Inappropriate Care Research Articles

THU667 Severe Hypothyroidism With Paradoxically Elevated Direct Free T4 Due To Anti-thyroxine Antibodies

Abstract Disclosure: O. Magvanjav: None. M.J. McPhaul: None. I. Choucair: None. E. Holt: None. Introduction Laboratory interference may cause abnormal thyroid function test (TFT) results, leading to misdiagnosis and inappropriate patient care. There are several major types of interference. Here, we describe a hypothyroid patient with an elevated thyroid stimulating hormone (TSH) level with a paradoxically elevated direct free thyroxine (FT4) level caused by interference from anti-thyroxine autoantibodies (THAAB). Clinical Case Our patient is a 38-year-old man who was found to have markedly elevated TSH and FT4 levels during an outpatient workup for Lyme disease. The patient was overall well-appearing but reported some symptoms suggestive of hypothyroidism including excessive fatigue, non-pitting edema, and dry skin. Physical exam was notable elevated blood pressure (systolic blood pressure of 150 mmHg and diastolic blood pressure of 95 mmHg), normal temperature, normal heart rate (72 bpm), regular heart rhythm, and normal body mass index. He had non-tender thyromegaly without nodules, non-pitting edema of bilateral hands and legs, decreased leg hair over bilateral shins, and coarse, dry skin of his hands. Initial TSH level was >150 mIU/ml, with a paradoxically elevated direct FT4 of 10 ng/dl (normal range 0.80-1.70 ng/dL). The FT4 level by equilibrium dialysis was <0.2 ng/dl. Outside laboratory testing to eliminate the effect of heterophile antibodies using two different assays again returned with elevated FT4 levels. Screening for macro TSH confirmed the markedly elevated TSH level. Further investigations at a second outside laboratory revealed that he had THAAB. A repeat FT4 level by dialysis confirmed the markedly low FT4 levels. He was empirically started on low dose levothyroxine and after increasing the levothyroxine dose, he showed improvement in clinical symptoms and the expected decline in TSH. Conclusions Here we present a rare case of THAAB that caused laboratory interference during thyroid function testing, leading to falsely elevated thyroid hormone levels on immunoassays. This case shows the importance of suspecting interference when there is a discrepancy between clinical symptoms and laboratory results or between results obtained from different testing methods. Our patient likely had a genetic predilection for autoimmunity, and Lyme disease is a known trigger for various autoimmune conditions. Our case also emphasizes the importance of taking a systematic approach to investigate the cause of the laboratory interference. This will help prevent misdiagnosis of thyroid disorders that may lead to additional unnecessary testing and treatment. Presentation: Thursday, June 15, 2023

Perspectives and Experiences Regarding the Impacts of Emergency Department Overcrowding: A Rapid Qualitative Review


 This review used a rapid best-fit framework analysis approach to synthesize 9 included studies exploring how people who engage with emergency department (ED) services experience and understand the impacts of ED overcrowding, access block, and boarding on quality of care, patient safety, and the well-being of health care professional learners and staff working in the ED. None of the included studies were conducted in Canada.
 The included studies detailed how people who engage with ED services understand the ED as a location that is appropriate for providing short-term treatment to people requiring critical or emergent care, but inappropriate for providing care to patients for extended lengths of time. Study participants described experiencing ED overcrowding, boarding, and access block as transforming the ED into an unsafe environment where the risk of avoidable patient harm increased due to the accelerated depletion of available equipment, space, and human resources. They observed that this unsafe environment led to patients experiencing delayed, missed, and inappropriate care, resulting in potential or actual physical harm, threats to their human rights and dignity, exposures to secondary suffering, reduced satisfaction, and worsening emotional and psychological states.
 Participants reported that ED overcrowding, access block, and boarding had, for the most part, negative impacts on health care professional learners and staff working in the ED. Some ED staff reported that these phenomena led them to experience increased exposure to violence and physical harm, emotional and moral distress, dimensions of burnout, and/or missed learning opportunities for health care professional learners. Some ED staff reported experiences of camaraderie and collaboration necessarily forged as a coping mechanism to manage adversity in the context of overcrowding. Amid the challenges experienced within their practice setting, some experienced staff also perceived overcrowding as providing opportunities to exercise and expand their existing knowledge and skills.
 Considering these findings, decision-makers seeking to address the adverse impacts of ED overcrowding, access block, and boarding on quality of care and patient safety may explore facilitating the integration of routine preventive care into ED processes; enhancing communication within the ED; optimizing available equipment and space; giving patients information before and during their stay to manage their expectations; and enhancing staff’s access to education and resources necessary to better address the needs of patients who frequently experience extended stays in the ED and require specialized care beyond that which ED staff typically have the training and experience to provide. They may prioritize interventions that alleviate, rather than add to, the workload of ED staff. Additionally, they may assess and explore working conditions in the ED with a lens of promoting the well-being and retention of ED staff. By drawing on the findings of this review, they may, for example, consider exploring how to incentivize senior staff to remain in their positions, enhance learning opportunities for health care professional learners, and promote interprofessional collaboration. They may also consider investigating and addressing systemic factors contributing to overcrowding, access block, and the recruiting and retaining of health care providers in their jurisdictions.
 Decision-makers may also further explore how proposed interventions might address or exacerbate ethical and equity issues raised by ED overcrowding, including: the fair and equitable allocation of scarce resources; harms and forgone benefits to patients, health care providers, and other hospital staff; and inequitable access to and experience of ED care by patients, including impacts on patients’ dignity, relationships with care providers, and trust in EDs or health care systems. They may consider providing targeted support to groups identified as disproportionately at risk of harm in overcrowded EDs, including but not limited to: those requiring extended lengths of stay, those with limited agency to self-advocate or gain appropriate attention and care, those who are unable to perform activities of daily living, or those experiencing mental health emergencies. They also may consider that the included studies provided limited or no insight into the perspectives of people belonging to equity-deserving groups with a history of harm and lack of agency in the ED, including but not limited to: Indigenous people, Black people, and other people of colour; people with disabilities; people experiencing houselessness; those experiencing language barriers without access to a professional interpreter; and members of the 2SLGBTQ+ community. More research is needed to understand how these and other equity-deserving groups experience overcrowding, access block, and boarding as impacting their quality of care and safety.

A Quality Improvement Initiative to Increase Documentation of Preferences for Life-Sustaining Treatment in Hospitalized Adults

Portable Orders for Life-Sustaining Treatment (POLST) forms allow patients to codify their preferences for life-sustaining treatments across inpatient and outpatient settings. In 2019 only 29.5% of our hospitalized internal medicine patients with an inpatient do-not-resuscitate (DNR) order and no DNR POLST at admission discharged with a DNR POLST. This presented an opportunity to improve POLST completion and avoid undesired or inappropriate care after discharge. Using electronic health record (EHR) data, the authors identified hospitalized adults (age ≥ 50 years) admitted to an internal medicine service with a DNR order and discharged alive. Patient records were cross-referenced with the state's POLST registry for an active POLST form. Among patients with a missing or full-code POLST form at admission, the authors calculated the proportion with a DNR POLST form completed by discharge. These data were tracked over time with control charts to detect performance shifts following three Plan-Do-Study-Act (PDSA) cycles over 34 months, which included a single educational training on electronic POLST navigation, an EHR discharge navigator notification, and quarterly e-mailed individualized performance reports. The study population (N = 387) was 55.0% male and predominately non-Hispanic white (80.9%). Patients discharging to a skilled nursing facility or hospice were three times more likely to discharge with a DNR POLST compared to patients discharging home. Overall, the proportion of DNR POLST forms completed by discharge increased from 0.36 to 0.60 after three PDSA cycles (p < 0.001). This quality improvement initiative demonstrated improved POLST form completion rates in a target population of adults at elevated risk for readmission and death.

Trajectories of Controller Therapy Use Before and After Asthma-Related Hospitalization in Children and Adults: Population-Based Retrospective Cohort Study.

Inappropriate use of inhaled corticosteroids (ICSs) for asthma impairs control and may cause exacerbation, including asthma-related hospitalization (ARH). In prospective studies, ICS use peaked around ARH, but information on routine care use is limited. Since ARH is a major outcome, controller therapy use in routine care before and after ARH should be documented. This study aimed to distinguish ICS use typologies (trajectories) before and after ARH, and assess their relationships with sociodemographic, disease, and health care characteristics. A retrospective cohort study was performed using a 1% random sample of the French claims database. All patients hospitalized for asthma between January 01, 2013, and December 31, 2015, were classified as either children (aged 1-10 years) or teens/adults (aged ≥11 years). Health care resource use was assessed between 24 and 12 months before ARH. ICS use was computed with the Continuous Measures of Medication Acquisition-7 (CMA7) for the 4 quarters before and after ARH. Initially, the overall impact of hospitalization on the CMA7 value was studied using a segmented regression analysis in both children and teens/adults. Then, group-based trajectory modeling differentiated the groups with similar ICS use. We tested different models having 2 to 5 distinct trajectory groups before selecting the most appropriate trajectory form. We finally selected the model with the lowest Bayesian Information Criterion, the highest proportion of patients in each group, and the maximum estimated probability of assignment to a specific group. Overall, 863 patients were included in the final study cohort, of which 447 (51.8%) were children and 416 (48.2%) were teens/adults. In children, the average CMA7 value was 12.6% at the start of the observation period, and there was no significant quarter-to-quarter change in the value (P=.14) before hospitalization. Immediately after hospitalization, the average CMA7 value rose by 34.9% (P=.001), before a significant decrease (P=.01) of 7.0% per quarter. In teens/adults, the average CMA7 value was 31.0% at the start, and there was no significant quarter-to-quarter change in the value (P=.08) before hospitalization. Immediately after hospitalization, the average CMA7 value rose by 26.9% (P=.002), before a significant decrease (P=.01) of 7.0% per quarter. We identified 3 and 5 trajectories before ARH in children and adults, respectively, and 5 after ARH for both groups. Trajectories were related to sociodemographic characteristics (particularly, markers of social deprivation) and to potentially inappropriate health care, such as medical management and choice of therapy. Although ARH had an overall positive impact on ICS use trajectories, the effect was often transient, and patient behaviors were heterogeneous. Along with overall trends, distinct trajectories were identified, which were related to specific patients and health care characteristics. Our data reinforce the evidence that inappropriate use of ICS paves the way for ARH.

ASCVD- Should We Treat It or Eradicate?

Editorial Note Atherosclerotic cardiovascular disease (ASCVD) is a leading global health concern, signiϐicantly contributing to acute cardiovascular events such as myocardial infarction and ischemic stroke. Research consistently links elevated levels of low-density lipoprotein cholesterol (LDL-C) to ASCVD. Preventive measures and early interventions can mitigate the disease’s progression [1]. Yet, despite advancements in medical treatments and the known beneϐits of lifestyle modiϐications like exercise and reduced saturated fat intake, ASCVD mortality rates continue to rise globally. Modern medical practices often fall short of eradicating ASCVD risk, emphasizing the need for more precise and proactive approaches. Delayed or inappropriate care ampliϐies the risk and complications of ASCVD, urging the necessity for improved preventive guidelines and risk assessment tools.

Conducting inclusive research in genetics for transgender, gender-diverse, and sex-diverse individuals: Case analyses and recommendations from a clinical genomics study.

A person's phenotypic sex (i.e., endogenous expression of primary, secondary, and endocrinological sex characteristics) can impact crucial aspects of genetic assessment and resulting clinical care recommendations. In studies with genetics components, it is critical to collect phenotypic sex, information about current organ/tissue inventory and hormonal milieu, and gender identity. If researchers do not carefully construct data models, transgender, gender diverse, and sex diverse (TGSD) individuals may be given inappropriate care recommendations and/or be subjected to misgendering, inflicting medical and psychosocial harms. The recognized need for an inclusive care experience should not be limited to clinical practice but should extend to the research setting, where researchers must build an inclusive experience for TGSD participants. Here, we review three TGSD participants in the Family History and Cancer Risk Study (FOREST) to critically evaluate sex- and gender-related survey measures and associated data models in a study seeking to identify patients at risk for hereditary cancer syndromes. Furthermore, we leverage these participants' responses to sex- and gender identity-related questions in FOREST to inform needed changes to the FOREST data model and to make recommendations for TGSD-inclusive genetics research design, data models, and processes.

Did the evidence-based intervention (EBI) programme reduce inappropriate procedures, lessen unwarranted variation or lead to spill-over effects in the National Health Service?

Health systems are under pressure to maintain services within limited resources. The Evidence-Based Interventions (EBI) programme published a first list of guidelines in 2019, which aimed to reduce inappropriate use of interventions within the NHS in England, reducing potential harm and optimising the use of limited resources. Seventeen procedures were selected in the first round, published in April 2019. We evaluated changes in the trends for each procedure after its inclusion in the EBI's first list of guidelines using interrupted time series analysis. We explored whether there was any evidence of spill-over effects onto related or substitute procedures, as well as exploring changes in geographical variation following the publication of national guidance. Most procedures were experiencing downward trends in the years prior to the launch of EBI. We found no evidence of a trend change in any of the 17 procedures following the introduction of the guidance. No evidence of spill-over increases in substitute or related procedures was found. Geographic variation in the number of procedures performed across English CCGs remained at similar levels before and after EBI. The EBI programme had little success in its aim to further reduce the use of the 17 procedures it deemed inappropriate in all or certain circumstances. Most procedure rates were already decreasing before EBI and all continued with a similar trend afterwards. Geographical variation in the number of procedures remained at a similar level post EBI. De-adoption of inappropriate care is essential in maintaining health systems across the world. However, further research is needed to explore context specific enablers and barriers to effective identification and de-adoption of such inappropriate health care to support future de-adoption endeavours.

A narrative review of management of wounds in palliative care setting.

A chronic wound is one that is physiologically compromised as a result of a disturbance of the wound-healing cycle brought on by, among other parameters, poor angiogenesis, innervation, or cellular migration. Given the high frequency and incidence rates of different wound categories in clinical practice in the setting of chronically ill patients, wound management is becoming an increasingly important component and pillar of the overall care of patients with terminal illnesses. The purpose of this narrative review is to provide an overview and evaluation of the assessment methods and management of chronic wounds in the clinical practice of palliative care. Papers on the management of wounds in palliative care have been retrieved using PubMed to July 2023. The search terms used included "wounds", "ulcers", "palliative care", "palliative management", and "end of life". The review highlights the importance of early palliative care referral and total pain management in the management of wounds. Patients with wounds often report multiple symptoms, and pain is one of the most common and distressing among them. Despite the availability of multiple guidelines about treatment to relieve pain, almost half of all cancer patients still receive inappropriate care for pain. The review also discusses the etiology of pain and provides strategies for managing the painful wound once it has been identified. The greatest need today in the treatment of chronic wounds is consensus-based knowledge vetted by practical experience and backed up by scientific evidence, which is easily communicated and available to all wound care practitioners. High-quality research together with wound care practice that leads to the best outcomes might include pain reduction, exudate management, odor management, and/or other quality-of-life benefits to wound care. There is a need for specialized palliative care teams to manage expectations throughout the process while maintaining hope.

Community Pharmacies in the Asian Countries of Developing Health System: Formation, Regulation, and Implication.

Community pharmacies (CPs) in Asian countries are often the first point of contact for patients withinthe healthcare system and their preferred place to purchase medicines. The number of CPs may vary across Asian countries, and each country has developed its own design and functioning. The regulatory environment plays a crucial role in shaping and governing CPs. The aim of this study was to conduct a comprehensive literature review in order to enhance understanding of the establishment and regulation of CPs. By undertaking this review, the researchers, policymakers, and practitioners sought to gain a deeper insight into the performance and functions of CPs and the regulatory frameworks that govern them. Moreover, this review shed light on implementation strategies, effects on patient outcomes, and the barriers and challenges associated with their establishment. A narrative literature review method was adopted with specific inclusion and exclusion criteria. Significant disparities can be observed when comparing the stated intentions of regulations with their actual implementation. Recently, there has been an inclusion of public health practices. Unfortunately, pharmacy procedures conducted in such environments have been characterized by inadequate understanding and inappropriate care. This poor performance can be attributed to employees' focus on maximizing profits. Several shortcomings can arise, including incomplete patient history documentation, failure to refer patients who require medical attention, unauthorized dispensing of prescription-only medicines (POM), dispensing clinically inappropriate or excessive medication doses, selling incomplete antibiotic courses, and inadequate information and counseling services. Regulatory interventions can help strengthen these services.

Diagnostic and Therapeutic Approaches in Neurorehabilitation after Traumatic Brain Injury and Disorders of Consciousness

Severe traumatic brain injury (TBI) may cause disorders of consciousness (DoC) in the form of coma, unresponsive wakefulness syndrome (UWS), or minimally conscious state (MCS). Despite significant advancements made over the last two decades in detecting, predicting, and promoting the recovery of consciousness in TBI patients with DoC, the available diagnostic and treatment choices remain limited. In cases of severe TBI, the dissolution of consciousness both in the acute and post-acute phases constitutes one of the major clinical findings and challenges. In clinical settings, neurologists and neurorehabilitation specialists are called on to discern the level of consciousness in patients who are unable to communicate, and to project outcomes and recommend approaches to treatment. Standards of care are not available to guide clinical decision-making for this population, often leading to inconsistent, inaccurate, and inappropriate care. Recent studies refer to network-based mechanisms of consciousness as a more promising method to predict outcomes and functional recovery. A further goal is the modulation of neural networks underlying awareness and arousal as the main components of consciousness. This review centers on the difficulties in characterizing individuals experiencing post-traumatic DoC and on the recent advancements made in the identification and prognostication of consciousness recovery through the utilization of advanced neuroimaging and electrophysiological techniques as well as biomarkers. Moreover, we discuss new treatment approaches and summarize recent therapeutic recommendations.

Models using private general practitioners to provide caesarean deliveries at five South African district public hospitals: insights for public-private contracting for obstetric care in rural areas

ABSTRACT Background Harnessing of private sector resources could play an important role in efforts to promote universal access to safe obstetric care including caesarean delivery in low- and middle-income countries especially in rural contexts but any such attempt would need to ensure that the care provided is appropriate and patterns of inappropriate care, such as high caesarean delivery rates, are not reproduced for the entire population. Objective To examine the contracting arrangements for using private general practitioners to provide caesarean delivery services in rural district hospitals in South Africa. Method We utilised a mixed-method study design to examine the contracting models adopted by five rural district hospitals in the Western Cape, South Africa. Between April 2021 and March 2022, we collected routine data from delivery and theatre registers to capture the profile of deliveries and utilisation of contracted private GPs. We also conducted 23 semi-structured qualitative interviews with key stakeholders to explore perceptions of the contracting arrangements. Results All five hospitals varied in the level of use of private general practitioners and the contracting models (three private in-sourcing models – via locum agencies, sessional contracts, and tender contracts) used to engage them. Qualitative interviews revealed insights related to the need for flexibility in the use of contractual models to meet local contextual needs, cost implications and administrative burden. Conclusion Structured appropriately, private public partnerships can fill important gaps in human resources in rural district hospitals. Policy makers should look to developing a ‘contracting framework’ which requires compliance with a set of underlying principles but allows for flexibility in developing context specific contracting arrangements. These underlying principles should include a ‘risk’ based delivery model, adherence to public sector- evidence-based protocols, time-based rather than per delivery/type of delivery remuneration models, group liability arrangements, and processes to monitor outcomes.

‘Is it worth potentially dealing with someone who won't get it?’: LGBTQA+ university students’ perspectives on mental health care

ABSTRACT LGBTQA+ university students have unique mental health needs and high rates of mental distress compared to their cisgender heterosexual peers; however, it is likely that many LGBTQA+ individuals remain untreated or receive inappropriate or insensitive care. The aim of this study was to explore the experiences and preferences in mental health care of LGBTQA+ university students in Aotearoa New Zealand. Twenty-eight young adults participated across 12 focus groups or interviews in which they were asked about their experiences and preferences. We used thematic analysis to identify patterns of meaning in the data. Researchers developed three themes of I can do this on my own, but others should seek help; you have to be lucky to access mental health care; and ‘therapists just need to be a bit more like up with the programme’. The results of this study mirror those found in more general studies of LGBTQA+ mental healthcare experiences, however, also adds to considerations for university campus healthcare services. The findings of this study should be considered by all mental health providers working with LGBTQA+ young adult university students.

Post-Endoscopy Care for Patients Presenting with Esophageal Food Bolus Impaction: A Population-Based Multicenter Cohort Study.

Esophageal food bolus impactions (FBIs) are a common gastrointestinal emergency. Appropriate management includes not only index endoscopy for disimpaction, but also medical follow-up and treatment for the underlying esophageal pathology. We evaluated the appropriateness of post-endoscopy care for patients with FBIs, and assessed patient-, physician- and system-related factors that may contribute to loss to follow-up. We conducted a retrospective, population-based, multi-center cohort study of all adult patients undergoing endoscopy for FBI in the Calgary Health Zone, Canada from 2016-2018. Appropriate post-endoscopy care was defined by a composite of a clinical or endoscopic follow-up visit, appropriate investigations (e.g., manometry), or therapy (e.g., proton pump inhibitors, endoscopic dilation). Predictors of inappropriate care were assessed using multivariable logistic regression. A total of 519 patients underwent endoscopy for FBI: 25.2% (131/519) did not receive appropriate post-endoscopy care. Half of patients (55.3%, 287/519) underwent follow-up endoscopy or attended clinic, and amongst this group, 22.3% (64/287) had a change in their initial diagnosis after follow-up, including three new cases of esophageal cancer. Patients in whom a suspected underlying esophageal pathology was not identified at the index endoscopy were 7-fold (adjusted odds ratio 7.28 [95% CI: 4.49-11.78], p<0.001) more likely to receive inappropriate post-endoscopy follow-up and treatment, even after adjusting age, sex, rural residence, timing of endoscopy, weekend presentation, and endoscopic interventions. One quarter of patients presenting with an FBI do not receive appropriate post-endoscopy care. This is strongly associated with failure to identify a potential underlying pathology at index presentation.

Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients

ObjectiveTo characterise the extent of unnecessary care in general surgery inpatients using a triple bottom line approach.DesignPatients with uncomplicated acute surgical conditions were retrospectively evaluated for unnecessary bloodwork according to...

Racial and Ethnic Bias in Risk Prediction Models for Colorectal Cancer Recurrence When Race and Ethnicity Are Omitted as Predictors

ImportanceIncluding race and ethnicity as a predictor in clinical risk prediction algorithms has received increased scrutiny, but there continues to be a lack of empirical studies addressing whether simply omitting race and ethnicity from the algorithms will ultimately affect decision-making for patients of minoritized racial and ethnic groups.ObjectiveTo examine whether including race and ethnicity as a predictor in a colorectal cancer recurrence risk algorithm is associated with racial bias, defined as racial and ethnic differences in model accuracy that could potentially lead to unequal treatment.Design, Setting, and ParticipantsThis retrospective prognostic study was conducted using data from a large integrated health care system in Southern California for patients with colorectal cancer who received primary treatment between 2008 and 2013 and follow-up until December 31, 2018. Data were analyzed from January 2021 to June 2022.Main Outcomes and MeasuresFour Cox proportional hazards regression prediction models were fitted to predict time from surveillance start to cancer recurrence: (1) a race-neutral model that explicitly excluded race and ethnicity as a predictor, (2) a race-sensitive model that included race and ethnicity, (3) a model with 2-way interactions between clinical predictors and race and ethnicity, and (4) separate models by race and ethnicity. Algorithmic fairness was assessed using model calibration, discriminative ability, false-positive and false-negative rates, positive predictive value (PPV), and negative predictive value (NPV).ResultsThe study cohort included 4230 patients (mean [SD] age, 65.3 [12.5] years; 2034 [48.1%] female; 490 [11.6%] Asian, Hawaiian, or Pacific Islander; 554 [13.1%] Black or African American; 937 [22.1%] Hispanic; and 2249 [53.1%] non-Hispanic White). The race-neutral model had worse calibration, NPV, and false-negative rates among racial and ethnic minority subgroups than non-Hispanic White individuals (eg, false-negative rate for Hispanic patients: 12.0% [95% CI, 6.0%-18.6%]; for non-Hispanic White patients: 3.1% [95% CI, 0.8%-6.2%]). Adding race and ethnicity as a predictor improved algorithmic fairness in calibration slope, discriminative ability, PPV, and false-negative rates (eg, false-negative rate for Hispanic patients: 9.2% [95% CI, 3.9%-14.9%]; for non-Hispanic White patients: 7.9% [95% CI, 4.3%-11.9%]). Inclusion of race interaction terms or using race-stratified models did not improve model fairness, likely due to small sample sizes in subgroups.Conclusions and RelevanceIn this prognostic study of the racial bias in a cancer recurrence risk algorithm, removing race and ethnicity as a predictor worsened algorithmic fairness in multiple measures, which could lead to inappropriate care recommendations for patients who belong to minoritized racial and ethnic groups. Clinical algorithm development should include evaluation of fairness criteria to understand the potential consequences of removing race and ethnicity for health inequities.

Contributory factors to early neonatal deaths in the Upper East Regional Hospital in Ghana.

This study examined factors identified during early neonatal death audits contributing to preventable newborn deaths at the Upper East Regional Hospital. Data for this study was collected retrospectively from perinatal death audit forms using three data collectors. Data collection lasted two weeks, from 18th June to 2nd July 2021. The data collectors submitted 113 filled hard copy data collection forms. This was then entered into a designed Excel sheet and exported to STATA software version 15.0 for analysis. The analysis was descriptive statistics with cross-tabulation. The results were presented in charts and tables focusing on percentages. Most of the 113 neonatal deaths were from birth asphyxia (63%). Forty-six (40.7%) of the deaths occurred within 24 hrs after birth. There were 38 factors reported 254 times in the audits as contributory to all the newborn deaths; 17 health personnel-related factors stated 141 (55.5%) times, four transportation and communication-related factors stated 43 (16.9%) times, seven health facility factors stated 31 (12.2%) times. Inappropriate care during transportation to the regional hospital was reported most - 21 times, followed by delay in referral - 18 times. The study identified many factors, such as medical personnel-related factors, transportation and communication factors, family-related factors, and health facility administration factors, contributing to early neonatal deaths. Effective implementation of neonatal death audit-based recommendations arising from these contributory factors is critical to preventing avoidable newborn deaths. This project was funded by Upper East Regional Hospital.

ANALYSIS OF DIARRHEA MANAGEMENT IN CHILDREN UNDER TWO YEARS OLD IN INDONESIA

Background: Diarrhea in children under two is still a severe problem in Indonesia, affecting achieving SDG target 3. Providing good care will reduce the risk of death in children caused by diarrhea. Purpose: This study aimed to analyze the relationship between socio-demographic characteristics, place of residence, and access to media in mothers with children under two years old and diarrhea management in children in Indonesia. Methods: This study used secondary data from the 2017 Indonesian Health Demographic Survey (DHS) with a cross-sectional study design. Analyzed were the responses of 1,061 mothers whose children under two had diarrhea in the two weeks before the survey. Samples were taken using two-stage sampling methods. The data were analyzed by chi-square and multiple logistic regression. Multiple logistic regression was adjusted for the complex sampling designs of DHS for data analysis. Results: 59.50% of children received inappropriate treatment. Older mothers (AOR 20–24 = 2.03, 95% CI = 1.03–3.98) who lived in rural areas (AOR = 1.41, 95% CI = 1.03–1.94), had access to several media (AOR = 2.03, 95% CI = 1.01–4.10), and all media (AOR = 2.23, 95% CI = 1.07–4.64), had higher odds of having a child whose diarrhea treatment was not appropriate after controlling for other variables. Conclusion: Mothers' age, residence, and access to media have a significant relationship with inappropriate diarrhea care for their children. Therefore, interventions need to focus on women who live in rural areas and have access to the media. Conclusion: Mother’s age, residence, and access to media have a significant relationship with inappropriate diarrhea care for their children. Therefore, interventions need to focus on women who live in rural areas and have access to the media. It is hoped that this intervention can increase mother's knowledge to provide good care when her child has diarrhea.

Measurement of unmet healthcare needs to assess progress on universal health coverage - exploring a novel approach based on household surveys

BackgroundUniversal Health Coverage (UHC) aims to ensure universal access to quality healthcare according to health needs. The extent to which population health needs are met should be a key measure for progress on UHC. The indicators in use for measuring access mostly relate to physical accessibility or insurance coverage. Or, utilization of services is taken as indirect measure for access but it is assessed against only the perceived healthcare needs. The unperceived needs do not get taken into account. The present study was aimed at demonstrating an approach for measuring the unmet healthcare needs using household survey data as an additional measure of UHC.MethodsA household survey was conducted in Chhattisgarh state of India, covering a multi-stage sample of 3153 individuals. Healthcare need was measured in terms of perceived needs which would be self-reported and unperceived needs where clinical measurement supplemented the interview response. Estimation of unperceived healthcare needs was limited to three tracer conditions- hypertension, diabetes and depression. Multivariate analysis was conducted to find the determinants of the various measures of the perceived and unperceived needs.ResultsOf the surveyed individuals, 10.47% reported perceived healthcare needs for acute ailments in the last 15 days. 10.62% individuals self-reported suffering from chronic conditions. 12.75% of those with acute ailment and 18.40% with chronic ailments received no treatment, while 27.83% and 9.07% respectively received treatment from unqualified providers. On an average, patients with chronic ailments received only half the medication doses required annually. The latent need was very high for chronic ailments. 47.42% of individuals above 30 years age never had blood pressure measured. 95% of those identified with likelihood of depression had not sought any healthcare and they did not know they could be suffering from depression.ConclusionTo assess progress on UHC more meaningfully, better methods are needed to measure unmet healthcare needs, taking into account both the perceived and unperceived needs, as well as incomplete care and inappropriate care. Appropriately designed household surveys offer a significant potential to allow its periodic measurement. Their limitations in measuring the ‘inappropriate care’ may necessitate supplementation with qualitative methods.

765 When All Hell Breaks Loose: The Need for Specialized Burn Provider Expertise During Crisis

Abstract Introduction The COVID-19 pandemic prompted health care organizations to create or revisit crisis standards of care (CSC) guidelines. The goal of these plans is to preemptively determine the most effective way to allocate resources under circumstances in which not all patients can be treated in accordance with general standards of care. In 2020, the American Burn Association (ABA) released professional recommendations for the development of CSC guidelines. Specifically, the ABA provided triage tables that could be incorporated into organizational CSC guidelines with the intention of assisting providers by predicting mortality based on a patient’s age and burn size. These tables are often misinterpreted by non-burn providers who tend to overestimate burn size and conclude that a patient has a higher predicted mortality than they actually do. Inaccurate predicted mortalities can result in inappropriate care plans and ultimately impact patient outcomes. We argue that the ABA predicted mortality tables are helpful when used by experienced burn providers, but that there are inherent ethical risks when they are utilized by providers who lack appropriate burn care experience. Methods We conducted a literature review of CSC guidelines that included specific instructions for the triage of burn patients. We reviewed 15 publicly available CSC guidelines, 8 of which specifically mentioned burn patients, and examined each to see if/how they utilized ABA triage tables for predicting burn patient mortality. Results Of the 8 CSC plans that acknowledged burn patients, 5 utilized the mortality predictors outlined in the ABA triage tables to guide resource allocation. In the majority of plans, patients with a predicted mortality of &amp;gt;90% were not eligible to receive treatment and/or transfer. None of the plans specified the involvement of a specialized burn provider in assessing burns. Conclusions Our findings indicate that the expert evaluation of burns and thus predicted mortality can be the difference between receiving and not receiving potentially life-saving interventions under CSC guidelines. If a non-burn provider overestimates a burn size, for example, a patient may be undertreated for potentially survivable injuries under some CSC guidelines. This may further perpetuate health disparities given vulnerable populations are at higher risk of suffering burn injuries and often face a higher risk of morbidity and mortality. Applicability of Research to Practice This project demonstrates the need for expert input from specialized burn providers in assessing burns, especially in CSC scenarios, to ensure these assessments are reliable and accurate. Involving expert burn providers in this process will help ensure ethically appropriate clinical care decisions are being made which will improve patient outcomes and resource management in crises and decrease provider distress.

Strategi Seorang Ibu Dalam Merawat Bayi Baru Lahir Di Tengah Pandemi Covid-19 (Studi Kasus Keluarga Ibu Alfiatul Maulidah Desa Grenden Puger Jember)

The COVID-19 pandemic has had an impact on society. Things that need to be considered include maintaining a safe distance (physical distancing), wearing masks, and washing hands frequently with soap and running water. Problems in newborns can be minimized by caring for newborns by a mother or her family, which cannot be separated from the role and support of health workers in improving the ability to care for babies. Newborns (BBL) are very susceptible to infections caused by exposure to viruses and germs during labor and shortly after birth. Inappropriate BBL care can cause health problems in infants and even death. The error was due to the lack of knowledge and low readiness of mothers about infant care, in addition to the activity of the Toddler Posyandu being temporarily postponed during the pandemic, information related to the growth and development of infants and toddlers was less than optimal. The results of activities regarding newborn care during this pandemic show satisfaction from the target families. Mothers who have newborns can understand and understand proper newborn care.