Why do patients who are triaged as low-acuity visit the emergency department? - A Polish perspective.

BACKGROUND: Emergency departments (EDs) worldwide are dealing with overcrowding, system fragmentation, and coordination problems, which impact patient wait times, staff job satisfaction, and patient outcomes. Inappropriate ED visits, particularly those for low acuity conditions, exacerbate these challenges. However, the motivations behind these visits are poorly understood, with limited data from the patient perspective. This study investigated patient-reported motives behind ED visits triaged as low acuity in Poznan, Poland, to propose health care system flow enhancements. MATERIAL AND METHODS: A cross-sectional survey and retrospective chart review were conducted in the ED of the Hipolit Cegielski Medical Center in Poznan, Poland, over three months in 2022-23. Patients who were triaged to have low acuity conditions were invited to participate in the survey. The data collected through the questionnaire included patient and ED visit characteristics. Additional information on the visits was extracted from the patient charts. MAIN RESULTS: This study involved 293 patients who underwent low-acuity triage. Among them, 58 % were deemed to have conditions that could have been treated in primary care. Most of the patients (74 %) visited the ED of their own volition due to concerns about their health. Other reasons for ED attendance were challenges accessing primary care or a specialist clinic (11 %), system navigation problems (5 %), or a lack of trust in their primary care provider (2 %). CONCLUSIONS: This study showed that of the patients surveyed, the majority had conditions that could have been treated outside of the ED setting. We recommend prioritizing education, particularly among younger adults, to increase awareness about nonurgent care options while improving health care policies.

New paramedic scope of practice in Poland based on the 2022 reform.

Emergency medical systems in the world are mainly based on two main models: the Franco-German System (FGS) and the Anglo-American System (AAS). The characteristic feature of the FGS is the "Stay and Play" principle, while the AAS system is based on the "Scoop and Run" principle. The Polish model is a mix of those two systems mainly based on the work of paramedics. Their scope of operations and powers have changed over time. As a result of the advocacy undertaken by paramedics in Poland, legislation was drafted and became law in June 2023. The central changes include: the introduction of a paramedic register, the establishment of a professional self-government of paramedics, the expansion of professional competencies such as the ability to declare death, and new opportunities for professional development including speciality training or paid training leave. This article discusses the new law in the context of previous legislative solutions in the field of emergency medicine in Poland and in other European countries.

Characteristics and outcomes of patients with COVID-19 who return to the emergency department: a multicentre observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Unplanned return emergency department (ED) visits can reflect clinical deterioration or unmet need from the original visit. We determined the characteristics and outcomes of patients with COVID-19 who return to the ED for COVID-19-related revisits. METHODS: This retrospective observational study used data for all adult patients visiting 47 Canadian EDs with COVID-19 between 1 March 2020 and 31 March 2022. Multivariable logistic regression assessed the characteristics associated with having a no return visit (SV=single visit group) versus at least one return visit (MV=return visit group) after being discharged alive at the first ED visit. RESULTS: 39 809 patients with COVID-19 had 44 862 COVID-19-related ED visits: 35 468 patients (89%) had one visit (SV group) and 4341 (11%) returned to the ED (MV group) within 30 days (mean 2.2, SD=0.5 ED visit). 40% of SV patients and 16% of MV patients were admitted at their first visit, and 41% of MV patients not admitted at their first ED visit were admitted on their second visit. In the MV group, the median time to return was 4 days, 49% returned within 72 hours. In multivariable modelling, a repeat visit was associated with a variety of factors including older age (OR=1.25 per 10 years, 95% CI (1.22 to 1.28)), pregnancy (1.86 (1.46 to 2.36)) and presence of comorbidities (eg, 1.72 (1.40 to 2.10) for cancer, 2.01 (1.52 to 2.66) for obesity, 2.18 (1.42 to 3.36) for organ transplant), current/prior substance use, higher temperature or WHO severe disease (1.41 (1.29 to 1.54)). Return was less likely for females (0.82 (0.77 to 0.88)) and those boosted or fully vaccinated (0.48 (0.34 to 0.70)). CONCLUSIONS: Return ED visits by patients with COVID-19 within 30 days were common during the first two pandemic years and were associated with multiple factors, many of which reflect known risk for worse outcomes. Future studies should assess reasons for revisit and opportunities to improve ED care and reduce resource use. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT04702945.

Limitations of COVID-19 testing and case data for evidence-informed health policy and practice.

BACKGROUND: Coronavirus disease 2019 (COVID-19) became a pandemic within a matter of months. Analysing the first year of the pandemic, data and surveillance gaps have subsequently surfaced. Yet, policy decisions and public trust in their country's strategies in combating COVID-19 rely on case numbers, death numbers and other unfamiliar metrics. There are many limitations on COVID-19 case counts internationally, which make cross-country comparisons of raw data and policy responses difficult. PURPOSE AND CONCLUSIONS: This paper presents and describes steps in the testing and reporting process, with examples from a number of countries of barriers encountered in each step, all of which create an undercount of COVID-19 cases. This work raises factors to consider in COVID-19 data and provides recommendations to inform the current situation with COVID-19 as well as issues to be aware of in future pandemics.

Barriers to and strategies to address COVID-19 testing hesitancy: a rapid scoping review.

BACKGROUND: Testing is a foundational component of any COVID-19 management strategy; however, emerging evidence suggests that barriers and hesitancy to COVID-19 testing may affect uptake or participation and often these are multiple and intersecting factors that may vary across population groups. To this end, Health Canada's COVID-19 Testing and Screening Expert Advisory Panel commissioned this rapid review in January 2021 to explore the available evidence in this area. The aim of this rapid review was to identify barriers to COVID-19 testing and strategies used to mitigate these barriers. METHODS: Searches (completed January 8, 2021) were conducted in MEDLINE, Scopus, medRxiv/bioRxiv, Cochrane and online grey literature sources to identify publications that described barriers and strategies related to COVID-19 testing. RESULTS: From 1294 academic and 97 grey literature search results, 31 academic and 31 grey literature sources were included. Data were extracted from the relevant papers. The most cited barriers were cost of testing; low health literacy; low trust in the healthcare system; availability and accessibility of testing sites; and stigma and consequences of testing positive. Strategies to mitigate barriers to COVID-19 testing included: free testing; promoting awareness of importance to testing; presenting various testing options and types of testing centres (i.e., drive-thru, walk-up, home testing); providing transportation to testing centres; and offering support for self-isolation (e.g., salary support or housing). CONCLUSION: Various barriers to COVID-19 testing and strategies for mitigating these barriers were identified. Further research to test the efficacy of these strategies is needed to better support testing for COVID-19 by addressing testing hesitancy as part of the broader COVID-19 public health response.

Community-informed, integrated, and coordinated care through a community-level model: A narrative synthesis on community hubs.

We identify the core services included in a community hub model of care to improve the understanding of this model for health leaders, decision-makers in community-based organizations, and primary healthcare clinicians. We searched Medline, PubMed, CINAHL, Scopus, Web of Science, and Google from 2000 to 2020 to synthesize original research on community hubs. Eighteen sources were assessed for quality and narratively synthesized (n = 18). Our analysis found 4 streams related to the service delivery in a community hub model of care: (1) Chronic disease management; (2) mental health and addictions; (3) family and reproductive health; and (4) seniors. The specific services within these streams were dependent upon the needs of the community, as a community hub model of care responds and adapts to evolving needs. Our findings inform the work of health leaders tasked with implementing system-level transformations towards community-informed models of care.

Association Between Dementia Care Programs in Assisted Living Facilities and Transitions to Nursing Homes in Ontario, Canada: A Population-Based Cohort Study.

OBJECTIVE: We investigate whether older adults who were newly diagnosed with dementia (severity unspecified) and resided in an assisted living facility that offered a dementia care program had a lower rate of transition to a nursing home, compared to those who resided in an assisted living facility without such a program. DESIGN: Population-based retrospective cohort study. SETTING AND PARTICIPANTS: Linked, person-level health system administrative data on older adults who were newly diagnosed with dementia and resided in an assisted living facility in Ontario, Canada, from 2014 to 2019 (n = 977). METHODS: Access to a dementia care program in an assisted living facility (n = 57) was examined. Multivariable Cox proportional hazards regression with robust standard errors clustered on the assisted living facility was used to model the time to transition to a nursing home from the new dementia diagnosis. RESULTS: There were 11.8 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility with a dementia care program, compared with 20.5 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility without a dementia care program. After adjustment for relevant characteristics at baseline, older adults who resided in an assisted living facility with a dementia care program had a 40% lower rate of transition to a nursing home (hazard ratio 0.60, 95% confidence interval 0.44, 0.81), compared with those in an assisted living facility without such a program at any point during the follow-up period. CONCLUSIONS AND IMPLICATIONS: The rate of transition to a nursing home was significantly lower among older adults who resided in an assisted living facility that offered a dementia care program. These findings support the expansion of dementia care programs in assisted living facilities.

Do assisted living facilities that offer a dementia care program differ from those that do not? A population-level cross-sectional study in Ontario, Canada.

BACKGROUND: Many residents of assisted living facilities live with dementia, but little is known about the characteristics of assisted living facilities that provide specialized care for older adults who live with dementia. In this study, we identify the characteristics of assisted living facilities that offer a dementia care program, compared to those that do not offer such a program. METHODS: We conducted a population-level cross-sectional study on all licensed assisted living facilities in Ontario, Canada in 2018 (n = 738). Facility-level characteristics (e.g., resident and suite capacities, etc.) and the provision of the other 12 provincially regulated care services (e.g., pharmacist and medical services, skin and wound care, etc.) attributed to assisted living facilities were examined. Multivariable Poisson regression with robust standard errors was used to model the characteristics of assisted living facilities associated with the provision of a dementia care program. RESULTS: There were 123 assisted living facilities that offered a dementia care program (16.7% versus 83.3% no dementia care). Nearly half of these facilities had a resident capacity exceeding 140 older adults (44.7% versus 21.6% no dementia care) and more than 115 suites (46.3% versus 20.8% no dementia care). All assisted living facilities that offered a dementia care program also offered nursing services, meals, assistance with bathing and hygiene, and administered medications. After adjustment for facility characteristics and other provincially regulated care services, the prevalence of a dementia care program was nearly three times greater in assisted living facilities that offered assistance with feeding (Prevalence Ratio [PR] 2.91, 95% Confidence Interval [CI] 1.98 to 4.29), and almost twice as great among assisted living facilities that offered medical services (PR 1.78, 95% CI 1.00 to 3.17), compared to those that did not. CONCLUSIONS: A dementia care program was more prevalent in assisted living facilities that housed many older adults, had many suites, and offered at least five of the other 12 regulated care services. Our findings deepen the understanding of specialized care for dementia in assisted living facilities.

Outcomes for Implemented Macroeconomic Policy Responses and Multilateral Collaboration Strategies for Economic Recovery After a Crisis: A Rapid Scoping Review.

To promote postpandemic recovery, many countries have adopted economic packages that include fiscal, monetary, and financial policy measures; however, the effects of these policies may not be known for several years or more. There is an opportunity for decision makers to learn from past policies that facilitated recovery from other disease outbreaks, crises, and natural disasters that have had a devastating effect on economies around the world. To support the development of the United Nations Research Roadmap for COVID-19 Recovery, this review examined and synthesized peer-reviewed studies and gray literature that focused on macroeconomic policy responses and multilateral coalition strategies from past pandemics and crises to provide a map of the existing evidence. We conducted a systematic search of academic and gray literature databases. After screening, we found 22 records that were eligible for this review. The evidence found demonstrates that macroeconomic and multilateral coalition strategies have various impacts on a diverse set of countries and populations. Although the studies were heterogeneous in nature, most did find positive results for macroeconomic intervention policies that addressed investments to strengthen health and social protection systems, specifically cash and unconventional/nonstandard monetary measures, in-kind transfers, social security financing, and measures geared toward certain population groups.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 1: Overview and critical appraisal.

BACKGROUND: Ankle and foot sprains and fractures are common injuries affecting many individuals, often requiring considerable and costly medical interventions. The objectives of this systematic review are to collect, assess, and critically appraise the published literature on the health economics of ankle and foot injury (sprain and fracture) treatment. METHODS: A systematic literature review of Ovid MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, AMED, Ovid Healthstar, and CINAHL was conducted for English-language studies on the costs of treating ankle and foot sprains and fractures published from January 1980 to December 2014. Two reviewers assessed the articles for study quality and abstracted data. RESULTS: The literature search identified 2047 studies of which 32 were analyzed. A majority of the studies were published in the last decade. A number of the studies did not report full economic information, including the sources of the direct and indirect costs, as suggested in the guidelines. The perspective used in the analysis was missing in numerous studies, as was the follow-up time period of participants. Only five of the studies undertook a sensitivity analysis which is required whenever there are uncertainties regarding cost data. CONCLUSION: This systematic review found that publications do not consistently report on the components of health economics methodology, which in turn limits the quality of information. Future studies undertaking economic evaluations should ensure that their methods are transparent and understandable so as to yield accurate interpretation for assistance in forthcoming economic evaluations and policy decision-making.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 2: The direct and indirect costs of injury.

BACKGROUND: Ankle and foot sprains and fractures are prevalent injuries, which may result in substantial physical and economic consequences for the patient and place a financial burden on the health care system. Therefore, the objectives of this paper are to examine the direct and indirect costs of treating ankle and foot injuries (sprains, dislocations, fractures), as well as to provide an overview of the outcomes of full economic analyses of different treatment strategies. METHODS: A systematic review was carried out among seven databases to identify English language publications on the health economics of ankle and foot injury treatment published between 1980 and 2014. The direct and indirect costs were abstracted by two independent reviewers. All costs were adjusted for inflation and reported in 2016 US dollars (USD). RESULTS: Among 2047 identified studies, 32 were selected for analysis. The direct costs of ankle sprain management ranged from $292 to $2268 per patient (2016 USD), depending on the injury severity and treatment strategy. The direct costs of managing ankle fractures were higher ($1908-$19,555). Foot fracture treatment had similar direct costs ranging from $998 to $21,801. The economic evaluations were conducted from the societal or payer's perspectives. CONCLUSION: The costs of treating ankle and foot sprains and fractures varied among the studies, mostly due to differences in injury type and study characteristics, which impacted the ability of directly comparing the financial burden of treatment. Nonetheless, the review showed that the costs experienced by the patient and the health care system increased with injury complexity.

Caregiver Out-of-Pocket Costs for Octogenarian Intensive Care Unit Patients in Canada.

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.

Change in health care use after coordinated care planning: a quasi-experimental study.

BACKGROUND: We sought to determine whether patients with a coordinated care plan developed using the Health Links model of care in the Hamilton Niagara Haldimand Brant Local Health Integration Network differed in their use of health care (no. of emergency department visits, inpatient admissions, length of inpatient stay) when compared with a matched control group of patients with no care plans. METHODS: We performed a propensity score-matched study of 12 months pre- and 12 months post-health care use. Patients who had a coordinated care plan that started between 2013 and 2015 were propensity score matched to patients in a control group. Patient information was obtained from Client Health and Related Information System, National Ambulatory Care Reporting System and Discharge Abstract Database. Differences in health care use pre- and post-index date were compared using the Wilcoxon signed-rank test. A negative binomial regression model was fit for each health care use outcome at 6 and 12 months post-index date. RESULTS: Six hundred coordinated care plan enrollees and 25 449 potential control patients were included in the matching algorithm, which resulted in 548 matched pairs (91.3%). Both groups showed decreases in health care use post-index date. Matched care plan enrollees had significantly fewer emergency department visits at 6 (incidence rate ratio [IRR] 0.81, 95% confidence interval [CI] 0.72-0.91, p < 0.01) and 12 months post-index date (IRR 0.88, 95% CI 0.79-0.99, p < 0.05) compared with the matched controls. Other use parameters were not significantly different between care plan enrollees and the control group. INTERPRETATION: Care plan enrollees show a decrease in the number of times they visit emergency departments, which may be attributed to integrated and coordinated care planning. This association should be examined to see whether these reductions persist for more than 1 year.