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Abstract
Background: In the recent past, there have been inconsistent reports of India witnessing a decreasing trend in the incidence of orofacial clefts (OFC). To date, little comprehensive evidence has been published. To identify the prevalence, associated burden in terms of epidemiological parameters and to estimate the “unmet” OFC treatment needs, the present study was undertaken. Materials and Methods: Using the Global Burden of Diseases 2016 approach and its assumptions, an attempt was made to estimate the prevalence to quantify the burden of OFC in India as disability-adjusted life years (DALYs), years of life lost (YLL), and years lived with disability (YLD) as well as death due to OFC. The results from such an approach are presented. Using previous estimates of “unmet” OFC treatment needs, an attempt was made to estimate the current volume of “unmet” OFC treatment needs. Results: In the present study, it was estimated that a total of 0.033% of all Indian population suffers from OFC. In 2016, the estimated prevalence rate/100,000 was 33.27 for males, 31.01 for females, and 32.18 combined for both genders. It was estimated that for all ages, the DALYs lost were 2.05 for 100,000 males, 2.66 for females and 2.34 for both sexes. The OFC birth prevalence model revealed that the birth prevalence (as a proportion) in 2016 in India showed an odds ratio of 0.48 (1.56–1.65) and fixed factor of nonrecording 0.83 (0.15–6.63), underreporting 0.97 (0.88–1), gender 1.09 (1.02–1.16), chromosomal diagnoses included 1.22 (1.22–1.22), and stillbirth 1.22 (1.22–1.22). The total unmet cleft treatment need was estimated at 79,430 or 18.76% of the total Indian cleft population with OFC. Conclusions: Within the constraints of the mathematical modeling and based on all available surveys, literature, and reported data, the overall birth prevalence and the prevalence of OFC in India are presented. Till reliable data emerges, the present estimates could serve as a robust estimate of the prevalence and burden of OFC in India. The present enterprise highlights the need for well-designed, high-quality Pan-India, community-based, observational studies to accurately estimate the burden of OFC in India.
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Affiliation(s)
- S M Balaji
- Director & Consultant, Oral and Maxillofacial Surgeon, Balaji Dental and Craniofacial Hospital, Chennai, Tamil Nadu, India
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302
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Haider A, Scott JW, Gause CD, Meheš M, Hsiung G, Prelvukaj A, Yanocha D, Baumann LM, Ahmed F, Ahmed N, Anderson S, Angate H, Arfaa L, Asbun H, Ashengo T, Asuman K, Ayala R, Bickler S, Billingsley S, Bird P, Botman M, Butler M, Buyske J, Capozzi A, Casey K, Clayton C, Cobey J, Cotton M, Deckelbaum D, Derbew M, deVries C, Dillner J, Downham M, Draisin N, Echinard D, Elneil S, ElSayed A, Estelle A, Finley A, Frenkel E, Frykman PK, Gheorghe F, Gore-Booth J, Henker R, Henry J, Henry O, Hoemeke L, Hoffman D, Ibanga I, Jackson EV, Jani P, Johnson W, Jones A, Kassem Z, Kisembo A, Kocan A, Krishnaswami S, Lane R, Latif A, Levy B, Linos D, Linz P, Listwa LA, Magee D, Makasa E, Marin ML, Martin C, McQueen K, Morgan J, Moser R, Neighbor R, Novick WM, Ogendo S, Omigbodun A, Onajin-Obembe B, Parsan N, Philip BK, Price R, Rasheed S, Ratel M, Reynolds C, Roser SM, Rowles J, Samad L, Sampson J, Sanghvi H, Sellers ML, Sigalet D, Steffes BC, Stieber E, Swaroop M, Tarpley J, Varghese A, Varughese J, Wagner R, Warf B, Wetzig N, Williamson S, Wood J, Zeidan A, Zirkle L, Allen B, Abdullah F. Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance). World J Surg 2018; 41:2426-2434. [PMID: 28508237 PMCID: PMC5596034 DOI: 10.1007/s00268-017-4028-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.
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Affiliation(s)
- Adil Haider
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - John W Scott
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Colin D Gause
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Ave, Box 63, Chicago, IL, 60611, USA
| | - Mira Meheš
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
| | - Grace Hsiung
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Ave, Box 63, Chicago, IL, 60611, USA
| | - Albulena Prelvukaj
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
| | - Dana Yanocha
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
| | - Lauren M Baumann
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Ave, Box 63, Chicago, IL, 60611, USA
| | | | | | | | - Herve Angate
- The Pan African Association of Surgeons, Parktown, Johannesburg, South Africa
| | - Lisa Arfaa
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
| | - Horacio Asbun
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
- Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA, USA
| | - Tigistu Ashengo
- St. Paul Medical College, Addis Ababa, Ethiopia
- Jhpiego, An Affiliate of Johns Hopkins University Baltimore, Baltimore, MD, USA
| | - Kisembo Asuman
- African Agency for Integrated Development, Kampala, Uganda
| | | | - Stephen Bickler
- Alliance for Surgery and Anaesthesia Presence, Lupsingen, Switzerland
| | | | - Peter Bird
- AIC Kijabe Hospital, Kijabe County, Kenya
| | - Matthijs Botman
- Netherlands Society for International Surgery, Amsterdam, The Netherlands
| | | | - Jo Buyske
- American Board of Surgery, Philadelphia, PA, USA
| | | | - Kathleen Casey
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
| | | | - James Cobey
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
- Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Michael Cotton
- International Collaboration for Essential Surgery, Angwin, CA, USA
| | - Dan Deckelbaum
- Centre for Global Surgery, Montreal, QC, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | - Miliard Derbew
- The College of Surgeons of East, Central and Southern Africa, Arusha, Tanzania
| | - Catherine deVries
- University of Utah Center for Global Surgery, Salt Lake City, UT, USA
| | | | - Max Downham
- International College of Surgeons, Chicago, IL, USA
| | | | | | | | | | | | | | | | - Philip K Frykman
- Global Pediatric Surgical Technology and Education Project, Irvine, CA, USA
| | | | | | - Richard Henker
- American Association of Nurse Anesthetists, Park Ridge, IL, USA
| | - Jaymie Henry
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
| | | | | | | | - Iko Ibanga
- Pro-Health International, Edwardsville, IL, USA
| | | | - Pankaj Jani
- The College of Surgeons of East, Central and Southern Africa, Arusha, Tanzania
| | - Walter Johnson
- WHO Global Initiative for Emergency and Essential Surgical Care, Geneva, Switzerland
| | | | | | - Asuman Kisembo
- African Agency for Integrated Development, Kampala, Uganda
| | - Abbey Kocan
- Kupona Foundation, Saratoga Springs, NY, USA
| | - Sanjay Krishnaswami
- World Journal of Surgery, Portland, OR, USA
- Oregon Health and Science University, Portland, OR, USA
| | - Robert Lane
- International Federation of Surgical Colleges, Bogis-Bossey, Switzerland
| | - Asad Latif
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Barbara Levy
- American College of Obstetricians and Gynecologists, Washington, DC, USA
| | - Dimitrios Linos
- Institute of Preventive Medicine, Environmental and Occupational Health - Prolepsis, Attica, Greece
- National and Kapodistrian University, Athens Medical School, Athens, Greece
| | | | | | - Declan Magee
- Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Emmanuel Makasa
- Permanent Mission of the Republic of Zambia to the United Nations, Geneva, Switzerland
| | | | | | - Kelly McQueen
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - William M Novick
- University of Tennessee Health Science Center, Memphis, TN, USA
- William Novick Global Cardiac Alliance, Memphis, TN, USA
| | - Stephen Ogendo
- The College of Surgeons of East, Central and Southern Africa, Arusha, Tanzania
| | | | | | - Neil Parsan
- Organization of American States, Washington, DC, USA
| | | | - Raymond Price
- University of Utah Center for Global Surgery, Salt Lake City, UT, USA
| | - Shahnawaz Rasheed
- The Institute of Global Health Innovation, Imperial College London, London, UK
| | | | | | - Steven M Roser
- International Association of Oral and Maxillofacial Surgeons, Chicago, IL, USA
| | - Jackie Rowles
- International Federation of Nurse Anesthetists, Sursee, Switzerland
| | | | - John Sampson
- Global Surgery Initiative, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - David Sigalet
- World Federation of Associations of Pediatric Surgeons, Geneva, Switzerland
| | | | | | - Mamta Swaroop
- Association for Academic Surgery, Los Angeles, CA, USA
| | - John Tarpley
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | | | | | | | | | - Anne Zeidan
- 2nd Chance Association Reconstructive Surgery for Life Reconstruction, Meyrin, Switzerland
| | | | - Brendan Allen
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Ave, Box 63, Chicago, IL, 60611, USA.
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, New York, NY, USA.
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Gajewski J, Bijlmakers L, Brugha R. Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa. Int J Health Policy Manag 2018; 7:481-484. [PMID: 29935124 PMCID: PMC6015509 DOI: 10.15171/ijhpm.2018.27] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/14/2018] [Indexed: 12/20/2022] Open
Abstract
Surgery has the potential to address one of the largest, neglected burdens of disease in low- and middle-income countries (LMICs), especially in sub-Saharan Africa (SSA). The Lancet Commission on Global Surgery (LCoGS) has provided a blueprint for a systems approach to making safe emergency and elective surgery accessible and affordable and has started to enable African governments to develop national surgical plans. This editorial outlines an important gap, which is the need for surgical systems research, especially at district hospitals which are the first point of surgical care for rural communities, to inform the implementation of country plans. Using the Lancet Commission as a starting point and illustrated by two European Union (EU) funded research projects, we point to the need for implementation research to develop and evaluate contextualised strategies. As illustrated by the case study of Zambia, coordination by global and external stakeholders can enable governments to lead national scale-up of essential surgery, supported by national partners including surgical specialist associations.
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Affiliation(s)
| | - Leon Bijlmakers
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ruairí Brugha
- Royal College of Surgeons in Ireland, Dublin 2, Ireland
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305
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Fagan JJ. Workforce Considerations, Training, and Diseases in Africa. Otolaryngol Clin North Am 2018; 51:643-649. [DOI: 10.1016/j.otc.2018.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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306
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Hutch A, Bekele A, O'Flynn E, Ndonga A, Tierney S, Fualal J, Samkange C, Erzingatsian K. The Brain Drain Myth: Retention of Specialist Surgical Graduates in East, Central and Southern Africa, 1974-2013. World J Surg 2018; 41:3046-3053. [PMID: 29038829 DOI: 10.1007/s00268-017-4307-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study assesses the retention of specialist surgical graduates from training programmes across eight countries in East, Central and Southern Africa from 1974 to 2013. It addresses the gap in existing data by analysing retention rates of surgical graduates by comparing graduating institution to current location. Data were assessed by country, region, specialty and gender with a view to informing national and regional healthcare and education strategies. METHODS Twenty-five institutions train surgeons in the ten countries covered by the College of Surgeons of East, Central and Southern Africa (COSECSA)-24 Universities and the College itself. These institutions were requested in November 2014 to supply details of graduates from their postgraduate surgical training programmes. Complete graduate lists were returned by the College and 14 universities by March 2016. These surgical graduates were compared against the database of current practising surgeons in the region held by COSECSA. Data were cross-checked against medical council registers, surgical society records, and with members and fellows of COSECSA. RESULTS Data were incomplete for 126 surgical graduates. Of the remaining 1038 surgical graduates, 85.1% were retained in the country they trained in, while 88.3% were retained within the COSECSA region. Ninety-three per cent (93.4%) were retained within Africa. Of the eight countries, Malawi had the highest retention rate with 100% of surgical graduates remaining in country, while Zimbabwe had the lowest rate with 65.5% remaining. CONCLUSION High surgical graduate retention rates across the region indicate that the expansion of national surgical training initiatives is an effective solution to addressing the surgical workforce shortage in East, Central and Southern Africa and counters long-held arguments regarding brain drain in this region.
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Affiliation(s)
- Avril Hutch
- Department of Surgical Affairs, Royal College of Surgeons in Ireland/College of Surgeons of East, Central and Southern Africa Collaboration Programme (RCSI/COSECSA), 121 St Stephen's Green, Dublin 2, Ireland.
| | - Abebe Bekele
- College of Surgeons of East, Central and Southern Africa (COSECSA), Njiro Road, Arusha, Tanzania.,Department of Surgery, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eric O'Flynn
- Department of Surgical Affairs, Royal College of Surgeons in Ireland/College of Surgeons of East, Central and Southern Africa Collaboration Programme (RCSI/COSECSA), 121 St Stephen's Green, Dublin 2, Ireland
| | - Andrew Ndonga
- College of Surgeons of East, Central and Southern Africa (COSECSA), Njiro Road, Arusha, Tanzania.,Department of Surgery, Mater Hospital Kenya, Along Dunga Road, South B, Nairobi, Kenya
| | - Sean Tierney
- Department of Surgical Affairs, Royal College of Surgeons in Ireland (RCSI), 121 St Stephen's Green, Dublin 2, Ireland
| | - Jane Fualal
- College of Surgeons of East, Central and Southern Africa (COSECSA), Njiro Road, Arusha, Tanzania.,Department of Surgery, Mulago Hospital, 256, Kampala, Uganda
| | - Christopher Samkange
- College of Surgeons of East, Central and Southern Africa (COSECSA), Njiro Road, Arusha, Tanzania.,College of Health Sciences, University of Zimbabwe, Mazowe Street Campus, Avondale, P.O. Box A178, Harare, Zimbabwe
| | - Krikor Erzingatsian
- College of Surgeons of East, Central and Southern Africa (COSECSA), Njiro Road, Arusha, Tanzania.,School of Medicine, University of Zambia, Nationalist Road, University Teaching Hospital, P.O. Box 50110, Lusaka, Zambia
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307
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Mulwafu W, Fagan JJ, Mukara KB, Ibekwe TS. ENT Outreach in Africa: Rules of Engagement. OTO Open 2018; 2:2473974X18777220. [PMID: 30480217 PMCID: PMC6239148 DOI: 10.1177/2473974x18777220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/25/2018] [Indexed: 11/23/2022] Open
Abstract
To address inequality of access to ear, nose, and throat (ENT) care, there must be significant and sustained investment in education and training of surgeons, audiologists, speech therapists, clinical officers, anesthetists, and specialized nurses engaged in ENT in sub-Saharan Africa and other developing nations. Outreach by ENT surgeons from developed countries is essential if we are to address the critical lack of access to ENT care in SSA. However, it should be based on mutual respect, shared values, aspirations, a desire to create a durable and sustainable impact, and internationally accepted best practice. In this article, we propose rules of engagement for outreach projects in SSA and other developing countries to optimize their contributions by making them useful, sustainable, productive, and developmental. These proposed rules of engagement are based on our personal experiences and observations—good and bad—of outreach activities in our countries.
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Affiliation(s)
| | - Johannes J Fagan
- Division of Otorhinolaryngology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Titus S Ibekwe
- Department of Otorhinolaryngology, University of Abuja and University of Abuja Teaching Hospital, Abuja, Nigeria
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308
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Hung YC, Bababekov YJ, Stapleton SM, Mukhopadhyay S, Huang SL, Briggs SM, Chang DC. Reducing road traffic deaths: where should we focus global health initiatives? J Surg Res 2018; 229:337-344. [PMID: 29937011 DOI: 10.1016/j.jss.2018.04.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/26/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Current global surgery initiatives focus on increasing surgical workforce; however, it is unclear whether this approach would be helpful globally, as patients in low-resource countries may not be able to reach hospitals in a timely fashion without formal Emergency Medical Services (EMS). We hypothesize that increased surgical workforce correlates with decreased road traffic deaths (RTDs) only in countries with EMS. METHODS Estimated RTDs were obtained from the Global Status Report on Road Safety 2013, which estimated the RTD rate in 2010 (RTD 2010). The classification of EMS was defined by the Global Status Report on Road Safety 2009. The density of surgeons, anesthesiologists, and obstetricians (SAO density) and 2010 income classification were accessed from the World Bank. Multivariable regression analysis was performed adjusting for different countries, income levels, and trauma system characteristics. Sensitivity analysis was performed. RESULTS One-fourth of the countries reported not having formal EMS (n = 41, 23.4%). On adjusted analysis, SAO density was not associated with changes in RTD 2010 in countries without EMS (n = 25, P = 0.50). However, in countries with EMS, each increase in SAO density per 100,000 population decreased RTDs by 0.079 per 100,000 population (n = 97, P <0.001). Income was the only other factor resulting in reduced mortality rates (P = 0.004). Sensitivity analysis confirmed these findings. CONCLUSIONS Increases in surgical workforce reduce RTDs only when EMS exist. Surgical workforce and EMS must be seen as part of the same system and developed together to maximize their effect in reducing RTDs. Global health initiatives should be tailored to individual country need. LEVEL OF EVIDENCE Level II (Ecological study).
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts; National Yang Ming University, School of Public Health, Taipei, Taiwan.
| | - Yanik J Bababekov
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sahael M Stapleton
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts; University of Connecticut Health Center, Farmington, Connecticut
| | - Song-Lih Huang
- National Yang Ming University, School of Public Health, Taipei, Taiwan
| | - Susan M Briggs
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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309
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Li Z, Yang J, Wu Y, Pan Z, He X, Li B, Zhang L. Challenges for the surgical capacity building of township hospitals among the Central China: a retrospective study. Int J Equity Health 2018; 17:55. [PMID: 29720175 PMCID: PMC5932883 DOI: 10.1186/s12939-018-0766-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/16/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND China's rapid transition in healthcare service system has posed considerable challenges for the primary care system. Little is known regarding the capacity of township hospitals (THs) to deliver surgical care in rural China with over 600 million lives. We aimed to ascertain its current performance, barriers, and summary lessons for its re-building in central China. METHODS This study was conducted in four counties from two provinces in central China. The New Rural Cooperative Medical System (NRCMS) claim data from two counties in Hubei province was analyzed to describe the current situation of surgical care provision. Based on previous studies, self-administered questionnaire was established to collect key indicators from 60 THs from 2011 to 2015, and social and economic statuses of the sampling townships were collected from the local statistical yearbook. Semi-structured interviews were conducted among seven key administrators in the THs that did not provide appendectomy care in 2015. Determinants of appendectomy care provision were examined using a negative binominal regression model. RESULTS First, with the rapid increase in inpatient services provided by the THs, their proportion of surgical service provision has been nibbled by out-of-county facilities. Second, although DY achieved a stable performance, the total amount of appendectomy provided by the 60 THs decreased to 589 in 2015 from 1389 in 2011. Moreover, their proportion reduced to 26.77% in 2015 from 41.84% in 2012. Third, an increasing number of THs did not provide appendectomy in 2015, with the shortage of anesthesiologists and equipment as the most mentioned reasons (46.43%). Estimation results from the negative binomial model indicated that the annual average per capita disposable income and tightly integrated delivery networks (IDNs) negatively affected the amount of appendectomy provided by THs. By contrast, the probability of appendectomy provision by THs was increased by performance-related payment (PRP). Out-of-pocket (OOP) cost gap of appendectomy services between the two different levels of facilities, payment method, and the size of THs presented no observable improvement to the likelihood of appendectomy care in THs. CONCLUSION The county-level health system did not effectively respond to the continuously increasing surgical care need. The surgical capacity of THs declined with the surgical patterns' simplistic and quantity reduction. Deficits and critical challenges for surgical capacity building in central China were identified, including shortage of human resources and medical equipment and increasing income. Moreover, tight IDNs do not temporarily achieve capacity building. Therefore, the reimbursement rate should be further ranged, and physicians should be incentivized appropriately. The administrators, policy makers, and medical staff of THs should be aware of these findings owing to the potential benefits for the capacity building of the rural healthcare system.
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Affiliation(s)
- Zhong Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Jian Yang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
- Department of Medical Affairs, Guangdong General Hospital, Guangzhou, 510080 Guangdong China
| | - Yue Wu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Zijin Pan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Xiaoqun He
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Boyang Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
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Dewan MC, Rattani A, Baticulon RE, Faruque S, Johnson WD, Dempsey RJ, Haglund MM, Alkire BC, Park KB, Warf BC, Shrime MG. Operative and consultative proportions of neurosurgical disease worldwide: estimation from the surgeon perspective. J Neurosurg 2018:1-9. [PMID: 29749918 DOI: 10.3171/2017.10.jns17347] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 10/18/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe global magnitude of neurosurgical disease is unknown. The authors sought to estimate the surgical and consultative proportion of diseases commonly encountered by neurosurgeons, as well as surgeon case volume and perceived workload.METHODSAn electronic survey was sent to 193 neurosurgeons previously identified via a global surgeon mapping initiative. The survey consisted of three sections aimed at quantifying surgical incidence of neurological disease, consultation incidence, and surgeon demographic data. Surgeons were asked to estimate the proportion of 11 neurological disorders that, in an ideal world, would indicate either neurosurgical operation or neurosurgical consultation. Respondent surgeons indicated their confidence level in each estimate. Demographic and surgical practice characteristics-including case volume and perceived workload-were also captured.RESULTSEighty-five neurosurgeons from 57 countries, representing all WHO regions and World Bank income levels, completed the survey. Neurological conditions estimated to warrant neurosurgical consultation with the highest frequency were brain tumors (96%), spinal tumors (95%), hydrocephalus (94%), and neural tube defects (92%), whereas stroke (54%), central nervous system infection (58%), and epilepsy (40%) carried the lowest frequency. Similarly, surgery was deemed necessary for an average of 88% cases of hydrocephalus, 82% of spinal tumors and neural tube defects, and 78% of brain tumors. Degenerative spine disease (42%), stroke (31%), and epilepsy (24%) were found to warrant surgical intervention less frequently. Confidence levels were consistently high among respondents (lower quartile > 70/100 for 90% of questions), and estimates did not vary significantly across WHO regions or among income levels. Surgeons reported performing a mean of 245 cases annually (median 190). On a 100-point scale indicating a surgeon's perceived workload (0-not busy, 100-overworked), respondents selected a mean workload of 75 (median 79).CONCLUSIONSWith a high level of confidence and strong concordance, neurosurgeons estimated that the vast majority of patients with central nervous system tumors, hydrocephalus, or neural tube defects mandate neurosurgical involvement. A significant proportion of other common neurological diseases, such as traumatic brain and spinal injury, vascular anomalies, and degenerative spine disease, demand the attention of a neurosurgeon-whether via operative intervention or expert counsel. These estimates facilitate measurement of the expected annual volume of neurosurgical disease globally.
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Affiliation(s)
- Michael C Dewan
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
| | - Abbas Rattani
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,3Meharry Medical College, School of Medicine, Nashville, Tennessee
| | - Ronnie E Baticulon
- 4University of the Philippines College of Medicine-Philippine General Hospital, Manila, Republic of the Philippines
| | - Serena Faruque
- 5Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Walter D Johnson
- 6Emergency & Essential Surgical Care Programme Lead, World Health Organization, Geneva, Switzerland
| | - Robert J Dempsey
- 7Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
| | - Michael M Haglund
- 8Division of Global Neurosurgery and Neurology, Department of Neurosurgery and Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Blake C Alkire
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,9Office of Global Surgery and Health
| | - Kee B Park
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine
| | - Benjamin C Warf
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,10Department of Neurological Surgery, Boston Children's Hospital, Harvard Medical School
| | - Mark G Shrime
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine.,11Department of Otolaryngology, Massachusetts Eye and Ear Infirmary
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311
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Graf J, Cook M, Schecter S, Deveney K, Hofmann P, Grey D, Akoko L, Mwanga A, Salum K, Schecter W. Coalition for Global Clinical Surgical Education: The Alliance for Global Clinical Training. JOURNAL OF SURGICAL EDUCATION 2018; 75:688-696. [PMID: 28867584 DOI: 10.1016/j.jsurg.2017.08.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/19/2017] [Accepted: 08/15/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Assessment of the effect of the collaborative relationship between the high-income country (HIC) surgical educators of the Alliance for Global Clinical Training (Alliance) and the low-income country surgical educators at the Muhimbili University of Health and Allied Sciences/Muhimbili National Hospital (MUHAS/MNH), Dar Es Salaam, Tanzania, on the clinical global surgery training of the HIC surgical residents participating in the program. DESIGN A retrospective qualitative analysis of Alliance volunteer HIC faculty and residents' reports, volunteer case lists and the reports of Alliance academic contributions to MUHAS/MNH from 2012 to 2017. In addition, a survey was circulated in late 2016 to all the residents who participated in the program since its inception. RESULTS Twelve HIC surgical educators provided rotating 1-month teaching coverage at MUHAS/MNH between academic years 2012 and 2017 for a total of 21 months. During the same time period 11 HIC residents accompanied the HIC faculty for 1-month rotations. HIC surgery residents joined the MUHAS/MNH Department of Surgery, made significant teaching contributions, performed a wide spectrum of "open procedures" including hand-sewn intestinal anastomoses. Most had had either no or limited previous exposure to hand-sewn anastomoses. All of the residents commented that this was a maturing and challenging clinical rotation due to the complexity of the cases, the limited resources available and the ethical and emotional challenges of dealing with preventable complications and death in a resource constrained environment. CONCLUSIONS The Alliance provides an effective clinical global surgery rotation at MUHAS/MNH for HIC Surgery Departments wishing to provide such an opportunity for their residents and faculty.
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Affiliation(s)
- Jahanara Graf
- Department of Surgery, University of California/East Bay, Oakland, California
| | - Mackenzie Cook
- Department of Surgery, Oregon Health Science University, Portland, Oregon; The Alliance for Global Clinical Training, San Francisco, California
| | - Samuel Schecter
- Santa Rosa Department of Surgery, Kaiser Permanente Medical Center, Santa Rosa, California
| | - Karen Deveney
- Department of Surgery, Oregon Health Science University, Portland, Oregon; The Alliance for Global Clinical Training, San Francisco, California
| | - Paul Hofmann
- The Alliance for Global Clinical Training, San Francisco, California
| | - Douglas Grey
- The Alliance for Global Clinical Training, San Francisco, California
| | - Larry Akoko
- Muhimbili University of Health and Allied Sciences, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Ali Mwanga
- Muhimbili University of Health and Allied Sciences, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Kitembo Salum
- Muhimbili University of Health and Allied Sciences, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - William Schecter
- The Alliance for Global Clinical Training, San Francisco, California; Department of Surgery, University of California, San Francisco, San Francisco, California.
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312
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Premkumar A, Ying X, Mack Hardaker W, Massawe HH, Mshahaba DJ, Mandari F, Pallangyo A, Temu R, Masenga G, Spiegel DA, Sheth NP. Access to Orthopaedic Surgical Care in Northern Tanzania: A Modelling Study. World J Surg 2018; 42:3081-3088. [DOI: 10.1007/s00268-018-4630-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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313
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Efficacy of Facilitated Capacity Building in Providing Cleft Lip and Palate Care in Low- and Middle-Income Countries. J Craniofac Surg 2018; 28:1737-1741. [PMID: 28872505 DOI: 10.1097/scs.0000000000003884] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Providing surgical repair for congenital anomalies such as cleft lip and palate (CLP) can be challenging in low- and middle-income countries. One nonprofit organization seeks to address this need through a partnership model. This model provides long-term aid on multiple levels: surgeon and healthcare provider education, community outreach, and funding. The authors examined the effectiveness of this partnership model in providing CLP care and increasing cleft care capacity over time. This organization maintains data on each partner and procedure and collected data on hospital and patient characteristics through voluntary partner surveys from 2010 to 2014. Effectiveness of care provision outcomes included number of surgeries/partner hospital and patient demographics. Cleft surgical system strengthening was measured by the complexity of repair, waitlist length, and patient follow-up. From 2001 to 2014, the number of procedures/hospital/year grew from 15 to 109, and frequency of alveolar bone grafts increased from 1% to 3.4%. In addition, 97.9% of partners reported that half to most patients come from rural areas. Waitlists decreased, with 9.2% of partners reporting a waitlist of ≥50 in 2011 versus 2.7% in 2014 (P < 0.001). Patient follow-up also improved: 35% of partners in 2011 estimated a follow-up rate of ≥75%, compared with 51% of partners in 2014 (P < 0.001). The increased number of procedures/hospital/year supports the partnership model's effectiveness in providing CLP care. In addition, data supports cleft surgical system strengthening-more repairs use alveolar bone grafts, waitlists decreased, and follow-up improved. These findings demonstrate that the partnership model may be effective in providing cleft care and increasing cleft surgical capacity.
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314
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Dare AJ, Onajin-Obembe B, Makasa EM. A snapshot of surgical outcomes and needs in Africa. Lancet 2018; 391:1553-1554. [PMID: 29306588 DOI: 10.1016/s0140-6736(18)30002-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/13/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Anna J Dare
- Department of Surgery and Centre for Global Heath Research, University of Toronto, ON, M5B 1T8, Canada.
| | | | - Emmanuel M Makasa
- Ministry of Foreign Affairs of Zambia, Zambia; Department of Surgery, University of Witwatersrand, Johannesburg, South Africa
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315
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Albutt K, Yorlets RR, Punchak M, Kayima P, Namanya DB, Anderson GA, Shrime MG. You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda. PLoS One 2018; 13:e0195986. [PMID: 29664956 PMCID: PMC5903624 DOI: 10.1371/journal.pone.0195986] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/03/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception. METHODS From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis. RESULTS The Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need. CONCLUSION Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda's surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.
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Affiliation(s)
- Katherine Albutt
- Program in Global Surgery and Social Change (PGSSC), Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States of America
| | - Rachel R. Yorlets
- Program in Global Surgery and Social Change (PGSSC), Harvard Medical School, Boston, Massachusetts, United States of America
| | - Maria Punchak
- Program in Global Surgery and Social Change (PGSSC), Harvard Medical School, Boston, Massachusetts, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Peter Kayima
- Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Didacus B. Namanya
- Ministry of Health (MOH), Kampala, Uganda
- Uganda Martyrs University (UMU), Nkozi, Uganda
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change (PGSSC), Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States of America
| | - Mark G. Shrime
- Program in Global Surgery and Social Change (PGSSC), Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary (MEEI), Boston, Massachusetts, United States of America
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316
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Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study. Surg Endosc 2018. [PMID: 29623470 PMCID: PMC6061087 DOI: 10.1007/s00464-018-6064-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION NCT02179112.
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317
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O'Hara NN, Mugarura R, Potter J, Stephens T, Rehavi MM, Francois P, Blachut PA, O'Brien PJ, Mezei A, Beyeza T, Slobogean GP. The Socioeconomic Implications of Isolated Tibial and Femoral Fractures from Road Traffic Injuries in Uganda. J Bone Joint Surg Am 2018; 100:e43. [PMID: 29613934 DOI: 10.2106/jbjs.17.00439] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to determine the socioeconomic implications of isolated tibial and femoral fractures caused by road traffic injuries in Uganda. METHODS This prospective longitudinal study included adult patients who were admitted to Uganda's national referral hospital with an isolated tibial or femoral fracture. The primary outcome was the time to recovery following injury. We assessed recovery using 4 domains: income, employment status, health-related quality of life (HRQoL) recovery, and school attendance of the patients' dependents. RESULTS The majority of the study participants (83%) were employed, and they were the main income earner for their household (74.0%) at the time of injury, earning a mean annual income of 2,375 U.S. dollars (USD). All of the patients had been admitted with the intention of surgical treatment; however, because of resource constraints, only 56% received operative treatment. By 2 years postinjury, only 63% of the participants had returned to work, and 34% had returned to their previous income level. Overall, the mean monthly income was 62% less than preinjury earnings, and participants had accumulated 1,069 USD in debt since the injury; 41% of the participants had regained HRQoL scores near their baseline, and 62% of school-aged dependents, enrolled at the time of injury, were in school at 2 years postinjury. CONCLUSIONS At 2 years postinjury, only 12% of our cohort of Ugandan patients who had sustained an isolated tibial or femoral fracture from a road traffic injury had recovered both economically and physically. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rodney Mugarura
- Department of Orthopaedics, Makerere University, Kampala, Uganda
| | - Jeffrey Potter
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Trina Stephens
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - M Marit Rehavi
- Vancouver School of Economics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Francois
- Vancouver School of Economics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Piotr A Blachut
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter J O'Brien
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Mezei
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tito Beyeza
- Department of Orthopaedics, Makerere University, Kampala, Uganda
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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318
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Chan DXH, Sim YE, Chan YH, Poopalalingam R, Abdullah HR. Development of the Combined Assessment of Risk Encountered in Surgery (CARES) surgical risk calculator for prediction of postsurgical mortality and need for intensive care unit admission risk: a single-center retrospective study. BMJ Open 2018; 8:e019427. [PMID: 29574442 PMCID: PMC5875658 DOI: 10.1136/bmjopen-2017-019427] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/03/2018] [Accepted: 01/31/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Accurate surgical risk prediction is paramount in clinical shared decision making. Existing risk calculators have limited value in local practice due to lack of validation, complexities and inclusion of non-routine variables. OBJECTIVE We aim to develop a simple, locally derived and validated surgical risk calculator predicting 30-day postsurgical mortality and need for intensive care unit (ICU) stay (>24 hours) based on routinely collected preoperative variables. We postulate that accuracy of a clinical history-based scoring tool could be improved by including readily available investigations, such as haemoglobin level and red cell distribution width. METHODOLOGY Electronic medical records of 90 785 patients, who underwent non-cardiac and non-neuro surgery between 1 January 2012 and 31 October 2016 in Singapore General Hospital, were retrospectively analysed. Patient demographics, comorbidities, laboratory results, surgical priority and surgical risk were collected. Outcome measures were death within 30 days after surgery and ICU admission. After excluding patients with missing data, the final data set consisted of 79 914 cases, which was divided randomly into derivation (70%) and validation cohort (30%). Multivariable logistic regression analysis was used to construct a single model predicting both outcomes using Odds Ratio (OR) of the risk variables. The ORs were then assigned ranks, which were subsequently used to construct the calculator. RESULTS Observed mortality was 0.6%. The Combined Assessment of Risk Encountered in Surgery (CARES) surgical risk calculator, consisting of nine variables, was constructed. The area under the receiver operating curve (AUROC) in the derivation and validation cohorts for mortality were 0.934 (0.917-0.950) and 0.934 (0.912-0.956), respectively, while the AUROC for ICU admission was 0.863 (0.848-0.878) and 0.837 (0.808-0.868), respectively. CARES also performed better than the American Society of Anaesthesiologists-Physical Status classification in terms of AUROC comparison. CONCLUSION The development of the CARES surgical risk calculator allows for a simplified yet accurate prediction of both postoperative mortality and need for ICU admission after surgery.
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Affiliation(s)
| | - Yilin Eileen Sim
- Division of Anaesthesiology, Singapore General Hospital, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Hairil Rizal Abdullah
- Division of Anaesthesiology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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Abstract
Background District hospitals in sub-Saharan Africa are in need of investment if countries are going to progress towards universal health coverage, and meet the sustainable development goals and the Lancet Commission on Global Surgery time-bound targets for 2030. Previous studies have suggested that government hospitals are likely to be highly cost-effective and therefore worthy of investment. Methods A retrospective analysis of the inpatient logbooks for two government district hospitals in two sub-Saharan African hospitals was performed. Data were extracted and DALYs were calculated based on the diagnosis and procedures undertaken. Estimated costs were obtained based on the patient receiving ideal treatment for their condition rather than actual treatment received. Results Total cost per DALY averted was 26 (range 17–66) for Thyolo District Hospital in Malawi and 363 (range 187–881) for Bo District Hospital in Sierra Leone. Conclusion This is the first published paper to support the hypothesis that government district hospitals are very cost-effective. The results are within the same range of the US$32.78–223 per DALY averted published for non-governmental hospitals.
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320
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Developing Process Maps as a Tool for a Surgical Infection Prevention Quality Improvement Initiative in Resource-Constrained Settings. J Am Coll Surg 2018; 226:1103-1116.e3. [PMID: 29574175 DOI: 10.1016/j.jamcollsurg.2018.03.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/01/2018] [Accepted: 03/01/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical infections cause substantial morbidity and mortality in low-and middle-income countries (LMICs). To improve adherence to critical perioperative infection prevention standards, we developed Clean Cut, a checklist-based quality improvement program to improve compliance with best practices. We hypothesized that process mapping infection prevention activities can help clinicians identify strategies for improving surgical safety. STUDY DESIGN We introduced Clean Cut at a tertiary hospital in Ethiopia. Infection prevention standards included skin antisepsis, ensuring a sterile field, instrument decontamination/sterilization, prophylactic antibiotic administration, routine swab/gauze counting, and use of a surgical safety checklist. Processes were mapped by a visiting surgical fellow and local operating theater staff to facilitate the development of contextually relevant solutions; processes were reassessed for improvements. RESULTS Process mapping helped identify barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. Compliance with most processes improved significantly following organizational changes to align tasks with specific process goals. CONCLUSIONS Enumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. Simplifying these process maps into an adaptable tool could be a powerful strategy for improving safe surgery delivery in LMICs.
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321
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Grimes CE, Quaife M, Kamara TB, Lavy CBD, Leather AJM, Bolkan HA. Macroeconomic costs of the unmet burden of surgical disease in Sierra Leone: a retrospective economic analysis. BMJ Open 2018; 8:e017824. [PMID: 29540407 PMCID: PMC5857688 DOI: 10.1136/bmjopen-2017-017824] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The Lancet Commission on Global Surgery estimated that low/middle-income countries will lose an estimated cumulative loss of US$12.3 trillion from gross domestic product (GDP) due to the unmet burden of surgical disease. However, no country-specific data currently exist. We aimed to estimate the costs to the Sierra Leone economy from death and disability which may have been averted by surgical care. DESIGN We used estimates of total, met and unmet need from two main sources-a cluster randomised, cross-sectional, countrywide survey and a retrospective, nationwide study on surgery in Sierra Leone. We calculated estimated disability-adjusted life years from morbidity and mortality for the estimated unmet burden and modelled the likely economic impact using three different methods-gross national income per capita, lifetime earnings foregone and value of a statistical life. RESULTS In 2012, estimated, discounted lifetime losses to the Sierra Leone economy from the unmet burden of surgical disease was between US$1.1 and US$3.8 billion, depending on the economic method used. These lifetime losses equate to between 23% and 100% of the annual GDP for Sierra Leone. 80% of economic losses were due to mortality. The incremental losses averted by scale up of surgical provision to the Lancet Commission target of 80% were calculated to be between US$360 million and US$2.9 billion. CONCLUSION There is a large economic loss from the unmet need for surgical care in Sierra Leone. There is an immediate need for massive investment to counteract ongoing economic losses.
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Affiliation(s)
- Caris E Grimes
- King's Centre for Global Health and Health Partnerships, King's College London and King's Health Partners, Weston Education Centre, London, UK
- Colorectal Surgery, Medway NHS Foundation Trust, Gillingham, United Kingdom
| | - Matthew Quaife
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Thaim B Kamara
- Department of Surgery, College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | | | - Andy J M Leather
- King's Centre for Global Health and Health Partnerships, King's College London and King's Health Partners, Weston Education Centre, London, UK
| | - Håkon A Bolkan
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim, Norway
- CapaCare, Trondheim, Norway
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322
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Burgos CM, Bolkan HA, Bash-Taqi D, Hagander L, von Schreeb J. The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap. World J Surg 2018; 42:652-665. [PMID: 28932917 PMCID: PMC5801385 DOI: 10.1007/s00268-017-4244-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met. AIM To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone. METHODS We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair. RESULTS In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0-15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0-15 years of age. The estimated unmet need for inguinal hernia repair was 88%. CONCLUSIONS The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.
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Affiliation(s)
| | - Håkon Angell Bolkan
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Lars Hagander
- Surgery and Public Health, Pediatric Surgery, Department of Clinical Sciences in Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johan von Schreeb
- Global Health-Health System and Policy Department of Public Health Sciences, Centre for Research on Health Care in Disasters, Stockholm, Sweden
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323
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Stephens T, Mezei A, O'Hara NN, Potter J, Mugarura R, Blachut PA, O'Brien PJ, Beyeza T, Slobogean GP. When Surgical Resources are Severely Constrained, Who Receives Care? Determinants of Access to Orthopaedic Trauma Surgery in Uganda. World J Surg 2018; 41:1415-1419. [PMID: 28097413 DOI: 10.1007/s00268-017-3874-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In low- and middle-income countries, the volume of traumatic injuries requiring orthopaedic intervention routinely exceeds the capacity of available surgical resources. The objective of this study was to identify predictors of surgical care for lower extremity fracture patients at a high-demand, resource-limited public hospital in Uganda. METHODS Skeletally mature patients admitted with the intention of definitive surgical treatment of an isolated tibia or femur fractures to the national referral hospital in Uganda were recruited to participate in this study. Demographic, socioeconomic, and clinical data were collected through participant interviews at the time of injury and 6 months post-injury. Social capital (use of social networks to gain access to surgery), financial leveraging, and ethnicity were also included as variables in this analysis. A probit estimation model was used to identify independent and interactive predictors of surgical treatment. RESULTS Of the 64 patients included in the final analysis, the majority of participants were male (83%), with a mean age of 40.6, and were injured in a motor vehicle accident (77%). Due to resource constraints, only 58% of participants received surgical care. The use of social capital and femur fractures were identified as significant predictors of receiving surgical treatment, with social capital emerging as the strongest predictor of access to surgery (p < 0.05). CONCLUSION Limited infrastructure, trained personnel, and surgical supplies rations access to surgical care. In this environment, participants with advantageous social connections were able to self-advocate for surgery where demand for these services greatly exceeded available resources.
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Affiliation(s)
- Trina Stephens
- School of Medicine, Queen's University, 99 University Ave, Kingston, ON, K7L 3N6, Canada
| | - Alexander Mezei
- Faculty of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, 110 South Paca St., Baltimore, MD, 21201, USA
| | - Jeffrey Potter
- Division of Orthopaedic Surgery, Queen's University, 76 Stuart St., Kingston, ON, L7L 2V7, Canada
| | - Rodney Mugarura
- Department of Orthopaedics, Makerere University, PO Box 7051, Kampala, Uganda
| | - Piotr A Blachut
- Department of Orthopaedics, University of British Columbia, 3114 - 910 West 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Peter J O'Brien
- Department of Orthopaedics, University of British Columbia, 3114 - 910 West 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Tito Beyeza
- Department of Orthopaedics, Makerere University, PO Box 7051, Kampala, Uganda
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, 110 South Paca St., Baltimore, MD, 21201, USA.
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Abstract
Surgery is a mainstay treatment for patients with solid tumours. However, despite surgical resection with a curative intent and numerous advances in the effectiveness of (neo)adjuvant therapies, metastatic disease remains common and carries a high risk of mortality. The biological perturbations that accompany the surgical stress response and the pharmacological effects of anaesthetic drugs, paradoxically, might also promote disease recurrence or the progression of metastatic disease. When cancer cells persist after surgery, either locally or at undiagnosed distant sites, neuroendocrine, immune, and metabolic pathways activated in response to surgery and/or anaesthesia might promote their survival and proliferation. A consequence of this effect is that minimal residual disease might then escape equilibrium and progress to metastatic disease. Herein, we discuss the most promising proposals for the refinement of perioperative care that might address these challenges. We outline the rationale and early evidence for the adaptation of anaesthetic techniques and the strategic use of anti-adrenergic, anti-inflammatory, and/or antithrombotic therapies. Many of these strategies are currently under evaluation in large-cohort trials and hold promise as affordable, readily available interventions that will improve the postoperative recurrence-free survival of patients with cancer.
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325
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Gibbs A, Bashford T, Wilson IH. What is the real oximeter gap? Anaesthesia 2017; 72:1565-1567. [DOI: 10.1111/anae.14146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A. Gibbs
- Milton Keynes University Hospital; Milton Keynes UK
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326
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Gajewski J, Dharamshi R, Strader M, Kachimba J, Borgstein E, Mwapasa G, Cheelo M, McCauley T, Bijlmakers L, Brugha R. Who accesses surgery at district level in sub-Saharan Africa? Evidence from Malawi and Zambia. Trop Med Int Health 2017; 22:1533-1541. [DOI: 10.1111/tmi.12989] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ruairi Brugha
- Royal College of Surgeons in Ireland; Dublin 2 Ireland
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327
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Carlson LC, Stewart BT, Hatcher KW, Kabetu C, VanderBurg R, Magee WP. A Model of the Unmet Need for Cleft Lip and Palate Surgery in Low- and Middle-Income Countries. World J Surg 2017; 40:2857-2867. [PMID: 27417108 DOI: 10.1007/s00268-016-3637-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is a significant unmet need for the cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) ; however, country-level estimates that can be used to inform local and international cleft care program strategies are lacking. METHODS Using data from Operation Smile surgical programs in twelve LMICs and country-level indicators from the World Health Organization and World Bank, we developed a model to estimate the proportion of individuals with CL/Ps older than respective surgery age targets for cleft lip and cleft palate surgery (1 and 2 years, respectively). After extrapolating this model to other LMICs with available indicator data, we combined these findings with estimates of CL/P prevalence among live births to estimate the total number of unrepaired CL/P cases in LMICs worldwide. RESULTS The models were constructed from a total of 887 cases of cleft palate and 576 cases of cleft lip across the twelve countries. From these, we estimated that there are 616,655 cases of unrepaired CL/P (95 % CI 564,893-678,503) in the 113 countries with available data for extrapolation. The rate of unrepaired CL/Ps ranged from 2.5 per 100,000 population in Romania to 28.5 per 100,000 in Cambodia, respectively (median rate 10.7 per 100,000 population). CONCLUSIONS Our model provides marked insight into the global surgical backlog due to cleft lip and palate. While the most populated LMICs have the largest number of unrepaired CL/Ps, low-income countries with relatively less healthcare infrastructure have exceptionally high rates (e.g., Cambodia, Afghanistan, and Nepal). These estimates can be used by local and international cleft care organizations to set program priorities, estimate resource requirements, and inform strategies to support cleft care.
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Affiliation(s)
- Lucas C Carlson
- Department of Emergency Medicine, Brigham and Women's Hospital, 10 Vining St., Neville House-2nd Floor, Boston, MA, 02115, USA.
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Charles Kabetu
- Department of Anesthesiology, Kenyatta National Hospital, Nairobi, Kenya
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328
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Barriers to Surgical Care and Health Outcomes: A Prospective Study on the Relation Between Wealth, Sex, and Postoperative Complications in the Republic of Congo. World J Surg 2017; 41:14-23. [PMID: 27473131 DOI: 10.1007/s00268-016-3676-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Approximately thirty percent of the global burden of disease is comprised of surgical conditions. However, five billion people lack access to surgery, with complex factors acting as barriers. We examined whether patient demographics predict barriers to care, and the relation between these factors and postoperative complications in a prospective cohort. METHODS Participants included people presenting to a global charity in Republic of Congo with a surgical condition between August 2013 and May 2014. The outcomes were self-reported barrier to care and postoperative complications documented by medical record. Logistic regression was used to adjust for covariates. RESULTS Of 1237 patients in our study, 1190 (96.2 %) experienced a barrier to care and 126 (10.2 %) experienced a postoperative complication. The most frequently reported barrier was cost (73 %), followed by lack of provider (8.2 %). Greater wealth was associated with decreased odds of cost as a barrier (OR 0.72 [0.57, 0.90]). Greater wealth (OR 1.52 [1.03, 2.25]) and rural home location (OR 3.35 [1.16, 9.62]) were associated with increased odds of no surgeon being available. Cost as a barrier (OR 2.82 [1.02, 7.77]), female sex (OR 3.45 [1.62, 7.33]), and lack of surgeon (OR 5.62 [1.68, 18.77]) were associated with increased odds of postoperative complication. Patient wealth was not associated with odds of postoperative complication. CONCLUSIONS Barriers to surgery were common in Republic of Congo. Patient wealth and home location may predict barriers to surgery. Addressing gender disparities, access to providers, and patient perception of barriers in addition to removal of barriers may help maximize patient health benefits.
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329
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White MC, Hamer M, Biddell J, Claus N, Randall K, Alcorn D, Parker G, Shrime MG. Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar. BMJ Glob Health 2017; 2:e000427. [PMID: 29071129 PMCID: PMC5640035 DOI: 10.1136/bmjgh-2017-000427] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/26/2017] [Accepted: 08/31/2017] [Indexed: 11/18/2022] Open
Abstract
Over two-thirds of the world’s population lack access to surgical care. Non-governmental organisation’s providing free surgeries may overcome financial barriers, but other barriers to care still exist. This analysis paper discusses two different case-finding strategies in Madagascar that aimed to increase the proportion of poor patients, women and those for whom multiple barriers to care exist. From October 2014 to June 2015, we used a centralised selection strategy, aiming to find 70% of patients from the port city, Toamasina, and 30% from the national capital and two remote cities. From August 2015 to June 2016, a decentralised strategy was used, aiming to find 30% of patients from Toamasina and 70% from 11 remote locations, including the capital. Demographic information and self-reported barriers to care were collected. Wealth quintile was calculated for each patient using a combination of participant responses to asset-related and demographic questions, and publicly available data. A total of 2971 patients were assessed. The change from centralised to decentralised selection resulted in significantly poorer patients undergoing surgery. All reported barriers to prior care, except for lack of transportation, were significantly more likely to be identified in the decentralised group. Patients who identified multiple barriers to prior surgical care were less likely to be from the richest quintile (p=0.037) and more likely to be in the decentralised group (p=0.046). Our country-specific analysis shows that decentralised patient selection strategies may be used to overcome barriers to care and allow patients in greatest need to access surgical care.
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Affiliation(s)
- Michelle C White
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK.,Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Mirjam Hamer
- Hospital Department, Mercy Ships, Toamasina, Madagascar.,Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasmin Biddell
- Hospital Department, Mercy Ships, Toamasina, Madagascar.,Department of Emergency Care, Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia
| | - Nathan Claus
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Kirsten Randall
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | | | - Gary Parker
- Hospital Department, Mercy Ships, Cotonou, Benin.,Hospital Department, Mercy Ships, Toamasina, Madagascar
| | - Mark G Shrime
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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330
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Shrime MG, Hamer M, Mukhopadhyay S, Kunz LM, Claus NH, Randall K, Jean-Baptiste JH, Maevatombo PH, Toh MPS, Biddell JR, Bos R, White M. Effect of removing the barrier of transportation costs on surgical utilisation in Guinea, Madagascar and the Republic of Congo. BMJ Glob Health 2017; 2:e000434. [PMID: 29225959 PMCID: PMC5717941 DOI: 10.1136/bmjgh-2017-000434] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/25/2017] [Accepted: 08/31/2017] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND 81 million people face impoverishment from surgical costs every year. The majority of this impoverishment is attributable to the non-medical costs of care-for transportation, for food and for lodging. Of these, transportation is the largest, but because it is not viewed as an actual medical cost, it is frequently unaddressed. This paper examines the effect on surgical utilisation of paying for transportation. METHODS A hierarchical logistic regression was performed on 2692 patients presenting for surgical care to a non-governmental organisation operating in the Republic of the Congo, Guinea and Madagascar. Controlling for distance from the hospital, age, gender, the need for air travel and time between appointments, the effect of payment for transportation on the surgical no-show rate was evaluated. RESULTS After adjustment for observed confounders, paying for transportation drops the surgical no-show rate by 45% (OR 0.55; 95% CI 0.40 to 0.77; p<0.001). Age, delay between appointments and the number of hours travelled for surgery also predict surgical no-show. For 28% of no-show patients, the cost of transportation from their homes to a nearby predetermined pick-up point remained a barrier, even when transportation from the pick-up point to the hospital was free. CONCLUSION Transportation costs are a significant barrier to surgical care in low-resource settings, and paying for it halves the no-show rate. This finding highlights that decreasing demand-side barriers to surgical care cannot be limited only to the removal of user fees.
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Affiliation(s)
- Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, USA
| | - Mirjam Hamer
- Paediatric Intensive Care Unit, University Medical Center, Utrecht, The Netherlands
- Mercy Ships, Lindale, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | - Michelle White
- Mercy Ships, Lindale, USA
- Anaesthesia, Great Ormond Street Hospital, London, UK
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331
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Implicating anaesthesia and the perioperative period in cancer recurrence and metastasis. Clin Exp Metastasis 2017; 35:347-358. [DOI: 10.1007/s10585-017-9862-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/08/2017] [Indexed: 12/25/2022]
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332
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Fallah PN, Bernstein M. Unifying a fragmented effort: a qualitative framework for improving international surgical teaching collaborations. Global Health 2017; 13:70. [PMID: 28882188 PMCID: PMC5588718 DOI: 10.1186/s12992-017-0296-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 08/30/2017] [Indexed: 01/02/2023] Open
Abstract
Background Access to adequate surgical care is limited globally, particularly in low- and middle-income countries (LMICs). To address this issue, surgeons are becoming increasingly involved in international surgical teaching collaborations (ISTCs), which include educational partnerships between surgical teams in high-income countries and those in LMICs. The purpose of this study is to determine a framework for unifying, systematizing, and improving the quality of ISTCs so that they can better address the global surgical need. Methods A convenience sample of 68 surgeons, anesthesiologists, physicians, residents, nurses, academics, and administrators from the U.S., Canada, and Norway was used for the study. Participants all had some involvement in ISTCs and came from multiple specialties and institutions. Qualitative methodology was used, and participants were interviewed using a pre-determined set of open-ended questions. Data was gathered over two months either in-person, over the phone, or on Skype. Data was evaluated using thematic content analysis. Results To organize and systematize ISTCs, participants reported a need for a centralized/systematized process with designated leaders, a universal data bank of current efforts/progress, communication amongst involved parties, full-time administrative staff, dedicated funds, a scholarly approach, increased use of technology, and more research on needs and outcomes. Conclusion By taking steps towards unifying and systematizing ISTCs, the quality of ISTCs can be improved. This could lead to an advancement in efforts to increase access to surgical care worldwide. Electronic supplementary material The online version of this article (10.1186/s12992-017-0296-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
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Hughes C, Campbell J, Mukhopadhyay S, Mccormack S, Silverman R, Lalikos J, Babigian A, Charles C. Remote Digital Preoperative Assessments for Cleft Lip and Palate May Improve Clinical and Economic Impact in Global Plastic Surgery. Cleft Palate Craniofac J 2017; 54:535-539. [DOI: 10.1597/15-305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objective Reconstructive surgical care can play a vital role in the resource-poor settings of low- and middle-income countries. Telemedicine platforms can improve the efficiency and effectiveness of surgical care. The purpose of this study is to determine whether remote digital video evaluations are reliable in the context of a short-term plastic surgical intervention. Setting The setting for this study was a district hospital located in Latacunga, Ecuador. Patients Participants were 27 consecutive patients who presented for operative repair of cleft lip and palate. Main Outcome Measures We calculated kappa coefficients for reliability between in-person and remote digital video assessments for the classification of cleft lip and palate between two separate craniofacial surgeons. We hypothesized that the technology would be a reliable method of preoperative assessment for cleft disease. Results Of the 27 (81.4%) participants, 22 received operative treatment for their cleft disorder. Mean age was 11.1 ± 8.3 years. Patients presented with a spectrum of disorders, including cleft lip (24 of 27, 88.9%), cleft palate (19 of 27, 70.4%), and alveolar cleft (19 of 27, 70.4%). We found a 95.7% agreement between observers for cleft lip with substantial reliability (κ = .78, P .01). There was an 82.6% agreement between observers for cleft palate, with a moderate interrater reliability (κ = .55, P = .01). We found only a 47.8% agreement between observers for alveolar cleft with a nonsignificant, weak kappa agreement (κ = .06, P .74). Conclusions Remote digital assessments are a reliable way to preoperatively diagnose cleft lip and palate in the context of short-term plastic surgical interventions in low- and middle-income countries. Future work will evaluate the potential for real-time, telemedicine assessments to reduce cost and improve clinical effectiveness in global plastic surgery.
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Affiliation(s)
| | - Jacob Campbell
- Department of Surgery, University of Connecticut, Farmington
| | | | - Susan Mccormack
- Senior Speech-Language Pathologist, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Silverman
- Division of Plastic and Reconstructive Surgery St. Elizabeth's Medical Center, Brighton
| | - Janice Lalikos
- Department of Plastic and Reconstructive Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Alan Babigian
- Department of Surgery, University of Connecticut, Farmington, Connecticut; Division of Plastic and Reconstructive Surgery, Hartford Hospital, Hartford, Connecticut; and Center for Global Health, Hartford Hospital, Hartford
| | - Castiglione Charles
- Department of Surgery, University of Connecticut, Farmington, Connecticut; Division of Plastic and Reconstructive Surgery, Hartford Hospital, Hartford, Connecticut; and Division of Plastic and Reconstructive Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
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Gajewski J, Mweemba C, Cheelo M, McCauley T, Kachimba J, Borgstein E, Bijlmakers L, Brugha R. Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia. HUMAN RESOURCES FOR HEALTH 2017; 15:53. [PMID: 28830528 PMCID: PMC5568330 DOI: 10.1186/s12960-017-0233-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/14/2017] [Indexed: 05/04/2023]
Abstract
BACKGROUND Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. MLs have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. METHODS This qualitative study aimed to describe the role, contributions and challenges surgically active MLs have experienced. Based on 43 interviewees, it includes the perspective of MLs, their district hospital colleagues-medical officers (MOs), nurses and managers; and surgeon-supervisors and national stakeholders. RESULTS In Zambia, MLs play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with MOs, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, MLs often face professional recognition problems and tensions around relationships with MOs that impact their ability to utilise their surgical skills. CONCLUSIONS The paper provides new evidence concerning the benefits of 'task shifting' and identifies challenges that need to be addressed if MLs are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use NPCs to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.
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Affiliation(s)
- Jakub Gajewski
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
| | - Carol Mweemba
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Mweene Cheelo
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Tracey McCauley
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
| | - John Kachimba
- Surgical Society of Zambia, Department of Surgery, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Eric Borgstein
- College of Medicine, Malawi, Mahatma Gandhi, Blantyre, Malawi
| | - Leon Bijlmakers
- Radboud University Medical Centre Netherlands, Geert Grooteplein Zuid 10, 6525 Nijmegen, GA Netherlands
| | - Ruairi Brugha
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
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336
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Cao B, Bray F, Beltrán-Sánchez H, Ginsburg O, Soneji S, Soerjomataram I. Benchmarking life expectancy and cancer mortality: global comparison with cardiovascular disease 1981-2010. BMJ 2017; 357:j2765. [PMID: 28637656 PMCID: PMC5477919 DOI: 10.1136/bmj.j2765] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2017] [Indexed: 12/24/2022]
Abstract
Objective To quantify the impact of cancer (all cancers combined and major sites) compared with cardiovascular disease (CVD) on longevity worldwide during 1981-2010.Design Retrospective demographic analysis using aggregated data.Setting National civil registration systems in member states of the World Health Organization.Participants 52 populations with moderate to high quality data on cause specific mortality.Main outcome measures Disease specific contributions to changes in life expectancy in ages 40-84 (LE40-84) over time in populations grouped by two levels of Human Development Index (HDI) values.Results Declining CVD mortality rates during 1981-2010 contributed to, on average, over half of the gains in LE40-84; the corresponding gains were 2.3 (men) and 1.7 (women) years, and 0.5 (men) and 0.8 (women) years in very high and medium and high HDI populations, respectively. Declines in cancer mortality rates contributed to, on average, 20% of the gains in LE40-84, or 0.8 (men) and 0.5 (women) years in very high HDI populations, and to over 10% or 0.2 years (both sexes) in medium and high HDI populations. Declining lung cancer mortality rates brought about the largest LE40-84 gain in men in very high HDI populations (up to 0.7 years in the Netherlands), whereas in medium and high HDI populations its contribution was smaller yet still positive. Among women, declines in breast cancer mortality rates were largely responsible for the improvement in longevity, particularly among very high HDI populations (up to 0.3 years in the United Kingdom). In contrast, losses in LE40-84 were observed in many medium and high HDI populations as a result of increasing breast cancer mortality rates.Conclusions The control of CVD has led to substantial gains in LE40-84 worldwide. The inequality in improvement in longevity attributed to declining cancer mortality rates reflects inequities in implementation of cancer control, particularly in less resourced populations and in women. Global actions are needed to revitalize efforts for cancer control, with a specific focus on less resourced countries.
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Affiliation(s)
- Bochen Cao
- Section of Cancer Surveillance, International Agency for Research on Cancer, 69372 Lyon CEDEX 08, France
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, 69372 Lyon CEDEX 08, France
| | - Hiram Beltrán-Sánchez
- Fielding School of Public Health and California Center for Population Research, University of California, Los Angeles, CA, USA
| | - Ophira Ginsburg
- Laura and Isaac Perlmutter Cancer Center, Department of Population Health, NYU Langone Medical Center, New York, NY, USA
| | - Samir Soneji
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Isabelle Soerjomataram
- Section of Cancer Surveillance, International Agency for Research on Cancer, 69372 Lyon CEDEX 08, France
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Laparoscopic Versus Open Cholecystectomy: A Cost-Effectiveness Analysis at Rwanda Military Hospital. World J Surg 2017; 41:1225-1233. [PMID: 27905020 DOI: 10.1007/s00268-016-3851-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries. Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings. METHODS A cost-effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were performed to determine the robustness of the results. RESULTS The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost-effectiveness ratio for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay (WTP) thresholds greater than $3975/QALY. CONCLUSIONS At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to combat these barriers and provide laparoscopic surgery.
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Bruno E, White MC, Baxter LS, Ravelojaona VA, Rakotoarison HN, Andriamanjato HH, Close KL, Herbert A, Raykar N, Saluja S, Shrime MG. An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan. World J Surg 2017; 41:1218-1224. [PMID: 27905017 DOI: 10.1007/s00268-016-3847-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework. METHOD Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators. RESULTS In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate. CONCLUSION Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.
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Affiliation(s)
- Emily Bruno
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar.,University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA.,Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Michelle C White
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar. .,M/V Africa Mercy, Mercy Ships, Port of Cotonou, Benin.
| | - Linden S Baxter
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar
| | | | | | | | - Kristin L Close
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar.,M/V Africa Mercy, Mercy Ships, Port of Cotonou, Benin
| | - Alison Herbert
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Saurabh Saluja
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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339
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Rayne S, Burger S, Straten SV, Biccard B, Phaahla MJ, Smith M. Setting the research and implementation agenda for equitable access to surgical care in South Africa. BMJ Glob Health 2017; 2:e000170. [PMID: 29242749 PMCID: PMC5584486 DOI: 10.1136/bmjgh-2016-000170] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 02/06/2017] [Indexed: 01/09/2023] Open
Abstract
South Africa is an upper-middle-income country with widespread social and geographical inequality of surgical provision. The National Forum on Surgery and Anaesthesia in South Africa brought together various stakeholders, including government, societies, academic clinicians and the biomedical industry, to define the core strategy for a national surgical plan. During the forum, presentations and breakaway workshops explored and reported the challenges and opportunities these stakeholders may have in sustaining and improving surgical provision in South Africa. We present the recommendations of these reports with a literature review and other recent reports from organisations involved in healthcare systems in South Africa. We acknowledge the importance of access to safe and affordable surgery for all as a core component of healthcare provision for South Africa. The proposed core strategies for a South African National Surgical Plan to achieve these goals are the following. First, research will focus on high-quality interdisciplinary collaborative research and audit, which addresses the Global Surgery indices, adopts internationally consistent data points and focuses particularly on maternal mortality and the 'Bellwether procedures'. Second, workforce and training must be tailored to the country's specific surgical needs, based on a primary healthcare and district hospital model, which is supported by government and academic organisations. Third, the surgical infrastructure and service delivery needs to be strengthened by the district hospital. Finally, strong leadership with appropriate financial support by healthcare managers who partner with clinicians both locally and nationally is needed to achieve these objectives.
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Affiliation(s)
- Sarah Rayne
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sule Burger
- Department of Surgery, Tembisa Hospital, Johannesburg, South Africa
| | - Stephanie Van Straten
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bruce Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Martin Smith
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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340
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Kibwana S, Teshome M, Molla Y, Carr C, Akalu L, van Roosmalen J, Stekelenburg J. Education, Practice, and Competency Gaps of Anesthetists in Ethiopia: Task Analysis. J Perianesth Nurs 2017; 33:426-435. [PMID: 30077285 DOI: 10.1016/j.jopan.2017.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/01/2017] [Accepted: 02/05/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This study assessed the needs and gaps in the education, practice and competencies of anesthetists in Ethiopia. DESIGN A cross-sectional study design was used. METHODS A questionnaire consisting of 74 tasks was completed by 137 anesthetists who had been practicing for 6 months to 5 years. FINDINGS Over half of the respondents rated 72.9% of the tasks as being highly critical to patient outcomes, and reported that they performed 70.2% of all tasks at a high frequency. More than a quarter of respondents reported that they performed 15 of the tasks at a low frequency. Nine of the tasks rated as being highly critical were not learned during pre-service education by more than one-quarter of study participants, and over 10% of respondents reported that they were unable to perform five of the highly critical tasks. CONCLUSIONS Anesthetists rated themselves as being adequately prepared to perform a majority of the tasks in their scope of practice.
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341
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Raykar NP, Ng-Kamstra JS, Bickler S, Davies J, Greenberg SLM, Hagander L, Johnson W, Leather AJM, McQueen KAK, Mukhopadhyay S, Suzuki E, Weiser T, Shrime MG, G Meara J. New global surgical and anaesthesia indicators in the World Development Indicators dataset. BMJ Glob Health 2017; 2:e000265. [PMID: 29225929 PMCID: PMC5717956 DOI: 10.1136/bmjgh-2016-000265] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 04/03/2017] [Accepted: 04/04/2017] [Indexed: 12/03/2022] Open
Affiliation(s)
- Nakul P Raykar
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua S Ng-Kamstra
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Bickler
- Department of Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Justine Davies
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK.,MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah L M Greenberg
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lars Hagander
- Pediatric Surgery, Department of Clinical Sciences in Lund, Division of Pediatrics, Lund University, Lund, Sweden
| | - Walt Johnson
- Emergency and Essential Surgical Care Programme, World Health Organization, Geneva, Switzerland
| | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - K A Kelly McQueen
- Vanderbilt Anesthesia Global Health & Development, Nashville, Tennessee, USA.,Department of Anesthesia, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, University of Connecticut School of Medicine, Hartford, Connecticut, USA
| | - Emi Suzuki
- Development Economics Data Group, World Bank Group, Washington, DC, USA
| | - Thomas Weiser
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology and the Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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342
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Schwartz M, Jeng CJ, Chuang LT. Laparoscopic surgery for gynecologic cancer in low- and middle-income countries (LMICs): An area of need. Gynecol Oncol Rep 2017; 20:100-102. [PMID: 28393094 PMCID: PMC5377001 DOI: 10.1016/j.gore.2017.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/03/2017] [Accepted: 03/22/2017] [Indexed: 11/25/2022] Open
Abstract
Over 90% of people living in low- and middle-income countries (LMICs) do not have access to surgical care. In the absence of appropriate surgical care, there is high morbidity and mortality from surgically curable diseases, such as cervical cancer. Laparoscopic surgery for gynecologic cancer in LMICs is extremely limited. The benefits of laparoscopy over open surgery are even more pronounced in LMICs than in resource-rich countries. Barriers to implementation of laparoscopic surgery in LMICs should be identified and addressed in order to improve global cancer care and the lives of women worldwide.
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Affiliation(s)
- Melissa Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Cherng-Jye Jeng
- Department of Obstetrics and Gynecology, School of Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Linus T. Chuang
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Gynecologic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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343
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Pediatric surgical capacity in Africa: Current status and future needs. J Pediatr Surg 2017; 52:843-848. [PMID: 28168989 DOI: 10.1016/j.jpedsurg.2017.01.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/23/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND African pediatric surgery (PS) faces multiple challenges. Information regarding existing resources is limited. We surveyed African pediatric surgeons to determine available resources and clinical, educational, and collaborative needs. METHODS Members of the Pan-African Pediatric Surgical Association (PAPSA) and the Global Pediatric Surgery Network (GPSN) completed a structured email survey covering PS providers, facilities, resources, workload, education/training, disease patterns, and collaboration priorities. RESULTS Of 288 deployed surveys, 96 were completed (33%) from 26 countries (45% of African countries). Median PS providers/million included 1 general surgeon and 0.26 pediatric surgeons. Median pediatric facilities/million included 0.03 hospitals, 0.06 ICUs, and 0.17 surgical wards. Neonatal ventilation was available in 90% of countries, fluoroscopy in 70%, TPN in 50%, and frozen section pathology in 35%. Median surgical procedures/institution/year was 852. Median waiting time was 40days for elective procedures and 7 days? for emergencies. Weighted average percent mortality for key surgical conditions varied between 1% (Sierra Leone) and 54% (Burkina Faso). Providers ranked collaborative professional development highest and direct clinical care lowest priority in projects with high-income partners. CONCLUSIONS The broad deficits identified in PS human and material resources in Africa suggest the need for a global collaborative effort to address the PS gaps. LEVEL OF EVIDENCE Level 5, expert opinion without explicit critical appraisal.
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344
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LaGrone LN, Isquith-Dicker LN, Egoavil EH, Herrera-Matta JJ, Fuhs AK, Checa DO, Revoredo F, Rodriguez Castro MJ, Mock CN. Surgery and trauma care providers' perception of the impact of dual-practice employment on quality of care provided in an Andean country. Br J Surg 2017; 104:704-709. [PMID: 28251600 PMCID: PMC5391273 DOI: 10.1002/bjs.10478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 10/03/2016] [Accepted: 12/04/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dual-practice, simultaneous employment by healthcare workers in the public and private sectors is pervasive worldwide. Although an estimated 30 per cent of the global burden of disease is surgical, the implications of dual practice on surgical care are not well understood. METHODS Anonymous in-depth individual interviews on trauma quality improvement practices were conducted with healthcare providers who participate in the care of the injured at ten large hospitals in Peru's capital city, Lima. A grounded theory approach to qualitative data analysis was employed to identify salient themes. RESULTS Fifty interviews were conducted. A group of themes that emerged related to the perceived negative and positive impacts of dual practice on the quality of surgical care. Participants asserted that the majority of physicians in Lima working in the public sector also worked in the private sector. Dual practice has negative impacts on physicians' time, quality of care in the public sector, and surgical education. Dual practice positively affects patient care by allowing physicians to acquire management and quality improvement skills, and providing incentives for research and academic productivity. In addition, dual practice provides opportunities for clinical innovations and raises the economic status of the physician. CONCLUSION Surgeons in Peru report that dual practice influences patient care negatively by creating time and human resource conflicts. Participants assert that these conflicts widen the gap in quality of care between rich and poor. This practice warrants redirection through national-level regulation of physician schedules and reorganization of public investment in health via physician remuneration.
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Affiliation(s)
| | | | | | | | - Amy K. Fuhs
- Indiana University School of Medicine, Indianapolis, USA
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345
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Abdelgadir J, Tran T, Muhindo A, Obiga D, Mukasa J, Ssenyonjo H, Muhumza M, Kiryabwire J, Haglund MM, Sloan FA. Estimating the Cost of Neurosurgical Procedures in a Low-Income Setting: An Observational Economic Analysis. World Neurosurg 2017; 101:651-657. [DOI: 10.1016/j.wneu.2017.02.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/07/2017] [Accepted: 02/08/2017] [Indexed: 10/20/2022]
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346
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Kahan BC, Koulenti D, Arvaniti K, Beavis V, Campbell D, Chan M, Moreno R, Pearse RM. Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries. Intensive Care Med 2017; 43:971-979. [PMID: 28439646 DOI: 10.1007/s00134-016-4633-8] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 11/21/2016] [Indexed: 10/19/2022]
Abstract
PURPOSE As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality. METHODS Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests. RESULTS 44,814 patients from 474 hospitals in 27 countries were available for analysis. Death was more frequent amongst patients admitted directly to critical care after surgery (critical care: 103/4317 patients [2%], standard ward: 99/39,566 patients [0.3%]; adjusted OR 3.01 [2.10-5.21]; p < 0.001). This association may differ with national income (high income countries OR 2.50 vs. low and middle income countries OR 4.68; p = 0.07). At hospital level, there was no association between mortality and critical care admission directly after surgery (p = 0.26), critical care admission to treat complications (p = 0.33), or provision of critical care beds (p = 0.70). Findings of the hospital-level analyses were not affected by national income status. A sensitivity analysis including only high-risk patients yielded similar findings. CONCLUSIONS We did not identify any survival benefit from critical care admission following surgery.
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347
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Stewart BT, Carlson L, Hatcher KW, Sengupta A, Vander Burg R. Estimate of Unmet Need for Cleft Lip and/or Palate Surgery in India. JAMA FACIAL PLAST SU 2017; 18:354-61. [PMID: 27281157 DOI: 10.1001/jamafacial.2016.0474] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE The unmet need for cleft lip and/or palate (CL/P) care in India is significant. However, estimates required for CL/P care program planning are lacking. OBJECTIVE To estimate the unmet need for CL/P surgery in India at the state level. DESIGN, SETTING, AND PARTICIPANTS To determine the proportion of individuals with CL/P who presented for care in India, data were used from patients who received care at Operation Smile programs in 12 low- and middle-income countries from June 1, 2013, to May 31, 2014. The resulting model describes the prevalent unmet need for cleft surgery in India by state and includes patients older than the surgery target ages of 1 and 2 years for cleft lip and cleft palate repair, respectively. Next, the total number of unrepaired CL/P cases in each state was estimated using state-level economic and health system indicators. MAIN OUTCOMES AND MEASURES Prevalent unmet need for CL/P repair. RESULTS In the 28 states with available data, an estimated 72 637 cases of unrepaired CL/P (uncertainty interval, 58 644-97 870 cases) were detected. The percentage of individuals with unrepaired CL/P who were older than the respective target ages ranged from 37.0% (95% CI, 30.6%-43.8%) in Goa to 65.8% (95% CI, 60.3%-70.9%) in Bihar (median, 57.9%; interquartile range, 52.6%-63.4%). The rate of unrepaired CL/Ps ranged from less than 3.5 per 100 000 population in Kerala and Goa to 10.9 per 100 000 population in Bihar (median rate, 5.9 [interquartile range, 4.6-7.3] per 100 000 population). CONCLUSIONS AND RELEVANCE An estimated 72 000 cases of unrepaired CL/P are found in India. Poor states with less health care infrastructure have exceptionally high rates (eg, Bihar). These estimates are useful for informing international and national CL/P care strategies, allocating resources, and advocating for individuals and families affected by CL/P more broadly. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Barclay T Stewart
- Department of Surgery, University of Washington, Seattle2School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana3Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lucas Carlson
- Harvard Affiliated Emergency Medicine Residency, Brigham & Women's Hospital, Boston, Massachusetts
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Manske MCB, Rios Roque JJ, Zelaya GR, James MA. Pediatric Hand Surgery Training in Nicaragua: A Sustainable Model of Surgical Education in a Resource-Poor Environment. Front Public Health 2017; 5:75. [PMID: 28443277 PMCID: PMC5387056 DOI: 10.3389/fpubh.2017.00075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 03/22/2017] [Indexed: 11/17/2022] Open
Abstract
Recent reports have demonstrated that nearly two-thirds of the world's population do not have access to adequate surgical care, a burden that is borne disproportionately by residents of resource-poor countries. Although the reasons for limited access to surgical care are complex and multi-factorial, among the most substantial barriers is the lack of trained surgical providers. This is particularly true in surgical subspecialties that focus on life-improving, rather than life-saving, treatments, such as pediatric hand and upper extremity surgery, which manages such conditions as congenital malformations, trauma and post-traumatic deformities including burns, and neuromuscular conditions (brachial plexus birth palsy, spinal cord injury, and cerebral palsy). Many models of providing surgical care in resource-limited environments have been described and implemented, but few result in sustainable models of health-care delivery. We present our experience developing a pediatric hand and upper extremity surgery training program in Nicaragua, a resource-limited nation, that grew out of a collaboration of American and Nicaraguan orthopedic surgeons. We compare this experience to that of surgeons undergoing subspecialty training in pediatric upper limb surgery in the US, highlighting the similarities and differences of these training programs. Finally, we assess the results of this training program and identify areas for further growth and development.
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Affiliation(s)
| | | | | | - Michelle A. James
- Shriners Hospital for Children Northern California, Sacramento, CA, USA
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349
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Gunn JKL, Ehiri JE, Jacobs ET, Ernst KC, Pettygrove S, Center KE, Osuji A, Ogidi AG, Musei N, Obiefune MC, Ezeanolue CO, Ezeanolue EE. Prevalence of Caesarean sections in Enugu, southeast Nigeria: Analysis of data from the Healthy Beginning Initiative. PLoS One 2017; 12:e0174369. [PMID: 28355302 PMCID: PMC5371319 DOI: 10.1371/journal.pone.0174369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 03/07/2017] [Indexed: 11/29/2022] Open
Abstract
Background In order to meet the Sustainable Development Goal to decrease maternal mortality, increased access to obstetric interventions such as Caesarean sections (CS) is of critical importance. As a result of women’s limited access to routine and emergency obstetric services in Nigeria, the country is a major contributor to the global burden of maternal mortality. In this analysis, we aim to establish rates of CS and determine socioeconomic or medical risk factors associated with having a CS in Enugu, southeast Nigeria. Methods Data for this study originated from the Healthy Beginning Initiative study. Participant characteristics were obtained from 2300 women at baseline via a semi-structured questionnaire. Only women between the ages of 17–45 who had singleton deliveries were retained for this analysis. Post-delivery questionnaires were used to ascertain mode-of-delivery. Crude and adjusted logistic regressions with Caesarean as the main outcome are presented. Results In this sample, 7.22% women had a CS. Compared to women who lived in an urban setting, those who lived in a rural setting had a significant reduction in the odds of having a CS (aOR: 0.58; 0.38–0.89). Significantly higher odds of having a CS were seen among those with high peripheral malaria parasitemia compared to those with low parasitemia (aOR: 1.54; 1.04–2.28). Conclusion This study revealed that contrary to the increasing trend in use of CS in low-income countries, women in this region of Nigeria had limited access to this intervention. Increasing age and socioeconomic proxies for income and access to care (e.g., having a tertiary-level education, full-time employment, and urban residence) were shown to be key determinants of access to CS. Further research is needed to ascertain the obstetric conditions under which women in this region receive CS, and to further elucidate the role of socioeconomic factors in accessing CS.
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Affiliation(s)
- Jayleen K. L. Gunn
- Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
- * E-mail:
| | - John E. Ehiri
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Elizabeth T. Jacobs
- Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
- University of Arizona Cancer Center, Tucson, Arizona, United States of America
| | - Kacey C. Ernst
- Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Sydney Pettygrove
- Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | | | - Alice Osuji
- Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria
| | - Amaka G. Ogidi
- Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria
| | - Nnabundo Musei
- Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria
| | - Michael C. Obiefune
- Healthy Sunrise Foundation, Castle Ridge Avenue, Las Vegas, Nevada, United States of America
- Institute of Human Virology, University of Maryland, Baltimore, Maryland, United States of America
| | - Chinenye O. Ezeanolue
- Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria
| | - Echezona E. Ezeanolue
- Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GS, Enugu, Enugu State, Nigeria
- Healthy Sunrise Foundation, Castle Ridge Avenue, Las Vegas, Nevada, United States of America
- Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, Nevada, United States of America
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350
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Reynolds TA, Stewart B, Drewett I, Salerno S, Sawe HR, Toroyan T, Mock C. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health 2017; 38:507-532. [DOI: 10.1146/annurev-publhealth-032315-021412] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Injury is a leading cause of death globally, and organized trauma care systems have been shown to save lives. However, even though most injuries occur in low- and middle-income countries (LMICs), most trauma care research comes from high-income countries where systems have been implemented with few resource constraints. Little context-relevant guidance exists to help policy makers set priorities in LMICs, where resources are limited and where trauma care may be implemented in distinct ways. We have aimed to review the evidence on the impact of trauma care systems in LMICs through a systematic search of 11 databases. Reports were categorized by intervention and outcome type and summarized. Of 4,284 records retrieved, 71 reports from 32 countries met inclusion criteria. Training, prehospital systems, and overall system organization were the most commonly reported interventions. Quality-improvement, costing, rehabilitation, and legislation and governance were relatively neglected areas. Included reports may inform trauma care system planning in LMICs, and noted gaps may guide research and funding agendas.
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Affiliation(s)
- Teri A. Reynolds
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, Washington 98105
| | - Isobel Drewett
- School of Medicine, Monash University, Melbourne 3800, Australia
| | - Stacy Salerno
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Hendry R. Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam 11103, Tanzania
| | - Tamitza Toroyan
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, Washington 98105
- Department Global Health, University of Washington, Seattle, Washington 98105
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