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Kifle F, Kenna P, Daniel S, Maswime S, Biccard B. A scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa. Perioper Med (Lond) 2024; 13:86. [PMID: 39095850 PMCID: PMC11297632 DOI: 10.1186/s13741-024-00435-2] [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: 05/28/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a patient-centered approach to surgery designed to reduce stress responses and facilitate faster recovery. ERAS protocols have been widely adopted in high-income countries, supported by robust research demonstrating improved patient outcomes. However, in Africa, there is limited evidence regarding its implementation. This review aims to identify the existing literature on the implementation of ERAS principles in Africa, the reported clinical outcomes, and the challenges and recommendations for successful implementation. METHODS We conducted a librarian-assisted literature search of electronic research databases between October and November 2023. Titles and abstracts were screened for eligibility, and duplicates were then removed, followed by full-text assessment of potentially eligible studies. We utilized the summative content analysis method to synthesize and group the data into fewer categories based on agreed-upon criteria. Descriptive statistics were used to describe the results. RESULTS The search identified 342 potential studies resulting in 15 eligible studies for inclusion in the review. The publication years ranged from 2016 to 2023. The studies originated from three countries: Egypt (n = 10), South Africa (n = 4), and Uganda (n = 1). Successful implementation was associated with reduced hospital length of stay (n = 12), lower mortality rates (n = 3), and improved pain outcomes (n = 7). Challenges included protocol adherence (n = 5) and limitations of the research design to generate strong evidence (n = 3). Recommendations included formal adoption of ERAS principles (n = 5), the need for sustained research commitment, and exploration of the applicability of ERAS in diverse surgical contexts (n = 8). Large-scale implementation beyond individual institutions was encouraged to further validate its impact on patient outcomes and healthcare costs (n = 1). CONCLUSIONS Despite the limited number of studies on ERAS implementation in Africa, the available evidence suggests that it reduces the length of hospital stays and mortality rates. This is crucial for the region, given its higher mortality rates, necessitating more collaborative, methodically well-designed studies to establish stronger evidence for ERAS in lower-resource environments.
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Affiliation(s)
- Fitsum Kifle
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- Network for Perioperative and Critical Care, Debre Birhan University Asrat Woldeyes Health Sciences Campus, Debre Birhan, Ethiopia.
| | - Peniel Kenna
- Network for Perioperative and Critical Care, Debre Birhan University Asrat Woldeyes Health Sciences Campus, Debre Birhan, Ethiopia
| | - Selam Daniel
- Department of Anesthesiology and Critical Care, Kidus Petros Hospital, Addis Ababa, Ethiopia
| | - Salome Maswime
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Bruce Biccard
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, Western Cape, South Africa
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2
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Yadeta DA, Manyazewal T, Demessie DB, Kleive D. Incidence and predictors of postoperative complications in Sub-Saharan Africa: a systematic review and meta-analysis. FRONTIERS IN HEALTH SERVICES 2024; 4:1353788. [PMID: 38784705 PMCID: PMC11112115 DOI: 10.3389/frhs.2024.1353788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/17/2024] [Indexed: 05/25/2024]
Abstract
Background Postoperative complications remain a significant challenge, especially in settings where healthcare access and infrastructure disparities exacerbate. This systematic review and meta-analysis aimed to determine the pooled incidence and risk factors of postoperative complications among patients undergoing essential surgery in Sub-Saharan Africa (SSA). Method PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar were searched from January 2010 to November 2022 for completed studies reporting the incidence and risk factors associated with postoperative complications among patients undergoing essential surgery in SSA. Severity of postoperative complications was ranked based on the Clavien-Dindo classification system, while risk factors were classified into three groups based on the Donabedian structure-process-outcome quality evaluation framework. Studies quality was appraised using the JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI), and data were analyzed using Comprehensive Meta-Analysis (CMA) software. The study protocol adhered to the PRISMA guidelines and was registered in PROSPERO (CRD42023414342). Results The meta-analysis included 19 studies (10 cohort and 9 cross-sectional) comprising a total of 24,136 patients. The pooled incidence of postoperative complications in SSA was 20.2% (95% CI: 18.7%-21.8%), with a substantial heterogeneity of incidence observed. The incidence varied from 14.6% to 27.5% based on the Clavien-Dindo classification. The random-effects model indicated significant heterogeneity among the studies (Q = 54.202, I = 66.791%, p < 0.001). Contributing factors to postoperative complications were: structure-related factors, which included the availability and accessibility of resources, as well as the quality of both the surgical facility and the hospital.; process-related factors, which encompassed surgical skills, adherence to protocols, evidence-based practices, and the quality of postoperative care; and patient outcome-related factors such as age, comorbidities, alcohol use, and overall patient health status. Conclusion The meta-analysis reveals a high frequency of postoperative complications in SSA, with noticeable discrepancies among the studies. The analysis highlights a range of factors, encompassing structural, procedural, and patient outcome-related aspects, that contribute to these complications. The findings underscore the necessity for targeted interventions aimed at reducing complications and improving the overall quality of surgical care in the region. Systematic Reviews Registration https://www.crd.york.ac.uk/PROSPERO/, identifier (CRD42023414342).
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Affiliation(s)
- Daniel Aboma Yadeta
- School of Public Health, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Dereje Bayissa Demessie
- School of Public Health, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Podda M, Di Martino M, Pata F, Nigri G, Pisanu A, Di Saverio S, Pellino G, Ielpo B. Global disparities in surgeons' workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study. Updates Surg 2024:10.1007/s13304-024-01859-7. [PMID: 38684574 DOI: 10.1007/s13304-024-01859-7] [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: 03/02/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI.
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Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, Policlinico Universitario "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, SS 554, Km 4,500, 09042, Cagliari, Monserrato, Italy.
| | - Marcello Di Martino
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Francesco Pata
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Giuseppe Nigri
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, Policlinico Universitario "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, SS 554, Km 4,500, 09042, Cagliari, Monserrato, Italy
| | - Salomone Di Saverio
- Department of Surgery, Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Gianluca Pellino
- Department of Colorectal Surgery, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Benedetto Ielpo
- Hepatobiliary Surgery Unit, Hospital del Mar, University Pompeu Fabra, Barcelona, Spain
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Takoutsing BD, Endalle G, Senyuy WP, Celestin BM, Kwasseu GK, Tanyi PB, Jumbam DT, Kanmounye US. Identifying opportunities for global surgery in Cameroon: an analysis of existing health policies and events. Pan Afr Med J 2024; 47:143. [PMID: 38933430 PMCID: PMC11204985 DOI: 10.11604/pamj.2024.47.143.38399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/18/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction the burden of diseases amenable to surgery, obstetrics, trauma, and anesthesia (SOTA) care is increasing globally but low- and middle-income countries are disproportionately affected. The Lancet Commission on Global Surgery proposed National Surgical, Obstetrics, and Anesthesia Plans as national policies to reduce the global SOTA burden. These plans are dependent on comprehensive stakeholder engagement and health policy analysis. Objective: in this study, we analyzed existing national health policies and events in Cameroon to identify opportunities for SOTA policies. Methods we searched the Cameroonian Ministry of Health´s health policy database to identify past and current policies. Next, the policies were retrieved and screened for mentions of SOTA-related interventions using relevant keywords in French and English, and analyzed using the 'eight-fold path´ framework for public policy analysis. Results we identified 136 policies and events and excluded 16 duplicates. The health policies and events included were implemented between 1967 and 2021. Fifty-nine policies and events (49.2%) mentioned SOTA care: governance (n=25), infrastructure (n=21), service delivery (n=11), workforce (n=11), information management (n=10), and funding (n=8). Most policies and events focused on maternal and neonatal health, followed by anesthesia, ophthalmologic surgery, and trauma. National, multinational civil society organizations and private stakeholders supported these policies and events, and the Cameroonian Ministry of Public Health was the largest funder. Conclusion most Cameroonian SOTA-related policies and events focus on maternal and neonatal care, and health financing is the health system component with the least policies and events. Future SOTA policies should build on existing strengths while improving neglected areas, thus attaining shared global and national goals by 2030.
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Affiliation(s)
- Berjo Dongmo Takoutsing
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Geneviève Endalle
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Wah Praise Senyuy
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Bilong Mbangtang Celestin
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | | | | | - Desmond Tanko Jumbam
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Greater Accra, Ghana
| | - Ulrick Sidney Kanmounye
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
- Department of Policy and Advocacy, Operation Smile Ghana, Accra, Greater Accra, Ghana
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Borodova A, Diallo AA, Wood R, Tounkara O, Rocha C, Bayo M, Landsmann L, Cherif MS, Borchert M, Meinus C, Nabé I, Doumbouya S, Diallo KM, Diallo M, Arvand M, Müller SA. PASQUALE - A long-term partnership to improve hand hygiene and capacity building in infection prevention and control in the Faranah region of Guinea. Int J Med Microbiol 2024; 314:151612. [PMID: 38394878 DOI: 10.1016/j.ijmm.2024.151612] [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: 10/13/2023] [Revised: 01/12/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
Across the globe, hand hygiene (HH) is promoted to fight the spread of healthcare associated infections. Despite multiple ongoing HH campaigns and projects, the healthcare associated infection rates remain high especially in low- and middle-income countries. In the narrative overview presented here, we aim to share objectives, framework, successes and challenges of our long-term partnership in Guinea to offer guidance for other projects aiming to sustainably improve HH.
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Affiliation(s)
- Anna Borodova
- Centre for International Health Protection, Robert Koch Institute, Nordufer 20, 13353 Berlin, Germany.
| | | | - Rebekah Wood
- Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
| | | | - Carlos Rocha
- Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
| | - Mouctar Bayo
- German Agency for International Cooperation (GIZ), Conakry, Guinea
| | - Lena Landsmann
- Unit for Hospital Hygiene, Infection Prevention and Control, Robert Koch Institute, Berlin, Germany
| | | | - Matthias Borchert
- Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
| | - Carolin Meinus
- Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
| | | | | | | | | | - Mardjan Arvand
- Unit for Hospital Hygiene, Infection Prevention and Control, Robert Koch Institute, Berlin, Germany
| | - Sophie A Müller
- Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
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6
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Alayande BT, Forbes C, Masimbi O, Kingpriest P, Shimelash N, Wina F, Hey MT, Philipo GS, Abahuje E, Robertson JM, Yule S, Riviello RR, Bekele A. The Implementation of Simulation-Based Learning for Training Undergraduate Medical Students in Essential Surgical Care Across Sub-Saharan Africa: a Scoping Review. MEDICAL SCIENCE EDUCATOR 2024; 34:237-256. [PMID: 38510415 PMCID: PMC10948665 DOI: 10.1007/s40670-023-01898-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 03/22/2024]
Abstract
Much surgery in sub-Saharan Africa is provided by non-specialists who lack postgraduate surgical training. These can benefit from simulation-based learning (SBL) for essential surgery. Whilst SBL in high-income contexts, and for training surgical specialists, has been explored, SBL for surgical training during undergraduate medical education needs to be better defined. From 26 studies, we identify gaps in application of simulation to African undergraduate surgical education, including lack of published SBL for most (65%) World Bank-defined essential operations. Most SBL is recent (2017-2021), unsustained, occurs in Eastern Africa (78%), and can be enriched by improving content, participant spread, and collaborations.
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Affiliation(s)
- Barnabas T. Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Callum Forbes
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Ornella Masimbi
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | | | - Natnael Shimelash
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | - Felix Wina
- Department of Surgery, Bingham University Teaching Hospital, Jos, Nigeria
| | - Matthew T. Hey
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Godfrey Sama Philipo
- Research and Patient Outcomes, College of Surgeons of East Central and Southern Africa, Arusha, Tanzania
| | - Egide Abahuje
- Department of Surgery, University of Rwanda, Kigali, Rwanda
- Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Jamie M. Robertson
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
- Department of Surgery, Harvard Medical School, Boston, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Steven Yule
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland UK
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
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7
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KingPriest PT, Alayande BT, Clement EW, Muhammed M, Egbiri JO, Shanabo M, Osayande EK, Atunrase AA, Abubakar JI, Eze DC, Adekoya S, Chiroma GB, Aikhuomogbe OM, Gaila FS, Yaga D, Thomas NN, Chukwunta CA, Hey MT, Forbes C, Riviello RR, Ismaila BO. A national perspective on exposure to essential surgical procedures among medical trainees in Nigeria: a cross-sectional survey and recommendations. BMC MEDICAL EDUCATION 2023; 23:913. [PMID: 38037034 PMCID: PMC10691202 DOI: 10.1186/s12909-023-04847-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND In sub-Saharan Africa, recent graduates from medical school provide more direct surgical and procedural care to patients than their counterparts from the Global North. Nigeria has no nationally representative data on the procedures performed by trainees before graduation from medical school and their confidence in performing these procedures upon graduation has also not been evaluated. METHODS We performed an internet-based, cross-sectional survey of recent medical school graduates from 15 accredited Federal, State, and private Nigerian medical schools spanning six geopolitical zones. Essential surgical procedures, bedside interventions and three Bellwether procedures were incorporated into the survey. Self-reported confidence immediately after graduation was calculated and compared using cumulative confidence scores with subgroup analysis of results by type and location of institution. Qualitative analysis of free text recommendations by participants was performed using the constant comparative method in grounded theory. RESULTS Four hundred ninety-nine recent graduates from 6 geopolitical zones participated, representing 15 out of a total of 44 medical schools in Nigeria. Male to female ratio was 2:1, and most respondents (59%) graduated from Federal institutions. Students had greatest practical mean exposure to bedside procedures like intravenous access and passing urethral foley catheters and were most confident performing these. Less than 23% had performed over 10 of any of the assessed procedures. They had least exposures to chest tube insertion (0.24/person), caesarean Sect. (0.12/person), and laparotomy (0.09/person). Recent graduates from Federal institutions had less procedural exposure in urethral catheterization (p < 0.001), reduction (p = 0.035), and debridement (p < 0.035). Respondents that studied in the underserved North-East and North-West performed the highest median number of procedures prior to graduation. Cumulative confidence scores were low across all graduates (maximum 25/60), but highest in graduates from Northern Nigeria and private institutions. Graduates recommended prioritizing medical students over senior trainees, using simulation-based training and constructive individualized non-toxic feedback from faculty. CONCLUSION Nigerian medical students have poor exposure to procedures and low confidence in performing basic procedures after graduation. More attention should be placed on training for essential surgeries and procedures in medical schools.
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Affiliation(s)
- Paul Tunde KingPriest
- Surgical Equity and Research Hub, Jos, Nigeria
- The Global Health Network, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Barnabas Tobi Alayande
- Surgical Equity and Research Hub, Jos, Nigeria.
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda.
- Harvard TH Chan School of Public Health, Boston, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Matthew T Hey
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Callum Forbes
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Robert R Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Bashiru O Ismaila
- University of Jos, Jos, Nigeria
- Jos University Teaching Hospital, Jos, Nigeria
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8
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Alayande BT, Forbes CW, Iradakunda J, Majyambere JP, Hey MT, Powell BL, Perl J, McCall N, Paul T, Ingabire JA, Shimelash N, Mutabazi E, Kimto EO, Danladi GM, Tubasiime R, Rickard J, Karekezi C, Makiriro G, Bigirimana SP, Harelimana JG, ElSayed A, Ndibanje AJ, Mpirimbanyi C, Masimbi O, Ndayishimiye M, Ntabana F, Haonga BT, Anderson GA, Byringyiro JC, Ntirenganya F, Riviello RR, Bekele A. Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference. Cureus 2023; 15:e43625. [PMID: 37600431 PMCID: PMC10433784 DOI: 10.7759/cureus.43625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 08/22/2023] Open
Abstract
Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.
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Affiliation(s)
- Barnabas T Alayande
- General Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Global Health and Population, Harvard School of Public Health, Boston, USA
| | - Callum W Forbes
- Anesthesiology, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Jules Iradakunda
- School of Medicine, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - Jean Paul Majyambere
- General Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Surgery, Butaro District Hospital, Kigali, RWA
| | - Matthew T Hey
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Brittany L Powell
- Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Juliana Perl
- Biodesign, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - Natalie McCall
- Division of Clinical Medicine, University of Global Health Equity, Kigali, RWA
| | - Tomlin Paul
- Educational Development and Quality Center, University of Global Health Equity, Kigali, RWA
| | - Jc Allen Ingabire
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | - Natnael Shimelash
- Biodesign, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - Emmanuel Mutabazi
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | | | | | | | | | - Claire Karekezi
- Surgery, Neurosurgery Unit, Rwanda Military Hospital, Kigali, RWA
| | - Gabriel Makiriro
- Division of Clinical Medicine, University of Global Health Equity, Kigali, RWA
| | - Simon Pierre Bigirimana
- School of Medicine, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | - James G Harelimana
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | | | | | | | - Ornella Masimbi
- Simulation, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
| | | | - Frederick Ntabana
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
| | - Billy Thomson Haonga
- Orthopaedic Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, TZA
| | - Geoffrey A Anderson
- Trauma, Burns, and Critical Care, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Jean Claude Byringyiro
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
- Orthopedics, University Teaching Hospital of Kigali, Kigali, RWA
| | - Faustin Ntirenganya
- Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, RWA
- Surgery, University Teaching Hospital of Kigali, Kigali, RWA
- NIHR Research Hub on Global Surgery, University of Rwanda, Kigali, RWA
| | - Robert R Riviello
- Trauma, Burns, and Critical Care, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
- Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Kigali, RWA
| | - Abebe Bekele
- Cardiothoracic Surgery, Center for Equity in Global Surgery, University of Global Health Equity, Kigali, RWA
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9
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MacQuene T, Du Toit J, Hugo D, Alexander M, Ramasar S, Letswalo M, Swanepoel M, Brown C, Chu K. The impact of a decentralised orthopaedic service on tertiary referrals in Cape Town, South Africa. S Afr Med J 2023; 113:e833. [PMID: 37283150 DOI: 10.7196/samj.2023.v113i4.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND In South Africa (SA), district hospitals (DHs) have limited capacity to manage the high burden of traumatic injuries. Scaling up decentralised orthopaedic care could strengthen trauma systems and improve timely access to essential and emergency surgical care (EESC). Khayelitsha township in Cape Town, SA, has the highest trauma burden in the Cape Metro East health district. OBJECTIVES The primary objective of this study was to describe the impact of Khayelitsha District Hospital (KDH) on acute orthopaedic services in the health district, with a focus on the volume and type of orthopaedic services provided without tertiary referral. METHODS This retrospective analysis described acute orthopaedic cases from Khayelitsha and their management between 1 January 2018 and 31 December 2019. Orthopaedic resources and the proportion of cases referred to the tertiary hospital by all DHs in the Cape Metro East health district are described. RESULTS In 2018 - 2019, KDH performed 2 040 orthopaedic operations, of which 91.3% were urgent or emergencies. KDH had the most orthopaedic resources and the lowest referral ratio (0.18) compared with other DHs (0.92 - 1.35). In Khayelitsha, 2 402 acute orthopaedic cases presented to community health clinics. Trauma (86.1%) was the most common mechanism of injury for acute orthopaedic referrals. Of clinic cases, 2 229 (92.8%) were referred to KDH and 173 (7.2%) directly to the tertiary hospital. The most common reason for direct tertiary referral was condition related (n=157; 90.8%). CONCLUSION This study outlines a successful example of a decentralised orthopaedic surgical service that increased EESC accessibility and alleviated the high burden of tertiary referrals compared with other DHs with fewer resources. Further research on the barriers to scaling up orthopaedic DH capacity in SA is needed to improve equitable access to surgical care.
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Affiliation(s)
- T MacQuene
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - J Du Toit
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - D Hugo
- Department of Orthopaedic Surgery, Khayelitsha District Hospital, Cape Town, South Africa.
| | - M Alexander
- Department of Orthopaedic Surgery, Khayelitsha District Hospital, Cape Town, South Africa.
| | - S Ramasar
- 6th-year medical student, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - M Letswalo
- 5th-year medical student, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - M Swanepoel
- 6th-year medical student, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - C Brown
- Department of Orthopaedic Surgery, Khayelitsha District Hospital, Cape Town, South Africa.
| | - K Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana.
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10
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Nwanna-Nzewunwa O, Agwang E, Carvalho M, Ajiko MM, Oke R, Yoon C, Diab MM, Kirya F, Marseille E, Juillard C, Dicker RA. A cost-effectiveness analysis of surgical care delivery in Eastern Uganda-a societal perspective. BMC Health Serv Res 2023; 23:256. [PMID: 36918844 PMCID: PMC10015833 DOI: 10.1186/s12913-023-09216-x] [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: 10/13/2022] [Accepted: 02/24/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures. METHODS This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data. RESULTS Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained. CONCLUSION Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.
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Affiliation(s)
- Obieze Nwanna-Nzewunwa
- Department of Surgery, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
| | - Esther Agwang
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rasheedat Oke
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA
| | - Christopher Yoon
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Mohamed M Diab
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Fred Kirya
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Elliot Marseille
- Principal, Health Strategies International, 555 59th Street, Oakland, CA, USA
| | - Catherine Juillard
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA
| | - Rochelle A Dicker
- Program for the Advancement of Surgical Equity (PASE), University of California Los Angeles, Los Angeles, CA, USA.
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11
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Alayande B, Chu KM, Jumbam DT, Kimto OE, Musa Danladi G, Niyukuri A, Anderson GA, El-Gabri D, Miranda E, Taye M, Tertong N, Yempabe T, Ntirenganya F, Byiringiro JC, Sule AZ, Kobusingye OC, Bekele A, Riviello RR. Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. CURRENT TRAUMA REPORTS 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
Purpose of Review Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information The online version contains supplementary material available at 10.1007/s40719-022-00229-1.
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Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Alliance Niyukuri
- Hope Africa University, Bujumbura, Burundi
- Mercy Surgeons-Burundi, Research Department, Bujumbura, Burundi
- Mercy James Center for Paediatric Surgery and Intensive Care-Blantyre, Blantyre, Malawi
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Deena El-Gabri
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Mulat Taye
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ngyal Tertong
- International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK
| | - Tolgou Yempabe
- Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali, Rwanda
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Olive C. Kobusingye
- Makerere University School of Public Health, Kampala, Uganda
- George Institute for Global Health, Sydney, Australia
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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12
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Ibrahim AO, Abiola PO, Aremu SK, Shabi OM, Agbesanwa TA. Pattern of Surgical Emergencies in Rural Southwestern Nigeria. J Emerg Trauma Shock 2022; 15:23-28. [PMID: 35431476 PMCID: PMC9006714 DOI: 10.4103/jets.jets_76_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/06/2021] [Accepted: 10/22/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Considering the magnitude of deaths prevailing in the accident and emergency department (AED) in health facilities of sub-Sahara Africa, there is a need to have information on the burden of admissions and deaths due to surgical emergencies. Few studies in Nigerian hospitals in urban and suburban areas have been documented, but none in the rural setting. The objectives of this study were to ascertain the sociodemographic profile, causes and outcomes of admissions, and the pattern and causes of deaths due to surgical emergencies. Methods A retrospective survey using a data form and a predetermined questionnaire was used to review the patients admitted for surgical emergencies at the AED of a tertiary hospital in rural southwestern Nigeria from January 2015 to December 2019. The data were analyzed using SPSS version 22.0. The results were presented in descriptive and tabular formats. Results Surgical emergencies constituted 43.9% of all admissions. The mean age of admissions was 42 ± 16.9 years, and majorities were in the young and middle-aged groups. There were more males (66.4%) than females (33.6%). Trauma(60.9%) of which road traffic accident (RTAs)(56.0%), was the leading mechanism of trauma. The mortality rate was 5.4% and was caused majorly by RTAs (33.0%), diabetes mellitus foot ulcers (11.0%), and malignancies (9.8%). Conclusion In this study, surgical emergencies constituted 43.9%, and a majority of the patients were male. Trauma caused by RTA is the most cause of admission. The mortality rate was 5.4%. This finding may provide an impetus for prospective research on this outcome.
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Affiliation(s)
| | - Paul O Abiola
- Department of Surgery, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
| | - Shuaib Kayode Aremu
- Department of Ear, Nose and Throat, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
| | - Olabode M Shabi
- Department of Family Medicine, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
| | - Tosin Anthony Agbesanwa
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria
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