Unmet Surgical Needs and Trust Deficit in Marginalized Communities in India: A Comparative Cross-Sectional Survey.

INTRODUCTION: We carried out a household study of surgical unmet needs and trust in the physician and perception of quality in the health system in a rural Tribal area and an urban slum in India. METHODS: A community-based, cross-sectional study was carried out in a Tribal and in an urban slum in Gujarat, India. We surveyed 7914 people in 2066 households in urban slum and 5180 people of 1036 households in rural Tribal area. The Surgeons Overseas Assessment of Surgical need was used to identify surgical met and unmet needs. Two instruments for trust deficit 'the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting' and 'Patient perceptions of quality' were also administered to understand perception about healthcare. Frequencies and proportions (categorical variable) summarized utilization of surgical services and surgical needs. P < 0.05 was statistically significant. RESULTS: Slums and Tribal areas were significantly different in sociodemographic indicators. Unmet surgical needs in Tribal area were less than 5% versus 39% in the urban slum. Major need of surgery in Tribal area was for eye conditions in older population, while surgical conditions in extremities and abdomen were predominant in the urban area. Trust level was high for physicians in both areas. CONCLUSIONS: Surgical unmet needs were significantly lower in Tribal versus urban area, possibly due to high priority given by the Indian government to alleviate poverty, social deprivation and participation of NGOs. Our study will give impetus to study unmet surgical needs and formulation of health policies in India and low-and-middle- income countries.

Global health diplomacy: Provision of specialist medical services in the Republic of Botswana.

Global Health Diplomacy (GHD) can be defined as the convergence between public health and international affairs. The following case report demonstrates the impact of "brain drain" on provision of specialist medical services in Botswana, a middle-income country in Southern Africa and how GHD is being used to address the challenge. Botswana's priorities include the attainment of Sustainable Development Goals (SDGs) by 2030 which are embedded within the Ministry of Health and Wellness (MOHW) strategy. MOHW strategies include access to health services, reduction in the cost of referral of specialist services, and strengthening primary health care (PHC), which is the vehicle for attaining Universal Health Coverage (UHC). Botswana has, in the past tried to bridge this gap through strategic partnerships with private institutions and bilateral treaties with other states such as the Republic of Cuba and the People's Republic of China. In the private sector, the Ministry has partnered with Indus Medical Group, and a range of private medical institutions both in-country and outside the country. However, challenges experienced with previous partnerships were that the objectives were more service-driven than capacity building, which proved to be unsustainable. The case report outlines the negotiation process between the Government of Botswana represented by MOHW, and St. Paul Medical Missions, a religion-based NGO from Egypt. It demonstrated the importance of all actors and countries being clear on their health priorities at the start of negotiations. GHD is a relatively new concept that can be explored by countries in forming durable partnerships.

Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study.

INTRODUCTION: We investigated the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India. METHODS: A community-based cross-sectional study was carried out from August to December 2019. Inclusion criteria was age > 14 years; any type of injury/condition that requires surgery; subject has had surgery in last 1 year, and death information of family members. Data were stored and coded in Microsoft excel and exported to IBM SPSS statistics version 25 software for data analysis. Frequencies and proportions (categorical variable) are used to summarize utilization of surgical services and understanding surgical need. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the "Tablet" to collect information and stress-free workflow in field. RESULTS: Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% (n = 274) people needed surgery; 116 did not avail surgery and were categorized in "unmet need." Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care. CONCLUSIONS AND RELEVANCE: Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city. We propose creation of community healthcare workers focused on surgical conditions.

Kidney Transplantation in HIV-Positive Patients: A Single-Center, 16-Year Experience.

Hahnemann University Hospital has performed 120 kidney transplantations in human immunodeficiency virus (HIV)-positive individuals during the last 16 years. Our patient population represents ∼10% of the entire US population of HIV-positive kidney recipients. In our earlier years of HIV transplantation, we noted increased rejection rates, often leading to graft failure. We have established a multidisciplinary team and over the years have made substantial protocol modifications based on lessons learned. These modifications affected our approach to candidate evaluation, donor selection, perioperative immunosuppression, and posttransplantation monitoring and resulted in excellent posttransplantation outcomes, including 100% patient and graft survival at 1 year and patient and graft survival at 3 years of 100% and 96%, respectively. We present key clinical data, including a granular patient-level analysis of the associations of antiretroviral therapy regimens with long-term survival, cellular and antibody-mediated rejection rates, and the causes of allograft failures. In summary, we provide details on the evolution of our approach to HIV transplantation during the last 16 years, including strategies that may improve outcomes among HIV-positive kidney transplantation candidates throughout the United States.

Developing a Sustainable Renal Transplant Program in Low- and Middle-Income Countries: Outcome, Challenges, and Solutions.

INTRODUCTION: The initiation of a kidney transplant program, in a low- and middle-income country, while striving to maintain excellent outcomes and adhere to high ethical, legal standards, is a formidable task. Herein, we review the outcomes and challenges of a living donor kidney transplant program from its inception to sustainability, in Guyana, South America. METHODS: This is a retrospective review of a living donor kidney transplant program instituted in Guyana in 2008. Data included recipient and donor demographics, cause of renal failure, donor-recipient matching and relationship, perioperative complications, timing and cause of death, graft failure, surgical technique, and laterality of organ procured. Patient and donor data were compared by phases and additionally compared to United States Renal Data Base System. Survival outcomes were compared by phases and by Kaplan-Meier curves. RESULTS: To date, 45 kidney transplants have been completed. Phase I (2007-2008) was the initiation of the program, which was comprised of upgrading hospital and operating rooms, obtaining antirejection medications, educating local providers, fostering a relationship with the government, and screening patients and living donors. We also began vascular access and peritoneal dialysis in the country, as well as introduced the companion public health service initiative: the SEVAK program. Phase II (2008-2014) involved completion of 25 living donor kidney transplants, of which there have been 11 confirmed deaths and 10 lost to follow-up. In Phase III (2015-present), 20 transplants have been completed to date, of whom only 1 died and none were lost to follow-up. In the third phase, we also introduced corneal transplantation to Guyana and have performed over 100 transplants. CONCLUSION: Kidney transplantation can be safely and ethically performed in a low- and middle-income country. We applied lessons learnt from the first two phases to improve follow-up by appointing a local coordinator who goes to patient's homes in remote villages. Currently, there is a stable local team that is performing transplants and following the patients. We believe that our model of public-private partnership can sustain kidney, as well as corneal, transplantation and could be replicated in other countries.

Microeconomic Benefit of Corneal Transplantation in a Developing Country via Public-Private Partnership Model.

BACKGROUND: We measured the microeconomic benefit, QOL, DALYs averted and clinical outcomes of corneal transplant surgery via a public-private partnership in Guyana. Corneas were obtained, ex gratia, from US eye banks, and the work was done at no cost to the patient or the Governments of USA or Guyana. METHODS: We obtained qualitative data using a "semi-structured interview technique" to question 60 recent recipients of corneal transplants in Guyana. Our questions covered schooling in children, training for job, and type and income of job, both before and after surgery. We also discussed improvement in family income and quality of life (QOL) using a Likert scale of 1 lowest to 5 highest. RESULTS: Our data came from five humanitarian missions from July 2014 to July 2017. All school-going children (n = 6) were able to return to school and participate in educational activities. Young adults (n = 13), were able to acquire new jobs (50%) or training positions (50%) with higher income. Patients in the middle-age adult group (n = 20) re-acquired their employment positions (25%) or found new work (75%). Elderly patients (n = 21) after transplant were able to perform odd jobs to increase the family income. A consistent theme across all age groups was a dramatic improvement in the QOL. Two hundred and sixty DALYs (4.3 per patient) were averted. In this cohort of 62 surgery cases, mean preoperative visual acuity was 0.03 and postoperative mean visual acuity was 0.20. CONCLUSIONS: We have shown microeconomic benefits and improved QOL of corneal transplantation in a low-income country.

Mortality after Renal Allograft Failure and Return to Dialysis.

INTRODUCTION: The outcomes of patients who fail their kidney transplant and return to dialysis (RTD) has not been investigated in a nationally representative sample. We hypothesized that variations in management of transplant chronic kidney disease stage 5 leading to kidney allograft failure (KAF) and RTD, such as access, nutrition, timing of dialysis, and anemia management predict long-term survival. METHODS: We used an incident cohort of patients from the United States Renal Data System who initiated hemodialysis between January 1, 2003 and December 31, 2008, after KAF. We used Cox regression analysis for statistical associations, with mortality as the primary outcome. RESULTS: We identified 5,077 RTD patients and followed them for a mean of 30.9 ± 22.6 months. Adjusting for all possible confounders at the time of RTD, the adjusted hazards ratio (AHR) for death was increased with lack of arteriovenous fistula at initiation of dialysis (AHR 1.22, 95% CI 1.02-1.46, p = 0.03), albumin <3.5 g/dL (AHR 1.33, 95% CI 1.18-1.49, p = 0.0001), and being underweight (AHR 1.30, 95% CI 1.07-1.58, p = 0.006). Hemoglobin <10 g/dL (AHR 0.96, 95% CI 0.86-1.06, p = 0.46), type of insurance, and zip code-based median household income were not associated with higher mortality. Glomerular filtration rate <10 mL/min/1.73 m2 at time of dialysis initiation (AHR 0.83, 95% CI 0.75-0.93, p = 0.001) was associated with reduction in mortality. CONCLUSIONS: Excess mortality risk observed in patients starting dialysis after KAF is multifactorial, including nutritional issues and vascular access. Adequate preparation of patients with failing kidney transplants prior to resuming dialysis may improve outcomes.

Patient characteristics associated with the level of patient-reported care coordination among male patients with colorectal cancer in the Veterans Affairs health care system.

BACKGROUND: The current study was performed to determine whether patient characteristics, including race/ethnicity, were associated with patient-reported care coordination for patients with colorectal cancer (CRC) who were treated in the Veterans Affairs (VA) health care system, with the goal of better understanding potential goals of quality improvement efforts aimed at improving coordination. METHODS: The nationwide Cancer Care Assessment and Responsive Evaluation Studies survey involved VA patients with CRC who were diagnosed in 2008 (response rate, 67%). The survey included a 4-item scale of patient-reported frequency ("never," "sometimes," "usually," and "always") of care coordination activities (scale score range, 1-4). Among 913 patients with CRC who provided information regarding care coordination, demographics, and symptoms, multivariable logistic regression was used to examine odds of patients reporting optimal care coordination. RESULTS: VA patients with CRC were found to report high levels of care coordination (mean scale score, 3.50 [standard deviation, 0.61]). Approximately 85% of patients reported a high level of coordination, including the 43% reporting optimal/highest-level coordination. There was no difference observed in the odds of reporting optimal coordination by race/ethnicity. Patients with early-stage disease (odds ratio [OR], 0.60; 95% confidence interval [95% CI], 0.45-0.81), greater pain (OR, 0.97 for a 1-point increase in pain scale; 95% CI, 0.96-0.99), and greater levels of depression (OR, 0.97 for a 1-point increase in depression scale; 95% CI, 0.96-0.99) were less likely to report optimal coordination. CONCLUSIONS: Patients with CRC in the VA reported high levels of care coordination. Unlike what has been reported in settings outside the VA, there appears to be no racial/ethnic disparity in reported coordination. However, challenges remain in ensuring coordination of care for patients with less advanced disease and a high symptom burden. Cancer 2015;121:2207-2213. © 2015 American Cancer Society.

Impact of Poverty and Health Care Insurance on Arteriovenous Fistula Use among Incident Hemodialysis Patients.

BACKGROUND: The impact of socioeconomic factors on arteriovenous fistula (AVF) creation in hemodialysis (HD) patients is not well understood. We assessed the association of area and individual-level indicators of poverty and health care insurance on AVF use among incident end-stage renal disease (ESRD) patients initiated on HD. METHODS: In this retrospective cohort study using the United States Renal Data System database, we identified 669,206 patients initiated on maintenance HD from January 1, 2007 through December 31, 2012. We assessed the Medicare-Medicaid dual-eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data obtained from the 2010 United States Census. We conducted logistic regression of AVF use at start of dialysis as the outcome variable. RESULTS: The proportions of dual-eligible and non-dual-eligible patients who initiated HD with an AVF were 12.53 and 16.17%, respectively (p<0.001). Dual eligibility was associated with significantly lower likelihood of AVF use upon initiation of HD (adjusted odds ratio (aOR) 0.91; 95% CI 0.90-0.93). Patients in the lowest area-level MHI quintile had an aOR of 0.97 (95% CI 0.95-0.99) compared to those in higher quintile levels. However, dual eligibility and area-level MHI were not significant in patients with Veterans Affairs (VA) coverage. CONCLUSIONS: Individual- and area-level measures of poverty were independently associated with a lower likelihood of AVF use at the start of HD, the only exception being patients with VA health care benefits. Efforts to improve incident AVF use may require focusing on pre-ESRD care to be successful.

Reimagining the role of community health workers in SAARC countries.

Following the Alma Ata declaration, SAARC countries have established their workforce of community health workers (CHWs) to address primary healthcare needs. Initially focused on maternal and child health, the countries now confront a changing healthcare landscape characterized by noncommunicable diseases (NCDs), mental health issues, and surgical conditions. These developments have led to the emergence of specialized CHWs tasked with managing NCDs and mental health concerns, prompting a reevaluation of the balance between specialization and maintaining a generalist approach. The effectiveness of CHWs during crises hinges on critical factors such as standardized training, opportunities for career advancement, and equitable compensation. This viewpoint makes a call to introduce a specialist category of CHW to align with evolving healthcare requirements in SAARC countries.

Reimagining diaspora diplomacy during the COVID-19 crisis in India.

Diasporas are organized groups motivated by common cultural, ideological, political and religious values and common concerns for their countries of origin. Diaspora diplomacy has gained prominence worldwide, particularly in India, spurred by harrowing images of deaths and devastation due to the COVID-19 pandemic. A new generation of diaspora professionals modeled as social entrepreneurs uses collaborative and non-profit models to establish relationships with their counterparts to facilitate medical services and research. Teleradiology and telepsychiatry facilitate communication between diaspora members and their counterparts. We propose a common telehealth platform to standardize advice given by the Indian diaspora in the Global North as protocols change rapidly in acute pandemics. Consideration should be given to the well-known digital divide in India and other low- and middle-income countries. We advocate for diaspora members to train themselves in the art of global health diplomacy, to promote transparency and accountability in the collection of funds and a mandatory provision of outcome measurement by independent monitors rather than through social media. In the long run, Indian-Americans should play an active role in strengthening the domain of public health, which has historically been neglected in India, by focusing on the country's long-term infrastructure needs. The lessons learned from various diaspora efforts should be independently evaluated and recorded as best practice for future pandemics and humanitarian crises.

Community health workers to reduce unmet surgical needs in an urban slum in India: an implementation study.

BACKGROUND: The Surgical Accredited & Trained Healthcare Initiative (SATHI) project demonstrates how community healthcare workers (CHWs) with merely 8 y of formal schooling and training for a short period can reduce unmet surgical needs. METHODS: A pilot study was carried out in the slums of a metropolitan city in India to know the effectiveness of a SATHI in reducing the burden of unmet surgical needs. In total, 12 730 people from 3000 households were included in the study for a duration of 6 months. RESULTS: We found 10% surgical needs (n=293) out of which 57% had unmet surgical needs. Out of total surgical needs, about half of the needs were cataract and abdominal, followed by extremities and chest conditions. SATHIs were able to convert 99 patients (60%) from unmet to met needs, who underwent surgery/treatment. The conversion from unmet to met among all surgery needs was highest for abdominal conditions (29%) followed by cataracts (17%). CONCLUSIONS: SATHIs with short training can reduce the burden of unmet surgical needs. SATHIs were able to convert a significant proportion of unmet to met needs by trust building, facilitating access to healthcare and ensuring post-operative adherence. Scaling up could help in the achievement of equitable healthcare across India.

Practice patterns in evaluation of living kidney donors in United Network for Organ Sharing-approved kidney transplant centers.

INTRODUCTION: The current pattern of evaluation for living kidney donors was investigated. METHODS: We designed a 37-question electronic survey to collect information about living kidney donor evaluation. Of the 181 United Network for Organ Sharing (UNOS)-approved centers, 72 responded. Survey responses were coded and downloaded into SPSS. Data was expressed as means and standard deviations or the percentage of centers with specific responses. RESULTS: 66% of the centers used a cut-off of <80 ml/min for exclusion of living kidney donors. 24-hour urine measuring creatinine clearance (CrCl) was the most common screening method for glomerular filtration rate (GFR) assessment in potential living donors. 56% of the centers excluded donors with blood pressure (BP) >140/90, whereas 22.7 and 7.1% excluded patients with pre-hypertension with a cut-off BP of 130/85 and 120/80, respectively. 66% of the centers used 24-hour urine creatinine to assess for proteinuria. 20% of the centers accepted living kidney donors with microalbuminuria and 84% accepted patients with a history of nephrolithiasis. 24% of the centers reported use of formal cognitive testing of potential living donors. DISCUSSION: There were significant variations in exclusion criteria based on GFR, history of kidney stones, body mass index, BP and donors with urinary abnormalities. The definitions for hematuria and proteinuria were variable. There is a need for uniformity in selection and for a living donor registry. We also recommend raising the cut-off for estimated GFR to 90 ml/min to account for 10-15% overestimation when CrCl is used.

Bayesian modeling of pretransplant variables accurately predicts kidney graft survival.

INTRODUCTION: Machine learning can enable the development of predictive models that incorporate multiple variables for a systems approach to organ allocation. We explored the principle of Bayesian Belief Network (BBN) to determine whether a predictive model of graft survival can be derived using pretransplant variables. Our hypothesis was that pretransplant donor and recipient variables, when considered together as a network, add incremental value to the classification of graft survival. METHODS: We performed a retrospective analysis of 5,144 randomly selected patients (age ≥18, deceased donor kidney only, first-time recipients) from the United States Renal Data System database between 2000 and 2001. Using this dataset, we developed a machine-learned BBN that functions as a pretransplant organ-matching tool. RESULTS: A network of 48 clinical variables was constructed and externally validated using an additional 2,204 patients of matching demographic characteristics. This model was able to predict graft failure within the first year or within 3 years (sensitivity 40%; specificity 80%; area under the curve, AUC, 0.63). Recipient BMI, gender, race, and donor age were amongst the pretransplant variables with strongest association to outcome. A 10-fold internal cross-validation showed similar results for 1-year (sensitivity 24%; specificity 80%; AUC 0.59) and 3-year (sensitivity 31%; specificity 80%; AUC 0.60) graft failure. CONCLUSION: We found recipient BMI, gender, race, and donor age to be influential predictors of outcome, while wait time and human leukocyte antigen matching were much less associated with outcome. BBN enabled us to examine variables from a large database to develop a robust predictive model.

Effectiveness of Health Promotion Curriculum in Enhancing Non-communicable Diseases Health Literacy in Indian Youth.

Background There is a theory-praxis gap related to health literacy interventions focused on non-communicable diseases (NCDs) among young people. We designed an NCD curriculum and investigated its' effect on health literacy in non-medical, non-nursing college students in India. We deliberately selected non-medical and non-nursing college students (age 17 to 22 years) as we hypothesized, they would have a minimum baseline knowledge of NCDs. Methods We initially carried out a pilot study on 85 students in a four-day-long workshop (32 teaching hours) using empirically developed health literacy instrument. We administered the curriculum to 120 randomly selected students in four colleges, while 50 students were assigned to the comparison group. The curriculum was given over four days for a total of 32 hours. Approval was sought to give four credits for completion of the course. Each lecture comprised didactics, followed by discussion, and skills testing of measuring blood pressure and blood sugar. Health literacy was measured using a specifically designed tool at baseline and endline. The difference in health literacy scores between the two time-points (timepoint 1: before delivering the curriculum, time-point 2: at the end of four days of training) was analyzed using the t-test. Multiple linear and Poisson regression models were used to account for covariates. Results The average difference between the intervention and the control group in baseline scores was 0.05% points (unpaired t-test statistics: -1.36, degrees of freedom 103.15, p>0.05). The same at endline was 20.59% points (unpaired t-test statistics: -11.31, degrees of freedom 138.14, p<0.001). The endline to baseline difference in health literacy scores was 18.54% points higher in the intervention group versus the control group (unpaired t-test statistics: -10.88, degrees of freedom 161.32, p<0.001). The difference-in-difference scores remained significant after accounting for college setting and baseline score (Multivariable linear regression model, ß: 19.62% points, p<0.001). None of the socio-economic characteristics were significantly associated with the difference in the difference scores, independent of the intervention effect. The proportion of participants scoring 40% or above on the health literacy measure at endline was significantly higher in the intervention versus the control group (p<0.001). Conclusions We provide empirical data to support the incorporation of NCDs as a credit course in college curricula in low- and middle-income countries. Our findings showed that a theory-driven skills-focused curriculum may be a tool for enhancing NCD health literacy in Indian youth from diverse academic and socio-economic backgrounds.

Could global surgery overcome a decline in surgical cases?

•There have been three distinct landmarks for the US surgical trainees leading to a decline in surgical volume and in open number of cases.•Global surgery experiences have been adopted to expose trainees to surgical problems not routinely seen in the Global North.•Global Surgery also exposes trainees to empathic and collaborative approaches.•Benefits of global surgery to compensate for the decline in volume, variety and open surgical cases need to be studied through an academic, ethical, and economic lens.•LMICs trainees could travel to HIC for research and clinical training in exchange for the skills and case volume that HIC trainees would obtain in LMICs.

Unconditional cash transfer to reduce the burden of unmet surgical needs.

Recent years have seen scandals involving international humanitarian organizations. Short term surgical missions from high to low- and middle-income countries have been criticized as 'parachute' missions. There are significant surgical unmet needs in low- and middle-income countries. Universal health coverage has been underutilized in low- and middle-income countries for surgical conditions. We suggest a two-fold solution: first, restructuring of aid organizations by splitting them into smaller units to make them transparent and responsive to local needs. Secondly, unconditional cash transfer directly to beneficiaries giving them a choice to select physician and hospital for surgical treatment.