Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda.

BACKGROUND: Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level. METHODS: A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%. RESULTS: Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters. CONCLUSION: Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.

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.

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.

Burden of emergency conditions and emergency care usage: new estimates from 40 countries.

OBJECTIVE: To estimate the global and national burden of emergency conditions, and compare them to emergency care usage rates. METHODS: We coded all 291 Global Burden of Disease 2010 conditions into three categories to estimate emergency burden: conditions that, if not addressed within hours to days of onset, commonly lead to serious disability or death; conditions with common acute decompensations that lead to serious disability or death; and non-emergencies. Emergency care usage rates were obtained from a systematic literature review on emergency care facilities in low-income and middle-income countries (LMICs), supplemented by national health system reports. FINDINGS: All 15 leading causes of death and disability-adjusted life years (DALYs) globally were conditions with potential emergent manifestations. We identified 41 facility-based reports in 23 countries, 12 of which were in LMICs; data for 17 additional countries were obtained from national or regional reports on emergency usage. Burden of emergency conditions was the highest in low-income countries, with median DALYs of 47 728 per 100 000 population (IQR 45 253-50 085) in low-income, 25 186 (IQR 21 982-40 480) in middle-income and 15 691 (IQR 14 649-16 382) in high-income countries. Patterns were similar using deaths to measure burden and excluding acute decompensations from the definition of emergency conditions. Conversely, emergency usage rates were the lowest in low-income countries, with median 8 visits per 1000 population (IQR 6-10), 78 (IQR 25-197) in middle-income and 264 (IQR 177-341) in high-income countries. CONCLUSIONS: Despite higher burden of emergency conditions, emergency usage rates are substantially lower in LMICs, likely due to limited access to emergency care.

Educating a new generation of doctors to improve the health of populations in low- and middle-income countries.

Francesca Celletti and colleagues from WHO argue that a transformation in the scale-up of medical education in low- and middle-income countries is needed, and detail what this might look like.

A survey of past participants in the Annals of Emergency Medicine editorial board fellowship program.

Annals of Emergency Medicine established the Resident Editorial Fellow program for senior residents in 1998. As of 2009, 14 residents had completed the 1-year program. We survey the literature on training of medical editors, describe the structure of the fellowship, and present the results of a survey of all past participants, documenting their subsequent professional positions and the perceived influence of the fellowship on their careers. The response rate was 100%.