Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

The impact of comorbid psychiatric disorders on chronic obstructive pulmonary disease (COPD) hospitalizations: a nationwide retrospective study

AIMS

To characterize the register of a secondary diagnosis of mental illnesses in all chronic obstructive pulmonary disease (COPD) hospitalizations registered in Portugal from 2008 to 2015 and explore their impact on hospitalization outcomes.

METHODS

A retrospective observational study was conducted. Hospitalizations of patients with at least 40 years old, discharged between 2008 and 2015 with a primary diagnosis of COPD (ICD-9-CM codes 491.x, 492.x and 496) were retrieved from a national administrative database. Comorbid psychiatric diagnoses were identified and defined by the HCUP Clinical Classification Software (CCS) category codes 650-670 (excluding 662). Length of hospital stay (LoS), admission type, in-hospital mortality, and estimated hospital charges were analyzed according to psychiatric diagnostic categories using sex and age-adjusted models.

RESULTS

Of 66,661 COPD hospitalizations, 25,869 (38.8%) were episodes with a registered psychiatric comorbidity. These were more likely to correspond to younger inpatients (OR = 2.16, 95%CI 2.09-2.23; p < 0.001), to stay longer at the hospital (aOR = 1.08, 95%CI 1.05-1.12; p < 0.001), to incur in higher estimated hospital charges (aOR = 1.37, 95%CI 1.33-1.42; p < 0.001) and to be urgently admitted (aOR = 1.33, 95%CI 1.23-1.44; p < 0.001). After adjustment for age, in-hospital mortality was lower for episodes with psychiatric diagnoses (aOR = 0.90; 95%CI 0.84-0.96; p < 0.001), except for organic and neurodegenerative diseases category and developmental disorders, intellectual disabilities and disorders usually diagnosed in infancy, childhood, or adolescence category.

DISCUSSION

These findings corroborate the additional burden placed by psychiatric disorders on COPD hospitalizations, highlighting the importance of individualizing care to address these comorbidities and minimize their impact on treatment outcomes.

Willingness to institutionalize a relative with dementia: a web-platform assessment with the Portuguese adapted version of the Desire-to-Institutionalize Scale

Introduction

Older persons with dementia (PwD) are more likely to be institutionalized than their counterparts without dementia. The caregiver's desire to institutionalize has been suggested as the most important predictor of actual institutionalization. This cross-sectional study aimed to culturally adapt the Desire to Institutionalize Scale (DIS) to a country with a high prevalence of dementia (Portugal) and examine its psychometric properties.

Methods

The reliability, structural validity, and criterion validity of the DIS-PT were assessed by applying the scale using a remote measurement web platform. A sample of 105 dementia caregivers completed the DIS-PT and several psychosocial measures, including caregiver burden, anxiety, depression, quality of life, PwD functional independence, and neuropsychiatric symptoms.

Results

The DIS-PT demonstrated good structural validity, with one factor explaining 75% of the total variance. The internal consistency of the scale was high (α = 0.802). Most caregivers (65.7%) endorsed at least one item on the DIS-PT (Mdn 2). The caregiver's desire to institutionalize was significantly associated with the caregiver, care recipient, and contextual variables previously known to affect institutional placement. These included the caregivers' occupational status, perceived burden, anxiety (but not depression), physical and psychological quality of life, care recipient education, severity of neuropsychiatric symptoms, and cohabitation with the caregiver.

Discussion

This study offers preliminary support for the psychometric quality of the DIS-PT. The scale has practical applications in the early identification of caregivers considering nursing home placement, providing room for intervention in modifiable risk factors that may otherwise lead to the institutionalization of PwD. Remote measurement tools may hold value in assessing caregiving dyads non-intrusively and inexpensively.

Multidisciplinary Development and Initial Validation of a Clinical Knowledge Base on Chronic Respiratory Diseases for mHealth Decision Support Systems

Most mobile health (mHealth) decision support systems currently available for chronic obstructive respiratory diseases (CORDs) are not supported by clinical evidence or lack clinical validation. The development of the knowledge base that will feed the clinical decision support system is a crucial step that involves the collection and systematization of clinical knowledge from relevant scientific sources and its representation in a human-understandable and computer-interpretable way. This work describes the development and initial validation of a clinical knowledge base that can be integrated into mHealth decision support systems developed for patients with CORDs. A multidisciplinary team of health care professionals with clinical experience in respiratory diseases, together with data science and IT professionals, defined a new framework that can be used in other evidence-based systems. The knowledge base development began with a thorough review of the relevant scientific sources (eg, disease guidelines) to identify the recommendations to be implemented in the decision support system based on a consensus process. Recommendations were selected according to predefined inclusion criteria: (1) applicable to individuals with CORDs or to prevent CORDs, (2) directed toward patient self-management, (3) targeting adults, and (4) within the scope of the knowledge domains and subdomains defined. Then, the selected recommendations were prioritized according to (1) a harmonized level of evidence (reconciled from different sources); (2) the scope of the source document (international was preferred); (3) the entity that issued the source document; (4) the operability of the recommendation; and (5) health care professionals' perceptions of the relevance, potential impact, and reach of the recommendation. A total of 358 recommendations were selected. Next, the variables required to trigger those recommendations were defined (n=116) and operationalized into logical rules using Boolean logical operators (n=405). Finally, the knowledge base was implemented in an intelligent individualized coaching component and pretested with an asthma use case. Initial validation of the knowledge base was conducted internally using data from a population-based observational study of individuals with or without asthma or rhinitis. External validation of the appropriateness of the recommendations with the highest priority level was conducted independently by 4 physicians. In addition, a strategy for knowledge base updates, including an easy-to-use rules editor, was defined. Using this process, based on consensus and iterative improvement, we developed and conducted preliminary validation of a clinical knowledge base for CORDs that translates disease guidelines into personalized patient recommendations. The knowledge base can be used as part of mHealth decision support systems. This process could be replicated in other clinical areas.

Development and Evaluation of a Natural Language Processing System for Curating a Trans-Thoracic Echocardiogram (TTE) Database

BACKGROUND

Although electronic health records (EHR) provide useful insights into disease patterns and patient treatment optimisation, their reliance on unstructured data presents a difficulty. Echocardiography reports, which provide extensive pathology information for cardiovascular patients, are particularly challenging to extract and analyse, because of their narrative structure. Although natural language processing (NLP) has been utilised successfully in a variety of medical fields, it is not commonly used in echocardiography analysis.

OBJECTIVES

To develop an NLP-based approach for extracting and categorising data from echocardiography reports by accurately converting continuous (e.g., LVOT VTI, AV VTI and TR Vmax) and discrete (e.g., regurgitation severity) outcomes in a semi-structured narrative format into a structured and categorised format, allowing for future research or clinical use.

METHODS

135,062 Trans-Thoracic Echocardiogram (TTE) reports were derived from 146967 baseline echocardiogram reports and split into three cohorts: Training and Validation (n = 1075), Test Dataset (n = 98) and Application Dataset (n = 133,889). The NLP system was developed and was iteratively refined using medical expert knowledge. The system was used to curate a moderate-fidelity database from extractions of 133,889 reports. A hold-out validation set of 98 reports was blindly annotated and extracted by two clinicians for comparison with the NLP extraction. Agreement, discrimination, accuracy and calibration of outcome measure extractions were evaluated.

RESULTS

Continuous outcomes including LVOT VTI, AV VTI and TR Vmax exhibited perfect inter-rater reliability using intra-class correlation scores (ICC = 1.00, p < 0.05) alongside high R2 values, demonstrating an ideal alignment between the NLP system and clinicians. A good level (ICC = 0.75-0.9, p < 0.05) of inter-rater reliability was observed for outcomes such as LVOT Diam, Lateral MAPSE, Peak E Velocity, Lateral E' Velocity, PV Vmax, Sinuses of Valsalva and Ascending Aorta diameters. Furthermore, the accuracy rate for discrete outcome measures was 91.38% in the confusion matrix analysis, indicating effective performance.

CONCLUSIONS

The NLP-based technique yielded good results when it came to extracting and categorising data from echocardiography reports. The system demonstrated a high degree of agreement and concordance with clinician extractions. This study contributes to the effective use of semi-structured data by providing a useful tool for converting semi-structured text to a structured echo report that can be used for data management. Additional validation and implementation in healthcare settings can improve data availability and support research and clinical decision-making.

Socioeconomic Inequalities and Predictors of Cardiac Rehabilitation Referral: Real-World Evidence

OBJECTIVE

The aim of the study is to identify factors associated with cardiac rehabilitation referral after an acute coronary syndrome at a university hospital.

DESIGN

We analyzed 2814 hospitalizations due to acute coronary syndrome between 2017 and 2019 in Centro Hospitalar São João. The hospital's morbidity database was used to retrieve patient information. Cardiac rehabilitation referral and participation were identified from administrative databases and clinical records. Socioeconomic data were obtained from municipality of residence-level data rather than patient-specific data.

RESULTS

Of 2814 hospitalizations, 72% (2028 cases) were eligible for cardiac rehabilitation. Mean age was 65.2 ± 13.4 yrs; 72% men, 33% diabetic, 57.1% hypertensive, and 63.6% dyslipidemic. Cardiac rehabilitation referral rate was low, at 18.8%, with 42 (11.0%) not attending cardiac rehabilitation and 39 (10.2%) dropping out. Females (odds ratio = 0.72 [95% confidence interval = 0.52-1.00]), older patients (odds ratio = 0.57 [0.42-0.77]; 55-64 vs. <55 yrs), and those coming from lower-income municipalities (odds ratio = 0.53 [0.41-0.69], below median vs. above median) with lower education level (odds ratio = 0.70 [0.54-0.92]; ≤4 vs. >4 yrs) were less likely to be referred to cardiac rehabilitation.

CONCLUSIONS

There is a need for new strategies to promote cardiac rehabilitation in disadvantaged groups, as sex, age, and socioeconomic inequities in access to cardiac rehabilitation remain unresolved.

Epilepsy hospitalizations and mental disorders: A Portuguese population-based observational retrospective study (2008-2015)

BACKGROUND

Psychiatric comorbidities are highly frequent in people with epilepsy and were found to be markers of poorer prognosis. These comorbidities increase the use of healthcare resources, including emergency department visits and inpatient care. Despite this, there is little information on healthcare utilization associated with a wide range of comorbid mental disorders in people with epilepsy (PWE).

OBJECTIVE

To characterize registered mental disorders among all hospitalizations with a primary diagnosis of epilepsy and to analyze their association with crucial hospitalization outcomes.

METHODS

An observational retrospective study was performed using administrative data from hospitalization episodes with epilepsy as the primary diagnosis discharged between 2008 and 2015. Mental disorder categories 650 to 670 from Clinical Classification Software were selected as secondary diagnoses. Mann-Whitney U, Kruskall-Wallis, and Chi-squared tests were used to establish comparisons. For each episode, data regarding hospitalization outcomes was retrieved, including length of stay (LoS), in-hospital mortality (IHM), 8-year period readmissions, and total estimated charges.

RESULTS

Overall, 27,785 hospitalizations were analyzed and 33.9% had registered mental disorders, with alcohol-related disorders being the most prevalent (11.7%). For episodes with a concomitant register of a mental disorder, LoS was significantly longer (5.0 vs. 4.0 days, P <0.001), and IHM was higher (2.8% vs. 2.2%, P <0.001), as were readmissions (25.5% vs. 23.7%, P <0.001), and median episodes' charges (1,578.7 vs. 1,324.4 euros, P <0.001).

CONCLUSION

Epilepsy-related hospitalizations with registered mental disorders heightened the utilization of healthcare resources, stressing the importance of diagnosing and treating mental disorders in PWE.

Comparing Decentralized Learning Methods for Health Data Models to Nondecentralized Alternatives: Protocol for a Systematic Review

BACKGROUND

Considering the soaring health-related costs directed toward a growing, aging, and comorbid population, the health sector needs effective data-driven interventions while managing rising care costs. While health interventions using data mining have become more robust and adopted, they often demand high-quality big data. However, growing privacy concerns have hindered large-scale data sharing. In parallel, recently introduced legal instruments require complex implementations, especially when it comes to biomedical data. New privacy-preserving technologies, such as decentralized learning, make it possible to create health models without mobilizing data sets by using distributed computation principles. Several multinational partnerships, including a recent agreement between the United States and the European Union, are adopting these techniques for next-generation data science. While these approaches are promising, there is no clear and robust evidence synthesis of health care applications.

OBJECTIVE

The main aim is to compare the performance among health data models (eg, automated diagnosis and mortality prediction) developed using decentralized learning approaches (eg, federated and blockchain) to those using centralized or local methods. Secondary aims are comparing the privacy compromise and resource use among model architectures.

METHODS

We will conduct a systematic review using the first-ever registered research protocol for this topic following a robust search methodology, including several biomedical and computational databases. This work will compare health data models differing in development architecture, grouping them according to their clinical applications. For reporting purposes, a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 flow diagram will be presented. CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies)-based forms will be used for data extraction and to assess the risk of bias, alongside PROBAST (Prediction Model Risk of Bias Assessment Tool). All effect measures in the original studies will be reported.

RESULTS

The queries and data extractions are expected to start on February 28, 2023, and end by July 31, 2023. The research protocol was registered with PROSPERO, under the number 393126, on February 3, 2023. With this protocol, we detail how we will conduct the systematic review. With that study, we aim to summarize the progress and findings from state-of-the-art decentralized learning models in health care in comparison to their local and centralized counterparts. Results are expected to clarify the consensuses and heterogeneities reported and help guide the research and development of new robust and sustainable applications to address the health data privacy problem, with applicability in real-world settings.

CONCLUSIONS

We expect to clearly present the status quo of these privacy-preserving technologies in health care. With this robust synthesis of the currently available scientific evidence, the review will inform health technology assessment and evidence-based decisions, from health professionals, data scientists, and policy makers alike. Importantly, it should also guide the development and application of new tools in service of patients' privacy and future research.

TRIAL REGISTRATION

PROSPERO 393126; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=393126.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45823.

A Remote Monitoring Platform for the Management of Lower Limb Vascular Diseases

This short paper describes a remote monitoring platform proposed in the Inno4health project. The platform aims to guide patients and clinicians during the treatment of lower limb vascular disorders, namely, to correct abnormal foot pressure and temperature to prevent diabetic foot ulcers and to monitor interface pressure, leg position and elevation for venous ulcers patients.

Mobile Application for Improvement of Self-Management of Type 2 Diabetes: Usability Pilot Test

We intend to evaluate the usability of a mobile app developed for the self-management of T2DM. A pilot usability cross-sectional study was performed with a convenience sample of 6 smartphone users aged 45 years. Participants performed tasks autonomously in a mobile app to assess if users could complete them and filled out a usability and satisfaction questionnaire. About half of the tasks had a successful completion rate. The result of the usability questionnaire was 64/100, below the acceptable value, but the satisfaction value was considered good. This study was fundamental as it allowed us to verify which improvements should be implemented in the next version of the app, contributing to its better acceptance.

Secur-e-Health Project: Towards Federated Learning for Smart Pediatric Care

The application of machine learning (ML) algorithms to electronic health records (EHR) data allows the achievement of data-driven insights on various clinical problems and the development of clinical decision support (CDS) systems to improve patient care. However, data governance and privacy barriers hinder the use of data from multiple sources, especially in the medical field due to the sensitivity of data. Federated learning (FL) is an attractive data privacy-preserving solution in this context by enabling the training of ML models with data from multiple sources without any data sharing, using distributed remotely hosted datasets. The Secur-e-Health project aims at developing a solution in terms of CDS tools encompassing FL predictive models and recommendation systems. This tool may be especially useful in Pediatrics due to the increasing demands on Pediatric services, and the current scarcity of ML applications in this field compared to adult care. Herein we provide a description of the technical solution proposed in this project for three specific pediatric clinical problems: childhood obesity management, pilonidal cyst post-surgical care and retinography imaging analysis.

Impact of multimorbidity patterns in hospital admissions: the case study of asthma

Most previous studies assessing multimorbidity in asthma assessed the frequency of individual comorbid diseases. We aimed to assess the frequency and clinical and economic impact of co-occurring groups of comorbidities (comorbidity patterns using the Charlson Comorbidity Index) on asthma hospitalizations. We assessed the dataset containing a registration of all Portuguese hospitalisations between 2011-2015. We applied three different approaches (regression models, association rule mining, and decision trees) to assess both the frequency and impact of comorbidities patterns in the length-of-stay, in-hospital mortality and hospital charges. For each approach, separate analyses were performed for episodes with asthma as main and as secondary diagnosis. Separate analyses were performed by participants' age group. We assessed 198340 hospitalizations in patients >18 years old. Both in hospitalizations with asthma as main or secondary diagnosis, combinations of diseases involving cancer, metastasis, cerebrovascular disease, hemiplegia/paraplegia, and liver disease displayed a relevant clinical and economic burden. In hospitalizations having asthma as a secondary diagnosis, we identified several comorbidity patterns involving asthma and associated with increased length-of-stay (average impact of 1.3-3.2 additional days), in-hospital mortality (OR range = 1.4-7.9) and hospital charges (average additional charges of 351.0 to 1025.8 Euro compared with hospitalizations without any registered Charlson comorbidity). Consistent results were observed with association rules mining and decision tree approaches. Our findings highlight the importance not only of a complete assessment of patients with asthma, but also of considering the presence of asthma in patients admitted by other diseases, as it may have a relevant impact on clinical and health services outcomes.

Unsupervised algorithms to identify potential under-coding of secondary diagnoses in hospitalisations databases in Portugal

BACKGROUND

Quantifying and dealing with lack of consistency in administrative databases (namely, under-coding) requires tracking patients longitudinally without compromising anonymity, which is often a challenging task.

OBJECTIVE

This study aimed to (i) assess and compare different hierarchical clustering methods on the identification of individual patients in an administrative database that does not easily allow tracking of episodes from the same patient; (ii) quantify the frequency of potential under-coding; and (iii) identify factors associated with such phenomena.

METHOD

We analysed the Portuguese National Hospital Morbidity Dataset, an administrative database registering all hospitalisations occurring in Mainland Portugal between 2011-2015. We applied different approaches of hierarchical clustering methods (either isolated or combined with partitional clustering methods), to identify potential individual patients based on demographic variables and comorbidities. Diagnoses codes were grouped into the Charlson an Elixhauser comorbidity defined groups. The algorithm displaying the best performance was used to quantify potential under-coding. A generalised mixed model (GML) of binomial regression was applied to assess factors associated with such potential under-coding.

RESULTS

We observed that the hierarchical cluster analysis (HCA) + k-means clustering method with comorbidities grouped according to the Charlson defined groups was the algorithm displaying the best performance (with a Rand Index of 0.99997). We identified potential under-coding in all Charlson comorbidity groups, ranging from 3.5% (overall diabetes) to 27.7% (asthma). Overall, being male, having medical admission, dying during hospitalisation or being admitted at more specific and complex hospitals were associated with increased odds of potential under-coding.

DISCUSSION

We assessed several approaches to identify individual patients in an administrative database and, subsequently, by applying HCA + k-means algorithm, we tracked coding inconsistency and potentially improved data quality. We reported consistent potential under-coding in all defined groups of comorbidities and potential factors associated with such lack of completeness.

CONCLUSION

Our proposed methodological framework could both enhance data quality and act as a reference for other studies relying on databases with similar problems.

Should we adjust health expenditure for age structure on health systems efficiency? A worldwide analysis

INTRODUCTION

Healthcare expenditure, a common input used in health systems efficiency analyses is affected by population age structure. However, while age structure is usually considered to adjust health system outputs, health expenditure and other inputs are seldom adjusted. We propose methods for adjusting Health Expenditure per Capita (HEpC) for population age structure on health system efficiency analyses and assess the goodness-of-fit, correlation, reliability and disagreement of different approaches.

METHODS

We performed a worldwide (188 countries) cross-sectional study of efficiency in 2015, using a stochastic frontier analysis. As single outputs, healthy life expectancy (HALE) at birth and at 65 years-old were considered in different models. We developed five models using as inputs: (1) HEpC (unadjusted); (2) age-adjusted HEpC; (3) HEpC and the proportion of 0-14, 15-64 and 65 + years-old; (4) HEpC and 5-year age-groups; and (5) HEpC ageing index. Akaike and Bayesian information criteria, Spearman's rank correlation, intraclass correlation coefficient and information-based measure of disagreement were computed.

RESULTS

Models 1 and 2 showed the highest correlation (0.981 and 0.986 for HALE at birth and HALE at 65 years-old, respectively) and reliability (0.986 and 0.988) and the lowest disagreement (0.011 and 0.014). Model 2, with age-adjusted HEpC, presented the lowest information criteria values.

CONCLUSIONS

Despite different models showing good correlation and reliability and low disagreement, there was important variability when age structure is considered that cannot be disregarded. The age-adjusted HE model provided the best goodness-of-fit and was the closest option to the current standard.

Social Vulnerability of Brazilian Metropolitan Schools and Teachers' Absence from Work Due to Vocal and Psychological Symptoms: A Multilevel Analysis

Teachers' voices and psychological symptoms are the main reasons for absence from work. The objectives of this study were: (i) to spatially represent, through a webGIS, the standardized rates of teachers' absences due to voice (outcome 1) and psychological symptoms (outcome 2) in each Brazilian Federative Unit (FU = 26 states plus Federal District) and (ii) to analyze the relationship between each national outcome rate and the Social Vulnerability Index (SVI) of the municipality where urban schools are located, adjusted for sex, age, and working conditions. This cross-sectional study comprised 4979 randomly sampled teachers working in basic education urban schools, of which 83.3% are women. The national absence rates were 17.25% for voice symptoms and 14.93% for psychological symptoms. The rates, SVI, and school locations in the 27 FUs are dynamically visualized in webGIS. The multilevel multivariate logistic regression model showed a positive association between voice outcome and high/very high SVI (OR = 1.05 [1.03; 1.07]), whereas psychological symptoms were negatively associated with high/very high SVI (OR = 0.86 [0.85 0.88]) and positively associated with intermediate SVI (OR = 1.15 [1.13; 1.16]), in contrast with low/very low SVI. Being a woman (voice: OR = 1.36 [1.35; 1.38]; psychological: 1.22 [1.21; 1.24]) and working in schools with various precarious conditions (17 variables) increased the odds of being absent due to voice and psychological symptoms. The results confirm the need for investments to improve working conditions in schools.

Dementia-related agitation: a 6-year nationwide characterization and analysis of hospitalization outcomes

OBJECTIVES

To characterize all hospitalizations held in mainland Portugal (2010-2015) with dementia-related agitation based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding, and to investigate whether there is a relationship between agitation and hospitalization outcomes.

METHODS

A retrospective observational study was conducted using an administrative dataset containing data from all mainland Portuguese public hospitals. Only hospitalization episodes for patients aged over 65 years who have received a dementia diagnosis ascertained by an ICD-9-CM code of dementia with behavioral disturbance (294.11 and 294.21) and dementia without behavioral disturbance (294.10 and 294.20) were selected. Episodes were further grouped according to the presence of an agitation code. For each episode, demographic data and hospitalization outcomes, including length of stay (LoS), in-hospital mortality, discharge destination and all-cause hospital readmissions, were sourced from the dataset. Comparative analyses were performed and multivariable logistic methods were used to estimate the adjusted associations between agitation (exposure) and outcomes.

RESULTS

Overall, 53,156 episodes were selected, of which 6,586 had an agitation code. These were mostly related to male, younger inpatients (mean 81.19 vs. 83.29 years, p < 0.001), had a higher comorbidity burden, stayed longer at the hospital (median 9.00 vs. 8.00 days, p < 0.001) and frequently ended being transferred to another facility with inpatient care. Agitation was shown to independently increase LoS (aOR = 1.385; 95%CI:1.314-1.461), but not the risk of a fatal outcome (aOR = 0.648; 95%CI:0.600-0.700).

CONCLUSION

These results support the importance of detecting and managing agitation early on admission, since its prompt management may prevent lengthy disruptive hospitalizations.

Validity of the Paediatric Canadian Triage Acuity Scale in a Tertiary Hospital: An Analysis of Severity Markers' Variability

With the increasing influx of patients and frequent overcrowding, the adoption of a valid triage system, capable of distinguishing patients who need urgent care, from those who can wait safely is paramount. Hence, the aim of this study is to evaluate the validity of the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) in a Portuguese tertiary hospital. Furthermore, we aim to study the performance and appropriateness of the different surrogate severity markers to validate triage. This is a retrospective study considering all visits to the hospital's Paediatric Emergency Department (PED) between 2014 and 2019. This study considers cut-offs on all triage levels for dichotomization in order to calculate validity measures e.g. sensitivity, specificity and likelihood ratios, ROC curves; using hospital admission, admission to intensive care and the use of resources as outcomes/markers of severity. Over the study period there were 0.2% visits triaged as Level 1, 5.7% as Level 2, 39.4% as Level 3, 50.5% as Level 4, 4.2% as Level 5, from a total of 452,815 PED visits. The area under ROC curve was 0.96, 0.71, 0.76, 0.78, 0.59 for the surrogate markers: "Admitted to intensive care"; "Admitted to intermediate care"; "Admitted to hospital"; "Investigations performed in the PED" and "Uses PED resources", respectively. The association found between triage levels and the surrogate markers of severity suggests that the PedCTAS is highly valid. Different surrogate outcome markers convey different degrees of severity, hence different degrees of urgency. Therefore, the cut-offs to calculate validation measures and the thresholds of such measures should be chosen accordingly.

Smart Wearable Systems for the Remote Monitoring of Selected Vascular Disorders of the Lower Extremity: A Systematic Review

This systematic review aims at providing an overview of the state of the art regarding smart wearable systems (SWS) applications to monitor the status of patients suffering from vascular disorders of the lower extremity. Peer-reviewed literature has been analyzed to identify employed data collection methods, system characteristics, and functionalities, and research challenges and limitations to be addressed. The Medline (PubMed) and SCOPUS databases were considered to search for publications describing SWS for remote or continuous monitoring of patients suffering from intermittent claudication, venous ulcers, and diabetic foot ulcers. Publications were first screened based on whether they describe an SWS applicable to the three selected vascular disorders of the lower extremity, including data processing and output to users. Information extracted from publications included targeted disease, clinical parameters to be measured and wearable devices used; system outputs to the user; system characteristics, including capabilities of remote or continuous monitoring or functionalities resulting from advanced data analyses, such as coaching, recommendations, or alerts; challenges and limitations reported; and research outputs. A total of 128 publications were considered in the full-text analysis, and 54 were finally included after eligibility criteria assessment by four independent reviewers. Our results were structured and discussed according to three main topics consisting of data collection, system functionalities, and limitations and challenges.

Healthcare Equity and Commissioning: A Four-Year National Analysis of Portuguese Primary Healthcare Units

Equal and adequate access to healthcare is one of the pillars of Portuguese health policy. Despite the controversy over commissioning processes' contribution to equity in health, this article aims to clarify the relationship between socio-economic factors and the results of primary healthcare (PHC) commissioning indicators through an analysis of four years of data from all PHC units in Portugal. The factor that presents a statistically significant relationship with a greater number of indicators is the organizational model. Since the reform of PHC services in 2005, a new type of unit was introduced: the family health unit (USF). At the time of the study, these units covered 58.1% of the population and achieved better indicator results. In most cases, the evolution of the results achieved by commissioning seems to be similar in different analyzed contexts. Nevertheless, the percentage of patients of a non-Portuguese nationality and the population density were analyzed, and a widening of discrepancies was observed in 23.3% of the cases. The commissioning indicators were statistically related to the studied context factors, and some of these, such as the nurse home visits indicator, are more sensitive to context than others. There is no evidence that the best results were achieved at the expense of worse healthcare being offered to vulnerable populations, and there was no association with a reduction in inequalities in healthcare. It would be valuable if the Portuguese Government could stimulate the increase in the number of working USFs, especially in low-density areas, considering that they can achieve better results with lower costs for medicines and diagnostic tests.

Measuring health expectancy in the European Union

Background

Healthy life expectancy (HLE) is a population health measure that combines mortality and morbidity, which can be calculated using different methods. In this study, we aimed to assess the correlation, reliability and (dis)agreement between two estimates monitored in the European Union (EU), that is, the European Commission's HLE based on self-perceived health (SPH-HLE) and the Institute for Health Metrics and Evaluation's HLE based on disability weight (DW-HLE), by sex, and comparing these results with LE and proportion of life spent in good health (%GH).

Methods

We performed a retrospective study in the EU28 countries, between 2010 and 2017. The HLE methods differ in definition, measurement and valuation of health states. While SPH-HLE relies directly on one question, DW-HLE relies on epidemiological data adjusted for DW. Spearman's r, intraclass correlation coefficient, information-based measure of disagreement and Bland-Altman plots were used to assess reliability, correlation and disagreement in HLE resulting from both methods and in LE or %GH measured by both institutions.

Results

Correlation and reliability between SPH-HLE and DW-HLE were good (better for males), with low disagreement, and were even better for LE between both institutions. The HLE Bland-Altman plots suggest a variability range of approximately 6 years for both sexes, higher for females. There was also an increasing HLE difference between methods with higher average HLE for both sexes.

Conclusions

We showed wide variations between both methods with a clear and different high impact on female and male HLE, showing a tendency for countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Acknowledgements: This presentation was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020)

Key messages

• Different methods for evaluating health expectancy lead to significantly different results.

• There is a systematic tendency with countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Depressive Disorder Related Hospitalizations in Portugal Between 2008-2015: a Nationwide Observational Study

Depression is a prevalent disease, being one of the most relevant contributors of disability in the overall global burden of diseases. Hospitalization episodes are important quality indicators in psychiatric care. The primary aim of this study is to analyse depressive disorder related hospitalizations in Portuguese public hospitals and to detail clinical and sociodemographic differences among various subtypes of depression. Admissions with a primary diagnosis of depression in adult patients(> = 18 years) were selected from a national mainland hospitalization database. ICD-9-CM codes were used to select the diagnoses of interest: 296.2 × to 296.3x (Major depressive disorder), 300.4 (Dysthymic disorder) and 311 (Depressive disorder, not elsewhere classified). Birth date, sex, residence address, primary and secondary diagnoses, admission date, discharge date, length of stay (LoS), discharge status, and hospital estimated charges were obtained. A total of 28,569 hospitalizations (22,387 patients) with a primary diagnosis of depression were analysed. In the 8-year period of the study, 19.1% of all hospitalizations with a primary diagnosis of psychiatric disorder were linked to Depression. Major Depressive episodes were the most common (n = 15,384; 53.8%), followed by Depression unspecified episodes (n = 6,793; 23.8%), and Dysthymia (n = 6,392; 22.4%). Most episodes occurred in female patients (70.2%; n = 20,052), with a mean age of 50.6 years, and 37.0% (n = 10,564) of the episodes were associated to other psychiatric comorbidities. Depressive disorders are one of the leading causes of hospitalization in Portuguese psychiatric departments, being responsible for approximately 1 in 5 hospitalizations with a psychiatric diagnosis.

Portuguese Primary Healthcare and Prevention Quality Indicators for Diabetes Mellitus - A Data Envelopment Analysis

BACKGROUND

Diabetes mellitus (DM) is a worldwide public health priority. The increasing prevalence and the budget constraints force to have effective healthcare, especially at the primary healthcare (PHC) level. We aim to assess primary care efficiency considering the best use of human resources to produce optimal diabetes care in terms of prevention quality indicators (PQIs) rates across national ACES (health centre groupings).

METHODS

We conducted a two-stage data envelopment analysis (DEA) to assess the technical efficiency of 54 Portuguese primary care health centre groupings for the 2016-2017 biennium. In the first stage, efficiency scores were obtained through five output-oriented DEA models under vector return to scale (VRS) assumption, using three input variables representing key primary care human resources and one output representing each one of the five PQIs related to diabetes. In the second stage, Tobit regression models were estimated to assess the determinants of primary care efficiency in diabetes care.

RESULTS

A total of 13 ACES reached the efficiency frontier. Better managing human resources could reduce PQI rates by 52.3% in 2016 and 49.1% in 2017. Higher proportion of patients under 65 years old and better controlled with a hemoglobin A1c (HbA1c) ≤6.5% were associated with better efficiency in diabetes care, whereas higher prevalence of DM and unemployment worsened hospitalizations rates by diabetes short-term complications and lower-extremity amputation.

CONCLUSION

Inefficiency in DM care was found in most of the primary care settings which can substantially improve the avoidable hospitalization rates by DM using their current level human resources. These findings help to improve diabetes care by targeting human resources at primary care level, which should be integrated into performance assessments considering broader and integrated scopes.

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review

Background

Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies.

Methods

We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021.

Results

We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables.

Conclusions

Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13925-z.

Characterization of Innovation to Fight Child Mortality: A Systematic Scoping Review

Objectives: This study aims to summarize how child mortality—a Sustainable Development Goal stated by the United Nations—has been explicitly addressed in the context of innovations.

Methods: A scoping review following the PRISMA-ScR Statement was performed analysing indexed and non-indexed literature.

Results: Empirical and non-disruptive innovation in the context of process targeting under-five mortality rate was the main subset of literature included in this article. The increment of literature on innovation in the context of SDGs over the last years denotes its growing importance and even though innovation aiming to reduce child mortality is currently being done, a significant part of it is not published in indexed databases but as grey literature.

Conclusion: Empirical, disruptive innovation under a structural approach and empirical, non-disruptive innovation under a project point of view are the main types of innovation addressed in the literature and would be of utmost potential to reduce child mortality rate. A systematic review of the methods used for the measures of evaluation of applied innovations, their quality and results would be of great importance in the future.

Schizophreniform disorder related hospitalizations – a Big Data analysis of a national hospitalization database

Introduction

Patients with schizophreniform disorder(SD) and schizophrenia present similar symptoms, however, SD has a shorter duration, varying between at least 1 month and 6 months.

Objectives

To describe and analyse Schizophreniform disorder related hospitalizations in a national hospitalization database.

Methods

We performed a retrospective observational study using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015. Hospitalizations with a primary diagnosis of schizophreniform diso72.1-der were selected based on International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) code of diagnosis 295.4x. Birth date, sex, residence address, primary and secondary diagnoses, admission date, discharge date, length of stay (LoS), discharge status, and hospital charges were obtained. Comorbidities were analysed using the Charlson Index Score. Independent Sample T tests were performed to assess differences in continuous variables with a normal distribution and Mann-Whitney-U tests when no normal distribution was registered.

Results

In Portuguese public hospitals, a total of 594 hospitalizations with a primary diagnosis of Schizophreniform disorder were registered during the 8-year study period. Most were associated to the male sex patients, 72.1% (n=428). The mean age at admission was 35.99 years and differed significantly between sexes (males - 34.44; females- 40.19; p<0.001). The median LoS was 17.00 days and the in-hospital mortality was 0.5% (n=3). Only 6.1% (n=36) of the hospitalization episodes had 1 or more registered comorbidities.

Conclusions

Hospitalizations with a primary diagnosis of Schizophreniform disorder occur more frequently in young male patients. This is the first nationwide study analysing all hospitalization episodes in Portugal.

Disclosure

No significant relationships.

Stroke care in people with and without schizophrenia: a retrospective, observational study

Introduction

Serious mental illness tends to course with a higher prevalence of comorbidities and schizophrenia is a disabling disease that affects approximately 1% of the world population. Worldwide, cerebrovascular accidents are an important cause of mortality and disability and in Portugal they are one of the leading causes of death in the general population. There is growing evidence that the prevalence of strokes is higher in people with schizophrenia, with pronounced age and gender variations.

Objectives

To describe the sociodemographic and clinical differences among patients hospitalized with a primary diagnosis of cerebrovascular disease with and without a secondary diagnosis of schizophrenia in Portugal.

Methods

We performed a retrospective observational study using a natiowide hopitalization database containing all hosptalizations registered in Portuguese hosptals from 2008 to 2015. Based on the International Classification of diseases version 9, clinical modification, hospitalizations with a primary diagnosis of stroke were selected (431;433;434), and from those, the ones with a secundary diagnosis of schizophrenia (295.xx) were isolated for a sociodemographic and clinical comparative study. Comorbidities were analysed using the Chalson index score.

Results

Episodes associated with a secondary diagnosis of schizophrenia were younger (mean: 66 vs 73.7 years; p<0.001) and had longer median LoS (10.0 vs 8.0 days; p<0.001). In-hospital mortality was lower in patients with schizophrenia (11.7% vs 13.2%).

Conclusions

The understanding of the association of cerebrovascular accidents with schizophrenia is complex. Although some studies show conflicting evidence, more attention should be given to the investigation of the incidence, prevalence and impact of cerebrovascular diseases within this particular population.

Disclosure

No significant relationships.

Childbirth hospitalizations in Bipolar disorder patients: a nationwide study protocol

Introduction

Bipolar disorder (BD) is usually diagnosed in adulthood, around childbearing age. Research has shown that BD has deleterious effects on pregnant women and birth outcomes. However, few nationwide studies using administrative data have approached this at-risk population focusing specifically on childbirth.

Objectives

This study aims to characterize hospitalizations of women with BD in the peripartum period regarding sociodemographic and clinical variables and to investigate the impact BD has on hospitalization outcomes.

Methods

An observational retrospective study will be performed using an administrative database that comprises routinely collected hospitalization data from all mainland Portuguese public hospitals. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes will be used to identify all women’s admissions for childbirth purposes (V27.X) and codes 296.XX (except 296.2X, 296.3X, 296.9X) will be used to ascertain BD. Episodes will be assigned to one of two mutually exclusive groups (with vs without BD). Multivariate methods will be used to compare both groups concerning key variables and outcomes. This work will comply with the RECORD statement recommendations.

Results

Descriptive and analytical statistics will be conducted in order to describe and characterize this group of patients. Results will be presented as crude and adjusted odds ratio quantifying the risk associated with BD in pregnancy, childbirth and hospitalization outcomes. Findings will be disseminated via publication in peer-reviewed journals.

Conclusions

With this nationwide analysis, we expect to contribute to a better understanding of the demographic and clinical profile of pregnant women with BD and to encourage timely medical and psychological interventions during gestation and childbirth.

Disclosure

No significant relationships.

The impact of depression in Alzheimer’s disease hospitalized patients: a study protocol for a nationwide retrospective study

Introduction

Alzheimer’s disease (AD) is the leading cause of dementia worldwide. About 40-50% of AD patients are also affected by depression, with mounting evidence suggesting its association with worse disease prognosis and negative outcomes, such as lower quality of life, higher mortality and more hospitalizations. However, few studies have specifically measured the association of depression with AD hospitalization outcomes.

Objectives

To characterize depression among all hospitalizations with a registered diagnosis of AD and to explore its association with hospitalization outcomes, including in-hospital mortality, length of stay and discharge destination.

Methods

A retrospective observational study will be conducted following the RECORD statement. A Portuguese nationwide hospitalization database from all mainland public hospitals will be used. Episodes of inpatients ≥65 years old with a primary or secondary diagnosis of AD (ICD-9-CM code 331.0), discharged between 2008-2015, will be selected. Codes 296.2X, 296.3X, 300.4 and 311 will be used to identify episodes with a concomitant registry of depression at any diagnostic position. Descriptive, univariate and multivariate approaches will be used.

Results

A total of 61 361 episodes complying with the fixed criteria will be assigned to one of two groups (with vs without depression). Groups will be compared regarding sociodemographic characteristics, comorbidity profile, type of admission (planned vs urgent) and hospitalization outcomes. Results regarding the association of depression and outcomes will be presented as crude and adjusted odds ratios (OR).

Conclusions

With this nationwide analysis, we expect to contribute to the clarification of depression impact on AD hospitalizations, so that best-practice care may be provided to these patients.

Disclosure

No significant relationships.

Depression among Endometrial Cancer hospitalizations - Preliminary results of a nationwide retrospective study

Introduction

Uterine cancer is the most common gynecologic malignant neoplasm in developed countries. While depression is up to 3-5 times more common in patients with cancer than in the general population, literature is still limited regarding the relation between Endometrial Cancer and depression.

Objectives

To analyze Depression among Endometrial Cancer hospitalizations in mainland Portuguese public hospitals (2008-2015).

Methods

A retrospective observational study was conducted using administrative data from all hospitalizations in Portuguese mainland public hospitals between 2008-2015. All women’s hospitalizations(≥18 years) with a primary diagnosis of Endometrial Cancer (ICD-9-CM 182.x) were selected. Secondary diagnosis of depression was identified with ICD-9-CM 296.2x, 296.3x and 311x codes. Surgical procedures codes 68.4x, 65.6x, 40.3x, 40.5x, 68.6x, 68.9x and 68.8x were used to divide the hospitalizations into surgical vs non-surgical. Groups were compared with Pearson Chi-square test and crude odds ratio(OR) was used to estimate the association between surgery and depression.

Results

From 10227 hospitalizations with a primary diagnosis of Endometrial Cancer, 533 had a registry of depression(5.2%). Annual depression frequency rose from 2.0% (2008) to 8.3% (2015). Among patients with a record of depression, 73.2% had surgery. Women who had surgery were significantly more likely to have registered depression (p<0.001). The OR for depression in surgical vs non-surgical patients was 1.73 (95%IC:1.42-2.10).

Conclusions

Patients hospitalized due to Endometrial Cancer and submitted to surgery had almost two-fold more risk of having a registry of depression. This trend reinforces the importance of early depression screening of these patients, enabling the implementation of timely therapeutic strategies before and after surgery.

Disclosure

No significant relationships.

Suicide Mortality Rate as a Sustainable Development Goal (SDG): A Bibliometric Analysis

Suicidal behaviors are a serious but potentially preventable cause of premature death. Increased awareness of the importance of mental health for global health has led to new initiatives, supported by the World Health Organization (WHO) and the United Nations (UN). The suicide mortality rate is one of the indicators covered in the UN's Sustainable Development Goal (SDG) 3. The aim of this study is to identify the scientific production and its temporal evolution related to the suicide mortality rate indicator in the context of mental disorders and as one of the SDG. A bibliometric analysis was performed in Scopus to assess the related research on suicide mortality rate, including on the context of the third SDG, from inception to September 2, 2020. The set of articles were analyzed for bibliometric measures. A total of 3126 documents about mental health and suicide mortality rate on the context of SDG were collected. Articles were the predominant type of literature on this area (78.3%), with significant expression on the last years, more evident around 2015, the year of adoption of SDGs. Despite a large volume of evidence, the debate about suicide mortality rate as an indicator of SDG is still very sparse suggesting a need for better consensus on its evaluation methods. This study presents useful characteristics for the formulation of new studies and provides specific targets for the construction or improvement of public policies on the context of the SDGs for further discussion on this strategy proposed by the UN.

Early systolic lengthening in patients with ST-elevation myocardial infarction: a novel tool for risk stratification

Funding Acknowledgements

Type of funding sources: None.

Background

After an ST-elevation myocardial infarction (STEMI), the risk of subsequent cardiovascular events is high. Risk stratification at index hospitalization remains a core challenge, especially in patients with subtle changes in LV function. Early systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force and it has been correlated with infarct size and prognosis in STEMI patients with mildly impaired LV function. In this study, we aimed to evaluate the correlation of ESL with common echocardiographic parameters and its prognostic value in STEMI patients with preserved LV function.

Methods

We retrospectively included all the patients admitted to an intensive care unit with STEMI and a left ventricle ejection fraction ≥55% from January to June of 2016. Patients with inadequate image quality for speckle tracking echocardiographic examination were excluded (n = 14). We evaluated the ESL index, defined as follows: [−100×(peak positive systolic strain/peak negative strain in cardiac cycle)], and ESL duration.

Results

A total of 37 patients were included in the study. Mean age was 63 ± 12 years with a male preponderance (81%). All patients were submitted to complete revascularization. Median values of the ESL index and ESL duration were 7% (IQR, 4%–10%) and 37 msec (IQR, 21–55 msec), respectively. No significant differences were found between ESL index and ESL duration groups, except for a higher prevalence of heart failure at hospitalization in both highest groups, and women were more prevalent in the ESL index higher group (Tables 1 and 2). ESL index was correlated with post-systolic index (PSI) (r2 = 0.34, p = 0.04) and showed a weak correlation with E/A ratio (r2=-0.37, p = 0.02). ESL duration was correlated with ESL index (r2 = 0.76, p &lt; 0.001) and PSI (r2 = 0.43, p = 0.008). During a median follow-up of 3.2 years (interquartile range, 2.9–3.4 years), 7 (18.9%) patients experienced major adverse cardiovascular events (MACE), a composite of heart failure admission, myocardial infarction, and all-cause mortality Both ESL index (HR 2.5; 95%CI 1.2–5.3; P = 0.02) and ESL duration (HR 1.7; 95%CI 1.1–2.7; P = 0.02) were independent predictors of MACE. Both associations remained significant after adjusting for clinical confounders.

Conclusions

In our cohort of STEMI patients with preserved LV function, assessment of ESL yielded important and significant prognostic information on MACE. ESL may be a useful tool to enhance routine risk stratification in this population. Abstract TABLE 1  Abstract TABLE 2

Clinical and echocardiographic features of platypnea-orthodeoxia syndrome: a single-centre experience

Funding Acknowledgements

Type of funding sources: None.

Background

Platypnea-orthodeoxia syndrome (POS) is an uncommon condition characterized by dyspnoea and hypoxemia in the upright position that improves with recumbency.1 Possible causes are intracardiac shunt, pulmonary arteriovenous shunt, and V/Q mismatch.1,2 Echocardiography is the cornerstone of POS diagnosis, with special focus on atrial septal defect (ASD) morphology and right-to-left shunt confirmation.3

Purpose

To evaluate the clinical and echocardiographic features of patients presenting with POS due to a cardiac cause.

Methods

We performed a retrospective analysis of patients diagnosed with POS in our centre between 2015 January and 2021 August. Routine blood tests and transthoracic echocardiogram (TTE) were performed in all patients. Demographics, clinical presentation, blood test results, TTE information, and PFO closure procedure details were recorded.

Results

Seven patients were included, 85.7% female (n = 6). The median (IQR) age was 78 (72-85) years. The most prevalent cardiovascular risk factors were hypertension (100%; n = 7) and overweight/obesity (85.7%; n = 6). Two patients (28.6%) had chronic pulmonary disease. The most common symptoms were fatigue and exercise intolerance (n= 5; 71.4%) and the most frequent sign was persistent hypoxemia (n = 7; 100%), although 28.6% (n = 2) patients did not present the typical positional changes in peripheral oxygen saturation. Haemoglobin levels [14.1 (13.3-15.2)] were within the normal range and serum NTproBNP levels [656 (287-1196)] were slightly elevated. Left ventricle function was preserved in all patients; right ventricle morphology and function were normal in 85.7% (n = 6) patients, low probability of pulmonary hypertension in TTE was found in 85.7% (n = 6), and exuberant Eustachian valve was observed in 14.3% (n = 1). All patients presented atrial septal hypermobility, 87.5% (n = 6) meeting atrial septal aneurysm criteria. Patent foramen ovale was found in 85.7% of patients (n = 6) and ostium secundum ASD in 14.3% (n = 1). POS precipitating factors were aortic root dilation (28.6%; n = 2), chest trauma (14.3%; n = 1), right hip arthroplasty (14.3%; n = 1), atrial septal stretching regarding right volume overload (14.3%; n = 1). The underlying mechanism was unknown in 28.6% (n = 2) of patients. ASD closure was performed in 57.1% (n = 4) of patients: 75% (n = 3) showed residual shunt, but clinical improvement was reported by all. No acute complications were described, except for paroxysmal atrial fibrillation (14.3%; n = 1).

Conclusion

POS diagnosis depends on high clinical suspicion: the most common manifestations are fatigue and persistent hypoxemia. Typical positional changes in oxygen saturation are not present in all patients. Polycythaemia, right chambers dilation, and pulmonary hypertension are not common. Echocardiography is fundamental for diagnosis, allowing right-to-left shunt confirmation and ASD morphology evaluation to outline a successful closure procedure.

Nationwide Access to Endovascular Treatment for Acute Ischemic Stroke in Portugal

INTRODUCTION

Since the publication of endovascular treatment trials and European Stroke Guidelines, Portugal has re-organized stroke healthcare. The nine centers performing endovascular treatment are not equally distributed within the country, which may lead to differential access to endovascular treatment. Our main aim was to perform a descriptive analysis of the main treatment metrics regarding endovascular treatment in mainland Portugal and its administrative districts.

MATERIAL AND METHODS

A retrospective national multicentric cohort study was conducted, including all ischemic stroke patients treated with endovascular treatment in mainland Portugal over two years (July 2015 to June 2017). All endovascular treatment centers contributed to an anonymized database. Demographic, stroke-related and procedure-related variables were collected. Crude endovascular treatment rates were calculated per 100 000 inhabitants for mainland Portugal, and each district and endovascular treatment standardized ratios (indirect age-sex standardization) were also calculated. Patient time metrics were computed as the median time between stroke onset, first-door, and puncture.

RESULTS

A total of 1625 endovascular treatment procedures were registered. The endovascular treatment rate was 8.27/100 000 inhabitants/year. We found regional heterogeneity in endovascular treatment rates (1.58 to 16.53/100 000/year), with higher rates in districts closer to endovascular treatment centers. When analyzed by district, the median time from stroke onset to puncture ranged from 212 to 432 minutes, reflecting regional heterogeneity.

DISCUSSION

Overall endovascular treatment rates and procedural times in Portugal are comparable to other international registries. We found geographic heterogeneity, with lower endovascular treatment rates and longer onset-to-puncture time in southern and inner regions.

CONCLUSION

The overall national rate of EVT in the first two years after the organization of EVT-capable centers is one of the highest among European countries, however, significant regional disparities were documented. Moreover, stroke-onset-to-first-door times and in-hospital procedural times in the EVT centers were comparable to those reported in the randomized controlled trials performed in high-volume tertiary hospitals.

Bipolar disorder and medical comorbidities: A Portuguese population-based observational retrospective study (2008-2015)

BACKGROUND

This study aimed to use the Charlson Comorbidity Index (CCI) to assess the prevalence of medical comorbidities among hospitalization episodes with a primary Bipolar Disorder (BD) diagnosis, and to analyze its association with hospitalization outcomes.

METHODS

A population-based observational retrospective study was conducted using a Portuguese administrative database containing all mainland public hospitalizations. From 2008-2015, hospitalization episodes with a primary diagnosis of BD were analysed. Outcomes included: length of stay (LoS), in-hospital mortality and discharge destination.

RESULTS

Overall, 20807 hospitalization episodes were analysed. Mean±standard deviation age at admission was 47.9±14.3 years, and these episodes mostly refer to women's admissions (66.6%). Median (1st quartile; 3rd quartile) LoS was 16.0 (9.0; 25.0) days. A total of 2145 (10.3%) episodes had ≥1 CCI comorbidities registered, being diabetes the most prevalent. LoS was significantly higher for episodes with secondary diagnoses of congestive heart failure, cerebrovascular disease, dementia, diabetes, renal disease and malignancy (all p<0.05). Episodes with a registry of myocardial infarction, peripheral vascular disease, malignancy and renal disease diagnoses had higher in-hospital mortality.

LIMITATIONS

Limitations include the use of data registered for administrative reasons rather than research purposes, and the analysis of hospitalization episodes, instead of patients.

CONCLUSIONS

In this Portuguese nationwide study, greater comorbidity had a measurable impact on BD hospitalization outcomes. During the study period the prevalence of CCI comorbidities rose from 8.1% to 17.4%, which may reflect the overall increasing quality of hospital-coded data in Portugal throughout the years. The detection and timely management of medical comorbid conditions will likely prevent the high BD medical burden.

COVID-19 surveillance data quality issues: a national consecutive case series

OBJECTIVES

High-quality data are crucial for guiding decision-making and practising evidence-based healthcare, especially if previous knowledge is lacking. Nevertheless, data quality frailties have been exposed worldwide during the current COVID-19 pandemic. Focusing on a major Portuguese epidemiological surveillance dataset, our study aims to assess COVID-19 data quality issues and suggest possible solutions.

SETTINGS

On 27 April 2020, the Portuguese Directorate-General of Health (DGS) made available a dataset (DGSApril) for researchers, upon request. On 4 August, an updated dataset (DGSAugust) was also obtained.

PARTICIPANTS

All COVID-19-confirmed cases notified through the medical component of National System for Epidemiological Surveillance until end of June.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data completeness and consistency.

RESULTS

DGSAugust has not followed the data format and variables as DGSApril and a significant number of missing data and inconsistencies were found (eg, 4075 cases from the DGSApril were apparently not included in DGSAugust). Several variables also showed a low degree of completeness and/or changed their values from one dataset to another (eg, the variable 'underlying conditions' had more than half of cases showing different information between datasets). There were also significant inconsistencies between the number of cases and deaths due to COVID-19 shown in DGSAugust and by the DGS reports publicly provided daily.

CONCLUSIONS

Important quality issues of the Portuguese COVID-19 surveillance datasets were described. These issues can limit surveillance data usability to inform good decisions and perform useful research. Major improvements in surveillance datasets are therefore urgently needed-for example, simplification of data entry processes, constant monitoring of data, and increased training and awareness of healthcare providers-as low data quality may lead to a deficient pandemic control.

Electroconvulsive Therapy Use in Psychiatric Hospitalizations in Portugal: A Nationwide Descriptive Study

OBJECTIVES

The primary aim of this study was to describe a Portuguese nationwide epidemiological perspective on the use of electroconvulsive therapy (ECT) in hospitalized psychiatric patients. The secondary aims of the study were to characterize clinical and sociodemographic trends of hospitalized patients treated with ECT.

METHODS

A retrospective-observational study was conducted using an administrative database gathering every registered Portuguese public hospital hospitalizations from 2008 to 2015. We selected all hospitalizations with a procedure code 94.27 (Other electroshock therapy) defined by the International Classification of Diseases version 9, Clinical Modification. Variables included birth date, sex, address, primary and secondary diagnoses, admission/discharge date, length of stay, and discharge status from each single hospitalization episode. We also calculated Portugal's inpatient ECT prevalence rate (iP%).

RESULTS

There were a total of 879 registered hospitalizations with ECT within the 8-year period of this study. Most occurred in female patients (53.4%), belonging to the age group of 51 to 70 years old, with a mean age of 50.5 years. The median length of stay was 43.0 days with an interquartile range of 27.0 to 68.0. The most frequent primary diagnosis was major depressive disorder, recurrent episode, representing 19.6% of all hospitalizations. The iP% for the study period was 0.71%.

CONCLUSIONS

In Portugal, most of the patients who received ECT were women above middle age, and depressive disorders were the most common indication. Portugal's iP% represents a low rate when compared with other European countries, which might indicate an underutilization of ECT in Portuguese psychiatric hospitals.

Risk factors and their contribution to population health in the European Union (EU-28) countries in 2007 and 2017

BACKGROUND

The Global Burden of Disease (GBD) study has generated a wealth of data on death and disability outcomes in Europe. It is important to identify the disease burden that is attributable to risk factors and, therefore, amenable to interventions. This paper reports the burden attributable to risk factors, in deaths and disability-adjusted life years (DALYs), in the 28 European Union (EU) countries, comparing exposure to risks between them, from 2007 to 2017.

METHODS

Retrospective descriptive study, using secondary data from the GBD 2017 Results Tool. For the EU-28 and each country, attributable (all-cause) age-standardized death and DALY rates, and summary exposure values are reported.

RESULTS

In 2017, behavioural and metabolic risk factors showed a higher attributable burden compared with environmental risks, with tobacco, dietary risks and high systolic blood pressure standing out. While tobacco and air quality improved significantly between 2007 and 2017 in both exposure and attributable burden, others such as childhood maltreatment, drug use or alcohol use did not. Despite significant heterogeneity between EU countries, the EU-28 burden attributable to risk factors decreased in this period.

CONCLUSION

Accompanying the improvement of population health in the EU-28, a comparable trend is visible for attributable burden due to risk factors. Besides opportunities for mutual learning across countries with different disease/risk factors patterns, good practices (i.e. tobacco control in Sweden, air pollution mitigation in Finland) might be followed. On the opposite side, some concerning cases must be highlighted (i.e. tobacco in Bulgaria, Latvia and Estonia or drug use in Czech Republic).

Real-world, very long-term follow up survival of incident patients with pulmonary hypertension

Background

Pulmonary hypertension (PH) is a clinical syndrome characterized by an increase in pulmonary artery pressure. Among the five groups of PH, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) stand out due to their ominous prognosis without specific treatment. However, very long-term outcomes data are scarce.

Purpose

We aimed to assess the very long-term survival of PAH and CTEPH patients followed in a Portuguese PH referral center.

Methods

Between January 2009 and January of 2020, all incident PH cases were consecutively enrolled in a prospective cohort study. A total of 177 patients were followed up for a median of 5.0 [interquartile range 2.3–8.7] years. Kaplan-Meier survival analysis was used to estimate 1-, 5- and 9-year survival and multivariate regression was used to predict independent prognostic factors.

Results

Mean age was 49±20 years with a clear female preponderance (67%). The most common PH subgroups were congenital heart disease (PAH-CHD) (n=62; 35%), followed by CTEPH (n=52; 29,4%), connective tissue disease (PAH-CTD) (n=31; 17.5%), idiopathic/hereditary PAH (I/HPAH (n=22; 12.4%) and portopulmonary hypertension (PoPH) (n=8; 4.5%) (Table 1). PAH-specific drugs were used in 91% of the patients, dual combination therapy in 47.5%, and triple combination in 12.4%. The remaining 9% successfully received non-pharmacological treatment, namely cardiac surgery in PAH-CHD (n=7) and endarterectomy or angioplasty in CTEPH (n=9). Survival rates at 1-, 5- and 9-years were 97%, 80% and 66%, respectively. Age (hazard ratio [HR] 1.02; 95% CI 1.01–1.04; P=0.049), BNP [HR 2.04 (1.16–3.60); P=0.01], admission for decompensation of heart failure (HF) [HR 3.15 (1.71–5.83); P&lt;0.001] and PH type [P=0.01] were predictors of all-cause mortality. PAH-CHD had the better long-term survival (9-year survival of 83%), whereas PAH-CTD and PoPH were associated with a worse prognosis (9-year survival of 24% and 28%, respectively) (Figure 1). Regarding admissions for decompensated right HF, BNP was an independent predictor [HR 3.39 (2.12– 5.43); P&lt;0.001] and no difference was found between PH etiologies.

Conclusions

In this cohort of incident PH patients, the overall 9-year survival rate was 66%. PAH-CHD patients had better overall prognosis, while patients with PAH-CTD and PoPH had the worst prognosis. Additionally, older age, higher BNP and admission for HF were associated with higher mortality.

Funding Acknowledgement

Type of funding sources: None.

Analysis of root causes of problems affecting the quality of hospital administrative data: A systematic review and Ishikawa diagram

INTRODUCTION

Administrative hospital databases represent an important tool for hospital financing in many national health systems and are also an important data source for clinical, epidemiological and health services research. Therefore, the data quality of such databases is of utmost importance. This paper aims to present a systematic review of root causes of data quality problems affecting administrative hospital data, creating a catalogue of potential issues for data quality analysts to explore.

METHODS

The MEDLINE and Scopus databases were searched using inclusion criteria based on two following concept blocks: (1) administrative hospital databases and (2) data quality. Studies' titles and abstracts were screened by two reviewers independently. Three researchers independently selected the screened studies based on their full texts and then extracted the potential root causes inferred from them. These were subsequently classified according to the Ishikawa model based on 6 categories: "Personnel", "Material", "Method", "Machine", "Mission" and "Management".

RESULTS

The result of our investigation and the contribution of this paper is a classification of the potential (105) root causes found through a systematic review of the 77 relevant studies we have identified and analyzed. The result was represented by an Ishikawa diagram. Most of the root causes (25.7%) were associated with the category "Personnel" - people's knowledge, preferences, education and culture, mostly related to clinical coders and health care providers activities. The quality of hospital documentation, within category "Material", and aspects related to financial incentives or disincentives, within category "Mission", were also frequently cited in the literature as relevant root causes for data quality issues.

CONCLUSIONS

The resultant catalogue of root causes, systematized using the Ishikawa framework, provides a compilation of potential root causes of data quality issues to be considered prior to reusing these data and that can point to actions aimed at improving data quality.

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050

BACKGROUND

The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020.

METHODS

We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050.

FINDINGS

In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7-8·8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5-0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0-25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied.

INTERPRETATION

Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all.

FUNDING

Bill & Melinda Gates Foundation.

Schizophrenia hospitalizations - a big data approach

Introduction

Schizophrenia is characterized by long hospitalizations and a recurrent use of chronic and acute psychiatric care.

Objectives

The aim of this study was to analyze schizophrenia related hospitalizations in Portugal.

Methods

A retrospective observational study was conducted using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015.Hospitalizations with a primary diagnosis of schizophrenia were selected and schizophrenia subtypes were grouped using the International Classification of Diseases version 9, Clinical Modification(ICD-9-CM) codes of diagnosis 295.xx.

Results

There was a total of 25,385 hospitalizations in public hospitals of Portugal between 2008 and 2015 with a primary diagnosis of Schizophrenia or other psychotic disorders. A total of 14,279 patients were hospitalized during the study period with an average of 1,78 hospitalizations episodes per patient in the 8-year interval(0.22 hospitalizations/patient/year). 68.0% of the hospitalizations occurred in male patients and the median length of stay was 18.0 days. Mean hospitalization charges were 3,509.7€ per hospitalization, summed to a total charge of 89.1M€. Throughout the study period there was a significant linear decrease in the number of hospitalizations (r = 0.940; B= -47.488; p = 0.001). The last year of the study(2015) had the lowest number of hospitalizations with a total of 2,958 (vs. 3,314 in 2008). When adjusted for the yearly population, there was also a decrease of the number of hospitalizations per 100,000 inhabitants from 31.39 to 28.56 hospitalizations per 100,000 inhabitants between 2008 and 2015, respectively.

Conclusions

We found differences in hospitalization characteristics by gender, age and primary diagnosis.

Disclosure

No significant relationships.

The use of big data in psychiatry – the role of pharmacy registries

Introduction

Administrative databases (AD) are repositories of administrative and clinical data related to patient contact episodes with all sorts of health facilities (primary care, hospitals, pharmacies,…).The large number of patients/contact episodes with pharmaceutical facilities available, the systematic and broad register and the fact that AD provides Real-world data are some of the pros in using AD data.

Objectives

To perform a narrative review on the role of Big Data pharmaceutical registries in Mental Health research.

Methods

We conducted a narrative review using MEDLINE and Google Scholar databases in order to analyse current literature regarding the role of BigData pharmaceutical registries in Mental Health Research.

Results

Administrative variables like drug names and prices may be used and linked to other clinical variables such as patients disease, in-hospital mortality, length of stay,(…). The use of electronic medical records may also contribute to systematic surveillance approaches like local or national pharmacovigilance strategies, identification of patients at risk of developing complications and software pop-up warnings related to medication dosage, duplication and lateral effects. The use of Big Data pharmaceutical registries allows to create predictive epidemiological models regarding drugs lateral effects or interactions and may help to perform pharmacovigilance phase 4 clinical trials. Its use may be applied to the optimization of clinical decision, monitoring of drug adverse events, drug cost and administrative monitoring and as surrogate measures of quality care indicators.

Conclusions

Big Data use in pharmaceutical registries allows to collect large and important clinical and administrative data that may be later used in Mental Health care and research.

Disclosure

No significant relationships.