Evaluation of the Chronic Disease Co-Care Pilot Scheme

This study aims to evaluate the quality of care, feasibility, acceptability, effectiveness and cost-effectiveness of the CDCC Pilot Scheme in Hong Kong. The objectives of this study are the following:

1. Describe the characteristics of participants of the CDCC Pilot Scheme; 2. Measure the standards of adherence to care criteria achieved by healthcare providers participating in the CDCC Pilot Scheme; 3. Evaluate participant acceptability by self-reported outcomes on enablement, experience and satisfaction level about the services of CDCC; 4. Evaluate the effectiveness of the CDCC Pilot Scheme on improving health outcomes among CDCC participants over 12 months; 5. Determine the provider costs and cost-effectiveness for delivering the CDCC Pilot Scheme relative to its effectiveness on participants health outcomes

The detailed study design of each objective are:

Objective (a): All participants in CDCC Pilot Scheme between 1 Jan 2024 and 30 Jun 2024 will be included in the evaluation. The characteristics including demographics, comorbidities, and medications of the participants will be summarized using descriptive statistics.

Objective (b): For the evaluation of the structure of care, quantitative data will be collected through structured questionnaires on the quality of care with DHC/DHC Express managers at 6 months and repeated at 12 months. Each DHC/DHC Express will also nominate two family doctors and one of each network allied health professionals (optometrists, podiatrists, dietitians, and physiotherapists subject to the availability in each center) within their service network to complete the questionnaire at 12 months. For the evaluation of the standards on process and outcome of care, all participants in the CDCC Pilot Scheme between 1 Jan 2024 and 30 Jun 2024 will be included.

Objective (c): Participants will be conveniently sampled after completion of the Health Risk Factor Assessment (HRFA) at DHC/DHC Express between 1 Jan 2024 and 31 Mar 2024 to complete surveys on self-reported outcomes. For the first survey at 3 months, a questionnaire will be used to assess participants' enablement level and experience during the screening phase. The second follow-up survey will be administered at 12 months to assess participants' experience in clinical encounters.

Objective (d): This will be a 1-year comparative cohort study including CDCC and non-CDCC participants to evaluate the effectiveness of the CDCC Pilot Scheme. A total of 264 CDCC participants, and 264 non-CDCC participants screened positive for HT, pre-DM, or DM will be included as intervention and comparison group, respectively. All participants will be followed up 12 months. Records for CDCC participants who meet the inclusion criteria between 1 Jan 2024 and 30 Apr 2024, will be extracted from the Electronic Health Record Sharing System database. Meanwhile, a convenient sample of 1,886 non-CDCC participants (comparison group) will be recruited from the community between 1 Jan 2024 and 30 Apr 2024.

Objective (e): This will be a 1-year comparative cohort study including CDCC and non-CDCC participants to evaluate the costs and cost-effectiveness of the CDCC Pilot Scheme. The total costs incurred on the CDCC Pilot Scheme from 1st January 2024 to 31st December 2024, including set-up costs, ongoing operational costs and ongoing administrative and maintenance costs will be collected via questionnaires. Direct medical costs for CDCC participants and non-CDCC participants will be collected after 12 months.

• Experience and satisfaction of CDCC participants by the experience and enablement questionnaire [Срок оценки: Experience and satisfaction of CDCC participants will be evaluated at 3 months and 12 months after recruitment]
• Number of attendance to doctor consultation on times in comparison groups [Срок оценки: 12 months]
• Rate of diagnosis of HT and/or DM on dichotomous yes/no response in comparison groups [Срок оценки: 12 months]
• Changes in mean HbA1c/FPG in percent between two groups [Срок оценки: 12 months]
• Changes in mean SBP and DBP in millimeter of mercury between two groups [Срок оценки: 12 months]
• Changes in mean of HbA1c in percent between two groups [Срок оценки: 12 months]
• Changes in BMI in kilogram per square metre between two groups [Срок оценки: 12 months]
• Changes in the rate of smoking cessation and rate of alcohol abstinence between two groups by the Health Risk Factor Assessment [Срок оценки: 12 months]
• The predicted 10-year cardiovascular disease (CVD) risk between two groups [Срок оценки: 12 months]
• Amount of direct medical costs between two groups [Срок оценки: 12 months]