A Systematic Review of Economic Analysis of Surgical Mission Trips Using the World Health Organization Criteria

Modeling the Lifetime Impact of Reconstructive Plastic Surgery Training: Implications for Building Capacity in Global Surgery

Background

Training local surgeons and building local surgical capacity is critical to closing the gap in unmet surgical burden in low- and middle-income country (LMIC) settings. We propose a conceptual framework to quantify the impact of a single surgeon's training across multiple generations of trainees.

Methods

A literature review was conducted to identify existing models for quantifying the impact of training. A model to estimate the attributable impact of surgical training was devised, based on a surgeon's attributable impact on a trainee and the lifetime number of cases trainees would perform. A quantitative survey was sent to high-income country and LMIC-based surgeons to determine the model's inputs across eight index procedures in reconstructive plastic surgery.

Results

We found no existing models for quantifying the multigenerational impact of training in surgery, medicine, or nonmedical fields. Twenty-eight US-based academic plastic surgeons and 19 LMIC-based surgeons representing 10 countries provided responses. The lifetime impact of multigenerational surgical training ranged from 4100 attributable cases (skin graft) to 51,900 attributable cases (cleft lip repair) in high-income countries and from 18,200 attributable cases (carpal tunnel release) to 134,300 attributable cases (cleft lip repair) in LMICs.

Conclusions

There is a sizeable impact in the first generation of training, and this impact is even greater in the second generation of training, highlighting the importance of a "multiplier effect," particularly in LMIC settings. Given the paucity of surgeons, this multiplier effect is critical in closing the surgical gap, as efforts are underway to train new cohorts of reconstructive plastic surgeons.

Cost-Effectiveness of Pediatric Hand International Medical Missions

PURPOSE

Limited access and resources in low- and middle-income countries leave many individuals deprived of medical care. Surgical mission trips offer a solution to provide sound surgical care to underserved areas but require a sizable financial support. Previous analyses of such trips have not included values of donated supplies and costs borne by the host country. We hypothesized that the orthopedic mission trips, utilizing the World Pediatric Project (WPP) model, can be executed in a cost-effective manner according to the World Health Organization thresholds even when considering cost to the organizations and host country.

METHODS

World Pediatric Project records for the most recent pediatric upper extremity orthopedic mission trips of 2016, 2018, and 2019 were obtained. Cost estimates were based on documentation from each of the mission trips. Total costs included the costs borne by the WPP, estimates of the value of donated supplies, and costs borne by the host country. The cost-effectiveness of the surgical mission trips was determined by the total cost and potential benefit of performing the orthopedic surgeries using disability-adjusted life years averted.

RESULTS

Three separate mission trips to St. Vincent and the Grenadines were analyzed. Forty-five pediatric patients had received surgical care. The cost was calculated to be $431.50 per disability-adjusted life years averted when only the WPP costs are considered; including donated supplies and cost borne by the host country in the total cost, the cost was $6898.10 per disability-adjusted life years averted. After comparing the cost values to the per capita gross domestic product of St. Vincent and the Grenadines, $7,463.54, the WPP mission trips were determined to be cost-effective according to the WHO-CHOICE thresholds in all 5 categories.

CONCLUSIONS

Orthopedic medical mission trips can provide cost-effective surgical treatments for the upper extremity even when the costs to the organization and host country and trip donations are considered.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

Short-term general, gynecologic, orthopedic, and pediatric surgical mission trips in Nicaragua: A cost-effectiveness analysis

Background

Short-term surgical missions facilitated by non-governmental organizations (NGOs) may be a possible platform for cost-effective international global surgical efforts. The objective of this study is to determine if short-term surgical mission trips provided by the non-governmental organization (NGO) Esperança to Nicaragua from 2016 to 2020 are cost-effective.

Methods

Using a provider perspective, the costs of implementing the surgical trips were collected via Esperança’s previous trip reports. The reports and patient data were analyzed to determine disability-adjusted life years averted from each surgical procedure provided in Nicaragua from 2016-2020. Average cost-effectiveness ratios for each surgical trip specialty were calculated to determine the average cost of averting one disability-adjusted life year.

Results

Esperança’s surgical missions’ program in Nicaragua from 2016 to 2020 was found to be cost-effective, with pediatric and gynecology surgical specialties being highly cost-effective and general and orthopedic surgical specialties being moderately cost-effective. These results were echoed in both scenarios of the sensitivity analysis, except for the orthopedic specialty which was found to not be cost-effective when testing an increased discount rate.

Conclusions

The cost-effectiveness of short-term surgical missions provided by NGOs can be cost-effective, but limitations include inconsistent data from a societal perspective and lack of an appropriate counterfactual. Future studies should examine the capacity for NGOs to collect adequate data and conduct rigorous economic evaluations.

Low- and Middle-Income Country Host Perceptions of Short-Term Experiences in Global Health: A Systematic Review

PURPOSE

Stakeholders have expressed concerns regarding the impact of visiting trainees and physicians from high-income countries (HICs) providing education and/or short-term clinical care in low- and middle-income countries (LMICs). This systematic review aimed to summarize LMIC host perceptions of visiting trainees and physicians from HICs during short-term experiences in global health (STEGH).

METHOD

In September 2018 then again in August 2020, the authors searched 7 databases (PubMed, Embase, Scopus, Web of Science, ERIC, Cochrane Library, Global Index Medicus) for peer-reviewed studies that described LMIC host perceptions of STEGH. They extracted information pertaining to study design, participant demographics, participant perceptions, representation of LMICs and HICs, and HIC visitors' roles and used thematic synthesis to code the text, develop descriptive themes, and generate analytical themes.

RESULTS

Of the 4,020 studies identified, 17 met the inclusion criteria. In total, the studies included 448 participants, of which 395 (88%) represented LMICs. The authors identified and organized 42 codes under 8 descriptive themes. They further organized these descriptive themes into 4 analytical themes related to STEGH: (1) sociocultural and contextual differences, (2) institutional and programmatic components, (3) impact on host institutions and individuals, and (4) visitor characteristics and conduct.

CONCLUSIONS

STEGH can have both beneficial and detrimental effects on LMIC host institutions and individuals. The authors translated these findings into a set of evidence-based best practices for STEGH that provide specific guidance for LMIC and HIC stakeholders. Moving forward, LMIC and HIC institutions must work together to focus on the quality of their relationships and create conditions in which all stakeholders feel empowered to openly communicate to ensure equity and mutual benefit for all parties.

Barriers to Obtaining Informed Consent on Shortterm Surgical Missions

Short-term surgical missions (STSMs) enable visiting surgeons to help address inequalities in the provision of surgical care in resource-limited settings. One criticism of STSMs is a failure to obtain informed consent from patients before major surgical interventions. We aim to use collective evidence to establish the barriers to obtaining informed consent on STSMs and in resource-limited settings and suggest practical solutions to overcome them.

METHODS

A systematic review was performed using PubMed and Web of Science databases and following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. In addition to the data synthesized from the systematic review, we also include pertinent data from a recent long-term follow-up study in Ethiopia.

RESULTS

Of the 72 records screened, 11 studies were included in our review. The most common barrier to obtaining informed consent was a paternalistic approach to medicine and patient education. Other common barriers were a lack of ethics education among surgeons in low-income and middle-income countries, cultural beliefs toward healthcare, and language barriers between the surgeons and patients. Our experience of a decade of reconstructive surgery missions in Ethiopia corroborates this. In a long-term follow-up study of our head-and-neck patients, informed consent was obtained for 85% (n = 68) of patients over a 14-year period.

CONCLUSIONS

This study highlights the main barriers to obtaining informed consent on STSMs and in the resource-limited setting. We propose a checklist that incorporates practical solutions to the most common barriers surgeons will experience, aimed to improve the process of informed consent on STSMs.

Guidelines for Short-Term Hand Surgery Outreach Trips: Building Trust and Establishing Continuity

Global outreach in hand surgery can be exceptionally rewarding for volunteers and their organizations, patients and their communities, and the host medical community. Success can be defined by individual cases that restore function and provide opportunities for a patient and family to contribute to society; however, the broader missions of medical collaboration, education, cultural exchange, and personal growth are critical factors toward building trust and establishing continuity of care for long-term success. Each outreach site and brigade encounters challenges; however, careful planning facilitates optimal conditions and reasonable expectations for enhancing outcomes.

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.

Evaluating the Economic Impact of Plastic and Reconstructive Surgical Efforts in the Developing World: The ReSurge Experience

BACKGROUND

As the global burden of disease continues to rise, it becomes increasingly important to determine the sustainability of specialty surgery in the developing world. The authors aim to (1) evaluate the cost-effectiveness of plastic and reconstructive surgery in the developing world and (2) quantify the economic benefit.

METHODS

In this study, the authors performed a retrospective analysis of surgical trips performed by ReSurge International from 2014 to 2017. The organization gathered data on trip information, cost, and clinical characteristics. The authors measured the cost-effectiveness of the interventions using cost per disability-adjusted life-years and defined cost-effectiveness using World Health Organization Choosing Interventions That Are Cost-Effective thresholds. The authors also performed a cost-to-benefit analysis using the human capital approach.

RESULTS

A total of 22 surgical trips from eight different developing countries were included in this study. The authors analyzed a total of 756 surgical interventions. The cost-effectiveness of the surgical trips ranged from $52 to $11,410 per disability-adjusted life-year averted. The economic benefit for the 22 surgical trips was $9,795,384. According to World Health Organization Choosing Interventions That Are Cost-Effective thresholds, 21 of the surgical trips were considered very cost-effective or cost-effective.

CONCLUSIONS

Plastic and reconstructive operations performed during short-term surgical trips performed by this organization are economically sustainable. High-volume trips and those treating complex surgical conditions prove to be the most cost-effective. To continue to receive monetary funding, providing fiscally sustainable surgical care to low- and middle-income countries is imperative.

Impact of short-term reconstructive surgical missions: a systematic review

Introduction

Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries.

Methods

A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates.

Results

Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months’ follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics.

Conclusions

Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems.

PROSPERO registration number

CRD42018099285.

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.

Surgical and Teaching Mission to Mongolia: Experience and Lessons

BACKGROUND

For decades, the disparity in medical care across the world along with the fundamental essence of medicine as service has laid the foundation for the global medical mission. Mongolia, a country often overlooked as an area in need of medical aid, harbors a fertile environment for long-term change. In the last 15-20 years, after the fall of the Union of Soviet Socialist Republics, Mongolia has turned to a free-market healthcare model and has been struggling with the transition from the formally state-run system. These changes have slowed the original progress noted among surgical specialties, namely neurosurgery, in Mongolia. A lack of resources, a desire for international interaction, and a need for technical mentorship remain a real struggle for local neurosurgeons.

METHODS

Under the auspices of the Virtue Foundation (www.virtuefoundation.org), we report on our 3-year experiences during our surgical and teaching mission to Mongolia and look towards long-term improvements in Mongolian neurosurgery.

RESULTS

A total of 15 operations were performed and more than 50 patients seen in clinic during the 3-year experience. Patients ranged from 1 to 77 years of age. No patients encountered any significant peri- or postoperative complications.

CONCLUSIONS

In our experience with the surgical and teaching mission to Mongolia, when directed appropriately, medical missions can serve as the perfect medium in fostering that environment, providing local healthcare professionals with the knowledge, skills, and motivation to create self-sustaining improvement in their own country, hence promoting intellectual and technological advancement and raising the standard of care.

International short-term medical missions: a systematic review of recommended practices

OBJECTIVES

To identify practices for conducting international short-term medical missions (STMMs) recommended in the literature and examine how these link STMMs to recipient countries' existing health systems.

METHODS

Systematic review of PubMed-indexed articles on STMMs and their bibliographies using preferred reporting items for systematic reviews and meta-analyses guidelines. Recommendations were organized using the World Health Organization Health Systems Framework.

RESULTS

In 92 publications, 67 % offered at least one recommendation that would link STMMs to the recipient country's health system. Among these recommendations, most focused on service delivery and few on health financing and governance. There is a lack of consensus around a proper standard of care, patient selection, and trip duration.

CONCLUSIONS

Comprehensive global standards are needed for STMM work to ensure that services are beneficial both to patients and to the broader healthcare systems of recipient countries. By providing an overview of the current recommendations and important gaps where practice recommendations are needed, this study can provide relevant input into the development of global standards for STMMs.