Clinical profile and outcomes of paediatric patients with acute seizures: a prospective cohort study at an urban emergency department of a tertiary hospital in Tanzania.

OBJECTIVE: Children with seizures require immediate and appropriate intervention in the emergency department (ED). This study describes the clinical profile and outcome of paediatric patients with seizures at the ED in a country with limited resources. DESIGN: A prospective, observational cohort study of paediatric patients with seizure presenting to an ED conducted over a six-month period from 1 August 2019 to 31 January2020. SETTING: The study was conducted at the ED of Muhimbili National Hospital, a level 1 trauma centre located in Dar es Salaam, Tanzania. PARTICIPANTS: Paediatric patients aged 1 month to 14 years presenting at the ED with acute seizure, defined as any seizure occurring from 24 hours to 7 days prior to the visit, were included in this study. Patients were consecutively enrolled during times a research assistant was present in the department. Newborns, children with repeat visits or no signs of life on arrival were excluded. OUTCOME: The primary outcome was the proportion of paediatric patients presenting with seizures and their mortality rate; secondary outcome was risk factors for mortality. RESULT: During the study period, 1011 children were seen in the department, of whom 114 (11.3%) (95% CI 9.3% to 13.3%) presented with seizures. Median age was 24 months (IQR 9-60), 78.1% were under 5 years and 55.3% were males. The majority 76 (66.7%) of the patients presented with generalised seizures. Half 58 (50.9%) of patients presented with fever. Meningitis was the most common aetiology, diagnosed in 30 (26.3%). Overall mortality was 16.7% (95% CI 10.3% to 24.8%). Using negative log binominal analysis, fever (relative risk, RR 2.7), altered mental status (RR 21.1), hypoxia (RR 3.3), abnormal potassium (RR 2.4) and clinical diagnosis of meningitis (RR 3.4) were statistically significantly associated with mortality. CONCLUSIONS: Findings from this study revealed higher incidence of paediatric patients with seizures than that reported in high-income countries and other low-income and middle-income countries. The acuity of illness was high, with 16.7% mortality rate. The presence of fever, altered mental status, hypoxia, abnormal potassium levels and meningitis diagnosis were associated with higher risk of mortality. Further research is needed to develop interventions to improve outcomes in paediatric patients with seizures in our setting.

The cost of opioid use disorder-related conditions in Medicare.

BACKGROUND: Medicare coverage excludes some levels of substance use disorder (SUD) care, such as intensive outpatient and residential treatment. Expanding access to SUD treatment could increase Medicare spending. However, these costs could be offset if SUD treatment resulted in cost savings from reducing SUD-related medical events and SUD-related medical comorbidities. METHODS: This study estimated cost savings from expanding access to SUD treatment for persons with opioid use disorders (OUD) using three methods. First, we compared total Medicare fee-for-service spending on individuals with OUD and no treatment with OUD medications (MOUD) to Medicare spending on individuals without OUD after matching on age/sex/Medicare-Medicaid eligibility status. Second, we compared Medicare spending on individuals with OUD who received MOUD to spending individuals with OUD who did not receive MOUD. Third, we determined OUD-attributable Medicare spending for comorbid physical and mental conditions with a strong association with OUD. RESULTS: Beneficiaries with OUD but no MOUD totaled $15.8 billion more than beneficiaries without OUD. Beneficiaries with OUD but no MOUD totaled $12.1 billion more than individuals with OUD and MOUD. Lastly, Medicare spending on OUD-attributable comorbidities was $4.7 billion if all medical and mental health comorbidities were included and $3.0 billion with only medical comorbidities. The totals could be 1.7 times higher if Medicare Advantage enrollees were included. CONCLUSION: Expanding Medicare coverage of appropriate levels of care could improve access to effective treatment and reduce the costs associated with untreated OUD. This will likely result in substantial Medicare cost savings.

Out-of-pocket cost for medical care of injured patients presenting to emergency department of national hospital in Tanzania: a prospective cohort study.

OBJECTIVE: We aimed to determine the out-of-pocket (OOP) costs for medical care of injured patients and the proportion of patients encountering catastrophic costs. DESIGN: Prospective cohort study SETTING: Emergency department (ED) of a tertiary-level hospital in Dar es Salaam, Tanzania. PARTICIPANTS: Injured adult patients seen at the ED of Muhimbili National Hospital from August 2019 to March 2020. METHODS: During alternating 12-hour shifts, consecutive trauma patients were approached in the ED after stabilisation. A case report form was used to collect social-demographics and patient clinical profile. Total charges billed for ED and in-hospital care and OOP payments were obtained from the hospital billing system. Patients were interviewed by phone to determine the measures they took to pay their bills. PRIMARY OUTCOME MEASURE: The primary outcome was the proportion of patients with catastrophic health expenditure (CHE), using the WHO definition of OOP expenditures ≥40% of monthly income. RESULTS: We enrolled 355 trauma patients of whom 51 (14.4%) were insured. The median age was 32 years (IQR 25-40), 238 (83.2%) were male, 162 (56.6%) were married and 87.8% had ≥2 household dependents. The majority 224 (78.3%) had informal employment with a median monthly income of US$86. Overall, 286 (80.6%) had OOP expenses for their care. 95.1% of all patients had an Injury Severity Score <16 among whom OOP payments were US$176.98 (IQR 62.33-311.97). Chest injury and spinal injury incurred the highest OOP payments of US$282.63 (84.71-369.33) and 277.71 (191.02-874.47), respectively. Overall, 85.3% had a CHE. 203 patients (70.9%) were interviewed after discharge. In this group, 13.8% borrowed money from family, and 12.3% sold personal items of value to pay for their hospital bills. CONCLUSION: OOP costs place a significant economic burden on individuals and families. Measures to reduce injury and financial risk are needed in Tanzania.

Patterns and Predictors of Timely Presentation and Outcomes of Polytrauma Patients Referred to the Emergency Department of a Tertiary Hospital in Tanzania.

Background: Polytrauma patients require special facilities to care for their injuries. In HICs, these patients are rapidly transferred from the scene or the first-health facility directly to a trauma center. However, in many LMICs, prehospital systems do not exist and there are long delays between arrivals at the first-health facility and the trauma center. We aimed to quantify the delay and determine the predictors of mortality among polytrauma patients. Methodology. We consecutively enrolled adult polytrauma patients (≥18 years) with ISS >15 referred to the Emergency Medicine Department of Muhimbili National Hospital, a major trauma center in Tanzania between August 2019 and January 2020. Based on a pilot study, the arrival of >6 hours after injury was considered a delay. The outcome of interest was factors associated with delayed presentation and the association of timeliness with 7-day mortality. Results: We enrolled 120 (4.5%) referred polytrauma adult patients. The median age was 30 years (IQR 25-39) and the ISS was 29 (IQR 24-34). The majority (85%) were males. While the median time from injury to first-health facility was 40 minutes (IQR 33-50), the median time from injury to arrival at EMD-MNH, was 377 minutes (IQR 314-469). Delayed presentation was noted in more than half (54.2%) of participants, with the odds of dying being 1.4 times higher in the delayed group (95% CI 0.3-5.6). Having a GCS <8 (AOR 16.3 (95% CI 3.1-86.3), hypoxia <92% (AOR 8.3 (95% CI 1.4-50.9), and hypotension <90 mmHg (R 7.3 (95% CI 1.6-33.6) were all independent predictors of mortality. Conclusion: The majority of polytrauma patients arrive at the tertiary facilities delayed for more than 6 hours and a distance of more than 8 km between facilities is associated with delay. Hypotension, hypoxia, and GCS of less than 8 are independent predictors of poor outcome. In the interim, there is a need to expedite the transfer of polytrauma patients to trauma care capable centers.

Predictors and outcome of cardiac arrest in paediatric patients presenting to emergency medicine department of tertiary hospitals in Tanzania.

BACKGROUND: The survival of children who suffer cardiac arrest is poor. This study aimed to determine the predictors and outcome of cardiac arrest in paediatric patients presenting to an emergency department of a tertiary hospital in Tanzania. METHODOLOGY: This was a prospective cohort study of paediatric patients > 1 month to ≤ 14 years presenting to Emergency Medicine Department of Muhimbili National Hospital (EMD) in Tanzania from September 2019 to January 2020 and triaged as Emergency and Priority. We enrolled consecutive patients during study periods where patients' demographic and clinical presentation, emergency interventions and outcome were recorded. Logistic regression analysis was performed to identify the predictors of cardiac arrest. RESULTS: We enrolled 481 patients, 294 (61.1%) were males, and the median age was 2 years [IQR 1-5 years]. Among studied patients, 38 (7.9%) developed cardiac arrest in the EMD, of whom 84.2% were ≤ 5 years. Referred patients were over-represented among those who had an arrest (84.2%). The majority 33 (86.8%) of those who developed cardiac arrest died. Compromised circulation on primary survey (OR 5.9 (95% CI 2.1-16.6)), bradycardia for age on arrival (OR 20.0 (CI 1.6-249.3)), hyperkalemia (OR 8.2 (95% CI 1.4-47.7)), elevated lactate levels > 2 mmol/L (OR 5.2 (95% CI 1.4-19.7)), oxygen therapy requirement (OR 5.9 (95% CI 1.3-26.1)) and intubation within the EMD (OR 4.8 (95% CI 1.3-17.6)) were independent predictors of cardiac arrest. CONCLUSION: Thirty-eight children developed cardiac arrest in the EMD, with a very high mortality. Those who arrested were more likely to present with signs of hypoxia, shock and acidosis, which suggest they were at later stage in their illness. Outcomes can be improved by strengthening the pre-referral care and providing timely critical management to prevent cardiac arrest.

Predictors and outcome of time to presentation among critically ill paediatric patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania.

BACKGROUND: Mortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown. In this study delay was defined as presentation to the emergency department of tertially hospital i.e. Muhimbili National Hospital, more than 48 h from the onset of the index illness. METHODOLOGY: This was a prospective cohort study of critically ill children aged 28 days to 14 years attending emergency department at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was the association of delay with mortality and secondary outcomes were predictors of delay among critically ill paediatric patients. Logistic regression and relative risk were calculated to measure the strength of the predictor and the relationship between delay and mortality respectively. RESULTS: We enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR = 9-60] months and 63.9% were males. The median time to Emergency Department arrival was 3 days [IQR = 1-5] and more than half (56.6%) of critically ill children presented to Emergency Department in > 48 h whereby being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.4(95% CI 1.4-4.0) and 1.8(95% CI 1.1-2.8) times increased odds of presenting late to the Emergency Department respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR = 1.3, CI: 0.9-1.9). Majority died > 24 h of Emergency Department arrival (P-value = 0.021). CONCLUSION: The risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill pediatric patients to identify preventable delays in care.

Predictive Value of Coronary Artery Calcium in Patients Receiving Computed Tomography Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department.

PURPOSE: Coronary artery calcium (CAC) is a frequent incidental finding on computed tomography pulmonary angiogram (CTPA) in the evaluation of pulmonary embolism (PE) in the emergency department (ED); however, its prognostic value is unclear. In this study, we interrogate the prognostic value of CAC identified on CTPA in predicting adverse outcomes in the evaluation of PE in the ED. MATERIALS AND METHODS: In this retrospective cohort study, we identified 610 patients presenting to the ED in 2013 and evaluated with CTPA for suspected PE. Ordinal CAC scores were evaluated as absent (0), mild (1), moderate (2), or severe (3) in each of the 4 main coronary arteries. Composite CAC scores were subsequently compared against adverse clinical outcomes, defined as intensive care unit admission, hospital stay longer than 72 hours, or death during hospital course or at 6-month follow-up, using univariate and multivariate logistic regression analyses. Relevant exclusion criteria included a history of cardiovascular disease. RESULTS: In all, 365 patients met the inclusion criteria (231 women, mean age 56±16 y) with 132 patients (36%) having some degree of CAC and 16 (4%) having severe CAC. Known malignancy was present in 151 (41%) patients and composite adverse clinical outcomes were observed in 98 patients (32%). Age, presence of acute PE, malignancy, and presence of CAC were significant predictors of adverse outcomes on both univariate and multivariate analyses. CAC was not an independent predictor of short-term adverse outcomes on multivariate analysis ( P =0.06) when all patients were considered. However, when patients with known malignancy were excluded, CAC was an independent predictor of short-term adverse outcomes (odds ratio=2.5, confidence interval=1.1-5.5, P =0.03) independent of age and presence of PE. CONCLUSION: The presence of CAC on CT PA was predictive of adverse outcomes in patients without known cardiac disease presenting to the ED with suspected PE.

Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers.

INTRODUCTION: This study aimed to determine the prevalence of treated and untreated substance use disorders among Medicare beneficiaries, the characteristics of Medicare beneficiaries with substance use disorders, and reasons for their unmet needs. METHODS: This study used data from the National Survey of Drug Use and Health, 2015-2019. Substance use disorder was defined based on DSM-IV dependence or abuse criteria. Descriptive analyses were conducted in 2021, including testing for differences in unadjusted means. RESULTS: Approximately 1.7 million Medicare beneficiaries were estimated to have past-year substance use disorder (8% of Medicare beneficiaries aged <65 years and 2% aged ≥65 years). Overall, 77% had an alcohol use condition, 16% had a prescription drug use condition, and 10% had a marijuana use condition. Of those who had past-year substance use disorder, 11% received treatment for their condition. Common reasons for not receiving treatment were lack of motivation (41%), financial barriers (33%), concern about what others might think (24%), logistical barriers such as lack of transportation (21%), and uncertainty about treatment efficacy (13%). Medicare beneficiaries with substance use disorders were more than twice as likely to have past-year serious psychological distress as those without substance use disorders (44% vs 21%, p<0.001 for those aged <65 years; 14% vs 4%, p<0.001 for those aged ≥65 years). Percentages of past-year suicidal ideation were also much higher among Medicare beneficiaries with substance use disorders than without (24% vs 6%, p<0.001 for those aged <65 years; 7% vs 2%, p=0.006 for those aged ≥65 years). CONCLUSIONS: Few Medicare beneficiaries who need substance use disorder treatment receive it. Reducing Medicare coverage gaps and stigma may help meet this need.

Clinical profile and mortality among adult patients presenting with altered mental status to the emergency departments of a tertiary hospital in Tanzania: a descriptive cohort study.

Introduction: Altered mental status (AMS) in the Emergency Department (ED) can be associated with morbidity and mortality. In high income countries, mortality rate is under 10% for patients presenting with AMS. There is a paucity of data on the profile and mortality amongst this group of patients in limited income countries. Methods: this was a prospective cohort study of adults ≥18 years presenting to the Emergency Departments of Muhimbili National Hospital (MNH) Upanga and Mloganzila in Tanzania with Altered Mental Status (AMS) unrelated to psychiatric illness or trauma, from August 2019 to February 2020. Patient demographic data, clinical profile, disposition and 7-day outcome were recorded. The outcome of mortality was summarized using descriptive statistics. Results: among 26,125 patients presenting during the study period, 2,311 (8.9%) patients had AMS and after exclusion for trauma and psychiatric etiology, 226 (9.8%) patients were included. The median age was 56 years (43-69 years) and 127 (56.2%) were male. Confusion 88 (38.9%) was the most common presenting symptom. Hypertension 121 (53.5%) was the most frequent associated comorbidity. The overall mortality was 80 (35.4%) within 7 days. Of 173 patients admitted to the wards, 54 (31.2%) died and of the 46 (20.4%) admitted to the intensive care unit (ICU), 20 (43.5%) died within 7 days. Six (2.7%) patients died in the emergency department. Conclusion: patients with AMS presenting to two EDs in Tanzania have substantially higher mortality than reported from Hospital Incident Command System (HICS). This could be due to underlying disease, comorbidities or management. Further research could help identify individual etiologies involved and high risk groups which can cater to better understanding this population.

The association of Medicare Part D prior authorization for buprenorphine-naloxone with adherence to opioid use disorder treatment guidelines in the United States.

AIMS: To assess differences in the quality of opioid use disorder (OUD) treatment received by Medicare beneficiaries enrolled in health plans that used prior authorization (PA) for buprenorphine-naloxone compared with those enrolled in plans that did not use PA. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional observational study, United States. Continuously enrolled beneficiaries (71 294) with an OUD who filled at least one prescription for buprenorphine-naloxone between March 2012 and July 2017. MEASUREMENTS: Percentage of patients tested for hepatis B, hepatis C, HIV and liver functioning; percentage of patients with urine drug screens and number of urine drug screens; continuous use of buprenorphine-naloxone for at least 180 days; co-use of benzodiazepines; number of outpatient visits with and without an OUD diagnosis. FINDINGS: PA was significantly associated with a lower likelihood of testing for hepatitis B [-3.5, 95% confidence interval (CI) = -4.4, -2.7] and C (-5.9, 95% CI = -6.9, -4.9), but the findings were inconclusive as to whether or not there was a difference in HIV (-1.1, 95% CI = -2.5, 0.4) or liver function testing (1.3, 95% CI = -0.1, 2.7). PA was associated with a lower likelihood of urine drug screening (-25.5, 95% CI = -26.8, -24.1) and with fewer drug screens (-2.5, 95% CI = -3.0, -2.1). Findings were inconclusive as to whether or not there was a difference in continuous use of buprenorphine-naloxone (0.3, 95% CI = -1.2, 1.8). PA was associated with fewer outpatient visits (-2.1, 95% CI = -3.0, -1.2) and fewer outpatient visits with an OUD diagnosis (-1.7, 95% CI = -2.1, -1.3). PA was associated with a lower likelihood of filling benzodiazepine prescriptions before and after buprenorphine-naloxone induction (-28.9, 95% CI = -29.6, -28.3) but a greater likelihood of only using benzodiazepines after buprenorphine-naloxone induction (10.6, 95% CI = 9.3, 11.8). CONCLUSIONS: US Medicare patients subject to prior authorization for buprenorphine-naloxone are not more likely to receive high-quality treatment for opioid use disorder than patients not subject to prior authorization.

Feasibility and efficacy of text messaging to promote care among trauma patients screened for HIV at an urban emergency department in Tanzania.

BACKGROUND: Due to the high prevalence of human immunodeficiency virus (HIV) in Tanzania, provider-initiated HIV testing for patients attending any health care setting is recommended. However, follow-up and linkage to care by those tested remain poor. We determined the feasibility and efficacy of text messaging to promote follow-up among otherwise healthy trauma patients who underwent provider-initiated HIV testing and counseling at an emergency department (ED) in Tanzania. MATERIAL AND METHODS: This randomized controlled trial (RCT) was conducted at Muhimbili National Hospital (MNH) ED between September 2019 and February 2020. Adult trauma patients consenting to HIV testing and follow-up text messaging were randomized to standard care (pre-test and post-test counseling) or standard care plus a series of three short message service (SMS) text message reminders for follow-up in an HIV clinic, if positive, or for retesting, if negative. Investigators blinded to the study assignment called participants 2 months after the ED visit if HIV-positive or 4 months if HIV-negative. We compared the proportion of people in the intervention and control groups completing recommended follow-up. Secondary outcomes were the proportion of patients agreeing to testing, proportion of patients agreeing to receiving text messages, and the proportion of HIV-positive and HIV-negative patients in each study arm who followed up. RESULTS: Of the 290 patients approached, 255 (87.9%) opted-in for testing and agreed to receive a text message. The median age of the study population was 29 [IQR 24-40] years. There were 127 patients randomized to the intervention group and 128 to the control group. The automated SMS system verified that 381 text messages in total were successfully sent. We traced 242 (94.9%) participants: 124 (51.2%) in the intervention group and 18 (488%) in the control group. A total of 100 (39.2%) subjects reported completing a follow-up visit, of which 77 (60.6%) were from the intervention group and 23 (17.9%) were from the control group (RR = 3.4, 95% CI 2.3-5.0). This resulted in a number needed to treat (NNT) of 2.3. Of the 246 HIV-negative participants, 37% underwent repeat screening: 59% of those in the intervention group and 16% in the control group (RR = 3.7, P = < 0.0001, NNT 2.3). Among the nine positive patients, all five in the intervention group and only three in the controls had follow-up visits. CONCLUSION: Automated text message is a feasible and effective way to increase follow-up in HIV-tested individuals in a limited income country.

Prior Authorization for Opioid Use Disorder Versus Pain Medications: Lessons Learned for Parity Enforcement.

OBJECTIVE: This study characterized the use of prior authorization for opioid use disorder medications as compared with that for opioid pain medications in the United States among Medicare Part D plans. METHOD: Medicare Part D formulary data from 2017-2019 were used to describe differences in prior authorization between opioid use disorder medications and opioid pain medications. RESULTS: In 2017, 72% of Medicare Part D formularies required prior authorization for brand buprenorphine-naloxone, whereas 6% of formularies required prior authorization for brand oxycodone. In 2019, 3% of formularies required prior authorization for brand buprenorphine-naloxone, whereas 16% of formularies required prior authorization for brand oxycodone. Throughout the study period, other formulary restrictions such as quantity limits were similar for both medications. CONCLUSIONS: The disparate use of prior authorization in 2017 for opioid use disorder medications as compared with opioid pain medications suggests that formulary decision making may be inconsistent between medications used to treat substance use disorders and those used to treat pain. If Part D formularies publicly released their decision-making criteria, then there would be a greater understanding of why prior authorization was differentially applied. Greater transparency would help ensure that formulary decisions are not the result of biases and stigma toward substance use disorders.

Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania.

BACKGROUND: The burden of trauma in low and middle-income countries (LMICs) is disproportionately high: LMICs account for nearly 90% of the global trauma deaths. Lack of trauma data has been identified as one of the major challenges in addressing the quality of trauma care and informing injury-preventing strategies in LMICs. This study aimed to explore the barriers and facilitators of current trauma documentation practices towards the development of a national trauma registry (TR). METHODS: An exploratory qualitative study was conducted at five regional hospitals between August 2018 and December 2018. Five focus group discussions (FGDs) were conducted with 49 participants from five regional hospitals. Participants included specialists, medical doctors, assistant medical officers, clinical officers, nurses, health clerks and information communication and technology officers. Participants came from the emergency units, surgical and orthopaedic inpatient units, and they had permanent placement to work in these units as non-rotating staff. We analysed the gathered information using a hybrid thematic analysis. RESULTS: Inconsistent documentation and archiving system, the disparity in knowledge and experience of trauma documentation, attitudes towards documentation and limitations of human and infrastructural resources in facilities we found as major barriers to the implementation of trauma registry. Health facilities commitment to standardising care, Ministry of Health and medicolegal data reporting requirements, and insurance reimbursements criteria of documentation were found as major facilitators to implementing trauma registry. CONCLUSIONS: Implementation of a trauma registry in regional hospitals is impacted by multiple barriers related to providers, the volume of documentation, resource availability for care, and facility care flow processes. However, financial, legal and administrative data reporting requirements exist as important facilitators in implementing the trauma registry at these hospitals. Capitalizing in the identified facilitators and investing to address the revealed barriers through contextualized interventions in Tanzania and other LMICs is recommended by this study.