Advancing research on the economic value of emergency care

Evaluation of emergency care education and triage implementation: an observational study at a hospital in rural Liberia

INTRODUCTION

In Liberia, emergency care is still in its early development. In 2019, two emergency care and triage education sessions were done at J. J. Dossen Hospital in Southeastern Liberia. The observational study objectives evaluated key process outcomes before and after the educational interventions.

METHODS

Emergency department paper records from 1 February 2019 to 31 December 2019 were retrospectively reviewed. Simple descriptive statistics were used to describe patient demographics and χ² analyses were used to test for significance. ORs were calculated for key predetermined process measures.

RESULTS

There were 8222 patient visits recorded that were included in our analysis. Patients in the post-intervention 1 group had higher odds of having a documented full set of vital signs compared with the baseline group (16% vs 3.5%, OR: 5.4 (95% CI: 4.3 to 6.7)). After triage implementation, patients who were triaged were 16 times more likely to have a full set of vitals compared with those who were not triaged. Similarly, compared with the baseline group, patients in the post-intervention 1 group had higher odds of having a glucose documented if they presented with altered mental status or a neurologic complaint (37% vs 30%, OR: 1.7 (95% CI: 1.3 to 2.2)), documented antibiotic administration if they had a presumed bacterial infection (87% vs 35%, OR: 12.8 (95% CI: 8.8 to 17.1)), documented malaria test if presenting with fever (76% vs 61%, OR: 2.05 (95% CI: 1.37 to 3.08)) or documented repeat set of vitals if presenting with shock (25% vs 6.6%, OR: 8.85 (95% CI: 1.67 to 14.06)). There was no significant difference in the above process outcomes between the education interventions.

CONCLUSION

This study showed improvement in most process measures between the baseline and post-intervention 1 groups, benefits that persisted post-intervention 2, thus supporting the importance of short-course education interventions to durably improve facility-based care.

Association between universal health coverage and the disease burden of acute illness and injury at the global level

BACKGROUND

This study examines the relationship between universal health coverage (UHC) and the burden of emergency diseases at a global level.

METHODS

Data on Disability-Adjusted Life Years (DALYs) from emergency conditions were extracted from the Institute for Health Metrics and Evaluation (IHME) database for the years 2015 and 2019. Data on UHC, measured using two variables 1) coverage of essential health services and 2) proportion of the population spending more than 10% of household income on out-of-pocket health care expenditure, were extracted from the World Bank Database for years preceding our outcome of interest. A linear regression was used to analyze the association between UHC variables and DALYs for emergency diseases, controlling for other variables.

RESULTS

A total of 132 countries were included. The median national coverage of essential health services index was 67.5/100, while the median national prevalence of catastrophic spending in the sample was 6.74% of households. There was a strong significant relationship between health service coverage and the burden of emergency diseases, with an 11.5-point reduction in DALYs of emergency medical diseases (95% CI -9.5, -14.8) for every point increase in the coverage of essential health services index. There was no statistically significant relationship between catastrophic expenditures and the burden of emergency diseases, which may be indicative of inelastic demand in seeking services for health emergencies.

CONCLUSION

Increasing the coverage of essential health services, as measured by the essential health services index, is strongly correlated with a reduction in the burden of emergency conditions. In addition, data affirms that financial protection remains inadequate in many parts of the globe, with large numbers of households experiencing significant economic duress related to seeking healthcare. This evidence supports a strategy of strengthening UHC as a means of combating death and disability from health emergencies, as well as extending protection against impoverishment related to healthcare expenses.

Defining measures of emergency care access in low-income and middle-income countries: a scoping review

BACKGROUND

Over 50% of annual deaths in low-income and middle-income countries (LMICs) could be averted through access to high-quality emergency care.

OBJECTIVES

We performed a scoping review of the literature that described at least one measure of emergency care access in LMICs in order to understand relevant barriers to emergency care systems.

ELIGIBILITY CRITERIA

English language studies published between 1 January 1990 and 30 December 2020, with one or more discrete measure(s) of access to emergency health services in LMICs described.

SOURCE OF EVIDENCE

PubMed, Embase, Web of Science, CINAHL and the grey literature.

CHARTING METHODS

A structured data extraction tool was used to identify and classify the number of 'unique' measures, and the number of times each unique measure was studied in the literature ('total' measures). Measures of access were categorised by access type, defined by Thomas and Penchansky, with further categorisation according to the 'Three Delay' model of seeking, reaching and receiving care, and the WHO's Emergency Care Systems Framework (ECSF).

RESULTS

A total of 3103 articles were screened. 75 met full study inclusion. Articles were uniformly descriptive (n=75, 100%). 137 discrete measures of access were reported. Unique measures of accommodation (n=42, 30.7%) and availability (n=40, 29.2%) were most common. Measures of seeking, reaching and receiving care were 22 (16.0%), 46 (33.6%) and 69 (50.4%), respectively. According to the ECSF slightly more measures focused on prehospital care-inclusive of care at the scene and through transport to a facility (n=76, 55.4%) as compared with facility-based care (n=57, 41.6%).

CONCLUSIONS

Numerous measures of emergency care access are described in the literature, but many measures are overaddressed. Development of a core set of access measures with associated minimum standards are necessary to aid in ensuring universal access to high-quality emergency care in all settings.

Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda

BACKGROUND

Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level.

METHODS

A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%.

RESULTS

Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters.

CONCLUSION

Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.

Understanding factors impacting global priority of emergency care: a qualitative policy analysis

INTRODUCTION

The high burden of emergency medical conditions has not been met with adequate financial and political prioritisation especially in low and middle-income countries. We examined the factors that have shaped the priority of global emergency care and highlight potential responses by emergency care advocates.

METHODS

We conducted semistructured interviews with key experts in global emergency care practice, public health, health policy and advocacy. We then applied a policy framework based on political ethnography and content analysis to code for underlying themes.

RESULTS

We identified problem definition, coalition building, paucity of data and positioning, as the main challenges faced by emergency care advocates. Problem definition remains the key issue, with divergent ideas on what emergency care is, should be and what solutions are to be prioritised. Proponents have struggled to portray the urgency of the issue in a way that commands action from decision-makers. The lack of data further limits their effectiveness. However, there is much reason for optimism given the network's commitment to the issue, the emerging leadership and the existence of policy windows.

CONCLUSION

To improve global priority for emergency care, proponents should take advantage of the emerging governance structure and build consensus on definitions, generate data-driven solutions, find strategic framings and engage with non-traditional allies.

Emergency medicine - A great career field for the anaesthesiologist!

Emergency Medicine (EM) is a fast upcoming medical speciality wherein patients presenting with emergent life-saving medical and surgical problems are managed. Emergency physicians are first-line providers of emergency care. They diagnose important clinical conditions even before completing patient assessment, order investigations, interventions, resuscitation and treatment for life-threatening acute conditions. There are several interesting sub-specialisations of EM like trauma care, disaster medicine, toxicology, ultrasonography, critical care medicine, hyperbaric medicine, etc. In some countries, the speciality of EM is a popular choice among medical students; whereas in some other countries, the speciality is now evolving. In India, the speciality is growing fast; Nonetheless, the National Medical Commission has made the existence of the department of EM compulsory in all medical colleges in India from the session of 2022-23. Anaesthesiologists suit the speciality of EM because they have quick decision making skills and swift reflexes as well as diverse knowledge and skills in the fields of critical care, resuscitation and pain management. This article written by anaesthesiologists working in the field of EM, attempts to guide the postgraduate students wanting to take up a career in EM.

A Review of Various Methods of Management of Risk in the Field of Emergency Medicine

BACKGROUND:

The main concept of risk management in the emergency department (ED) contains a broader meaning, so that; it’s known as a sudden event or situation which would happen at an uncertain future that has some negative or positive impacts which could be called threat or opportunity respectively. However, the knowledge of risk management could cover the overall procedures involved with administering the planning of risk management, identification, investigation, monitoring and also step by step clinical examination. One of the main tools for preventing adversities is evaluating and management of possible risks.

AIM:

One of the main objectives of the present study is recognising the most frequent types of the risk happening in the EDs. Moreover, the present study is trying to evaluate the possible risks which could happen among various ED sections.

METHODS:

Six databases of EMBASE, HubMed, Cochrane Library, MEDLINE, PubMed, CHBD and Goggle scholar were chosen for discovering much-related articles from the year 2005 to 2019. A total number of 68 were chosen finally to be reviewed more precisely based on the main objective of the present study.

RESULTS:

Precise planning, preparing sufficiently and conducting the process of continuous monitoring are needed for ensuring the fact that any possible risks could be managed through these planned strategies. On the other hand, by modifying the patients’ beliefs, anticipations and the available social culture about the importance of risk management issue, the overall objective of the present study could be achieved at higher rates.

CONCLUSION:

Moreover, because the potential of occurrence of risk in EDs is high and approximately more than half of them are fatal, more precise adequate systematic plans for management of them should result.