The impact of socioeconomic status on emergency department outcome in a low-income country setting: A registry-based analysis.

BACKGROUND: The impact of socioeconomic status on health has been established via a broad body of literature, largely from high-income countries. Investigative efforts in low- and middle-income countries have suffered from a lack of reporting standardization required to draw comparisons across countries of varying economic strata. In this study we aimed to evaluate the impact of socioeconomic status on emergency department outcomes in a low-income African country using international data classification systems. METHODS: This was a retrospective cohort study was conducted at a tertiary care center in northern Madagascar. Data were abstracted from paper charts into an electronic registry using Integrated Public Use Microdata Series codes for occupation, Nam-Powers-Boyd (NPB) scores for socioeconomic status, and Clinical Classifications Software ICD-9 equivalents for diagnosis. Outcome was dichotomized to the combined disposition of death or transfer directly to operating theater (OT) versus discharge. We used t-tests to compare baseline characteristics between these groups. We used chi-square analysis to test the association between occupational class and diagnosis. Finally, multivariate logistic regression analysis was performed examining the impact of NPB score on death/OT outcome, adjusting for age, gender, diagnosis and occupation. RESULTS: 5271 patients were seen during the 21-month study period with a death/OT rate of 9.7%. Older age and male gender were more common in death/OT patients (both p<0.001), and were shown to have positive odds ratios for this outcome in multivariate modeling (p<0.006 and <0.001). Occupational class was found to influence diagnosis for all classes (p<0.001) except Sales and Office. Adjusting for these 3 factors, we found a strong independent association between NPB quartile and death/OT outcome. Relative to the 1st quartile, the odds ratio in the 4th quartile was 2.9 (p = 0.004), the 3rd quartile 1.8 (p = 0.094), and the 2nd quartile 3.1 (p<0.001). CONCLUSION: To our knowledge, this is the first Malagasy study describing the relationship between socioeconomic status on emergency care outcomes. We found a stronger effect on health in this setting than in high-income countries, highlighting an important healthcare disparity. By using standardized classification systems we hope this study will serve as a model to facilitate future comparative efforts.

The clinical practice of emergency medicine in Mahajanga, Madagascar.

INTRODUCTION: Little is documented concerning the clinical practice of emergency care in low- and middle-income countries. The lack of structural models presents serious obstacles to the development of effective emergency care services. This study provides such a model by describing the clinical practice at the emergency centre of the Centre Hôpitalier Universitaire de Mahajanga in Madagascar. METHODS: This was a retrospective chart review of all adult patients presenting to the emergency centre from September to November 2012. Archived chart data were extracted into a computer database. Data included: age, sex, date, diagnostic investigations, procedures, medications, and diagnosis. RESULTS: 727 charts were reviewed, averaging eight patients per day. The three most frequent pathologies observed were trauma, gastrointestinal, and infectious disease. A total of 392 received diagnostic investigations. These were chiefly complete blood counts (n = 218), blood glucose (n = 155) and ECG (n = 92). Chest X-rays (n = 83), extremity X-rays (n = 55) and skull/face X-rays (n = 44) comprised the most common imaging. Ultrasounds were primarily abdominal (n = 9), renal/genitourinary (n = 6), and obstetric (n = 2). Therapeutic interventions were performed in 564 patients, most commonly intravenous access (n = 452) and wound/orthopaedic care (n = 185). Medications were administered to 568 patients, mostly anti-inflammatory/analgesics (n = 463) and antibiotics (n = 287). CONCLUSION: This is the first descriptive study of the clinical practice of emergency medicine in Mahajanga, Madagascar. It provides both the Malagasy and international medical communities with an objective analysis of the practice of emergency care in Madagascar from both diagnostic and therapeutic standpoints. Emergency care here focuses on the management of traumatic injury and infectious disease. The diagnostic imaging, pharmacologic and procedural therapeutic interventions reflect the burdens placed upon this institution by these diseases. We hope this study will provide guidance for the further development of Malagasy-specific emergency care systems.

INTRODUCTION: La pratique clinique des soins d'urgence dans les pays à revenu faible et intermédiaire est peu documentée. L'absence de modèles structurels pose de sérieux obstacles au développement de services de soins d'urgence efficaces. Cette étude propose un tel modèle en décrivant la pratique clinique au centre d'urgence du Centre Hospitalier Universitaire de Mahajanga, à Madagascar. MÉTHODES: Il s'agit ici d'un examen rétrospectif des dossiers de tous les patients adultes s'étant présentés au centre d'urgence de septembre à novembre 2012. Des données tirées de dossiers archivés ont été extraites et saisies dans une base de données informatique. Il s'agissait notamment de: l'âge, le sexe, la date, les enquêtes de diagnostic, les procédures, les médicaments et le diagnostic. RÉSULTATS: 727 dossiers ont été examinés, soit en moyenne huit patients par jour. Les trois pathologies les plus fréquemment observées étaient les traumatismes ainsi que les maladies gastro-intestinales et infectieuses. Un total de 392 dossiers avaient fait l'objet d'enquêtes de diagnostic. Elles portaient principalement sur la numération et formule sanguine (n = 218), la glycémie (n = 155) et l'ECG (n = 92). Les types d'imagineries les plus courantes étaient les radiographies du thorax (n = 83), les radiographies des extrémités (n = 55) et les radiographies du crâne et du massif facial (n = 44). Les échographies étaient principalement abdominales (n = 9), rénales/génito-urinaires (n = 6) et obstétricales (n = 2). Des interventions thérapeutiques ont été effectuées chez 564 patients; il s'agissait le plus souvent d'une perfusion intraveineuse (n = 452) et du traitements de plaies/orthopédiques (n = 185). Des médicaments ont été administrés à 568 patients, pour la plupart des anti-inflammatoires/analgésiques (n = 463) et des antibiotiques (n = 287). CONCLUSION: Il s'agit de la première étude descriptive de la pratique clinique en médecine d'urgence à Mahajanga, Madagascar. Elle fournit à la communauté malgache et à la communauté médicale internationale une analyse objective de la pratique des soins d'urgence à Madagascar du point de vue diagnostique comme du point de vue thérapeutique. Les soins d'urgence se concentrent ici sur la gestion des lésions traumatiques et des maladies infectieuses. L'imagerie diagnostique, les interventions thérapeutiques pharmacologiques et de procédure reflètent les charges que représentent ces maladies sur cette institution. Nous espérons que cette étude fournira des orientations pour la poursuite du développement de systèmes de soins d'urgence propres au contexte malgache.

The burden of acute disease in Mahajanga, Madagascar - a 21 month study.

BACKGROUND: Efforts to develop effective and regionally-appropriate emergency care systems in sub-Saharan Africa are hindered by a lack of data on both the burden of disease in the region and on the state of existing care delivery mechanisms. This study describes the burden of acute disease presenting to an emergency unit in Mahajanga, Madagascar. METHODS AND FINDINGS: Handwritten patient registries on all emergency department patients presenting between 1 January 2011 and 30 September 2012 were reviewed and data entered into a database. Data included age, sex, diagnosis, and disposition. We classified diagnoses into Clinical Classifications Software (CCS) multi-level categories. The population was 53.5% male, with a median age of 31 years. The five most common presenting conditions were 1) Superficial injury; contusion, 2) Open wounds of head; neck; and trunk, 3) Open wounds of extremities, 4) Intracranial injury, and 5) Unspecified injury and poisoning. Trauma accounted for 48%, Infectious Disease for 15%, Mental Health 6.1%, Noncommunicable 29%, and Neoplasms 1.2%. The acuity seen was high, with an admission rate of 43%. Trauma was the most common reason for admission, representing 19% of admitted patients. CONCLUSIONS: This study describes the burden of acute disease at a large referral center in northern Madagascar. The Centre Hôpitalier Universitaire de Mahajanga sees a high volume of acutely ill and injured patients. Similar to other reports from the region, trauma is the most common pathology observed, though infectious disease was responsible for the majority of adult mortality. Typhoid fever other intestinal infections were the most lethal CCS-coded pathologies. By utilizing a widely understood classification system, we are able to highlight contrasts between Mahajanga's acute and overall disease burden as well as make comparisons between this region and the rest of the globe. We hope this study will serve to guide the development of context-appropriate emergency medicine systems in the region.

Patterns of reading performance in acute stroke: A descriptive analysis.

UNLABELLED: One of the main sources of information regarding the underlying processes involved in both normal and impaired reading has been the study of reading deficits that occur as a result of brain damage. However, patterns of reading deficits found acutely after brain injury have been little explored. The observed patterns of performance in chronic stroke patients might reflect reorganization of the cognitive processes underlying reading or development of compensatory strategies that are not normally used to read. METHOD: 112 acute left hemisphere stroke patients were administered a task of oral reading of words and pseudowords within 1-2 days of hospital admission; performance was examined for error rate and type, and compared to that on tasks involving visual lexical decision, visual/auditory comprehension, and naming. RESULTS: Several distinct patterns of performance were identified. Although similarities were found between the patterns of reading performance observed acutely and the classical acquired dyslexias generally identified more chronically, some notable differences were observed. Of interest was the finding that no patient produced any pure semantic errors in reading, despite finding such errors in comprehension and naming.