Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

The catastrophic cost of motorcycle road traffic injuries: Experience from a major reference centre in a lower-middle income country

BACKGROUND

Motorcycle crashes are an increasing public health problem in low- and middle-income countries (LMICs). An accurate estimation of the economic burden of these crashes could be complex owing to a prevalent system of out-of-pocket (OOP) payment for health care services in these countries. Our study aims to objectively evaluate the cost implication of motorcycle Road Traffic Injuries (RTIs) among road crash victims managed at a major trauma reference hospital in Nigeria. Two economic evaluation methods were used to accurately reflect the cost-of-care (C-o-C) of each victim as well as for cross-validation.

METHOD

This is a prospective cohort study conducted between August 2020 and May 2021. All patients involved in motorcycle road traffic crashes presenting to the Emergency Department of the University College Hospital, Ibadan, Nigeria, were included in the study. For each patient, all medical expenses from the time of injury (T0) to 30 days after injury (T30) or Time to death (TD) - whichever occurred first, were valued in costs, and added (Activity-based costing or ABC), while also estimating overall cost-of-care (C-o-C) at T30 or TD, using the willingness-to-pay (WTP) method. Following the WHO definition, catastrophic expenditure was defined as expenditure > 25% of the patient's estimated annual household income.

RESULTS

Of the 150 consecutively managed motorcycle crashes victims during the study period, 112 had complete data. The median monthly household income for the cohort was $121 with 75% of them earning less than $180. The median cost-of-care (C-o-C), by ABC, was $242 ($143 - 828). For individual care items, expenditure on surgical intervention(s) was the highest followed by prosthesis and implant procurement, and radiological investigations. On the other hand, the estimated medical cost was $2356 (IQR $938 - 6475) by WTP. Only 14% had health insurance coverage. The overall expenditure was catastrophic for 46% of the patients. Monthly household income of < $180 (AOR=9.2; 95% CI=2.6-32.8; p < 0.001), absence of health insurance coverage (AOR=10.7; 95% CI=1.1-101.6; p = 0.040), and prolonged hospital stay above 14 days (AOR=25.1; 95% CI=5.5 -115.1; p = 0.001) were predictors of catastrophic expenditure. There was a weak positive correlation between actual cost-of-care using the ABC method and WTP (r = 0.247; p = 0.102).

CONCLUSION

The aggregate cost of motorcycle RTIs is catastrophic for nearly half of the victims attending the University College Hospital, Ibadan. The willingness-to-pay method, though less tedious is often less reliable in these settings owing to a prevalent OOP payment system. This study identified the need to implement effective financial protection mechanisms against the high OOP expenditure faced by motorcycle crash victims in LMICs.

The Global Anesthesia Workforce Survey: Updates and Trends in the Anesthesia Workforce

BACKGROUND

There is a large global deficit of anesthesia providers. In 2016, the World Federation of Societies of Anaesthesiologists (WFSA) conducted a survey to count the number of anesthesia providers worldwide. Much work has taken place since then to strengthen the anesthesia health workforce. This study updates the global count of anesthesia providers.

METHODS

Between 2021 and 2023, an electronic survey was sent to national professional societies of physician anesthesia providers (PAPs), nurse anesthetists, and other nonphysician anesthesia providers (NPAPs). Data included number of providers and trainees, proportion of females, and limited intensive care unit (ICU) capacity data. Descriptive statistics were calculated by country, World Bank income group, and World Health Organization (WHO) region. Provider density is reported as the number of providers per 100,000 population.

RESULTS

Responses were obtained for 172 of 193 United Nations (UN) member countries. The global provider density was 8.8 (PAP 6.6 NPAP 2.3). Seventy-six countries had a PAP density <5, whereas 66 countries had a total provider density <5. PAP density increased everywhere except for high- and low-income countries and the African region.

CONCLUSIONS

The overall size of the global anesthesia workforce has increased over time, although some countries have experienced a decrease. Population growth and differences in which provider types that are counted can have an important impact on provider density. More work is needed to define appropriate metrics for measuring changes in density, to describe anesthesia cadres, and to improve workforce data collection processes. Effort to scale up anesthesia provider training must urgently continue.

Perioperative medicine: challenges and solutions for global health

The emerging field of perioperative medicine has the potential to make significant contributions to global health. Perioperative medicine aims to help reduce unmet surgical need, decrease variation in quality and systematically improve patient outcomes. These aims are also applicable to key challenges in global health, such as limited access to surgical care, variable quality and workforce shortages. This article describes the areas in which perioperative medicine can contribute to global health using case studies of successful care pathways, risk prediction tools, strategies for effective grassroots research and novel workforce approaches aimed at effectively using limited resources.

Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa

BACKGROUND

Out-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient.

METHODS

A prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child's surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure.

RESULTS

In all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308-2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26-174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child's surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002).

CONCLUSION

A full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.

Obstetric anaesthesia manpower and service provision issues (introduction and European perspective)

Global health is an important and far-reaching concept in which health and access to surgical and anaesthetic care is crucial. Universal access to anaesthesia is a challenge in many countries. Manpower shortages are an important cause of difficulties and each European country has found different ways of facing a lack of healthcare professionals. In obstetric anaesthesia, the availability of competent anaesthesiologists has been related to the morbidity and mortality outcomes of patients. In this narrative review, authors from different European countries explain how manpower is managed in obstetric anaesthesia in delivery suites and obstetric operating rooms in different settings. To address manpower difficulties and issues, the goals are to achieve a minimum standard of care and at the same time, to promote clinical excellence through training, delegation to younger or less experienced colleagues, direct or at-a-distance supervision, or other means. The experience of sharing knowledge about the way in which manpower and service provision are organised in other healthcare settings is a significant opportunity to develop strategies for advancing tomorrow's obstetric anaesthesia in the world. While taking into account the level of socio-economic development in different countries, the aim is to standardise practice and workload organisation. Co-operative international projects in training and education in obstetric anaesthesia are ways in which better obstetric patient care can be achieved in the future.

Evaluating the status of the Lancet Commission on Global Surgery indicators for India

For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.

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.

Teaching and Learning Obstetric Anaesthesia in Low- and Middle-Income Countries: Current Situation and Perspectives

Purpose of Review

Our goal in this review is to describe the current context and peculiarities of obstetric anaesthesia in low- and middle-income countries (LMIC) and the ongoing actions and perspectives in terms of teaching and learning, focusing on improving maternal outcomes.

Recent Findings

Correct identification of barriers and lack of infrastructures and anaesthesia providers are still major problems despite efforts of different stakeholders. International consensus and commitment for 2030 goals are trying to be achieved.

Summary

Structured training courses look a good option as short- and long-term evaluations show a positive impact. Future efforts will have to be also focused on indicators that may help to decrease the high mortality and morbidity ratios in LMIC.

Quality indicators for anesthesia and perioperative medicine

PURPOSE OF REVIEW

Routine monitoring of care quality is fundamental considering the high reported rates of preventable perioperative morbidity and mortality. However, no set of valid and feasible quality indicators is available as the gold standard for comprehensive routine monitoring of the overall quality of perioperative care. The purpose of this review is to describe underlying difficulties, to summarize current trends and initiatives and to outline the perspectives in support of suitable perioperative quality indicators.

RECENT FINDINGS

Most perioperative quality indicators used in the clinical setting are based on low or no evidence. Evidence-based perioperative quality indicators validated for research purposes are not always applicable in routine care. Developing a core set of perioperative quality indicators for clinical practice may benefit from matching feasible routine indicators with evidence-based indicators validated for research, from evaluating additional new indicators, and from including patients' views.

SUMMARY

A core set of valid and feasible quality indicators is essential for monitoring perioperative care quality. The development of such a set may benefit from matching evidence-based indicators with feasible standard indicators and from including patients' views.

Determining the Minimum Dataset for Surgical Patients in Africa: A Delphi Study

BACKGROUND

It is often difficult for clinicians in African low- and middle-income countries middle-income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry.

METHODS

A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds).

RESULTS

Forty-one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk-adjusted perioperative mortality rate was also described.

CONCLUSIONS

The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.

Monitoring Indicators of Universal Access to Accessible and Safe Anesthetic and Surgical Care in a Peruvian Region: An Ambispective Study

INTRODUCTION

The Lancet Commission on Global Surgery indicators for monitoring anesthetic and surgical care allow the identification of access barriers, evaluate the safety of surgeries, facilitate planning, and assess changes over time. The primary objective was to measure these indicators in all health facilities of a Peruvian region in 2020.

METHODS

This was an ambispective observational study to measure the anesthetic and surgical care indicators in Piura, a region in Peru, between January 2020 and June 2021. Public and private health facilities in the Piura region that performed surgical care or had specialists from any surgical specialty participated in the study. Data were collected from all regional health facilities that provided surgical care to estimate the density of surgical workforce. Likewise, the percentage of the population with access to an operating room within 2 h was estimated using georeferenced tools. Finally, a public database was accessed to determine the surgical volume, the percentage of the regional population protected with health insurance.

RESULTS

In 2020, 88.4% of the inhabitants of this Peruvian region had access to timely essential surgery. There were 18.4 surgical specialists and 1174 surgeries per 100,000 populations, and 91% of the population had health insurance. In addition, there was a rate of 2.1 working operating rooms per 100,000 inhabitants in 2021.

CONCLUSIONS

This Peruvian region presented an increasing trend with respect to the population's access to essential and timely surgical care, and health insurance coverage. However, the workforce distribution was inequitable among the provinces of the region, the surgical volume was reduced, and timely access was hindered because of the SARS-CoV-2 pandemic.

Timely Access to Essential Surgery, Surgical Workforce, and Surgical Volume: Global Surgery Indicators in Mexico

INTRODUCTION

The Lancet Commission on Global Surgery seeks to improve surgical care outcomes and equity for the world population through 6 indicators outlined in its 2030 Global Surgery Report. Our study aimed to estimate the percentage of the Mexican population with access to surgical care within the 2-hour distance range (indicator 1), the surgical workforce density (indicator 2), and the number of surgical procedures performed per 100,000 inhabitants (indicator 3) during the year 2020. Knowing these indicators can help to design and implement policies to increase surgical care access coverage and equity in our country.

METHODS

Data related to population distribution, local referral hospitals, and surgical volume were obtained from the 2020 Mexican National Census. Information relating to hospital characteristics and surgical specialists was collected from the Secretariat of Health's public records. We calculated travel time between health care facilities and municipalities using the TrueWay Matrix API and R Studio.

RESULTS

Taking into consideration the health care system affiliation, the proportion of the Mexican population with timely access to essential surgery was 81.7%, with 29.3 specialists per 100,000 inhabitants and 726.9 annual procedures performed per 100,000 inhabitants. We identified clusters of municipalities where a low proportion of the population has timely access to essential surgery.

CONCLUSION

These findings illustrate that changes in Mexican policy are required to facilitate more equitable and timely access to essential surgical care among the population.

Indications, Challenges, and Characteristics of Successful Implementation of Perioperative Registries in Low Resource Settings: A Systematic Review

Perioperative registries can be utilised to track outcomes, develop risk prediction models, and make evidence-based decisions and interventions. To better understand and support initiatives to establish clinical registries, this study aimed to assess the indications, challenges, and characteristics of successful perioperative registries in low-resource settings, where there is unmet surgical demand and patients have a mortality rate up to double that of high-income countries. We conducted a librarian-assisted literature search of international research databases of articles published between January 1969 and January 2021. Studies were filtered using predefined criteria and responses to two Mixed Method Appraisal Tool screening questions. A Direct Content Analysis Method was used to synthesis. e data for eligible studies based on predefined criteria. The search identified 2793 abstracts. After removing duplicates and excluding studies that did not meet eligibility criteria, twelve studies were included, conducted in South America (n = 4), Africa (n = 5), the Middle East (n = 2), and Asia (n = 1). The lack of context-specific data for determining and evaluating patient outcomes (n = 7) was the major indication for implementation. Organising local research teams and engaging stakeholders in the host country were associated with successful implementation. Inadequate funding for data collectors and monitoring data quality were identified as challenges (n = 4). The goal of a perioperative registry is to generate data to influence and support quality improvement, and national surgical policies. Efforts to establish perioperative registries in low- and middle-income countries should engage local teams and stakeholders and seek to overcome challenges in data collection and monitoring.

Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

Elective Courses in Global Surgery for Undergraduate Medical Students: A Narrative Review and a Proposal for European Universities

Global surgery (GS) is the discipline of improving health by expanding universal access to surgical care. GS is an essential part of the global health (GH) concept, but it is almost invariably neglected in academic settings. This review assesses the engagement of undergraduate medical students in the field of GS. PubMed, Embase, and Web of Science were searched with focus on electives organized by universities and only eight results were found. The scientific literature on this topic is scarce and uneven, and the number of students involved in these experiences is considerably low. Although few, the existing electives prove that building sustainable and useful GS projects is possible and that both students from high-income countries (HICs) and low-income and middle-income countries (LMICs) can extensively benefit from these experiences. Given the currently low involvement of European universities and medical schools, of which the authors are part, this review aims at encouraging European universities to organize GS electives for their students. In addition, this review suggests key activities to undertake in such electives including theoretical sections, research projects, and bilateral international rotations between HICs and LMICs.

Global pediatric surgery and anesthesia inequities: how do we have a global effort?

PURPOSE OF REVIEW

The SARS-CoV-2 (COVID-19) pandemic has highlighted the inequities in access to healthcare while also revealing our global connectivity. These inequities are emblematic of decades of underinvestment in healthcare systems, education, and research in low-middle income countries (LMICs), especially in surgery and anesthesiology. Five billion people remain without access to safe surgery, and we must take appropriate action now.

RECENT FINDINGS

The pediatric perioperative mortality in low-resourced settings may be as high as 100 times greater than in high-resourced settings, and a pediatric surgery workforce density benchmark of 4/1 million population could increase survivability to over 80%. Delay in treatment for congenital surgically correctable issues dramatically increases disability-adjusted life years. Appropriate academic partnerships which promote education are desired but the lack of authorship position priority for LMIC-based researchers must be addressed. Five perioperative benchmark indicators have been published including: geospatial access to care within 2 h of location; workforce/100,000 population; volume of surgery/100,000 population; perioperative mortality within 30 days of surgery or until discharged; and risks for catastrophic expenditure from surgical care.

SUMMARY

Research that determines ethical and acceptable partnership development between high- and low-resourced settings focusing on education and capacity building needs to be standardized and followed.

Access to care following injury in Northern Malawi, a comparison of travel time estimates between Geographic Information System and community household reports

INTRODUCTION

Injuries disproportionately impact low- and middle-income countries like Malawi. The Lancet Commission on Global Surgery's indicators include the population proportion accessing laparotomy and open fracture care, key trauma interventions, within two hours. The "Golden Hour" for receiving facility-based resuscitation also guides injury care system strengthening. Firstly, we estimated the proportion of the local population able to reach primary, secondary and tertiary facility care within two and one hours using Geographic Information System (GIS) analysis. Secondly, we compared community household-reported with GIS-estimated travel time.

METHODS

Using information from a Health and Demographic Surveillance Site (Karonga, Malawi) on road network, facility location, and local staff-estimated travel speeds, we used a GIS-generated friction surface to calculate the shortest travel time from all households to each facility serving the population. We surveyed community households who reported travel time to their preferred, closest, government secondary and tertiary facilities. For recently injured community members, time to reach facility care was recorded. To assess the relationship between community household-reported travel time and GIS-estimated travel time, we used linear regression to generate a proportionality constant. To assess associations and agreement between injured patient-reported and GIS-estimated travel time, we used Kendall rank and Cohen's kappa tests.

RESULTS

Using GIS, we estimated 79.1% of households could reach any secondary facility, 20.5% the government secondary facility, and 0% the government tertiary facility, within two hours. Only 28.2% could reach any secondary facility within one hour, 0% for the government secondary facility. Community household-reported travel time exceeded GIS-estimated travel time. The proportionality constant was 1.25 (95%CI 1.21-1.30) for the closest facility, 1.28 (95%CI 1.23-1.34) for the preferred facility, 1.45 (95%CI 1.33-1.58) for the government secondary facility, and 2.12 (95%CI 1.84-2.41) for tertiary care. Comparing injured patient-reported with GIS-estimated travel time, the correlation coefficient was 0.25 (SE 0.047) and Cohen's kappa was 0.15 (95%CI 0.078-0.23), suggesting poor agreement.

DISCUSSION

Most households couldn't reach government secondary care within recognised thresholds indicating poor temporal access. Since GIS-estimated travel time was shorter than community-reported travel time, the true proportion may be lower still. GIS derived estimates of population emergency care access in similar contexts should be interpreted accordingly.

Global surgery is an essential component of global health

Global surgery as an essential component of global health. Global surgery is the study and practice of improving access to timely, quality, and affordable surgical care. It emphasizes horizontal health systems strengthening through addressing a range of health challenges in surgical care that improve health outcomes, particularly in vulnerable populations. Global surgery specifically contributes to achievement of the Sustainable Development Goals 2030 (SDGs) by addressing the elimination of poverty (SDG 1), ensuring good health and well-being (SDG 3), promoting decent work and economic growth (SDG 8), and reducing inequalities (SDGs 5 and 10). Global surgery issues transcend national boundaries and intersect with other global health issues such as migration and the COVID-19 pandemic. These issues are nested in a highly politicised environment, therefore power and politics should be considered when identifying problems and solutions. Despite evidence of its importance, the global surgery network has not generated substantial attention and resources compared to other global health networks. Global surgery can further increase its effectiveness through linking with health systems strengthening agendas, and identifying unified solutions to improve access to quality surgical care in low- and middle-income countries. Global surgery is indispensable in the achievement of health and well-being for all.