Clinical decision making in older adults with COVID-19 in developing countries: looking beyond chronological age

ABSTRACT Background: The coronavirus disease 2019 (COVID-19) has been declared a global pandemic. Older adults have been found as a vulnerable group for developing severe forms of disease and increased mortality. Objective: The objective of the study was to propose a pathway to assist the decision-making process for hospital resource allocation for older adults with COVID-19 using simple geriatric assessment-based tools. Methods: We reviewed the available literature at this point of the COVID-19 outbreak, focusing in older adult care to extract key recommendations for those health-care professionals who will be treating older adults in the hospital emergency ward (HEW) in developing countries during the COVID-19 pandemic. Results: We listed a series of easy recommendations for non-geriatrician doctors in the HEW and suggested simple tools for hospital resource allocation during critical care evaluation of older adults with COVID-19 in low- and middle-income countries. Conclusions: Age must not be used as the sole criterion for resource allocation among older adults with COVID-19. Simple and efficient tools are available to identify components of the comprehensive geriatric assessment, which could be useful to predict outcomes and provide high-quality care that would fit the particular needs of older adults in resource-limited settings amidst this global pandemic.

Desafios para o trabalho em saúde: um estudo comparado de Hospitais Universitários na Argélia, Brasil e França / Challenges for work in healthcare: comparative study on University Hospitals in Algeria, Brazil and France

Resumo O estudo compara os desafios no trabalho em serviços de emergência de hospitais universitários públicos na Argélia, Brasil e França. A descrição e a análise estão organizadas em três eixos: contexto e trajetória dos sistemas, hospitais e serviços de emergência, e os desafios enfrentados. Nos serviços foram feitas entrevistas, questionários, observação e "groupes de rencontre du travail"/GRT. Para o processo analítico utilizou-se técnicas do "participatory appraisal" complementadas com triangulação de fontes e dados. Os principais desafios referidos foram: déficit da força de trabalho; falta de leitos nos serviços de internação; déficit de infraestrutura e materiais; excesso de atividades cronofágicas; transição geracional; violência pelos usuários e familiares. Medidas de racionalização e contenção de gastos repercutem de modo mais intenso na Argélia e no Brasil onde há um baixo patamar de financiamento público. Nota-se que a gestão hospitalar não pode estar dissociada do planejamento da rede de atenção, tendo em vista as crescentes pressões do complexo produtivo, da transição demográfica e epidemiológica. A médio prazo, medidas que possam atenuar atividades cronofágicas, o deficit de materiais e a violência devem ser consideradas na melhoria do trabalho em emergências.

Abstract This study compares the challenges for work in emergency services of publicuniversity hospitals in Algeria, Brazil and France. The description and analysis are organized in three topics: context and trajectory of the health systems; hospitals and emergency services; and the challenges that are faced. The research carried out interviews, surveys, observation and "groupes de rencontre du travail" / GRT. The data analysis was done using participatory appraisal techniques associated to triangulation of sources and data. The main challenges found were: workforce deficit; lack of hospitals beds in inpatient units; deficit of infrastructure and materials; excess of "chronophagic activities"; generational transition; and violence by patients and families.Despite their particularities, the countries coincide regarding the challenges. Measures to rationalize and restrain spending have a greater impact on Algeria and Brazil due to the low level of public funding, but they also occur in France. The hospital management cannot be dissociated from healthcare system planningconsidering the increasing pressures of the demographic and epidemiological transition. In medium term, measures that may mitigate "chronophagic activities", materials deficit and the violence should be considered to improve work in emergencies.

Evolution of incidence, mortality and cost of nontraumatic abdominal emergencies treated in Brasil in a period of nine years

SUMMARY OBJECTIVE: To evaluate the incidence, mortality and cost of non-traumatic abdominal emergencies treated in Brazilian emergency departments. METHODS: This paper used DataSus information from 2008 to 2016 (http://www.tabnet.datasus.gov.br). The number of hospitalizations, costs - AIH length of stay and mortality rates were described in acute appendicitis, acute cholecystitis, acute pancreatitis, acute diverticulitis, gastric and duodenal ulcer, and inflammatory intestinal disease. RESULTS: The disease that had the highest growth in hospitalization was diverticular bowel disease with an increase of 68.2%. For the period of nine years, there were no significant changes in the average length of hospital stay, with the highest increase in gastric and duodenal ulcer with a growth of 15.9%. The mortality rate of gastric and duodenal ulcer disease increased by 95.63%, which is significantly high when compared to the other diseases. All had their costs increased but the one that proportionally had the highest increase in the last nine years was the duodenal and gastric ulcer, with an increase of 85.4%. CONCLUSION: Non-traumatic abdominal emergencies are extremely prevalent. Hence, the importance of having updated and comparative data on the mortality rate, number of hospitalization and cost generated by these diseases to provide better healthcare services in public hospitals.

RESUMO OBJETIVO: Avaliar a evolução da Incidência, mortalidade e custo das urgências abdominais não traumáticas atendidas nos serviços de emergência do Brasil durante o período de nove anos. MÉTODOS: Este trabalho utilizou informações do DataSus de 2008 a 2016, (http://www.tabnet.datasus.gov.br). Foram analisados número de internações, valor médio das internações (AIH), valor total das internações, dias de permanência hospitalar e taxa de mortalidade das seguintes doenças: apendicite aguda, colecistite aguda, pancreatite aguda, diverticulite aguda, úlcera gástrica e duodenal, e doença inflamatória intestinal. RESULTADOS: A doença que teve o maior crescimento do número de internações foi a doença diverticular do intestino, com o valor de 68,2%. Ao longo dos nove anos não houve grandes variações da média de permanência hospitalar, sendo que o maior aumento foi o da úlcera gástrica e duodenal, com crescimento de 15,9%. A taxa de mortalidade da doença por úlcera gástrica e duodenal teve um aumento de 95,63%, consideravelmente significante quando comparada com as outras doenças. Todas tiveram seus valores de AIH aumentados, porém, a que proporcionalmente teve o maior aumento nos últimos nove anos foi a úlcera gástrica e duodenal, com um acréscimo de 85,4%. CONCLUSÃO: As urgências abdominais de origem não traumática são de extrema prevalência, por isso a importância em ter dados atualizados e comparativos sobre a taxa de mortalidade, o número de internações e os custos gerados por essas doenças, para melhor planejamento dos serviços públicos de saúde.

Costos directos de atención médica de accidentes de tránsito en Bogotá D. C / Direct costs involved in providing medical attention associated with traffic accidents in Bogotá

Objetivo Determinar los costos de atención médica generados por la accidentalidad vial en Bogotá. Metodología Estudio observacional prospectivo con datos de pacientes mayores de edad atendidos en la central de urgencias de 6 instituciones hospitalarias. Resultados El promedio del costo totalde atención por paciente fue de $1'112.000 El costo promedio día de paciente hospitalizado fue de $1'200.000. Pacientes con atención ambulatoria tuvieron un costo promedio de $247.400. El costo promedio por accidente se calculó en $2'333.700. Los costos médicos por accidentes en el periodo de análisis en Bogotá fueron aproximadamente $2.301'028.200. Cifras en pesos de 2011. Conclusiones Los costos de la atención médica de los accidentes de tránsito constituyen una carga económica considerable.

Objective To determine the cost of medical attention associated with traffic accidents in Bogotá, Colombia. Methods Prospective observational study with data from adult patients attended to in the emergency centers of 6 hospitals. Results Average total cost per patient was $1'112.000 COP. Average daily cost of hospitalized patients was $1'200.000 COP. Average cost of ambulatory treated patients ascended to $247.400 COP. Cost per accident calculated was $2'333.700 COP. In the whole city during study period, total medical costs were around $2.301'028.200 COP. All data was expressed in 2011 Colombian pesos. Conclusion The medical cost of transit accidents is a significant economic burden.

The Impact of an Emergency Fee Increase on the Composition of Patients Visiting Emergency Departments / 예방의학회지

OBJECTIVES: This study aimed to test our hypothesis that a raise in the emergency fee implemented on March 1, 2013 has increased the proportion of patients with emergent symptoms by discouraging non-urgent emergency department visits. METHODS: We conducted an analysis of 728 736 patients registered in the National Emergency Department Information System who visited level 1 and level 2 emergency medical institutes in the two-month time period from February 1, 2013, one month before the raise in the emergency fee, to March 31, 2013, one month after the raise. A difference-in-difference method was used to estimate the net effects of a raise in the emergency fee on the probability that an emergency visit is for urgent conditions. RESULTS: The percentage of emergency department visits in urgent or equivalent patients increased by 2.4% points, from 74.2% before to 76.6% after the policy implementation. In a group of patients transferred using public transport or ambulance, who were assumed to be least conscious of cost, the change in the proportion of urgent patients was not statistically significant. On the other hand, the probability that a group of patients directly presenting to the emergency department by private transport, assumed to be most conscious of cost, showed a 2.4% point increase in urgent conditions (p<0.001). This trend appeared to be consistent across the level 1 and level 2 emergency medical institutes. CONCLUSIONS: A raise in the emergency fee implemented on March 1, 2013 increased the proportion of urgent patients in the total emergency visits by reducing emergency department visits by non-urgent patients.

Use of Drug-eluting Stents Versus Bare-metal Stents in Korea: A Cost-minimization Analysis Using Population Data / 예방의학회지

OBJECTIVES: The goal of this study was to perform an economic analysis of a primary stenting with drug-eluting stents (DES) compared with bare-metal stents (BMS) in patients with acute myocardial infarction (AMI) admitted through an emergency room (ER) visit in Korea using population-based data. METHODS: We employed a cost-minimization method using a decision analytic model with a two-year time period. Model probabilities and costs were obtained from a published systematic review and population-based data from which a retrospective database analysis of the national reimbursement database of Health Insurance Review and Assessment covering 2006 through 2010 was performed. Uncertainty was evaluated using one-way sensitivity analyses and probabilistic sensitivity analyses. RESULTS: Among 513 979 cases with AMI during 2007 and 2008, 24 742 cases underwent stenting procedures and 20 320 patients admitted through an ER visit with primary stenting were identified in the base model. The transition probabilities of DES-to-DES, DES-to-BMS, DES-to-coronary artery bypass graft, and DES-to-balloon were 59.7%, 0.6%, 4.3%, and 35.3%, respectively, among these patients. The average two-year costs of DES and BMS in 2011 Korean won were 11 065 528 won/person and 9 647 647 won/person, respectively. DES resulted in higher costs than BMS by 1 417 882 won/person. The model was highly sensitive to the probability and costs of having no revascularization. CONCLUSIONS: Primary stenting with BMS for AMI with an ER visit was shown to be a cost-saving procedure compared with DES in Korea. Caution is needed when applying this finding to patients with a higher level of severity in health status.

Efectividad de un programa de promoción de la salud en la disminución de costos médicos asistenciales / A health promotion programme's effectiveness in reducing medical care costs

Objetivo La práctica regular de actividad física sería capaz de reducir la frecuencia de enfermedades y podría repercutir en la reducción de costos médicos asistenciales. Explorar la posible reducción de costos asistenciales en personas activas. Métodos En una institución prestadora de servicios de salud, se contrastan los costos médicos de un grupo de personas activas con un grupo control de personas tomadas aleatoriamente del resto de la población afiliada. Resultados Los costos médicos son más bajos en las personas activas en aspectos como urgencias, hospitalizaciones y medicamentos. Se observa reducción en la frecuencia de los casos y en el costo promedio por paciente y por servicio. Conclusión La actividad física practicada en forma regular reduce los requerimientos de atención médica y con ello se genera un ahorro significativo en los costos asistenciales. Se abren perspectivas promisorias para la implementación de programas de promoción de la salud a nivel poblacional y para la racionalización de los recursos económicos en el sector salud.

Objective Regularly engaging in physical activity should enable disease incidence to become reduced and may result in reducing healthcare costs. Exploring possible health care cost reduction in active people. Methods An active group of people's medical costs were contrasted with those of a control group of people taken at random from the rest of the population so covered in a health-care providing institution. Results Medical costs were lower for active people in areas such as emergency room visits, hospitalization and providing medication; a reduction was observed in the frequency of cases and the average cost per patient and per service. Conclusion Regular physical activity reduces health care requirements and thereby leads to significant savings in health-care costs. This leads to promising perspectives for implementing health promotion programmes amongst the population and rationalising health sector financial resources.

Continuity of Care for Elderly Patients with Diabetes Mellitus, Hypertension, Asthma, and Chronic Obstructive Pulmonary Disease in Korea

We sought to assess continuity of care for elderly patients in Korea and to examine any association between continuity of care and health outcomes (hospitalization, emergency department visits, health care costs). This was a retrospective cohort study using the Korea National Health Insurance Claims Database. Elderly people, 65-84 yr of age, who were first diagnosed with diabetes mellitus (n=268,220), hypertension (n=858,927), asthma (n=129,550), or chronic obstructive pulmonary disease (COPD, n=131,512) in 2002 were followed up for four years, until 2006. The mean of the Continuity of Care Index was 0.735 for hypertension, 0.709 for diabetes mellitus, 0.700 for COPD, and 0.663 for asthma. As continuity of care increased, in all four diseases, the risks of hospitalization and emergency department visits decreased, as did health care costs. In the Korean health care system, elderly patients with greater continuity of care with health care providers had lower risks of hospital and emergency department use and lower health care costs. In conclusion, policy makers need to develop and try actively the program to improve the continuity of care in elderly patients with chronic diseases.

Complejidad de las consultas en un servicio de urgencia con consultorio municipal adosado / Complexity of the consultations in a service of urgency with leaned municipal physicians offices

Se analizó la complejidad de las atenciones registradas durante el año 2003 en el Servicio de Urgencia del Hospital de Purranque. Para su clasificación se consideraron las acciones médicas y de enfermería necesarias para resolver la consulta de los pacientes, considerando que no son urgencia aquellas que sólo necesitaron una indicación médica o una acción clínica simple. Los resultados muestran que un 79,4 por ciento de consultas son de baja morbilidad, las cuales se concentran más en las mujeres. No existió una variación importante en las proporciones durante los meses del año ni entre los días de semana y fines de semana, lo que apoya la idea de que las soluciones primaria se centran más en calidad que en el número de atenciones. La carga de costo que significa para el hospital llega casi ser el doble de los costos de las urgencias reales. Finalmente se propone ocupar este instrumento para monitorizar los cambios que se introduzcan en la atención primaria.

Custos hospitalares das cefaléias agudas em uma unidade de emergência pública brasileira / Hospitalar costs of acute headaches in a Brazilian public emergency room unit

Cefaléia é uma das queixas mais freqüentes na prática médica e causa bastante comum de atendimento em unidades de emergência, implicando custos consideravelmente altos. Foram estudados retrospectivamente os casos de cefaléia atendidos na Unidade de Emergência do Hospital das Clinicas de Ribeirao Preto (UE) no ano de 1996. Neste ano, 1254 pacientes procuraram a UE com queixa de cefaléia aguda, sendo que 64 necessitaram de internaçao. O custo estimado com o atendimento, investigaçao e tratamento clínico das cefaléias agudas foi da ordem de R$ 138,573.31 (US$ 76,985.17). Os gastos apenas com exames laboratoriais foram R$ 23,801.54 (US$ 13,223.07). Os custos cirúrgicos foram R$ 5,817.90 (US$ 3,232.17). Os custos totais foram RS$ 144,391.21 (US$ 80,217.34), o que equivale a R$ 115,14 (US$ 63.97) por paciente. Tais cálculos estimulam discussao adicional acerca de custos e eficácia do modelo de saúde vigente, em que os recursos financeiros sao precários e as necessidades da populaçao dependente do estado sao proporcionalmente maiores

Sistema de residencias y relación costo/beneficio con respecto a otros sistemas de atención médica / Residence system and cost/benefit related to other medical assistance systems

Ante el planteo del problema de si la residencia es un adecuado sistema de asistencia, y frente al desconocimiento de la relación costo/beneficio en la atención médica por residentes, y con el objetivo de comparar un grupo de variables (número de diagnósticos, uso de exámenes de laboratorio, mortalidad global y días de estadía) entre pacientes asistidos por la Residencia (1990-1991) y por la Planta (1986-1987), se estudiaron retrospectivamente 609 pacientes, en quienes se registraron sexo, edad, diagnósticos efectuados, días de estadía, uso de métodos complementarios y condiciones de alta. Los resultados arrojaron una estadía por paciente más corta, un mayor número de diagnósticos, mayor índice de sobrevida y menor índice de mortalidad en pacientes asistidos por la Residencia, con un mayor costo en el uso de métodos de laboratorio

The nature of interpersonal violence in Jamaica and its strain on the national health system

A random prospective study of 640 victims (76.6 per cent in the 15-39-year-old age group) of interpersonal violence (IPV) at the Kingston Public Hospital was conducted over three months. About 87.5 per cent of the aggression on males and 74.5 per cent on females was committed by males. However, there was more female/female than female/male violence. Weapons used ranged from guns to a variety of cooking wares, though knives were used most frequently (34.8 per cent ) for stabbing 48 per cent of the victims. Head, neck and upper limb were the main sites of injury; only 13.4 per cent of all the injured had complications, and 63 per cent of these required hospitalization. Family members and acquaintances contributed to about 84 per cent of the violence. Instinctive spontaneous aggression aimed at maiming the victim characterizes IPV in Jamaica. The Jamaican taxpayer bears 90-94 per cent of the cost of managing trauma injuries. These costs should be recovered from the assailants, even in the form of blood donations and community service.