Travel time to emergency care not by geographic time, but by optimal time: A nationwide cross-sectional study for establishing optimal hospital access time to emergency medical care in South Korea

Intentional transit practice through a nearby hospital for remote area emergencies provides earlier primary care than helicopter emergency medical services alone in rural emergencies: a single-center, observational study

Objective

Providing emergency care to serious patients in rural areas remains challenging. Intentional transit practice involves transporting a serious patient to a nearby hospital while requesting the Helicopter Emergency Medical Services (HEMS). This study aims to evaluate its effectiveness on earlier primary medical interventions and the decision of the destination hospital.

Patient and Methods

We conducted a single-center, retrospective observational study at a HEMS base hospital in a rural area of Japan. The study participants included patients who underwent the intentional transit practice between April 2012 and March 2019. We compared actual times to estimated times for each case treated with the HEMS alone (HEMS-alone model). Outcomes were the time from ambulance call to reaching the physician (physician reaching time), arrival at the final destination facility (destination hospital arrival time), and helicopter waiting time at the landing zone (helicopter waiting time). Subgroup analyses by region and an analysis of the relationship between diagnostic tests performed at the transit hospital and the type of destination facility were performed.

Results

Eighty-seven patients were eligible for analysis. Compared to the HEMS-alone model, the intentional transit practice reduced the physician reaching time (median [interquartile] min) (26 [21-32] vs. 37 [29-47], P<0.0001) while increasing the destination hospital arrival time and the helicopter waiting time (71 [58-93] vs. 65 [59-80], P=0.03; 24 [18-34] vs. 19 [18-21], P<0.0001; respectively). Subgroup analysis showed a consistent result for physician reaching time but heterogeneity in the other time courses by region. Diagnostic tests were related to transportation to facilities other than the HEMS base hospital.

Conclusion

The intentional transit practice is beneficial for providing primary care earlier than the HEMS alone and for transport to more specific facilities. However, it delays arrival at the destination facility and increases helicopter waiting time.

Sex Differences in Pediatric Sepsis Mortality: A Systematic Review and Meta-Analysis

OBJECTIVES

Pediatric sepsis remains a leading cause of childhood mortality worldwide. Sex differences have been shown to modify risk factors, treatment, and outcome of various diseases, and adult studies revealed sex differences in pathophysiological responses to septic shock. We aimed to perform a systematic review and meta-analysis on the association of sex with outcomes in hospitalized children with sepsis.

DATA SOURCES

Medline and Embase databases were searched for studies of children < 18 years with sepsis published between January 01, 2005, and March 31, 2022.

STUDY SELECTION

We included cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years which included sepsis, severe sepsis or septic shock, and mortality as an outcome.

DATA EXTRACTION

Study characteristics, patient demographics, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

We screened 14,791 studies, with 912 full-text reviews and inclusion of 124 studies. The total population involved 426,163 patients, of which 47% (201,438) were girls. Meta-regression showed moderate evidence for a higher mortality in boys compared with girls. The estimated risk difference of mortality between boys and girls with all types of sepsis was -0.005 (95% CI, -0.0099 to -0.00001; p = 0.049), indicating slightly higher mortality for boys. When including the World Bank income level as a moderator, the effect was -0.008 (95% CI, -0.013 to -0.002; p = 0.005).

CONCLUSIONS

This large systematic review and meta-analysis on sex differences in pediatric sepsis mortality showed moderate evidence for a higher sepsis mortality in boys compared with girls. The effect persisted when adjusting for country's income level.

Tackling Cardiovascular Care Deserts in Romania: Expanding Population Access in Underserved Areas

BACKGROUND

Cardiovascular deserts are areas that lack medical facilities, specialists and equipment to effectively diagnose, treat and manage cardiovascular diseases (CVDs). Romania registers the highest incidence and the highest mortality due to CVDs in Europe. Population ageing is a significant concern, as it increases the risk of CVDs and the demand for specialised care. Although almost 50% of Romanians still live in rural areas, most medical resources are concentrated in a few large cities, leaving large parts of the country underserved.

METHODS

This study used the Application Programming Interface (API) Matrix service from Google Maps and open data sources to identify cardiovascular (CV) deserts.

RESULTS

This research indicates that over 64% of the Romanian population resides in areas lacking CV care, having to travel more than 60 km and over 30 min to reach the nearest facility that offers specialised treatment. Moreover, 14% live in areas affected by a high degree of cardiovascular desertification. These areas are primarily located in northeastern, southern and western Romania. They experience higher mortality rates from CVDs and an ageing population, along with a shortage of general physicians and a scarcity of cardiologists.

CONCLUSIONS

The identified cardiovascular deserts in this study overlap mountainous regions, the Danube Delta and remote rural areas with poor transportation infrastructure. Implementing telemedicine or mobile healthcare services, involving community healthcare workers and policy support could be solutions to expand access to specialised care in cardiovascular deserts.

High-Volume Hospital Had Lower Mortality of Severe Intracerebral Hemorrhage Patients

OBJECTIVE

Intracerebral hemorrhage (ICH) accompanies higher mortality rates than other type of stroke. This study aimed to investigate the association between hospital volume and mortality for cases of ICH.

METHODS

We used nationwide data from 2013 to 2018 to compare high-volume hospitals (≥32 admissions/year) and low-volume hospitals (<32 admissions/year). We tracked patients' survival at 3-month, 1-year, 2-year, and 4-year endpoints. The survival of ICH patients was analyzed at 3-month, 1-year, 2-year, and 4-year endpoints using Kaplan-Meier survival analysis. Multivariable logistic regression analysis and Cox regression analysis were performed to determine predictive factors of poor outcomes at discharge and death.

RESULTS

Among 9086 ICH patients who admitted to hospital during 18-month period, 6756 (74.4%) and 2330 (25.6%) patients were admitted to high-volume and low-volume hospitals. The mortality of total ICH patients was 18.25%, 23.87%, 27.88%, and 35.74% at the 3-month, 1-year, 2-year, and 4-year, respectively. In multivariate logistic analysis, high-volume hospitals had lower poor functional outcome at discharge than low-volume hospitals (odds ratio, 0.80; 95% confidence interval, 0.72-0.91; p<0.001). In the Cox analysis, high-volume hospitals had significantly lower 3-month, 1-year, 2-year, and 4-year mortality than low-volume hospitals (p<0.05).

CONCLUSION

The poor outcome at discharge, short- and long-term mortality in ICH patients differed according to hospital volume. High-volume hospitals showed lower rates of mortality for ICH patients, particularly those with severe clinical status.

Systematic review: Comparative analysis of international approaches to the organisation of emergency departments at the primary health care level

The study aims to review the different systems of emergency care in North American, European, and Pan-Asian countries and to perform a comparative analysis of these modes of organisation. The emergency care systems of Kyrgyzstan, Germany, the United States of America, the United Kingdom, South Korea, Turkey and the United Arab Emirates were analysed, and it was determined that the Anglo-American and Franco-German model of emergency care is currently dominant in the world. The main difference with the system built in Kazakhstan is that ambulance brigades in the above countries consist of nursing staff, in these countries there is a double triage of patients at the stage of call and the stage of distribution of patients in the emergency department, and the last main difference is that the emergency department in Kazakhstan is organised based on an emergency room and does not include intensive care, dynamic observation, there is no diagnostic unit and palliative care unit. Another difference is the training of non-medical services in the comparison countries, such as police and firefighters, who have the necessary basic skills to provide emergency care. This study will help in the future to use foreign experience in the organisation of emergency care in the Republic of Kazakhstan, which may have a positive impact on the quality and speed of emergency care

Long-term exposure to PM2.5 and mortality in a national cohort in South Korea: effect modification by community deprivation, medical infrastructure, and greenness

BACKGROUND

Long-term exposure to PM2.5 has been linked to increased mortality risk. However, limited studies have examined the potential modifying effect of community-level characteristics on this association, particularly in Asian contexts. This study aimed to estimate the effects of long-term exposure to PM2.5 on mortality in South Korea and to examine whether community-level deprivation, medical infrastructure, and greenness modify these associations.

METHODS

We conducted a nationwide cohort study using the National Health Insurance Service-National Sample Cohort. A total of 394,701 participants aged 30 years or older in 2006 were followed until 2019. Based on modelled PM2.5 concentrations, 1 to 3-year and 5-year moving averages of PM2.5 concentrations were assigned to each participant at the district level. Time-varying Cox proportional-hazards models were used to estimate the association between PM2.5 and non-accidental, circulatory, and respiratory mortality. We further conducted stratified analysis by community-level deprivation index, medical index, and normalized difference vegetation index to represent greenness.

RESULTS

PM2.5 exposure, based on 5-year moving averages, was positively associated with non-accidental (Hazard ratio, HR: 1.10, 95% Confidence Interval, CI: 1.01, 1.20, per 10 µg/m3 increase) and circulatory mortality (HR: 1.22, 95% CI: 1.01, 1.47). The 1-year moving average of PM2.5 was associated with respiratory mortality (HR: 1.33, 95% CI: 1.05, 1.67). We observed higher associations between PM2.5 and mortality in communities with higher deprivation and limited medical infrastructure. Communities with higher greenness showed lower risk for circulatory mortality but higher risk for respiratory mortality in association with PM2.5.

CONCLUSIONS

Our study found mortality effects of long-term PM2.5 exposure and underlined the role of community-level factors in modifying these association. These findings highlight the importance of considering socio-environmental contexts in the design of air quality policies to reduce health disparities and enhance overall public health outcomes.

Trends in emergency department visits for emergency care-sensitive conditions before and during the COVID-19 pandemic: a nationwide study in Korea, 2019-2021

OBJECTIVE

Emergency care systems worldwide have been significantly affected by the COVID-19 pandemic. This study investigated the trend of emergency department (ED) visits for emergency care-sensitive conditions (ECSCs) in Korea before and during the pandemic.

METHODS

We performed a longitudinal study using the national ED database in Korea from January 2019 to December 2021. We calculated the number and incidence rate of visits for ECSCs per 100,000 ED visits, and the incidence rate ratio of 2021 relative to the value in 2019. The selected ECSCs were intracranial injury, ischemic heart disease, stroke, and cardiac arrest.

RESULTS

The number of ED visits for all causes decreased by about 23% during the pandemic. The number of ED visits for intracranial injuries decreased from 166,695 in 2019 to 133,226 in 2020 and then increased to 145,165 in 2021. The number of ED visits for ischemic heart disease and stroke decreased in 2020 but increased to 2019 levels in 2021. In contrast, the number of ED visits for cardiac arrest increased from 23,903 in 2019 to 24,344 in 2020 and to 27,027 in 2021. The incidence rate and incidence rate ratio of these four ECSCs increased from 2019 to 2021, suggesting increasing relative proportions of ECSCs in total ED visits.

CONCLUSION

During the COVID-19 pandemic, the number of cardiac arrests seen in the EDs increased, but that of other ECSCs decreased. The decrease in ED visits for ECSCs was not as pronounced as the decrease in ED visits for all causes during the pandemic. Further studies are needed to determine clinical outcomes in patients with ECSC during the pandemic.

Using laws, common sense, and statistical approaches to design indicators for 'medical desertification'. An application on the Romanian case

The study of spatial accessibility to healthcare services is key to health policy (Pförtner et al., 2019; Vergier et al., 2017). Terms such as 'rurality' or 'medical desertification' were employed to stress the relevance of the topic. Within the existing literature, there is little (if any) concern with the legitimacy of the existing ways to measure inequality. Expert systems were assumed to be in place, and discrepancies or consistency with existing regulations or to views of relevant stakeholders were not considered. This paper discusses spatial accessibility of medical services in three distinct approaches: normative, that is following what national regulations consider as standard; relative, that is what statistical approaches reveal; consensual, which adjusts the indexes based on representations of stakeholders. The three approaches are compared for the case of Romania, an EU country with low population density, ideal to inspect geographical discrepancies. For the relative and the consensual approach, population is adjusted according to different demand expressed by age groups, and also including population and providers from the nearby localities. The normative approach follows official regulations. The refinements in the consensual model are based on survey data from stakeholders and consider distances to neighbouring localities and adjustments according to the age structure of the population in the catchment area. The results reveal high consistency between the consensual and the relative approach. Both are more permissive with respect to detecting medical desertification as compared to the normative approach but prove to be more effective in directing policy when resources are scarce. The normative approach, however, is relevant in depicting the state of the system as contrasted to a desired standard. The relative approach also overlaps with the consensual one. Therefore, to fully characterize spatial accessibility to general practitioners (GPs) and pharmacies, one needs to consider at least the normative and the relative approaches.

Doctors' experiences of providing care in rural hospitals in Southern New Zealand: a qualitative study

OBJECTIVE

To explore rural hospital doctors' experiences of providing care in New Zealand rural hospitals.

DESIGN

The study had a qualitative design, using qualitative content analysis.

SETTING

The study was conducted in South Island, New Zealand, and included nine different rural hospitals.

RESPONDENTS

Semistructured interviews were conducted with 16 rural hospital doctors.

RESULTS

Three themes were identified: 'Applying a holistic perspective in the care', 'striving to maintain patient safety in sparsely populated areas' and 'cooperating in different teams around the patient'. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience.Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context.

CONCLUSIONS

This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.

The relationship between hospital selection by employer and disabilities in occupational accidents in Korea

Background

In the event of an industrial accident, the appropriate choice of hospital is important for worker health and prognosis. This study investigates whether the choice of hospital by the employer in the case of industrial accidents affects the prognosis of injured employees.

Methods

Data from the 2018 Panel Study of Workers’ Compensation Insurance in Korea were used in an unmatched case-controlled study. The exposure variable is “hospital selection by an employer,” and the outcome variable is ‘worker’s disability.” Odds ratios (ORs) were estimated by modified Poisson regression and adjusted for age, gender, underlying disease, injury severity, and workplace size and stratified by industrial classification. The group at increased risk was analyzed and stratified by age, gender, and area.

Results

In the construction industry, hospital selection by the employer was significantly associated with increased risk of disability (adjusted OR 1.26; 95% confidence interval [CI]: 1.20–1.32) and severe disability (adjusted OR 1.38; 95% CI: 1.08–1.76) among the injured. Female and younger workers not living in the Seoul capital area were more at risk of disability and severe disability than those living in the Seoul capital area.

Conclusions

Hospital selection by employers affects the prognosis of workers injured in an industrial accident. For protecting workers’ health and safety, workplace emergency medical systems should be improved, and the selection of appropriate hospitals to supply treatment should be reviewed.