Over the past few decades, health care integration has absorbed physician practices and hospitals into large health systems, a practice which was heralded as the way to cut health care costs and boosting quality of care.
But integrated health systems appear to be failing on both fronts, according to the results of a new US study published in JAMA. For patients in health systems, care is only marginally improved while costs are significantly higher compared to those at independent practices or hospitals.
In the US, health systems have grown exponentially in size and market share through mergers and acquisitions of physician practices and hospitals and the joining of separate health systems.
Proponents of consolidation have argued over the years that physicians and hospitals working together in integrated, coordinated systems provide better patients care while being more efficient than independent physician practices and hospitals. This would drive quality of care up while keeping spending steady and even driving costs down.
“One of the key arguments for hospital mergers and practice acquisition was that health systems would deliver better-value care for patients. This study provides the most comprehensive evidence yet that this isn’t happening,” said study first author Nancy Beaulieu at Harvard Medical School.
Today, these systems are responsible for a large proportion of the medical care delivered in the US, some employing thousands of physicians. But despite their impact on population health and the economy, little is known about the actual performance of integrated health organisations, the study authors noted.
A lack of detailed data on performance and scale is a key obstacle. The current analysis is believed to be the first comprehensive national study to compare outcomes between patients receiving care within health systems and outside of them, including patients with private insurance as well as traditional Medicare, which is the US health insurance system for those over 65 or which certain disabilities or conditions.
The analysis included a total of 580 health systems, accounting 40% of physicians and 84% of general acute care hospital beds. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%).
System hospitals were larger than hospitals than nonsystem ones, with 67% of system hospitals having more than 100 beds, while only 23% of nonsystem hospitals having more than 100 beds. System physician practices were also more likely to have more than 100 physicians compared with nonsystem practices (74% vs 12%). Integrated systems delivered primary care to 41% of traditional Medicare beneficiaries.
As for quality and cost of care delivered within systems, patients with primary care physicians in health systems reported slightly better satisfaction and overall care experience than patients of independent physicians.
This is the case even though many patients with nonsystem primary care providers also receive some of their care in hospitals or specialist practices that are part of a health system. However, care in systems came at a much higher price, contributing to higher overall spending on health care, the research showed.
Prices for services from physicians and hospitals within health systems were significantly higher than for independent healthcare, the study found. Physician services delivered within health systems cost between 12% and 26% more, compared with independent practices. System-based hospital services cost an average of 31% more than care delivered by independent hospitals.
Small differences in quality combined with large differences in cost of care suggests that health systems have not, on average, realised their potential for better care at equal or lower cost, the researchers said.
Members of the research team have compiled a database from various sources to help characterise these health systems and to link claims data with information on health care providers in and out of health systems. The database, housed at NEBR, will be made available for free to other researchers in the near future.
“There’s no question that large, sophisticated health systems have benefits over independent systems,” said study author David Cutler, Harvard economic professor. “Big systems tend to be less vulnerable to economic downturns and they can provide specialised care that would be difficult to maintain in smaller systems. But the hoped-for cost savings benefits of integrated health systems have not yet materialised.”
Despite stringent infection-control efforts around the world, hospital-acquired infections (HAIs)keep on popping up from new strains of bacteria. In Science Translational Medicine, researchers report evidence pointing to an unexpected source of such bacteria: the hospitalised patients themselves.
From experiments with mice, researchers at Washington University School of Medicine in St. Louis discovered that urinary tract infections (UTIs) can arise after sterile tubes, called catheters, are inserted into the urinary tract, even when no bacteria are detectable in the bladder beforehand. Such tubes are commonly used in hospitals to empty the bladders of people undergoing surgery. In the mice, inserting the tubes activated dormant Acinetobacter baumannii bacteria hidden in bladder cells, triggering them to emerge, multiply and cause UTIs, the researchers said.
The findings suggest that screening patients for hidden reservoirs of dangerous bacteria could supplement infection-control efforts and help prevent deadly HAIs.
“You could sterilise the whole hospital, and you would still have new strains of A. baumannii popping up,” said co-senior author Mario Feldman, PhD, a professor of molecular microbiology. “Cleaning is just not enough, and nobody really knows why. This study shows that patients may be unwittingly carrying the bacteria into the hospital themselves, and that has implications for infection control. If someone has a planned surgery and is going to be catheterised, we could try to determine whether the patient is carrying the bacteria and cure that person of it before the surgery. Ideally, that would reduce the chances of developing one of these life-threatening infections.”
The notoriously multidrug-resistant A. baumannii is a major threat to patients, causing many cases of UTIs in people with urinary catheters, pneumonia in people on ventilators, and bloodstream infections in people with central-line catheters into their veins.
The researchers set out to investigate why so many A. baumannii UTIs develop after people receive catheters.
Most UTIs among otherwise healthy people are caused by the bacterium Escherichia coli. Research has shown that E. coli can hide out in bladder cells for months after a UTI seems to have been cured, and then re-emerge to cause another infection.
The researchers investigated whether A. baumannii can hide inside cells like E. coli can. They studied mice with UTIs caused by A. baumannii. They used mice with weakened immune systems because, like people, healthy mice can fight off A. baumannii.
Once the infections had resolved and no bacteria were detected in the mice’s urine for two months, the researchers inserted catheters into the mice’s urinary tracts with a sterile technique. Within 24 hours, about half of the mice developed UTIs caused by the same strain of A. baumannii as the initial infection.
“The bacteria must have been there all along, hiding inside bladder cells until the catheter was introduced,” said co-senior author Scott J. Hultgren, PhD, a professor and expert on UTIs. “Catheterisation induces inflammation, and inflammation causes the reservoir to activate, and the infection blooms.”
Since A. baumannii rarely causes symptoms in otherwise healthy people, many people who carry the bacteria may never know they’re infected, the researchers said. According to the researchers’ literature search, 2% of healthy people carry A. baumannii in their urine.
“I wouldn’t put much weight on the precise percentage, but I think we can say with certainty that some percentage of the population is walking around with A. baumannii,” Feldman said. “As long as they’re basically healthy, it doesn’t cause any problems, but once they’re hospitalised, it’s a different matter. This changes how we think about infection control. We can start considering how to check if patients already have Acinetobacter before they receive certain types of treatment; how we can get rid of it; and if other bacteria that cause deadly outbreaks in hospitals, such as Klebsiella, hide in the body in the same way. That’s what we’re working on figuring out now.”
Premature birth is the main cause of brain injury and cerebral palsy in babies. Evidence shows that babies can be protected from brain injury by giving magnesium sulfate to women who are at risk of premature birth, reducing the risk of cerebral palsy by a third. From a societal and lifetime perspective, the health gains and cost savings associated with the preventative treatment generated a net monetary benefit of £866 per preterm baby, according to an evaluation published in Archives of Disease in Childhood.
The prevention of cerebral palsy in pre-term labour (PReCePT) programme was developed in 2014 and aimed to support all maternity units in England to increase the use of magnesium sulfate in premature births. It was then piloted in five NHS trusts in the West of England, and this pilot was evaluated by the NIHR Applied Research Collaboration West (NIHR ARC West). It has since been rolled out across England via the AHSN Network as a national programme.
The evaluation of the national programme, also led by NIHR ARC West, found that PReCePT was both effective and cost-effective. The researchers looked at data from the UK National Neonatal Research Database for the year before and year after PReCePT was implemented in maternity units in England.
While use of magnesium sulfate had been increasing before, the study showed that PReCePT was able to accelerate uptake. It increased by 6.3 percentage points on average across all maternity units in England during the first year, over and above the increase that would be expected over time as the practice spread organically. After also adjusting for variations in when maternity units started the programme, the increase in use of magnesium sulfate was 9.5 percentage points. By May 2020, on average 86.4% of eligible mothers were receiving magnesium sulfate.
The researchers also estimated that the programme’s first year could be associated with a lifetime saving to society of £3 million. This accounts for the costs of the programme, administering the treatment and of cerebral palsy to society over a lifetime, and the associated health gains of avoiding cases. This is across all the extra babies the programme helped get access to the treatment during the first year.
In the five pilot sites, the improved use of magnesium sulfate has been sustained over the years since PReCePT was implemented. As the programme costs were mostly in the first year of implementation, longer-term national analysis may show that PReCePT is even more cost-effective over a longer period.
John Macleod, NIHR ARC West Director, Professor in Clinical Epidemiology and Primary Care at the University of Bristol and principal investigator of the evaluation, said: “Our in-depth analysis has been able to demonstrate that the PReCePT programme is both effective and cost-effective. The programme has increased uptake of magnesium sulfate, which we know is a cost-effective medicine to prevent cerebral palsy, much more quickly than we could have otherwise expected.
Professor Lucy Chappell, Chief Executive Officer of the National Institute for Health and Care Research, said: “This important study shows the impact of taking a promising intervention that had been shown to work in a research setting and scaling it up across the country. Giving magnesium sulfate to prevent cerebral palsy in premature babies is a simple, inexpensive intervention that can make such a difference to families and the health service. We look forward to seeing ongoing use of magnesium sulfate across our maternity units so that these benefits continue.”
Following established guidelines about prescription drugs would seem an obvious choice, especially for the professionals that do the prescribing. Yet doctors – and their family members – are less likely than other people to comply with those guidelines, according to a large-scale study published in the American Economic Review: Insights.
This result could be surprising or else prompt a knowing nod. In any case, the finding flies in the face of past scholarly hypotheses. Previously, it was assumed that greater knowledge and easier communication with medical providers leads patients to follow instructions more closely.
The new study is based on over a decade of population-wide data from Sweden and includes suggestive evidence about why doctors and their families may ignore medical advice. Overall, the research shows that the rest of the population adheres to general medication guidelines 54.4% of the time, while doctors and their families lag 3.8% behind that.
“There’s a lot of concern that people don’t understand guidelines, that they’re too complex to follow, that people don’t trust their doctors,” says Amy Finkelstein, a professor in MIT’s Department of Economics. “If that’s the case, you should see the most adherence when you look at patients who are physicians or their close relatives. We were struck to find that the opposite holds, that physicians and their close relatives are less likely to adhere to their own medication guidelines.”
The paper, “A Taste of Their Own Medicine: Guideline Adherence and Access to Expertise,” is The authors are Finkelstein, the John and Jennie S. MacDonald Professor of Economics at MIT; Petra Persson, an assistant professor of economics at Stanford University; Maria Polyakova PhD ’14, an assistant professor of health policy at the Stanford University School of Medicine; and Jesse M. Shapiro, the George Gund Professor of Economics and Business Administration at Harvard University.
Millions of data points
To conduct the study, the scholars examined Swedish administrative data from 2005 through 2016, for 63 prescription drug guidelines. Doctors and their close relatives were selected. All told, the research involved 5 887 471 people to whom at least one of the medication guidelines applied. Of these people, 149 399 were doctors or their close family members.
Using information on prescription drug purchases, hospital visits, and diagnoses, the researchers could see if people were adhering to medication guidelines by examining whether prescription drug decisions matched these patients’ medical circumstances. In the study, six guidelines pertained to antibiotics; 20 involved medication use by the elderly; 20 focused on medication attached to particular diagnoses; and 17 were about prescription drug use during pregnancy.
Some guidelines recommended use of a particular prescription drug, like a preference of narrow-spectrum antibiotics for an infection; other guidelines were about not taking certain medications, such as the recommendation that pregnant women avoid antidepressants.
Out of the 63 guidelines used in the study, doctors and their families followed the standards less often in 41 cases, with the difference being statistically significant 20 times. Doctors and their families followed the guidelines more often in 22 cases, with the difference being statistically significant only three times.
“What we found, which is quite surprising, is that they [physicians] are on average less adherent to guidelines,” says study author Maria Polyakova PhD, an assistant professor of health policy at the Stanford University School of Medicine. “So, in this paper we are also trying to figure out what experts do differently.”
Ruling out other answers
Since doctors and their close relatives adhere to medical guidelines less often than the rest of the population, what exactly explains this phenomenon? While homing in on an answer, the research team examined and rejected several hypotheses.
First, the lower compliance by those with greater access to expertise is unrelated to socioeconomic status. In society overall, there is a link between income and adherence levels, but physicians and their families are an exception to this pattern. As the researchers wrote, special “access to doctors is associated with lower adherence despite, rather than because of, the high socioeconomic status” of those families.
Additionally, the researchers did not find any link between existing health status and adherence. They also studied whether a greater comfort with prescription medication – due to being a doctor or related to one – makes people more likely to take prescription drugs than guidelines recommend. This does not appear to be the case. The lower adherence rates for doctors and their relatives were similar in magnitude whether the guidelines pertained to taking medication or, alternately, not taking medication.
“There are a number of first-order alternative explanations that we could rule out,” Polyakova says.
Resolving a medical mystery
Instead, the researchers believe the answer is that doctors possess “superior information about guidelines” for prescription drugs – and then deploy that information for themselves. In the study, the largest difference in adherence to guidelines is for antibiotics: Doctors and their families are 5.2% less in compliance than everyone else.
Most guidelines in this area recommend starting patients off with “narrow-spectrum” antibiotics, which are more targeted, rather than “broader-spectrum” antibiotics. The latter might be more likely to eradicate an infection, but greater use of them also increases the chances that bacteria will develop resistance to these valuable medications, which can reduce efficacy for other patients. Thus for things like a respiratory tract infection, guidelines call for a more targeted antibiotic first.
The issue, however, is that what is good for the public in the long run – trying more targeted drugs first – may not work well for an individual patient. For this reason, doctors could be more likely to prescribe broader-spectrum antibiotics for themselves and their families.
“From a public-health perspective, what you want to do is kill it [the infection] off with the narrow-spectrum antibiotic,” Finkelstein observes. “But obviously any given patient would want to knock that infection out as quickly as possible.” Therefore, she adds, “You can imagine the reason doctors are less likely to follow the guidelines than other patients is because they … know there’s this wedge between what’s good for them as a patients and what’s good for society.”
Another suggestive piece of data comes from different types of prescription drugs that are typically avoided during pregnancies. For so-called C-Class drugs, where empirical evidence about the dangers of the drugs is slightly weaker, doctors and their families have an adherence rate 2.3 percentage points below other people (meaning, in this case, that they are more likely to take these medications during pregnancy). For so-called D-Class drugs with slightly stronger evidence of side effects, that dropoff is only 1.2 percentage points. Here too, doctors’ expert knowledge may be influencing their actions.
“The results imply that probably what’s going on is that experts have a more nuanced understanding of what is the right course of action for themselves, and how that might be different than what the guidelines suggest,” Polyakova says.
Still, the findings suggest some unresolved tensions in action. It could be, as Polyakova suggests, that guidelines about antibiotics should be more explicit about the public and private tradeoffs involved, providing more transparency for patients. “Maybe it’s better for the guidelines to be transparent and say they recommend this not because it is [always] the best course of action for you, but because it is the best for society,” she says.
Additional research could also aim to identify areas where lower expert adherence with guidelines may be associated with better health outcomes –to see how often doctors have a point, as it were. Or, as the researchers write in the paper, “An important avenue for further research is to identify whether and when nonadherence is in the patient’s best interest.”
Unsafe sex, interpersonal violence, high body mass index (BMI), high systolic blood pressure, and alcohol consumption are the top risk factors for disease and death in South Africa, according to the Second Comparative Risk Assessment (SACRA2) study conducted by the South African Medical Research Council’s Burden of Disease (BOD) Research Unit in collaboration with a long list of researchers. The study was recently published in a series of 15 related articles in the South African Medical Journal.
The study differs from other assessments of what people in South Africa die of in that it focusses on risk factors rather than on the eventual cause of death. This is, for example, why the study considers factors like unsafe sex or high body mass index rather than HIV or diabetes.
According to a related policy brief, the aim of the study was “to quantify the contribution of 18 selected risk factors to identify areas of public health priority”. The idea is that policymakers can use these findings to address the underlying causes of death and disease in South Africa since the identified risk factors are considered to be modifiable.
“We have to reduce the underlying drivers of disease and death if we are to improve the health of South Africans,” said CEO and President of the SAMRC Professor Glenda Gray in a statement. “Knowing that this is possible, should strengthen our resolve to ensure that this is accomplished.”
Causes of lost DALYs
Rather than only looking at what people died of, the researchers estimated the lost disability-adjusted life years (DALYs) associated with various risk factors. The World Health Organization describes DALYs as “a time-based measure that combines years of life lost due to premature mortality (YLLs) and years of life lost due to time lived in states of less than full health, or years of healthy life lost due to disability (YLDs). One DALY represents the loss of the equivalent of one year of full health.”
The researchers calculated the proportion of the total burden of disease (measured as DALYs) that can be attributed to each of the 18 risk factors in South Africa in 2012. Unsafe sex was top of the list at 26.6%, followed by interpersonal violence at 8.5%, high body mass index at 6.9%, high systolic blood pressure at 5.8%, and alcohol consumption at 5.6%. There were some differences by sex, with alcohol consumption, for example, ranking third in males, while it ranked fifth overall.
“Improvements have been observed, in particular, the reductions in the burden attributable to household air pollution and water and sanitation,” read the policy brief. “On the other hand, shifts in cardiometabolic risk factors, particularly the rapid emergence of high fasting plasma glucose accompanied by increases in high systolic blood pressure and high BMI, can be seen as well as the increased impact of ambient air pollution.”
According to project lead and BOD Unit Director Professor Debbie Bradshaw, while unsafe sex and interpersonal violence remained high on South Africa’s risk profile for the study period, non-communicable diseases combined are at an all-time high and are highly likely to overtake unsafe sex and interpersonal violence as causes of death and disease in South Africa.
Findings only up to 2012
The SACRA2 findings cover the period from 2000 to 2012. One reason for it only being published now is that the study required access to a wide variety of data sources. “Each data set had to be evaluated to identify any weaknesses or possible bias so that we can develop a robust understanding [of] the trends in the risk factors. This is a painstaking task, involving a large number of scientists, and means that we have only been able to describe the trends for the period 2000 – 2012,” says Bradshaw.
While robust and more up-to-date estimates would likely only come from the next SACRA study, it seems likely that some of the trends identified in SACRA2 would have continued in the years since 2012. For example, findings from SACRA2 suggest that the burden attributable to unsafe sex peaked in 2006 and has been declining ever since, largely due to the provision of antiretroviral treatment. Evidence from other sources, such as Thembisa, the leading mathematical model of HIV in South Africa, suggests that the decline in HIV-related deaths and the increase in treatment coverage have continued in the years since 2012.
Bradshaw describes unsafe sex as a lack of condom use which leads to sexually transmitted infections (STIs) and the possible transmission of HIV.
“Condom use is very important. If we get rid of unsafe sex, we will see the number of people being infected with HIV and STIs being reduced,” she said. “It is important that these epidemic drivers are not neglected in the push towards meeting the 90-90-90 management targets for 2022 and the 95-95-95 targets by 2030. HIV communication programmes should continue to promote male circumcision and risk awareness in the context of non-marital relationships to prevent HIV transmission.” (The first 90/95 refers to the percentage of people living with HIV who are diagnosed, the second to the percentage of those diagnosed on treatment, and the third to the percentage of those on treatment who are virally suppressed.)
Interpersonal violence declining
As with unsafe sex, the trend with interpersonal violence in South Africa also appears to be downward, although, as Megan Prinsloo, a researcher at the SAMRC, and colleagues highlight in one of the 15 papers, it continues to be a leading public health problem for the country.
The researchers found that between 2000 and 2012, there was a decrease in the death rate associated with interpersonal violence from 100 per 100 000 to 71 per 100 000. There was also a decrease in lost DALYs attributable to interpersonal violence from an estimated 2 million in 2000 to 1.75 million in 2012.
“Further strengthening of existing laws pertaining to interpersonal violence, and other prevention measures are needed to intensify the prevention of violence, particularly gender-based violence,” the researchers wrote.
High BMI and high blood pressure
Image by Marcelo Leal on Unsplash
A high BMI is associated with several cardiovascular diseases, diabetes, and chronic kidney disease, among others. According to one of the SACRA2 papers, high BMI caused around 59 000 deaths in 2012. Over the study period, the burden was higher in males than in females. Type 2 diabetes was the leading cause of death attributable to high BMI in 2012, followed by hypertensive heart disease, haemorrhagic stroke, ischaemic heart disease, and ischaemic stroke.
The researchers found that the average BMI increased between 2000 and 2012 and accounted for a growing proportion of both total deaths and DALYs.
High systolic blood pressure is similarly linked to an increased risk of several conditions, including stroke and heart disease. According toa paper by Beatrice Nojilana, a senior research scientist at the SAMRC, and colleagues, the prevalence of hypertension in people aged 25 and older increased from 2000 to 2012 – 31% to 39% in men and 34% to 40% in women.
But there is some interesting nuance. In both men and women, age-standardised rates for deaths and DALYs associated with raised systolic blood pressure increased between 2000 and 2006 but decreased from 2006 to 2012.
High systolic blood pressure is estimated to have caused around 62 000 deaths in South Africa in 2012. Stroke (haemorrhagic and ischaemic), hypertensive heart disease, and ischaemic heart disease accounted for over 80% of the disease burden attributable to raised systolic blood pressure over the period.
Alcohol abuse
Source: Pixabay CC0
In another SACRA2 paper, Dr Richard Matzopoulos, chief specialist scientist at the SAMRC, and colleagues, point out that alcohol abuse has widespread effects on health and contributes to over 200 health conditions. They write that, although the pattern of heavy episodic drinking independently increases the risk for injuries and transmission of some infectious diseases, long-term average consumption is the fundamental predictor of risk for most conditions.
The researchers used data from 17 population surveys to estimate age- and sex-specific trends in alcohol consumption in the adult population of South Africa between 1998 and 2016. For each survey, they calculated sex- and age-specific estimates of the prevalence of drinkers and the distribution of individuals across consumption categories.
Among males, the prevalence of drinkers was found to have decreased between 1998 and 2009, from 56.2% to 50.6%, but had increased again by 2016. Among females, the prevalence of current drinkers rose slightly from 19% in 1998 to 20% in 2016.
Speaking to Spotlight, Matzopoulos stresses that alcohol abuse puts a heavy burden on the already strained health system. “When you enter the trauma unit at hospitals on weekends, all you can smell is alcohol,” he said.
He says in some of his research he has noted a shift where young females are engaging in heavy drinking and young males are engaging in binge drinking over weekends. “These patterns are alarming because alcohol abuse can lead to unsafe sex, which may lead to the transmission of HIV and STIs. Excessive alcohol use also has an impact on some NCDs and can compromise the immune system of a person who is on ARV treatment,” he said.
Matzopoulos said government can put in place policies such as the restriction of alcohol sales, banning alcohol advertising, and increasing the price of alcohol.
Services at the Dora Nginza Hospital in Gqeberha, Eastern Cape are under strain as the nurse’s strike entered its second day on Friday. The striking nurses are demanding that management provide more beds and staff to the maternity wards, among other demands. They claim that their previous engagements with the health department have been fruitless.
On Thursday, some patients were moved to another hospital. Dora Nginza Hospital is the centre for maternal and paediatric care for the western part of the Eastern Cape.
A pregnant woman at the hospital described the maternity ward as “chaotic”.
“Heavily pregnant women were crying for help that was not coming. Many people are sleeping on the cold floor and there is a smell of blood in the ward. The few nurses there are overwhelmed,” she said.
Vuyo Nodlawu, regional chairperson of the Democratic Nursing Organisation of South Africa (DENOSA), told GroundUp that the maternity wards do not have enough beds and resources to cope with the influx of patients since Monday. “Patients, be it prenatal or postnatal, did not have beds to sleep on. The situation has been getting worse, to the extent that patients who had given birth were removed from beds to accommodate those in labour,” he said.
Nodlawu said the hospital’s management had told medical practitioners to stop admitting patients if there were no more beds available or until the matter was resolved. “However, the doctors continued to admit patients. Nurses then decided to allocate all available beds within the maternal department to everyone who didn’t have a bed,” said Nodlawu.
A meeting was called between the maternal directorate from the head office and the hospital but it was unsuccessful.
Mzikazi Nkatha, provincial deputy secretary of the National Union of Public Service and Allied Workers (NUPSAW)’s, said, “Nurses are saying enough is enough. They can’t continue as normal when patients have to lie on the floor and not on hospital beds. This is also an overwhelming number of patients and not enough health providers to care for them.”
Health department spokesperson Yonela Dekeda said union leaders have not been willing to negotiate with officials sent by management. Dekeda said plans to “decongest” Dora Nginza Hospital are underway, with emergency cases being referred to Port Elizabeth Provincial Hospital.
She said a team from other hospitals across the district were deployed to assist. The team included Anaesthetics, Obstetrics , Gynaecology, Paediatrics, Neonatology, Nursing and non-clinical support services.
“The designated ward and theatre at the Provincial Hospital has been staffed and equipped with the relevant equipment and medication. The Emergency Medical Services is also part of the response team and will coordinate patient transfers between facilities,” she said.
Dekeda said the department considers the nurses’ action as an unprotected strike. “These essential workers are refusing to engage with senior management nor do they want to return to work. The department takes this very seriously and the administrative and legal remedies at our disposal are being deployed,” she said.
DENOSA’s deputy regional chairperson Vuyo Dlanga has vowed that nurses would continue their action until provincial government officials meet them to resolve the issues.
For certain patients with vomiting and nausea in the emergency department (ED), haloperidol may be a better alternative to the usual ondansetron, according to a small study presented at the American College of Emergency Physicians annual meeting.
“[Haloperidol] is definitely a drug that’s going to help young patients with benign abdomens who come in with vomiting and generalised abdominal pain,” study presenter Jessica McCoy, MD, told MedPage Today.
Dr McCoy presented data showing that, at 90 minutes, median abdominal pain Visual Analogue Scale (VAS) score fell from 5 to 0 in the patients who received haloperidol compared with a VAS score drop from 6 to 3.5 in the ondansetron group.
Also at 90 minutes, median nausea VAS score fell from 7 to 0.5 in the haloperidol group versus 6 to 3.5 in the ondansetron group.
Of 48 patients (ages 18-55) who were included and completed the study, 22 were randomised to receive 2.5mg of intravenous haloperidol (half the usual dose) and 26 to receive 4mg of IV ondansetron.
Dr McCoy said despite concern over haloperidol prolonging the QT interval, no sign of a difference between the drugs was found. Among the 29 cannabis users in the study, haloperidol was not found to be superior at 90 minutes post-treatment, she said.
Halving the dose of haloperidol seemed to prevent common side effects of anxiety, sedation, and restlessness, Dr McCoy noted.
Adverse effects, which resolved by the time of discharge from the ED, included three cases of anxiety/restlessness and one case of tongue swelling in the haloperidol group and single cases of restlessness, sleepiness, and irritated throat in the ondansetron group.
Nausea and vomiting is commonly reported by ED patients, one of the top five complaints in the ED, and a diagnosis may be elusive if urgent treatment is not needed, she explained. “There’s this whole list of things it could be that make you feel lousy for a little bit but get better on their own.”
Increased chronic cannabis use, meanwhile, has caused more cases of nausea and vomiting, she said.
ED physicians often use ondansetron, developed for nausea in chemotherapy patients, Dr McCoy said. However, ondansetron “doesn’t work great. And it really wasn’t developed for people who were actively vomiting.”
The new study follows on from Dr McCoy’s previous research demonstrating the benefit of haloperidol for severe benign headache. She noted that the new study is small and was halted at the interim analysis due to COVID. At that time, ED waits were six or seven hours long, she said, and some patients with nausea and vomiting gave up and went home.
Dr McCoy noted that the ED physicians at her institution continue to turn to alternatives to ondansetron such as haloperidol in appropriate cases, especially in patients with anxiety. Haloperidol, however, is not appropriate, she cautioned, for more complex cases such as patients with rigid abdomens, possible dissections, or who have a need for surgery.
Like ondansetron, haloperidol is inexpensive, she added. “I hope [the new research] spurs more interest in studying this drug and its pain-relieving properties.”
Doctors experiencing burnout are twice as likely to be involved in patient safety incidents and four times more likely to be dissatisfied with their job, suggests research published today in The BMJ.
The scale of burnout amongst clinicians and the serious impact it can have on patient safety and staff turnover has been revealed in the largest and most comprehensive systematic review and analysis of studies on the subject to date.
Evidence is showing that burnout is is reaching global epidemic levels among physicians. Representatives have warned that spare capacity in the field of medicine is nearing what they call crisis point.
Burnout is defined as emotional exhaustion, cynicism and detachment from the job, and a feeling of reduced personal accomplishment. In the UK, a third of trainee doctors report that they experience burnout to a high or very high degree, while in the US, four in 10 physicians report at least one symptom of burnout. And in a recent review of low and middle income countries the overall single-point prevalence of burnout ranged from 2.5% to 87.9% among 43 studies.
Yet there is a lack of evidence about the association of burnout with a physician’s career engagement and how that potentially impacts on the quality of patient care.
To address this, a team of researchers based in the UK and Greece set out to examine the association of burnout with the career engagement of physicians and the quality of patient care globally.
To do this, they selected and analysed the results of 170 observational studies on the subject involving nearly 240 000 physicians.
Their analysis showed that physicians with burnout were up to four times more likely to be dissatisfied with their job and more than three times as likely to have thoughts or intentions to leave their job (turnover) or to regret their career choice.
Equally worrying was the finding that physicians with burnout were twice as likely to be involved in patient safety incidents and show low professionalism, and over twice as likely to receive low satisfaction ratings from patients.
The analysis also found that burnout and poorer job satisfaction was greatest in hospital settings, physicians aged 31–50 years, and those working in emergency medicine and intensive care, while burnout was lowest in general practitioners.
The association with burnout and patient safety incidents was strongest among physicians aged 20–30 years and emergency medicine workers.
The study authors acknowledge some limitations in their research including the fact that precise definitions of terms, such as patient safety, professionalism, and job satisfaction, varied between the studies analysed so may have led to some overestimation of their association with burnout.
The assessment methods varied widely between the 170 studies, and the design of the original studies imposed limits on their ability to establish causal links between physician burnout and patient care or career engagement.
Nevertheless, the authors concluded: “Burnout is a strong predictor for career disengagement in physicians as well as for patient care. Moving forward, investment strategies to monitor and improve physician burnout are needed as a means of retaining the healthcare workforce and improving the quality of patient care.”
“Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency,” they added.
This research adds to growing evidence that the poor mental health of healthcare providers jeopardises the quality and the safety of patient care, says Matthias Weigl, Professor of Patient Safety at Bonn University, in a linked editorial.
“The pervasive nature of physician burnout indicates a defective work system caused by deep societal problems and structural problems across the sector,” Prof Weigl warned.
“Urgent action is imperative for the safety of physicians, patients, and health systems, including interventions that are evidence based and system oriented, to design working environments that promote staff engagement and prevent burnout,” he concluded.
The High Court in Gqeberha has found that the Eastern Cape MEC for Health and Livingstone Hospital are liable to pay damages to the widow of a man who died after falling from the fifth floor of the hospital.
In the ruling last week, Acting Judge Ivana Bands found that the patient, George Williams, had not been properly medicated or monitored. She said that had this been done, Williams would not have been “pacing up and down the ward, in confused, restless and disoriented state”, and would not have fallen to his death from the window.
Judge Bands said the conduct of the medical and nursing personnel who treated Williams after he was admitted to the hospital on 3 October 2013, “fell far short of what is regarded as sound practice” in dealing with patients suffering from alcohol withdrawal – delirium tremens which involves sudden and severe mental or nervous system changes – and secondary schizophrenia.
“Had he been properly medicated, it cannot be gainsaid [denied] that he would have been reduced to a calm and lightly dozing state. This would have enabled the medical and nursing staff to monitor his vital signs and his condition appropriately until such time that delirium tremens had abated,” Judge Bands said.
Judge Bands’s finding of negligence means that Williams’s widow Jeanine can now pursue a monetary damages claim against the MEC and hospital. This could be determined at another trial or through negotiation.
Jeanine Williams, in her papers, contended that the hospital staff were under a legal duty to provide her husband with adequate and timeous medical treatment; that they had not properly sedated him, restricted his movements and monitored his condition.
The defendants, however, argued that Williams had been treated with sedatives, including diazepam (Valium) and that he had been put in an “enclosed locked ward” close to the nurses’ station.
Bands said Wiliams was a known alcoholic who was admitted to the hospital late on 3 October 2013. In the early hours of the morning, he had been given diazepam, with little effect. During the evening of 4 October, he was given more sedatives and an antipsychotic agent, also with no effect.
Soon after, at about 10:30pm, Williams broke the outside entrance glass door of the nurses’ tearoom and fell from the fifth floor. He died about an hour later.
Two key witnesses during the trial were Dr Candice Harris, a professional nurse and general practitioner, who testified for Williams, and Dr Michelle Walsh, a general surgeon, who testified for the MEC and the hospital.
In her evidence, Harris had said delirium tremens was a “medical emergency” and, according to guidelines, immediate management of the condition was necessary. She had stressed the importance of re-orientating the patient and said it was the nurse’s duty to inform the doctor if the patient was not responding to medication.
The judge said Walsh’s evidence was that it was not that the hospital was doing nothing – “they were doing something”.
“She said the sedation prescribed is usually based on what the assessing doctor thinks will have the desired effect to calm the patient to the extent that they would sit calmly in a chair. It is common cause that this desired state was never reached,” the judge said.
“Not only was he under-sedated, there is no evidence that the initial dose, which had no effect, was ever increased as per the published guidelines, in spite of multiple entries in the hospital records that he remained confused, disorientated, restless and walking up and down – and that he had become so agitated that the nursing staff feared he would assault them,” the judge said.
Bands said Williams had not been treated according to the guidelines, thus the MEC and the hospital are liable for any proven damages.
Police were present at Kalafong Hospital in Tshwane on Wednesday after the Gauteng Health Department obtained an interdict to prevent members of Operation Dudula from threatening immigrants. Photo: Mosima Rafapa
Members of Operation Dudula were outside Kalafong provincial hospital in Tshwane on Wednesday, shouting at immigrant patients and employees. Police were present, enforcing the court interdict obtained last week by the Gauteng Health Department against the threats.
A security guard who did not want to give his name said for most of August Operation Dudula members had been operating outside the hospital, until the Gauteng Department of Health obtained a court interdict last Friday.
“They greeted patients who were of a dark skin colour one by one, to check which language they spoke and to listen to their accent. The local language here is Tswana or Pedi. If they found that you don’t know those languages, they turned you away,” said the security officer, whose station is not far from the pedestrian entrance.
Since 4 August, Operation Dudula has been trying to deny access to patients and employees from other countries.
“I’m here at 5:30 in the morning. Just before 8am this morning, a member of Operation Dudula was speaking through a loudspeaker saying they don’t want makwerekwere. On Monday, they checked their ID documents before people could enter the hospital. Today, they were about five or six of them outside. I think they wanted to scare people away because they just stood there until the police arrived,” he added.
Last Friday, the Gauteng MEC for Health obtained a court interdict against the members from threatening or denying access to patients and employees. The interdict was pinned to the notice board outside the hospital.
When GroundUp arrived just after 10am, a handful of Operation Dudula members were still gathered outside. Some were shouting that foreigners should leave.
Chairperson of Operation Dudula in Atteridgeville and regional coordinator in Greater Tshwane Elias Makgwadi said they were picketing outside the hospital entrance to get management to enforce the hospital’s admission rules and not admit “illegal foreign nationals”.
“We are saying, enforce your own rules. If illegal foreign nationals have been admitted to hospitals they must be discharged to law enforcement officers and immigration officers. That’s why we’re here, ” said Makgwadi.
Members of the Economic Freedom Fighters (EFF) put up a tent outside the hospital entrance and started chanting songs. Provincial spokesperson Phillip Makwala told the crowd: “Operation Dudula is acting as doctors, they are interfering with the process of the South African Police Service and the immigration office.”
Police officers were stationed outside the hospital.
Verrah Frace, from Zomba in Malawi, condemned the xenophobia. She works as a domestic worker in Laudium, west of Pretoria. Frace, who had come to visit her sick sister, said it was painful to see what Operation Dudula was doing.
“I came to South Africa in 2019 to look for a job because we are very poor back in Malawi. We are in South Africa to earn a living,” said Frace.
GroundUp heard a hospital employee wearing a pharmacy tag praising the Operation Dudula members. “These people get our medicine for free. They get everything for free. You guys are helping us. You are doing a great job,” said the employee before going back inside the hospital.
James Chasiya, from Magochi in Malawi, was at the hospital to see his wife who had given birth to a premature baby. He arrived in South Africa in 2014 and works as a plumber, living in one room in Laudium with his wife.
“Sometimes the piece jobs are hard to come by so I sell some of the furniture I have in order to pay rent. It’s not as easy living here as people think. We struggle. My wife works at a creche but it’s still hard. I’m undocumented so I can’t find a real job. There’s no way I can pay for a private hospital,” said Chasiya.
Head of Communication for the Gauteng Department of Health Motalatale Modiba had not responded to GroundUp’s questions by the time of publication.
The health department’s Motalatale Modiba said that the facility reported that operations are continuing as normal with no change in the number of patients.
“There is now increased police monitoring the situation. Patients are no longer obstructed from coming into the facility. The Department would like to assure patients that the hospital continues to render services to all who need such care,” he said.
Modiba said the department will not hesitate “to call law enforcement agencies to act against those that put the lives of patients and staff at risk”. He said the Department obtained a court interdict on 26 August from the High Court in Pretoria “to prevent a group of people from threatening, preventing and denying patients (deemed to be non-South African) and employees at Kalafong Hospital from accessing the facility to receive medical attention and to administer care respectively”.
