Maternal mortality is preventable in Lebanon: A case series of maternal deaths to identify lessons learned using the "Three Delays" model

OBJECTIVE

To identify the lessons learned from women who died during pregnancy or childbirth in Lebanon between 2018 and 2020.

METHOD

This is a case series and synthesis of maternal deaths between 2018 and 2020 that were reported by healthcare facilities to the Ministry of Public Health in Lebanon. The notes recorded from the maternal mortality review reports were analyzed using the "Three Delays" model to identify preventable causes and lessons learned.

RESULTS

A total of 49 women died before, during, or after childbirth, with hemorrhage being the most frequent cause (n = 16). The possible factors that would have prevented maternal deaths included a prompt recognition of clinical severity, availability of blood for transfusion and magnesium sulfate for eclampsia, adequate transfer to tertiary care hospitals comprising specialist care, and involvement of skilled medical staff in obstetric emergencies.

CONCLUSION

Many maternal deaths in Lebanon are preventable. Better risk assessment, use of an obstetric warning system, access to adequately skilled human resources and medications, and improved communication and transfer mechanisms between private and tertiary care hospitals may avoid future maternal deaths.

Healthcare Providers' Perceptions of Potentially Preventable Rural Hospitalisations: A Qualitative Study

Potentially preventable hospitalisations (PPHs) are common in rural communities in Australia and around the world. Healthcare providers have a perspective on PPHs that may not be accessible by analysing routine patient data. This study explores the factors that healthcare providers believe cause PPHs and seeks to identify strategies for preventing them. Physicians, nurses, paramedics, and health administrators with experience in managing rural patients with PPHs were recruited from southern Tasmania, Australia. Semi-structured telephone interviews were conducted, and reflexive thematic analysis was used to analyse the data. Participants linked health literacy, limited access to primary care, and perceptions of primary care services with PPH risk. The belief that patients did not have a good understanding of where, when, and how to manage their health was perceived to be linked to patient-specific health literacy challenges. Access to primary healthcare was impacted by appointment availability, transport, and financial constraints. In contrast, it was felt that the prompt, comprehensive, and free healthcare delivered in hospitals appealed to patients and influenced their decision to bypass rural primary healthcare services. Strategies to reduce PPHs in rural Australian communities may include promoting health literacy, optimising the delivery of existing services, and improving social support structures.

Clarifying the concept of avoidable emergency department attendance

Emergency department attendances are rising in several countries. Many of the policies aimed at reducing emergency department attendances are based on the assumption that a proportion of current utilization is ‘avoidable’ and therefore could be reduced. In considering how to achieve this aim, it is important to first understand the problem. In this essay, we review the literature on the concept and identification of avoidable emergency department attendances in England. We identified three areas of inconsistency surrounding avoidable emergency department attendances: the terminology, the underlying definition, and the method used to identify avoidable attendances. We offer a more nuanced definition which may better support action to reduce emergency department activity. Recognizing that there are different types of undesirable utilization which vary by underlying causes and potential solutions will aid policy makers in identifying areas where policies targeting reductions in emergency department attendances would best be directed.

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements

BACKGROUND

This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt.

METHODS

This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage.

RESULTS

The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant.

CONCLUSION

Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.

Avoidable emergency department visits: a starting point

Objective

To better characterize and understand the nature of a very conservative definition of 'avoidable' emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits.

Design/setting

We performed a retrospective analysis of a very conservative definition of 'avoidable' ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011.

Participants

We examined a total of 115 081 records, representing 424 million ED visits made by patients aged 18-64 years who were seen in the ED and discharged home.

Main outcome measures

We defined 'avoidable' as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home.

Results

In total, 3.3% (95% CI: 3.0-3.7) of all ED visits were 'avoidable.' The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% (95% CI: 5.7-8.0) of avoidable visits, and dental disorders accounted for 3.9% (95% CI: 3.0-4.8) of CCS-grouped discharge diagnoses.

Conclusions

A significant number of 'avoidable' ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these 'avoidable' ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.

Potentially Avoidable Readmissions in United States Hemodialysis Patients

Introduction

Patients with end-stage kidney disease have a high risk of 30-day readmission to hospital. These readmissions are financially costly to health care systems and are associated with poor health-related quality of life. The objective of this study was to describe and analyze the frequency, causes, and predictors of 30-day potentially avoidable readmission to hospital in patients on hemodialysis.

Methods

We conducted a retrospective cohort study using the US Renal Data System data from January 1, 2008, to December 31, 2008. A total of 107,940 prevalent United States hemodialysis patients with 248,680 index hospital discharges were assessed for the main outcome of 30-day potentially avoidable readmission, as identified by a computerized algorithm.

Results

Of 83,209 30-day readmissions, 59,045 (70.1%) resulted in a 30-day potentially avoidable readmission. The geographic distribution of 30-day potentially avoidable readmission in the United States varied by state. Characteristics associated with 30-day potentially avoidable readmission included the following: younger age, shorter time on hemodialysis, at least 3 or more hospitalizations in preceding 12 months, black race, unemployed status, treatment at a for-profit facility, longer length of index hospital stay, and index hospitalizations that involved a surgical procedure. The 5-, 15-, and 30-day potentially avoidable readmission cumulative incidences were 6.0%, 15.1%, and 25.8%, respectively.

Conclusion

Patients with end-stage kidney disease on maintenance hemodialysis are at high risk for 30-day readmission to hospital, with nearly three-quarters (70.1%) of all 30-day readmissions being potentially avoidable. Research is warranted to develop cost-effective and transferrable interventions that improve care transitions from hospital to outpatient hemodialysis facility and reduce readmission risk for this vulnerable population.

Patient crossover and potentially avoidable repeat computed tomography exams across a health information exchange

OBJECTIVE

The purpose of this study was to measure the number of repeat computed tomography (CT) scans performed across an established health information exchange (HIE) in New York City. The long-term objective is to build an HIE-based duplicate CT alerting system to reduce potentially avoidable duplicate CTs.

METHODS

This retrospective cohort analysis was based on HIE CT study records performed between March 2009 and July 2012. The number of CTs performed, the total number of patients receiving CTs, and the hospital locations where CTs were performed for each unique patient were calculated. Using a previously described process established by one of the authors, hospital-specific proprietary CT codes were mapped to the Logical Observation Identifiers Names and Codes (LOINC®) standard terminology for inter-site comparison. The number of locations where there was a repeated CT performed with the same LOINC code was then calculated for each unique patient.

RESULTS

There were 717 231 CTs performed on 349 321 patients. Of these patients, 339 821 had all of their imaging studies performed at a single location, accounting for 668 938 CTs. Of these, 9500 patients had 48 293 CTs performed at more than one location. Of these, 6284 patients had 24 978 CTs with the same LOINC code performed at multiple locations. The median time between studies with the same LOINC code was 232 days (range of 0 to 1227); however, 1327 were performed within 7 days and 5000 within 30 days.

CONCLUSIONS

A small proportion (3%) of our cohort had CTs performed at more than one location, however this represents a large number of scans (48 293). A noteworthy portion of these CTs (51.7%) shared the same LOINC code and may represent potentially avoidable studies, especially those done within a short time frame. This represents an addressable issue, and future HIE-based alerts could be utilized to reduce potentially avoidable CT scans.

Trends of mortality in Greece 1980-2007: a focus on avoidable mortality

BACKGROUND

Avoidable mortality (AM) refers to deaths from certain conditions considered avoidable given timely and effective health care. AM rates in Greece between 1980 and 2007 were examined in order to investigate the extent to which health care has contributed to the decline in mortality rates in Greece over recent decades and detect possible shortcomings in the Greek healthcare system.

METHODS

Mortality data from the General Secretariat of the National Statistic Service were used. The list of avoidable conditions was the basis of the analysis in which avoidable deaths were classified into conditions amenable to medical care (treatable avoidable mortality) and conditions responsive to health policy (preventable avoidable mortality). Ischaemic heart disease (IHD) was examined separately following relevant studies. Age standardized mortality rates were calculated according to the European Community standard population.

RESULTS

A steady decline of the percentage of AM over all-cause mortality was documented (1980-1984:27%; 2000- 2007:22.9%). AM rate fell by 30.5% (1980-1984:217.4/100,000 population; 2000-2007: 151.1/100,000). Treatable mortality rate fell by 48.1%, marking the largest contribution to the decline in AM (1980-1984:110.9/100,000; 2000- 2007:57.5/100,000). Ischaemic heart disease death rate fell by 13.1% (1980-1984:52.7/100,000; 2000-2007:45.8/100,000). Preventable mortality rates fell by 11%, marking a modest contribution to the decline in AM (1980-1984: 53.7/100,000; 2000-2007: 47.8/100,000).

CONCLUSIONS

Trends in AM in Greece between 1980-2007 were similar to those of other European countries, with Greece performing particularly well with respect to treatable mortality. Although the decline in AM may also reflect changes in factors that influence mortality, such as disease occurrence, environment and socioeconomic conditions, they are suggestive of the health care system being an important determinant of health improvements in Greece during the recent decades. Further studies are needed in order to access the quality of care and to examine the structure and adequacy of health care in Greece.