A global country-level comparison of the financial burden of surgery

Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review

INTRODUCTION

Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs).

METHODS

We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery.

RESULTS

77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE.

CONCLUSIONS

CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

Codesigning an E-Health Intervention for Surgery Preparation and Recovery

Surgery is a significant part of healthcare, but its demand is increasing, leading to challenges in managing patient care. Inefficient perioperative practices and traditional linear models contribute to adverse outcomes and patient anxiety. E-health interventions show promise in improving surgical care, but more research is needed. The purpose of this study was to involve patients and healthcare workers during the design phase of an e-health intervention that aims to support the perioperative care of elective surgery preparation and recovery. This study used an Information Systems Research Framework to guide collaborative codesign through semistructured interviews and cocreation workshops. Semistructured interviews collected insights on the perioperative journey and e-health needs from healthcare workers and consumers, resulting in the creation of a patient surgery journey map, experience map, and a stakeholder needs table. Collaborative work between consumers and healthcare workers in the cocreation workshops identified priority perioperative journey issues and proposed solutions, as well as prioritizing application software needs, guiding the development of the wireframe. The development of an e-health application aimed at supporting surgery preparation and recovery is a significant step toward improving patient engagement, satisfaction, and postsurgical health outcomes.

Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity.

RESULTS

Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile.

CONCLUSIONS

An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.

Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia

South Asia is a demographically crucial, economically aspiring, and socio-culturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region-wide, as well as country-specific challenges are highlighted. We also discuss potential directions-initiatives and innovations-toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC).

Socioeconomic disparities in risk of financial toxicity following elective cardiac operations in the United States

BACKGROUND

While insurance reimbursements allay a portion of costs associated with cardiac operations, uncovered and additional fees are absorbed by patients. An examination of financial toxicity (FT), defined as the burden of patient medical expenses on quality of life, is warranted. Therefore, the present study used a nationally representative database to demonstrate the association between insurance status and risk of financial toxicity (FT) among patients undergoing major cardiac operations.

METHODS

Adults admitted for elective coronary artery bypass grafting (CABG) and isolated or concomitant valve operations were assessed using the 2016-2019 National Inpatient Sample. FT risk was defined as out-of-pocket expenditure >40% of post-subsistence income. Regression models were developed to determine factors associated with FT risk in insured and uninsured populations. To demonstrate the association between insurance status and risk of FT among patients undergoing major cardiac operations.

RESULTS

Of an estimated 567,865 patients, 15.6% were at risk of FT. A greater proportion of uninsured patients were at risk of FT (81.3 vs. 14.8%, p<0.001), compared to insured. After adjustment, FT risk among insured patients was not affected by non-income factors. However, Hispanic race (Adjusted Odds Ratio [AOR] 1.60), length of stay (AOR 1.17/day), and combined CABG-valve operations (AOR 2.31, all p<0.05) were associated with increased risk of FT in the uninsured.

CONCLUSION

Uninsured patients demonstrated higher FT risk after undergoing major cardiac operation. Hispanic race, longer lengths of stay, and combined CABG-valve operations were independently associated with increased risk of FT amongst the uninsured. Conversely, non-income factors did not impact FT risk in the insured cohort. Culturally-informed reimbursement strategies are necessary to reduce disparities in already financially disadvantaged populations.

Modeling the global impact of reducing out-of-pocket costs for children's surgical care

Over 1.7 billion children lack access to surgical care, mostly in low- and middle-income countries (LMICs), with substantial risks of catastrophic health expenditures (CHE) and impoverishment. Increasing interest in reducing out-of-pocket (OOP) expenditures as a tool to reduce the rate of poverty is growing. However, the impact of reducing OOP expenditures on CHE remains poorly understood. The purpose of this study was to estimate the global impact of reducing OOP expenditures for pediatric surgical care on the risk of CHE within and between countries. Our goal was to estimate the impact of reducing OOP expenditures for surgical care in children for 149 countries by modeling the risk of CHE under various scale-up scenarios using publicly available World Bank data. Scenarios included reducing OOP expenditures from baseline levels to paying 70%, 50%, 30%, and 10% of OOP expenditures. We also compared the impact of these reductions across income quintiles (poorest, poor, middle, rich, richest) and differences by country income level (low-income, lower-middle-income, upper-middle-income, and high-income countries).Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal. The risk of CHE due to a surgical procedure for children was highest in low-income countries. An unexpected observation was that upper-middle income countries were at higher risk for CHE than LMICs. The most vulnerable regions were Africa and Latin America. Across all countries, the poorest quintile had the greatest risk for CHE. Increasing interest in financial protection programs to reduce OOP expenditures is growing in many areas of global health. Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal across countries, wealth groups, or even by wealth groups within countries. Understanding these complexities is critical to develop appropriate policies to minimize the risks of poverty.

Financial toxicity risk among patients with gastric banding complications in the United States: analysis of the National Inpatient Sample

BACKGROUND

Laparoscopic adjustable gastric banding (AGB) was historically among the most performed bariatric procedures but has fallen out of favor in recent years due to poor long-term weight loss and high revisional surgery rates. Significant financial hardship of medical care, known as "financial toxicity," can occur from experiencing unexpected complications of AGB.

OBJECTIVE

To investigate the risk of financial toxicity among patients being admitted for AGB complications.

SETTING

United States.

METHODS

All uninsured and privately-insured patients who were admitted for AGB complications were identified from the National Inpatient Sample 2015-2019. Publicly available government data (U.S. Census Bureau, Bureau of Labor, The Centers for Medicare and Medicaid Services) were utilized to estimate patient income, food expenditures, and average maximum out-of-pocket expenditures. Financial toxicity was defined as total admission cost from AGB complications ≥40% of postsubsistence income.

RESULTS

Among 28,005 patients, 66% patients had private insurance and 44% patients were uninsured. Median total admission cost was $12,443 (interquartile range $7959-$19,859) and $15,182 for those who received revisional bariatric surgery. Approximately 55% of the uninsured patients and 1% of insured patients were at risk of financial toxicity after admission for banding-related complications. Patients who had an emergency admission, revisional surgery, or postoperative intensive care unit admission were more likely to experience financial catastrophe following admission (P < .01).

CONCLUSIONS

About 1 in 2 uninsured patients admitted for AGB-related complications were at risk of financial toxicity. In addition to surgical risks, providers should consider the potential financial consequences of AGB when counselling patients on their choice of surgery.

Catastrophic health expenditure in nonneurological injury due to motor vehicle crash

BACKGROUND

Motor vehicle crashes (MVCs) are a leading cause of nonfatal injury in the United States and impose a high financial cost to the patient and the economy. For many patients, this cost may be financially devastating and contribute to worsening health outcomes after injury. We aimed to describe the population level risk of catastrophic health expenditure (CHE) and determine factors associated with risk of CHE.

METHODS

We performed a retrospective review using the 2014-2017 Nationwide Inpatient Sample. The study population consisted of uninsured and privately insured adults aged 26 to 64 years who were hospitalized for nonneurologic traumatic injury due to MVCs. Our measure of financial hardship was CHE, which was defined as hospital charges ≥40% of postsubsistence income. Income estimates were derived from zip-code level data using Γ distribution modeling.

RESULTS

Our sample included 189,000 patients, of which 149,705 had private insurance and 39,375 were uninsured. The median estimated income for the study cohort was $66,118 (interquartile range, $65,353-$66,884). The median cost of hospitalization was $53,467 (interquartile range, $29,854-$99,914). In addition, 91.5% of uninsured patients suffering from MVC are at risk for CHE, and 10.1% of privately insured patients are at risk for CHE. Among the insured, Black, Hispanic, and low income were associated with CHE.

CONCLUSION

Nine of 10 uninsured patients are at risk for CHE after hospitalization for MVC. Despite having insurance, 10% of patients are still at risk of CHE. Black, Hispanic, and low-income communities are at highest risk of having private insurance and still experiencing CHE. This is the first population level analysis after the implementation of the Affordable Care Act that assesses the financial burden of no insurance and underinsurance. These data are important to understand the effectiveness of insurance coverage and guide hospital and policy level interventions to prevent CHE.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Evaluating the status of the Lancet Commission on Global Surgery indicators for India

For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.

Does reducing out-of-pocket costs for children's surgical care protect families from poverty in Somaliland? A cross-sectional, national, economic evaluation modelling study

OBJECTIVES

An estimated 1.7 billion children around the world do not have access to safe, affordable and timely surgical care, with the financing through out-of-pocket (OOP) expenses being one of the main barriers to care. Our study modelled the impact of reducing OOP costs related to surgical care for children in Somaliland on the risk of catastrophic expenditures and impoverishment.

DESIGN AND SETTING

This cross-sectional nationwide economic evaluation modelled several different approaches to reduction of paediatric OOP surgical costs in Somaliland.

PARTICIPANTS AND OUTCOME MEASURES

A surgical record review of all procedures on children up to 15 years old was conducted at 15 surgically capable hospitals. We modelled two rates of OOP cost reduction (reduction of OOP proportion from 70% to 50% and from 70% to 30% reduction in OOP costs) across five wealth quintiles (poorest, poor, neutral, rich, richest) and two geographical areas (urban and rural). The outcome measures of the study are catastrophic expenditures and risk of impoverishment due to surgery. We followed the Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

We found that the risk of catastrophic and impoverishing expenditures related to OOP expenditures for paediatric surgery is high across Somaliland, but most notable in the rural areas and among the poorest quintiles. Reducing OOP expenses for surgical care to 30% would protect families in the richest wealth quintiles while minimally affecting the risk of catastrophic expenditure and impoverishment for those in the lowest wealth quintiles, particularly those in rural areas.

CONCLUSION

Our models suggest that the poorest communities in Somaliland lack protection against the risk of catastrophic health expenditure and impoverishment, even if OOP payments are reduced to 30% of surgical costs. A comprehensive financial protection in addition to reduction of OOP costs is required to prevent risk of impoverishment in these communities.

Timely Access to Essential Surgery, Surgical Workforce, and Surgical Volume: Global Surgery Indicators in Mexico

INTRODUCTION

The Lancet Commission on Global Surgery seeks to improve surgical care outcomes and equity for the world population through 6 indicators outlined in its 2030 Global Surgery Report. Our study aimed to estimate the percentage of the Mexican population with access to surgical care within the 2-hour distance range (indicator 1), the surgical workforce density (indicator 2), and the number of surgical procedures performed per 100,000 inhabitants (indicator 3) during the year 2020. Knowing these indicators can help to design and implement policies to increase surgical care access coverage and equity in our country.

METHODS

Data related to population distribution, local referral hospitals, and surgical volume were obtained from the 2020 Mexican National Census. Information relating to hospital characteristics and surgical specialists was collected from the Secretariat of Health's public records. We calculated travel time between health care facilities and municipalities using the TrueWay Matrix API and R Studio.

RESULTS

Taking into consideration the health care system affiliation, the proportion of the Mexican population with timely access to essential surgery was 81.7%, with 29.3 specialists per 100,000 inhabitants and 726.9 annual procedures performed per 100,000 inhabitants. We identified clusters of municipalities where a low proportion of the population has timely access to essential surgery.

CONCLUSION

These findings illustrate that changes in Mexican policy are required to facilitate more equitable and timely access to essential surgical care among the population.

Cardiac surgery and the sustainable development goals: a review

Background

In 2015, the United Nations adopted the Sustainable Development Goals (SDGs) as key priorities to improve the global health and international development agenda in an intersectoral manner, highlighting 17 SDGs. Six billion people lack access to safe, timely, and affordable cardiac surgical care due to capacity, geographic, and financial barriers. Nevertheless, cardiac surgery is largely disregarded on the global health agenda. In this review, we explore the intersection between cardiac surgery and the SDGs to delineate potential policy and advocacy avenues for the cardiothoracic surgical community.

Main body

A narrative review was performed using the PubMed/MEDLINE, Scopus, and WHO databases with variations of the search terms “cardiac surgery,” “cardiovascular diseases,” and keywords extracted from individual SDGs. All SDGs were manually reviewed to define intersectionality with global cardiac surgery. Out of 17 SDGs, 15 are relevant and require additional attention from the cardiovascular community. SDG3, “Good Health and Well-being,” is the most relevant, although the intersection between global cardiac surgery and other SDGs is apparent. A call for interdisciplinary collaboration through increased preventive mechanisms, rigorous, all-inclusive clinical trials, advocacy with relevant legislators, and mobilizing capacity building mechanisms are made.

Conclusion

Meeting the SDGs will require recognition of cardiovascular disease management, including cardiac surgical care. Cardiac surgeons are essential stakeholders of multidisciplinary collaborations working to improve access to safe, timely, and affordable cardiac surgery for all. Their role as advocates will be vital to establish local, national, regional, and international partnerships and to ensure progress towards SDG attainment.

A Narrative Review of Kenya's Surgical Capacity Using the Lancet Commission on Global Surgery's Indicator Framework

Surgery, anesthesia, and obstetric (SAO) care is quickly being recognized for its critical role in cost-effectively improving global morbidity and mortality. Six core indicators for SAO capacity were established in 2015 by the Lancet Commission on Global Surgery (LCoGS) and include: SAO provider density, population proximity to surgery-ready facilities, annual national operative volume, a system to track perioperative mortality rate, and protection from impoverishing and catastrophic expenditures. The surgical capacity of Kenya, a lower-middle-income country, has not been evaluated using this framework. Our goal was to review published literature on surgery in Kenya to assess the country's surgical capacity and system strength. A narrative review of the relevant literature provided estimates for each LCoGS indicator. While progress has been made in expanding access to care across the country, key steps remain in the effort to provide equitable, affordable, and timely care to Kenya's population through universal health coverage. Additional investment into training SAO providers, operative infrastructure, and accessibility are recommended through a national surgery, obstetric, and anesthesia plan.

Financing Pediatric Surgery: A Provider's Perspective from the Global Initiative for Children's Surgery

BACKGROUND

Half the world's population is at risk of catastrophic health expenditure (CHE, out-of-pocket spending of more than 10% of annual expenditure) should they require surgery. Protection against CHE is a key indicator of successful health care delivery and has been identified as a priority area by the Global Initiative for Children's Surgery (GICS). Data specific to pediatric surgical patients is limited. This study examines the financial risks for pediatric surgical patients and their families from a provider's perspective.

METHODS

We surveyed GICS members about the existing financial protection mechanisms and estimated expenditures for their patients. Questions were structured based on the National Surgical, Obstetric and Anesthesia Planning Surgical Indicators and finalized based on multi-institutional consensus between high-income country and low-and middle-income country (LMIC) providers. Chi-squared test, Fisher's exact test and student's t-test were used as appropriate.

RESULTS

Among 107 respondents, 72.4% were from low income or lower-middle income (LIC/LMIC) countries, and 55.1% were attending or consultant physicians. Families were most likely to decline surgery in LIC/LMIC due to inability to afford treatment (mean Likert = 3.77 ± 1.06). The odds of incurring CHE after children's surgery are up to 17 times greater in LIC/LMIC (P = 0.001, unadjusted OR 17.28, 95%CI 2.13-140.02). Over 50% of families of children undergoing major surgery in these settings face CHE. An estimated 5.1% of providers in LIC/LMIC and 56.2% (P < 0.001) of providers in UMIC/HIC reported that families are able to pay for their direct medical costs with the assistance available to them and were more likely to sell assets (74.4% vs. 33.3%, P = 0.005).

CONCLUSION

Patients in LMICs are at greater risk for CHE and have less financial risk protection than their HIC counterparts. Given this disparity, intervention is needed to make safe surgery affordable for children worldwide.

Long-Term Impact of a Low-Cost Paediatric Intussusception Air Enema Reduction Simulation-Based Education Programme in a Low-Middle Income Country

INTRODUCTION

Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Low- and Middle-Income Countries (LMICs) undergo an invasive operative intervention. Supported by simulation-based education (SBE), the Air Enema (AE) non-operative technique was introduced in 2016 in Myanmar. This study assesses the long-term outcomes.

METHODS

Mixed methods study design over 4 years including clinical outcomes and surgeon's attitudes towards the AE technique and SBE. Prospectively collected clinical outcomes and semi-structured interview with reflexive thematic analysis (RTA). Primary outcome measure was a long-term shift to non-operative intervention.

SECONDARY OUTCOMES

Length of Stay (LoS), recurrence rates, intestinal resection rates, compared to the operative group. The data was analysed according to intention to treat. Quantitative data analysis with Mann-Whitney U test, Fisher's exact test, Student's T-Test or Wilcoxon Signed-Rank Test utilised. A p-value of <.05 was considered significant.

RESULTS

A total of 311 infants with intussusception were included. A sustained shift to AE was revealed with high success rates (86.1-91.2%). AE had a reduced LoS (4 vs. 7 days p ≤ 0.0001), Duration of Symptoms (DoS) was lower with AE (1.9/7 vs. 2.5/7, p = 0.002). Low recurrence rates (0-5.8%) and intestinal resection rates stabilised at 30.5-31.8% vs.15.3% pre-intervention. Four RTA themes were identified: Expanding conceptions of healthcare professional education and training; realising far reaching advantages; promoting critical analysis and reflective practice of clinicians; and adapting clinical practice to local context. RTA revealed an overall positive paradigm shift in attitudes and application of SBE.

CONCLUSIONS

A sustained change in clinical outcomes and appreciation of the value of SBE was demonstrated following the intervention.

Proctologic Surgery Prioritization After the Lockdown: Development of a Scoring System

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has shown a very critical impact on surgical procedures all over the world. Italy faced the deepest impact from the beginning of March 2020. Elective operations, screening, and follow-up visits had been suspended giving priority to urgent and oncologic surgery.

Patients

An observational study was carried out in the Surgical Coloproctology Unit of the Val Vibrata Hospital on 152 patients awaiting a proctological surgical treatment during the national lockdown.

Methods

In order to monitor the health status of patients and reschedule postlockdown surgical activities, patients were interviewed by telephone submitting a questionnaire based upon the judgment of an expert senior clinician. Following the interview, we calculated a severity index for all the proctologic diseases (hemorrhoidal disease, anal fissure, anal sepsis, slow transit or obstructed defecation, incontinence), classifying the patients according to the score. Mean age of patients was 53 (±16) years, and there were 84 males (55.3%) and 68 females (44.7%). In total, 31% of our patients suffered from anal fissure, 28% suffered from hemorrhoidal disease, 14% suffered from anal sepsis, and the remaining patients suffered from benign anorectal diseases to a lesser extent.

Results

A total of 137 patients were available and divided into three classes: priority surgery (PS) with 49 patients (36.2%), deferrable surgery (DS) with 25 patients (18.1%), and long-term surgery (L-TS) with 63 patients (45.6%). There was a significant correlation between the perceived health status reported during the interview and the priority class index (Spearman's rho = 0.97, p < 0.001).

Differences related to age and sex were not significant (F-test = 0.43, p = 0.653; chi-squared test = 0.693, p = 0.707). 49 patients in class PS needed a prompt surgical treatment, while 24 patients allocated in class DS and 65 patients allocated in class L-TS could wait for a new ride plan for surgery.

Conclusion

New tools, such as this simple score obtained during the telephone interview, can be useful for prioritization of patients on the waiting list for surgical coloproctology after the lockdown without further clinical examination and hospital access.

Assessing Catastrophic Health Expenditures Among Uninsured People Who Seek Care in US Hospital-Based Emergency Departments

Question

What is the risk of a single treat-and-release emergency department (ED) visit contributing to a catastrophic health expenditure (CHE; health care costs exceeding 40% of post-subsistence income) among uninsured people?

Findings

In this cross-sectional study of 41.7 million ED visits from 2006 to 2017, nearly 1 in 5 (18%) uninsured treat-and-release ED patient encounters were at risk of CHE. This risk has grown over time and disproportionately burdens those with low incomes.

Meaning

Policies such as broadening financial risk protection for unscheduled care may help to mitigate CHE risk among uninsured people, who have few alternatives for care outside of the ED.

Importance

Uninsured people uniquely rely on the emergency department (ED) for care as they are less likely to have access to lower-cost alternatives. Prior work has demonstrated that most uninsured patients are at risk of catastrophic health expenditure (CHE) after being hospitalized for life-saving care. The risk of CHE for a single treat-and-release ED visit that does not result in a hospitalization among uninsured patient encounters is currently unknown.

Objective

To estimate the overall national risk of CHE among uninsured patients after a single treat-and-release ED visit from 2006 through 2017, and to characterize this risk across key traits.

Design, Setting, and Population

This cross-sectional study is based on a nationally representative sample of hospital-based ED visits between 2006 and 2017 in the United States (US) from the Nationwide Emergency Department Sample (NEDS). It examined outpatient ED visits among uninsured patients.

Main Outcomes and Measures

Risk of CHE for ED care defined as an ED charge that exceeds 40% of one’s estimated annual post-subsistence income.

Results

From 2006 to 2017, there were 41.7 million NEDS encounters that met inclusion criteria for this analysis, equating to a nationally weighted estimate of 184.6 million uninsured treat-and-release ED encounters over this period. The median ED charge for a single treat-and-release encounter grew from $842 in 2006 to $2033 by 2017. Approximately 1 in 5 uninsured patients (18% [95% CI, 18.0%-18.0%]) were at risk of CHE for a single treat-and-release ED visit over the study period. This estimated CHE risk increased from 13.6% (95% CI, 13.6%-13.6%) in 2006 to 22.6% (95% CI, 22.6%-22.7%) in 2017. Those living in the lowest income quartile faced a disproportionate share of this risk, with nearly 1 in 3 (28.5% [95% CI, 28.5%-28.6%]) facing CHE risk in 2017. In 2017, an estimated 3.2 million patient encounters nationally were at risk of CHE after a single treat-and-release ED visit.

Conclusions and Relevance

This cross-sectional analysis from 2006 to 2017 of 184.6 million uninsured treat-and-release visits found that 1 in 5 uninsured patient encounters are at risk for CHE. This risk has grown over time. Future policies designed to improve access for unscheduled care must consider the unique role of the ED as the de facto safety net and ensure that uninsured patients are not at undue risk of financial harm for seeking care.

Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review

OBJECTIVE

This study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA).

SETTING

Surgical and anaesthesia services across all levels of care-primary, secondary and tertiary.

DESIGN

We performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing.

RESULTS

The search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives.

CONCLUSION

Financing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.

Should Ketamine Not Be Banned? A Scoping Review

OBJECTIVES

Although the importance of ketamine in clinical practice and in resource-poor settings and disaster zones, several attempts were made to reschedule it because of the issues around its misuse. Resisting future moves to reschedule ketamine is important for its continuous availability where needed. This scoping review addresses the question of whether ketamine should or should not be banned and the state of preparedness of low resource settings if ketamine petitions become successful in the future.

METHODS

A search was performed using PubMed and Google Scholar to identify articles published in the English language from March 2015 to August 2020. The articles were searched with a wide range of priori search terms related to the research questions. The selection of articles was based on relevance and eligibility.

RESULTS

Seventy-five articles were selected and grouped into 4 ethical themes. The search revealed that several articles addressed the importance of ketamine, pharmacology, misuse, supply, and consequences of a ketamine ban; however, none addressed how resource-poor countries should prepare for a future without the overreliance of ketamine.

CONCLUSION

Four ketamine petitions in about 10 years are an indication that another may resurface soon; therefore, it is important to continue to study the clinical importance of ketamine while discouraging its overreliance for clinical practice.

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative

BACKGROUND

Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI.

METHODS

Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed.

RESULTS

For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure.

CONCLUSION

Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

Overcoming Barriers to Accessing Surgery and Rehabilitation in Low and Middle-Income Countries: An Innovative Model of Patient Navigation in Nepal

BACKGROUND

Injury and disability are prominent public health concerns, globally and in the country of Nepal. Lack of locally available medical infrastructure, socioeconomic barriers, social marginalization, poor health literacy, and cultural barriers prevent patients from accessing surgical and rehabilitative care. Overcoming these barriers is an insurmountable challenge for the most vulnerable and marginalized, resulting in absence of treatment or even death.

METHODS

Sundar Dhoka Saathi Sewa (SDSS), a non-government organization, provides a patient navigation service which facilitates referrals to tertiary centers from Nepal's most remote areas. Specific criteria ensure that patient referrals are appropriate in regard to clinical and socioeconomic need, while comprehensive counselling helps guide the patient and family. The SDSS staff meet patients upon arrival in Kathmandu and facilitate admission to the appropriate tertiary hospital. They advocate for the patient, provide medicine, supply food and cover all treatment costs.

RESULTS

This project has enabled access to treatment for more than 1200 children for conditions leading to long-term disability and/or congenital heart disease. Interventions include a wide range of surgical and rehabilitative procedures such as complex orthopedics, cleft lip and palate, congenital talipes equinovarus, burn contractures, neurological cases, and cardiac surgery for valvular disease, septal defects and other congenital malformations.

DISCUSSION

The SDSS model of patient navigation is effective in overcoming the barriers to access surgical care and rehabilitation in Nepal. The success is owed to committed international donors, capacity building, effective counselling, advocacy, compassion, and community. We believe that this model could be replicated in other LMICs.

The Basic vs. Ability-to-Pay Approach: Evidence From China's Critical Illness Insurance on Whether Different Measurements of Catastrophic Health Expenditure Matter

Alleviating catastrophic health expenditure (CHE) is one of the vital objectives of health systems, as defined by the World Health Organization. However, no consensus has yet been reached on the measurement of CHE. With the aim of further relieving the adverse effects of CHE and alleviating the problem of illness-caused poverty, the Critical Illness Insurance (CII) program has been operational in China since 2012. In order to verify whether the different measurements of CHE matter under China's CII program, we compare the two-layer CII models built by using the basic approach and the ability-to-pay (ATP) approach at a range of thresholds. Exploiting the latest China family panel studies dataset, we demonstrate that the basic approach is more effective in relieving CHE for all insured households, while the ATP approach works better in reducing the severity of CHE in households facing it. These findings have meaningful implications for policymaking. The CII program should be promoted widely as a supplement to the current Social Basic Medical Insurance system. To improve the CII program's effectiveness, it should be based on the basic approach, and the threshold used to measure CHE should be determined by the goal pursued by the program.

What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure

OBJECTIVES

To measure the financial burden associated with accessing surgical care in Sierra Leone.

DESIGN

A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed.

SETTING

The main tertiary-level hospital in Freetown, Sierra Leone.

PARTICIPANTS

335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards.

OUTCOME MEASURES

Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived.

RESULTS

Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance.

CONCLUSION

Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.

What factors shape surgical access in West Africa? A qualitative study exploring patient and provider experiences of managing injuries in Sierra Leone

INTRODUCTION

Surgical access is central to universalising health coverage, yet 5 billion people lack timely access to safe surgical services. Surgical need is particularly acute in post conflict settings like Sierra Leone. There is limited understanding of the barriers and opportunities at the service delivery and community levels. Focusing on fractures and wound care which constitute an enormous disease burden in Sierra Leone as a proxy for general surgical need, we examine provider and patient perceived factors impeding or facilitating surgical care in the post-Ebola context of a weakened health system.

METHODS

Across Western Area Urban (Freetown), Bo and Tonkolili districts, 60 participants were involved in 38 semistructured interviews and 22 participants in 5 focus group discussions. Respondents included surgical providers, district-level policy-makers, traditional healers and patients. Data were thematically analysed, combining deductive and inductive techniques to generate codes.

RESULTS

Interacting demand-side and supply-side issues affected user access to surgical services. On the demand side, high cost of care at medical facilities combined with the affordability and convenient mode of payment to the traditional health practitioners hindered access to the medical facilities. On the supply side, capacity shortages and staff motivation were challenges at facilities. Problems were compounded by patients' delaying care mainly spurred by sociocultural beliefs in traditional practice and economic factors, thereby impeding early intervention for patients with surgical need. In the absence of formal support services, the onus of first aid and frontline trauma care is borne by lay citizens.

CONCLUSION

Within a resource-constrained context, supply-side strengthening need accompanying by demand-side measures involving community and traditional actors. On the supply side, non-specialists could be effectively utilised in surgical delivery. Existing human resource capacity can be enhanced through better incentives for non-physicians. Traditional provider networks can be deployed for community outreach. Developing a lay responder system for first-aid and front-line support could be a useful mechanism for prompt clinical intervention.

Forecasting surgical costs: Towards informed financial consent and financial risk reduction

BACKGROUND

Health care expenditure is increasing around the world and surgery is a major cause of financial hardship to patients and their families. Using pancreatoduodenectomy (PD), one of the most complex, morbid and costly operation as an example, this study aimed to identify the cost drivers of surgery, estimate relative contribution of these drivers, and derive and validate a cohort-specific cost forecasting tool.

METHODS

Data on the costs of 1406 patients undergoing PD in three tertiary hospitals in India, Italy and the United States were analysed. Cost drivers were identified and cost models developed using a 4-stage process.

RESULTS

There was a significant difference in overall cost of PD between the 3 cohorts. The cost drivers common to the 3 cohorts included duration of hospital stay and the outcome of death (Clavien-Dindo 5). Significant cohort-specific cost drivers included co-morbidities, operating theatre utilisation times and operative blood loss, development of pancreatectomy-specific complications (POPF, DGE, PPH), and need for interventional radiology to manage complications. Based on this, a cost forecasting tool was developed.

CONCLUSIONS

Drivers of costs for a surgical procedure (e.g. PD) are different between hospitals. Developing cost models/nomograms to predict the expected cost of surgery and perioperative care will not be applicable between hospitals. However, the approach could be used to develop context-specific data that will provide patients (at the time of the informed financial consent) and funding agencies with a more realistic cost estimate for a given operation. The developed cost forecasting tool warrants future validation.

Surgical site infection after gastrointestinal surgery in children: an international, multicentre, prospective cohort study

INTRODUCTION

Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings.

METHODS

A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI).

RESULTS

Of 1159 children across 181 hospitals in 51 countries, 523 (45·1%) children were from high HDI, 397 (34·2%) from middle HDI and 239 (20·6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI.

CONCLUSION

The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.

Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans

BACKGROUND

The COVID-19 pandemic has disrupted routine hospital services globally. This study estimated the total number of adult elective operations that would be cancelled worldwide during the 12 weeks of peak disruption due to COVID-19.

METHODS

A global expert response study was conducted to elicit projections for the proportion of elective surgery that would be cancelled or postponed during the 12 weeks of peak disruption. A Bayesian β-regression model was used to estimate 12-week cancellation rates for 190 countries. Elective surgical case-mix data, stratified by specialty and indication (surgery for cancer versus benign disease), were determined. This case mix was applied to country-level surgical volumes. The 12-week cancellation rates were then applied to these figures to calculate the total number of cancelled operations.

RESULTS

The best estimate was that 28 404 603 operations would be cancelled or postponed during the peak 12 weeks of disruption due to COVID-19 (2 367 050 operations per week). Most would be operations for benign disease (90·2 per cent, 25 638 922 of 28 404 603). The overall 12-week cancellation rate would be 72·3 per cent. Globally, 81·7 per cent of operations for benign conditions (25 638 922 of 31 378 062), 37·7 per cent of cancer operations (2 324 070 of 6 162 311) and 25·4 per cent of elective caesarean sections (441 611 of 1 735 483) would be cancelled or postponed. If countries increased their normal surgical volume by 20 per cent after the pandemic, it would take a median of 45 weeks to clear the backlog of operations resulting from COVID-19 disruption.

CONCLUSION

A very large number of operations will be cancelled or postponed owing to disruption caused by COVID-19. Governments should mitigate against this major burden on patients by developing recovery plans and implementing strategies to restore surgical activity safely.

Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions

Atherosclerotic cardiovascular disease (ASCVD) has posed an increasing burden on Americans and the United States healthcare system for decades. In addition, ASCVD has had a substantial economic impact, with national expenditures for ASCVD projected to increase by over 2.5‐fold from 2015 to 2035. This rapid increase in costs associated with health care for ASCVD has consequences for payers, healthcare providers, and patients. The issues to patients are particularly relevant in recent years, with a growing trend of shifting costs of treatment expenses to patients in various forms, such as high deductibles, copays, and coinsurance. Therefore, the issue of “financial toxicity” of health care is gaining significant attention. The term encapsulates the deleterious impact of healthcare expenditures for patients. This includes the economic burden posed by healthcare costs, but also the unintended consequences it creates in form of barriers to necessary medical care, quality of life as well tradeoffs related to non‐health–related necessities. While the societal impact of rising costs related to ASCVD management have been actively studied and debated in policy circles, there is lack of a comprehensive assessment of the current literature on the financial impact of cost sharing for ASCVD patients and their families. In this review we systematically describe the scope and domains of financial toxicity, the instruments that measure various facets of healthcare‐related financial toxicity, and accentuating factors and consequences on patient health and well‐being. We further identify avenues and potential solutions for clinicians to apply in medical practice to mitigate the burden and consequences of out‐of‐pocket costs for ASCVD patients and their families.

Analysis of Financial Risk Protection Indicators in Myanmar for Paediatric Surgery

PURPOSE

To estimate proportion of Myanmar paediatric population at risk of impoverishment and catastrophic expenditure due to emergency surgical intervention.

METHODS

Prospective data were collected at two tertiary surgical centres including income, household expenses, expenses related to surgery. Data analysis was performed to estimate out-of-pocket (OOP) direct medical costs and OOP total costs. Catastrophic expenditure: expense exceeded 10% of household income. Risk of impoverishment: net income drops were below an impoverishment threshold (PPP-purchasing power parity): I$ 2.00 PPP/day, I$ 1.25/day PPP, national poverty line. Distribution of income was estimated using a gamma distribution. Comparison to an adult cohort was performed using Chi-square test with a p value of <0.05 being significant.

RESULTS

A total of 145 surveys were collected, and 119 (82.1%) contained sufficient data: Paediatric Centre (n = 99) and Adult Centre (n = 20). Overall average per patient direct medical and non-medical OOP costs was I$493: Centre 1: I$540 PPP (range I$41-6,588 PPP) and Centre 2: I$437 PPP (range I$ 36-1,405 PPP). 64% experienced catastrophic expense. There is no significant difference between the centres in the risks of impoverishment or catastrophic expenditure (p = 0.05). Up to 44% are at risk of catastrophic expenditure should surgery be required. Most of the risk (90%) is derived from direct non-medical costs. A high proportion were at the national poverty line threshold (36.1%). Seeking surgical treatment would imperil up to 37% at the national poverty line threshold, and up to 5.7% at the I$2 PPP per day limit.

CONCLUSIONS

A large proportion of the Myanmar population are at risk of impoverishment or catastrophic expenditure should they require surgery. Financial risk protection mechanisms are needed.

Lifting the burden: State Medicaid expansion reduces financial risk for the injured

BACKGROUND

Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain because of high out-of-pocket (OOP) health care costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington (WA) state, which extended coverage to more than 600,000 WA residents, was associated with a reduction in financial risk among trauma patients.

METHODS

We analyzed all trauma patients aged 18 to 64 years admitted to the sole level 1 trauma center in WA from 2012 to 2017. We defined 2012 to 2013 as the prepolicy period and 2014 to 2017 as the postpolicy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate postsubsistence income and OOP expenses for our sample and then applied these two estimates to determine catastrophic health expenditure (CHE) risk as defined by the World Health Organization (OOP health expenses ≥40% of estimated household postsubsistence income).

RESULTS

A total of 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0%, and the uninsured rate decreased from 19.2% to 3.7% (p < 0.001 for both). There was no significant change in private insurance coverage. Medicaid expansion was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and less than 0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p < 0.01).

CONCLUSION

State ME led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers.

LEVEL OF EVIDENCE

Economic analysis, level II.

Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis

BACKGROUND

Health-care regionalisation, in which selected services are concentrated in higher-level facilities, has successfully improved the quality of complex medical care. However, the effectiveness of this strategy in routine maternal care is unknown. Malawi has established a national goal of halving its neonatal mortality by 2030. In this study, we aimed to assess the effect of obstetric service regionalisation in pregnant women and their newborn babies in Malawi.

METHODS

In this analysis, we assessed regionalisation through the use of an agent-based simulation model. We used a previously estimated utilisation function, incorporating both patient-specific and health-facility-specific characteristics, to inform patient choice. The model was validated against known utilisation patterns in Malawi. Four regionalisation scenarios were compared with the status quo: scenario 1 restricted deliveries to facilities currently capable of providing caesarean sections; scenario 2 had the same restrictions as scenario 1, but with selected facilities upgraded to provide caesarean sections; scenario 3 restricted delivery to facilities that provided five or more basic emergency obstetric and neonatal care services in the preceding 3 months; and scenario 4 had the same restrictions as scenario 3, but with selected facilities upgraded to provide at least five basic emergency obstetric and neonatal care services. We assessed neonatal mortality, utilisation, travel distance, median out-of-pocket expenditure, and proportion of women facing catastrophic expenditure. The effects of upgrading the obstetric readiness of all facilities, of removing all user fees, and of upgrading without restriction were considered in scenario analyses. Heterogeneity and parameter uncertainty were incorporated to create 95% posterior credible intervals (PCIs).

FINDINGS

Scenarios restricting women to give birth in facilities with caesarean section capabilities reduced neonatal mortality by 11·4 deaths per 1000 livebirths (scenario 1; 95% PCI 9·8-13·1) and 11·6 deaths per 1000 livebirths (scenario 2; 10·2-13·1), whereas scenarios restricting women to facilities that provided five or more basic emergency obstetric and neonatal care services did not affect neonatal mortality. Similarly, the caesarean section rate in Malawi, which is 4·6% under the status quo, was predicted to rise significantly in scenario 1 (14·7%, 95% PCI 14·5-14·9; p<0·0001) and scenario 2 (10·4%, 10·2-10·6; p<0·0001), but not in scenarios 3 and 4. Women were required to travel longer distances in scenario 1 (increase of 7·2 km, 95% PCI 4·5-9·9) and in scenario 2 (4·4 km, 1·5-7·2) than in the status quo (p<0·0001). Out-of-pocket costs tripled (p<0·0001; status quo vs scenario 1 and scenario 2), and the risk of catastrophic expenditure significantly increased from a baseline of 6·4% (95% PCI 6·1-6·6) to 14·7% (14·5-14·9) in scenario 1 and 11·3% (11·0-11·5) in scenario 2. This increase was especially pronounced among the poor (p<0·0001; status quo vs scenario 1 and scenario 2).

INTERPRETATION

Policies restricting women to give birth in facilities with caesarean section capabilities is likely to result in significant decreases in neonatal mortality and might allow Malawi to meet its goal of halving its neonatal mortality by 2030. However, this improvement comes at the cost of increased distances to care and worsening financial risks among women.

FUNDING

Bill & Melinda Gates Foundation, Damon Runyon Cancer Research Foundation.

How much is enough? Exploring the dose-response relationship between cash transfers and surgical utilization in a resource-poor setting

Objective

Cash transfers are a common intervention to incentivize salutary behavior in resource-constrained settings. Many cash transfer studies do not, however, account for the effect of the size of the cash transfer in design or analysis. A randomized, controlled trial of a cash-transfer intervention is planned to incentivize appropriate surgical utilization in Guinea. The aim of the current study is to determine the size of that cash transfer so as to maximize compliance while minimizing cost.

Methods

Data were collected from nine coastal Guinean hospitals on their surgical capabilities and the cost of receiving surgery. These data were combined with publicly available data about the general Guinean population to create an agent-based model predicting surgical utilization. The model was validated to the available literature on surgical utilization. Cash transfer sizes from 0 to 1,000,000 Guinean francs were evaluated, with surgical compliance as the primary outcome.

Results

Compliance with scheduled surgery increases as the size of a cash transfer increases. This increase is asymptotic, with a leveling in utilization occurring when the cash transfer pays for all the costs associated with surgical care. Below that cash transfer size, no other optima are found. Once a cash transfer completely covers the costs of surgery, other barriers to care such as distance and hospital quality dominate

Conclusion

Cash transfers to incentivize health-promoting behavior appear to be dose-dependent. Maximal impact is likely only to occur when full patient costs are eliminated. These findings should be incorporated in the design of future cash transfer studies.

The application of simulation-based medical education in low- and middle-income countries; the Myanmar experience

Simulation-based medical education (SBME) has become a routine part of practice in many disciplines including paediatric surgery. There is an evolving evidence base of its benefits both for surgical education, training and also patient education in high-income countries (HICs) but not in the low- and middle-income country (LMIC) setting. The advantages are hypothesised to be the same in both of these settings, although our experience is that they may be increased. In this article we describe the various modalities of SBME that maybe utilised in a LMIC in South East Asia. The various tips for the establishment of a successful simulation-based paediatric surgical programme and the potential pitfall that should be avoided are discussed.

Clinical Impact of the Introduction of Pediatric Intussusception Air Enema Reduction Technology in a Low- to Middle-Income Country Using Low-Cost Simulation-Based Medical Education

INTRODUCTION

Pediatric intussusception is a common cause of bowel obstruction in infants. Air enema (AE) reduction is routine first-line management in many countries; however, there is a high rate of operative intervention in low- and middle-income countries. The aims of the study were to use simulation-based medical education with an intussusception simulator to introduce AE reduction to Myanmar and to assess its effect on provider behaviors and the resulting clinical care.

METHODS

Clinical evaluation was conducted by comparing clinical outcomes data for children with intussusception 12 months before implementation with that from 12 months subsequent to implementation. These included the following: AE success rates, recurrence rates, length of stay, intestinal resection, and operative intervention rates. An educational workshop was developed that used a low-cost mannequin to facilitate practice at the reduction of intussusception using AE. Curriculum evaluation was performed through 5-point rating scale self-assessment in several domains. Data analysis was performed with Mann-Whitney U test, Student t test, or Wilcoxon signed-ranks test as appropriate; a P value of less than 0.05 was considered to be significant.

RESULTS

After implementation, there was a significant reduction in the overall operative intervention rates [82.5% (85/103) vs. 58.7% (44/75), P = 0.006]. Intestinal resection rates increased [15.3% (13/85) vs. 35.9% (14/39), P = 0.02]. The success rate with attempted AE reduction was 94.4% (34/36), with a recurrence rate of 5.6% (2/36). The simulation-based medical education workshop was completed by 25 local participants. There was a significant difference in the confidence of performing (1.9 vs. 3.6, P ≤ 0.0001) or assisting (2.8 vs. 3.7, P = 0.018) an AE reduction before and after the workshop.

CONCLUSIONS

Simulation-based educational techniques can be successfully applied in a low- and middle-income country to facilitate the safe introduction of new equipment and techniques with significant beneficial impact on provider behaviors and the resulting clinical care.

What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health

'Global surgery' is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems. Sitting at the interface between numerous clinical and non-clinical specialisms, it encompasses multiple aspects that surround the treatment of surgical disease and its equitable provision across health systems globally. From defining the role of, and need for, optimal surgical care through to identifying barriers and implementing improvement, global surgery has an expansive remit. Advocacy, education, research and clinical components can all involve surgeons, anaesthetists, nurses and allied healthcare professionals working together with non-clinicians, including policy makers, epidemiologists and economists. Long neglected as a topic within the global and public health arenas, an increasing awareness of the extreme disparities internationally has driven greater engagement. Not necessarily restricted to specific diseases, populations or geographical regions, these disparities have led to a particular focus on surgical care in low-income and middle-income countries with the greatest burden and needs. This review considers the major factors defining the interface between surgery, anaesthesia and public health in these settings.

Association of Out-of-Pocket Annual Health Expenditures With Financial Hardship in Low-Income Adults With Atherosclerotic Cardiovascular Disease in the United States

Importance

Health insurance is effective in preventing financial hardship from unexpected major health care events. However, it is also essential to assess whether vulnerable patients, particularly those from low-income families, are adequately protected from longitudinal health care costs for common chronic conditions such as atherosclerotic cardiovascular disease (ASCVD).

Objective

To examine the annual burden of total out-of-pocket health expenses among low-income families that included a member with ASCVD.

Design, Setting, and Participants

In this cross-sectional study of the Medical Expenditure Panel Survey from January 2006 through December 2015, all families with 1 or more members with ASCVD were identified. Families were classified as low income if they had an income under 200% of the federal poverty limit. Analyses began December 2017.

Main Outcomes and Measures

Total annual inflation-adjusted out-of-pocket expenses, inclusive of insurance premiums, for all patients with ASCVD. We compared these expenses against annual family incomes. Out-of-pocket expenses of more than 20% and more than 40% of family income defined high and catastrophic financial burden, respectively.

Results

We identified 22 521 adults with ASCVD, represented in 20 600 families in the Medical Expenditure Panel Survey. They correspond to an annual estimated 23 million or 9.9% of US adults with a mean (SE) age of 65 (0.2) years and included 10.9 million women (47.1%). They were represented in 21 million or 15% of US families. Of these, 8.2 million families (39%) were low income. The mean annual family income was $57 143 (95% CI, $55 377-$58 909), and the mean out-of-pocket expense was $4415 (95% CI, $3735-$3976). While financial burden from health expenses decreased throughout the study, even in 2014 and 2015, low-income families had 3-fold higher odds than mid/high-income families of high financial burden (21.4% vs 7.6%; OR, 3.31; 95% CI, 2.55-4.31) and 9-fold higher odds of catastrophic financial burden (9.8% vs 1.2%; OR, 9.35; 95% CI, 5.39-16.20), representing nearly 2 million low-income families nationally. Further, even among the insured, 1.6 million low-income families (21.8%) experienced high financial burden and 721 000 low-income families (9.8%) experienced catastrophic out-of-pocket health care expenses in 2014 and 2015.

Conclusions and Relevance

One in 4 low-income families with a member with ASCVD, including those with insurance coverage, experience a high financial burden, and 1 in 10 experience a catastrophic financial burden due to cumulative out-of-pocket health care expenses. To alleviate economic disparities, policy interventions must extend focus to improving not only access, but also quality of coverage, particularly for low-income families.

Cured into Destitution: Catastrophic Health Expenditure Risk Among Uninsured Trauma Patients in the United States

OBJECTIVE

To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk.

BACKGROUND

Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk.

METHODS

We performed a retrospective review, using data from the 2007-2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18-64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income.

RESULTS

Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286-$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196-$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%-71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16).

CONCLUSIONS

Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.

Out-of-pocket payments and catastrophic household expenditure to access essential surgery in Malawi - A cross-sectional patient survey

BACKGROUND

Having to pay out-of-pocket for health care can be prohibitive and even cause financial catastrophe for patients, especially those with low and irregular incomes. Health services at Government-owned hospitals in Malawi are provided free of charge but patients do incur costs when they access facilities and some of them forego income. This research paper presents findings on the direct and indirect expenditure incurred by patients who underwent hernia surgery at district and central hospitals in Malawi. It reports the main cost drivers, how costs relate to patients' household incomes, the financial burden of undergoing surgery and the extent to which hernia patients had recovered and restored their capacity to work and earn an income.

MATERIALS AND METHODS

Using a cross-sectional study design, surveys were held with patients who had undergone hernia surgery in four district and two central hospitals in Malawi. Interviews were conducted by surgically trained clinical officers, trained in survey administration, and included, inter alia, questions about patients' hospital stay, the direct and indirect cost they incurred in accessing surgery, and how they financed the expenditure. Follow-up interviews by telephone were held 8-10 weeks after discharge.

RESULTS

The sample included 137 patients from district and 86 patients from central hospitals. The main direct cost drivers were transport and food & groceries. More than three quarters of patients who had their surgery at a district hospital incurred indirect costs, because of income lost due to hospital admission, compared with just over a third among central hospital patients. Median reported income losses were US$ 90 and US$ 71, respectively. Catastrophic expenditure for surgery occurred in 94% of district and 87% of central hospital patients. When indirect costs are added to the out-of-pocket expenditure, it constituted more than 10% of the monthly per capita income for 97% and 90% of the district and central hospital patients, respectively.

CONCLUSION

Out-of-pocket household expenditure associated with essential surgery in Malawi is high and in many instances catastrophic, putting households, especially those who are already poor, at risk of further impoverishment. The much needed scaling-up of surgical services in rural areas of Malawi needs to be accompanied by financial risk protection measures.

Global children's surgery: recent advances and future directions

PURPOSE OF REVIEW

Two-thirds of the world's population lacks access to surgical care, many of them being children. This review provides an update on recent advances in global children's surgery.

RECENT FINDINGS

Surgery is being increasingly recognized as an essential component of global and child health. There is a greater focus on sustainable collaborations between high-income countries (HICs) and low-and-middle-income countries (HICs and LMICs). Recent work provides greater insight into the global disease burden, perioperative outcomes and effective context-specific solutions. Surgery has continued to be identified as a cost-effective intervention in LMICs. There have also been substantial advances in research and advocacy for a number of childhood surgical conditions.

SUMMARY

Substantial global disparities persist in the care of childhood surgical conditions. Recent work has provided greater visibility to the challenges and solutions for children's surgery in LMICs. Capacity-building and scale up of children's surgical care, more robust implementation research and ongoing advocacy are needed to increase access to children's surgical care worldwide.

Quality and outcomes in global cancer surgery: protocol for a multicentre, international, prospective cohort study (GlobalSurg 3)

INTRODUCTION

Empirical, observational data relating to the diagnosis, management and outcome of three common worldwide cancers requiring surgery is lacking. However, it has been demonstrated that patients in low/middle-income countries undergoing surgery for cancer are at increased risk of death and major complications postoperatively. This study aims to determine quality and outcomes in breast, gastric and colorectal cancer surgery across worldwide hospital settings.

METHODS AND ANALYSIS

This multicentre, international prospective cohort study will be undertaken by any hospital providing emergency or elective surgical services for breast, gastric or colorectal cancer. Centres will collect observational data on consecutive patients undergoing primary emergency or elective surgery for breast, gastric or colorectal cancer during a 6-month period. The primary outcome is the incidence of mortality and major complication rate at 30 days after cancer surgery. Infrastructure and care processes in the treatment of these cancers worldwide will also be characterised.

ETHICS AND DISSEMINATION

This project will not affect clinical practice and has been classified as clinical audit following research ethics review. The protocol will be disseminated through the international GlobalSurg network.

TRIAL REGISTRATION NUMBER

NCT03471494; Pre-results.

Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda

Background

There are few prospective studies of outcomes following surgery in rural district hospitals in sub-Saharan Africa. This study aimed to estimate the prevalence and predictors of surgical-site infection (SSI) following caesarean section at Kirehe District Hospital in rural Rwanda.

Methods

Adult women who underwent caesarean section between March and October 2017 were given a voucher to return to the hospital on postoperative day (POD) 10 (±3 days). At the visit, a physician evaluated the patient for an SSI. A multivariable logistic regression model was used to identify risk factors for SSI, built using backward stepwise selection.

Results

Of 729 women who had a caesarean section, 620 were eligible for follow-up, of whom 550 (88·7 per cent) returned for assessment. The prevalence of SSI on POD 10 was 10·9 per cent (60 women). In the multivariable analysis, the following factors were significantly associated with SSI: bodyweight more than 75 kg (odds ratio (OR) 5·98, 1·56 to 22·96; P = 0·009); spending more than €1·1 on travel to the health centre (OR 2·42, 1·31 to 4·49; P = 0·005); being a housewife compared with a farmer (OR 2·93, 1·08 to 7·97; P = 0·035); and skin preparation with a single antiseptic compared with a combination of two antiseptics (OR 4·42, 1·05 to 18·57; P = 0·043). Receiving either preoperative or postoperative antibiotics was not associated with SSI.

Conclusion

The prevalence of SSI after caesarean section is consistent with rates reported at tertiary facilities in sub-Saharan Africa. Combining antiseptic solutions for skin preparation could reduce the risk of SSI.

Ethics in humanitarian efforts: when should resources be allocated to paediatric heart surgery?

BACKGROUND

In countries with ample resources, no debate exists as to whether heart surgery should be provided. However, where funding is limited, what responsibility exists to care for children with congenital heart defects? If children have a "right" to surgical treatment, to whom is the "duty" to provide it assigned? These questions are subjected to ethical analysis.

METHODS

Examination is initially based on the four principles of medical ethics: autonomy, beneficence, non-maleficence, and justice. Consideration of beneficence and justice is expanded using a consequentialist approach.

RESULTS

Social structures, including governments, exist to foster the common good. Society, whether by means of government funding or otherwise, has the responsibility, according to the means available, to assure health care for all based on the principles of beneficence, non-maleficence, and justice. In wealthy countries, adequate resources exist to fund appropriate treatment; hence it should be provided to all based on distributive justice. In resource-limited countries, however, decisions regarding provision of care for expensive or complex health problems must be made with consideration for broader effects on the general public. Preliminary data from cost-effectiveness analysis indicate that many surgical interventions, including cardiac surgery, may be resource-efficient. Given that information, utilitarian ethical analysis supports dedication of resources to congenital heart surgery in many low-income countries. In the poorest countries, where access to drinking water and basic nutrition is problematic, it will often be more appropriate to focus on these issues first.

CONCLUSION

Ethical analysis supports dedication of resources to congenital heart surgery in all but the poorest countries.

Evaluating the collection, comparability and findings of six global surgery indicators

Background

In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates.

Methods

Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates.

Results

Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed.

Conclusion

Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.

Surgical Capacity at District Hospitals in Zambia: From 2012 to 2016

BACKGROUND

Sub-Saharan Africa has one of the highest burdens of surgically treatable conditions in the world and the highest unmet need, especially in rural areas. Zambia is one of the countries in the region taking steps to improve surgical care for its rural populations.

AIM

To demonstrate changes in surgical capacity in Zambia's district hospitals over a 3-year period and to provide a baseline from which future interventions in surgical care can be assessed.

METHODS

A cross-sectional assessment of surgical capacity, using a modified WHO questionnaire, was administered in first-level hospitals in nine of Zambia's ten provinces between November 2012 and February 2013 and again between February and April 2016. The two assessments allowed measurement of changes in surgical workforce, infrastructure, equipment, drugs and consumables; and numbers of major surgical procedures performed over two 12-month periods prior to the assessments.

RESULTS

There was a significant increase, 2013-2016, in number of theatre staff, from 174 (mean 4.4; SD 1.7) to 235 (mean 6; SD 2.9), P = 0.02. However, the percentage of hospitals with functioning anaesthetic machines dropped from 64 to 41%. There was also a drop in hospitals reporting availability of instruments, drugs and consumables from 38 to 24 (97-62%) and from 28 to 24 (72-62%), respectively. The median number of caesarean sections in 2012 was 99 [interquartile range (IQR) 42-187] and 100 (IQR 42-126) in 2015 (P value =0.53). The median number of major surgical procedures in 2012 was 54 (IQR 10-113) and 66 (IQR 18-168) in 2015 (P = 0.45).

CONCLUSION

An increase in the first-level hospital surgical workforce between 2013 and 2016 was accompanied by reductions in essential equipment and consumables for surgery, and no changes in surgical output. Periodic monitoring of resource availability is needed to address shortages and make safe surgery available to rural populations.

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis

BACKGROUND

Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure.

METHODS

As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure.

RESULTS

Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001).

CONCLUSIONS

The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

Clinical Outcome, Social Impact and Patient Expectation: a Purposive Sampling Pilot Evaluation of Patients in Benin Seven Years After Surgery

BACKGROUND

Access to affordable and timely surgery is not equitable around the world. Five billion people lack access, and while non-governmental organizations (NGOs) help to meet this need, long-term surgical outcomes, social impact or patient experience is rarely reported.

METHOD

In 2016, Mercy Ships, a surgical NGO, undertook an evaluation of patients who had received surgery seven years earlier with Mercy Ships in 2009 in Benin. Using purposive sampling, patients who had received maxillofacial, plastics or orthopedic surgery were invited to attend a surgical evaluation day. In this pilot study, we used semi-structured interviews and questionnaire responses to assess patient expectation, surgical and social outcome.

RESULTS

Our results show that seven years after surgery 35% of patients report surgery-related pain and 18% had sought further care for a clinical complication of their condition. However, 73% of patients report gaining social benefit from surgery, and overall patient satisfaction was 89%, despite 35% of patients saying that they were unclear what to expect after surgery indicating a mismatch of doctor/patient expectations and failure of the consent process.

CONCLUSION

In conclusion, our pilot study shows that NGO surgery in Benin provided positive social impact associated with complication rates comparable to high-income countries when assessed seven years later. Key areas for further study in LMICs are: evaluation and treatment of chronic pain, consent and access to further care.