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Beard JH, Ohene-Yeboah M, Kasu ES, Affram N, Tabiri S, Amoako JKA, Abantanga FA, Löfgren J. Long-Term Outcomes Following Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana. ANNALS OF SURGERY OPEN 2024; 5:e460. [PMID: 39310350 PMCID: PMC11415131 DOI: 10.1097/as9.0000000000000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/05/2024] [Indexed: 09/25/2024] Open
Abstract
Objective To assess long-term outcomes following inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana. Background Task sharing of surgical care with nonsurgeons can increase access to essential surgery. Long-term safety and outcomes of task sharing are not well-described for hernia repair. Methods This prospective cohort study was conducted in Ho, Ghana. After completing a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repairs with mesh on men with primary, reducible hernias. The primary outcome of this study was hernia recurrence at 5 years. The noninferiority limit was 5 percentage points. Secondary endpoints included pain and self-assessed health status at 5 years. Results A total of 242 operations in 241 participants were included, including 119 hernia repairs performed by the medical doctors and 123 performed by the surgeons. One hundred and sixty-nine participants (70.1%) were seen in follow-up at 5 years, 29 participants (12.0%) had died and 43 (17.8%) were lost to follow-up. The overall 5-year recurrence rate was 4.7% (n = 8). The absolute difference in recurrence rate between the medical doctor group (2 [2.3%]) and the surgeon group (6 [7.3%]) was -5.0 (1-tailed 95% confidence interval, -10.5; P = 0.06), demonstrating noninferiority of the medical doctors. Participants experienced improvements in groin pain and self-assessed health status that persisted at 5 years. Conclusions Long-term outcomes of elective mesh inguinal hernia repair in men performed by medical doctors and surgeons in Ghana were excellent. Task sharing is a critical tool to address the substantial morbidity of unmet hernia surgery needs in Ghana.
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Affiliation(s)
- Jessica H. Beard
- From the Department of Surgery, Division of Trauma Surgery and Surgical Critical Care, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Michael Ohene-Yeboah
- Department of Surgery, School of Medicine and Dentistry, University of Ghana, Accra, Ghana
| | | | - Nelson Affram
- Department of Surgery, Ho Teaching Hospital, Ho, Ghana
| | - Stephen Tabiri
- Department of Surgery, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - Joachim K. A. Amoako
- Department of Surgery, School of Medicine and Dentistry, University of Ghana, Accra, Ghana
| | - Francis A. Abantanga
- Department of Surgery, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - Jenny Löfgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Malemo LK, Yap A, Mitume B, Salmon C, Karafuli K, Poenaru D, Onyango R. Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo. BMC Surg 2024; 24:95. [PMID: 38519894 PMCID: PMC10958871 DOI: 10.1186/s12893-024-02386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volume are unknown in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). We aimed to determine the surgical capacity and its associated factors within the DRC. METHODS Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multiple linear regressions were performed. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people. RESULTS Twenty-eight hospitals in North Kivu were assessed over one year in 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region in one year. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate linear regression analysis, each additional SAO added 239 additional cases annually (p = 0.023), while each additional perioperative provider added 110 cases annually (p < 0.001). In our multiple regression analysis adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant. CONCLUSIONS The surgical workforce in DRC did not meet the LCoGS benchmark of 20 SAOs per 100,000 people but was not an independent predictor of surgical capacity. Major investment is needed to simultaneously bolster healthcare facilities and increase surgical workforce training.
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Affiliation(s)
- Luc Kalisya Malemo
- School of Medicine, The University of Goma, Goma, Democratic Republic of Congo.
| | - Ava Yap
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, USA
| | - Boniface Mitume
- Department of Computer Engineering, Université Officielle de Ruwenzori, Butembo, Democratic Republic of Congo
| | - Christian Salmon
- Centre for Global Health Engineering, Department of Engineering Management and Industrial Engineering, Western New England University, Springfield, MA, USA
| | - Kambale Karafuli
- Université Libre des Pays des Grands Lacs, Goma, Democratic Republic of Congo
| | - Dan Poenaru
- Department of Pediatric Surgery, McGill University, Montreal, QC, Canada
| | - Rosebella Onyango
- Department of Community Health and Development, Great Lakes University of Kisumu, Kisumu, Kenya
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van Kesteren J, Meylahn-Jansen PJ, Conteh A, Lissenberg-Witte BI, van Duinen AJ, Ashley T, Bonjer HJ, Bolkan HA. Inguinal hernia surgery learning curves by associate clinicians. Surg Endosc 2023; 37:2085-2094. [PMID: 36303045 PMCID: PMC10017565 DOI: 10.1007/s00464-022-09726-5] [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: 04/28/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Open inguinal hernia repair is the most commonly performed procedure in general surgery in sub-Saharan Africa, but data on its learning curve are lacking. This study evaluated the learning curve characteristics to improve surgical training and enable scaling up hernia surgery in low- and middle-income countries. METHODS Logbook data of associate clinicians enrolled in a surgical training program in Sierra Leone were collected and their first 55 hernia surgeries following the Bassini technique (herniorrhaphies) were analyzed in cohorts of five cases. Studied variables were gradient of decline of operating time, variation in operating time, and length of stay (LOS). Eleven subsequent cohorts of each five herniorrhaphies were investigated. RESULTS Seventy-five trainees enrolled in the training program between 2011 and 2020 were eligible for inclusion. Thirty-one (41.3%) performed the minimum of 55 herniorrhaphies, and had also complete personal logbook data. Mean operating times dropped from 79.6 (95% CI 75.3-84.0) to 48.6 (95% CI 44.3-52.9) minutes between the first and last cohort, while standard deviation in operating time nearly halved to 15.4 (95% CI 11.7-20.0) minutes, and LOS was shortened by 3 days (8.5 days, 95%CI 6.1-10.8 vs. 5.4 days, 95% 3.1-7.6). Operating times flattened after 31-35 cases which corresponded with 1.5 years of training. CONCLUSIONS The learning curve of inguinal hernia surgery for associate clinicians flattens after 31-35 procedures. Training programs can be tailored based on this finding. The recorded learning curve may serve as a baseline for future training techniques.
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Affiliation(s)
- Jurre van Kesteren
- Department of Surgery, Amsterdam University Medical Centers, Location Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Global Surgery Amsterdam, Amsterdam, The Netherlands.
| | - Pauline J Meylahn-Jansen
- Global Surgery Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Surgery, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
- CapaCare, Trondheim, Norway
| | - Thomas Ashley
- CapaCare, Trondheim, Norway
- Kamakwie Wesleyan Hospital, Kamakwie, Sierra Leone
- Department of General Surgery, North Cumbria University Hospital, Carlisle, UK
| | - H Jaap Bonjer
- Department of Surgery, Amsterdam University Medical Centers, Location Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Global Surgery Amsterdam, Amsterdam, The Netherlands
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Surgery, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
- CapaCare, Trondheim, Norway
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Båvenäs E, Möller C, Bhandarkar P, Mulowooza J, Löfgren J. Predictors of immediate neonatal outcome after cesarean section in Uganda. Int J Gynaecol Obstet 2021; 158:101-109. [PMID: 34655232 DOI: 10.1002/ijgo.13986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/07/2021] [Accepted: 10/14/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify predictors of low Apgar score, immediate neonatal death, and stillbirth after cesarean section in Uganda. METHODS Records of cesarean sections performed at all 14 regional referral hospitals and also 14 first-level (district) hospitals in Uganda were reviewed. Both elective and emergency cases were included. Data comprised mother's age, indication, type of anesthesia, and immediate outcome of the newborn. To evaluate the relation of the predictor variables to outcome, regression analysis was performed. RESULTS A total of 37 585 cesarean sections were recorded. The indications for cesarean section that led to the highest neonatal mortality and stillbirth rates and lowest mean Apgar scores were uterine rupture and hemorrhage. Emergency surgery and general anesthesia had worse neonatal outcomes than elective surgery and spinal anesthesia. Compared with general anesthesia, spinal anesthesia was favorable for neonatal outcomes. CONCLUSION Elective surgical planning and scale-up of the use of spinal anesthesia may potentially reduce stillbirths and immediate neonatal deaths.
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Affiliation(s)
- Erica Båvenäs
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Prashant Bhandarkar
- WHO Collaborating Centre (WHOCC) for Research in Surgical Needs in LMICs, BARC Hospital, Mumbai, India.,School of Health System Studies, Tata Institute of Social Sciences (TISS), Mumbai, India
| | - Jude Mulowooza
- Makerere University School of Public Health, Kampala, Uganda
| | - Jenny Löfgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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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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Ashley T, Ashley H, Wladis A, Bolkan HA, van Duinen AJ, Beard JH, Kalsi H, Palmu J, Nordin P, Holm K, Ohene-Yeboah M, Löfgren J. Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2032681. [PMID: 33427884 PMCID: PMC7801936 DOI: 10.1001/jamanetworkopen.2020.32681] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Task sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial. OBJECTIVE To determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone. DESIGN, SETTING, AND PARTICIPANTS This single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019. INTERVENTIONS All patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs. MAIN OUTCOMES AND MEASURES The primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations. RESULTS A total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, -6.0 [95% CI, -11.2 to 0.7] percentage points; P < .001). CONCLUSIONS AND RELEVANCE These findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income countries. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN63478884.
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Affiliation(s)
- Thomas Ashley
- Kamakwie Wesleyan Hospital, Kamakwie, Sierra Leone
- Department of General Surgery, North Cumbria University Hospital, Carlisle, United Kingdom
| | | | - Andreas Wladis
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Håkon A. Bolkan
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Surgery, Trondheim University Hospital, Trondheim, Norway
| | - Alex J. van Duinen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Surgery, Trondheim University Hospital, Trondheim, Norway
| | - Jessica H. Beard
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | | | | | - Pär Nordin
- Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
| | | | | | - Jenny Löfgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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7
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Beard JH, Ohene-Yeboah M, Tabiri S, Amoako JKA, Abantanga FA, Sims CA, Nordin P, Wladis A, Harris HW, Löfgren J. Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana. JAMA Surg 2020; 154:853-859. [PMID: 31241736 DOI: 10.1001/jamasurg.2019.1744] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance Inguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair. Objective To compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana. Design, Setting, and Participants This prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia. Main Outcomes and Measures The primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year. Results Two-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was -1.9 (1-tailed 95% CI, -4.8; P < .001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons. Conclusions and Relevance This study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease.
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Affiliation(s)
- Jessica H Beard
- Lewis Katz School of Medicine, Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Temple University, Philadelphia, Pennsylvania
| | - Michael Ohene-Yeboah
- Department of Surgery, School of Medicine and Dentistry, University of Ghana, Accra
| | - Stephen Tabiri
- Department of Surgery, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - Joachim K A Amoako
- Department of Surgery, School of Medicine and Dentistry, University of Ghana, Accra
| | - Francis A Abantanga
- Department of Surgery, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - Carrie A Sims
- Trauma Center at Penn, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Pär Nordin
- Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Andreas Wladis
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Hobart W Harris
- Department of Surgery, University of California, San Francisco
| | - Jenny Löfgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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8
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Abstract
BACKGROUND Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.
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9
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Mansourati M, Kumar V, Khajanchi M, Saha ML, Dharap S, Seger R, Gerdin Wärnberg M. Mortality following surgery for trauma in an Indian trauma cohort. Br J Surg 2018; 105:1274-1282. [DOI: 10.1002/bjs.10862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/08/2018] [Accepted: 02/15/2018] [Indexed: 11/07/2022]
Abstract
Abstract
Background
India accounts for 20 per cent of worldwide trauma mortality. Little is known about the quality of trauma surgery in an Indian setting. The aim of this study was to estimate the overall perioperative mortality rate, and to assess the association between type of acute surgical intervention and perioperative mortality among adult patients treated for trauma in an urban Indian setting.
Methods
Data were obtained from injured adult patients enrolled in four urban Indian hospitals during 2013–2015. Those who had surgery within 24 h of arrival at hospital were included in the analysis. Patients with missing data were excluded. The perioperative mortality rate was measured at 48 h and 30 days after arrival at hospital. Generalized linear mixed models were used for risk adjustment of procedure-specific mortality.
Results
Among 2986 patients who underwent trauma surgery, the overall 48-h mortality rate was 6·0 per cent, and the 30-day mortality rate was 23·1 per cent. The highest adjusted odds ratios (ORs) for 48-h mortality were found for patients who underwent surgery on the peripheral vasculature (OR 4·71, 95 per cent c.i. 1·18 to 16·59; P = 0·030) and the digestive system and spleen (OR 3·77, 1·33 to 9·01; P = 0·010) compared with those who had nervous system surgery.
Conclusion
In this study of surgery in an Indian trauma cohort, there was an excess of late perioperative deaths. Mortality differed significantly according to the type of surgery being undertaken.
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Affiliation(s)
- M Mansourati
- Global Health: Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - V Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - M Khajanchi
- Department of Surgery, Seth G. S. Medical College and King Edward Memorial Hospital, Mumbai, India
| | - M L Saha
- Department of Surgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, India
| | - S Dharap
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - R Seger
- Global Health: Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - M Gerdin Wärnberg
- Global Health: Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Ruhumuriza J, Odhiambo J, Riviello R, Lin Y, Nkurunziza T, Shrime M, Maine R, Omondi JM, Mpirimbanyi C, de la Paix Sebakarane J, Hagugimana P, Rusangwa C, Hedt-Gauthier B. Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing. BJS Open 2018; 2:25-33. [PMID: 29951626 PMCID: PMC5952380 DOI: 10.1002/bjs5.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/09/2017] [Indexed: 01/09/2023] Open
Abstract
Background In low‐ and middle‐income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings. Methods This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time‐driven activity‐based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices. Results Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent). Conclusion The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale‐up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location‐related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.
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Affiliation(s)
- J Ruhumuriza
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - J Odhiambo
- Partners In Health, Harvard Medical School Boston Massachusetts USA
| | - R Riviello
- College of Medicine and Health Sciences University of Rwanda Kigali Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Program in Global Surgery and Social Change, Harvard Medical School Boston Massachusetts USA.,Center for Surgery and Public Health, Brigham and Women's Hospital Boston Massachusetts USA
| | - Y Lin
- Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Department of Surgery University of Colorado Denver Colorado USA
| | - T Nkurunziza
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - M Shrime
- Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA.,Office of Surgery and Health, Massachusetts Eye and Ear Infirmary Boston Massachusetts USA
| | - R Maine
- Department of Surgery University of Washington Seattle Washington USA
| | - J M Omondi
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda.,Ministry of Health, Butaro District Hospital Burera Rwanda
| | - C Mpirimbanyi
- College of Medicine and Health Sciences University of Rwanda Kigali Rwanda
| | | | - P Hagugimana
- Ministry of Health, Butaro District Hospital Burera Rwanda
| | - C Rusangwa
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda
| | - B Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima University of Rwanda Kigali Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School Boston Massachusetts USA
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Abstract
OBJECTIVE To quantify the burden of surgical conditions in Uganda. BACKGROUND Data on the burden of disease have long served as a cornerstone to health policymaking, planning, and resource allocation. Population-based data are the gold standard, but no data on surgical burden at a national scale exist; therefore, we adapted the Surgeons OverSeas Assessment of Surgical Need survey and conducted a nation-wide, cross-sectional survey of Uganda to quantify the burden of surgically treatable conditions. METHODS The 2-stage cluster sample included 105 enumeration areas, representing 74 districts and Kampala Capital City Authority. Enumeration occurred from August 20 to September 12, 2014. In each enumeration area, 24 households were randomly selected; the head of the household provided details regarding any household deaths within the previous 12 months. Two household members were randomly selected for a head-to-toe verbal interview to determine existing untreated and treated surgical conditions. RESULTS In 2315 households, we surveyed 4248 individuals: 461 (10.6%) reported 1 or more conditions requiring at least surgical consultation [95% confidence interval (CI) 8.9%-12.4%]. The most frequent barrier to surgical care was the lack of financial resources for the direct cost of care. Of the 153 household deaths recalled, 53 deaths (34.2%; 95% CI 22.1%-46.3%) were associated with surgically treatable signs/symptoms. Shortage of time was the most frequently cited reason (25.8%) among the 11.6% household deaths that should have, but did not, receive surgical care (95% CI 6.4%-16.8%). CONCLUSIONS Unmet surgical need is prevalent in Uganda. There is an urgent need to expand the surgical care delivery system starting with the district-level hospitals. Routine surgical data collection at both the health facility and household level should be implemented.
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Anderson GA, Ilcisin L, Abesiga L, Mayanja R, Portal Benetiz N, Ngonzi J, Kayima P, Shrime MG. Surgical volume and postoperative mortality rate at a referral hospital in Western Uganda: Measuring the Lancet Commission on Global Surgery indicators in low-resource settings. Surgery 2017; 161:1710-1719. [PMID: 28259351 DOI: 10.1016/j.surg.2017.01.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery recommends that every country report its surgical volume and postoperative mortality rate. Little is known, however, about the numbers of operations performed and the associated postoperative mortality rate in low-income countries or how to best collect these data. METHODS For one month, every patient who underwent an operation at a referral hospital in western Uganda was observed. These patients and their outcomes were followed until discharge. Prospective data were compared with data obtained from logbooks and patient charts to determine the validity of using retrospective methods for collecting these metrics. RESULTS Surgical volume at this regional hospital in Uganda is 8,515 operations/y, compared to 4,000 operations/y reported in the only other published data. The postoperative mortality rate at this hospital is 2.4%, similar to other hospitals in low-income countries. Finding patient files in the medical records department was time consuming and yielded only 62% of the files. Furthermore, a comparison of missing versus found charts revealed that the missing charts were significantly different from the found charts. Logbooks, on the other hand, captured 99% of the operations and 94% of the deaths. CONCLUSION Our results describe a simple, reproducible, accurate, and inexpensive method for collection of the Lancet Commission on Global Surgery variables using logbooks that already exist in most hospitals in low-income countries. While some have suggested using risk-adjusted postoperative mortality rate as a more equitable variable, our data suggest that only a limited amount of risk adjustment is possible given the limited available data.
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Affiliation(s)
- Geoffrey A Anderson
- Department of Surgery, Massachusetts General Hospital, Boston, MA; Program in Global Surgery and Social Medicine, Department of Global Health and Social Medicine, Harvard University, Boston, MA
| | - Lenka Ilcisin
- Program in Global Surgery and Social Medicine, Department of Global Health and Social Medicine, Harvard University, Boston, MA
| | - Lenard Abesiga
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ronald Mayanja
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Peter Kayima
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark G Shrime
- Program in Global Surgery and Social Medicine, Department of Global Health and Social Medicine, Harvard University, Boston, MA.
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13
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Löfgren J, Matovu A, Wladis A, Ibingira C, Nordin P, Galiwango E, Forsberg BC. Cost-effectiveness of groin hernia repair from a randomized clinical trial comparing commercial versus low-cost mesh in a low-income country. Br J Surg 2017; 104:695-703. [PMID: 28206682 DOI: 10.1002/bjs.10483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/27/2016] [Accepted: 12/03/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Over 200 million people worldwide live with groin hernia and 20 million are operated on each year. In resource-scarce settings, the superior surgical technique using a synthetic mesh is not affordable. A low-cost alternative is needed. The objective of this study was to calculate and compare costs and cost-effectiveness of inguinal hernia mesh repair using a low-cost versus a commercial mesh in a rural setting in Uganda. METHODS This is a cost-effectiveness analysis of a double-blinded RCT comparing outcomes from groin hernia mesh repair using a low-cost mesh and a commercially available mesh. Cost-effectiveness was expressed in US dollars (with euros in parentheses, exchange rate 30 December 2016) per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained. RESULTS The cost difference resulting from the choice of mesh was $124·7 (€118·1). In the low-cost mesh group, the cost per DALY averted and QALY gained were $16·8 (€15·9) and $7·6 (€7·2) respectively. The corresponding costs were $58·2 (€55·1) and $33·3 (€31·5) in the commercial mesh group. A sensitivity analysis was undertaken including cost variations and different health outcome scenarios. The maximum costs per DALY averted and QALY gained were $148·4 (€140·5) and $84·7 (€80·2) respectively. CONCLUSION Repair using both meshes was highly cost-effective in the study setting. A potential cost reduction of over $120 (nearly €120) per operation with use of the low-cost mesh is important if the mesh technique is to be made available to the many millions of patients in countries with limited resources. TRIAL REGISTRATION NUMBER ISRCTN20596933 (http://www.controlled-trials.com).
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Affiliation(s)
- J Löfgren
- Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - A Matovu
- Mubende Regional Referral Hospital, Makerere University, Kampala, Uganda
| | - A Wladis
- Department of Surgery, St Göran's Hospital, Stockholm, Sweden
| | - C Ibingira
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - P Nordin
- Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - E Galiwango
- School of Public Health, Iganga/Mayuge Health and Demographic Surveillance Site, Iganga, Uganda
| | - B C Forsberg
- Department of Public Health Sciences, The Karolinska Institute, Solna, Sweden
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14
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Ajiko MM, Davé D, Feldhaus I, Smith RN, Juillard C, Dicker RA. Patterns of surgical presentation at an African regional referral hospital: surveillance as a step towards improving access to care. Eur J Trauma Emerg Surg 2016; 43:265-272. [PMID: 26869519 DOI: 10.1007/s00068-016-0644-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/01/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Surgical disease is being increasingly recognized as a significant health burden in Africa. Efforts have been made to describe surgical disease and capacity at the district hospital level. Little is known about patterns seen at regional hospitals supporting the district hospital network. METHODS This retrospective study was conducted at Uganda's Soroti Regional Referral Hospital, serving eight districts. Data were collected from July 2010 to March 2012 using operative and inpatient records as available. Univariate and bivariate analyses were performed to explore patterns of procedures performed and in-patient diagnoses. RESULTS There were 8511 procedures recorded in the operative log between July 2010 and June 2011, averaging 709 per month. Caesarian sections (41 %), dilation and evacuations (28 %), and laparotomies (19 %) were most frequent. Referrals to Soroti averaged 260 per month, while transfers out averaged 5 patients per month. Inpatient records documented 2949 surgically related diagnoses between July 2010 and May 2011. In patients >4 years old, 21 % of mortality was due to surgical disease, 29 % of which was trauma-related. Women comprised 80 % of violent injury. Common hospital record elements, such as demographic data, important clinical information, and operative notes were absent from these data sources. CONCLUSIONS The World Health Assembly recently recognized strengthening of first referral hospitals as a crucial element to achieving universal health coverage. Inconsistencies in recordkeeping despite the large volume of surgical disease suggest that sustainable surveillance systems and capacity building at the referral hospital level are potential building blocks to improving access to surgical care.
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Affiliation(s)
- M M Ajiko
- Soroti Regional Referral Hospital, Soroti-Lira Rd, Soroti, Uganda
| | - D Davé
- Department of Surgery, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, USA.,Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA
| | - I Feldhaus
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA
| | - R N Smith
- Department of Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, 51 N 39th St., Philadelphia, PA, USA
| | - C Juillard
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA
| | - R A Dicker
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA.
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