Global surgical initiatives to reduce the surgical burden of disease

Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project

In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Geospatial Mapping of International Neurosurgical Partnerships and Evaluation of Extent of Training and Engagement

OBJECTIVE

To evaluate the presence, extent, and temporality of transnational neurosurgical partnerships, to understand and inform measures to address neurosurgical deficiencies in low- and middle-income countries (LMICs).

METHODS

A Web search was conducted to identify actors from high-income countries (HICs) participating in neurosurgical delivery and/or capacity-building with LMICs from 2010 to 2018. Descriptive data on current neurosurgical partnerships were collected from published case reports, literature reviews, reports from academic institutions, and information on stakeholder Web pages. The level of training and engagement of each partnership was separately graded based on prespecified criteria, in which grade 3 represented partnerships that have most extensive training and engagement, and grade 1, the least extent. Data were analyzed using descriptive statistics and geospatially depicted on ArcMap GIS software.

RESULTS

A total of 123 unique HIC-LMIC partnerships were described. Of these partnerships, 85 (69%) are derived from HICs in North America, followed by Europe, with 23 (19%). The most common LMIC partners were from Africa (n = 56, 45%) and Latin America (n = 32, 26%). In addition, most partnerships provided services in pediatric neurosurgery (88%). The most frequent engagement classifications were grade 2 (35%) or 1 (36%). Similarly, for training, the most common classifications were grade 1 (40%) or 2 (30%).

CONCLUSIONS

A robust network of HIC-LMIC partnerships exists with varying degrees of engagement and training activities. Several regions are particularly suitable for growth and development. Systematic consolidation and indexing of transnational neurosurgical partnerships aim to enhance resource allocation and present opportunities for future partnership.

The Impact of Regulation on Resident International Experiences: A Multispecialty Review of Current ACGME and RRC Standards for International Electives

OBJECTIVE

Partnerships between industrialized and nonindustrialized institutions have accelerated the growth of surgery and surgical subspecialties in the developing world. The results of these partnerships include qualitive and quantitative clinical benefits as well as unique opportunities for the development of resident clinical and surgical skills. Surveys demonstrate surgical residents have a strong interest in international humanitarian work. Ultimately, the opportunities for residents to participate in international work as a program elective are subject to the regulations of the Accreditation Council of Graduate Medical Education (ACGME) and the Residency Review Committees (RRC) that govern residency accreditation. The regulations from accreditation bodies serve to ensure resident safety and educational value; however, excessive regulation can be a major hurdle to programs initiating international electives. Though the regulations are publicly available there is no comparison of various subspecialty standards in the literature. Nor is there a review of how standards affect resident education and safety or the ability for individual residencies to initiate international electives.

METHODS

The regulations as defined by the ACGME and RRC of 7 surgical specialties (general, plastics, neurological, otolaryngology, ophthalmology, orthopedics, and urology) were reviewed from the available data on the ACGME website.

RESULTS

The regulations demonstrate a great deal of diversity in how the specialties regulate international work. On one end of spectrum, 2 programs have robust guidelines and an approval process that ultimately allows residents to claim credit for cases performed internationally. On the other end, the regulations for some programs make little mention of international rotations other than to deny that cases be counted for credit.

CONCLUSIONS

ACGME regulations have a strong effect on resident experiences while training internationally. Ideally, regulations should ensure resident safety and education without being overly cumbersome and preventing smaller programs from developing international electives. This would allow more residents access to the educational benefits available through meaningful international electives. Beyond the educational benefits, resident participation in international training creates a foundation for continued international work throughout their career. This could, in turn, increase the number of surgeons willing to travel internationally and bolster the development and consistency of international humanitarian e`fforts.

Economic Analyses of Surgical Trips to the Developing World: Current Concepts and Future Strategies

The surgical burden of disease disproportionately affects individuals living in the developing world. In response, the surgical community has increased efforts to provide care to patients in these countries during short-term surgical trips. This article (1) summarizes the current concepts used in the economic evaluation of surgical outreach and (2) presents a conceptual model to describe the ideal approach to performing an economic analysis of surgical interventions in developing countries. This model may ensure that policymakers are provided with information to decrease cost and improve the access to specialty surgery in the developing world.

Update on the management of craniomaxillofacial trauma in low-resource settings

PURPOSE OF REVIEW

Craniomaxillofacial (CMF) trauma is a common cause of global morbidity and mortality. Although in high resource settings the management of CMF trauma has improved substantially over the past several decades with internal rigid fixation technology; these advancements have remained economically unviable and have not yet reached low and middle-income countries (LMICs) en masse. The purpose of this review is to discuss the current management of CMF injuries in low-resource settings.

RECENT FINDINGS

Trauma injuries remain a global epidemic with head and neck injuries among the most common. CMF trauma injuries largely occur in LMICs, with motor vehicle trauma being a common cause. Patients present in a delayed fashion which increases complications. Diagnostic methods are often limited to plain radiographs as computed tomography is not always available. In low-resource settings, CMF trauma continues to be treated primarily by closed reduction, maxillomandibular fixation, and transosseous wiring, yielding acceptable results through affordable methods. With the advent of less expensive plating systems, internal fixation with plates and screws are gradually finding their place in the management of facial trauma in low-resource settings. A shortage of CMF surgeons in LMICs is a recognized problem and is being addressed by targeted curricula.

SUMMARY

CMF trauma is a major cause of morbidity and mortality globally that remains poorly addressed. Currently, conventional methods of treating CMF trauma in low-resource settings have evolved to meet resource constraints. The education of CMF surgeons remains a key leverage point in improving CMF trauma care globally.

Global incidence of brain and spinal tumors by geographic region and income level based on cancer registry data

While obtaining accurate estimates of tumor incidence volume is a difficult technical problem because it requires collating and analyzing data from dozens of world-wide sources curated under different conditions, our study aims to determine the global incidence of brain and spinal tumors. We analyzed 207 tumor registries on five continents, and calculated age-standardized rates to compare tumor incidence between geographic regions and income levels. Based on data available in current cancer registries, the apparent global incidence of malignant brain tumors was 4.25 cases per 100,000 person-years (95% CI [4.21-4.29]), and varied by region from 6.76 [6.71-6.80] in Europe to 2.81 [2.64-2.99] in Africa. Incidence also varied by World Bank income group, ranging from 6.29 [6.26-6.32] cases per 100,000 in high income countries (HICs), to 4.81 [4.77-4.86] in low and middle-income countries (LMICs). Malignant spinal tumors were much less frequent globally (0.098 [0.093-0.104]) and varied similarly by region and income group. The incidence of brain and spinal tumors varies by region and income group, although case ascertainment bias driven by limited resources in low income regions likely plays a role in variance. The burden of neurosurgical disease in LMICs is large, and similar in scale to HICs.

[Global Health Care]

Global health data are changing rapidly and they show large regional differences. The incidence and mortality of infectious diseases can be reduced by successes in medical research, national health plans and large financial expenditure. In contrast, illnesses that are caused by unhealthy and changing environmental and living conditions are on the rise. The Global Health Care concept is a cross-sectoral master plan taking into account that worldwide health cannot be established by healthcare workers alone. It was designed to have a lasting impact on the cause of disease through global health programs, of which improved medical services, including essential surgical treatment need to play a key role.

Cost-Effectiveness Analysis of Humanitarian Hand Surgery Trips According to WHO-CHOICE Thresholds

PURPOSE

Hand surgery outreach programs to low- and middle-income countries (LMICs) provide much-needed surgical care to the underserved populations and education to local providers for improved care. The cost-effectiveness of these surgical trips has not been studied despite a long history of such efforts. This study aimed to examine the economic impact of hand surgery trips to LMICs using data from the Touching Hands Project and ReSurge International. We hypothesized that hand surgery outreach would be cost-effective in LMICs.

METHODS

We analyzed data on the cost of each trip and the surgical procedures performed. Using methods from the World Health Organization (WHO-Choosing Interventions That Are Cost-Effective [WHO-CHOICE]), we determined whether the procedures performed during the outreach trips would be cost-effective.

RESULTS

For the 14 hand surgery trips, 378 patients received surgical treatment. Trips varied in the country where interventions were provided, the number of patients served, the severity of the conditions, and the total cost. The cost per disability-adjusted life-year averted ranged from United States (US)$222 to $1,525, all of which were very cost-effective according to WHO-CHOICE thresholds. The cost-effectiveness of global hand surgery was comparable to that of other medical interventions such as multidrug-resistant tuberculosis treatment in similar regions. We also identified a lack of standardized record keeping for these surgical trips.

CONCLUSIONS

Hand surgeries performed in LMICs are cost-effective based on WHO-CHOICE criteria. However, a standardized record-keeping method is needed for future research and longitudinal comparison. Understanding the economic impact of hand surgery global outreach is important to the success and sustainability of these efforts, both to allocate resources effectively and to identify areas for improvement.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

General Thoracic Surgery in Rwanda: An Assessment of Surgical Volume and of Workforce and Material Resource Deficits

BACKGROUND

Benchmarking operative volume and resources is necessary to understand current efforts addressing thoracic surgical need. Our objective was to examine the impact on thoracic surgery volume and patient access in Rwanda following a comprehensive capacity building program, the Human Resources for Health (HRH) Program, and thoracic simulation training.

METHODS

A retrospective cohort study was conducted of operating room registries between 2011 and 2016 at three Rwandan referral centers: University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and King Faisal Hospital. A facility-based needs assessment of essential surgical and thoracic resources was performed concurrently using modified World Health Organization forms. Baseline patient characteristics at each site were compared using a Pearson Chi-squared test or Kruskal-Wallis test. Comparisons of operative volume were performed using paired parametric statistical methods.

RESULTS

Of 14,130 observed general surgery procedures, 248 (1.76%) major thoracic cases were identified. The most common indications were infection (45.9%), anatomic abnormalities (34.4%), masses (13.7%), and trauma (6%). The proportion of thoracic cases did not increase during the HRH program (2.07 vs 1.78%, respectively, p = 0.22) or following thoracic simulation training (1.95 2013 vs 1.44% 2015; p = 0.15). Both university hospitals suffer from inadequate thoracic surgery supplies and essential anesthetic equipment. The private hospital performed the highest percentage of major thoracic procedures consistent with greater workforce and thoracic-specific material resources (0.89% CHUK, 0.67% CHUB, and 5.42% KFH; p < 0.01).

CONCLUSIONS AND RELEVANCE

Lack of specialist providers and material resources limits thoracic surgical volume in Rwanda despite current interventions. A targeted approach addressing barriers described is necessary for sustainable progress in thoracic surgical care.

Pediatric Urology and Global Health: Why Now and How to Build a Successful Global Outreach Program

Global health programs in pediatric surgical fields are needed more than ever to ease the global burden of congenital anomalies. Pediatric urology is an ideal field for global health programs because genitourinary diseases account for a large proportion of congenital diseases and access to surgical subspecialists is lacking in most low- and middle-income countries. By following several key guidelines with particular emphasis on team building, visiting and local team collaboration, long-term commitment, and surgical training, global health partnerships can lead to a sustainable model for increasing surgical capacity.

Evaluation of Resources Necessary for Provision of Trauma Care in Botswana: An Initiative for a Local System

BACKGROUND

Developing countries face the highest incidence of trauma, and on the other hand, they do not have resources for mitigating the scourge of these injuries. The World Health Organization through the Essential Trauma Care (ETC) project provides recommendations for improving management of the injured and building up of systems that are effective in low-middle-income countries (LMICs). This study uses ETC project recommendations and other trauma-care guidelines to evaluate the current status of the resources and organizational structures necessary for optimal trauma care in Botswana; an African country with relatively good health facilities network, subsidized public hospital care and a functioning Motor Vehicle Accident fund covering road traffic collision victims.

METHOD

A cross-sectional descriptive design employed convenience sampling for recruiting high-volume trauma hospitals and selecting candidates. A questionnaire, checklist, and physical verification of resources were utilized to evaluate resources, staff knowledge, and organization-of-care and hospital capabilities. Results are provided in plain descriptive language to demonstrate the findings.

RESULTS

Necessary consumables, good infrastructure, adequate numbers of personnel and rehabilitation services were identified all meeting or exceeding ETC recommendations. Deficiencies were noted in staff knowledge of initial trauma care, district hospital capability to provide essential surgery, and the organization of trauma care.

CONCLUSION

The good level of resources available in Botswana may be used to improve trauma care: To further this process, more empowering of high-volume trauma hospitals by adopting trauma-care recommendations and inclusive trauma-system approaches are desirable. The use of successful examples on enhanced surgical skills and capabilities, effective trauma-care resource management, and leadership should be encouraged.

Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital

BACKGROUND

Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility-based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes.

METHODS

An electronic, tablet-based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in-patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in-patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes.

RESULTS

A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity.

CONCLUSION

The establishment of hospital-based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs.

Surgical volunteerism or voluntourism - Are we doing more harm than good?

The significant rise in the number of international health electives undertaken by medical students and doctors in the US, Canada and UK reflects acknowledgement of the inter-connected nature of these challenges to health systems and the drive to help solve them. However, the next generation of international volunteers often operate under a conflicting duality: whilst many of their role models have devoted their lives to global health following a similar volunteering experience, there are pervasive ethical problems associated with transient global health work that must be identified and addressed to ensure positive outcomes for all parties involved. The majority of populations served by shortterm surgical volunteer trips are vulnerable communities; this raises ethical questions such as the lack of informed consent, use of unauthorised photos for marketing, and practicing new procedural techniques. 2 Whilst there exist various models that can be used to facilitate effective international health electives, there is a lack of stringent monitoring and enforcement both on the part of healthcare institutions deploying volunteers as well as recipient bodies in LMICS. Well-organised programmes prevent cases of 'poor care given to poor people' as medical students and doctors are expected to act in their patients' best interests as they would do in their home country. As clinician interest in global health projects continue to rise, too-common trainee naivety - while rooted in goodwill - must be supplanted by adequate training, ethical coherence, and cultural fluency. The onus lies on medical schools and healthcare bodies endorsing international electives to ensure that individuals are appropriately prepared and only travel through programmes that are able to demonstrate that they meet the necessary requirements and follow guidelines to avoid doing more harm than good.

Are the SDGs leaving safer surgical systems behind?

The World Health Organisation (WHO) has set out its new aims for the post-2015 global agenda in the form of the Sustainable Development Goals (SDGs). Discussions around the historically neglected role of emergency and essential surgical interventions in global health has attracted widespread attention with the help of well-timed, high-profile reports including the Lancet Commission for Global Surgery [1]. The case for promoting safe surgery is clear with evidence suggesting that at least two-thirds of the years of life lost globally will be attributed to surgical conditions by 2025 [1]. In 2010 alone, almost 17 million lives, and more than 70 million disability-adjusted life years (DALYs) were lost due to surgically treatable conditions [1]. A central component of the SDGs is its renewed focus on health as a human right in the form of Universal Health Coverage (UHC). However, there are doubts as to how nations will be able to keep the 'promise of leaving no-one behind' without explicit reference to global surgery within the SDG framework [2].

Postoperative adverse outcomes among physicians receiving major surgeries: A nationwide retrospective cohort study

Outcomes after surgeries involving physicians as patients have not been researched. This study compares postoperative adverse events between physicians as surgical patients and nonhealth professional controls.Using reimbursement claims data from Taiwan's National Health Insurance Program, we conducted a matched retrospective cohort study of 7973 physicians as surgical patients and 7973 propensity score-matched nonphysician controls receiving in-hospital major surgeries between 2004 and 2010. We compared postoperative major complications, length of hospital stay, intensive care unit (ICU), medical expenditure, and 30-day mortality.Compared with nonphysician controls, physicians as surgical patients had lower adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of postoperative deep wound infection (OR 0.63, 95% CI 0.40-0.99; P < 0.05), prolonged length of stay (OR 0.68, 95% CI 0.62-0.75; P < 0.0001), ICU admission (OR 0.74, 95% CI 0.66-0.83; P < 0.0001), and increased medical expenditure (OR 0.80, 95% CI 0.73-0.88; P < 0.0001). Physicians as surgical patients were not associated with 30-day in-hospital mortality after surgery. Physicians working at medical centers (P < 0.05 for all), dentists (P < 0.05 for all), and those with fewer coexisting medical conditions (P < 0.05 for all) had lower risks for postoperative prolonged length of stay, ICU admission, and increased medical expenditure.Although our study's findings suggest that physicians as surgical patients have better outcomes after surgery, future clinical prospective studies are needed for validation.

Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa

INTRODUCTION

Traumatic injuries account for the greatest portion of global surgical burden particularly in low- and middle-income countries (LMICs). To assess effectiveness of a developing trauma system, we hypothesize that there are survival differences between direct and indirect transfer of trauma patients to a tertiary hospital in sub Saharan Africa.

METHODS

Retrospective analysis of 51,361 trauma patients within the Kamuzu Central Hospital (KCH) trauma registry from 2008 to 2012 was performed. Analysis of patient characteristics and logistic regression modelling for in-hospital mortality was performed. The primary study outcome is in hospital mortality in the direct and indirect transfer groups.

RESULTS

There were 50,059 trauma patients were included in this study. 6578 patients transferred from referring facilities and 43,481 patients transported from the scene. The indirect and direct transfer cohorts were similar in age and sex. The mechanism of injury for transferred patients was 78.1% blunt, 14.5% penetrating, and 7.4% other, whereas for the scene group it was 70.7% blunt, 24.0% penetrating, and 5.2% other. Median times to presentation were 13 (4-30) and 3 (1-14)h for transferred and scene patients, respectively. Mortality rate was 4.2% and 1.6% for indirect and direct transfer cohorts, respectively. A total of 8816 patients were admitted of which 3636 and 5963 were in the transfer and scene cohort, respectively. After logistic regression analysis, the adjusted in-hospital mortality odds ratio was 2.09 (1.24-3.54); P=0.006 for indirect transfer versus direct transfer cohort, after controlling for significant covariates.

CONCLUSIONS

Direct transfer of trauma patients from the scene to the tertiary care centre is associated with a survival benefit. Our findings suggest that trauma education and efforts directed at regionalization of trauma care, strengthening pre-hospital care and timely transfer from district hospitals could mitigate trauma-related mortality in a resource-poor setting.

The effect of a new surgery residency program on case volume and case complexity in a sub-Saharan African hospital

BACKGROUND

Improved access to surgical care could prevent a significant burden of disease and disability-adjusted life years, and workforce shortages are the biggest obstacle to surgical care. To address this shortage, a 5-year surgical residency program was established at Kamuzu Central Hospital (KCH) in July 2009. As the residency enters its fourth year, we hypothesized that the initiation of a general surgical residency program would result in an increase in the overall case volume and complexity at KCH.

METHODS

We conducted a retrospective analysis of operated cases at KCH during the 3 years before and the third year after the implementation of the KCH surgical residency program, from July 2006 to July 2009 and the calendar year 2012, respectively.

RESULTS

During the 3 years before the initiation of the surgical residency, an average of 2317 operations were performed per year, whereas in 2012, 2773 operations were performed, representing a 20% increase. Before residency, an average of 1191 major operations per year were performed, and in 2012, 1501 major operations were performed, representing a 26% increase.

CONCLUSION

Our study demonstrates that operative case volume and complexity increase following the initiation of a surgical residency program in a sub-Saharan tertiary hospital. We believe that by building on established partnerships and emphasizing education, research, and clinical care, we can start to tackle the issues of surgical access and care.

Sustainability assessment of a short-term international medical mission

BACKGROUND

Few studies have analyzed the tangible impact of global, philanthropic medical missions. We used qualitative methods to analyze the work of one such mission, Operation Walk Boston, which has made yearly trips to a Dominican Republic hospital since 2008.

METHODS

We interviewed twenty-one American and Dominican participants of the Operation Walk Boston team to investigate how the program led to changes at the host Dominican hospital and how the experience caused both mission protocols and U.S. practices to change. Transcripts were analyzed with the use of content analysis.

RESULTS

Participants noted that Operation Walk Boston's technical knowledge transfer and managerial examples led to sustainable changes at the Dominican hospital. Additionally, participants observed an evolution in nursing culture, as the program inspired greater independence in decision-making. Participants also identified barriers such as language and organizational hierarchy that may limit bidirectional knowledge transfer. U.S. participants noted that their practices at home changed as a result of better appreciation for different providers' roles and for managing cost in a resource-constrained environment.

CONCLUSIONS

Operation Walk Boston catalyzed sustainable changes in the Dominican hospital. Cultural norms and organizational structure are important determinants of program sustainability.

Is safe surgery possible when resources are scarce?

The greatest burden of surgical disease exists in low- and middle-income countries, where the quality and safety of surgical treatment cause major challenges. Securing necessary and appropriate medical supplies and infrastructure remains a significant and under-recognised limitation to providing safe and high-quality surgical care in these settings. The majority of surgical instruments are sold in high-income countries. Limited market pressures lead to superfluous designs and inflated costs for these devices. This context creates an opportunity for frugal innovation-the search for designs that will enable low-cost care without compromising quality. Although progressive examples of frugal surgical innovations exist, policy innovation is required to augment design pathways while fostering appropriate safety controls for prospective devices. Many low-cost, high-quality medical technologies will increase access to safe surgical care in low-income countries and have widespread applicability as all countries look to reduce the cost of providing care, without compromising quality.

An innovative paradigm for surgical education programs in resource-limited settings

The burden of surgical disease in low-income countries remains significant, in part owing to continued surgical workforce shortages. We describe a successful paradigm to expand Rwandan surgical capacity through the implementation of a surgical education partnership between the National University of Rwanda and the Centre for Global Surgery at the McGill University Health Centre. Key considerations for such a program are highlighted.

The burden of musculoskeletal disease in Sierra Leone

BACKGROUND

Musculoskeletal disease is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in developing countries are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure the incidence and prevalence of surgically treatable conditions, including musculoskeletal conditions, in patients in low- and middle-income countries, and was administered in the West African nation of Sierra Leone in 2012.

PURPOSE

We attempted to quantify the burden of potentially treatable musculoskeletal conditions in patients in Sierra Leone.

METHODS

A cross-sectional two-stage cluster-based survey was performed in Sierra Leone using the SOSAS. Two individuals from each randomly selected household underwent a verbal head to toe examination. The musculoskeletal-related questions from the SOSAS survey in Sierra Leone were analyzed to determine the prevalence of musculoskeletal problems in the study population. Prevalence is reported as the number of respondents with a musculoskeletal problem now and number of respondents with a musculoskeletal problem during the past year. Respondents had "no need" for care, they "received care", or they faced a barrier that prevented them from receiving care.

RESULTS

One thousand eight hundred seventy-five households were targeted, with 1843 undergoing the survey, which yielded 3645 individual respondents. Of the individual respondents, 462 (n=3645; 12.6% of total; 95% CI, 12%-13%) had a traumatic musculoskeletal problem during the past year, and 236 (n=3645; 6% of total; 95% CI, 5%-7%) respondents had a musculoskeletal problem of nontraumatic etiology. Of respondents with either a traumatic or nontraumatic musculoskeletal problem, 359 (n=562; 63.9% of total; 95% CI, 59.5-68.3%) needed care but were unable to receive it with the major barrier reported as financial.

CONCLUSION

Resource allocation decisions in global health are made based on burden of disease data in low- and middle-income countries. The data provided here for Sierra Leone may offer some generalizable insight into the scope of the burden of musculoskeletal disease for low- and middle-income countries, especially in Sub-Saharan Africa, and provide concrete evidence that musculoskeletal health should be included in the global health discussion. However, there may be important differences across countries in this region, and further study to elucidate these differences seems critical given the large burden of disease and the limited resources available in these regions to manage it.

Cleft lip-cleft palate in Zimbabwe: estimating the distribution of the surgical burden of disease using geographic information systems

OBJECTIVES/HYPOTHESIS

To evaluate the prevalence and unmet need for cleft lip-cleft palate reconstructive surgery by using incidence. Our hypotheses were that the age of presentation to screening clinics will decrease between 2006 and 2012, and the geospatial distribution of cases will expand to a more rural catchment area.

STUDY DESIGN

Longitudinal cross-sectional/geospatial distribution study.

METHODS

An online, secure database was created from intake forms for children with cleft lip-cleft palate (N=604) in Zimbabwe (2006-2012). Univariate analysis was completed. A linear regression model was fitted to test the time trend of a child's age at the time of presentation. Unique patient addresses (n=411) were matched. Maps presenting cleft diagnosis and presentation year were created with geographic information systems (GIS) software.

RESULTS

The median age of presentation was greater for isolated cleft palate (4.2 years, n=106) than isolated cleft lip (1.5 years, n=251) and cleft lip-cleft palate (2.0 years, n=175). Cleft lip cases were mostly left sided with equal gender distribution. The overall age of presentation remained stable (P=.83). The age of children with isolated cleft palate decreased by 0.8 years per surgical trip (P=.01), suggesting the prevalence of unrepaired cleft palate is decreasing due to local and visiting surgeons. The catchment area extended to a less populous area, but clustered around Harare and Bulawayo.

CONCLUSIONS

This study gives Zimbabwe-specific evidence that supports reports of the persistent burden of disease requiring attention. The GIS software provided data for the primary needs assessment, which will direct communication to healthcare providers and prospective patients outside of the current catchment area.

LEVEL OF EVIDENCE

3

Household survey in Sierra Leone reveals high prevalence of surgical conditions in children

BACKGROUND

Although great efforts are being undertaken to reduce child morbidity and mortality globally, there is limited knowledge about the need for pediatric surgical care. Some data on surgical need is available from hospital registries, but it is difficult to interpret for countries with limited surgical capacity.

METHODS

A cross-sectional two-stage cluster-based sample survey was undertaken in Sierra Leone, using the Surgeons OverSeas Assessment of Surgical Need tool. Data were collected and analyzed on numbers of children needing surgical care and pediatric deaths that may have been averted if surgical care had been available.

RESULTS

A total of 1,583 children out of 3,645 individuals (43.3 %) were interviewed. Most (64.0 %, n = 1,013) participants lived in rural areas. At the time of interview, 279 (17.6; 95 % confidence interval (95 % CI): 15.7-19.5 %) had a possible surgical condition in need of a consultation. Children in the northern and eastern provinces of Sierra Leone were much more likely to report a surgical problem than those in the urban-west.

CONCLUSIONS

There is a high need for surgical care in the pediatric population of Sierra Leone. While additional resources should be allocated to address that need, more research is needed. Ideally, questions on surgically treatable conditions should be added to the frequently performed health care surveys on the pediatric population.

Surgical Care in the Developing World-Strategies and Framework for Improvement

The purpose of this study was to identify the various problems with surgical care in the developing world and enumerate identified strategies or propose solutions. We also sought to rank these strategies in order of potential impact. The MEDLINE database was sought. Studies published in English, reporting currently employed solutions to identified barriers or problems to surgical care in developing countries or potential solution(s) and published between 2000 and 2012 were eligible for inclusion. 2156 articles were identified for possible inclusion. MeSH terms include surgery, general surgery, developing countries, health services accessibility and quality improvement. Forty-nine full articles with a primary focus on the solutions to the challenges to surgical care in the developing world were included in the final review. Many articles identified problems with infrastructure, workforce shortage, inadequate or inappropriate policies, and poor financing as major problems with healthcare in the developing world. Solutions addressing these problems are multifactorial and would require active participation of local authorities and collaboration with providers from the developed world. The burden of surgical care is increasing. There is poor access to surgical services in the developing world. If and when surgical care is received, the quality could be less than the standard in developed nations. Solutions exist to tackle these problems but require a multidimensional approach to be successful.

Enhancing the quality of international orthopedic medical mission trips using the blue distinction criteria for knee and hip replacement centers

BACKGROUND

Several organizations seek to address the growing burden of arthritis in developing countries by providing total joint replacements (TJR) to patients with advanced arthritis who otherwise would not have access to these procedures. Because these mission trips operate in resource poor environments, some of the features typically associated with high quality care may be difficult to implement. In the U.S., many hospitals that perform TJRs use the Blue Cross/Shield's Blue Distinction criteria as benchmarks of high quality care. Although these criteria were designed for use in the U.S., we applied them to Operation Walk (Op-Walk) Boston's medical mission trip to the Dominican Republic. Evaluating the program using these criteria illustrated that the program provides high quality care and, more importantly, helped the program to find areas of improvement.

METHODS

We used the Blue Distinction criteria to determine if Op-Walk Boston achieves Blue Distinction. Each criterion was grouped according to the four categories included in the Blue Distinction criteria--"general and administrative", "structure", "process", or "outcomes and volume". Full points were given for criteria that the program replicates entirely and zero points were given for criteria that are not replicated entirely. Of the non-replicated criteria, Op-Walk Boston's clinical and administrative teams were asked if they compensate for failure to meet the criterion, and they were also asked to identify barriers that prevent them from meeting the criterion.

RESULTS

Out of 100 possible points, the program received 71, exceeding the 60-point threshold needed to qualify as a Blue Distinction center. The program met five out of eight "required" criteria and 11 out of 19 "informational" criteria. It scored 14/27 in the "general" category, 30/36 in the "structure" category, 17/20 in the "process" category, and 10/17 in the "outcomes and volume" category.

CONCLUSION

Op-Walk Boston qualified for Blue Distinction. Our analysis highlights areas of programmatic improvement and identifies targets for future quality improvement initiatives. Additionally, we note that many criteria can only be met by hospitals operating in the U.S. Future work should therefore focus on creating criteria that are applicable to TJR mission trips in the context of developing countries.

Pediatric emergency and essential surgical care in Zambian hospitals: a nationwide study

PURPOSE

Pediatric surgical care in developing countries is not well studied. We sought to identify the range of pediatric surgery available, the barriers to provision, and level of safety of surgery performed for the entire pediatric population in Zambia.

METHODS

In cooperation with the Ministry of Health, we validated and adapted a World Health Organization instrument. During onsite visits, the availability of 32 emergency and essential surgical procedures relevant to children was surveyed. The availability of basic World Health Organization surgical safety criteria was determined.

RESULTS

A single interviewer visited 103 (95%) of 108 surgical hospitals in Zambia and carried out 495 interviews. An average of 68% of the 32 emergency and essential surgical procedures was available (range 32%-100%). Lack of surgical skill was the primary reason for referral in 72% of procedure types, compared with 24%, 2% and 3% due to lack of equipment, supplies and anesthesia skills, respectively (p<0.001). Minimum pediatric surgical safety criteria were met by 14% of hospitals.

CONCLUSION

The primary limitation to providing pediatric surgical care in Zambia is lack of surgical skills. Minimum safety standards were met by 14% of hospitals. Efforts to improve pediatric surgery should prioritize teaching surgical skills to expand access and providing safety training, equipment and supplies to increase safety.

The burden of pediatric surgical conditions in low and middle income countries: a call to action

Recently, the role of surgery in global health has gained greater attention, although pediatric surgery has received little specific emphasis. This paper highlights pediatric surgical conditions as a part of global public health, and identifies gaps in knowledge and possible areas of action for the global pediatric surgical community. The burden of disease concept is discussed with examples of its application to pediatric surgery, and further information required to improve measurement of the global burden of pediatric surgical conditions. In addition, selected tools to measure access to surgical care and the unmet need for surgery in low and middle-income countries (LMICs) are reviewed, with recent innovative approaches and other possible adaptations to pediatric surgery. Finally, some of the strategies used to improve access to care for pediatric surgical conditions are discussed, with possible future directions.

Multi-institutional neurosurgical training initiative at a tertiary referral center in Mwanza, Tanzania: where we are after 2 years

BACKGROUND

The paucity of neurosurgical care in East Africa remains largely unaddressed. A sustained investment in local health infrastructures and staff training is needed to create an independent surgical capacity. The Madaktari organization has addressed this issue by starting initiatives to train local general surgeons and assistant medical officers in basic neurosurgical procedures. We report illustrative cases since beginning of the program in Mwanza in 2009 and focus on the most recent training period.

METHODS

A multi-institutional neurosurgical training program and a surgical database was created at a tertiary referral center in Mwanza, Tanzania. We collected clinical data on consecutive patients who underwent a neurosurgical procedure between September 9th and December 1st, 2011. All procedures were performed by a local surgeon under the supervision of a visiting neurosurgeon. Since the inception of the training initiative, comprehensive multidisciplinary training courses in Tanzania and an annual visiting fellowship for East African surgeons to travel to a major U.S. medical center have been established.

RESULTS

At initial visits infrastructure and feasibility of complex case scenarios was assessed. Surgeries for brain tumors and complex spinal cases were performed. During the 3-month training period, 62 patients underwent surgery. Pediatric hydrocephalus comprised 52% of patients, 11% suffered from meningomyelocelia, and 6% presented with an encephalocele. A total of 24% of patients were treated for trauma-related conditions, representing 75% of the adult patients. A total of 10% of patients had surgery because of traumatic spine injury, and 15% of operations were on patients with severe head injury. A total of 6% of patients presented with degenerative spine disease. One patient sustained a fatal perioperative complication. At the end of the training period, the local general surgeon was able to perform all basic neurosurgical cases independently.

CONCLUSIONS

Neurosurgical care in Tanzania needs to address a diverse, unique disease burden. We found that local surgeons could be enabled to safely perform basic cranial and spinal neurosurgical procedures through immersive, 1-on-1 on-site collaborations, multidisciplinary courses, and educational visiting fellowships.

Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey

BACKGROUND

Surgical care is increasingly recognised as an important part of global health yet data for the burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) was developed to measure the prevalence of surgical conditions and surgically treatable deaths in low-income and middle-income countries. We administered this survey countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development Index.

METHODS

The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters, with a probability proportional to the population size. In each cluster 25 households were randomly selected to take part in the survey. Data were collected via handheld tablets by trained local medical and nursing students. A household representative was interviewed to establish the number of household members (defined as those who ate from the same pot and slept in the same structure the night before the interview), identify deaths in the household during the previous year, and establish whether any of the deceased household members had a condition needing surgery in the week before death. Two randomly selected household members underwent a head-to-toe verbal examination and need for surgical care was recorded on the basis of the response to whether they had a condition that they believed needed surgical assessment or care.

FINDINGS

Of the 1875 targeted households, data were analysed for 1843 (98%). 896 of 3645 (25%; 95% CI 22·9-26·2) respondents reported a surgical condition needing attention and 179 of 709 (25%; 95% CI 22·5-27·9) deaths of household members in the previous year might have been averted by timely surgical care.

INTERPRETATION

Our results show a large unmet need for surgical consultations in Sierra Leone and provide a baseline against which future surgical programmes can be measured. Additional surveys in other low-income and middle-income countries are needed to document and confirm what seems to be a neglected component of global health.

FUNDING

Surgeons OverSeas, Thompson Family Foundation.