["Children cannot wait": why mothers seek urgency and emergency care services for their children in non-urgent situations]

Costs and characteristics of admissions due to ambulatory care-sensitive conditions in children under one year of age in São Paulo, Brazil

This research aimed to estimate the direct costs and analyze the epidemiological aspects of ambulatory care-sensitive conditions (ACSC) in children under one year of age, São Paulo municipality, 2011-2022. Total and average costs were calculated according to ACSC diagnosis groups by components (early neonatal, late neonatal, and post-neonatal). The trend in ACSC rates was analyzed using Prais-Winsten generalized linear regression. 98,679 hospitalizations were identified. There was an annual increase of 10.2% in the ACSC rate of early neonates and in the other components the trend was stationary. The cost for the period was estimated at R$ 130.5 million in <1 year, a reduction of 8.6%. The highest absolute values were related to the most frequent causes, such as lung diseases with 43.7% of the cost in <1 year, 52.5% in late neonates, and 48.8% in post-neonates. In early neonates, 83.5% of the cost was attributed to prenatal-related diseases, especially congenital syphilis. It is concluded that it was possible to identify the costs and characteristics of hospitalizations, showing an increase in ACSC rates and the conditions that require greater attention from primary health care services to reduce hospitalizations and hospital costs in the public sector.

Epidemiological patterns related to deaths caused by visceral leishmaniasis in the southern Amazon region of Brazil

Background

We analysed the spatial and spatiotemporal patterns of visceral leishmaniasis (VL) mortality at the municipality level in an endemic state in the southern Amazon region of Brazil. Individual-level factors associated with death due to VL were also investigated.

Methods

All VL cases and deaths reported between 2007 and 2018 were included. The global and local bivariate Moran's index assessed the space–time autocorrelation of smoothed triennial VL mortality. Kulldorff's scan statistics investigated spatial and spatiotemporal clusters. A multivariable logistic regression explored sociodemographic, diagnostic and clinical variables associated with death due to VL.

Results

We observed an overall VL mortality and lethality of 0.14 cases/100 000 inhabitants and 11.2%, respectively. A total of 14% of the municipalities registered at least one VL-related death. In the southeastern mesoregion of the state, we detected high-risk spatial (relative risk [RR] 14.14; p&lt;0.001) and spatiotemporal (RR 15.91; p&lt;0.001) clusters for VL mortality. Bivariate Moran's analysis suggested a high space–time autocorrelation of VL mortality. Death by VL was associated with age ≥48 y (odds ratio [OR] 7.2 [95% confidence interval {CI} 3.4 to 15.3]), displacement for notification (OR 3.3 [95% CI 1.5 to 7.2]) and occurrence of oedema (OR 2.8 [95% CI 1.3 to 6.1]) and bleeding (OR 5.8 [95% CI 2.6 to 12.8]).

Conclusions

VL mortality has a heterogeneous spatiotemporal distribution. The death-related factors suggest late diagnosis as an underlying cause of mortality.

Fever in children: parents' search for urgent and emergency services

The study analyses the understanding of parents or guardians of children aged zero to five years old about fever, the conduct and care for this condition, carried out in the urgent and emergency service. The qualitative research, which used the thematic analysis technique, was carried out through interviews with 14 parents or guardians who sought an urgent and emergency Pediatric Service in a municipality in the countryside of São Paulo for this reason. The experiences of parents who seek these services are associated to three main topics: fear of fever; care for a febrile child; and the experience of care at the urgent and emergency services. It was identified that an exaggerated fear of fever predominates and that parents / guardians feel safe regarding the existing technology found in urgent and emergency services. The adopted precautions, however, are not always those recommended for the existing situation.

Where, when, and how the diagnosis of human visceral leishmaniasis is defined: answers from the Brazilian control program

BACKGROUND

Timely diagnosis is recommended by the Brazilian Visceral Leishmaniasis (VL) Surveillance and Control Program to reduce case fatality. Attempts at assessing this topic in Brazil are scarce.

OBJECTIVE

This study aimed to describe where, when, and how the diagnosis of VL has been performed in a Brazilian endemic setting.

METHODS

Data of all autochthonous cases confirmed between 2011 and 2016 (N = 81) were recorded. The care-seeking itinerary until the confirmation of VL diagnosis was assessed among 57 patients.

FINDINGS

The majority of VL cases (79.1%) were reported by referral hospitals. The patients mainly sought primary health care centres at the onset of symptoms. However, they had to visit seven health services on average to achieve a confirmed diagnosis. The time from the onset of symptoms to the diagnosis of VL (T_D) ranged from 1-212 (median, 25) days. The T_D was longer among adult patients. There was a direct correlation between the patient’s age and T_D (r = 0.22; p = 0.047) and a higher occurrence of deaths due to the disease among older patients (p = 0.002). Almost all the patients (98.9%) underwent laboratory investigation, and the VL diagnosis was mainly confirmed based on clinical-laboratory criteria (92.6%). Positive results for the indirect fluorescence antibody test (22.7%) and parasitological examination plus rk39-based immunochromatographic tests (21.3%) were commonly employed.

MAIN CONCLUSIONS

VL diagnosis was predominantly conducted in hospitals with a long T_D and wide application of serology. These findings may support measures focused on early diagnosis, including a greater involvement of the primary health care system.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Background

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design

Mixed-methods sequential design.

Setting

Four counties in southern England coterminous with a NHS 111 provider area.

Methods

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration

This study is registered as UKCRN 32207.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Manchester Triage System: main flowcharts, discriminators and outcomes of a pediatric emergency care

Objetive:

to characterize the care services performed through risk rating by the Manchester Triage System, identifying demographics (age, gender), main flowcharts, discriminators and outcomes in pediatric emergency

Method:

cross-sectional quantitative study. Data on risk classification were obtained through a search of computerized registration data from medical records of patients treated in the pediatric emergency within one year. Descriptive statistics with absolute and relative frequencies was used for the analysis.

Results:

10,921 visits were conducted in the pediatric emergency, mostly male (54.4%), aged between 29 days and two years (44.5%). There was a prevalence of the urgent risk category (43.6%). The main flowchart used in the care was worried parents (22.4%) and the most prevalent discriminator was recent event (15.3%). The hospitalization outcome occurred in 10.4% of care performed in the pediatric emergency, however 61.8% of care needed to stay under observation and / or being under the health team care in the pediatric emergency.

Conclusion:

worried parents was the main flowchart used and recent events the most prevalent discriminator, comprising the hospitalization outcomes and permanency in observation in the pediatric emergency before discharge from the hospital.

The therapeutic itinerary in urgent/emergency pediatric situations in a Maroon community

The goal was to understand the therapeutic itinerary of Maroon children in urgent/emergency situation. Is a descriptive research with a qualitative approach that uses the Health Care System model of Arthur Kleinman as its theoretical support. Participants included 12 mothers of children who had experienced any urgent or emergency medical situation. Data collection took place from December 2013 to June 2014 through semi-structured interviews with a thematic analysis of the data. The care of the child started in the "informal" subsystem, and access to a "formal" subsystem was characterized as a pilgrimage for health services. A development of specific strategies is needed to ensure and facilitate full access to the services of the professional subsystem for Maroon communities.

Analgésicos, antipiréticos e anti-inflamatórios não esteroides em prescrições pediátricas

O uso de analgésicos, antipiréticos e anti-inflamatórios não esteroides por crianças muitas vezes não tem aprovação das agências reguladoras, nem respaldo das evidências científicas. Prescrições pediátricas podem ser influenciadas por fatores que não favorecem o uso racional dos medicamentos desta classe. O objetivo deste trabalho foi avaliar a utilização de analgésicos, antipiréticos e anti-inflamatórios não esteroides em crianças, considerando os setores público (SUS) e privado (N-SUS). A amostra foi composta por 150 prescrições (101 SUS e 49 N-SUS) seguidas de entrevista aos cuidadores, em dezoito locais (nove drogarias privadas e nove Unidades de Saúde do SUS). Os medicamentos foram prescritos de forma apropriada, segundo faixa etária, somente em 21,8% (SUS) e 29,6% (N-SUS) das prescrições. Mais de 95% das receitas, independente da origem, não atenderam aos critérios estabelecidos para avaliação do uso racional, com erros de dose, frequência e duração do tratamento. A análise das prescrições de analgésicos, antipiréticos e anti-inflamatórios não esteroides para crianças não apresentou diferenças significantes nos setores público e privado.