S. Saluja4,5,6, S. Mukhopadhyay4,6,8, A. Silverstein4,6,10, Y. Lin4,6,9, R. Sood4,6,10, N. Raykar3,6, P. Moberger12, J. Von Schreeb11, J. G. Meara4,6, M. G. Shrime6,7 3Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 4Children’s Hospital Boston,Department Of Plastic Surgery,Boston, MA, USA 5Weill Cornell Medical College,Department Of Surgery,New York, NY, USA 6Harvard Medical School,Program In Global Surgery And Social Change,Boston, MA, USA 7Massachusetts Eye And Ear Infirmary,Boston, MA, USA 8University Of Connecticut,Department Of Surgery,Storrs, CT, USA 9University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA 10University Of Miami,Miami, FL, USA 11Karolinska Institutet,Health System And Policy Research,Stockholm, , Sweden 12Uppsala University,Department Of Surgery,Uppsala, , Sweden
Introduction:
In recent years, there has been a large and successful movement towards putting surgery on the global health agenda. Thus far much work has focused on improving access to care. The study of surgical quality, however, remains a nascent field, especially in low- and middle-income countries. We systematically evaluate the literature assessing surgical quality in LMIC and discuss possible areas for further investigation.
Methods:
We conducted a search of the English language literature published after January 1, 2000 using Medline and Embase. MeSH, Emtree, and individual word searches were used to capture three domains: quality of care, surgical procedure, and low- and middle-income country. We included studies evaluating surgeries that comprise the DCP-3 Essential Surgery Package for first level hospitals, excluding studies of thoracostomy, colposcopy, and vacuum extraction/forceps delivery. Furthermore, we excluded any study where all patients did not undergo surgical intervention. The data extracted included: sample size, study design, type of surgery performed, and whether processes or outcomes were evaluated. We further determined whether authors evaluated checklist utilization, mortality, morbidity, or health-related quality of life (HRQL). Our search and extraction followed PRISMA guidelines.
Results:
Our search identified a total of 4885 articles; 301 studies remained for data extraction after title and abstract screening. The mean sample size of the studies was 1841 patients (SD 9359.7) with a median of 104 patients. 78.2% of studies were observational, of which 55.6% were retrospective. 28.9% of studies evaluated multiple surgical procedures. Studies of operative fracture reduction (11.9%), hernia surgery (11.2%), Cesarean sections (11.2%), and laparotomy for perforated viscus (10.9%) were the most common of the DCP-3 procedures evaluated. There were no studies evaluating quality for patients specifically undergoing escharotomy/fasciotomy and only one study each for dilation & curettage, skin graft, vasectomy, and debridement of osteomyelitis. We found process-based measures reported in 10.3% of studies; 99% of studies reported outcomes-based measures. Amongst studies reporting processes, 22.6% were of checklists. Amongst studies reporting outcomes, mortality was reported in 47.2%, morbidity in 88.0% and HRQL in 16.3%.
Conclusion:
As LMICs expand access to surgical care, there must be a directed effort to monitor the care delivered. Studies of surgical quality vary greatly in size, but many are small. The vast majority of these studies are observational in design. Further, HRQL and process-based measures are frequently overlooked dimensions of quality, while numerous essential surgeries are underrepresented in the literature. Future studies should expand on these parameters to close gaps in the literature.