Reduction in Emergency Department Presentations in a Regional Health System during the Covid-19 Pandemic

Analysis of the Prognosis Outcomes and Treatment Delay Among ST-Segment Elevation Myocardial Infarction Patients in Emergency Department Based on the Presence of Symptoms Suggestive of COVID-19

BACKGROUND

During COVID-19 pandemic, the emergency department (ED) was challenged to treat patients with COVID-19-related symptom. Therefore, the aim of this study was to investigate treatment delay and prognostic outcomes in ST-segment elevation myocardial infarction (STEMI) patients during COVID-19 pandemic due to isolation or precaution and compare it with pre-COVID-19 period.

METHODS

This was a retrospective observation study using multicenter data with different case mix. Anonymized data were collected through each center's electronic medical data of common case report form. Primary outcomes were number and rate of in-hospital mortality within 28 days. Secondary outcomes were door-to-balloon time and length of stay in the ED. Kaplan-Meier estimation and Cox proportional hazard regression analysis were performed to determine impact of predictors on 28-day in-hospital mortality.

RESULTS

Door-to-balloon time was longer in STEMI patients with COVID-19-related symptom(s) than those without symptom during the COVID-19 period (97.0 [74.8, 139.8] vs. 69.0 [55.0, 102.0] minutes, P<.001). However, there was no significant statistical difference in door-to-balloon time between STEMI patients with and without COVID-19-related symptom(s) during the pre-COVID-19 period (73.0 [61.0, 92.0] vs. 67.0 [54.5, 80.0] minutes, P=.2869). The 28-day mortality rate did not show a statistically significant difference depending on symptoms suggestive of COVID-19 during the pre-COVID-19 period (15.4% vs. 6.8%, P=.1257). However, it was significantly higher during the COVID-19 period (21.1% vs. 6.7%, P=.0102) in patients with COVID-19 suggestive symptoms than in patients without the symptoms.

CONCLUSION

In Korea, symptoms suggestive of COVID-19 during the pandemic had a significant effect on the increase of door-to-balloon time and 28-day mortality in STEMI patients. Thus, health authorities need to make careful decision in designating symptoms indicated for isolation in ED based on opinions of various medical field experts.

Two-year follow-up of a clustered randomised controlled trial of a multicomponent general practice intervention for people at risk of poor health outcomes

BACKGROUND

This study was a two-year follow-up evaluation of health service use and the cost-effectiveness of a multicomponent general practice intervention targeted at people at high risk of poor health outcomes.

METHODS

A two-year follow-up study of a clustered randomised controlled trial was conducted in South Australia during 2018-19, recruiting 1044 patients from three cohorts: children; adults (aged 18-64 years with two or more chronic diseases); and older adults (aged ≥ 65 years). Intervention group practices (n = 10) provided a multicomponent general practice intervention for 12 months. The intervention comprised patient enrolment to a preferred general practitioner (GP), access to longer GP appointments and timely general practice follow-up after episodes of hospital care. Health service outcomes included hospital use, specialist services and pharmaceuticals. The economic evaluation was based on quality-adjusted life years (QALYs) calculated from EuroQoL 5 dimensions, 5 level utility scores and used an A$50,000 per QALY gained threshold for determining cost-effectiveness.

RESULTS

Over the two years, there were no statistically significant intervention effects for health service use. In the total sample, the mean total cost per patient was greater for the intervention than control group, but the number of QALYs gained in the intervention group was higher. The estimated incremental cost-effectiveness ratio (ICER) was A$18,211 per QALY gained, which is lower than the A$50,000 per QALY gained threshold used in Australia. However, the intervention's cost-effectiveness was shown to differ by cohort. For the adult cohort, the intervention was associated with higher costs and lower QALYs gained (vs the total cohort) and was not cost-effective. For the older adults cohort, the intervention was associated with lower costs (A$540 per patient), due primarily to lower hospital costs, and was more effective than usual care.

CONCLUSIONS

The positive cost-effectiveness results from the 24-month follow-up warrant replication in a study appropriately powered for outcomes such as hospital use, with an intervention period of at least two years, and targeted to older people at high risk of poor health outcomes.

Measuring efficiency of public hospitals under the impact of Covid-19: the case of Türkiye

The Covid-19 pandemic has had serious medical, administrative and financial effects on the health system and hospitals around the world. In Türkiye, compared to 2019 realizations, in 2020 and 2021 respectively there were 39% and 21% decrease in the number of outpatient services and 29% and 17% decline in total inpatient services of public hospitals. The main subject of this research is how the pandemic period affects the Turkish public hospitals' efficiency. We have measured the technical efficiency of outpatient and inpatient care services of Turkish public hospitals using Stochastic Frontier Analysis (SFA). The dataset includes 563 hospitals for the years 2015 through 2021. Inputs of number of physicians, nurses and other medical staff, and number of beds and their interactions with each other are introduced to the SFA models of outputs of outpatient visits and inpatient discharges adjusted with case mix index are derived. Firstly, we found that the years associated with Covid-19 have a significant negative impact on the inpatient service efficiency. Training and Research and City Hospitals have low efficiency scores in outpatient services but high efficiency scores in inpatient services. In addition, the regions with high population rates have positive impact in outpatient efficiency and negative impact in inpatient efficiency. During the pandemic, city hospitals, have received large investments, gained a key role by increasing both the patient load and their efficiency. Future reforms can be guided by taking advantage of the efficiency differences of hospitals in different environmental factors.