Bellwether Procedures Research Articles

Bellwether Procedures for Monitoring Subnational Variation of All-cause Perioperative Mortality in Brazil.

All-cause perioperative mortality rate (POMR) is a commonly reported metric to assess surgical quality. Benchmarking POMR remains difficult due to differences in surgical volume and case mix combined with the burden of reporting and leveraging this complex and high-volume data. We seek to determine whether the pooled and individual procedure POMR of each bellwether (cesarean section, laparotomy, management of open fracture) correlate with state-level all-cause POMR in the interest of identifying benchmark procedures that can be used to make standardized regional comparisons of surgical quality. The Brazilian National Healthcare Database (DATASUS) was queried to identify unadjusted all-cause POMR for all patient admissions among public hospitals in Brazil in 2018. Bellwether procedures were identified as any procedure involving laparotomy, cesareansection, or treatment of open long bone fracture and then classified as emergent or elective. The pooled POMR of all bellwether procedures as well as for each individual bellwether procedure was compared with the all-cause POMR in each of the 26 states, and one federal district and correlations were calculated. Funnel plots were used to compare surgical volume to perioperative mortality for each bellwether procedure. 4,756,642 surgical procedures were reported to DATASUS in 2018: 237,727 emergent procedures requiring laparotomy, 852,821 emergent cesarean sections, and 210,657 open, long bone fracture repairs. Pooled perioperative mortality for all of the bellwether procedures was correlated with all-procedure POMR among states (r = 0.77, p < 0.001). POMR for emergency procedures (2.4%) correlated with the all-procedure (emergent and elective) POMR (1.6%, r = 0.93, p < .001), while POMR for elective procedures (0.4%) did not (p = .247). POMR for emergency laparotomy (4.4%) correlated with all-procedure POMR (1.6%,r = 0.52, p = .005), as did the POMR for open, long bone fractures (0.8%, r = 0.61, p < .001). POMR for emergency cesareansection (0.05%) did not correlate with all-procedure POMR (p = 0.400). There was a correlation between surgical volume and emergency laparotomy POMR (r = - 0.53, p = .004), but not for emergency cesareansection or open, long bone fractures POMR. Procedure-specific POMR for laparotomy and open long bone fracture correlates modestly with all-procedure POMR among Brazilian states which is primarily driven by emergency procedure POMR. Selective reporting of emergency laparotomy and open fracture POMR may be a useful surrogate to guide subnational surgical policy decisions.

District General Hospital Surgical Capacity and Mortality Trends in Patients with Acute Abdomen in Malawi.

The burden of emergency general surgery conditions is high in sub-Saharan Africa, and poor access to surgical care leads to poor patient outcomes. We examined the trends in mortality in patients presenting with an acute abdomen to a referral hospital. A retrospective analysis of the prospectively collected Kamuzu Central Hospital Acute Care Surgery database was performed (January 2014 to July 2019). Bivariate analysis was conducted by year of admission. A multivariate Poisson regression was performed to identify predictors of mortality. During the study, 2509 patients with acute abdomen presented. The majority of patients presenting were transferred from outside hospitals (n = 2097, 83.9%). Mortality was highest in patients with preoperative diagnosis of peritonitis (n = 119, 22.2%), bowel obstruction (n = 214, 18.7%), and volvuli (n = 51, 18.6%). There was no difference in mortality by year, p = 0.1. On multivariate Poisson regression, there was an increased relative risk of mortality with being transferred (RR 1.31, 95% CI 1.12-1.55, p = 0.002), as well as undergoing an operation within 1-2days (RR 1.48, 95% CI 1.16-1.87, p < 0.001) and >2days (RR 1.46, 95% CI 1.17-1.82, p = 0.001) after presentation. The majority of patients in our study who presented with an acute abdomen were transferred from district hospitals, which resulted in high mortality due to delays in surgical care. Therefore, the WHO's recommendation that the majority of district hospitals perform the Bellwether procedures does not occur in district hospitals in central Malawi. District hospitals require significant resource investment to reduce transfers needs and patient mortality.

Are Rural Hospitals in Pakistan Responding to the Global Surgery Movement? An Analysis of the Gaps, Challenges and Opportunities.

Access to essential surgical care is vital for reduction in mortality and morbidity as a result of surgical conditions. These account for 28-32% of the overall global burden of disease, yet billions of people lack access to safe, affordable surgical and anesthesia care when needed. The purpose of this study was to assess the capacity for surgical care in rural hospitals across four provinces of Pakistan. This was a cross-sectional study undertaken in 10 rural hospitals across four provinces of the country. Of these, six were district and four sub-district hospitals that were purposively selected in consultation with the government. Data were gathered using the WHO-PGSSC Surgical Assessment Tool. This study estimated 3 of the 6 indicators proposed by the Lancet Commission on Global Surgery. While most hospitals had basic provisions of infrastructure and equipment, severe shortage of specialists was observed with 0.56 specialists (surgeons, gynecologists and anesthetists) present per 100,000 population. Two-hour access was possible for the catchment population of 7 out of the 10 hospitals. Of the 43 essential surgical procedures assessed, 13 or 30% procedures were available per hospital. The three Bellwether procedures were provided by only 1 hospital. Mean number of surgeries performed was 753 ± 979 per 100,000 population. Our study has demonstrated major gaps in the provision of surgical care in rural hospitals in Pakistan. While developing a strategy and national action plan is necessary, implementation can immediately begin at the local level to address the gaps that need urgent attention.

'We are all serving the same Ugandans': A nationwide mixed-methods evaluation of private sector surgical capacity in Uganda.

Half of all Ugandans (49%) turn to the private or private-not-for-profit (PNFP) sectors when faced with illness, yet little is known about the capacity of these sectors to deliver surgical services. We partnered with the Ministry of Health to conduct a nationwide mixed-methods evaluation of private and PNFP surgical capacity in Uganda. A standardized validated facility assessment tool was utilized to assess facility infrastructure, service delivery, workforce, information management, and financing at a randomized nationally representative sample of 16 private and PNFP hospitals. Semi-structured interviews were conducted to qualitatively explore facilitating factors and barriers to surgical, obstetric and anaesthesia (SOA) care. Hospitals walk-throughs and retrospective reviews of operative logbooks were completed. Hospitals had a median of 177 beds and two operating rooms. Ten hospitals (62.5%) were able to perform all Bellwether procedures (cesarean section, laparotomy and open fracture treatment). Thirty-day surgical volume averaged 102 cases per facility. While most hospitals had electricity, oxygen, running water, and necessary equipment, many reported pervasive shortages of blood, surgical consumables, and anesthetic drugs. Several themes emerged from the qualitative analysis: (1) geographic distance and limited transportation options delay reaching care; (2) workforce shortages impede the delivery of surgical care; (3) emergency and obstetric volume overwhelm the surgical system; (4) medical and non-medical costs delay seeking, reaching, and receiving care; and (5) there is poor coordination of care with insufficient support systems. As in Uganda's public sector, barriers to surgery in private and PNFP hospitals in Uganda are cross-cutting and closely tied to resource availability. Critical policy and programmatic developments are essential to build and strengthen Ugandan surgical capacity across all sectors.

Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste’s national referral hospital

ObjectivesOur objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving...

The Operative Output of District Hospitals in KwaZulu-Natal Province is Heavily Skewed Toward Obstetrical Care.

District hospitals are key to providing universal coverage of essential surgery and for strengthening surgical care in general. This audit set out to quantify the surgical output of all the district hospitals in KwaZulu-Natal Province (KZN) over a 6-month period to see whether district hospitals were delivering the surgical care they are expected to deliver. There were a total of 18,871 operations performed at 37 district hospitals in KwaZulu-Natal from July to December 2015. The number of operations per hospital varied widely between 2150 at a single large district hospital and 68 at a small district hospital, respectively. Surgical operations for obstetrical conditions made up by far the majority of operations at 57%, with gynecological operations making up the second highest at 15%. Only 12% of operations were for general surgical conditions. With regards to the bellwether procedures, 96.1% of these were cesarean sections, 2.1% were laparotomies and 1.8% were ORIFs. For almost all the 37 hospitals, the percentage of laparotomies and ORIFs performed was small to negligible, while the percentage of cesarean sections performed was high. The number of bellwether operations performed per 100,000 population was much higher than the number of general surgical or orthopedic operations performed, primarily because of the preponderance of cesarean sections conducted in each hospital. We observed a strong and significant positive correlation (+0.691, 95% CI +0.538 to +0.800, p < 0.001) between increasing distance to nearest regional referral hospital and rate of laparotomies and ORIF procedures performed. The surgical output of district hospitals in KZN is heavily skewed toward obstetrics and gynecology. Further work is required to understand the reasons for this, but the current data imply that district hospitals are not delivering surgical and orthopedic care at district hospitals in KwaZulu-Natal.

Pediatric neurosurgical bellwether procedures for infrastructure capacity building in hospitals and healthcare systems worldwide.

Quantifying the global burden of pediatric neurosurgical disease-and current efforts addressing it-is challenging, particularly in the absence of uniform terminology. We sought to establish bellwether procedures for pediatric neurosurgery, in order to standardize terminology, establish priorities, and facilitate goal-oriented capacity building. Members of international pediatric neurosurgical and pediatric surgical societies were surveyed via the Research Electronic Data Capture (REDCap) platform. Among 15 proposed neurosurgical procedures, respondents assigned numerical grades of surgical necessity and selected hospital-level designation within a three-tiered system. A procedure was considered a bellwether if (a) the majority of respondents deemed it necessary for either a primary- or secondary-level hospital and (b) the procedure was graded at or above the 90th percentile on a continuous scale of essentiality. Data were compiled and analyzed using Stata software. Complete responses were obtained from 459 surgeons from 76 countries, the majority of whom practiced in a tertiary referral hospital (88%), with a primarily public patient population (64%). Six bellwether procedures were identified for pediatric neurosurgery: shunt for hydrocephalus, myelomeningocele closure, burr holes, trauma craniotomy, external ventricular drain (EVD) insertion, and cerebral abscess evacuation. Few differences in bellwether criteria designations were observed among respondents from different World Health Organization regions and World Bank income groups. The six bellwether procedures identified can be used as markers of infrastructure capacity at various hospital levels, hence allowing targeted neurosurgical capacity-building in low-resource settings in order to avert disability and death from childhood neurosurgical disease.

Challenges of Running an Orthopaedic and Trauma Services in a Rural, Remote Setting in India—Our Experience

The WHO’s emergency and essential surgical care (EESC) programme and the Lancet Commission on Global Surgery have emphasised the need for essential surgical service as an “integral, “indivisible, indispensable” part of universal health care. Facilities for the management of open fractures, one of the “Bellwether procedures” as identified by the WHO, should be available within 2 h of reach, where safe effective emergency surgery can be performed. We share our experience from a remote, rural, hilly town in India. Of the three Ms—man, machine, medicine—it is manpower that we find difficult to rectify to provide “safe surgery”. In accordance with the report of Lancet Commission on Global Surgery, we have the data to support our needs. It is for the government and non-governmental organisations to rise up and provide the three Ms so that safe, essential surgical services can be carried out even in the remotest parts of India.

Improving Anesthesia Safety in Low-Resource Settings.

The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the "Bellwether Procedures" (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.

Global Surgery System Strengthening: It Is All About the Right Metrics.

Progress in achieving "universal access to safe, affordable surgery, and anesthesia care when needed" is dependent on consensus not only about the key messages but also on what metrics should be used to set goals and measure progress. The Lancet Commission on Global Surgery not only achieved consensus on key messages but also recommended 6 key metrics to inform national surgical plans and monitor scale-up toward 2030. These metrics measure access to surgery, as well as its timeliness, safety, and affordability: (1) Two-hour access to the 3 Bellwether procedures (cesarean delivery, emergency laparotomy, and management of an open fracture); (2) Surgeon, Anesthetist, and Obstetrician workforce >20/100,000; (3) Surgical volume of 5000 procedures/100,000; (4) Reporting of perioperative mortality rate; and (5 and 6) Risk rates of catastrophic expenditure and impoverishment when requiring surgery. This article discusses the definition, validity, feasibility, relevance, and progress with each of these metrics. The authors share their experience of introducing the metrics in the Pacific and sub-Saharan Africa. We identify appropriate messages for each potential stakeholder-the patients, practitioners, providers (health services and hospitals), public (community), politicians, policymakers, and payers. We discuss progress toward the metrics being included in core indicator lists by the World Health Organization and the World Bank and how they have been, or may be, used to inform National Surgical Plans in low- and middle-income countries to scale-up the delivery of safe, affordable, and timely surgical and anesthesia care to all who need it.

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

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

Retrospective review of Surgical Availability and Readiness in 8 African countries

ObjectivesThe purpose of this study was to assess surgical availability and readiness in 8 African countries using the WHO's Service Availability and Readiness Assessment (SARA) tool.SettingWe analysed data for surgical...

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures.

Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known. To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana. Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014. All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis. Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure-capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement. Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.

Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures.

Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures. The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p<0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.