White Paper on Early Critical Care Services in Low Resource Settings.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Assessment of Local Health Worker Attitudes toward International Medical Volunteers in Low- and Middle-income Countries: A Global Survey.

BACKGROUND: International Medical Volunteers (IMVs) positively and negatively impact host countries, and the goals of their trips may not always align with the interests of the hosts in Low- and Middle-Income Countries (LMICs). We sought to better understand local physicians' interest of hosting IMVs and what type of support they desired. METHODS: This study was a convenience sample survey-based needs assessment. The surveys were distributed to local physicians by 28 professional society groups in LMICs. FINDINGS: A total of 102 physicians from 51 countries completed the survey. Despite 61.8% participants having no experience with IMVs, 75% were interested in hosting them. Host physicians most desired clinical education (39%), research collaboration (18%), and Systems Development (11%). The most requested specialties were obstetrics and gynecology (25%) and emergency medicine (11%). Respondents considered public hospitals (62%) to be the most helpful clinical setting in which IMVs could work, and 3 months (47%) as the ideal length of stay.Respondents expressed interest in advertising the specific needs of the host country to potential IMVs (80%). Qualitative analyses suggested hosts wanted more training opportunities, inclusion of all stakeholders, culturally competent volunteers, and aid focused on subspecialty education, health policy, public health, and research. CONCLUSION: Hosts desire more bidirectional clinical education and research capacity building than just direct clinical care. Importantly, cultural competence is key to a successful host partnership, potentially improved through IMV preparation. Finally, respondents want IMVs to ensure that they stay within their scope of practice and training.

Disparities in mortality after blunt injury: does insurance type matter?

BACKGROUND: Insurance-related outcomes disparities are well-known, but associations between distinct insurance types and trauma outcomes remain unclear. Prior studies have generally merged various insurance types into broad groups. The purpose of this study is to determine the association of specific insurance types with mortality after blunt injury. MATERIALS AND METHODS: Cases of blunt injury among adults aged 18-64 y with an injury severity score >9 were identified using the 2007-2009 National Trauma Data Bank. Crude mortality was calculated for 10 insurance types. Multivariable logistic regression was employed to determine difference in odds of death between insurance types, controlling for injury severity score, Glasgow Coma Scale motor, mechanism of injury, sex, race, and hypotension. Clustering was used to account for possible inter-facility variations. RESULTS: A total of 312,312 cases met inclusion criteria. Crude mortality ranged from 3.2 to 6.0% by insurance type. Private Insurance, Blue Cross Blue Shield, Workers Compensation, and Medicaid yielded the lowest relative odds of death, while Not Billed and Self Pay yielded the highest. Compared with Private Insurance, odds of death were higher for No Fault (OR 1.25, P = 0.022), Not Billed (OR 1.77, P < 0.001), and Self Pay (OR 1.77, P < 0.001). Odds of death were higher for Medicare (OR 1.52, P < 0.001) and Other Government (OR 1.35, P = 0.049), while odds of death were lower for Medicaid (OR 0.89, P = 0.015). CONCLUSIONS: Significant differences in mortality after blunt injury were seen between insurance types, even among those commonly grouped in other studies. Policymakers may use this information to implement programs to monitor and reduce insurance-related disparities.