Cost Analysis of the Mongolian ATLS© Program: A Framework for Low- and Middle-Income Countries.

BACKGROUND: Trauma is the leading cause of death among Mongolians aged 24-44. To improve initial management of injured patients, the Mongolian National University of Medical Sciences (MNUMS) implemented the American College of Surgeons' (ACS) Advanced Trauma Life Support (ATLS) training program in 2015. Cost analysis demonstrates that such programs can have clear pathways to self-sufficiency. METHODS: Costs associated with an ACS Mongolian ATLS program were quantified based on discussions with the Mongolian government, MNUMS, ATLS Australasia headquarters, and existing pricing data. Costs were then classified as either essential or contingencies. These classifications determined budgetary items for each program. Savings projections for contingencies included training Mongolian instructors and educators. Scenarios for funding the budget were then assessed. RESULTS: The minimum annual cost of ATLS in Mongolia, which includes 3 ATLS student courses/1 instructor course, is $10,709. A budget of $19,900 includes additional contingencies. The scenario that involves foreign instructors is the most expensive one. An initial investment of $85,000 to train Mongolian instructors reduces annual costs by $48,305 (71% reduction). An investment of $4050 to train a Mongolian educator will reduce costs by $1750 annually. ATLS can be sustained with 0.04% of Mongolia's current spending on public health and preventative services. CONCLUSIONS: Initial investment to train Mongolian ATLS instructors leads to substantial savings. Training a Mongolian educator lowers long-term costs. When minimum costs for ATLS courses are understood, these can be scaled up and supported with different contingencies and minimal funding by government or third-party stakeholders.

Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery.

OBJECTIVES: To inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country's ability to collect the indicators aided by a well-developed health information system. DESIGN: An 11-year retrospective analysis of the Mongolian surgical system using data from the Health Development Center, National Statistics Office and Household Socio-Economic Survey. Access estimates were based on travel time to capable hospitals. Provider density, surgical volume and postoperative mortality were calculated at national and regional levels. Protection against impoverishing and catastrophic expenditures was assessed against standard out-of-pocket expenditure at government hospitals for individual operations. SETTING: Mongolia's 81 public hospitals with surgical capability, including tertiary, secondary and primary/secondary facilities. PARTICIPANTS: All operative patients in Mongolia's public hospitals, 2006-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were national-level results of the indicators. Secondary outcomes include regional access; surgeons, anaesthesiologists and obstetricians (SAO) density; surgical volume; and perioperative mortality. RESULTS: In 2016, 80.1% of the population had 2-hour access to essential surgery, including 60% of those outside the capital. SAO density was 47.4/100 000 population. A coding change increased surgical volume to 5784/100 000 population, and in-hospital mortality decreased from 0.27% to 0.14%. All households were financially protected from caesarean section. Appendectomy carried 99.4% and 98.4% protection, external femur fixation carried 75.4% and 50.7% protection from impoverishing and catastrophic expenditures, respectively. Laparoscopic cholecystectomy carried 42.9% protection from both. CONCLUSIONS: Mongolia meets national benchmarks for access, provider density, surgical volume and postoperative mortality with notable limitations. Significant disparities exist between regions. Unequal access may be efficiently addressed by strengthening or building key district hospitals in population-dense areas. Increased financial protections are needed for operations involving hardware or technology. Ongoing monitoring and evaluation will support the development of context-specific interventions to improve surgical care in Mongolia.

Inferior vena cava stenosis-induced sinusoidal obstructive syndrome after living donor liver transplantation.

The sinusoidal obstructive syndrome (SOS) is a complication that usually follows hematopoietic stem cell transplantation. It is also known as veno-occlusive disease, which is a rare complication of living donor liver transplantation (LDLT). Herein, we reported a 34 year-old female patient presenting SOS after LDLT. Its underlying cause was presumed to be associated with liver abscess and subsequent inferior vena cava stenosis. SOS led to graft failure, thus requiring retransplantation with a deceased donor liver graft. The underlying causes of SOS are complex pathologic entity with multifactorial etiology. It is likely that its multifactorial etiology includes a decrease of hepatic venous outflow that is caused by graft liver infection and inferior vena cava stenosis.