Development of a Needs Assessment Tool to Promote Capacity Building in Hand Surgery Outreach Trips: A Methodological Triangulation Approach

The Impact of Surgical Outreach on Trainee Education: American Society for Surgery of the Hand Touching Hands

PURPOSE

The American Society for Surgery of the Hand Touching Hands Project was created to provide essential hand care to underserved populations in low- and middle-income countries. This study aimed to characterize the educational benefits of participation among United States (US) hand surgery trainees.

METHODS

A web-based survey was distributed to all US trainees who participated in the Touching Hands trip to San Pedro Sula, Honduras between 2015 and 2024. Questions assessed the impact and educational value of the trip as well as barriers to participation in future outreach trips.

RESULTS

The response rate was 88% (29 out of 33). Most respondents were hand surgery fellows (25 out of 29, 86%). The average faculty to trainee ratio was 5:4. Trainees indicated they received an educational value of 5 out of 5. All respondents reported learning novel approaches to medical problems and techniques that they otherwise would not have been exposed to during their training. These included surgical techniques and concepts as well as problem-solving with limited resources. All participants reported interest in attending a similar outreach trip; however, many noted potential barriers including expense and time away from family and work.

CONCLUSIONS

Participation in international surgical outreach such as the American Society for Surgery of the Hand Touching Hands initiative introduces trainees to new and unique approaches to surgical techniques and pathology that they would otherwise not have exposure to in their training. Trainees reported that time and expense are potential barriers to future outreach involvement.

CLINICAL RELEVANCE

These findings demonstrate that involvement in surgical outreach during training benefits the education of US trainees through diversity of experience and exposure to different faculty mentors.

Scoping Review of Ethical Discourse in Global Cleft Surgery Literature

BACKGROUND

The ethical discourse regarding the delivery of global surgical care has increased in the 21st century. The aims of this manuscript are to explore the differences in ethical domains in the global cleft surgical literature discussed by authors from high-income countries versus lower-middle-income countries and to elucidate changes in ethical discussions over the last decade.

METHODS

A thematic coding analysis was completed using NVivo 12 qualitative data analysis software. Articles were analyzed and coded for discussion of 24 distinct subdomains in the global cleft surgical literature from 1992 to 2022.

FINDINGS

The domains with the most significant discourse in the global cleft surgery literature found were (1) clinical care and delivery and (2) engagement in collaborations and partnerships. Furthermore, when manuscripts are first authored by low- and middle-income country (LMIC) authors, the subdomains of (1) level of visiting trainee supervision, (2) relevance of educational activities, and (3) patient/procedure/location selection increase in relative discourse. The impact of visiting trainees on local educational programs is the ethical subdomain that has the largest increase in the last decade. There are barriers to publication as evidenced by the exclusion of abstracts which included LMIC authors but did not result in publications in peer-reviewed journals.

CONCLUSIONS

A critical finding of this study is that the distribution of discussed ethical domains differs when LMIC authors are included as authors, in particular when primary authorship is from an LMIC author. To the authors' knowledge, there is no other study to date which has attempted this form of analysis.

The state of global surgery assessment and data collection tools: A scoping review

BACKGROUND

There has been a proliferation of global surgery assessment tools designed for use in low- and middle-income countries. This scoping review sought to categorize and organize the breadth of global surgery assessment tools in the literature.

METHODS

The search was conducted using PubMed from October 2022 to April 2023 according to PRISMA extension for scoping review guidelines. The search terms were (("global surgery"[All Fields]) AND ("assessment"[All Fields]) OR (data collection)). Only tools published in English that detailed surgical assessment tools designed for low- and middle-income countries were included.

RESULTS

The search resulted in 963 papers and 46 texts described unique tools that were included for the final review. Of these, 30 (65%) tools were quantitative, 1 (2%) qualitative, and 15 (33%) employed mixed-methods. 25 (54%) tools evaluated surgery in general, whereas 21 (46%) were focused on various surgical subspecialties. Qualitatively, major themes among the tools were noted. There was significant overlap of many tools.

CONCLUSIONS

Nonspecialty surgery was represented more than any specialty surgery and many specialties had little or no representation in the literature. Ideally, local leadership should be involved in surgical assessment tools. Different methodologies, such as checklists and observational studies, aimed to target varying aspects of surgery and had distinct strengths and weaknesses. Further efforts should focus on expanding tools in neglected specialties.

Clinical Practice Guidelines to Support Capacity Building in Orthopaedic Surgical Outreach: An International Consensus Building Approach

BACKGROUND

Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel.

METHODS

We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it.

RESULTS

An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques.

CONCLUSIONS

As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs) 1 , 2 . It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs) 3 . Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources 4-6 . In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account 7 , 8 .

Bidirectional needs assessment of otolaryngology-head and neck surgery short-term surgical trips in Zimbabwe

Objectives

To describe findings from an otolaryngology-specific needs assessment tool in Zimbabwe.

Methods

Surveys were developed and shared with Low-Middle Income Country (LMIC) hosting institutions in Zimbabwe and to High-Income Country surgical trip participants (HIC). Respondents were otolaryngologists identified online and through professional networks who had participated in a surgical trip.

Results

The most common procedures Zimbabwe otolaryngologists reported treating were adenotonsillectomy (85.7%), chronic rhinosinusitis (71.4%), chronic otitis (57.1%), and head and neck tumor intervention (57.1%). The most common untreatable conditions that host physicians wanted to treat were skull base surgery (71.4%), flap reconstructions (57.1%), and laryngotracheal reconstruction (57.1%). The largest discrepancy between host desires and visiting team offerings were flap reconstruction (57.1%), nasal bone deformities (37.1%), and laryngotracheal reconstruction (17.1%). Perceptions of short-term surgical trips (STST) were recorded for host and visiting teams, and important differences between the public and private sectors of care in Zimbabwe were also identified.

Conclusion

The surveys utilized in this study served as a bidirectional needs assessment of the requirements and care goals of host institutions and visiting teams in Zimbabwe. Differences between public and private sectors of care, particularly regarding infrastructure, resources, and surgical goals, were revealed, and the results can be utilized as part of efforts to maximize efforts within global surgical partnerships.

Level of Evidence

VI.

Orthopedic surgery in Palau-Current capacity, needs, and future directions

BACKGROUND

Palau, an island nation in Micronesia, is a medically underserved area with a shortage of specialty care services. Orthopedic diagnoses in Palau remain among the three most common reasons for costly off-island medical referral. The purpose of this study was to assess Palau's current orthopedic surgery capacity and needs to inform interventions to build capacity to improve care access and quality.

METHODS

Orthopedic needs and capacity assessment tools developed by global surgical outreach experts were utilized to gather information and prompt discussions with a broad range of Palau's most knowledgeable stakeholders (n = 6). Results were reported descriptively.

RESULTS

Finance, community impact, governance, and professional development were the lowest-scored domains from the Capacity Assessment Tool for orthopedic surgery (CAT-os), indicating substantial opportunity to build within these domains. According to administrators (n = 3), governance and finance were the greatest capacity-building priorities, followed by professional development and partnership. Belau National Hospital (BNH) had adequate surgical infrastructure. Skin grafting, soft tissue excision/resection, infection management, and amputation were the most commonly selected procedures by stakeholders reporting orthopedic needs.

CONCLUSIONS

This study utilizes a framework for orthopedic capacity-building in Palau which may inform partnership between Palau's healthcare system and orthopedic global outreach organizations with the goal of improving the quality, safety, and value of the care delivered. This demonstration of benchmarking, implementation planning, and subsequent re-evaluation lays the foundation for the understanding of capacity-building and may be applied to other medically underserved areas globally to improve access to high-quality orthopedic care.

Clinical spine care partnerships between high-income countries and low-and-middle-income countries: A scoping review

BACKGROUND

Clinical collaboration between spine professionals in high-income countries (HICs) and low-and-middle-income countries (LMICs) may provide improvements in the accessibility, efficacy, and safety of global spine care. Currently, the scope and effectiveness of these collaborations remain unclear. In this review, we describe the literature on the current state of these partnerships to provide a framework for exploring future best practices.

METHODS

PubMed, Embase, and Cochrane Library were queried for articles on spine-based clinical partnerships between HICs and LMICs published between 2000 and March 10, 2023. This search yielded 1528 total publications. After systematic screening, nineteen articles were included in the final review.

RESULTS

All published partnerships involved direct clinical care and 13/19 included clinical training of local providers. Most of the published collaborations reviewed involved one of four major global outreach organizations with the majority of sites in Africa. Participants were primarily physicians and physicians-in-training. Only 5/19 studies reported needs assessments prior to starting their partnerships. Articles were split on evaluative focus, with some only evaluating clinical outcomes and some evaluating the nature of the partnership itself.

CONCLUSIONS

Published studies on spine-focused clinical partnerships between HICs and LMICs remain scarce. Those that are published often do not report needs assessments and formal metrics to evaluate the efficacy of such partnerships. Toward improving the quality of spine care globally, we recommend an increase in the quality and quantity of published studies involving clinical collaborations between HICs and LICs, with careful attention to reporting early needs assessments and evaluation strategies.

Bidirectional needs assessment of otolaryngology-head and neck surgery short-term surgical trips to Ethiopia and Kenya

Objectives

To create an otolaryngology-specific needs assessment tool for short-term global surgical trips and to describe our findings from its implementation.

Methods

Surveys 1 and 2 were developed based on a literature review and disseminated to Low-Middle Income (LMIC) hosting institutions in Kenya and Ethiopia and to High-Income surgical trip participants (HIC), respectively. Respondents were otolaryngologists identified online, through professional organizations, and by word-of-mouth, who had participated in a surgical trip of <4 weeks.

Results

HIC and LMIC respondents shared similar goals of expanding host surgical skills through education and training while building sustainable partnerships. Discrepancies were identified between LMIC desired surgical skills and supply needs and HIC current practices. Microvascular reconstruction (17.6%), advanced otologic surgery (17.6%), and FESS (14.7%) were most desired skills and high-demand equipment needs were FESS sets (89%), endoscopes (78%), and surgical drills (56%). Frequently taught techniques included advanced otologic surgery (36.6%), congenital anomaly surgery (14.6%), and FESS (14.6%) with the largest gap between LMIC-need and HIC-offerings being in microvascular reconstruction (17.6% vs. 0%). We also highlight the discrepancy in expectations of responsibility for trip logistics, research, and patient follow-up.

Conclusion

We created and implemented the first otolaryngology-specific needs assessment tool in the literature. With its implementation in Ethiopia and Kenya, we were able to identify unmet needs as well as attitudes and perceptions of LMIC and HIC participants. This tool may be adapted and utilized to assess specific needs, resources, and goals of both host and visiting teams to facilitate successful global partnerships.

Level of Evidence

Level VI.

A Framework and Blueprint for Building Capacity in Global Orthopaedic Surgical Outreach

BACKGROUND

Nongovernmental organizations (NGOs) from high-income countries provide surgical outreach for patients in low and middle-income countries (LMICs); however, these efforts lack a coordinated measurement of their ability to build capacity. While the World Health Organization and others recommend outreach trips that aim to build the capacity of the local health-care system, no guidance exists on how to accomplish this. The objective of this paper is to establish a framework and a blueprint to guide the operations of NGOs that provide outreach to build orthopaedic surgical capacity in LMICs.

METHODS

We conducted a qualitative analysis of semistructured interviews with 16 orthopaedic surgeons and administrators located in 7 countries (6 LMICs) on the necessary domains for capacity-building; the analysis was guided by a literature review of capacity-building frameworks. We subsequently conducted a modified nominal group technique with a consortium of 10 U.S.-based surgeons with expertise in global surgical outreach, which was member-checked with 8 new stakeholders from 4 LMICs.

RESULTS

A framework with 7 domains for capacity-building in global surgical outreach was identified. The domains included professional development, finance, partnerships, governance, community impact, culture, and coordination. These domains were tiered in a hierarchical system to stratify the level of capacity for each domain. A blueprint was developed to guide the operations of an organization seeking to build capacity.

CONCLUSIONS

The developed framework identified 7 domains to address when building capacity during global orthopaedic surgical outreach. The framework and its tiered system can be used to assess capacity and guide capacity-building efforts in LMICs. The developed blueprint can inform the operations of NGOs toward activities that focus on building capacity in order to ensure a measured and sustained impact.

Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist

INTRODUCTION

While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent.

METHODS

We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain.

RESULTS

A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience.

CONCLUSION

As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

Investigating acceptability of a training programme in precision medicine for frontline healthcare professionals: a mixed methods study

BACKGROUND

Precision Medicine offers tailored prevention, diagnosis, treatment and management to patients that considers genomics, lifestyle and environmental factors. If implementation of Precision Medicine is to advance, effective, focused upskilling of frontline healthcare professionals through quality continuing professional development is needed. This study reports on an evidence-based approach to needs assessment to investigate the current level of knowledge of Precision Medicine, acceptable content for training, the perceived potential of a more precision approach to patient care and motivation to participate in a training programme among pharmacists, advanced practice nurses and general practitioners. Investigating perceived needs can avoid a top-down approach and support a design that is fit for purpose to targeted professions.

METHODS

This study reports on 2 focus groups (n = 12) delivered in French and German with equal professional participation of the targeted professions. The research objectives were investigated in two phases. During the first phase, a literature review and expert consultations were conducted to develop a definition of PM, patient cases and content for training. In a second phase, these investigations were further explored using focus groups to investigate acceptable learning objectives, the potential of PM to relevant professions and motivation of participants. Quantitative investigations using rating scales and visual analogues were incorporated. The focus groups were audio recorded, transcribed by intelligent verbatim and translated to English. NVivo was used for data analysis and interpretation following a hybrid approach using the Framework Method and thematic analysis. The analytical framework, Implementation Science, was applied to organise and present research data.

RESULTS

Precision Medicine is considered a new topic area, largely unfamiliar to frontline healthcare professionals.. There was acceptance of a more precision approach to care among all participants with perceived positive implications for patients. Valuable insight was gathered on acceptable content and form for training. All participants expressed concerns on readiness within their professions which included an insufficient system infrastructure, a lack of time to attend needed training, a lack of clarity for use in practice and the time needed to build a support network.

CONCLUSIONS

A precision approach to patient care is on the horizon for health care professionals not only in hospital settings but also at the community level. Our results conclude that an adaptable and flexible training programme in PM is timely, contextually relevant and conducive to the needs of targeted health professions for successful implementation. A training programme in PM will require support across sectors and stakeholders, supporting insurance models, educated patients and integrated care supported by innovative technology. Implementation Science outcomes are a useful strategy towards design of an effective training programme that can have measurable impact in practice.

Establishing Sustainable Arthroscopy Capacity in Low- and Middle-Income Countries (LMICs) through High-Income Country/LMIC Partnerships

Disparities exist in treatment modalities, including arthroscopic surgery, for orthopaedic injuries between high-income countries (HICs) and low- and middle-income countries (LMICs). Arthroscopy training is a self-identified goal of LMIC surgeons to meet the burden of musculoskeletal injury. The aim of this study was to determine the necessary “key ingredients” for establishing arthroscopy centers in LMICs in order to build capacity and expand training in arthroscopy in lower-resource settings.

Validation of a manual of care plans for people hospitalized with COVID-19

Aim

Validate a manual of care plans for people hospitalized for coronavirus disease, COVID‐19.

Design

Validation study with a mixed‐method design.

Methods

Design and validation of a care plans manual for people hospitalized by COVID‐19. Care plans used standardized languages: NANDA‐I, Nursing Outcomes Classification (NOC) and Nursing Intervention Classification (NIC). The design included external and internal validation with quantitative and qualitative analysis. Data collection was between March and June 2020. The study methods were compliant with the Good Reporting of a Mixed Methods Study (GRAMMS) checklist.

Results

The manual integrated 24 NANDA‐I diagnoses, 34 NOC and 47 NIC different criteria. It was validated by experts of Scientific‐Technical Commission, who recommended linking the diagnoses to an assessment. The internal validation validated 17 of 24 diagnoses, 56 of 65 NOC and 86 of the 104 NIC. During the discussion group, 6 new diagnoses proposed were validated and the non‐validated diagnoses were linked to the baseline condition of the person.

Quality Measures to Deliver Safe, High-Quality Care on Hand Surgery Outreach Trips to Low and Middle-Income Countries

BACKGROUND

The burden of hand surgery in low and middle-income countries (LMICs) is immense and growing. Although outreach trips to LMICs have been increasing, there has remained a gap regarding assessment of quality of care on outreach trips. We developed quality measures to assess hand surgery outreach trips to LMICs.

METHODS

We followed the recommendations set forth by the World Health Organization for practice guideline development. We used the results of a systematic review to inform the development of quality measures. Eight hand and upper-extremity surgeons with extensive global outreach experience (mean surgical outreach experience of >15 years, completed >3,000 surgeries in 24 countries) completed a modified RAND/UCLA (University of California Los Angeles) Delphi process to evaluate the importance, the feasibility, the usability, and the scientific acceptability of 83 measures. Validity was defined according to established methods.

RESULTS

A tiering system that was based on the resources available at an outreach site (essential, intermediate, and advanced) was developed to classify the application of the measures since care delivery in LMICs often is constrained by local resources. Twenty-two (27%) of 83 measures were validated. All 22 (100%) were classified as essential (e.g., availability of interpretation services for the visiting team); no measures that were classified as intermediate or advanced were validated.

CONCLUSIONS

Field-testing and implementation of quality measures served to identify the safety and the quality of hand surgical care that was provided on outreach trips to LMICs and inform improvement efforts. Tiers of care can be applied to quality measures to incorporate resource and capacity limitations when assessing their performance.

CLINICAL RELEVANCE

Ensuring safety and high-quality care on hand surgical outreach trips to LMICs is foundational to all participating organizations and physicians. Valid quality measures can be implemented by organizations undertaking outreach trips to LMICs.