Financial Risk Protection and Hospital Admission for Trauma in Cameroon: An Analysis of the Cameroon National Trauma Registry.

BACKGROUND: Half of the global population is at risk for catastrophic health expenditure (CHE) in the event that they require surgery. Universal health coverage fundamentally requires protection from CHE, particularly in low- and middle-income countries (LMICs). Financial risk protection reports in LMICs covering surgical care are limited. We explored the relationship between financial risk protection and hospital admission among injured patients in Cameroon to understand the role of health insurance in addressing unmet need for surgery in LMICs. METHODS: The Cameroon National Trauma Registry, a database of all injured patients presenting to the emergency departments (ED) of three Cameroonian hospitals, was retrospectively reviewed between 2015 and 2017. Multivariate regression analysis identified predictors of hospital admission after injury and of patient report of cost inhibiting their care. RESULTS: Of the 7603 injured patients, 95.7% paid out-of-pocket to finance ED care. Less than two percent (1.42%) utilized private insurance, and more than half (54.7%) reported that cost inhibited their care. In multivariate analysis, private insurance coverage was a predictor of hospital admission (OR 2.17, 95% CI: 1.26, 3.74) and decreased likelihood of cost inhibiting care (OR 0.34, 95% CI: 0.20, 0.60) when compared to individuals paying out-of-pocket. CONCLUSION: The prevalence of out-of-pocket spending among injured patients in Cameroon highlights the need for financial risk protection that encompasses surgical care. Patients with private insurance were more likely to be admitted to the hospital, and less likely to report that cost inhibited care, supporting private health insurance as a potential financing strategy.

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.

Epidemiology and cost of pediatric injury in Yaoundé, Cameroon: a prospective study.

PURPOSE: Unintentional injury is the leading cause of death among children aged 10-19 years and over 95% of injury deaths occur in low- and middle-income countries (LMICs). As patterns of injury in the pediatric population may differ from those in adults, risks specific to children in LMICs need to be identified for effective injury prevention and treatment. This study explores patterns of pediatric injury epidemiology and cost in Yaoundé, Cameroon to inform injury prevention and resource allocation. METHODS: Pediatric (age < 20 years) trauma patient data were collected at the emergency department (ED) of Central Hospital of Yaoundé (CHY) from April through October 2009. Univariate, bivariate, and multivariate analyses were used to explore injury patterns and relationships between variables. Regression analyses were conducted to identify predictors of receiving surgical care. RESULTS: Children comprised 19% (544) of trauma cases. About 54% suffered road traffic injuries (RTIs), which mostly affected the limbs and pelvis (37.3%). Half the RTI victims were pedestrians. Transportation to CHY was primarily by taxi or bus (69.4%) and a preponderance (71.1%) of the severely and profoundly injured patients used this method of transport. Major or minor surgical intervention was necessary for 17.9% and 20.8% of patients, respectively. Patients with an estimated injury severity score ≥ 9 (33.2%) were more likely to need surgery (p < 0.01). The median ED cost of pediatric trauma care was USD12.71 [IQR 12.71, 23.30]. CONCLUSIONS: Injury is an important child health problem that requires adequate attention and funding. Policies, surgical capacity building, and health systems strengthening efforts are necessary to address the high burden of pediatric injuries in Cameroon. Pediatric injury prevention efforts in Cameroon should target pedestrian RTIs, falls, and burns and consider school-based interventions.

Assessment of Blood Donation and Transfusion in Eastern Uganda: A Mixed-Methods Study.

BACKGROUND: Blood and blood products are essential in the management of injuries, medical illnesses, and childbirth. Chronic shortages in the blood supply perpetuates the high levels of morbidity and mortality from injury and treatable diseases. Patients in low- and middle-income countries are frequently unable to access blood units necessary for transfusion in a timely manner. OBJECTIVES: This study aimed to gain insight into the community and hospital factors that contribute to the observed insufficient supply of blood units available for transfusion at a regional referral hospital in rural Eastern Uganda. METHODS: A mixed-methods approach was utilized; community members were surveyed on knowledge, attitudes, and practices of blood donation and health professionals were queried on hospital factors affecting blood transfusions. Transfusion records were prospectively collected and analyzed, and the pathway of a single blood unit was observed and recorded. FINDINGS: Among the 82 community members that were surveyed, knowledge was poor (<50% correct) regarding age, weight, and volume of blood to be able to donate, but participants were overall knowledgeable on general characteristics that would exclude individuals from donating blood. Major themes elicited during qualitative interviews included a positive attitude towards and lack of information regarding blood donation. Health professionals expressed frustration in delayed testing of transfusion transmissible infections. The majority of blood transfusions were allocated to female patients (55.8%) and children under five years of age (33.2%). CONCLUSIONS: Broadened inclusion and education of the general population in blood donation and increased outreach programs may be promising interventions to increase the blood supply at the Soroti Regional Referral Hospital. To reduce the current bottleneck seen in TTI testing, the feasibility and cost-effectiveness of local TTI testing technology should be investigated further.

Identifying Information Gaps in a Surgical Capacity Assessment Tool for Developing Countries: A Methodological Triangulation Approach.

BACKGROUND: Surgical capacity assessment in low- and middle-income countries (LMICs) is challenging. The Surgeon OverSeas' Personnel Infrastructure Procedure Equipment and Supplies (PIPES) survey tool has been proposed to address this challenge. There is a need to examine the gaps in veracity and context appropriateness of the information obtained using the PIPES tool. METHODS: We performed a methodological triangulation by comparing and contrasting information obtained using the PIPES tool with information obtained simultaneously via three other methods: time and motion study (T&M); provider focus group discussions (FGDs); and a retrospective review of hospital records. RESULTS: In its native state, the PIPES survey does not capture the role of non-physician clinicians who contribute immensely to surgical care delivery in LMICs. The surgical workforce was more accurately captured by the FGDs and T&M. It may also not reflect the improvisations (e.g., patients sharing beds, partitioning the operating theater, and using preoperative rooms for surgery, etc.) that occur to expand surgical capacity to overcome the limited infrastructure and equipment. CONCLUSIONS: The PIPES tool captures vital surgical capacity information but has gaps that can be filled by modifying the tool and/or using ancillary methodologies. The interests of the researcher and the local stakeholders' perspectives should inform such modifications.

Outcome after internal fixation of intraarticular distal humerus (AO type B & C) fractures: Preliminary results with anatomical distal humerus LCP system.

PURPOSE: The treatment of intraarticular fractures of the distal humerus is challenging and involves the risk of complications and bad functional results. Anatomical and stable internal fixation with early postoperative mobilization is expected to improve the functional outcomes. The objective of this study was to evaluate the functional and radiological results, along with the complications associated, of open reduction and internal fixation using precontoured anatomical locking LCP plate system for intraarticular distal humerus fractures in adult patients. METHODS: This prospective study consist of 31 patients with a mean age of 41.2 years (range 19-62) were treated with open reduction and angular stable internal fixation. All underwent posterior transolecranon surgical approach. Mean follow-up to the final interview was 10 months (from 6 to 20 months). All operated patients were available at the time of last followup. AO classification showed 26 C-fractures (9*13C 1, 12*13C2,5* 13C3) and 5 B-fracture (1* 13B1,1* 13B2,3* 13B3). There were 25 closed fractures and 6 open grade 1 fractures. The clinical followup using Mayo elbow performance score (MEPS) and radiographic follow up with elbow anterior-posterior and lateral view X-rays were performed postoperatively. RESULTS: The mean MEPS was 87.9 points out of 100 (range 55-100) with 61% Excellent, 29% good and 10% fair and poor scores. Mean elbow flexion of 115.8° (range 85°-150°). The mean deficit in extension was 19° (range 5°-35°). All olecranon osteotomy were united .Nonunion of distal humerus fracture occurred in 2 cases. Other complications were hardware prominence in 3 cases, superficial infection in 4 cases and Ulnar nerve neuropraxia in 1 case which was recovered uneventfully. Revision surgery was not required in any complication. CONCLUSION: Open reduction and internal fixation with precontoured distal humerus anatomical locking plate system is a good method of treatment for complex Supra- intercondylar fracture of distal humerus with good functional outcome and low rates of complications. Even though early results are promising, longer term investigations and larger patient groups are necessary to confirm the presented data.