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Roa L, Caddell L, Choksi N, Devi S, Pyda J, Boatin AA, Shrime M. Optimizing availability of obstetric surgical care in India: A cost-effectiveness analysis examining rates and access to Cesarean sections. PLOS Glob Public Health 2022; 2:e0001369. [PMID: 36962905 PMCID: PMC10021835 DOI: 10.1371/journal.pgph.0001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
The objective of this study is to assess the cost-effectiveness of three different strategies with different availabilities of cesarean sections (CS). The setting was rural and urban areas of India with varying rates of CS and access to comprehensive emergency obstetric care (CEmOC) for women of reproductive age in India. Three strategies with different access to CEmOC and CS rates were evaluated: (A) India's national average (50.2% access, 17.2% CS rate), (B) rural areas (47.2% access, 12.8% CS rate) and(C) urban areas (55.7% access, 28.2% CS rate). We performed a first-order Monte Carlo simulation using a 1-year cycle time and 34-year time horizon. All inputs were derived from literature. A societal perspective was utilized with a willingness-to-pay threshold of $1,940. The outcome measures were costs and quality-adjusted life years were used to calculate the incremental cost-effectiveness ratio (ICER). Maternal and neonatal outcomes were calculated. Strategy C with the highest access to CEmOC despite the highest CS rate was cost-effective, with an ICER of 354.90. Two-way sensitivity analysis demonstrated this was driven by increased access to CEmOC. The highest CS rate strategy had the highest number of previa, accreta and ICU admissions. The strategy with the lowest access to CEmOC had the highest number of fistulae, uterine rupture, and stillbirths. In conclusion, morbidity and mortality result from lack of access to CEmOC and overuse of CS. While interventions are needed to address both, increasing access to surgical obstetric care drives cost-effectiveness and is paramount to optimize outcomes.
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Affiliation(s)
- Lina Roa
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, AB, Canada
| | - Luke Caddell
- Department of General Surgery, Stanford University, Stanford, CA, United States of America
| | - Namit Choksi
- Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
- School of Healthcare, Rishihood University, Sonepat, Haryana, India
| | - Shylaja Devi
- Gudalur Adivasi Hospital, Gudalur, Nilgiris, Tamil Nadu, India
| | - Jordan Pyda
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Adeline A Boatin
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Mark Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Witkowski P, Odorico J, Pyda J, Anteby R, Stratta RJ, Schrope BA, Hardy MA, Buse J, Leventhal JR, Cui W, Hussein S, Niederhaus S, Gaglia J, Desai CS, Wijkstrom M, Kandeel F, Bachul PJ, Becker YT, Wang LJ, Robertson RP, Olaitan OK, Kozlowski T, Abrams PL, Josephson MA, Andreoni KA, Harland RC, Kandaswamy R, Posselt AM, Szot GL, Ricordi C. Arguments against the Requirement of a Biological License Application for Human Pancreatic Islets: The Position Statement of the Islets for US Collaborative Presented during the FDA Advisory Committee Meeting. J Clin Med 2021; 10:jcm10132878. [PMID: 34209541 PMCID: PMC8269003 DOI: 10.3390/jcm10132878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/25/2022] Open
Abstract
The Food and Drug Administration (FDA) has been regulating human islets for allotransplantation as a biologic drug in the US. Consequently, the requirement of a biological license application (BLA) approval before clinical use of islet transplantation as a standard of care procedure has stalled the development of the field for the last 20 years. Herein, we provide our commentary to the multiple FDA’s position papers and guidance for industry arguing that BLA requirement has been inappropriately applied to allogeneic islets, which was delivered to the FDA Cellular, Tissue and Gene Therapies Advisory Committee on 15 April 2021. We provided evidence that BLA requirement and drug related regulations are inadequate in reassuring islet product quality and potency as well as patient safety and clinical outcomes. As leaders in the field of transplantation and endocrinology under the “Islets for US Collaborative” designation, we examined the current regulatory status of islet transplantation in the US and identified several anticipated negative consequences of the BLA approval. In our commentary we also offer an alternative pathway for islet transplantation under the regulatory framework for organ transplantation, which would address deficiencies of in current system.
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Affiliation(s)
- Piotr Witkowski
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
- Correspondence: ; Tel.: +1-773-834-3524
| | - Jon Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI 53792, USA;
| | - Jordan Pyda
- Beth Israel Deaconess Medical Center, Department of Surgery, Harvard Medical School, Boston, MA 02115, USA;
| | - Roi Anteby
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Robert J. Stratta
- Section of Transplantation, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA;
| | - Beth A. Schrope
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; (B.A.S.); (M.A.H.)
| | - Mark A. Hardy
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; (B.A.S.); (M.A.H.)
| | - John Buse
- Division of Endocrinology, Department of Medicine, University of NC, Chapel Hill, NC 27516, USA;
| | - Joseph R. Leventhal
- Department of Surgery, Northwestern University School of Medicine, Chicago, IL 60611, USA;
| | - Wanxing Cui
- Cell Therapy Manufacturing Facility, Georgetown University Hospital, Washington, DC 20007, USA;
| | - Shakir Hussein
- Detroit Medical Center, Department of Surgery, Wayne State School of Medicine, Detroit, MI 48201, USA;
| | - Silke Niederhaus
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Jason Gaglia
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA;
| | - Chirag S. Desai
- Department of Surgery, Section of Transplantation, University of NC, Chapel Hill, NC 27516, USA;
| | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Fouad Kandeel
- Department of Translational Research and Cellular Therapeutics, Diabetes and Metabolism Research Institute, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA;
| | - Piotr J. Bachul
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - Yolanda Tai Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - Ling-Jia Wang
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - R. Paul Robertson
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Washington, Seattle, WA 98133, USA;
| | | | - Tomasz Kozlowski
- Division of Transplantation, Department of Surgery, The University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Peter L. Abrams
- MedStar Georgetown Transplant Institute, Washington, DC 20007, USA;
| | | | - Kenneth A. Andreoni
- Department of Surgery, University of Florida, College of Medicine, Gainesville, FL 32610-0118, USA;
- Case Western Reserve University, Cleveland, OH 44106-5047, USA
| | - Robert C. Harland
- Department of Surgery, University of Arizona, Tucson, AZ 85711, USA;
| | - Raja Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Andrew M. Posselt
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (A.M.P.); (G.L.S.)
| | - Gregory L. Szot
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (A.M.P.); (G.L.S.)
| | - Camillo Ricordi
- Diabetes Research Institute and Cell Transplant Center, University of Miami, Miami, FL 33136, USA;
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Anteby R, Lucander A, Bachul PJ, Pyda J, Grybowski D, Basto L, Generette GS, Perea L, Golab K, Wang LJ, Tibudan M, Thomas C, Fung J, Witkowski P. Evaluating the Prognostic Value of Islet Autoantibody Monitoring in Islet Transplant Recipients with Long-Standing Type 1 Diabetes Mellitus. J Clin Med 2021; 10:jcm10122708. [PMID: 34205321 PMCID: PMC8233942 DOI: 10.3390/jcm10122708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 12/03/2022] Open
Abstract
(1) Background: The correlation between titers of islet autoantibodies (IAbs) and the loss of transplanted islets remains controversial. We sought to evaluate the prognostic utility of monitoring IAbs in diabetic patients after islet transplantation (ITx); (2) Methods: Twelve patients with Type 1 diabetes mellitus and severe hypoglycemia underwent ITx. Serum concentration of glutamic acid decarboxylase (GAD), insulinoma antigen 2 (IA-2), and zinc transport 8 (ZnT8) autoantibodies was assessed before ITx and 0, 7, and 75 days and every 3 months post-operatively; (3) Results: IA-2A (IA-2 antibody) and ZnT8A (ZnT8 antibody) levels were not detectable before or after ITx in all patients (median follow-up of 53 months (range 24–61)). Prior to ITx, GAD antibody (GADA) was undetectable in 67% (8/12) of patients. Of those, 75% (6/8) converted to GADA+ after ITx. In 67% (4/6) of patients with GADA+ seroconversion, GADA level peaked within 3 months after ITx and subsequently declined. All patients with GADA+ seroconversion maintained long-term partial or complete islet function (insulin independence) after 1 or 2 ITx. There was no correlation between the presence of IAb-associated HLA haplotypes and the presence of IAbs before or after ITx; (4) Conclusions: There is no association between serum GADA trends and ITx outcomes. IA-2A and ZnT8A were not detectable in any of our patients before or after ITx.
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Affiliation(s)
- Roi Anteby
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Harvard School of Public Health, Boston, MA 02115, USA
| | - Aaron Lucander
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Piotr J. Bachul
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Jordan Pyda
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
| | - Damian Grybowski
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Lindsay Basto
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Gabriela S. Generette
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Laurencia Perea
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Karolina Golab
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Ling-jia Wang
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Martin Tibudan
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Celeste Thomas
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA;
| | - John Fung
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
| | - Piotr Witkowski
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA; (R.A.); (A.L.); (P.J.B.); (D.G.); (L.B.); (G.S.G.); (L.P.); (K.G.); (L.-j.W.); (M.T.); (J.F.)
- Correspondence: ; Tel.: +1-773-702-2447
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Vu MT, Pyda J, Johnson WD. Perspectives on progress in global surgery. ANZ J Surg 2021; 90:1836-1837. [PMID: 33710731 DOI: 10.1111/ans.15490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/15/2019] [Accepted: 08/21/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Megan T Vu
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jordan Pyda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Walter D Johnson
- Emergency and Essential Surgical Care Programme, World Health Organization, Geneva, Switzerland
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Wilson MK, Thosiac JP, Patterson RH, Bowder AN, Pyda J, Dodgion C, Ward LE, Padovany MN. Access to Surgical Care and Late-Presenting Disease in Rural Haiti. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pyda J, Patterson RH, Caddell L, Wurdeman T, Koch R, Polatty D, Card B, Meara JG, Corlew DS. Towards resilient health systems: opportunities to align surgical and disaster planning. BMJ Glob Health 2019; 4:e001493. [PMID: 31275620 PMCID: PMC6577360 DOI: 10.1136/bmjgh-2019-001493] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/08/2019] [Accepted: 05/11/2019] [Indexed: 11/10/2022] Open
Abstract
Natural disasters significantly contribute to human death and suffering. Moreover, they exacerbate pre-existing health inequalities by imposing an additional burden on the most vulnerable populations. Robust local health systems can greatly mitigate this burden by absorbing the extraordinary patient volume and case complexity immediately after a disaster. This resilience is largely determined by the predisaster local surgical capacity, with trauma, neurosurgical, obstetrical and anaesthesia care of particular importance. Nevertheless, the disaster management and global surgery communities have not coordinated the development of surgical systems in low/middle-income countries (LMIC) with disaster resilience in mind. Herein, we argue that an appropriate peridisaster response requires coordinated surgical and disaster policy, as only local surgical systems can provide adequate disaster care in LMICs. We highlight three opportunities to help guide this policy collaboration. First, the Lancet Commission on Global Surgery and the Sendai Framework for Disaster Risk Reduction set forth independent roadmaps for global surgical care and disaster risk reduction; however, ultimately both advocate for health system strengthening in LMICs. Second, the integration of surgical and disaster planning is necessary. Disaster risk reduction plans could recognise the role of surgical systems in disaster preparedness more explicitly and pre-emptively identify deficiencies in surgical systems. Based on these insights, National Surgical, Obstetric, and Anesthesia Plans, in turn, can better address deficiencies in systems and ensure increased disaster resilience. Lastly, the recent momentum for national surgical planning in LMICs represents a political window for the integration of surgical policy and disaster risk reduction strategies.
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Affiliation(s)
- Jordan Pyda
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rolvix H Patterson
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Luke Caddell
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,University of Miami School of Medicine, Miami, Florida, USA
| | - Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,University of Miami School of Medicine, Miami, Florida, USA
| | - Rachel Koch
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Polatty
- Humanitarian Response Program, US Naval War College, Newport, Rhode Island, USA
| | - Brittany Card
- Humanitarian Response Program, US Naval War College, Newport, Rhode Island, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniel Scott Corlew
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
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Caddell L, Wurdeman T, Patterson RH, Pyda J, Koch R, Meara JG, Corlew S. Reporting of surgical response to disasters in low-income and middle-income countries: a literature review. The Lancet Global Health 2019. [DOI: 10.1016/s2214-109x(19)30120-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Koch R, Roa L, Pyda J, Kerrigan M, Barthélemy E, Meara JG. The Bill & Melinda Gates Foundation: An opportunity to lead innovation in global surgery. Surgery 2018; 165:273-280. [PMID: 30316576 DOI: 10.1016/j.surg.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Bill and Melinda Gates Foundation has made unparalleled contributions to global health and human development by bringing together generous funding, strategic partnerships, and innovative leadership. For the last twenty years, the Gates Foundation has supported the expansion of programs that directly address the fundamental barriers to the advancement of marginalized communities around the globe, with a transformative focus on innovations to combat communicable diseases and to ensure maternal and child health. Despite the wide spectrum of programs, the Gates Foundation has not, as of yet, explicitly supported the development of surgical care. METHODS This article explores the pivotal role that the Gates Foundation could play in advancing the emerging global surgery agenda. First, we demonstrate the importance of the Gates Foundation's contributions by reviewing its history, growth, and evolution as a pioneering supporter of global health and human development. Recognizing the Foundation's use of metrics and data in strategic planning and action, we align the priorities of the Foundation with the growing recognition of surgical care as a critical component of efforts to ensure universal health care. RESULTS To promote healthy lives and well-being for all, development of quality and affordable capacity for surgery, obstetrics and anesthesia is more important than ever. We present the unique opportunity for the Gates Foundation to bring its transformative vision and programing to the effort to ensure equitable, timely, and quality surgical care around the world.
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Affiliation(s)
- Rachel Koch
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Lina Roa
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Jordan Pyda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Monica Kerrigan
- Vice President, Jhpiego, Baltimore, MD; Family Planning Strategy, Bill & Melinda Gates Foundation, Seattle, WA
| | - Ernest Barthélemy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
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O'Neill KM, Mandigo M, Pyda J, Nazaire Y, Greenberg SLM, Gillies R, Damuse R. Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study. Surgery 2015; 158:747-55. [PMID: 26150200 DOI: 10.1016/j.surg.2015.04.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 04/10/2015] [Accepted: 04/22/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Women in low- and middle-income countries account for 51% of breast cancer cases globally. These patients often delay seeking care and, therefore, present with advanced disease, partly because of fear of catastrophic health care expenses. Although there have been efforts to make health care affordable in low- and middle-income countries, the financial burden of out-of-pocket (OOP) expenses for nonmedical costs, such as transportation and lost wages, often is overlooked. METHODS An institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. In total, 61 patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were selected via convenience sampling. They were interviewed between March and May 2014 to quantify the expenses they incurred during the course of diagnosis and treatment. These expenses included medical costs at outside facilities, as well as nonmedical costs (eg, transportation, meals, etc). RESULTS The median, nonmedical OOP expenses incurred by breast cancer patients at HUM were $233 (95% confidence interval [95% CI] $170-304) for diagnostic visits, $259 (95% CI $200-533) for chemotherapy visits, and $38 (95% CI $23-140) for surgery visits. The median total OOP expense (including medical costs) was $717 (95% CI $619-1,171). To pay for these expenses, 52% of participants stated that they went into debt; however, the amount of debt was not quantified. The median income of these patients was $1,333 (95% CI $778-2,640), and the median sum of OOP expenses and lost wages was $2,996 (95% CI $1,676-5,179). CONCLUSION Despite receiving free care: at HUM, more than two-thirds of participants met conservative criteria for catastrophic medical expenses (defined as spending more than 40% of their potential household income on OOP payments). Further studies are needed to understand the magnitude of OOP health care expenses for the poor worldwide, how to aid them during their treatment program, and its impact on their health outcomes.
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Affiliation(s)
- Kathleen M O'Neill
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Plastic & Oral Surgery, Boston Children's Hospital, Boston, MA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Morgan Mandigo
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Plastic & Oral Surgery, Boston Children's Hospital, Boston, MA; University of Miami Miller School of Medicine, Miami, FL
| | - Jordan Pyda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Sarah L M Greenberg
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Rowan Gillies
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Department of Plastic & Oral Surgery, Boston Children's Hospital, Boston, MA; Plastic, Reconstructive and Burns, Royal North Shore Hospital, St Leonards, Australia
| | - Ruth Damuse
- Zanmi Lasante/Partners in Health, Mirebalais, Haiti
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Matousek AC, Addington SR, Jean-Louis RRE, Pierre JH, Fils J, Hoyler M, Matousek SB, Pyda J, Farmer PE, Riviello R. The struggle for equity: an examination of surgical services at two NGO hospitals in rural Haiti. Lancet 2015; 385 Suppl 2:S20. [PMID: 26313067 DOI: 10.1016/s0140-6736(15)60815-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Health systems must deliver care equitably to serve the poor. Both L'Hôpital Albert Schweitzer (HAS) and L'Hôpital Bon Sauveur (HBS) have longstanding commitments to provide equitable surgical care in rural Haiti. HAS charges fees that reflect a preference for the rural population near the hospital, with free care available for the poorest. HBS does not charge fees. The two hospitals are otherwise similar in surgical capacity and rural location. Using geography as a proxy for poverty, we analysed the equity achieved under the financial system at both hospitals. METHODS We retrospectively reviewed operative case-logs for general surgery and orthopaedic cases at both hospitals from June 1, to Aug 31, 2012. The records were compared by total number of operations, geographic distribution of patients, and number of elective operations. The service areas were defined as the governmental administrative units closest to both hospitals. For HAS, we analysed the number of operations performed on patients from the most poor and least poor regions within the service area; similarly detailed geographic information was not available from HBS. Rates were compared with χ(2) tests. The Ethics Committees at both hospitals and the Institutional Review Board at Partners Healthcare approved the study. FINDINGS Patients from the rural service area received 306 operations (86·2%) at HAS compared with 149 (38·1%) at HBS (p<0·0001). Only 16 operations (4·5%) at HAS were performed on patients from outside the service area for elective conditions compared with 179 (47·0%) at HBS (p<0·0001). Within its rural service area, HAS performed fewer operations on patients from the most destitute areas compared with other locations (4·0 operations per 10 000 population vs 10·1 operations per 10 000 population; p<0·0001). INTERPRETATION Use of fees as part of an equity strategy will likely disadvantage the poorest patients, while providing care without fees might encourage patients to travel from urban areas that contain other hospitals. Health systems striving to serve the poor should continually evaluate and seek to improve equity, even within systems that provide free care. FUNDING None.
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Affiliation(s)
- Alexi C Matousek
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
| | - Stephen R Addington
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Jacky Fils
- The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Marguerite Hoyler
- The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | | | - Jordan Pyda
- The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Paul E Farmer
- The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Robert Riviello
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; The Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
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O'Neill KM, Mandigo M, Pyda J, Nazaire Y, Greenberg SLM, Gillies R, Damuse R. Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti. Lancet 2015; 385 Suppl 2:S48. [PMID: 26313097 DOI: 10.1016/s0140-6736(15)60843-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Women with breast cancer in low-income and middle-income countries (LMICs) account for 51% of cases globally and often present with advanced disease. Fear of costs contributes to delay in seeking care, as health expenditures are financially catastrophic for families worldwide. Despite efforts to improve affordability of health care in LMICs, the financial burden of indirect costs (eg, transportation and lost wages) is often overlooked. We aimed to identify and quantify the expenditures of patients seeking breast cancer care in a LMIC. METHODS Patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were interviewed to quantify their costs and assess the effect of these costs on patients and families. These costs included expenses for food, lodging, transportation, childcare, medical costs at other institutions, and lost wages. 61 patients were interviewed during diagnostic, chemotherapy, and surgical visits between March 1, and May 12, 2014. Institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante. FINDINGS The median non-medical out-of-pockent expenses incurred by breast cancer patients at HUM were US$233 (95% CI 170-304) for diagnostic visits, US$259 (95% CI 200-533) for chemotherapy, and US$38 (95% CI 23-140) for surgery. The median total out-of-pockent expense (including medical costs) was US$717 (95% CI 619-1171). These costs forced 52% of participants into debt and 20% to sell possessions. The median percentage of potential individual income spent on out-of-pocket costs was 60%. The median sum of out-of-pocket costs and lost wages was US$2996 (95% CI 1676-5179). INTERPRETATION In Haiti, 74% of people earn less than US$2 per day. Even when breast cancer treatment is provided for free, out-of-pocket expenses could account for more than 91% of annual earnings at this income level. This financial burden is an overwhelming obstacle for Haiti's poorest citizens, and probably for many patients in LMICs. High-powered, multisite studies are needed to further characterise this burden worldwide. Funders and health-care providers should reduce indirect costs to achieve equitable access to oncology care. FUNDING Boston Children's Hospital and Partners in Health.
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Affiliation(s)
- Kathleen M O'Neill
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Morgan Mandigo
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA; University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jordan Pyda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Sarah L M Greenberg
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rowan Gillies
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA; Plastic, Reconstructive and Burns, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ruth Damuse
- Zanmi Lasante/Partners in Health, Mirebalais, Haiti
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Mogilevkina I, Jani P, Aboutanos M, Bedada A, Ajuzieogu O, Nasir A, Muchemwa F, Bekele A, Holmer H, Ddungu R, Singh K, Ingabire J, Swaroop M, Ogundele J, Ajiko M, Bush C, Ajuzieogu O, Malemo K, Pemberton J, Livingston M, Nagengast E, Skelton T, Nsereko E, Razek T, Hackenberg B, Twagirumugabe T, Elobu A, Ajuzieogu O, Allen Ingabire JC, Wandwi W, Mwizerwa O, Abdur-Rahman L, Makama J, Ademola S, Ogundele J, Abdur-Rahman L, Lymburner E, Esau D, Bos C, Bos C, Rothstein D, Nikolaou S, Rajkumar S, Westerholm J, Culp A, Baison G, Ong C, Knapp G, Klimovytskyiy F, Prudnikov Y, Jayaraman S, Mata L, Mora F, Ordóñez C, Pino L, Quiodettis M, Morales. C, Hsiao M, Bakanisi B, Motsumi J, Azzie. G, Achi J, Amucheazi A, Ikeani. C, Abdur-Rahman L, Oyedepo O, Arowona L, Alonge D, Rufai Z, Adeniran J, Abraham M, Olatinwo. A, Tadesse A, Gillies R, Meara J, Liljestrand J, Oyerinde K, Hagander. L, Namuddu R, Nakonde I, Mukasa. R, Marbaniang D, Byiringiro J, Calland J, Petrose R, Jayaraman S, Ntakiyiruta. G, Schuetz S, Iss N, Laguna M, Shapiro M, Gallardo. J, Ifesanya A, Riviello E, Irakiza J, Mvukiyehe J, Maine R, Kim W, Manirakiza F, Reshamwalla S, Mwumvaneza T, Kymanaywa P, Ntakiyiruta G, Kiviri W, Finlayson S, Berry W, Twagirumugabe. T, Amucheazi A, Achi J, Ezike H, Salmon M, Salmon C, Mutendi M, Reynolds. T, Frankfurter C, Cameron B, Poenaru D, D’Cruz J, Pemberton J, Ozgediz D, Poenaru. D, Caterson E, Magee W, Hatcher K, Ramos M, Campbell. A, Nshimyumuremyi I, Livingston P, Zolpys L, Mukwesi C, Uwineza. B, Evans. F, Marquis C, Linois-Davidson C, Ramos M, Campbell A, Resch S, Finlayson S, Howaldt H, Caterson. E, Irakiza J, Mvukiyehe J, Maine R, Bush C, Riviello E, Kim W, Manirakiza F, Reshamwalla S, Mwumvaneza T, Kymanaywa P, Ntakiyiruta G, Kiviri W, Finlayson S, Berry. W, Amucheazi A, Achi J, Ikeani. C, Ssebufu R, Kyamanywa P, Bayisenga J, Bikoroti J, Mazimpaka. D, Mpoki U, Muleshe S, Zwane. S, Calland J, Byiringiro J, Ntakiyiruta. G, Nasir A, Adeniran J, Bamigbola K, Irribhogbe P, Ameh. E, Olawoye O, Iyun A, Micheal A, Oluwatosin. O, Adebayo R, Abdulraheem N, Nasir A, Adeniran. J, Cameron B, Ho P, Blair G, Duffy D, O’Hara N, Ajiko M, Kapoor. V, Westerholm. J, Westerholm. J, Baron E, Herard P, Lassalle X, Teicher. C, Maraka J, Asige E, Owori F, Obaikol. R, Maine R, Nsengiyumva E, Ntakiyiruta G, Mubiligi J, Riviello R, Havugimana. J, Chavarri A, Meara J, Pyda J, Shulman L, Damuse R, Pierre. J, Hoogerboord M, Ernest A, Gesase. A. Abstracts of the 13th Bethune Round Table Conference on International Surgery. May 10-11, 2013. Vancouver, British Columbia, Canada. Can J Surg 2013; 56:S44-52. [PMID: 23883512 DOI: 10.1503/cjs.015713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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