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Delaney PG, Moussally J, Wachira BW. Future directions for emergency medical services development in low- and middle-income countries. Surgery 2024; 176:220-222. [PMID: 38599983 DOI: 10.1016/j.surg.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/20/2024] [Accepted: 02/29/2024] [Indexed: 04/12/2024]
Abstract
The lack of prehospital care access in low- and middle-income countries is one of the greatest unmet needs and, therefore, one of the most urgent priorities in global health. Establishing emergency medical services in low- and middle-income countries poses significant challenges and complexities, requiring solutions tailored to prevailing conditions, informed by needs assessments, and adapted to meet local demands in a culturally appropriate and sustainable manner. In areas without existing emergency medical services, patients must rely on informal networks of untrained bystanders and community members to provide first aid and transport to definitive care. Since 2005, training lay first responders has been recommended by the World Health Organization as the first step toward formal emergency medical services development. However, efforts to formalize lay first responders networks have not expanded with the increasing need for prehospital emergency care in low- and middle-income countries, despite their potential. The rapid expansion of communication technologies like mobile smartphones penetrating resource-limited settings offers effective and inexpensive options for dispatching and coordinating lay first responders that were not previously available. These technologies can also be used for more advanced emergency medical services, obviating expensive communications and dispatch infrastructure. Despite disproportionately bearing the global injury burden, lay first responders frequently lack accurate and comprehensive surveillance data secondary to widespread underreporting, especially for non-fatal events. Lay first responders expand surveillance, which may inform future targeted prevention efforts, assisting in the development of tailored countermeasures suited to local hazards and diseases. Emergency medical services development in low- and middle-income countries involves a strategic approach focused on understanding the unique needs of diverse communities, requiring broad stakeholder involvement to create a sense of ownership to maintain volunteer networks and enhance sustainability. By embracing these relatively low-cost, bottom-up strategies, low- and middle-income countries can develop more accessible, efficient, and community-oriented emergency medical systems, ultimately improving public health outcomes and averting preventable deaths to address the emergency burden.
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Affiliation(s)
- Peter G Delaney
- LFR International, Makeni, Sierra Leone; Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH.
| | - Jon Moussally
- TraumaLink, Dhaka, Bangladesh; Harvard T.H. Chan School of Public Health, Boston, MA
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Sun JH, de Vries S, Mould-Millman NK. Emergency medical services (EMS) infrastructure development and operations in low- and middle-income countries: Formal, professional-driven (Tier-2) systems. Surgery 2024; 176:217-219. [PMID: 38599981 DOI: 10.1016/j.surg.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/17/2024] [Accepted: 02/26/2024] [Indexed: 04/12/2024]
Abstract
The World Health Organization recognized timely healthcare as a human right and called for the expansion of two-tiered prehospital and out-of-hospital emergency care systems in low- and middle-income countries. Tier-1 systems involve community-based first responder care, and Tier-2 systems involve more formalized emergency medical services designed as a sustainable system of services, including dedicated ambulances, personnel, and equipment. Tier-2 systems can play a crucial role in reducing mortality and disability due to emergency medical and surgical conditions worldwide. However, the implementation and operation of robust Tier-2 systems in low- and middle-income countries face significant challenges. This article examines the current state, challenges, and opportunities of Tier-2 system development and operations in low- and middle-income countries, highlighting the limited coverage and resourcing of existing systems. The challenges faced in developing Tier-2 systems in low- and middle-income countries include a lack of global awareness, financial constraints, regulatory and planning issues, cultural appropriateness, and workforce shortages. Additionally, the availability and maintenance of equipment, technology, transportation, facilities, and interfacility transfers pose significant hurdles. Localized adaptation of emergency medical services models to suit the diverse contexts of different low- and middle-income countries is critical, as are community partnerships in navigating the complexities of specific communities. Furthermore, Tier-2 systems in low- and middle-income countries should prioritize alignment with national policies and integration into their broader healthcare systems. There is also a need for innovative financial sustainability approaches, such as private-public partnerships and cost-sharing schemes, to overcome the upfront costs of establishing Tier-2 system infrastructure. Additionally, strategies for strengthening the emergency medical services workforce, including targeted recruitment and training, are explored. By addressing these challenges and opportunities, Tier-2 systems in low- and middle-income countries can better operate within their available resources and potentially contribute to improved healthcare outcomes. The sharing of best practices and collaborative networks between systems in low- and middle-income countries will also be critical for the development of Tier-2 system infrastructure in these areas.
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Affiliation(s)
- Jared H Sun
- Department of Emergency Medicine, Los Angeles General Medical Center, University of Southern California, CA.
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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Delaney PG, De Vos S, Eisner ZJ, Friesen J, Hingi M, Mirza UJ, Kharel R, Moussally J, Smith N, Slingers M, Sun J, Thullah AH. Challenges, opportunities, and priorities for tier-1 emergency medical services (EMS) development in low- and middle-income countries: A modified Delphi-based consensus study among the global prehospital consortium. Injury 2024:111522. [PMID: 38599953 DOI: 10.1016/j.injury.2024.111522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION Though the disease burden addressable by prehospital and out-of-hospital emergency care(OHEC) spans communicable diseases, maternal conditions, chronic conditions and injury, the single largest disability-adjusted life year burden contributor is injury, primarily driven by road traffic injuries(RTIs). Establishing OHEC for RTIs and other common emergencies in low- and middle-income countries(LMICs) where the injury burden is disproportionately greatest is a logical first step toward more comprehensive emergency medical services(EMS). However, with limited efforts to formalize and expand existing informal bystander care networks, there is a lack of consensus on how to develop and maintain bystander-driven Tier-1 EMS systems in LMICs. Resultantly, Tier-1 EMS development is fragmented among non-governmental organizations and the public sector globally. METHODS A steering committee coordinated a 9-round, modified Delphi-based expert discussion to identify current challenges, opportunities, and priorities in Tier-1 EMS development globally. 11 panelists represented seven Global Prehospital Consortium(GPC) member organizations with a mean 9.57 years of organizational Tier-1 EMS development/implementation experience(median = 9 years). The consortium represents the largest collaboration between organizations directing Tier-1 EMS programs globally across 12 countries on 3 continents(Americas, sub-Saharan Africa, and South Asia) with 22,000 first responders. RESULTS The GPC identified seven priority areas for Tier-1 EMS development: infrastructure/operations, communication, education/training, impact evaluation, financing, governance/legal, and transportation/equipment. A high level of consensus exists regarding priorities for investigation, including Tier-1 responder density/distribution, Tier-1 patient data variable standardization for trauma registries/quality improvement, dispatch technologies/protocols, modular curricula, broader cost-effectiveness and impact evaluation indices capturing secondary impacts of EMS, standardizing legal protections for first responders, and transportation/equipment standards. DISCUSSION Consensus is necessary to avoid duplicative and disorganized efforts due to the fragmented nature of parallel Tier-1 EMS efforts globally. A Delphi-like multi-round expert discussion among the members of the largest collaboration between organizations directing Tier-1 EMS programs globally generated relevant priorities to direct future efforts.
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Li W, Jiang G, Yang G, Qiu F. Comprehensive Study on Mineral Processing Methods and Mineral Technical Economics of Manganese Ore in Chongqing Chengkou. ACS OMEGA 2024; 9:10929-10936. [PMID: 38463324 PMCID: PMC10918821 DOI: 10.1021/acsomega.3c10272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 03/12/2024]
Abstract
Chongqing Chengkou manganese deposit is a large carbonate-type manganese deposit in the upper reaches of the Yangtze River, located in Gaoyan Town, Chengkou County, Chongqing. In order to improve the recovery rate of low-grade manganese ore and concentrate grade index, achieve efficient utilization of mineral resources, and sustainable development of Gaoyan manganese ore deposit in Chengkou, Chongqing, China, in this paper, by means of optical microscope analysis, high-resolution X-ray tomography technology, three-dimensional image analysis technology, X-ray diffraction analysis, X-ray fluorescence spectrum analysis, and technical and economic analysis, the occurrence state and process mineralogy of manganese are studied, and the technical and economic analysis of flotation, high-intensity magnetic separation, and gravity separation are carried out. It provides a reference for other mining enterprises to choose the most suitable beneficiation method according to the specific mineral species.
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Affiliation(s)
- Wensheng Li
- School of Chemistry and Chemical
Engineering, Chongqing University of Technology, Chongqing 400054, China
| | - Guangchao Jiang
- School of Chemistry and Chemical
Engineering, Chongqing University of Technology, Chongqing 400054, China
| | - Guangzhou Yang
- School of Chemistry and Chemical
Engineering, Chongqing University of Technology, Chongqing 400054, China
| | - Facheng Qiu
- School of Chemistry and Chemical
Engineering, Chongqing University of Technology, Chongqing 400054, China
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Ali AE, Ademuyiwa AO, Lakhoo K, Kefas J, Houmenou E, Abdulsalam M, Leopold A, Bankole R, Gbenou S, Covi P. A Prospective Epidemiological Survey of Paediatric Trauma in Africa: A Cross-Sectional Study. Afr J Paediatr Surg 2024; 21:6-11. [PMID: 38259013 PMCID: PMC10903722 DOI: 10.4103/ajps.ajps_80_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 12/20/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Trauma is a leading cause of morbidity and mortality in children worldwide. There is a need for development and provision of efficient paediatric trauma services based on adequate information and funding which are lacking in low- and middle-income countries. AIMS This study was carried out to assess the scale of the problem, identify the most common causes of trauma in Pan African Paediatric Surgical Association (PAPSA) zone and to define the limiting factors for provision of the necessary services required to reduce the potential mortality and disability. MATERIALS AND METHODS Data were collected through an electronic form sent out in PAPSA platform. Members were requested to provide prospective data on all paediatric major trauma admitted to or seen at their health facilities between the beginning of April 2019 and the end of June 2020. Hospital location, child's age, gender, type of injury, mechanism of injury, severity, initial management, method of transport, time to arrive to hospital, availability of surgical specialities, length of hospital stay and injury outcome were analysed. RESULTS There were 531 entries. The mean age was 3.53 years and median age 1.34 years. Male-to-female ratio was 2:1. The leading causes for injuries were falls 194 (36.53%) and motor vehicle crashes (MVCs) 176 (33.15%) followed by obstetrical 42 (7.9%), thermal 27 (5.1%) and domestic injuries 22 (4.1%). The most common injuries were limb fractures 181 (34.1%) and traumatic brain injury 111 (20.9%). Public and private transport were used in 313 (58.9%), while ambulance service was used in only 54 (10.1%). Distances to a health facility varied between 1 and 157 km. 70.2% of cases did not receive any primary care, while definitive care was received in 95.5% of the cases. Outcome was full recovery in 90.6% of patients, morbidity in 8.1% and a mortality rate of 1.3%. CONCLUSIONS Most of the injuries were in the under 5-year age group. The two main causes of trauma in children in this study were the falls from height and MVCs. Long distance travels to reach health-care facilities were noticeable in this study, together with substantial lack of adequate ambulance facilities and shortage in necessary subspecialty services such as neurosurgical, orthopaedics and rehabilitation. Implementing proposed recommendations can reduce the burden.
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Affiliation(s)
| | - Adesoji O Ademuyiwa
- Department of Surgery, College of Medicine, Honorary Consultant and Chief Paediatric Surgery Unit, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
| | - Kokila Lakhoo
- Department of Paediatric Surgery, University of Oxford, Oxford University Hospitals, Oxford, England
| | - John Kefas
- Department of Surgery, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
| | - Esperance Houmenou
- Department of Paediatric Surgery, Services Paediatric Du Chd/Zc, Abomey, Benin
| | - Moruf Abdulsalam
- Department of Surgery, Lagos State University Teaching Hospital, Ikeja, Nigeria
| | - Azakpa Leopold
- Department of Paediatric Surgery, Saint Jean De Dieu, Tanguieta, Benin
| | - Rouma Bankole
- Department of Paediatric Surgery, Teaching Hospital Treichvile, Abidjan, Côte D'ivoire
| | - Seraphin Gbenou
- Department of Paediatric Surgery, University Teaching Hospital of Mother and Child Lagoon, Cotonou, Benin
| | - Pautin Covi
- Department of Paediatric Surgery, National University Teaching Hospital HKM, Cotonou, Benin
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Schnaubelt S, Garg R, Atiq H, Baig N, Bernardino M, Bigham B, Dickson S, Geduld H, Al-Hilali Z, Karki S, Lahri S, Maconochie I, Montealegre F, Tageldin Mustafa M, Niermeyer S, Athieno Odakha J, Perlman JM, Monsieurs KG, Greif R. Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC. Lancet Glob Health 2023; 11:e1444-e1453. [PMID: 37591590 DOI: 10.1016/s2214-109x(23)00302-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 08/19/2023]
Abstract
Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.
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Affiliation(s)
- Sebastian Schnaubelt
- European Resuscitation Council, Niel, Belgium; Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria; Department of Emergency Medicine, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium.
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, Dr Braich All India Institute of Medical Sciences, New Delhi, India
| | - Huba Atiq
- Department of Anaesthesiology, Centre of Excellence for Trauma & Emergency, The Aga Khan University Hospital, Karachi, Pakistan
| | - Noor Baig
- Department of Emergency Medicine, Centre of Excellence for Trauma & Emergency, The Aga Khan University Hospital, Karachi, Pakistan
| | - Marta Bernardino
- Centro de Simulacion, Hospital Universitario Fundacion Alcorcon, Madrid, Spain; Spanish Society of Anaesthesiology and Intensive Care, Madrid, Spain
| | - Blair Bigham
- Department of Anesthesia, Division of Critical Care, Stanford University, Palo Alto, CA, USA
| | | | - Heike Geduld
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | | | - Sanjaya Karki
- Department of Emergency and Pre-hospital Care, Mediciti Hospital, Bhaisepati, Lalitpur, Nepal
| | - Sa'ad Lahri
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, Imperial College Healthcare Trust, London, UK
| | - Fernando Montealegre
- Department of Anaesthesiology, José Casimiro Ulloa Emergency Hospital, Peruvian Resuscitation Council, Lima, Peru
| | | | - Susan Niermeyer
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Justine Athieno Odakha
- Department of Emergency Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jeffrey M Perlman
- Department of Pediatrics, Division of Newborn Medicine, New York Presbyterian Hospital, Weill Cornell Medicine, NY, USA
| | - Koenraad G Monsieurs
- European Resuscitation Council, Niel, Belgium; Department of Emergency Medicine, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Robert Greif
- European Resuscitation Council, Niel, Belgium; University of Bern, Bern, Switzerland; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
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Hirner S, Dhakal J, Broccoli MC, Ross M, Calvello Hynes EJ, Bills CB. Defining measures of emergency care access in low-income and middle-income countries: a scoping review. BMJ Open 2023; 13:e067884. [PMID: 37068910 PMCID: PMC10111883 DOI: 10.1136/bmjopen-2022-067884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Over 50% of annual deaths in low-income and middle-income countries (LMICs) could be averted through access to high-quality emergency care. OBJECTIVES We performed a scoping review of the literature that described at least one measure of emergency care access in LMICs in order to understand relevant barriers to emergency care systems. ELIGIBILITY CRITERIA English language studies published between 1 January 1990 and 30 December 2020, with one or more discrete measure(s) of access to emergency health services in LMICs described. SOURCE OF EVIDENCE PubMed, Embase, Web of Science, CINAHL and the grey literature. CHARTING METHODS A structured data extraction tool was used to identify and classify the number of 'unique' measures, and the number of times each unique measure was studied in the literature ('total' measures). Measures of access were categorised by access type, defined by Thomas and Penchansky, with further categorisation according to the 'Three Delay' model of seeking, reaching and receiving care, and the WHO's Emergency Care Systems Framework (ECSF). RESULTS A total of 3103 articles were screened. 75 met full study inclusion. Articles were uniformly descriptive (n=75, 100%). 137 discrete measures of access were reported. Unique measures of accommodation (n=42, 30.7%) and availability (n=40, 29.2%) were most common. Measures of seeking, reaching and receiving care were 22 (16.0%), 46 (33.6%) and 69 (50.4%), respectively. According to the ECSF slightly more measures focused on prehospital care-inclusive of care at the scene and through transport to a facility (n=76, 55.4%) as compared with facility-based care (n=57, 41.6%). CONCLUSIONS Numerous measures of emergency care access are described in the literature, but many measures are overaddressed. Development of a core set of access measures with associated minimum standards are necessary to aid in ensuring universal access to high-quality emergency care in all settings.
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Affiliation(s)
- Sarah Hirner
- School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jyotshila Dhakal
- College Undergraduate Degree Programs & Studies, University of Colorado Denver, Denver, Colorado, USA
| | | | - Madeline Ross
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Emilie J Calvello Hynes
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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Delaney PG, Eisner ZJ, Thullah AH, Turay P, Sandy K, Boonstra PS, Raghavendran K. Evaluating feasibility of a novel mobile emergency medical dispatch tool for lay first responder prehospital response coordination in Sierra Leone: A simulation-based study. Injury 2023; 54:5-14. [PMID: 36266111 DOI: 10.1016/j.injury.2022.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/02/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The global injury burden, driven by road traffic injuries, disproportionately affects low- and middle-income countries, which lack robust emergency medical services (EMS) to address injury. The WHO recommends training lay first responders (LFRs) as the first step toward formal EMS development. Emergency medical dispatch (EMD) systems are the recognized next step but whether small groups of LFRs equipped with mobile dispatch infrastructure can efficiently respond to geographically-dispersed emergencies in a timely fashion and the quality of prehospital care provided is unknown. MATERIALS AND METHODS We piloted an EMD system utilizing a mobile phone application in Sierra Leone. Ten LFRs were randomly selected from a pool of 61 highly-active LFRs trained in 2019 and recruited to participate in an emergency simulation-based study. Ten simulation scenarios were created matching proportions of injury conditions across 1,850 previous incidents (June-December 2019). Fifty total simulations were launched in randomized order over 3 months, randomized along 10 km of highway in Makeni. Replicating real-world conditions, highly-active LFR participants were blinded to randomized dispatch timing/scenario to assess response time and skill performance under direct observation with a checklist using standardized patient actors. We used novel cost data tracked during EMD pilot implementation to inform the calculation of a new cost-effectiveness ratio ($USD cost per disability-adjusted life year averted (DALY)) for LFR programs equipped with dispatch, following WHOCHOICE guidelines, which state cost-effectiveness ratios less than gross domestic product (GDP) per capita are considered "very cost-effective." RESULTS Median total response interval (notification to arrival) was 5 min 39 s (IQR:0:03:51, 0:09:18). LFRs initially trained with a 5-hour curriculum and refresher training provide high-quality prehospital care during simulated emergencies. Median first aid skill checklist completion was 89% (IQR: 78%, 90%). Cost-effectiveness equals $179.02USD per DALY averted per 100,000 people, less than Sierra Leonean GDP per capita ($484.52USD). CONCLUSION LFRs equipped with mobile dispatch demonstrate appropriate response times and effective basic initial management of simulated emergencies. Training smaller cohorts of highly-active LFRs equipped with mobile dispatch appears highly cost-effective and may be a feasible model to facilitate efficient dispatch to expand emergency coverage while conserving valuable training resources in resource-limited settings.
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Affiliation(s)
- Peter G Delaney
- University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI 48109, United States; LFR International, 4835 Oak Park Ave, Encino, California, United States; Michigan Center for Global Surgery, Ann Arbor, Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, United States.
| | - Zachary J Eisner
- University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI 48109, United States; LFR International, 4835 Oak Park Ave, Encino, California, United States; Michigan Center for Global Surgery, Ann Arbor, Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, United States
| | - Alfred H Thullah
- LFR International - Sierra Leone, Plot 4, Lunsar-Makeni Highway, Makeni, Sierra Leone
| | | | - Kpawuru Sandy
- Sierra Leone Red Cross Society, 6, Liverpool St., Freetown, Sierra Leone
| | - Philip S Boonstra
- University of Michigan Department of Biostatistics, 1415 Washington Heights, Ann Arbor, MI, United States
| | - Krishnan Raghavendran
- Michigan Center for Global Surgery, Ann Arbor, Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, United States; University of Michigan Health System Department of Surgery, 1500 E Medical Center Dr, Ann Arbor, MI, United States
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Werner K, Risko N, Kalanzi J, Wallis LA, Reynolds TA. Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda. PLoS One 2022; 17:e0279074. [PMID: 36516176 PMCID: PMC9750003 DOI: 10.1371/journal.pone.0279074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level. METHODS A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%. RESULTS Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters. CONCLUSION Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.
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Affiliation(s)
- Kalin Werner
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | | | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Teri A. Reynolds
- Department for Clinical Services and Systems, Integrated Health Services, World Health Organization (WHO), Geneva, Switzerland
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Stassen W, Theron E, Slingsby T, Wylie C. Out-of-hospital cardiac arrests in the city of Cape Town metropole of the Western Cape province of South Africa: a spatio-temporal analysis. Cardiovasc J Afr 2022; 33:260-266. [PMID: 35687073 PMCID: PMC9887433 DOI: 10.5830/cvja-2022-019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/01/2022] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The incidence of out-of-hospital cardiac arrest (OHCA) is expected to increase in sub-Saharan Africa along with the incidence of cardiovascular disease. In low-resource settings (LRS), OHCA carries a negligible survival rate. Interventions to improve OHCA survival might not be cost effective for many LRS, and therefore need to be targeted to areas of high incidence. The aim of this study was to describe the temporal and geographic distribution of OHCA in the City of Cape Town, South Africa, and their proximity to percutaneous coronary intervention (PCI) resources. METHODS In this retrospective study, OHCA data between 1 January and 31 December 2018 were extracted from public and one private emergency medical services in the Western Cape. For temporal analysis, distribution of OHCA according to time of day, day of the week and month of the year were subjected to chi-squared testing. For geospatial analysis, cluster and outlier, and hotspot analyses were performed. Proximity analysis was employed to determine the driving time from OHCA location to the closest PCI-capable facility. RESULTS A total of 929 patients with OHCA received an emergency medical services response in the City of Cape Town, corresponding to an annual prevalence of 23.2 per 100 000 persons. The distribution of OHCA incidence was not explained by month of the year (p = 0.08) or day of the week (p = 0.67). A statistically significant variation in OHCA incidence was explained by time of day (p < 0.01) with 30% (n = 279) of all OHCAs occurring from 05:00 to 09:59. Geospatial analysis yielded a large area of hotspots (99% confidence interval) over the centre of the metropole, Cape Flats and southern suburbs. The median (interquartile range) driving time from the incident to the closest PCI-capable facility was 10:22 (08:05) minutes. CONCLUSIONS Incidents of OHCA occurred predominantly at home during the mid-morning, with hotspots around the city centre and residential suburbs of Cape Town. While the incidents occurred close to PCI-capable facilities, some areas remained underserved and access to PCI for OHCA victims may be impossible due to socio-economic factors. With an increase in OHCA incidence expected, it is essential that contextual, cost-effective management interventions be developed and implemented.
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Affiliation(s)
- Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
| | - Elzarie Theron
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Thomas Slingsby
- Geographic Information Systems Support, Digital Library Services, University of Cape Town, Cape Town, South Africa
| | - Craig Wylie
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa; Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Trehan I, Kivlehan SM, Balhara KS, Bonney J, Hexom BJ, Pousson AY, Quao NSA, Rybarczyk MM, Selvam A, Nicholson BD, Bhaskar N, Becker TK, Balhara KS, Bandolin NS, Bannon‐Murphy H, Becker TK, Bhaskar N, Bonney J, Boone A, Broccoli MC, Charlton ADI, Cho DK, Ciano JD, Collier A, Dawson‐Amoah NA, Dyal JW, Flaherty KE, Hartford EA, Hayward AS, Hexom BJ, Hunter C, Jacobson AA, Joiner AP, Jones JE, Kampalath VN, Kivlehan SM, Laurence CE, Leanza J, Ledger E, Lee JA, Levine AC, Lowsby R, McCuskee S, Moretti KR, Nicholson BD, Pigoga JL, Pousson AY, Quao NSA, Rees CA, Roy CM, Rybarczyk MM, Selvam A, Skarpiak BJ, Strong JM, Trehan I, Vogel LD, Wang AH, Wegman KM, Winders WT. Global emergency medicine: A scoping review of the literature from 2020. Acad Emerg Med 2021; 28:1328-1340. [PMID: 34310782 DOI: 10.1111/acem.14356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective was to identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research (OR) and review articles (RE) in global emergency medicine (EM) published in 2020 in the peer-reviewed and gray literature. METHODS A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review (GEMLR) Group to identify those that met our criteria of OR or RE in the domains of disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and EM development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in-depth narrative summarization. RESULTS The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year's search. From these, 364 were scored based on their full text. Nearly three-fourths of the scored articles constituted OR, of which nearly three-fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID-19. Research involving ECRLS again constituted most of the articles in this year's review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in-depth narrative critiques. CONCLUSIONS The number of studies relevant to global EM identified by our search was very similar to that of last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to DHR. The number of COVID-19-related articles is likely to continue to increase in subsequent years.
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Affiliation(s)
- Indi Trehan
- Departments of Pediatrics, Global Health, and Epidemiology University of Washington Seattle Washington USA
| | - Sean M. Kivlehan
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
- Harvard Humanitarian Initiative Cambridge Massachusetts USA
| | - Kamna S. Balhara
- Department of Emergency Medicine Johns Hopkins University Baltimore Maryland USA
| | - Joseph Bonney
- Department of Emergency Medicine Komfo Anokye Teaching Hospital Kumasi Ghana
- Global Health and Infectious Disease Research Group Kumasi Center for Collaborative Research in Tropical Medicine Kumasi Ghana
| | - Braden J. Hexom
- Department of Emergency Medicine Rush University Medical Center Chicago Illinois USA
| | - Amelia Y. Pousson
- Department of Emergency Medicine Johns Hopkins University Baltimore Maryland USA
| | - Nana S. A. Quao
- Department of Emergency Medicine, Accident and Emergency Centre Korle Bu Teaching Hospital Accra Ghana
| | - Megan M. Rybarczyk
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Anand Selvam
- Department of Emergency Medicine Yale University New Haven Connecticut USA
| | - Benjamin D. Nicholson
- Department of Emergency Medicine Virginia Commonwealth University Richmond Virginia USA
| | | | - Torben K. Becker
- Department of Emergency Medicine University of Florida Gainesville Florida USA
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12
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Delaney PG, Eisner ZJ, Bustos A, Hancock CJ, Thullah AH, Jayaraman S, Raghavendran K. Cost-Effectiveness of Lay First Responders Addressing Road Traffic Injury in Sub-Saharan Africa. J Surg Res 2021; 270:104-112. [PMID: 34649070 DOI: 10.1016/j.jss.2021.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/29/2021] [Accepted: 08/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND To investigate the cost-effectiveness of training lay first responders (LFRs) to address road traffic injury (RTI) in sub-Saharan Africa (SSA) as the first step toward formal emergency medical services (EMS) development. MATERIALS/METHODS Cost data from five LFR programs launched between 2008 and 2019 in SSA was collected for LFR cost estimation, including three prospective collections from our group. We systematically reviewed literature and projected aggregate disability-adjusted life years (DALYs) from RTI in SSA that are addressable by LFRs to inform cost-effectiveness ratios ($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP) to determine the cost-effectiveness of LFRs addressing RTIs in SSA, following WHO-CHOICE guidelines, which state cost-effectiveness ratios less than GDP per capita are considered "very cost-effective." RESULTS Average annual cost per LFR trained across five programs was calculated to be 16.32USD (training=4.04USD, supplies=12.28USD). Following WHO and Disease Control Priorities recommendations for adequate emergency catchment, initial training of 750 LFRs per 100,000 people would cost 12,239.47USD with projected total annual DALYs averted equal to 227.7 per 100,000. Cost per DALY averted would therefore be 53.75USD with appropriate LFR availability, less than sub-Saharan African GDP per capita (1,585.40USD) and the lowest sub-Saharan African GDP per capita (Burundi, 261.20USD). CONCLUSION Following WHO-CHOICE guidelines, training LFRs can be a highly cost-effective means to address RTI morbidity and mortality across sub-Saharan Africa. With EMS unavailable for 91.3% of the African population, training LFRs can be an affordable first step toward formal EMS development.
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Affiliation(s)
- Peter G Delaney
- University of Michigan Medical School,Ann Arbor, Michigan; LFR International, Los Angeles, California; Michigan Center for Global Surgery, Ann Arbor, Michigan.
| | - Zachary J Eisner
- LFR International, Los Angeles, California; Washington University in St. Louis, St. Louis, Missouri
| | - Aiza Bustos
- LFR International, Los Angeles, California; Washington University in St. Louis, St. Louis, Missouri
| | - Canaan J Hancock
- LFR International, Los Angeles, California; Washington University in St. Louis, St. Louis, Missouri
| | | | - Sudha Jayaraman
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Krishnan Raghavendran
- Michigan Center for Global Surgery, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
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13
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Baek Y, Ademi Z, Paudel S, Fisher J, Tran T, Romero L, Owen A. Economic Evaluations of Child Nutrition Interventions in Low- and Middle-Income Countries: Systematic Review and Quality Appraisal. Adv Nutr 2021; 13:282-317. [PMID: 34510178 PMCID: PMC8803532 DOI: 10.1093/advances/nmab097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/24/2021] [Accepted: 07/27/2021] [Indexed: 11/12/2022] Open
Abstract
Economic evaluation is crucial for cost-effective resource allocation to improve child nutrition in low and middle-income countries (LMICs). However, the quality of published economic evaluations in these settings is not well understood. This systematic review aimed to assess the quality of existing economic evaluations of child nutrition interventions in LMICs and synthesize the study characteristics and economic evidence. We searched 9 electronic databases, including MEDLINE, with the following concepts: economic evaluation, children, nutrition, and LMICs. All types of interventions addressing malnutrition, including stunting, wasting, micronutrient deficiency, and overweight, were identified. We included economic evaluations that examined both costs and effects published in English peer-reviewed journals and used the Drummond checklist for quality appraisal. We present findings through a narrative synthesis. Sixty-nine studies with diverse settings, perspectives, time horizons, and outcome measures were included. Most studies used data from sub-Saharan Africa and South Asia and addressed undernutrition. The mortality rate, intervention effect, intervention coverage, cost, and discount rate were reported as predictors among studies that performed sensitivity analyses. Despite the heterogeneity of included studies and the possibility of publication bias, 81% of included studies concluded that nutrition interventions were cost-effective or cost-beneficial, mostly based on a country's cost-effectiveness thresholds. Regarding quality assessment, the studies published after 2016 met more criteria than studies published before 2016. Most studies had well-stated research questions, forms of economic evaluation, interventions, and conclusions. However, reporting the perspective of the analyses, justification of discount rates, and describing the role of funders and ethics approval were identified as areas needing improvement. The gaps in the quality of reporting could be improved by consolidated guidance on the publication of economic evaluations and the use of appropriate quality appraisal checklists. Strengthening the evidence base for child malnutrition across different regions is necessary to inform cost-effective investment in LMICs. Trial registration: PROSPERO CRD42020194445.
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Affiliation(s)
- Yeji Baek
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Susan Paudel
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jane Fisher
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thach Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Barriers to Trauma Care in South and Central America: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1163-1177. [PMID: 34392445 PMCID: PMC9279262 DOI: 10.1007/s00590-021-03080-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
Introduction Trauma is widespread in Central and South America and is a significant cause of morbidity and mortality. Providing high quality emergency trauma care is of great importance. Understanding the barriers to care is challenging; this systematic review aims to establish current the current challenges and barriers in providing high-quality trauma care within the 21 countries in the region. Methods OVID Medline, Embase, EBM reviews and Global Health databases were systematically searched in October 2020. Records were screened by two independent researchers. Data were extracted according to a predetermined proforma. Studies of any type, published in the preceding decade were included, excluding grey literature and non-English records. Trauma was defined as blunt or penetrating injury from an external force. Studies were individually critically appraised and assessed for bias using the RTI item bank. Results 57 records met the inclusion criteria. 20 countries were covered at least once. Nine key barriers were identified: training (37/57), resources and equipment (33/57), protocols (29/57), staffing (17/57), transport and logistics (16/57), finance (15/57), socio-cultural (13/57), capacity (9/57), public education (4/57). Conclusion Nine key barriers negatively impact on the provision of high-quality trauma care and highlight potential areas for improving care in Central & South America. Many countries in the region, along with rural areas, are under-represented by the current literature and future research is urgently required to assess barriers to trauma management in these countries. No funding was received. Clinical Trial Registration: PROSPERO CRD42020220380.
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Khan SU, Khan MZ, Khan MU, Khan MS, Mamas MA, Rashid M, Blankstein R, Virani SS, Johansen MC, Shapiro MD, Blaha MJ, Cainzos-Achirica M, Vahidy FS, Nasir K. Clinical and Economic Burden of Stroke Among Young, Midlife, and Older Adults in the United States, 2002-2017. Mayo Clin Proc Innov Qual Outcomes 2021; 5:431-441. [PMID: 33997639 PMCID: PMC8105541 DOI: 10.1016/j.mayocpiqo.2021.01.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective To assess trends of stroke hospitalization rates, inpatient mortality, and health care resource use in young (aged ≤44 years), midlife (aged 45-64 years), and older (aged ≥65 years) adults. Patients and Methods We studied the National Inpatient Sample database (January 1, 2002 to December 31, 2017) to analyze stroke-related hospitalizations. We identified data using the International Classification of Diseases, Ninth/Tenth Revision codes. Results Of 11,381,390 strokes, 79% (n=9,009,007) were ischemic and 21% (n=2,372,383) were hemorrhagic. Chronic diseases were more frequent in older adults; smoking, alcoholism, and migraine were more prevalent in midlife adults; and coagulopathy and intravenous drug abuse were more common in young patients with stroke. The hospitalization rates of stroke per 10,000 increased overall (31.6 to 33.3) in young and midlife adults while decreasing in older adults. Although mortality decreased overall and in all age groups, the decline was slower in young and midlife adults than older adults. The mean length of stay significantly decreased in midlife and older adults and increased in young adults. The inflation-adjusted mean cost of stay increased consistently, with an average annual growth rate of 2.44% in young, 1.72% in midlife, and 1.45% in older adults owing to the higher use of health care resources. These trends were consistent in both ischemic and hemorrhagic stroke. Conclusion Stroke-related hospitalization and health care expenditure are increasing in the United States, particularly among young and midlife adults. A higher cost of stay counterbalances the benefits of reducing stroke and mortality in older patients.
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Affiliation(s)
- Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, WV
| | | | - Muhammad U Khan
- Department of Medicine, West Virginia University, Morgantown, WV
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom.,Department of Medicine, Jefferson University, Philadelphia, PA
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Salim S Virani
- Michael E. DeBakey Veterans Affair Medical Center.,Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Michael D Shapiro
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, MD
| | - Miguel Cainzos-Achirica
- Division of Cardiovascular Prevention and Wellness, Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart and Vascular Center.,Center for Outcomes Research, Houston Methodist, Houston, TX
| | - Farhaan S Vahidy
- Division of Cardiovascular Prevention and Wellness, Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart and Vascular Center
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart and Vascular Center.,Center for Outcomes Research, Houston Methodist, Houston, TX
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Werner K, Lin TK, Risko N, Osiro M, Kalanzi J, Wallis L. The costs of delivering emergency care at regional referral hospitals in Uganda: a micro-costing study. BMC Health Serv Res 2021; 21:232. [PMID: 33726738 PMCID: PMC7961167 DOI: 10.1186/s12913-021-06197-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/19/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Uganda experiences a high morbidity and mortality burden due to conditions amenable to emergency care, yet few public hospitals have dedicated emergency units. As a result, little is known about the costs and effects of delivering lifesaving emergency care, hindering health systems planning, budgeting and prioritization exercises. To determine healthcare costs of emergency care services at public facilities in Uganda, we estimate the median cost of care for five sentinel conditions and 13 interventions. METHODS A direct, activity-based costing was carried out at five regional referral hospitals over a four-week period from September to October 2019. Hospital costs were determined using bottom-up micro-costing methodology from a provider perspective. Resource use was enumerated via observation and unit costs were derived from National Medical Stores lists. Cost per condition per patient and measures of central tendency for conditions and interventions were calculated. Kruskal-Wallis H-tests and Nemyeni post-hoc tests were conducted to determine significant differences between costs of the conditions. RESULTS Eight hundred seventy-two patient cases were captured with an overall median cost of care of $15.53 USD ($14.44 to $19.22). The median cost per condition was highest for post-partum haemorrhage at $17.25 ($15.02 to $21.36), followed by road traffic injuries at $15.96 ($14.51 to $20.30), asthma at $15.90 ($14.76 to $19.30), pneumonia at $15.55 ($14.65 to $20.12), and paediatric diarrhoea at $14.61 ($13.74 to $15.57). The median cost per intervention was highest for fracture reduction and splinting at $27.77 ($22.00 to $31.50). Cost values differ between sentinel conditions (p < 0.05) with treatments for paediatric diarrhoea having the lowest median cost of all conditions (p < 0.05). CONCLUSION This study is the first to describe the direct costs of emergency care in hospitals in Uganda by observing the delivery of clinical services, using robust activity-based costing and time motion methodology. We find that emergency care interventions for key drivers of morbidity and mortality can be delivered at considerably lower costs than many priority health interventions. Further research assessing acute care delivery would be useful in planning wider health care delivery systems development.
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Affiliation(s)
- Kalin Werner
- Division of Emergency Medicine, University of Cape, Cape Town, South Africa.
| | - Tracy Kuo Lin
- Department of Social and Behavioral Sciences, Institute for Health & Aging, University of California, San Francisco, San Francisco, CA, USA
| | - Nicholas Risko
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martha Osiro
- Division of Emergency Medicine, University of Cape, Cape Town, South Africa
| | | | - Lee Wallis
- Division of Emergency Medicine, University of Cape, Cape Town, South Africa
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Ramesh A, Mehdiratta L, Parimal T, Sahu S, Bajwa SJS. Emergency medicine - A great career field for the anaesthesiologist! Indian J Anaesth 2021; 65:61-67. [PMID: 33767505 PMCID: PMC7980235 DOI: 10.4103/ija.ija_1472_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 11/04/2022] Open
Abstract
Emergency Medicine (EM) is a fast upcoming medical speciality wherein patients presenting with emergent life-saving medical and surgical problems are managed. Emergency physicians are first-line providers of emergency care. They diagnose important clinical conditions even before completing patient assessment, order investigations, interventions, resuscitation and treatment for life-threatening acute conditions. There are several interesting sub-specialisations of EM like trauma care, disaster medicine, toxicology, ultrasonography, critical care medicine, hyperbaric medicine, etc. In some countries, the speciality of EM is a popular choice among medical students; whereas in some other countries, the speciality is now evolving. In India, the speciality is growing fast; Nonetheless, the National Medical Commission has made the existence of the department of EM compulsory in all medical colleges in India from the session of 2022-23. Anaesthesiologists suit the speciality of EM because they have quick decision making skills and swift reflexes as well as diverse knowledge and skills in the fields of critical care, resuscitation and pain management. This article written by anaesthesiologists working in the field of EM, attempts to guide the postgraduate students wanting to take up a career in EM.
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Affiliation(s)
- Aruna Ramesh
- Department of Emergency Medicine, MS Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Lalit Mehdiratta
- Department of Anaesthesiology, Critical Care and Emergency Medicine, Narmada Trauma Center, Bhopal, Madhya Pradesh, India
| | - Tarlika Parimal
- Department of Anaesthesiology, BJ Medical College, Ahmedabad, Gujarat, India
| | - Sandeep Sahu
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
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