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Riccardi J, Benson R, Parvin-Nejad F, Padmanaban V, Jalloh S, Gyakobo M, Sifri Z. Breaking Barriers: Ensuring Gender Neutral Care on Short Term Surgical Missions. J Surg Res 2024; 303:181-188. [PMID: 39366284 DOI: 10.1016/j.jss.2024.09.004] [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: 03/06/2024] [Revised: 08/04/2024] [Accepted: 09/02/2024] [Indexed: 10/06/2024]
Abstract
INTRODUCTION Gender discrimination is prevalent worldwide in medical and surgical care. In the setting of short-term surgical missions (STSMs) conducted to address the global burden of surgical disease, patient selection raises ethical considerations regarding equitable distribution of limited clinical resources. The goal of this study was to examine if equitable distribution of operative care between male and female patients occurs in STSMs. METHODS The International Surgical Health Initiative (ISHI) is a US based nonprofit, nongovernmental organization. Records from surgical missions to Ghana (2014-2023) and Sierra Leone (2013-2023) were analyzed to evaluate for gender equity in inguinal hernia repairs, the most common procedure performed. A control group was created from a literature review inclusive of all studies of inguinal hernia repairs that included over 500 patients and patient gender. RESULTS The review of 26 studies, representing 3,239,043 patients, demonstrated a gender distribution of 13% female. In Sierra Leone 246 inguinal hernia repairs were performed between 2013 and 2023. 28 (11.4%) of the hernia repairs were in females, which was not significantly different from the control group (P = 0.45). In Ghana 150 inguinal hernia repairs were performed between 2014 and 2023. 12 (8%) of the hernia repairs were in females. This was not significantly different from the control group (P = 0.07). CONCLUSIONS This is the first study investigating the gender equity conducted within the context of humanitarian surgical outreach. Equitable patient selection is a paramount consideration in STSMs, particularly to address gender-related disparities in surgical care.
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Affiliation(s)
- Julia Riccardi
- Department of Surgery, University of California Davis, Sacramento, California.
| | - Ryan Benson
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | | | - Samba Jalloh
- University of Medicine and Allied Health Sciences (COMAHS), Freetown, Sierra Leone
| | - Mawuli Gyakobo
- Department of Internal Medicine and Therapeutics, University of Cape Coast, Cape Coast, Ghana
| | - Ziad Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Otoki K, Parker AS, Many HR, Parker RK. Gender Disparities in Complications, Costs, and Mortality After Emergency Gastrointestinal Surgery in Kenya. J Surg Res 2024; 295:846-852. [PMID: 37543494 DOI: 10.1016/j.jss.2023.06.050] [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: 02/24/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Little is known about the impact of gender on emergency surgery within Kenya. Therefore, we aimed to investigate the association of gender on outcomes of postoperative complications, health care costs, and mortality. METHODS We evaluated an established cohort of patients undergoing emergency gastrointestinal surgery in rural Kenya between January 1st, 2016 and June 30th, 2019. Utilizing logistic regression, we examined the association between self-reported patient gender and the outcomes of postoperative complications and mortality. A generalized linear model was created for total hospital costs, inflation-adjusted in international dollars purchasing power parity, to examine the impact of gender. Confounding factors were controlled by Africa Surgical Outcomes Study Surgical Risk Score. RESULTS Among 484 patients reviewed, 149 (30.8%) were women. 165 (34.1%) patients developed complications, with women experiencing more than men (40.9% versus 31.0%; P = 0.03) and longer hospital stays (median 6 days (4-9) versus 5 (4-7); P = 0.02). After controlling for Africa Surgical Outcomes Study Surgical Risk Score, odds of developing complications for women were 1.67 (95% confidence interval: 1.09-2.55; P = 0.019) times higher than men, and the odds of death were 2.38 (95% confidence interval: 1.12-5.09; P = 0.025) times greater for women than men, despite similar failure-to-rescue rates and intensive care unit utilization. Total hospital costs were increased for women by 531 international dollars purchasing power parity (117-946; P = 0.012) when compared to men, attributed to longer lengths of stay. CONCLUSIONS These findings demonstrate that a discrepancy exists between men and women undergoing emergency gastrointestinal surgery in our setting. Further exploration of the underlying causes of this inequity is necessary for quality improvement for women in rural Kenya.
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Affiliation(s)
- Kemunto Otoki
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/kemuntootoki
| | - Andrea S Parker
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/AP_the_surgeon
| | - Heath R Many
- Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
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Macias V, Garcia Z, Pavlis W, Hill S, Fowler Z, del Valle DD, Uribe-Leitz T, Gilbert H, Roa L, Good MJD. Rethinking referral systems in rural chiapas: A mixed methods study. DIALOGUES IN HEALTH 2023; 3:100156. [PMID: 38515804 PMCID: PMC10953926 DOI: 10.1016/j.dialog.2023.100156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/01/2023] [Accepted: 10/01/2023] [Indexed: 03/23/2024]
Abstract
Background Despite the assurance of universal health coverage, large disparities exist in access to surgery in the state of Chiapas. The purpose of this study was to determine the effectiveness of the surgical referral system at hospitals operated by the Ministry of Health in Chiapas. Methods 13 variables were extracted from surgical referrals data from three public hospitals in Chiapas over a three-year period. Interviews were performed of health care workers involved in the referral system and surgical patients. The quantitative and qualitative data was analyzed convergently and reported using a narrative approach. Findings In total, only 47.4% of referred patients requiring surgery received an operation. Requiring an elective, gynecological, or orthopedic surgery and each additional surgery cancellation were significantly associated with lower rates of receiving surgery. The impact of gender and surgical specialty, economic fragility of farmers, dependence upon economic resources to access care, pain leading people to seek care, and futility leading patients to abandon the public system were identified as main themes from the mixed methods analysis. Interpretation Surgical referral patients in Chiapas struggle to navigate an inefficient and expensive system, leading to delayed care and forcing many patients to turn to the private health system. These mixed methods findings provide a detailed view of often overlooked limitations to universal health coverage in Chiapas. Moving forward, this knowledge must be applied to improve referral system coordination and provide hospitals with the necessary workforce, equipment, and protocols to ensure access to guaranteed care. Funding Harvard University and the Abundance Fund provided funding for this project. Funding sources had no role in the writing of the manuscript or decision to submit it for publication.
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Affiliation(s)
| | | | - William Pavlis
- Department of Orthopaedics, University of Miami, Miami, FL, USA
| | - Sarah Hill
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Zachary Fowler
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Diana D. del Valle
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Tarsicio Uribe-Leitz
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
- Epidemiology, Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Hannah Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
- University of Alberta, Edmonton, Canada
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Mehta K, Thrikutam N, Hoyte-Williams PE, Falk H, Nakarmi K, Stewart B. Epidemiology and Outcomes of Cooking- and Cookstove-Related Burn Injuries: A World Health Organization Global Burn Registry Report. J Burn Care Res 2023; 44:508-516. [PMID: 34850021 PMCID: PMC10413420 DOI: 10.1093/jbcr/irab166] [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: 01/26/2021] [Indexed: 11/13/2022]
Abstract
Cooking- and cookstove-related burns (CSBs) comprise a large proportion of burn injuries globally, but there are limited data on cooking behavior patterns to inform prevention and advocacy. Therefore, we aimed to describe the epidemiology, risk factors, and outcomes of these injuries and highlight the potential of the World Health Organization (WHO) Global Burn Registry (GBR). Patients with cooking-related burns were identified in the WHO GBR. Patient demographics, cooking arrangement, injury characteristics, and outcomes were described and compared. Bivariate regression was performed to identify risk factors associated with CSBs. Analysis demonstrated that 25% of patients in the GBR sustained cooking-related burns (n = 1723). The cooking environment and cooking fuels used varied significantly by country income level ([electricity use: LIC 1.6 vs MIC 5.9 vs HIC 49.6%; P < .001] [kerosene use: LIC 5.7 vs MIC 10.4 vs HIC 0.0%; P < .001]). Of cooking-related burns, 22% were cookstove-related burns (CSBs; 311 burns). Patients with CSBs were more often female (65% vs 53%; P < .001). CSBs were significantly larger in TBSA size (30%, IQR 15-45 vs 15%, IQR 10-25; P < .001), had higher revised Baux scores (70, IQR 46-95 vs 28, IQR 10-25; P < .001) and more often resulted in death (41 vs 11%; P < .001) than other cooking burns. Patients with CSBs were more likely to be burned by fires (OR 4.74; 95% CI 2.99-7.54) and explosions (OR 2.91, 95% CI 2.03-4.18) than other cooking injuries. Kerosene had the highest odds of CSB compared to other cooking fuels (OR 2.37, 95% CI 1.52-3.69). In conclusion, CSBs specifically have different epidemiology than cooking-related burns. CSBs were more likely caused by structural factors (eg, explosion, fire) than behavioral factors (eg, accidental movements) when compared to other cooking burns. These differences suggest prevention interventions for CSBs may require distinctive efforts than typically deployed for cooking-related injuries, and necessarily involve cookstove design and safety regulations to prevent fires and explosions.
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Affiliation(s)
- Kajal Mehta
- Department of Surgery, University of Washington, Seattle, USA
| | | | - Paa Ekow Hoyte-Williams
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Reconstructive Plastic Surgery and Burns Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Henry Falk
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kiran Nakarmi
- Department of Burns, Plastic, and Reconstructive Surgery, Kirtipur Hospital, Public Health Concern Trust-Nepal,Kathmandu, Nepal
| | - Barclay Stewart
- Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery, University of Washington, UW Medicine Regional Burn Center, Seattle, USA
- Harborview Injury Prevention & Research Center, Seattle, Washington, USA
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Sex-Based Differences in Survival Among Patients with Acute Abdomen Undergoing Surgery in Malawi: A Propensity Weighted Analysis. World J Surg 2023; 47:895-902. [PMID: 36622437 PMCID: PMC9838258 DOI: 10.1007/s00268-023-06896-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Sex disparities in access to health care in low-resource settings have been demonstrated. Still, there has been little research on the effect of sex on postoperative outcomes. We evaluated the relationship between sex and mortality after emergency abdominal surgery. METHODS We performed a retrospective cohort study using the acute care surgery database at Kamuzu Central Hospital (KCH) in Malawi. We included patients who underwent emergency abdominal surgery between 2013 and 2021. We created a propensity score weighted Cox proportional hazards model to assess the relationship between sex and inpatient survival. RESULTS We included 2052 patients in the study, and 76% were males. The most common admission diagnosis in both groups was bowel obstruction. Females had a higher admission shock index than males (0.91 vs. 0.81, p < 0.001) and a longer delay from admission until surgery (1.47 vs. 0.79 days, p < 0.001). Females and males had similar crude postoperative mortality (16.3% vs. 15.3%, p = 0.621). The final Cox proportional hazards regression model was based on the propensity-weighted cohort. The mortality hazard ratio was 0.65 among females compared to males (95% CI 0.46-0.92, p = 0.014). CONCLUSIONS Our results show a survival advantage among female patients undergoing emergency abdominal surgery despite sex-based disparities in access to surgical care that favors males. Further research is needed to understand the mechanisms underlying these findings.
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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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Mehta K, Arega H, Smith NL, Li K, Gause E, Lee J, Stewart B. Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study. Am J Surg 2022; 223:157-163. [PMID: 34330521 PMCID: PMC8688305 DOI: 10.1016/j.amjsurg.2021.07.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels. METHODS In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality. RESULTS Among 6431 burn patients (38 % female; 62 % male), females less frequently received surgical treatment during index hospitalization (49 % vs 56 %, p < 0.001), and more frequently died in-hospital (26 % vs 16 %, p < 0.001) than males. Odds of in in-hospital death was 2.16 (95 % CI: 1.73-2.71) times higher among females compared to males in middle-income countries. CONCLUSIONS Across national income levels, there appears to be important gender-based disparities among burn injury epidemiology, treatment received and outcomes that require redress. Multinational registries can be utilized to track and to evaluate initiatives to reduce gender disparities at national, regional and global levels.
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Affiliation(s)
- Kajal Mehta
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Hana Arega
- School of Public Health, University of Washington, Seattle, WA, USA
| | | | - Kathleen Li
- Krieger School of Arts & Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - Emma Gause
- Harborview Injury Prevention & Research Center, Seattle, WA, USA
| | - Joohee Lee
- Public Health Concern Trust-Nepal, Kathmandu, Nepal
| | - Barclay Stewart
- Harborview Injury Prevention & Research Center, Seattle, WA, USA; Department of Surgery, University of Washington, Seattle, WA, USA
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8
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Powell BL, Luckett R, Bekele A, Chao TE. Sex Disparities in the Global Burden of Surgical Disease. World J Surg 2020; 44:2139-2143. [PMID: 32189033 DOI: 10.1007/s00268-020-05484-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Brittany L Powell
- Stanford University School of Medicine, Stanford, CA, USA.,Program in Global Surgery and Social Change, Boston, MA, USA
| | - Rebecca Luckett
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Botswana Harvard AIDS Initiative Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
| | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda
| | - Tiffany E Chao
- Stanford University School of Medicine, Stanford, CA, USA. .,Santa Clara Valley Medical Center, San Jose, CA, USA.
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9
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Long-Term Follow-Up of Humanitarian Surgeries: Outcomes and Patient Satisfaction in Rural Ghana. J Surg Res 2020; 246:106-112. [DOI: 10.1016/j.jss.2019.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/28/2019] [Accepted: 08/29/2019] [Indexed: 02/06/2023]
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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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Mathais Q, Montcriol A, Cotte J, Gil C, Contargyris C, Lacroix G, Prunet B, Bordes J, Meaudre E. Anesthesia during deployment of a military forward surgical unit in low income countries: A register study of 1547 anesthesia cases. PLoS One 2019; 14:e0223497. [PMID: 31584991 PMCID: PMC6777794 DOI: 10.1371/journal.pone.0223497] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/22/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Military anesthesia meets unique logistical, technical, tactical, and human constraints, but to date limited data have been published on anesthesia management during military operations. OBJECTIVE This study aimed to describe and analyze French anesthetic activity in a deployed military setting. METHODS Between October 2015 and February 2018, all patients managed by Sainte-Anne Military Hospital anesthesiologists deployed in mission were included. Anesthesia management was described and compared with the same surgical procedures in France performed by the same anesthesia team (hernia repair, lower and upper limb surgeries). Demographics, type of surgical procedure, and surgical activity were also described. The primary endpoint was to describe anesthesia management during the deployment of forward surgical teams (FST). The secondary endpoint was to compare anesthesia modalities during FST deployment with those usually used in a military teaching hospital. RESULTS During the study period, 1547 instances of anesthesia were performed by 11 anesthesiologists during 20 missions, totaling 1237 days of deployment in nine different theaters. The majority consisted of regional anesthesia, alone (43.5%) or associated with general anesthesia (21%). Compared with France, there was a statistically significant increase in the use of regional anesthesia in hernia repair, lower and upper limb surgeries during deployment. The majority of patients were civilians as part of medical support to populations. CONCLUSION In the context of an austere environment, the use of regional anesthesia techniques predominated when possible. These results show that the training of military anesthetists must be complete, including anesthesia, intensive care, pediatrics, and regional anesthesia.
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Affiliation(s)
- Quentin Mathais
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
- * E-mail:
| | - Ambroise Montcriol
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
| | - Jean Cotte
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
| | - Céline Gil
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
| | - Claire Contargyris
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
| | - Guillaume Lacroix
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
| | - Bertrand Prunet
- Service Médical de la Brigade des Sapeurs Pompiers de Paris, Paris, France
- French Military Health Service Academy Unit, Ecole du Val-De-Grâce, Paris, France
| | - Julien Bordes
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
- French Military Health Service Academy Unit, Ecole du Val-De-Grâce, Paris, France
| | - Eric Meaudre
- Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France
- French Military Health Service Academy Unit, Ecole du Val-De-Grâce, Paris, France
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12
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Improving Benchmarks for Global Surgery: Nationwide Enumeration of Operations Performed in Ghana. Ann Surg 2019; 268:282-288. [PMID: 28806300 DOI: 10.1097/sla.0000000000002457] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the operation rate in Ghana and characterize it by types of procedures and hospital level. BACKGROUND The Lancet Commission on Global Surgery recommended an annual rate of 5000 operations/100,000 people as a benchmark at which low- and middle-income countries could achieve most of the population-wide benefits of surgery, but did not define procedure-type benchmarks. METHODS Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district-level (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Operations were categorized into those deemed as essential procedures (most cost-effective, highest population impact) by the World Bank's Disease Control Priorities Project versus other. RESULTS An estimated 232,776 [95% uncertainty interval (95% UI) 178,004 to 287,549] operations were performed nationally. The annual rate of operations was 869 of 100,000 (95% UI 664 to 1073). The rate fell well short of the benchmark. 77% of the estimated annual national surgical output was in the essential procedure category. Most operations (62%) were performed at district-level hospitals. Most district-level hospitals (54%) did not have fully trained surgeons, but nonetheless performed 36% of district-level hospital operations. CONCLUSION The operation rate was short of the Lancet Commission benchmark, indicating large unmet need, although most operations were in the essential procedure category. Future global surgery benchmarking should consider both total numbers and priority levels. Most surgical care was delivered at district-level hospitals, many without fully trained surgeons. Benchmarking to improve surgical care needs to address both access deficiencies and hospital and provider level.
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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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Cost-Effectiveness of a Locally Organized Surgical Outreach Mission: Making a Case for Strengthening Local Non-Governmental Organizations. World J Surg 2017; 41:3074-3082. [PMID: 28741201 DOI: 10.1007/s00268-017-4131-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Sex disparities among persons receiving operative care during armed conflicts. Surgery 2017; 162:366-376. [PMID: 28400124 DOI: 10.1016/j.surg.2017.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/01/2017] [Accepted: 03/04/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Armed conflict increasingly involves civilian populations, and health care needs may be immense. We hypothesized that sex disparities may exist among persons receiving operative care in conflict zones and sought to describe predictors of disparity. METHODS We performed a retrospective analysis of operative interventions performed between 2008 and 2014 at Médecins Sans Frontières Operation Center Brussels conflict projects. A Médecins Sans Frontières Operation Center Brussels conflict project was defined as a program established in response to human conflict, war, or social unrest. Intervention- and country-level variables were evaluated. For multivariate analysis, multilevel mixed-effects logistic regression was used with random-effect modeling to account for clustering and population differences in conflict zones. RESULTS Between 2008 and 2014, 49,715 interventions were performed in conflict zones by Médecins Sans Frontières Operation Center Brussels. Median patient age was 24 years (range: 1-105 years), and 34,436 (69%) were men. Patient-level variables associated with decreased interventions on women included: American Society of Anesthesiologists score (P = .003), degree of urgency (P = .02), mechanism (P < .0001), and a country's predominant religion (P = .006). Men were 1.7 times more likely to have an operative intervention in a predominantly Muslim country (P = .006). CONCLUSION Conflict is an unfortunate consequence of humanity in a world with limited resources. For most operative interventions performed in conflict zones, men were more commonly represented. Predominant religion was the greatest predictor of increased disparity between sexes, irrespective of the number of patients presenting as a result of traumatic injury. It is critical to understand what factors may underlie this disparity to ensure equitable and appropriate care for all patients in an already tragic situation.
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Tansley G, Stewart BT, Gyedu A, Boakye G, Lewis D, Hoogerboord M, Mock C. The Correlation Between Poverty and Access to Essential Surgical Care in Ghana: A Geospatial Analysis. World J Surg 2017; 41:639-643. [PMID: 27766400 PMCID: PMC5558014 DOI: 10.1007/s00268-016-3765-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical disease burden falls disproportionately on individuals in low- and middle-income countries. These populations are also the least likely to have access to surgical care. Understanding the barriers to access in these populations is therefore necessary to meet the global surgical need. METHODS Using geospatial methods, this study explores the district-level variation of two access barriers in Ghana: poverty and spatial access to care. National survey data were used to estimate the average total household expenditure (THE) in each district. Estimates of the spatial access to essential surgical care were generated from a cost-distance model based on a recent surgical capacity assessment. Correlations were analyzed using regression and displayed cartographically. RESULTS Both THE and spatial access to surgical care were found to have statistically significant regional variation in Ghana (p < 0.001). An inverse relationship was identified between THE and spatial access to essential surgical care (β -5.15 USD, p < 0.001). Poverty and poor spatial access to surgical care were found to co-localize in the northwest of the country. CONCLUSIONS Multiple barriers to accessing surgical care can coexist within populations. A careful understanding of all access barriers is necessary to identify and target strategies to address unmet surgical need within a given population.
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Affiliation(s)
- Gavin Tansley
- Department of Surgery, Dalhousie University, Room 8-821, 1276 South Park St, Halifax, NS, B3H2Y9, Canada.
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Adam Gyedu
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Godfred Boakye
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Daniel Lewis
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Marius Hoogerboord
- Department of Surgery, Dalhousie University, Room 8-821, 1276 South Park St, Halifax, NS, B3H2Y9, Canada
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention & Research Centre, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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