Ratio of cesarean deliveries to total operations and surgeon nationality are potential proxies for surgical capacity in central Haiti

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

INTRODUCTION

The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs).

METHODOLOGY

We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed.

RESULTS

A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries.

CONCLUSION

Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.

A systematic review and meta-analysis of valued obstetric and gynecologic (OB/GYN) procedures in resource-poor areas

Background

Obstetric and gynecologic procedures are valuable in rural settings. Data identifying common procedures may better prepare surgeons to meet patient needs in remote settings.

Materials and methods

A literature review using key MeSH terms was performed according to methods described by the Cochrane Collaboration and PRISMA on studies that described obstetric and gynecologic surgery in rural high-income countries or any setting in middle- to low-income countries. Meta-analysis was performed using random effects modeling for odds ratios of cesarean delivery and hysterectomy as proportions of total surgical volume.

Results

A total of 195 studies were included for qualitative synthesis and 22 for quantitative analysis. Obstetric and gynecologic procedures made up a 19% of all surgical cases. As compared to other obstetric and gynecologic surgical procedures, cesarean delivery was the most common procedure with odds ratio of 2.39 (95% confidence interval 1.48–3.86), and hysterectomy was the second most common procedure with odds ratio of 1.60 (1.57–1.64). However, heterogeneity between the studies was extremely high and risk of bias was high, limiting quality of findings.

Conclusion

Greater provision of surgical care can be enhanced by defining which procedures are most needed, which include many obstetric and gynecologic procedures, most commonly cesarean delivery and hysterectomy.

Estimating obstetric and gynecologic surgical rate: A benchmark of surgical capacity building in Ghana

OBJECTIVE

To estimate the annual rate of obstetric and gynecologic (ObGyn) operations performed in Ghana and establish a baseline for tracking the expansion of Ghana's surgical capacity.

METHODS

Data were obtained for ObGyn operations performed in Ghana between 2014 and 2015 from a nationally representative sample of hospitals and scaled up for national estimates. Operations were classified as "essential" or "other" according to The World Bank's Disease Control Priorities Project. Data were used to calculate cesarean-to-total-operation ratio (CTR) and estimate the rate of cesarean deliveries based on the number of live births in 2014.

RESULTS

A total of 90 044 (95% uncertainty interval [UI] 69 461-110 628) ObGyn operations were performed nationally over the 1-year period, yielding an annual national ObGyn operation rate of 881/100 000 females aged 12 years and over (95% UI 679-1082). Eighty-seven percent were essential procedures, 80% of which were cesarean deliveries. District hospitals performed 71% of ObGyn operations. The national rate of cesarean deliveries was 7.2% and the CTR was 0.27.

CONCLUSION

The cesarean delivery rate of 7.2% suggests inadequate access to obstetric care. The CTR of 0.27 suggests inadequate overall surgical capacity. These measures, along with estimates of distribution of procedures by hospital level, provide useful baseline data to support surgical capacity building efforts in Ghana and similar countries.

Intraoperative Mortality in Malawi

BACKGROUND

Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality.

METHODS

This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality.

RESULTS

There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001).

CONCLUSIONS

Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.

Caesarean section performed by medical doctors and associate clinicians in Sierra Leone

BACKGROUND

Many countries lack sufficient medical doctors to provide safe and affordable surgical and emergency obstetric care. Task-sharing with associate clinicians (ACs) has been suggested to fill this gap. The aim of this study was to assess maternal and neonatal outcomes of caesarean sections performed by ACs and doctors.

METHODS

All nine hospitals in Sierra Leone where both ACs and doctors performed caesarean sections were included in this prospective observational multicentre non-inferiority study. Patients undergoing caesarean section were followed for 30 days. The primary outcome was maternal mortality, and secondary outcomes were perinatal events and maternal morbidity.

RESULTS

Between October 2016 and May 2017, 1282 patients were enrolled in the study. In total, 1161 patients (90·6 per cent) were followed up with a home visit at 30 days. Data for 1274 caesarean sections were analysed, 443 performed by ACs and 831 by doctors. Twin pregnancies were more frequently treated by ACs, whereas doctors performed a higher proportion of operations outside office hours. There was one maternal death in the AC group and 15 in the doctor group (crude odds ratio (OR) 0·12, 90 per cent confidence interval 0·01 to 0·67). There were fewer stillbirths in the AC group (OR 0·74, 0·56 to 0·98), but patients were readmitted twice as often (OR 2·17, 1·08 to 4·42).

CONCLUSION

Caesarean sections performed by ACs are not inferior to those undertaken by doctors. Task-sharing can be a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors.

Operative volume and surgical case distribution in Uganda's public sector: a stratified randomized evaluation of nationwide surgical capacity

Background

Little is known about operative volume, distribution of cases, or capacity of the public sector to deliver essential surgical services in Uganda.

Methods

A standardized mixed-methods surgical assessment and retrospective operative logbook review were completed at 16 randomly selected public hospitals serving 64·0% of Uganda’s population.

Results

A total of 3014 operations were recorded, annualizing to a surgical volume of 36,670 cases/year or 144·5 operations/100,000people/year. Absolute surgical volume was greater at regional referral than general hospitals (p < 0·001); but, relative surgical volume/catchment population was greater at the general versus regional level (p = 0·03). Most patients undergoing operations were women (78·3%) with a mean age of 26·9 years. The overall case distribution was 69·0% obstetrics/gynecology, 23·7% general surgery, 4·0% orthopedics, and 3·3% other subspecialties. Cesarean sections were the most common operation (55·8%). Monthly operative volume was strongly predicted by number of surgical, anesthetic, and obstetric physician providers (훽=10·72, p = 0·005, R² = 0·94) when controlling for confounders. Notably, operative volume was not correlated with availability of electricity, oxygen, light source, suction, blood, instruments, suture, gloves, intravenous fluid, or antibiotics.

Conclusion

An understanding of operative case volume and distribution is essential in facilitating targeted interventions to strengthen surgical capacity. These data suggest that surgical workforce is the critical driver of operative volume in the Ugandan public sector. Investment in the surgical workforce is imperative to ensure access to safe, timely, and affordable surgical and anaesthesia care.

Emergency-to-Elective Surgery Ratio: A Global Indicator of Access to Surgical Care

BACKGROUND

Surgical care is essential to health systems but remains a challenge for low- and middle-income countries (LMICs). Current metrics to assess access and delivery of surgical care focus on the structural components of surgery and are not readily applicable to all settings. This study assesses a new metric for surgical care access and delivery, the ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries.

METHODS

A systematic search of PubMed and Medline was conducted for studies describing surgical volume and acuity published between 2006 and 2016. The relationship between Ee ratio and three national indicators (gross domestic product, per capital healthcare spending, and physician density) was analyzed using weighted Pearson correlation coefficients (r _w) and linear regression models.

RESULTS

A total of 29 studies with 33 datasets were included for analyses. The median Ee ratio was 14.6 (IQR 5.5-62.6), with a range from 1.6 to 557.4. For countries in sub-Saharan Africa the median value was 62.6 (IQR 17.8-111.0), compared to 9.4 (IQR 3.4-13.4) for the United States and 5.5 (IQR 4.4-10.1) for European countries. In multivariable linear regression, the per capita healthcare spending was inversely associated with the Ee ratio, with a 63-point decrease in the Ee ratio for each 1 point increase in the log of the per capita healthcare spending (regression coefficient β = -63.2; 95% CI -119.6 to -6.9; P = 0.036).

CONCLUSIONS

The Ee ratio appears to be a simple and valid indicator of access to available surgical care. Global health efforts may focus on investment in low-resource settings to improve access to available surgical care.

A Model of the Unmet Need for Cleft Lip and Palate Surgery in Low- and Middle-Income Countries

BACKGROUND

There is a significant unmet need for the cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) ; however, country-level estimates that can be used to inform local and international cleft care program strategies are lacking.

METHODS

Using data from Operation Smile surgical programs in twelve LMICs and country-level indicators from the World Health Organization and World Bank, we developed a model to estimate the proportion of individuals with CL/Ps older than respective surgery age targets for cleft lip and cleft palate surgery (1 and 2 years, respectively). After extrapolating this model to other LMICs with available indicator data, we combined these findings with estimates of CL/P prevalence among live births to estimate the total number of unrepaired CL/P cases in LMICs worldwide.

RESULTS

The models were constructed from a total of 887 cases of cleft palate and 576 cases of cleft lip across the twelve countries. From these, we estimated that there are 616,655 cases of unrepaired CL/P (95 % CI 564,893-678,503) in the 113 countries with available data for extrapolation. The rate of unrepaired CL/Ps ranged from 2.5 per 100,000 population in Romania to 28.5 per 100,000 in Cambodia, respectively (median rate 10.7 per 100,000 population).

CONCLUSIONS

Our model provides marked insight into the global surgical backlog due to cleft lip and palate. While the most populated LMICs have the largest number of unrepaired CL/Ps, low-income countries with relatively less healthcare infrastructure have exceptionally high rates (e.g., Cambodia, Afghanistan, and Nepal). These estimates can be used by local and international cleft care organizations to set program priorities, estimate resource requirements, and inform strategies to support cleft care.

Size and distribution of the global volume of surgery in 2012

OBJECTIVE

To estimate global surgical volume in 2012 and compare it with estimates from 2004.

METHODS

For the 194 Member States of the World Health Organization, we searched PubMed for studies and contacted key informants for reports on surgical volumes between 2005 and 2012. We obtained data on population and total health expenditure per capita for 2012 and categorized Member States as very-low, low, middle and high expenditure. Data on caesarean delivery were obtained from validated statistical reports. For Member States without recorded surgical data, we estimated volumes by multiple imputation using data on total health expenditure. We estimated caesarean deliveries as a proportion of all surgery.

FINDINGS

We identified 66 Member States reporting surgical data. We estimated that 312.9 million operations (95% confidence interval, CI: 266.2-359.5) took place in 2012, an increase from the 2004 estimate of 226.4 million operations. Only 6.3% (95% CI: 1.7-22.9) and 23.1% (95% CI: 14.8-36.7) of operations took place in very-low- and low-expenditure Member States representing 36.8% (2573 million people) and 34.2% (2393 million people) of the global population of 7001 million people, respectively. Caesarean deliveries comprised 29.6% (5.8/19.6 million operations; 95% CI: 9.7-91.7) of the total surgical volume in very-low-expenditure Member States, but only 2.7% (5.1/187.0 million operations; 95% CI: 2.2-3.4) in high-expenditure Member States.

CONCLUSION

Surgical volume is large and growing, with caesarean delivery comprising nearly a third of operations in most resource-poor settings. Nonetheless, there remains disparity in the provision of surgical services globally.

Assessing cesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed in Sierra Leone in 2012

BACKGROUND

The traditional tools to assess surgical capacity in low-income countries require significant amounts of time and resources, and have thus not been utilized systematically in this context. Proxy indicators have been suggested as a simpler tool to estimate surgical volume. The aim of this study was to assess caesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed per capita in a given region of sub-Saharan Africa.

METHODS

Surgical data was compiled from 58 health institutions (96.7%) that performed major surgery in Sierra Leone in 2012. In total, 24,152 operative procedures were included in the study. Validity of proxy indicators was tested by logistic regression analyses with the rate of caesarean sections compared with total operations (%CS), hernia repairs (%HR) or both (%CS&HR) as dependent variables and the operations per 100,000 capita as the covariate.

RESULTS

There was significant correlation for each of the proxy indicators, with the estimated odds ratio for %CS being 0.675 (95% CI, 0.520-0.876; P < .01), the estimated odds ratio for %HR being 0.822 (95% CI, 0.688-0.983; P < .05), and the estimated odds ratio for %CS&HR being 0.838 (95% CI, 0.731-0.962; P < .05).

CONCLUSION

The unmet need for surgical services in a region of sub-Saharan Africa can be estimated by using any of the 3 proxy indicators. However, it seems that %CS is more sensitive for small changes in operations per 100,000 capita, compared with the %HR. There is no obvious added benefit for using the combined proxy indicator.

An Analysis of Cesarean Section and Emergency Hernia Ratios as Markers of Surgical Capacity in Low-Income Countries Affected by Humanitarian Emergencies from 2008 - 2014 at Médecins sans Frontières Operations Centre Brussels Projects

Background: Surgical capacity assessments in low-income countries have demonstrated critical deficiencies. Though vital for planning capacity improvements, these assessments are resource intensive and impractical during the planning phase of a humanitarian crisis. This study aimed to determine cesarean sections to total operations performed (CSR) and emergency herniorrhaphies to all herniorrhaphies performed (EHR) ratios from Médecins Sans Frontières Operations Centre Brussels (MSF-OCB) projects and examine if these established metrics are useful proxies for surgical capacity in low-income countries affected by crisis. Methods: All procedures performed in MSF-OCB operating theatres from July 2008 through June 2014 were reviewed. Projects providing only specialty care, not fully operational or not offering elective surgeries were excluded. Annual CSRs and EHRs were calculated for each project. Their relationship was assessed with linear regression. Results: After applying the exclusion criteria, there were 47,472 cases performed at 13 sites in 8 countries. There were 13,939 CS performed (29% of total cases). Of the 4,632 herniorrhaphies performed (10% of total cases), 30% were emergency procedures. CSRs ranged from 0.06 to 0.65 and EHRs ranged from 0.03 to 1.0. Linear regression of annual ratios at each project did not demonstrate statistical evidence for the CSR to predict EHR [F(2,30)=2.34, p=0.11, R2=0.11]. The regression equation was: EHR = 0.25 + 0.52(CSR) + 0.10(reason for MSF-OCB assistance). Conclusion: Surgical humanitarian assistance projects operate in areas with critical surgical capacity deficiencies that are further disrupted by crisis. Rapid, accurate assessments of surgical capacity are necessary to plan cost- and clinically-effective humanitarian responses to baseline and acute unmet surgical needs in LICs affected by crisis. Though CSR and EHR may meet these criteria in ‘steady-state’ healthcare systems, they may not be useful during humanitarian emergencies. Further study of the relationship between direct surgical capacity improvements and these ratios is necessary to document their role in humanitarian settings.

Anaesthesia, surgery, obstetrics, and emergency care in Guyana

The surgical and anaesthesia needs of low-income countries are mostly unknown due to the lack of data on surgical infrastructure and human resources. The goal of this study is to assess the surgical and anaesthesia capacity in Guyana. A survey tool adapted from the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to survey nine regional and district hospitals within the Ministry of Health system in Guyana. In nine hospitals across Guyana, there were an average of 0.7 obstetricians/gynaecologists, 3.5 non-OB surgeons, and 1 anaesthesiologist per hospital. District and regional hospitals performed an annual total of 1520 and 10,340 surgical cases, respectively. All but 2 district hospitals reported the ability to perform surgery. An average hospital has two operating rooms; 6 out of 9 hospitals reported routine medication shortages, and 4 out of 9 hospitals reported routine water or electricity shortages. Amongst the three regional hospitals, 16.1% of pregnancies resulted in Caesarean section. Surgical capacity varies by hospital type, with district hospitals having the least surgical capacity and surgical volume. District level hospitals routinely do not perform surgery due to lack of basic infrastructure and human resources.

Development of a ratio of emergent to total hernia repairs as a surgical capacity metric

INTRODUCTION

Non-communicable diseases including surgical conditions are gaining attention in developing countries. Despite this there are few metrics for surgical capacity. We hypothesized that (a) the ratio of emergent to total hernia repairs (E/TH) would correlate with per capita health care expenditures for any given country, and (b) the E/TH is easy to obtain in resource-poor settings.

METHODS

We performed a systematic review to identify the E/TH for as many countries as possible (Prospero registry CRD42013004645). We screened 1285 English language publications since 1990; 23 met inclusion criteria. Primary data was also collected from Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. A total of 13 countries were represented. Regression analysis was used to determine the correlation between per capita health care spending and the E/TH.

RESULTS

There is a strong correlation between the log values of the ratio emergent to total groin hernias and the per capita health care spending that is robust across country income levels (R(2) = 0.823). Primary data from KCH was easily obtained and demonstrated a similar correlation.

CONCLUSIONS

The ratio of emergent to total groin hernias is a potential measure of surgical capacity using data that is easily attainable. Further studies should validate this metric against other accepted health care capacity indicators. Systematic review registered with Prospero (CRD42013004645).