scholarly journals Mortality Outcomes in Task-Sharing for Emergency Care: Impact of Emergency Physician Supervision on Non-Physician Emergency Care in Rural Uganda

2021 ◽  
Author(s):  
Brian Rice ◽  
Ashley E Pickering ◽  
Colleen Laurence ◽  
Prisca Kizito ◽  
Rebecca Alisa Leff ◽  
...  
Keyword(s):  
Emergency Care ◽  
Ad Hoc ◽  
Vital Signs ◽  
Multivariable Logistic Regression Analysis ◽  
Task Sharing ◽  
Direct Supervision ◽  
Middle Income ◽  
Study Objective ◽  
Ed Visits ◽  
Overall Mortality

Introduction Emergency care (EC) capacity is limited by physician shortages in low- and middle-income countries like Uganda. Task-sharing (delegating tasks to more narrowly trained cadres) including EC nonphysician clinicians (NPCs) is a proposed solution. However, little data exists to guide emergency medicine (EM) physician supervision of NPCs. The study objective was to assess the mortality impact of decreasing EM physician supervision of EC NPCs. Methods Retrospective analysis of prospectively collected data from an EC NPC training program in rural Uganda included three cohorts: Direct (2009-2010): EM physicians supervised all NPC care; Indirect (2010-2015): NPCs consulted EM physicians on an ad hoc basis; Independent (2015-2019): NPC care without EM physician supervision. Multivariable logistic regression analysis of three-day mortality included demographics, vital signs, co-morbidities and supervision. Sensitivity analysis stratified patients by numbers of abnormal vital signs. Results Overall, 38,344 ED visits met inclusion criteria. From the Direct to the Unsupervised period patients with greater than or equal to 3 abnormal vitals (25.2% to 10.2%, p<0.001) and overall mortality (3.8% to 2.7%, p<0.001) decreased significantly. Indirect and Independent supervision were independently associated with increased mortality compared to Direct supervision (Indirect Odds Ratio (OR)=1.49 [95%CI 1.07 - 2.09], Independent OR=1.76 [95%CI 1.09 - 2.86]). The 86.2% of patients with zero, one or two abnormal vitals had similar mortality across cohorts, but the 13.8% of patients with greater than or equal to abnormal vitals had significantly reduced mortality with Direct supervision (Indirect OR=1.75 [95%CI 1.08 - 2.85], Independent (OR=2.14 [95%CI 1.05 - 4.34]). Conclusion Direct EM physician supervision of NPC care significantly reduced overall mortality as the highest risk ~10% of patients had nearly 50% reduction in mortality. However, for the other ~90% of ED visits, independent EC NPC care had similar mortality outcomes as directly supervised care, suggesting a synergistic model could address current staffing shortages limiting EC access and quality.

scholarly journals Tuberculosis and Non-Communicable Disease Multimorbidity: An Analysis of the World Health Survey in 48 Low- and Middle-Income Countries

2021 ◽  
Vol 18 (5) ◽  
pp. 2439
Author(s):  
Brendon Stubbs ◽  
Kamran Siddiqi ◽  
Helen Elsey ◽  
Najma Siddiqi ◽  
Ruimin Ma ◽  
...  
Keyword(s):  
Health Survey ◽  
Low Income ◽  
World Health ◽  
Low Income Countries ◽  
Multivariable Logistic Regression Analysis ◽  
World Health Survey ◽  
Middle Income ◽  
Middle Income Countries ◽  
The World ◽  
Low And Middle Income

Tuberculosis (TB) is a leading cause of mortality in low- and middle-income countries (LMICs). TB multimorbidity [TB and ≥1 non-communicable diseases (NCDs)] is common, but studies are sparse. Cross-sectional, community-based data including adults from 21 low-income countries and 27 middle-income countries were utilized from the World Health Survey. Associations between 9 NCDs and TB were assessed with multivariable logistic regression analysis. Years lived with disability (YLDs) were calculated using disability weights provided by the 2017 Global Burden of Disease Study. Eight out of 9 NCDs (all except visual impairment) were associated with TB (odds ratio (OR) ranging from 1.38–4.0). Prevalence of self-reported TB increased linearly with increasing numbers of NCDs. Compared to those with no NCDs, those who had 1, 2, 3, 4, and ≥5 NCDs had 2.61 (95% confidence interval (CI) = 2.14–3.22), 4.71 (95%CI = 3.67–6.11), 6.96 (95%CI = 4.95–9.87), 10.59 (95%CI = 7.10–15.80), and 19.89 (95%CI = 11.13–35.52) times higher odds for TB. Among those with TB, the most prevalent combinations of NCDs were angina and depression, followed by angina and arthritis. For people with TB, the YLDs were three times higher than in people without multimorbidity or TB, and a third of the YLDs were attributable to NCDs. Urgent research to understand, prevent and manage NCDs in people with TB in LMICs is needed.

scholarly journals Prehospital triage of patients with acute cardiac complaints: study protocol of HART-c, a multicentre prospective study

BMJ Open ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. e041553
Author(s):  
Enrico de Koning ◽  
Tom E Biersteker ◽  
Saskia Beeres ◽  
Jan Bosch ◽  
Barbra E Backus ◽  
...  
Keyword(s):  
Real Time ◽  
Patient Outcomes ◽  
Medical Records ◽  
Vital Signs ◽  
Hospital Data ◽  
Ed Overcrowding ◽  
Prehospital Triage ◽  
Ed Visits ◽  
Multicentre Prospective Study ◽  
At Home

IntroductionEmergency department (ED) overcrowding is a major healthcare problem associated with worse patient outcomes and increased costs. Attempts to reduce ED overcrowding of patients with cardiac complaints have so far focused on in-hospital triage and rapid risk stratification of patients with chest pain at the ED. The Hollands-Midden Acute Regional Triage—Cardiology (HART-c) study aimed to assess the amount of patients left at home in usual ambulance care as compared with the new prehospital triage method. This method combines paramedic assessment and expert cardiologist consultation using live monitoring, hospital data and real-time admission capacity.Methods and analysisPatients visited by the emergency medical services (EMS) for cardiac complaints are included. EMS consultation consists of medical history, physical examination and vital signs, and ECG measurements. All data are transferred to a newly developed platform for the triage cardiologist. Prehospital data, in-hospital medical records and real-time admission capacity are evaluated. Then a shared decision is made whether admission is necessary and, if so, which hospital is most appropriate. To evaluate safety, all patients left at home and their general practitioners (GPs) are contacted for 30-day adverse events.Ethics and disseminationThe study is approved by the LUMC’s Medical Ethics Committee. Patients are asked for consent for contacting their GPs. The main results of this trial will be disseminated in one paper.DiscussionThe HART-c study evaluates the efficacy and feasibility of a prehospital triage method that combines prehospital patient assessment and direct consultation of a cardiologist who has access to live-monitored data, hospital data and real-time hospital admission capacity. We expect this triage method to substantially reduce unnecessary ED visits.

Heterogeneity of reasons for attendance in frequent attenders of emergency departments and its relationship to future attendance

2021 ◽  
pp. emermed-2020-210412
Author(s):  
Richard Hotham ◽  
Colin O'Keeffe ◽  
Tony Stone ◽  
Suzanne M Mason ◽  
Christopher Burton
Keyword(s):  
Mental Health ◽  
Mental Disorder ◽  
Emergency Care ◽  
Health Problem ◽  
Patient Characteristics ◽  
Health Needs ◽  
Data Set ◽  
Frequent Attenders ◽  
History Of ◽  
Ed Visits

BackgroundEDs globally are under increasing pressure through rising demand. Frequent attenders are known to have complex health needs and use a disproportionate amount of resources. We hypothesised that heterogeneity of patients’ reason for attendance would be associated with multimorbidity and increasing age, and predict future attendance.MethodWe analysed an anonymised dataset of all ED visits over the course of 2014 in Yorkshire, UK. We identified 15 986 patients who had five or more ED encounters at any ED in the calendar year. Presenting complaint was categorised into one of 14 categories based on the Emergency Care Data Set (ECDS). We calculated measures of heterogeneity (count of ECDs categories and entropy of categories) and examined their relationship to total number of ED visits and to patient characteristics. We examined the predictive value of these and other features on future attendance.ResultsMost frequent attenders had more than one presenting complaint type. Heterogeneity increased with number of attendances, but heterogeneity adjusted for number of attendances did not vary substantially with age or sex. Heterogeneity was associated with the presence of one or more contacts for a mental health problem. For a given number of attendances, prior mental health contact but not heterogeneity was associated with further attendance.ConclusionsHeterogeneity of presenting complaint can be quantified and analysed for ED use: it is increased where there is a history of mental disorder but not with age. This suggests it reflects more than the number of medical conditions.

scholarly journals Early prediction of hospital admission for emergency department patients: a comparison between patients younger or older than 70 years

2017 ◽  
Vol 35 (1) ◽  
pp. 18-27 ◽  
Author(s):  
Jacinta A Lucke ◽  
Jelle de Gelder ◽  
Fleur Clarijs ◽  
Christian Heringhaus ◽  
Anton J M de Craen ◽  
...  
Keyword(s):  
Heart Rate ◽  
Hospital Admission ◽  
Older Patients ◽  
Prediction Models ◽  
Age Groups ◽  
Vital Signs ◽  
Area Under The Curve ◽  
University Hospital ◽  
Multivariable Logistic Regression Analysis ◽  
Younger Patients

ObjectiveThe aim of this study was to develop models that predict hospital admission to ED of patients younger and older than 70 and compare their performance.MethodsPrediction models were derived in a retrospective observational study of all patients≥18 years old visiting the ED of a university hospital during the first 6 months of 2012. Patients were stratified into two age groups (<70 years old and ≥70 years old). Multivariable logistic regression analysis was used to identify predictors of hospital admission among factors available immediately after patient arrival to the ED. Validation of the prediction models was performed on patients presenting to the ED during the second half of the year 2012.Results10 807 patients were included in the derivation and 10 480 in the validation cohorts. The strongest independent predictors of hospital admission among the 8728 patients <70 years old were age, sex, triage category, mode of arrival, performance of blood tests, chief complaint, ED revisit, type of specialist, phlebotomised blood sample and all vital signs. The area under the curve (AUC) of the validation cohort for those <70 years old was 0.86 (95% CI 0.85 to 0.87). Among the 2079 patients ≥70 years, the same factors were predictive, except for gender, type of specialist and heart rate; the AUC was 0.77 (95% CI 0.75 to 0.79). The prediction models could identify a group of 10% of patients with the highest risk in whom hospital admission was predicted at ED triage, with a positive predictive value (PPV) of 71% (95% CI 68% to 74%) in younger patients and PPV of 87% (95% CI 81% to 92%) in older patients.ConclusionDemographic and clinical factors readily available early in the ED visit can be useful in identifying patients who are likely to be admitted to the hospital. While the model for the younger patients had a higher AUC, the model for older patients had a higher PPV in identifying the patients at highest risk for admission. Of note, heart rate was not a useful predictor in the older patients.

scholarly journals Closing the Equity Gap of Access to Emergency Departments of Private Hospitals in Thailand

2018 ◽  
Vol 2018 ◽  
pp. 1-5
Author(s):  
Paibul Suriyawongpaisal ◽  
Pongsakorn Atiksawedparit ◽  
Samrit Srithamrongsawad ◽  
Thanita Thongtan
Keyword(s):  
Emergency Care ◽  
Private Hospital ◽  
Financial Incentive ◽  
Gender Disparity ◽  
Lessons Learned ◽  
Care Seeking ◽  
Health Coverage ◽  
Private Hospitals ◽  
Middle Income ◽  
Strategic Policies

Background. Previous policy implementation in 2012 to incentivize private hospitals in Thailand, a country with universal health coverage, to provide free-of-charge emergency care using DRG-based payment resulted in an equity gap of access and copayment. To bridge the gap, strategic policies involving financial and legal interventions were implemented in 2017. This study aims to assess whether this new approach would be able to fill the gap. Methods. We analyzed an administrative dataset of over 20,206 patients visiting private hospital EDs from April 2017 to October 2017 requested for the preauthorization of access to emergency care in the first 72 hours free of charge. The association between types of insurance and the approval status was explored using logistic regression equation adjusting for age, modes of access, systolic blood pressure, respiratory rate, and Glasgow coma scores. Results and Discussion. The strategic policies implementation resulted in reversing ED payer mix from the most privileged scheme, having the major share of ED visit, to the least privileged scheme. The data showed an increasing trend of ED visits to private hospitals indicates the acceptance of the financial incentive. Obvious differences in degrees of urgency between authorized and unauthorized patients suggested the role of preauthorization as a barrier to the noncritical patient visiting the ED. Furthermore, our study depicted the gender disparity between authorized and unauthorized patients which might indicate a delay in care seeking among critical female patients. Lessons learned for policymakers in low-and-middle income countries attempting to close the equity gap of access to private hospital EDs are discussed.

Hospital competition, quality, and cost of prostate cancer care.

2021 ◽  
Vol 39 (6_suppl) ◽  
pp. 235-235
Author(s):  
Ravishankar Jayadevappa ◽  
Sumedha Chhatre ◽  
S. Bruce Malkowicz ◽  
Thomas J. Guzzo ◽  
Alan J. Wein ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Cancer Care ◽  
Disease Stage ◽  
Medical Care Cost ◽  
Hospital Competition ◽  
Advanced Stage ◽  
Study Objective ◽  
American Hospital ◽  
Localized Disease ◽  
Overall Mortality

235 Background: Hospital competition is important for addressing the disparity in quality and cost of prostate cancer care. Study objective was to examine the association of hospital competition with process of care (time to treatment, treatment and overuse) and outcomes (medial care use, complications, mortality and cost) in Medicare fee-for-service beneficiaries with prostate cancer. Methods: This was a population-based cohort study of Surveillance, Epidemiological, and End Results-Medicare (SEER-Medicare) data from 1995- 2016, linked with American Medical Association for physician data and American Hospital Association for hospital level data. Eligible patients were men 66 years or older with localized or advanced stage prostate cancer at diagnosis. The Hirschman-Herfindahl index (HHI) was computed for all serving hospitals based on number of competitors, i.e., number of hospitals situated within the hospital referral region(HRR). The Overuse Index (OI) was used to composite measure of overuse during treatment (one year after diagnosis) and follow-up care phase. Outcomes were overall and prostate cancer-specific survival, complications, readmissions, ER visits, and cost. We used survival analysis, including competing risk analysis, Poisson (zero inflated) models for count data, and GLM (log-link) models for cost data. Propensity score and instrumental variable approaches were used to minimize potential biases. Results: In our study cohort of 434,264, 85% of patients had localized disease stage, and 15% had advanced stage. For both localized and advanced stage groups, age, race and ethnicity, geographic region, comorbidity, socio-economic status, and primary treatment differed by hospital competition (high competition vs. low competition). Hospitals within high competition area were more likely to perform surgery, whereas hospitals within low competition area were more likely to perform radiation therapy. Among localized disease patients, low hospital competition was associated with higher hazard of overall mortality (HR = 1.08, 95% CI = 1.07 - 1.10) and prostate cancer-specific mortality (HR = 1.13, 95% CI = 1.09 - 1.17) and higher odds of ER visits (OR = 1.13, 95% CI = 1.11 - 1.15). For advanced stage patients, low hospital competition was associated with higher hazard of overall mortality (HR = 1.11, 95% CI = 1.08 - 1.15) and prostate cancer-specific death (HR = 1.15, 95% CI = 1.09 - 1.18) and higher odds of ER visits (OR = 1.16, 95% CI = 1.11 - 1.22). Higher scores of the OI were associated with higher total medical costs per capita per year, and not associated with overall mortality. Conclusions: This novel study showed that higher hospital competition is associated with improved quality of care (reduced mortality, complications and ER visits) and increased/lower direct medical care cost among patients with localized or advanced stage prostate cancer. Policy measures should be implemented to improve hospital competition.

scholarly journals Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems

2019 ◽  
Vol 4 (Suppl 6) ◽  
pp. e001265 ◽  
Author(s):  
Rachel T Moresky ◽  
Junaid Razzak ◽  
Teri Reynolds ◽  
Lee A Wallis ◽  
Benjamin W Wachira ◽  
...  
Keyword(s):  
Health Systems ◽  
Emergency Care ◽  
Low Income ◽  
Communicable Diseases ◽  
Middle Income ◽  
Care Research ◽  
Middle Income Countries ◽  
Emergency Care Systems ◽  
Care Systems ◽  
Research Questions

Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.

scholarly journals Emergency Department Visits for Opioid Overdoses Among Patients With Cancer

2019 ◽  
Vol 112 (9) ◽  
pp. 938-943 ◽  
Author(s):  
Vikram Jairam ◽  
Daniel X Yang ◽  
James B Yu ◽  
Henry S Park
Keyword(s):  
At Risk ◽  
Emergency Department ◽  
Statistical Tests ◽  
Temporal Trends ◽  
The United States ◽  
Emergency Department Visits ◽  
Multivariable Logistic Regression Analysis ◽  
Opioid Overdose ◽  
Patients With Cancer ◽  
Ed Visits

Abstract Background Patients with cancer may be at risk of high opioid use due to physical and psychosocial factors, although little data exist to inform providers and policymakers. Our aim is to examine overdoses from opioids leading to emergency department (ED) visits among patients with cancer in the United States. Methods The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was queried for all adult cancer-related patient visits with a primary diagnosis of opioid overdose between 2006 and 2015. Temporal trends and baseline differences between patients with and without opioid-related ED visits were evaluated. Multivariable logistic regression analysis was used to identify risk factors associated with opioid overdose. All statistical tests were two-sided. Results Between 2006 and 2015, there were a weighted total of 35 339 opioid-related ED visits among patients with cancer. During this time frame, the incidence of opioid-related ED visits for overdose increased twofold (P &lt; .001). On multivariable regression (P &lt; .001), comorbid diagnoses of chronic pain (odds ratio [OR] 4.51, 95% confidence interval [CI] = 4.13 to 4.93), substance use disorder (OR = 3.54, 95% CI = 3.28 to 3.82), and mood disorder (OR = 3.40, 95% CI = 3.16 to 3.65) were strongly associated with an opioid-related visit. Patients with head and neck cancer (OR = 2.04, 95% CI = 1.82 to 2.28) and multiple myeloma (OR = 1.73, 95% CI = 1.32 to 2.26) were also at risk for overdose. Conclusions Over the study period, the incidence of opioid-related ED visits in patients with cancer increased approximately twofold. Comorbid diagnoses and primary disease site may predict risk for opioid overdose.

Sign in / Sign up

Export Citation Format

Share Document