90.12 A Systematic Review of Delays and Barriers to the Care of Colorectal Cancer in LMIC

Posted on January 31, 2019

N. R. Brand1, L. Qu2, A. Chao3, A. Ilbawi4  1University Of California – San Francisco,Surgery,San Francisco, CA, USA 2Monash University,Faculty Of Medicine, Nursing & Health Sciences,Victoria, Australia 3National Cancer Institute,Center For Global Health,Bethesda, MD, USA 4World Health Organization,Management Of Noncommunicable Diseases Unit, Department For Management Of Noncommunicable Diseases, Disability, Violence And Injury Prevention,Geneva, Switzerland

Introduction:
Of the 746,000 colorectal cancer (CRC) diagnoses made each year, the majority occur in high-income countries (HIC), while over 50% of deaths occur in low- and middle-income countries (LMIC).  Stage of disease at diagnosis is a significant prognosticator of survival and the higher rates of advanced stage diagnoses made in LMIC may contribute to the difference in death rates between HIC and LMIC.  This review focuses on delays and barriers to CRC diagnoses of patients in LMIC, where CRC incidence is increasing.

Methods:
We conducted a systematic review of peer reviewed literature published on these topics in LMIC.  Inclusion criteria for our systematic review was any full text article that addressed barriers to care or delays in early diagnosis of CRC that was conducted in LMIC.   Studies were required to contain any of the following: (i) defined or reported delay intervals in the diagnosis of symptomatic CRC or (ii) reported predictive factors or barriers that delayed early diagnosis of symptomatic CRC.

Results:
Of the 10,193 abstracts screened, 9 studies met inclusion criteria. All 9 studies were conducted in middle-income countries.  Five studies assessed the intervals along the pathway from symptom onset to cancer treatment, and significant delays were identified along all stages of the cancer care continuum.  All 5 studies identified that the greatest delay occurred prior to disease diagnosis.  Of the 4 studies that assessed individual intervals of CRC diagnosis; 2 (50%) found the greatest delay occurred during the interval between symptom onset and presentation to the healthcare system, and 2 (50%) found the greatest delay occurred between first presentation to the healthcare system and cancer diagnosis.  Six studies assessed barriers to cancer care, and 4 studies assessed knowledge of CRC. All studies found low levels of knowledge of CRC as a disease, its risk factors, or how it is diagnosed, in both the general population and among healthcare workers.

Conclusion:
Despite the  increasing burden of CRC in LMIC, there is little published research on delays to CRC diagnosis and treatment or the barriers that cause them in resource-limited settings. Our review demonstrates significant delays throughout the entire process of cancer diagnosis and treatment and identifies the period prior to CRC diagnosis as the most vulnerable to delays.  In addition, we have identified low levels of knowledge about CRC in both the general population and healthcare workers.  Our study highlights the tremendous need for research and action to reduce CRC morbidity and mortality in LMIC.

90.09 Head and Neck Surgical Capacity in Rural Haiti

Posted on January 31, 2019

R. Patterson1,2, M. Wilson2, A. Bowder2,3, C. Dodgion3, L. Ward2, M. Padovany2  1Tufts University School of Medicine,Boston, MA, USA 2St. Boniface Hospital,General Surgery,Fond-des-Blancs, SUD, Haiti 3Medical College of Wisconsin,General Surgery,Milwaukee, WI, USA

Introduction:

Surgery is a neglected component of global health, and surgical subspecialty care is particularly absent in low- and middle-income countries (LMICs). Worldwide, head and neck (H&N) conditions contribute to 375,000 deaths per year. Typically managed by otolaryngologists in high-income countries, access to specialists is severely limited in LMICs.

Currently, Haiti has 16 practicing otolaryngologists for a population of 11 million. Thus, many general surgeons manage H&N conditions. In southern Haiti, surgical care at St. Boniface Hospital (SBH) is provided by two Haitian general surgeons and one rotating resident who manage a breadth of surgical disease including H&N conditions. Since 2015, SBH surgical capacity has grown in three distinct phases. Here, we examine the ability of SBH general surgeons to care for H&N conditions by analyzing the volume, complexity, and mortality of cases traditionally treated by otolaryngologists.

 

Methods:
A retrospective review was performed of all H&N surgical cases at SBH between February 2015 and August 2017. These procedures were divided into three phases correlating to increasing level of general surgery capacity: phase 1 (P1) with visiting surgical teams, phase 2 (P2) with one full-time general surgeon, and phase 3 (P3) with a surgical center, two general surgeons, and residents. Diagnosis, procedure details, and patient demographics were recorded in the surgical logbook.

Results:
SBH surgeons performed 2,068 surgical procedures, including 165 (8%) H&N procedures. No H&N procedures were performed in P1, but there were 73 in P2 and 92 in P3, with a monthly average of 4.6 and 10.6 in P2 and P3, respectively. Most cases were thyroidectomies (30.3%), excisions of unspecified head and neck masses (26.7%), and facial plastics procedures (9.7%). The transition from P2 to P3 allowed for increased rates of more complex surgery like H&N mass resections (mean of 1.1 to 2.3 per month, [range of 0-8]), Sistrunk procedures (0.1 to 0.8, [0-2]), and Ludwig’s Angina procedures (0.1 to 0.6, [0-2]). Few specialized procedures of the ear, nose, or throat were performed. There were no recorded mortalities of H&N patients.

Conclusion:
Building general surgery capacity contributed to SBH’s ability to care for H&N disease. SBH’s experience suggests that general surgeons can safely fill gaps in settings with limited subspecialty care. National surgical plans and otolaryngology training should prioritize general surgery cross-training to build on existing H&N surgical skills. This approach should be combined with strengthening referral networks and subspecialty H&N capacity at tertiary centers in order to maximize the availability of specialized care.

90.08 Reasons for Surgical Referral in Rural Ethiopian Hospitals

Posted on January 31, 2019

K. Garringer1, O. Ahearn1, J. Incorvia1, L. Drown1, K. Iverson1,3, D. Burssa2, S. Esseye2,6, V. Smith4, J. Meara1,5, A. Beyene1,7, A. Bekele1,7, S. Bari1  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 2Federal Ministry of Health, Ethiopia,Addis Ababa, ADDIS ABABA, Ethiopia 3University Of California – Davis,Department Of Surgery,Sacramento, CA, USA 4Assist International,Safe Surgery 2020,Ripon, CA, USA 5Children’s Hospital Boston,Department Of Pediatric Plastic And Oral Surgery,Boston, MA, USA 6Jhpiego,Safe Surgery 2020,Addis Ababa, ADDIS ABABA, Ethiopia 7Addis Ababa University,School Of Medicine, Department Of Surgery,Addis Ababa, ADDIS ABABA, Ethiopia

Introduction: In Ethiopia, the Safe Surgery 2020 initiative is a collaborative effort of partner organizations that implement innovative programs to improve the surgical system. This initiative directly supports the Federal Ministry of Health’s national surgical planning effort that aims to improve access to surgical and anesthesia care in hospitals at all levels of the health system.

Surgical referrals are common within health systems in low- and middle-income countries, where high-quality surgical services are often only available at referral and specialized hospitals located in urban areas. It is important to understand the specific reasons for referrals that are being made for surgical services. This will lend insight to gaps in surgical care and will serve to strengthen primary hospital capacity and reduce the referral burden on higher level hospitals. This study intended to determine the most common reasons for referrals from primary-level hospitals to general and specialized-level hospitals in the Amhara region of Ethiopia.

Methods:  Data on surgical referrals and specific reasons for referral were recorded by surgical team members using newly designed and implemented clinical registries at five primary-level hospitals in the Amhara region of Ethiopia. A descriptive, cross-sectional study was conducted by reviewing the reasons for all emergency and elective surgical referrals that were made to higher-level hospitals during the month of May 2018.

Results: A total of 327 surgical referrals were recorded in the month of May among five primary-level hospitals included in this study (Table 1). The monthly median number of referrals was 70 referrals (IQR 65 – 70). The majority of the referrals (89.9%) were attributed to a ‘lack of specialist care’ at the referring hospitals. The next most common reasons for referral were: a ‘lack of diagnostic equipment’ (3.1%), a ‘lack of drugs’ (1.8%) and ‘patient preference’ (1.8%).

Conclusion: There is a substantial need for specialized surgical care in the Amhara region of Ethiopia, as there is a limited capacity to perform advanced surgical procedures in primary-level hospitals. This finding reiterates the importance of increasing the specialist surgical workforce in Ethiopia, in line with recommendations made by the Lancet Commission on Global Surgery in 2015. A lack of necessary equipment, supplies, and resources in these hospitals also leads to referrals. Results indicate that further consideration of referral reasons among hospitals throughout the country could help to identify focus areas for Safe Surgery 2020 programs and future Ministry of Health interventions meant to increase surgical capacity at the primary-hospital level.

90.07 Burden of Surgical Disease on Interfacility Ambulance Transfers in a Middle-Income Country

Posted on January 31, 2019

P. Truche1, R. NeMoyer1, S. Patiño-Franco2, M. Torres3, L. F. Pino4, G. L. Peck1  1Rutgers-Robert Wood Johnson Medical School,Department Of Acute Care Surgery,New Brunswick, NJ, USA 2Universidad de Antioquia,Facultad De Medicina,Medellín, ANTIOQUIA, Colombia 3Red de Salud del Centro E.S.E.,Cali, VALLE DEL CAUCA, Colombia 4Hospital Universitario del Valle – Evaristo García,Cali, VALLE DEL CAUCA, Colombia

Introduction:   Surgically treatable conditions account for thirty percent of the global burden of disease. Access to timely and safe surgical care has gained increasing priority in low- and middle-income countries (LMICs). MICs frequently report a large rate of interfacility ambulance transfer, which remains largely under-investigated, reflecting an opportunity to optimize timeliness and safety of definitive surgical treatment. Herein, we investigate surgical burden within interfacility transfers, differentiate the burden with respect to the public and private sectors, and provide a preliminary cost estimate for a large urban city in a middle-income country.

 

Methods:   A large retrospective review was conducted on transfer records for a public emergency medical service in Cali, Colombia. Comparisons were made between public and private healthcare facilities initiating transfer. Chi squared analysis was performed and odds ratios calculated comparing diagnosis, transferring specialty, and facility type. ICD9 codes were subcategorized and compared to transferring specialty using pairwise comparisons with a Bonferroni correction. Cost estimates were performed by comparing collected data with the 2016 ambulance fee schedule.

 

Results:  31,659 patients were transferred over a 1-year period including 21,790 interfacility transfers. 7,808 (34.6%) of transfers were for surgical conditions with 69.8% of these transfers at a surgeon’s request. Surgical conditions accounted for more transfers among public vs. private facilities (33% vs. 15%; p <.001). Private hospitals transferred to private hospitals 77% of the time, while public hospitals transferred to public hospitals 61% of the time. The most common surgical conditions requiring transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). The odds of transfer originating from a public facility were 4.4x higher in patients with appendicitis (OR=4.4, CI [3.3-5.8times]) and 7.5x higher with wounds (OR= 7.5, CI [5.2-10.8] P<.001]), but not statistically different for fractures (OR = 1.2, CI [0.99-1.3 P<0.06], abdominal pain (OR = 0.99, CI [0.8-1.2] P<0.63), or trauma (OR=0.99, CI [0.8-1.2] P<0.92). Total cost of surgical interfacility transfers was estimated to be 719,420 USD.

 

Conclusion:  Surgical disease contributed to roughly one-third of interfacility ambulance transfers. The most common reasons for transfer reflect basic surgical disease with a significant cost burden to the public health system. Public and private hospitals contribute unequally to transfer burden and tend to transfer to public and private hospitals, respectively. More research is needed to determine the true cost to Colombia’s health system and correlate clinical outcomes to transfer burden to assess and inform implications this may have on infrastructure, workforce, finance, and national surgical system strengthening.

90.05 Stuck with the Consequences: The Prevalence of Untreated Hernias in Southwest Cameroon

Posted on January 31, 2019

W. T. Chendjou3, S. A. Christie1, M. M. Carvalho1, T. Nana4, E. Wepngong3, D. Dickson1, R. Dicker2, A. Chichom Mefire3, C. Juillard1  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 2University Of California – Los Angeles,Department Of Surgical Critical Care,Los Angeles, CA, USA 3University of Buea,Faculty Of Health Sciences,Buea, SOUTHWEST, Cameroon 4Regional Hospital Limbe,Department Of Surgery,Limbe, SOUTHWEST, Cameroon

Introduction:  Hernias are one of the most commonly encountered surgical conditions, and every year, more than 20 million hernia repairs are performed worldwide. The surgical management of hernia, however, is largely neglected as a public health priority in developing countries, despite its cost-effectiveness. To date, the prevalence and impact of hernia has not been formally studied in a community setting in Cameroon. The aim of this study was to determine the prevalence and characteristics of untreated hernia in the Southwest region of Cameroon.

Methods:  This study was a sub-analysis of a cross-sectional community-based survey on injury in Southwest Cameroon. Households were sampled using a three-stage cluster sampling method. Household representatives were asked to identify all untreated hernias occurring in the past year. Data on socio-economic factors, hernia symptoms – including the presence of hernia incarceration- and treatment attempts were collected between January 2017 and March 2017.

Results: Among 8065 participants, 73 persons reported symptoms of untreated hernia, resulting in an overall prevalence of 7.4 cases per 1000 persons (95% CI: 4.98-11.11). Groin hernias were most commonly reported (n=49, 67.1%) and predominant in young adult males. Over half of persons with untreated hernia reported having symptoms of incarceration (52.1%, n=38), yet 42.1% of these participants did not receive any surgical treatment. Moreover, 21.9 % (n=16) of participants with untreated hernias never presented to formal medical care, primarily due to the high-perceived cost of care. Untreated hernias caused considerable disability as 21.9 % of participants were unable to work due to their symptoms and 15.1% of households earned less money.

Conclusion: Hernia is a significant surgical problem in Southwest, Cameroon. Despite over half of persons with unrepaired hernias reporting symptoms of incarceration, home treatment and non-surgical management was common. Costs associated with formal medical services are a major barrier to obtaining consultation and repair. Greater awareness of hernia complications and cost restructuring should be considered to prevent disability and mortality due to hernia. 

 

90.03 Hernia Repair in a Mobile Surgical Unit

Posted on January 31, 2019

M. Gurakar1,2, E. Kwon2, B. Guzhnay1, A. L. Vicuna3,4, H. B. Perry2, S. P. Jayaraman1, M. B. Aboutanos1, E. B. Rodas1,3  1Virginia Commonwealth University,Program For Global Surgery, Department Of Surgery,Richmond, VA, USA 2Johns Hopkins Bloomberg School of Public Health,Baltimore, MD, USA 3CINTERANDES Foundation,Cuenca, Ecuador 4Universidad del Azuay,Cuenca, Ecuador

Introduction:

Hernias are one of the leading causes of morbidity in low and middle-income countries. Herein, we describe the results of a Mobile Surgical Unit (MSU) performing hernia repairs for remote and underserved populations in Ecuador.

Methods:
A retrospective review from 2013 to 2017 of all patients undergoing hernia repair by a non-profit foundation (CINTERANDES). Data was extracted from medical records and a database was constructed in Excel.

Results:
In a five-year period, MSU carried out 260 hernia repairs on 233 patients. Thirty-one took place in the home base city of Cuenca and 202 in other small towns and rural settings. Female 49% and male 51%; mean age 46.7 ± 15.3 years, mean BMI 26.1 ± 3.9 kg/m2. Hernia repair with mesh was the most common form of repair (59.2%). Repairs included 122 inguinal hernias (46.9%), 98 umbilical (37.7%), 26 epigastric (10.0%), and 14 incisional (5.4%). Patients underwent local (51.0%), spinal (33.0%), or general anesthesia (15.9%). Mean operative time was 62.6 ± 33.3 min. Intraoperative and post-operative complications encountered include wound infection (5), dehiscence (3), hematoma formation (2), and one infection requiring mesh explant at six months. Follow-ups were conducted at one week for 182 patients (78.1%) via videoconference (42.8%), telephone (36.3%), and in-person interview (20.9%).

Conclusion:

Hernia repair can be safely performed in a MSU with low complication rates comparable to hospital-based surgery. Using Mobile Surgery to supplement existing healthcare infrastructure can expand the availability of hernia repair to those in isolated communities.
 

90.02 The Epidemiology of Mass−Casualty Incident Patients Presenting to 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:  There is a dearth of information regarding mass-casualty incidents (MCIs) in low resource settings like Malawi. Most literature describes single catastrophic events that expose the fragility of a trauma system and its limited ability to handle the sudden increase in patients. However, in low resource environments, events that can stress the hospital care delivery system are more common than large disasters. We aim to describe the frequency and characteristics of mass casualty events at a tertiary hospital in Malawi.

Methods:  We retrospectively analyzed trauma registry data at a tertiary hospital in Malawi from January 1, 2012 through December 31, 2016. We defined MCI as ≥4 trauma patients presenting simultaneously. We present descriptive statistics and a bivariate analysis comparing patient, trauma mechanism, and outcome characteristics for MCI and non-MCI trauma patients. Categorical variables were compared with chi-squared or Fisher’s exact test and continuous variables were compared using the t-test or the Wilcoxon rank sum test. Statistical significance was defined as p?0.05.

Results: From 2012 to 2016, 75,278 trauma patients arrived at the casualty department; 2,227 patients (3%) arrived as part of an MCI. A total of 341 occurred during five years, an average of 1.1 per week. Most MCIs involved between 4 and 6 people. More women were part of an MCI, 35% vs. 27% for non-MCI. MCI victims were older than non-MCI patients (29±15 vs. 23±14 years). The most common mode of transportation overall was private vehicles for both MCI (52%) and non-MCI (35%) respectively. The median time to hospital presentation is shorter for MCI patients (1hr vs. 4hrs, p<0.0001). More of the MCI patients presented between 6pm and 6am (41% vs. 25%, p<0.0001), when staffing at the hospital is the lowest. Vehicle-related trauma was the most common mechanism for MCI, 77%, compared to 25% for non-MCI (p<0.0001). MCI patients were also admitted to the hospital more frequently (20% vs. 16%). A higher proportion of MCI victims were brought in dead (3% vs. 1%, p<0.0001). While overall mortality was higher among MCI victims (4% vs. 2%, p<0.0001), in-hospital mortality was 5.6% for both MCI and non-MCI patients.

Conclusion: In Malawi, MCIs occur frequently, and most MCIs arrive between 6pm and 6am when staffing is most limited. Hospital and public health efforts should address staff capacity for MCIs and efforts to decrease road traffic crashes. While overall mortality is higher in MCI, MCI patients who arrive at the hospital alive, have an equal chance of survival to discharge rate as admitted non-MCI patients. Establishing pre-hospital care and an organized trauma system to improve triage could improve post MCI survival.

90.01 A Field Survey of Peruvian Healthcare Workers: Access, Barriers and Solutions to Surgical Care

Posted on January 31, 2019

F. Lema1, C. Flores1, V. Padmanaban2, P. F. Johnston2, F. R. Muñoz Córdova3, Z. C. Sifri2  1New Jersey Medical School,Newark, NJ, USA 2University Of Medicine And Dentistry Of New Jersey,Surgery,Newark, NJ, USA 3Universidad Privada Antenor Orrego (UPAO),Trujillo, Peru

Introduction:

The Peruvian government offers Seguro Integral de Salud (SIS), a free health insurance program, to any citizen below a defined poverty level. Despite the ostensible availability of this coverage, many patients lack access to surgical care. Local healthcare workers involved in surgical care may provide additional insight into this problem. We conducted a survey to investigate the perceptions of local healthcare workers on access and barriers to surgical care in Trujillo, Peru.

Methods:

A qualitative survey was issued on paper in Spanish to healthcare workers (HCWs) in the urban center of Trujillo, Peru at three main hospitals. The survey asked providers questions regarding health services in Peru with emphasis on access, barriers and potential solutions to surgical care delivery. Data on basic demographics, medical role and specialty, and years of clinical experience was collected.

Results:

Forty-seven HCWs who completed surveys averaged 35 ± 15 years of age and 9.5 ± 13 years employed in the Peruvian healthcare system. Fifty-five percent of participants included 26 physicians: 7 general surgeons, 1 trauma surgeon, 1 anesthesiologist, 12 interns, 1 pediatrician, 1 gynecologist, and 3 in rural medicine.

The majority of study participants either disagreed (45%) or strongly disagreed (6%) when asked if they believe health services are accessible to every Peruvian regardless of their economic situation. Seventy-four percent of HCWs agreed that there is a problem with access to surgical care in Trujillo and furthermore, this perception by HCW was the same regardless of medical role, gender, years of clinical service, and hospital sites.

Factors that HCWs cited as barriers to surgical care included inadequate funding, deficits in surgical infrastructure, long wait times, lack of qualified surgeons and a lack of surgical resources. Participants elaborated that the lack of surgical resources is a stimulus for patients’ out-of-pocket expenditures, precluding the most impoverished Peruvian patients. Additionally, HCWs agree (47%) and strongly agree (53%) that surgical international humanitarian organizations are an important part of the care for Peru’s poorest patients.

Conclusion:

Notably, the majority of healthcare workers surveyed believe there exists a problem with access to both health services in Peru and surgical care in Trujillo. Furthermore, all participants consider that international surgical teams are a necessary part of the local healthcare system, especially for the care of the poorest citizens. Given that participants were able to name several of these organizations, indicated that their belief is supported by experience. Further study to identify long-term sustainable solutions is warranted.

85.02 Learning from England’s Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Outcomes

Posted on January 31, 2019

C. K. Zogg1,2,3, D. Metcalfe3, A. Judge4, D. C. Perry3, M. L. Costa3, B. J. Gabbe5, A. H. Haider2  1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University of Oxford,Oxford, United Kingdom 4University of Bristol,Bristol, United Kingdom 5Monash University,Melbourne, Australia

Introduction: Since passage of the Patient Protection and Affordable Care Act in 2010, Medicare has renewed efforts to improve the quality of older adult health through the introduction of an expanding set of outcome-based readmission and mortality pay-for-performance (P4P) measures. Among trauma patients, potential P4P has met with mixed success given concerns about the heterogeneous nature of patients that trauma providers treat and resultant variations in outcome measures. A novel approach taken by the National Health Service in England could offer a viable alternative plan. The objective of this study was to assess the effectiveness of the 2007-2010 English provider consensus-driven, process measure-based P4P Hip Fracture Best Practice Tariff (BPT) on improving trauma outcomes.

Methods: Quasi-experimental interrupted time-series and difference-in-difference analysis of 2000-2014 death certificate-linked data from England (Hospital Episode Statistics), Scotland (Scottish Morbidity Records), and the United States (100% Medicare all-payer claims). The study compared before-and-after differences in English temporal trends relative to those of Scotland and the US. Outcomes included: 30/90/365-day mortality, readmission, index hospital length of stay, and time to surgery. The study also assessed projections for the number of lives saved and readmissions averted were the BPT to be implemented in Scotland and the US.

Results: A total of 878,860 English, 97,487 Scottish, and 2,994,748 US index fractures were included among adults ≥65y. Following BPT introduction in England, 30-day mortality decreased instantaneously by an absolute value of -2.6 (95%CI -3.5, -1.7) percentage-points and continued to drop by an average of -0.2 (-0.4, -0.1) percentage-points per year (DID-Scotland: -1.6; DID-US: -2.2). 90-day mortality decreased more precipitously, dropping by an absolute value of -5.6 (-7.1, -4.2) percentage-points and an annual average thereafter of -0.2 (-0.5, 0.0) percentage-points per year (DID-Scotland: -1.9; DID-US: -2.9). Similar improvements were observed in readmission (e.g. 30-day ITSA: -1.4 [-2.3, -0.5]), time to surgery, and length of stay. Projections suggest that were the BPT to be implemented in Scotland and the US (Figure), by 2030, as many as 1,377 Scottish and 11,434 US lives could be saved.

Conclusion: In contrast to outcome-based P4P, process measure P4P such as that implemented through the English Hip Fracture BPT could result in significant improvements in outcomes for US patients while remaining more applicable to heterogeneous trauma populations and acceptable to trauma providers. As efforts to improve older adult health continue to increase, there are important lessons to be learned from initiatives like the BPT

63.05 GoogleGlass for Surgical Tele-proctoring in Low-Resource Settings: A Feasibility Study in Mozambique

Posted on January 31, 2019

M. C. McCullough5, L. Kulber2, P. Sammons5, P. Santos3, D. Kulber5,6  2Mending Kids, International,Los Angeles, CA, USA 3Matola Hospital,Plastic And Reconstructive Surgery,Matola, Mozambique 5University Of Southern California,Plastic And Reconstructive Surgery,Los Angeles, CA, USA 6Cedars-Sinai Medical Center,Plastic And Reconstructive Surgery,Los Angeles, CA, USA

Introduction: Untreated surgical conditions account for one third of the total global burden of disease, and a lack of trained providers is a significant contributor to the paucity of surgical care in low and middle-income countries (LMICs). Wearable technology with real-time tele-proctoring has been demonstrated in high-resource settings to be an innovative method of advancing surgical education and connecting providers, but application to LMICs has not been well-described. We share our six-month experience with Google Glass in Mozambique and demonstrate the feasibility of using wearable technology with tele-proctoring to expand access to training opportunities in reconstructive surgery in this low resource setting.

Methods:  Google Glass with live-stream capability was utilized to facilitate pre and intra-operative tele-proctoring sessions between a surgeon in Mozambique and a reconstructive surgeon in the United States over a six month period.  At the completion of the pilot period a survey was administered regarding the acceptability of the image quality as well as the overall educational benefit of the technology in different surgical contexts.  Additional narrative interviews were conducted with both participants to gain further insight into potential challenges and limitations of the program. 

Results: Twelve surgical procedures were remotely proctored using the technology.  No complications were experienced in any patients.  Survey results demonstrate the biggest limitations to the experience, from the perspective of both participants, were issues related to image distortion.  Image quality was sufficient for the mentor surgeon to perceive and to comment on pertinent anatomical structures, instrument handling, positioning and technique, but distortion due to light over-exposure, motion artifact and image resolution were rated as moderate impairments.  Video-stream latency and connection disruption were also cited as limitations. Despite image distortion, both surgeons found the technology to be highly useful as a training tool in both the intraoperative and perioperative setting.  

Conclusion: Our experience in Mozambique demonstrates the feasibility of wearable technology to enhance the reach and availability of specialty surgical training in LMICs. Surgical aid to LMICs has long been dominated by short-term trips by high-income country volunteers, and creative solutions are needed to re-focus efforts on surgical education and prioritize the development of local surgeons within their countries and local practice settings.  Despite shortcomings in the technology and logistical challenges inherent to international collaborations, this educational model holds promise for connecting surgeons across the globe, introducing expanded access to education and mentorship in areas with limited opportunities for surgical trainees and generating discussion around the potential for innovative technologies to address needs in training and care delivery in LMICs. 

 

62.11 Adapting the AAS Fundamentals of Surgical Research Course to West Africa: A 10-year evaluation

Posted on January 31, 2019

A. Ekeh1, J. Laryea2, B. Nwomeh4, A. Omigbodun5, J. Ladipo6, K. Yawe7, S. Krishnaswami8, F. Nwariaku3  1Wright State University,Surgery,Dayton, OH, USA 2University Of Arkansas for Medical Sciences,Surgery,Little Rock, AR, USA 3University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 4Ohio State University,Surgery,Columbus, OH, USA 5University of Ibadan,Obstetrics And Gynaecology,Ibadan, OYO STATE, Nigeria 6University of Ibadan,Surgery,Ibadan, OYO STATE, Nigeria 7University of Abuja,Surgery,Abuja, FCT, Nigeria 8Oregon Health And Science University,Surgery,Portland, OR, USA

Introduction:

The Association for Academic Surgery (AAS) has annually administered the Fundamentals of Surgical Research  (FSR) course for almost 30 years – designed primarily for residents and junior faculty in surgery and surgical specialties. In 2008, the course was launched internationally, starting in West Africa. Commencing as a collaboration between the AAS and the West African College of Surgeons (WACS), the course was held 6 times between 2008 and 2014 in different West African countries, and utilized chiefly US based faculty who traveled to the region to participate in conjunction with local faculty. In 2015, the course was reconfigured to utilize primarily local faculty based in the sub region, fewer US based personnel and further adapted to local needs We evaluated the course after 4 consecutive years of this new format, with respect to the attendance, the number of US based faculty utilized, costs from external sources (above and beyond participant registration fees) and participants evaluations.

Methods: Data collating the number of attendees, funding from external sources (sponsorships), the number of US based faculty and student evaluations were obtained for the first 6 iterations of the AAS FSR West African course (2008 -2014). The same data was obtained for the next 4 courses (2015 – 18) which had been renamed the WACS/AAS Research Methodology Course (RMC). The mean number of attendees, external support (above and beyond registration fees in US Dollars) and the number of US faculty were compared statistically using student t-tests.  

Results:
In the first 6 years of the AAS FSR course (2008 – 2014) the average number of attendees per course was 67 (range 20 to 120) while the mean number of attendees for the WACS/AAS RMC was 150 (range 141 – 160), p = 0.0032. The average costs from external sources for the AAS FSR was $29,183 (range $20000 to $50000) and for the WACS/AAS RMC $5000. p = 0.0106. On average, 9.7 US faculty were used for the AAS FSR and just 2.3 for the WACS/AAS RMC. (p < 0.0001)  Student evaluations were more difficult to directly compare as the highest tiers were rated " Good and Excellent " in the AAS FSR period and "Useful and Very Useful " in the WACS/AAS RMC period. Over 90% of the evaluations however were in these two highest tiers in every course in both periods.  

 

Conclusion:
The adaptation of the AAS Fundamentals of Research Course to the West African region has correlated with increased average attendance, reduced external support costs over and above participant fees, a reduced number of US faculty utilized and similar excellent evaluations from the course participants.  With appropriate mentorship, the regional adoption of courses like the AAS FSR course in different environments is feasible.  The with the utilization of local faculty, the reduced need for external funding and equivalent evaluations by participants makes this approach attractive for the implementation of such courses in resource-poor environments

 

62.07 "Cross-Sectional Analysis of Global Surgery Opportunities Among General Surgery Residency Programs"

Posted on January 31, 2019

P. J. Abraham1, M. N. Abraham1, B. Lindeman1, H. Chen1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Global surgery is a rising field within academic surgery. With the publication of recent landmark papers highlighting the need for increased global efforts to combat surgical disease, many general surgery residents seek opportunities to gain clinical, research, and educational experience related to global surgery during residency. This study aims to quantify the global surgery opportunities that are publicly available to residents training in ACGME-accredited general surgery programs.

Methods: The websites of all ACGME-accredited general surgery residency programs were surveyed for mention of global surgery training opportunities. Each opportunity was recorded in a database and categorized based on type. Recorded categories include international clinical rotations, international surgical research opportunities, and formal tracks or training pathways for global surgery.

Results: Of the 299 ACGME-accredited general surgery training programs, 38 (12.7%) mention some form of international surgical opportunity on their website. Among these programs, 7 (18.4%) note both clinical and research opportunities, 19 (50.0%) mention only clinical opportunities, and 12 (31.6%) list only research opportunities. Ten programs (26.3%) described a global surgery track or pathway within their program. The large majority of global surgery opportunities were based in training programs at academic medical centers (n=35, 92%), with the remaining 3 based in programs at community teaching hospitals.

Conclusion: Very few general surgery residency programs mention international training opportunities on their program websites. For those programs that do offer global surgery opportunities, these are typically international rotations offered as electives for upper-level residents. Increased global surgery opportunities are needed at residency programs nationwide to meet the desire of residents wishing to pursue a career in academic global surgery.

 

62.06 Surgical Coaching for Advancement of Global Surgical Skills and Capacity: a Systematic Review

Posted on January 31, 2019

D. El-Gabri1, A. D. McDow1, S. R. Pavuluri Quamme2, C. C. Greenberg3, K. L. Long1  1University Of Wisconsin,Division Of Endocrine Surgery/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 3University Of Wisconsin,Division Of Surgical Oncology/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA

Introduction:
Surgical coaching is an emerging concept of education and collaboration demonstrated to improve surgical performance, perceptions and attitudes of practicing surgeons. Continued surgical education in low-resource settings remains a challenge due to confounding barriers of access, resources, and sustainability. Despite early successes of surgical coaching in academic institutions, to our knowledge, no formal assessments of coaching as a means to improve surgical quality in low-middle income countries (LMICs) exist. The purpose of this review is to explore if surgical coaching is an effective method of fostering continued medical education and promoting advancement of surgical skills for established surgeons in low resource settings.

Methods:
We conducted a systematic literature search through PubMed, Scopus, Web of Science, and CINAHL in July 2018. Included studies were in English, peer-reviewed, and met pre-established study criteria. Studies must have assessed surgical coaching- specifically defined as a means to establish continuous professional growth of trainees and practicing surgeons. Additionally, we conducted a reference and citation analysis as well as a data quality assessment on included studies.

Results:
Our search produced 1377 results and 151 were selected for full text analysis, of which 23 met inclusion criteria for summary analysis. While the majority of the articles (13/23) evaluated coaching of trainees, 10 articles assessed or evaluated coaching surgeons in established careers. Of the articles that discussed skill acquirement (18/23), 3 assessed non-technical skills alone, and 14 assessed technical skills or both technical and non-technical skills. In studies that assessed skill performance after a coaching intervention (9/23), all of them (9/9) demonstrated skill improvement compared to a control. The idea of remote or cross-institutional coaching was explored in 8 of the 23 studies. None of the studies reviewed discussed or evaluated coaching in LMICs.

Conclusion:
Coaching is a widely applicable method of teaching surgeons at multiple stages of a career with clear educational benefits. The explored advantages of surgical coaching in academic institutions may be applied to continuous performance improvement and collaboration with surgeons in LMICs. Furthermore, coaching may aid in assessment of the well-established Lancet Global Surgery Indicators thereby improving surgical capacity in LMICs.
 

52.17 Evaluation of Preventable Risk Factors for Trauma Mortality in Western Kenya

Posted on January 31, 2019

K. Carpenter1, C. H. Keung1,2, E. Rutto2, E. Chepkemoi2, J. Hogan3, H. W. Li1,4, J. Kisorio2  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2Moi University,Department Of Surgery And Anaesthesiology,Eldoret, UASIN GISHU COUNTY, Kenya 3University of Alberta,Office Of International Surgery,Edmonton, ALBERTA, Canada 4Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:
Ninety percent of the 5 million annual deaths from traumatic injuries occur in low- and middle-income countries (LMICs). Kenya is one such nation, with limited trauma prevention policies and infrastructure. Road traffic accidents (RTAs), in particular, are a frequent cause of traumatic injury and subsequent mortality which continue to increase in incidence. This loss disproportionately impacts young people. Moi Teaching and Referral Hospital (MTRH) is a national tertiary referral hospital in Eldoret, Kenya, serving Western Kenya. In order to characterize the scope of traumatic injuries in this region, a prospective trauma registry was implemented at MTRH in September 2017. The purpose of this study was to identify how preventable risk factors affect mortality in RTAs in order to provide evidence-based recommendations for primary and secondary trauma prevention efforts.

Methods:
Data were collected prospectively on all patients presenting to MTRH primarily for acute traumatic injuries beginning in September 2017. Trauma registry data were retrospectively reviewed for patients involved in RTAs. Pedestrians struck were excluded. Data collected included mechanism of injury. Exposures of interest were seatbelt use, helmet use, and alcohol consumption. The outcome of interest was all-cause mortality within 30 days of presentation to MTRH. After patients with missing exposure data were excluded, Chi-square analysis and odds ratios were calculated using SAS 9.4.

Results:
Between September 2017 and April 2018, 1841 patients presented to MTRH following a traumatic injury. Of these, 870 patients were involved in an RTA. Exposure data was unknown or not recorded for 339 patients. 389 patients were involved in motorcycle accidents. Of these, only 10 patients (2.6%) were wearing a helmet at the time of the injury. No mortalities were recorded among helmeted patients. Unhelmeted patients had a 7.79% mortality rate and 2.5 greater odds of dying, though this was not significant (95% CI: 0.14-44.68, p=0.6002). 463 patients sustained injuries in RTAs involving automobiles. Only 2 (0.4%) were restrained and these both survived. Mortality among unrestrained patients was 7.1%. No significant relationship between seatbelt use and mortality was identified (p=0.2833). 17.2% of RTA injuries involved alcohol use. These patients had increased odds of mortality compared to those who had not consumed alcohol, which was not statistically significant (OR 1.41, 95% CI 0.65-3.09, p=0.3841). 

Conclusion:
Seatbelt and motorcycle helmet use is exceedingly rare among trauma patients in Western Kenya, while alcohol use is high. No mortalities were recorded among patients using a seatbelt or wearing a motorcycle helmet. Trauma prevention efforts in Western Kenya should target all three of these risk factors. More thorough patient data collection will be necessary to accurately monitor the success of such programs.

 

36.09 Refugee Access to Surgical Care in Lebanon: A Post Hoc Analysis of the SCAR Study

Posted on January 31, 2019

M. W. El Hechi1, J. M. Khalifeh2, E. P. Ramly3,4, J. Abed Elahad1, A. I. Eid1, A. Bonde1, G. Velmahos1, J. Hoballah5, H. Kaafarani1  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Washington University,School Of Medicine,St. Louis, MO, USA 3New York University School Of Medicine,Hansjörg Wyss Department Of Plastic Surgery,New York, NY, USA 4Oregon Health And Science University,Department Of Surgery,Portland, OR, USA 5American University of Beirut Medical Center,Department Of General Surgery,Beirut, Lebanon

Introduction:

Lebanon, a country of 6 million people, hosts approximately one million Syrian refugees registered with the United Nations High Commissioner for Refugees (UNHCR). The UNHCR contracts with select hospitals throughout the country to facilitate the provision of affordable and accessible basic primary health and emergency care to refugees. We aimed to assess the surgical capabilities of UNHCR-covered hospitals in Lebanon.

Methods:

Cross-sectional data from the Surgical Capacity in Areas with Refugees (SCAR) study were combined with hospital affiliation data directly obtained from the UNHCR. The SCAR study evaluated surgical capacity in Lebanon by mapping all acute care hospitals in the country and administering the validated five domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool to each hospital. Surgical capacity, specifically overall and domain-specific PIPES indices and mean numbers of surgeons, anesthesiologists, and hospital beds, were compared between UNHCR affiliated and non-affiliated hospitals. In an effort to understand regional disparities, the geographic distribution of UNHCR-affiliated hospitals was cross-referenced with refugee population distributions across the country.

Results:

A total of 129 hospitals were included and the PIPES tool was successfully administered in all hospitals (100%) between 2014 and 2017. Out of the 35 hospitals affiliated with the UNHCR, 43% were public, while 57% were operated privately. The mean overall and domain-specific PIPES indices and the mean number of hospital beds were similar between the UNHCR affiliated and non-affiliated hospitals (Figure 1). The mean numbers of general surgeons and anesthesiologists per hospital were also similar between the two groups (7.94 vs. 7.52, p=0.64; 3.86 vs. 4.05, p=0.68, respectively). Upon geographical mapping of hospital coordinates and refugee populations across Lebanon, the greatest disparity was found in the Northeastern region of the country (Baalbeck-Hermel): that region had the highest number of refugees but lacked any UNHCR-coverage.

Conclusion:

Hospitals covered by the UNHCR performed similarly to non-affiliated hospitals with respect to all aspects of the PIPES surgical capacity tool. However, there is a concerning geographic mismatch between UNHCR hospital coverage and refugee density, specifically in the underserved Northeastern region of Lebanon.
 

36.08 Helmet Usage in New Delhi: Revision of the Exemption

Posted on January 31, 2019

C. Pathak1, S. Siddiqui2, S. Sagar3, M. Swaroop1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA 3The All India Institute Of Medical Sciences,New Delhi, India, India

Introduction:  Helmet usage laws have been a cornerstone in preventing and minimizing injuries in motorized two-wheeled (MTW) vehicle accidents. In 1988, India passed the Motor Vehicle Act nationally, making it mandatory for MTW riders to wear helmets. In 1999, the Act was challenged as undermining religious expression in the New Delhi High Court and an exemption was passed, allowing women and Sikhs to ride pillion without wearing helmets. These exemptions made the law difficult to enforce. In a study conducted of MTW pillions in New Delhi in 2011, 58.7% were helmeted and 41.3% were unhelmeted. In 2014, the New Delhi government revised the exemption requiring all MTW riders to wear helmets, with fewer exemptions. The purpose of this study was to determine the prevalence of helmet usage in MTW vehicle riders in New Delhi, India following the revision of the exemption.

Methods:  An observational video study was conducted to determine the prevalence of helmet usage in MTW riders in New Delhi, India. At least twenty-five minutes of traffic video was recorded in the morning rush hour, mid-day and evening rush hour from June 15 to June 25, 2016 at four representative intersections in the city: Rajiv Chawk Circle and Barakhambha road, AIIMS Trauma Center and Mahatma Ghandi road, India Gate C Hexagon, and Safdarjung Hospital and Mahatma Gandhi road intersections. The video recordings were analyzed for the number of MTW riders, gender, approximate age (adult or child), and helmet usage by two reviewers who are versed in Indian culture.

Results: A total of 12,625 MTW riders were observed on video. Of those, 88% (11,121) were male, 10% (1198) were female and 2% (237) were children. Compared to the 2011 study, the percentage of MTWs who used helmets increased from 88.4% to 93% for males, p<0.001 and from 0.6% to 45% for females, p<0.001. While the percentage of women who were helmeted increased from the 2011 study, there remained a significant difference, p<0.0001, in the percentage of males and females that were helmeted. Of the children observed, only 6% were helmeted. However, there are no data points for comparison from the 2011 study for children.

Conclusion: Since the revision of the exemption, there has been an increase in male and female MTWs using helmets. While males already demonstrated a high rate of helmet usage, the rate of increase in helmet usage by women has been dramatic. Overall, however, the rate of helmet usage for women remains low, at 45%. Additionally, helmet usage in children remains exceptionally low at 6%. While the change in mandatory helmet laws is a significant factor in influencing an increase in overall helmet usage, additional factors including improved media and public educational campaigns, law enforcement, and shifting cultural norms may affect usage as well. Barriers to helmet usage by women and children need to be studied further to improve the rate of helmet usage in these populations.

36.07 The Efficacy of Trauma Transfers in a Resource Poor Setting

Posted on January 31, 2019

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

Introduction: Trauma is a leading cause of morbidity and mortality worldwide with the burden borne by low- and middle-income countries (LMICs). Important trauma principles are early triage, expedited care, and transfer of patients to appropriate higher levels of care. Inappropriate transfers (IT), or overtriage, tax overburdened hospitals in LMICs. Little data exists on efficacy of trauma transfers in LIMCs. We sought to determine the rate and characteristics of inappropriate trauma transfer patients in Malawi.

Methods: A retrospective analysis of prospectively collected data was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. IT were defined as patients discharged alive from the emergency department or patients admitted for less than one day without undergoing surgery. Variables included were demographics, injury severity and characteristics. Bivariate analysis, Kruskal-Wallis, t-Test, and logistic regression were utilized when appropriate.

Results: From February 2008 – July 2017, 120,573 trauma patients presented. Transferred patients constituted 17.0% (n=20,460), of these 57.3% (n=11,725) were IT. Inappropriately transferred patients were younger (mean 21.9±17.2 yrs, CI: 21.6 – 22.2) than appropriately transferred (mean 26.3±19.8 yrs, CI: 25.8 – 26.7), p<0.001. IT occurred more in women than men, 60.5% versus 56.0%, respectively (p<0.001). Primary extremity injury were more often IT (n=6,975, 61.7%) compared to primary torso (n=1,764, 48.5%) or head injuries (n=2,862, 54.0%), p<0.001. IT (median 1 hr, IQR 1-1 hr) arrived at KCH faster than appropriate transfers (median 1 hr, IQR 1-2), p=0.002. Fewer IT occurred at night (n=2554, 46.6%, p,0.001) vs day (n=9141, 61.4%) and on weekends (n=2653,55.8%, p=0.02) vs weekdays (n=2563, 55.8%). The injury mechanisms with the highest rate of IT were lacerations (n=320, 69.3%), animal bites (n=295, 70.7%), and falls (n=4199, 64.1%). IT rates were lowest in motor vehicle collisions (n=3098, 50.0%) and burns (n=429, 31.3%) injury mechanisms. In the logistic regression model, lacerations (OR 2.26, CI 1.63 – 3.13), animal bites (OR 1.97, CI 1.48 – 2.63), assault (OR 1.76, CI 1.54 – 2.00), falls (OR 1.25, CI 1.12 – 1.40), and female sex (OR 1.21, CI 1.10 – 1.32) had increased odds of IT, p<0.001. Night admits (OR 0.54, CI 0.49 – 0.59) and burn injuries (OR 0.44, CI 0.37–0.54) were protective for IT, p<0.001. Primary head (OR 1.34, CI 1.17 – 1.52) and extremity injuries (OR 1.86, CI 1.65 – 2.10) had increased odds of IT compared to torso injuries, p<0.001.

Conclusion: The majority of patients transferring to KCH for injury care are inappropriately transferred. The lack of clear transfer triage criteria and protocols contribute to this overtriage. Implementation of transfer criteria, trauma protocols, and inter-hospital clinician communication can mitigate the strain of IT in the resource limited setting.

36.04 Financial Risk Protection in Cesarean Section Patients at a Rural District Hospital in Rwanda

Posted on January 31, 2019

R. Koch1, T. Nkurunziza2, H. L. Irasubiza2, M. Shrime1, B. Hedt-Gauthier2,3, F. Kateera2  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Boston, MA, USA 2Partners in Health/Inshuti Mu Buzima,Kigali, Rwanda 3Harvard School Of Medicine,Global Health And Social Medicine,Boston, MA, USA

Introduction:  To ensure universal health coverage (UHC), essential surgical care must be affordable. In Rwanda, more than 90% of citizens have community-based health insurance (Mutuelle de Sante). For all but the poorest citizens who are fully covered, insured members are responsible for a 10% co-pay as out of pocket (OOP) payment at time of service. However, 59.5% of the population is already below the international poverty line meaning that even this amount along with associated care-seeking costs have a significant impact on a family’s financial health. The aim of this study was to describe OOP payments for cesarean sections in the context of Mutuelle de Sante and determine if having insurance reduces catastrophic health expenditure in rural Rwanda.

Methods:  This study is nested in a larger study of women undergoing cesarean section at a rural district hospital in the Eastern Province of Rwanda. All eligible women between March and June 2018 were surveyed at time of discharge. Data included demographics, household income and routine monthly expenditures and direct and indirect spending related to the cesarean delivery hospitalization. Catastrophic health expenditure (CHE) can be defined as >10% estimated total yearly expenses or >40% annual non-food expenses.

Results: Of 346 women, 339 (98.0%) met the World Bank definition of extreme poverty (income <$1.90/person/day). 339 (98.0%) reported having health insurance; the majority (93.2%, n=316) have Mutelle de Sante. The median OOP expenditure for a direct medical costs related to a cesarean section was $26.29 (IQR 21.20-29.48). 30 (8.7%) patients had unpaid balances at time of discharge. The average cost including transportation to the hospital was $34.35 (IQR 26.99-40.93). 168 patients (48.6%) had to borrow money and 43 (12.4%) had to sell possessions to pay for the hospitalization. The direct medical costs alone were a CHE, defined as >10% estimated total yearly expenses, for 22 patients (6.3%). However, this increased to 33 (9.5%) when including direct non-medical costs such as transportation and food and 94 (27.0%) when including indirect expenses such as lost wages. Using 40% of non-food expenses to define CHE, up to 51.5% of patients experienced CHE when including other direct and indirect costs.

Conclusion: Despite universal health insurance, essential surgery still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although insurance offers some protection against catastrophic expenditure from the cost of healthcare alone, when adding in the cost of non-medical expenses, cesarean section is still too often a catastrophic financial event. Further innovation in financial risk protection is needed in order to provide equitable UHC.

 

36.03 Burden, Outcomes, and Economic Benefit of Neonatal Surgery in Uganda: Results of a Five-Year Follow-up Study

Posted on January 31, 2019

S. Ullrich1, N. Kakembo2, P. Kisa3, A. Muzira4, M. Nabukenya8, J. Tumukunde3, T. Fitzgerald5, M. Langer6, M. Situma7, J. Sekabira2, O. Doruk1  1Yale University School Of Medicine,Pediatric Surgery,New Haven, CT, USA 2Mulago Hospital,Surgery,Kampala, Uganda 3Makerere University,College Of Health Sciences,Kampala, Uganda 4University of British Columbia,Surgery,Vancouver, BC, Canada 5Duke University,Department Of Surgery,Durham, NC, USA 6Ann & Robert H Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA 7Mbarara Regional Referral Hospital,Surgery,Mbarara, Uganda 8Mulago Hospital,Anesthesia,Kampala, Uganda

Introduction: Ninety-four percent of congenital anomalies occur in low and middle-income countries (LMICs). In Uganda, only four pediatric surgeons and three pediatric anesthesiologists serve over 20 million children. This study estimates burden, outcomes, and coverage of neonatal surgical conditions in Uganda and compares them with our prior estimates. We also estimate economic benefit of neonatal surgery.

 

Methods: A prospectively collected database was reviewed for neonatal (age < 30 days) general surgical admissions from January 1 2012, to May 31, 2017 at the only two sites with specialist pediatric surgical coverage, one that started providing services in mid-2014. Outcomes were compared with high-income countries, and met and unmet need were estimated using disability-adjusted life years (DALYs). We estimated economic benefit using a value of a statistical life-year approach.

 

Results: A total of 1,177 neonatal admissions were identified, representing 25% of all pediatric surgery admissions. Mean age of presentation was 7 days and overall mortality was 36%. Mean distance travelled was 92 km. The most common conditions were anorectal malformations (18%), gastroschisis (17%), omphalocele (15%), and intestinal atresia (10%). Almost half of presenting neonates (49%) underwent surgical intervention. Post-operative mortality was 24%.  Mortality for neonates was significantly associated with surgical intervention (p<0.001) and age (p<0.001). Highest mortality conditions were gastroschisis (85%) and biliary atresia (80%). Gastroschisis (42%) and anorectal malformations (42%) had the greatest reduction in mortality with surgical intervention. Met need was 3,531 DALYs/ year and 140,220 DALYS were potentially avertable (unmet need). The current met need corresponds to a $2.9 million net economic benefit to Uganda, with a potential additional benefit of $116 million if unmet need were fully addressed. Approximately 2.3% of the total need was met by the healthcare system.   

 

Conclusions: Neonatal surgery improves survival for most conditions despite resource limitations such as lack of neonatal intensive care. Despite slight increases in workforce and infrastructure, a negligible proportion of the need for neonatal surgery is currently being met in Uganda, similar to estimates five years ago (3%). This is likely multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial. More advocacy is needed to increase capacity for pediatric surgical care in Uganda and similarly resourced LMICs.

36.02 Preparing for Increased Surgical Need in an Era of Improved Infant and Child Mortality

Posted on January 31, 2019

C. Ewbank1,4, A. L. Kushner2,3, C. Newton1, W. Stehr1,5  1UCSF Benioff Children’s Hospital Oakland,Surgery,Oakland, CA, USA 2Johns Hopkins Bloomberg School of Public Health,Center For Humanitarian Health,Baltimore, MD, USA 3Surgeons OverSeas,New York, NY, USA 4University Of California – San Francisco East Bay,Surgery,Oakland, CA, USA 5Presbyterian Hospital,Surgery,Albuquerque, NM, USA

Introduction:

Successful interventions by the global health community have reduced the total number of under-five deaths from 12.6 million to 5.6 million (55.6%) since 1990. Over the same time period, neonatal mortality fell from 37 deaths per 1,000 to 19 (49%). With more babies surviving childbirth and into early childhood, the incidence of life-threatening pediatric surgical diseases will likely increase. We sought to characterize this increased surgical need for children under five years old based upon the improvement in child mortality worldwide.

Methods:

The incidence of ten common emergent pediatric surgical conditions, excluding those resulting from trauma, was compared to country level data from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) and the 2017 United Nations World Population Prospects probabilistic projections to estimate and characterize global surgical need among children under five by 2030.

Results:

Children under five are projected to require a mean net total of 83,557 additional essential procedures/year by 2030. The majority of additional surgical need is projected to be from incarcerated inguinal hernias (48,224 mean additional procedures, 57.7% of the total increase). Hypertrophic pyloric stenosis and intussusception represent other major contributors to overall surgical need (18,543 (22.2% of total) and 7,467 (8.9% of total), respectively). The countries with the greatest projected need due to increase in under-five population were Nigeria (117,814 additional needed procedures/year (28.7% increase)), the Democratic Republic of the Congo (68,430 additional needed procedures/year (36.8%)), and the United Republic of Tanzania (45,158 additional needed procedures/year (36.3% increase)). Although the overall global surgical need was net positive, many countries are projected to have significant decreases in under-five surgical need by 2030, the largest of which were China (236,067 fewer needed procedures (20.8% decrease)), India (50,999 fewer needed procedures (3.2% decrease)), and Iran (31,841 fewer needed procedures (35.0% decrease)).

Conclusion:

Children under five will require nearly 100,000 additional life-saving procedures each year by 2030, with many developing nations and remote areas within developed nations already unable to treat the current essential pediatric surgical need. This need is overwhelmingly projected to affect the least developed nations, and particularly those in Sub-Saharan Africa, where neonatal and early childhood disease treatable by surgical intervention represent a tremendous opportunity to improve morbidity and mortality. As population growth slows in many parts of the world, continued research and clinical efforts should be directed toward children in those places where the need is the greatest.
 

« Previous Page
Next Page »