Application of the HKRF
The Hong Kong Reference Framework (HKRF) is designed for all primary healthcare providers. As the local standard care protocol, each book presents a comprehensive and concise set of recommendations with respective care components on the topic. To facilitate efficient and safe implementation in busy primary healthcare practice setting in a coordinated manner, additional information is provided on the roles and training requirement of responsible healthcare providers, reference materials and available community resources.
1. Recommendations (i.e. What should be done?)
Evidence-based recommendations on each topic were developed by adopting or adapting relevant existing guideline recommendations, or by using systematic reviews of evidence. Preference was given to guidelines developed by local health authorities and/or professional bodies, and high-quality evidence generated from local studies. The levels of evidence and grades of recommendations proposed by the Scottish Intercollegiate Guidelines Network (SIGN) are adopted.
Levels of Evidence^
| 1++ | High quality meta-analyses, systematic reviews of randomised clinical trials (RCTs), or RCTs with a very low risk of bias |
| 1+ | Well conducted meta-analysis, systematic reviews of RCTs, or RCTs with a low risk of bias |
| 1- | Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias |
| 2++ | High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal |
| 2+ | Well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal |
| 2- | Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal |
| 3 | Non-analytic studies, e.g. case reports, case series |
| 4 | Expert opinion |
Grades of Recommendations^
| A | At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results |
| B | A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ |
| C | A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ |
| D | Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ |
Λ Scottish Intercollegiate Guidelines Network (SIGN) classification
2. Recommended Care Components (i.e. How? For Who? When? By Whom?)
To guide safe and efficient implementation of respective recommendations in a coordinated manner, an actionable step-by-step care pathway was developed for each health topic:
- Empowerment on self-care
- Assessment of individual’s risks and needs according to life stage
- Identification of red flag conditions
- Risk-guided interventions, including screening test, non-pharmacological interventions, prescription and timely referral to appropriate level of care
A colour coding system is introduced to demonstrate the strength and direction of each recommended care component, as well as important practice points where evidence is yet lacking.
Colour Coding System for Recommended Care Components
| Recommended (Strong) Denotes strong confidence that the benefits of an intervention clearly outweigh the harms |
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| Conditionally recommended Denotes uncertainty over the balance of benefits (e.g. when the evidence quality is low or very low or when personal preferences or costs are expected to impact the decision) and, as such, refers to decisions where consideration of personal preferences is essential for decision making |
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| Practice points Used to address important aspects of care that are not addressed by relevant source guidelines, or where evidence is lacking. These were developed by consensus of the Expert Panel and Advisory Group |
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| Generally not recommended Denotes uncertainty over the balance of harms (e.g. when the evidence quality is low or very low or when personal preferences or costs are expected to impact the decision) and, as such, refers to decisions where consideration of personal preferences is essential for decision making |
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| Not recommended (Strong) Denotes strong confidence that the harms of an intervention clearly outweigh the benefits |
3. Consideration for Collaborative Care
To optimise patient care and use of healthcare resources, conditions warranting referral for further evaluation and/or specialist care (i.e. vertical collaborative care) and conditions requiring multi-disciplinary interventions (i.e. horizontal collaborative care) are clearly listed for easy reference.
4. Further Readings
Justifications and supportive evidence for the recommendation listed are presented in point form and tables to improve readability.
5. Reference Materials for Healthcare Professionals
Links to main reference sources, including manual of suggested assessment tools and interventions, are listed.
6. Education and Self-Help Materials for the General Public
Links to education pamphlets and self-help material on the topic for the general public are provided.
7. Community Resources
List of providers of relevant services is compiled, together with links their respective websites.
Web Format versus Book Format
To facilitate accessibility, the HKRF book is published in web format, which can be adapted in mobile version.
A printable version containing section 1-4 can be accessed on the website.