Critical care delivery across health care systems in low-income and low-middle-income country settings: A systematic review

Emily S. Bartlett, Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA.
Andrew Lim, Section of Critical Care Medicine, Virginia Mason Franciscan Health, Seattle, Washington, USA.
Sean Kivlehan, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Lia I. Losonczy, Department of Emergency Medicine, Department of Anaesthesia and Critical Care Medicine, George Washington University Medical Center, Washington, District of Columbia, USA.
Srinivas Murthy, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
Richard Lowsby, Department of Critical Care Medicine, Department of Emergency Medicine, Mid Cheshire Hospitals National health Service Foundation Trust, Cheshire, UK.
Alfred Papali, Pulmonary and Critical Care Medicine, Atrium Health, Pineville, North Carolina, USA.
Madiha Raees, Division of Critical Care Medicine, Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Bhavna Seth, Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA.
Natalie Cobb, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA.
Jason Brotherton, Department of Internal Medicine and Paediatrics, Africa Inland Church Kijabe Hospital, Kijabe Kenya.
Enrico Dippenaar, University of Cape Town, Cape Town, South Africa.
Gaurav Nepal, Ministry of Health and Population, Kathmandu, Nepal.
Gentle S. Shrestha, Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
Shih-Chiang E. Kuo, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
J Ryan Skrabal, Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA.
Margaret Davis, Department of Emergency Medicine, University of Washington, Seattle, Washington, USA.
Cappi Lay, Department of Neurosurgery, Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York, USA.
Sojung Yi, Stanford University, Stanford, California, USA.
Michael Jaung, Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA.
Brandon Chaffay, Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA.
Nana Sefa, Department of Emergency Medicine, Department of Critical Care, Medstar Washington Hospital Center, Washington, District of Columbia, USA.
Marc Lc Yang, Accident and Emergency Medicine, The Chinese University of Hong Kong Faculty of Medicine, Hong Kong.
P Andrew Stephens, Department of Emergency Medicine, Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Amir Rashed, Albert Einstein College of Medicine, New York, New York, USA.
Nicole Benzoni, Critical Care Medicine, Virginia Mason Franciscan Health, Silverdale, Washington, USA.
Bernadett Velasco, Department of Emergency Medicine, East Avenue Medical Center, Quezon City, National Capital Region, Philippines.
Neill Kj Adhikari, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada.
Teri Reynolds, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland.

Document Type

Journal Article

Publication Date

12-1-2023

Journal

Journal of global health

Volume

13

DOI

10.7189/jogh.13.04141

Abstract

BACKGROUND: Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higher rate of mortality from critical illness than high-income countries (HICs). There is a pressing need for improved critical care delivery in LLMICs to reduce this inequity. This systematic review aimed to characterise the range of critical care interventions and services delivered within LLMIC health care systems as reported in the literature. METHODS: A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles with human subjects describing at least one critical care intervention or service in an LLMIC setting published between 1 January 2008 and 1 January 2020. RESULTS: A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% on infants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of the care described (94%) was delivered in-hospital, with the remainder (6.2%) taking place in out-of-hospital care settings. Overall, 49% of critical care described was delivered outside of a designated intensive care unit. Specialist physicians delivered critical care in 60% of the included studies. Additional critical care was delivered by general physicians (40%), as well as specialist physician trainees (22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%), ambulance providers (3.3%) and respiratory therapists (3.1%). CONCLUSIONS: This review represents a comprehensive synthesis of critical care delivery in LLMIC settings. Approximately 50% of critical care interventions and services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved in care delivery in the included studies, however generalist physicians were commonly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding critical care practice in LLMICs, demonstrating a paucity of interventional and cost-effectiveness studies. Future research is needed to understand better how to optimise critical care interventions, services, care delivery and costs in these settings. REGISTRATION: PROSPERO CRD42019146802.

Department

Emergency Medicine

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