Immediate Impact of Centralization on Abdominal Aortic Aneurysm Repair Outcomes for a Vascular Network in the South West of England: A Retrospective Cohort Study.

OBJECTIVE: Our aim was to assess the short-term impact of centralization on the outcomes of patients undergoing abdominal aortic aneurysm repair in a vascular network in the South West of England. BACKGROUND: The centralization of vascular services has been implemented nationally across the National Health Service to improve patient outcomes. The full impact of these major changes has not yet been fully analyzed. METHODS: A retrospective cohort study examining outcomes of patients undergoing abdominal aortic aneurysm repair, based on prospectively entered National Vascular Registry data, pre and post centralization in the South West of England. The primary outcome was mortality at 30 days. Secondary measures included 30-day morbidity, length of hospital stay, and length of intensive care unit stay. RESULTS: The 30-day mortality was unchanged pre and post-centralization (11% vs 12%, P = 0.84). The 30-day morbidity rate was also unchanged (24% vs 25%, P = 0.83), as was length of intensive care unit stay (3 vs 3 days, P = 0.74). Overall length of stay was not significantly different (8 vs 6 days, P = 0.76). Subgroup analysis of patients with elective, ruptured, and symptomatic aneurysm repair demonstrated no differences in 30-day mortality. There was a significantly shorter stay post-centralization for patients with symptomatic aneurysms (6 vs 12 days pre-centralization, P = 0.012). CONCLUSIONS: The process of centralization of abdominal aortic aneurysm repair in a vascular network was safe for patients and had no immediate impact on outcomes. Longer-term outcome measures and financial data will be required to further assess the benefit of centralization.

The diagnostic upper GI endoscopy camp: a pilot for enhancing service provision and training in eastern Uganda.

Background: Upper gastrointestinal (UGI) symptoms are common in East Africa but there is limited diagnostic endoscopy availability. Surgical camps are a recognised method of providing intensive service provision and training. We describe a novel application of the camp model for diagnostic UGI endoscopy in eastern Uganda. Methods: A 7-day camp took place in an existing endoscopy department of Mbale Regional Referral Hospital. Patients with symptoms warranting investigation were invited for free diagnostic UGI endoscopy, biopsy and H.pylori testing. Results: 148 patients underwent endoscopy. 47 were deemed to have significant pathology, 7 with malignancy. 61% had H.Pylori. A resident surgeon was trained and performed 55 supervised unassisted procedures. Conclusion: Our pilot has illustrated that camps are a safe and efficient way of providing intense endoscopy service and training in an established department. Camps can be utilised for scaling up much needed endoscopy services and training in low- and middle-income countries.

Upper gastrointestinal endoscopy findings in Mbale Regional Referral Hospital, Eastern Uganda: a 10-year retrospective analysis.

BACKGROUND: Endoscopy is required for formal diagnosis of many upper gastrointestinal (UGI) conditions including oesophageal cancer (OC). There is a paucity of data on endoscopy findings in East Africa as access to testing is challenging for patients. We describe the findings of 10 years of UGI endoscopy in Mbale Regional Referral Hospital (MRRH). METHOD: Records of patients that underwent UGI endoscopy in MRRH, November 2009 - March 2019 were retrospectively analysed. Indication, macroscopic findings, histology and patient demographics were retrieved. Sub-group analyses were performed on those with a histological diagnosis of oesophageal cancer. RESULTS: 833 eligible patients received single UGI procedures during the study period. Mean age was 54.8 years, range 16-93 years and 56.9% of patients were male. The main indication was dysphagia (42%) and the most common findings OC (34%) and gastritis (28%). 151 patients had histologically proven OC with a median age of 60 years and a 2:1 male to female ratio. 145/151 (96%) of samples tested revealed squamous cell carcinoma (SCC). CONCLUSION: Those undergoing endoscopy in MRRH are most commonly male patients presenting in their 5th decade with dysphagia. There is a high proportion of significant findings including gastritis, peptic ulcer disease, and oesophageal cancer.

Economic impact of surgery on households and individuals in low income countries: A systematic review.

BACKGROUND: Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) - the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com). METHODS: We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. RESULTS: 31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs. CONCLUSION: Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective.