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

What makes global healthcare partnerships successful? A systematic review

Academic communities are increasingly involved in efforts to address the overwhelming burden of disease in low-middle income countries. There is, however, little research dedicated to understanding the best approach to creating a successful and sustainable global healthcare project. Our objective was to review the shared characteristics of successful healthcare partnerships between high- and low-middle income countries. Two independent reviewers conducted a systematic review. Articles, describing collaborative, healthcare partnerships between a high- and low-middle income countries between 1910 and September 2018, were included. Twenty-six articles were included. The majority of collaborations were initiated by either the host institution or as a joint decision between institutions. The primary goal of these collaborations revolved around medical education/training and curriculum development. Two partnerships, after more than a decade of collaboration, had achieved a self-sustaining programme. Lack of funding was identified as a major barrier to sustainability. Successful global healthcare partnerships require true collaboration and equal participation of all partners. Funding should be secured prior to programme development in anticipation of a minimum 10-year project. A minimum list of guidelines has been proposed to improve the chances of both a successful and sustainable collaboration.

Facing The World in Vietnam: Feedback From Trainees on the Educational Value of Surgical Missions to Help Patients With Craniofacial Deformities

BACKGROUND

Education and training of local healthcare staff is a crucial component of a surgical mission. Facing The World (FTW) is a UK-based craniofacial charity that provides facial reconstructive surgery to children with complex, craniofacial anomalies. As part of its global initiative, FTW has developed a training outreach program in Vietnam. The aim of this study was to analyze feedback data to evaluate the educational value of the training program and identify areas for improvement.

METHODS

Feedback was obtained through both 5-point Likert scale and open-ended response questions on written questionnaires. Six postmission reports were reviewed, and used as a base for the content of the questionnaires. Selective sampling was used, with questionnaires distributed to all Vietnamese and UK trainees who have been part of the FTW training program.

RESULTS

Seven Vietnamese trainee questionnaires were completed, a response rate of 87.5%. Twelve UK trainees completed the feedback questionnaire, giving a response rate of 85.7%. One hundred percent of local trainees and 83.3% of UK trainees found the training program to be useful or very useful, with no trainees deeming the training program not useful or of no use at all.

CONCLUSION

The training missions offered by FTW have successfully provided education to both UK and Vietnamese surgeons in Craniofacial surgical techniques and patient care. No negative responses were identified in both questionnaires. The feedback provides evidence of FTW's effective training program, while allowing insight into where further improvements can be made.

Systematic Review of Surgical Literature from Resource-Limited Countries: Developing Strategies for Success

BACKGROUND

Injuries and surgical diseases are leading causes of global mortality. We sought to identify successful strategies to augment surgical capacity and research endeavors in low-income countries (LIC's) based on existing peer-reviewed literature.

METHODS

A systematic review of literature from or pertaining to LIC's from January 2002 to December 2011 was performed. Variables analyzed included type of intervention performed, research methodology, and publication demographics such as surgical specialty, partnerships involved, authorship contribution, place and journal of publication.

FINDINGS

A total of 2049 articles met the inclusion criteria between 2002 and 2011. The two most common study methodologies performed were case series (44%) and case reports (18%). A total of 43% of publications were without outcome measures. Only 21% of all publications were authored by a collaboration of authors from low-income countries and developed country nationals. The five most common countries represented were Nepal (429), United States (408), England (170), Bangladesh (158), and Kenya (134). Furthermore, of countries evaluated, Nepal and Bangladesh were the only two with a specific national journal.

INTERPRETATION

Based on the results of this research, the following recommendations were made: (1) Describe, develop, and stimulate surgical research through national peer-reviewed journals, (2) Foster centers of excellence to promote robust research competencies, (3) Endorse partnerships across regions and institutions in the promotion of global surgery, and (4) Build on outcome-directed research.

Rural surgery in Guinea Bissau: an experience of Doctors Worldwide Turkey

OBJECTIVE

In Africa, there is critical shortage of surgeons. Majority of the surgeons work in urban centers, and almost none of them is working in the rural areas. This study documents surgical interventions performed in Guinea-Bissau by Doctors Worldwide Turkey.

METHODS

A group of surgeons from the Doctors Worldwide Turkey performed various surgical interventions in the Simao Mendes, Gabu and Bafata community hospitals. Demographics, surgical methods, anesthesia techniques and complications were recorded.

RESULTS

Sixty- four procedures were undertaken between 5-16 February 2010 and 6-11 May 2011. The patient population consisted of 47 male (82.5%) and 10 female (17.5%) patients with a mean age of 44.5 (range: 6-81) years. Five emergency cases were observed. Hartmann's procedure for rectal carcinoma; modified radical mastectomy for breast carcinoma; 2 right total thyroidectomies, 1 bilateral subtotal thyroidectomy; 2 incisional hernia repairs with mesh, 1 breast lumpectomy, 3 mass excisions, 2 keloidectomies, and various techniques of hernia repair for 35 inguinal hernias (4 bilateral, 3 strangulated and 2 coexisting with hydrocele), Winkelmann's procedure for 5 hydroceles (1 bilateral), and unilateral orchiectomy for 1 bilateral hydrocele were recorded. Sixteen patients received general (23.5%), 23 spinal (33.8%), 7 epidural (10.3%), 15 local (22.1%), and 7 ketamine (10.3%) anesthesia. There was no mortality.

CONCLUSION

Surgical diseases, majority of which are hernias threaten public health in underdeveloped regions of Africa. Blitz surgery may be an efficient temporary solution.

Building surgical capacity in low-resource countries: a qualitative analysis of task shifting from surgeon volunteers' perspectives

INTRODUCTION

Surgical volunteer organizations (SVOs) focus considerable resources on addressing the backlog of cases in low-resource countries. This model of service may perpetuate dependency. Efforts should focus on models that establish independence in providing surgical care. Independence could be achieved through surgical capacity building. However, there has been scant discussion in literature on SVO involvement in surgical capacity building.

METHODS

Using qualitative methods, we evaluated the perspectives of surgeons with extensive volunteer experience in low-resource countries. We collected data through in-depth interviews that centered on SVOs using task shifting as a tool for surgical capacity building.

RESULTS

Some of the key themes from our analysis include the ethical ramifications of task shifting, the challenges of addressing technical and clinical education in capacity building for low-resource settings, and the allocation of limited volunteer resources toward surgical capacity building.

CONCLUSION

These themes will be the foundation of subsequent studies that will focus on other stakeholders in surgical capacity building including host communities and SVO administrators.

Trauma consults on humanitarian surgery trips: A perspective on the Haitian trauma system and the humanitarian’s role

Ubiquitous access to surgical care, especially trauma surgery, is recognized as an essential component of public health. We present two trauma cases—an upper arm machete laceration and a penetrating chest wound—that highlight barriers facing trauma patients in Haiti and describe how it relates to humanitarian surgery trips. An Emory University student–faculty collaborative, partnering with the non-profit Project Medishare (PM) for Haiti since 2008, provides elective and urgent surgical care to the underserved population of the Haitian Central Plateau. This partnership collaborates with a main referral center known for providing quality surgical care at little or no cost. Elective urological and general surgical cases comprise the bulk of the case load but urgent trauma services have been provided when required. Future trauma system initiatives must focus on increasing access to vehicles, telecommunications, and first responders. Our recommendations are reinforced by preliminary results from a trauma needs assessment performed in the Central Plateau and surrounding departments during July 2013. Humanitarian teams can contribute by preparing for emergencies prior to departure and sharing new procedural knowledge with local providers. Supplementing the ability to intercede in emergency surgical situations furthers the goal of short-term surgical trips to diminish indigenous patient morbidity and mortality. We advocate extensive preparation for such situations and increased bidirectional knowledge sharing with local staff.

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.

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.

Cost analysis of establishing a relationship between a surgical program in the US and Vietnam

"Twinning" refers to a constructive partnership between hospitals in developed and developing nations. Such an effort may contribute immensely to capacity building for the developing nation, but one of the reasons given for the lack of sustainability is cost. We share a detailed operating cost analysis of our recent experience with an institution in Vietnam. We were awarded a 1-year $54,000 grant from the Vietnam Education Foundation (VEF) to conduct a live tele-video conferencing course on the "Fundamentals of Clinical Surgery" with Thai Binh Medical University (TBMU). In-country lectures as well as an assessment of the needs at TBMU were performed. Total financial assistance and expenditures were tabulated to assess up-front infrastructure investment and annual cost required to sustain the program. The total amount of direct money ($66,686) and in-kind services ($70,276) was $136,962. The initial infrastructure cost was $41,085, which represented 62% of the direct money received. The annual cost to sustain the program was approximately $11,948. We concluded that the annual cost to maintain a "twinning" program was relatively low, and the efforts to sustain a "twinning" program were financially feasible and worthwhile endeavors. "Twinning" should be a critical part of the surgical humanitarian volunteerism effort.

Surgical care in the Solomon Islands: a road map for universal surgical care delivery

BACKGROUND

Access to surgical care and emergency obstetrical care is limited in low-income countries. The Solomon Islands is one of the poorest countries in the Pacific region. Access to surgical care in Solomon Islands is limited and severely affected by a country made up of islands. Surgical care is centralized to the National Referral Hospital (NRH) on Guadalcanal, leaving a void of care in the provinces where more than 80% of the people live.

METHODS

To assess the ability to provide surgical care to the people living on outer islands in the Solomon Islands, the provincial hospitals were evaluated using the World Health Organization's Global Initiative for Emergency and Essential Surgical Care Needs Assessment Tool questionnaire. Data on infrastructure, workforce, and equipment available for treating surgical disease was collected at each provincial hospital visited.

RESULTS

Surgical services are centralized to the NRH on Guadalcanal in Solomon Islands. Two provincial hospitals provide surgical care when a surgeon is available. Six of the hospitals evaluated provide only very basic surgical procedures. Infrastructure problems exist at every hospital including lack of running water, electricity, adequate diagnostic equipment, and surgical supplies. The number of surgeons and obstetricians employed by the Ministry of Health is currently inadequate for delivering care at the outer island hospitals.

CONCLUSIONS

Shortages in the surgical workforce can be resolved in Solomon Islands with focused training of new graduates. Training surgeons locally, in the Pacific region, can minimize the "brain drain." Redistribution of surgeons and obstetricians to the provincial hospitals can be accomplished by creating supportive connections between these hospitals, the NRH, and international medical institutions.

Emergency surgical care delivery in post-earthquake Haiti: Partners in Health and Zanmi Lasante experience

BACKGROUND

The earthquake that struck Haiti on 12 January 2010 caused significant devastation to both the country and the existing healthcare infrastructure in both urban and rural areas. Most hospital and health care facilities in Port-au-Prince and the surrounding areas were significantly damaged or destroyed. Consequently, large groups of Haitians fled Port-au-Prince for rural areas to seek emergency medical and surgical care. In partnership with the Haitian Ministry of Health, Partners in Health (PIH) and Zanmi Lasante (ZL) have developed and maintained a network of regional and district hospitals in rural Haiti for over twenty-five years. This PIH/ZL system was ideally situated to accommodate the increased need for emergent surgical care in the immediate quake aftermath. The goal of the present study was to provide a cross-sectional assessment of surgical need and care delivery across PIH/ZL facilities after the earthquake in Haiti.

METHODS

We conducted a retrospective review of hospital case logs and operative records over the course of three weeks immediately following the earthquake.

RESULTS

Roughly 3,000 patients were seen at PIH/ZL sites by a combination of Haitian and international surgical teams. During that period 513 emergency surgical cases were logged. Other than wound debridement, the most commonly performed procedure was fixation of long bone fractures, which constituted approximately one third of all surgical procedures.

CONCLUSIONS

There was a significant demand for emergent surgical care after the earthquake in Haiti. The PIH/ZL hospital system played a critical role in addressing this acutely increased burden of surgical disease, and it allowed for large numbers of Haitians to receive needed surgical services. Our experiences reinforce that access to essential surgery is an essential pillar in public health.