Free-for-all: Does crowding impact outcomes because hospital emergency departments do not prioritise effectively?

Unexpected peaks in volumes of attendances at hospital emergency departments (EDs) have been found to affect waiting times, intensity of care and outcomes. We ask whether these effects of ED crowding on patients are caused by poor clinical prioritisation or a quality-quantity trade-off generated by a binding capacity constraint. We study the effects of crowding created by lower-severity patients on the outcomes of approximately 13 million higher-severity patients attending the 140 public EDs in England between April 2016 and March 2017. Our identification approach relies on high-dimensional fixed effects to account for planned capacity. Unexpected demand from low-severity patients has very limited effects on the care provided to higher-severity patients throughout their entire pathway in ED. Detrimental effects of crowding caused by low-severity patients materialise only at very high levels of unexpected demand, suggesting that binding resource constraints impact patient care only when demand greatly exceeds the ED's expectations. These effects are smaller than those caused by crowding induced by higher-severity patients, suggesting an efficient prioritisation of incoming patients in EDs.

Outcomes for university students following emergency care presentation for deliberate self-harm: a retrospective observational study of emergency departments in England for 2017/2018.

OBJECTIVES: Identify university-aged students and contrast their healthcare provision and outcomes with other patients in the same age group attending emergency departments for deliberate self-harm. DESIGN: Retrospective cross-sectional observational study. SETTING: Patients visiting 129 public hospital emergency departments across England between April 2017 and March 2018. PARTICIPANTS: 14 074 patients aged 18-23 visiting emergency departments for conditions linked to deliberate self-harm, 1016 of which were identified as university-aged students. OUTCOME MEASURES: We study various outcomes across the entire patient pathway in the emergency department: waiting time to initial assessment on arrival at the emergency department, count of investigations delivered, discharge destination (patients refusing treatment or leave before being seen, referred to another provider or admitted to inpatient care, discharged with no follow-up) and unplanned follow-up visit within 7 days. RESULTS: We find a statistically significant difference of 0.262 (-0.491 to -0.0327) less investigations delivered to students compared with non-students (about 8% compared with the baseline number of investigations for non-students). Stratified analyses reveal that this difference is concentrated among students visiting the emergency department outside of regular working hours (-0.485 (-0.850 to -0.120)) and students visiting for repeated deliberate self-harm episodes (-0.881 (-1.510 to -0.252)). Unplanned reattendance within 7 days is lower among students visiting emergency departments during out of hours (-0.0306 (-0.0576 to -0.00363)), while students arriving by ambulance are less likely to be referred to another provider (-0.0708 (-0.140 to -0.00182)) compared with non-students. CONCLUSIONS: We find evidence of less-intense investigations being delivered to patients aged 18-23 identified as students compared with non-students visiting emergency departments after an episode of deliberate self-harm. Given the high risk of suicide attempts after episodes of deliberate self-harm among students, our findings may highlight the need for more focused interventions on this group of patients.

Gender-related self-reported mental health inequalities in primary care in England: a cross-sectional analysis using the GP Patient Survey.

BACKGROUND: Transgender, non-binary, and gender diverse people face discrimination and barriers to accessing health care. Existing evidence suggests higher rates of mental health conditions among these groups compared with binary and cisgender groups. However, information is limited by poor gender recording in health records and surveys. We aimed to provide the first national estimates of gender-related inequalities in self-reported mental health conditions and mental health support across 15 gender groups in England. METHODS: We used changes to the 2021 and 2022 nationally representative cross-sectional English General Pracitioner (GP) Patient Surveys and used age-adjusted logistic regression to predict probabilities of two outcomes: first, self-reporting a mental health condition and second, self-reporting unmet mental health needs. We report results for 15 exposure groups: five gender groups (female, male, non-binary, prefer to self-describe, and prefer not to say), within three cisgender or transgender identity groups (cisgender, transgender, or prefer not to say). We explored potential mediation by adding covariates. FINDINGS: Of the 1 520 457 respondents in the estimation sample, 861 017 (51·4%) were female, 645 300 (47·4%) were male, 2600 (0·3%) were non-binary, 2277 (0·2%) self-described their gender, and 9263 (0·7%) preferred not to state their gender. 1 499 852 (98·3%) respondents were cisgender, 7994 (0·7%) were transgender, and 12 611 (1·0%) preferred not to say their cisgender or transgender identity. We found wide gender-related inequalities in the probability of self-reporting a mental health condition, with the highest probabilities among non-binary patients who were transgender (47·21% [95% CI 42·86-51·60]) or preferred not to say their cisgender or transgender identity (32·90% [26·50-40·00]), and among transgender patients who self-described their gender (35·03% [27·39-43·53]). With the exception of non-binary patients in each case, probabilities were lowest among cisgender patient groups (ranging from male at 8·80% [8·69-8·92] to female at 11·97% [11·86-12·07]) and patients who preferred not to say their cisgender or transgender identity (ranging from female 7·15% [6·06-8·42] to prefer to self-describe 10·37% [7·13-14·86]). Inequalities in other health conditions and socioeconomic factors might mediate some of these inequalities. Probabilities of self-reported unmet mental health needs were lowest among cisgender male (15·55% [15·33-15·76]) and female (15·93% [15·76-16·10]) patients with increased probabilities among all other groups, ranging from 19·95% (17·57-22·57) in transgender male patients to 28·64% (26·23-31·17) among patients who preferred not to say their gender or their cisgender or transgender identity. Inequalities in interactions with health-care professionals may mediate much of these inequalities. INTERPRETATION: Together with existing evidence, our findings showed large gender-related inequalities in self-reported mental health outcomes in England. Given the existence of self-reported unmet mental health needs, we suggest that better health care system inclusivity and health-care professional training are needed, alongside broader improvements in the social and legal environment for transgender, non-binary, and gender diverse people. FUNDING: National Institute for Health and Care Research.

Do Informal Care Recipients Internalise Carer Burden? Examining the Impact of Informal Care Receipt on Health Behaviours.

BACKGROUND: Providing informal care has a negative effect on the caregiver's health and well-being, but little is known about how individuals respond to receiving informal care. Care recipients may improve their health behaviours to minimise the onerousness of caregiving and the stress faced by their carer from seeing a loved one in ill-health. OBJECTIVE: We aimed to examine whether informal care recipients internalise the potential for carer spillovers through changes in health behaviours. METHODS: We used data from 3250 older adults with care needs who took part in the UK Household Longitudinal Study between 2017 and 2019. We examined the response to informal care receipt in terms of the probability of engaging in four health behaviours: healthy diet, physical activity, smoking and alcohol consumption. We estimated average treatment effects using regression adjustment with inverse probability treatment weights, comparing individuals that received informal care to those receiving either formal or no care. RESULTS: We found that informal care receipt increased the probability of refraining from negative health behaviours (smoking and alcohol consumption) but reduced the probability of engaging in positive health behaviours (eating fruits and/or vegetables and physical activity). CONCLUSIONS: The asymmetric effects detected suggest that the underlying mechanisms are different, and care recipients may be engaging in risk and effort compensation between negative and positive health behaviours. Failure to account for the behavioural responses from informal care recipients may lead to under-estimation or over-estimation of the extent of caregiving burden and the effectiveness of interventions impacting informal carers.

Evaluating primary care networks in low-income and lower middle-income countries: a scoping review.

INTRODUCTION: Primary care networks (PCNs) are claimed to be an effective model to organise and deliver primary healthcare through collaborative relationships and effective coordination of primary care activities. Though increasingly implemented in different contexts, there is limited evidence on the effectiveness of PCNs in low-income and lower middle-income countries (LLMICs). OBJECTIVE: Our scoping review aims to understand how PCNs in LLMICs have been conceptualised, implemented and analysed in the literature and further explores the evidence of the effectiveness of these networks. METHODS: We structured our review using Arksey and O'Malley's framework for scoping reviews and recommendations by Levac et al. We also used the population, concept and context (PCC) guide of the Joanna Briggs Institute (JBI) methodology for scoping reviews to define the search strategy. The identified documents were then mapped, using Cunningham's evaluation framework for health networks, to understand how PCNs are conceived in LLMIC settings. RESULTS: We identified 20 documents describing PCNs in five LLMICs. The selected documents showed differing forms and complexities of networks, with a majority resourced by government, non-governmental and donor entities. Most networks were mandated, and established with defined goals, although these were not always understood by stakeholders. Unlike PCNs in developed settings, the scoping review did not identify integration of care as a major goal for the establishment of PCNs in LLMICs. Network evaluation relationships, outputs and outcomes also varied across the five networks in the identified documents, and perceptions of effectiveness differed across stakeholder groups. CONCLUSION: PCNs in LLMICs benefit from clearly stated goals and measurable outcomes, which facilitates evaluation. In order to maximise the benefits, careful attention to the aspects of network design and operation is required. Future research work could shed light on some of the missing pieces of evidence on their effectiveness by, for example, considering differential consequences of modes of network establishment and operation, including unintended consequences in the systems within which they reside, and evaluating long-term implications.

Socioeconomic inequality in access to timely and appropriate care in emergency departments.

In publicly-funded healthcare systems, waiting times for care should be based on need rather than ability to pay. Studies have shown that individuals with lower socioeconomic status face longer waits for planned inpatient care, but there is little evidence on inequalities in waiting times for emergency care. We study waiting times in emergency departments (EDs) following arrival by ambulance, where health consequences of extended waits may be severe. Using data from all major EDs in England during the 2016/17 financial year, we find patients from more deprived areas face longer waits during some parts of the ED care pathway. Inequalities in waits are small, but more deprived individuals also receive less complex ED care, are less likely to be admitted for inpatient care, and are more likely to re-attend ED or die shortly after attendance. Patient-physician interactions and unconscious bias towards more deprived patients may be important sources of inequalities.

Skill-mix change and outcomes in primary care: Longitudinal analysis of general practices in England 2015-2019.

BACKGROUND: Increasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortages of GPs and nurses. However, evidence of the impacts this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England. METHODS: We obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked 10 indicators of quality of care covering the dimensions of accessibility, clinical effectiveness, user experiences and health system costs. We used both fixed-effect and first-differences regressions to model changes in staff composition and outcomes, adjusting for practice and population factors. RESULTS: Employment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 FTE per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, -0.078] and 0.116 [-0.161, -0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups. CONCLUSIONS: Introduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.

Primary care workforce composition and population, professional, and system outcomes: a retrospective cross-sectional analysis.

BACKGROUND: The diversification of types of staff delivering primary care may affect professional, population, and system outcomes. AIM: To estimate associations between workforce composition and outcomes. DESIGN AND SETTING: Cross-sectional analysis of 6210 GP practices from a range of geographical settings across England in 2019. METHOD: A multivariable regression analysis was undertaken, relating numbers of staff in four groups - GPs, nurses, healthcare professionals, and health associate professionals - to patient access and satisfaction, quality of clinical care and prescribing, use of hospital services, GP working conditions (subsample of practices), and costs to the NHS. Data were obtained from the GP Patient Survey 2019, Quality and Outcomes Framework, prescribing data, the Hospital Episode Statistics database, the NHS Payments to General Practice 2019/2020, and the Tenth National GP Worklife Survey 2019. RESULTS: Having additional GPs was associated with higher levels of satisfaction for the GPs themselves and for patients, whereas additional staff of other types had opposite associations with these outcomes. Having additional nurses and health associate professionals was associated with lower costs per prescription but more prescribing activity than having additional staff from the other two groups. Having more GPs was associated with higher costs per prescription and lower use of narrow-spectrum antibiotics compared with the other staff groups. Except for health associate professionals, greater staff numbers were associated with more hospital activity. CONCLUSION: Professional, population, and system outcomes showed a variety of associations with primary care workforce composition. Having additional nurses was associated with lower quality in some aspects, and higher costs and activity. The association between additional healthcare professionals or health associate professionals and higher costs was less than that for additional GPs, but was also linked to lower patient and GP satisfaction.

Framework for identification and measurement of spillover effects in policy implementation: intended non-intended targeted non-targeted spillovers (INTENTS).

BACKGROUND: There is increasing awareness among researchers and policymakers of the potential for healthcare interventions to have consequences beyond those initially intended. These unintended consequences or "spillover effects" result from the complex features of healthcare organisation and delivery and can either increase or decrease overall effectiveness. Their potential influence has important consequences for the design and evaluation of implementation strategies and for decision-making. However, consideration of spillovers remains partial and unsystematic. We develop a comprehensive framework for the identification and measurement of spillover effects resulting from changes to the way in which healthcare services are organised and delivered. METHODS: We conducted a scoping review to map the existing literature on spillover effects in health and healthcare interventions and used the findings of this review to develop a comprehensive framework to identify and measure spillover effects. RESULTS: The scoping review identified a wide range of different spillover effects, either experienced by agents not intentionally targeted by an intervention or representing unintended effects for targeted agents. Our scoping review revealed that spillover effects tend to be discussed in papers only when they are found to be statistically significant or might account for unexpected findings, rather than as a pre-specified feature of evaluation studies. This hinders the ability to assess all potential implications of a given policy or intervention. We propose a taxonomy of spillover effects, classified based on the outcome and the unit experiencing the effect: within-unit, between-unit, and diagonal spillover effects. We then present the INTENTS framework: Intended Non-intended TargEted Non-Targeted Spillovers. The INTENTS framework considers the units and outcomes which may be affected by an intervention and the mechanisms by which spillover effects are generated. CONCLUSIONS: The INTENTS framework provides a structured guide for researchers and policymakers when considering the potential effects that implementation strategies may generate, and the steps to take when designing and evaluating such interventions. Application of the INTENTS framework will enable spillover effects to be addressed appropriately in future evaluations and decision-making, ensuring that the full range of costs and benefits of interventions are correctly identified.

Bad law or implementation flaws? Lessons from the implementation of the new law on epidemics during the response to the first wave of COVID-19 in Switzerland.

After the 2009-2010 H1N1 pandemic, Switzerland overhauled its 1970 law on epidemics. The reform aimed at improving early detection, surveillance, and preparedness for future outbreaks of infectious diseases. Notably, the law introduced stronger coordination between Federal and Cantonal authorities, better management tools and international cooperation. The new law entered into force in 2016 after a long legislative process. During the process, the law survived a referendum fuelled by concerns about vaccine safety and pharmaceutical industry interference. The law was first applied during the COVID-19 pandemic in early 2020. The epicentre of the outbreak in Europe was in Lombardy, a large Italian region adjacent to Switzerland and with strong economic ties with its southern region of Ticino. The first months of pandemic response highlighted two major weaknesses. Firstly, the mechanisms introduced by the new law did not ease the tension between Cantonal autonomy and central coordination of the pandemic response. Central and Cantonal authorities will need to put in place new rules and arrangements to avoid dangerous delayed responses to foreseeable problems related to the spread of infectious diseases. Secondly, relevant stakeholders excluded from the policymaking process (trade unions, firms, large industries) should be involved to allow the introduction of harsh restrictions when needed, both internally and in relation to cross-border workers.

Corona and coffee on your commute: a spatial analysis of COVID-19 mortality and commuting flows in England in 2020.

BACKGROUND: The COVID-19 pandemic forced governments to implement lockdown policies to curb the spread of the disease. These policies explicitly encouraged homeworking, hence reducing the number of commuters with the implicit assumption that restricting peoples' movement reduces risk of infection for travellers and other people in their areas of residence and work. Yet, the spatial interrelation of different areas has been rarely addressed both in the public discourse and in early accounts of the various consequences of COVID-19. METHODS: Our study proposes a spatial analysis of the association between commuting flows and COVID-19 mortality in England between March and June 2020, using a range of publicly available area-level data. To account for spatial correlation, we used a structural mobility gravity model to analyze commuting flows between Local Authority Districts. By accounting for these spatial dependencies, we temper concerns of bias and inefficiency affecting simple linear estimates. Additionally, we disentangle the direct and indirect (from other areas) influence of commuting on COVID-19 mortality. RESULTS: The results of our spatial regression models suggest that higher commuting flows-in general and particularly by public transport-are associated with higher COVID-19 mortality. Our results are consistent with a reduction in COVID-related mortality after the introduction of a national lockdown in March. The spatial-lag term is statistically significant, highlighting the importance of accounting for spatial dependencies. CONCLUSION: We suggest that considering spatial interactions through commuting or travel motivations may offer interesting perspectives on the trade-off between health and economic activity during lockdowns.

Impact of social accountability monitoring on health facility performance: Evidence from Tanzania.

Social accountability programs are increasingly used to improve the performance of public service providers in low-income settings. Despite their growing popularity, evidence on the effectiveness of social accountability programs remains mixed. In this manuscript, we assess the impact of a social accountability intervention on health facility management exploring quasiexperimental variation in program exposure in Tanzania. We find that the social accountability intervention resulted in a 1.8 SD reduction in drug stockouts relative to the control group, but did not improve facility infrastructure maintenance. The results of this study suggest that social accountability programs may be effective in areas of health service provision that are responsive to changes in provider behavior but may not work in settings where improvements in outcomes are conditional on larger health systems features.

A network analysis of patient referrals in two district health systems in Tanzania.

Patient referral systems are fragile and overlooked components of the health system in Tanzania. Our study aims at exploring patient referral networks in two rural districts in Tanzania, Kilolo and Msalala. Firstly, we ask whether secondary-level facilities act as gatekeepers, mediating referrals from primary- to tertiary-level facilities. Secondly, we explore the facility and network-level determinants of patient referrals focusing on treatment of childhood illnesses and non-communicable diseases. We use data collected across all public health facilities in the districts in 2018. To study gatekeeping, we employ descriptive network analysis tools. To explore the determinants of referrals, we use exponential random graph models. In Kilolo, we find a disproportionate share of patients referred directly to the largest hospital due to geographical proximity. In Msalala, small and specialized secondary-level facilities seem to attract more patients. Overall, the results call for policies to increase referrals to secondary facilities avoiding expensive referrals to hospitals, improving timeliness of care and reducing travel-related financial burden for households.

Going operational with health systems governance: supervision and incentives to health workers for increased quality of care in Tanzania.

Improving the quality of care is increasingly recognized as a priority of health systems in low- and middle-income countries. Given the labour-intensive nature of healthcare interventions, quality of care largely depends upon the number, training and management of health workers involved in service delivery. Policies available to boost the performance of health workers-and thus the quality of healthcare-include regulation, incentives and supervision-all of which are typically included in quality improvement frameworks and policies. This was the case in Tanzania, where we assessed the role of selected quality improvement policies. To do so, we analysed data from a representative sample of Tanzanian government-managed health facilities, part of the 2014/15 Service Provision Assessment component of the Demographic and Health Survey. We constructed two healthcare quality indicators from data on patient visits: (1) compliance with Integrated Management of Childhood Illness (IMCI) guidelines and (2) patient satisfaction. Using multilevel ordered logistic regression models, we estimated the associations between the outcomes and selected indicators of incentives and supervisory activity at health worker and health facility level. We did not identify any association for the different indicators of top-down supervision at facility and individual level, neither with IMCI compliance nor with patients' satisfaction. Bottom-up supervision, defined as meetings between community and health facility staff, was significantly associated with higher patient satisfaction. Financial incentives in the form of salary top-ups were positively associated with both IMCI compliance and patient satisfaction. Both housing allowances and government-subsidized housing were positively associated with our proxies of quality of care. Good healthcare quality is crucial for promoting health in Tanzania not only through direct outcomes of the process of care but also through increased care-seeking behaviour in the communities. The results of this study highlight the role of community involvement, better salary conditions and housing arrangements for health workers.

E-health in Switzerland: The laborious adoption of the federal law on electronic health records (EHR) and health information exchange (HIE) networks.

Within the framework of a broader e-health strategy launched a decade ago, in 2015 Switzerland passed a new federal law on patients' electronic health records (EHR). The reform requires hospitals to adopt interoperable EHRs to facilitate data sharing and cooperation among healthcare providers, ultimately contributing to improvements in quality of care and efficiency in the health system. Adoption is voluntary for ambulatories and private practices, that may however be pushed towards EHRs by patients. The latter have complete discretion in the choice of the health information to share. Moreover, careful attention is given to data security issues. Despite good intentions, the high institutional and organisational fragmentation of the Swiss healthcare system, as well as the lack of full agreement with stakeholders on some critical points of the reform, slowed the process of adoption of the law. In particular, pilot projects made clear that the participation of ambulatories is doomed to be low unless appropriate incentives are put in place. Moreover, most stakeholders point at the strategy proposed to finance technical implementation and management of EHRs as a major drawback. After two years of intense preparatory work, the law entered into force in April 2017.

Pharmacokinetic profile after multiple deltoid or gluteal intramuscular injections of paliperidone palmitate in patients with schizophrenia.

Paliperidone palmitate (PP) is a once-monthly long-acting injectable antipsychotic approved for the treatment of schizophrenia in many countries. To evaluate the different injection-site options, we compared the pharmacokinetic profile of paliperidone after multiple injections of PP 100 mg eq. (156 mg of PP, equivalent to 100 mg of paliperidone) on days 1, 8, 36, and 64 into the deltoid (n = 24) or gluteal muscle (n = 25) in patients with schizophrenia. After four injections in the deltoid muscle, paliperidone exposure was higher for AUCτ and Cmax , compared with the gluteal muscle (geometric mean AUCτ -based ratio: 120% [90% CI: 93.1-154.7%], and geometric mean Cmax -based ratio: 130% [90% CI: 100.6-168.9%]). The mean [SD] fluctuation index was higher, with a larger interpatient variability, after deltoid-injections (75.9% [30.9%]) than gluteal-injections (58.5% [14.3%]). The median tmax was similar for both sites. PP was generally tolerable in patients, with more favorable local-site tolerability for gluteal-injection. In conclusion, to achieve therapeutic-concentrations quickly, the first-two injections of PP are best administered into the deltoid muscle, whereas thereafter maintenance-injections can be administered either in the deltoid or gluteal muscle.

[Temporary and permanent central venous catheters for hemodialysis]. / Primjena trajnih i privremenih centralnih venskih katetera za hemodijalizu.

The usage of temporary and permanent dialysis catheters for hemodialysis vascular access has been on continual increase. The reason for this increase is aging population on hemodialysis with blood vessels inappropriate for arteriovenous fistula creation. Complications may occur during catheter insertion as well as in the already inserted catheters, e.g., thrombosis and infections. The severity of complications is determined by experience of the operator as well as the quality and localization of blood vessels. Monitoring of dialysis catheter function, choice of the site of catheter insertion and methods of salvaging catheters from thrombosis and treating catheter-related local and systemic infections are described in this paper. Constant evaluation, proper care and hygiene of dialysis catheters are highly recommended.