South Asia and societal challenges : a regional perspective

This paper is a summary of the South Asian region’s status and interests concerning the seven thematic societal challenges identified under the EU’s Horizon 2020 research programme: Health, demographic change and wellbeing; Food security, sustainable agricultures, marine and maritime research and the bio-based economy; Clean and efficient energy; Smart, green and integrated transport; Climate action, resource efficiency and raw materials; A changing world - inclusive, innovative and reflective societies; and, Secure societies - protecting freedom and security of the country and its citizens. This paper considers the position of seven countries in South Asia: Afghanistan; Bangladesh; Bhutan; Maldives; Nepal; Pakistan; and, Sri Lanka1. It also identifies national and regional priorities for the seven themes under consideration. This paper is an output of the CASCADE project (Collaborative Action towards Societal Challenges through Awareness, Development, and Education) that aims to provide the foundation for a future International Cooperation Network programme targeting South Asian Countries, which will promote bi-regional coordination of Science & Technology cooperation. The EU recognise a need to strengthen internationalisation through strategic policy action. The need for linkages with Asian countries has been highlighted given the region’s rapidly growing research and innovation capacities and the urgency to address global challenges. The project coincides with the launch of Horizon 2020, a Europe 2020 flagship initiative aimed at securing Europe’s global competitiveness. Running from 2014 to 2020 with a budget of just over €80 billion, the EU’s new programme for research and innovation is part of the drive to tackle global societal challenges, and create new growth and jobs. International cooperation in research and innovation is an essential element for meeting the objectives of Europe 2020. Recognising the global nature of producing and using knowledge, Horizon 2020 builds on the success of international cooperation in previous framework programmes and is fully open to participation from third countries

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Reducing Emergency Department demand through expanded primary healthcare practice: Full report of the research and findings.Vol. 1.

BackgroundDemand for public hospital emergency departments’ services and care is increasing, placing considerable restraint on their performance and threatens patient safety. Many factors influence such demand including individual characteristics (e.g. perceptions, knowledge, values and norms), healthcare availability, affordability and accessibility, population aging, and internal health system factors (e.g patient flow, discharge process). To alleviate demand, many initiatives have been trialled or suggested, including early identification of at-risk patients, better management of chronic disease to reduce avoidable ED presentation, expanded capacity of front-line clinician to manage sub-acute and non-urgent care, improved hospital flow to reduce access block, and diversion to alternate site for care. However, none have had any major or sustained impact on the growth in ED demand.A major focus of the public discourse on ED demand has been the use and integration of primary healthcare and ED, based on the assumption that between 10%–25% of ED presentations are potentially avoidable if patients’ access to appropriate primary healthcare (PHC) services were enhanced. However, this requires not only improved access but also appropriateness in terms of the patients’ preference and PHC providers’ capacity to address the needs. What is not known at the moment is the extent of the potential for diversion of non-urgent ED patients to PHC and the cost-benefits of such policy and funding changes required, particularly in the Australian context. There is a need to better understand ED patients’ needs and capacity constraint so as to effect delivery of accessible, affordable, efficient and responsive services.Aim and objectivesThe main aim of this study was to investigate, from a whole-of-system perspective, the suitability, features and viability of primary healthcare (PHC) as an alternative to emergency department (ED) care for non-urgent acute illness.The objectives of this project were to:1. Identify the features required of PHC as a suitable ED alternative for acute care from patients’ perspectives;2. Identify the factors that affect patients’ preference and choice between ED care and PHC;3. Validate and quantify the suitability and features required of PHC as an ED alternative, and measure the relative impact of factors that affect patients’ preferences and choice between ED care and PHC;4. Quantify the number and type of ED patients that may be suitable for receiving PHC;5. Identify through stakeholders' engagement viable PHC models, and evaluate the economic, policy and system changes required to manage the provision of acute care in non-ED settings safely, effectively and efficiently.Research methodWe conducted a multistage mixed methods study within the Brisbane Metro North area. The study involved:1) Cross-sectional survey of 514 patients attending the four major public hospital EDs in the area (Caboolture, Redcliffe, The Prince Charles, Royal Brisbane &amp; Women’s);2) Secondary analysis of over 822,000 presentations data related to patients attending the above named EDs during the three year period of 2014-15 to 2016-17;3) In-depth interviews with 11 health providers and/or policy experts and decision-makers from medical, nursing and pharmaceutical backgrounds whose views could inform the study objectives.FindingsSurvey of ED patients identified their main reasons for presenting to ED, their contact with GP beforehand, and their decision-making. For 85% of the respondents, attending the ED was because they perceived they required immediate (urgent) care. When asked how they rated the urgency of their condition prior to attending the ED, the mean score was 7 out of 10. Around 43% reported they had contacted their GP, but in many instances, either the GP or the receptionist referred them on to the ED due to various reasons, e.g not having an appointment, requiring extra care or services not available at the GP. Nearly 30% also reported having contacted the ambulance, 13Health or a pharmacist in relation to their illness prior to presenting to the ED. Forty percent were confident a GP would be able to treat their illness, however, mostly agreed that right settings and arrangements were required for GPs to be able to become involved in acute care, including special equipment and facilities, prioritising system for urgent cases, availability and bulk-billing.We also assessed if the patients would hypothetically accept the ED triage nurse’s advice if the nurse advises them that their condition could be treated by a GP. Over 80% reported they would accept the advice. However, further analyses showed that this potential acceptance was contingent upon perceived seriousness, availability of alternative/primary care, and affordability. This finding has significant implications for patient navigation and care coordination. It should be emphasised that we only assessed the patient’s acceptance hypothetically and no advice was actually offered. We did not investigate practicalities of providing such advice, long-term sustainability and effectiveness of such initiatives in practice, for instance patients’ compliance, and whether it reduces ED demand.Our analysis of the EDIS data (number of patient presentations to the four EDs during 2014-15 to 2016-17) showed that between 6% to 26.7% of the presentations were potentially of GP-type, according to three different methods. However, two methods returned close estimates (6% and 7.5%) while the AIHW method returned 26.7%. All three methods showed that the proportion of GP-type presentations decreased over time. The costs of treating GP-type patients in EDs were estimated at around $400 while for non-GP-type patients it varied between$500 and $700 for children and adults and different methods. We did not have a comparable data for similar patients who are treated in a GP setting. The key issues emerged from this analysis included:- Defining and identifying the so-called GP-type patients in ED is contested and challenging;- The considerable number of GP-type patients who are admitted plus their long length of stay in ED indicate that these patients may not be simply suitable for GP care with a standard consultation time of about 15 minutes;- The cost of treating GP-type patients in an ED setting, inclusive of all ancillary costs, is far less than non-GP-type patients. However, in the absence of comparable GP data, we cannot rule out that the ED may still be the most cost-effective place for managing these patients.Our interviews with healthcare providers and decision-makers identified the following major issues:1) Barriers to provision of acute care in PHC, including: inadequate renumeration, high costs of specialised equipment, staff availability, litigation and Medicare audits, EDs’ legal duty not to divert patients, and GPs’ varied skills and interests;2) Barriers to patient use of PHC instead of ED, including: timely access, convenience, confidence, and out of pocket expenses;3) Suggestions for a new healthcare model, including: dedicated centres for less acute or low urgency cases staffed by primary care providers, and optimising or repurposing existing GP facilities for afterhours use;4) Suggestions for improving the current ED model, including: reducing bed block, enhancing workforce model and efficiency (e.g. recruiting salaried GPs in EDs), and improving communication between EDs and PHC sector;5) Enablers for GPs to provide acute care, including: financial incentives, training and professional development, and enhancing hospital-ED-GP collaborative care.The way forwardProviding patient-centred care requires a deep understanding of the social-psychological determinants of health seeking behaviour, which are embedded in and impacted by the societal and political environments within which health systems and actors operate. Our research findings provide evidence about these interrelationships within the context of ED demand and PHC’s role in acute care. To reduce demand for EDs, multiple approaches and alternatives are required in order to ensure patients’ needs for healthcare are met in a safe and suitable way. GPs and PHC sector in general are one of the alternatives that have the potential to, at least partly, alleviate such demand. This requires effective care coordination and patient navigation systems, patient education; legal, financial, clinical and technical support; communication and collaboration among various stakeholders (e.g. PHC, pre-hospital and hospital-based acute care providers); and responsiveness to changing population needs and challenges as they arise (e.g. pandemics and disasters, aging, migration). Furthermore, all new initiatives and alternatives require monitoring their impacts and rigorous economic evaluation to ensure their cost-effectiveness and sustainability

Thigh-length compression stockings and DVT after stroke

Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease