Quality (122) WHO Bulletin: Emergency care with lay responders in underserved populations: a systematic review - How do we define 'poor quality care'?

9 July, 2021

'First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.' Thisis the conclusion of a systematic review in the current July issue of the WHO Bulletin. Citation, abstract and a comment from me below, including a question relevant to our current discusssion on quality: How do we define 'poor quality care'?

CITATION: Emergency care with lay responders in underserved populations: a systematic review

Aaron M Orkin et al.

Bull World Health Organ. 2021 Jul 1; 99(7): 514–528H.

Published online 2021 Apr 29. doi: 10.2471/BLT.20.270249

ABSTRACT

Objective: To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide.

Methods: We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format.

Findings: Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies).

Conclusion: First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.

COMMENT (NPW)

It would be interesting to assess whether and how individual healthcare information resources can reduce morbidity and mortality. One such resource is Where there is no doctor, whose target audience includes lay health workers, covering the full spectrum of health care including emergencies. Another is the First Aid app from the Red Cross, available free in multiple versions for different countries and languages. Would anyone like to volunteer to look into these questions?

I also note the introduction: 'Conditions that could be treated with prehospital and emergency care account for an estimated 24 million lives lost each year in low- and middle-income countries'. This refers to a 2015 study in the World Journal of Surgery which is restricted access so I cannot read it and it's impossible to say how the authors define this. I would be grateful if someone can explain the data of the latter study and the 2018 Lancet study which found that '15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care'.

These two studies are measuring different things, but it seems to me likely that there was 'poor quality care' (whether pre-hospital or in-hospital) in many if not most of the 24 million lives lost each year from conditions that could be treated with prehospital care. If this is the case, then the 5 million attributed to poor care in The Lancet article is probably a gross underestimate.

Of course, this all depends on how we define 'poor quality care'. In the Lancet study, a misdiagnosis by a community health worker resulting in the death of a child would not be considered 'poor quality care' because the latter was defined by the authors (personal communication) as care received after arrival at a health facility.

Best wishes, Neil

Neil Pakenham-Walsh, HIFA Coordinator, neil@hifa.org www.hifa.org