Defining the critical pediatric surgical workforce density for improving surgical outcomes: a global study

PURPOSE

Low- and middle-income countries (LMICs) have only 19% of the global surgical workforce yet see 80% of worldwide deaths from noncommunicable diseases. We aimed to interrogate the correlation between pediatric surgical workforce density (PSWD) and survival from pediatric surgical conditions worldwide.

METHODS

A systematic review of online databases identified outcome studies for key pediatric surgical conditions (gastroschisis, esophageal atresia, intestinal atresia, and typhoid perforation) as well as PSWD data across low-income (LICs), middle-income (MICs), and high-income countries (HICs). PSWD was expressed as the number of PSs/million children under 15 years of age and we correlated this to surgical outcomes for our case series.

RESULTS

PSWD ranged between zero (Burundi, The Gambia, and Mauritania) and 125.2 (Poland) across 86 countries. Outcomes for at least one condition were obtained in 61 countries: 50 outcomes in HICs, 52 in MICs and 8 in LICs. The mean survival in our case series was 42.3%, 69.4% and 91.6% for LICs, MICs, and HICs, respectively. A PSWD ≥4 PSs/million children under 15 years of age significantly correlated to odds of survival ≥80% (OR 16.8, p < 0.0001, 95% CI 5.66-49.88). Specifically in the studied LICs and MICs, increasing the PSWD to 4 would require training 1427 additional surgeons.

CONCLUSION

Using a novel approach, we have established a benchmark for the scale-up of pediatric surgical workforce, which may support broader efforts to reduce childhood deaths from congenital disease.

LEVELS OF EVIDENCE

2c - Outcomes Research.

A population-based study of chronic hepatitis C in immigrants and non-immigrants in Quebec, Canada

BACKGROUND

Immigrants originating from intermediate and high HCV prevalence countries may be at increased risk of exposure to hepatitis C infection (HCV) in their countries of origin, however they are not routinely screened after arrival in most low HCV prevalence host countries. We aimed to describe the epidemiology of HCV in immigrants compared to the Canadian born population.

METHODS

Using the reportable infectious disease database linked to the landed immigration database and several provincial administrative databases, we assembled a cohort of all reported cases of HCV in Quebec, Canada (1998-2008). Underlying co-morbidities were identified in the health services databases. Stratum specific rates of reported cases/100,000, rate ratios (RRs) and trends over the study period were estimated.

RESULTS

A total of 20,862 patients with HCV were identified, among whom 1922 (9.2%) were immigrants. Immigrants were older and diagnosed a mean of 9.8 ± 7 years after arrival. The Canadian born population was more likely to have behavior co-morbidities (problematic alcohol or drug use) and HIV co-infection. Immigrants from Sub-Saharan Africa, Asia and Eastern Europe had the highest HCV reported rates with RRs compared to non-immigrants ranging from 1.5 to 1.7. The age and sex adjusted rates decreased by 4.9% per year in non-immigrants but remained unchanged in immigrants. The proportion of HCV occurring in immigrants doubled over the study period from 5 to 11%.

CONCLUSIONS

Immigrants from intermediate and high HCV prevalence countries are at increased risk for HCV and had a mean delay in diagnosis of almost 10 years after arrival suggesting that they may benefit from targeted HCV screening and earlier linkage to care.