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15th December 2021
The use of a therapeutic rather than prophylactic dose of heparin provided a mortality benefit to moderately ill, hospitalised patients with COVID-19. This is the key finding of a study by researchers from the Departments of Medicine, and Laboratory Medicine and Pathobiology, University of Toronto, Canada.
The lung changes in patients with COVID-19 has been found to display marked microvascular thrombosis and haemorrhage.1 In addition, analysis of factors associated with a poor prognosis once infected with the virus include significantly elevated levels of D-dimer and fibrin degradation products.2 With anticoagulants such as heparin able to reduce D-dimer levels and some evidence of anti-inflammatory activity,3 these drugs might be of benefit to those hospitalised with COVID-19. However, the currently available evidence is somewhat mixed. For example, in a study of hospitalised, but not critically ill, COVID-19 patients, therapeutic doses of heparin increased the probability of survival,4 whereas in contrast, among hospitalised but critically ill patients, heparin was not beneficial.5
With some uncertainty over the possible advantages of heparin among those hospitalised with COVID-19, the Canadian team established the Therapeutic Anticoagulation versus Standard Care as a Rapid Response to the COVID-19 pandemic (RAPID) trial.6 The overarching aim of the trial was to determine whether therapeutic rather than prophylactic doses of heparin were superior in reducing the composite of admission to an intensive care unit (ICU), mechanical ventilation or death, in moderately ill hospitalised COVID-19 patients with elevated D-dimer levels. The RAPID trial enrolled patients who were admitted to a hospital ward (but not ICU) and not mechanically ventilated, with elevated D-dimer levels (above the upper limit of the normal range) within the first five days of admission. Patients were randomised 1:1 to therapeutic or prophylactic heparin with the former representing a higher dosage. For example, using enoxaparin, a therapeutic dose for a patient with a body mass index less than 40 would be 1mg/kg every 12 hours. In contrast, the prophylactic dose for a patient of the same weight would be 40mg every 24 hours. The primary outcome of the study was a composite of ICU admission, non-invasive or invasive mechanical ventilation or death up to 28 days. There were several secondary outcomes including all-cause mortality, ICU admission, ventilation-free days alive, need for renal replacement therapy etc.
Findings
A total of 465 patients with a mean age of 60 years (56.7% male) and with 42.3% of White ethnicity were randomised to either dose of heparin. The main co-morbidities included hypertension and diabetes and baseline D-dimer levels were 2.3-fold above the upper limit for normal.
The primary outcome occurred in 16.2% of those assigned to therapeutic heparin and 21.9% given a prophylactic dose and this difference was not statistically significant (odds ratio, OR = 0.69, 95% CI 0.43–1.10, p = 0.12). In contrast, all-cause mortality occurred in 1.8% of the therapeutic and 7.6% of the prophylactic groups (OR = 0.22, 95% CI 0.07–0.65, p = 0.006). There were no differences in secondary outcomes apart from the mean number of ventilation-free days although this was borderline (p = 0.042).
Commenting on their findings, the authors noted that while there was no difference in the primary outcome, the 78% lower mortality among those given therapeutic heparin was significant. Based on these findings, they concluded that therapeutic heparin is beneficial in moderately ill patients with COVID-19.
References
An analysis of patients’ platelet function to various agonists important in the clotting process has revealed at least six different phenotypes, potentially leading the way towards more personalised medicine.
This was the finding of a study by a group of researchers from the Institute for Cardiovascular and Metabolic Research, University of Reading, and the Department of Haematology, University of Cambridge.1 Although platelets have an essential role in haemostasis, these cell fragments are also involved in the clotting process that can lead to a myocardial infarction or stroke. It has been apparent for some time, that an individual’s platelet response to clotting agonists can vary,2 and that these differences might be genetically controlled.3 Nevertheless, the reasons for this heterogeneity in response remains to be determined and the Reading and Cambridge team wanted to get a better understanding of why an individual might be a hypo-responder to one agonist yet a hyper-responder to another.
In trying to answer this question, the team developed Platelet Phenomic Analysis (PPAnalysis), a platform designed to assess platelet function across a group of individuals.
The PPAnalysis used multiple clotting agonists over a wide range of concentrations to try and fully characterise platelet reactivity. In validating the PPAnalysis system, the researchers recruited a group of healthy, fasted, blood donors and assessed the sensitivity of samples to various agonists as well as the strength (or capacity) of the platelet response. The team used varying concentrations of 6 agonists: collagen-related peptide (CRP), epinephrine, thrombin receptor activator peptide 6 (TRAP-6), U46619 (a thromboxane A2 analogue and adenosine diphosphate (ADP). Together, these agonists allowed the researchers to assess fibrinogen binding and the exposure of P-selectin on the platelet surfaces, which is a marker of alpha-granule secretion, i.e., adhesive proteins that mediate platelet–platelet interactions. In addition, the team recruited a second group of healthy donors, which included non-fasted individuals who were aged between 18 and 75.
Findings
Overall, the study observed that the sensitivity and capacity for fibrinogen binding and the P-selectin exposure did not correlate, in other words, the two measures were independent. In addition, the sensitivity of fibrinogen binding and P-selectin exposure to the individual agonists did correlate (r > 0.91, p < 0.01) but to a greater degree than the capacity to generate these responses (r < 0.76). Nevertheless, the sensitivity to individual agonists did vary, so that one individual could, for example, be highly sensitive to ADP but not be sensitive to CRP. In a separate analysis, the authors did not find any differences between donor responses based on age, gender, or body mass index.
Based on these results, which were replicated in a second, different donor group, the researchers identified at least six different phenotypes with high capacity and low sensitivity and vice versa. These results suggested that individuals were not simply ‘high’ or ‘low’ platelet responders but that there was a graded response in between these two extremes. When considering the results from the second group of donors, there was no difference in response.
In discussing their findings, the authors noted that the separation of platelet function into sensitivity and capacity was a novel approach, and which could be of value from a clinical perspective rather than adopting the ‘one size fits all’ current approach. For example, individuals with a low sensitivity and capacity might be more prone to bleeding when using anti-platelet drugs or, in contrast, more treatment-resistant when both sensitivity and capacity are high.
While the present study was preliminary, as part of an ongoing programme, the researchers wanted to investigate the association between phenotypic groups using PPAnalysis and the risk of both bleeding and thrombosis in patients.
References
This was the finding of a retrospective analysis by a team from Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking, China.
SAA represents a rare, life-threatening disease with an estimated prevalence of 1.5–7 cases per million inhabitants per year.1 Immunosuppressive therapy (IST) would normally be started for patients with SAA, especially in cases where there is no matched sibling donor; however, evidence suggests that up to a third of patients do not respond to IST and also that a third relapse after initial therapy. In contrast, haploidentical donor HSCT is a curative treatment approach for those with SAA especially in the absence of a suitable identical donor and in those who are refractory to IST.2
Nevertheless, there are mortality risks associated with HSCT and thus a pre-transplant risk assessment should be undertaken for all patients. Although several risk assessment tools are available, most have been derived from patients with haematological malignancies and none have been validated for patients with SAA. This led the Chinese team to develop a scoring system to enable the prediction of post-transplant mortality incorporating several different factors.3
The team turned to data held in a single centre and included all patients who had been diagnosed with SAA and who had subsequently undergone haplo-HSCT. They defined death without disease progression as ‘treatment-related mortality’ (TRM) and this served as the primary outcome measure. Prior to the transplant, co-morbidities were assessed using the haematopoietic cell transplantation specific co-morbidity index (HCT-CI) and the Eastern Cooperative Oncology group (ECOG) performance status score and for both tools, lower values are associated with a reduced risk. For the purposes of training and validating the predictive model, patients were randomly assigned to either subset, with the training set used to develop the scoring system and the validation cohort to test the model.
Findings
The analysis included 432 patients who were divided into training (288) and validation (144) cohorts. The median age of patients in the training cohort was 16 years (57.6% male) and slightly younger (median age 13 years) and median duration of follow-up was 1131 days. In addition, among those in the training cohort, for 42.7% of patients, the time from SAA diagnosis to HSCT was less than 12 months, with a similar proportion (45.1%) in the validation cohort. The two groups were also matched in terms ECOG and HCT-CI scores prior to their transplant.
In the overall population, the probability of TRM after three years was estimated to be 12% and the 3-year overall survival, was estimated to be 87%. In the predictive model, only three variables were found to be independent predictors of TRM; time for diagnosis to HSCT and both ECOG and HCT-CI scores. Combining these three variables, the authors categorised patients as being at a low, intermediate, and high risk of TRM. Using the model, they calculated the hazard ratio for TRM to be 3.43 for intermediate risk patients and 9.57 for those at high risk when using the low-risk group as the reference point.
The authors concluded that the use of these three parameters would be useful in predicting treatment-related mortality for patients with SAA after HSCT.
References
Support for the development of this article was provided by Sight Diagnostics
Since the inception of the Coulter Principle – automated CBC testing that harnesses resistive pulse sensing or flow cytometry to evaluate blood specimens – seven decades ago, reputable haematology systems have relied on large laboratory equipment that requires a special set-up for reagent management and liquid waste disposal. Although many of these robust systems are respected worldwide for their accuracy and speed, they have not suited point of care (POC) settings since they require high overheads and skilled lab technicians for daily quality control, calibration and maintenance.
For large clinical laboratories running countless CBC tests per day, these complex and expensive haematology systems – regardlessof a delay in reporting results due to the transportation of specimens to central laboratories – are deemed cost-effective and efficient, but for small laboratories with small to medium test volumes or point of care settings with time-sensitive cases, this can be limiting or prohibitive. Hence there is an opportunity within the blood diagnostics industry to address these system inefficiencies and develop a system that enables faster, non-compromising, on-site CBC testing closer to patients without transporting specimens to one central laboratory.1
Challenging the Coulter Principle for POC settings
Over the years, there have been attempts to miniaturise legacy lab analysers, but due to the simplification of an often highly complex system, this miniaturisation has often resulted in “reduced numbers of parameters” (e.g., three-part instead of five-part differential), narrowed reportable ranges, reduced abnormal cell flagging capabilities and, in some cases, a reduction in accuracy (as indicated by the small number of FDA clearances). These CBC analysers have also inherited many of the product attributes of their larger relatives, including the requirements for liquid reagent replacement, washout and calibration procedures, and frequent quality-control processes,” which in the point of care context can be very restrictive.2
Sight OLO represents a new breed of blood diagnostic technology
Developed from a decade of research, Sight OLO – an AI-driven haematology analyser – implements innovations in physics, chemistry, biology, optics, sample preparation and computer science to provide actionable five-part differential CBC results at the POC
in minutes.
The self-contained quantitative multi-parameter analyser and its disposable cartridge deliver fast and accurate CBC results by digitising blood samples. According to Yossi Pollak, the co-founder and CEO of Sight Diagnostics, OLO takes two drops of blood and automatically creates a monolayer of cells within the self-contained cartridge. Once the specimen cartridge is placed inside the analyser, the device captures over 1000 images within minutes. Then – in real-time – the device uses artificial intelligence to classify, enumerate and identify anomalies in the blood samples to produce the final CBC results.1
Building on OLO’s excellent performance, Sight constantly evolves OLO’s AI-powered CBC models as well as exploring ways to expand on the application of OLO’s underlying technology. For example, machine vision-based technology enables the digitalisation of blood samples into image data. This image data continues to fuel further research and development efforts into clinical conditions with visual signatures in the blood samples.
OLO’s performance is comparable to analysers that are 50-times bigger and much more complicated to operate. The ability to take that much analytical power outside of the central lab and bring it to any setting where you can perform a CBC analysis in minutes has huge implications for hospital wards, such as oncology clinics, emergency rooms and beyond.
Dr Carlo Brugnara, Director of the Haematology Lab at the Boston Children’s Hospital in Boston, Massachusetts, US.
Lab-grade accuracy for all CBC parameters at the POC
During a Sight study published in July 2021, the accuracy of OLO was compared with the Sysmex XN-1000 System. Samples – covering a broad clinical range for each tested parameter from 355 males (52%) and 324 females (48%) aged 3 months to 94 years – were analysed. The regression analysis results showed a consonance in correlation coefficient and slope, bias and intercept between OLO and Sysmex XN (Figure 3). Therefore, the study concluded that OLO performs with high accuracy for all CBC parameters and is clinically proven to be substantially equivalent to the gold standard – the Sysmex XN-1000.2
Uncompromising precision at low ranges
In a Sight report summarising the accumulated results from 17 clinical method comparison studies focusing on low counts for clinically significant CBC parameters, OLO also showed an excellent performance in enumerating low ranges (Table 1). The studies compared the performance and accuracy of OLO to comparative haematology analysers (e.g., Sysmex XN and Beckman Coulter DxH models) at various institutes and clinical settings – including oncology departments, an epidemic clinic and central labs of both general and paediatric hospitals – in different countries. Overall, the high agreement between OLO and the comparative analysers and the versatility of technologies, locations, operators, and clinical settings confirmed the robustness and accuracy of OLO across different variables.
Sight OLO empowers clinicians to provide high-quality patient care
Since OLO leverages AI to produce novel digital pathology, the analyser can produce CBC results within a few minutes at the POC (via a touchscreen interface, printout, email, or LIS/middleware),
so there is no need to transport specimens to one central laboratory. By delivering fast yet accurate results – whenever and wherever – OLO allows healthcare providers to efficiently and effectively run their operations without needing to defer to central labs. As a result, this pioneering technology has the potential to speed up diagnosis and ultimately elevate the overall quality of treatment and patient outcomes.
OLO is CE Marked according to the IVD European directive for performing CBC tests in point of care settings. The device is also FDA 510(k) cleared for use in moderately complex settings in the United States. For full indication for use and safety information, please visit the Quality and Compliance page at www.sightdx.com.
References
Support for the development of this article was provided by Sight Diagnostics
With the rise of telemedicine and home-based care, healthcare is increasingly becoming decentralised. And due to the recent challenges catalysed by the COVID-19 pandemic, this need for patient-care models outside of traditional hospital settings has intensified – calling for innovative care pathways, especially in decentralised locations.1
Although most diagnostic technologies – blood gas, urinalysis, blood glucose monitoring, infectious markers, etc – have transitioned to various point of care (POC) offerings, CBC testing still occurs in laboratories with high operational overheads. This is primarily due to technical limitations requiring highly trained operators and expensive laboratory equipment with a special set-up for daily quality control, calibration, reagent management and liquid waste disposal. But given the ubiquitous nature of CBCs, the lack of fast and accurate CBC analysers in POC settings prevent care modalities from providing the best treatment.
According to Tony Cambridge, the lead biomedical scientist in the pathology management team at the University Hospital Plymouth NHS Foundations Trust, the healthcare community is on the cusp of a pivotal breakthrough to bring testing closer to patients. Cambridge further asserts that community-based diagnostics – if stewarded correctly – can reform problems in the health services landscape, such as growing waiting lists, care delays, accumulating costs and undesirable patient outcomes.1 Since legacy haematology processes are rife with similar limitations and CBCs play such a critical role in ensuring adequate care, there is an urgent call for CBC diagnostics to join in the decentralised healthcare movement by reimagining the clinician–patient experience.
Diagnostics offered closer to the patient are in no way designed to undermine the service provided by pathology laboratories, but to enhance it, and safeguard optimal care for the patient. Used in an appropriate way, decentralised testing can reduce pressure on support services, such as pathology and phlebotomy, by redirecting workload to other workstreams, preserving the laboratory testing for specialist and urgent hospital cases.
Tony Cambridge, lead biomedical scientist in the pathology management team, blood sciences and point of care testing at the University Hospital Plymouth NHS Foundations Trust1
Important considerations for the adoption of CBC technology in decentralised settings
To enable care providers to efficiently and effectively run their operations while providing high-quality treatment to patients whenever – and wherever – there are a few standards POC CBC technology needs to uphold:
Achieving high accuracy for all CBC parameters
Currently, the majority of POC CBC analysers are miniature versions of legacy analysers. However, due to the simplification required to downscale this technology, the accuracy often gets affected, resulting in only a few FDA clearances for POC CBC analysers of late.2 Consequently, additional tests are required to confirm the accuracy of the test results, causing the drawing of more blood, which in effect delays – rather than speeds up – the entire process.
Sight OLO is an innovative haematology system designed to address these current limitations in POC blood diagnostics (Figure 1). By leveraging innovations in physics, optics, sample preparation, and AI-driven computer vision technology, the self-contained quantitative multi-parameter analyser digitises blood samples to deliver five-part differential CBC results with 19 parameters and sophisticated flagging capabilities at the point of care.
During a Sight study published in July 2021, the accuracy of OLO was compared with the Sysmex XN-1000 System. Samples – covering a broad clinical range for each tested parameter from 355 males (52%) and 324 females (48%) aged 3 months to 94 years – were analysed. The regression analysis results showed a consonance in correlation coefficient and slope, bias and intercept between OLO and Sysmex XN. Therefore, the study concluded that OLO performs with lab-grade accuracy for all CBC parameters (Figure 2).
Prioritising sampling convenience, accessibility and turnaround time
Traditional blood testing requires a phlebotomist to draw vials of blood through venipuncture – a time-intensive and highly skilled process – which can pose challenges in near-patient settings. Thus, for CBC testing to work in decentralised conditions, the system’s sample preparation process must empower care providers, not necessarily skilled phlebotomists by trade, to effectively sample a patient’s blood. Additionally, it is essential for the sampling methods to be accessible to sensitive patients in delicate situations, i.e., babies (older than three months), elderly patients with difficult veins and patients with mental health problems (especially patients diagnosed with schizophrenia).
Sight OLO is the first CBC analyser that is FDA 510(k) cleared for blood taken directly from a finger prick. Each test requires just two drops of blood from a finger prick, making OLO convenient for healthcare workers and accessible to sensitive patients aged three months and above. Furthermore, operators can complete this sampling process in under one minute and obtain the full results in minutes.
Amid one study conducted in November 2020 in an oncology day centre in Israel, Sight evaluated OLO’s accuracy for finger prick samples across the OLO reportable range. The study results showed high correlations between the finger prick results of OLO vs the venous results of OLO (Table 1). During the study, Sight also tested the device’s turnaround time compatibility to the centre. An OLO and Beckman Coulter DxH800 (the centre’s current system) comparison revealed that OLO decreased the average time from phlebotomy to CBC results by 45%.
Scaling CBC technologies for decentralised settings
When traditional CBC analysers are merely miniaturised, they often inherit “many of the product attributes of their larger relatives, including the requirements for liquid reagent replacement, washout and calibration procedures, and frequent quality-control processes which in the POC context can be limiting or prohibitive.”2 Therefore for CBC technology to scale for use in decentralised environments, all the accompanying attributes must be addressed.
Sight OLO is perfectly suited for POC in various clinical settings. It has a small footprint (284mm x 254mm x 323mm), and the analyser comes factory calibrated for a quick set-up, requires no maintenance or quality control*, and only needs a power outlet. Hence the device requires no scheduled downtime, is always “on” without needing time to warm up or shut-down and does not necessitate a skilled lab technician to operate the device. Additionally, OLO uses one disposable cartridge per test, which can be stored without refrigeration and has a shelf life of over a year. thus eliminating the need for reagent procurement, hazardous material storage and liquid waste disposal, rendering the device suitable to be placed on any stable surface.
*There is no manufacturer requirement for QC. Additional QC may be required according to local regulations
At the beginning of 2019, Sight conducted a usability study to test the ease of usage and training and determine users’ consequent understanding of the Sight OLO system. “In this observational study, 16 participants, representing a wide variety of potential operators, easily, safely, and effectively performed all critical tasks for the intended use of the OLO device when provided with the level of training and documentation provided in standard commercial use”.3 During the usability study, Sight also concluded that OLO’s internal Failsafe designs — to mitigate significant risks and operator errors — are all adequate and effective. And that “no use errors, task failures, or user interface shortcomings encountered will lead to an unacceptable level of harm to the patient, environment, or operator.”3
For ease of oversight at decentralised locations – beyond Sight OLO’s internal Failsafe mitigations, ease of use and training – OLO’s technology also enables lab managers to set different access permissions for various operators with varying experience and trace operator activities.
Reimagining CBC blood diagnostics
It has become evident that for CBC testing to work in decentralised settings, it is vital to reimagine the entire CBC diagnostics principle.2 As an innovator, Sight Diagnostics investigated how legacy laboratories utilise microscopists to review out of range or invalidated results produced by their analysers. To address these limitations and ensure high quality and consistent results, Sight created a digital microscopy approach with an AI-trained algorithm. After years of research, Sight Diagnostics’ use of computer vision and AI represents this digitised CBC leap within the POC space, consequently eliminating unnecessary reflex and wasted time.
According to Yossi Pollak, the co-founder and CEO of Sight Diagnostics, OLO’s system takes two drops of blood and automatically creates a monolayer of cells within the self-contained cartridge. Once the specimen cartridge is placed inside the analyser, the device captures over 1000 images within minutes, turning the blood sample into a set of high-resolution digital images. Then – in real-time – the device uses AI to classify, enumerate and identify anomalies in the blood samples to produce the final CBC results.4 Imagine the same microscopist all day, every day, providing gold standard results; that’s OLO.
Building on Sight OLO’s excellent performance in POC settings, Sight constantly evolves OLO’s AI-powered CBC models as well as exploring ways to expand on the application of OLO’s underlying technology. For example, machine vision-based technology enables the digitalisation of blood samples into image data. This image data will continue to fuel further research and development efforts into clinical conditions with visual signatures in the blood samples.
Overall, Sight Diagnostics has successfully responded to the call for CBC testing to decentralise healthcare and bring diagnostics closer to patients. Now is the time for CBC-reliant health services and laboratories to implement this pioneering technology and follow suit.
OLO is CE Marked according to the IVD European directive for performing CBC tests in point of care settings. The device is also FDA 510(k) cleared for use in moderately complex settings in the United States.
For full indications for use and safety information, please visit the Quality and Compliance page at www.sightdx.com.
References
26th November 2021
Before the COVID-19 crisis, European healthcare systems were already facing numerous challenges: the long-term impacts of financial and economic crisis; the increasing demand of an ever-expanding ageing population; increasing numbers of chronic patients; increasing requests and availability of technological innovations; and new roles, new skills, and new responsibilities for the health workforce.
The figures given in this document provide the most up-to-date comparative picture of healthcare and hospitals in Europe. They aim to provide an overview of the healthcare systems within the EU member states before the pandemic. This edition will not only focus on hospital care but also on long-term care, a sector impacted heavily by the COVID-19 pandemic and often under-looked in healthcare but increasingly important with the rising elderly population. The article will also cover ambulatory care. Unfortunately, the data used for these two new sections are scarce, and the figures presented must be interpreted with caution, but at least provide a good indication of the pre-pandemic state of the health care systems.
The main source of data and figures is OECD Health Statistics (last update July 2021). Data on health expenditure as a percentage of total general government expenditure and on hospital beds in public or privately owned hospitals have been extracted from the Eurostat Database on Health (last update July 2021). All EU member states belonging to OECD are considered, plus Switzerland, the United Kingdom (UK) and Serbia (as HOPE has members in those countries), when data are available. In the text, these are reported as EU. When averages are reported, they result from our own calculation. The considered trends normally refer to the years 2016–2019. When data in 2016 or 2019 are not available, or they have not been gathered for enough countries, the closest year is considered.
The current health expenditure per capita shows huge diversity in Europe. The total current health expenditure per capita in 2019 in the EU was between 2074 PPP$ (purchasing power parity) in Latvia and 6518 PPP$ in Germany, with an average of 4153 PPP$. In Switzerland, this indicator reached 7138 PPP. Since 2016, the total health expenditure per capita has varied positively in all the countries of this analysis. Major increases have been seen in Lithuania (30%), Czechia (28%) and Latvia (29%); smaller increases were registered in Greece (4%) and Switzerland (5%).
Current public health expenditure includes all schemes aimed at ensuring access to basic health care for the whole society, a large part of it, or at least some vulnerable groups. Included are government schemes, compulsory contributory health insurance schemes, and compulsory medical savings accounts. Current private health expenditure includes voluntary health care payments schemes and household out-of-pocket payments. The first component includes all domestic pre-paid health care financing schemes under which the access to health services is at the discretion of private players. The second component corresponds to direct payments for health care goods and services from the household primary income or savings: the payment is made by the user at the time of the purchase of goods or use of the service.1
In 2019, the percentage of public sector health expenditure to the total current health expenditure was more than 70% in most countries, except for Latvia (61%), Greece (60%), Portugal (61%), Hungary (68%), Lithuania (66%) and outside the EU, in Switzerland (67%). In Luxembourg, Sweden and Germany, it was above 85%. The private share ranged from 40% in Greece to 15% in Germany, Sweden and Luxembourg (Chart 1).
In the last years, health expenditure of the public sector accounted on average for 77% of the total health expenditure.
Chart 2 shows the trend in the share of government expenditure in health from 2008 to 2019.
In 2019, the percentage of government expenditure devoted to health in the total health expenditure ranged from 11% in Greece to 19% in Ireland.
The average trends illustrated in Chart 2 are generally positive between 2008 and 2019. In some countries such as Greece, expenditure decreased until 2015 when it started to increase again.
Out-of-pocket payments show the direct burden of medical costs that households bear at the time-of-service use.
In 2019, the household private contribution to healthcare spending in the EU accounted on average for 18% of total current health expenditure (down from 20% in 2016).
In 2019, the private contribution to healthcare spending was around 18% in the EU, ranging from 9% in France to 37% in Latvia. Other lowest values were registered in Luxembourg (10%), the Netherlands (11%) and Slovenia (12%), while the other highest values were registered in Greece (35%) and Lithuania (32%). It is worth noting that Latvia, Lithuania and Greece are at the same time among the countries with the lower current health expenditure on health in PPP$ that year.
Between 2016 and 2019 the household out-of-pocket payments in PPP$ per capita have increased in all the EU countries because of the increase in the demand of healthcare services and due to an increase in the total health expenditure. The exceptions were Switzerland (0%) and Luxembourg (-1%). The most relevant increases registered were in Estonia and Lithuania (30%), whereas the EU average increase was 11%.
Chart 3 illustrates the 2016–2019 trend of both the total current health expenditure per capita and the private households’ out-of-pocket payments on health. The chart highlights the fast growth of both expenses in the countries shown at the upper right of the chart, such as Lithuania, Czechia and Estonia. For those shown in the lower-left of the chart, the out-of-pocket payments grew more slowly compared with the total current health expenditure.
In most of the EU member states, 30%–40% of current health expenditure (excluding investments and capital outlays) is devoted to hospital care (Chart 4).
More than 30%–40% of current health expenditure finances hospital care: 18%–30% for ambulatory care and 4–24% for long-term care, which shows a hospital-centric health system in 2019.
In 2019, current hospital expenditure represented about 41% of total current health expenditure, ranging from 28% in Germany to 45% in Greece, and 44% in Estonia, Spain, Italy, and Denmark. In all countries, even if a part of the total health expenditure is always funded by private insurances and out-of-pocket payments, almost the entire amount of inpatient health expenditure is publicly financed. The total expenditure on in-patient care (PPP$ per capita) in the EU follows a growing trend (Chart 5).
Although reforms have encouraged systems to have a greater emphasis on primary care, the data from 2019 still show major differences between countries. Ambulatory care is defined as establishments that are primarily engaged in providing health care services directly to outpatients who do not require inpatient services. This includes both offices of general medical practitioners and medical specialists, and establishments specialising in the treatment of day-cases and in the delivery of home care services.
The EU average expenditure on ambulatory care was 25% of the total healthcare expenditure compared with 41% invested in hospitals; this situation is seen in most EU countries (Chart 6). The biggest differences between the two can be found in Greece (45% hospital, 19% ambulatory care), Spain (44% hospital, 22% ambulatory care), Estonia and Italy (44% hospital, 23% ambulatory care). The smallest differences are in Luxembourg (33% hospital, 30% ambulatory care) and Belgium (38% hospital, 32% ambulatory care). The only EU country that spent more on ambulatory care than on hospital care was Germany (28% hospital, 31% ambulatory care).
Furthermore, the lowest expenditures on ambulatory care were seen in the Netherlands (18%), Greece (19%) and Ireland (20%), whereas the highest were observed in Belgium (32%), Germany (31%) and Finland (31%).
Another increasingly important healthcare area is long-term care; due to the increasingly elderly population in Europe and the big impact of the pandemic, it is important to review its state to that before COVID-19. The spending in long-term care is also extremely low compared with hospital expenditure. Long-term care (health and social) consists of a range of medical, personal care and assistance services that are provided with the primary goal of alleviating pain and reducing or managing the deterioration in health status for people with a degree of long-term dependency.
The EU average is 10%, with the lowest expenditure found in Poland, Lithuania (1%), Greece (2%), Switzerland, Latvia, and Hungary (3%). The highest expenditure was in the Netherlands (28%) and Ireland (17%). The country with the smallest difference in expenditure between hospital care and long-term care was the Netherlands, while Poland and Greece had the biggest difference, as well as the smallest expenditure.
From 2016 to 2019, expenditure on hospitals as part of the total healthcare expenditure increased by an average of 14% in the EU; the biggest increases took place in Latvia (31%), Czechia (24%) and Poland (22%). There were no decreases in any of the EU countries with available data showing an overall positive trend. Greece (4%), France (6%) and Switzerland (5%) had the smallest increases in the EU.
When comparing the variation of hospital expenditure with ambulatory care there is also a positive trend, with an average EU increase of 11%, except in Poland (-15%), Finland (-8%), Switzerland (-6%). The biggest increase was observed in Latvia (66%).
Long-term care expenditure also follows a positive trend, with a 13% average increase in the EU and no decreases in any of the countries with available data. The biggest increases were observed in Estonia (106%), and lowest in Sweden, Luxembourg (6%), Ireland (7%) and Switzerland (5%).
In recent years, healthcare reforms or other initiatives implemented all over Europe aimed at rationalising the use and provision of hospital care, improving its quality and appropriateness, and reducing its costs.
The number of hospital facilities decreased in most countries while the number of hospital beds dropped off on average. These reforms and initiatives also resulted in a broad reduction of acute care admissions and length of stay, as well as in improvements in the occupancy rate of acute care beds.
This was made possible thanks to a package of financial and organisational measures addressed to improve coordination and integration between the different levels of care, increase the use of day-hospital and day-surgery and introduce new and more efficient methodologies of hospital financing to incentivise appropriateness (for example, the replacement of per diem payments – known to encourage longer hospitalisation – by prospective payment).
In most European countries these policies led to changes in the management of patients within hospitals and offered a possibility to reduce the number of acute care hospital beds.
However, the bed-occupancy rates registered more disparate trends across Europe, depending also on the demographic and epidemiological structure of population and from the specific organisation of local, social, and healthcare systems, i.e., the structure of primary care, the presence and the efficiency of a gate-keeping system, the modality of access to secondary care, availability of home care and development of community care.
Between 2016 and 2019 the number of hospitals decreased in most of the countries, with the number of hospital beds decreasing to about 2%.
The total number of hospitals barely decreased in 2019 compared with a decrease ranging between 9% and 41% during 2006–2016. Minimal changes happened in 2016–2019 in Ireland, Estonia, Slovenia (0%) and Lithuania (+1%). The biggest decrease took place in Luxembourg (-17%) and the biggest increase in Poland (+16%) (Chart 7).
In the same period, few changes in the number of hospitals beds were registered in Slovenia, Switzerland, Slovakia, and Czechia (0%) The biggest increase was 3% in Portugal. Major decreases were registered in Finland (-15%), Sweden and the Netherlands (-8%) (Chart 8).
Moreover, there were on average 466 hospital beds for 100,000 inhabitants in the EU in 2019, ranging from 207 in Sweden to 791 in Germany (Chart 9).
Between 2008 and 2016, there was a decrease in the total number of beds that was, in many countries, accompanied by a slight increase in the number of private inpatient beds (Chart 10). The biggest increases in these years were in Romania (+560%) and Bulgaria (+154%). However, in 2019 there were few increases in private beds, with only some countries, such as Romania and Lithuania (28%) showing an increase; there was even a decrease in some countries. In 2019, countries with the highest percentage of private beds were Belgium (74%) and Germany (60%). Those with the fewest were Slovenia, Lithuania (1%) and Croatia (2%).
The rate of acute care hospital beds for 100,000 inhabitants in 2019 in the EU ranged from 234 in Sweden to 791 in Germany. The other highest figures were in Austria (719) and Hungary (691) whereas the other lowest figures were in UK (245), Denmark (259) and Ireland (288).
Between 2016 and 2019, the number of acute care hospital beds per 100,000 populations registered an average reduction of 4% in the EU. The most significant decreases were in Finland (-16%), Sweden (-12%) and Luxembourg (-11%). The only exception was Portugal (4%), and Slovakia, Greece, Italy, and Denmark showed no significant changes (Chart 11).
Residential long-term care facilities are establishments primarily engaged in providing residential long-term care that combines nursing, supervisory or other types of care as required by the residents. In these establishments, a significant part of the production process and the care provided is a mix of health and social services, with the health services being largely at the level of nursing care, in combination with personal care services. They include long-term nursing care facilities and other residential long-term care facilities.
The number of long-term beds per 100,000 inhabitants in 2019 in the EU was 768, ranging from 27 in Bulgaria to 1378 in the Netherlands. On average there was a 2% increase in the number of beds per 100,000 inhabitants from 2016 to 2019, with a few countries having a bigger than average increase such as Serbia (+20%) and Austria (+12%). Although most countries show a positive increase a few had a decrease in the number of beds per 100,000 inhabitants: Croatia (-8%), Bulgaria (-11%) and Denmark (-17%) (Chart 12).
To better understand the state of the healthcare system in the EU, we also need to look at the number of primary healthcare units; however, there are few data available, or from recent years. The countries with available data from 2000 to 2009 (most recent years available) are Bulgaria, Croatia, Czechia, Estonia, Hungary, Lithuania, Latvia, Finland, Portugal, Slovenia, Slovakia, Sweden, and Romania. They show minimal increases, with the biggest increase occurring in Latvia (from 116 to 121) and the biggest decrease in Croatia (from 79 to 73).
The number of acute care discharges involves the entire pathway of hospitalisation of a patient, who normally stays in hospital for at least one night and is then discharged, returns home, is transferred to another facility, or dies. Curative care comprises health care contacts during which the principal intent is to relieve symptoms of illness or injury, to reduce the severity of an illness or injury, or to protect against exacerbation and/or complication of an illness or injury that could threaten life or normal function. Curative care includes all components of curative care of illness (including both physical and mental/psychiatric illnesses) or treatment of injury, diagnostic, therapeutic and surgical procedures, and obstetric services. It excludes rehabilitative care, long-term care, and palliative care.
The average length of stay measures the total number of occupied hospital bed-days, divided by the total number of discharges. In 2019, the average length of stay in acute care hospitals ranged from 10 bed-days in Hungary and in Czechia to 6 bed-days in Sweden, Ireland, and Belgium.
In 2019, the rates of in-patient discharges in the European countries were quite dissimilar, ranging from 25 discharges per 100 in Germany to 11 discharges per 100 in Italy.
The average length of stay is around 8 days in the EU.
The link between the rate of admissions and the length of stay can be a very sensitive issue for hospitals, since it is commonly acknowledged that too short length of stay may increase the risk of re-admissions with a consequent waste of resources both for the hospital and for the patients and their carers. At the same time, staying too long in a hospital may indicate inappropriate settlements of patients, also causing a waste of resources.
Chart 13 compares the rate of hospital discharges and the average length of stay for acute care hospitals in 2019. The last updated data show that the average European figures correspond to a mean rate of discharges of 17% and a mean length of stay of 8 days for acute care hospitals. The chart shows that both indicators are higher than the EU average in France, Latvia, Czechia, Hungary, Austria, and Germany.
The bed occupancy rate represents the average number of days when hospital beds are occupied during the whole year and generally mirrors how intensively hospital capacity is used.
In 2019, the average acute care occupancy rate in Europe was equal to 75%, but the gap between the highest and the lowest rate was 16 percentage points (p.p.).
Between 2008 and 2019, the average rate of acute bed occupancy decreased in Europe. The biggest reductions were in Hungary (-4.7), Slovakia (-3.20) and Czechia (-3.20). A particularly big increase was observed in Luxembourg (6.90). These large variations are usually due to changes in the number of admissions, average length of stay and the extent to which alternatives to full hospitalisation have been developed in each country (Chart 14).
Despite the growing interest in self-treatment and the growing role of digital health especially during the pandemic, health workers remain the crucial component of health systems, providing health services to the population. Despite the numbers of health workers tending to grow in the last 15 years, policy makers are raising issues about the upcoming retirement of the ‘baby-boom’ generation of doctors and nurses, exacerbating the workforce shortage. Health workforce concerns shifted from worries on shortages towards issues related to the right skill-mix, to better respond to evolving population health needs. The financial constraints are leading in most European countries to a decrease in the resources available for healthcare professionals, reducing the possibilities of hiring new staff. Additionally, several countries, especially in central and eastern Europe, are experiencing migrations of their healthcare workforces.
European countries, European organisations and EU institutions are discussing possible impacts and achievable solutions to these issues. Interestingly, several countries are shifting competences from doctors to nurses, creating new educational pathways and bachelors’ degrees targeted to nurses. In many cases, nurses and general practitioners acquire new skills and competencies relieving the burden of hospital care by enforcing primary care institutions and community services.
The trends described above are likely to have major impacts on the hospital sector, as in-patient care alone absorbs about a third of the healthcare resources and because the hospital sector gives work to more than half of active physicians.
An overview of the European healthcare workforce in 2019 showed an average rate of approximately 2.5 nurses per physician.
In 2019, the share of practising nurses per 100,000 registered the lowest values in Greece (338), Latvia (439), Poland (510) and Spain (589). The highest values were in Germany (1395), Belgium (1107), Sweden (1085) and Switzerland (1796). For the same year, the lowest shares of practising physicians were registered in Poland (238), the UK (295), Belgium (316) and France (317) whereas the highest values were seen in Austria (532), Lithuania (457) and Germany (439) (Chart 15).
These figures provide evidence of the trends for the management of healthcare professionals, especially concerning the allocation of resources and responsibilities between physicians and nurses. In the EU, the average rate of nurses per physicians is about 2.4 points. In 2019, the highest values were in Germany (5.4), Luxembourg (4.0), Belgium (3.5) and Switzerland (4.0). In these countries, there is a high shift of competencies from physicians to nurses. Conversely, in countries where the values are lowest – such as Lithuania (1.7), Latvia (1.4), Spain (1.4) and Italy (1.4) – physicians continue to perform most of the clinical activities.
In 2019, according to available data, physicians working in hospital (full or part time) were approximately more than 50% of the total, with the EU average reaching 67%
The highest rates registered are in Belgium (209%), France (83%) and Switzerland (77%). By contrast, the lowest values are the Netherlands (36%), Latvia (45%), Spain (54%), Ireland and Austria (55%).
The long-term workforce can be categorised as formal and informal, and as there are sparse data available for informal workers, we will focus on the formal workers exclusively; these include nurses and personal care workers. Moreover, we will focus on long-term workers working with the 65-years-old and over population.
Data for long-term care formal workers per 100,000 population aged 65 years old and over in 2016–2019 were only available in a few countries; Portugal, Spain, Germany, Switzerland, Austria, the Netherlands, Estonia, Denmark, Sweden, Luxembourg, Slovakia, Ireland, and Hungary. In 2019, Sweden (11,900) had the highest number of formal workers per 100,000 population aged 65 years old and over, whereas the lowest was found in Portugal (800). From 2016 to 2019, Portugal (+14%), Spain (+7%), Germany (+6%), Switzerland and Austria (+2%) had an increase in the number long-term care formal workers per 100,000 population aged 65 years old and over, whereas Estonia (-2%), Denmark (-3%), Sweden (-4%), Luxembourg (-5%), Slovakia, Ireland (-7%), and Hungary (-14%) had a decrease in the number for workers. There was no significant change in the Netherlands.
Long-term workforce is also categorised by those working in institutions and those working at patients’ homes. Long-term care at home is provided to people with functional restrictions who mainly reside at their own home. It also applies to the use of institutions on a temporary basis to support continued living at home – such as in the case of community care and day care centres, and respite care. Home care also includes specially designed or adapted living arrangements (for example, sheltered housing) for persons who require help on a regular basis while guaranteeing a high degree of autonomy and self-control, and supportive living arrangements. Long-term care institutions herein refer to nursing and residential care facilities which provide accommodation and long-term care as a package. They refer to specially designed institutions or hospital-like settings where the predominant service component is long-term care, and the services are provided for people with moderate to severe functional restrictions.
For this, data are only available for a handful of countries: Estonia, Denmark, Hungary, Germany, Netherlands, Luxembourg, Austria, Portugal, and Switzerland. In countries where data are available, there is a higher percentage of workers working in institutions than at patients’ homes. The percentage of long-term care workers working at an institution varied from 83% in Portugal to 21% in Estonia. While for those at home it ranged from 79% in Estonia to 17% in Portugal.
In 2019, the average number of physicians and nurses graduated for every 100,000 inhabitants were respectively about 15 and 41 in the EU. However, the values across countries were quite different. The number of medical graduates per 100,000 inhabitants ranged from 10 in France and Estonia to 24 and 25 in Latvia and Ireland, respectively. The number of nurses graduated per 100,000 inhabitants ranged from 11 and 18 in Luxembourg and Italy to 82 and 108 in Finland and Switzerland (Charts 16 and 17).
Compared with 2016, the number of medical graduates per 100,000 inhabitants in the EU registered an overall positive variation (Chart 18). The countries that registered the highest increases were Latvia (+44%), Italy (+33%), Lithuania (+27%), Greece and Belgium (+23%). Minor positive variations occurred in Switzerland, Sweden (+12%), and Hungary (+11%) whereas decreases occurred in Slovenia (-12%), Estonia (-6%), Portugal (-4%), the Netherlands and Finland (-1%). The number of nurses graduated per 100,000 inhabitants showed different trends across the EU. Major positive variations were registered in Czechia (81%), the Netherlands (35%), Latvia (34%) and Poland (33%), whereas minor positive variations were registered in Denmark (2%), and Portugal (8%). The most relevant decreases were registered in Belgium (-44%) and Slovakia (-27%) (Chart 19).
Data were obtained from the OECD, Eurostat and WHO. When data were not available for one of the specific years, the closer year was used (denoted by *)
Austria determined a country-wide prioritisation. The prioritisation focuses on medical criteria for people with a high risk of severe and fatal outcomes when infected with SARS-CoV-2, or with high exposition while being part of essential services (e.g., health care staff, long-term care staff). The organisation and planning of the vaccinations was done regionally, on the level of the federal states. In the beginning of the vaccination process the in the EU known lack of sufficient vaccination doses led to fewer possible immunisations. First batches of vaccines were assigned to residents of retirement and nursing homes, the respective personnel and to health care workers and were administered on-site. These groups were followed by the general population of and over the age of 80. Gradually the pace picked up, with more doses available vaccines were further administered to the most vulnerable groups in age and underlying disease.
By 31 May 2021, 41% of the Austrian population had received at least one dose of the COVID-19 vaccine. A dashboard is available with online tracking of the progress and actual delivery of vaccine doses: https://info.gesundheitsministerium.at/. Austria is set on having immunised all people who want to receive the vaccination by the end of July 2021.
The health care workers were immunised directly in the hospitals and the adherence of physicians was very high, whereas nurses and other health care professions had a vaccination rate of approximately 50%–60%. Some federal states have vaccination centres for the general public, others also relied on their general practitioners right from the start of the vaccination process. In addition, mobile vaccination sites (‘Impfboxen’) were installed to offer low-threshold access to the COVID-19 vaccination.
During the three COVID-19 waves, some or all elective surgeries in the federal states had to be reduced to ensure enough capacities for COVID-19 patients in intensive care units. Until now, these treatments are being made up for. The long-term consequences cannot substantially be determined at this point. Mental health is a big focus, as depression, anxiety disorders and other mental health problems have been aggravated during the pandemic. In the Ministry of Health, an advisory group of experts works on necessary measures to be taken, also addressing the mental health state of children and juveniles and the subsequent issues arising.
We commissioned a study on the impact of the pandemic on inpatient care in Austria in 2020 (available at https://jasmin.goeg.at/1633/). Unfortunately, the study is only available in German. Result is: In the areas analysed there was, with the exception of strokes, a reduction in inpatient stays in the months of March to May 2020 and in November and December 2020 compared with previous years, although the reduction during the second lockdown was not as significant. Due to sufficient personal protective equipment, more testing possibilities and an increased knowledge about COVID-19 gained over the course of the first phase of the pandemic, the reduction was comparatively moderate, taking into account the relatively high number of hospitalised COVID-19 patients.
In general, there has been a high willingness in Denmark to receive the vaccine. By mid-September 2021, all citizens over the age of 12 had been offered vaccination against COVID-19. As of today, more than 4.4 million citizens have been vaccinated with at least one dose; this is equivalent to more than 75% of the total population and over 86% of the population above 12 years.
The Danish COVID-19 Vaccination programme is centrally governed. The Danish Health Authority has been responsible for planning the programme and determines who should be vaccinated and in which order. At first, the limited supply of vaccine was prioritised to citizens in nursing homes, health staff and the elderly and vulnerable population. Afterwards the roll-out has generally been based on age.
The authorities in Denmark’s five regions have been administering and carrying out the vaccinations. The regions are administrative entities at a level above the municipalities and below the central government and in charge of health care and public hospitals.
Most citizens were invited for vaccination through a secure public e-mail system (eBoks) that allows them to book a time for vaccination digitally. Most vaccinations take place in regional vaccination centres established for this specific purpose. Some take place in more local settings with outgoing units from the vaccination centres carrying out the vaccinations: for instance, for residents and staff at nursing homes or immobile citizens. Vaccination of hospital staff and hospitalised patients is administered at the hospitals. Vaccination is voluntary and free of charge.
It has been very important for the Danish regions to find out the consequences of coronavirus for non-COVID patients. Therefore, the regions created a panel of experts, which has been investigating the consequences on the health and well-being in Denmark and make recommendations. Although Denmark was in an extraordinary situation as a result of the coronavirus, the situation has shown that the Danish Healthcare System overall has been able to adapt to a crisis situation. Examination and treatment of patients with acute and life-threatening diseases has been prioritised and maintained throughout the entire pandemic. In an international perspective, cancer treatment in Denmark has, for instance, performed well during the crisis. However there has been a periodically decline in the activity in the non-acute and non-life-threatening areas, so that health care resources could be prioritized to treat corona patients.
Studies indicate that some citizens have experienced an impact on their mental health during the pandemic due to, for example, increased loneliness and isolation. It is likely that mental health will normalise for many in the wake of the crisis, but for some groups, we can expect more long-term negative effects. It is not yet possible to assess whether the mental health of the population in general will return to the same level as before coronavirus, once society is reopened, or whether the people who have been affected negatively will have poorer mental health in the long run. This requires follow-up studies and an increased focus moving ahead.
The vaccination target in Estonia was for 70% of adults to be vaccinated by the start of autumn; unfortunately, this does not seem to have been achieved in time. From the start, Estonian data were very similar to those in Sweden, the main difference being Sweden has a greater number of elderly people already vaccinated. Today our numbers are lower. The vaccination programme started just after Christmas 2020, with healthcare workers and older people in care homes. This was a wise decision as hospitalisation cases dropped among the elderly (from over 20% to 1% among residents of care homes). The decrease of morbidity among healthcare professionals has also been remarkable, and this significantly increased the capacity of the health care system to cope with the crises. Later the State Immunoprophylaxis Expert Committee gave new instructions on selection of risk groups to vaccinate next, step by step. As there was very high demand at the start, this was done according to the amount of vaccine available in Estonia at that moment. Vaccination centres opened in May 2021 and vaccination was available to all adults in Estonia, including non-nationals. In addition to the vaccination centres, hospitals and family physicians continued to carry out vaccinations. As of September 2021, 66% of the adult population, including 72% of elderly people, had been vaccinated. Our biggest challenge concerning vaccination today is primarily a socio-psychological one.
There was a considerable burden on hospitals during the second wave, because infection rates increased rapidly and many people needed specialised care. In March and April during the peak, there were over 700 people (over 54 per 100 000 inhabitants) hospitalised with COVID. Our health professionals have given their best to solve the crisis. We were also able to widely involve medical and nursing students with cooperation of University of Tartu and two Health Care Colleges.
To contain the virus, strict restrictions were also established by the Government of Estonia from 11 March 2021. The synergies between these activities were finally effective.
Long-COVID, mental health and waiting lists are also areas of concern in Estonia. Mental health problems – depression, anxiety, burnout, etc – had already emerged during the first wave of the virus crisis, and been exacerbated by the second wave. Continuous feeling of danger and stress among health professionals and other professions who have close contact with other people, has had and will have long-term effect on mental health.
During this difficult time, the Estonian Hospitals’ Association was also negotiating with health care workers’ unions regarding a collective agreement. In the last days of April 2021, after long discussions through a national conciliator, the Hospitals Association, the Medical Association, the Healthcare Workers Professional Association and the Professional Association of Clinical Psychologists reached an agreement, and a new collective deal was signed. This agreement contained for the first time also clauses about workers’ mental health and care. Unfortunately, the Nurses Union separated and did not sign this agreement, but the interests of nursing staff are considered in the same way.
The annual increase in morbidity started three months earlier than last year. At the beginning of September 2021, the Estonian government decided to implement a new COVID-19 risk level assessment model. The introduction of the new matrix will help to assess the situation of COVID-19 in the country more realistically, as more than half of the population have been vaccinated for COVID-19 at least once, which was not considered in the previous risk matrix.
From end of December 2020, Germany followed a stepwise and group-wise vaccination approach to prioritise COVID-19 vaccination (Vaccination approach RKI). The five groups were defined by the Robert-Koch-Institut (RKI) in the form of a recommendation. As in Germany it is up to the Federal states (Bundesländer) to translate these recommendations into binding legal acts, there were minor differences in the definition of the priority groups and in the timing of the vaccinations between the Bundesländer. In the first phase (28 December 2020 to 7 April 2021), the vaccinations were carried out exclusively in vaccination centres set up for this purpose. As of 7 April 2021, vaccinations were also administered by general practitioners and by in-house company doctors. Hospital staff were immunised as the first priority group from January 2021. For this purpose, the German hospitals received the corresponding doses for the vaccination of their staff. Beyond that, hospitals were not involved in the vaccination of the population. As of mid-September (15 September 2021), 63% of the total population is fully vaccinated and 67% of the total population is at least partially vaccinated (primary vaccination). As in many other European countries, Germany is currently discussing different motivational/incentive systems and mandatory options.
As in our neighbouring countries, the unprecedented COVID-19 crisis has created major challenges for regular inpatient and outpatient care. In Germany, the Federal States (Bundesländer) are responsible for the on-site organisation and planning of hospital care. In 2020, from mid-March onwards, the Bundesländer enacted regulations to create a legal framework for the downscaling of elective care procedures to be prepared for a worst-case scenario. The German hospitals largely followed the national request and the regional regulations. All decisions taken by the hospitals were guided by the principle that the evaluation of elective procedures is subject to the primacy of medicine. Decisions were taken most carefully after an in-house evaluation of each individual medical situation. Thanks to the treatment capacities in the German hospital sector, the teams were fortunately able to catch up on most of the procedures in the subsequent summer months. We can be grateful that we are currently not struggling with an unmanageable backlog situation. However, consequences on the care delivered to non-COVID patients, both in terms of somatic and mental health, must be further evaluated.
On 12 September 2021, Luxembourg had 1067 active infections and a total of 77,100 infections since February 2020. In total, 834 people have died since March 2020. Yet, there are only 27 people in the hospital due to COVID-19, including 9 people in ICU. Seventy-two per cent of the eligible population (12+) are fully vaccinated and 1000 people are vaccinated every day with EMA-approved vaccines. The AstraZeneca vaccine is only used in the older population and for younger patients on a voluntary basis. In hospitals, 75% of workers are vaccinated, professionals always have priority, but it is not mandatory. This will not change in the future. The current practice in hospitals is for workers to perform a test before starting the day; this is only a recommendation but, if they refuse, they will be assigned to a service without risk to patients. Visitors also require testing, and a COVID-19 passport is currently being implemented.
Meanwhile, a general COVID check obligation will apply in hospitals in future: according to this, every person entering a hospital must in principle show proof of vaccination, a negative test result or recovery. Only emergency patients are exempt.
Concerning non-COVID patients, there have been few issues thus far, except in mental health, but this is a pre-existing problem as there are not enough psychiatric centres. COVID-19 counselling centres have been closed and the general practitioners are the points of contact. There is also a two-way stream being implemented in emergency services for COVID-19 patients and for non-COVID-19 patients.
Vaccination in Portugal is centralised, managed by the Vaccination Task Force, designated by the Government. Vaccination is administrated by the Portuguese National Health Service (Serviço Nacional de Saúde – SNS) network, following the Vaccination Plan against COVID-19, which is dynamic and adjusted according to the evolution of scientific knowledge, the epidemiological situation at each moment and the availability of vaccines.
The plan foresees three phases. At the moment, Portugal is in the third phase, vaccinating mostly young people and a second dose to the rest of eligible population. An average daily rate in the fourth week of September 2021 was 34,515 vaccinated people (with the record of 148,000 on 12 July 2021).
As of 26 September 2021, 88% of the population had already received at least the first dose of the vaccine and 85% of the population has already been fully vaccinated, meaning that 98% of all of those eligible for vaccines – anyone over 12 – have been fully vaccinated.
In order to give priority to COVID patients, the activities in the Portuguese National Health Service were suspended for some time in 2020, so public hospitals carried out 18% fewer operations than the year before. At the end of 2020, hospitals started recovery plans that had to be interrupted at the beginning of 2021 due to the second wave of COVID-19 that overcrowded the institutions, preventing them, even for safety reasons, from allocating resources to non-COVID patients. Currently most institutions have already resumed recovery plans for suspended non-COVID activities, so they either work normally or with extended schedules to restore the waiting lists, but it will be a slow process.
In September 2021, there were more than 37 million people vaccinated (78% of the population, being 75% fully vaccinated). Vaccination is seen as one of the main achievements of health care services, either at central level, the Ministry of Health, or at regional levels. Organisation is perceived as effective by the population. All types of facilities are being used for the Vaccination Programme. Neither health care professionals nor the general population encountered problems being vaccinated. Vaccine hesitancy is not significant. A COVID passport is seen as one of the potential solutions for the tourism sector crisis.
As in other EU countries, the delivery of non-COVID-related health care services has been directly pressured and often compromised at all levels because of the pandemic. In general, there has been a postponement of elective medical procedures while there has been an increase in digital healthcare technologies use for regular consultations.
Postponement of elective medical procedures was mainly due to the lack of workforce, operating rooms and availability of beds. Some professionals were reallocated. Waiting lists have increased approximately from 7% to 19% depending on the region.
Studies done during the first wave showed: a decrease in cancer routine procedures; 97% of consultations were by phone; and 20% fewer biopsies and consultations. It is estimated that in this period 1 out of 5 patients has had a delayed diagnosis. There has also been a decrease in the number of urgent consultations for stroke, cardiovascular and neurological conditions in emergency rooms, by 15%–32% depending on the region. For primary care, studies show 75% fewer face-to-face consultations and an important increase in telemedicine. From the patients’ point of view, procedures planned before the pandemic were delayed or cancelled, and problems with medications were also reported. Temporary closure of primary care centres occurred and waiting lists for family care doctors have increased from 1–3 days to 3–6 days in 2020. A mental health study has shown an increase of eating disorders in children and adolescents during the pandemic. In public health, as the workforce was prioritised to the pandemic, screening programmes were affected as well as usual networks for other diseases.
Although the pandemic is still affecting healthcare services directly, great efforts are being made during 2021 to ensure access, rapid and appropriate services to non-COVID patients to recover the pre-pandemic situation. Waves of COVID infection and lack of workforce appear to be the main obstacles to achieving this goal.
In Sweden, vaccination is voluntary and the willingness to be vaccinated is generally high. As of 22 September 2021, 83% of all residents aged 16 and over had received at least one dose and 75% had received two doses. The rate of vaccination was higher among elderly people, as this age-group had been given priority, and the lowest among 16- and 17-year-olds who could start receiving the vaccine at the end of the summer of 2021. From October 2021, it will be possible also for young people aged 12–15 to get vaccinated in Sweden.
Statistics also showed that the vaccination rate was much higher among healthcare staff compared with other people of working age. But among social care staff, the figures were about the same as for the population in general.
A big challenge is the fact that the vaccination rate is lower among residents born outside Sweden, and among persons with low education and low incomes. This is something that requires targeted actions, and great efforts are being made to reach these groups as well.
In Sweden, vaccination is a regional responsibility. COVID-19 vaccinations take place in many different settings: often in temporary premises or drive-in centres, but sometimes also at primary care centres and hospitals. To reach out wider, the regions have also started mobile vaccination services offering vaccination outside schools, universities, churches, sports arenas etc.
Sweden has mainly used the Pfizer/BioNTech vaccine, but also the Moderna vaccine.
The COVID-19 pandemic has had many different effects on the Swedish healthcare services. Before the pandemic, Sweden had a low number of ICU beds, but then hospitals in a short time managed to transform wards into intensive care units, and transfer healthcare professionals from one part of the system to another. There was also a significant increase of digital services, a change that is expected to continue.
At the same time, there was less pressure on other parts of hospital services (cardio, cancer) and less pressure on primary care. Planned treatment was postponed and waiting times were extended. Between March 2020 and January 2021, the total number of surgeries decreased by 22% compared with the same period in 2019–2020. The number of planned surgeries decreased by 30%. The largest decreases in the total number of surgeries/interventions occurred in orthopaedics, general surgery and ophthalmology. The number of people waiting more than 90 days for a surgery/intervention has increased significantly since March 2020.
By September 2021, the UK had had over 7 million cases1 and 156,000 deaths where COVID-19 was recorded on the death certificate.2 The more transmissible delta variant led to a large uptick in cases from July 2021 onwards, with cases peaking at over 60,000 on one day; however, the vaccination roll out has helped break the link between cases and deaths. Public Health England estimates that over 143,000 hospitalisations for those over 65 have been prevented as a result of the vaccination programme, and estimated deaths prevented are now over 105,000.3
Initially the vaccination programme was managed by hospitals but has since been well established at local sites in primary care and mass vaccination sites. Healthcare staff, the elderly and vulnerable were initially prioritised but now over 80% of people aged 16 and over have had both vaccinations (over 43 million people) and nearly 89% have had one dose.4 The latest figures we saw suggested 90 % of frontline staff have been fully vaccinated and 80% of all staff had received both doses. Some NHS organisations have started to redeploy staff who have not been vaccinated away from the frontline. Research shows high vaccination trust compared to other countries, with a study in June noting 87% of respondents ‘had faith in the jab’.5 Reasons given by people to not get vaccinated are mainly fear of side effects, and long impacts that people did not feel could yet be known. Research by the Office of National Statistics (ONS) also showed a secondary factor of people feeling they did not think COVID-19 vaccines were necessary as they did not think it was a significant risk to them, often because they were younger and did not think they would develop serious symptoms, or they would not need to the jab because they felt they were taking adequate steps to avoid catching COVID-19.6
The UK initially took a policy of a three-month gap between doses which led to more people being vaccinated, but with the delta variant spike during the summer, people were encouraged to bring their vaccination forward to the eight-week mark.7
The main challenge is the backlog of care. Nearly 5.5 million people were waiting for treatment as of June 2021, the highest number since records began,8 in February 2020 before the pandemic, this stood at under 4.5 million. It is estimated that over 7 million people did not come forward for treatment during the pandemic that would have come forward usually and there is now a question of how many of those people will present for treatment, increasing the demand on the service as it recovers. More than 300,000 people in June 2021 were waiting more than 52 weeks; this is compared with just over 1600 in February 2020.
There has also been a rise in some mental health issues, with data showing a considerable rise in young people treated for eating disorders as well as those waiting for treatment, the latter of which increased 173% from the end of 2019/20 to the end of 2020/21.9
Research predicts England will have up to 10 million people who need support with mental health issues because of the pandemic.10 Long-COVID is also a topic of interest in the UK, both in the general public and across NHS staff, with figures in April suggesting that over 120,000 health care workers may have been affected.11
4th November 2021
The main use of anticoagulant drugs is to prevent thromboembolic events linked with atrial fibrillation, mechanical heart valves and deep vein thrombosis. Although anticoagulants are an effective form of treatment, the drugs are associated with an increased risk of bleeding. Moreover, the proportion of older patients experiencing major trauma has doubled from 2007 to 2016, increasing by around 4.3% per year and attributable to a greater number of falls and transport-related events.1 While greater use of anticoagulants such as warfarin has been shown to be an independent predictor or mortality in trauma patients,2 other data have not supported this conclusion.3 Furthermore, there are few data on the long-term outcome of trauma patients prescribed anticoagulants.
With such a lack of data, a team from the School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia, sought to quantify the association between anticoagulant and antiplatelet use and the short- and long-term outcomes in older patients with major trauma.4 They included all older (defined as 65 years and older) hospitalised trauma patients from 2017 to 2018 and retrieved the information from the Victorian State Trauma System (VSTR), a population-based registry that collects data on all hospitalised trauma patients in Victoria, New South Wales, Australia. Using the VSTR, the researchers included patients who met the following inclusion criterion: death due to injury, higher injury severity scores (> 12 on the Abbreviated Injury Scale), admission to intensive care for more than 24 hours and requiring mechanical ventilation for part of their stay, urgent surgery, 20–29% total body surface area partial or full thickness burns. The team also extracted drug information, including those prescribed either an anticoagulant or antiplatelet, categorising patients as: anticoagulant users, antiplatelet users and non-anticoagulant users. Groups were compared in terms of in-hospital mortality, length of hospital stay and Extended Glasgow Outcome Scale (GOS-E) at six months after their injury. The GOS-E categories patient function into eight different categories, with upper values indicating good recovery.
Findings
A total of 1323 patients were eligible for inclusion in the study, of whom 18.8% were prescribed anticoagulants and 28.7% antiplatelets. Among those taking anticoagulants, the majority (45.8%) were aged 75–84 years of age and 59.4% were males. The most common major trauma was a subdural haematoma (45.6%). In-hospital mortality was 31.7% among those taking anticoagulants and after adjustment for age and various other factors, the risk of in-hospital mortality was significantly higher compared with the non-anticoagulant group (odds ratio, OR = 2.38, 95% CI 1.58–3.59). Similarly, the adjusted odds ratio for those prescribed antiplatelets was also higher than non-users, although the difference was not significant (OR = 1.12, 95% CI 0.74–1.71). When comparing the GOS-E at 6 months, there was no evidence of an association between GOS-E scores and anticoagulant use (OR = 0.71, 95% CI 0.48–1.05) or antiplatelets (OR = 1.02, 95% CI 0.73–1.42).
The authors concluded that while there was evidence of an effect of both anticoagulants and antiplatelets with in-hospital mortality after a major trauma, there was no evidence of an association between function and anticoagulant use after six months.
References
Atraumatic back pain (i.e., with minimal tissue damage) is a common problem at emergency departments (ED), with a 2017 systematic review finding that it accounts for between 0.9% and 17.1% of all attendances.1 Cauda equine syndrome (CES) is a rare condition in which the lumbosacral nerve roots are compressed (hence the term cauda equine compression) that is commonly due to a central disc prolapse at the L4/5 or L5/SI level.2 There is some uncertainty over the incidence of the condition but a 2020 systematic review found a combined estimate of 0.27% from four studies of those with low-back pain presenting to secondary care.3 Untreated or missed as a diagnosis, CES can lead to permanent neurological dysfunction and which includes loss of bladder control, sexual function and a sensory/motor deficit. Although the diagnosis can be confirmed by MRI, access to this imaging modality is limited in ED hence clinicians need to identify those patients who require urgent imaging.
Which, if any, clinical symptoms obtained during a routine examination have predictive accuracy for the diagnosis of CES, was the subject of a study by a team from the Department of Spinal Surgery, Salford Royal NHS Foundation Trust, Salford, UK.4 The team undertook a retrospective case review over a 4-year period of all ED atraumatic pain at a single site major trauma spinal referral centre. They included patients 18 years and older who had undergone a reference standard imaging (MR spine) due to a clinical suspicion of CES. The team undertook a univariate logistic regression analysis to identify those subjective and objective risk factors associated with a diagnosis of CES and included only those that were deemed statistically significant (p < 0.05) in a multivariate analysis.
During the 4-year study period, 2036 patients presented at the ED with back pain of which 996 were referred to exclude CES. These patients had a median age of 46 years and radiological compression of the cauda equine was reported in 11.1% (111/996) of them, of whom 109 went on to have urgent surgical decompression. Looking at the clinical symptoms, both bilateral leg pain (with or without back pain) was significantly more frequent in those with CES (p < 0.001) as was the perception of bilateral weakness (p = 0.002).
In multivariate analysis, there were three significant and independent predictors of CES. Bilateral leg pain, with or without back pain (odds ratio, OR = 1.90, 95% CI 1.2–3.0, p = 0.006), objective sensory loss in a dermatomal distribution (OR = 1.70, 95% CI 1.1–2.7, p = 0.01) and finally, the loss of bilateral ankle and/or knee jerk reflexes (OR = 3.4, 95% CI 1.8–6.6, p < 0.0001). The team found limited diagnostic utility for a digital rectal examination.
The authors concluded that further prospective work was needed to validate their findings and to develop risk prediction tools to guide emergency imaging decisions.
According to the World Health Organization, asthma affected around 262 million people in 2019, leading to an estimated 461,000 deaths and is the most common chronic disease among children.1 Moreover, one US study found that visits to the emergency department (ED) for asthma in children increased by 13.3% between 2001 and 2010.2 Guidance on the treatment of acute asthma within the ED has discouraged the routine use of chest X-rays and antibiotics while encouraging the use of systemic corticosteroids.3 Though some studies have examined the level of agreement with these individual recommendations, finding, for example, that the use of chest X-rays and antibiotics were less likely,4 no studies have examined these three quality markers, i.e., no chest X-ray, no antibiotics given and provision of systemic corticosteroids, simultaneously. Consequently, a team from the Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, US, set out to examine the rates of adherence to these three indices during ED visits for children with asthma.5 For comparative purposes, the team also compared alignment with these measures in both general and paediatric ED centres.
The team used a cross-sectional design and captured data from the National Hospital Ambulatory Medical Care Survey, which is a nationally representative survey of hospital ED visits, and which is conducted annually. The researchers focused on all ED visits for patients aged between 2 and 18 years of age from 2005 to 2013 with a diagnosis of asthma and documentation of bronchodilator administration at the ED. They used a composite outcome measure based on the three criteria of administration of a systemic corticosteroid either in the ED or via a prescription, no use or prescription of an antibiotic and no chest X-ray being used.
The dataset included 7,794,163 eligible ED visits with 877,342 made to a paediatric ED. Overall, 44% of visits were for children aged 2–6 years (59% male). The majority of children were of White (54%) or Black (41%) ethnicity with the remainder being Hispanic or Latino (27%) or other (5%). When comparing general and paediatric ED visits, there was no difference in the rates of corticosteroid use (63% vs 62%, paediatric vs general, p = 0.80) although rates of antibiotic prescribing were significantly lower at paediatric centres (11% vs 20%, paediatric vs general, p = 0.01). In contrast, use of chest X-rays was significantly higher in general EDs (26% vs 40%, paediatric vs general, p = 0.002). Overall, guideline-based acute asthma paediatric care was significantly more likely at a paediatric ED centre (42% vs 31%, paediatric vs general, p = 0.004). Interestingly, multivariate analysis revealed how only paediatric ED type, Black ethnicity and hospitals located in the western part of the country were independently associated with guideline-compliant care.
The authors concluded that guideline-based ED care for acute exacerbations of asthma occurred relatively infrequently in US EDs but was more common, although still less than optimal, within paediatric ED centres. They called for future studies to examine the factors associated with optimal, guideline-based care.
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