Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review.

INTRODUCTION: Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs). METHODS: We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery. RESULTS: 77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE. CONCLUSIONS: CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

International Perspective on Extremity Vascular Trauma in Children: A Scoping Review.

OBJECTIVE: Extremity vascular trauma in children can result in significant morbidity and mortality. Most published studies have focused on supracondylar humeral fracture related injuries, with little focus on other injuries. This scoping review describes the current state of knowledge on paediatric vascular injuries in the upper and lower limbs, excluding injuries related to supracondylar humeral fractures. METHODS: MEDLINE, PubMed, Web of Science, and Cochrane databases were searched for relevant studies evaluating the epidemiology, diagnosis, management, and outcomes of upper and lower limb vascular trauma in those aged under 18 years. Studies related to supracondylar humeral fractures were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews was used. RESULTS: A total of 39 studies was included, all of which were retrospective, and 74% of which were based in North America or Europe. Extremity vascular trauma was reported to cause 0.6 - 4.4% of all paediatric trauma admissions, with penetrating mechanisms and upper limb injuries being the most common. Operative intervention was reported in 80 - 100% of children in the included studies. Primary repair was the most commonly reported operative intervention, followed by interposition graft and bypass graft. Synthetic graft use was less commonly reported (incidence range 0.5 - 33%). Lower limb fasciotomies and amputations were not commonly reported (incidence range 0 - 23% and 0 - 13%, respectively). The mortality rate appeared low, with 23 studies reporting no deaths (incidence range 0 - 4%). Complications were reported inconsistently, with no uniform outcome or follow up measures used. CONCLUSION: The incidence of extremity vascular trauma appears low in children, with penetrating mechanisms and upper extremity injuries appearing to dominate. Most studies are from high income countries, with probable selection bias towards those treated by operative intervention. Prospective studies are required focusing on patterns of injury, rates of operative and endovascular intervention, and long term outcomes.

The Global Otolaryngology-Head and Neck Surgery Workforce.

Importance: A core component of delivering care of head and neck diseases is an adequate workforce. The World Health Organization report, Multi-Country Assessment of National Capacity to Provide Hearing Care, captured primary workforce estimates from 68 member states in 2012, noting that response rates were a limitation and that updated more comprehensive data are needed. Objective: To establish comprehensive workforce metrics for global otolaryngology-head and neck surgery (OHNS) with updated data from more countries/territories. Design, Setting, and Participants: A cross-sectional electronic survey characterizing the OHNS workforce was disseminated from February 10 to June 22, 2022, to professional society leaders, medical licensing boards, public health officials, and practicing OHNS clinicians. Main Outcome: The OHNS workforce per capita, stratified by income and region. Results: Responses were collected from 121 of 195 countries/territories (62%). Survey responses specifically reported on OHNS workforce from 114 countries/territories representing 84% of the world's population. The global OHNS clinician density was 2.19 (range, 0-61.7) OHNS clinicians per 100 000 population. The OHNS clinician density varied by World Bank income group with higher-income countries associated with a higher density of clinicians. Regionally, Europe had the highest clinician density (5.70 clinicians per 100 000 population) whereas Africa (0.18 clinicians per 100 000 population) and Southeast Asia (1.12 clinicians per 100 000 population) had the lowest. The OHNS clinicians deliver most of the surgical management of ear diseases and hearing care, rhinologic and sinus diseases, laryngeal disorders, and upper aerodigestive mucosal cancer globally. Conclusion and Relevance: This cross-sectional survey study provides a comprehensive assessment of the global OHNS workforce. These results can guide focused investment in training and policy development to address disparities in the availability of OHNS clinicians.

Female and low- and middle-income authorship trends in high-impact ENT journals (2011-2020).

Introduction: Despite a recent drive to increase diversity, the global academic workforce is skewed in favor of authors from high-income countries, and women are under-represented in the published medical literature. Objectives: To explore the trends in authorship of three high-impact otolaryngology journals over a ten-year period (2011-2020). Methods: Journals selected: JAMA Otolaryngology-Head and Neck Surgery, The Laryngoscope and Rhinology. Articles were reviewed from four issues per journal per year, and data was collected on: time of publication; subspeciality; number of authors; sex of first and last authors; country of practice of first author and country where each study was conducted. Trends were examined though univariate and multivariate logistic regression models. Results: 2998 articles were included. 93.9% of first authors and 94.2% of studies were from high-income countries.Women were first authors in 31.5% (n = 912) and senior authors in 18.4% (n = 524) of articles. Female first authorship significantly increased between 2011 and 2020 however female senior authorship remained the same. There have been no significant changes in the proportion of published articles from low-and middle-income countries (LMIC) over time (p = .65). Amongst the LMIC articles, 72% came from Brazil, Turkey or China and there were no published papers from countries with a low-income economy (gross national income per capita of $1085 or less). Conclusions: Although female first authorship has increased in the last decade, there has been minimal other demographic change in authorship over this time. High-impact otolaryngology journals poorly represent academia in low-and-middle income countries. There is a need for increased advocacy promoting gender and geographical research equity in academic medicine. Level of Evidence: III.

Supportive care of patients diagnosed with high grade glioma and their carers in Australia.

PURPOSE: This study aimed to: determine the supportive care available for Australian patients with High Grade Glioma (HGG) and their carers; identify service gaps; and inform changes needed to implement guidelines and Optimal Care Pathways. METHODS: This cross-sectional online survey recruited multidisciplinary health professionals (HPs) who were members of the Cooperative Trials Group for Neuro-Oncology involved in management of patients diagnosed with HGG in Australian hospitals. Descriptive statistics were calculated. Fisher's exact test was used to explore differences between groups. RESULTS: 42 complete responses were received. A majority of MDT meetings were attended by a: neurosurgeon, radiation oncologist, medical oncologist, radiologist, and care coordinator. Less than 10% reported attendance by a palliative care nurse; physiotherapist; neuropsychologist; or speech therapist. Most could access referral pathways to a cancer care coordinator (76%), neuropsychologist (78%), radiation oncology nurse (77%), or psycho-oncologist (73%), palliative care (93-100%) and mental health professionals (60-85%). However, few routinely referred to an exercise physiologist (10%), rehabilitation physician (22%), dietitian (22%) or speech therapist (28%). Similarly, routine referrals to specialist mental health services were not standard practice. Nearly all HPs (94%) reported HGG patients were advised to present to their GP for pre-existing conditions/comorbidities; however, most HPs took responsibility (≤ 36% referred to GP) for social issues, mental health, symptoms, cancer complications, and treatment side-effects. CONCLUSIONS: While certain services are accessible to HGG patients nationally, improvements are needed. Psychosocial support, specialist allied health, and primary care providers are not yet routinely integrated into the care of HGG patients and their carers despite these services being considered essential in clinical practice guidelines and optimal care pathways.

Systematic analysis of authorship demographics in global surgery.

BACKGROUND: Global surgery has recently gained prominence as an academic discipline within global health. Authorship inequity has been a consistent feature of global health publications, with over-representation of authors from high-income countries (HICs), and disenfranchisement of researchers from low-income and middle-income countries (LMICs). In this study, we investigated authorship demographics within recently published global surgery literature. METHODS: We performed a systematic analysis of author characteristics, including gender, seniority and institutional affiliation, for global surgery studies published between 2016 and 2020 and indexed in the PubMed database. We compared the distribution of author gender and seniority across studies related to different topics; between authors affiliated with HICs and LMICs; and across studies with different authorship networks. RESULTS: 1240 articles were included for analysis. Most authors were male (60%), affiliated only with HICs (51%) and of high seniority (55% were fully qualified specialist or generalist clinicians, Principal Investigators, or in senior leadership or management roles). The proportion of male authors increased with increasing seniority for last and middle authors. Studies related to Obstetrics and Gynaecology had similar numbers of male and female authors, whereas there were more male authors in studies related to surgery (69% male) and Anaesthesia and Critical care (65% male). Compared with HIC authors, LMIC authors had a lower proportion of female authors at every seniority grade. This gender gap among LMIC middle authors was reduced in studies where all authors were affiliated only with LMICs. CONCLUSION: Authorship disparities are evident within global surgery academia. Remedial actions to address the lack of authorship opportunities for LMIC authors and female authors are required.