ObjectiveTo conduct a systematic review of emergency care in low- and middle-income countries (LMICs).MethodsWe searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards.FindingsWe identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2–5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3–8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5–6.3%). The median number of patients was 30 000 per year (IQR: 10 296–60 000), most of whom were young (median age: 35 years; IQR: 6.9–41.0) and male (median: 55.7%; IQR: 50.0–59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care.ConclusionAvailable data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.

IMPORTANCE More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it. OBJECTIVE To compare utilization and costs of health care for patients with poor-prognosis cancers enrolled in hospice vs similar patients without hospice care. DESIGN, SETTING, AND PARTICIPANTS Matched cohort study of patients in hospice and nonhospice care using a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies) enrolled in hospice before death were matched to similar patients who died without hospice care. EXPOSURES Period between hospice enrollment and death for hospice beneficiaries, and the equivalent period of nonhospice care before death for matched nonhospice patients. MAIN OUTCOMES AND MEASURES Health care utilization including hospitalizations and procedures, place of death, cost trajectories before and after hospice start, and cumulative costs, all during the last year of life. RESULTS Among 86 851 patients with poor-prognosis cancers, median time from first poor-prognosis diagnosis to death was 13 months (interquartile range [IQR], 3–34), and 51 924 (60%) entered hospice before death. Matching yielded a cohort balanced on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization, with 18 165 patients in the hospice group and 18 165 in the nonhospice group. Nonhospice Group (n = 18 165) Hospice Group (n = 18 165) Risk Ratio (95% CI) Hospitalizations, % (95% CI) 65.1 (64.4–65.8) 42.3 (41.5–43.0) 1.5 (1.5–1.6) Intensive care unit admission, % (95% CI) 35.8 (35.1–36.5) 14.8 (14.3–15.3) 2.4 (2.3–2.5) Invasive procedures, % (95% CI) 51.0 (50.3–51.7) 26.7 (26.1–27.4) 1.9 (1.9–2.0) Death in hospital or nursing facility 74.1 (73.5–74.8) 14 (13.5–14.5) 5.3 (5.1–5.5) Costs in last year of life, $ (95% CI) 71 517 (70 543–72 490) 62 819 (62 082–63 557) Difference, 8697 (7560–9835) After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. Nonhospice beneficiaries had significantly greater health care utilization, largely for acute conditions not directly related to cancer and higher overall costs. CONCLUSIONS AND RELEVANCE In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.

Objective To estimate the global and national burden of emergency conditions, and compare them to emergency care utilization rates. Methods We coded all 291 Global Burden of Disease 2010 conditions into three categories to estimate emergency burden: conditions that, if not addressed within hours to days of onset, commonly lead to serious disability or death; conditions with common acute decompensations that lead to serious disability or death; and non-emergencies. Emergency care utilization rates were obtained from a systematic literature review on emergency care facilities in low- and middle-income countries (LMICs), supplemented by national health system reports. Findings All 15 leading causes of death and DALYs globally were conditions with potential emergent manifestations. We identified 41 facility-based reports in 23 countries, 12 of which were in LMICs; data for 17 additional countries were obtained from national or regional reports on emergency utilization. Burden of emergency conditions was the highest in low-income countries, with median DALYs of 47,728 per 100,000 population (IQR 45,253-50,085) in low-income, 25,186 (IQR 21,982-40,480) in middle-income, and 15,691 (IQR 14,649-16,382) in high-income countries. Patterns were similar using deaths to measure burden and excluding acute decompensations from the definition of emergency conditions. Conversely, emergency utilization rates were the lowest in low-income countries, with median 8 visits per 1,000 population (IQR 6-10), 78 (IQR 25-197) in middle-income, and 264 (IQR 177-341) in high-income countries. Conclusion Despite higher burden of emergency conditions, emergency utilization rates are substantially lower in LMICs, likely due to limited access to emergency care.

Diabetic patients are known to have an increased risk of cataract development and cataract surgery is a common surgical procedure for diabetic individuals. Cataract extraction (CE) in diabetic patients as compared to non-diabetic patients is associated with higher risks of reported complications such as capsular contraction and opacification as well as post-surgical worsening of macular edema (ME) and diabetic retinopathy (DR). In this paper, we review the pathogenesis of diabetic cataract, the risk factors contributing to cataract complications as well as DR progression, and assess preventive measures and treatment options for DR and ME following CE.

IntroductionThere is little research on emergency care delivery in low- and middle-income countries (LMICs). To facilitate future research, we aimed to assess the set of key metrics currently used by researchers in these settings and to propose a set of standard metrics to facilitate future research.MethodsSystematic literature review of 43,109 published reports on general emergency care from 139 LMICs. Studies describing care for subsets of emergency conditions, subsets of populations, and data aggregated across multiple facilities were excluded. All facility- and patient-level statistics reported in these studies were recorded and the most commonly used metrics were identified.ResultsWe identified 195 studies on emergency care delivery in LMICs. There was little uniformity in either patient- or facility-level metrics reported. Patient demographics were inconsistently reported: only 33% noted average age and 63% the gender breakdown. The upper age boundary used for paediatric data varied widely, from 5 to 20 years of age. Emergency centre capacity was reported using a variety of metrics including annual patient volume (n = 175, 90%); bed count (n = 60, 31%), number of rooms (n = 48, 25%); frequently none of these metrics were reported (n = 16, 8%). Many characteristics essential to describe capabilities and performance of emergency care were not reported, including use and type of triage; level of provider training; admission rate; time to evaluation; and length of EC stay.ConclusionWe found considerable heterogeneity in reporting practices for studies of emergency care in LMICs. Standardised metrics could facilitate future analysis and interpretation of such studies, and expand the ability to generalise and compare findings across emergency care settings.