AMR a “global crisis”, says UN report

According to a new report “No Time to Wait: Securing the future from drug-resistant infections” drug-resistant diseases could cause 10 million deaths each year by 2050 and by the year 2030, antimicrobial resistance could force up to 24 million people into extreme poverty. The report also states:

• Tuberculosis (TB) is becoming untreatable
• Lifesaving medical procedures like surgeries carry increasing risks because of "alarming levels" of resistance to antimicrobial drugs
• Resistance to antibiotics, antivirals, antifungals and antiprotozoals, which has been seen in countries of all income levels, is now a "global crisis"
• Drug-resistant diseases cause at least 700,000 deaths globally a year, including 230,000 deaths from multidrug-resistant TB
• 10 million people may die annually by 2030 as a result of drug-resistant diseases.
• Two million Americans develop antibiotic resistance infections each year, and 23,000 die from those infections
• 6 out of every 10 infectious diseases found in humans are spread from animals, the CDC estimates.
• CDC describes three "urgent" antimicrobial resistant threats in the United States: Clostridium difficile, Carbapenem-resistant Enterobacteriaceae (CRE) and Neisseria gonorrhoeae

Five recommendations

1. Accelerate progress (including implementation of One Health National Antimicrobial Resistance Action Plans)
2. Innovate to secure the future (including development of new antimicrobials)
3. Collaborate for more effective action
4. Invest for sustainable response

5.         Strengthen accountability and global governance.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Antibiotics are prescribed more often during teleconsultations

NIH: In direct-to-consumer telemedicine visits people use their personal devices to connect with doctors. Using telemedicine for children, particularly for acute problems like respiratory tract infections, can be harmful.

The situations include colds, sore throats, and ear infections. Kids may not be able to describe their symptoms. Specific physical exams or tests might also be needed that aren’t possible during telemedicine visits. For example, diagnosing an ear infection requires the doctor to look inside the ear canal. Diagnosing strep throat requires a strep test.

A team led by Dr. Kristin Ray at the University of Pittsburgh compared the quality of care delivered to children via telemedicine with that at urgent care facilities and during primary care visits. The team used 2015–2016 claims data from a large national health plan to assess how frequently doctors prescribed antibiotics to children for respiratory infections.

More than 5,000 children with respiratory infections received care via telemedicine, about 88,000 at urgent care, and more than 1 million by primary care doctors.

The team tallied the antibiotics dispensed within 2 days for each type of visit. The research was supported by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Results appeared online on April 8, 2019, in Pediatrics.

Among visits matched by patient and visit characteristics, the team found that doctors prescribed antibiotics for respiratory infections at 52% of telemedicine visits, 42% of urgent care visits, and 31% of primary care visits.

Next, the team analyzed whether antibiotics were prescribed according to clinical guidelines for the diagnoses received. Only 59% of telemedicine visits met the guidelines, compared with 67% of urgent care visits and 78% of primary care visits.

Primary care and urgent care settings provide higher quality care for respiratory infections than direct-to-consumer telemedicine.

Not seeing a patient physically can be an important cause of AMR.  

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Why universal medical insurance is on the way

Dr KK Aggarwal

Universal health care (universal health coverage, universal coverage, universal care, or socialized health care) is a national health care system that provides health care and financial protection to all citizens of a country. It provides a specified package of benefits to all members of a society with an aim of providing financial risk protection, improved access to health services, and improved health outcomes. The health care does not cover everything for everyone.

The critical components are

·         Who is covered?

·         What medical services are covered?

·         How much of the cost is covered?

As part of Sustainable Development Goals (SDGs), United Nations member states have agreed to work toward worldwide universal health coverage by 2030.

In India with a population of 133.92 crores, Ayushman Bharat will cover 50% of the population (40% or 50 crore people in conventional scheme + additional 10 % people with income less than 8 lakh per annum). For them insurance premium will be paid and shared by the central government (60%) and state government (40%) from the central and state taxes collected from the people.

Another 32% of the population is medically covered by Employee State Insurance (ESI) (8% employees + 10% unrecognised sector); Railway (9%); Defence (1.1%), state health insurance schemes (1%), Municipal corporations (1%); CGHS (36,67,795 people) and PSUs (0.75 crore family beneficiaries) [1%] another 1% is covered through private companies (corporates).

The remaining 18% of the population comprises people with annual income of more than 8 lakh per annum who can easily afford individual private insurance.

To make universal coverage possible the options include:

·         The government should make it mandatory to have insurance for those not covered by any government, PSU or NGO scheme.

·         Like ESI, it should be mandatory to have the employee insured by the employer as part of his or her salary package.

·         Around 41% of the population has some life cover, which should provide some medical cover.

·         Any individual with salary up to Rs 21,000 per month is entitled for ESI insurance; this should also be allowed for all those will salaries less than Rs 8 lakh per annum.

·         Ayushman Bharat provides coverage for up to 5 lakh for the family. However, most packages are capped, and the average expenditure is only Rs 18000/- per admission. Till today in the last 4 months, only 10 lakh people have been treated with an expenditure of only Rs 1800 crores (@ Rs 18000/- per person). At this rate, the annual expenditure will be only Rs 7200 crore (shared by center and state in a ratio of 60:40). This amounts to very little for the country.

·         If required, the government can cover additional 18% of the population also. With this the government will be able to ensure coverage for 100% population and provide general ward basic and emergent treatment to all admissions

For this to happen the government must also ensure affordable health care by implementing one company - one drug - one price policy; incentives to open Ayushman-only hospitals by small healthcare doctor-owned setups and capping the prices of National List of Essential Drugs, devices, reagents, investigations, equipment and disposables.

The government should also make it mandatory for all establishments to provide 10% beds for Ayushman patients.

The cost of providing universal national immunization; “nationalizing” diseases and health issues of national importance like TB, AMR, Leprosy, cancer, dialysis and providing free treatments to all should continue via the national health annual budget, which itself should be raised by another 25% to be made around Rs 75000 crores. This budget should cover the proposed 1.5 lakh wellness centers.

To further improve the health budget, the total budget for environmental pollution (air, water, earth); budget for women and child health, mid-day school meal, Swachh Bharat, road safety, pharma sector, food industry etc. should be merged with an aim to reduce the disease burden.

The government should provide coverage only for general ward treatment. There will still be enough business left for private and national insurance companies for additional insurance coverage for private wards and diseases not covered under Ayushman Bharat.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

High bed occupancy rates in hospitals denote inferior quality of care

High bed occupancy rates in hospitals denote inferior quality of care

Dr KK Aggarwal

Padma Shri Awardee

When patients choose a hospital for treatment, they usually judge a hospital by its location, the infrastructure, the amenities and services it provides, quality of care and cost of care.

Bed occupancy rate is an indicator of hospital utilization. It is a measurement of efficiency and effectiveness of a hospital. Bed occupancy rate of a hospital varies at any given point of time. While a ‘full house’ would perhaps appear to be most satisfying, it is not actually so, especially for a hospital.

According to the Australian Medical Association, Irish Medical Organisation, Australasian College for Emergency Medicine and NHS England, a bed occupancy rate above 85% or ‘overcrowding’ is considered to have an adverse effect on patient safety and the operational efficiency of the hospital.

High bed occupancy rate increases the risk of spread of hospital-acquired infections such as MRSA and Clostridium difficile via cross transmission. Such hospitals also run the risk of bed shortages when they are most needed, such as during outbreaks, or disasters. 

Overcrowding means not enough beds for patients from emergency department. A long waiting time for transfer to the appropriate inpatient bed increases mortality and chances of adverse events.

Overcrowding compromises quality of care. Medications may not be administered in time; the chances and frequency of errors increase as well.

Hospitals, in particular Govt. hospitals, have a policy of not denying admission to any patient, even if this means allotting the same hospital bed to two inpatients, or sometimes even three in pediatric wards. The outcome is an inferior quality of care, at the same time, it also creates an impression that we can manage even with inadequate infrastructure and resources available to us.

No hospital, whether Govt. or private, should have more than 85% bed occupancy rate.  Admitting 150 patients in a 100-bedded hospital is not correct. This means that for 50 extra patients, you are compromising care of 100 patients as resources are shared for a much larger number of patients than meant for.

This would also be applicable to govt. hospitals, if they over admit patients in view of the recent govt. notification, which makes it mandatory for all clinical establishments, chemists/pharmacists to notify every case of TB or else face penal provisions under sections 269 and 270 of the Indian Penal Code