Population Health Metrics for Surgery: Effective Coverage of Surgical Services in Low-Income and Middle-Income Countries

First American College of Surgeons National Surgical Quality Improvement Program Report from a Low-Middle-Income Country: A 1-Year Outcome Analysis of Neurosurgical Cases

BACKGROUND

Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks.

METHODS

Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients' medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs.

RESULTS

Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP.

CONCLUSIONS

Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries.

Effective coverage for hypertension treatment among middle-aged adults and the older population in China, 2011 to 2013: A nationwide longitudinal study

Methods

We used the baseline survey and first follow-up surveys of the China Health and Retirement Longitudinal Study of middle-aged and older populations conducted between 2011 and 2013. Correlates of effective coverage and treatment coverage for hypertension were analysed using multivariate logistic regression models, after controlling for demographic characteristics.

Results

In 2011, 38.40% of 13 702 individuals surveyed were identified with hypertension. Overall, the effective treatment coverage among the middle-aged and older population in China from 2011 to 2013 was only 22.40% compared to the treatment coverage of 55.86%. Variations in effective coverage among patients enrolled in the three public health insurance schemes ranged from 22.60% to 29.31%.

Conclusions

The level of effective coverage for hypertension treatment in China was still very low, and that health insurance schemes play a significant role in improving treatment coverage and effective coverage for hypertension treatment. In the implementation of China’s health system reform, health equity and health care equality should be emphasised and enhanced by offering more equitable benefits packages across social health insurance schemes.

Developing Metrics to Define Progress in Children's Surgery

There is a need for relevant, valid, and practical metrics to better quantify both need and progress in global pediatric surgery and for monitoring systems performance. There are several existing surgical metrics in use, including disability-adjusted life years (DALYs), surgical backlog, effective coverage, cost-effectiveness, and the Lancet Commission on Global Surgery indicators. Most of these have, however, not been yet applied to children's surgery, leaving therefore significant data gaps in the burden of disease, infrastructure, human resources, and quality of care assessments in the specialty. This chapter reviews existing global surgical metrics, identifies settings where these have been already applied to children's surgery, and highlights opportunities for further inquiry in filling the knowledge gaps. Directing focused, intentional knowledge translation efforts in the identified areas of deficiency will foster the maturation of global pediatric surgery into a solid academic discipline able to contribute directly to the cause of improving the lives of children around the world.

Effective coverage as a new approach to health system performance assessment: a scoping review

Background

Delivering interventions is the main task of health systems whose accurate measurement is an essential input into tracking performance. Recently, the concept of effective coverage was introduced by World Health Organization to incorporate into health system performance assessment. The aim of present scoping review was mapping the key elements and steps of effective coverage assessment in practical efforts including kinds of interventions, criteria for selecting them and the need, use and quality estimation approaches and strategies of each intervention.

Methods

We conducted a scoping review of health system/program assessments which assessed effective coverage till May 2017. Seven databases were systematically searched with no time and language restriction through applying combined keyword of “effective coverage”.

Results

Eighteen studies contributed findings on monitoring effective coverage of health interventions and they all were included in the review. Only 4 contributed findings on health system and the others were related to specific intervention(s) assessment. The interventions monitored by effective coverage were mainly in child health, prenatal and antenatal care and delivery, and chronic conditions areas. Potential impact on the burden of disease, leading causes of mortality and morbidity, and high occurrence and prevalence rate were among the main intervention selection criteria. Availability of data was the critical prerequisite, especially, in all of the studies applied ex post approach in estimating effective coverage. Estimation based on a norm, self- reporting from surveys and biomarkers were the main strategies and methods of need, utilization and quality measurement, respectively.

Conclusions

More studies are needed to contribute to the ongoing improvement in the development of effective coverage concept and increasing practical efforts, especially through defining prospective approaches and strategies into estimation of composite measures based on the effective coverage framework. Also, further attention needs to be paid to quality measures of effective coverage in a manner that better conceptualizes and measures the connection between coverage rates and interventions’ effectiveness. At the administrative system level, more innovation is needed to develop data systems in order to enhance capacity of routine health service information.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3692-7) contains supplementary material, which is available to authorized users.

Evaluating quality standards' adherence in surgical care: a case study from Pakistan

Objective

To explore the extent of adherence to surgical quality standards and areas of improvement.

Design

Multi-method case study was done. Assessment of observed/actual and self-reported adherence to quality standards in surgical care was done on WHO's safe-surgery checklist. Client satisfaction through exit interviews assessed of all operated during 1 month. Semi-structured interviews of key informants were conducted to identify areas of improvements in surgical care in this hospital.

Setting

Conducted in a tertiary care teaching hospital in Lahore, Pakistan.

Participants

Out of all 154 patients during 1 month were admitted with indications for surgery and 35.71% patients gave consent and participated in the study.

Outcome measure

Actual and reported adherence data were categorized in excellent, good, satisfactory and poor adherence to standards. For in-depth interviews, themes were identified from textual data.

Results

Overall activities in surgical department were performed well, patients were satisfied and hospital surgical mortality rate was zero but infection control measures needs attention and these practices were found poor with high re-operation and re-admissionrate (P-value < 0.001). Adherence to standards of surgical quality was inadequate in pre-operative, operative and post-op steps as assessed on the checklist but actual adherence was different from reported adherence by surgical care providers.

Conclusion

This case study shows a complete picture of surgical care quality in a hospital of Pakistan. Discrepancy between perceived/reported adherence and actual practice was found. Patients' satisfaction is not a reliable outcome measure of surgical care quality.

When Surgical Resources are Severely Constrained, Who Receives Care? Determinants of Access to Orthopaedic Trauma Surgery in Uganda

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.

Determining the effective coverage of maternal and child health services in Kenya, using demographic and health survey data sets: tracking progress towards universal health coverage

OBJECTIVES

Effective coverage (EC) is a measure of health systems' performance that combines need, use and quality indicators. This study aimed to assess the extent to which the Kenyan health system provides effective and equitable maternal and child health services, as a means of tracking the country's progress towards universal health coverage.

METHODS AND RESULTS

The Demographic Health Surveys (2003, 2008-2009 and 2014) and Service Provision Assessment surveys (2004, 2010) were the main sources of data. Indicators of need, use and quality for eight maternal and child health interventions were aggregated across interventions and economic quintiles to compute EC. EC has increased from 26.7% in 2003 to 50.9% in 2014, but remains low for the majority of interventions. There is a reduction in economic inequalities in EC with the highest to lowest wealth quintile ratio decreasing from 2.41 in 2003 to 1.65 in 2014, but maternal health services remain highly inequitable.

CONCLUSIONS

Effective coverage of key maternal and child health services remains low, indicating that individuals are not receiving the maximum possible health gain from existing health services. There is an urgent need to focus on the quality and reach of maternal and child health services in Kenya to achieve the goals of universal health coverage.

Health workforce metrics pre- and post-2015: a stimulus to public policy and planning

BACKGROUND

Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015.

METHODS

Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies.

RESULTS

There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed.

CONCLUSIONS

There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning.

Is safe surgery possible when resources are scarce?

The greatest burden of surgical disease exists in low- and middle-income countries, where the quality and safety of surgical treatment cause major challenges. Securing necessary and appropriate medical supplies and infrastructure remains a significant and under-recognised limitation to providing safe and high-quality surgical care in these settings. The majority of surgical instruments are sold in high-income countries. Limited market pressures lead to superfluous designs and inflated costs for these devices. This context creates an opportunity for frugal innovation-the search for designs that will enable low-cost care without compromising quality. Although progressive examples of frugal surgical innovations exist, policy innovation is required to augment design pathways while fostering appropriate safety controls for prospective devices. Many low-cost, high-quality medical technologies will increase access to safe surgical care in low-income countries and have widespread applicability as all countries look to reduce the cost of providing care, without compromising quality.

Unmet surgical needs in children: a household survey in Nepal

PURPOSE

While an estimated two billion people lack access to surgical care, little data are available on surgical conditions for pediatric populations in low- and middle-income countries. Our study aims to assess pediatric surgical needs in Nepal.

METHODS

A countrywide cross-sectional study was performed in 15 randomly chosen districts; 3 clusters (2 rural; 1 urban) per district were selected. The prevalence of surgical conditions, unmet surgical needs, and barriers to care were analyzed among children (0-18 years of age).

RESULTS

Overall, 1,350 households and 2,695 individuals were surveyed (response rate: 97 %); 800 respondents (29.7 %, 95 % CI 27.9-31.4 %) were pediatric; 59.8 % (95 % CI 56.3-63.2 %) were male; median age was 10 years (IQR 5-15). Of them, 84 (10.5 %, 95 % CI 8.5-12.8 %) had a surgical condition; 48 (6.0 %, 95 % CI 4.5-7.9 %) reported an unmet need for surgical care. Based on this, we estimate that 706,076 (95 % CI 529,557-929,666) children live with untreated surgical conditions. Barriers to care included limited availability of services (31.3 %), funds (22.9 %), time (4.2 %), and fear/mistrust of medical services (16.7 %).

CONCLUSION

Close to 700,000 children in Nepal are estimated to need surgical consultation. Programs to address this should be developed alongside efforts by policy makers and donors to rectify the lack of care, bolster limited funds, and strengthen healthcare systems.

Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes

OBJECTIVES

Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters.

METHODS

We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (non-transfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests.

RESULTS

Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was "lack of satisfactory surgical care." There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values <0.001) between transferred and non-transferred patients. In 56 patients there was a further delay in admission, and the most common reason was bed availability, followed by financial constraints. Three patients were shifted out of the hospital due to lack of ventilator, and 14 patients left against medical advice due to financial limitations. One patient died.

CONCLUSIONS

Inter-facility transfer of patients with surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.

Effective coverage: a metric for monitoring Universal Health Coverage

A major challenge in monitoring universal health coverage (UHC) is identifying an indicator that can adequately capture the multiple components underlying the UHC initiative. Effective coverage, which unites individual and intervention characteristics into a single metric, offers a direct and flexible means to measure health system performance at different levels. We view effective coverage as a relevant and actionable metric for tracking progress towards achieving UHC. In this paper, we review the concept of effective coverage and delineate the three components of the metric - need, use, and quality - using several examples. Further, we explain how the metric can be used for monitoring interventions at both local and global levels. We also discuss the ways that current health information systems can support generating estimates of effective coverage. We conclude by recognizing some of the challenges associated with producing estimates of effective coverage. Despite these challenges, effective coverage is a powerful metric that can provide a more nuanced understanding of whether, and how well, a health system is delivering services to its populations.

Innovative bridging of the rural-urban divide: comparison of scope, safety, and impact of collaborative rural surgery camps and an urban surgical program

BACKGROUND

In medically under-resourced regions worldwide, non-permanent surgery programs or camps have been conducted to expand access to surgical services. Surgery camp programs have been reported in rural India, primarily in the ophthalmic and obstetric fields; however, the provision of general surgical services in these settings is largely unknown.

METHODS

A 12-month retrospective review of non-ambulatory procedures performed at a rural hospital surgery camp program and at an urban hospital in Maharashtra, India, was completed to characterize relative differences in procedural activity, frequency and severity of perioperative complications, and to evaluate efficacy of care.

RESULTS

A total of 449 cases performed in rural hospital surgery camps were compared with 344 cases performed in an urban hospital during the course of the study period. The majority of rural surgical cases were elective and of intermediate complexity. Approximately 4% of rural cases were complex-major compared to 17% of urban cases. Intraoperative complications occurred in 0.2% rural cases compared to 5.5% of urban cases; p = 0.01. Postoperative complications were predominantly low grade in both groups. The postoperative complication rate was higher among rural surgical patients (43.4%; 23.5%; p < 0.01), though the Surgical Risk Score was significantly lower in this group (p < 0. 01). Rural surgery camp activity over 12 months achieved diagnostic and/or therapeutic goals in 92.2% of procedures and rendered 1.74-2.69 disability-adjusted life-years (DALYs) averted per patient.

CONCLUSIONS

Rural general surgery camps can safely and effectively provide a wide range of surgical services under appropriate collaborative and clinical conditions. Surgery camps may be a safe, temporizing solution to unmet needs until substantial gains in rural healthcare are realized.

Cleft lip-cleft palate in Zimbabwe: estimating the distribution of the surgical burden of disease using geographic information systems

OBJECTIVES/HYPOTHESIS

To evaluate the prevalence and unmet need for cleft lip-cleft palate reconstructive surgery by using incidence. Our hypotheses were that the age of presentation to screening clinics will decrease between 2006 and 2012, and the geospatial distribution of cases will expand to a more rural catchment area.

STUDY DESIGN

Longitudinal cross-sectional/geospatial distribution study.

METHODS

An online, secure database was created from intake forms for children with cleft lip-cleft palate (N=604) in Zimbabwe (2006-2012). Univariate analysis was completed. A linear regression model was fitted to test the time trend of a child's age at the time of presentation. Unique patient addresses (n=411) were matched. Maps presenting cleft diagnosis and presentation year were created with geographic information systems (GIS) software.

RESULTS

The median age of presentation was greater for isolated cleft palate (4.2 years, n=106) than isolated cleft lip (1.5 years, n=251) and cleft lip-cleft palate (2.0 years, n=175). Cleft lip cases were mostly left sided with equal gender distribution. The overall age of presentation remained stable (P=.83). The age of children with isolated cleft palate decreased by 0.8 years per surgical trip (P=.01), suggesting the prevalence of unrepaired cleft palate is decreasing due to local and visiting surgeons. The catchment area extended to a less populous area, but clustered around Harare and Bulawayo.

CONCLUSIONS

This study gives Zimbabwe-specific evidence that supports reports of the persistent burden of disease requiring attention. The GIS software provided data for the primary needs assessment, which will direct communication to healthcare providers and prospective patients outside of the current catchment area.

LEVEL OF EVIDENCE

3

Evaluation of surgical care in El Salvador using the WHO surgical vital statistics

OBJECTIVE

Vital statistics to assess surgical care worldwide have been published by the World Health Organization. These data have not been reported for any Latin American country. We sought to measure these metrics as a starting point for understanding how to improve the safety of surgery in El Salvador.

METHODS

We designed an institutional survey that was sent to 21 hospitals and used national administrative data sources to estimate the number of surgeons, anesthesia professionals, operating rooms, and annual surgical volume for El Salvador. We reviewed surgical and death logs for 12 Ministry of Health hospitals to calculate day-of-surgery and postoperative in-hospital mortality ratios for a 6-month period (October 2009-March 2010).

FINDINGS

We estimate there to be 1,222 surgeons [95 % confidence interval (CI) 1,137-1,307], 539 anesthesia providers, 168 operating rooms (95 % CI 136-199), and 172,972 operations (95 % CI 171,961-173,983) annually in El Salvador. There were on average 1,197 annual cases per operating room and 436 annual cases per surgeon in the 21 hospitals we studied. The day-of-surgery mortality ratio was 0.42 % (95 % CI 0.35-0.5), whereas the postoperative in-hospital mortality ratio was 1.58 % (95 % CI 1.44-1.72). The postoperative in-hospital mortality ratio was higher for hospitals with a greater number of hospital beds (p = 0.01) and operating rooms (p = 0.02).

CONCLUSIONS

Despite the challenges that El Salvador faces to provide surgical care, national collection of surgical vital statistics is feasible. Collection of additional process and outcome measures may be insightful for improving the surgical safety in El Salvador and elsewhere.

Surgical Care in the Developing World-Strategies and Framework for Improvement

The purpose of this study was to identify the various problems with surgical care in the developing world and enumerate identified strategies or propose solutions. We also sought to rank these strategies in order of potential impact. The MEDLINE database was sought. Studies published in English, reporting currently employed solutions to identified barriers or problems to surgical care in developing countries or potential solution(s) and published between 2000 and 2012 were eligible for inclusion. 2156 articles were identified for possible inclusion. MeSH terms include surgery, general surgery, developing countries, health services accessibility and quality improvement. Forty-nine full articles with a primary focus on the solutions to the challenges to surgical care in the developing world were included in the final review. Many articles identified problems with infrastructure, workforce shortage, inadequate or inappropriate policies, and poor financing as major problems with healthcare in the developing world. Solutions addressing these problems are multifactorial and would require active participation of local authorities and collaboration with providers from the developed world. The burden of surgical care is increasing. There is poor access to surgical services in the developing world. If and when surgical care is received, the quality could be less than the standard in developed nations. Solutions exist to tackle these problems but require a multidimensional approach to be successful.

Socioeconomic and disability consequences of injuries in the Sudan: a community-based survey in Khartoum State

BACKGROUND

Fatal and non-fatal injuries are of increasing public health concern globally, particularly in low and middle-income countries. Injuries sustained by individuals also impact society, creating a loss of productivity with serious economic consequences. In Sudan, there is no documentation of the burden of injuries on individuals and society.

METHODS

A community-based survey was performed in Khartoum State, using a stratified two-stage cluster sampling technique. Households were selected in each cluster by systematic random sampling. Face-to-face interviews during October and November 2010 were conducted. Fatal injuries occurring during 5 years preceding the survey and non-fatal injuries occurring during 12 months preceding interviews were included.

RESULTS

The total number of individuals included was 5661, residing in 973 households. There were 28 deaths due to injuries out of a total of 129 reported deaths over 5 years. A total of 441 cases of non-fatal injuries occurred during the 12 months preceding the survey. The number of disability days differed significantly between mechanisms of injury. Road traffic crashes and falls caused the longest duration of disability. Men had a higher probability than women of losing a job due to an injury.

CONCLUSIONS

This study demonstrates the importance of prioritising prevention of road traffic crashes and falls. The loss of productivity in lower socioeconomic strata highlights the need for social security policies. Further research is needed for estimating the economic cost of injuries in Sudan.

A material cost-minimization analysis for hernia repairs and minor procedures during a surgical mission in the Dominican Republic

INTRODUCTION

Expenditures on material supplies and medications constitute the greatest per capita costs for surgical missions. We hypothesized that supply acquisition at non-profit organization (NPO) costs would lead to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for hernia repairs and minor procedures during a surgical mission in the Dominican Republic.

METHODS

Items acquired for a surgical mission were uniquely QR-coded for accurate consumption accounting. Both NPO and US academic institution unit costs were associated with each item in an electronic inventory system. Medication doses were recorded and QR codes for consumed items were scanned into a record for each sampled procedure. Mean material costs and cost-savings ± SDs were calculated in US dollars for each procedure type. Cost-minimization analyses between the NPO and the US academic institution platforms for each procedure type ensued using a two-tailed Wilcoxon matched-pairs test with α = 0.05. Item utilization analyses generated lists of most frequently used materials by procedure type.

RESULTS

The mean cost-savings of supply acquisition at NPO costs for each procedure type were as follows: $482.86 ± $683.79 for unilateral inguinal hernia repair (n = 13); $332.46 ± $184.09 for bilateral inguinal hernia repair (n = 3); $127.26 ± $13.18 for hydrocelectomy (n = 9); $232.92 ± $56.49 for femoral hernia repair (n = 3); $120.90 ± $30.51 for umbilical hernia repair (n = 8); $36.59 ± $17.76 for minor procedures (n = 26); and $120.66 ± $14.61 for pediatric inguinal hernia repair (n = 7).

CONCLUSION

Supply acquisition at NPO costs leads to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for inguinal hernia repair, hydrocelectomy, umbilical hernia repair, minor procedures, and pediatric inguinal hernia repair during a surgical mission in the Dominican Republic. Item utilization analysis can generate minimum-necessary material lists for each procedure type to reproduce cost-savings for subsequent missions.

Costs of surgical procedures in Indian hospitals

OBJECTIVE

Despite a growing volume of surgical procedures in low-income and middle-income countries, the costs of these procedures are not well understood. We estimated the costs of 12 surgical procedures commonly conducted in five different types of hospitals in India from the provider perspective, using a microcosting method.

DESIGN

Cost and utilisation data were collected retrospectively from April 2010 to March 2011 to avoid seasonal variability.

SETTING

For this study, we chose five hospitals of different types: a 57-bed charitable hospital, a 200-bed private hospital, a 400-bed district hospital, a 655-bed private teaching hospital and a 778-bed tertiary care teaching hospital based on their willingness to cooperate and data accessibility. The hospitals were from four states in India. The private, charitable and tertiary care hospitals serve urban populations, the district hospital serves a semiurban area and the private teaching hospital serves a rural population.

RESULTS

Costs of conducting lower section caesarean section ranged from rupees 2469 to 41 087; hysterectomy rupees 4124 to 57 622 and appendectomy rupees 2421 to 3616 (US$1=rupees 52). We computed the costs of conducting lap and open cholecystectomy (rupees 27 732 and 44 142, respectively); hernia repair (rupees 13 204); external fixation (rupees 8406); intestinal obstruction (rupees 6406); amputation (rupees 5158); coronary artery bypass graft (rupees 177 141); craniotomy (rupees 75 982) and functional endoscopic sinus surgery (rupees 53 398).

CONCLUSIONS

Estimated costs are roughly comparable with rates of reimbursement provided by the Rashtriya Swasthya Bima Yojana (RSBY)-India's government-financed health insurance scheme that covers 32.4 million poor families. Results from this type of study can be used to set and revise the reimbursement rates.

Ratio of cesarean sections to total procedures as a marker of district hospital trauma capacity

BACKGROUND

There are few established metrics to define surgical capacity in resource-limited settings. Previous work hypothesizes that the relative frequency of cesarean sections (CS) at a hospital, expressed as a proportion of total operative procedures (%CS), may serve as a proxy measure of surgical capacity. We attempted to evaluate this hypothesis as it specifically relates to hospital capacity for emergency interventions for injury.

METHODS

We conducted a WHO survey of emergency surgical capacity at 40 Rwandan district hospitals in November 2010 and extracted annual operative volume for 2010 from the Ministry of Health centralized statistical system. We dichotomized the 40 hospitals into low and high %CS groups below and above the median proportion of CS performed. We compared low and high %CS groups across self-reported capabilities related to facility characteristics, trauma supplies, procedural capacity, and surgical training using bivariate χ(2) statistics with significance indicated at p ≤ 0.05. We evaluated herniorrhaphy proportion of total procedures (%Hernia) as a representative general surgery procedure in the same manner.

RESULTS

High %CS hospitals were less likely to report capability related to blood banking (p = 0.05), amputation (p = 0.04), closed fracture repair (p = 0.04), inhalational anesthesia (p = 0.05), and chest tube insertion (p = 0.05). Availability of reliable electricity was the only measure that showed statistical significance with the %Hernia measure (p = 0.02).

CONCLUSIONS

Cesarean section proportion shows some utility as a marker for district hospital injury-care capacity in resource-limited settings.

Burden of Surgical Disease: Strategies to Manage an Existing Public Health Emergency

The World Health Organization estimates that the burden of surgical disease due to war, self-inflicted injuries, and road traffic incidents will rise dramatically by 2020. During the 2009 Harvard Humanitarian Initiative's Humanitarian Action Summit (HHI/HAS), members of the Burden of Surgical Disease Working Group met to review the state of surgical epidemiology, the unmet global surgical need, and the role international organizations play in filling the surgical gap during humanitarian crises, conflict, and war. An outline of the group's findings and recommendations is provided.

Ethical issues of medical missions: the clinicians' view

Surgery is an important part of health care worldwide. Without access to surgical treatments, morbidity and mortality increase. Access to surgical treatment is a significant problem in global public health because surgical services are not equally distributed in the world. There is a disproportionate scarcity of surgical access in low-income countries. There are many charitable organizations around the world that sponsor surgical missions to under served nations. One such organization is Operation Smile International, a group with which both authors have volunteered. This paper will describe the purpose and processes involved in Operation Smile and identify some of the key ethical issues that arise in short term medical volunteer work highlighting the importance of sustainability.

Implementing surgical services in a rural, resource-limited setting: a study protocol

INTRODUCTION

There are well-established protocols and procedures for the majority of common surgical diseases, yet surgical services remain largely inaccessible for much of the world's rural poor. Data on the process and outcome of surgical care expansion, however, are very limited, and the roll-out process of rural surgical implementation in particular has never been studied. Here, we propose the first implementation research study to assess the surgical scale-up process in the rural district of Achham, Nepal.

METHODS AND ANALYSIS

Based primarily on the protocols of the WHO's Integrated Management for Emergency and Essential Surgical Care (IMEESC), this study's threefold implementation strategy will include: (1) the core IMEESC surgical care program, (2) community-based follow-up via health workers, and (3) hospital-based quality improvement programs. The implementation program will employ additional emergency and surgical care protocols developed collaboratively by physicians, nurses and the authors. This strategy will be referred to as IMEESC-Plus. This study will employ both qualitative and quantitative research methodologies to collect clinical data and information on the reception and utilisation of services. The first 18 months of the implementation process will be studied and divided into an initial phase (first 6 months) and a consolidation phase (subsequent 12 months).

DISCUSSION

This study aims to describe the logistics of the implementation process of IMEESC-Plus, and assess the quality of the resulting IMEESC-Plus services during the course of the implementation process. Using data generated from this study, larger, multi-site implementation studies can be planned that assess the scale-up of surgical services worldwide in resource-limited areas.

Expanding laparoscopic cholecystectomy to rural Mongolia

BACKGROUND

Although laparoscopic cholecystectomy was first introduced in Mongolia in 1994, the benefits of the laparoscopic approach have been largely unavailable to the majority of the population. The burden of gallbladder disease in Mongolia is significant. Despite the barriers to expanding laparoscopic surgery in Mongolia (lack of physical resources and adequate training opportunities, a difficult political situation, and an austere environment), the Health Sciences University of Mongolia (HSUM) began looking for ways to further the development of laparoscopy for the entire country, including the rural areas where half the population resides.

METHODS

Combined didactic and practical training courses lasting 2 weeks were developed collaboratively by a private nongovernmental organization and HSUM. The courses were taught at tertiary care centers in the capital city (Ulaanbaatar) and in a smaller, rural city (Erdenet), the regional northern referral center. Demographic data, preoperative diagnosis, ultrasound and operative findings, operative times, length of hospital stay, and intraoperative and postoperative complication rates were compared from 2007-2008 from hospitals in Ulaanbaatar and Erdenet.

RESULTS

A total of 36 surgeons participated in the training classes, and a total of 410 laparoscopic cholecystectomies were performed. Ultrasound was used as a diagnostic tool in all cases. There was no significant difference in intraoperative or postoperative complications between hospitals in the capital, where the procedures were performed by skilled laparoscopic surgeons, and in Erdenet, where the training courses first introduced laparoscopic cholecystectomy. Neither were there differences in complication rates between cases during the teaching and nonteaching periods.

CONCLUSIONS

Laparoscopic cholecystectomy can be expanded safely to the regional diagnostic referral centers in rural Mongolia through short-term training courses as a method to markedly improve access and outcomes for the 50% of the country previously denied the benefits of minimally invasive surgery.

Surgery and global public health: the UNC-Malawi surgical initiative as a model for sustainable collaboration

Addressing global health disparities in the developing world gained prominence during the first decade of the twenty-first century. The HIV/AIDS epidemic triggered much interest in and funding for health improvement and mortality reduction in low- and middle-income nations, particularly in sub-Saharan Africa. Alliances between U.S. academic medical centers and African nations were created through the departments of internal medicine and infectious disease. However, the importance of addressing surgical disease as part of global public health is becoming recognized as part of international health development efforts. We propose a novel model to reduce the global burden of surgical diseases in resource poor settings by incorporating a sustained institutional surgical presence with our residency training experience by placing a senior surgical resident to provide continuity of care and facilitate training of local personnel. We present the experiences of the University of North Carolina (UNC) Department of Surgery as part of the UNC Project in Malawi as an example of this innovative approach.

Addressing the global burden of surgical disease: proceedings from the 2nd annual symposium at the American College of Surgeons

In the past decade, interest in surgery as a means to improve public health and engage in international service has increased significantly. International organizations, academic institutions, professional associations, and humanitarian aid organizations recognize that disparate access to surgical care affects global health and they have recently joined forces to address access to surgical care. Current initiatives focus on quantitatively defining surgical disparity, prioritizing a surgical agenda, and developing economically sustainable models for health care assistance, training, and delivery. The Global Burden of Surgical Disease Working Group (GBoSD WG) strives to (1) quantitatively define global disparity in surgical care; (2) assess unmet surgical need; (3) identify priorities; (4) develop sustainable models for improved health care delivery; and (5) advocate for a surgical presence within the global public health agenda. This article formally introduces the GBoSD Working Group and papers presented during the 2009 Symposium at the American College of Surgeons in Chicago.

Global aspects of cardiothoracic surgery with focus on developing countries

The incidence and prevalence of cardiothoracic disease continue to increase globally, especially in emerging economies and developing countries. Cardiothoracic surgery is also growing despite limited access, availability of surgical centers, political and cost issues. The increase in atherosclerotic coronary artery disease, rheumatic heart disease, congenital heart disease, trauma, and thoracic malignancies is a more urgent problem than realized in these emerging economies and developing countries, or low- and middle-income countries. A determined focus and cooperation between the preventive and curative elements of care is warranted. This represents a paradigm shift to develop a consensus that fosters a multi-integrated disease-specific approach that includes prevention, promotion, diagnosis, treatment, and rehabilitation. In addition, the concept or acceptance of surgery as a necessary component of public health policy is critical to improving overall global healthcare.

Providing specialist services in Australia across barriers of distance and culture

Most of Australia's population live in urban environments and have ready access to high-quality specialist surgical services. The 1% of Australians (210,600 people) who live in the Northern Territory of Australia sparsely occupy more than one-sixth of Australia's land mass and have varied cultural backgrounds. The organization of surgical services in the Northern Territory provides a case study in providing specialist surgical services to disadvantaged, rural and remote populations in a developed country. Historical and current initiatives to overcome barriers of distance include a coordinated network of health clinics, regional hospitals, and specialist surgical facilities staffed by health care practitioners with broad training and a wide scope of practice. Aeromedical services that facilitate patient and medical team transport were among the first worldwide. Recent initiatives to overcome barriers posed by cultural differences include an Indigenous Languages Interpreter Service, dedicated Indigenous health educators, and specialist outreach visits. Specialist services in the Northern Territory are delivered locally by appropriately trained generalists in cooperation with and supported by specialists from larger centers. This cooperative model of delivery of specialist services maximizes population access to the whole range of surgical therapies and encourages the efficient use of both specialists and generalists. Adoption of the principles of this model may lead to increasingly efficient delivery of specialist services in more densely populated regions.

Improving the quantitative basis of the surgical burden in low-income countries

Theo Vos discusses how surgery is beginning to be considered an essential component of primary health care in low-income countries, and how we need to improve our understanding of the burden of surgical conditions in these settings.

Breast cancer issues in developing countries: an overview of the Breast Health Global Initiative

BACKGROUND

Of the 411,000 breast cancer deaths around the world in 2002, 221,000 (54%) occurred in low- and middle-income countries (LMCs). Guidelines for breast health care (early detection, diagnosis, and treatment) that were developed in high-resource countries cannot be directly applied in LMCs, because these guidelines do not consider real world resource constraints, nor do they prioritize which resources are most critically needed in specific countries for care to be most effectively provided.

METHODS

Established in 2002, the Breast Health Global Initiative (BHGI) created an international health alliance to develop evidence-based guidelines for LMCs to improve breast health outcomes. The BHGI held two Global Summits in October 2002 (Seattle) and January 2005 (Bethesda) and using an expert consensus, evidence-based approach developed resource-sensitive guidelines that define comprehensive pathways for step-by-step quality improvement in health care delivery.

RESULTS

The BHGI guidelines, now published in English and Spanish, stratify resources into four levels (basic, limited, enhanced, and maximal), making the guidelines simultaneously applicable to countries of differing economic capacities. The BHGI guidelines provide a hub for linkage among clinicians and alliance among governmental agencies and advocacy groups to translate guidelines into policy and practice.

CONCLUSIONS

The breast cancer problem in LMCs can be improved through practical interventions that are realistic and cost-effective. Early breast cancer detection and comprehensive cancer treatment play synergistic roles in facilitating improved breast cancer outcomes. The most fundamental interventions in early detection, diagnosis, surgery, radiation therapy, and drug therapy can be integrated and organized within existing health care schemes in LMCs. Future research will study what implementation strategies can most effectively guide health care system reorganization to assist countries that are motivated to improve breast cancer outcome in their populations.