Health inequity and social determinants of healthcare utilization in the disadvantaged community of Hong Kong.

Access to appropriate healthcare among disadvantaged populations in countries with universal healthcare requires a critical understanding of the relationships between poverty, social exclusion and health in the local context. The qualitative study explored the experiences of healthcare utilization in an inner-city impoverished community living in slum conditions in Hong Kong. Interviews with 40 slum residents in one of the poorest neighbourhoods in the city explored the following domains: experience and perceptions of the community, housing conditions, informal social capital and support system, interactions with community workers, and experiences in utilizing social and healthcare services. Framework analysis was conducted to identify local themes under the model of healthcare utilization: approachability, acceptability, availability and accommodation, affordability and appropriateness. Despite the subsidized public healthcare system, multiple barriers were identified. Low literacy of healthcare systems was prevalent. Specifically, structural barriers relating mainly to the availability, accommodation and affordability of health services were salient to impede access to healthcare. The barriers related to healthcare providers primarily stemmed from the interactions of healthcare providers, perceived stigma and the lack of patient-centred care. In addition, poverty-related sociocultural norms and personal beliefs of healthcare were found to be significant barriers to healthcare access. Despite the well-established subsidized public healthcare system, healthcare inequity was evident. Lack of quality healthcare access needs to be addressed by providing social and educational resources that facilitate collective efficacy for healthcare, community engagement from public sectors and person-centred care with healthcare providers.

Access to appropriate healthcare among disadvantaged populations in countries with universal healthcare requires a critical understanding of the relationships between poverty, social exclusion and health in the local context. This study explored the experiences and views of healthcare access among residents living in slum conditions in an inner-city impoverished community in Hong Kong. The findings indicated that in addition to low functional health literacy that is rooted in structural barriers of public resources, a lack of patient-centred care was prevalent due to stigma attached to poverty. Poor quality interactions with healthcare providers and systems resulted in fatalistic beliefs in health promotion. Social and educational resources should be provided to the disadvantaged to enhance collective efficacy to build a resilient health community.

Correspondence: is there an association between centre volume and survival or neurological outcomes among out-of-hospital cardiac arrest patients?

This commentary discusses the findings of a study by Tsuchida et al. on the effect of annual hospital admissions of out-of-hospital cardiac arrest patients on survival and neurological outcomes in OHCA patients in the context of existing literature on the topic, and the implications on future studies investigating the volume-outcome relationship in cardiac arrest.

Association of High-Volume Centers With Survival Outcomes Among Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

Importance: Although high volume of cases of out-of-hospital cardiac arrest (OHCA) is a key feature of cardiac arrest centers, which have proven survival benefit, the role of center volume as an independent variable associated with improved outcomes is unclear. Objective: To assess the association of high-volume centers with survival and neurological outcomes in nontraumatic OHCA. Data Sources: Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to October 11, 2021, for studies including adult patients with nontraumatic OHCA who were treated at high-volume vs non-high-volume centers. Study Selection: Randomized clinical trials, nonrandomized studies of interventions, prospective cohort studies, and retrospective cohort studies were selected that met the following criteria: (1) adult patients with OHCA of nontraumatic etiology, (2) comparison of high-volume with low-volume centers, (3) report of a volume-outcome association, and (4) report of outcomes of interest. At least 2 authors independently reviewed each article, blinded to each other's decision. Data Extraction and Synthesis: Data abstraction and quality assessment were independently conducted by 2 authors. Meta-analyses were performed for adjusted odds ratios (aORs) and crude ORs using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures: Survival and good neurological outcomes according to the Cerebral Performance Categories Scale at hospital discharge or 30 days. Results: A total of 16 studies involving 82 769 patients were included. Five studies defined high volume as 40 or more cases of OHCA per year; 3 studies defined high volume as greater than 100 cases of OHCA per year. All other studies differed in definitions. Survival to discharge or 30 days improved with treatment at high-volume centers, regardless of whether aORs (1.28 [95% CI, 1.00-1.64]) or crude ORs (1.43 [95% CI, 1.09-1.87]) were pooled. There was no association between center volume and good neurological outcomes at 30 days or hospital discharge in patients with OHCA (aOR, 0.96 [95% CI, 0.77-1.20]). Conclusions and Relevance: In this meta-analysis and systematic review, care at high-volume centers was associated with improved survival outcomes, even after adjustment for potential confounders, but was not associated with improved neurological outcomes for patients with nontraumatic OHCA. More studies evaluating the relative importance of center volume compared with other variables (eg, the availability of treatment modalities) associated with survival outcomes in patients with OHCA are required.

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review.

BACKGROUND: Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method. METHODS: MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use. RESULTS: 1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA. CONCLUSION: Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

Background The role of cardiac arrest centers (CACs) in out-of-hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out-of-hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self-declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta-analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty-six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52-2.26]), even when including high-volume centers (aOR, 1.50 [95% CI, 1.18-1.91]) or including improved-care centers (aOR, 2.13 [95% CI, 1.75-2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59-2.32]), even when including high-volume centers (aOR, 1.74 [95% CI, 1.38-2.18]) or when including improved-care centers (aOR, 1.97 [95% CI, 1.71-2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out-of-hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.