Laparoscopic cholecystectomy critical view of safety (LC-CVS): a multi-national validation study of an objective, procedure-specific assessment using video-based assessment (VBA).

BACKGROUND: A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were "poor-unsafe", "adequate-safe", or "excellent-safe". METHODS: A multi-national consortium of 12 expert LC surgeons applied the OPSA-LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet's AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of "poor-unsafe" vs. "adequate/excellent-safe". RESULTS: Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00. CONCLUSIONS: The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation.

Governance for injury care systems in Ghana, South Africa and Rwanda: development and pilot testing of an assessment tool.

OBJECTIVES: This study aims to evaluate health systems governance for injury care in three sub-Saharan countries from policymakers' and injury care providers' perspectives. SETTING: Ghana, Rwanda and South Africa. DESIGN: Based on Siddiqi et al's framework for governance, we developed an online assessment tool for health system governance for injury with 37 questions covering health policy and implementation under 10 overarching principles of strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness of institutions, equity, effectiveness or efficiency, accountability, ethics and intelligence and information. A literature review was also done to support the scoring. We derived scores using two methods-investigator scores and respondent scores. PARTICIPANTS: The tool was sent out to purposively selected stakeholders, including policymakers and injury care providers in Ghana, Rwanda and South Africa. Data were collected between October 2020 and February 2021. PRIMARY AND SECONDARY OUTCOMES: Investigator-weighted and respondent percentage scores for health system governance for injury care. This was calculated for each country in total and per principle. RESULTS: Rwanda had the highest overall investigator-weighted percentage score (70%), followed by South Africa (59%). Ghana had the lowest overall investigator score (48%). The overall results were similar for the respondent scores. Some areas, such as participation and consensus, scored high in all three countries, while other areas, such as transparency, scored very low. CONCLUSION: In this multicountry governance survey, we provide insight into and evaluation of health system governance for trauma in three low- and middle-income countries (LMICs) in sub-Saharan Africa. It highlights areas of improvement that need to be prioritised, such as transparency, to meet the high burden of trauma and injuries in LMICs.

Cost-Effectiveness Analysis of Inguinal Hernia Repair With Mesh Performed by Surgeons and Medical Doctors in Ghana.

OBJECTIVES: Task-sharing is the pragmatic sharing of tasks between providers with different levels of training. To our knowledge, no study has examined the cost-effectiveness of surgical task-sharing of hernia repair in a low-resource setting. This study has aimed to evaluate and compare the cost-effectiveness of mesh repair performed by Ghanaian surgeons and medical doctors (MDs) following a standardized training program. METHODS: This cost-effectiveness analysis included data for 223 operations on adult men with primary reducible inguinal hernia. Cost per surgery was calculated from the healthcare system perspective. Disability weights were calculated using pre- and postoperative pain scores and benchmarks from the Global Burden of Disease Study 2017. RESULTS: The mean cost/disability-adjusted life-year (DALY) averted in the surgeon group was 444.9 United States dollars (USD) (95% confidence interval [CI] 221.2-668.5) and 278.9 USD (95% CI 199.3-358.5) in the MD group (P = .168), indicating that the operation is very cost-effective when performed by both providers. The incremental cost/DALY averted showed that task-sharing with MDs is also very cost-effective (95% bootstrap CI -436.7 to 454.9). The analysis found that increasing provider salaries is cost-effective if productivity remains high. When only symptomatic cases were analyzed, the mean cost/DALY averted reduced to 232.0 USD (95% CI 17.1-446.8) for the surgeon group and 129.7 USD (95% CI 79.6-179.8) for the MD group (P = .348), and the incremental cost/DALY averted increased by 45% but remained robust. CONCLUSIONS: Elective inguinal hernia repair with mesh performed by Ghanaian surgeons and MDs is a low-cost procedure and very cost-effective in the context of the study. To maximize cost-effectiveness, symptomatic patients should be prioritized over asymptomatic patients and a high level of productivity should be maintained.

A Qualitative Exploration of Nutrition Screening, Assessment and Oral Support Used in Patients Undergoing Cancer Surgery in Low- and Middle-Income Countries.

Preoperative undernutrition is a prognostic indicator for postoperative mortality and morbidity. Evidence suggests that treating undernutrition can improve surgical outcomes. This study explored the provision of nutritional screening, assessment and support on surgical cancer wards in low- and middle-income countries (LMICs). This was a qualitative study and participants took part in one focus group or one individual interview. Data were analysed thematically. There were 34 participants from Ghana, India, the Philippines and Zambia: 24 healthcare professionals (HCPs) and 10 patients. Results showed that knowledge levels and enthusiasm were high in HCPs. Barriers to adequate nutritional support were a lack of provision of ward and kitchen equipment, food and sustainable nutritional supplements. There was variation across countries towards nutritional screening and assessment which seemed to be driven by resources. Many hospitals where resources were scarce focused on the care of individual patients in favour of an integrated systems approach to identify and manage undernutrition. In conclusion, there is scope to improve the efficiency of nutritional management of surgical cancer patients in LMICs through the integration of nutrition assessment and support into routine hospital policies and procedures, moving from case management undertaken by interested personnel to a system-based approach including the whole multidisciplinary team.

Economic evaluation of expanding inguinal hernia repair among adult males in Ghana.

An unmet need for inguinal hernia repair is significant in Ghana where the number of specialist general surgeons is extremely limited. While surgical task sharing with medical doctors without formal specialist training in surgery has been adopted for inguinal hernia repair in Ghana, no prior research has been conducted on the long-term costs and health outcomes associated with expanding operations to repair all inguinal hernias among adult males in Ghana. The study aimed to estimate cost-effectiveness of elective open mesh repair performed by medical doctors and surgeons for adult males with primary inguinal hernia compared to no treatment in Ghana and to project costs and health gains associated with expanding operation services through task sharing between medical doctors and surgeons. The study analysis adopted a healthcare system perspective. A Markov model was constructed to assess 10-year differences in costs and outcomes between operations conducted by medical doctors or surgeons and no treatment. A 10-year budget impact analysis on service expansion for groin hernia repair through increasing task sharing between the providers was conducted. Incremental cost-effectiveness ratios for medical doctors and surgeons were USD 120 and USD 129 respectively per disability-adjusted life year (DALY) averted compared to no treatment, which are below the estimated threshold value for cost-effectiveness in Ghana of USD 371-491. Repairing all inguinal hernias (1.4 million) through task sharing between the providers in the same timeframe is estimated to cost USD 194 million. Total health gains of 1.5 million DALYs averted are expected. Inguinal hernia repair is cost-effective regardless of the type of surgical provider. Scaling up of inguinal hernia repair is worthwhile, with the potential to substantially reduce the disease burden in the country.

The use of mesh for inguinal hernia repair in northern Ghana.

BACKGROUND: Despite the recognition that inguinal hernia (IH) repair is cost-effective, repair rates in low- and middle-income countries remain low. Estimated use of mesh in low- and middle-income countries also remains low despite publications about low-cost, noncommercial mesh. The purpose of our study was to assess the current state of IH repair in the northern and transitional zone of Ghana. MATERIALS AND METHODS: A retrospective review of surgical case logs of IH repairs from 2013 to 2017 in 41 hospitals was performed. Multivariate logistic regression was used to determine predictors of mesh use. RESULTS: Eight thousand eighty male patients underwent IH repair. The range of IH repair in each region was 96 to 295 (overall 123) per 100,000 population. Most cases were performed at district hospitals (84%) and repaired nonurgently (93%) by nonsurgeon physicians (66%). Suture repair was most common (85%) although mesh was used in 15%. The strongest predictor of mesh use was when a surgeon performed surgery (odds ratio [OR] 3.13, P <0.001), followed by surgery being performed in a teaching hospital (OR 2.31, P <0.001). Repair at a regional hospital was a negative predictor of mesh use (OR 0.08, P <0.001) as was the use of general anesthesia (OR 0.40, P = 0.001). CONCLUSIONS: Most IH repairs are performed in district hospitals, by nonsurgeon physicians, and without mesh. Rates of repair and the use of mesh are higher than previous estimates in Ghana and Sub-Saharan Africa but not as high as high-income countries.

Our Experience with the Use of Low Cost Mesh in Tension-Free Inguinal Hernioplasty in Northern Ghana.

OBJECTIVES: To describe our experience and success in the use of low cost mesh for the repair of inguinal hernias in consenting adult patients. METHODS: A prospective study was carried out from August 2010 to December 2013 in ten district hospitals across Northern Ghana. The patients were divided into four groups according to Kingsnorth's classification of hernias. Low cost mesh was used to repair uncomplicated groin hernia. Those hernias associated with complications were excluded. We assessed the patients for wound infection, long term incisional pain and recurrence of hernia. The data collected was entered, cleaned, validated and analyzed. RESULTS: One hundred and eighty-four patients had tension-free repair of their inguinal hernias using non-insecticide impregnated mosquito net mesh. The median age of the patients was 51 years. The male to female ratio was 7:1. Using Kingsnorth's classification, H3 hernias were (62, 33.7%), followed by the H1 group (56, 30.4%). Local anaesthesia was used in 70% and less than 5% had general anaesthesia. The cost of low cost mesh to each patient was calculated to be $ 1.8(GH¢7.2) vs $ 45(GH¢ 180) for commercial mesh of same size. The benefit to the patient and the facility was enormous. Wound hematoma was noticed in 7% while superficial surgical site infection was 3%. No patient reported of long term wound pain. There was no recurrence of hernia. CONCLUSION: Low cost mesh such as sterilized mosquito net mesh for use in hernioplasty in resource-limited settings is reasonable, acceptable and cost-effective, it should be widely propagated. FUNDING: None declared.

Assessment of the environmental risk factors for a gastric ulcer in northern Ghana.

Numerous risk factors have been implicated in the development of a gastric ulcer. Common risk factors are Helicobacter pylori infection, chronic non-steroidal anti-inflammatory intake, and alcohol consumption. The aim of the current study was to identify environmental risk factors for a gastric ulcer in northern Ghana. The data for this retrospective study were obtained from 2035 patient records from the Minimal Access Therapy and Operative Endoscopy unit of the Tamale Teaching Hospital in Tamale, Ghana from 2010 to 2014. A separate questionnaire was administered to assess the environmental risk factors. The rapid urease test was used to determine the presence of H. pylori. The Statistical Package for Social Sciences version 20.0 was used to analyse the data. Univariate and bivariate analyses were performed, and the results were presented in tables provided. The Chi-square values of the bivariate analysis were considered statistically significant when P < 0.05. Bivariate analysis revealed a strong association between gastric ulcer and various risk factors such as smoking (P = 0.001, χ2 = 27.3), fasting (P = 0.001, χ2 = 42.6), H. pylori infection (P = 0.01, χ2 = 19.9), and alcohol consumption (P = 0.001, χ2 = 30.6). There was no association between the traditional herbal preparation usage (P = 0.251, χ2 = 1.8) and the gastric ulcer. Environmental risk factors responsible for the development of a gastric ulcer in people of the northern part of Ghana show a similar pattern to other geographical regions of the world.

Assessing Trauma Care Capabilities of the Health Centers in Northern Ghana.

INTRODUCTION: Traffic-related injury is a major and increasing cause of global mortality, especially in low- and middle-income countries (LMICs). However, trauma systems, personnel, resources, and infrastructure are frequently insufficient to meet the needs of the population in this at-risk population in LMICs. In addition, these resources are not uniformly distributed, coordinated, nor well described within most countries. Trauma care resources have not previously been characterized in the Northern Region of Ghana. METHODS: We performed uniform site evaluations and interviews at 92 hospitals in Northern Ghana. Trauma systems, material resources, and human resources were quantified. Equipment was characterized as available in the Emergency Department (ED), in the hospital only, or unavailable. Hospitals were categorized as primary, district, or referral. RESULTS: Forty-two primary hospitals, 48 district hospitals, 3 regional hospitals, and 1 teaching hospital were surveyed. Over 95 % of hospitals reported having no training or systems for the care of injured patients. Substantial clinical equipment deficits were found at most primary hospitals. In over 90 % of these hospitals, the majority of circulation and monitoring, airway and breathing, and diagnostic imagining resources were not available. Equipment was also frequently unavailable at district and regional hospitals. When available, these resources were infrequently present in the ED. CONCLUSIONS: Although resources may be unavoidably constrained, there are substantial opportunities to improve the systematic management of trauma care and improve the education of the medical providers regarding care of injured patients in the region studied.