Impact of the French National Lockdown on Admissions to 14 Pediatric Intensive Care Units During the 2020 COVID-19 Pandemic–A Retrospective Multicenter Study

Background: After the COVID-19 pandemic reached France in January 2020, a national lockdown including school closures was officially imposed from March 17, 2020, to May 10, 2020. Pediatric intensive care units (PICUs) admit critically ill infants, children and teenagers with severe acute conditions, in particular infectious and traumatic diseases. We hypothesized that PICU admissions would be considerably modified by the lockdown.Aims: The objectives of the study were to describe the type of admissions to French PICUs and to compare the occupation of PICU beds according to local epidemic conditions during the French national lockdown period, compared with the same period the previous year.Methods: We conducted a retrospective multicenter study in 14 French PICUs. All children aged from 7 days to 18 years admitted to one of the 14 participating PICUs over two 3-month period (March 1, 2020, to May 31, 2020 and March 1, 2019, to May 31, 2019) were included. Analysis was based on data extracted from the medicalized information systems program (a national database used in all French hospitals, into which all admissions and their diagnoses are coded for the purpose of calculating hospital funding). Each main diagnosis was reclassified in 13 categories, corresponding to normal PICU admissions.Results: We analyzed a total of 3,040 admissions, 1,323 during the 2020 study period and 1,717 during the same period in 2019. Total admissions decreased by 23% [incidence rate ratio (IRR) 0.77, 95% CI 0.71–0.83, p < 0.001], in particular for viral respiratory infections (−36%, IRR 0.64, 95% CI 0.44–0.94, p = 0.001). Admissions for almost all other diagnostic categories decreased, except intoxications and diabetes which increased, while admissions for cardiac and hemodynamic disorders were stable. Patient age and the sex ratio did not differ between the two periods. Median length of stay in the PICU was longer in 2020 [4 (IQR 2–9) vs. 3 (IQR 1–8) days, p = 0.002] in 2019. Mortality remained stable.Conclusions: In this large national study, we showed a decrease in the number of PICU admissions. The most severe patients were still admitted to intensive care and overall mortality remained stable.

Predicting diagnostic coding in hospitals: individual level effects of price incentives

The purpose of this paper is to test if implicit price incentives influence the diagnostic coding of hospital discharges. We estimate if the probability of being coded as a complicated patient was related to a specific price incentive. This paper tests empirically if upcoding can be linked to shifts in patient composition through proxy measures such as age composition, length of stay, readmission rates, mortality- and morbidity of patients. Data about inpatient episodes in Norway in all specialized hospitals in the years 1999–2012 were collected, N = 11 065 330. We examined incentives present in part of the hospital funding system. First, we analyse trends in the proxy measures of diagnostic upcoding: can hospital behavioural changes be seen over time with regards to age composition, readmission rates, length of stay, comorbidity and mortality? Secondly, we examine specific patient groups to see if variations in the price incentive are related to probability of being coded as complicated. In the first years (1999–2003) there was an observed increase in the share of episodes coded as complicated, while the level has become more stable in the years 2004–2012. The analysis showed some indications of upcoding. However, we found no evidence of widespread upcoding fuelled by implicit price incentive, as other issues such as patient characteristics seem to be more important than the price differences. This study adds to previous research by testing individual level predictions. The added value of such analysis is to have better case mix control. We observe the presence of price effects even at individual level.

Comparing COVID-19 risk factors in Brazil using machine learning: the importance of socioeconomic, demographic and structural factors

The COVID-19 pandemic continues to have a devastating impact on Brazil. Brazil’s social, health and economic crises are aggravated by strong societal inequities and persisting political disarray. This complex scenario motivates careful study of the clinical, socioeconomic, demographic and structural factors contributing to increased risk of mortality from SARS-CoV-2 in Brazil specifically. We consider the Brazilian SIVEP-Gripe catalog, a very rich respiratory infection dataset which allows us to estimate the importance of several non-laboratorial and socio-geographic factors on COVID-19 mortality. We analyze the catalog using machine learning algorithms to account for likely complex interdependence between metrics. The XGBoost algorithm achieved excellent performance, producing an AUC-ROC of 0.813 (95% CI 0.810–0.817), and outperforming logistic regression. Using our model we found that, in Brazil, socioeconomic, geographical and structural factors are more important than individual comorbidities. Particularly important factors were: The state of residence and its development index; the distance to the hospital (especially for rural and less developed areas); the level of education; hospital funding model and strain. Ethnicity is also confirmed to be more important than comorbidities but less than the aforementioned factors. In conclusion, socioeconomic and structural factors are as important as biological factors in determining the outcome of COVID-19. This has important consequences for policy making, especially on vaccination/non-pharmacological preventative measures, hospital management and healthcare network organization.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis

Background Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery. Methods This was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends. Results The difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was − 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours − 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy. Conclusions We found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

What Does It Take to Become an Academic Plastic Surgeon in Canada: Hiring Trends Over the Last 50 Years

Objective: Academic plastic surgery positions have become highly competitive secondary to delayed retirement, stagnant hospital funding, and an increasing number of plastic surgery graduates. Little information is available to help residents navigate this challenging landscape. Our objectives were to evaluate the training backgrounds of all Canadian academic plastic surgeons and to develop recommendations for residents interested in an academic career. Methods: All Canadian academic plastic surgeons were included. Training histories were obtained from institutions’ websites. Surgeons were subsequently emailed to confirm this information and complete missing details. Multivariate regressions were designed to analyze the effect of gender and FRCSC year on graduate and fellowship training and time to first academic position. Results: Training information was available for 196 surgeons (22% female), with a 56% email response rate; 91% of surgeons completed residency in Canada; 94% completed fellowship training, while 43% held graduate degrees; 74% were employed where they previously trained. Female gender significantly lengthened the time from graduation to first academic job, despite equal qualification. Younger surgeons were more likely to hold graduate degrees ( P < .01). Conclusions: We identified objective data that correlate with being hired at an academic centre, including training at the same institution, obtaining a graduate degree during residency, and pursuing fellowship training. In addition, we demonstrated that women take significantly longer to acquire academic positions ( P < .01), despite equal qualification. Trainees should consider these patterns when planning their careers. Future research should explore gender-based discrepancies in hiring practices.

Exercise-based cardiac rehabilitation adaptation protocol during COVID-19 pandemic achieved similar results as compared to non-pandemic usual practice: a single-center retrospective study

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Dr. Sardjito Hospital Funding Background During the COVID-19 pandemic, exercise-based cardiac rehabilitation (EBCR) faced challenges. Patients could not freely attend EBCR in hospital. In our hospital, cardiac rehabilitation (CR) service adapted to the pandemic condition by reducing to sessions per week. Purpose This study aimed to investigate whether the adaptation protocol of EBCR during COVID-19 period influenced the CR result. Methods This was a retrospective cohort study. The subjects were patients underwent EBCR program in CR Service of our hospital. We retrieved the CR program registry and divided it into two periods, namely the non-pandemic period (January 2019 – February 2020) and the COVID-19 period (March 2020 – December 2020). During the non-pandemic period, subjects performed EBCR 3 times (@45 min) per week for 10-12 total sessions. During the COVID-19 period, the EBCR session was reduced 2 times (@45 min) per week for 10-12 total sessions. However, patients might modify the sessions provided space availability and acceptable reason. After total sessions were completed, the treadmill test evaluation was performed. We compared the duration and metabolic equivalent (METs) achieved in the treadmill test evaluation. Results There was nearly 50% reduction in patients who underwent EBCR during the COVID-19 pandemic (n = 48), compared to during the non-pandemic period (n = 96). Post septal defect closure (42.7% vs. 60.4%) and mitral valve surgery (35.4% vs. 29.2%) predominated subjects registered for EBCR during the non-pandemic and the COVID-19 period, whereas post CABG was the minority (4.2% vs. 4.2%). Among 144 registered subjects, majority completed EBCR sessions and underwent treadmill test evaluation (79 (82.3%) vs. 37 (77.1%) during the non-pandemic and the COVID-19 period). During the COVID-19 period, the most common sessions were 2 times per week (48.6%), followed by 5 times per week (32.4%), whereas during the non-pandemic period, 3 times per week was the most common (77.2%), followed by 5 times per week (19.0%) (p &lt; 0.001). Total sessions did not significantly differ between the non pandemic and the COVID-19 period. Total sessions also did not significantly differ among subjects undergoing 2 times per week, 3 times per week, and 5 times per week sessions. There was no difference in duration (7.1 ± 1.9 min vs. 6.6 ± 1.9 min, p = 0,136) and METs (7.5 ± 1.8 vs. 6.9 ± 1.9, p = 0.192) achieved on treadmill evaluation between subjects on two time periods. There was no significant difference in duration (6.9 ± 1.9 min, 7.0 ± 1.9 min and 6.8 ± 1.8 min)and METs (7.1 ± 1.9, 7.3 ± 1.7 and 7.4 ± 2.1) achieved on treadmill evaluation among subjects who underwent EBCR 2 times per week, 3 times per week and 5 times per week respectively. Conclusion The adaptation protocol of EBCR during the COVID-19 period by reducing sessions per week did not influence the duration and METs achieved on treadmill evaluation at the end of CR as compared to usual EBCR practice.

Comparing COVID-19 risk factors in Brazil using machine learning: the importance of socioeconomic, demographic and structural factors

BackgroundThe COVID-19 pandemic continues to have a devastating impact on Brazil. Brazil’s social, health and economic crises are aggravated by strong societal inequities and persisting political disarray. This complex scenario motivates careful study of the clinical, socioeconomic, demographic and structural factors contributing to increased risk of mortality from SARS-CoV-2 in Brazil specifically.MethodsWe consider the Brazilian SIVEP-Gripe catalog, a very rich respiratory infection dataset which allows us to estimate the importance of several non-laboratorial and socio-geographic factors on COVID-19 mortality. We analyze the catalog using machine learning algorithms to account for likely complex interdependence between metrics.FindingsThe XGBoost algorithm achieved excellent performance, producing an AUC-ROC of 0.813 (95%CI 0.810–0.817), and outperforming logistic regression. Using our model we found that, in Brazil, socioeconomic, geographical and structural factors are more important than individual comorbidities. Particularly important factors were: The state of residence and its development index; the distance to the hospital (especially for rural and less developed areas); the level of education; hospital funding model and strain. Ethnicity is also confirmed to be more important than comorbidities but less than the aforementioned factors.InterpretationSocioeconomic and structural factors are as important as biological factors in determining the outcome of COVID-19. This has important consequences for policy making, especially on vaccination/non-pharmacological preventative measures, hospital management and healthcare network organization.FundingNone.

Divergent notions of “quality” in healthcare policy implementation: a framing perspective

PurposeThis paper examines how “quality” was framed in the design and implementation of a policy to reform hospital funding and associated care delivery. The aims of the study were: (1) To describe how government policy-makers who designed the policy and managers and clinicians who implemented the policy framed the concept of “quality” and (2) To explore how frames of quality and the framing process may have influenced policy implementation.Design/methodology/approachThe authors conducted a secondary analysis of data from a qualitative case study involving semi-structured interviews with 45 purposefully selected key informants involved in the design and implementation of the quality-based procedures policy in Ontario, Canada. The authors used framing theory to inform coding and analysis.FindingsThe authors found that policy designers perpetuated a broader frame of quality than implementers who held more narrow frames of quality. Frame divergence was further characterized by how informants framed the relationship between clinical and financial domains of quality. Several environmental and organizational factors influenced how quality was framed by implementers.Originality/valueAs health systems around the world increasingly implement new models of governance and financing to strengthen quality of care, there is a need to consider how “quality” is framed in the context of these policies and with what effect. This is the first framing analysis of “quality” in health policy.

Analisis Mikrobia dan Organoleoptik Makanan Cair Instan Berbasis Pangan Lokal untuk Perbaikan Status Gizi Pasien

ABSTRACT Background: Every hospital has high demand of nutritional support for patient but limitation of hospital funding to get commercial enteral nutrition that may influence the hospital of making its own enteral nutrition. It has some weakness such as not ready to use, not durable, and unstandardized nutrition content. Pumpkin, fish cork, and tempeh are less costly local food which contain high protein and antioxidant that may lead nutritional status improvement. Objectives: Determining total fungal count, total bacterial count and organoleptic properties of instant local food based-enteral nutrition.Methods: Pure-experimental study with completely random design was conducted on March-August 2018. There are 4 flavors of the instant formula such as vanilla, ginger, cinnamon, and original. Total fungal count (TFC) and total bacterial count (TBC) were used for microbiological analysis. Organoleptic properties was evaluated by 80 panelists from Yayasan Stroke Indonesia. Inclusion criterias: aged 19-years or above and signing the informed consent. Organoleptic evaluation determined by 5 score of appearance, taste, texture, odour and overall formula. Statistical analysis used Kruskal Wallis to determine the difference of enteral nutrition acceptability for each flavor. Results: Mean of TBC of local food based-enteral nutrition was 3.5 x 104 ± 0.14 cfu/mg and mean of TFC was 1.65 x 102 ± 0.21 cfu/g. The acceptability of local food based-enteral nutrition was significantly different based on taste, odour, and overall aspect.Conclusions: Based on microbiology analysis showed that local food based-enteral nutrition was desirable. Panelist liked original flavor most based on appearance, taste, and texture. While the vanilla flavor was liked the most based on the odour and overall aspect. The score of acceptability showed significantly different on ginger, vanilla, and original flavors based on taste, odour, and overall aspect.ABSTRAKLatar Belakang: Tingginya kebutuhan dukungan gizi pasien namun terbatasnya biaya penyediaan makanan enteral komersial mendorong Rumah Sakit (RS) untuk membuat formula enteral sendiri. Kekurangan dari formula enteral buatan RS diantaranya tidak praktis, tidak tahan lama, dan nilai gizi yang tidak terpantau. Labu kuning, ikan gabus dan tempe merupakan bahan pangan lokal yang terjangkau dengan kandungan protein dan antioksidan tinggi bermanfaat untuk perbaikan status gizi.Tujan: Mengetahui angka total mikrobia (bakteri dan jamur) dan sifat organoleptik dari makanan cair instan berbasis pangan lokal.Metode: Penelitian eksperimental dengan rancangan acak lengkap dilakukan pada Maret-Agustus 2018. Formula makanan cair memiliki 4 varian: vanilla, jahe, kayu manis, dan original. Analisis mikrobiologi menggunakan metode angka lempeng total (ALT) untuk bakteri dan jamur. Pengujian sifat organoleptik formula dilakukan oleh 80 panelis tidak terlatih dari anggota Yayasan Stroke Indonesia. Kriteria inklusi untuk panelis uji organoleptik antara lain bersedia menjadi panelis dengan mengisi informed consent, usia ≥19 tahun. Uji organoleptik dengan 5 skala kesukaan berdasarkan aspek warna, aroma, rasa, tekstur, dan keseluruhan. Uji statistik menggunakan Kruskal Wallis untuk melihat perbedaan tingkat kesukaan dari tiap varian formula makanan cair.Hasil: Hasil analisis mikrobia dari formula menunjukkan rerata ALT bakteri 3,5 x 104 ± 0,14 cfu/mg, dan ALT jamur 1,65 x 102 ± 0,21 cfu/g. Terdapat perbedaan yang signifikan pada tingkat kesukaan varian formula makanan cair dari segi rasa, aroma, dan keseluruhan formula.Kesimpulan: Uji mikrobia formula makanan cair masih dalam batas aman untuk dikonsumsi. Responden paling menyukai varian rasa original dari aspek warna, rasa, dan tekstur, sedangkan secara keseluruhan dan aroma formula rasa vanilla yang paling disukai. Perbedaan rerata skor yang signifikan ditunjukkan pada varian rasa jahe, vanilla dan original dari segi rasa, serta varian rasa jahe dengan vanilla dari segi aroma dan keseluruhan.