Disparities in Telemedicine Use Among Children Seen in Surgical Clinics During the COVID-19 Pandemic: Experience of One Tertiary Care Freestanding Children's Hospital.

Background: Telemedicine use dramatically increased during the COVID-19 pandemic. However, the effects of telemedicine on pre-existing disparities in pediatric surgical access have not been well described. We describe our center's early experience with telemedicine and disparities in patients' access to outpatient surgical care. Methods: A retrospective study of outpatient visits within all surgical divisions from May to December 2020 was conducted. We assessed the rates of scheduled telemedicine visits during that period, as well as the rate of completing a visit after it has been scheduled. Descriptive and logistic regression analyses were used to test for associations between these rates and patient characteristics. Results: Over the study period, 109,601 visits were scheduled. Telemedicine accounted for 6.1% of all visits with lower cancellation rates than in-person visits (26.9% vs. 34.7%). More scheduled telemedicine encounters were observed for older patients, White, English speakers, those with private insurance, and those living in rural areas. Lower odds of telemedicine visit completion were observed among patients with public insurance (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.64-0.77), Spanish language preference (OR 0.84, 95% CI 0.72-0.97), and those living in rural areas (OR 0.73, 95% CI 0.64-0.84). In contrast, higher odds of telemedicine visit completion were associated with a higher Social Deprivation Index score (OR 1.41, 95% CI 1.27-1.58). Telemedicine visit completion was also associated with increasing community-level income and distance from the hospital. Conclusions: Telemedicine use for outpatient surgical care was generally low during the peak of the pandemic, and certain populations were less likely to utilize it. These findings call for further action to bridge gaps in telemedicine use.

Measuring the Efficacy of Thymectomy for Pediatric Myasthenia Gravis Across Tertiary Children's Hospitals.

BACKGROUND: Thymectomy is a treatment for pediatric myasthenia gravis, but the efficacy over time is unknown. Multi-institutional data are also lacking. Therefore, the objective of this study was to determine the efficacy of thymectomy for pediatric myasthenia gravis using medication burden and health care utilization as proxies for disease severity. METHODS: This was a cross-sectional study of the Pediatric Health Information System database among children who underwent thymectomy at one of 49 children's hospitals from 2004 to 2022. Differences in annual median number of doses of myasthenia-related medications, admissions, and health care costs in the year before thymectomy to three years after were compared. A comparison cohort that did not undergo thymectomy was utilized. Medians were compared using the Wilcoxon signed-rank test. Generalized linear regression estimated the effect of surgical approach on outcomes. RESULTS: A total of451 patients (238 patients who underwent thymectomy and 213 nonthymectomy patients) were identified. Following thymectomy, the decrease in annual median total number of myasthenia-related doses was 12.0 (interquartile range: 6 to 31) (P < 0.001). The decrease in number of annual admissions was 2.0 (1 to 4) (P < 0.001), which represented a cost difference of $5292 ($3533 to $8681) (P < 0.001). No differences were observed in the control cohort. In a generalized linear regression model, surgical approach was not associated with the efficacy of thymectomy (P = 0.55). CONCLUSIONS: Thymectomy is an effective treatment for pediatric myasthenia gravis, evidenced by the decreased medication burden and health care utilization after surgery. Surgical approach did not influence the success of surgery. Thymectomy should be considered earlier in the treatment algorithm.

Innovation versus Experimentation: An Application of Ethical Frameworks to the Acceptance of Fluorescence-Guided Pediatric Surgery.

Innovation is essential to the advancement of the field of pediatric surgery. The natural skepticism toward new technologies in pediatrics leads to frequent confusion of surgical innovation and research. Using fluorescence-guided surgery as an archetype for this ethical discussion, we apply existing conceptual frameworks of surgical innovation to understand the distinction between innovation and experimentation, acknowledging the spectrum and "grey zone" in between. In this review, we discuss the role of Institutional Review Boards in evaluating surgical practice innovations, and the aspects of certain surgical innovations that are distinct from experimentation, including a thorough understanding of the risk profile, preexisting use in humans, and adaptation from related fields. Examining fluorescence-guided surgery through these existing frameworks as well as the concept of equipoise, we conclude that new applications of indocyanine green do not constitute human subjects research. Most importantly, this example gives practitioners a lens through which they may appraise potential surgical innovations to allow for a sensible and efficient improvement of the field of pediatric surgery. LEVEL OF EVIDENCE: V.

A Call to Expand the Scope of Digital Phenotyping.

Digital phenotyping refers to near-real-time data collection from personal digital devices, particularly smartphones, to better quantify the human phenotype. Methodology using smartphones is often considered the gold standard by many for passive data collection within the field of digital phenotyping, which limits its applications mainly to adults or adolescents who use smartphones. However, other technologies, such as wearable devices, have evolved considerably in recent years to provide similar or better quality passive physiologic data of clinical relevance, thus expanding the potential of digital phenotyping applications to other patient populations. In this perspective, we argue for the continued expansion of digital phenotyping to include other potential gold standards in addition to smartphones and provide examples of currently excluded technologies and populations who may uniquely benefit from this technology.

Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam Versus Ceftriaxone with Metronidazole.

INTRODUCTION: Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database. METHODS: We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated. RESULTS: We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant. CONCLUSION: Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Retrospective Comparative Study.

Fluorescence-guided surgery: National trends in adoption and application in pediatric surgery.

BACKGROUND: Fluorescence-guided surgery (FGS) with indocyanine green (ICG) is a rapidly diffusing surgical innovation, but its utilization in pediatrics remains unknown. We present a cross-sectional descriptive analysis of trends from a national database. METHODS: The Pediatric Health Information System (PHIS) database was queried for patient encounters between January 2016 and July 2021 with an associated ICG administration within 3 days prior to surgery. All procedure codes from each encounter were reviewed by two surgeons to determine the most likely associated FGS procedure and assign an operative category. RESULTS: 1270 encounters were identified from 38 participating hospitals. The mean patient age (SD) was 8.3 (6.4) years, 54.5% were male, 63.8% were white, and 30.1% were Hispanic. The most common categories for ICG use were neurosurgery (21.3%), biliary (18.3%), perfusion (14.8%), urology (12.5%), gastrointestinal (10.8%), ophthalmology (8.8%), and thoracic (5.6%). Utilization over time increased for some categories (thoracic, visceral perfusion, and neurological procedures) or remained stable for other categories. Overall ICG utilization has increased in 2020 (n = 314) compared to 2016 (N = 83). The number of centers utilizing ICG has also increased from 14 hospitals in 2016 to 29 hospitals in 2020 though adoption remains unevenly distributed, with 5 high-utilization hospitals accounting for 56.8% of all ICG FGS cases. CONCLUSION: ICG is being used across a wide variety of pediatric surgical disciplines. Trends over time show increasingly frequent adoption across the country, with a few high-volume centers driving the innovation. Fluorescence-guided surgery is commercially available and is becoming more commonplace for pediatric surgeons. Dedicated efforts will now be needed to assess outcomes using this promising technology. LEVEL OF EVIDENCE: Level IV. STUDY TYPE: Retrospective study.

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy.

BACKGROUND: Laparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database. METHODS: We queried the Pediatric Health Information System (PHIS) for patients ages 3-18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 - 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation. RESULTS: In total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8-14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 - 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 - 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis. CONCLUSION: SBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Retrospective Comparative Study.

Discordance between Subjective and Objective Assessments of Activity after Pediatric Appendectomy.

BACKGROUND: Physical activity recovery after pediatric surgery can be assessed using objective measures such as step counts, but practice currently relies on subjective assessment by proxy. It is unclear how subjective and objective assessments of activity relate. We compared caregiver assessment of return to normal physical activity after pediatric appendectomy to step count recovery measured by a Fitbit. METHODS: Pediatric patients who underwent appendectomy were recruited between 2020 and 2022 to be monitored for 21 d with a Fitbit. Patients were grouped by the postoperative day (POD) (7, 14, or 21) their caregiver first reported their activity was "back to normal." Objective return to normal step count was estimated for each group by modeling the inflection point from increasing steps to a plateau. These measures were determined discordant if the subjective report remained outside the modeled 95% confidence interval (CI) for the day the group plateaued. RESULTS: Thirty-nine simple appendicitis and 40 complicated appendicitis patients were recruited. Among simple appendicitis patients, daily steps plateaued on POD 10.8 (95% CI 7.4-14.3), POD 14.0 (95% CI 11.0-17.1), and POD 11.1 (95% CI 6.9-15.3) for the day 7, day 14, and day 21 groups, respectively. Complicated appendicitis groups plateaued on POD 12.8 (95% CI 8.7-16.9), POD 15.2 (95% CI 11.1-19.3), and POD 16.7 (95% CI 12.3-21.0), respectively. Significant discordance was observed between subjective and objective assessments for the day 7 and day 14 simple groups and for the day 7 complicated group. CONCLUSIONS: There was significant discordance between caregiver and accelerometer-assessed activity recovery after pediatric surgery. Development of objective measures of recovery could help standardize assessment of children's recovery after surgery.

Association Between Neighborhood-Level Social Determinants of Health and Access to Pediatric Appendicitis Care.

Importance: Presenting with complicated appendicitis, which is associated with higher rates of complications and readmissions compared with simple appendicitis, may indicate delayed access to care. Although both patient-level and neighborhood-level social determinants of health are associated with access to care, little is known about the association between neighborhood factors and access to acute pediatric surgical care. Objective: To examine the association between neighborhood factors and the odds of presenting with complicated appendicitis and unplanned postdischarge health care use. Design, Setting, and Participants: A retrospective cohort study of patients aged 18 years or younger diagnosed with appendicitis was conducted. Discharge data from October 1, 2015, to September 30, 2018, were obtained from the Pediatric Health Information System Database and linked to the Child Opportunity Index (COI) 2.0 Database. Data analysis was conducted from January 1 through July 1, 2021. Exposures: The COI, a composite score of zip code neighborhood opportunity level information, divided into quintiles ranging from very low to very high opportunity. Main Outcomes and Measures: Based on COI level, the main outcome was the odds of presenting with complicated appendicitis, which was defined using the Agency for Healthcare Research and Quality-specified International Statistical Classification of Diseases, 10th Edition, Clinical Modification codes. The secondary outcome was the odds of unplanned postdischarge health care use (emergency department visits and/or readmissions) for patients with simple and with complicated appendicitis. Results: A total of 67 489 patients (mean [SD] age, 10.5 [3.9] years) had appendicitis, with 31 223 cases (46.3%) being complicated. A total of 1699 patients (2.5%) were Asian, 24 234 (35.9%) were Hispanic, 4447 (6.6%) were non-Hispanic Black, and 29 234 (43.3%) were non-Hispanic White; 40 549 patients (60.1%) were male; and 32 343 (47.9%) were publicly insured. Patients living in very low-COI neighborhoods had 28% higher odds of presenting with complicated appendicitis (odds ratio, 1.28; 95% CI, 1.20-1.35) compared with those in very high-COI neighborhoods. There was no significant association between COI level and unplanned postdischarge health care use (very high COI, 20.8%; very low COI, 19.1%). Conclusions and Relevance: In this cohort study, children from lower-COI neighborhoods had increased odds of presenting with complicated appendicitis compared with those from higher-COI neighborhoods, even after controlling for patient-level social determinants of health factors. These findings may inform policies and programs that seek to improve access to pediatric surgical care.

Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals.

OBJECTIVE: To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals. STUDY DESIGN: We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay. RESULTS: In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons. CONCLUSIONS: Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.

Effect of the COVID-19 pandemic on presentation and severity of traumatic injury due to physical child abuse across US children's hospitals.

BACKGROUND: Physical child abuse affects 9 in every 1,000 children in the United States and associated traumatic injuries are often identified by the healthcare system. The COVID-19 pandemic has intensified risk factors for physical child abuse and increased avoidance of the healthcare system. This study examined the effect of the COVID-19 pandemic on presentation and severity of physical child abuse. METHODS: A retrospective, cross-sectional study utilizing the Pediatric Health Information System was performed. An interrupted time series analysis estimated the effect of the COVID-19 pandemic on the number of children <15 years old presenting with physical child abuse to children's hospitals from March 1st to June 30th of 2020 by comparing to those presenting during the same period for years 2016-2019. Hierarchical regression models estimated the effect of the pandemic on likelihood of operative intervention, ICU admission, traumatic brain injury, and mortality. RESULTS: Over the study period, 20,346 physical child abuse encounters were reported by 47 children's hospitals. An interrupted times series model predicted a significant decline in cases due to the effect of the COVID-19 pandemic, representing a deficit of 2,645 cases (p = 0.001). Children presenting during the pandemic had increased odds of requiring ICU admission (p = 0.03) and having a traumatic brain injury in those under 5 years of age (p=<0.001). CONCLUSIONS: The number of children with physical child abuse presenting to children's hospitals significantly declined during the COVID-19 pandemic, but those that did were more likely to be severe. The pandemic may be a risk factor for worse outcomes associated with physical child abuse.

Utilization Trends and Disparities in Adolescent Bariatric Surgery in the United States 2009-2017.

Background: Current reports of adolescent bariatric surgery underutilization for treating severe obesity do not comprehensively assess the extent of existing disparities. We sought to describe national trends in adolescent bariatric surgery over a 9-year period and investigate previously described ethnoracial-, insurance-, income-, and geographic-based disparities. Methods: A cross-sectional analysis of adolescents aged 10-19 years who underwent bariatric surgery from 2009 to 2017 was conducted using Healthcare Cost and Utilization Kids' Inpatient Database and National Inpatient Sample Databases. Annual rates and types of bariatric surgery were assessed using trend analysis and stratified by patient, hospital, and regional characteristics. Results: The rate of bariatric surgeries per 1,000,000 adolescents with severe obesity increased over time (227 cases in 2009 to 331cases in 2017). Roux-en-Y gastric bypass and gastric band significantly decreased (p < 0.001), while sleeve gastrectomy became the most commonly performed bariatric surgery (p < 0.001). Surgeries were increasingly performed in urban teaching hospitals (77.9%) and most commonly in the Northeast (34.4%) and South (40.9%). The proportion of black patients (12.1%-15.8%) undergoing bariatric surgery increased, although was not significant and remained below that of white patients (p = 0.06). The proportion of publicly insured patients undergoing bariatric surgery significantly increased (17.0% to 30.7%, p < 0.001), although no changes were observed based on median household income. Conclusions: Over the study period, utilization of adolescent bariatric surgery has increased. Yet, vulnerable populations, who have the highest rates of severe obesity, continue to undergo bariatric surgery at disproportionately lower rates. Further efforts to address disparities and barriers to care are urgently needed to care for these children.

Effect of consumer-grade wearable device data on clinician decision making during post-discharge telephone calls after pediatric surgery.

BACKGROUND: During post-discharge telephone calls after pediatric surgery, clinicians must rely on parents/caregivers' assessment of symptoms, which can be inaccurate and often lead to unnecessary emergency department (ED) visits. Physiology (heart rate and physical activity) data from consumer-grade wearables, e.g., Fitbit™, may inform clinical decision making, yet there has been little study of clinician interpretation of this data. This study assessed whether wearable data availability, during simulated telephone calls about postoperative, post-discharge pediatric patients, affects clinician decision making. METHODS: Three simulated telephone call scenarios were presented to a diverse group of pediatric surgery clinicians. The scenarios were based on actual postoperative patients (scenarios 1 and 3 have worrisome symptoms and scenario 2 has non-worrisome symptoms) who had worn a Fitbit™ postoperatively. Each scenario was presented to clinicians (1) without any wearable data; (2) with "concerning" wearable data; and (3) with "reassuring" wearable data. Clinicians rated their likelihood, on a scale of 1-10, of recommending an emergency department (ED) visit for the three instances of each scenario, 10 being definitely ED. RESULTS: Twenty-four (24) clinicians participated in the study. When presented with "reassuring" wearable data, clinicians' likelihood of recommending an ED visit decreased from a median score of 6 to 1 (p < 0.001) for scenario 1 and from 9 to 3 (p < 0.001) for scenario 3. When presented with "concerning" wearable data, the median likelihood of recommending an ED visit increased from 1 to 6 (p = 0.003) for scenario 2. CONCLUSION: This study showed that wearable data affect clinicians' decision making and may be useful in triaging postoperative, post-discharge pediatric patients. LEVEL OF EVIDENCE: V.

Utility of Wearable Sensors to Assess Postoperative Recovery in Pediatric Patients After Appendectomy.

BACKGROUND: Despite more than two million pediatric operations performed in the United States annually, normal postoperative recovery remains difficult to define. Wearable sensors that assess physical activity and vital signs in real time represent a tool to assess postoperative recovery. This study examined the use of a wearable, the FitBit Inspire HR, to describe recovery in children after appendectomy and to determine the sensitivity of wearable data to distinguish disease severity. MATERIALS AND METHODS: Children 3-18 y old undergoing appendectomy in a tertiary children's hospital were invited to participate. Participants wore the FitBit Inpire HR after surgery for 21 d. t-tests compared daily step counts, and piecewise linear regression models were fit to examine recovery trajectories for patients with simple and complicated appendicitis. RESULTS: Thirty-two patients were enrolled, and 26 met eligibility criteria. Nine (35%) children had complicated appendicitis, and 14 (54%) were female; the mean age was 9.1 y (standard deviation: 2.9). Four hundred nineteen postoperative days were captured (range: 8-22 d; median: 16 d). Step counts increased after surgery; however, piecewise models showed that patients with simple appendicitis had a more rapid increase (P < 0.01) and reached a plateau (approximately 8000 steps/d) on postoperative day 9, whereas patients with complicated appendicitis did not reach a plateau and had lower step counts during the entire 21-postoperative day period (P < 0.01). CONCLUSIONS: Recovery in children after surgery can be characterized using wearables, which can also distinguish recovery trajectories based on disease severity. Establishing such "normative" recovery patterns may lead to earlier detection of complications.

Cost-Effectiveness of Exploratory Laparotomy in a Regional Referral Hospital in Eastern Uganda.

BACKGROUND: Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. MATERIALS AND METHODS: A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. RESULTS: Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. CONCLUSIONS: This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.

Prognosis and delay of diagnosis among Kaposi's sarcoma patients in Uganda: a cross-sectional study.

BACKGROUND: In low- and middle-income countries, the association between delay to treatment and prognosis for Kaposi's sarcoma (KS) patients is yet to be studied. METHODS: This is a prospective study of HIV-infected adults with histologically-confirmed KS treated at the Uganda Cancer Institute (UCI). Standardized interviews were conducted in English or Luganda. Medical records were abstracted for KS stage at admission to UCI. Multivariable logistic regression assessed relationships between diagnostic delay and stage at diagnosis. RESULTS: Of 161 patients (90% response rate), 69% were men, and the mean age was 34.0 years (SD 7.7). 26% had been seen in an HIV clinic within 3 months, 72% were on antiretroviral therapy, and 26% had visited a traditional healer prior to diagnosis. 45% delayed seeking care at UCI for ≥3 months from symptom onset. Among those who delayed, 36% waited 6 months, and 25% waited 12 months. Common reasons for delay were lack of pain (48%), no money (32%), and distance to UCI (8%). In adjusted analysis patients who experienced diagnostic delay were more likely than those who did not delay to have poor-risk KS stage (OR 3.41, p = 0.002, 95% CI: 1.46-7.45). In adjusted analyses visiting a traditional healer was the only variable associated with greater likelihood of delay (OR 2.69, p = 0.020, 95% CI: 1.17-6.17). CONCLUSIONS: Diagnostic delay was associated with poor-risk stage at diagnosis, and visiting a traditional healer was associated with higher odds of delay. The relationship between traditional and Western medicine presents a critical intervention point to improve KS-related outcomes in Uganda.