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Altieri MS, Carter J, Aminian A, Docimo S, Hinojosa MW, Cheguevara A, Campos GM, Eisenberg D. American Society for Metabolic and Bariatric Surgery literature review on prevention, diagnosis, and management of internal hernias after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2023; 19:763-771. [PMID: 37268518 DOI: 10.1016/j.soard.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/26/2023] [Indexed: 06/04/2023]
Affiliation(s)
- Maria S Altieri
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jonathan Carter
- Department of General Surgery, University of California, San Francisco, California
| | - Ali Aminian
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Salvatore Docimo
- Department of Surgery, University of South Florida, Tampa, Florida
| | | | - Afaneh Cheguevara
- New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | | | - Dan Eisenberg
- Department of Surgery, Stanford School of Medicine, Stanford, California
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Zadey S, Iyer H, Nayan A, Shetty R, Sonal S, Smith ER, Staton CA, Fitzgerald TN, Nickenig Vissoci JR. Evaluating the status of the Lancet Commission on Global Surgery indicators for India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100178. [PMID: 37383563 PMCID: PMC10306037 DOI: 10.1016/j.lansea.2023.100178] [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: 10/08/2022] [Revised: 02/03/2023] [Accepted: 03/02/2023] [Indexed: 06/30/2023]
Abstract
For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.
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Affiliation(s)
- Siddhesh Zadey
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
- Dr. D.Y. Patil Medical College, Hospital, and Research Centre, Pune, Maharashtra, 411018, India
| | - Himanshu Iyer
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
| | - Anveshi Nayan
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Ritika Shetty
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Terna Medical College and Hospital, Navi Mumbai, Maharashtra, 400706, India
| | - Swati Sonal
- Association for Socially Applicable Research (ASAR), Pune, Maharashtra, 411007, India
- Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
- Department of Surgery, Harvard Medical School, Boston, MA, 02114, USA
| | - Emily R. Smith
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
| | - Catherine A. Staton
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
| | - Tamara N. Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27707, USA
- Global Emergency Medicine Innovation and Implementation Research Center, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Durham, NC, 27710, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, 27707, USA
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Monitoring Indicators of Universal Access to Accessible and Safe Anesthetic and Surgical Care in a Peruvian Region: An Ambispective Study. J Surg Res 2023; 283:127-136. [PMID: 36403406 PMCID: PMC10118244 DOI: 10.1016/j.jss.2022.10.024] [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: 02/04/2022] [Revised: 08/23/2022] [Accepted: 10/15/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The Lancet Commission on Global Surgery indicators for monitoring anesthetic and surgical care allow the identification of access barriers, evaluate the safety of surgeries, facilitate planning, and assess changes over time. The primary objective was to measure these indicators in all health facilities of a Peruvian region in 2020. METHODS This was an ambispective observational study to measure the anesthetic and surgical care indicators in Piura, a region in Peru, between January 2020 and June 2021. Public and private health facilities in the Piura region that performed surgical care or had specialists from any surgical specialty participated in the study. Data were collected from all regional health facilities that provided surgical care to estimate the density of surgical workforce. Likewise, the percentage of the population with access to an operating room within 2 h was estimated using georeferenced tools. Finally, a public database was accessed to determine the surgical volume, the percentage of the regional population protected with health insurance. RESULTS In 2020, 88.4% of the inhabitants of this Peruvian region had access to timely essential surgery. There were 18.4 surgical specialists and 1174 surgeries per 100,000 populations, and 91% of the population had health insurance. In addition, there was a rate of 2.1 working operating rooms per 100,000 inhabitants in 2021. CONCLUSIONS This Peruvian region presented an increasing trend with respect to the population's access to essential and timely surgical care, and health insurance coverage. However, the workforce distribution was inequitable among the provinces of the region, the surgical volume was reduced, and timely access was hindered because of the SARS-CoV-2 pandemic.
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Pérez-Rivera CJ, Lozano-Suárez N, Velandia-Sánchez A, Polanía-Sandoval CA, García-Méndez JP, Idarraga-Ayala SV, Corso-Ramírez JM, Conde-Monroy D, Cruz-Reyes DL, Durán-Torres CF, Barrera-Carvajal JG, Rojas-Serrano LF, Garcia-Zambrano LA, Agudelo-Mendoza SV, Briceno-Ayala L, Cabrera-Rivera PA. Perioperative mortality in Colombia: perspectives of the fourth indicator in The Lancet Commission on Global Surgery - Colombian Surgical Outcomes Study (ColSOS) - a protocol for a multicentre prospective cohort study. BMJ Open 2022; 12:e063182. [PMID: 36450427 PMCID: PMC9716983 DOI: 10.1136/bmjopen-2022-063182] [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] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Death following surgical procedures is a global health problem, accounting for 4.2 million deaths annually within the first 30 postoperative days. The fourth indicator of The Lancet Commission on Global Surgery is essential as it seeks to standardise postoperative mortality. Consequently, it helps identify the strengths and weaknesses of each country's healthcare system. Accurate information on this indicator is not available in Colombia, limiting the possibility of interventions applied to our population. We aim to describe the in-hospital perioperative mortality of the surgical procedures performed in Colombia. The data obtained will help formulate public policies, improving the quality of the surgical departments. METHODS AND ANALYSIS An observational, analytical, multicentre prospective cohort study will be conducted throughout Colombia. Patients over 18 years of age who have undergone a surgical procedure, excluding radiological/endoscopic procedures, will be included. A sample size of 1353 patients has been projected to achieve significance in our primary objective; however, convenience sampling will be used, as we aim to include all possible patients. Data collection will be carried out prospectively for 1 week. Follow-up will continue until hospital discharge, death or a maximum of 30 inpatient days. The primary outcome is perioperative mortality. A descriptive analysis of the data will be performed, along with a case mix analysis of mortality by procedure-related, patient-related and hospital-related conditions ETHICS AND DISSEMINATION: The Fundación Cardioinfantil-Instituto de Cardiología Ethics Committee approved this study (No. 41-2021). The results are planned to be disseminated in three scenarios: the submission of an article for publication in a high-impact scientific journal and presentations at the Colombian Surgical Forum and the Congress of the American College of Surgeons. TRIAL REGISTRATION NUMBER NCT05147623.
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Affiliation(s)
- Carlos J Pérez-Rivera
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
| | - Nicolás Lozano-Suárez
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Alejandro Velandia-Sánchez
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Vascular and Endovascular Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
| | - Camilo A Polanía-Sandoval
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
- Vascular and Endovascular Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
| | - Juan P García-Méndez
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Sharon V Idarraga-Ayala
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
| | - Julián M Corso-Ramírez
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Danny Conde-Monroy
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Danna L Cruz-Reyes
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Carlos F Durán-Torres
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Juan G Barrera-Carvajal
- Vascular and Endovascular Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Surgery, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
| | | | - Laura Alejandra Garcia-Zambrano
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Silvia Valentina Agudelo-Mendoza
- General Surgery Research Group, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
| | - Leonardo Briceno-Ayala
- Public Health Research Group, Universidad Del Rosario Escuela de Medicina y Ciencias de la Salud, Bogotá, Colombia
| | - Paulo A Cabrera-Rivera
- Escuela de Medicina y Ciencias de la Salud, Universidad Del Rosario, Bogotá, Colombia
- Surgery, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
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Nunez JM, Nellermoe J, Davis A, Ruhnke S, Gonchigjav B, Bat-Erdene N, Zorigtbaatar A, Jalali A, Bagley K, Katz M, Pioli H, Bat-Erdene B, Erdene S, Orgoi S, Price RR, Lundeg G. Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery. BMJ Open 2022; 12:e051838. [PMID: 35863828 PMCID: PMC9316021 DOI: 10.1136/bmjopen-2021-051838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country's ability to collect the indicators aided by a well-developed health information system. DESIGN An 11-year retrospective analysis of the Mongolian surgical system using data from the Health Development Center, National Statistics Office and Household Socio-Economic Survey. Access estimates were based on travel time to capable hospitals. Provider density, surgical volume and postoperative mortality were calculated at national and regional levels. Protection against impoverishing and catastrophic expenditures was assessed against standard out-of-pocket expenditure at government hospitals for individual operations. SETTING Mongolia's 81 public hospitals with surgical capability, including tertiary, secondary and primary/secondary facilities. PARTICIPANTS All operative patients in Mongolia's public hospitals, 2006-2016. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were national-level results of the indicators. Secondary outcomes include regional access; surgeons, anaesthesiologists and obstetricians (SAO) density; surgical volume; and perioperative mortality. RESULTS In 2016, 80.1% of the population had 2-hour access to essential surgery, including 60% of those outside the capital. SAO density was 47.4/100 000 population. A coding change increased surgical volume to 5784/100 000 population, and in-hospital mortality decreased from 0.27% to 0.14%. All households were financially protected from caesarean section. Appendectomy carried 99.4% and 98.4% protection, external femur fixation carried 75.4% and 50.7% protection from impoverishing and catastrophic expenditures, respectively. Laparoscopic cholecystectomy carried 42.9% protection from both. CONCLUSIONS Mongolia meets national benchmarks for access, provider density, surgical volume and postoperative mortality with notable limitations. Significant disparities exist between regions. Unequal access may be efficiently addressed by strengthening or building key district hospitals in population-dense areas. Increased financial protections are needed for operations involving hardware or technology. Ongoing monitoring and evaluation will support the development of context-specific interventions to improve surgical care in Mongolia.
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Affiliation(s)
- Jade M Nunez
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Jonathan Nellermoe
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Andrea Davis
- Department of Geography, University of Utah, Salt Lake City, Utah, USA
| | - Simon Ruhnke
- Berliner Institut für Empirische Integrations- und Migrationsforschung/BIM, Berlin, Germany
| | | | - Nomindari Bat-Erdene
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | | | - Ali Jalali
- Cornell University Joan and Sanford I Weill Medical College, New York City, New York, USA
| | - Kevin Bagley
- Southwest Memorial Hospital, Cortez, Colorado, USA
| | - Micah Katz
- Cayuga Medical Center, Ithaca, New York, USA
| | - Hannah Pioli
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Batsaikhan Bat-Erdene
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Sarnai Erdene
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Sergelen Orgoi
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Raymond R Price
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ganbold Lundeg
- Department of Critical Care and Anaesthesia, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
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Firth PG, Mushagara R, Musinguzi N, Liu C, Boatin AA, Mugabi W, Kayaga D, Naturinda P, Twesigye D, Sanyu F, Mugyenyi G, Ngonzi J, Ttendo SS. Surgical, Obstetric, and Anesthetic Mortality Measurement at a Ugandan Secondary Referral Hospital. Anesth Analg 2021; 133:1608-1616. [PMID: 34415855 DOI: 10.1213/ane.0000000000005734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The health care systems of low-income countries have severely limited capacity to treat surgical diseases and conditions. There is limited information about which hospital mortality outcomes are suitable metrics in these settings. METHODS We did a 1-year observational cohort study of patient admissions to the Surgery and the Obstetrics and Gynecology departments and of newborns delivered at a Ugandan secondary referral hospital. We examined the proportion of deaths captured by standardized metrics of mortality. RESULTS There were 17,015 admissions and 9612 deliveries. A total of 847 deaths were documented: 385 (45.5%) admission deaths and 462 (54.5%) perinatal deaths. Less than one-third of admission deaths occurred during or after an operation (n = 126/385, 32.7%). Trauma and maternal mortality combined with perioperative mortality produced 79.2% (n = 305/385) of admission deaths. Of 462 perinatal deaths, 412 (90.1%) were stillborn, and 50 (10.9%) were early neonatal deaths. The combined metrics of the trauma mortality rate, maternal mortality ratio, thirty-day perioperative mortality rate, and perinatal mortality rate captured 89.8% (n = 761/847) of all deaths documented at the hospital. CONCLUSIONS The combination of perinatal, maternal, trauma, and perioperative mortality metrics captured most deaths documented at a Ugandan referral hospital.
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Affiliation(s)
- Paul G Firth
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rhina Mushagara
- Harvard-Mbarara University of Science and Technology Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nicholas Musinguzi
- Harvard-Mbarara University of Science and Technology Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Charles Liu
- Department of Surgery, Lucille Packard Children's Hospital at Stanford, Palo Alto, California
| | - Adeline A Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Walter Mugabi
- Harvard-Mbarara University of Science and Technology Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dorothy Kayaga
- Harvard-Mbarara University of Science and Technology Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Phionah Naturinda
- Harvard-Mbarara University of Science and Technology Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | | | - Stephen S Ttendo
- Department of Anaesthesia and Critical Care, Mbarara Regional Referral Hospital, Mbarara, Uganda
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Davies JI, Gelb AW, Gore-Booth J, Martin J, Mellin-Olsen J, Åkerman C, Ameh EA, Biccard BM, Braut GS, Chu KM, Derbew M, Ersdal HL, Guzman JM, Hagander L, Haylock-Loor C, Holmer H, Johnson W, Juran S, Kassebaum NJ, Laerdal T, Leather AJM, Lipnick MS, Ljungman D, Makasa EM, Meara JG, Newton MW, Østergaard D, Reynolds T, Romanzi LJ, Santhirapala V, Shrime MG, Søreide K, Steinholt M, Suzuki E, Varallo JE, Visser GHA, Watters D, Weiser TG. Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report. PLoS Med 2021; 18:e1003749. [PMID: 34415914 PMCID: PMC8415575 DOI: 10.1371/journal.pmed.1003749] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.
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Affiliation(s)
- Justine I. Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
- Department of Public Health, Wits University, Johannesburg, South Africa
- * E-mail:
| | - Adrian W. Gelb
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
- Department of Anesthesia & Perioperative Care, University of California San Francisco, California, United States of America
| | - Julian Gore-Booth
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
| | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
| | - Jannicke Mellin-Olsen
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
- Department of Anaesthesia and Intensive Care Medicine, Baerum Hospital, Sandvika, Norway
| | - Christina Åkerman
- Dell Medical School, University of Texas at Austin, Austin, Texas, United States of America
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, Massachusetts, United States of America
| | - Emmanuel A. Ameh
- Division of Paediatric Surgery, The National Hospital, Abuja, Nigeria
- National Surgical, Obstetric and Anaesthesia Planning Committee, Federal Ministry of Health, Abuja, Nigeria
| | - Bruce M. Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Cape Town, South Africa
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Western Cape, South Africa
| | - Geir Sverre Braut
- Research Department of Community Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Miliard Derbew
- School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
| | - Hege Langli Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Norway
| | | | - Lars Hagander
- Paediatric Surgery, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Carolina Haylock-Loor
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
- Department of Anesthesia, Intensive Care Medicine, Interventional Pain Unit, Hospital Del Valle, San Pedro Sula, Honduras
| | - Hampus Holmer
- Paediatric Surgery, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Walter Johnson
- Department of Neurosurgery, Loma Linda University, Loma Linda, California, United States of America
| | - Sabrina Juran
- Population and Development, United Nations Population Fund, New York, New York, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Nicolas J. Kassebaum
- Anesthesiology and Pain Medicine, Health Metrics Sciences, Global Health, and Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | | | - Andrew J. M. Leather
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Michael S. Lipnick
- Center for Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, United States of America
| | - David Ljungman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emmanuel M. Makasa
- SADC-Wits Regional Collaboration Centre for Surgical Healthcare (WitSSurg), Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - John G. Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Mark W. Newton
- Department of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Tennessee, United States of America
- AIC Kijabe Hospital, Kenya
| | - Doris Østergaard
- Copenhagen Academy for Medical Education and Simulation, The University of Copenhagen, Copenhagen, Denmark
| | - Teri Reynolds
- Clinical Services and Systems, Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Lauri J. Romanzi
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Vatshalan Santhirapala
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Anaesthesia and Perioperative Care, Guy’s and St. Thomas’ Hospital, London, United Kingdom
| | - Mark G. Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Margit Steinholt
- Helgeland Hospital Trust, Sandnessjøen, Norway
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Emi Suzuki
- The World Bank, Washington, DC, United States of America
| | - John E. Varallo
- Department of Safe Surgery, Jhpiego, Baltimore, Maryland, United States of America
| | - Gerard H. A. Visser
- Department of Obstetrics, University Medical Center, Utrecht, the Netherlands
| | - David Watters
- University Hospital Geelong, Victoria, Australia
- Faculty of Health, School of Medicine, Deakin University, Victoria, Australia
- Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Thomas G. Weiser
- Stanford University School of Medicine, Department of Surgery Division of General Surgery, Section of Trauma & Critical Care Stanford University, Stanford, United States of America
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland
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Hoh SM, Wahab MYA, Hisham AN, Guest GD, Watters DAK. Mapping timely access to emergency and essential surgical services: The Malaysian experience. ANZ J Surg 2021; 92:223-227. [PMID: 34075677 DOI: 10.1111/ans.16986] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/05/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical conditions form a significant proportion of the global burden of disease. Since the 2015 World Health Assembly resolution A68.15, there is recognition that the provision of essential surgical care is an integral part of universal access to health care. The Lancet Commission on Global Surgery proposed its first surgical indicator to measure a population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours. Bellwether access is a proxy for emergency and essential surgical care. This project aims to map essential surgical access to the Bellwether procedures in Malaysia. METHODS The location and capability of hospitals to perform the Bellwether procedures was obtained from the Ministry of Health (MoH) and MoH hospital specific websites. The Malaysian population data were retrieved from the national department of statistics. Times for patients to travel to hospital were calculated by combining manual contouring and geospatial mapping. RESULTS There were 49 Bellwether-capable MoH hospitals serving a national population of 32.5 million. Overall 94% of Malaysia's population have access to the Bellwethers within two hours. This coverage is universal in West (Peninsular) Malaysia, but there is only 73% coverage in East Malaysia, with 1.8 million residents of Sabah and Sarawak not having timely access. Malaysia's Bellwether capacity compares well with other countries in World Health Organisation's Western Pacific region. CONCLUSION There is good access to essential and emergency surgical services in Malaysia. The incomplete access for 1.8 million people in East Malaysia will inform national surgical planning.
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Affiliation(s)
- Su Mei Hoh
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | | | | | - Glenn D Guest
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | - David A K Watters
- Department of Surgery, University Hospital Geelong, Deakin University and Barwon Health, Geelong, Victoria, Australia
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9
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McLeod E, Watters D. Global Health in the ANZ Journal of Surgery. ANZ J Surg 2021; 90:1833-1834. [PMID: 33710740 DOI: 10.1111/ans.16305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Elizabeth McLeod
- Department of Neonatal and Paediatric Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.,RACS Global Health, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - David Watters
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia.,RACS Global Health, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
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10
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Nagra S, Singh S, Kaur B, McCaig E, Tangi V, Guest G, Watters DA. How is surgery included in the Strategic Health Plans of the Pacific, Papua New Guinea and Timor-Leste? ANZ J Surg 2021; 91:795-801. [PMID: 33870624 DOI: 10.1111/ans.16651] [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: 02/03/2020] [Revised: 10/06/2020] [Accepted: 10/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Papua New Guinea, Pacific Island nations, and Timor-Leste represent a range of island nations with populations ranging from a few thousand to 8 million. They perform on average about 25% of the Lancet Commission of Global Surgery's target 5000 per 100 000 population and their health workforce have significant deficits of trained surgeons and anaesthetists. This study was conducted to determine how the current national health plans of these nations have included surgery and anaesthesia. METHODS The most recent (as of December 2018) published national health plans of 10 Pacific Island nations (Cook Islands, Fiji, Nauru, Federated States of Micronesia, Kiribati, Samoa, Solomon Islands, Tonga, Tuvalu and Vanuatu), Papua New Guinea and Timor-Leste were reviewed for content and process, searching for key words and identifying themes related to surgery and anaesthesia. RESULTS There were 12 national health plans with a combined total of 478 pages. There was limited surgical and/or anaesthesia input within the planning process. Injuries, blindness, cancer and non-communicable diseases were included themes, but the potential role of surgical care in addressing these conditions was not well documented. The need for better information and registries was noted by several nations but possible surgical care delivery or outcome metrics were not included. CONCLUSION There is limited mention of surgical and anaesthesia care planning within current health plans in the Pacific, PNG and TL. There is a need for greater surgical and anaesthesia engagement in future plans with performance measured against World Health Organization core surgical indicators.
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Affiliation(s)
- Sonal Nagra
- Department of Surgery, Deakin University and Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia
| | - Sheetal Singh
- Health System Improvement and Innovation, Ministry of Health, Wellington, New Zealand
| | - Balbindar Kaur
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia
| | | | | | - Glenn Guest
- Department of Surgery, Deakin University and Epworth Hospital, University Hospital Geelong, Geelong, Victoria, Australia
| | - David A Watters
- Department of Surgery, Deakin University and Epworth Hospital, University Hospital Geelong, Geelong, Victoria, Australia
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11
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Myatra SN, Tripathy S, Einav S. Global health inequality and women - beyond maternal health. Anaesthesia 2021; 76 Suppl 4:6-9. [PMID: 33682098 DOI: 10.1111/anae.15431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Affiliation(s)
- S N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - S Tripathy
- Department of Anaesthesia and Critical Care, AIIMS Bhubaneswar, Bhubaneswar, India
| | - S Einav
- Department of Anaesthesia and Intensive Care, Hebrew University Faculty of Medicine and General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
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12
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Watters DA, Wilson L. The Comparability and Utility of Perioperative Mortality Rates in Global Health. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-020-00432-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Kluyts HL, Biccard BM. The role of peri-operative registries in improving the quality of care in low-resource environments. Anaesthesia 2021; 76:888-891. [PMID: 33645733 DOI: 10.1111/anae.15445] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 12/20/2022]
Affiliation(s)
- H-L Kluyts
- Department of Anaesthesiology, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - B M Biccard
- Department of Anaesthesia and Peri-operative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Dahir S, Cotache-Condor CF, Concepcion T, Mohamed M, Poenaru D, Adan Ismail E, Leather AJM, Rice HE, Smith ER. Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study. BMJ Open 2020; 10:e042968. [PMID: 33376180 PMCID: PMC7778782 DOI: 10.1136/bmjopen-2020-042968] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions. METHODS In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region. RESULTS The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection. CONCLUSION We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.
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Affiliation(s)
- Shukri Dahir
- Edna Adan University Hospital, Hargeisa, Somaliland
| | | | - Tessa Concepcion
- Global Health Institute, Duke University, Durham, North Carolina, USA
| | | | - Dan Poenaru
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Québec, Canada
| | | | - Andy J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Henry E Rice
- Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Emily R Smith
- Department of Public Health, Baylor University, Waco, Texas, USA
- Global Health Institute, Duke University, Durham, North Carolina, USA
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15
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van Duinen AJ, Adde HA, Fredin O, Holmer H, Hagander L, Koroma AP, Koroma MM, Leather AJ, Wibe A, Bolkan HA. Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone. BMJ Glob Health 2020; 5:e003943. [PMID: 33355267 PMCID: PMC7754652 DOI: 10.1136/bmjgh-2020-003943] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. METHODS Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. RESULTS The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). CONCLUSION The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.
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Affiliation(s)
- Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håvard A Adde
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ola Fredin
- Geological Survey of Norway, Trondheim, Norway
- Department of Geography, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Hagander
- Centre for Surgery and Public Health, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Alimamy P Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Michael M Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Andrew Jm Leather
- King's Centre for Global Health & Health Partnerships, King's College London, London, UK
| | - Arne Wibe
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Greive-Price T, Mistry H, Baird R. North-South surgical training partnerships: a systematic review. Can J Surg 2020; 63:E551-E561. [PMID: 33253513 DOI: 10.1503/cjs.008219] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Fostering the success of surgical trainees from low- and middle-income countries (LMICs) plausibly addresses the existing workforce deficit in a sustainable manner, but it is unclear whether and how these trainees are targeted as strategic learners for educational exchanges. The purpose of this review was to assess the quality and outcomes of existing literature on exchanges of surgical trainees between high-income countries (HICs) and LMICs. Methods We conducted a systematic review of reported instances of surgical training exchanges between HICs and LMICs. After database searching, 2 independent reviewers evaluated titles, abstracts and manuscripts. Selected studies were critically appraised with the use the Critical Assessment Skills Programme Qualitative Checklist and analyzed for trainee level, institutions, countries and subspecialties, as well as reported outcomes of the exchange. Results Twenty-eight reports met the inclusion criteria and were analyzed. Most publications (18 [64%]) detailed North-to-South exchanges; 1 exchange was bidirectional. General surgery was the most common discipline identified, with 9 other subspecialties described involving learners at all phases of training. Reports were generally of good quality, although outcomes were reported variably, and most authors failed to acknowledge the ethical implications of their study. Conclusion The articles identified described a variety of surgical exchanges across disciplines, learner types and host/home countries. Few of the exchanges prioritized the learning of surgical trainees from LMICs. There is an increasing need to formalize these exchanges via clear goals and objectives, as well as to prioritize the proper matching of educational goals with local clinical needs. Level of evidence V - Evidence from systematic reviews of descriptive and qualitative studies.
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Affiliation(s)
- Tim Greive-Price
- From the Division of Pediatric Surgery, University of British Colombia, Vancouver, BC
| | - Hardee Mistry
- From the Division of Pediatric Surgery, University of British Colombia, Vancouver, BC
| | - Robert Baird
- From the Division of Pediatric Surgery, University of British Colombia, Vancouver, BC
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Identifying a Basket of Surgical Procedures to Standardize Global Surgical Metrics: An International Delphi Study. Ann Surg 2020; 274:1107-1114. [PMID: 33214454 DOI: 10.1097/sla.0000000000004611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We aimed to define a globally applicable list of surgical procedures, or "basket", which could represent a health system's capacity to provide surgical care and standardize global surgical measurement. SUMMARY OF BACKGROUND DATA Six indicators have been proposed to assess access to safe, affordable, timely surgical and anesthesia care, with a focus on laparotomy, caesarean section, and treatment of open fracture. However, comparability, particularly for these procedures, has been limited by a lack of definitional clarity and their overly broad scope. METHODS We conducted a three round international expert Delphi exercise between April and June 2019 using REDCap to identify a set of procedures representative of surgical capacity. To be included, procedures had to be important for treating common conditions, well-defined, and impactful (i.e. well-recognized clinical or functional benefit). Procedures were eliminated or prioritized in each round, and those noted as "extremely" or "very important" by ≥ 50% of respondents in round 3 were included in the final "basket". RESULTS Altogether 331 respondents from 78 countries participated in the Delphi process. A final basket of 32 procedures representing diseases categories in trauma, cancer, congenital anomalies, maternal/reproductive health, aging, and infection were identified as important for inclusion to assess surgical capacity. CONCLUSIONS This surgical basket could allow a more standardized assessment of a country's surgical system. Further testing and refinement will likely be needed, but this basket can be used immediately to guide ongoing monitoring and evaluation of global surgery capacities to improve and strengthen surgery and anesthesia care.
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The Burden of Emergency Abdominal Surgery Heavily Outweighs Elective Procedures in KwaZulu-Natal Province, South Africa. J Surg Res 2020; 259:414-419. [PMID: 33616075 DOI: 10.1016/j.jss.2020.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/29/2020] [Accepted: 09/22/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND South Africa is a middle-income country with major discrepancies in wealth and access to care. There is a significant burden of surgical disease and limited access to quality health care for a large proportion of the population. This article quantifies the burden of abdominal surgery over a 6-month period in KwaZulu-Natal (KZN) province and quantifies the emergency to elective (Ee) ratio for these operations. METHODS This study describes the abdominal operations conducted at all regional and tertiary hospitals in the public health sector of KZN province for the period of 1 July to December 31, 2015. Operations performed were tabulated in a spreadsheet and categorized as elective, emergency, and trauma. They were further subdivided by anatomical region and by specific predetermined procedures. Uncertain criteria were clarified using a modified Delphi discussion. The Ee ratio was determined using the recently described technique. RESULTS Between June, 1st and December 31, 2015, of 13,282 operations, there were 4580 (34.5%) elective operations, 7777 (58.6%) emergency operations, and 925 (6.9%) trauma-related operations. A total of 5630 abdominal operations were performed of which 2949 were emergency procedures. There were 660 trauma-related abdominal procedures and 2021 elective procedures. There was a heavy weighting toward emergency surgeries with an Ee ratio of 145 for abdominal surgery. The previous sub-Saharan African ratio was estimated to be 62.6. CONCLUSIONS An overview of abdominal surgery in KZN reveals a high ratio of emergency to elective surgery. This suggests that the current primary health care program is failing to detect and treat acute surgical disease timeously.
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Evaluation of a Managed Surgical Consultation Network in Malawi. World J Surg 2020; 45:356-361. [PMID: 33026475 DOI: 10.1007/s00268-020-05809-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Access to surgery is a challenge for low-income countries like Malawi due to shortages of specialists, especially in rural areas. District hospitals (DH) cater for the immediate surgical needs of rural patients, sending difficult cases to central hospitals (CH), usually with no prior communication. METHODS In 2018, a secure surgical managed consultation network (MCN) was established to improve communication between specialist surgeons and anaesthetists at Queen Elizabeth and Zomba Central Hospitals, and surgical providers from nine DHs referring to these facilities. RESULTS From May to December 2018, DHs requested specialist advice on 249 surgical cases through the MCN, including anonymised images (52% of cases). Ninety six percent of cases received advice, with a median of two specialists answering. For 74% of cases, a first response was received within an hour, and in 68% of the cases, a decision was taken within an hour from posting the case on MCN. In 60% of the cases, the advice was to refer immediately, in 26% not to refer and 11% to possibly refer at a later stage. CONCLUSION The MCN facilitated quick access to consultations with specialists on how to manage surgical patients in remote rural areas. It also helped to prevent unnecessary referrals, saving costs for patients, their guardians, referring hospitals and the health system as a whole. With time, the network has had spillover benefits, allowing the Ministry of Health closer monitoring of surgical activities in the districts and to respond faster to shortages of essential surgical resources.
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20
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Hanna JS, Herrera-Almario GE, Pinilla-Roncancio M, Tulloch D, Valencia SA, Sabatino ME, Hamilton C, Rehman SU, Mendoza AK, Gómez Bernal LC, Salas MFM, Navarro MAP, Nemoyer R, Scott M, Pardo-Bayona M, Rubiano AM, Ramirez MV, Londoño D, Dario-Gonzalez I, Gracias V, Peck GL. Use of the six core surgical indicators from the Lancet Commission on Global Surgery in Colombia: a situational analysis. LANCET GLOBAL HEALTH 2020; 8:e699-e710. [PMID: 32353317 DOI: 10.1016/s2214-109x(20)30090-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Surgical, anaesthetic, and obstetric (SAO) health-care system strengthening is needed to address the emergency and essential surgical care that approximately 5 billion individuals lack globally. To our knowledge, a complete, non-modelled national situational analysis based on the Lancet Commission on Global Surgery surgical indicators has not been done. We aimed to undertake a complete situation analysis of SAO system preparedness, service delivery, and financial risk protection using the core surgical indicators proposed by the Commission in Colombia, an upper-middle-income country. METHODS Data to inform the six core surgical system indicators were abstracted from the Colombian national health information system and the most recent national health survey done in 2007. Geographical access to a Bellwether hospital (defined as a hospital capable of providing essential and emergency surgery) within 2 h was assessed by determining 2 h drive time boundaries around Bellwether facilities and the population within and outside these boundaries. Physical 2 h access to a Bellwether was determined by the presence of a motor vehicle suitable for individual transportation. The Department Administrativo Nacional de Estadística population projection for 2016 and 2018 was used to calculate the SAO provider density. Total operative volume was calculated for 2016 and expressed nationally per 100 000 population. The total number of postoperative deaths that occurred within 30 days of a procedure was divided by the total operative volume to calculate the all-cause, non-risk-adjusted postoperative mortality. The proportion of the population subject to impoverishing costs was calculated by subtracting the baseline number of impoverished individuals from those who fell below the poverty line once out-of-pocket payments were accounted for. Individuals who incurred out-of-pocket payments that were more than 10% of their annual household income were considered to have experienced catastrophic expenditure. Using GIS mapping, SAO system preparedness, service delivery, and cost protection were also contextualised by socioeconomic status. FINDINGS In 2016, at least 7·1 million people (15·1% of the population) in Colombia did not have geographical access to SAO services within a 2 h driving distance. SAO provider density falls short of the Commission's minimum target of 20 providers per 100 000 population, at an estimated density of 13·7 essential SAO health-care providers per 100 000 population in 2018. Lower socioeconomic status of a municipality, as indicated by proportion of people enrolled in the subsidised insurance regime, was associated with a smaller proportion of the population in the municipality being within 2 h of a Bellwether facility, and the most socioeconomically disadvantaged municipalities often had no SAO providers. Furthermore, Colombian providers appear to be working at or beyond capacity, doing 2690-3090 procedures per 100 000 population annually, but they have maintained a relatively low median postoperative mortality of 0·74% (IQR 0·48-0·84). Finally, out-of-pocket expenses for indirect health-care costs were a key barrier to accessing surgical care, prompting 3·1 million (6·4% of the population) individuals to become impoverished and 9·5 million (19·4% of the population) individuals to incur catastrophic expenditures in 2007. INTERPRETATION We did a non-modelled, indicator-based situation analysis of the Colombian SAO system, finding that it has not yet met, but is working towards achieving, the targets set by the Lancet Commission on Global Surgery. The observed interdependence of these indicators and correlation with socioeconomic status are consistent with well recognised factors and outcomes of social, health, and health-care inequity. The internal consistency observed in Colombia's situation analysis validates the use of the indicators and has now informed development of an early national SAO plan in Colombia, to set a data-informed stage for implementation and evaluation of timely, safe, and affordable SAO health care, within the National Public Health Decennial Plan, which is due in 2022. FUNDING Zoll Medical.
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Affiliation(s)
- Joseph S Hanna
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA.
| | - Gabriel E Herrera-Almario
- Fundación Santa Fe de Bogotá, Bogotá, Colombia; School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | | | - David Tulloch
- Center for Remote Sensing and Spatial Analysis, Rutgers School of Environmental and Biological Sciences, The State University of New Jersey, New Brunswick, NJ, USA
| | | | - Marlena E Sabatino
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Charles Hamilton
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Shahyan U Rehman
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Ardi Knobel Mendoza
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | | | | | | | - Rachel Nemoyer
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Michael Scott
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | | | - Andres M Rubiano
- School of Medicine and Neuroscience Institute, Universidad el Bosque, Bogotá, Colombia
| | | | | | | | - Vicente Gracias
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; Rutgers New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Gregory L Peck
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; Rutgers School of Public Health, Rutgers Biomedical and Health Sciences, Piscataway, NJ, USA
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James K, Borchem I, Talo R, Aihi S, Baru H, Didilemu F, Moore EM, McLeod E, Watters DA. Universal access to safe, affordable, timely surgical and anaesthetic care in Papua New Guinea: the six global health indicators. ANZ J Surg 2020; 90:1903-1909. [PMID: 33710739 DOI: 10.1111/ans.16148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The unmet global burden of surgical disease is substantial. The Lancet Commission on Global Surgery (LCoGS) estimated that 5 billion people do not have access to safe, affordable and timely surgical care, with 80% of those without access living in low- and middle-income countries. The Milne Bay Province (pop 331 000) of Papua New Guinea, with an archipelago of islands up to 750 km from its capital, Alotau, has only one hospital capable of performing Caesarean Section, Emergency Laparotomy and managing an open fracture, the three Bellwether procedures. This paper aims to report the six Lancet Commission on Global Surgery metrics for Milne Bay Province. METHODS The study was conducted between January and August 2019. Bellwether access was investigated by a prospective study on 115 patients presenting to hospital. The surgical, anaesthesia and obstetric (SAO) workforce, surgical volume and perioperative mortality rate, were calculated for 2012-2018 from hospital records and operation registers. Financial risk metrics were calculated by surveying 50 patients at discharge from hospital. RESULTS Bellwether access: Only 27.8% (n = 32) of the study population (n = 115) experienced less than 2-hours second delay (journey time to hospital). The average SAO provider density was 1.8 per 100 000 population. There were 606 procedures performed per 100 000 with a mean annual perioperative mortality rate of 0.3%. Catastrophic expenditure is a risk for 29% of the population. CONCLUSION Milne Bay Province can perform surgery safely, but there is limited access to timely surgical care when needed with a significant proportion put at financial risk by requiring it.
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Affiliation(s)
- Kennedy James
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Isaiah Borchem
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Rodney Talo
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Sonia Aihi
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Helai Baru
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Fiona Didilemu
- Alotau Provincial Hospital, Milne Bay Provincial Health Authority, Milne Bay, Papua New Guinea
| | - Eileen M Moore
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia
| | - Elizabeth McLeod
- Paediatric and Neonatal Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - David A Watters
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
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Zhou Y, Zhang H, Yu S, Patterson D. Research on Surgical Anaesthesia Information Management System Based on Data Structure of BS Three-tier Architecture (Preprint). JMIR Med Inform 2020. [DOI: 10.2196/21031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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23
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Watters DA, Tangi V, Guest GD, McCaig E, Maoate K. Advocacy for global surgery: a Pacific perspective. ANZ J Surg 2020; 90:2084-2089. [DOI: 10.1111/ans.15972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/16/2022]
Affiliation(s)
- David A. Watters
- Department of Surgery Deakin University and Barwon Health Geelong Victoria Australia
- RACS Global Health Royal Australasian College of Surgeons Melbourne Victoria Australia
| | - Viliami Tangi
- Department of Surgery Ministry of Health Nuku'alofa Tonga
| | - Glenn D. Guest
- Department of Surgery Deakin University and Barwon Health Geelong Victoria Australia
- RACS Global Health Royal Australasian College of Surgeons Melbourne Victoria Australia
- Department of Surgery Epworth Geelong Geelong Victoria Australia
| | - Eddie McCaig
- Department of Surgery Fiji National University Suva Fiji
| | - Kiki Maoate
- Department of Surgery Epworth Geelong Geelong Victoria Australia
- Department of Surgery University of Otago Christchurch New Zealand
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Nagra S, Kaur B, Singh S, Tangi V, Mccaig E, Stupart D, Moore EM, Meara JG, Guest GD, Watters DA. How will increasing surgical volume affect mortality in the Pacific, Papua New Guinea and Timor Leste? ANZ J Surg 2020; 90:1915-1919. [PMID: 32419325 DOI: 10.1111/ans.15989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 04/12/2020] [Accepted: 04/23/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nine South Pacific nations, Papua New Guinea and Timor Leste, have collaborated to report and publish their surgical metrics as recommended by the Lancet Commission on Global Surgery (LCoGS). Currently, these countries experience about 750 postoperative deaths per year, representing 1% of crude mortality in the region. Given that more than 400 000 annual procedures are needed in the nine nations to reach the LCoGS target of 5000/100 000, we aimed to calculate the potential contribution of perioperative mortality to national mortality where these procedures are performed. METHODS We utilized reported surgical metrics with current rates for surgical volume (SV) and perioperative mortality (POMR), as well as World Bank/WHO mortality statistics, to predict the likely impact of surgical scale-up to recommended targets by 2030. We tested correlations between SV and POMR in countries from our region using Pearson's r statistic. Funnel plots were used to evaluate the dataset for outliers. RESULTS Surgical scale up would result in perioperative mortality contributing on average to 3.3% of all national crude mortality. This prediction assumes POMR stays the same, which is challenging to predict. In our region countries that achieved the LCoGS target (n = 5) had a lower POMR than countries that did not (n = 8). CONCLUSIONS Surgical volumes in the South Pacific region must increase to meet the LCoGS target. Postoperative mortality as a proportion of all mortality may increase with the surgical scale up, however, the overall number of premature deaths is expected to reduce with better access to timely and safe surgical care.
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Affiliation(s)
- Sonal Nagra
- Deakin University, Melbourne, Victoria, Australia.,Barwon Health, Melbourne, Victoria, Australia
| | | | | | | | | | - Douglas Stupart
- Deakin University, Melbourne, Victoria, Australia.,Barwon Health, Melbourne, Victoria, Australia
| | - Eileen M Moore
- Deakin University, Melbourne, Victoria, Australia.,Barwon Health, Melbourne, Victoria, Australia
| | | | - Glenn D Guest
- Deakin University, Melbourne, Victoria, Australia.,Barwon Health, Melbourne, Victoria, Australia
| | - David A Watters
- Deakin University, Melbourne, Victoria, Australia.,Barwon Health, Melbourne, Victoria, Australia
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Pittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Trop Med Int Health 2020; 25:824-833. [PMID: 32324928 DOI: 10.1111/tmi.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Reliable referral systems are essential to the functionality and efficiency of the wider health care system in low- and middle-income countries (LMICs), particularly in surgery as the disease burden is growing while resources remain constrained and unevenly distributed. Yet, this is a critically under-researched area. This study aimed to provide a comprehensive assessment of surgical referral systems in a LMIC, Malawi, with a view to shedding light on this important aspect of public health and share lessons learned. METHODS We conducted a prospective analysis of all inter-hospital referrals received at Queen Elizabeth Central Hospital (QECH) in 2014-2015. A subsample of 255 referrals was assessed by three independent surgical experts against necessity and quality of the transfer to identify any inefficiencies in the referral process. RESULTS 1317 patients were referred to QECH during the study period (average 53/month), 80% sent by government district hospitals. One in 3 cases were referred unnecessarily, many of which could have been managed locally. In 82% of cases, there was no communication with QECH prior to referral, 41% had incorrect/incomplete diagnosis by the referring clinicians and 39% of referrals were not timely. CONCLUSIONS Our findings provide the first evidence on the state of the surgical referral system in Malawi and contribute to building the body of knowledge necessary to inform system improvements. Responses should include reducing inappropriate use of specialist care and ensuring better care pathways for surgical patients, especially in rural areas, where access to specialist expertise is not available at present.
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Affiliation(s)
- Chiara Pittalis
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Nijmegen International Centre for Health Systems Research and Education, Radboud University, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Eric Borgstein
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Abstract
There is a need for relevant, valid, and practical metrics to better quantify both need and progress in global pediatric surgery and for monitoring systems performance. There are several existing surgical metrics in use, including disability-adjusted life years (DALYs), surgical backlog, effective coverage, cost-effectiveness, and the Lancet Commission on Global Surgery indicators. Most of these have, however, not been yet applied to children's surgery, leaving therefore significant data gaps in the burden of disease, infrastructure, human resources, and quality of care assessments in the specialty. This chapter reviews existing global surgical metrics, identifies settings where these have been already applied to children's surgery, and highlights opportunities for further inquiry in filling the knowledge gaps. Directing focused, intentional knowledge translation efforts in the identified areas of deficiency will foster the maturation of global pediatric surgery into a solid academic discipline able to contribute directly to the cause of improving the lives of children around the world.
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The Impact of Implementing a Comprehensive Surgical Program on the Surgical Cohort at a Remote Referral Hospital in Southeastern Liberia. World J Surg 2019; 44:680-688. [PMID: 31722076 DOI: 10.1007/s00268-019-05277-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Liberia has an extreme health workforce shortage, particularly with respect to surgery. JJ Dossen Memorial (JJD) is a public referral hospital supported by Partners in Health. METHODS We designed and implemented a comprehensive surgical program at JJD. Using case logs, clinic records, and transfer data between December 2016 and April 2018, we evaluated the impact of this program on the surgical cohort and examined temporal trends in patient origin using GIS. RESULTS The mean number of cases per day increased from 1.7 ± 1.0 to 2.4 ± 1.3 (p < 0.001). The proportion of females decreased from 59.8 to 51.2% (p = 0.03), and mean age decreased from 32.2 ± 14.2 to 29.8 ± 16.5 years (p = 0.05). The proportion of elective procedures, C-sections, and laparotomies did not change, but hernias decreased from 28.9 to 22.3% (p = 0.05) and oncologic surgery increased from 0.0 to 5.6% (p < 0.001). A smaller proportion of cases were performed under local or general anesthesia, while a larger proportion were performed under spinal and sedation (p < 0.001). Outward surgical transfers decreased from 13.1 to 5.4% (p < 0.001). The mean distance from patient residence to JJD increased from 24.8 ± 29.0 to 32.3 ± 41.9 km (p = 0.01). GIS analysis revealed a broader distribution of patient origins. CONCLUSIONS Surgeons are desperately needed in referral hospitals to address the large burden of surgical disease in Liberia. The implementation of a surgical program significantly changed the demographics of the surgical cohort and the surgical case mix. Our data can inform training for health workers in Liberia and elsewhere.
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Fierro JJ, Cave B, Khouzam RN. P2Y12 inhibitors: do they increase cancer risk? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:409. [PMID: 31660308 DOI: 10.21037/atm.2019.07.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Treatment with dual antiplatelet therapy (DAPT), typically combining a P2Y12 inhibitor with aspirin, is the standard of care for the prevention of coronary stent thrombosis, especially post revascularization and in the setting of acute coronary syndromes (ACS). Determining the appropriate duration has been debated as prolonged courses have been associated with reduced thrombotic complications. Despite proven benefit, there have been reports of a potential cancer risk associated with DAPT following the FDA's review of the TRITON-TIMI 38 trial and the DAPT trial. The latter revealed an increased risk of non-cardiovascular death, which was driven by more bleeding and cancer-related deaths. This further clouds the decision if longer courses of DAPT should be recommended. Several trials and meta-analyses have been conducted to further review this cancer risk with P2Y12 inhibitors. This manuscript intends to evaluate current literature to determine if there is a risk of cancer for patients on DAPT and its consequences in the management of cardiovascular disease.
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Affiliation(s)
- Joseph J Fierro
- Department of Pharmacy, James A. Haley Veterans Hospital, Tampa, FL, USA
| | - Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Rami N Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
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Bagguley D, Fordyce A, Guterres J, Soares A, Valadares E, Guest GD, Watters D. Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital. BMJ Open 2019; 9:e029812. [PMID: 31446414 PMCID: PMC6720142 DOI: 10.1136/bmjopen-2019-029812] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Our objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures. SETTING The study was conducted at Timor Leste's national referral hospital in Dili, the country's capital. PARTICIPANTS All patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES Data pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework. RESULTS Fifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05). CONCLUSIONS Substantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.
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Affiliation(s)
- Dominic Bagguley
- Department of Surgery, Northern Health, Epping, Victoria, Australia
| | - Andrew Fordyce
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Jose Guterres
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Alito Soares
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Edgar Valadares
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Glenn Douglas Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - David Watters
- Royal Australasian College of Surgeons, Geelong, Victoria, Australia
- Surgery, Deakin University Faculty of Health, Geelong, Victoria, Australia
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Vissoci JRN, Ong CT, de Andrade L, Rocha TAH, da Silva NC, Poenaru D, Smith ER, Rice HE. Disparities in surgical care for children across Brazil: Use of geospatial analysis. PLoS One 2019; 14:e0220959. [PMID: 31430312 PMCID: PMC6701804 DOI: 10.1371/journal.pone.0220959] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 07/26/2019] [Indexed: 11/22/2022] Open
Abstract
Background Health systems for surgical care for children in low- and middle-income countries remain poorly understood. Our goal was to characterize the delivery of surgical care for children across Brazil and to identify associations between surgical resources and childhood mortality. Methods We performed a cross-sectional, ecological study to analyze surgical care for children in the public health system (Sistema Único de Saúde) across Brazil from 2010 to 2015. We collected data from several national databases, and used geospatial analysis (two-step floating catchment, Getis-Ord-Gi analysis, and geographically weighted regression) to explore relationships between infrastructure, workforce, access, procedure rate, under-5 mortality rate (U5MR), and perioperative mortality rate (POMR). Results A total of 246,769 surgical procedures were performed in 6,007 first level/ district hospitals and 491 referral hospitals across Brazil over the study period. The surgical workforce is distributed unevenly across the country, with 0.13–0.26 pediatric surgeons per 100,000 children in the poorer North, Northeast and Midwest regions, and 0.6–0.68 pediatric surgeons per 100,000 children in the wealthier South and Southeast regions. Hospital infrastructure, procedure rate, and access to care is also unequally distributed across the country, with increased resources in the South and Southeast compared to the Northeast, North, and Midwest. The U5MR varies widely across the country, although procedure-specific POMR is consistent across regions. Increased access to care is associated with lower U5MR across Brazil, and access to surgical care differs by geographic region independent of socioeconomic status. Conclusions There are wide disparities in surgical care for children across Brazil, with infrastructure, manpower, and resources distributed unevenly across the country. Access to surgical care is associated with improved U5MR independent of socioeconomic status. To address these disparities, policy should direct the allocation of surgical resources commensurate with local population needs.
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Affiliation(s)
- João R. N. Vissoci
- Duke Global Health Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Emergency Medicine, Duke University Medical Center, Durham, NC, United States of America
- Division of Global Neurosurgery and Neurology, Duke University Medical Center, Durham, NC, United States of America
- Graduate program in Health Sciences, State University of Maringá, Maringá, PR, Brazil
| | - Cecilia T. Ong
- Duke Global Health Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, United States of America
| | - Luciano de Andrade
- Graduate program in Health Sciences, State University of Maringá, Maringá, PR, Brazil
| | - Thiago Augusto Hernandes Rocha
- Federal University of Minas Gerais, School of Economics, Center of Post-Graduate and Research in Administration, Belo Horizonte, Minas Gerais, Brazil
| | - Nubia Cristina da Silva
- Federal University of Minas Gerais, Faculty of Economics, Observatory of Human Resources in Health, Belo Horizonte, Minas Gerais, Brazil
| | - Dan Poenaru
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Emily R. Smith
- Duke Global Health Institute, Duke University Medical Center, Durham, NC, United States of America
- Robbins College of Health and Human Services, Baylor University, Waco, TX, United States of America
| | - Henry E. Rice
- Duke Global Health Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, United States of America
- * E-mail:
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Herrera-Almario G, Hanna J, Peck G. Global Surgical Oncology Efforts Using a Common Language. Ann Surg Oncol 2019; 26:877-878. [PMID: 31399816 DOI: 10.1245/s10434-019-07682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Gabriel Herrera-Almario
- School of Medicine, University of los Andes, Bogotá, Colombia. .,Department of Surgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia.
| | - Joseph Hanna
- Department of Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Gregory Peck
- Department of Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Cooper MG, Morriss WW, Stone M, Merry AF. Global health and anaesthesia: An exciting time. Anaesth Intensive Care 2019; 47:322-325. [DOI: 10.1177/0310057x19861975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael G Cooper
- The Children's Hospital at Westmead, Sydney, Australia
- St George Hospital, Sydney, Australia
- World Federation of Societies of Anaesthesiologists, London, UK
| | - Wayne W Morriss
- World Federation of Societies of Anaesthesiologists, London, UK
- Christchurch Hospital, Christchurch, New Zealand
- University of Otago, Otago, New Zealand
| | | | - Alan F Merry
- St George Hospital, Sydney, Australia
- World Federation of Societies of Anaesthesiologists, London, UK
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Allanson ER, Powell A, Bulsara M, Lee HL, Denny L, Leung Y, Cohen P. Morbidity after surgical management of cervical cancer in low and middle income countries: A systematic review and meta-analysis. PLoS One 2019; 14:e0217775. [PMID: 31269024 PMCID: PMC6608935 DOI: 10.1371/journal.pone.0217775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 05/19/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To investigate morbidity for patients after the primary surgical management of cervical cancer in low and middle-income countries (LMIC). METHODS The Pubmed, Cochrane, the Cochrane Central Register of Controlled Trials, Embase, LILACS and CINAHL were searched for published studies from 1st Jan 2000 to 30th June 2017 reporting outcomes of surgical management of cervical cancer in LMIC. Random-effects meta-analytical models were used to calculate pooled estimates of surgical complications including blood transfusions, ureteric, bladder, bowel, vascular and nerve injury, fistulae and thromboembolic events. Secondary outcomes included five-year progression free (PFS) and overall survival (OS). FINDINGS Data were available for 46 studies, including 10,847 patients from 11 middle income countries. Pooled estimates were: blood transfusion 29% (95%CI 0.19-0.41, P = 0.00, I2 = 97.81), nerve injury 1% (95%CI 0.00-0.03, I2 77.80, P = 0.00), bowel injury, 0.5% (95%CI 0.01-0.01, I2 = 0.00, P = 0.77), bladder injury 1% (95%CI 0.01-0.02, P = 0.10, I2 = 32.2), ureteric injury 1% (95%CI 0.01-0.01, I2 0.00, P = 0.64), vascular injury 2% (95% CI 0.01-0.03, I2 60.22, P = 0.00), fistula 2% (95%CI 0.01-0.03, I2 = 77.32, P = 0.00,), pulmonary embolism 0.4% (95%CI 0.00-0.01, I2 26.69, P = 0.25), and infection 8% (95%CI 0.04-0.12, I2 95.72, P = 0.00). 5-year PFS was 83% for laparotomy, 84% for laparoscopy and OS was 85% for laparotomy cases and 80% for laparoscopy. CONCLUSION This is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in LMIC, which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation.
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Affiliation(s)
- Emma R. Allanson
- Division of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Western Australia, Crawley, WA, Australia
| | - Aime Powell
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Hong Lim Lee
- Obstetrics and Gynaecology, Joondalup Health Campus, Joondalup, WA, Australia
| | - Lynette Denny
- Department Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council Gynaecological Cancer Research Centre, Cape Town, South Africa
| | - Yee Leung
- Division of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Western Australia, Crawley, WA, Australia
| | - Paul Cohen
- Division of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Western Australia, Crawley, WA, Australia
- Department of Gynaecological Oncology, Bendat Family Comprehensive Cancer Centre, St John of God, Subiaco, WA, Australia
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Tefera A, Lutge E, Sartorius B, Clarke D. The Operative Output of District Hospitals in KwaZulu-Natal Province is Heavily Skewed Toward Obstetrical Care. World J Surg 2019; 43:1653-1660. [DOI: 10.1007/s00268-019-04985-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stenberg E, Ottosson J, Szabo E, Näslund I. Comparing Techniques for Mesenteric Defects Closure in Laparoscopic Gastric Bypass Surgery—a Register-Based Cohort Study. Obes Surg 2019; 29:1229-1235. [DOI: 10.1007/s11695-018-03670-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Watters DA, McCaig E, Nagra S, Kevau I. Surgical training programmes in the South Pacific, Papua New Guinea and Timor Leste. Br J Surg 2019; 106:e53-e61. [DOI: 10.1002/bjs.11057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 10/26/2018] [Indexed: 11/07/2022]
Abstract
Abstract
Background
There is a surgical workforce shortage in Papua New Guinea (PNG), the Pacific and Timor Leste. Previously, Pacific Island specialists who trained overseas tended to migrate.
Methods
A narrative review was undertaken of the training programmes delivered through the University of Papua New Guinea and Fiji National University's Fiji School of Medicine, and support provided through Australian Aid and the Royal Australasian College of Surgeons (RACS), including scholarships and visiting medical teams.
Results
The Fiji School of Medicine MMed programme, which commenced in 1998, has 39 surgical graduates. Sixteen of 22 Fijians, nine of ten Solomon Islanders and four of five in Vanuatu currently reside and/or work in-country. Surgical training in PNG began in 1975, and now has 104 general surgical graduates, 11 of whom originate from the Pacific Islands or Timor Leste. The PNG retention rate of local graduates is 97 per cent, with 80 per cent working in the public sector. Twenty-two surgeons have also undertaken subspecialty training. Timor Leste has trained eight surgical specialists in PNG, Fiji, Indonesia or Malaysia. All have returned to work in-country. The RACS has managed Australian Aid programmes, providing pro bono visiting medical teams to support service delivery and, increasingly, capacity building in the region. The RACS has funded scholarships and international travel grants to further train or sustain the surgical specialists.
Conclusion
The local MMed programmes have been highly successful in retaining specialists in the region. Partnerships with Australian Aid and RACS have been effective in ensuring localization of the faculty and ongoing professional development.
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Affiliation(s)
- D A Watters
- Deakin University and Barwon Health, Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - E McCaig
- Fiji School of Medicine, Fiji National University, Suva, Fiji
| | - S Nagra
- Deakin University and Barwon Health, Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - I Kevau
- Department of Surgery, Port Moresby General Hospital, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
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Peck GL, Hanna JS. The National Surgical, Obstetric, and Anesthesia Plan (NSOAP): Recognition and Definition of an Empirically Evolving Global Surgery Systems Science Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa". Int J Health Policy Manag 2018; 7:1151-1154. [PMID: 30709092 PMCID: PMC6358650 DOI: 10.15171/ijhpm.2018.87] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/02/2018] [Indexed: 11/23/2022] Open
Abstract
In 2015, the Lancet Commission on Global Surgery (LCoGS) working groups developed a National Surgical, Obstetric, and Anesthesia Plan (NSOAP) framework to guide national surgical system development globally predicated on six data points (indicators) which can assess surgical systems. Zambia as well as other subSaharan Africa (SSA) countries have forged ahead in designing and implementing interventions based on LCoGS indicators collected to inform NSOAP. Concurrently, the Zambian team and others have recognized the need for rigorous scientific inquiry to assess and iteratively improve upon the NSOAP process and outputs. Based on the Zambian experience, as well as that of ours in Colombia, we have identified "core principles" through convergent works which inform a scientific framework through which NSOAP can be evaluated. We propose that when contextualized, participatory action research (PAR) and dissemination and implementation science are methodologies upon which a robust framework can be developed to achieving objective and iterative NSOAP evaluation, and ultimately universal health coverage as envisioned by the World Health Organization (WHO).
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Affiliation(s)
- Gregory L Peck
- Department of Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Joseph S Hanna
- Department of Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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