Differences in Medical Care Usage between Two Mass-Gathering Sporting Events

Quantitative Metrics in Mass-Gathering Studies: A Comprehensive Systematic Review

INTRODUCTION

Mass gatherings are events where many people come together at a specific location for a specific purpose, such as concerts, sports events, or religious gatherings, within a certain period of time. In mass-gathering studies, many rates and ratios are used to assess the demand for medical resources. Understanding such metrics is crucial for effective planning and intervention efforts. Therefore, this systematic review aims to investigate the usage of rates and ratios reported in mass-gathering studies.

METHODS

In this systematic review, the PRISMA guidelines were followed. Articles published through December 2023 were searched on Web of Science, Scopus, Cochrane, and PubMed using the specified keywords. Subsequently, articles were screened based on titles, abstracts, and full texts to determine their eligibility for inclusion in the study. Finally, the articles that were related to the study's aim were evaluated.

RESULTS

Out of 745 articles screened, 55 were deemed relevant for inclusion in the study. These included 45 original research articles, three special reports, three case presentations, two brief reports, one short paper, and one field report. A total of 15 metrics were identified, which were subsequently classified into three categories: assessment of population density, assessment of in-event health services, and assessment of out-of-event health services.

CONCLUSION

The findings of this study revealed notable inconsistencies in the reporting of rates and ratios in mass-gathering studies. To address these inconsistencies and to standardize the information reported in mass-gathering studies, a Metrics and Essential Ratios for Gathering Events (MERGE) table was proposed. Future research should promote consistency in terminology and adopt standardized methods for presenting rates and ratios. This would not only enhance comparability but would also contribute to a more nuanced understanding of the dynamics associated with mass gatherings.

Measuring the Masses: The Current State of Mass-Gathering Medical Case Reporting (Paper 1)

INTRODUCTION

Case reports are commonly used to report the health outcomes of mass gatherings (MGs), and many published reports of MGs demonstrate substantial heterogeneity of included descriptors. As such, it is challenging to perform rigorous comparisons of health services and outcomes between similar and dissimilar events. The degree of variation in published reports has not yet been investigated.

OBJECTIVE

Examine patterns of post-event medical reporting in the existing literature and identify inconsistencies in reporting.

METHODS

A systematic review of case reports was conducted. Included were English studies, published between January 2009 and December 2018, in Prehospital and Disaster Medicine (PDM) or Current Sports Medicine Reports (CSMR). Analysis of each paper was used to develop a list of 27 categories of data.

RESULTS

Seventy-five studies were initially reviewed with 54 publications meeting the inclusion criteria. Forty-two were full case reports (78%) and 12 were conference proceedings (22%). Of the 27 categories of data studied, only 13 were consistently reported in more than 50% of publications. Reporting patterns included inconsistent use of terminology/language and variable retrievability of reports. Reporting on event descriptors, hazard and risk analysis, and clinical outcomes were also inconsistent.

DISCUSSION

Case reports are essential tools for researchers and event team members such as medical directors and event producers. The authors found that current case reports, in addition to being inconsistent in content, were generally descriptive rather than explanatory; that is, focused on describing the outcomes as opposed to exploring possible connections between context and health outcomes.

CONCLUSION

This paper quantifies and demonstrates the current state of heterogeneity in MG event reporting. This heterogeneity is a significant impediment to the functional use of published reports to further the science of MG planning and to improve health outcomes. Future work based on the insights gained from this analysis will aim to align and standardize reporting to improve the quality and value of event reporting.

Measuring the Masses: A Proposed Template for Post-Event Medical Reporting (Paper 4)

BACKGROUND

Standardizing and systematizing the reporting of health outcomes from mass gatherings (MGs) will improve the quality of data being reported. Setting minimum standards for case reporting is an important strategy for improving data quality. This paper is one of a series of papers focused on understanding the current state, and shaping the future state, of post-event case reporting.

METHODS

Multiple data sources were used in creating a lean, yet comprehensive list of essential reporting fields, including a: (1) literature synthesis drawn from analysis of 54 post-event case reports; (2) comparison of existing data models for MGs; (3) qualitative analysis of gaps in current case reports; and (4) set of data domains developed based on the preceding sources.

FINDINGS

Existing literature fails to consistently report variables that may be essential for not only describing the health outcomes of a given event, but also for explaining those outcomes. In the context of current and future state reporting, 25 essential variables were identified. The essential variables were organized according to four domains, including: (i) Event Domain; (ii) Hazard and Risk Domain; (iii) Capacity Domain; and (iv) Clinical Domain.

DISCUSSION

The authors propose a first-generation template for post-event medical reporting. This template standardizes the reporting of 25 essential variables. An accompanying data dictionary provides background and standardization for each of the essential variables. Of note, this template is lean and will develop over time, with input from the international MG community. In the future, additional groups of variables may be helpful as "overlays," depending on the event category and type.

CONCLUSIONS

This paper presents a template for post-event medical reporting. It is hoped that consistent reporting of essential variables will improve both data collection and the ability to make comparisons between events so that the science underpinning MG health can continue to advance.

Measuring the Masses: Domains Driving Data Collection and Analysis for the Health Outcomes of Mass Gatherings (Paper 3)

INTRODUCTION

Without a robust evidence base to support recommendations for medical services at mass gatherings (MGs), levels of care will continue to vary and preventable morbidity and mortality will exist. Accordingly, researchers and clinicians publish case reports and case series to capture and explain some of the health interventions, health outcomes, and host community impacts of MGs. Streamlining and standardizing post-event reporting for MG medical services and associated health outcomes could improve inter-event comparability, thereby supporting and promoting growth of the evidence base for this discipline. The present paper is focused on theory building, proposing a set of domains for data that may support increasingly comprehensive, yet lean, reporting on the health outcomes of MGs. This paper is paired with another presenting a proposal for a post-event reporting template.

METHODS

The conceptual categories of data presented are based on a textual analysis of 54 published post-event medical case reports and a comparison of the features of published data models for MG health outcomes.

FINDINGS

A comparison of existing data models illustrates that none of the models are explicitly informed by a conceptual lens. Based on an analysis of the literature reviewed, four data domains emerged. These included: (i) the Event Domain, (ii) the Hazard and Risk Domain, (iii) the Capacity Domain, and (iv) the Clinical Domain. These domains mapped to 16 sub-domains.

DISCUSSION

Data modelling for the health outcomes related to MGs is currently in its infancy. The proposed illustration is a set of operationally relevant data domains that apply equally to small, medium, and large-sized events. Further development of these domains could move the MG community forward and shift post-event health outcomes reporting in the direction of increasing consistency and comprehensiveness.

CONCLUSION

Currently, data collection and analysis related to understanding health outcomes arising from MGs is not informed by robust conceptual models. This paper is part of a series of nested papers focused on the future state of post-event medical reporting.

Measuring the Masses: Mass-Gathering Medical Case Reporting, Conceptual Modeling - The DREAM Model (Paper 5)

INTRODUCTION

Without a robust evidence base to support recommendations for first aid, health, and medical services at mass gatherings (MGs), levels of care will continue to vary. Streamlining and standardizing post-event reporting for MG medical services could improve inter-event comparability, and prospectively influence event safety and planning through the application of a research template, thereby supporting and promoting growth of the evidence base and the operational safety of this discipline. Understanding the relationships between categories of variables is key. The present paper is focused on theory building, providing an evolving conceptual model, laying the groundwork for exploring the relationships between categories of variables pertaining the health outcomes of MGs.

METHODS

A content analysis of 54 published post-event medical case reports, including a comparison of the features of published data models for MG health outcomes.

FINDINGS

A layered model of essential conceptual components for post-event medical reporting is presented as the Data Reporting, Evaluation, & Analysis for Mass-Gathering Medicine (DREAM) model. This model is relational and embeds data domains, organized operationally, into "inputs," "modifiers," "actuals," and "outputs" and organized temporally into pre-, during, post-event, and reporting phases.

DISCUSSION

Situating the DREAM model in relation to existing models for data collection vis a vis health outcomes, the authors provide a detailed discussion on similarities and points of difference.

CONCLUSION

Currently, data collection and analysis related to understanding health outcomes arising from MGs is not informed by robust conceptual models. This paper is part of a series of nested papers focused on the future state of post-event medical reporting.

Public Health Threats in Mass Gatherings: A Systematic Review

Mass gatherings (MGs) are held throughout the world. The aim of this review was to assess and identify the health threats based on the type of the MG, type of diseases, and injuries. Research platforms such as Web of Science, Medline, and Scopus were searched through June 2017. All epidemiologic studies that investigated the health threats during the MGs, such as communicable diseases, injuries, high-risk behaviors, and environmental health problems, were included in this review. Out of 1264 references, 45 articles were included in the review.Three main types of MGs include religious, festival, and sporting event; and fairs such as trade, book, and agricultural types were also reported in the selected studies. In the religious MGs, infectious diseases were the most common health threat. Road traffic accidents and environmental health problems were additional health threats. At MG sporting events, injuries were the most common health problems. Infectious diseases and alcohol and drug-related disorders were other reported public health concerns. In the festival MGs, alcohol and drug-related problems were commonly reported. This review showed that health threats vary, based on the type of mass gathering. The health organizers of MGs should consider the type of the MG and the health needs and safety of the participants to help them plan their action and provide the needed health care services.

Drug and Alcohol Related Patient Presentations to Emergency Departments during Sporting Mass-Gathering Events: An Integrative Review

BACKGROUND

Drug and alcohol consumption at sporting mass-gathering events (MGEs) has become part of the spectator culture in some countries. The direct and indirect effects of drug and alcohol intoxication at such MGEs has proven problematic to in-event health services as well as local emergency departments (EDs). With EDs already under significant strain from increasing patient presentations, resulting in access block, it is important to understand the impact of sporting and other MGEs on local health services to better inform future planning and provision of health care delivery.

AIM

The aim of this review was to explore the impact of sporting MGEs on local health services with a particular focus on drug and alcohol related presentations.

METHOD

A well-established integrative literature review methodology was undertaken. Six electronic databases and the Prehospital and Disaster Medicine (PDM) journal were searched to identify primary articles related to the aim of the review. Articles were included if published in English, from January 2008 through July 2019, and focused on a sporting MGE, mass-gathering health, EDs, as well as drug and alcohol related presentations.

RESULTS

Seven papers met the criteria for inclusion with eight individual sporting MGEs reported. The patient presentation rate (PPR) to in-event health services ranged from 0.18/1,000 at a rugby game to 41.9/1,000 at a recreational bicycle ride. The transport to hospital rate (TTHR) ranged from 0.02/1,000 to 19/1,000 at the same events. Drug and alcohol related presentations from sporting MGEs contributed up to 10% of ED presentations. Alcohol was a contributing factor in up to 25% of cases of ambulance transfers.

CONCLUSIONS

Drug and alcohol intoxication has varying levels of impact on PPR, TTHR, and ED presentation numbers depending on the type of sporting MGE. More research is needed to understand if drug and alcohol intoxication alone influences PPR, TTHR, and ED presentations or if it is multifactorial. Inconsistent data collection and reporting methods make it challenging to compare different sporting MGEs and propose generalizations. It is imperative that future studies adopt more consistent methods and report drug and alcohol data to better inform resource allocation and care provision.

Evaluating the impact of a mass gathering (2018 Commonwealth Games) on emergency department presentations with communicable diseases: A retrospective cohort study

OBJECTIVE

To identify the impact of a mass gathering event (MGE) on emergency department (ED) patient presentations with communicable diseases and underpinning syndromic indicators (SIs).

METHODS

This retrospective observational cohort study was undertaken in one large public teaching hospital ED in Queensland, Australia. Routinely collected ED data for patient presentations with an ICD-10 diagnosis corresponding to a communicable disease were used to compare demographic characteristics, clinical characteristics, and outcomes before (March 23 to April 3), during (April 4 to April 15), and after (April 16 to April 27) the 2018 Commonwealth Games.

RESULTS

Over the study period, there were 10 595 patient presentations to the ED; 14.2% (n = 1503) were diagnosed with a communicable disease. The median age of those with a communicable disease was 8 years, 50.5% (n = 759) were female, and 24.8% (n = 373) arrived by ambulance. The most common communicable disease profile was respiratory in nature (51.4%, n = 772). The most common SI was altered breathing (24.0%, n = 185). ED length of stay (LOS) increased over the study period (pre: 160 min; during: 163 min; post: 180 min, p < 0.001).

CONCLUSIONS

The 2018 Commonwealth Games had an impact on ED presentations with communicable diseases, in terms of LOS. A longer LOS and higher percentage of patients with a LOS of more than 4 hrs in the ED were noted following the MGE period. This outcome indicates a potential need to continue with up-scaled services. Future research is required to understand the broader impact on other EDs in the area, and longitudinal patient follow-up is needed to determine the potential spread of communicable diseases.

Health Care Provision During a Sporting Mass Gathering: A Structure and Process Description of On-Site Care Delivery

INTRODUCTION

Mass gatherings such as marathons are increasingly frequent. During mass gatherings, the provision of timely access to health care services is required for the mass-gathering population, as well as for the local community. However, the nature and impact of health care provision during sporting mass gatherings is not well-understood.

PURPOSE

The aim of this study was to describe the structures and processes developed for an emergency health team to operate an in-event, acute health care facility during one of the largest mass-sporting participation events in the southern hemisphere, the Gold Coast Marathon (Queensland, Australia).

METHODS

A pragmatic, qualitative methodology was used to describe the structures and processes required to operate an in-event, acute health care facility providing services for marathon runners and spectators. Content analysis from 12 semi-structured interviews with emergency department (ED) clinical staff working during the two-day event was undertaken in 2016.

FINDINGS

Important structural elements of the in-event health care facility included: physical spaces, such as the clinical zones in the marathon health tent and surrounding area, and access and egress points; and resources such as bilingual staff, senior medical staff, and equipment such as electrocardiograms (ECGs) and intravenous fluids. Process elements of the in-event health care facility included clear communication pathways, as well as inter-professional care coordination and engagement involving shared knowledge of and access to resources, and distinct but overlapping clinical scope between nurses and doctors. This was seen to be critical for timely care provision and appropriate case management. Staff reported many perceived benefits and opportunities of in-event health care delivery, including ED avoidance and disaster training.

CONCLUSIONS

This in-event model of emergency care delivery, established in an out-of-hospital location, enabled the delivery of acute health care that could be clearly described and defined. Staff reported satisfaction with their ability to provide a meaningful contribution to hospital avoidance and to the local community. With the number of sporting mass gatherings increasing, this temporary, in-event model of health care provision is one option for event and health care planners to consider.JohnstonANB, WadhamJ, Polong-BrownJ, AitkenM, RanseJ, HuttonA, RichardsB, CrillyJ.Health care provision during a sporting mass gathering: a structure and process description of on-site care delivery. Prehosp Disaster Med. 2019;34(1):62-71.

Impact of Patients Presenting with Alcohol and/or Drug Intoxication on In-Event Health Care Services at Mass-Gathering Events: An Integrative Literature Review

BACKGROUND

There is a growing body of literature relating to mass-gathering events. A common thread amongst this literature, particularly the literature relating to music festivals, is the incidence of patients presenting with substance and/or alcohol intoxication. However, the impact of alcohol and/or drugs on the provision of in-event health care services has not been explored in detail.AimThe goal of this review was to develop an understanding of the impact of alcohol and/or drugs on in-event health care services at mass-gathering events.

METHOD

This paper used integrative review as a methodology. The articles included in this literature review were sourced by searching databases inclusive of Medline (Ovid; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), Scopus (Elsevier; Amsterdam, Netherlands), PsycINFO (Ovid; American Psychological Association; Washington DC, USA), and Pub Med (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA). Identified manuscripts that met the inclusion criteria were thematically analyzed.

RESULTS

In total, 12 manuscripts met the inclusion criteria for this review. A thematic analysis of these manuscripts identified three main themes: (i) predictive factors, (ii) patient presentation rates, and (iii) levels of care.

CONCLUSION

Substance use and/or intoxication can place a strain on in-event medical services at mass-gathering events. Of the various types of mass-gathering events, music festivals appear to be the most affected by substance use and intoxication. BullockM, RanseJ, HuttonA. Impact of patients presenting with alcohol and/or drug intoxication on in-event health care services at mass-gathering events: an integrative literature review. Prehosp Disaster Med. 2018;33(5):539-542.

ANALYSIS OF MEDICAL ASSISTANCE PROVIDED TO SPECTATORS AT THE 2014 FIFA WORLD CUP MATCHES

Objective:

Several studies have already described the main injuries to soccer players during FIFA World Cup events; however, little is known about the main reasons spectators require medical assistance during these matches. The aim of this study is to assess the number of cases and main reasons spectators required medical assistance during the 2014 World Cup matches in Brazil.

Methods:

Data were collected from spectators who received medical assistance on all game days, and factors related to the assistance provided were analyzed.

Results:

Medical assistance was given to spectators in a total of 6,222 cases during the 64 games played in Brazil, an average of 97.2 times per game. The total number of spectators removed from the stadiums by ambulance was 167, a mean of 2.6 removals per game. The main reasons spectators required medical assistance during the World Cup games were headache, gastrointestinal problems, and trauma.

Conclusions:

Most spectators required medical assistance during the World Cup games for headache, gastrointestinal problems, and trauma; this information is fundamental to develop new prevention strategies and plan medical assistance for large-scale events. Level of Evidence IV; Case series.

Retrospective Analysis of Patient Presentations at the Sydney (Australia) Royal Easter Show from 2012 to 2014

Introduction

Comprehensive studies on the relationship between patient demographics and subsequent treatment and disposition at a single mass-gathering event are lacking. The Sydney Royal Easter Show (SRES; Sydney Olympic Park, New South Wales, Australia) is an annual, 14-day, agricultural mass-gathering event occurring around the Easter weekend, attracting more than 800,000 patrons per year. In this study, patient records from the SRES were analyzed to examine relationships between weather, crowd size, day of week, and demographics on treatment and disposition. This information would help to predict factors affecting patient treatment and disposition to guide ongoing training of first responders and to evaluate the appropriateness of staffing skills mix at future events.

Hypothesis

Patient demographics, environmental factors, and attendance would influence the nature and severity of presentations at the SRES, which would influence staffing requirements.

Methods

A retrospective analysis of 4,141 patient record forms was performed for patients who presented to St John Ambulance (Australian Capital Territory, Australia) at the SRES between 2012 and 2014 inclusive. Presentation type was classified using a previously published minimum data set. Data on weather and crowd size were obtained from the Australian Bureau of Meteorology (Melbourne, Victoria, Australia) and the SRES, respectively. Statistical analyses were performed using SPSS v22 (IBM; Armonk, New York USA).

Results

Between 2012 to 2014, over 2.5 million people attended the SRES with 4,141 patients treated onsite. As expected, the majority of presentations were injuries (49%) and illnesses (46%). Although patient demographics and presentation types did not change over time, the duration of treatment increased. A higher proportion of patients were discharged to hospital or home compared to the proportion of patients discharged back to the event. Patients from rural/regional locations (accounting for 15% of all patients) were more likely to require advanced treatment, health professional review, and were more likely to be discharged to hospital or home rather than discharged back to the event. Extremes of temperature were associated with a lower crowd size and higher patient presentation rate (PPR), but had no impact on transfer or referral rates to hospital.

Conclusion

This study demonstrated that analyses of patient presentations at an agricultural show provide unique insights on weather, attendance, and demographic features that correlated with treatment and disposition. These data can help guide organizers with information on how to better staff and train health care providers at future mass-gathering events of this type.

CrabtreeN,MoS,OngL,JegatheesT,WeiD,FaheyD,LiuJ.Retrospective analysis of patient presentations at the Sydney (Australia) Royal Easter Show from 2012 to 2014.Prehosp Disaster Med.2017;32(2)187–194.

Travelers to the FIFA world cup 2014 in Brazil: Health risks related to mass gatherings/sports events and implications for the Summer Olympic Games in Rio de Janeiro in 2016

BACKGROUND

Health threats during mass gatherings, such as the FIFA world cup 2014 differ from traditional health risks. The influence of event type, demographics of attendees and environmental conditions are still not fully understood.

METHODS

An observational, prospective case-control survey conducted at the Frankfurt international airport in Germany on 544 travelers to the FIFA world cup 2014 and 432 regular travelers to Brazil departing after the end of the world cup.

RESULTS

Travelers to the FIFA world cup 2014 were predominantly male whereas the gender distribution in the control group was more balanced. The majority in both groups obtained insect bites and sunburns as environmental risk factors. Every third traveler suffered from diarrheal complaints in both groups, whereas the proportion of travelers with flu-like symptoms was higher in the case group. Travelers to the FIFA world cup 2014 indicated alcohol intake and sexual contacts outside of a relationship more frequently than travelers in the control group.

CONCLUSIONS

The additional health risks of travelers to sporting events as the FIFA world cup 2014 should be addressed in addition to traditional health threats in pre-travel counseling for the Summer Olympic Games 2016 in Brazil.

Enhancing the Minimum Data Set for Mass-Gathering Research and Evaluation: An Integrative Literature Review

Introduction

In 2012, a minimum data set (MDS) was proposed to enable the standardized collection of biomedical data across various mass gatherings. However, the existing 2012 MDS could be enhanced to allow for its uptake and usability in the international context. The 2012 MDS is arguably Australian-centric and not substantially informed by the literature. As such, an MDS with contributions from the literature and application in the international settings is required.

Methods

This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2013. Data were analyzed and categorized using the existing 2012 MDS as a framework.

Results

In total, 19 manuscripts were identified that met the inclusion criteria. Variation in the patient presentation types was described in the literature from the mass-gathering papers reviewed. Patient presentation types identified in the literature review were compared to the 2012 MDS. As a result, 16 high-level patient presentation types were identified that were not included in the 2012 MDS.

Conclusion

Adding patient presentation types to the 2012 MDS ensures that the collection of biomedical data for mass-gathering health research and evaluation remains contemporary and comprehensive. This review proposes the addition of 16 high-level patient presentation categories to the 2012 MDS in the following broad areas: gastrointestinal, obstetrics and gynecology, minor illness, mental health, and patient outcomes. Additionally, a section for self-treatment has been added, which was previously not included in the 2012 MDS, but was widely reported in the literature.

RanseJ, HuttonA, TurrisSA, LundA. Enhancing the minimum data set for mass-gathering research and evaluation: an integrative literature review. Prehosp Disaster Med. 2014;29(3):1-10.