Care Allocation Research Articles

Trends and risk factors of in-hospital mortality of patients with COVID-19 in Germany

Abstract Background Unselected data of nationwide studies of hospitalized patients with COVID-19 is still sparse, but these data are of outstanding interest not to exceed hospital capacities and to avoid overloading of national health-care systems. Purpose Thus, we sought to analyze seasonal/regional trends, predictors of in-hospital case-fatality and mechanical ventilation (MV) in patients with COVID-19 in Germany. Methods We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany between January 1st and December 31st in 2020 (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2020, own calculations). Covid-19-inpatients with MV vs. without MV and survivors vs. non-survivors were compared. Logistic regression models were calculated to investigate associations between patients' characteristics as well as adverse events and i) necessity of MV and ii) in-hospital death. Results We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19-infection. Among those, 31,607 (17.9%) died, whereby in-hospital case-fatality grew exponentially with age. Cardiovascular comorbidities were common in hospitalized patients with confirmed COVID-19-infections: Overall, almost half of the patients (46.8%; n=82,480) had arterial hypertension and 25,574 (14.4%) had a diagnosis of coronary artery disease. In 60.7% (n=106,913) of the hospitalizations, pneumonia was reported, 8.6% (n=15,061) had an acute infection of the upper or lower airways other than pneumonia, and 6.6% (n=11,594) suffered from an acute respiratory distress syndrome (ARDS) during hospitalization Age ≥70 years (OR 5.91, 95% CI 5.70–6.13, P<0.001), pneumonia (OR 4.58, 95% CI 4.42–4.74, P<0.001) and acute respiratory distress syndrome (OR 8.51, 95% CI 8.12–8.92, P<0.001) were strong predictors of in-hospital death. Most COVID-19-patients were treated in hospitals in urban areas (n=92,971) associated with lowest case-fatality (17.5%) as compared to hospitals in suburban (18.3%) or rural areas (18.8%). MV demand was highest in November/December 2020 (32.3%, 20.3%) in patients between 6th and 8th age-decade. In the first age-decade, 78 of 1861 children (4.2%) with COVID-19-infection were treated with MV and five of them died (0.3%). Conclusion The results of our study indicate seasonal and regional variations concerning number of COVID-19-patients, necessity of MV and case-fatality in Germany. These findings may help to ensure flexible allocation of intensive care (human) resources, which is essential for managing enormous societal challenges worldwide to avoid overloaded regional health-care systems. Funding Acknowledgement Type of funding sources: None.

Impact of Dual Intensive Care Unit and Rapid Response Team Nursing Roles on Service Delivery in the Intensive Care Unit.

Rapid response teams generally consist of multidisciplinary specialist staff members with advanced knowledge and skills to manage deteriorating patients outside of the intensive care unit. These teams consist predominantly of intensive care unit nurses, who often undertake intensive care unit and rapid response team duties concurrently. Little has been published on the impact of these nurses' absence while attending a rapid response call on the nursing workforce, patient care, and resource allocation in the intensive care unit. To explore the impact of nurses' absence due to attending rapid response calls in other areas of the hospital on service delivery and resource allocation in the intensive care unit. A comprehensive search of 3 databases was performed to identify studies on relationships among the rapid response team, the intensive care unit, and nursing staff. The search yielded 6 quantitative studies, 2 qualitative studies, and a mixed-methods study that were included for analysis. Four key themes were identified: (1) workforce, staffing processes, and resource allocation; (2) alterations to workload and resource allocation; (3) adverse events or incidents; and (4) funding variability of rapid response team models. Review of the studies indicated that dual intensive care unit and rapid response team nursing roles have negative effects on nurses' workload, increase the risk of adverse events, and may compromise patient safety. The staffing of both the intensive care unit and the rapid response team should be examined carefully with an eye toward sustainability, cost-effectiveness, and clear outcome measures.

Assessment of influencing factors of hospitalization expenses for Crohn's disease patients: Based on LASSO and linear mixed model.

AimsCrohn's disease (CD) is a global disease that is dramatically increasing. This study aimed to identify the primary drivers of hospitalization expenses for CD patients to provide guidance on the allocation and control of health care costs.MethodsThis study retrospectively collected the homepage data of the electronic medical records of CD patients in two tertiary hospitals in Zhejiang Province, China, from January 2016 to December 2021. The influencing factors of hospitalization expenses for CD were analyzed. A linear mixed model with least absolute shrinkage (LASSO-LMM) was used to develop a predictive model for hospitalization expenses for CD patients.ResultsA total of 4,437 CD patients were analyzed in this study. CD patients' age, length of hospital stay, admission route, comorbidities, and main treatment were found to be statistically significant variables for CD patients' hospitalization expenses. The AIC and BIC of LASSO-LMM model were 319.033 and 306.241, respectively. Patients who were older, had a longer hospital stay, and had comorbidities had higher hospitalization expenses. The hospitalization expenses of outpatients were lower than those of emergency patients. The weight of surgical treatment was the highest among three treatments (0.602).ConclusionsIdentifying and examining factors that influence hospitalization expenses for CD patients can help to control healthcare expenditures. Treatment mode was the most important impact on CD hospitalization expenses. Medical security departments can consider implement personalized and precise hospitalization expense compensation scheme base on LASSO-LMM prediction model in the future.

To adjust or not to adjust: Cut-off scores in performance validity testing in Portuguese older adults with dementia.

The rising demographic of older adults worldwide has led to an increase in dementia cases. In order to ensure the proper allocation of care and resources to this clinical group, it is necessary to correctly distinguish between simulated versus bona-fide cognitive deficits typical of dementia. Performance Validity Tests (PVTs) are specifically designed to assess a lack of effort and the possible simulation of cognitive impairment. Previous research demonstrates that PVTs may be sensitive to dementia, thus inaccurately classifying real memory impairment as simulation. Here, we analyzed the sensitivity of PVTs in discriminating between dementia and simulation using receiver operating characteristic (ROC) curve analyses. Further, we examined the potential need for adjusting cut-off scores for three stand-alone (Test of Memory Malingering, Rey-15 Item Memory Test, and Coin in Hand-Extended Version) and one embedded (Reliable Digit Span) PVT for Portuguese older adults with dementia. The results showed that (1) all measures, except for the Coin in Hand— Extended version (CIH-EV), were sensitive to one or more sociodemographic and/or cognitive variables, and (2) it was necessary to adjust cut-off points for all measures. Additionally, the Rey-15 Item Memory Test did not demonstrate sufficient discriminating capacity for dementia. These results present important implications for clinical practice and the daily life of patients, as the use of incorrect cut-off points could impede patients from getting the resources they need.

SP4.1.3 Validation of the Emergency Surgery Score (ESS) in the UK patient population and comparison with NELA scoring: a retrospective multi-centre cohort study

Abstract Aims Accurate risk scoring in emergency general surgery (EGS) is vital for consent, resource allocation and benchmarking quality of care. The emergency surgery score (ESS) is a reliable predictor of post-operative outcomes in EGS, but has only been studied in the US population. Our primary aim was to perform an external validation study of the ESS in a UK population. Our secondary aim was to compare the accuracy of ESS and NELA scores. Methods We conducted an observational cohort study of adult patients undergoing emergency laparotomy over three years in two UK centres. ESS was calculated retrospectively. NELA score and all other variables were obtained from the prospectively held Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database. Primary outcome was 30-day mortality. Secondary outcome was need for post-operative ICU admission. Results 609 patients were included. Both ESS and NELA were good predictors of 30-day mortality (c-statistic=0.78 [95% CI: 0.71–0.85] for ESS and c-statistic=0.83 [95% CI: 0.77–0.88] for NELA). Similarly, both scores were good predictors of need for post-operative ICU admission (c-statistic=0.76 [95% CI: 0.71–0.81] for ESS and 0.80 [95% CI: 0.76–0.85] for NELA). There was no significant difference in performance between the two scores for predicting 30-day mortality (p=0.20) or need for ICU admission (p=0.09). Conclusion We recommend that ESS can be used in the UK population. It is non-inferior to NELA in predicting 30-day mortality and need for ICU admission, but has been validated for a wider range of outcomes and does not require scoring of intra-operative variables.

The Influence of the Structure on the Attention of Organization Managers

We aim to understand the aspects of the structural distribution of attention that influence the attention of individuals in organizations. We performed two distinct and interlinked studies considered experiments using an eye tracking tool. In the first study, we evaluated the effect of training (as a proxy for the function) on managerial care and the individual characteristics of future managers (n=151). In the second study, we evaluated the effect of function/position on managerial care and the individual characteristics of professionals (n=140) working in organizations. We conclude that the professional profile and the organizational environment (internship) influence the choice of information in the areas of interest (AOI) of future managers. About managers, we concluded that the professional profile influences the choice of information (AOI) for the allocation of care. The initial training of decision-makers (managers) becomes less relevant than their professional profile, which is shaped based on their professional experiences and practices.

The effect of a more community-oriented curriculum on nursing students’ intervention choice in community care: A quasi-experimental cohort study

AimThe aim of this study is to investigate the effect of a more ‘community-oriented’ baccalaureate nursing curriculum on students’ intervention choice in community care. BackgroundFollowing a healthcare shift with increased chronic diseases in an ageing patient population receiving care at home, nursing education is revising its curricula with new themes (e.g., self-management) on community care. Although it seems obvious that students incorporate these themes in their nursing care interventions, this is unclear. This study investigates the effect of a redesigned curriculum on students’ care intervention choice in community nursing. DesignA quasi-experimental quantitative study. MethodsThis study with an historic control group (n = 328; study cohorts graduating in 2016 and 2017; response rate 83 %) and an intervention group n = 152; graduating in 2018; response rate 80 %) was performed at a University of Applied Sciences in the Netherlands. The intervention group experienced a curriculum-redesign containing five new themes related to community care (e.g., enhancing self-management, collaboration with the patients’ social network, shared decision making, using health technology and care allocation). The primary outcome 'intervention choice in community nursing’ was assessed with a specially developed vignette instrument ‘Assessment of Intervention choice in Community Nursing’ (AICN). Through multiple regression analyses we investigated the effect of the curriculum-redesign on students’ intervention choice (more ‘traditional’ interventions versus interventions related to the five new themes). The control and intervention groups were compared on the number of interventions per theme and on the number of students choosing a theme, with a chi-square or T-test. ResultsStudents who studied under the more community-oriented curriculum chose interventions related to the new themes significantly more often, F(1461) = 14.827, p = <0.001, R2 = .031. However, more traditional interventions are still favourite (although less in the intervention group): 74.5 % of the chosen interventions in the historic control group had no relation with the new curriculum-themes, vs. 71.3 % in the intervention group; p = .055). ConclusionsStudents who experienced a more ‘community-oriented’ curriculum were more likely, albeit to a limited extent, to choose the new community care themes in their caregiving. Seeing this shift in choices as a step in the right direction, it can be expected that the community care field in the longer term will benefit from these better skilled graduates.

Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore

To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25-35.99; 6.30, 95% CI 1.15-34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease.

Morbidity Patterns in Primary Care in Hong Kong: Protocol for a Practice-Based Morbidity Survey.

BackgroundUp-to-date and accurate information about the health problems encountered by primary care doctors is essential to understanding the morbidity pattern of the community to better inform health care policy and practice. Morbidity surveys of doctors allow documentation of actual consultations, reflecting the patient’s reason for seeking care as well as the doctor’s diagnostic interpretation of the illness and management approach. Such surveys are particularly critical in the absence of a centralized primary care electronic medical record database.ObjectiveWith the changing sociodemographic profile of the population and implementation of health care initiatives in the past 10 years, the aim of this study is to determine the morbidity and management patterns in Hong Kong primary care during a pandemic and compare the results with the last survey conducted in 2007-2008.MethodsThis will be a prospective, practice-based survey of Hong Kong primary care doctors. Participants will be recruited by convenience and targeted sampling from both public and private sectors. Participating doctors will record the health problems and corresponding management activities for consecutive patient encounters during one designated week in each season of the year. Coding of health problems will follow the International Classification of Primary Care, Second Edition. Descriptive statistics will be used to calculate the prevalence of health problems and diseases as well as the rates of management activities (referral, investigation, prescription, preventive care). Nonlinear mixed effects models will assess the differences between the private and public sectors as well as factors associated with morbidity and management patterns in primary care.ResultsThe data collection will last from March 1, 2021, to August 31, 2022. As of April 2022, 176 doctor-weeks of data have been collected.ConclusionsThe results will provide information about the health of the community and inform the planning and allocation of health care resources.Trial RegistrationClinicalTrials.gov NCT04736992; https://clinicaltrials.gov/ct2/show/NCT04736992International Registered Report Identifier (IRRID)DERR1-10.2196/37334

The Value of the C-Reactive Protein/Albumin and Fibrinogen/Albumin Ratios in Predicting Disease Severity and Mortality in Elderly COVID-19 Patients

Objective: Due to the high mortality levels associated with the novel coronavirus, reliable predictors for determining disease mortality and severity are needed to permit the careful allocation of health services and for earlier clinical intervention and follow-up. The purpose of this study was to determine the predictive value of the C-reactive protein (CRP)/albumin ratio (CAR) and the fibrinogen/albumin ratio (FAR) in determining mortality and evaluate correlations between these values and thoracic computed tomography (CT) findings. Material and Methods: COVID-19 patients aged over 65 presenting to the emergency department of a tertiary training and research hospital between Oct 15, 2021, and Jan 15, 2022, were examined in this single-center, retrospective study. The study population was established based on inclusion and exclusion criteria. The patients’ mortality status and pulmonary involvement percentages were compared with their laboratory parameters. Results: The relationships between patients’ CAR and FAR values and mortality and disease severity were investigated. Cut-off points of 3.0 for CAR (AUC 0.767, sensitivity 76.5% and specificity 70.1%) and 14.4 for FAR (AUC 0.731, sensitivity 75.0% and specificity 69.0%) were determined for the prediction of mortality. In terms of prediction of disease severity, cut-off points were 4.2 for CAR (AUC 0.786, sensitivity 73.7%, and specificity 75.2%) and 15.2 for FAR (AUC 0.789, sensitivity 84.2%, and specificity 69.6%). Conclusion: Based on our study findings, CAR and FAR values may be useful in the early differentiation of mortality and pulmonary parenchymal involvement in elderly COVID-19 patients.

#37 Human Toxocariasis: eleven-year experience in a tertiary-care level pediatric hospital in Mexico City

Abstract Background In Mexico, human toxocariasis is not subject to continuous epidemiological surveillance. However, some studies that report seroprevalence show a significant association between larva migrans (LM) and pediatric cases (OR 3.2; IC95 2.541-4.279). Data is scarce about infection in animal reservoirs, more specifically dogs, in which there are reports of a 12-18% positivity rate. As for the role of the environment there is evidence to support high contamination levels. Most symptomatic pediatric patients develop ocular presentations that can lead to permanent vision loss, and diagnosis becomes a challenge because serological markers and peripheral eosinophilia can be absent. Method A retrospective, transverse, descriptive study including 17 patients with diagnosis of toxocariasis according to electronic medical records. For categoric variables, frequencies and percentages were analyzed and for discrete variables median and ranges were calculated. Results Nine patients (52.9%) presented with ocular LM of which, 55.6% were female with a median age of 5 years at diagnosis (IQR=9). 44.4% came from the coastal state of Veracruz and 88.9% had close contact with either dogs or cats. Two patients presented with eosinophilia and only one had positive anti-Toxocara antibodies at 2.12 OD. Under suspicion of retinoblastoma, two patients underwent enucleation and diagnosis was made with pathology findings. Eight patients (47.1%) presented with visceral LM of which, 62.5% were female with a median age of 7.5 years at diagnosis (IQR=12). 62.5% of them had close contact with either dogs or cats. In this case, all patients had history of peripheral eosinophilia but it was only in 75% that it was corroborated during initial workup at our institution ranging between 500-9400 cells/mm3 and all of them had positive antibodies that ranged between 1.02-3.2 OD. Five patients received oral treatment with albendazole for 3-7 days. Conclusion Human toxocariasis is a neglected parasitic disease with scarce published data. Pediatric patients are an important vulnerable group specially for ocular presentations. The differential diagnosis of leukochoria should always include retinoblastoma, but as shown in this study, also ocular LM. As new approaches to global health move towards prevention, our study can set a precedent in order to standardize patient care and resource allocation.

Affective partisan polarization and moral dilemmas during the COVID-19 pandemic

AbstractRecent scholarship on affective polarization documents partisan animosity in people's everyday lives. But does partisan dislike go so far as to deny fundamental rights? We study this question through a moral dilemma that gained notoriety during the COVID-19 pandemic: triage decisions on the allocation of intensive medical care. Using a conjoint experiment in five countries we analyze the influence of patients’ partisanship next to commonly discussed factors determining access to intensive medical care. We find that while participants’ choices are consistent with a utilitarian heuristic, revealed partisanship influences decisions across most countries. Supporters of left or right political camps are more likely to withhold support from partisan opponents. Our findings offer comparative evidence on affective polarization in non-political contexts.

Are we on the same page? Multiple stakeholders and service users priorities for dementia care and policy: A Delphi study

BackgroundIt's crucial to develop a national policy for dementia due to the growing number of persons living with the condition and the attendant impact on individuals, families, and society at large. However, there has been limited exploration of the views on long-term goals for dementia of different stakeholders involved in different aspects of service use, planning or delivery. ObjectiveThis study aims to examine and compare the perceived priorities of service users (i.e., people living with dementia and their family caregivers) and other multiple stakeholders for dementia care and policy. DesignTwo independent Delphi studies were conducted in Hong Kong. Setting(s) and participantsIn Delphi study 1, 75 stakeholders were recruited from public and private nursing, medical and social care providers, philanthropic organizations, policy-makers and government sectors. In Delphi study 2, 45 people living with dementia and 55 family caregivers were recruited from community care settings. MethodsThe Delphi study 1 was conducted using online surveys, while the Delphi study 2 was conducted using phone interviews. Each Delphi study comprised a qualitative study for exploring the range of views of the two panels and a quantitative validation for generating consensus. We systematically compared the two panels' identified priorities in terms of contents and consensus levels. ResultsMultiple stakeholders identified 32 consensus-based statements and service users identified 25 statements, most of which achieved moderate to high level of consensus. Through content analysis, statements from the two panels were converged into six common themes: (1) early prevention, detection and referral systems for dementia, (2) care and intervention services, (3) health and social care workforce capacity building within and across service sectors, (4) supportive services for family caregivers, (5) development of longer-term dementia service planning and a policy framework, and (6) promotion of a dementia-friendly community. Despite the similarity of the themes expressed by the two panels, critical comparison of their priorities identified the dementia service and policy gaps in providing integrated and informed healthcare, a mechanism for sensitive care allocation, enabling seamless social inclusion, and proactive health orientation of dementia caregivers. ConclusionsDiscrepancies between two panels reflect the distinctive value of service user engagement in the policy-making process. Our findings have implications for developing a multi-disciplinary integrated action plan for the local health response across the primary and secondary care settings to dementia and expanding the practice scope of person-centered dementia care in a collaborative way. Tweetable abstractThe voices of user, caregivers and service stakeholders excel the person-centered care and policy context for integrated dementia care.

Association Between Intensive Care Unit Admission Practices and Outcomes in Patients with Isolated Traumatic Subarachnoid Hemorrhage: A Nationwide Inpatient Database Analysis in Japan.

Patients with traumatic brain injury associated with intracranial hemorrhage are commonly admitted to the intensive care unit (ICU); however, the need for ICU care for patients with isolated traumatic subarachnoid hemorrhage (tSAH) remains unclear. We aimed to investigate the association between the ICU admission practices and outcomes in patients with isolated tSAH. This observational study used a nationwide administrative database in Japan. We identified patients with isolated tSAH from the Japanese Diagnostic Procedure Combination inpatient database from July 1, 2010, to March 31, 2020. The primary outcome was in-hospital mortality, whereas the secondary outcomes were neurosurgical interventions, activities of daily living at discharge, and total hospitalization cost. We performed a risk-adjusted mixed-effect regression analysis to evaluate the association between hospital-level ICU admission rates and study outcomes. The ICU admission rates were categorized into quartiles: lowest, middle-low, middle-high, and highest. Moreover, we assessed the robustness of the results with a patient-level instrumental variable analysis. Of the 61,883 patients with isolated tSAH treated at 962 hospitals, 16,898 (27.3%) patients were admitted to the ICU on the day of admission. Overall, 2465 (4.0%) patients died in the hospital, and 783 (1.3%) patients underwent neurosurgical interventions. There was no significant difference between the lowest and highest ICU admission quartile in terms of in-hospital mortality (3.7% vs. 4.3%; adjusted odds ratio 0.93; 95% confidence interval [CI] 0.78-1.10), neurosurgical interventions, and activities of daily living at discharge. However, the total hospitalization cost in the lowest ICU admission quartile was significantly lower than that in the highest quartile (US $3032 vs. $4095; adjusted difference US $560; 95% CI 33-1087). The patient-level instrumental variable analysis did not reveal a significant difference in in-hospital mortality between the patients who were admitted to the ICU and those who were not (risk difference 0.2%; 95% CI - 0.1 to 0.5). There was no significant association between the ICU admission practices and outcomes in patients with isolated tSAH, whereas higher ICU admission rates were associated with significantly higher hospitalization costs. Our results provide an opportunity for improved health care allocation in the management of patients with isolated tSAH.

An exploration of attitudes towards spiritual care for the recovery from post-traumatic stress disorder

Spiritual-based care has been increasingly explored and investigated for its effectiveness in assisting the recovery from mental illness, such as post-traumatic stress disorder (PTSD) in the United States of America (Harris et al., 2018). Although research studies have attempted to explore attitudes towards spiritual care and the effectiveness of spiritual-based care for PTSD, few have explored attitudes regarding spiritual care for recovery from PTSD, especially from Undergraduate Allied Health students.&amp;nbsp;This paper explores the attitudes towards spiritual care for the recovery from PTSD, from Undergraduate Allied Health students. The study adopted an interpretivist approach that deployed qualitative methods. The data collection method used for the study was semi-structured interviews. In total, four participants participated in the interviews, and reflexive thematic analysis was utilised to examine the datasets from the interviews.&amp;nbsp;The research revealed that the majority of participants had negative opinions regarding traditional medical treatment for PTSD and mental illness recovery. This led to the identification of barriers, such as stigma and cultural barriers, for seeking treatment for mental illness. The participants expressed positive opinions regarding spiritual care for assisting PTSD recovery, with the recommendation that religious and spiritual needs must be assessed before the allocation of spiritual-based care to prevent any conflict with patients’ religious or cultural beliefs.&amp;nbsp;&amp;nbsp;

Vascular injury-An underestimated entity?

HintergrundIn der Traumatologie sind Gefäße eher selten betroffen und isolierte vaskuläre Traumata (VT) sind rar. Es existieren daher wenig belastbare und aktuelle Zahlen zu Inzidenz und Mortalität.FragestellungEs wird anhand ausgewählter Referenzen sowie eigener abgeschlossener und laufender Studien aus Registerdaten des TraumaRegister DGU® (TR-DGU) zum VT im Rahmen der Schwerverletztenversorgung in Deutschland berichtet.Material und MethodePointierte Literaturübersicht und Bericht über 2 retrospektive Auswertungen von Datensätzen des TraumaRegister DGU® (TR-DGU): Daten mit moderatem bis schwerem VT im Verletzungsmuster werden mit Daten ohne VT (non-VT) bei gleicher Verletzungsschwere verglichen. Zielgrößen sind Morbidität, Mortalität sowie Verlaufs- und Prognoseparameter.ErgebnisseIn der Auswertung 2002–2012 (TR-DGU Projekt-ID 2013-011) zeichnete sich der Einfluss von Allokation und Versorgungsstufe der Traumazentren auf erwartete (EM) und beobachtete Mortalität (OM) von 2961 Fällen mit VT unter 42.326 Schwerverletzten (7 %) ab: Die Differenz von OM zu EM bei VT beträgt + 3,4 % vs. ± 0,1 % bei non-VT. Aufgrund der OM bei schwerem VT von 33,8 % vs. 16,4 % bei non-VT mit gleicher Verletzungsschwere wurde 2018 eine Folgeauswertung veranlasst (2008–2017; TR-DGU Projekt-ID 2018-045). Hier kann die Substratifizierung von isoliertem, führendem und begleitendem VT in der Versorgungsrealität signifikante Effekte von Versorgungsstufe, Allokation und Transport auf die OM zeigen. Nur bei VT zeigt sich eine relevante Nichtübereinstimmung von OM zu EM. Im Mittel etwa + 2 % und in Hochrisikokonstellationen mit VT bis zu + 29 % als Maß für die Relevanz von VT in der Traumaversorgung.SchlussfolgerungenDiese Ergebnisse legen eine weitere Optimierung der Schwerverletztenversorgung bei VT nahe, da sich VT-Vigilanz, Allokation, Transport und eine niedrigschwellige Frühverlegung als Ansatzpunkte ableiten lassen.

Cost-effectiveness analysis of paediatric mental health interventions: a systematic review of model-based economic evaluations

Mental health disorders among children and youth are causing significant burden on health care systems. Hence, identifying cost-effective interventions is important for effective mental health care allocation. Although model-based economic evaluations are an essential component of assessing cost-effectiveness, evidence are limited in the context of child and youth mental health care. The objective was to systematically review the model-based economic evaluations of mental health interventions for children and youth.MethodsFour databases (MEDLINE, EMBASE, PsycINFO and Web of Science) were searched using appropriate search terms to retrieve model-based economic evaluations of mental health interventions for children and youth. The reporting quality of the included studies were appraised using the Consolidated health economic evaluation reporting standards (CHEERS) checklist.ResultsThe database search yielded 1921 records. Of the 12 selected for review, 66% were published after year 2015. Most of the studies were related to anxiety and post-traumatic stress disorder. There were eight cost-utility studies, three cost-effectiveness studies, and one study using both forms of analysis. Six studies used Markov models, three used decision trees, and three studies used both types of models. However, the model structure, health states, time horizon, and economic perspective showed wide variation. The reporting quality of the included studies varied from 91 to 96%.ConclusionModel based mental health economic evaluations among children and youth are increasingly being reported in recent research. The included studies used Markov models and decision trees, either alone or in combination, and the majority of the articles were of good reporting quality.

Job satisfaction in midwives and its association with organisational and psychosocial factors at work: a nation-wide, cross-sectional study

BackgroundMidwives report a challenging work environment globally, with high levels of burnout, insufficient work resources and low job satisfaction. The primary objective of this study was to identify factors in the organisational and psychosocial work environment associated with midwives’ job satisfaction. A secondary objective was to identify differences in how midwives assess the organisational and psychosocial work environment compared to Swedish benchmarks.MethodsThis nation-wide, cross-sectional web survey study analysed midwives’ assessment of their organisational and psychosocial work environment using the COPSOQ III instrument. A multivariable, bi-directional, stepwise linear regression was used to identify association with job satisfaction (N = 1747, 99.6% women). A conventional minimal important score difference (MID ± 5 as a noticeable difference with clinical importance) were used to compare midwives’ results with Swedish benchmarks.ResultsA multivariable regression model with 13 scales explained the variance in job satisfaction (R2 = .65). Five scales, possibilities for development, quality of work, role conflict, burnout and recognition, explained most of the variance in midwives’ job satisfaction (R2 = .63) and had β values ranging from .23 to .10. Midwives had adverse MID compared to Swedish benchmarks with higher difference in mean values regarding quantitative demands (8.3), work pace (6.0) emotional demand (20.6), role conflicts (7.9) and burnout (8.3). In addition, lower organisational justice (-6.4), self-rated health (-8.8), influence (-13.2) and recognition at work (-5.8). However, variation and meaning of work showed a beneficial difference in mean values with 7.9 and 13.7 respectively.ConclusionsMidwives reported high levels of meaningfulness in their work, and meaningfulness was associated with job satisfaction. However, midwives also reported adversely high demands and a lack of influence and recognition at work and in addition, high role conflict and burnout compared to Swedish benchmarks. The lack of organisational resources are modifiable factors that can be taken into account when structural changes are made regarding organisation of care, management and resource allocation. Midwives are necessary to a high quality sexual, reproductive and perinatal health care. Future studies are needed to investigate if job satisfaction can be improved through professional recognition and development, and if this can reduce turnover in midwives.

International Practice Heterogeneity in Pediatric Left Heart Disease Related Pulmonary Hypertension

<h3>Purpose</h3> Elevated pulmonary vascular resistance (PVR) in left heart disease contributes to poor outcomes after pediatric heart transplant (HT). Medical management of high PVR pre-HT is controversial and insufficiently described. <h3>Methods</h3> We sought to characterize practice internationally by surveying physicians at pediatric HT centers via ISHLT and other networks. <h3>Results</h3> We received 49 complete responses from 39 centers in 16 countries. The majority of respondents were pediatric cardiologists (90%) practicing at centers offering pediatric heart (86%) and lung (55%) transplant. In patients with left heart failure and elevated baseline PVR, most centers (88%) perform acute vasoreactivity testing (AVT) during catheterization. Only half (51%) have established a maximum PVR for transplant eligibility, with most citing 6 WU*m² or lower (80%) [range 4-8 WU], obtained after AVT (84%). The highest post-AVT PVR ever listed ranged from 4-14.4, median 6 WU*m² (Figure). Pre-HT, phosphodiesterase 5 inhibitors are most frequently used to treat high PVR (65%); however, 31% never use pulmonary vasodilators. Implantation of a left ventricular assist device (LVAD) increases likelihood of medical therapy for PVR, though timing of initiation (pre- vs post-HT) and duration of therapy varies. Case scenarios demonstrate HT listing with post-transplant pulmonary vasodilator therapy is the favored approach for restrictive cardiomyopathy and elevated PVR, whereas LVAD +/- pulmonary vasodilators is favored for patients with dilated cardiomyopathy or postop LV dysfunction and high PVR, regardless of vasoreactivity. Most continue vasodilator therapy until PVR normalizes or short term (<6 months) post-transplant. <h3>Conclusion</h3> Practice regarding medical management of elevated PVR in children awaiting HT is heterogenous, with variable use of pulmonary vasodilators and a wide range of acceptable PVR cutoffs. Evidence-based guidelines are needed to ensure standardized care and equitable organ allocation.

Fertility rates in women with intellectual and developmental disabilities in Wisconsin Medicaid

BackgroundWomen with intellectual and developmental disabilities (IDD) face stigma and inequity surrounding opportunity and care during pregnancy. Little work has quantified fertility rates among women with IDD which prevents proper allocation of care. ObjectiveOur objective was to cross-sectionally describe fertility patterns among women with and without intellectual and developmental disabilities (IDD) in 10-years of Medicaid-linked birth records. Study designOur sample was Medicaid-enrolled women with live births in Wisconsin from 2007 to 2016. We identified IDD through prepregnancy Medicaid claims. We calculated general fertility-, age-specific-, and the total fertility-rates and 95% confidence intervals (95% CI) for women with and without IDD and generated estimates by year and IDD-type. ResultsGeneral fertility rate in women with IDD was 62.1 births per 1000 women with IDD (95% CI 59.2, 64.9 per 1000 women) and 77.1 per 1000 for women without IDD (95% CI: 76.8, 77.4 per 1000 women). General fertility rate ratio was 0.81 (95% CI: 0.7, 0.9). Total fertility was 1.80 births per woman with IDD and 2.05 births per woman without IDD (rate ratio: 0.89 95% CI: 0.5, 1.5). Peak fertility occurred later for autistic women (30–34 years), compared with women with other IDD (20–24 years). ConclusionIn Wisconsin Medicaid, general fertility rate of women with IDD was lower than women without IDD: the difference was attenuated when accounting for differing age distributions. Results highlight the disparities women with IDD face and the importance of allocating pregnancy care within Medicaid