|Author(s):||R. Y. Hsia*1, J. Razzak2, A. C. Tsai3|
|Affiliation(s):||1Department of Emergency Medicine, San Francisco General Hospital, University of California at San Francisco, USA, 2Emergency Medicine, Aga Khan University, Karachi, Pakistan, 3Department of Psychiatry, University of California at San Francisco, USA|
|Keywords:||Burden of disease; emergency care; cost-effectiveness analysis; economic evaluation|
Because public health has traditionally focused on prevention and primary care, emergency and surgical care has often been conceptualized as peripheral, costlier services that only well-developed and well-funded health systems are able to offer. However, there is emerging data showing that there are numerous treatable conditions within emergency and surgical care, such as road traffic injury that can significantly decrease morbidity and mortality of those in developing countries. Unfortunately, research activity correlates poorly with the injury burden in developing countries.
Because of the lack of work in this area, there are considerable methodological challenges specific to the evaluation of emergency and surgical services and interventions. Our research focuses on the definition of emergency and surgical care, as well as methodological advances in quantifying these conditions.
Defining what constitutes emergency care is the first task that must be undertaken before any measurements can be made. First, there must be recognition of the variety of presentations that present emergently. Emergency care obviously includes stabilization and treatment of injury-related illness and disease, such as road traffic accidents. Emergency care, however, extends beyond injury-related illness. It should be recognized that many in low-income and middle-income countries often do not seek care until a disease is in its later stages and thus may be prone to more emergent presentations. Consider the treatment of hernia, for example, while an efficient primary care system would, ideally, lessen the proportion of emergent presentations, conditions that require emergency and surgical care will always contribute significantly to a population’s disease burden, especially in countries with a high prevalence of unmet medical need. Treating those who present emergently (such as strangulation or incarceration, which if untreated could lead to severe morbidity and even mortality) would significantly reduce the morbidity and mortality of certain conditions and almost certainly be cost-effective. Clearly, the burden of emergency and surgical need extends beyond disease calculations themselves. Rather than population-based cross-sectional studies of presentations to an emergency ward, or creating a list of these ‘emergent’ entities and deriving calculations of incidence and prevalence, the method we propose consists of using existing burden of disease calculations and determining what percentage of them might present emergently. One could theoretically calculate what percentage of diabetes presents as diabetes ketoacidosis emergently, or malaria as cerebral malaria, or chronic obstructive pulmonary disease or asthma as acute respiratory distress. For example, one could calculate the annual burden of emergency obstetrical care based on knowledge that a minimum of 3-5% of all deliveries need emergency obstetric care to avoid mortality or severe morbidity.
We believe emergency and surgical care should be a priority of global health research and initiatives. An emphasis on the role of these services does not detract from current initiatives; indeed, many of Millennium Development Goals – e.g., cutting the maternal mortality ratio by three quarters between 1990 and 2015 – must be met by increasing access to emergency and surgical services. The focus on preventive health programmes in isolation from treating patients with urgent and emergent conditions who either die or live for the remainder of their lives with disabilities that are socially and economically costly to themselves and their families and to society must be revisited to compose a public health strategy that is comprehensive to include an understanding and appreciation of these issues.