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Sykes AG, Seyi-Olajide J, Ameh EA, Ozgediz D, Abbas A, Abib S, Ademuyiwa A, Ali A, Aziz TT, Chowdhury TK, Abdelhafeez H, Ignacio RC, Keller B, Klazura G, Kling K, Martin B, Philipo GS, Thangarajah H, Yap A, Meara JG, Bundy DAP, Jamison DT, Mock CN, Bickler SW. Estimates of Treatable Deaths Within the First 20 Years of Life from Scaling Up Surgical Care at First-Level Hospitals in Low- and Middle-Income Countries. World J Surg 2022; 46:2114-2122. [PMID: 35771254 PMCID: PMC9334432 DOI: 10.1007/s00268-022-06622-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life. METHODS Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. RESULTS An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. CONCLUSIONS Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.
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Affiliation(s)
| | | | - Emmanuel A Ameh
- Division of Pediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
| | - Doruk Ozgediz
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Simone Abib
- Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Adesoji Ademuyiwa
- Department of Surgery, College of Medicine, University of Lagos, Lagos, Nigeria
| | | | | | | | | | - Romeo C Ignacio
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego School of Medicine, 9500 Gilman Drive #0739, La Jolla, San Diego, CA, 92093-0739, USA
| | - Benjamin Keller
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego School of Medicine, 9500 Gilman Drive #0739, La Jolla, San Diego, CA, 92093-0739, USA
| | - Greg Klazura
- Loyola University Medical Center, Chicago, IL, USA
| | - Karen Kling
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego School of Medicine, 9500 Gilman Drive #0739, La Jolla, San Diego, CA, 92093-0739, USA
| | - Benjamin Martin
- Department of Paediatric Surgery and Urology, Bristol Children's Hospital, Bristol, UK
| | | | - Hariharan Thangarajah
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego School of Medicine, 9500 Gilman Drive #0739, La Jolla, San Diego, CA, 92093-0739, USA
| | - Ava Yap
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Donald A P Bundy
- Global Research Consortium for School Health and Nutrition, London School of Hygiene and Tropical Medicine, London, UK
| | - Dean T Jamison
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - Stephen W Bickler
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego School of Medicine, 9500 Gilman Drive #0739, La Jolla, San Diego, CA, 92093-0739, USA.
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2
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Breedt DS, Odland ML, Bakanisi B, Clune E, Makgasa M, Tarpley J, Tarpley M, Munyika A, Sheehama J, Shivera T, Biccard B, Boden R, Chetty S, de Waard L, Duys R, Groeneveld K, Levine S, Mac Quene T, Maswime S, Naidoo M, Naidu P, Peters S, Reddy CL, Verhage S, Muguti G, Nyaguse S, D'Ambruoso L, Chu K, Davies JI. Identifying knowledge needed to improve surgical care in Southern Africa using a theory of change approach. BMJ Glob Health 2021; 6:bmjgh-2021-005629. [PMID: 34130990 PMCID: PMC8208008 DOI: 10.1136/bmjgh-2021-005629] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022] Open
Abstract
Surgical healthcare has been prioritised in the Southern African Development Community (SADC), a regional intergovernmental entity promoting equitable and sustainable economic growth and socioeconomic development. However, challenges remain in translating political prioritisation into effective and equitable surgical healthcare. The AfroSurg Collaborative (AfroSurg) includes clinicians, public health professionals and social scientists from six SADC countries; it was created to identify context-specific, critical areas where research is needed to inform evidence-grounded policy and implementation. In January 2020, 38 AfroSurg members participated in a theory of change (ToC) workshop to agree on a vision: ‘An African-led, regional network to enable evidence-based, context-specific, safe surgical care, which is accessible, timely, and affordable for all, capturing the spirit of Ubuntu[1]’ and to identify necessary policy and service-delivery knowledge needs to achieve this vision. A unified ToC map was created, and a Delphi survey was conducted to rank the top five priority knowledge needs. In total, 45 knowledge needs were identified; the top five priority areas included (1) mapping of available surgical services, resources and providers; (2) quantifying the burden of surgical disease; (3) identifying the appropriate number of trainees; (4) identifying the type of information that should be collected to inform service planning; and (5) identifying effective strategies that encourage geographical retention of practitioners. Of the top five knowledge needs, four were policy-related, suggesting a dearth of much-needed information to develop regional, evidenced-based surgical policies. The findings from this workshop provide a roadmap to drive locally led research and create a collaborative network for implementing research and interventions. This process could inform discussions in other low-resource settings and enable more evidenced-based surgical policy and service delivery across the SADC countries and beyond.
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Affiliation(s)
- Danyca Shadé Breedt
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Balisi Bakanisi
- Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Edward Clune
- Department of Anaesthesia, University of Botswana, Gaborone, Botswana
| | | | - John Tarpley
- Department of Surgery, University of Botswana, Gabarone, Botswana
| | - Margaret Tarpley
- Department of Medical Education, University of Botswana, Gaborone, Botswana
| | - Akutu Munyika
- Department of Surgery, University of Namibia, Windhoek, Namibia.,Department of Surgery, Onandjokwe Lutheran Hospital, Oniipa, Namibia
| | | | | | - Bruce Biccard
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Regan Boden
- Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Sean Chetty
- Anaesthesiology and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Liesl de Waard
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rowan Duys
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Kristin Groeneveld
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Susan Levine
- Department of Anthropology, Humanities Faculty, University of Cape Town, Cape Town, South Africa
| | - Tamlyn Mac Quene
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Salome Maswime
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Megan Naidoo
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Priyanka Naidu
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Shrikant Peters
- Executive Management, Groote Schuur Hospital, Department of Public Health and Familiy Medicine, University of Cape Town, Cape Town, South Africa
| | - Ché L Reddy
- Harvard Medical School, Boston, Massachusetts, USA
| | - Savannah Verhage
- Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Godfrey Muguti
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shingai Nyaguse
- Division of Anaesthesia, Parirenyatwa Hospital, Harare, Zimbabwe
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Kathryn Chu
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Perera SK, Jacob S, Sullivan R, Barton M. Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis. Lancet Oncol 2021; 22:173-181. [PMID: 33485459 DOI: 10.1016/s1470-2045(20)30589-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/31/2020] [Accepted: 09/21/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model. METHODS We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006-12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations. FINDINGS Surgical treatment was indicated in 58% (95% CI 57-59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17-27) for prostate cancer to 99% (96-99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (-14%). INTERPRETATION The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences. FUNDING University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.
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Affiliation(s)
- Sathira Kasun Perera
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
| | - Susannah Jacob
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Richard Sullivan
- Institute of Cancer Policy, School of Cancer Sciences, Kings College London, London, UK
| | - Michael Barton
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute of Applied Medical Research, South West Clinical School, University of New South Wales, Sydney, NSW, Australia
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de Burlet KJ, Ing AJ, Larsen PD, Dennett ER. Systematic review of diagnostic pathways for patients presenting with acute abdominal pain. Int J Qual Health Care 2019; 30:678-683. [PMID: 29668935 DOI: 10.1093/intqhc/mzy079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 04/03/2018] [Indexed: 12/12/2022] Open
Abstract
Purpose Abdominal pain is the most common reason for surgical referral. Imaging, aids early diagnosis and treatment. However unnecessary requests are associated with increased costs, radiation exposure and increased length of stay. Pathways can improve the quality of the diagnostic process. The aim of this systematic review was to identify the current evidence for diagnostic pathways and their use of imaging and effect on final outcomes. Data sources A systematic search of Embase, Medline and Cochrane databases was performed using keywords and MeSH terms for abdominal pain. Study selection All papers describing a pathway and published between January 2000 and January 2017 were included. Data extraction Data was obtained about the use of imaging, complications and length of stay. Quality assessment was performed using MINORS and Level of Evidence. Results Ten articles were included, each describing a different pathway. Five studies based the pathway on literature reviews alone and five studies on the results of their prospective study. Of the latter five studies, four showed that routine imaging increased diagnostic accuracy, but without showing a reduction in length of stay, complication rate or mortality. None of the studies included evaluated use of hospital resources or costs. Conclusion Pathways incorporating routine imaging will improve early diagnosis, but has not been proven to reduce complication rates or hospital length of stay. On the basis of this systematic review conclusions can therefore not be drawn about the pathways described and their benefit to the diagnostic process for patients presenting with abdominal pain.
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Affiliation(s)
- Kirsten J de Burlet
- Department of General Surgery, Capital and Coast DHB Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Andrew J Ing
- Department of General Surgery, Capital and Coast DHB Wellington, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Elizabeth R Dennett
- Department of General Surgery, Capital and Coast DHB Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
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5
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de Burlet KJ, Desmond B, Harper SJ, Larsen PD, Dennett ER. Patients requiring an acute operation: where are the delays in the process? ANZ J Surg 2018; 88:865-869. [PMID: 29984457 DOI: 10.1111/ans.14718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/29/2018] [Accepted: 05/01/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Delays to surgery for patients requiring an acute operation are associated with increased morbidity and mortality. A recent study from our institution observed long waiting times for patients booked for an acute operation. The aim of this study was to evaluate the patient's progress from presentation to arrival in the operating theatre and to identify where delays occurred. METHODS Patients undergoing acute general surgery between July 2016 and May 2017 were studied. Data were obtained for time of presentation, imaging, theatre and booking. A time interval from presentation to booking for theatre of greater than 6 h was defined as a diagnostic delay. A time interval from booking to theatre greater than the category defined time (four-level priority system) was defined as a logistic delay. RESULTS A total of 683 patients were included. A diagnostic delay was observed in 55.1%. This occurred more frequently in patients who required imaging prior to their operation (82.5 versus 41.1%, P < 0.001). Logistic delay occurred in 31.0% of the patients, and this was most common for patients booked as a category 3 (requiring surgery within 6 h, 41.8%, P < 0.001). Patients who had a diagnostic delay were significantly more likely to have a post-operative complication compared to patients who did not (17.2 versus 10.0%, P = 0.009). CONCLUSION There are significant delays associated with patients presenting to the acute general surgery service and their transition to theatre. Addressing both the diagnostic and the logistic delays in our institution should result in a significant improvement in patient care.
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Affiliation(s)
- Kirsten J de Burlet
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Brendan Desmond
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Simon J Harper
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Elizabeth R Dennett
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
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6
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de Burlet KJ, Crane G, Cullinane R, Larsen PD, Dennett ER. Review of appendicectomies over a decade in a tertiary hospital in New Zealand. ANZ J Surg 2017; 88:1253-1257. [PMID: 28994178 DOI: 10.1111/ans.14203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/23/2017] [Accepted: 07/26/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute appendicectomy is the most common emergency operation for patients with abdominal pain. In the last decade, computed tomography (CT) scans have increasingly been used to aid in the diagnosis in order to reduce the negative appendicectomy rate. The aim of this study was to evaluate our institution's negative appendicectomy rate and the use of pre-operative imaging. METHODS A retrospective review was undertaken for all adult patients (>16 years), who underwent an appendicectomy on emergency basis in the years 2004, 2009 and 2014. Cases were identified from the hospital electronic theatre record system. Data were also obtained from the patients records and laboratory reports. RESULTS A total of 874 patients were included, 227 in 2004, 308 in 2009 and 339 in 2014. The negative appendicectomy rate was 29.1% in 2004, 20.1% in 2009 and 19.5% in 2014 (P = 0.014). Negative appendicectomies were more common in women (P = <0.001), patients between the ages of 16-30 years (P = <0.001) and were associated with low inflammatory markers (median white cell count of 10.2, C-reactive protein of 8, P = <0.001). The use of CT scan prior to operation increased between 2009 and 2014 (34 (11.0%) versus 64 (18.9%), P = <0.001). CONCLUSION Though the number of appendicectomies being performed in our institution has increased over the last decade, the negative appendicectomy rate remains fairly static and the increased use of CT scans did not further decrease the proportion of negative appendicectomies between 2009 and 2014.
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Affiliation(s)
- Kirsten J de Burlet
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Grant Crane
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Ruth Cullinane
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Elizabeth R Dennett
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
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Rose J, Weiser TG, Hider P, Wilson L, Gruen RL, Bickler SW. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health 2015; 3 Suppl 2:S13-20. [PMID: 25926315 PMCID: PMC5746187 DOI: 10.1016/s2214-109x(15)70087-2] [Citation(s) in RCA: 249] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Surgery is a foundational component of health-care systems. However, previous efforts to integrate surgical services into global health initiatives do not reflect the scope of surgical need and many health systems do not provide essential interventions. We estimate the minimum global volume of surgical need to address prevalent diseases in 21 epidemiological regions from the Global Burden of Disease Study 2010 (GBD). METHODS Prevalence data were obtained from GBD 2010 and organised into 119 disease states according to the WHO's Global Health Estimate (GHE). These data, representing 187 countries, were then apportioned into the 21 GBD epidemiological regions. Using previously defined values for the incident need for surgery for each of the 119 GHE disease states, we calculate minimum global need for surgery based on the prevalence of each condition in each region. FINDINGS We estimate that at least 321·5 million surgical procedures would be needed to address the burden of disease for a global population of 6·9 billion in 2010. Minimum rates of surgical need vary across regions, ranging from 3383 operations per 100 000 in central Latin America to 6495 operations per 100 000 in western sub-Saharan Africa. Global surgical need also varied across subcategories of disease, ranging from 131 412 procedures for nutritional deficiencies to 45·8 million procedures for unintentional injuries. INTERPRETATION The estimated need for surgical procedures worldwide is large and addresses a broad spectrum of disease states. Surgical need varies between regions of the world according to disease prevalence and many countries do not meet the basic needs of their populations. These estimates could be useful for policy makers, funders, and ministries of health as they consider how to incorporate surgical capacity into health systems. FUNDING US National Institutes of Health.
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Affiliation(s)
- John Rose
- Division of Pediatric Surgery, Radys Children's Hospital, University of California, San Diego, CA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas G Weiser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Phil Hider
- Department of Population Health, University of Otago, Christchurch, New Zealand; Perioperative Mortality Review Committee, Health Quality and Safety Commission, Wellington, New Zealand
| | - Leona Wilson
- Perioperative Mortality Review Committee, Health Quality and Safety Commission, Wellington, New Zealand; Department of Anesthesia, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Russell L Gruen
- National Trauma Research Institute, Alfred and Monash University, Melbourne, VIC, Australia; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Stephen W Bickler
- Division of Pediatric Surgery, Radys Children's Hospital, University of California, San Diego, CA, USA.
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