Testing telediagnostic obstetric ultrasound in Peru: a new horizon in expanding access to prenatal ultrasound.

BACKGROUND: Ninety-four percent of all maternal deaths occur in low- and middle-income countries, and the majority are preventable. Access to quality Obstetric ultrasound can identify some complications leading to maternal and neonatal/perinatal mortality or morbidity and may allow timely referral to higher-resource centers. However, there are significant global inequalities in access to imaging and many challenges to deploying ultrasound to rural areas. In this study, we tested a novel, innovative Obstetric telediagnostic ultrasound system in which the imaging acquisitions are obtained by an operator without prior ultrasound experience using simple scan protocols based only on external body landmarks and uploaded using low-bandwidth internet for asynchronous remote interpretation by an off-site specialist. METHODS: This is a single-center pilot study. A nurse and care technician underwent 8 h of training on the telediagnostic system. Subsequently, 126 patients (68 second trimester and 58 third trimester) were recruited at a health center in Lima, Peru and scanned by these ultrasound-naïve operators. The imaging acquisitions were uploaded by the telemedicine platform and interpreted remotely in the United States. Comparison of telediagnostic imaging was made to a concurrently performed standard of care ultrasound obtained and interpreted by an experienced attending radiologist. Cohen's Kappa was used to test agreement between categorical variables. Intraclass correlation and Bland-Altman plots were used to test agreement between continuous variables. RESULTS: Obstetric ultrasound telediagnosis showed excellent agreement with standard of care ultrasound allowing the identification of number of fetuses (100% agreement), fetal presentation (95.8% agreement, κ =0.78 (p < 0.0001)), placental location (85.6% agreement, κ =0.74 (p < 0.0001)), and assessment of normal/abnormal amniotic fluid volume (99.2% agreement) with sensitivity and specificity > 95% for all variables. Intraclass correlation was good or excellent for all fetal biometric measurements (0.81-0.95). The majority (88.5%) of second trimester ultrasound exam biometry measurements produced dating within 14 days of standard of care ultrasound. CONCLUSION: This Obstetric ultrasound telediagnostic system is a promising means to increase access to diagnostic Obstetric ultrasound in low-resource settings. The telediagnostic system demonstrated excellent agreement with standard of care ultrasound. Fetal biometric measurements were acceptable for use in the detection of gross discrepancies in fetal size requiring further follow up.

"From the technology came the idea": safe implementation and operation of a high quality teleradiology model increasing access to timely breast cancer assessment services for women in rural Australia.

Breast cancer is the most commonly diagnosed cancer in Australian women. Providing timely diagnostic assessment services for screen-detected abnormalities is a core quality indicator of the population-based screening program provided by BreastScreen Australia. However, a shortage of local and locum radiologists with availability and appropriate experience in breast work to attend onsite assessment clinics, limits capacity of services to offer assessment appointments to women in some regional centres. In response to identified need, local service staff developed the remote radiology assessment model for service delivery. This study investigated important factors for establishing the model, the challenges and enablers of successful implementation and operation of the model, and factors important in the provision of a model considered safe and acceptable by service providers. METHODS: Semi-structured interviews were conducted with service providers at four assessment services, across three jurisdictions in Australia. Service providers involved in implementation and operation of the model at the service and jurisdictional level were invited to participate. A social constructivist approach informed the analysis. Deductive analysis was initially undertaken, using the interview questions as a classifying framework. Subsequently, inductive thematic analysis was employed by the research team. Together, the coding team aggregated the codes into overarching themes. RESULTS: 55 service providers participated in interviews. Consistently reported enablers for the safe implementation and operation of a remote radiology assessment clinic included: clinical governance support; ability to adapt; strong teamwork, trust and communication; and, adequate technical support and equipment. Challenges mostly related to technology and internet (speed/bandwidth), and maintenance of relationships within the group. CONCLUSIONS: Understanding the key factors for supporting innovation, and implementing new and safe models of service delivery that incorporate telemedicine, will become increasingly important as technology evolves and becomes more accessible. It is possible to take proposed telemedicine solutions initiated by frontline workers and operationalise them safely and successfully: (i) through strong collaborative relationships that are inclusive of key experts; (ii) with clear guidance from overarching bodies with some flexibility for adapting to local contexts; (iii) through establishment of robust teamwork, trust and communication; and, (iv) with appropriate equipment and technical support.

Mental Health Care for Rural and Remote Australians During the Coronavirus Disease 2019 Pandemic.

The aims of this article are to comment on pre-coronavirus disease 2019 (COVID-19) mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions. The COVID-19 pandemic has resulted in significant air medical activity from rural and remote Australia. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries.

General surgery in Canada: current scope of practice and future needs.

BACKGROUND: The scope of practice of general surgeons in Canada is highly variable. The objective of this study was to examine the demographic characteristics of general surgeons in Canada and compare surgical procedures performed across community sizes and specialties. METHODS: Data from the Canadian Institute for Health Information's National Physician Database were used to analyze fee-for-service (FFS) care provided by general surgeons and other providers across Canada in 2015/16. RESULTS: Across 8 Canadian provinces, 1669 general surgeons provided FFS care. The majority of the surgeons worked in communities with more than 100 000 residents (71%), were male (78%), were aged 35-54 years (56%) and were Canadian medical graduates (76%). Only 7% of general surgeons practised in rural areas and 14% in communities with between 10 000 and 50 000 residents. Rural communities were significantly more likely to have surgeons who were international medical graduates or who were older than 65 years. The surgical procedures most commonly performed by general surgeons were hernia repairs, gallbladder and biliary tree surgery, excision of skin tumours, colon and intestine resections and breast surgery. Many general surgeons performed procedures not listed in their Royal College of Physicians and Surgeons of Canada training objectives. CONCLUSION: Canadian general surgeons provide a wide array of surgical services, and practice patterns vary by community size. Surgeons practising in rural and small communities require proficiency in skills not routinely taught in general surgery residency. Opportunities to acquire these skills should be available in training to prepare surgeons to meet the care needs of Canadians.

CONTEXTE: La pratique des chirurgiens généralistes au Canada varie grandement. Cette étude visait à examiner les caractéristiques démographiques des chirurgiens généralistes au Canada et à comparer les interventions réalisées selon la spécialité et la taille des collectivités. MÉTHODES: Des données de la Base de données nationale sur les médecins de l'Institut canadien d'information sur la santé ont été utilisées pour analyser les soins rémunérés à l'acte dispensés par des chirurgiens généralistes et d'autres fournisseurs de soins au Canada en 2015­2016. RÉSULTATS: Dans 8 provinces canadiennes, 1669 chirurgiens généralistes ont fourni des soins rémunérés à l'acte. La majorité d'entre eux travaillaient dans des collectivités de plus de 100 000 résidents (71 %), étaient des hommes (78 %), avaient entre 35 et 54 ans (56 %) et avaient obtenu leur diplôme de médecine au Canada (76 %). Seuls 7 % des chirurgiens généralistes travaillaient en région rurale et 14 %, dans des collectivités comptant entre 10 000 et 50 000 résidents. En région rurale, la probabilité que les chirurgiens soient des diplômés internationaux en médecine ou aient plus de 65 ans était significativement plus élevée. Les interventions les plus fréquentes étaient la réparation d'une hernie, la chirurgie de la vésicule biliaire et des voies biliaires, le retrait de tumeurs de la peau, la résection du côlon ou de l'intestin et la chirurgie mammaire. De nombreux chirurgiens généralistes ont réalisé des procédures ne faisant pas partie des objectifs de formation du Collège royal des médecins et chirurgiens du Canada. CONCLUSION: Les chirurgiens généralistes canadiens réalisent une large gamme d'interventions chirurgicales et leur pratique varie selon la taille de la collectivité dans laquelle ils travaillent. Les chirurgiens exerçant en milieu rural et dans les petites collectivités doivent avoir des compétences qui ne sont habituellement pas enseignées durant la résidence en chirurgie générale. La formation devrait intégrer des occasions d'acquérir ces compétences pour préparer les chirurgiens à répondre aux besoins en matière de soins des Canadiens.

Transcatheter Aortic Valve Replacement in Low-Population Density Areas: Assessing Healthcare Access for Older Adults With Severe Aortic Stenosis.

BACKGROUND: Restricting transcatheter aortic valve replacement (TAVR) to centers based on volume thresholds alone can potentially create unintended disparities in healthcare access. We aimed to compare the influence of population density in state of Florida in regard to access to TAVR, TAVR utilization rates, and in-hospital mortality. METHODS AND RESULTS: From 2011 to 2016, we used data from the Agency for Health Care Administration to calculate travel time and distance for each TAVR patient by comparing their home address to their TAVR facility ZIP code. Travel time and distance, TAVR rates, and mortality were compared across categories of low to high population density (population per square miles of land). Of the 6531 patients included, the mean (SD) age was 82 (9) years, 43% were female and 91% were White. Patients residing in the lowest category (<50/square miles) were younger, more likely to be men, and less likely to be a racial minority. Those residing in the lowest category density faced a longer unadjusted driving distances and times to their TAVR center (mean extra distance [miles]=43.5 [95% CI, 35.6-51.4]; P<0.001; mean extra time (minutes)=45.6 [95% CI, 38.3-52.9], P<0.001). This association persisted regardless of the methods used to determine population density. Excluding uninhabitable land, there was a 7-fold difference in TAVR utilization rates in the lowest versus highest population density regions (7 versus 45 per 100 000, P-for-pairwise-comparisons <0.001) and increase in TAVR in-hospital mortality (adjusted OR, 6.13 [95% CI, 1.97-19.1]; P<0.001). CONCLUSIONS: Older patients living in rural counties in Florida face (1) significantly longer travel distances and times for TAVR, (2) lower TAVR utilization rates, and (3) higher adjusted TAVR mortality. These findings suggest that there are trade-offs between access to TAVR, its rate of utilization, and procedural mortality, all of which are important considerations when defining institutional and operator requirements for TAVR across the country.

A Model for Assessing Necessary Conditions for Rural Health Care's Mobile Health Readiness: Qualitative Assessment of Clinician-Perceived Barriers.

BACKGROUND: Mobile health (mHealth) technology dissemination has penetrated rural and urban areas alike. Yet, health care organization oversight and clinician adoption have not kept pace with patient use. mHealth could have a unique impact on health and quality of life for rural populations. If organizations are prepared to manage mHealth, clinicians may improve the quality of care for their patients, both rural and urban. However, many organizations are not yet prepared to prescribe or prohibit third-party mHealth technologies. OBJECTIVE: This study explored organizational readiness for rural mHealth adoption, the use of patient-reported data by clinical care teams, and potential impact on improving rural health care delivery. METHODS: Semistructured, open-ended interviews were used to investigate clinicians' current practices, motivators, and perceived barriers to their use of mHealth technologies in rural settings. RESULTS: A total of 13 clinicians were interviewed, and 53.8% (7/13) reported encouraging use of mHealth apps or wearable devices with rural patients. Perceived barriers to adoption were categorized into three primary themes: (1) personal (clinician), (2) patient, and (3) organizational. Organizational was most prominent, with subcodes of time, uniformity, and policy or direction. Thematic analysis revealed code-category linkages that identify the complex nature of a rural health care organization's current climate from a clinician's perspective. A thematic map was developed to visualize the flow from category to code. Identified linkages guided the development of a refined rural mHealth readiness model. CONCLUSIONS: Clinicians (including physicians) have limited time for continuing education, research, or exploration of emerging technologies. Clinicians are motivated to learn more, but they need guidance through organization-led directives. Rural health care institutions should consider investing in mHealth analysis, tool development, and formal recommendations of sanctioned tools for clinicians to use with patients.

Expectations of telemedicine health service adoption in rural Bangladesh.

This study analyzes the antecedent factors that influence patients' expectations of telemedicine adoption in centres hosted by rural public hospitals in Bangladesh. It examines five antecedents of patients' expectations of telemedicine adoption-self-efficacy, telemedicine experience, knowledge, enjoyment, and prior satisfaction. A conceptual research model was formulated, encompassing a set of hypotheses that were developed and tested by employing partial least squares structural equation modelling. Using a structured survey questionnaire, a cross-sectional survey was conducted among 500 telemedicine users in different rural areas in Bangladesh. Except knowledge, four antecedents significantly contribute to patients' expectations of telemedicine health service adoption explaining 66% of the variance (R2) in expectations. These findings provide support for explaining antecedents to the formation of patients' expectations of telemedicine adoption and the institutionalisation of favourable policy guidelines as an early guidance for the development of successful healthcare industries in Bangladesh and other similar settings. Specific policy interventions and recommendations are provided, including current research limitations leading to opportunities for future research.

The daily routine of nurses in rural areas in the Family Health Strategy.

OBJECTIVE: to analyze the daily work of rural Family Health Strategy (FHS) nurses. METHOD: a qualitative, descriptive and exploratory research. The data were collected with eleven rural nurses of the city of Campina Grande, Paraíba State, through semi-structured interviews, between January and March of 2017, using Content Analysis. RESULTS: rural nurses have a strong relationship with the population. However, they reveal a daily work with various organizational barriers that range from the team displacement to the workplace to the operationalization of health actions, which are mediated by the characteristics of rurality. Some of these barriers can be remedied by a more proactive action from the management. FINAL CONSIDERATIONS: conditioned by the characteristics of rurality, the differentiated dynamics work reveal weaknesses in the quality of nursing care and lower effectiveness of the FHS.

The daily routine of nurses in rural areas in the Family Health Strategy / El cotidiano de enfermeros en áreas rurales en la Estrategia Salud de la Familia / O cotidiano de enfermeiros em áreas rurais na estratégia saúde da família

ABSTRACT Objective: to analyze the daily work of rural Family Health Strategy (FHS) nurses. Method: a qualitative, descriptive and exploratory research. The data were collected with eleven rural nurses of the city of Campina Grande, Paraíba State, through semi-structured interviews, between January and March of 2017, using Content Analysis. Results: rural nurses have a strong relationship with the population. However, they reveal a daily work with various organizational barriers that range from the team displacement to the workplace to the operationalization of health actions, which are mediated by the characteristics of rurality. Some of these barriers can be remedied by a more proactive action from the management. Final considerations: conditioned by the characteristics of rurality, the differentiated dynamics work reveal weaknesses in the quality of nursing care and lower effectiveness of the FHS.

RESUMEN Objetivo: analizar el cotidiano de trabajo de enfermeros de la Estrategia Salud de la Familia (ESF) que actúan en áreas rurales. Método: investigación cualitativa, descriptiva-exploratoria. Los datos fueron recolectados con once enfermeros del área rural del municipio de Campina Grande-PB, a través de entrevistas semiestructuradas, entre enero y marzo de 2017, con análisis a partir del Análisis de Contenido. Resultados: los enfermeros de las áreas rurales tienen relación de vínculo intensa con la población. Sin embargo, revelan un cotidiano de trabajo con varias barreras organizacionales que van desde el desplazamiento del equipo al lugar de trabajo a la operacionalización de las acciones de salud, siendo estas mediadas por las características de la ruralidad. Algunas de esas barreras pueden ser sanadas por la acción más propositiva de la gestión. Consideraciones finales: la dinámica de trabajo diferenciada, condicionada por las características propias de la ruralidad, revelan fragilidades en la calidad de la asistencia de enfermería y menor efectividad de la ESF.

RESUMO Objetivo: analisar o cotidiano de trabalho de enfermeiros da Estratégia Saúde da Família (ESF) que atuam em áreas rurais. Método: pesquisa qualitativa, descritiva-exploratória. Os dados foram coletados com onze enfermeiros da área rural do município de Campina Grande-PB, por meio de entrevistas semiestruturadas, entre janeiro e março de 2017, com análise a partir da técnica de Análise de Conteúdo. Resultados: os enfermeiros das áreas rurais têm relação de vínculo intensa com a população, no entanto, revelam um cotidiano de trabalho com várias barreiras organizacionais que vão desde o deslocamento da equipe ao local de trabalho à operacionalização das ações de saúde, sendo essas mediadas pelas características da ruralidade. Algumas dessas barreiras podem ser sanadas pela ação mais propositiva da gestão. Considerações finais: a dinâmica de trabalho diferenciada, condicionada pelas características próprias da ruralidade, revelam fragilidades na qualidade da assistência de enfermagem e menor efetividade da ESF.

Facility management associated with improved primary health care outcomes in Ghana.

BACKGROUND: Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. METHODS: We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes. FINDINGS: On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68-0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes-integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider's advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039). INTERPRETATION: Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes.

Factors related to rural general practitioners supervising general practice registrars in Australia: A national cross-sectional study.

BACKGROUND AND OBJECTIVES: General practice training in Australia is uniquely structured to allow half of all registrars to train in rural areas, in order to increase rural workforce development and access to rural primary care. There is, however, limited national-scale information about rural general practice supervisors who underpin the capacity for rural general practice training. The objective of this research was to explore the factors related to rural general practitioners (GPs) supervising general practice registrars. METHOD: Results were obtained using multivariate analysis of the 2016 Medicine in Australia: Balancing Employment and Life survey data. RESULTS: Overall, 57.8% of rural GPs were supervising registrars. Supervising was strongly related to being Australian-trained, working in a larger practice, and supervising medical students and interns. DISCUSSION: Rural supervising capacity could be increased through supporting GPs in smaller practices to engage in supervision and maintaining the strong involvement of GPs in larger practices. Other important factors may include a greater number of Australian-trained graduates working in rural general practice and increased support for international medical graduates to Fellow and feel confident to supervise.

Increased access to nurse practitioner care in rural Nebraska after removal of required integrated practice agreement.

Nebraska is a largely rural state with many communities defined as medically underserved by primary care providers. In 2014, the state legislature voted to eliminate the requirement for an integrated practice agreement (IPA) between nurse practitioners (NPs) and physicians. This report describes changes in access to primary health care in rural and underserved areas of Nebraska after removal of the IPA barrier to practice. The report compares the number of primary care NPs working in medically underserved areas before and after the legislation that ended the required IPA. In addition, anecdotes will be provided of NP and patient experiences in rural, NP-owned practices in Nebraska after IPA requirements were eliminated.

An Argument Against Cross-Platform Development: Lessons From an Augmented Reality App Prototype for Rural Emergency Responders.

BACKGROUND: Mobile augmented reality (MAR) apps offer potential support for emergency responders in rural areas. OBJECTIVE: In this report, we described lessons learned from the development process of augmented reality (AR) Farm Mapping to Assist, Protect and Prepare Emergency Responders (MAPPER), a MAR app that provides emergency responders onsite information about the agricultural operation they enter. METHODS: Cross-platform frameworks were used to create AR MAPPER to accommodate budget constraints and overcome issues with markerless MAR technologies. Although the single codebase and Web technologies streamlined development, cross-device hardware limitations impacted location accuracy, lengthened the development cycle, and required regular updates to third-party libraries. RESULTS: A hybrid development approach of using Web-based technologies with native tie-ins for specialized components and enhanced performance cut time and costs. This also led to consistency across multiple platforms and ensured that there is only a single set of source files to modify for Android and iPhone operating systems. Meanwhile, active development was delayed by some major hurdles. Apple and Google both released new versions of their operating systems, and the Wikitude framework issued four major updates, each of which brought with it some important enhancements and also led to some new issues. CONCLUSIONS: Developers should consider single platform native development to benefit from platform-specific MAR implementations and to avoid development, testing, and maintenance costs associated with cross-platform implementation. Emergency response organizations may be more likely to utilize a single platform across the devices used by their command staff. This also reduces the benefits of cross-platform development. Furthermore, providing map-based, non-AR cross-platform apps for landowners, farmers, and ranchers would help improve and maintain data quality, which is crucial for the utility and user experience of MAR apps.

Avaliação do Programa Mais Médicos: relato de experiência / Evaluation of the More Doctors Program: experience report

RESUMO O acesso à saúde de forma universal e equitativa está preconizado na Constituição Federal de 1988, devendo ser garantida pelo Sistema Único de Saúde (SUS). Dentre os diversos fatores que contribuem para a não efetivação dos princípios do SUS, destacam-se a insuficiência de profissionais e as disparidades regionais na distribuição de recursos humanos, principalmente médicos. Este artigo relata a experiência de avaliação do Programa Mais Médicos (PMM) por uma equipe multidisciplinar composta por 28 pesquisadores, a partir de trabalho de campo em 32 municípios com 20% ou mais da população em extrema pobreza selecionados em todas as regiões do Brasil (áreas remotas, distantes das capitais e comunidades quilombolas rurais), além de análises sobre os 5.570 municípios brasileiros baseadas em bancos de dados do Ministério da Saúde. A pesquisa resultou em vasta produção científica, apontando importantes resultados, como ampliação do acesso à saúde e redução de internações evitáveis. As reflexões aqui trazidas permitem concluir que o PMM contribuiu para a efetivação e consolidação dos princípios e diretrizes do SUS e garantiu acesso à saúde, especialmente para as populações mais pobres, municípios pequenos e regiões remotas e longínquas.

ABSTRACT The universal and equitable access to health is established in the Brazilian Federal Constitution of 1988 and must be guaranteed by the Brazilian Unified Health System - the Sistema Único de Saúde (SUS). The lack of professionals and the large regional differences in the distribution of human resources, mainly physicians, are factors that contribute to the non-fulfillment of the SUS principles. This article reports the experience of evaluation of the More Doctors Program (PMM) by a multidisciplinary team composed of 28 researchers, based on field work in 32 municipalities with 20% or more of the population in extreme poverty selected in all regions of Brazil (remote areas, far from capitals, and rural maroon communities), as well as analyzes of the 5,570 Brazilian municipalities based on the Ministry of Health databases. The research resulted in a vast scientific production, pointing out important results, such as broadening of access to health and reducing of avoidable hospitalizations. The reflections brought here show that the PMM contributed to the implementation and consolidation of the SUS principles and guidelines, and guaranteed access to health, especially for the poorest populations, small municipalities and remote and distant regions.

The Impact of Increasing Surgical Capacity at a Tertiary Hospital in Southern Haiti.

BACKGROUND: St. Boniface Hospital (SBH) plays a critical role in providing safe, accessible surgery in rural southern Haiti. We examine the impact of SBH increasing surgical capacity on case volume, patient complexity, and inpatient mortality across three phases. MATERIALS AND METHODS: A retrospective review and geospatial analysis of all surgical cases performed at SBH between 2015 and 2017 were performed. Inpatient mortality was defined by in-hospital deaths divided by the number of procedures performed. RESULTS: Between February 2015 and August 2017, over 2000 procedures were performed. The average number of surgeries per week was 3.1 with visiting surgical teams in phase 1 (P1), 10.4 with a single general surgeon in phase 2 (P2), and 20.1 with two surgeons and a resident in phase 3 (P3). There was a six-fold increase in surgical volume between P1 and P3 and a significant increase in case complexity. The distribution of American Society of Anesthesiologists scores of 1, 2, 3, and 4 during P2 was 81.05%, 14.74%, 3.42%, and 0.79%, respectively, whereas in P3, the distribution was 68.91%, 22.55%, 7.70%, and 0.84%. Surgical mortality was 0%, 1.2%, and 1.67% across phases. CONCLUSIONS: Increasing resources and surgical staff at SBH allowed for greater delivery of safe surgical care. This study highlights that investing in surgery has a significant impact in regions of great surgical need.

The Lancet Commission on Global Surgery - Association of Rural Surgeons of India Karad Consensus Statement on Surgical System Strengthening in Rural India.

In India, 90% of the rural population is estimated to lack access to safe, affordable, and timely surgical care. Surgical care in these settings is often characterized by limited resources. Provision of rural surgical care often requires novel approaches as compared to those in higher income urban sectors, specifically in areas of infrastructure, workforce, and blood. This consensus statement draws upon the wealth of experience held by India's rural surgeons to identify key problems and lay forth actionable solutions in the areas of surgical infrastructure, workforce, and blood supply.

Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide.

BACKGROUND AND AIMS: The use of anesthesia assistance (AA) for outpatient colonoscopy has been increasing over the past decade, raising concern over its effects on procedure safety, quality, and cost. We performed a nationwide claims-based study to determine regional, patient-related, and facility-related patterns of anesthesia use as well as cost implications of AA for payers. METHODS: We analyzed the Premier Perspective database to identify patients undergoing outpatient colonoscopy at over 600 acute-care hospitals throughout the United States from 2006 through 2015, with or without AA. We used multivariable analysis to identify factors associated with AA and cost. RESULTS: We identified 4,623,218 patients who underwent outpatient colonoscopy. Of these, 1,671,755 (36.2%) had AA; the proportion increased from 16.7% in 2006 to 58.1% in 2015 (P < .001). Factors associated with AA included younger age (odds ratios [ORs], compared to patients 18-39 years old: 0.94, 0.82, 0.77, 0.72, and 0.77 for age groups 40-49 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years, respectively); and female sex (OR, 0.96 for male patients compared to female patients; 95% CI, 0.95-0.96). Black patients were less likely to receive AA than white patients (OR, 0.81; 95% CI, 0.81-0.82), although this difference decreased with time. The median cost of outpatient colonoscopy with AA was higher among all payers, ranging from $182.43 (95% CI, $180.80-$184.06) higher for patients with commercial insurance to $232.62 (95% CI, $222.58-$242.67) higher for uninsured patients. CONCLUSIONS: In an analysis of a database of patients undergoing outpatient colonoscopy throughout the United States, we found that the use of AA during outpatient colonoscopy increased significantly from 2006 through 2015, associated with increased cost for all payers. The increase in anesthesia use mandates evaluation of its safety and effectiveness in colorectal cancer screening programs.