N. Bellamkonda1, G. Motwani2, H. Wange3, C. DeBoer2, F. Kirya3, C. Juillard2, E. Marseille2, M. Ajiko3, R. Dicker1 1David Geffen School Of Medicine, University Of California At Los Angeles,Center For World Health,Los Angeles, CA, USA 2University Of California – San Francisco,Center For Global Surgical Studies, Department Of Surgery,San Francisco, CA, USA 3Soroti Regional Referral Hospital,Department Of Surgery,Soroti, Uganda
Introduction: Surgical disease increasingly contributes to global mortality and morbidity, particularly in low- and middle-income countries (LMICs). Sub-Saharan Africa as a region has the largest percentage of avertable injury-related surgical disease and surgical digestive diseases; however, estimates suggest that the rate of surgical treatment is drastically lower than the burden of disease. While preliminary modeling shows that global surgery has a more favorable cost-effectiveness ratio relative to HIV treatment, for example, the Lancet Commission on Global Surgery found that global cost-effectiveness data is lacking for a wide range of essential surgical procedures. This study aims to address this gap by defining the cost-effectiveness of exploratory laparotomies in the Ugandan context.
Methods: Over a four-month time period, the costs of patients undergoing emergency exploratory laparotomies at the Soroti Regional Referral Hospital in Soroti, Uganda were collected. A time-and-motion analysis was utilized to calculate operating theatre personnel costs per case. Ward personnel, medication, overhead, and supply costs were recorded and calculated using a micro-costing approach. The cost in USD per disability-adjusted-life-years (DALY) averted was then determined.
Results: Data for 60 exploratory laparotomy patients was collected. The most common cause for laparotomy was small bowel obstruction. The average cost per patient was $81.36, which divided into approximately $15 for ward personnel, $20 for medications, $19 for surgical personnel, $20 for admin/ancillary staff, $7 for operative supplies, and $1.32 for utilities. The post-operative mortality rate was 9.8%, and the complication rate was 11.4%. The average number of DALYs averted per patient was 15.44. The cost in USD per DALY averted was $5.27.
Conclusion: This data provides evidence that emergency exploratory laparotomy is cost-effective compared with other surgical interventions and basic public health interventions, such as bed nets for malaria prevention ($6.48-22.04/DALY averted), TB, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY). Given that injury-related surgical disease causes more death than malaria, TB, and HIV combined, this provides a strong argument for greater investment in surgical care on a global scale.