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Gyedu A, Issaka A, Appiah AB, Donkor P, Mock C. Care of Injured Children Compared to Adults at District and Regional Hospitals in Ghana and the Impact of a Trauma Intake Form: A Stepped-Wedge Cluster Randomized Trial. J Pediatr Surg 2024; 59:1210-1218. [PMID: 38154994 PMCID: PMC11105994 DOI: 10.1016/j.jpedsurg.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/16/2023] [Accepted: 12/03/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND This study aimed to determine the effectiveness of a standardized trauma intake form (TIF) to improve achievement of key performance indicators (KPIs) of initial trauma care among injured children, compared to adults, at non-tertiary hospitals in Ghana. METHODS A stepped-wedge cluster randomized trial was performed with research assistants directly observing the management of injured patients before and after introducing the TIF at emergency units of 8 non-tertiary hospitals for 17.5 months. Differences in outcomes between children and adults in periods before and after TIF introduction were determined with multivariable logistic regression. Differences in outcomes among children after TIF introduction were determined using generalized linear mixed regression. RESULTS Management of 3889 injured patients was observed; 757 (19%) were children <18 years. Trauma care KPIs at baseline were lower for children compared to adults. Improvements in primary survey KPIs were observed among children after TIF introduction. Examples include airway assessment [279 (71%) to 359 (98%); adjusted odds ratio (AOR): 74.42, p = 0.005)] and chest examination [225 (58%) to 349 (95%); AOR 53.80, p = 0.002)]. However, despite these improvements, achievement of KPIs was still lower compared to adults. Examples are pelvic fracture evaluation [children: 295 (80%) vs adults: 1416 (88%), AOR: 0.56, p = 0.001] and respiratory rate assessment (children: 310 (84%) vs adults: 1458 (91%), AOR: 058, p = 0.030). CONCLUSIONS While the TIF was effective in improving most KPIs of pediatric trauma care, more targeted education is needed to bridge the gap in quality between pediatric and adult trauma care at non-tertiary hospitals in Ghana and other low- and middle-income countries. TYPE OF STUDY Stepped-wedged cluster randomized controlled trial. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Adamu Issaka
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Anthony Baffour Appiah
- Ghana Field Epidemiology and Laboratory Training Program, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA; Harborview Injury Prevention and Research Center, Seattle, WA, USA
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Gyedu A, Amponsah-Manu F, Awuku K, Ameyaw E, Korankye KK, Donkor P, Mock C. Differences in trauma care between district and regional hospitals and impact of a trauma intake form with decision support prompts in Ghana: A stepped-wedge cluster randomized trial. World J Surg 2024; 48:527-539. [PMID: 38312029 PMCID: PMC10960944 DOI: 10.1002/wjs.12082] [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: 09/20/2023] [Accepted: 01/20/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at district (first-level) and regional (second-level) hospitals in Ghana and to assess the effectiveness of a standardized trauma intake form (TIF) to improve care. METHODS A stepped-wedge cluster randomized trial was performed with direct observations of trauma management before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs were assessed using multivariable logistic regression and generalized linear mixed regression. RESULTS Management of 4077 patients was observed; 30% at regional and 70% at district hospitals. Eight of 20 KPIs were performed significantly more often at regional hospitals. TIF improved care at both levels. Fourteen KPIs improved significantly at district and eight KPIs improved significantly at regional hospitals. After TIF, regional hospitals still performed better with 18 KPIs being performed significantly more often than district hospitals. After TIF, all KPIs were performed in >90% of patients at regional hospitals. Examples of KPIs for which regional performed better than district hospitals after TIF included: assessment for oxygen saturation (83% vs. 98%) and evaluation for intra-abdominal bleeding (82% vs. 99%, all p < 0.001). Mortality decreased among seriously injured patients (injury severity score ≥9) at both district (15% before vs. 8% after, p = 0.04) and regional (23% vs. 7%, p = 0.004) hospitals. CONCLUSIONS TIF improved care and lowered mortality at both hospital levels, but KPIs remained lower at district hospitals. Further measures are needed to improve initial trauma care at this level. CLINICAL TRIALS REGISTRATION Clinicaltrials.gov (NCT04547192).
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | | | | | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, Washington, USA
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Kang MJ, Kwesi Sakyi Ngissah R, Bo-Ib Buunaaim AD, Baidoo R, Odei-Ansong F, Wordui T, Adjepong-Tandoh EK, Baidoo PK, Aggrey-Orleans JEK. The need for hands-on training and supervision for entry-level physicians in a country with low surgical staffing density: a nationwide survey in Ghana. BMC MEDICAL EDUCATION 2023; 23:904. [PMID: 38031085 PMCID: PMC10687912 DOI: 10.1186/s12909-023-04880-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Despite the largely unmet need, relatively few medical school graduates enrol in surgical residency and fewer surgical specialists work rurally in low- and middle-income countries. Surgical housemanship is the only formal training for medical graduates who will become the main surgical care providers in underserved areas. This study aimed to evaluate Ghanaian surgical housemanship (internship) and its impact on independent medical practice. METHODS A nationwide questionnaire survey of surgical trainees from seven teaching or regional-level hospitals ascertained the experience and self-confidence levels for 35 training objectives set by the Medical and Dental Council of Ghana, and suggestions to improve surgical training quality. RESULTS Of 310 respondents, 59.7% experienced ≤ 10 cases for each topic, and 24.8% reported self-confidence as ≤ 2 points (out of 5). More than 90% of respondents experienced ≤ 10 cases for gastric, colorectal and liver cancer management. Teaching hospital trainees had lower proportions of those experiencing > 10 cases (36.6% versus 43.7%) and reporting self-confidence ≥ 4 (46.5% versus 55.8%), respectively, compared with those from regional/other-level hospitals. 40% of respondents were not confident about their surgical skills, and 70.5% requested better-supervised and practical surgical skills training. The proportion of respondents who reported limited supervision was higher among those from teaching hospitals, reported self-confidence scores < 4, and experienced ≤ 10 cases for each topic. 67% of respondents were satisfied with their surgical housemanship and 75.8% perceived surgical rotation as relevant to their future work. CONCLUSIONS Most surgical trainees are concerned about their surgical skills. A structured curriculum with specific goals and better-supervised surgical skills training should be established. Inclusion of regional/other-level hospitals in surgical training may reduce the supervisory burden in teaching hospitals.
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Affiliation(s)
- Mee Joo Kang
- Department of Surgery, Greater Accra Regional Hospital, P.O.Box 473, Accra, Republic of Ghana
- Department of Surgery, National Cancer Center, Goyang, Republic of Korea
| | | | | | - Richard Baidoo
- Department of Surgery, Cape Coast Teaching Hospital, Cape Coast, Republic of Ghana
| | | | - Theodore Wordui
- Department of Surgery, Korle-Bu Teaching Hospital, Accra, Republic of Ghana
| | | | - Paa Kwesi Baidoo
- Department of Surgery, Komfo-Anokye Teaching Hospital, Kumasi, Republic of Ghana
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Gyedu A, Stewart BT, Nakua E, Donkor P. Standardized trauma intake form with clinical decision support prompts improves care and reduces mortality for seriously injured patients in non-tertiary hospitals in Ghana: stepped-wedge cluster randomized trial. Br J Surg 2023; 110:1473-1481. [PMID: 37612450 PMCID: PMC10564400 DOI: 10.1093/bjs/znad253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/22/2023] [Accepted: 07/23/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND The WHO Trauma Care Checklist improved key performance indicators (KPIs) of trauma care at tertiary hospitals. A standardized trauma intake form (TIF) with real-time clinical decision support prompts was developed by adapting the WHO Trauma Care Checklist for use in smaller low- and middle-income country hospitals, where care is delivered by non-specialized providers and without trauma teams. This study aimed to determine the effectiveness of the TIF for improving KPIs in initial trauma care and reducing mortality at non-tertiary hospitals in Ghana. METHODS A stepped-wedge cluster randomized trial was conducted by stationing research assistants at emergency units of eight non-tertiary hospitals for 17.5 months to observe management of injured patients before and after introduction of the TIF. Differences in performance of KPIs in trauma care (primary outcomes) and mortality (secondary outcome) were estimated using generalized linear mixed regression models. RESULTS Management of 4077 injured patients was observed (2067 before TIF introduction, 2010 after). There was improvement in 14 of 16 primary survey and initial care KPIs after TIF introduction. Airway assessment increased from 72.9 to 98.4 per cent (adjusted OR 25.27, 95 per cent c.i. 2.47 to 258.94; P = 0.006) and breathing assessment from 62.1 to 96.8 per cent (adjusted OR 38.38, 4.84 to 304.69; P = 0.001). Documentation of important clinical data improved from 52.4 to 76.7 per cent (adjusted OR 2.14, 1.17 to 3.89; P = 0.013). The mortality rate decreased from 17.7 to 12.1 per cent among 302 patients (186 before, 116 after) with impaired physiology on arrival (hypotension or decreased level of consciousness) (adjusted OR 0.10, 0.02 to 0.56; P = 0.009). CONCLUSION The TIF improved overall initial trauma care and reduced mortality for more seriously injured patients. REGISTRATION NUMBER NCT04547192 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Surgery Unit, University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Emmanuel Nakua
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Patil P, Nathani P, Bakker JM, van Duinen AJ, Bhushan P, Shukla M, Chalise S, Roy N, Gadgil A. Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review. World J Surg 2023; 47:1930-1939. [PMID: 37191692 PMCID: PMC10310578 DOI: 10.1007/s00268-023-07029-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs). METHODOLOGY We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed. RESULTS A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries. CONCLUSION Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.
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Affiliation(s)
- Priti Patil
- Department of Statistics, BARC Hospital, Mumbai, 400094, India
| | - Priyansh Nathani
- Department of Surgery, Hinduhridaysamrat Balasaheb Thackeray Medical College, Dr. Rustom Narsi Cooper Municipal General Hospital, Mumbai, India
| | - Juul M Bakker
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Alex J van Duinen
- Clinic of Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Pranav Bhushan
- Department of Public Health, Institute of Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Minal Shukla
- Department of Maternal Health, UNICEF, Bhopal, India
| | - Samir Chalise
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institute, 171 77, Stockholm, Sweden.
- The George Institute for Global Health, New Delhi, India.
| | - Anita Gadgil
- The George Institute for Global Health, New Delhi, India
- Department of Surgery, BARC Hospital, Mumbai, 400094, India
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Jumbam DT, Amoako E, Blankson PK, Xepoleas M, Said S, Nyavor E, Gyedu A, Ampomah OW, Kanmounye US. The state of surgery, obstetrics, trauma, and anaesthesia care in Ghana: a narrative review. Glob Health Action 2022; 15:2104301. [PMID: 35960190 PMCID: PMC9586599 DOI: 10.1080/16549716.2022.2104301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Conditions amenable to surgical, obstetric, trauma, and anaesthesia (SOTA) care are a major contributor to death and disability in Ghana. SOTA care is an essential component of a well-functioning health system, and better understanding of the state of SOTA care in Ghana is necessary to design policies to address gaps in SOTA care delivery. Objective The aim of this study is to assess the current situation of SOTA care in Ghana. Methods A situation analysis was conducted as a narrative review of published scientific literature. Information was extracted from studies according to five health system domains related to SOTA care: service delivery, workforce, infrastructure, finance, and information management. Results Ghanaians face numerous barriers to accessing quality SOTA care, primarily due to health system inadequacies. Over 77% of surgical operations performed in Ghana are essential procedures, most of which are performed at district-level hospitals that do not have consistent access to imaging and operative room fundamentals. Tertiary facilities have consistent access to these modalities but lack consistent access to oxygen and/or oxygen concentrators on-site as well as surgical supplies and anaesthetic medicines. Ghanaian patients cover up to 91% of direct SOTA costs out-of-pocket, while health insurance only covers up to 14% of the costs. The Ghanaian surgical system also faces severe workforce inadequacies especially in district-level facilities. Most specialty surgeons are concentrated in urban areas. Ghana’s health system lacks a solid information management foundation as it does not have centralized SOTA databases, leading to incomplete, poorly coded, and illegible patient information. Conclusion This review establishes that surgical services provided in Ghana are focused primarily on district-level facilities that lack adequate infrastructure and face workforce shortages, among other challenges. A comprehensive scale-up of Ghana’s surgical infrastructure, workforce, national insurance plan, and information systems is warranted to improve Ghana’s surgical system.
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Affiliation(s)
- Desmond T Jumbam
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana.,Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Emmanuella Amoako
- Department of Paediatrics and Child Health, Cape Coast Teaching Hospital, Cape Coast, Ghana.,Department of Paediatrics and Child Health, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Paa-Kwesi Blankson
- Oral and Maxillofacial Surgery Unit, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Meredith Xepoleas
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Shady Said
- Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
| | - Elikem Nyavor
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,Department of Surgery, University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Opoku W Ampomah
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana.,Plastics and Reconstructive Surgery Unit, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Ulrick Sidney Kanmounye
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Ghana.,Department of Policy and Advocacy, Operation Smile, Virginia Beach, Virginia, USA
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Gyedu A, Quainoo E, Nakua E, Donkor P, Mock C. Achievement of Key Performance Indicators in Initial Assessment and Care of Injured Patients in Ghanaian Non-tertiary Hospitals: An Observational Study. World J Surg 2022; 46:1288-1299. [PMID: 35286419 PMCID: PMC9058212 DOI: 10.1007/s00268-022-06507-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We aimed to determine the level of achievement of key performance indicators (KPIs) during initial assessment and management of injured persons, as assessed by independent observers, at district and regional hospitals in Ghana. METHODS Trained observers were stationed at emergency units of six district (first level) and two regional (referral) hospitals, from October 2020 to February 2021, to observe management of injured patients by health service providers. Achievement of KPIs was assessed for all injured patients and for seriously injured patients (admitted for ≥ 24 h, referred, or died). RESULTS Management of 1006 injured patients was observed. Road traffic crash was the most common mechanism (63%). Completion of initial triage ranged from 65% for oxygen saturation to 92% for mobility assessment. For primary survey, airway was assessed in 77% of patients, chest examination performed in 66%, and internal abdominal bleeding assessed in 43%. Reassessment rates were low, ranging from 16% for respiratory rate to 23% for level of consciousness. Thirty-one percent of patients were seriously injured. Completion of KPIs was higher for these patients, but reassessment remained low, ranging from 25% for respiratory rate to 33% for level of consciousness. CONCLUSION KPIs were performed at a high level, but several specific elements should be performed more frequently, such as oxygen saturation and assessment for internal abdominal bleeding. Reassessment needs to be performed more frequently, especially for seriously injured patients. Overall, care for the injured at non-tertiary hospitals in Ghana could be improved with a more systematic approach.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, KNUST, Private Mail Bag, University Post Office, Kumasi, Ghana.
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Emmanuel Quainoo
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Emmanuel Nakua
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, KNUST, Private Mail Bag, University Post Office, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
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Otieku E, Fenny AP, Asante FA, Bediako-Bowan A, Enemark U. Cost-effectiveness analysis of an active 30-day surgical site infection surveillance at a tertiary hospital in Ghana: evidence from HAI-Ghana study. BMJ Open 2022; 12:e057468. [PMID: 34980632 PMCID: PMC8724807 DOI: 10.1136/bmjopen-2021-057468] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/14/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the cost-effectiveness of an active 30-day surgical site infection (SSI) surveillance mechanism at a referral teaching hospital in Ghana using data from healthcare-associated infection Ghana (HAI-Ghana) study. DESIGN Before and during intervention study using economic evaluation model to assess the cost-effectiveness of an active 30-day SSI surveillance at a teaching hospital. The intervention involves daily inspection of surgical wound area for 30-day postsurgery with quarterly feedback provided to surgeons. Discharged patients were followed up by phone call on postoperative days 3, 15 and 30 using a recommended surgical wound healing postdischarge questionnaire. SETTING Korle-Bu Teaching Hospital (KBTH), Ghana. PARTICIPANTS All prospective patients who underwent surgical procedures at the general surgical unit of the KBTH. MAIN OUTCOME MEASURES The primary outcome measures were the avoidable SSI morbidity risk and the associated costs from patient and provider perspectives. We also reported three indicators of SSI severity, that is, length of hospital stay (LOS), number of outpatient visits and laboratory tests. The analysis was performed in STATA V.14 and Microsoft Excel. RESULTS Before-intervention SSI risk was 13.9% (62/446) as opposed to during-intervention 8.4% (49/582), equivalent to a risk difference of 5.5% (95% CI 5.3 to 5.9). SSI mortality risk decreased by 33.3% during the intervention while SSI-attributable LOS decreased by 32.6%. Furthermore, the mean SSI-attributable patient direct and indirect medical cost declined by 12.1% during intervention while the hospital costs reduced by 19.1%. The intervention led to an estimated incremental cost-effectiveness ratio of US$4196 savings per SSI episode avoided. At a national scale, this could be equivalent to a US$60 162 248 cost advantage annually. CONCLUSION The intervention is a simple, cost-effective, sustainable and adaptable strategy that may interest policymakers and health institutions interested in reducing SSI.
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Affiliation(s)
- Evans Otieku
- Economics Division, Institute of Statistical, Social and Economic Research, University of Ghana, Legon, Greater Accra, Ghana
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Ama Pokuaa Fenny
- Economics Division, Institute of Statistical, Social and Economic Research, University of Ghana, Legon, Greater Accra, Ghana
| | - Felix Ankomah Asante
- Economics Division, Institute of Statistical, Social and Economic Research, University of Ghana, Legon, Greater Accra, Ghana
| | - Antoinette Bediako-Bowan
- Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana
- Department of Surgery, University of Ghana Medical School, Accra, Ghana
| | - Ulrika Enemark
- Department of Public Health, Aarhus University, Aarhus, Denmark
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A Nationwide Enumeration of the Surgical Workforce, its Production and Disparities in Operative Productivity in Liberia. World J Surg 2021; 46:486-496. [PMID: 34839375 PMCID: PMC8803679 DOI: 10.1007/s00268-021-06379-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 12/22/2022]
Abstract
Background Any health care system that strives to deliver good health and well-being to its population relies on a trained workforce. The aim of this study was to enumerate surgical provider density, describe operative productivity and assess the association between key surgical system characteristics and surgical provider productivity in Liberia. Methods A nationwide survey of operation theatre logbooks, available human resources and facility infrastructure was conducted in 2018. Surgical providers were counted, and their productivity was calculated based on operative numbers and full-time equivalent positions. Results A total of 286 surgical providers were counted, of whom 67 were accredited specialists. This translated into a national density of 1.6 specialist providers per 100,000 population. Non-specialist physicians performed 58.3 percent (3607 of 6188) of all operations. Overall, surgical providers performed a median of 1.0 (IQR 0.5–2.7) operation per week, and there were large disparities in operative productivity within the workforce. Most operations (5483 of 6188) were categorized as essential, and each surgical provider performed a median of 2.0 (IQR 1.0–5.0) different types of essential procedures. Surgical providers who performed 7–14 different types of essential procedures were more than eight times as productive as providers who performed 0–1 essential procedure (operative productivity ratio = 8.66, 95% CI 6.27–11.97, P < 0.001). Conclusion The Liberian health care system struggles with an alarming combination of few surgical providers and low provider productivity. Disaggregated data can provide a high-resolution picture of local challenges that can lead to local solutions.
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de Sá LA, Covre ER, de Melo WA, Gomes RM, Tostes MFDP. Public-private relationship in surgical hospitalizations through the Unified Health System. Rev Lat Am Enfermagem 2021; 29:e3467. [PMID: 34468624 PMCID: PMC8432587 DOI: 10.1590/1518-8345.4901.3467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/03/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to characterize surgical hospitalizations, length of stay, cost and mortality, according to the legal nature (public and private) of the hospital institution linked to the Unified Health System (Sistema Único de Saúde, SUS). Method: a descriptive study, of the survey type, with retrospective data collection (2008 to 2017) and a quantitative approach. The dependent variables surgical hospitalizations in Brazil, costs, length of stay and mortality and the independent variables regime/legal nature (public and private) were obtained from the Informatics Department of the Unified Health System. The Mann-Whitney test was used for analysis. RESULTS the average number of hospitalizations through the Unified Health System was 4,214,083 hospitalizations/year, 53.5% occurred in private hired hospitals and 46.5% in public hospitals (p=0.001). The financial transfer was greater for the private sector (60.6%) against 39.4% for the public (p=0.001). The average stay was 4.5 days in the public hospital and 3.1 days in its private counterpart (p<0.001). Mortality was higher in the public (1.8%) than in the private hospital (1.4%) (p<0.001). CONCLUSION there was predominance of surgical hospitalizations through the Unified Health System in private hospitals with greater financial transfer to this sector, to the detriment of the public. The diverse evidence produced contributes to the debate and actions to avoid budgetary asphyxiation in the public sector in favor of the private sector.
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Affiliation(s)
- Liane Alves de Sá
- Universidade Estadual do Paraná, Colegiado de Enfermagem, Paranavaí, PR, Brazil
- Scholarship holder at the Fundação Araucária, Universidade Estadual do Paraná, Brazil
| | - Eduardo Rocha Covre
- Universidade Estadual do Paraná, Colegiado de Enfermagem, Paranavaí, PR, Brazil
| | | | - Rogério Miranda Gomes
- Universidade Federal do Paraná, Departamento de Saúde Coletiva, Curitiba, PR, Brazil
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Butler EK, Gyedu A, Stewart BT, Quansah R, Donkor P, Mock CN. Nationwide enumeration of emergency operations performed in Ghana. Eur J Trauma Emerg Surg 2021; 47:1031-1039. [PMID: 31768586 PMCID: PMC7246178 DOI: 10.1007/s00068-019-01276-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/17/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To determine the population-based rate of emergency surgery performed in Ghana, categorized by hospital level. METHODS Data on operations performed from June 2014 to May 2015 were obtained from a nationally representative sample of hospitals and scaled up to nationwide estimates. Operations were categorized as to: "emergency" or "elective" and as to "essential" (most cost-effective, highest population impact) or "other" according to the World Bank's Disease Control Priorities project. RESULTS Of 232,776 (95% UI 178,004-287,549) total operations performed nationally, 48% were emergencies. 112,036 emergency operations (95% UI 92,105-131,967) were performed and the annual national rate was 416 per 100,000 population (95% UI 342-489). Most emergency operations (87%) were in the essential category. Of essential emergency procedures, 47% were obstetric and gynecologic, 22% were general surgery, and 31% were trauma. District (first-level) hospitals performed 54%, regional hospitals 10%, and tertiary hospitals 36% of all emergency operations. About half (54%) of district hospitals did not have a fully trained surgeon, however, these hospitals performed 36% of district hospital emergency operations and 20% of all emergency operations. CONCLUSIONS Emergency operations make up nearly half of all operations performed in Ghana. Most are performed at district hospitals, many of which do not have fully trained surgeons. Obstetric procedures make up a large portion of emergency operations, indicating a need for improved provision of non-obstetric emergency surgical care. These data are useful for future benchmarking efforts to improve availability of emergency surgical care in Ghana and other low- and middle-income countries.
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Affiliation(s)
- Elissa K Butler
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Private Mail Bag, University Post Office, Kumasi, Ghana.
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | | | - Robert Quansah
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Private Mail Bag, University Post Office, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Private Mail Bag, University Post Office, Kumasi, Ghana
| | - Charles N Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA
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Gaskill CE, Gyedu A, Stewart B, Quansah R, Donkor P, Mock C. Improving Global Surgical Oncology Benchmarks: Defining the Unmet Need for Cancer Surgery in Ghana. World J Surg 2021; 45:2661-2669. [PMID: 34152449 DOI: 10.1007/s00268-021-06197-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery (LCoGS) recommended an annual surgical rate at which low- and middle-income countries (LMICs) could achieve most of the population-wide benefits of surgery. However, condition-specific guidelines were not proposed. To inform rates of surgery for cancer, we sought to assess the current met and unmet need for oncologic surgery in Ghana. METHODS Data on all operations performed in Ghana over a one-year period (2014-15) were obtained from representative samples of 48/124 first-level and 12/16 referral hospitals and scaled-up for nationwide estimates. Procedures for cancer were identified by indication. Using modified LCoGS methodology with disease prevalence, Ghana's annual rate of cancer surgery was compared to that of New Zealand to quantify current unmet needs. RESULTS 232,776 surgical procedures were performed in Ghana; 2,562 procedures (95%UI 1878-3255) were for cancer. Of these, 964 (37%) were surgical biopsies. The annual rate of procedures treating cancer was 2115 surgeries/100,000 cancer cases, or 21% of the New Zealand benchmark. Cervical, breast, and prostate cancer were found to meet 2.1%, 17.2%, and 32.1% of their respective surgical need. CONCLUSIONS There is a large unmet need for cancer surgery in Ghana. Cancer surgery constitutes under 2% of the total surgeries performed in Ghana, an important proportion of which are used for biopsies. Therapeutic operative rate is deficient across most cancer types, and may lag behind improvements in screening efforts. As cancer prevalence and diagnosis increase in LMICs, cancer-specific surgical capacity must be increased to meet these evolving needs.
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Affiliation(s)
- Cameron E Gaskill
- Department of Surgery, University of Washington, Seattle, WA, USA.
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA.
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Robert Quansah
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Gyedu A, Stewart B, Gaskill C, Salia E, Wadie R, Abantanga F, Donkor P, Mock C. A Nationwide Enumeration of Operations Performed for Pediatric Patients in Ghana. Eur J Pediatr Surg 2021; 31:199-205. [PMID: 32242327 DOI: 10.1055/s-0040-1705130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Currently, there are no existing benchmarks for evaluating a nation's pediatric surgical capacity in terms of met and unmet needs. MATERIALS AND METHODS Data on pediatric operations performed from 2014 to 2015 were obtained from a representative sample of hospitals in Ghana, then scaled up for national estimates. Operations were categorized as "essential" (most cost-effective, highest population impact) as designated by the World Bank's Disease Control Priorities versus "other." Estimates were then compared with pediatric operation rates in New Zealand to determine unmet pediatric surgery need in Ghana. RESULTS A total of 29,884 operations were performed for children <15 years, representing an annual operation rate of 284/100,000 (95% uncertainty interval: 205-364). Essential procedures constituted 66% of all pediatric operations; 12,397 (63%) were performed at district hospitals. General surgery (8,808; 29%) and trauma (6,302; 21%) operations were most common. Operations for congenital conditions were few (826; 2.8%). Tertiary hospitals performed majority (55%) of operations outside of the essential category. Compared with the New Zealand benchmark (3,806 operations/100,000 children <15 years), Ghana is meeting only 7% of its pediatric surgical needs. CONCLUSION Ghana has a large unmet need for pediatric surgical care. Pediatric-specific benchmarking is needed to guide surgical capacity efforts in low- and middle-income country healthcare systems.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, Kwame Nkrumah University of Science and Technology College of Health Sciences, Kumasi, Ghana
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, Washington, United States
| | - Cameron Gaskill
- Department of Surgery, University of Washington, Seattle, Washington, United States
| | - Emmanuella Salia
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
| | - Raymond Wadie
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
| | - Francis Abantanga
- Department of Surgery, University for Development Studies, Tamale, Northern, Ghana
| | - Peter Donkor
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, Washington, United States
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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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Stewart BT, Gyedu A, Goodman SK, Boakye G, Scott JW, Donkor P, Mock C. Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children. Afr J Emerg Med 2021; 11:144-151. [PMID: 33680736 PMCID: PMC7910164 DOI: 10.1016/j.afjem.2020.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana. Methods We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE. Results Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55). Conclusions NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children. Despite strides toward universal health coverage with the National Health Insurance Scheme (NHIS) in Ghana, one third of injured children did not have insurance. Families on uninsured injured children pay markedly more out-of-pocket costs than families of insured children. Although families of uninsured children were more likely to experience catastrophic health expenditure (CHE), CHE was commonly experienced regardless of insurance. These findings have useful implications for NHIS, agencies working toward universal health coverage, and trauma systems generally.
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Letter to the Editor: Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians. World J Surg 2021; 45:913-914. [PMID: 33388998 DOI: 10.1007/s00268-020-05893-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 10/22/2022]
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Bhandarkar P, Gadgil A, Patil P, Mohan M, Roy N. Estimation of the National Surgical Needs in India by Enumerating the Surgical Procedures in an Urban Community Under Universal Health Coverage. World J Surg 2020; 45:33-40. [PMID: 32974741 PMCID: PMC7752785 DOI: 10.1007/s00268-020-05794-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 11/29/2022]
Abstract
Background 11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%. The Lancet Commission for Global Surgery (LCoGS) estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in LMICs. Studies from LMICs, estimating surgical burden based on enumeration of surgeries, are sparse. Method We performed this study in an urban population availing employees’ heath scheme in Mumbai, India. Surgical procedures performed in 2017 and 2018, under this free and equitable health scheme, were enumerated. We estimated the surgical needs for national population, based on age and sex distribution of surgeries and age standardization from our cohort. Result A total of 4642 surgeries were performed per year for a population of 88,273. Cataract (22.8%), Caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries. We estimated 3646 surgeries would be required per 100,000 Indian population per year. One-third of these surgeries would be needed for the age group 30–49 years, in the Indian population. Conclusion A total of 3646 surgeries were estimated annually to meet the surgical needs of Indian population as compared to the global estimate of 5000 surgeries per 100,000 people. Caesarean section, cataract, surgeries for fractures and hernia are the major contributors to the surgical needs. More enumeration-based studies are needed for better estimates from rural as well as other urban areas. Electronic supplementary material The online version of this article (10.1007/s00268-020-05794-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Prashant Bhandarkar
- Department of Statistics, BARC Hospital, 'WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs', Mumbai, India
| | - Anita Gadgil
- Department of Surgery, BARC Hospital, 'WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs', Mumbai, India
| | - Priti Patil
- Department of Statistics, BARC Hospital, 'WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs', Mumbai, India
| | - Monali Mohan
- Consultant, 'WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs', Mumbai, India
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institute, 17177, Stockholm, Sweden. .,WHO Collaboration Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India.
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Adde HA, van Duinen AJ, Oghogho MD, Dunbar NK, Tehmeh LG, Hampaye TC, Salvesen Ø, Weiser TG, Bolkan HA. Impact of surgical infrastructure and personnel on volume and availability of essential surgical procedures in Liberia. BJS Open 2020; 4:1246-1255. [PMID: 32949120 PMCID: PMC7709357 DOI: 10.1002/bjs5.50349] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/28/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Essential surgical procedures rank among the most cost-effective of all healthcare interventions. The aim of this study was to enumerate surgical volumes in Liberia, quantify surgical infrastructure, personnel and availability of essential surgical procedures, describe surgical facilities, and assess the influence of human resources and infrastructure on surgical volumes. METHODS An observational countrywide survey was done in Liberia between 20 September and 8 November 2018. All healthcare facilities performing surgical procedures requiring general, regional or local anaesthesia in an operating theatre between September 2017 and August 2018 were eligible for inclusion. Information on facility infrastructure and human resources was collected by interviewing key personnel. Data on surgical volumes were extracted from operating theatre log books. RESULTS Of 70 healthcare facilities initially identified as possible surgical facilities, 52 confirmed operative capacity and were eligible for inclusion; all but one shared surgical data. A national surgical volume of 462 operations per 100 000 population was estimated. The median hospital offered nine of 26 essential surgical procedures. Unequal distributions of surgical infrastructure, personnel, and essential surgical procedures were identified between facilities. In multivariable regression analysis, surgical human resources (β = 0·60, 95 per cent c.i. 0·34 to 0·87; P < 0·001) and infrastructure (β = 0·03, 0·02 to 0·04; P < 0·001) were found to be strongly associated with operative volumes. CONCLUSION The availability of essential surgical procedures in Liberia is extremely low. Descriptive tools can quantify inequalities, guide resource allocation, and highlight rational investment areas.
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Affiliation(s)
- H. A. Adde
- Department of Clinical and Molecular MedicineFaculty of Medicine and Health Sciences, NTNU — Norwegian University of Science and TechnologyTrondheimNorway
- Department of Surgery, St Olav's HospitalTrondheim University HospitalTrondheimNorway
| | - A. J. van Duinen
- Department of Clinical and Molecular MedicineFaculty of Medicine and Health Sciences, NTNU — Norwegian University of Science and TechnologyTrondheimNorway
- Department of Surgery, St Olav's HospitalTrondheim University HospitalTrondheimNorway
| | - M. D. Oghogho
- Department of Clinical and Molecular MedicineFaculty of Medicine and Health Sciences, NTNU — Norwegian University of Science and TechnologyTrondheimNorway
| | | | - L. G. Tehmeh
- Quality Management Unit, Ministry of HealthMonroviaLiberia
| | | | - Ø. Salvesen
- Department of Public Health and NursingFaculty of Medicine and Health Sciences, NTNU — Norwegian University of Science and TechnologyTrondheimNorway
| | - T. G. Weiser
- Department of SurgeryStanford University Medical CenterCaliforniaUSA
- Department of Clinical SurgeryUniversity of EdinburghEdinburghUK
| | - H. A. Bolkan
- Department of Clinical and Molecular MedicineFaculty of Medicine and Health Sciences, NTNU — Norwegian University of Science and TechnologyTrondheimNorway
- Department of Surgery, St Olav's HospitalTrondheim University HospitalTrondheimNorway
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Surgical Coaching for Advancement of Global Surgical Skills and Capacity: A Systematic Review. J Surg Res 2020; 246:499-505. [DOI: 10.1016/j.jss.2019.09.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/03/2019] [Accepted: 09/18/2019] [Indexed: 01/31/2023]
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Gyedu A, Lester L, Stewart B, Danso KA, Salia EL, Quansah R, Donkor P, Mock C. Estimating obstetric and gynecologic surgical rate: A benchmark of surgical capacity building in Ghana. Int J Gynaecol Obstet 2019; 148:205-209. [PMID: 31657458 DOI: 10.1002/ijgo.13019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/13/2019] [Accepted: 10/24/2019] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To estimate the annual rate of obstetric and gynecologic (ObGyn) operations performed in Ghana and establish a baseline for tracking the expansion of Ghana's surgical capacity. METHODS Data were obtained for ObGyn operations performed in Ghana between 2014 and 2015 from a nationally representative sample of hospitals and scaled up for national estimates. Operations were classified as "essential" or "other" according to The World Bank's Disease Control Priorities Project. Data were used to calculate cesarean-to-total-operation ratio (CTR) and estimate the rate of cesarean deliveries based on the number of live births in 2014. RESULTS A total of 90 044 (95% uncertainty interval [UI] 69 461-110 628) ObGyn operations were performed nationally over the 1-year period, yielding an annual national ObGyn operation rate of 881/100 000 females aged 12 years and over (95% UI 679-1082). Eighty-seven percent were essential procedures, 80% of which were cesarean deliveries. District hospitals performed 71% of ObGyn operations. The national rate of cesarean deliveries was 7.2% and the CTR was 0.27. CONCLUSION The cesarean delivery rate of 7.2% suggests inadequate access to obstetric care. The CTR of 0.27 suggests inadequate overall surgical capacity. These measures, along with estimates of distribution of procedures by hospital level, provide useful baseline data to support surgical capacity building efforts in Ghana and similar countries.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Lynette Lester
- New York University School of Medicine, New York, NY, USA
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Kwabena A Danso
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Emmanuella L Salia
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Robert Quansah
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA.,Harborview Injury Prevention & Research Center, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana. J Surg Res 2019; 247:280-286. [PMID: 31690530 DOI: 10.1016/j.jss.2019.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/01/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery recommended 5000 operations/100,000 persons annually, but did not define condition-specific guidelines. New Zealand, Lancet Commission on Global Surgery's benchmark country, documented 1158 trauma operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought to determine Ghana's annual trauma operation rate compared with this benchmark. METHODS Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5 tertiary hospitals and scaled up for nationwide estimates. Trauma operations were grouped by hospital level and categorized into "essential" (most cost-effective, highest population impact) versus "other" (specialized) as per the World Bank's Disease Control Priorities Project. Ghana's annual trauma operation rate was compared with the New Zealand benchmark to quantify current met needs for trauma surgery. RESULTS About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed "essential". Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare. CONCLUSIONS Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels.
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Academic Partnerships in Global Surgery: An Overview American Surgical Association Working Group on Academic Global Surgery. Ann Surg 2019; 271:460-469. [PMID: 31592897 DOI: 10.1097/sla.0000000000003640] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.
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Gyedu A, Stewart B, Wadie R, Antwi J, Donkor P, Mock C. Population-based rates of hernia surgery in Ghana. Hernia 2019; 24:617-623. [PMID: 31429025 DOI: 10.1007/s10029-019-02027-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/04/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To estimate the population-based annual rate of hernia surgery in Ghana, so as to better define the met and unmet need and to identify opportunities to decrease the unmet need. METHODS Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Rates of hernia surgery were compared to previously published annual incidence of symptomatic hernia in Ghana (210/100,000 population) and to published annual rates of hernia surgery in high-income countries (120-275/100,000). RESULTS Estimated 17,418 [95% uncertainty interval (UI) 8154-26,683] hernia operations were performed nationally. The annual rate of hernia operations was 65 operations/100,000 population (95% UI 30.2-99.0). The rate was considerably less than the annual incidence of new symptomatic hernia or rates of hernia surgery in high-income countries. Hernia operations represented 7.5% of all operations. Most hernia operations (74%) were performed at district hospitals. Most district hospitals (54%) did not have fully trained surgeons, but nonetheless performed 38% of district-level hernia operations. CONCLUSIONS The rate of hernia operations fell short of estimated need. Most hernia repairs were performed at district hospitals, many without fully trained surgeons. Future global surgery benchmarking needs to address both overall surgical rates as well as rates for specific highly important operations. Countries can strengthen their planning for surgical care by defining their total, met, and unmet need for hernia surgery.
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Affiliation(s)
- A Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Private Mail Bag, University Post Office, Kumasi, Ghana.
| | - B Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA.,Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - R Wadie
- School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - J Antwi
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - P Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Private Mail Bag, University Post Office, Kumasi, Ghana
| | - C Mock
- Department of Surgery, University of Washington, Seattle, WA, USA.,Harborview Injury Prevention and Research Center, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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Enumeration of Operations Performed for Elderly Patients in Ghana: An Opportunity to Improve Global Surgery Benchmarking. World J Surg 2019; 43:1644-1652. [PMID: 30824962 DOI: 10.1007/s00268-019-04963-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The Lancet Commission on Global Surgery proposed 5000 operations/100,000 people annually as a benchmark for developing countries but did not define benchmarks for different age groups. We evaluated the operation rate for elderly patients (≥65 years) in Ghana and estimated the unmet surgical need for the elderly by comparison to a high-income country benchmark. METHODS Data on operations performed for elderly patients over a 1-year period in 2014-5 were obtained from representative samples of 48/124 small district hospitals and 12/16 larger referral hospitals and scaled-up for nationwide estimates. Operations were categorized as essential (most cost-effective, highest population impact) versus other according to The World Bank's Disease Control Priority project (DCP-3). Data from New Zealand's National Minimum Dataset were used to derive a benchmark operation rate for the elderly. RESULTS 16,007 operations were performed for patients ≥65 years. The annual operation rate was 1744/100,000 (95% UI 1440-2048), only 12% of the New Zealand benchmark of 14,103/100,000. 74% of operations for the elderly were in the essential category. The most common procedures (15%) were for urinary obstruction. 58% of operations were performed at district hospitals; 54% of these did not have fully-trained surgeons. Referral hospitals more commonly performed operations outside the essential category. CONCLUSION The operation rate was well beneath the benchmark, indicating a potentially large unmet need for Ghana's elderly population. Most operations for the elderly were in the essential category and delivered at district hospitals. Future global surgery benchmarking should consider specific benchmarks for different age groups.
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Antibiotics for Groin Hernia Repair According to Evidence-Based Guidelines: Time for Action in Ghana. J Surg Res 2019; 238:90-95. [PMID: 30769249 DOI: 10.1016/j.jss.2019.01.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/05/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUD Groin hernia repairs (GHR), though classified as clean surgeries, are associated with varying rates of surgical site infections. We assessed the practices of surgeons in Ghana regarding antibiotic use for GHR in comparison to evidence-based international guidelines (EBIG). METHODS We interviewed surgeons trained by the Ghana College of Physicians and Surgeons (GCPS), from inception (2003) through 2016, about their use of antibiotics for GHR. We defined the outcome variable of consistently following EBIG in antibiotics use for GHR. Logistic regression was used to examine how a priori selected covariates contributed to the outcome. RESULTS Eighty-two of 117 surgeons reported performing/supervising at least one GHR per week. They performed/supervised a mean of five GHR per week. Thirty-two (40%) reported using mesh for at least 50% of GHR. For primary GHR, 75% of surgeons administered antibiotics according to EBIG, whereas for GHR with mesh only, 45% did so. Predictors of consistently following EBIG were increasing number of GHR performed per week (adjusted odds ratio 1.44, 95% CI 1.07-1.96) and increasing time spent for clinical work (adjusted odds ratio 0.95, 95% CI 0.91-0.99). Years of practice since GCPS graduation, total operations performed per week, and hospital level of practice were not predictive of the outcome variable. CONCLUSIONS Two-thirds of Ghanaian surgeons interviewed do not consistently administer antibiotics for GHR per EBIG, raising the need to improve access to evidence-based medical information overall to guide practice. Determining local surgical site infections rates to guide antibiotic use in GHR will be useful in Ghana and other LMICs.
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In-Country Training by the Ghana College of Physicians and Surgeons: An Initiative that has Aided Surgeon Retention and Distribution in Ghana. World J Surg 2018; 43:723-735. [DOI: 10.1007/s00268-018-4840-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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