Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.

(Dunbar, Mayer) Both Dr. Dunbar and Dr. Mayer are first authors, having contributed equally, and they are listed alphabetically.(Dunbar) Assistant Professor of Anesthesiology.(Mayer) Professor of Geography, Adjunct Professor of Medicine (Infectious Disease), Family Medicine-Health Services.(Fordyce) Doctoral Candidate.(Lishner) Associate Director.(Hagopian) Associate Director Community Health Services Development, Family Medicine; Clinical Assistant Professor Health Services, School of Public Health and Community Medicine.(Spanton) Certified Registered Nurse Anesthetist.(Hart) Research Associate Professor, Department of Family Medicine; Director of WWAMI Rural Health Research Center.ANESTHESIA has historically been an undersupplied specialty. Health personnel issues used to be dominated by the findings of the 1980 Graduate Medical Education National Advisory Committee study, which suggested that anesthesia would be a balanced specialty for the rest of the century.* Recent studies, however, have demonstrated that there is an oversupply of all specialists, including anesthesiology.*****[1,2]These studies take a “top down” view of health personnel through analysis of national statistics and exploration of subsets of the data by hospital size and rurality. This approach assumes that the databases of the American Hospital Association and the American Medical Association are accurate and do not take into account the presence of certified registered nurse anesthetists (CRNAs), who are the predominant providers of anesthesia care in the smallest and most remote hospitals in the United States. We compared the 1994 master file of the American Medical Association with our local knowledge of the practitioners in the rural areas of Washington state and found numerous small errors. These errors of one or two practitioners made no difference to the analysis of practitioner groups with more than approximately five people, but in the most rural communities the erroneous presence or absence of a single practitioner made a significant difference.The WWAMI Rural Health Research Center is a federally funded center dedicated to the study of the provision of health care in rural Washington, Wyoming, Alaska, Montana, and Idaho. Earlier studies of surgical and obstetric care in Washington state [3,4]validated the assumption that anesthesia care was integral to the quality and quantity of care delivered and to the economic viability of rural hospitals, suggesting there was a need to study delivery patterns of anesthesia care directly.Nearly all anesthesia in the United States is administered by anesthesiologists or CRNAs who practice alone or in a team care mode. Rural hospitals frequently depend on CRNAs to provide anesthesia services,****[5–7]and we hypothesized that small remote hospitals were even more dependent on CRNAs than larger rural hospitals. Therefore, the decreasing numbers of CRNAs graduating during the 1980s may have affected access to surgery in rural areas. [5]We knew the absolute numbers of anesthesia providers had increased, but it was not clear if physicians had moved into rural areas or if the there were local areas of shortage.***[1]We did not study practice mode (team or solo) as it was a secondary to the central question of availability of anesthesia personnel (Figure 1).We deliberately chose to examine anesthesia personnel from the perspective of the hospital administrator because administrators were the most consistent people in the rural hospital. We knew that many rural hospitals used itinerant medical personnel because 59% of the hospitals we planned to sample used nonlocal emergency room physicians. [8]We did not survey rural anesthesia providers because they might be working at more than one facility within the community or in another community, which would have made their responses difficult to interpret. We designed this study to provide basic information about who performs anesthesia in rural areas and how much anesthesia is performed. We did not investigate availability of pain management. We examined the perceived influence of the availability of anesthesia personnel on the capability of rural hospitals to include surgery. Finally, we attempted to determine if there were other obstacles to providing anesthesia service or surgery, such as conflicts between and among anesthesia, nursing, and surgical personnel. At the outset of this study, we hypothesized that inadequate availability of anesthesia inhibits surgery and obstetric services in rural hospitals.We mailed questionnaires to all short-stay, nonfederal, general rural hospitals in the states of Washington and Montana. A short-stay hospital was defined as one with an average length of stay of < 30 days. We excluded federal and specialty hospitals such as psychiatric hospitals. We defined rural counties using Urban Influence Codes (UIC) 3–9. In this article, counties in groups 3–7 are described as “rural” and those in 8 or 9 as “small remote rural.” The complete definition of UIC codes is given in Appendix 1. We defined “locally based” as those providers living in the same community as the hospital.The original information for this study came from a survey of rural hospital administrators. Therefore, our study reflects the perceptions of the administrators. The survey instrument rephrased many of the key questions more than once in an attempt to obtain as much objective information as possible. Both closed- and open-ended questions were used in this questionnaire. The open-ended questions encouraged administrators to express opinions that reflected their specific circumstances and asked for their top three concerns in order of importance. For hospitals in which surgery was performed, information was collected on types of anesthesia providers, types and volumes of surgery, and other related concerns of administrators. For hospitals in which surgery was not performed, information about obstacles to surgery, potential recruitment of surgical personnel, and concerns of administrators was collected. Further, we asked questions about staffing issues tangential to anesthesia to assess the relative importance of anesthesia staffing in the overall picture.The Rural Health Research Center team developed the questionnaire through an iterative process that included a literature review. The pilot questionnaire was then pretested on five rural hospital administrators in Idaho and was revised accordingly. The final questionnaire was four pages long. The first question asked whether the hospital did surgery. If the respondent answered yes, there were 24 follow-up questions-5 open-ended, 9 yes/no, 4 multiple choice, and 6 tables. If the respondent answered no, there were 6 follow-up questions-1 open-ended, 2 tables, and 3 yes/no (Appendix 2). We recommended that replies be completed with the assistance of the operating room supervisor in all but the smallest hospitals.We mailed questionnaires in June 1994 to the administrators of the 92 rural hospitals that fit study criteria. We included a letter of introduction and an explanation with all our mailings. We included handwritten reminders in the second and third mailings. If the administrator did not respond to our second mailing, we followed up by telephone before the third mailing.Additional information was obtained from the American Hospital Association [9]and Rand McNally Road Atlas.***** The American Hospital Association guide supplied information concerning hospital average daily census, hospital bed size, ownership type, and geographic location (county and state). Town population was obtained from Rand McNally, based on the United States census and updates. In addition, information regarding whether surgery was performed in the 13 nonrespondent hospitals was obtained through telephone calls to the hospitals.We tabulated multiple choice and numerical data for analysis. Follow-up calls to the hospital administrators clarified contradictory replies within questionnaires. We analyzed the content of responses to the open-ended questions, and each open-ended reply was classified in a content analysis. For example, one question yielded the following categories: cost volume concern, surgeon availability, and in-service training. In this way, the open-ended responses were able to be compared and analyzed.Standard two-tailed t tests and chi-square tests were used with a 0.05 significance criterion when making bivariate comparisons. Although the number of respondents was relatively small and the associated statistical power is consequently low, the response rate (86%) in this descriptive study includes nearly all the relevant hospital administrators. Therefore, we consider the results to be those of a population, not a sample. Medians were tested using the nonparametric two-sample median test. Results were considered significant if P < 0.05.Because three responses were allowed for each open-ended question, collapsing these responses into categories sometimes resulted in the same case giving the same response more than once. In such instances, all duplicate responses within a given case were eliminated.There was an overall response rate of 85.9%. Administrators from 79 rural hospitals responded and 13 did not. All the returned questionnaires were usable. There were no statistically significant differences between the hospitals that responded and those that did not respond regarding number of beds, daily census, town population, performance of surgery, or rurality. In a few instances, answers crucial to our analysis were omitted and surveyors called an administrator for clarification after they had returned the questionnaires.There were 17 responding nonsurgical hospitals. Surgery was not performed in 22.8% of the eligible rural hospitals in the two states being studied (including both survey respondents and nonrespondents). The 17 responding nonsurgical hospitals had a significantly smaller median number of beds (14 vs. 34), daily census (2 vs. 10), and town population (1,000 vs. 3,000)(P < 0.05). Two administrators indicated that their hospital would begin supporting surgery in the next year, but they were not actively recruiting surgeons or anesthesia personnel. Administrators' reasons for not performing surgery in response to the question “What are the three most important obstacles to the provision of surgery at your hospital (in order of importance)?” are presented in Table 1.Availability of anesthesia personnel was never listed as the most important reason for not performing surgery, although it was mentioned by 37.5% of the administrators.There were 62 responding surgical hospitals.Surgical Volume and Market. Of the 62 reporting hospitals that performed surgery, 44 had one or two operating rooms, 12 had three to five, and 3 had more than five (median, 2). Most of the hospitals were supported by a small number of surgeons living locally (median, 5). There were few visiting surgeons (median, 2), and these data were skewed by a few rural hospitals that had granted courtesy privileges to the entire surgical staffs of affiliated metropolitan hospitals. Hospitals supported an average of 40 inpatient (median, 11) and 68 outpatient (median, 24) procedures per month. There was a local outpatient surgery facility unrelated to the hospital in 21% of the towns, and in 43% of these facilities anesthesia personnel were being used.Obstetric Anesthesia. Eighty-seven percent of the hospitals performing surgery delivered obstetric care, and 76% did cesarean sections. Nine administrators reported that a shortage of anesthesia personnel affected their ability to deliver obstetric care. Three administrators specifically reported that lack of an epidural service limited obstetrics. No administrator reported obstetric anesthesia to be one of their top concerns.Supply of Anesthesia Personnel. The 62 hospitals had 89 anesthesiologists and 124 CRNAs associated with them. Of these, 82 anesthesiologists and 86 CRNAs resided locally. Surgery occurred on significantly more days per month in hospitals with anesthesiologists compared with those with only CRNAs. Forty-six percent of the anesthesiologists practiced in the same hospitals as CRNAs, but we do not know if that was in care team mode. Anesthesiologists were present in 36% of rural (UIC 3–7) counties, but the CRNAs were the sole providers of anesthesia service in the UIC 8 and 9 counties. Anesthesiologists in rural areas were more likely to live locally than CRNAs (Table 2). Administrators reported a total of 7 visiting anesthesiologists and 38 visiting CRNAs (there may have been some double counting). The ability to find coverage for leaves of absence was proportional to the daily census.Presence of Anesthesia. To test our secondary hypothesis that availability of anesthesia was most crucial to the smallest hospitals, we divided our rural hospitals by UIC. The small remote rural hospitals were significantly less likely to have local anesthesiologists and significantly more likely to have visiting CRNAs than other rural hospitals (P < 0.001;Table 3).Larger rural hospitals were significantly more likely to have only anesthesiologists, but small remote rural hospitals were more likely to have only CRNA coverage. We analyzed the data using the hospital as the unit of analysis. Figure 2shows the types of anesthesia providers, both local and visiting, that serve the 62 responding hospitals by UIC. They had an average of 1.5 operating rooms and billed an average of 6,191 operating room minutes per month. The figure also illustrates the extremely rural nature of our sample (Figure 2).Impressions of Administrators. Few administrators ranked the availability of anesthesia personnel as being one of the three most important issues facing rural surgery over the next decade (Table 4). The most important issues were related to reimbursement and surgeon nonavailability, with the nonavailability of anesthesia personnel mentioned as most important by only 2% of the administrators and mentioned at all by only 15.7% of the administrators (Table 4).Anesthesia staffing was relatively low on the list of administrators' personnel concerns; surgeon availability, call coverage, skilled nursing, technical, and reimbursement issues were reported as being of greater concern. Only 8% of the administrators rated nonavailability of anesthesia personnel as their most important personnel issue (Table 5).When asked directly if they would do more surgery if they had more anesthesia available, 85% of administrators said no. The same number (85%) said it would not affect their ability to do obstetrics. In towns with populations of < 3,000, however, 21.2% reported that surgery could be increased if they had more anesthesia personnel compared with 3.6% of administrators in larger towns (P = 0.10).There were few conflicts reported between or among anesthesia personnel, physicians performing surgery, and operating room personnel. Respondents were permitted to list more than one problem. They are:Differences in anesthesia coverage providers (i.e., needs and preferences; n = 5)Scheduling/personnel turnover (n = 4)Communication/role problems (n = 3)Problematic personal behaviors/personality conflicts (n = 2); andOther assorted problems (n = 3).None of the hospital administrators reported conflicts between anesthesiologist and CRNAs. Hospital administrators in larger hospitals (i.e., with more beds) reported more interpersonal problems than their smaller hospital counterparts. All the administrators rated the care provided in their anesthesia departments as either good or very good.Almost one fifth (19.4%) of the administrators considered their surgery programs to be “at risk of being no longer available,” with administrators of hospitals located in smaller towns (< 3,000 population) significantly more likely to feel this way than their larger town counterparts (31.3% vs. 6.9%; P = 0.04). Anesthesia personnel were cited by administrators as the primary risk factor in three of these ten “at-risk” hospitals.There were no meaningful differences between the data from Montana and Washington that could not be explained by differences in hospital size and location.Our results demonstrate that most hospital administrators do not believe that problems concerning availability of anesthesia seriously inhibits surgery or obstetric services in rural Washington and Montana.This article is the first evidence that the “trickle down” of specialists and subspecialists reported recently****** is having a perceptible effect at a local level. For instance, Montana, which is mostly rural, has increased the number of anesthesiologists from < 5 per 100,000 population in 1970 [10]to 11 per 100,000 in 1993. [11]Comparison of the distribution of anesthesiologists between 1970 and 1993 shows that Montana, the Dakotas, Colorado, Nevada, Arizona, Utah, New Mexico, and Wyoming all have increased numbers of anesthesiologists relative to the population. [10,11]This suggests that our results may be generalizable to these areas, but further study is needed at a local level for the extrapolation required to test this result for the country as a whole.Our study methodology is important because the emphasis is on the perceived need of a community rather than comparison of health personnel statistics against benchmark norms. Therefore, we used the information from and the opinions of the hospital administrators to determine whether they believed that they were short of anesthesia personnel. To reduce subjective bias, we attempted to get at the information through more than one question or combination of questions. For example, in response to one question, 15% of the respondents said they would do more surgery if they had more anesthesia help. A separate question forced the respondents to rank personnel concerns, resulting in the availability of support staff being cited as a more crucial concern.Administrators of both surgical and nonsurgical hospitals perceived that the availability of surgery was threatened by economic concerns tied to relatively small surgical volumes coupled with high fixed costs. The questionnaire structure, intended to assure the highest response rate, made a direct comparison of surgical and nonsurgical hospitals difficult, but the reasons for not performing surgery (Table 1) were strikingly similar to the factors threatening the continuing availability of surgery (Table 4). These economic factors appeared to be a greater threat to the continued existence of surgical services than supply of personnel. Surgeons were perceived to be in shorter supply than anesthesia personnel.The perceived shortage of rural surgeons confirmed the findings of Williamson et al. [3]in rural Washington state. As we found no difference in the perceptions of respondents between Washington and Montana, this may be a widespread concern. A full discussion of the appropriateness of rural surgical care and the risk benefits of volume-sensitive surgeries [12,13]is beyond the scope of this article, but outcomes for common surgeries and obstetric procedures were equivalent in rural and urban areas of in general [14]and in Washington state in particular. [15,16]Nevertheless, local rural residents often bypass local hospital services in favor of obtaining care in distant urban tertiary hospitals. [17]The availability of anesthesia for obstetrics was not a major concern of responding rural hospital administrators. The questionnaire directly addressed obstetric care in three questions, and the open-ended questions gave opportunity for comment, but there were only three responses regarding obstetric anesthesia.Rural hospitals have a significant influence on the local economy of rural areas and for their hinterlands. [18–20]Therefore, a rural hospital that is threatened with closure or drastic reduction in size or scope of services may have a significant negative effect on rural economic well-being. What is unclear, however, is the degree to which the availability of rural surgical services influences the viability of rural hospitals, and, less directly, the economic status of rural communities. We can presume that the present level of availability of anesthesia personnel cannot be considered a threat to the viability of the rural economy in the states we studied.This survey of administrators in rural Washington and Montana hospitals shows that surgery was available in most rural hospitals (although almost a quarter of them had no surgery provided). Hospital administrators were primarily concerned with the economic problems associated with providing surgical services and with the perception of a deficit of surgeons in rural areas. These problems were reported more often for smaller and more remote rural hospitals. Small remote rural hospitals were more dependent on CRNAs than were other rural hospitals. There currently appears to be no overall shortage of anesthesia providers in the two-state area examined in this study; shortages of surgeons and other professionals ranked as much more pressing concerns.This study defines “rural” as any county not located within a metropolitan area as defined by the Office of Management and Budget. Rurality was further distinguished by the 1993 Urban Influence Codes (UIC) of the Department of Agriculture (Parker T: Personal communication. Department of Agriculture. February 1996). The concepts of rural and urban are problematic as counties designated as metropolitan (or urban) may contain areas with a distinctly rural character, and nonmetropolitan (or rural) counties may contain sizable urban areas. The newly developed UIC help to determine the degree of rurality among the nonmetropolitan counties by defining each county in terms of adjacency to metropolitan areas, both large and small, and by the population of the largest city or town within the county. Because of the relatively small number of hospitals in this study, the hospitals were divided into two groups based on the UIC. The UIC groups numbered 3–7 were combined into a group henceforth referred to as “rural,” and those numbered 8 and 9 formed a group referred to as “small remote rural.”1. Large-Central and fringe counties of metropolitan areas of >or= to 1 million population2. Small-Counties in metropolitan areas of < 1 million population3. Adjacent to a large metropolitan area with a city of >or= to 10,0004. Adjacent to a large metropolitan area without a city of >or= to 10,0005. Adjacent to a small metropolitan area with a city of >or= to 10,0006. Adjacent to a small metropolitan area without a city of >or= to 10,0007. Not adjacent to a metropolitan area and with a city of >or= to 10,0008. Not adjacent to a metropolitan area and with a city of 2,500–9,999 population9. Not adjacent to a metropolitan area and with no city or a city with a population < 2,500Adjacent counties are physically adjacent to one or more metropolitan service areas and have >or= to 2% of the employed labor force in the nonmetropolitan county commuting to central metropolitan counties. The metropolitan-nonmetropolitan definition is based on the Office of Management and Budget definition (June 1, 1993).The questionnaire had four types of questions. One of each type is reproduced here.Question 1:“Is any surgery performed in your hospital?”Question 5:“How many days a month are each of the following used?(average number of full day equivalents per 28 day month)”MD/DO (Days per month)CRNAs (Days per month)Others (Days per month)Question 20:“How would you rate the quality of care provided by your anesthesia personnel?”Very GoodGoodAveragePoorVery PoorQuestion 21:“What are the three most important staffing issues that your surgery department faces (in order of importance)?”*Report of Graduate Medical Education National Advisory Committee to the Secretary of the US Department of Health and Social Security (GMENAC 1980). Washington, DC, US Government Printing Office, Health Resources and Services Administration, US Department of Health & Human Services, 1980.**Council on Graduate Medical Education Third Report: Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century. Washington, DC, US Government Printing Office, Health Resources and Services Administration, US Department of Health & Human Services, 1992.***Council on Graduate Medical Education Fourth Report: Recommendation to Improve Access to Health Care Through Physician Workforce Reform. Washington, DC, US Government Printing Office, Health Resources and Services Administration, US Department of Health & Human Services, Office of Health Care in Rural no. Washington, DC, US Government Printing Office, 1994 Road Rand McNally, The geographic distribution of anesthesiologists during in their supply

"Go to the People. Live Among Them." Reflections on Anesthetic and Surgical Care in Rural and Remote Regions.

71st World Health Assembly, Geneva, Switzerland 2018

Rural-urban disparities in the surgical and anesthesia workforce exist. This mixed-methods study describes the distribution of the surgical and anesthesia workforce and qualitatively explores how such workforce and other factors influence rural hospitals' provision of surgical services. We calculated provider counts by county from the Area Health Resource File. Using American Hospital Association survey data, we sampled rural hospitals, stratified by critical access status and state policies. We conducted qualitative semistructured interviews with administrators at 16 hospitals and performed directed content analysis of factors influencing surgical services provision at rural hospitals. Within rural counties, 55.1% of counties had no surgeon, 81.2% had no anesthesiologist, and 58.1% had no Certified Registered Nurse Anesthetist (CRNA). Administrators reported that rural hospitals struggled to provide many surgical services given lack of subspecialty surgeons and adequate postsurgical care. Rural hospitals likely struggle to generate volumes necessary to support safe and profitable subspecialty surgery programs. Anesthesia services were not reported as a current limitation given that CRNAs in particular had strong, diverse skills sets and many hospitals allowed high CRNA autonomy. However, meeting anesthesia needs for emergency surgeries and 24-hour obstetrics posed significant challenges. While rural hospitals reported meeting community needs for elective and noncomplex surgeries, rural hospitals continued to face significant challenges providing subspecialty surgeries, emergency surgeries, and 24-hour obstetrical services.

Provision of essential surgery is important in achieving Universal Health Coverage. However, data on the capacity of first-level hospitals to provide surgical care are currently unavailable in Sindh Province, Pakistan. To assess surgical care services and needs in public sector hospitals in Sindh Province, Pakistan. Between May and August 2021, we examined surgical care in 15 public sector district and subdistrict headquarters hospitals in Sindh Province, using the consolidated hospital assessment tool adapted from the WHO tool for assessing emergency and essential surgical care. We analysed the data using STATA version 15 and calculated the frequency of essential surgical procedures per 100 000 population for each health facility. Overall surgical beds density was 0.22 per 100 000 population, with 0.7 certified specialists and 1.4 combined certified and non-specialist physicians offering surgical and anaesthesia care per 100 000 population. Clinical support services were deficient, and only 76% of drugs for anaesthetic and surgical care were available. Outpatient procedures were performed in all facilities, while obstetrics/gynaecology, surgical and trauma-related procedures were performed in 87%, 60% and 53% of facilities, respectively. Three of the 15 hospitals performed the 3 Bellwether procedures. This study identified multiple deficiencies in infrastructure, workforce, governance, management, and support services for essential surgical services in Sindh Province of Pakistan. To achieve Universal Health Coverage in Pakistan, there is a need for more research on surgical services in Sindh Province to identify other gaps and implement strategies to bridge the gaps.

The Role of the WFSA in Reaching the Goals of the Lancet Commission on Global Surgery.

In 2003 the Rural Doctors Workforce Agency in South Australia (SA) facilitated the 'SA Rural Hospital After Hours Triage Education and Training Program'. It was designed to improve communication between rural general practitioners (GPs) and nurses undertaking after-hours triage, provide training in triage for rural nurses and develop local collaborative after-hours primary medical care models that can be applied in other settings. The program consisted of a series of three workshops. The first workshop provided an opportunity for GPs and nurses to discuss local issues relating to after-hours primary medical care service delivery. This was followed by a one-day workshop on triage for nurses. A follow-up refresher workshop was conducted approximately six months later. Twenty-three rural communities in SA. Rural GPs and nurses working in rural communities. This paper reports on the issues highlighted by clinicians in providing after-hours primary medical care in rural and remote communities. These included community expectations, systems of care, scope of practice, private practice/public hospital interface, and medico legal issues. The issues facing after-hours health services in rural communities are not new. There are many opportunities for improvement of systems. A formal program including workshops and training has provided a useful forum to commence service improvements.

Children's Anaesthesia and perioperative care challenges, and innovations

Significant barriers limit the safe and timely provision of surgical and anaesthetic care in low- and middle-income countries. Nearly one-half of Mongolia's population resides in rural areas where the austere geography makes travel for adequate surgical care very difficult. Our goal was to characterize the availability of surgical and anaesthetic services, in terms of infrastructure capability, physical resources (supplies and equipment), and human resources for health at primary level health facilities in Mongolia. A situational analysis of the capacity to deliver emergency and essential surgical care (EESC) was performed in a nonrandom sample of 44 primary health facilities throughout Mongolia. Significant shortfalls were noted in the capacity to deliver surgical and anesthetic services. Deficiencies in infrastructure and supplies were common, and there were no trained surgeons or anaesthesiologists at any of the health facilities sampled. Most procedures were performed by general doctors and paraprofessionals, and occasionally visiting surgeons from higher levels of the health system. While basic interventions such as suturing or abscess drainage were commonly performed, the availability of many essential interventions was absent at a significant number of facilities. This situational analysis of the availability of essential surgical and anesthetic services identified significant deficiencies in infrastructure, supplies, and equipment, as well as a lack of human resources at the primary referral level facilities in Mongolia. Given the significant travel distances to secondary level facilities for the majority of the rural population, there is an urgent need to strengthen the delivery of essential surgical and anaesthetic services at the primary referral level (soum and intersoum). This will require a multidisciplinary, multi-sectoral effort aimed to improve infrastructure, procure and maintain essential equipment and supplies, and train appropriate health professionals.

: Nearly a third of the global burden of disease require availability of surgical and anesthetic services. However, five billion people currently lack access to safe, affordable surgical and anesthesia care. Each year, appendicitis, hernia, open fracture and other common, treatable surgical diseases result in millions of disabilities and deaths. This is in part due to lack of political will, financial resource allocation, and relevant policy measures. To address these glaring needs, the lancet commission on global surgery (LCoGS) was formed to identify the barriers to access of surgical and anesthesia care, and the current state of these services worldwide. Additionally, its purpose was to identify opportunities for improvement and development to provide safe surgery in low-income and middle-income settings. To address the needs of surgical and anesthesia services LCoGS created 5 key messages, a set of 6 core surgical system indicators, and a health system strengthening framework for national surgical care planning. These key outputs of the commission highlighted that a widespread expansion of surgical care improves overall health and welfare of populations and improved economic returns. The findings were published as a report in the spring of 2015 to facilitate increased surgical care access that was safe, affordable, and cost-effective particularly for low-income and middle-income countries. In this review article, we summarize this seminal report and ldquo; global surgery 2030: evidence and solutions for achieving health, welfare, and economic development and rdquo; published in the Lancet 2015.

Global surgery

Professor Emeritus in Pediatrics and Anesthesiology. Received from the Department of Pediatrics and Anesthesiology, The George Washington University Medical Center, Washington, District of Columbia.I am honored to have been selected to deliver the 40th Annual Emery A. Rovenstine Memorial Lecture. At previous Rovenstine lectures, I learned about his pioneering efforts as the Director of the Anesthesia Service at Bellevue Hospital (New York City, New York) where he served from 1935 to 1960; his Presidency of the American Society of Anesthesiologists (ASA), 1943–1944; and as the recipient of the ASA's Distinguished Service Award in 1957. In the past year, however, two outstanding articles have been written that present material I was unaware of.Lucien Morris, M.D. (Professor Emeritus, Medical College of Ohio, Toledo, Ohio) authored the fascinating article “Ralph M. Waters’ Legacy: The Establishment of Academic Anesthesia Centers by the ‘Aqualumni’.”1The ’aqualumni,’ is defined as Waters’ own trainees. The article was written to commemorate the 75th Anniversary of Waters accepting an academic appointment to the medical faculty of the University of Wisconsin (Madison, Wisconsin).I found particularly interesting the section describing Professor Waters’ concern that when Dr. Rovenstine, one of his aqualumni, went to Bellevue Hospital, New York University (NYU, New York City, New York), he might not have sufficient staff to establish a new academic training center for anesthesia. As a result, Waters split his Wisconsin group, sending both staff and residents to New York City to ensure the success of Dr. Rovenstine at NYU. Waters had enough confidence in Dr. Rovenstine to predict that he would succeed. He would not disappoint Dr. Waters.David Waisel, M.D. (Department of Anesthesia, Children's Hospital, Boston, Massachusetts) provided a comprehensive review of “The Role of World War II and The European Theater of Operations in the Development of Anesthesiology as a Physician Specialty in the USA.”2In 1942, Waters and Rovenstine and others teamed up to train “90-day wonders” in 12-week courses “to prepare medical officers to take charge of the anesthesia sections of the various types of hospitals of the U.S. Army.” Courses were given at several institutions, including Bellevue, and were developed by the Subcommittee on Anesthesia of the National Research Council. The latter was chaired by Dr. Waters. Dr. Rovenstine was the Secretary. Many future anesthesiologists were attracted to the specialty as a result of their initial exposure to the field in World War II and the influence of role models such as Dr. Rovenstine.Although I did not know Dr. Rovenstine personally, I was trained by another aqualumnus of Dr. Waters, Robert D. Dripps, M.D. (Professor and Chair, Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania). Dr. Dripps was interested in attracting medical students into the field of Anesthesiology. One of his efforts led to the establishment of the ASA Preceptorship Program and the Committee on which I first served the ASA.In the 36 yr in which I have been involved in the activities of the ASA, 20 yr have been spent on developing guidelines for sedation for nonanesthesiologists. It has been the most challenging, frustrating, and contentious issue I have had to address.Even though ASA's efforts have been exemplary, the results have been misunderstood by not only the groups we have attempted to educate but also by our own members. I have decided to set the record straight by discussing the history of “ASA's Efforts in Developing Guidelines for Sedation and Analgesia for Nonanesthesiologists.” Some of the comments that follow are my own thoughts and interpretations; however, most of the statements are documented in the literature or are part of my own collection of documents. The latter will be donated to the Wood Library Museum (Park Ridge, Illinois) together with the script of this lecture.The formal process of ASA's evidence-based guideline development for members did not begin until 1990, and for nonanesthesiologists, in 1993. Other specialty groups began setting guidelines earlier and their efforts must be acknowledged before proceeding with ASA's efforts. It is not intended to provide a comprehensive or complete review of these accomplishments but rather to attempt to chronicle the background from which ASA developed some of its interest.Driscoll 3describes one of the anesthetic eras, “conscious and unconscious sedation,” as beginning in 1970. He notes that, previously, the use of diazepam along with local analgesia was relatively uncomplicated. However, soon meperidine, atropine, fentanyl, methohexital, and a host of other drugs were also added. Polypharmacy posed a potential problem.In 1972, “Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry” were published. 4These guidelines established a standard for training all dental personnel in this area of patient management. 5Apparently the dental profession continued to strive for a balance between minimizing fear and anxiety and maximizing safety. To resolve some of the issues, The National Institutes of Health (NIH), The Food and Drug Administration, and The NIH Office of Medical Applications of Research (Bethesda, Maryland) convened a Consensus Development Conference on Anesthesia and Sedation in the Dental Office. 6A host of experts, including anesthesiologists, agreed on developing answers to frequently asked questions. Although the principles and definitions described in the document are not necessarily original (but undoubtedly originated in the dental literature), they do represent important features, which continue to be emphasized, and must not be ignored. Several of these are as follows:From time to time, other Dental groups, such as The American Dental Association (Chicago, Illinois) and American Association of Oral and Maxillofacial Surgeons (Rosemont, Illinois), have issued comprehensive guidelines for sedation and anesthesia; however their design and content are beyond the scope of this discussion.My involvement with the formulation of guidelines related to sedation began in 1983 as a member of the Committee of the Section on Anesthesiology, American Academy of Pediatrics (AAP) (Elk Grove Village, Illinois). Sedation guidelines were developed by the AAP primarily because of the reporting of a number of deaths in dental offices. 7In 1985, The Committee on Drugs, Section on Anesthesiology, AAP, in conjunction with The American Academy of Pediatric Dentistry (Chicago, Illinois), published Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients. 8In this document, the three states were defined as were the requirements for selection of patients, personnel, monitoring procedures, facility, equipment, and recovery care. The definition of conscious sedation included the patient's ability to maintain a patent airway and that this be retained independently and “continuously.” It also noted that “the drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.”Although a number of anesthesiologists, including myself, were members of one of the committees drafting the Guidelines, the ASA was not officially involved. As a matter of fact, in its 1985 Annual Report, the ASA Committee on Pediatric Anesthesia stated “members of the committee, as well as others within the ASA, were interested and concerned with (these) guidelines …”*As a result, the 1985 ASA House of Delegates instructed the ASA Committee on Standards of Care to review the Guidelines and report back to the March Board of Directors. At the time of the referral, I was the Chair of this Committee. An official reply was drafted and specifically addressed items of concern, such as the requirement for the use of intravenous (IV) injections in patients undergoing Deep Sedation and General Anesthesia. †This was subsequently “clarified” by the AAP making it permissible for personnel expert in securing IV access in infants and children to be immediately available. Both the Committee on Pediatric Anesthesia and Standards of Care agreed that many portions of the AAP Guidelines were well designed but believed that it was “essential—that future undertakings of this type and importance have official input from the ASA.”In 1992, the AAP published a revision of the 1985 Guidelines. 9In this document, it was noted that “regardless of the intended level of sedation or route of administration, the sedation of a patient represents a continuum—and a patient may move easily from a light level of sedation to obtundation.” It also added that “the practitioner should be prepared to increase the level of vigilance corresponding to that necessary—” if the patient becomes more deeply sedated. Use of pulse oximetry was required for both conscious and deep sedation. (Note: I have not attempted to describe this important document in its entirety.) The 1992 Guidelines were reviewed and suggestions made by the ASA's Committees on Pediatric Anesthesia and Standards of Care before the document was published. Their contributions were acknowledged by the AAP.Several articles have been written that describe the evolution of the development of the AAP's Guidelines. 10,11Of particular interest to me are several references to the reason that ASA “renewed” its interest in the revised (1992) Guidelines. Striker and Coté11state, “at the time of revision, the Committee on Drugs felt it important to once again work with the ASA, since during the intervening years from the original guidelines, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Oakbrook Terrace, Illinois) took the torch of responsibility.” Further, “with renewed interest (in part because of the JCAHO), the ASA Committee on Standards reviewed each iteration of the revised pediatric guidelines.”These statements clearly imply that ASA was complacent until JCAHO provided the impetus for ASA to get moving. Nothing could be further from the truth. To the contrary, ASA had taken a different path in generating guidelines for sedation and, as early as 1985 through our liaison activities with JCAHO, we were able to convince them to incorporate the concept of sedation into their accreditation standards. ASA's initial concern and involvement related to deaths outside the operating room when nonanesthesiologists sedated adult patients with a new drug, midazolam (VERSED®, Hoffman–La Roche Laboratories, Nutley, NJ).In 1985, the Food and Drug Administration approved the use of midazolam, and in 1986, it was marketed in the United States. Midazolam was reported to be twice as potent as diazepam. 12There were warnings from abroad that the comparative potency with diazepam was underestimated. 13Midazolam had certain advantages over diazepam—water solubility, less venous irritation, potent amnesia, and “short” duration of action. As a result, its use was embraced by a variety of types of practitioners who administered sedation.Bailey et al. 14demonstrated in human volunteers that the combination of midazolam with fentanyl in reasonable doses produced hypoxemia. Subsequently, they cited data from the Department of Health and Human Services, Office of Epidemiology and Biostatistics, Center for Drug Evaluation and Research, Data Retrieval Unit, in which 86 deaths were collected in the United States after the use of midazolam. 15All but 3 occurred outside the operating room “in clinical situations where patients are typically unattended by anesthesia personnel.” Seventy-eight percent of these deaths were associated with oxygenation or ventilation difficulties, and in 57% of these respiratory deaths, various opioids were used.Bailey et al. 15also noted that endoscopists were beginning to document the risk of hypoxemia in their environment. Further, most of these midazolam-associated adverse drug reaction reports involved care outside the operating room, where standards for the assessment of ventilation and oxygenation had not been defined and therefore were variable.In 1986, the ASA published its first standards for its members—Standards for Basic Intraoperative Monitoring. These applied not only to the states of general and regional anesthesia but also to “Monitored Anesthesia Care” or “MAC.” The latter term was also introduced in 1986 and applies to the service provided by the anesthesia care team in which the same level of care is provided with sedation/analgesia as with general or regional anesthesia. In the 1986 Standards, the use of pulse oximetry was encouraged.In 1988, the package insert for midazolam HCl (VERSED®) was modified to state the “clinical experience has shown VERSED® to be 3–4 times as potent per mg. as diazepam. Because serious and life-threatening cardiorespiratory adverse events have been reported, provision for monitoring, detection, and correction of these reactions must be made for every patient to whom VERSED® injection is administered, regardless of age or health status” (injection, package insert, Hoffmann–La Roche, Nutley, NJ).In the early 1980s, the section in the JCAH manual titled “Anesthesia Services” focused primarily on organization; staffing; safety (electrical and explosion hazards); delivery of care (e.g. , written guidelines for use of all general anesthetics); and quality and appropriateness of care. In 1982, the ASA developed a liaison with the JCAH (no “O” at that time). Representation was established in the Hospital Professional and Technical Advisory Committee (HPTAC), and in the Ambulatory Health Care Professional and Technical Advisory Committee (AHCPTAC). 16ASA's representatives, Eli Brown, M.D. (then, Professor and Chair, Department of Anesthesiology, Wayne State University, Detroit, Michigan) and Harry Wong, M.D. (then, Medical Director and President of the Medical Staff, Salt Lake Surgical Center, Salt Lake City, Utah) brought to the JCAH their concerns with the deaths occurring outside the operating room when potent sedatives with or without narcotics were administered by the “operating practitioner” to patients who were not adequately monitored. Largely due to their influential efforts, in 1985 the JCAH drafted proposed Standards for Surgery and Anesthesia services that addressed the surgical and anesthesia care of patients wherever they receive care in a hospital and to reflect current practices in the delivery of surgery and anesthesia care.In 1986, a draft was sent for “field review” to 1951 organizations and individuals. This led to the landmark language of the 1988 Standards for Surgical and Anesthesia Services (SA).“The standards in this chapter apply to services for all patients who (1) receive general, spinal, or other major regional anesthesia or (2) undergo surgery or other invasive procedures when receiving general, spinal, or other major regional anesthesia and/or intravenous, intramuscular, or inhalation sedation/analgesia that, in the manner used in the hospital, may result in the loss of the patient's protective reflexes. Invasive procedures include, but are not necessarily limited to, percutaneous aspirations and biopsies, cardiac and vascular catheterizations, and endoscopies.”‡The Director of Anesthesia's clinical and administrative responsibilities included “assuring” the effective monitoring and evaluation of the quality of appropriateness of anesthesia care provided by individuals in any department/service of the hospital, including—dental, emergency, etc. Requirements for assuring the availability of continuing medical education programs, monitoring the quality and appropriateness of anesthesia services, and other key items were included. The Standards required that “patients with the same health status and condition receive a comparable level of quality of surgery and anesthesia care throughout the hospital.” Obviously, the standard applied to adults and children and was promulgated by an accrediting organization that required conformance or else “deemed status” might not be attained.The endoscopists, in particular, were very alarmed by this development and considered the whole issue to be a turf battle between them and the anesthesiologists. They objected to being placed under the category of “surgical and anesthesia services.” In 1988, I replaced Eli Brown, M.D. (then, Professor and Chair, Department of Anesthesiology, Wayne State University, Detroit, Michigan) as ASA's liaison with the JCAH HPTAC. At the request of Jim Roberts, M.D. (Vice President, JCAH), I met with him and a representative of the endoscopy community, David Fleisher, M.D. (Division of Gastroenterology, Georgetown University Hospital, Washington, DC). After a lengthy discussion, Dr. Roberts confirmed that the language in the JCAH Standards for Surgery and Anesthesia Services was intended to promote safety and uniformity in the quality of care and that, indeed, the requirements applied to endoscopists using sedation that “in the manner used—may result in the loss of protective reflexes.”One of the results of this meeting was the establishment of a dialogue between the endoscopists and anesthesiologists at a national level. In 1989 and 1992, I was invited to address the conventions of the American Society of Gastrointestinal Endoscopists (ASGE) (May, 1989, Washington, DC, and May, 1992, San Francisco, California). In 1989, The Society of Ambulatory Anesthesiologists (SAMBA invited the Chair of the Standard's Committee, ASGE, to SAMBA's annual meeting; April, 1989, San Antonio, Texas). Anesthesiologists and endoscopists began a dialogue but disagreed on several key issues: (1) the level of sedation for which the JCAH Standards applied, and (2) the use of the pulse “the role of pulse oximetry and monitoring during procedures is and The was that the of monitoring should be to the patient's risk of and the type and duration of the 1990, the JCAHO added to the for Anesthesia the requirement for the Director of Anesthesia Services to or through a with of other that provide anesthesia services in the formulation of and material that to provide quality of anesthesia services throughout the hospital.” language including to and the quality and appropriateness of anesthesia care in any department/service in the hospital requirement to was by many anesthesiologists as an to and procedures and to be for the activities of practitioners who outside their without the to their To to the of of Anesthesia were also to official ASA to incorporate into their and procedures for sedation. In an attempt to this issue and to our I authored an article for the ASA Anesthesia Services in other Hospital this I that the JCAHO standards only required that the Director of Anesthesia be for the of the members of to practitioners not with the ASA that could be used as the for and procedures such as Standards for Basic Intraoperative were many other events occurred in the of the language of the JCAHO Standards between and it to that and within ASA and between our organization and other In one by JCAHO of the definition of anesthesia care was and It the under which the sedation standards applied including or without for which is a reasonable that in the manner the sedation/analgesia will result in the loss of protective for a of a of In other if the and techniques used were not to a loss of consciousness for a of a of patients, sedation as used in the manner would not the with the Standards for Anesthesia endoscopists were The Board that during IV conscious sedation by most endoscopists, protective are not in a of JCAHO to the continued to , that in most procedures are and that cardiorespiratory are to this JCAHO revision, an ASA member to the President of the ASA is the of by the I am and to be a member of a which did not the role of patient's The ASA was I in on Accreditation for new language was by the of the JCAHO, the Board of without the or of the and without the field to JCAHO from ASA and The Society for Ambulatory Anesthesia were This that, if had been from our at the their might have been or modified by the two , Standards and Committee and The Board of 1985 and we learned many from Guidelines and Standards by other organizations and input from our members about they to their and related to the development of and procedures for the of nonanesthesiologists who provided sedation outside the operating began ASA's efforts to establish its own Guidelines for this The of 1989, The for Health Care and In 1990, President of the ASA, was by the Office of the for and in Health for Health Care and Research Department of Health and Human Services of new to and clinical The were to be from of the expert and of health care In ASA established the Committee on under the of M.D. (then, President for University of Medical the process that ASA for guideline development is the are beyond the scope of this it to the original members of the Committee and the of the two initial and of the were on the in The who the was Office of the for Department of Health and Human The Guidelines were to be 1992, was in of the development of an ASA to be titled or for nonanesthesiologists. President, Anesthesia (Park Ridge, Illinois), that the development of Standards, Guidelines, and/or should be the of the not He also noted in anesthesia it will be considered by the other specialty involved. by the is to have it at the level of the for Health Care and President, to President, ASA, took and to that they the they ASA would was not In ASA selected members of a and as its Chair, M.D. (Professor of Anesthesiology and University of of Dr. and I described the of the process in an article on Analgesia and Sedation by this article are several to its the on the guidelines from selected in the field of and from other in which sedation and analgesia is The draft was also to anesthesiologists and invited of specialty groups of nonanesthesiologists at several In the included as a M.D. (Department of Gastroenterology, an who was officially by The Guidelines for Sedation and Analgesia by was approved by the ASA House of Delegates and in was published in the Anesthesiology. Guidelines were also by the with the to the document to our for their in their President, to ASA, After yr of dialogue and on the to the sedated ASA and had Guidelines were by the ASA material was by Roche and and the was by in this material was a which was part of the ASA under the of the Committee on and the it that ASA had produced an evidence-based which would be embraced by all this was not the ASA's initial did not address the state of In its of it is stated that “patients is from a are sedated to a by The was on the state patients to procedures cardiorespiratory and the ability to to and/or pediatric anesthesiologists that most pediatric patients, a level of deep the new AAP (1992) sedation guidelines will the ASA and that less personnel and less monitoring and recovery are associated with the state of “conscious in current all sedation is conscious regardless of the of sedation procedures or procedures complete (e.g. , or be in a who is the is The of the of a state of conscious sedation in which pediatric patients are to in the of is were that the ASA was developing guidelines for nonanesthesiologists in to their turf and that, in the the to be a of by the without the of specialty groups was also JCAHO was of adverse events associated with the use of sedation by nonanesthesiologists outside the operating room environment. of the related to practitioners the of sedation provided and not the monitoring and efforts liaison to the JCAHO are members of the ASA Committee on and Administration the Chair, M.D. Memorial Healthcare of In to JCAHO staff in the Standards, Dr. a to address a report of the ASA Committee on Standards of Care to monitoring the of the House of Delegates of the definition of to a of the President

Too few general surgeons practice in rural American communities, and many hospitals in the smallest rural areas do not have a surgeon. Therefore, it is likely that some small rural hospitals are using alternative arrangements to provide surgical care, including hiring locum tenens surgeons. We describe the degree to which small rural hospitals are using locum tenens surgeons to provide surgical services. Administrators at 129 small rural hospitals were surveyed by telephone. The survey instrument was comprised of questions asking whether the hospital provides surgical services, if the hospital has recruited a surgeon, whether the hospital uses locum tenens surgeons and if so for what purposes. A total of 76% of surveyed rural hospitals have offered surgical services during the past 5 years. In all, 56% of hospitals providing surgical care have recruited a surgeon during the past 5 years. Of those who have been unsuccessful in their search, 30% have considered using a locum tenens surgeon, and 20% have done so. Given the difficulty of recruiting surgeons to practice in rural America, it is critical to develop strategies to address this problem. Although using locum tenens surgeons may allow rural hospitals to offer surgical services, the quality of surgical care could be compromised. Other means for delivering surgical services at rural hospitals that cannot recruit or retain a surgeon should be explored to ensure that rural residents have access to high quality surgical care.

Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.

BackgroundThe role of rural family physicians continues to evolve to accommodate the comprehensive care needs of aging societies. For older individuals in rural areas, rehabilitation is vital to ensure that they can continue to perform activities of daily living. In this population, a smooth discharge following periods of hospitalization is essential and requires management of multimorbidity, and rehabilitation therapists may require support from family physicians to achieve optimal outcomes. Therefore, this study aimed to investigate changes in the roles of rural family physicians in patient rehabilitation.MethodsAn ethnographic analysis was conducted with rural family physicians and rehabilitation therapists at a rural Japanese hospital. A constructivist grounded theory approach was applied as a qualitative research method. Data were collected from the participants via field notes and semi-structured interviews.ResultsUsing a grounded theory approach, the following three themes were developed regarding the establishment of effective interprofessional collaboration between family physicians and therapists in the rehabilitation of older patients in rural communities: 1) establishment of mutual understanding and the perception of psychological safety; 2) improvement of relationships between healthcare professionals and their patients; and 3) creation of new roles in rural family medicine to meet evolving needs.ConclusionEnsuring continual dialogue between family medicine and rehabilitation departments helped to establish understanding, enhance knowledge, and heighten mutual respect among healthcare workers, making the work more enjoyable. Continuous collaboration between departments also improved relationships between professionals and their patients, establishing trust in collaborative treatment paradigms and supporting patient-centered approaches to family medicine. Within this framework, understanding the capabilities of family physicians can lead to the establishment of new roles for them in rural hospitals. Family medicine plays a vital role in geriatric care in community hospitals, especially in rural primary care settings. The role of family medicine in hospitals should be investigated in other settings to improve geriatric care and promote mutual learning and improvement among healthcare professionals.