Independent Predictors Of Delay Research Articles

Predictors and outcome of time to presentation among critically ill paediatric patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania

BackgroundMortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown. In this study delay was defined as presentation to the emergency department of tertially hospital i.e. Muhimbili National Hospital, more than 48 h from the onset of the index illness.MethodologyThis was a prospective cohort study of critically ill children aged 28 days to 14 years attending emergency department at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was the association of delay with mortality and secondary outcomes were predictors of delay among critically ill paediatric patients.Logistic regression and relative risk were calculated to measure the strength of the predictor and the relationship between delay and mortality respectively.ResultsWe enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR = 9–60] months and 63.9% were males. The median time to Emergency Department arrival was 3 days [IQR = 1–5] and more than half (56.6%) of critically ill children presented to Emergency Department in > 48 h whereby being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.4(95% CI 1.4–4.0) and 1.8(95% CI 1.1–2.8) times increased odds of presenting late to the Emergency Department respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR = 1.3, CI: 0.9–1.9). Majority died > 24 h of Emergency Department arrival (P-value = 0.021).ConclusionThe risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill pediatric patients to identify preventable delays in care.

Treatment seeking delay and associated factors among tuberculosis patients attending health facility in Ethiopia from 2000 to 2020: A systematic review and meta analysis.

BackgroundTreatment seeking delay is defined as the time interval between the onset of the major symptoms of tuberculosis (TB) and the first visit to the formal health care facility. The patient was said to be delayed if the patient visited the health-facility after 3 weeks onset of major symptoms. However, in low-income countries like Ethiopia, the delay in treatment-seeking among tuberculosis patients contributes to a widespread transmission and high prevalence of tuberculosis.MethodsStudies were retrieved from PubMed, Cochrane Database, Cinahl, Scopus, Mednar, and Google Scholar by employing a combination of search terms with Boolean operators. Heterogeneity across studies was assessed using the Cochrane Q test. A funnel plot was used for visual assessment of publication bias. Subgroup analyses were performed to explore the possible causes of heterogeneity. Egger’s weighted regression test at a p-value < 0.05 was used to assess the presence of publication bias. Sensitivity analysis was performed to judge whether the pooled effect size was influenced by individual study. STATA software version 14 was used for all statistical analyses.ResultA total of 12 studies with 5122 total sample size were included. The national pooled prevalence of treatment seeking delay was 44.29% (95% CI: 39.805, 48.771). The visual inspection of the funnel plot showed the asymmetrical distribution, and the Egger test showed insignificant (P = 0.348). Patients who did not seek formal health care providers on a first contact had about 7 times more likely to delay than patients who sought formal health care provider on a first contact (OR: 7.192 ((95% CI 5.587–9.257), P = 0.001, I2: 85%). The others independent predictors of delay were rural residence (OR: 3.459 ((95% CI 1.469–8.148), P ≤ 0.001), extra pulmonary TB (OR: 2.520 ((95% CI 1.761–3.605), 0.180), lower educational level (OR 11.720 ((95% CI 1.006–2.938), P <0.001), and distance more than 10km from health facility (OR: 1.631 ((95% CI (10.858–3.101), P = 0.001).ConclusionIn this review, we identified a substantial treatment seeking delay among TB patients in Ethiopia. And, the independent predictors of delay were treatment sought before formal health care provider, residence of the patient, type of TB, educational level, and distance from a health facility. Thus, we recommend health extension workers, health professionals and other stakeholders to focus on patient education, and to continuously mobilize the whole communities on early treatment seeking with a special emphasis given to where treatment sought before formal health care provider, rural resident, extra pulmonary TB, and a patient living farther than 10km distance from health facility.

Determinants of delay in the head and neck oncology care pathway: The next step in value-based health care.

ObjectiveHead and neck squamous cell carcinomas (HNSCC) are relatively fast‐growing tumours, and delay of treatment is associated with tumour progression and adverse outcomes. The aim of this study is to identify determinants of delay in a head and neck oncology centre.MethodsThis cohort study with prospectively collected data investigated associations between patient (including geriatric assessment at first consultation), tumour and treatment characteristics and treatment delay. Two quality indicator intervals assessing value‐based healthcare were studied: care pathway interval (CPI, interval between first visit in an HNOC and treatment initiation) and time‐to‐treatment initiation (TTI, interval between histopathological confirmation of HNSCC and treatment initiation), using regression analyses.ResultsStage‐IV tumours and initial radiotherapy were independent predictors of delay in CPI. Initial radiotherapy was associated with delay in TTI. Overall, 37% of the patients started treatment within 30 days after first consultation (67% in case of initial surgical treatment and 11.5% if treated with (chemo)radiation, p < 0.001). Geriatric assessment outcomes were not associated with delay. Indicators for delay in initial surgery patients were stage‐IV tumours (CPI).ConclusionThe majority of HNSCC patients encounter delay in treatment initiation, specifically in patients with advanced‐stage tumours or when radiotherapy is indicated.

Risk factors for delay in surgery for patients undergoing elective anterior cervical discectomy and fusion.

Anterior cervical discectomy and fusion (ACDF) is well-tolerated by most patients and commonly necessitates only a short hospital admission. Surgical delay after hospital admission, however, may result in longer hospital stays, consequently increasing hospital resource utilization. The current study evaluates risk factors for surgical delay in patients undergoing elective ACDF. A retrospective analysis of ACS-NSQIP data from 2006-2015 was performed. Patients undergoing elective ACDF were selected using current procedural terminology (CPT) codes (22251, 22252, 22554). A surgical delay was defined as surgery that occurred one day or later after initial hospital admission. Differences in outcomes between the non-delayed and delayed cohorts were evaluated with univariate analysis. Multivariate logistic regression was performed to identify risk factors for surgical delay. There were a total of 771 (2.0%) surgical delays out of 39,371 patients undergoing elective ACDF from 2006-2015. Multivariate analysis found partially dependent functional status (OR 5.88; 95% CI: 4.48-7.71; P<0.001), totally dependent functional status (OR 18.22; 95% CI: 9.60-34.59; P<0.001), ASA class 4 (OR 2.73; 95% CI: 1.70-4.38; P<0.001), bleeding disorders (OR 1.75; 95% CI: 1.08-2.85; P=0.024), male sex (OR 1.19; 95% CI: 1.03-1.38; P=0.019), and chronic steroid use (OR 1.76; 95% CI: 1.30-2.37; P<0.001) as independent predictors of delay. Univariate analysis found surgical delay was associated with a higher rate of post-operative major adverse events (4.8% vs. 1.1%; P<0.001), mortality (1.0% vs. 0.2%; P<0.001) and greater than five-fold increase in total length of stay (9.52 vs. 1.65 days; P<0.001). Impaired pre-operative functional status, a higher comorbidity burden, and chronic steroid use are risk factors for surgical delay, increased complications, and length of stay in patients undergoing elective ACDF. This is helpful information to consider given a rising incidence of cervical fusions in the Medicare population, a wide variation in costs, and increasing popularity of bundled-payment models. 3.

Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions.

Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

Tuberculosis’ Total Health care system and patient side diagnosis and Treatment Delay and Associated Factors Among Pulmonary Tuberculosis Patients At Hadiya Zone Public Health Facilities, Southern Ethiopia.

Background: Delay in TB treatment is significant to both disease prognoses at the individual level and within the community. Even though studies conducted in TB treatment delay there is result inconsistencies due to differences in culture, environment and infrastructure.&#x0D; Objective: the aim of the study is to assess the tuberculosis treatment Delay and associated factor among pulmonary tuberculosis patients.&#x0D; Method: Facility based cross sectional study triangulated by Qualitative study was employed on 340 PTB patients in Hadiya zone public health facilities. Three woredas and health facilities were selected by Simple random sampling method. DOTS user at the beginning of data collection was consecutively recruited in to the study until the intended sample size was fulfilled. Multivariable binary Logistic regression was used. A P-value &lt; 0.05 at 95 % CI was considered statistical significance between dependent and predictors variables.&#x0D; Result: Among 340 PTB patients enrolled in the study, of which 49.1% experienced patient delay, 30% health system delay and 49.8% total delay. Unable to read and write, Poor knowledge of TB (AOR 3.96, 95% CI (2.28 6.86), self-treatment (AOR: 2, 95% CI (1.14, 3.93), financial constraint (AOR: 2.092, 95% CI (1.11, 3.945) , Visiting two or more health care providers (AOR: 3.40, 95% CI (1.910 – 6.07), prolonged referral (AOR: 3.004, 95% CI (1.59, 5.67) were independent predictors of delay.&#x0D; Conclusion: Nearly half of the total delay was contributed by patient delay. Unable to read and write, Poor knowledge of TB, self-treatment, financial constraints, prolonged referral, several visit of health care provider of two or more and ever used other drugs rather than Anti-TB drugs were found to have association with patient delay and health system delay.&#x0D; Keywords: Tuberculosis treatment delay, PTB, patient delay and health system delay, Hadiya zone, Ethiopia.

Factors associated with delay in transfer of patients with ST-segment elevation myocardial infarction from first medical contact to catheterization laboratory: Lessons from CRAC, a French prospective multicentre registry

It is critical to minimize the time between the first medical contact and primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. To identify factors associated with a delay of>120min between first medical contact and primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. Data were analysed from a regional French registry of patients undergoing coronary angioplasty for ST-segment elevation myocardial infarction<24h after symptom onset. Patients (n=2081) were grouped according to transfer times from first medical contact to primary percutaneous coronary intervention:>120min; or≤120min. Independent predictors of delay were identified by univariate and multivariable analyses. The median transfer time from first medical contact to primary percutaneous coronary intervention was 112min; 892 patients (42.9%) had a transfer time>120min. A delay of>120min was significantly associated with:≥75km distance from interventional cardiology centre at symptom onset (odds ratio 7.9); more than one medical practitioner involved before interventional cardiology centre (odds ratio 4.5); first admission to a hospital without an interventional cardiology centre (odds ratio 2.9); absence of emergency call (odds ratio 1.6); ≥90min between symptom onset and first medical contact (odds ratio 1.3); Killip class at admission>1 (odds ratio 1.8); lateral ischaemia (odds ratio 1.8); diabetes mellitus (odds ratio 1.6); and hypertension (odds ratio 1.3). In ST-segment elevation myocardial infarction, a transfer time from first medical contact to primary percutaneous coronary intervention of>120min was associated with geographic, systemic and comorbid factors, several of which appear reasonably actionable.

Independent predictors of delay in emergence from general anesthesia.

Some patients with intellectual disabilities spend longer than others in emergence from ambulatory general anesthesia for dental treatment. Although antiepileptic drugs and anesthetics might be involved, an independent predictor for delay of the emergence remains unclear. Thus, a purpose of this study is to identify independent factors affecting the delay of emergence from general anesthesia. This was a retrospective cohort study in dental patients with intellectual disabilities. Patients in need of sedative premedication were removed from participants. The outcome was time until emergence from general anesthesia. Stepwise multivariate regression analysis was used to extract independent factors affecting the outcome. Antiepileptic drugs and anesthetic parameters were included as predictor variables. The study included 102 cases. Clobazam, clonazepam, and phenobarbital were shown to be independent determinants of emergence time. Parameters relating to anesthetics, patients' backgrounds, and dental treatment were not independent factors. Delay in emergence time in ambulatory general anesthesia is likely to be related to the antiepileptic drugs of benzodiazepine or barbiturates in patients with intellectual disability.

Delay in diagnosis and treatment of symptomatic breast cancer in China.

Delay in diagnosis and treatment of cancer may lead to advanced tumor characteristics and poor prognosis. Research and investigation from economically developing countries such as China are warranted to support these conclusions, so we studied the impact on prognosis of delays and factors predicting delay in symptomatic breast cancer patients in China. Medical records and follow-up information were collected. Variables including demographic data, and clinical and tumor characteristics, including patient age, menstrual status, residential status, initial symptom, profession, comorbidities, tumor size, lymph node metastasis, distant metastasis, history of breast disease, and family history of breast cancer, were analyzed, as was survival information. A total of 1,431 women diagnosed with breast cancers between 1998 and 2005 in Qilu Hospital were enrolled and studied. Delays in diagnosis and treatment were correlated with larger tumor size, lymph node metastasis, late tumor stage, and worse disease-free survival, as assessed by multivariate logistic regression and Kaplan-Meier regression models. Patient residential status, initial symptom, menopausal status, and history of breast disease were independent predictors of delay. Stratified multivariate analyses confirmed that age was not associated with delay. Delay in diagnosis and treatment predicts worse clinical outcomes. Improvement of medical service in rural areas, especially for premenopausal women, can decrease delays and benefit breast cancer patients.

Factors Influencing Delay in Symptom-to-Door Time in Patients with Acute ST-Segment Elevation Myocardial Infarction

Background/Aims: Delay in symptom-to-door time (SDT) in patients with acute ST-segment elevation myocardial infarction (STEMI) is the most important factor in the prediction of short and long-term mortality. The purpose of this study was to investigate the social and clinical factors affecting SDT in patients with STEMI. Methods: We analyzed 784 patients (61.0 ± 13.2 years, 603 male) diagnosed with STEMI from November 2005 to February 2012. The patients were divided into four groups according to SDT: Group I (n = 163, ≤ 1 h), Group II (n = 183, 1-2 h), Group III (n = 142, 2-3 h) and Group IV (n = 296, > 3 h). Results: Delay in SDT increased with age (Group I, 58.4 ± 12.0; Group II, 59.4 ± 13.3; Group III, 62.0 ± 12.8; Group IV, 63.0 ± 13.8 years, p = 0.001). In 119 patients, transportation was less frequently used as the delay in SDT (41.7% vs. 29.0% vs. 26.1% vs. 9.8%, p < 0.001). By multiple logistic regression analysis, family history [OR, 0.488; CI, 0.248-0.959; p = 0.037], previous ischemic heart disease [OR, 0.572; CI, 0.331-0.989; p = 0.045], no occupation [OR, 1.600; CI, 1.076-2.380; p = 0.020] and method of transportation [OR, 0.353; CI, 0.239-0.520; p < 0.001] were independent predictors of delay in SDT. Conclusions: Our study shows that general education about cardiovascular symptoms and a prompt emergency call could be important to reduce SDT in STEMI. (Korean J Med 2014;87:429-438)

Slow-onset and Fast-onset Symptom Presentations In Acute Coronary Syndrome (ACS): New Perspectives on Prehospital Delay in Patients with ACS

BackgroundPatient decision delay is the main reason why many patients fail to receive timely medical intervention for symptoms of acute coronary syndrome (ACS). Study ObjectivesThis study examines the validity of slow-onset and fast-onset ACS presentations and their influence on ACS prehospital delay times. A fast-onset ACS presentation is characterized by sudden, continuous, and severe chest pain, and slow-onset ACS pertains to all other ACS presentations. MethodsBaseline data pertaining to medical profiles, prehospital delay times, and ACS symptoms were recorded for all ACS patients who participated in a large multisite randomized control trial (RCT) in Dublin, Ireland. Patients were interviewed 2–4 days after their ACS event, and data were gathered using the ACS Response to Symptom Index. ResultsOnly baseline data from the RCT, N = 893 patients, were analyzed. A total of 65% (n = 577) of patients experienced slow-onset ACS presentation, whereas 35% (n = 316) experienced fast-onset ACS. Patients who experienced slow-onset ACS were significantly more likely to have longer prehospital delays than patients with fast-onset ACS (3.5 h vs. 2.0 h, respectively, t = −5.63, df 890, p < 0.001). A multivariate analysis of delay revealed that, in the presence of other known delay factors, the only independent predictors of delay were slow-onset and fast-onset ACS (β = −.096, p < 0.002) and other factors associated with patient behavior. ConclusionSlow-onset ACS and fast-onset ACS presentations are associated with distinct behavioral patterns that significantly influence prehospital time frames. As such, slow-onset ACS and fast-onset ACS are legitimate ACS presentation phenomena that should be seriously considered when examining the factors associated with prehospital delay.

Socioeconomic and clinical factors associated with delayed initiation of adjuvant chemotherapy for stage III colon cancer.

173 Background: We have previously described an association between a greater than 8-week interval to initiation of adjuvant chemotherapy after resection of stage III adenocarcinoma of the colon and an approximately 20% increased risk of mortality. We sought to understand the factors that lead to delay in chemotherapy initiation. Methods: Patients who received adjuvant chemotherapy after resection of stage III colon cancer between 2003 and 2007 were identified from the National Cancer Data Base. Delayed chemotherapy was defined as the first date of chemotherapy administration being eight weeks or more after surgical resection. Comorbidity was categorized using the Charlson/Deyo index. Prolonged length of stay and unplanned readmission were used as surrogates for surgical complications. Multivariate logistic regression was performed to examine the associations between various clinical and socioeconomic variables and delay in the receipt of adjuvant chemotherapy. Results: 33,011 stage III colon cancer patients who received chemotherapy after surgery were identified. 8,036 (24.3%) initiated chemotherapy more than eight weeks after surgical resection. Unplanned readmission (OR 1.76, 95% CI 1.58-1.95), prolonged postoperative stay (OR 1.56, 95% CI 1.48-1.65), and comorbidity (OR 1.18, 95% CI 1.12-1.25) were all independent predictors of delay. Nonclinical factors, including African-American race (OR 1.34, 95% CI 1.24-1.45), lack of insurance (OR 1.63, 95% CI 1.43-1.87), and residence more than 100 miles from treating center (OR 1.23, 95% CI 1.01-1.51) were also independently associated with delayed chemotherapy. Conclusions: Delay in the initiation of adjuvant therapy for colon cancer beyond 8 weeks has previously been found to be an independent predictor of increased mortality. While some delays may result from patient frailty or postoperative complications, these data suggest that nonclinical factors may also contribute to delays. Increased focus on overcoming barriers to coordinated care should be prioritized to ensure that those patients who may benefit from adjuvant therapy receive it in a timely fashion to optimize survival advantages.

Relationship of Treatment Delay with Surgical Defect Size from Keratinocyte Carcinoma (Basal Cell Carcinoma and Squamous Cell Carcinoma of the Skin)

Larger keratinocyte carcinoma (KC) lesions are associated with higher morbidity. This study examined the association of potentially modifiable characteristics, including treatment delay, with KC defect size after Mohs micrographic surgery (MMS). A stratified random sample of patients treated for KC with MMS were selected for telephone interview. Two hundred and nineteen interviews were completed (refusal rate 24%). Regression models were used to examine the predictors to defect size and delay. Anatomic site, age, histology, and gender predicted defect size (R(2) = 0.39) and were used as control variables. Self-reported delay between initial physician examination and MMS predicted defect size (p = 0.0004), with greater than 1 y delay being associated with a doubling of defect size (adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.3-3.1). Delays of this duration were associated with initial examination by a primary provider (unadjusted OR 3.9; 95% CI 1.7-8.8), misdiagnosis (unadjusted OR 6.8; 95% CI 2.5-18.7), being treated without biopsy (unadjusted OR 23.3; 95% CI 6.5-83.7), and multiple surgical removals (unadjusted OR 6.2; 95% CI 2.5-15.5). All but provider specialty were independent predictors of delay. Attention to processes of care delivery for KC may have a greater impact on morbidity than efforts are earlier detection by the public.

Pulmonary morbidity in 100 survivors of congenital diaphragmatic hernia monitored in a multidisciplinary clinic

In 1990, the authors began a multidisciplinary follow-up clinic for congenital diaphragmatic hernia (CDH) patients. Although the nonpulmonary complications associated with CDH have been reported previously from this clinic, the purpose of this report is to detail the pulmonary outcome in survivors of CDH with severe pulmonary hypoplasia. Between 1990 and 1999, one hundred patients were seen in the clinic. Before hospital discharge, all patients had baseline tests performed, which were repeated per protocol at clinic during follow-up. The data were analyzed by regression analysis to identify and determine the impact of factors on outcomes associated with the long-term pulmonary morbidity. The average birth weight was 3.16 kg (+/-0.7) with a mean Apgar score of 7 (+/- 2) at 5 minutes. Forty-one patients had an antenatal diagnosis performed. Extracorporeal membrane oxygenation (ECMO) was utilized in 29 patients, and a patch repair was required in 32, whereas 16 patients received both. Average time to extubation was 20.7 (+/- 20) days and mean time to discharge was 59.7 (+/- 61) days. Regression analysis showed that both the need for ECMO and a patch repair were independent predictors of delay in extubation (P <. 001, R(2) = 36%), and delay in discharge from the hospital (P =.001, R(2) = 29%). ECMO also was significantly correlated with the need for diuretics at discharge (P <.001, R(2) = 18%), and with the presence of left-right mismatch (P =.009, R(2) = 9%) and V/Q mismatch (P =.005, R(2) = 11%) on subsequent pulmonary ventilation-perfusion examinations. Sixteen patients required O(2) at discharge, and diuretics were necessary in 43 patients. Seventeen patients at discharge required bronchodilators, and during the first year an additional 36 required at least transient therapy. Similarly, 6 patients at discharge required steroids, and an additional 35 patients required at least transient therapy during the first year. Chest x-rays, although frequently abnormal, had little correlation with clinical outcome, but did influence medical therapy. V/Q scans had limited utility in patient management, and the presence of V/Q mismatch was not highly specific for future obstructive airway disease. Nevertheless, V/Q mismatch was sensitive for obstructive airway disease assessed by spirometry. Twenty-five patients over 5 years of age performed pulmonary function tests (PFTs), which showed 72% normal PFT results and 28% with evidence of obstructive airway disease. Before January 1997, 2 of 8 patients who required urgent treatment in the emergency department (ED) were admitted to the intensive care unit (ICU) secondary to acute respiratory distress. After the implementation of respiratory syncytial viral prophylaxis in January 1997, 8 patients were treated in the ED for acute respiratory distress, but none required admission to the ICU. Pulmonary problems continue to be a source of morbidity for survivors of CDH long after discharge. The need for ECMO and the presence of a patch repair are both predictive of more significant morbidity, but the data clearly show that non-ECMO CDH survivors also require frequent attention to pulmonary issues beyond the neonatal period. These data show the need for long-term follow-up of CDH patients preferably with a multidisciplinary team approach.