 bis rue Manin, 75019, Paris, France.
- Department of Economics (LEDa) Paris-Dauphine University PSL, Place du Maréchal de Lattre de Tassigny, 75016, Paris, France.
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Wu Y, Fung H, Shum HM, Zhao S, Wong ELY, Chong KC, Hung CT, Yeoh EK. Evaluation of Length of Stay, Care Volume, In-Hospital Mortality, and Emergency Readmission Rate Associated With Use of Diagnosis-Related Groups for Internal Resource Allocation in Public Hospitals in Hong Kong. JAMA Netw Open 2022; 5:e2145685. [PMID: 35119464 PMCID: PMC8817200 DOI: 10.1001/jamanetworkopen.2021.45685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hong Kong's internal resource allocation system for public inpatient care changed from a global budget system to one based on diagnosis-related groups (DRGs) in 2009 and returned to a global budget system in 2012. Changes in patient and hospital outcomes associated with moving from a DRG-based system to a global budget system for inpatient care have rarely been evaluated. OBJECTIVE To examine associations between the introduction and discontinuation of DRGs and changes in length of stay, volume of care, in-hospital mortality rates, and emergency readmission rates in the inpatient population in acute care hospitals overall, stratified by age group, and across 5 medical conditions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data from patients aged 45 years or older who were hospitalized in public acute care settings in Hong Kong before the introduction (April 2006 to March 2009), during implementation (April 2009 to March 2012), and after discontinuation (April 2012 to November 2014) of the DRG scheme. Data analysis was conducted from January to June 2021. EXPOSURES Public hospitals transitioned from a global budget payment system to a DRG-based system in April 2009 and returned to a global budget system in April 2014. MAIN OUTCOMES AND MEASURES The main outcome was the association of use of DRGs with patient-level length of stay, in-hospital mortality rate, 1-month emergency readmission rate, and population-level number of admissions per month. An interrupted time series design was used to estimate changes in the level and slope of outcome variables after introduction and discontinuation of DRGs, accounting for pretrends. RESULTS This study included 7 604 390 patient episodes. Overall, the mean (SD) age of patients was 68.97 (13.20) years, and 52.17% were male. The introduction of DRGs was associated with a 1.77% (95% CI, 1.23%-2.32%) decrease in the mean length of stay, a 2.90% (95% CI, 2.52%-3.28%) increase in the number of patients admitted, a 4.12% (95% CI, 1.89%-6.35%) reduction in in-hospital mortality, and a 2.37% (95% CI, 1.28%-3.46%) decrease in emergency readmissions. Discontinuation of the DRG scheme was associated with a 0.93% (95% CI, 0.42%-1.44%) increase in the mean length of stay and a 1.82% (95% CI, 1.47%-2.17%) reduction in the number of patients treated after adjusting for covariates; no statistically significant change was observed in in-hospital mortality (-0.14%; 95% CI, -2.29% to 2.01%) or emergency readmission rate (-0.29%; 95% CI, -1.30% to 0.71%). CONCLUSIONS AND RELEVANCE In this cross-sectional study, the introduction of DRGs was associated with shorter lengths of stay and increased hospital volume, and discontinuation was associated with longer lengths of stay and decreased hospital volume. In-hospital mortality and emergency readmission rates did not significantly change after discontinuation of DRGs.
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Affiliation(s)
- Yushan Wu
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Hong Fung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Chinese University of Hong Kong Medical Centre, Hong Kong Special Administrative Region, Hong Kong, China
| | - Ho-Man Shum
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Shi Zhao
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Eliza Lai-Yi Wong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Ka-Chun Chong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Chi-Tim Hung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Eng-Kiong Yeoh
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Health Systems & Policy Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
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Lapid MI, Koopmans R, Sampson EL, Van den Block L, Peisah C. Providing quality end-of-life care to older people in the era of COVID-19: perspectives from five countries. Int Psychogeriatr 2020; 32:1345-1352. [PMID: 32389141 PMCID: PMC7251283 DOI: 10.1017/s1041610220000836] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Maria I. Lapid
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Raymond Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
- Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex University Hospital NHS Trust, London, UK
| | - Lieve Van den Block
- Aging and Palliative Care, VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Carmelle Peisah
- University New South Wales, Kensington, Australia
- Sydney University, Sydney, Australia
- Capacity Australia, Sydney, Australia
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Flierman I, van Seben R, van Rijn M, Poels M, Buurman BM, Willems DL. Health Care Providers' Views on the Transition Between Hospital and Primary Care in Patients in the Palliative Phase: A Qualitative Description Study. J Pain Symptom Manage 2020; 60:372-380.e1. [PMID: 32135201 DOI: 10.1016/j.jpainsymman.2020.02.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 11/26/2022]
Abstract
CONTEXT Inadequate handovers between hospital and home can lead to adverse health outcomes. A group particularly at risk is patients at the end of life because of complex health problems, frequent care transitions, and involvement of many professionals. OBJECTIVES To investigate health care providers' views and experiences with regard to the transition from hospital to primary care in palliative care. METHODS This was a descriptive qualitative study. Three focus group discussions were held with 28 nurses and two focus groups with nine physicians. Participants were recruited from primary and hospital care. The focus groups were audiorecorded, transcribed verbatim, and analyzed thematically. RESULTS The following themes emerged from the data: lack of identification of and communication about the last phase of life; incomplete and insufficient handover; and uncertainty about responsibilities. Professionals emphasize the importance of proper handovers and transitional processes in these vulnerable patients. The transition between hospital to primary care is hindered by a lack of identification of the palliative phase and uncertainties about patient awareness. Direct communication between professionals is needed but lacking. The handover itself is currently primarily focused on physical aspects where psychosocial aspects were also found necessary. Furthermore, uncertainties with regard to physicians' responsibility for the patient seem to further hinder professionals in the transitional process. CONCLUSION Efforts should be made to enhance knowledge and skills around identification of palliative needs and communication with patients about the end of life, especially in the hospital setting.
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Affiliation(s)
- Isabelle Flierman
- Section of Medical Ethics, Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Rosanne van Seben
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Marjon van Rijn
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Faculty of Health, ACHIEVE-Centre of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | | | - Bianca M Buurman
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Faculty of Health, ACHIEVE-Centre of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Li M, Hu R, Liu X, Tao S, Rong B. Post-discharge extended care contributes to the disease control of patients with COPD: a Chinese study. Int J Chron Obstruct Pulmon Dis 2018; 13:4005-4013. [PMID: 30587956 PMCID: PMC6300378 DOI: 10.2147/copd.s177038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background The aim of this study was to evaluate the efficacy of extended care in patients with COPD. Patients and methods A total of 140 patients with GOLD-2 to -4 of COPD were included in final analysis. The care efficacy was evaluated by the St George’s Respiratory Questionnaire 12-item General Health Questionnaire (GHQ-12), pulmonary function test and blood gas analysis. Results The extended care improved the activity ability of COPD patients, relieved the clinical symptoms as well as reduced the impact degree of COPD to daily life (P<0.05). In addition, the extended care improved the mental health condition of patients with COPD compared with usual care (P<0.05). Moreover, the extended care improved the ventilation function of COPD patients, reduced the acute exacerbation rate and improved the blood gas levels compared with the usual care (P<0.05). Conclusion The extended care improves the quality of life, respiratory function and the mental health condition of patients with COPD after discharge, indicating that it contributes to the disease control of patients with COPD.
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Affiliation(s)
- Min Li
- Department of Respiratory Medicine, Shenmu Hospital, Shenmu, Shaanxi, China,
| | - Rong Hu
- Department of Nursing, Shenmu Hospital, Shenmu, Shaanxi, China
| | - Xiaoyang Liu
- Department of Surgery, Shenmu Hospital, Shenmu, Shaanxi, China
| | - Shuping Tao
- Department of Respiratory Medicine, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Biaoxue Rong
- Department of Respiratory Medicine, Shenmu Hospital, Shenmu, Shaanxi, China, .,Department of Respiratory Medicine, First Affiliated Hospital, Xi'an Medical University, Xi'an, Shaanxi China,
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Kong ST, Fang CMS, Lou VWQ. Solving the "Personhood Jigsaw Puzzle" in Residential Care Homes for the Elderly in the Hong Kong Chinese Context. QUALITATIVE HEALTH RESEARCH 2017; 27:421-433. [PMID: 27502836 DOI: 10.1177/1049732316658266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
End-of-life care studies on the nature of personhood are bourgeoning; however, the practices utilized for achieving personhood in end-of-life care, particularly in a cultural context in which interdependent being and collectivism prevail, remain underexplored. This study seeks to examine and conceptualize good practices for achieving the personhood of the dying elderly in residential care homes in a Chinese context. Twelve interviews were conducted with both medical and social care practitioners in four care homes to collect narratives of practitioners' practices. Those narratives were utilized to develop an "end-of-life case graph." Constant comparative analysis led to an understanding of the practice processes, giving rise to a process model of "solving the personhood jigsaw puzzle" that includes "understanding the person-in-relationship and person-in-time," "identifying the personhood-inhibiting experiences," and "enabling personalized care for enhanced psychosocial outcomes." Findings show how the "relational personhood" of the elderly can be maintained when physical deterioration and even death are inevitable.
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Abele P, Morley JE. Advance Directives: The Key to a Good Death? J Am Med Dir Assoc 2016; 17:279-83. [PMID: 26952570 DOI: 10.1016/j.jamda.2016.01.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Patricia Abele
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO; Division of Endocrinology, Saint Louis University School of Medicine, St Louis, MO.
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Michel JP, Cha HB. Filling the Geriatric Education Gap Around the World. J Am Med Dir Assoc 2015; 16:1010-3. [DOI: 10.1016/j.jamda.2015.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 12/13/2022]
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End-of-life care research in Hong Kong: A systematic review of peer-reviewed publications. Palliat Support Care 2015; 13:1711-20. [DOI: 10.1017/s1478951515000802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTObjective:This systematic review aimed to examine end-of-life (EoL) care research undertaken in an Eastern cultural context—Hong Kong—with the hope of better informing EoL care professionals and policy makers and providing lessons for other countries or areas that share similar EoL care challenges.Method:Eight databases were searched from their respective inception through to August of 2014. All of the resulting studies conducted in Hong Kong and relevant to EoL care or palliative care were examined. The included studies were assessed with respect to study design, care settings, participants, research themes, and major findings.Results:Some 107 publications published between 1991 and 2014 were identified. These studies were undertaken at a range of places by different professionals. Of the total, 44 were led by physicians, 36 by nurses, 17 by social workers, and 10 by other professionals. Participants included both inpatients and outpatients with different illnesses, nursing home residents, older community-dwelling adults, deceased individuals, care staff, and informal caregivers. A total of 13 research themes were identified: (1) attitudes to or perceptions of death and dying; (2) utilization of healthcare services, (3) physical symptoms or medical problems; (4) death anxiety or mental health issues; (5) quality of life; (6) advance directives or advance care planning; (7) supportive care needs, (8) decision making; (9) spirituality; (10) cost-effectiveness or utility studies; (11) care professionals' education and training; (12) informal caregivers' perceptions and experience; and (13) scale development or validation.Significance of results:While there has been a wide and diverse range of research activities in Hong Kong, EoL care services at primary care settings should be strengthened. Some priority areas for further research are recommended.
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