Orthopedic surgery in Palau-Current capacity, needs, and future directions.

BACKGROUND: Palau, an island nation in Micronesia, is a medically underserved area with a shortage of specialty care services. Orthopedic diagnoses in Palau remain among the three most common reasons for costly off-island medical referral. The purpose of this study was to assess Palau's current orthopedic surgery capacity and needs to inform interventions to build capacity to improve care access and quality. METHODS: Orthopedic needs and capacity assessment tools developed by global surgical outreach experts were utilized to gather information and prompt discussions with a broad range of Palau's most knowledgeable stakeholders (n = 6). Results were reported descriptively. RESULTS: Finance, community impact, governance, and professional development were the lowest-scored domains from the Capacity Assessment Tool for orthopedic surgery (CAT-os), indicating substantial opportunity to build within these domains. According to administrators (n = 3), governance and finance were the greatest capacity-building priorities, followed by professional development and partnership. Belau National Hospital (BNH) had adequate surgical infrastructure. Skin grafting, soft tissue excision/resection, infection management, and amputation were the most commonly selected procedures by stakeholders reporting orthopedic needs. CONCLUSIONS: This study utilizes a framework for orthopedic capacity-building in Palau which may inform partnership between Palau's healthcare system and orthopedic global outreach organizations with the goal of improving the quality, safety, and value of the care delivered. This demonstration of benchmarking, implementation planning, and subsequent re-evaluation lays the foundation for the understanding of capacity-building and may be applied to other medically underserved areas globally to improve access to high-quality orthopedic care.

Quantifying the Burden of Unmet Upper Extremity Care Need in Low-Middle Income Countries: A Four-Country, Cluster-Randomized Study.

PURPOSE: Currently, no nationally implementable survey exists to identify the burden of hand and upper extremity conditions at the household level in low-middle income countries (LMICs). This study describes a randomized cluster survey approach to estimating the burden of hand and upper extremity conditions in four LMICs using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey. Additionally, this study identifies factors associated with responses of unmet surgical need at the multinational level. METHODS: The SOSAS instrument is a cluster-randomized, cross-sectional, countrywide survey of households administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. We identified nationwide trends for sociodemographic, anatomic, condition type, mechanism, prevalence, subjective disability, and barriers to care for upper extremity survey responses. A multivariable model identified factors associated with unmet upper extremity need across the four nations. RESULTS: Across the four countries, 13,763 individuals participated in the survey, with 883 conditions of the upper extremity identified (7.4% of all surgical conditions surveyed). Fractures accompanied many of the injuries (32.3%). Although most conditions were acquired, congenital conditions comprised 11% of all etiologies. Overall, open fire/explosion was the most common mechanism (22.9%). Rwandans had the highest proportion of individuals seeking care (91.0%) and receiving care (88.6%). Sierra Leone indicated the fewest seeking and receiving care (71% and 63%, respectively). Chronic injuries were significantly associated with receiving care, whereas illiteracy and worsening subjective disability were barriers to receiving care. CONCLUSIONS: In this survey of upper extremity conditions from four LMICs, upper extremity conditions primarily resulted from fire/explosions, and many reported sustaining a fracture. Illiteracy and more disabling conditions decreased the odds of receiving care by 30% to 40%, respectively. CLINICAL RELEVANCE: The SOSAS survey may provide a reproducible means to evaluate the unmet need for upper extremity care across similar LMICs.

Hand Surgery Outreach-From Short-Term "Missions" to Capacity Building.

Although great advancements have been made in global health over the past decades, progress has not been equivalent across the world. For example, the surgical burden (number of surgical cases per capita) remains highest in low- and middle-income countries (LMICs-a term used by The World Bank to classify countries on the basis of their gross national income), where there are frequently fewer surgeons per capita. Surgical outreach is on the rise, with the United States sponsoring more than 2,000 trips annually to LMICs to help address the mismatch in per capita surgical cases to per capita surgeons. These trips, however, are typically short-term in nature and effect and can have unintended consequences. In contrast, capacity building focuses on bidirectional partnerships to educate and empower individuals and organizations such that their care for the local community is enhanced. Capacity building is a priority of leading organizations (including the World Health Organization) but has often been absent in orthopedic and hand surgery outreach. We detail the evidence supporting the transition from short-term mission-based trips to that of capacity building, what we can learn from other specialties about capacity building, and how we can measure and build capacity to improve health in LMICs using our partnership with Costa Rican hand and upper-extremity surgeons as an example.

Implementation of Electronic Health Records During Global Outreach: A Necessary Next Step in Measuring and Improving Quality of Care.

There has been a marked improvement in health outcomes in low- and middle-income countries (LMICs) throughout the past several decades. Although access to care has increased, evidence demonstrates that over 8 million lives could be saved annually with high-quality health systems. Traumatic injuries that are often treatable by surgical services are a leading cause of global mortality. As such, increased efforts toward improving quality of care in addition to access are needed for surgical services in LMICs. Electronic health records have become standard in high-income countries, given their demonstrated ability to improve clinical care, prevent complications, and inform quality improvement. Electronic health records are not frequently used in LMICs and represent an opportunity to address the quality gap in these health systems. This review highlights the benefits of electronic health records in high-income countries, their potential benefits in LMICs, their current role in supporting surgical outreach, and their implementation on outreach trips to measure and improve quality of care.

Measuring and Improving the Quality of Care During Global Outreach Trips: A Primer for Safe and Sustainable Surgery.

Trauma is the leading cause of mortality in patients aged 5 years and older. Globally, trauma kills more people than malaria, tuberculosis, and HIV/AIDs combined. As the number of surgical outreach trips to low- and middle-income countries and resources provided for such trips increase, hand surgeons are uniquely positioned to address this global burden. However, the delivery of surgical care alone is insufficient without effectively evaluating the quality of care delivered. It is critical that the care provided on outreach trips improves patient and population health, does not harm patients, and develops the local health care ecosystem. An estimated 8 million lives could be saved annually in low- and middle-income countries with higher-quality health systems. Currently, data collection systems for evaluating quality during outreach trips are lacking. Insight into current methods of quality assessment and improvement in both developing and developed countries can help inform future efforts to implement innovative data collection systems. Thoughtful and sustainable collaboration with host sites in low- and middle-income countries can ensure that care delivery is culturally competent and improves population health.

The Namibian Children's Heart Project: a South-South partnership to provide cardiac care.

IntroductionCongenital and acquired heart diseases are highly prevalent in developing countries despite limited specialised care. Namibia established a paediatric cardiac service in 2009 with significant human resource and infrastructural constraints. Therefore, patients are referred for cardiac interventions to South Africa. OBJECTIVES: To describe the diagnoses, clinical characteristics, interventions, post-operative morbidity and mortality, and follow-up of patients referred for care. METHODS: Demographics, diagnoses, interventions, intra- and post-operative morbidity and mortality, as well as longitudinal follow-up data of all patients referred to South Africa, were recorded and analysed. RESULTS: The total cohort constituted 193 patients of which 179 (93%) had CHD and 7% acquired heart disease. The majority of patients (78.8%) travelled more than 400 km to Windhoek before transfer. There were 28 percutaneous interventions. Palliative and definitive surgery was performed in 27 and 129 patients, respectively. Out of 156 patients, 80 (51.3%) had post-operative complications, of which 15 (9.6%) were a direct complication of surgery. Surgical mortality was 8/156 (5.1%, 95% confidence interval 2.2-9.8), with a 30-day mortality of 3.2%. Prolonged ICU stay was associated with a 5% increased risk of death with hazard ratio 1.05, 95% confidence interval 1.02-1.08, p=0.001. Follow-up was complete in 151 (78%) patients for more than 7 years. CONCLUSIONS: Despite the challenges associated with a cardiac programme for referring patients seeking intervention in a neighbouring country and the adverse characteristics of multiple lesions and complexity associated with late presentation, we report good surgical and interventional outcomes. Our goal remains to develop a comprehensive sustainable cardiac service in Namibia.

Cost-Effectiveness Analysis of Humanitarian Hand Surgery Trips According to WHO-CHOICE Thresholds.

PURPOSE: Hand surgery outreach programs to low- and middle-income countries (LMICs) provide much-needed surgical care to the underserved populations and education to local providers for improved care. The cost-effectiveness of these surgical trips has not been studied despite a long history of such efforts. This study aimed to examine the economic impact of hand surgery trips to LMICs using data from the Touching Hands Project and ReSurge International. We hypothesized that hand surgery outreach would be cost-effective in LMICs. METHODS: We analyzed data on the cost of each trip and the surgical procedures performed. Using methods from the World Health Organization (WHO-Choosing Interventions That Are Cost-Effective [WHO-CHOICE]), we determined whether the procedures performed during the outreach trips would be cost-effective. RESULTS: For the 14 hand surgery trips, 378 patients received surgical treatment. Trips varied in the country where interventions were provided, the number of patients served, the severity of the conditions, and the total cost. The cost per disability-adjusted life-year averted ranged from United States (US)$222 to $1,525, all of which were very cost-effective according to WHO-CHOICE thresholds. The cost-effectiveness of global hand surgery was comparable to that of other medical interventions such as multidrug-resistant tuberculosis treatment in similar regions. We also identified a lack of standardized record keeping for these surgical trips. CONCLUSIONS: Hand surgeries performed in LMICs are cost-effective based on WHO-CHOICE criteria. However, a standardized record-keeping method is needed for future research and longitudinal comparison. Understanding the economic impact of hand surgery global outreach is important to the success and sustainability of these efforts, both to allocate resources effectively and to identify areas for improvement. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

Building a sustainable free flap program in a resource-limited setting: A 12-year humanitarian effort.

BACKGROUND: We present a sustainable complex reconstructive program built through 12 years of surgical outreach work at Kijabe Hospital in Kenya. METHODS: Retrospective chart review and anecdotal experiences. RESULTS: In 2011, surgeons from a US-medical center performed Kijabe Hospital's first 3 successful free flap surgeries. Since then, they have returned 7 times, performing a total of 31 tumor excisions with microvascular reconstruction. One flap failure occurred that was reconstructed on a subsequent trip. In 2013, a US-trained missionary surgeon and a Kenyan-trained general surgeon began working with the visiting team with the goal of performing these surgeries independently. In 2016 they performed their first independent free flap reconstruction and have since performed 32 independent cases with only three flap losses. Establishing infrastructure, staff education, selective patient criteria, and continuous communication are the factors that enabled the success of this program. CONCLUSIONS: Establishing a successful microvascular reconstruction program in a resource-limited setting is feasible.

Rates, Barriers, and Facilitators of Outcome Collection on Hand Surgery Outreach to Low- and Middle-Income Countries.

BACKGROUND: Global outreach to low- and middle-income countries (LMICs) continues to grow in an effort to improve global health. The practice of quality measurement is empirically lacking from surgical outreach trips to LMICs, which may limit the safety and quality of care provided. Using convergent mixed-methods, we aimed to: (1) identify and evaluate barriers and facilitators to outcome measure collection; and (2) report the sample rate of such collection on hand surgery outreach trips to LMICs. METHODS: Surgeons and administrators involved in hand surgery outreach trips completed a survey regarding rates of outcome measure collection and a semi-structured interview to explore barriers and facilitators of outcome collection. Survey data were reported descriptively. Interviews were recorded and transcribed, and excerpts were categorized according to the Pettigrew framework for strategic change (content, process, and context). Results were combined through convergent mixed-methods analysis. RESULTS: Thirty-three participants completed the survey, and 21 participated in interviews. Rates of collection were the most common for total case number (83%) and patient mortality (65%). Longitudinal outcomes (eg, patient follow-up or time away from work) were less frequently recorded (9% and 4%, respectively). Content analysis revealed barriers related to each domain of the Pettigrew framework. CONCLUSIONS: This analysis demonstrates low levels of outcome collection on outreach trips and identifies priority areas for improvement. Developing context-specific solutions aimed at addressing barriers (eg, resource/database availability) and promoting facilitators (eg, collaborative relationships) may encourage higher rates of collection, which stands to improve patient safety, quality of care, and accountability when conducting outreach trips to LMICs.

Anesthesia for inguinal hernia repair: Experience with a tertiary hospital-based surgical outreach in a developing world.

Background: The dearth of adequate facilities and anesthetists limits the number and extent of surgical cases that can be attended to in surgical outreach programs. Inguinal hernia remains a common health burden in the developing world. Tertiary hospitals provide good anesthetic complements to safe surgeries and will be a veritable tool in surgical outreaches. Objectives: The objective of the study is to assess the types/techniques of anesthesia used in uncomplicated open inguinal hernia repair in a tertiary hospital-based surgical outreach program. Materials and Methods: This study was a prospective analysis of anesthetic techniques used in all uncomplicated inguinal hernia repairs performed in outreach program over 1 week in May 2018. Data were collected with a pro forma, analyzed with SPSS, and presented in tables and figures. Results: One hundred and ninety-five patients with uncomplicated inguinal hernias were recruited for the study. The patients' age ranged from 0 to 89 years, with a mean age of 33.62 ± 22.75 years. Most cases occurred in children. The male-to-female ratio was 7:1, and the majority were primary hernia repairs. Eighty-seven (44.6%) patients had local anesthesia (LA), 65 (33.3%) had general anesthesia (GA), while 43 (22.1%) had spinal anesthesia (SA). One hundred and sixty-two (83.1%) patients needed intraoperative analgesic augmentation. One hundred and sixty-nine (86.7%) patients were operated as day-case surgeries, while 26 (13.3%) patients were discharged the day after surgery. The failure rate of LA and SA put together was 74.6%, but there was no conversion to GA. Anesthetic complication was observed in 3.4% of cases. Conclusion: Organizing inguinal hernia repair outreach in a tertiary hospital offers the benefit of a full complement of anesthesia, which ensures safe and smooth surgery with low anesthetic complications. Most cases were done as daycare surgeries despite the high failure rate of LA and SA. Contexte: Le manque d'installations adéquates et d'anesthésistes limite le nombre et l'étendue des cas chirurgicaux qui peuvent être traités dans les programmes de proximité chirurgicale. La hernie inguinale reste un fardeau de santé courant dans les pays en développement. Les hôpitaux tertiaires fournissent de bons compléments anesthésiques aux chirurgies sûres et seront un véritable outil dans les interventions chirurgicales. Objectifs: Évaluer les types / techniques d'anesthésie utilisés dans la réparation de hernie inguinale ouverte non compliquée dans un programme de proximité chirurgicale en milieu hospitalier tertiaire. Méthode: Une analyse prospective des techniques d'anesthésie utilisées dans toutes les réparations de hernie inguinale non compliquées effectuées dans le cadre d'un programme de sensibilisation sur une semaine en mai 2018. Les données ont été recueillies à l'aide d'un formulaire, analysées avec SPSS et présentées sous forme de tableaux et de figures. Résultats: Cent quatre-vingt-quinze patients atteints de hernies inguinales non compliquées ont été recrutés pour l'étude. L'âge des patients variait de 0 à 89 ans avec un âge moyen de 33,62 + 22,75 ans. La plupart des cas sont survenus chez des enfants. Le ratio homme / femme était de 7: 1 et la majorité était des réparations primaires de hernie. Quatre-vingt-sept (44,6%) des patients ont eu une anesthésie locale (LA), 65 (33,3%) une anesthésie générale (AG), tandis que 43 (22,1%) une anesthésie rachidienne (SA). Cent soixante-deux (83,1%) patients ont eu besoin d'une augmentation analgésique peropératoire. Cent soixante-neuf (86,7%) patients ont été opérés en garderie tandis que 26 (13,3%) patients ont obtenu leur congé le lendemain de la chirurgie. Le taux d'échec de LA et SA réunis était de 74,6%, mais il n'y a pas eu de conversion en GA. Une complication anesthésique a été observée dans 3,4% des cas. Conclusion: l'organisation de soins de proximité pour la réparation de la hernie inguinale dans un hôpital tertiaire offre l'avantage d'un complément complet d'anesthésie qui garantit une chirurgie sûre et en douceur avec de faibles complications anesthésiques. La plupart des cas ont été pratiqués en garderie malgré le taux d'échec élevé de l'anesthésie locale et rachidienne. Mots-clés: Réparation de hernie inguinale, chirurgie de jour, anesthésie générale, anesthésie locale, anesthésie rachidienne.

The mobile surgical outreach program for management of patients with genital fistula in the Democratic Republic of Congo.

OBJECTIVE: To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges. METHODS: A retrospective observational study of routinely collected health data from women treated via the MSO program (2013-2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico-surgical training, and community sensitization components. RESULTS: The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1-81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts. CONCLUSION: The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient-centered approach that brings medico-surgical care and psychosocial support to women with fistula in their own communities.

Creating the Successful Global Maxillofacial Surgeon: A 35-Year Perspective.

The success of global outreach surgical programs depends on many factors including the preparation of the surgeons involved in the program. Surgeons in preparing for global outreach programs often focus on surgical procedures or techniques as the most important aspect of the preparation for the program. Just as important to success of the outreach program is the surgeon's familiarity with the language, cultural, and social norms of the host country or region. This article provides valuable information on these issues from three oral and maxillofacial surgeons who have been engaged in global oral and maxillofacial surgery outreach programs for decades.

Taking Free Flap Surgery Abroad: A Collaborative Approach to a Complex Surgical Problem.

Accessibility to health care, especially complex surgical care, represents one of the major health care disparities in developing countries. While surgical teams may be willing to travel to these areas to help address these needs, there are many logistical and ethical dilemmas inherent in this pursuit. We reviewed our approach to the establishment of the team-based surgical outreach program, wherein we perform head and neck free tissue transfer surgery in Haiti. We describe the challenges encountered in the delivery of surgical care as well as ethical dilemmas relevant to surgical outreach trips, highlighting an approach reliant on strong local cooperation. Despite the obstacles in place, our experience shows that free flap surgery can be successfully and ethically performed in these areas of great need.

Collaboration in Outreach: The Kumasi, Ghana, Model.

Hand surgery does not have to be expensive. Substituting evidence-based field sterility for main operating room sterility and using wide-awake, local anesthesia, no tourniquet (WALANT) surgery instead of sedation makes hand surgery much more affordable worldwide. This article explains how North Americans collaborated with Ghanaian hand surgeons and therapists to establish more affordable hand care in Kumasi. It describes how multiple nonprofit organizations collaborate to create trans-Atlantic Webinars and a reverse fellowship program to share hand surgery and therapy knowledge between North American and Ghanaian hand care providers.

Paediatric surgical outreach in central region of Ghana.

BACKGROUND: Conditions that are amenable to surgery are found globally. However, surgery is not easily accessible for most people in low- and middle-income countries due to physical and financial barriers, among others. One-way of mitigating against this situation is through surgical outreach programmes. PATIENTS AND METHODS: A paediatric surgical outreach in a teaching hospital in the Central Region of Ghana was carried out by a paediatric surgeon from Korle Bu Teaching Hospital. Data on the cases done from June 2011 to June 2014 were analysed. RESULTS: A total of 185 patients had surgery during the study. There were 153 males with the mean age of 4.53 ± 3.67 years. Patients aged 1-5 years represented 51.9% of the patients. Twenty-four (13%) had major surgery and 161 (87%) had minor operations. The most common minor operation performed was inguinal herniotomy representing 47.2% of the cases. None of the patients had any complications. CONCLUSION: The need for paediatric surgical outreach programme has been shown in this paper as well as its cost-effectiveness. With the current rate of graduation of paediatric surgeons in Ghana, paediatric outreach programmes will be needed in Ghana in the foreseeable future. This outreach should be extended to other regions of the country to cover a larger percentage of children in Ghana.

Surgical outreach and microvascular surgery in developing countries.

Due to the discrepancy between surgical demand and resources in Low-Middle Income Countries (LMIC), surgical outreach programs (SOP) have increased in popularity. In these resource-constrained healthcare environments, the resources necessary to perform basic head and neck procedures are often lacking, and offering microvascular reconstruction adds yet another level of complexity. Here we discuss the difficulties and challenges in establishing a SOP abroad and more specifically some of the challenges specific to microvascular reconstruction - including patient selection, burden of cost, lack of infrastructure and equipment, and patient follow up and outcomes. Although challenges certainly exist, we present the feasibility and the benefit for patient care as well as the role it can play in the foundation development of a low-resource region. The goals of the SOP must be well-defined, and incorporating microvascular surgery can be used as an adjunct to enhance the development of many aspects of the LMIC healthcare system. We present a model of care in which the initial focus is centered on providing safe care to these patients undergoing complex procedures, but after the development of a strong foundation, the focus can begin to include program sustainability and education.