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Zadey S, Sharma D, Cotton M. Advocacy for surgeons: Ensuring excellence in patient care. Trop Doct 2024; 54:85-87. [PMID: 38456731 DOI: 10.1177/00494755241237599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Siddhesh Zadey
- Association for Socially Applicable Research (ASAR), Pune, MH, India
| | - Dhananjaya Sharma
- Professor and Head, Department of Surgery, NSCB Government Medical College Jabalpur (MP), MH, India
| | - Michael Cotton
- Professor of Clinical Practice, Consultant Surgeon, Quai Santé, Montreux, Switzerland
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Yan A, Castellanos SL, Chao AH. Plastic Surgical Outreach to Low- and Middle-income Countries and Global Health Priorities: An Analysis of 96 Nongovernmental Organizations. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5477. [PMID: 38148941 PMCID: PMC10749701 DOI: 10.1097/gox.0000000000005477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/24/2023] [Indexed: 12/28/2023]
Abstract
Background Conditions that are treated by surgery constitute a significant portion of the global burden of disease. In low- and middle-income countries (LMICs), allocation of resources toward the most cost-effective surgical procedures (essential surgery) and care delivery platforms is critical. Nongovernmental organizations (NGOs) and the plastic surgeons who work with them play a significant role in plastic surgical outreach to LMICs. However, it is unknown whether their work aligns with existing global public health recommendations. Methods A previously established internet-based methodology was used to identify plastic surgical NGOs. Through direct correspondence with NGOs and publicly available data, plastic surgical NGOs were cataloged with respect to the subspecialty areas of plastic surgery performed, care delivery platforms, and geographic sites. These results were then compared with the existing global public health recommendations. Results A total of 96 NGOs met inclusion criteria. The most common subspecialty area was cleft surgery (80.3%), followed by pediatric plastic surgery (46.9%). No NGOs used a continuous care delivery platform. Instead, all NGOs used an intermittent model through short-term surgical missions, of which 62.8% used a nonrotating care model and returned to the same site(s) annually, whereas 37.2% used a rotating care model. Conclusions Most NGOs perform cleft surgery, an area considered essential surgery, and thus, collectively, the work of NGOs largely aligns with global public health priorities. However, there is room for improvement for both the types of procedures performed and the care delivery platforms to provide the most cost-effective and sustainable care.
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Affiliation(s)
- Allison Yan
- From Ohio State University College of Medicine, Columbus, Ohio
| | | | - Albert H. Chao
- Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, Ohio
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Bognini MS, Oko CI, Kebede MA, Ifeanyichi MI, Singh D, Hargest R, Friebel R. Assessing the impact of anaesthetic and surgical task-shifting globally: a systematic literature review. Health Policy Plan 2023; 38:960-994. [PMID: 37506040 PMCID: PMC10506531 DOI: 10.1093/heapol/czad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/04/2023] [Accepted: 07/26/2023] [Indexed: 07/30/2023] Open
Abstract
The global shortage of skilled anaesthesiologists, surgeons and obstetricians is a leading cause of high unmet surgical need. Although anaesthetic and surgical task-shifting are widely practised to mitigate this barrier, little is known about their safety and efficacy. This systematic review seeks to highlight the existing evidence on the clinical outcomes of patients operated on by non-physicians or non-specialist physicians globally. Relevant articles were identified by searching four databases (MEDLINE, EMBASE, CINAHL and Global Health) in all languages between January 2008 and February 2022. Retrieved documents were screened against pre-specified inclusion and exclusion criteria, and their qualities were appraised critically. Data were extracted by two independent reviewers and findings were synthesized narratively. In total, 40 studies have been included. Thirty-five focus on task-shifting for surgical and obstetric procedures, whereas four studies address anaesthetic task-shifting; one study covers both interventions. The majority are located in sub-Saharan Africa and the USA. Seventy-five per cent present perioperative mortality outcomes and 85% analyse morbidity measures. Evidence from low- and middle-income countries, which primarily concentrates on caesarean sections, hernia repairs and surgical male circumcisions, points to the overall safety of non-surgeons. On the other hand, the literature on surgical task-shifting in high-income countries (HICs) is limited to nine studies analysing tube thoracostomies, neurosurgical procedures, caesarean sections, male circumcisions and basal cell carcinoma excisions. Finally, only five studies pertaining to anaesthetic task-shifting across all country settings answer the research question with conflicting results, making it difficult to draw conclusions on the quality of non-physician anaesthetic care. Overall, it appears that non-specialists can safely perform high-volume, low-complexity operations. Further research is needed to understand the implications of surgical task-shifting in HICs and to better assess the performance of non-specialist anaesthesia providers. Future studies must adopt randomized study designs and include long-term outcome measures to generate high-quality evidence.
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Affiliation(s)
- Maeve S Bognini
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Christian I Oko
- Division of Health Research, Lancaster University, Bailrigg, Lancaster LA1 4YW, United Kingdom
| | - Meskerem A Kebede
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Martilord I Ifeanyichi
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Darshita Singh
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Rachel Hargest
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
- University Hospital of Wales, Heath Park, Cardiff CF14 4XN, United Kingdom
| | - Rocco Friebel
- Global Surgery Policy Unit, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
- Center for Global Development, Abbey Gardens, Great College Street, London SW1P 3SE, United Kingdom
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Pittalis C, Drury G, Mwapasa G, Borgstein E, Cheelo M, Kachimba J, Juma A, Chilonga K, Cahill N, Brugha R, Lavy C, Gajewski J. Using participatory action research to empower district hospital staff to deliver quality-assured essential surgery to rural populations in Malawi, Zambia, and Tanzania. Front Public Health 2023; 11:1186307. [PMID: 37780427 PMCID: PMC10536269 DOI: 10.3389/fpubh.2023.1186307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Background In 2017 the SURG-Africa project set out to institute a surgical, obstetric, trauma and anesthesia (SOTA) care capacity-building intervention focused on non-specialist providers at district hospitals in Zambia, Malawi and Tanzania. The aim was to scale up quality-assured SOTA care for rural populations. This paper reports the process of developing the intervention and our experience of initial implementation, using a participatory approach. Methods Participatory Action Research workshops were held in the 3 countries in July-October 2017 and in October 2018-July 2019, involving representatives of key local stakeholder groups: district hospital (DH) surgical teams and administrators, referral hospital SOTA specialists, professional associations and local authorities. Through semi-structured discussions, qualitative data were collected on participants' perceptions and experiences of barriers to the provision of SOTA care at district level, and on the training and supervision needs of district surgical teams. Data were compared for themes across countries and across surgical team cadres. Results All groups reported a lack of in-service training to develop essential skills to manage common SOTA cases; use and care of equipment; essential anesthesia care including resuscitation skills; and infection prevention and control. Very few district surgical teams had access to supervision. SOTA providers at DHs reported a demand for more feedback on referrals. Participants prioritized training needs that could be addressed through regular in-service training and supervision visits from referral hospital specialists to DHs. These data were used by participants in an action-planning cycle to develop site-specific training plans for each research site. Conclusion The inclusive, participatory approach to stakeholder involvement in SOTA system strengthening employed by this study supported the design of a locally relevant and contextualized intervention. This study provides lessons on how to rebalance power dynamics in Global Surgery, through giving a voice to district surgical teams.
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Affiliation(s)
- Chiara Pittalis
- School of Population Health, Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Grace Drury
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Gerald Mwapasa
- Deparment of Surgery, College of Medicine, Kamuzu University of Health Sciences (former University of Malawi), Blantyre, Malawi
| | - Eric Borgstein
- Deparment of Surgery, College of Medicine, Kamuzu University of Health Sciences (former University of Malawi), Blantyre, Malawi
| | | | | | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Kondo Chilonga
- Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Niamh Cahill
- School of Medicine, University of South Carolina, Greenville, SC, United States
| | - Ruairi Brugha
- School of Population Health, Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Chris Lavy
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jakub Gajewski
- School of Population Health, Institute of Global Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Henry JA, Reyes AM, Ameh E, Yip CH, Nthumba P, Mehes M, Lelchuk A, Hollier L, Waqainabete I, Abdullah NH, Alliance T, Hill A, Ferguson MK. International consensus recommendations for the optimal prioritisation and distribution of surgical services in low-income and middle-income countries: a modified Delphi process. BMJ Open 2023; 13:e062687. [PMID: 36693687 PMCID: PMC9884888 DOI: 10.1136/bmjopen-2022-062687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To develop consensus statements regarding the regional-level or district-level distribution of surgical services in low and middle-income countries (LMICs) and prioritisation of service scale-up. DESIGN This work was conducted using a modified Delphi consensus process. Initial statements were developed by the International Standards and Guidelines for Quality Safe Surgery and Anesthesia Working Group of the Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance) and the International Society of Surgery based on previously published literature and clinical expertise. The Guidance on Conducting and REporting DElphi Studies framework was applied. SETTING The Working Group convened in Suva, Fiji for a meeting hosted by the Ministry of Health and Medical Services to develop the initial statements. Local experts were invited to participate. The modified Delphi process was conducted through an electronically administered anonymised survey. PARTICIPANTS Expert LMIC surgeons were nominated for participation in the modified Delphi process based on criteria developed by the Working Group. PRIMARY OUTCOME MEASURES The consensus panel voted on statements regarding the organisation of surgical services, principles for scale-up and prioritisation of scale-up. Statements reached consensus if there was ≥80% agreement among participants. RESULTS Fifty-three nominated experts from 27 LMICs voted on 27 statements in two rounds. Ultimately, 26 statements reached consensus and comprise the current recommendations. The statements covered three major themes: which surgical services should be decentralised or regionalised; how the implementation of these services should be prioritised; and principles to guide LMIC governments and international visiting teams in scaling up safe, accessible and affordable surgical care. CONCLUSIONS These recommendations represent the first step towards the development of international guidelines for the scaling up of surgical services in LMICs. They constitute the best available basis for policymaking, planning and allocation of resources for strengthening surgical systems.
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Affiliation(s)
- Jaymie A Henry
- Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA
- International Standards and Guidelines for Quality Safe Surgery and Anesthesia (ISG-QSSA), Global Alliance for Surgical, Obstetric, Trauma, and Anesthesia Care (G4 Alliance), Chicago, Illinois, USA
| | - Ana M Reyes
- Department of Surgery, University of Miami, Miami, Florida, USA
| | - Emmanuel Ameh
- Division of Paediatric Surgery, National Hospital, Abuja, Nigeria
| | - Cheng-Har Yip
- Department of Surgery, University of Malaya, Kuala Lumpur, Lembah Pantai, Malaysia
| | - Peter Nthumba
- Department of Surgery, AIC Kijabe Hospital, Kijabe, Kenya
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mira Mehes
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, Chicago, Illinois, USA
| | - Ashley Lelchuk
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, Chicago, Illinois, USA
| | - Larry Hollier
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas, USA
- Chairman of the Medical Board, Smile Train, New York, New York, USA
| | | | - Noor Hisham Abdullah
- Director General, Ministry of Health Malaysia, Putrajaya, Wilayah Persekutuan, Malaysia
| | - The Alliance
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, Chicago, Illinois, USA
| | - Andrew Hill
- Department of Surgery, The University of Auckland, Middlemore Hospital, Auckland, New Zealand
| | - Mark K Ferguson
- Department of Surgery, The University of Chicago, Chicago, Illinois, USA
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Pittalis C, Brugha R, Bijlmakers L, Cunningham F, Mwapasa G, Clarke M, Broekhuizen H, Ifeanyichi M, Borgstein E, Gajewski J. Using Network and Complexity Theories to Understand the Functionality of Referral Systems for Surgical Patients in Resource-Limited Settings, the Case of Malawi. Int J Health Policy Manag 2022; 11:2502-2513. [PMID: 35065544 PMCID: PMC9818113 DOI: 10.34172/ijhpm.2021.175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 12/20/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries (LMICs) have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country. METHODS This study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems (CAS) theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n=22 DLHs), interviews with clinicians (n=20), and a database of incoming referrals at two sentinel RHs over a six-month period. RESULTS Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-RH relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future. CONCLUSION Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.
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Affiliation(s)
- Chiara Pittalis
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairí Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frances Cunningham
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Brisbane, QLD, Australia
| | - Gerald Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Morgane Clarke
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Henk Broekhuizen
- Department of Health and Society, Wageningen University and Research, Wageningen, The Netherlands
| | - Martilord Ifeanyichi
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Siow SL, Wahab MYA, Chuah JS, Mahendran HA. Access to essential surgical care in district hospitals of Sarawak Malaysia: outcomes of an audit and the need for urgent attention. ANZ J Surg 2022; 92:1692-1699. [DOI: 10.1111/ans.17705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 02/02/2022] [Accepted: 03/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Sze Li Siow
- Department of General Surgery Sarawak General Hospital Kuching Sarawak Malaysia
| | | | - Jun Sen Chuah
- Department of General Surgery Sarawak General Hospital Kuching Sarawak Malaysia
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Hendriks TCC, Botman M, Binnerts JJ, Mtui GS, Nuwass EQ, Niemeijer AS, Mullender MG, Winters HAH, Nieuwenhuis MK, van Zuijlen PPM. The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up. Burns 2021; 48:215-227. [PMID: 34716045 DOI: 10.1016/j.burns.2021.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/04/2021] [Accepted: 04/23/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country. METHODS Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury. RESULTS Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns. CONCLUSION The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.
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Affiliation(s)
- T C C Hendriks
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands.
| | - M Botman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands
| | | | - G S Mtui
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - E Q Nuwass
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - A S Niemeijer
- Association of Dutch Burn Centers, Burn Center, The Netherlands; Burn Center, Martini Hospital, Groningen, The Netherlands
| | - M G Mullender
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands
| | - H A H Winters
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands
| | - M K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Center, The Netherlands; Burn Center, Martini Hospital, Groningen, The Netherlands
| | - P P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, Location AMC and VUmc, Amsterdam, The Netherlands
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Abstract
Introduction: Global surgical care is increasingly recognized in the global health agenda and requires multidisciplinary engagement. Despite high interest among medical students, residents and other learners, many surgical faculty and health experts remain uniformed about global surgical care. Methods: We have operated an interdisciplinary graduate-level course in Global Surgical Care based on didactics and interactive group learning. Students completed a pre- and post-course survey regarding their learning experiences and results were analyzed using the Wilcoxon signed-rank test. Results: Fourteen students completed the pre-course survey, and 11 completed the post-course survey. Eleven students (79%) were enrolled in a Master’s degree program in global health, with eight students (57%) planning to attend medical school. The median ranking of surgery on the global health agenda was fifth at the beginning of the course and third at the conclusion (p = 0.11). Non-infectious disease priorities tended to stay the same or increase in rank from pre- to post-course. Infectious disease priorities tended to decrease in rank (HIV/AIDS, p = 0.07; malaria, p = 0.02; neglected infectious disease, p = 0.3). Students reported that their understanding of global health (p = 0.03), global surgery (p = 0.001) and challenges faced by the underserved (p = 0.03) improved during the course. When asked if surgery was an indispensable part of healthcare, before the course 64% of students strongly agreed, while after the course 91% of students strongly agreed (p = 0.3). Students reported that the interactive nature of the course strengthened their skills in collaborative problem-solving. Conclusions: We describe an interdisciplinary global surgery course that integrates didactics with team-based projects. Students appeared to learn core topics and held a different view of global surgery after the course. Similar courses in global surgery can educate clinicians and other stakeholders about strategies for building healthy surgical systems worldwide.
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Abstract
OBJECTIVE To provide a general overview of the reported current surgical capacity and delivery in order to advance current knowledge and suggest targets for further development and research within the region of sub-Saharan Africa. DESIGN Scoping review. SETTING District hospitals in sub-Saharan Africa. DATA SOURCES PubMed and Ovid EMBASE from January 2000 to December 2019. STUDY SELECTION Studies were included if they contained information about types of surgical procedures performed, number of operations per year, types of anaesthesia delivered, cadres of surgical/anaesthesia providers and/or patients' outcomes. RESULTS The 52 articles included in analysis provided information about 16 countries. District hospitals were a group of diverse institutions ranging from 21 to 371 beds. The three most frequently reported procedures were caesarean section, laparotomy and hernia repair, but a wide range of orthopaedics, plastic surgery and neurosurgery procedures were also mentioned. The number of operations performed per year per district hospital ranged from 239 to 5233. The most mentioned anaesthesia providers were non-physician clinicians trained in anaesthesia. They deliver mainly general and spinal anaesthesia. Depending on countries, articles referred to different surgical care providers: specialist surgeons, medical officers and non-physician clinicians. 15 articles reported perioperative complications among which surgical site infection was the most frequent. Fifteen articles reported perioperative deaths of which the leading causes were sepsis, haemorrhage and anaesthesia complications. CONCLUSION District hospitals play a significant role in sub-Saharan Africa, providing both emergency and elective surgeries. Most procedures are done under general or spinal anaesthesia, often administered by non-physician clinicians. Depending on countries, surgical care may be provided by medical officers, specialist surgeons and/or non-physician clinicians. Research on safety, quality and volume of surgical and anaesthesia care in this setting is scarce, and more attention to these questions is required.
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Affiliation(s)
- Zineb Bentounsi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Grace Drury
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Surgical Task-Sharing to Non-specialist Physicians in Low-Resource Settings Globally: A Systematic Review of the Literature. World J Surg 2020; 44:1368-1386. [PMID: 31915975 DOI: 10.1007/s00268-019-05363-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND As the global community increasingly recognizes the large and unmet burden of surgical disease, a new emphasis is being placed on strengthening the health system at the first-level hospital. The shortage of surgical care providers at this district and rural level can be met by surgical task-shifting/sharing to non-physician clinicians (NPCs) and non-specialist physicians (NSPs). While the role of NPCs in low-middle-income countries (LMICs), in particular in sub-Saharan Africa (SSA), has been well documented in the literature, there has been little focus on NSPs. In addition to providing essential surgical services, this physician cadre also practices generalist medicine, an advantage at the first-level hospital. The present study seeks to explore where, across all country income groups, NSPs are providing surgical services and what additional surgical training, if any, is available in each identified country. METHODS A systematic review of the literature was performed, following PRISMA guidelines. Medline, EMBASE, EBM Reviews, and CINAHL were searched. Including hand-searching for further references, 53 publications met inclusion/exclusion criteria and were identified for data extraction purposes. Gray literature was also explored within the time limits for this study. RESULTS Surgical task-shifting/sharing to NSPs occurs across all country income groups; some provide surgical obstetrics, while others also provide a broader scope of surgical services. Within LMIC countries, the majority are in SSA. In SSA, 16 of 54 countries were included in the reviewed articles, only 4 of which (Ethiopia, Niger, Nigeria, and Sierra Leone) have a formal surgical program beyond the regular medical officer/general practitioner training. Canada and Australia have established programs for both surgical obstetrics and the broader scope, while the USA has several programs for surgical obstetrics and is developing a new, broad-scope program. CONCLUSION This study has demonstrated that NSPs are providing surgical services across all income groups, with varying degrees of additional training specific to the surgical needs of their district/rural location. To "close the gap" in needed surgical services at the first-level hospital, more task-sharing needs to occur to both NSPs (the focus of this study) and NPCs. Collaboration between practitioners and training programs, given the shared challenges and practice environments, would help support task-sharing at the first-level hospital and improve access to the 5 billion underserved people.
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Gallaher JR, Chise Y, Reiss R, Purcell LN, Manjolo M, Charles A. Underutilization of Operative Capacity at the District Hospital Level in a Resource-Limited Setting. J Surg Res 2020; 259:130-136. [PMID: 33279838 DOI: 10.1016/j.jss.2020.11.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Improving surgical care in a resource-limited setting requires the optimization of operative capacity, especially at the district hospital level. METHODS We conducted an analysis of the acute care surgery registry at Salima District Hospital in Malawi from June 2018 to November 2019. We examined patient characteristics, interventions, and outcomes. Modified Poisson regression modeling was used to identify risk factors for transfer to a tertiary center and mortality of patients transferred to the tertiary center. RESULTS Eight hundred eighty-eight patients were analyzed. The most common diagnosis was skin and soft tissue infection (SSTI) at 35.9%. 27.5% of patients were transferred to Salima District Hospital, primarily from health centers, with a third for a diagnosis of SSTI. Debridement of SSTI comprised 59% of performed procedures (n = 241). Of the patients that required exploratory laparotomy, only 11 laparotomies were performed, with 59 patients transferred to a tertiary hospital. The need for laparotomy conferred an adjusted risk ratio (RR) of 10.1 (95% confidence interval [CI] 7.1, 14.3) for transfer to the central hospital. At the central hospital, for patients who needed urgent abdominal exploration, surgery had a 0.16 RR of mortality (95% CI 0.05, 0.50) while time to evaluation greater than 48 h at the central hospital had a 2.81 RR of death (95% CI 1.19, 6.66). CONCLUSIONS Despite available capacity, laparotomy was rarely performed at this district hospital, and delays in care led to a higher mortality. Optimization of the district and health center surgical ecosystems is imperative to improve surgical access in Malawi and improve patient outcomes.
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Affiliation(s)
- Jared R Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | | | - Rachel Reiss
- School of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Laura N Purcell
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Salima District Hospital, Salima, Malawi
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13
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van Heemskerken P, Broekhuizen H, Gajewski J, Brugha R, Bijlmakers L. Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa-a scoping review. HUMAN RESOURCES FOR HEALTH 2020; 18:51. [PMID: 32680526 PMCID: PMC7368796 DOI: 10.1186/s12960-020-00490-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/07/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries. METHODS We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks. RESULTS Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties. CONCLUSION A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.
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Affiliation(s)
| | - Henk Broekhuizen
- Health Evidence Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jakub Gajewski
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairí Brugha
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Health Evidence Department, Radboud University Medical Centre, Nijmegen, The Netherlands
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14
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Pittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Trop Med Int Health 2020; 25:824-833. [PMID: 32324928 DOI: 10.1111/tmi.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Reliable referral systems are essential to the functionality and efficiency of the wider health care system in low- and middle-income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under-researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned. METHODS We conducted a prospective analysis of all inter-hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014-2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process. RESULTS 1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely. CONCLUSIONS Our findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present.
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Affiliation(s)
- Chiara Pittalis
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Nijmegen International Centre for Health Systems Research and Education, Radboud University, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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15
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Odhiambo J, Ruhumuriza J, Nkurunziza T, Riviello R, Shrime M, Lin Y, Rusangwa C, Omondi JM, Toma G, Nyirimodoka A, Mpunga T, Hedt-Gauthier BL. Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing. Matern Child Health J 2019; 23:613-622. [PMID: 30600515 DOI: 10.1007/s10995-018-2674-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.
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Affiliation(s)
- Jackline Odhiambo
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA.
| | | | | | - Robert Riviello
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Shrime
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Yihan Lin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Jack M Omondi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Ministry of Health, Kigali, Rwanda
| | - Gabriel Toma
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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16
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Nkurunziza T, Kateera F, Sonderman K, Gruendl M, Nihiwacu E, Ramadhan B, Cherian T, Nahimana E, Ntakiyiruta G, Habiyakare C, Ngamije P, Matousek A, Gaju E, Riviello R, Hedt-Gauthier B. Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda. Br J Surg 2019; 106:e121-e128. [PMID: 30620071 PMCID: PMC7938824 DOI: 10.1002/bjs.11060] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/30/2018] [Accepted: 10/30/2018] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | - F Kateera
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | - K Sonderman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Centre for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - M Gruendl
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Public Health, Technical University Munich, Munich, Germany
| | - E Nihiwacu
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | - B Ramadhan
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | - T Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - E Nahimana
- Partners In Health/Inshuti Mu Buzima, Rwanda
| | | | | | | | - A Matousek
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Centre for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E Gaju
- Ministry of Health Kigali, Rwanda
| | - R Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Centre for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - B Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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17
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Gianino MM, Lenzi J, Bonaudo M, Fantini MP, Siliquini R, Ricciardi W, Damiani G. The switch between cataract surgical settings: Evidence from a time series analysis across 20 EU countries. PLoS One 2018; 13:e0192620. [PMID: 29489834 PMCID: PMC5831096 DOI: 10.1371/journal.pone.0192620] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 01/27/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To analyze trajectories of cataract surgery rates and to confirm the switch between inpatient cases and day surgery or outpatient cases. DESIGN Pooled, cross-sectional, time series analysis. METHODS Data on 20 European countries from 2004 to 2014 retrieved from the OECD. RESULTS The number of cataract surgery cases per 100,000 population has increased since 2004 (b = 31.1, p < 0.001, 95% CI = 26.7, 35.6). A reversal of the inpatient cases and same-day cases was found: the first ones decreased (b = -14.7, p < 0.001, 95% CI = -17.7, -11.8) while day surgery and outpatient cases increased (b = 37.5, p < 0.001, 95% CI = 31.6, 43.4, and b = 8.3, p = 0.001, 95% CI = 3.6, 13.1, respectively). Since 2004, the ratio of day surgery and outpatient cases to inpatient cases has grown significantly (b = 3.3, p < 0.001, 95% CI = 2.5, 4.0), reaching a share of 31.7 in 2014. However, this slope of 3.3 was not constant and slowed over the years: from 4.5 per year during the first five years to 1.9 in the second five. No association was found between cataract surgery rate and two regressors: elderly people, and health care expenditure per capita. CONCLUSION EU countries have preserved cataract surgery, and this preservation is probably affected by the switch from inpatient to same-day surgery, thanks to the decrease in the cost and equivalent clinical outcomes. However, the slope of the switch slowed over time. Consequently, health care systems must support this process of change especially through reforms in financial and organizational fields.
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Affiliation(s)
- Maria Michela Gianino
- Department of Public Health Sciences and Pediatrics, Università di Torino, Turin, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum–Università di Bologna, Bologna, Italy
| | - Marco Bonaudo
- Department of Public Health Sciences and Pediatrics, Università di Torino, Turin, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum–Università di Bologna, Bologna, Italy
| | - Roberta Siliquini
- Department of Public Health Sciences and Pediatrics, Università di Torino, Turin, Italy
| | - Walter Ricciardi
- Department of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianfranco Damiani
- Department of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
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18
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Kelly CM, Starr N, Raykar NP, Yorlets RR, Liu C, Derbew M. Provision of surgical care in Ethiopia: Challenges and solutions. Glob Public Health 2018; 13:1691-1701. [DOI: 10.1080/17441692.2018.1436720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Nichole Starr
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Nakul P. Raykar
- Program in Global Surgery and Social Change, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rachel R. Yorlets
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Charles Liu
- Program in Global Surgery and Social Change, Department of Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Miliard Derbew
- Black Lion Hospital, Addis Ababa University, Addis Ababa, Ethiopia
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19
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Barriers to Surgical Care and Health Outcomes: A Prospective Study on the Relation Between Wealth, Sex, and Postoperative Complications in the Republic of Congo. World J Surg 2017; 41:14-23. [PMID: 27473131 DOI: 10.1007/s00268-016-3676-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Approximately thirty percent of the global burden of disease is comprised of surgical conditions. However, five billion people lack access to surgery, with complex factors acting as barriers. We examined whether patient demographics predict barriers to care, and the relation between these factors and postoperative complications in a prospective cohort. METHODS Participants included people presenting to a global charity in Republic of Congo with a surgical condition between August 2013 and May 2014. The outcomes were self-reported barrier to care and postoperative complications documented by medical record. Logistic regression was used to adjust for covariates. RESULTS Of 1237 patients in our study, 1190 (96.2 %) experienced a barrier to care and 126 (10.2 %) experienced a postoperative complication. The most frequently reported barrier was cost (73 %), followed by lack of provider (8.2 %). Greater wealth was associated with decreased odds of cost as a barrier (OR 0.72 [0.57, 0.90]). Greater wealth (OR 1.52 [1.03, 2.25]) and rural home location (OR 3.35 [1.16, 9.62]) were associated with increased odds of no surgeon being available. Cost as a barrier (OR 2.82 [1.02, 7.77]), female sex (OR 3.45 [1.62, 7.33]), and lack of surgeon (OR 5.62 [1.68, 18.77]) were associated with increased odds of postoperative complication. Patient wealth was not associated with odds of postoperative complication. CONCLUSIONS Barriers to surgery were common in Republic of Congo. Patient wealth and home location may predict barriers to surgery. Addressing gender disparities, access to providers, and patient perception of barriers in addition to removal of barriers may help maximize patient health benefits.
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20
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Fleming M, King C, Rajeev S, Baruwal A, Schwarz D, Schwarz R, Khadka N, Pande S, Khanal S, Acharya B, Benton A, Rogers SO, Panizales M, Gyorki D, McGee H, Shaye D, Maru D. Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal. BMC Health Serv Res 2017; 17:676. [PMID: 28946885 PMCID: PMC5613391 DOI: 10.1186/s12913-017-2624-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 09/15/2017] [Indexed: 11/11/2022] Open
Abstract
Background Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. Methods We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization’s Health Systems Framework. Results We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district’s per capita income. We identified and mapped challenges according to the World Health Organization’s Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. Conclusion The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization. Electronic supplementary material The online version of this article (10.1186/s12913-017-2624-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew Fleming
- Department of Surgery, Yale-New Haven Hospital, New Haven, CT, USA
| | - Caroline King
- Oregon Health & Sciences University, Portland, OR, USA
| | - Sindhya Rajeev
- Bellevue Hospital Center, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | | | - Dan Schwarz
- Possible, Sanfebagar-10, Achham, Nepal.,Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Ryan Schwarz
- Possible, Sanfebagar-10, Achham, Nepal.,Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Sami Pande
- United Nations Population Fund, Kathmandu, Nepal
| | - Sumesh Khanal
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Bibhav Acharya
- Possible, Sanfebagar-10, Achham, Nepal.,Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Adia Benton
- Department of Anthropology, Northwestern University, Evanston, IL, USA.,Program of African Studies, Northwestern University, Evanston, IL, USA
| | - Selwyn O Rogers
- Biological Sciences Division, Department of Surgery, University of Chicago, Chicago, IL, USA
| | | | - David Gyorki
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Heather McGee
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Shaye
- Massachusetts Eye and Ear Infirmary, Boston, MA, USA.,Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Duncan Maru
- Possible, Sanfebagar-10, Achham, Nepal. .,Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
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21
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Ramke J, Gilbert CE, Lee AC, Ackland P, Limburg H, Foster A. Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage. PLoS One 2017; 12:e0172342. [PMID: 28249047 PMCID: PMC5382971 DOI: 10.1371/journal.pone.0172342] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 02/03/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome). METHODS All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated. FINDINGS Datasets from 20 countries were included (2005-2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1-66.6%), CSOGood was 58.9% (IQR 53.7-67.6%) and CSOPoor was 17.7% (IQR 11.3-21.1%). Coverage and quality of cataract surgery were moderately associated-every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2-50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5-7.1%) than for CSC (median 2.3% IQR -1.5-11.6%). CONCLUSION eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.
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Affiliation(s)
- Jacqueline Ramke
- School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, New South Wales, Australia
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Clare E. Gilbert
- Department Clinical Research, Faculty Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Arier C. Lee
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Peter Ackland
- International Agency for the Prevention of Blindness, London, United Kingdom
| | - Hans Limburg
- Health Information Services, Nijenburg 32, Grootebroek, Netherlands
| | - Allen Foster
- Department Clinical Research, Faculty Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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22
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Agarwal-Harding KJ, von Keudell A, Zirkle LG, Meara JG, Dyer GSM. Understanding and Addressing the Global Need for Orthopaedic Trauma Care. J Bone Joint Surg Am 2016; 98:1844-1853. [PMID: 27807118 DOI: 10.2106/jbjs.16.00323] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.➤Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.➤The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.➤Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.➤Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.➤Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics.
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Affiliation(s)
- Kiran J Agarwal-Harding
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Arvind von Keudell
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, Massachusetts
| | | | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - George S M Dyer
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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23
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Roberts G, Roberts C, Jamieson A, Grimes C, Conn G, Bleichrodt R. Surgery and Obstetric Care are Highly Cost-Effective Interventions in a Sub-Saharan African District Hospital: A Three-Month Single-Institution Study of Surgical Costs and Outcomes. World J Surg 2016; 40:14-20. [PMID: 26470700 DOI: 10.1007/s00268-015-3271-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Lancet recently sponsored a commission examining the role of surgery in global health. There is a paucity of published information on the cost-effectiveness of surgery in low- and middle-income countries, a key metric in the prioritisation of limited resources. METHODS All patients undergoing emergency laparotomy, elective and emergency inguinal hernia repair, elective and emergency caesarean section, amputation, fracture manipulation, or fracture fixation over a 3 months period in a single district African hospital were assessed. World Health Organisation global burden of disease (GBD) methodology was used to calculate the disability-adjusted life years (DALYs) saved for each patient (using global and local life expectancy). Fully loaded costs were calculated for each patient’s care and providing the overall surgical service. Cost-effectiveness was calculated in year 2012 US$ per DALY saved for each procedure and overall. RESULTS A total of 428 patients were included, with an overall cost-effectiveness of $10.70 per DALY averted. The cost-effectiveness of individual procedures (global life expectancy) was: Amputation—$17.66; Emergency caesarean section—$7.42; Elective caesarean section—$20.50; Emergency laparotomy—$8.62; Elective hernia repair—$15.26; Emergency hernia repair—$4.36; Fracture/dislocation reduction—$69.03; Fracture/dislocation fixation—$225.89. CONCLUSIONS Surgery is a highly cost-effective healthcare measure in the setting of an African district hospital. The presented outcomes demonstrate that surgery is on a par with better-recognised and funded interventions such as HIV anti-retrovirals, malaria prevention and diarrhoea treatment. There are recognised limitations with the GBD methodology used here; however, this remains the best way to investigate the cost-effectiveness of health interventions. This study provides useful information on an, at present, under-studied field.
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24
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Affiliation(s)
- Jaymie Ang Henry
- International Collaboration for Essential Surgery (ICES), New York, USA
| | - Michael Cotton
- Service des Urgences, Centre Hospitalier Universitaire Vaudois, Rue Bugnon 46, 1011, Lausanne, Switzerland.
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25
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McDermott FD, Kelly ME, Warwick A, Arulampalam T, Brooks AJ, Gaarder T, Cotton BA, Winter DC. Problems and solutions in delivering global surgery in the 21st century. Br J Surg 2015; 103:165-9. [PMID: 26663000 DOI: 10.1002/bjs.9961] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/13/2015] [Accepted: 09/04/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Surgery has had low priority in global health planning, so the delivery of surgical care in low- and middle-income countries is often poorly resourced. A recent Lancet Commission on Global Surgery has highlighted the need for change. METHODS A consensus view of the problems and solutions was identified by individual surgeons from high-income countries, familiar with surgical care in remote and poorer environments, based on recent publications related to global surgery. RESULTS The major issues identified were: the perceived unimportance of surgery, shortage of personnel, lack of appropriate training and failure to establish surgical standards, failure to appreciate local needs and poor coordination of service delivery. CONCLUSION Surgery deserves a higher priority in global health resource allocation. Lessons learned from participation in humanitarian crises should be considered in surgical developments.
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Affiliation(s)
- F D McDermott
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - M E Kelly
- St Vincent's University Hospital, Dublin, Ireland
| | - A Warwick
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - T Arulampalam
- Surgical Division, Colchester University Hospital, Colchester, UK
| | - A J Brooks
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospital, Nottingham, UK
| | - T Gaarder
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - B A Cotton
- Division of Acute Care Surgery, University of Texas Health Science Center, Houston, Texas, USA
| | - D C Winter
- St Vincent's University Hospital, Dublin, Ireland
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26
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Farrelly PJ, Losty PD. Essential and non-essential paediatric surgery: implications for the future delivery of state health care in the UK. Pediatr Surg Int 2015; 31:879-83. [PMID: 26184827 DOI: 10.1007/s00383-015-3750-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delivery of health care in the UK faces enormous challenges with the Department of Health driving significant financial cost savings to ensure viability of public health services. We have analysed and modelled the concept of 'essential' and 'non-essential' paediatric surgery linked to the delivery of children's surgery in the NHS in England. METHODS Operation codes for surgical operations in newborns, children and adolescents were identified and Healthcare Resource Group tariffs-£Stg matched. Operations were designated as 'essential' or 'non-essential' based on the criteria-(1) life saving-neonatal surgery, emergency general surgery of childhood, cancer surgery; (2) debility if uncorrected; (3) aesthetics and (4) culture/attitude. Hospital Episode Statistics (HES) data were accessed and sampled for the total number of paediatric surgical operations-(age range 0-14 years) performed in NHS hospitals from 2009 to 2010. Annual costs (£) of both 'essential' and 'non-essential' operations were then calculated. RESULTS The commonest 'essential' operations performed in children and adolescents in the year 2009-2010 was appendicectomy at a cost of over £51 million pounds. Costs of performing a selection of 'non-essential' paediatric surgery operations were >£14 million pounds/year. The NHs funds for example almost 11,000 paediatric circumcisions annually at a cost of >£8 million pounds-50% are performed for non-therapeutic reasons. CONCLUSIONS Surgeons must engage and work actively with health care systems to ensure diminishing financial resources prioritise 'essential' operations for children. Commissioners must embrace evidence-based surgery. 'Essential' and 'non-essential' surgery has wide implications for the sustainability of the NHS and concepts herein developed can be applied to nations worldwide.
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Affiliation(s)
- Paul J Farrelly
- Division of Child Health, Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, University of Liverpool, Liverpool, UK
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27
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Monjok E. Letter to the Editor: Essential Surgery: The Way Forward. World J Surg 2015; 39:2836. [PMID: 26264459 DOI: 10.1007/s00268-015-3188-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Emmanuel Monjok
- Departments of Family and Community Medicine, University of Calabar and University of Calabar Teaching Hospital, Calabar, Nigeria.
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28
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Affiliation(s)
- Jaymie Ang Henry
- The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance), 101 Avenue of the Americas, Suite 908, New York, NY 10013, USA; The University of Chicago, Department of Surgery, A27 S Maryland Ave, Chicago, IL 60637, USA.
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