98.16 Perceptions of Quality in Health Care at the Volta River Authority Hospital, Ghana

Posted on January 31, 2019

M. G. Katz1, C. Spangler1, T. Valmont3, C. Arhinful3, S. Manortey2, S. Talboys2, R. Price1, S. Finlayson1, B. Smith1, M. McCrum1  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2Ensign College of Public Health,Kpong, EASTERN REGION, Ghana 3Volta River Authority Hospital,Department Of Surgery,Akosombo, EASTERN REGION, Ghana

Introduction:

Quality improvement is an essential component of surgical capacity building in low-and middle-income countries.  As quality of care may be viewed differently in this environment, developing a shared understanding of this concept and priorities for intervention is key to designing appropriate interventions and building global partnerships.  The Volta River Authority Hospital in Ghana holds a regional reputation for high-quality care.  We sought to understand provider perspectives of health care quality in this resource-limited setting.

Methods:

Semi-structured interviews were conducted with physicians, nurses and staff at the VRAH to explore perceptions of the meaning and importance of quality in health care.  Interviews were transcribed and qualitatively analyzed using emergent theme analysis.

Results:

Fourteen staff members weresurveyed. Patient-centeredness was a common theme, with most participants describing patient satisfaction as an essential element of quality care. While basic resources were mentioned as a challenge by most subjects, all agreed that resource limitations should not be a barrier to pursuing continuous quality improvement. Subjects stressed the importance of outcome measurement to support quality improvement, but acknowledgedthat a robust mechanism to do so is currently lacking. 

Conclusion:

Qualitative evaluation of perceptions of health care quality at VRAH reveal a focus on exceptional patient experience despite concerns specific to a low-resource setting.  All staff felt that delivering high-quality care is feasible in a resource-limited environment, and that outcome measurement should be prioritized.  These findings will inform efforts to design effective quality improvement initiatives at VRAH. Future work is needed to determine if these perceptions of quality are common across low-resource settings.

98.05 Early Qualitative Outcomes of Clean Cut, a Lifebox Surgical Safety Improvement Program in Ethiopia

Posted on January 31, 2019

A. Mattingly1, N. Starr2,3, S. Bitew3, J. A. Forrester3,5, S. Bereknyei Merrell6, T. Mammo7, T. G. Weiser3,5  1Stanford University,Palo Alto, CA, USA 2University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 3Lifebox Foundation,Boston, MA, USA 5Stanford University,Department Of Surgery,Palo Alto, CA, USA 6Stanford University,Department Of Surgery, S-SPIRE,Palo Alto, CA, USA 7Addis Ababa University,Department Of Pediatrics Surgery,Addis Ababa, Ethiopia

Introduction:  Clean Cut is a quality improvement intervention focusing on key perioperative infection prevention standards currently being implemented in Ethiopia. Developed by Lifebox, a non-profit dedicated to improving surgical safety, Clean Cut engages surgeons, nurses and anesthesia providers to identify and improve perioperative processes. In order to refine the implementation framework, we interviewed providers to better understand the benefits and challenges of implementing this program.

Methods:  We conducted a qualitative study using semi-structured interviews of staff perspectives on hospitals’ baseline performance, implementation barriers and facilitators, process improvement strategies, and sustainability. After obtaining consent, 20 Clean Cut team members (surgeons, nurses, anesthetists and managers) were interviewed. Audio recordings were transcribed, coded for themes, and analyzed using Dedoose software. Stanford University IRB approved the study.

Results: Major themes across all sites were the ability to enact perioperative process changes, enumeration of barriers to implementation, and strategies for improving adherence to surgical safety standards. Process changes focused on improving the appropriate use of the Surgical Safety Checklist (SSC), routine use of sterility indicators, discarding faulty gowns and drapes, and improved timing of prophylactic antibiotic administration. Challenges included lack of material resources such as computers and paper for data entry, functional autoclaves, sterile indicators, alcohol hand rub, and consistent running water. Payment for data collection affected motivation and incentives; non Clean Cut staff associated SSC completion and follow up as the responsibility of those who were being paid, rather than an inheret part of the job. Checklist completion led to increased perceived accountability that had both negative (fear of punishment) and positive (feelings of reassurance) effects. Benefits of implementation included perceived permanent changes in surgical practices: participants expressed improved self-reported patient satisfaction, incorporation of SSI education at discharge and increased training for staff on infection rates. Strategies for successful implementation included incorporating checklist interventions into routine OR behavior through evidence-based training and one-on-one conversations to overcome resistors.

Conclusion: Despite major barriers to implementation including lack of materials and staff resistance, Clean Cut was effective at producing changes in perioperative infection prevention practices. Expansion must consider an individualized approach to change longstanding surgical practices and motivate staff with evidence-based trainings. We identified a need for increased education to disseminate quantitative findings beyond Clean Cut participants, and a need for a new strategy of efficient data collection that minimizes payment conflicts.

93.11 Surgeon Education on Hemostatic Agents

Posted on January 31, 2019

C. Ochoa Chaar1, N. Gholitabar1, M. Devlin1, J. Luo1, Y. Zhang1, H. Hsia1, D. Silasi1, F. Lui1  1Yale University School Of Medicine,Vascular Surgery,New Haven, CT, USA

Introduction: Wide variation in use of Hemostatic agents (HA) by surgeons can significantly affect the cost of care. We postulate that surgeon’s education on HA impacts practice pattern and choice of products and can potentially be incorporated in a cost containment strategy.

Methods: A survey (17 questions) inquiring about the attitudes and preferences of surgeons regarding HA in a multi-hospital healthcare network was conducted electronically. Respondents were divided into 2 groups based on whether they had updated their knowledge and received education on HA (group A) or not (group B).   

Results: There were 148 respondents (25% response rate) in a variate of specialties. (Figure 1) Only 57 surgeons (38.5%) had received updated education on HA (group A). Group A surgeons were significantly more likely to select HA based on literature (33.3% vs 6.6%) while group B surgeons were more likely to rely on what they used in training (28.6% vs 14%) or what is available in the hospital (58.2% vs 47.4%) (P=0.0007). There was little influence by vendor marketing in the 2 groups (A=5.3% vs B=8.8%, P=0.5). Surgeons in group A were significantly more likely to be aware of the costs of HA (47.4% vs 28.6%, P=0.02) and correctly estimate the cost of Surgicel (26.3% vs 13.2%, P=0.05) compared to group B. In the operating room, most surgeons did not routinely open HA (A= 63.2% vs B= 71.4%, P =0.35). However, group A surgeons were more likely to be specific regarding the size and amount of HA requested (A=33.3% vs B=14.3%, P=0.0027). Group A surgeons were more receptive to changing the choice of HA compared to group B (63.2% vs 44%, P=0.03).

Conclusion: Surgeon education on HA is associated with increased awareness of cost and may affect practice pattern in the operating room. Surgeon education can potentially lead to cost-conscious behavior and improve engagement in cost containment strategies.

 

 

93.10 Global Health in Surgery- A Platform for Learner-Faculty Growth: The West African Experience.

Posted on January 31, 2019

E. O. Abara1,2, N. O. Abara2,3, S. Osaghae2, E. O. Abara1,2  1Northern Ontario School of Medicine,Clinical Sciences,Sudbury-Thunder Bay, ONTARIO, Canada 2Richmond Hill Urology and Prostate Institute,Global Health And Outreach Program,Richmond Hill, ONTARIO, Canada 3University of Texas Medical Branch, Internal Medicine, Geriatrics, Galveston, TX, USA

 

Introduction : Since 2012, a group of surgical health professionals have undertaken an outreach to marginalized populations in West Africa aimed at ‘building capacity while providing service’. By 2014, residents have been encouraged to attend to gain experience and develop professionalism. We report the 2017  Burkina Faso experience.

Methods:  For seven days, health professionals from 8 countries functioned as a team. We worked at the Ouahigouya District Hospital. The program included: Out-patient assessments and Surgeries-pediatric, oncology, general surgery, otolaryngology, orthopedics, gynecology, and urology. Transfer of skills and tricks of the trade among peers; Faculty Case-based Learning and an interactive workshop for peers and learners; Learner-Learner exchange of ideas from their institutions – all provided stimuli for professional growth. The host provided accommodation, meals and local transportation. Participants cared for their travel arrangements.

Results: There were 6 ‘diaspora ’ and 8 local surgeons, 2 anesthetists and several nurse anesthetists, OR nurses and support staff. Three residents (from the Cameroons and Texas, USA) were present. There were 200 cases in all. Short-term outcomes were satisfactory. Long-term results will be necessary to validate the efforts.  The educational content of the outreach was described by most as transformative as the professionals shared knowledge and skill while patients received excellent collaborative care.

Conclusion: Short-term surgical outreach like this can be questioned as ineffective and unsustainable. However, the building of interdisciplinary, collaborative partnerships that are respectful and culturally sensitive is an asset. Our learners become winners and partners in global health for all.

 

93.09 Surgery for Breast Cancer: Locally Advanced Breast Cancer Management in Myanmar, a Developing County

Posted on January 31, 2019

S. Myint1, T. Lwin1, A. L. Kushner2,3, W. Yee1, K. Khaing1, S. Mon1, T. Lwin1  1university of medicine (1), Yangon,Department Of Surgery,Yangon, YANGON, Myanmar 2Columbia University College Of Physicians And Surgeons,New York, NY, USA 3Johns Hopkins Bloomberg School Of Public Health,Department Of International Health,Baltimore, MD, USA

Introduction:
Breast cancer is a global problem and management in low income countries is difficult. Myanmar, with a population of 60 million is one of the poorest. Most surgical care is performed in the capital Yangon. To improve breast cancer care, we evaluated the management of locally advanced breast cancer (LABC).

Methods:

Patient charts for surgical admissions with a diagnosis of breast cancer from January 1 to December 31, 2013 at the Yangon General Hospital and the New Yangon General Hospital were reviewed. Data were recorded for patients with a diagnosis of LABC.

Results:
A total of 225 breast cancer patients were identified with 105(47%) diagnosed with LABC. Thirty two (30%) were younger than 45 and 7 (7%) older than 65. Biopsy was: fine needle in 10, incisional biopsy in 36, core needle in 50, and wedge biopsy in 9. On histology, 90(86%) invasive ductal carcinoma and 15(14%) invasive lobular. Estrogen receptors were positive in 46%, progesterone receptors positive in 44% and Her2µ positive in 45%. All patients underwent a mastectomy. Adjuvant therapy was given to 80, neo-adjuvant to 10 and 28 had hormonal. Postoperatively 34 developed a seroma and 7 had a surgical site infection.

Conclusion:
LABC contributes to a large proportion of breast cancer cases in Myanmar leading to significant surgical morbidity. With earlier diagnosis morbidity and mortality can be reduce. Breast cancer awareness should be promoted and screening programs warrant exploration. Also ongoing evaluation of surgical care for these patients and additional research is warranted.
 

93.08 Gender Equity in International Surgical Outreach: 10 Years of Mission Volunteers

Posted on January 31, 2019

V. Padmanaban1, A. Tran1, A. Gore2, P. Johnston1, S. Pentakota1, Z. C. Sifri1  1New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 2University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:  

Opportunities for the provision of surgical care in resource-poor settings are increasingly available to surgical residents and attending surgeons. While substantial gender inequity exists in the surgical workforce, these disparities are not described in the arena of surgical outreach. Therefore, we aim to study the contributions of female surgical attendings and residents to short term surgical missions (STSMs) in a single volunteer non-governmental organization over 10 years.

Methods:  

We performed a comprehensive review of STSMs conducted by the International Surgical Health Initiative (ISHI) from 2009-2018. Volunteer surgeons, anesthesiologists, emergency and medical physicians, and nurses were recruited from academic and non-academic institutions throughout the country.

Volunteer data was organized by gender, trainee status, site of mission, number of missions completed and duration of service. Mission sites included Guatemala, Haiti, Peru, Philippines, Bangladesh, Sierra Leone, and Ghana. Data was analyzed based on gender distribution at an individual level and a volunteer-mission level. Chi-square tests for categorical variables and Wilcoxon two-sample t-tests were used to analyze mission participation.

Results:

We studied a total of 23 STSMs carried out by ISHI volunteers over a period of 10 years. All 227 volunteers were included, 139 (61%) of whom were female. Non-surgical volunteers including anesthetists, internists, emergency physicians, and nurses were more likely to be female compared to surgical volunteers as an aggregate of attendings and residents (67% vs. 41%, p < 0.01). Nurses comprised the largest subgroup of volunteers, with 96 (42%) in total, of whom 82% were female. Of 22 surgical attendings, 8 (36%) were female; of 37 surgical residents, 18 (49%) were female with no significance noted on statistical comparison.

There were no gender differences noted by predilection for mission location. No gender differences were observed by average of missions completed or propensity for repeat missions (defined as greater than one mission). On subset analysis of mission participation by surgical volunteers, female surgical volunteers completed an average of 1.6 missions, while their male counterparts completed 2.1 missions, with no significant difference.

Conclusion:

Overall, female volunteers contribute substantially to surgical missions, representing over half the volunteers. Non-surgical volunteers are more likely to be female compared to surgical volunteers, in part due to the number of female nurses. Female surgeons contribute in parity with male surgeons when examining number of missions and propensity for repeat missions. This study found no gender inequity among surgical volunteers in this humanitarian organization. Additional studies of other surgical non-governmental organizations are needed to confirm these findings.

93.06 Global Health Conundrum: Ethnic Diet and Diverticular Disease Burden

Posted on January 31, 2019

K. Lung1, J. Yun2, D. Vyas1,3  1California Northstate University College of Medicine,Elk Grove, CA, USA 2Touro University of California,Vallejo, CA, USA 3San Joaquin General Hospital,Department Of Surgery,French Camp, CA, USA

Introduction:  Diverticular disease (DD) is among the most prevalent conditions in Western societies with incidence steadily increasing worldwide, resulting in mounting financial burden to healthcare systems globally. With this comes a notable rise in the total costs and hospitalizations attributable to DD. Once considered a phenomenon of Western cultures, DD has been increasingly documented in countries with historically low prevalence rates, such as Japan and Thailand. In today’s society, the blending of various ethnic cultures and diets across the globe has obfuscated our previous understanding of DD prevalence trends internationally. With the rise of DD worldwide, it is increasingly important to assess its prevalence, especially in non-Western societies where there is a growing influence of a Westernized diet.

Methods:  Literature search was performed using Pubmed, MEDLINE, and Scopus databases using MeSH terms: ‘diverticular disease’, ‘diverticulosis’, ‘diverticulitis’, and ‘dietary fiber’ with the Boolean operator ‘AND’ (all synonyms were combined with the Boolean operator ‘OR’). DD was defined as complications due to colonic diverticulosis, including lower gastrointestinal bleeding, inflammation, abscess, fistula, perforation, and death, as diagnosed via CT scan, barium enema, or histology post-operatively. Articles describing patients with surgical findings consistent with colorectal cancer were excluded. Retrospective and prospective population studies were used to determine prevalence in Western and non-Western countries.

Results: Data for DD prevalence rates of major nations (patients > age 50) were categorized as high (>40%), moderate (20-39%), low (5-19%), and very low (<5%). Countries with the highest prevalence were the most industrialized nations, notably the United Kingdom (47%) and the United States (41.7%). Japan (20.3%) and Thailand (28.5%) had moderate prevalence rates, while South Korea (12.1%), Mexico (6.65%), and Kenya (5.3%) recorded lower overall prevalence. China (1.97%) and India (4.4%) had the lowest prevalence rates. 0.77% of the global population are considered to have high DD prevalence (>40%), while 0.19% are considered to have very low DD prevalence (<5%).

Conclusion: With increasing global immigration and cultural and dietary assimilation, the etiology of DD, once considered related to ethnic dietary patterns, is called into question as possible genetics may be at play. Long-term this may influence the current prevalence trends, hence, it is important to identify potential factors that may mitigate DD incidence in high prevalence countries, while tempering possible increases within the low prevalence countries.

 

93.05 Risk Factors for Length of Stay and Readmission in Rural Ghana

Posted on January 31, 2019

D. J. Morrell1, B. S. Hendriksen1, L. Keeney1, X. Candela2, T. E. Arkorful4, P. Ssentongo5, R. H. Darko4, J. S. Oh1, C. S. Hollenbeak3, F. Amponsah4  1Penn State Health Milton S. Hershey Medical Center,Department Of Surgery,Hershey, PA, USA 2Penn State University College Of Medicine,Hershey, PA, USA 3The Pennsylvania State University,Department Of Health Policy And Administration,University Park, PA, USA 4Eastern Regional Hospital,Koforidua, EASTERN REGION, Ghana 5The Pennsylvania State University,University Park, PA, USA

Introduction:
Increased length of stay (LOS) and readmission represent significant economic burden on patients and families faced with surgical disease in low- and middle-income countries given limited surgical access, infrastructure, and variable insurance status. This study aims to identify risk factors of LOS and readmission in order to better direct future interventions in postoperative care in rural Ghana.

Methods:
Data for exploratory laparotomy procedures were obtained from surgical case logs collected at a regional referral hospital in Eastern Region, Ghana from July 2017 to June 2018. This information was compared with the hospital electronic medical record to collect demographic data, laboratory values, and outcomes. Multivariable analyses were used to model LOS and readmission controlling for potential confounders.

Results:
The study included 346 exploratory laparotomy procedures (286 adult, 60 pediatric) for various surgical diseases. Average age at surgery was 40 and males accounted for 65% of all procedures. 40% of patients were uninsured. Hemoglobin levels were measured on admission for 71% of patients and 44% of those patients were anemic. The major indications for surgery were appendicitis (31%), intestinal obstruction (23%), perforated peptic ulcer disease (12%), and trauma (7%). The overall LOS for adult and pediatric patients were 7.2 and 6.9 days respectively. Surgery for intestinal obstruction and major abdominal trauma resulted in increased LOS by 4.6 and 4.1 days respectively (p<0.001, p=0.031). Anemia increased LOS by 3 days (p=0.002). Rate of readmission for adults was 9.4% and 8% for pediatric patients. Patients with national health insurance had 2.7 times greater odds of being readmitted (OR=2.7, p=0.04) and those with anemia had 3.9 times greater odds of being readmitted (OR=3.9, p=0.002).

Conclusion:
Anemia represents a risk factor for both increased length of stay and readmission. Major abdominal trauma is also a risk factor for increased LOS. Future interventions aimed at preventing and treating anemia and improving trauma care may decrease some of the post-operative burden placed on patients and their families.

93.04 Eliminating the learning curve: the case for the recessed video stylette in global surgery.

Posted on January 31, 2019

A. N. Bowder2, R. Amin1, L. McCormick3, S. Siddiqui1,3  1Children’s Hospital Of Wisconsin,Pediatric Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 3Brio Device,Ann Arbor, MICHIGAN, USA

Introduction: There is a paucity of anesthesia providers worldwide. This severe shortage in the global surgery workforce has left billions of people without access to surgical care. A recent study by the World Federation of Societies of Anesthesiologists surveyed 153 countries and found there to be a limited number of physician anesthesia providers (PAP) in low and middle-income countries (LMICs). In the African and South East Asian Regions alone, there are on average 1.36 and 1.20 PAP. The global community continues to search for innovative solutions aimed at safely decreasing the discrepancy between anesthesia providers and the burden of surgical disease. We propose that the creation of an intuitive and safe intubation tool could be integral to increasing the anesthesia workforce globally.

Methods: We performed an IRB-approved single center prospective comparison of mannequin intubation by medical students using an articulating video stylet (AVS) and the Olympus bronchoscope. The device used first was alternated between consecutive participants to account for any learning effect.  Five successful intubations were completed with each device.  Time to intubation was measured from when the participant picked up the instrument until the tip had passed beyond the vocal cords.  The number of passes to successful intubation was also recorded.

Results:A total of 19 participants were recruited. The learning curve was noted to be less steep with the AVS (Table1). Intubation time was significantly shorter with use of the AVS. The mean intubation time for the AVS was on average 25.2 seconds less than for the bronchoscope (P<0.0001).  Additionally, more than one attempt were only required in 6% of the intubations using AVS compared to 18% with the bronchoscope (P=0.0057).

Conclusions:This study demonstrates the feasibility of creating an intubation device with little to no learning curve when performed in a standardized mannequin. These results merit continued development. We also will need to complete larger research trials aimed at validating our findings and evaluating the clinical safety of this device. If we are able to prove that the AVS is able to safely, decrease the learning curve in the clinical setting it has the potential to address the shortage of anesthesia providers promptly. Over fifty percent of countries surveyed reported 4 or more years of training required for a PAP. If we are able to decrease this training time even slightly we can make great strides towards reducing the overall burden of surgical disease. Furthermore, this innovative technology can be used by the global community as they develop sustainable task shifting models for non-physician anesthesia provide in LMICs

 

93.02 Geriatric Trauma in Santa Cruz, Bolivia

Posted on January 31, 2019

E. Ludi1, E. Foianini2, J. Monasterio3, S. South1, M. Boeck4, M. Swaroop1  1Feinberg School Of Medicine – Northwestern University,Division Of Trauma And Critical Care,Chicago, IL, USA 2Clinica Foianini,General Surgery,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 3Gobierno Departamental Autónomo,Department Of Health,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 4University Of California – San Francisco,Division Of Trauma And Critical Care,San Francisco, CA, USA

Introduction: Worldwide, the population older than age 60 years is expected to double by 2050 and triple by 2100. Those greater than 80 years old are expected to triple by 2050 and increase by seven times in 2100. The aging population of Latin America is predicted to increase from 7.1% in 1990 to 12.5% by 2050. Research from high-income countries demonstrates that trauma in the geriatric population (GP) is associated with higher morbidity and mortality secondary to comorbid conditions and decreased physiologic reserve. Minimal research exists on the prevalence and mechanisms of injury in the GP in low- and middle- income countries (LMICs), and no studies exist in Latin American LMICs, such as Bolivia.

Methods:  Patient data was collected in the Emergency Department (ED) of six hospitals in Santa Cruz, Bolivia participating in the Panamerican Trauma Society Trauma Registry from October 1, 2015 to July 31, 2018. Inclusion criteria were all patients presenting with trauma. Data were coded with Microsoft Excel and analyzed with SAS v9.4. Comparisons were made between the GP, age greater than 65 years, and the younger population (YP): ages 18-64 years.

Results: N=8,796 patients were entered in the trauma registry over the 34 month period. Age was recorded for N=7,912 (90.0%) of patients. Ten point one percent (N=797) of patients were aged 65 years or greater, and N=4,989 (63.1%) were aged 18-64 years. Among the GP, 43.7% were male, as opposed to 69.5% of the YP being male (p <0.0001). Only 0.04% of GP presented with alcohol involved in the trauma in contrast to 18.2% of the YP (p <0.0001). A large majority of the GP presented with falls (N=542, 69.8%) versus 1,638 (32.8%) in the YP (p < 0.0001). Motor vehicle crashes were the second most common in both populations representing N=64 geriatric injuries (8.0%) and N=886 (17.8%) YP injuries. The GP most commonly had isolated injuries of the pelvis or hip (21.9% vs. 1.9% of the YP, p <0.0001) and the upper extremity (21.8% vs 25.5% of the YP, p = 0.06). In contrast to the GP, the YP more commonly presented with polytrauma (YP 20.3% vs 11.6% of the GP, p<0.0001). Regarding ED disposition, the majority of patients were discharged home in both patient populations (GP 50.6% vs YP 58.0%, p=0.01), but the GP was more likely to be admitted to the hospital, 38.0% vs 26.8% (p<0.0001). There was no statistically significant difference in ICU admission (GP 1.03% vs YP 0.65%, p = 0.31) or mortality (GP 0.30% vs YP 0.29%, p=0.99).

Conclusion: As overall life expectancy improves, the number of geriatric patients presenting with trauma will increase. The geriatric trauma population in Bolivia is mostly female, who typically present after falls with isolated hip injuries, and more commonly require hospital admission as compared to their younger counterparts. Understanding how geriatric patient presentations differ compared to the YP can inform prevention methods, hospital resource distribution, and discharge planning.

93.01 Appendicitis Presentation and Outcomes at a Public Referral Hospital in Ghana

Posted on January 31, 2019

L. K. Keeney1, B. S. Hendriksen1, D. J. Morrell1, X. Candela2, T. E. Arkorful5, P. Ssentongo4, J. S. Oh1, C. S. Hollenbeak4, F. Amponsah5  1Penn State Health Hershey Medical Center,Hershey, PA, USA 2Penn State University College Of Medicine,Hershey, PA, USA 4Pennsylvania State University,State College, PA, USA 5Eastern Regional Hospital,Koforidua, Ghana

Introduction:
Appendicitis is a burdensome surgical disease for patients in low-middle income countries which have limited surgeons, infrastructure, and financial health coverage. Laparoscopy is often not feasible, so patients typically undergo exploratory laparotomy. This study aims to better understand common presentations and outcomes of appendicitis in rural Ghana to identify areas for future interventions.

Methods:
Data on laparotomies performed at a public surgical referral center in rural Ghana between July 2017 and June 2018 was obtained. Surgical log books and corresponding patient electronic medical records were reviewed to extract demographic data, clinical findings, and outcomes. All exploratory laparotomy operations were included if the record was complete. Appendicitis was identified as the indication for surgery retrospectively through the medical record diagnosis, operative note, or recorded surgical findings. 

Results:
Appendicitis was the post-operative diagnosis in 107 out of 346 (31%) exploratory laparotomy operations reviewed.  Of appendicitis cases, males accounted for 68%. The average age was 32, with 60% of cases occurring in adults ages 18 to 60. Nearly 40% of these patients did not have insurance. Laboratory values were obtained in 70% of cases of appendicitis. Of those with lab values, 37% were found to be anemic and 48% had a leukocytosis. Perforations of the appendix were identified in 59% of cases and were more common in married patients (p=0.0055). Length of stay for patients with perforations was significantly longer than those without perforations (5.2 vs 3.5 days, p=0.0003).  Readmission within 30 days was also more frequent in cases of perforation (7.9% vs 6.8%, p=0.0468). Overall mortality (0.9%) and the rate of surgical site infections (10.3%) did not differ between perforated and non-perforated appendicitis.

Conclusion:
Appendicitis represents a significant surgical burden in Ghana and many patients requiring appendectomy are uninsured. Presentation with perforation is common and results in worse outcomes. Future studies identifying modifiable risk factors of perforation and interventions for earlier diagnosis of appendicitis are warranted.
 

91.13 Economic Analysis of Implementation of Enhanced Recovery Protocols at a Community Hospital

Posted on January 31, 2019

A. D. Ardeljan1, D. Manjani1, D. Maurente1,6, S. Willis1,7, H. S. Abdul1,5, A. Johns1,4, S. Sennhauser1, M. Ghali1, A. M. Rashid1,2, M. Perez1,3, O. M. Rashid1,2  1Holy Cross Hospital, Michael And Dianne Bienes Comprehensive Cancer Center, Fort Lauderdale,Fort Lauderdale, FLORIDA, USA 2Massachusetts General Hospital, Cancer Center, Boston,Boston, MASSACHUSETTS, USA 3University Of Miami Miller School Of Medicine, Miami,,Miami, FLORIDA, USA 4East Norriton Community Hospital, Philadelphia,Philadelphia, PENNSYLVANIA, USA 5Kendall Regional Medical Center,Kendall, FLORIDA, USA 6Eastern Virginia Medical School,Norfolk, VA, USA 7Saint Barnabas Hospital Health System,New York, NEW YORK, USA

Introduction:  We have previously demonstrated that implementation of an enhanced recovery protocol (ERP) reduced Length of Stay (LOS) without any change in the readmission rate; however, the economic cost has not been quantified. The aim of this study was to evaluate the economic costs of ERP implementation at a community hospital.

Methods: Diagnostic Related Group (DRG) codes were used to assess costs associated with the hospitalizations of cases in the ERP versus non-ERP groups. The American Hospital Association (AHA) Annual Survey 1999-2015 was used to provide the expenses per day for inpatient hospitalization in the United States. Standard statistical methods were used.

Results: The AHA survey estimated the expenses of $2,265 incurred in a day for non-profit hospitals in Florida and $2,346 for the United States. For DRG 329, the reduction in LOS at a community hospital in ERP participating group reduced the cost of hospitalization from $27,297.96 (13.08 days) in the Non-ERP participating group to $7,033.19 (3.37 days); on average DRG 329, ERP reduced the cost by $20,264.77 per patient. For DRG 330, the reduction in LOS at a community hospital in ERP participating group reduced the cost of hospitalization from $22,664.82 (10.86 days) in the Non-ERP participating group to $ 9,558.46 (4.58 days); on average for DRG 330 ERP reduced the cost by $13,106.36 per patient. For DRG 331, the reduction in LOS at a community hospital in ERP participating group reduced the cost of hospitalization from $15,172.49 (7.27 days) in the Non-ERP participating group to $ 7,054.06 (3.38 days); on average for DRG 331, ERP reduced the cost by $8,118.43 per patient. LOS associated cost was compared between ERP and non-ERP groups: for DRG 329 the savings was $162,118.8 (n=12 non-ERP v n=8 ERP, p=4.39×10-18); for DRG 330, $314,552.64 (n=36 non-ERP v n=24 ERP, p=2.72×10-22); and for DRG 331, $89,302.73 (n=11 non-ERP v n=23 for ERP, p=4.19×10-20), respectively.

Conclusion: The implementation of ERP protocols significantly reduced the cost of hospitalization after bowel surgery based on the estimated expenses associated with LOS.

 

91.12 Cost-Effectiveness of Exploratory Laparotomy in Soroti, Uganda

Posted on January 31, 2019

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.

 

90.20 Cross-Border Transfer Leads to Delays in Care for Tibia Fractures

Posted on January 31, 2019

A. Brito1, L. N. Godat1, T. W. Costantini1, J. Doucet1, A. M. Smith1, A. E. Berndtson1  1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:  Tibia fractures are commonly seen after injury and often require operative fixation. Prior studies have shown that delays in care for treatment of tibia fractures are associated with poor functional outcomes. A sub-population of patients admitted to our trauma center are transferred from Mexico, adding barriers to prompt care for their injuries. We hypothesized that patients with tibia fractures transferred from Mexico would have delays in care and subsequently worse outcomes.

Methods:  The trauma registry of an ACS-verified level 1 trauma center was retrospectively reviewed for all tibia fractures admitted from 2010-2015. Data collection included demographics, country of injury, open vs. closed fracture, Gustilo classification, operative interventions required, complications and outcomes. Patients were then subdivided into those injured in the USA and in Mexico (MEX) and the two groups were compared.

Results: A total of 497 patients were identified, 439 from the USA and 58 transferred from MEX. MEX patients were more severely injured overall, with higher injury severity scores (Table) as well as a higher percentage of patients with AIS scores ≥ 3 for both Head (USA 14.4% vs. MEX 29.3%, p = 0.007) and Chest (USA 14.4% vs. MEX 31.0%, p = 0.004) regions. MEX patients had longer times from injury to admission, as well as increased times to both debridement and operative fixation after admission (Table). There was no difference in Gustilo classification of open fractures between groups. MEX patients were more likely to have a venous thromboembolism (USA 6.7% vs. MEX 15.6%, P = 0.003) or undergo lower extremity amputation (USA 0.91% vs. MEX 6.9%, p = 0.008).  Subgroup analysis of patients with isolated tibia fractures (other AIS < 3) still demonstrated longer times from arrival to both debridement and fixation in patients from MEX, though ISS was no longer statistically different (median ± IQR, USA 10 ± 8 vs. MEX 9 ± 4, p = 0.625).

Conclusion: Patients transferred from MEX for treatment of tibia fractures have resultant delays in time from injury to admission, but also have a longer period from admission to definitive care of their fracture.  Patients transferred from MEX also had worse outcomes, including increased rates of VTE and amputation compared to those injured in the US. Ongoing systems development is required to improve processes for transfer from Mexico to the US, when needed, in order to minimize delays in care and optimize outcomes.

 

90.18 Mortality Related to Mass-Casualty Incidents at a Malawian Tertiary Hospital

Posted on January 31, 2019

J. Kincaid1,3, G. Mulima3, N. Rodriguez-Ormaza2, A. Charles2, R. Maine2  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 3Kamuzu Central Hospital,Surgery,Lilongwe, Malawi

Introduction:  Mass-casualty incidents (MCI) suddenly strain a healthcare system with an influx of trauma patients. Little is known about how MCIs in low resource settings impact mortality. We aimed to determine if the resource strain from MCIs at a tertiary hospital in Malawi increased mortality for MCI patients and patients who arrived on the same day as an MCI compared to patients who presented days without MCIs.

Methods:  This is a retrospective analysis of a prospective trauma registry, from January 1, 2012 through December 31, 2016, at a tertiary hospital in Malawi. MCIs were defined as ≥ 4 trauma patients who present simultaneously to the casualty department. We conducted bivariate analysis comparing patient, mechanism of injury, and outcome characteristics by whether or not the event was an MCI. Next, we determined whether non-MCI patients presented on the same day as an MCI or on a non-MCI day and compared the same variables. Categorical variables were compared with Pearson chi-squared test or the Fisher’s exact test; continuous variables were compared using Student t-test, Wilcoxon rank sum test or the Kruskal-Wallis test by ranks, as appropriate. Multivariable analysis using a Modified Poisson regression was utilized to estimate risk ratios (RR) and 95% confidence intervals (CI). We adjusted for sex, age, primary body area injured, transfer status, nighttime presentation, vehicle-related trauma and admission year.  P-values <0.05 were statistically significant.

Results: The registry included 75,350 trauma patients; 3% (2,227) were part of an MCI and 11,365 (15%) presented on the same day as an MCI. Overall more patients who presented as part of an MCI died, 90 (4%) vs. 2,124 (2.9%), p <0.001). This difference was driven by a higher proportion of MCI patients who were dead on arrival (2.9% vs. 1.1%, p<0.001), as in-hospital mortality rates for MCI or non-MCI traumas did not differ statistically (4.1% vs. 3.7%, p=0.671). However, trauma patients who were not a part of an MCI but presented to the ED the same day as an MCI had higher in-hospital mortality than patients who presented on days without an MCI (7.0% vs. 5.4% vs. 5.6%, p=0.015).  When compared to non-MCI trauma patients presenting on a non-MCI day, being part of an MCI increased the risk of in-hospital mortality by 19% (RR=1.19, 95%CI: 0.98-1.44, p=0.0821).

Conclusion: MCIs presented frequently to this Malawian tertiary hospital, which stressed the hospital’s limited capacity. The higher in-hospital mortality of trauma patients not involved in MCI but who presented the same day as an MCI points to the strain on the limited resources resulting in poorer patient outcomes when the hospital suffers the stress of an MCI. Both improved capacity for treating trauma patients at the central hospital and district hospitals coupled with improved triage protocols could decrease inappropriate transfers of trauma patients, which contributes to overwhelming the central hospital.
 

90.17 Factors Influencing Delays In Care For Patients With Peritonitis At A Rwanda Referral Hospital

Posted on January 31, 2019

M. Munyaneza1,2, S. Jayaraman3, F. Ntirenganya1,2, J. Rickard2,4  1University of Rwanda,College Of Medicine And Health Sciences, Department Of Surgery,Kigali, XX, Rwanda 2University Teaching Hospital of Kigali,Department Of Surgery,Kigali, XX, Rwanda 3Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA 4University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA

Introduction:  

Peritonitis is a common surgical emergency with a high mortality rate. Prompt recognition and surgical treatment is the mainstay of therapy. In Rwanda, patients often present critically ill with delayed presentation. A better understanding of patient care prior to arrival at the referral hospital is needed to identify areas for improvement. The aim of this study was to describe delays in Rwandan patients presenting to a referral hospital with peritonitis.

Methods:  

This is a cross-sectional observational study of patients with peritonitis admitted to the department of surgery at a tertiary referral hospital in Rwanda. Data was collected on demographics, clinical course and patient delays. Patient delays were characterized according to the Three Delays Model. Factors related to delays in seeking care included consultation of traditional healers, understanding the need for medical attention, perceptions and acceptance of surgery and the healthcare system. Factors related to delays in reaching care included travel time, cost, and availability. Data entry and analysis was done using Google Form software.

Results: 

Over an 8-month time period, 54 patients with peritonitis were admitted to the referral hospital with peritonitis. Most (n=37, 68%) patients were male.  For education, 20 (37%) patients had attended only primary school and 15 (28%) never went to school. A large number (48%) were unemployed and most (n=45, 83%) patients used community-based health insurance. For most patients (n=44, 81%) the monthly income was less than 10,000 Rwandan Francs (11 U.S. Dollars).  The average duration of symptoms prior to presentation at the referral hospital was 48 hours.

A large number (n=37, 69%) of patients consulted a traditional healer prior to presentation at the healthcare system. Most (n=29, 53%) patients travelled more than 2 hours to reach a health facility. A large number (n=39, 72%) reported prior good experience with health system and believed that surgery could cure abdominal pain.

From the health center to the district hospital, most (n=36, 66%) patients travelled more than 10km. The cost of transportation ranged between 5000-10000 RWF (5-11 U.S. Dollars) for most of them, and 52% of patients arrived at the district hospital between 24 – 48 hours after the onset of abdominal pain. After arrival at the referral hospital, almost all (98%) patients were operated.

 

Conclusion: 

In this study, factors that were influencing seeking and reaching care were associated with sociodemographic characteristics, health-seeking behaviors, the cost of care, and travelling time. These findings may highlight points of interest to conduct a community-based survey, to understand better factors associated with delays in seeking and reaching care for patients with peritonitis.
 

90.16 Applying Lean Healthcare in Lean Settings: Early Results of a Pilot Program

Posted on January 31, 2019

P. K. Rao1, A. J. Cunningham1, M. C. Boulos1, D. Kenron1, P. Mshelbwala2, E. Ameh3, S. Krishnaswami1  1Oregon Health And Science University,Department Of Surgery,Portland, OR, USA 2University of Abuja-Teaching Hospital,Department Of Surgery,Gwagalada, FCT, Nigeria 3National Hospital,Department Of Surgery,Abuja, FCT, Nigeria

Introduction: Lean healthcare methodology is frequently utilized in high income settings to maximize capacity and operational efficiency during process improvement (PI) initiatives.  However, the utility of PI for healthcare in low and middle income countries (LMIC) has not been well studied. Operating theaters in LMIC are often characterized by high cancellation rates and delays resulting from suboptimal theater space, prolonged turnover times, and limited surgical workforce.  In order to study the applicability of lean methodology in LMIC, a comprehensive pilot program was developed in 2017 to promote sustainable operating theater efficiency at two hospitals in Abuja, Nigeria.

Methods: Perioperative committees were established at both institutions, a primary-tertiary center and a quaternary referral center, to evaluate current processes, identify problems therein, and compile a list of priorities.  A physician champion and a PI specialist in conjunction with local physician-partners held a workshop to address these priorities in December 2017 as part of an ongoing collaboration. The workshop was designed to teach practical applications of PI methodology, including process mapping, value stream thinking, and root cause analysis to nurses, surgeons, anesthesiologists, and administrators. Pre- and post-workshop surveys were administered to assess perceived benefit, and compared with a chi-square test of independence.

Results: In total, 42 individuals attended the PI workshop. 26/42 (62%) completed a pre-workshop survey, and 31/42 (74%) completed the post-workshop survey.  Pre-workshop, 10 respondents (38.5%) believed a process improvement workshop would be valuable for them as individual providers, and 11 (42.3%) saw its value for the perioperative committee.  After the workshop, all 31 respondents reported the workshop as valuable both personally and for the perioperative committee (p < 0.001), and all reported that PI methodology could benefit the institution overall. Workshop components identified as most valuable were development of quality improvement tools (52%), and fostering of team culture (36%). The most frequently listed barrier to PI implementation was the institutions’ ability to sustainably apply the concepts learned (40%).  Outcomes from the workshop led to development of block time utilization measurements, optimal staffing and avoidable-delay dashboards, and workflow diagrams to track trends and improve perioperative care.

Conclusion:
Lean methodology may be more applicable in lean settings than previously recognized.  All respondents noted that PI techniques have potential to improve operational efficiency. This could be of even greater relative benefit in such severely resource-constrained environments.  Interval measurement of outcome data is planned at 1 year. Sustainability will be facilitated by telementoring, and future efforts include expansion beyond the perioperative setting to inpatient wards and outpatient clinics.

90.15 Epidemiology and Perioperative Mortality of Exploratory Laparotomy at a Referral Center in Ghana

Posted on January 31, 2019

B. S. Hendriksen1, L. K. Keeney1, D. J. Morrell1, X. Candela2, P. Ssentongo3, J. S. Oh1, C. S. Hollenbeak3, T. E. Arkorful4, E. K. Marfo4, F. Amponsah4  1Penn State Health Milton S. Hershey Medical Center,Hershey, PA, USA 2Penn State University College Of Medicine,Hershey, PA, USA 3The Pennsylvania State University,University Park, PA, USA 4Eastern Regional Hospital,Koforidua, EASTERN REGION, Ghana

Introduction: Exploratory laparotomy represents one of the most common operations performed at rural surgical referral centers throughout Ghana. Late disease presentation combined with a frequent lack of pre-operative imaging makes these operations challenging. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate perioperative mortality as a benchmark quality measure.

Methods: Surgical logbooks were queried at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. The logbooks allowed for corroboration of patient data in the electronic medical record. Logistic regression was used to identify predictors of perioperative mortality.

Results: 
The study included 286 adult and 60 pediatric operations. Appendicitis (29%), obstruction (26%), perforated peptic ulcer disease (15%) and major abdominal trauma (6%) were the most common diagnoses in adults. Appendicitis (40%), intussusception (17%), major abdominal trauma (10%), and typhoid ileitis (7%) were the most common in children. Males accounted for 65% of cases. Only 60 % of operations were covered by national health insurance. The overall perioperative mortality rate was 11.5% (12.6% adults; 6.7% pediatric). 60% of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Mortality had 13 times greater odds with perforated peptic ulcer disease (OR 13.1, p=0.025) and 12 times greater odds with trauma (OR 11.7, p=0.042). Female gender (OR 0.3, p=0.016) and the national health insurance (OR 0.4, p=0.031) were protective variables. Individuals 60 and older (OR 3.3, p=0.016) had higher mortality.

Conclusion: 
Perforated peptic ulcer disease and major abdominal trauma carry significant risk of mortality and represent high impact areas for quality improvement. Efforts to improve national healthcare coverage and care for patients requiring surgical referral could decrease surgical mortalities.

 

90.14 Mortality Following Trauma Exploratory Laparotomy in Sub-Saharan Africa

Posted on January 31, 2019

L. N. Purcell1, A. N. Yohann1, R. N. Maine1, T. N. Reid1, C. Mabedi2, A. Charles1  1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA 2Kamuzu Central Hospital,General Surgery,Lilongwe, LILONGWE, Malawi

Introduction: Trauma is a leading cause of morbidity and mortality, particularly in those 15 to 45 years old.  Over 90% of trauma mortality occurs in low- and middle-income countries (LMICs), especially in sub-Saharan Africa. Head injury is the main driver of trauma mortality, specifically in the pre-hospital setting. For patients presenting with torso injury, mortality is potentially preventable if bleeding, particularly from solid organ injury, is controlled expeditiously. We therefore sought to determine the risk of mortality in trauma patients requiring laparotomy in Malawi.

Methods:  This is a retrospective analysis of prospectively collected data at Kamuzu Central Hospital from 2008 – 2017 of admitted patients with torso trauma. Data variables include basic demographics, injury severity and characteristics, surgical intervention, and mortality outcome. Bivariate analysis was performed for covariates based on exploratory laparotomy status. A Poisson regression analysis was performed to estimate risk of mortality after trauma laparotomy controlling for pertinent covariates (injury severity, night time and weekend penetration, injury mechanism, time from injury to presentation).

Results: Over the study period, there were 120,573 trauma patients. Of the 20,522 (17%) patients admitted, 6,474 (31.6%) had torso trauma. Of these, 341 (5.3%) had exploratory laparotomies. Exploratory laparotomy had a male and blunt injury mechanism preponderance of 73.3% and 92.8%, respectively. The crude mortality for patient undergoing exploratory laparotomy versus non-operative management was 9.5% and 6.6 %, respectively. There was an 6.8% overall mortality for torso trauma. Following Poisson regression analysis, the incidence risk ratio for mortality following exploratory laparotomy after controlling for covariates was 3.74 (CI 2.06 -6.78, p <0.001).

Conclusion: After adjusting for injury severity, there is a greater than three-fold increased risk of mortality following trauma exploratory laparotomy. This may be attributable to limited availability of allogenic blood transfusion, inadequate perioperative resuscitation, in-hospital delays to operative intervention including limited access to the operating room, and delays in providers’ decision to perform operative intervention. Trauma protocols are imperative in low-resource settings to optimize timely and appropriate operative management of torso trauma.

 

90.13 Comparison of the Incidence of Wilms’ Tumor across Global Regions

Posted on January 31, 2019

M. E. Cunningham1,2, T. D. Klug2, J. G. Nuchtern1,2, B. J. Naik-Mathuria1,2  1Baylor College of Medicine,Pediatric Surgery,Houston, TX, USA 2Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA

Introduction:
Wilms’ tumor, also known as nephroblastoma, accounts for more than 90% of kidney neoplasms and 6% of all cancers in children worldwide. Survival after diagnosis and treatment is excellent in most developed countries (>90%), but underdeveloped countries throughout Africa, Asia, and Latin America continue to struggle with detection and treatment resulting in a large discrepancy in survival. The International Agency for Research on Cancer (IARC) has been collecting incidence data since the 1970s and recently released its third volume. The purpose of this study was to compare the incidence of Wilms’ tumor across countries at a global level in order to identify at-risk populations.

Methods:
The World Health Organization (WHO) International Incidence of Childhood Cancer Volume III data set, derived from independent country-based data banks, was queried to identify the incidence of Wilms’ tumor (ages 0-14 years). When multiple registries were available for a single country, the most comprehensive registry was used. The age-specific rate (ASR) per million was compared between developed, transition, and developing countries. Descriptive statistics and independent-sample Kruskal-Wallis Test were utilized.

Results:
Data was available from 75 countries spanning six global regions. The initiation of data collection ranged from 1982-2010 and was last updated between 2006-2014. The median global incidence of Wilms tumor was 7.7 [IQR 5.4-9.1] ASR/million (Figure 1) with a median male to female distribution of 0.9:1. Diagnosis was more common in children aged 0-4 years (median 15.1[IQR 11.8-18.7] ASR/million) compared to 5-9 years (4.2[2.9-5.1]) and 10-14 years (0.7[0.4-1.1]), respectively (p<0.01). Incidence ranged from 2.8 ASR/million in Thailand to 21.2 ASR/million in Mali and was higher in developed (8.9[8.4-9.6] ASR/million) and transition (9.9[9-10.5] ASR/million) countries compared to developing countries (6.1[4.9-7.4] ASR/million) (p<0.01). Of the 6 global regions, the highest incidence was in North America (9.2[9.1-9.2] ASR/million), followed by Europe (9.1[8.6-9.7] ASR/million) and Oceania (8.5[8.2-8.7] ASR/million).

Conclusion:
Wilms’ tumor is a common cancer among children worldwide. It is reported more often in developed and transitional countries; however, this may reflect incomplete data reporting from the developing world. Continued consistent data collection is needed for further elucidation of trends and allocation of resources.
 

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