Hong Kong Primary Care Morbidity Survey 2021-2022

Julie Y Chen 陳芸, David VK Chao 周偉強, Samuel YS Wong 黃仰山, Emily TY Tse 謝翠怡, Eric YF Wan 尹旭輝, Joyce PY Tsang 曾佩欣, Cindy LK Lam 林露娟

HK Pract 2024;46:28-39

Summary

Objective: To determine the pattern and changes in morbidity in Hong Kong primary care since 2007
Design: A prospective practice-based survey.
Subjects: Practising primary care doctors in Hong Kong.
Main outcome Measures: Frequency of health problems encountered by primary care doctors as coded using the International Classification of Primary Care, Second Edition (ICPC-2).
Results: Forty-nine doctors participated the study and contributed 172 doctor-weeks of data from March 2021 – February 2022, resul t ing in 40,984 heal th problems based on 26,897 unique patient encounters. The most f requently recorded diagnoses were uncomplicated hypertension (12.9%), lipid disorders (10.6%), immunisation (6.3%), non-insulin dependent diabetes mellitus (6.3%) and upper respiratory tract infections (5.5%). Endocrine/metabolic (20.9%) and cardiovascular (18.2%) were the body systems with the most frequently encountered problems with also a large proportion falling in the general/unspecified category that encompassed preventive care (16.0%). Compared with the 2007-08 morbidity survey, the proportion of chronic conditions increased from 35.6% to 46.7% and psychological problems increased from 2.6% to 2.8% with a notable increase within the adolescent age group. Preventive care increased from 3.1% to 9.2%, with a high proportion of these encounters being COVID-19 vaccinations.
Conclusion: This study underscores the breadth of morbidity in primary care despite the COVID-19 outbreak and shows that the burden of chronic diseases, mental health and preventive care is increasing in primary care. A family-doctor model of primary care and an integrated system approach with dedicated resources are needed to better support doctors to care for patients in these key areas.
Keywords: Primary care, diagnoses, morbidity, epidemiology, common problems

摘要

目的：調查自2007年以來香港基層保健的發病率的模式和變化
設計：基於診所為本的前瞻性調查。
對象：在香港執業的基層醫療保健醫生。
主要量度目標：使用《國際基層醫療分類》第二版(ICPC- 2)編碼的基層醫療保健醫生遇到的健康問題的頻率。
結果：從2021年3月到2022年2月，49名醫生參與了這項研 究，貢獻了172個醫生周的資料，根據26,897次患者的個別 診症，產生了40,984個健康問題。最常記錄的診斷包括無 併發症的高血壓(12.9%)、高血脂疾病(10.6%)、免疫接種 (6.3%)、非胰島素依賴性糖尿病(6.3%)和上呼吸道感染 (5.5%)。內分泌/代謝(20.9%)和心血管(18.2%)是身體中最 常遇到問題的系統，其中很大部分也包括屬於預防性護理 （16.0%)的一般∕未指定類別。與2007-08年發病率調查相 比，慢性病的比例從35.6%上升到46.7%，心理問題從2.6% 上升到2.8%，青少年年齡組別明顯增加。預防性護理從 3.1%增加到9.2%，其中新冠肺炎疫苗接種的比例很高。
結論：這項研究顯示了儘管新冠肺炎爆發，但基層醫療處 理的疾病層面很廣泛，並表明基層醫療中慢性病、心理健 康和預防性護理的比重正在增加。以家庭醫生為本的基層 保健模式和具有專用資源的綜合醫療系統方案，可以更好 地支援醫生在這些關鍵領域中診治患者。
關鍵詞：基層醫療、診斷、發病率、流行病學、常見，問題

Introduction

Primary care is often the point of first contact with the healthcare system for members of a community so the vast majority of people who need to see a doctor will consult a primary care doctor.¹ The types of health problems encountered in primary care are therefore a reasonable proxy for the health problems affecting the population at large. Data on the prevalence and burden of various diseases and conditions at the local community level helps healthcare providers and policymakers understand the scope of health issues in a population, allocate resources appropriately, and plan preventive measures.

Methodological or practical considerations limit the usefulness of some commonly used approaches of gathering health and health service data in primary care. Population surveys such as general household surveys about individual health conditions and health service usage provide a broad-based perspective but are reliant on patient recollection and self-report which may not be wholly accurate.² Electronic registers of patient health care information provide rich databases for evaluating disease prevalence and morbidity trends in primary care as demonstrated in the Netherlands³ and in Sweden.⁴ However, in the absence of centralised computerised databases, or where all the desired information cannot be captured, practice-based morbidity surveys are a very useful option. This is particularly relevant in Hong Kong as primary care is mostly provided in the private sector where there is no universal electronic health record system.

According to a 2023 World Health Organization Western Region report, chronic disease is described as an epidemic that poses the most significant health burden to this part of the world.5 The last morbidity survey in Hong Kong conducted in 2007-08 had already found that chronic diseases made up an increasing and significant proportion of all problems seen by primary care doctors in Hong Kong.⁶ Since then, the HKSAR Government has implemented various primary care initiatives to encourage patients with chronic disease to seek care in the private sector. For instance, the General Outpatient Clinic Public Private Partnerships programme was implemented in mid-2014 to give clinically stable diabetic and/or hypertensive patients the opportunity to receive care from private doctors at no additional outof- pocket cost.

With an aging population, increasing prevalence of chronic disease and the implementation of primary care initiatives for chronic disease management in primary care, an updated primary care morbidity study is important and timely. It will help to inform primary health care policy and guide work force and service planning by providing evidence to support the allocation of resources to develop and to expand primary care initiatives that support the provision of quality chronic disease care and other high prevalence conditions, to enable continued surveillance of the morbidity trends in Hong Kong by providing data for comparison with past and future studies, and to inform the content of educational curricula for undergraduate education and postgraduate training of doctors to better meet the needs of the community. Therefore, the aim of this study was to determine the pattern and changes in morbidity in Hong Kong primary care since 2007.

Methods

This was a prospective practice-based morbidity survey. The study protocol has been previously reported.⁷ The 12-month data from March 2021 – February 2022 are presented in this paper.

Subjects
All practising primary care doctors in Hong Kong from both the public and private sectors were eligible to join the study.

Setting
Hong Kong has a mixed public-private health care system in which patients may consult primary care western doctors in the public general outpatient clinics (GOPC) under the government’s Hospital Authority or choose to see doctors in private practice in the community. The proportion of patients seeking health care in GOPCs was 36.4% while 63.6% sought care from private western doctors according to the 2019 Thematic Health Survey No. 68, the latest one that was conducted pre-pandemic.² The 2020-22 Hong Kong Population Health Survey revealed that 53% of patients with chronic disease were followed-up in the public sector.⁸ This morbidity survey was not planned to be carried out during the COVID-19 outbreak, which coincidentally began in January 2020, but it proceeded mainly between the 4^th and 5^th waves. The 4^th wave of the COVID-19 outbreak in Hong Kong started in November 2020 and subsided in May 2021 while the 5^th wave started in January 2022. Mass COVID-19 vaccination began in February 2021 in which the government established community vaccination centres and engaged private primary care doctors to give free COVID-19 vaccination⁹ coinciding with the start of the data collection period.

Data collection and analysis
Doctors were invited to join the study via mass email to members of the Hong Kong College of Family Physicians (HKCFP), honorary family medicine teachers of The University of Hong Kong, members of the Hong Kong Primary Care Research Network and through the chiefs of service of family medicine and primary care in most of the Hospital Authority clusters. Participating doctors provided background information including demographics, years in general practice, vocational training, participation in government-coordinated primary care initiatives and usage of the Primary Care Reference Frameworks (PCRF) which were locallydeveloped management guidelines for chronic disease and preventive care. A standardised data collection form was used to record information on consecutive patient encounters including patient demographics, presenting problems, diagnoses, and management activities. Diagnoses were recorded by writing in the diagnosis or logging the corresponding International Classification of Primary Care, Second Edition (ICPC-2) code.¹⁰

Participants were briefed on the study, how to complete the data collection forms including using ICPC-2 codes and were given a training handbook for reference. One week per month was pre-determined as the data-collection week which was the first full week of each month in which there were no public holidays to maximise the number of working days. Seasons were divided into 3-month periods based on historical climatological data with spring as March-May, summer as June-August, autumn as September-November, and winter as December-February. Thus, there were 3 weeks of data collection in each season. Each participant collected at least one week of data or a minimum of 100 patient encounters in each season of the year. Thirty-eight doctors collected at least one week of data. Eleven doctors collected data for more than one week until they reached 100 patient encounters because they were working part-time. One hundred patient encounters was about 50% of the average doctorʼs patient load based on the 2007 morbidity survey in which doctors averaged 187 patient encounters in a week. Hard copies or electronic data collection forms were distributed to participants according to preference. Completed hardcopy forms were collected by hand by a research assistant and electronic forms were returned by email.

Trained research assistants coded written diagnoses and when there was uncertainty, a clinical member of the research team advised the proper code. Data recorded on the forms were double-entered into a master database and the two sets of independently-entered data were compared with any discrepancies resolved by referring to the original data collection forms. Some ICPC-2 codes were grouped using the code groups in the Bettering the Evaluation and Care of Health study in Australia.¹¹ Chronic diseases were defined using the ICPC-2 code set defined for chronic conditions in primary care from the study by O’Halloran, et al.¹² Data were analysed using the Statistical Package for the Social Sciences Version 28 (SPSS-28) and prevalence of health problems diagnosed were presented by descriptive statistics.

Ethics Approval
This study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 19-806), Hong Kong East Cluster (HKECREC-2021-091), Kowloon East Cluster (REC(KC/KE)-21-0124/ER-2), Kowloon Central Cluster (REC(KC/KE)-21-0131/ER-2), Kowloon West Cluster (161-01), and New Territories East Cluster (2021.368).

Results

Participating doctors
Forty-nine doctors participated in the study contributing 172 doctor-weeks of data from March 2021- February 2022. Each full week of data collected by participating doctors is defined as a “doctor-week” of data. There was an even representation of male (51.0%) and female (49.0%) participants. Half (51.0%) practiced on Hong Kong Island and most (63%) worked in the private sector. A majority (74.4%) had more than 10 years of experience working in primary care and a similar proportion (73%) had vocational training in Family Medicine. More than half participated in at least one government primary care initiative and used at least one of the primary care reference frameworks in their practice. Table 1 shows the doctor demographic and practice characteristics.

Table 1: Doctor demographics and practice characteristics

Note: values may not add up to 100% due to missing data;
* Doctors with vocational training in other specialties included 2 in Medicine, 1 in Anaesthesia, and 1 in Paediatrics.
# Proportion of private doctors participating in primary care initiatives as these target private doctors

Patient encounters
There was a total of 26,897 unique patient encounters and of these, 11,304 (42.1%) were male with an overall median age of 56. The patients encountered in this study were generally older compared to the Hong Kong general population at year-end of 2021 (median age 56 vs 46.3)¹³, which was reflected most notably in the higher proportion of those in the elderly (age ≥ 65) age group in our study (32.1% vs 19.1%). This is consistent with the expectation that older people would be more likely to have health problems that necessitate a doctor visit. In our study there was also a lower proportion of younger adults and adolescents compared with the general population. Table 2 shows the demographic distribution of patients in the study compared with the HK general population.

Of the 26,897 patient encounters, 8200 (30.5%) of these took place in the public sector and 18,697 (69.5%) occurred in the private sector. However, according to the Thematic Health Survey No. 68 conducted in 2019², 36.4% of the Hong Kong general population actually sought western outpatient medical care in the public sector while 63.6% sought care from private doctors. Therefore, to better match the proportion of health service utilisation in the public/private sectors by the Hong Kong general population, we weighted the public sector data by a factor of 1.193 (36.4%/30.5%) and the private sector data by a factor of 0.915 (63.6%/69.5%) to make up for the underrepresentation of the public sector in our survey. Both the unweighted and weighted data resulted in similar frequencies and ranking of diagnoses, so we present only the weighted data in this paper.

The 26,897 patient encounters resulted in 40,984 health problems / diagnoses. Doctors in this study reported a median of 196 and mean of 229 (SD 143) patient encounters per week and diagnosed a median of 274 and mean of 354 (SD 216) health problems per week. Doctors in the public sector had more patient encounters per week than their private practice counterparts (median 240 vs 183) and also managed more health problems per week (median 513 vs 237).

Most common diagnoses
A total of 544 unique diagnoses were recorded, in which 13 of them had a frequency of at least 1%. These most common diagnoses comprised chronic diseases (hypertension, lipid disorder, non-insulin dependent diabetes, and obesity), acute conditions (upper respiratory tract infection, dermatitis, gastroenteritis, allergic rhinitis, dyspepsia/indigestion) as well as preventive care (immunisation, physical check-up) and abnormal test results. There were 83 diagnoses that occurred with a frequency of at least 0.2%, and 144 with frequency of at least 0.1%. The top 9 diagnoses accounted for 50% of all reasons for encounter, the top 46 diagnoses for 75% and the top 61 diagnoses for 80%. Table 3 shows the top 80% diagnoses. The most frequently recorded diagnoses by ICPC-2 code were uncomplicated hypertension (12.9%), lipid disorders (10.6%), immunisation (6.3%), non-insulin dependent diabetes mellitus (6.3%) and upper respiratory tract infections (URTI) (5.5%). The prevalence of all diagnoses by ICPC-2 code may be found at this link: https://fmpc.hku.hk/en/Resources/Resources/HKPrimary- Care-Morbidity-Survey-2021-22

Most common diagnoses by type, age group and sector

A large proportion of all diagnoses (43.8%) were chronic conditions. There was a higher proportion of chronic conditions in the public sector (67.8%) compared to those in private sector (25.1%). Health conditions involving three body systems constituted over 50% of all diagnoses in this study. They were endocrine/metabolic and nutritional (20.9%), cardiovascular (18.2%) and general /unspecified that also included preventive care (16.0%) as shown in Table 4. The frequency distribution of the top 10 diagnoses in each body system may be found at this link: https://fmpc.hku.hk/en/Resources/Resources/HKPrimary- Care-Morbidity-Survey-2021-22

Table 5 shows the top 10 diagnoses in each age group. Chronic conditions were most frequently seen among the adult and elderly age groups with hypertension, lipid disorders and diabetes predominating. Children and adolescents attended consultations most commonly for acute infections (URTI, gastroenteritis) and various kinds of dermatitis (contact, allergic and atopic). Consultations for immunisation, URTI and dermatitis were common to all age groups.

The comparison of the top 10 diagnoses in each healthcare service sector is found in Table 6. Chronic conditions comprised 5 of the top 10 most common problems diagnosed in the public sector. Hypertension was by far the most common, making up more than one-fifth of all the health encounters in the public sector followed by lipid disorders (16.7%) and diabetes (10.5%). In comparison, preventive care (immunisation and physical check-up) was the most common reason for encounter among private practitioners followed by URTI, neither of which made the top 10 in the public sector. Gastroenteritis and depressive disorder were the other most frequent diagnoses made in private practice but not in public.

Table 7 shows that compared with 2007-08, there was a statistically significant increase in the proportion of chronic diseases and preventive care, and an increase in psychological problems, though not reaching statistical significance.

Discussion

This study was conducted in a challenging time, between waves of COVID-19 infection, during which the HK Government had activated the Emergency Response Level (the highest level) in response to the latest situation of the pandemic. Because of the pandemic, patients’ usual healthcare-seeking practices and doctors’ clinical service provision were both affected. Patients tended to avoid seeking medical care especially in primary care¹⁴ and family doctors in both public and private sectors reported significant impact on their clinical practice including cancelling or changing regular non-acute patient appointments and shortening consultation times.¹⁵ Despite this, the study was able to include doctors from across the HKSAR who recorded a total 40,984 health problems encountered over one year. This exceeded the estimated 38,415 health problems needed to reliably determine and generalise the types, frequency and distribution of common problems encountered by doctors in the Hong Kong primary care setting.⁷

Common problems
From a clinician’s point of view, a practical definition of what is a common problem in primary care can be considered those conditions that are seen at least once over the course of a week, or at least once in a month, by the average family doctor. This study showed that the median number of problems encountered by doctors per week was 274 so one encounter per week equated to those problems encountered with at least a frequency of 0.4% (0.4% x 274= 1.096 encounters per week). Thus, the top 45 diagnoses were encountered at least once per week and the top 137 diagnoses (frequency of at least 0.092%) were encountered at least once per month. The results demonstrate the breadth of primary care. This list of common problems can be used to better tailor the primary care content of undergraduate medical and health professions curricula. Vocational training and continuing professional development initiatives can also draw on these data to better prepare primary care doctors to meet the needs of the local community.

Chronic diseases
Patients in this study, compared with 2007-08, were older (median age 56 in 2021-22 vs 43 years of age in 2007-08) and had a higher proportion of elderlies (>65) age group (32.1 % in 2021-22 vs 17.4% of all patients in 2007-08) which is consistent with the generally aging demographic trend in Hong Kong. Elderly patients also tend to seek healthcare in the public sector which can explain the higher proportion of patients who sought healthcare in the public sector in the current study (30.5% in 2021-22 vs 26.6% in 2007-08). The COVID-19 pandemic could also contribute to the age skew as those who made clinic visits were those who really needed to see a doctor such as for chronic disease monitoring, namely older adults and the elderly.

This may also be a contributing factor in the higher prevalence of chronic diseases encountered compared to the 2007-08 study, specifically for hypertension (complicated and uncomplicated) (14.2% vs 10.0%), non-insulin dependent diabetes mellitus (5.8% vs 4.0%) and lipid disorder (10.5% vs 2.7%). These three conditions comprised 49.0% of health problems in the public sector and 12.7% in private. The pattern of morbidity for chronic diseases for this study compared to 2007-08 also showed a resultant increase in frequency of problems affecting the cardiovascular system (18.2% vs 12.8%) and endocrine/metabolic system (20.9% vs 9.3%).

These data show a continuing and growing trend of chronic disease care provision by primary care doctors consistent with observations in other settings such as the United States which found that chronic conditions comprised 39% of ambulatory physician visits.¹⁶ Some of this may be reflected in doctor participation in formal government initiatives for managing chronic disease in primary care such as the shared-care General Outpatient Clinic Public Private Partnership programme (GOPCPPP) as more than one-third of doctors in this study participated, and more than half used the chronic disease reference frameworks to help guide their management of diabetes or hypertension. However, it has been suggested that this programme did not take advantage of the potential of family doctors to provide whole-person and longitudinal care since patients may only see the programme doctor for the specific chronic disease but not for other reasons.¹⁷ A new Chronic Disease Co-Care Pilot Scheme that started in November 2023 is trying to address this by recruiting family doctors to care for rostered patients not just for a specific chronic disease as in the GOPCPPP scheme, but to serve as their usual family doctor for all their healthcare needs.17 This is a promising initiative, as chronic disease management in primary care increasingly involves patients with multimorbidity.¹⁸ In the Hong Kong primary care public sector, the prevalence of multimorbidity was already found to be 54% in 2012 among the study population of patients over the age of 40¹⁹ and has certainly increased since then. Support and resources for doctors are needed to maintain and develop expertise in multimorbid chronic disease management, to be able to dedicate adequate consultation time to complex chronic disease patients and to be seamlessly integrated into a more cohesive primary care health system. This will facilitate the family-doctor model of primary care to help patients achieve the best outcomes possible.

Acute upper respiratory tract infection
The frequency of URTI diagnosis (5.5%) dropped precipitously from the Hong Kong primary care morbidity studies conducted in 1994 (34.6%)²⁰ and in 2007-08 (26.4%).⁶ This was also observed worldwide, likely due to public health measures such as wearing face masks and social distancing that were in place for COVID-19²¹ and perhaps increased self-management of less severe acute illness by patients who avoided the doctor’s office for fear of exposure to COVID-19. This decreased frequency of URTI was demonstrated in a local study that showed 17 clinically significant seasonal respiratory viruses declined in prevalence during the pandemic compared with pre-pandemic levels based on laboratory testing with a rebound of these viruses following the relaxation of pandemic control measures towards the end of 2022.²² However, URTI remained the most common diagnosis in primary care in the private sector as well as among the younger age groups who tend to attend private clinics. This may be explained by the intermittent outbreaks of URTI that occurred despite the pandemic infection control measures. For example, in April 2021 a notification from the Centre for Health Protection to school principals warned of an URTI outbreak in kindergartens and primary schools²³ and a Government press release alerted the public of another kindergarten / secondary school URTI outbreak in November 2021.²⁴

Psychological problems
The prevalence o f psychological problems encountered was slightly higher than in 2007-08 (2.8% vs 2.6%) and though the difference was not statistically significant, and again, the impact of the pandemic could have been a factor. Worry about being infected²⁵ and the loneliness that accompanies social isolation²⁶ are both known risks for psychological morbidity. A worrisome observation is the increase in depressive disorder among adolescents and young adults. Depressive disorder has risen to the 8^th most frequent diagnosis in both these age groups compared with 2007-08 when it was not within the top ten. This is not surprising as there has been a trend of worsening youth mental health noted worldwide, including in Hong Kong, with a recent local study also documenting an increase in prevalence of major depressive episodes among the youth study population from 13.2% before the pandemic to 18.1% during the COVID-19 pandemic.²⁷ These figures are even more worrisome as they are likely underestimations given adolescents’ suboptimal helpseeking behaviour.²⁷ With an increasing proportion of psychological problems, especially in the adolescent age groups, primary care practitioners play a role in recognising potential cases by taking any clinic visit as an opportunity for inquiring about psychological stressors and mental health. More resources should be available to refer them for early assessment and management.

Preventive care
The bulk o f diagnoses f o r preventive c a r e comprised immunisation and physical check-up. The high rate of preventive care diagnoses recorded (9.2%) during this study was due in part to the large proportion of immunisations (6.3%). Around 4.5% of immunisations were COVID-19 vaccinations because of the Government mass vaccination scheme implemented while this study was ongoing, but this is likely a conservative estimate. We were able to estimate the frequency of COVID-19 vaccinations because 90% of private doctors wrote in a diagnosis of ‘COVID-19 vaccination’ on the patient encounter form. This diagnosis occurred so frequently that the research team created a separate code (A44R1) for analysis purpose since there was no designated ICPC-2 code for it. On the other hand, in the public sector, doctors self-coded from a drop-down menu in the electronic health record system using ICPC-2 code A44 for immunisation so it was not possible to distinguish COVID-19 vaccination from others. In fact, public primary care doctors rarely have encounters for vaccination since COVID-19 vaccine is given without doctor consultation, and the only other vaccination available from GOPC is tetanus.

Even when excluding COVID-19 vaccinations, there is a clear trend of increasing preventive care provided by primary care doctors in this study (4.7%) compared with the morbidity studies from 2007-08 (3.8%) and 1994 (1.2%) which may be due in part to the introduction of the government-subsidised colorectal cancer screening programme since 2017. This trend is also observed in other countries in prepandemic times such as in the United States where there was a doubling in the proportion of preventive care visits in primary care from 12.8% to 24.6% according to the 2001-2019 National Ambulatory Medical Care Survey.²⁸ Patients are looking to their family doctors for care and advice as they become more aware of the importance of preventive healthcare, making this an area in which primary care doctors are well positioned to provide care.

Strengths and limitations
The strength of this study is that it involved a demographically diverse complement of doctors who practiced in both the public and private sectors in all three districts of Hong Kong, henceforth providing a good representation of different practices. Data on patient encounters were collected in each of the 12 months during the study period that reduced the seasonal bias for certain morbidities. However, as more than half of the data were collected from doctors practising on Hong Kong island which is generally more affluent than Kowloon and New Territories, this may have a bearing on the kinds of problems and diseases encountered. Because this survey was conducted during the COVID-19 outbreak, chronic disease proportions and psychological problems may be under-estimated because of avoidance of doctor visits. Other respiratory infections would be reduced because of surgical mask use. The focused nature of some practices (e.g. skin problems or pain management) would also have affected the scope of conditions reported in this study.

Conclusion

This study provided a comprehensive view of the morbidity patterns in Hong Kong primary care. It confirmed the continuing trend of increasing prevalence of chronic disease seen in primary care driven by an aging population as well as by proactive primary care initiatives; the troubling increase in psychological diagnoses especially notable in young people and the pronounced increase in preventive health-care seeking visits across all age groups. This study highlights the breadth of morbidity presenting to primary care despite the COVID-19 outbreak. It also identifies key areas in which primary care doctors need support and resources to build on the family doctor model of primary care to help patients achieve their best possible outcomes.

Acknowledgment

We thank the HKCFP Foundation Fund and the University Grants Council Research Matching Grants Scheme for funding this study.

We gratefully acknowledge our site coinvestigators, research assistants, student research assistants and most of all the doctors who generously gave their time to participate in this study despite the challenging circumstances imposed by the COVID-19 pandemic.

Site Co-investigators:

Maria KW Leung, MBBS (UK), FRACGP, FHKCFP, FHKAM (Family Medicine) Chief of Service & Consultant,
Department of Family Medicine and Primary Healthcare, New Territories East Cluster, Hospital Authority
Welchie WK Ko, MBBS, FHKAM (Family Medicine) Chief of Service,
Department of Family Medicine and Primary Healthcare, Hong Kong West Cluster, Hospital Authority
Yim-chu Li, MBBS(HK), FHKCFP, FRACGP, FHKAM (Family Medicine) Chief of Service,
Department of Family Medicine and Primary Healthcare, Kowloon Central Cluster, Hospital Authority
Catherine XR Chen, PhD (Medicine, HKU), MRCP (UK), FRACGP, FHKAM (Family Medicine) Consultant,
Department of Family Medicine and General Outpatient Clinics, Kowloon Central Cluster, Hospital Authority, Hong Kong
Wan Luk, MBChB (CUHK), FHKCFP, FRACGP, FHKAM (Family Medicine) Chief of Service and Consultant,
Department of Family Medicine and Primary Healthcare, Kowloon West Cluster, Hospital Authority
Thomas MC Dao, MBBS (HK), FRACGP, FHKCFP, MSc in Diagnostic Ultrasonography (CUHK) Associate Consultant,
Department of Family Medicine & Primary Healthcare, Kowloon West Cluster, Hospital Authority
Michelle MY Wong, MBBS (UNSW), FHKCFP, FRACGP, FHKAM (Family Medicine) Chief of Service and Consultant,
Department of Family Medicine and Primary Healthcare, Hong Kong East Cluster, Hospital Authority
Wanmie WM Leung, MBChB, FHKAM (Family Medicine) Consultant,
Department of Family Medicine and Primary Healthcare, Hong Kong East Cluster, Hospital Authority
FMPC Research Assistants
Ms. Karina Chan, Ms. Lanlan Li, Ms. Alice Zheng, Ms. Rannie Pan, Mr. John Cheng, Mr. Chi-Lam Cheung, Mr. Jie Mei.
FMPC Student Research Assistants
Ms. HL Li, Mr. Alex CF Lam, Mr. Nicholas YC Cheung, Mr. Joseph CY Wong, Ms. Nadya Christina, Ms. Ayla, KT Kwok, Ms. Emily HL Kiu, Ms. Teddy Yuqi Mi, Ms. Anna SY Sze.

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