Short-term surgical mission to the Dominican Republic: a cost-benefit analysis

Use of virtual platform for delivery of simulation-based laparoscopic training curriculum in LMICs

BACKGROUND

Laparoscopic surgery is rapidly expanding in low-and middle-income countries (LMICs), yet many surgeons in LMICs have limited formal training in laparoscopy. In 2017, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) implemented Global Laparoscopic Advancement Program (GLAP), an in-person simulation-based laparoscopic training curriculum for surgeons in LMICs. In light of COVID-19, SAGES adapted GLAP to a virtual format with telesimulation. This study explores the feasibility and efficacy of virtual laparoscopic simulation training in resource-limited settings.

METHODS

Participants from San Jose, Costa Rica, Leon, México, and Guadalajara, México enrolled in the virtual GLAP curriculum, meeting biweekly for 2-h didactic classes and 2-h hands-on live simulation practice. Surgical residents' laparoscopic skills were evaluated using the five Fundamentals of Laparoscopic Surgery (FLS) tasks during the initial and final weeks of the program. Participants also completed pre-and post-program surveys assessing their perception of simulation-based training.

RESULTS

The study cohort consisted of 16 surgical attendings and 20 general surgery residents. A minimum 70% response rate was recorded across all surveys in the study. By the end of GLAP, residents completed all five tasks of the FLS exam within less time relative to their performance at the beginning of the training program (p < 0.05). Respondents (100%) reported that the program was a good use of their time and that education via telesimulation was easily reproduced. Participants indicated that the practice sessions, guidance, and feedback offered by mentors were their favorite elements of the training.

CONCLUSION

A virtual simulation-based curriculum can be an effective strategy for laparoscopic skills training. Participants demonstrated an improvement in laparoscopic skills, and they appreciated the mentorship and opportunity to practice laparoscopic skills. Future programs can expand on using a virtual platform as a low-cost, effective strategy for providing laparoscopic skills training to surgeons in LMICs.

Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study

OBJECTIVE

To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians.

SUMMARY BACKGROUND DATA

STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians.

METHODS

Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence.

RESULTS

We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM.

CONCLUSIONS

While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.

Thyroidectomy in a Surgical Volunteerism Mission: Analysis of 464 Consecutive Cases

Although surgical volunteer missions (SVMs) have become a popular approach for reducing the burden of surgical disease worldwide, the outcomes of specific procedures in the context of a mission are underreported. The aim of this study was to evaluate outcomes and efficiency of thyroid surgery within a surgical mission. This was a retrospective analysis of medical records of all patients who underwent thyroid surgery within a SVM from 2006 to 2019. Postoperative complication rate was the safety endpoint, whereas length of hospital stay (LOS) was the efficiency endpoint. Serious complications were defined as Clavien-Dindo class 3-5 complications. Expected safety and efficiency outcomes were calculated using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical risk calculator and compared to their observed counterparts. A total of 464 thyroidectomies were performed during the study period. Mean age of the patients was 40.3 ± 10.8 years, and male-to-female ratio was 72 : 392. Expected overall (p=0.127) and serious complication rates (p=0.738) were not significantly different from their observed counterparts. Expected LOS was found to be significantly shorter as compared to its observed counterpart (0.6 ± 0.2 vs. 2.5 ± 1.0 days; p < 0.001). This study found thyroid surgery performed within a surgical mission to be safe. NSQIP surgical risk calculator underestimates the LOS following thyroidectomy in surgical missions.

Google Glass for Remote Surgical Tele-proctoring in Low- and Middle-income Countries: A Feasibility Study from Mozambique

BACKGROUND

Untreated surgical conditions account for one-third of the total global burden of disease, and a lack of trained providers is a significant contributor to the paucity of surgical care in low- and middle-income countries (LMICs). Wearable technology with real-time tele-proctoring has been demonstrated in high-resource settings to be an innovative method of advancing surgical education and connecting providers, but application to LMICs has not been well-described.

METHODS

Google Glass with live-stream capability was utilized to facilitate tele-proctoring between a surgeon in Mozambique and a reconstructive surgeon in the United States over a 6-month period. At the completion of the pilot period, a survey was administered regarding the acceptability of the image quality as well as the overall educational benefit of the technology in different surgical contexts.

RESULTS

Twelve surgical procedures were remotely proctored using the technology. No complications were experienced in any patients. Both participants reported moderate visual impairment due to image distortion and light over-exposure. Video-stream latency and connection disruption were also cited as limitations. Overall, both participants reported that the technology was highly useful as training tool in both the intraoperative and perioperative setting.

CONCLUSIONS

Our experience in Mozambique demonstrates the feasibility of wearable technology to enhance the reach and availability of specialty surgical training in LMICs. Despite shortcomings in the technology and logistical challenges inherent to international collaborations, this educational model holds promise for connecting surgeons across the globe and introducing expanded access to education and mentorship in areas with limited opportunities for surgical trainees.

Functional and Quality of Life Outcomes of a Hand Surgery Mission to Honduras

Background: The objective of this study was to assess functional, quality of life, and satisfaction outcomes of a hand surgery short-term surgical mission (STSM) to Honduras, and determine whether patient demographics and surgery characteristics during a surgical mission correlate with outcome. Methods: A total of 63 patients who received upper extremity surgery at a week-long hand surgery STSM to Honduras in March 2013 participated in the study. A before-after study design was used. Before receiving surgery, participants completed the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and the Short Form 12 Health Survey version 2 (SF12v2). Four months postoperatively, participants completed the QuickDASH, SF12v2, and Satisfaction Survey. Results: The mean QuickDASH score significantly improved preoperatively to postoperatively. Demographics measures of age, sex, education, and income did not correlate with QuickDASH scores. Preoperative QuickDASH statistically significantly correlated with surgery type: Carpal tunnel patients had the highest scores (worst functioning). Postoperatively, mass excision and scar contracture/skin graft patients were correlated with the lowest scores. Carpal tunnel and tendon surgery patients showed greatest correlation with QuickDASH improvement. SF-12 scores revealed improvements in mental domains and declines in physical domains. Conclusions: Hand surgery performed during STSMs can result in significant functional improvement, regardless of socioeconomic status. Patients benefited from both simpler and more complex operations. Four months after surgery, general health-related quality of life measures showed improved mental indices. Measured physical indices declined despite improved QuickDASH scores. This may be due to the early general postoperative state. Further outcome research in STSMs in additional countries and specialties is required to expand our conclusions to other STSM contexts and guide best practices in STSMs.

Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist

INTRODUCTION

Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold.

METHODS

The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created.

RESULTS

Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed.

CONCLUSION

Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.

Cost-Effectiveness Analysis of Total Hip Arthroplasty Performed by a Canadian Short-Stay Surgical Team in Ecuador

Background

Few charitable overseas surgical missions produce cost-effectiveness analyses of their work.

Methods

We compared the pre- and postoperative health status for 157 total hip arthroplasty (THA) patients operated on from 2007 to 2011 attended by an annual Canadian orthopedic mission to Ecuador to determine the quality-adjusted life years (QALYs) gained. The costs of each mission are known. The cost per surgery was divided by the average lifetime QALYs gained to estimate an incremental cost-effectiveness ratio (ICER) in Canadian dollars per QALY.

Results

The average lifetime QALYs (95% CI) gained were 1.46 (1.4–1.5), 2.5 (2.4–2.6), and 2.9 (2.7–3.1) for unilateral, bilateral, and staged (two THAs in different years) operations, respectively. The ICERs were $4,442 for unilateral, $2,939 for bilateral, and $4392 for staged procedures. Seventy percent of the mission budget was spent on the transport and accommodation of volunteers.

Conclusion

THA by a Canadian short-stay surgical team was highly cost-effective, according to criteria from the National Institute for Health and Care Excellence and the World Health Organization. We encourage other international missions to provide similar cost-effectiveness data to enable better comparison between mission types and between mission and nonmission care.

A Systematic Review of Economic Analysis of Surgical Mission Trips Using the World Health Organization Criteria

BACKGROUND

Although the World Health Organization (WHO) has developed tools to standardize economic evaluations of global health interventions, little is known about the cost-effectiveness of surgical mission trips and their economic values. Our objective was to systematically evaluate the current literature on surgical volunteering trips to measure their adherence to WHO CHOosing Interventions that are cost-effective (WHO-CHOICE). We hypothesized that the majority of studies use some type of cost-effectiveness analysis that do not adhere to these standards.

METHODS

A systematic review of Pubmed, Medline, and Embase databases was performed in accordance with PRISMA guidelines, with inclusion criteria set a priori. Of the 908 publications screened, 72 were selected for full text review; 17 met inclusion criteria.

RESULTS

Only 17 out of 72 studies reported some type of economic analysis. We categorized the studies into service, educational, and combination (service and educational) surgical trips. Although seven of the service studies calculated the cost per disability-adjusted life year averted, the results were not based on WHO-CHOICE standards to facilitate comparisons among alternative options. Furthermore, none of the three educational trips calculated the value of the education provided, but only published cost estimates of the resources used during the trip.

CONCLUSIONS

Although a few studies performed some type of economic analysis, owing to their non-adherence to WHO-CHOICE standards, the results were not comparable to other studies. International surgical trips are expensive. To improve the efficacy and optimal use of limited resources, studies on surgical trips should follow the guidelines set by the WHO-CHOICE.

Effects of Short–Term Medical Mission Trips to Chiapas, Mexico, on the Religiosity of the Missionaries

This study evaluates the effects that short-term, foreign, Catholic medical mission trips had on the religiosity of the United States-based participants. The subjects of this study participated in Catholic medical missions to Chiapas State, Mexico, in 2014 and 2015. Twenty-two of forty-two participants responded to a survey to assess for any changes in their religiosity and associated attitudes and behaviors. The results revealed that participation in the medical mission was associated with a significant increase in non-organizational religious activity, intrinsic religiosity, concern for health disparities and the burden of illness in the developing world, the promotion of further missions, the provision of service and/or monetary aid to the poor in the missionary's local community, and an increased likelihood to discuss the Christian faith in conversations with others. There was no statistically significant association with organizational religious activity or local participation in evangelization activities.

Summary

This article reports on the changes seen in the religious attitudes and charitable works performed following participation in a short-term medical mission. After serving on a mission trip to Mexico, we found that United States-based missionaries had an increase in their private religious activities, felt closer to God, were more likely to help the poor in their own neighborhoods, and were more likely to discuss their Christian faith than prior to the mission trip. We discuss possible reasons for these changes.

Cost-effectiveness of short-term neurosurgical missions relative to other surgical specialties

Background:

Short-term surgical relief efforts have helped close some gaps in the provision of surgical care in remote settings. We reviewed the published literature on short-term surgical missions to compare their cost-effectiveness across subspecialties.

Methods:

PubMed was searched using the algorithm [“cost-effectiveness” AND “surgery” AND (“mission” OR “volunteer”)]. Articles detailing the cost-effectiveness of short-term surgical missions in low and middle-income countries (LMIC) were included. Only direct mission costs were considered, and all costs were converted into 2014 USD.

Results:

Eight articles, representing 27 missions in 9 LMIC countries during 2006–2014, met our inclusion criteria. Latin America was the most frequently visited region. Per capita costs ranged from $259 for cleft lip/cleft palate (CL/CP) missions to $2900 for a neurosurgery mission. Mission effectiveness ranged from 3 disability adjusted life years (DALYs) averted per patient for orthopedic surgery missions to 8.12 DALYs averted per patient for a neurosurgery mission. CL/CP and general surgery missions were the most cost-effective, averaging $80/DALY and $87/DALY, respectively. The neurosurgical, orthopedic, and hand surgery missions averaged the highest costs/DALY averted, with the cost-effectiveness being $357/DALY, $435/DALY, and $445/DALY, respectively. All analyzed missions were very cost effective.

Conclusion:

To date, this is the first study to assess the cost-effectiveness of short-term surgical missions across surgical specialties. Neurosurgical missions avert the largest number of healthy life years compared to other specialties, and thus, could yield a greater long-term benefit to resource-poor communities. We recommend that further studies be carried out to assess the impact of surgical missions in low-resource settings.