Ten-Year Trends of Persistent Mortality With Gallstone Disease: A Retrospective Cohort Study in New Jersey.

BACKGROUND AND AIMS: Recent trends in mortality with gallstone disease remain scarce in the United States. Yet multiple changes in clinical management, such as rates of endoscopy, cholecystectomy, and cholecystostomy, and insurance access at the state level, may have occurred. Thus, we evaluated recent secular trends of mortality with gallstone disease in New Jersey. METHODS: We performed a retrospective, cohort study of mortality from 2009 to 2018 using the National Center for Health Statistics, Restricted Mortality Files. The primary outcome was any death with an International Classifications of Disease, 10th Revision, Clinical Modification diagnosis code of gallstone disease in New Jersey. Simple linear regression was used to model trends of incidence of death. RESULTS: 1580 deaths with diagnosed gallstone disease (dGD) occurred from 2009 to 2018. The annual trend of incidence of death was flat over 10 years. The incidence of death with dGD relative to all death changed only from 0.21% to 0.20% over 10 years. These findings were consistent also in 18 of 20 subgroup combinations, although the trend of death with dGD in Latinos 65 years or older increased [slope estimate 0.93, 95% confidence limit 0.42-1.43, P = .003]. CONCLUSION: The rate of death with dGD showed little change over the recent 10 years in New Jersey. This needs to be reproduced in other states and nationally. A closer examination of the changes in clinical care and insurance access is needed to help understand why they did not result in a positive change in this avoidable cause of death.

Decreased Emergency Cholecystectomy and Case Fatality Rate, Not Explained by Expansion of Medicaid.

INTRODUCTION: Population data on longitudinal trends for cholecystectomies and their outcomes are scarce. We evaluated the incidence and case fatality rate of emergency and ambulatory cholecystectomies in New Jersey (NJ) and whether the Medicaid expansion changed trends. MATERIALS AND METHODS: A retrospective population cohort design was used to study the incidence of cholecystectomies and their case fatality rate from 2009 to 2018. Using linear and logistic regression we explored the trends of incidence and the odds of case fatality after versus before the January 1, 2014 Medicaid expansion. RESULTS: Overall, 93,423 emergency cholecystectomies were performed, with 644 fatalities; 87,239 ambulatory cholecystectomies were performed, with fewer than 10 fatalities. The 2009 to 2018 annual incidence of emergency cholecystectomies dropped markedly from 114.8 to 77.5 per 100,000 NJ population (P < 0.0001); ambulatory cholecystectomies increased from 93.5 to 95.6 per 100,000 (P = 0.053). The incidence of emergency cholecystectomies dropped more after than before Medicaid expansion (P < 0.0001). The odds ratio for case fatality among those undergoing emergency cholecystectomies after versus before expansion was 0.85 (95% CI, 0.72-0.99). This decrease in case fatality, apparent only in those over age 65, was not explained by the addition of Medicaid. CONCLUSIONS: A marked decrease in the incidence of emergency cholecystectomies occurred after Medicaid expansion, which was not accounted for by a minimal increase in the incidence of ambulatory cholecystectomies. Case fatality from emergency cholecystectomy decreased over time due to factors other than Medicaid. Further work is needed to reconcile these findings with the previously reported lack of decrease in overall gallstone disease mortality in NJ.

Use of a New Prevention Model in Acute Care Surgery: A Population Approach to Preventing Emergency Surgical Morbidity and Mortality.

Whether patients undergo the more morbid and costly emergent rather than an elective type of surgery, may depend on many factors. Since tertiary prevention (preventing poor outcomes from emergency surgery) carries a much higher mortality than secondary prevention (preventing emergency surgery) or primary prevention (preventing the disease requiring surgery), the overall United States mortality might be reduced significantly, if emergency surgery could be avoided via high-quality primary prevention and non-surgical therapy or increasing elective surgery at the expense of emergency procedures, e.g., secondary prevention. The practice and study of acute care surgery then has the potential to broaden from a focus on the patient in the hospital emergency and operating rooms to the patient who no longer requires either, whose disease is treated or prevented in his/her/their community.

Access to paediatric cardiac surgery in Colombia: a population-based study.

OBJECTIVES: Globally congenital heart disease mortality is declining, yet the proportion of infant deaths attributable to heart disease rises in Colombia and other middle-sociodemographic countries. We aimed to assess the accessibility of paediatric cardiac surgery (PCS) to children <18 years of age in 2016 in the South American country of Colombia. METHODS: In Bogotá, Colombia, a multi-national team used cross-sectional and retrospective cohort study designs to adapt and evaluate 4 health system indicators at the national level: first, the population with timely geographic access to an institution providing PCS; second, the number of paediatric cardiac surgeons; third, this specialized procedure volume and its national distribution; and fourth, the 30-day perioperative mortality rate after PCS in Colombia. RESULTS: Geospatial mapping approximates 64% (n = 9 894 356) of the under-18 Colombian population lives within 2-h drivetime of an institution providing PCS. Twenty-eight cardiovascular surgeons report performing PCS, 82% (n = 23) with formal training. In 2016, 1281 PCS procedures were registered, 90% of whom were performed in 6 of the country's 32 departments. National non-risk-adjusted all-cause 30-day perioperative mortality rate after PCS was 2.73% (n = 35). CONCLUSIONS: Colombia's paediatric population had variable access to cardiac surgery in 2016, largely dependent upon geography. While the country may have the capacity to provide timely, high-quality care to those who need it, our study enables future comparative analyses to measure the impact of health system interventions facilitating healthcare equity for the underserved populations across Colombia and the Latin American region.

A longitudinal surgical systems strengthening research program for medical students: the exploration of a model for global health education.

BACKGROUND: In response to the staggering global burden of conditions requiring emergency and essential surgery, the development of international surgical system strengthening (SSS) is fundamental to achieving universal, timely, quality, and affordable surgical care. Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS, and include medical students. This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research. OBJECTIVES: We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS. PROGRAM DESIGN AND IMPLEMENTATION: In 2015, medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS. This included development of two longitudinal academic tracks in global health medical education and academic global surgery, which we differentiated by level of institutional resourcing. Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics. MAIN ACHIEVEMENTS: In the first two years of the program, there were 76 total applicants to the two longitudinal tracks. Six of the 16 (37.5%) accepted students selected global surgery faculty as mentors (Acute Care Surgery faculty participating in SSS with Colombia). These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS. As a quantitative measure of the program's success, the students collectively produced a total of twenty scholarly pieces in the form of accepted posters, abstracts, podium presentations, and manuscripts in partnership with Colombian research mentors. POLICY IMPLICATIONS: The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research. We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.

Non-English Primary Language is Associated with Emergency Surgery for Diverticulitis.

BACKGROUND: Language barriers can limit access to care for patients with a non-English primary language (NEPL). The objective of this study was to define the association between primary language and emergency versus elective surgery among diverticulitis patients. MATERIALS AND METHODS: Retrospective cohort study of adult patients from the 2009-2014 New Jersey State Inpatient Database. Patients were included if they had primary language data and underwent a partial colon resection for diverticulitis. Primary language was dichotomized into NEPL versus English primary language (EPL). The primary outcome was surgical admission type - urgent/emergent (referred to as "emergency") versus elective. Descriptive and multivariable analyses were performed. RESULTS: A total of 9,453 patients underwent surgery for diverticulitis, of which 592 (6.3%) had NEPL. Among NEPL patients, 300 (51%) had Spanish as primary language and 292 (49%) had another non-Spanish primary language. Patients with NEPL and EPL were similar in age (median age 58 versus 59 years; P = 0.54) and sex (52% versus 53% female; P = 0.45). Patients with NEPL were less likely to have commercial insurance (45% versus 59%; P <0.001). On multivariable analysis, compared to patients with EPL, NEPL was associated with increased odds of emergency surgery for diverticulitis (OR 1.35; 95% Confidence Interval 1.13-1.62; P = 0.001) CONCLUSION: Patients with NEPL have higher odds of emergency versus elective surgery for diverticulitis compared to patients with EPL. Further research is needed to examine differences in referral pathways, patient-provider communication, and health literacy that may hinder access to elective surgery in patients with diverticulitis.

Assessment of Cervical Cancer Prevention and Treatment Infrastructure in Belize.

PURPOSE: Belize has one of the highest cervical cancer burdens among Latin American and Caribbean countries, despite the implementation of national policies to increase access to prevention and treatment services. This study evaluates the policies, infrastructure, and workforce of the cervical cancer management system in Belize to inform capacity building efforts. METHODS: In 2018, health facility assessments were conducted across all six districts of Belize at the national pathology facility and 12 public facilities identified as critical to cervical cancer control. Human and infrastructure resource availability and existing policies related to cervical cancer screening and treatment services were assessed through a structured instrument. RESULTS: The public cervical cancer screening workforce in Belize consists of 75 primary care nurses and physicians-one per 1,076 screening-eligible women, with 44% conducting rural outreach. All districts have at least one screening facility, but 50% perform screening services only once per week. Colposcopy and loop electrical excision procedures are available in three and four districts, respectively; radical hysterectomy and chemotherapy are available in two districts; and radiation therapy is unavailable. Of essential pathology equipment, 38.5% were present and functional, 23% were present but nonfunctional, and 38.5% were unavailable. Additionally, 35% of supplies were unavailable at the time of assessment, and 75% were unavailable at least once in the 12 months before assessment. CONCLUSION: Public-sector cervical cancer management services differ among districts of Belize, with tertiary service availability concentrated in the largest district. Screening, outreach, and pathology are limited mostly by resource availability. This study characterizes the current capacity of services in Belize and pinpoints health system components for future investment and capacity-building efforts.

Mesenteric venous thrombosis: A lethal complication of hyperglycemic crises.

PURPOSE: Although hyperglycemic crises can lead to a hypercoagulable state, few instances of associated mesenteric venous thrombosis (MVT) have been reported. Worsening abdominal pain in the context of shock requiring vasopressor support should prompt urgent further investigation. SUMMARY: A 44-year-old Hispanic male arrived at an emergency department with chief complaints of lethargy, polydipsia, and polyuria. His past medical history included type 2 diabetes, epilepsy, obesity, tobacco smoking, and noncompliance with his medications. On arrival the patient had a serum glucose concentration of >1,600 mg/dL, and hyperosmolar hyperglycemic syndrome (HHS) was diagnosed. The patient was admitted to the intensive care unit with respiratory failure and subsequently developed shock refractory to fluid resuscitation, necessitating vasopressor support. On hospital day 4, a computerized tomogram obtained for investigation of increasing abdominal tenderness revealed superior MVT and pneumatosis intestinalis. Despite an emergency laparotomy and enterectomy, the patient ultimately succumbed on hospital day 41 due to recurrent pneumonia complicated by acute respiratory distress syndrome and septic shock. CONCLUSION: Shock that is refractory to aggressive fluid resuscitation, necessitating pressor support, in the setting of HHS or diabetic ketoacidosis should prompt investigation for the underlying source of shock. Other etiologies, including hypovolemic, cardiogenic, and obstructive shock, should be considered; however, infection is the leading trigger of hyperglycemic crises. Although rarely reported, MVT should be considered in the diagnostic algorithm in the absence of an identified infectious source. Prompt investigation should include use of diagnostic modalities such as computed tomography to assess for MVT.

Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting.

INTRODUCTION: Interfacility transfers may reflect a time delay of definitive surgical care, but few studies have examined the prevalence of interfacility transfers in the urban low- and middle-income (LMIC) setting. The aim of this study was to determine the number of interfacility transfers required for surgical and obstetric conditions in an urban MIC setting to better understand access to definitive surgical care among LMIC patients. METHODS: A retrospective analysis of public interfacility transfer records was conducted from April 2015 to April 2016 in Cali, Colombia. Data were obtained from the single municipal ambulance agency providing publicly funded ambulance transfers in the city. Interfacility transfers were defined as any patient transfer between two healthcare facilities. We identified the number of transfers for patients with surgical conditions and categorized transfers based on patient ICD-9-CM codes. We compared surgical transfers from public vs. private healthcare facilities by condition type (surgical, obstetric, nonsurgical), transferring physician specialty, and transfer acuity (code blue, emergent, urgent and nonurgent) using logistic regression. RESULTS: 31,659 patient transports occurred over the 13-month study period. 22250 (70.2%) of all transfers were interfacility transfers and 7777 (35%) of transfers were for patients with surgical conditions with an additional 2,244 (10.3%) for obstetric conditions. 49% (8660/17675) of interfacility transfers from public hospitals were for surgical and obstetric conditions vs 32% (1466/4580) for private facilities (P<0.001). The most common surgical conditions requiring interfacility transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). CONCLUSION: Surgical and obstetric conditions account for nearly half of all urban interfacility ambulance transfers. The most common reasons for transfer are basic surgical conditions with public healthcare facilities transferring a greater proportion of patient with surgical conditions than private facilities. Timely access to an initial healthcare facility may not be a reliable surrogate of definitive surgical care given the substantial need for interfacility transfers.

Integrating a Novel Global Surgery and Health Inequity Course to the Surgical Clerkship.

OBJECTIVE: Medical students report growing interest in health inequity and global surgery, subjects not currently integrated to their core curriculum. Currently, fundamental tenets of global surgical inequity are only available to students on an elective basis or in special interest groups. Therefore, an hour-long course with emphasis on global surgery was developed for third-year medical students. The aim of this study was to examine student response to this pilot course and to establish whether course content was applicable to clinical rotations. DESIGN: A 1-hour structured curriculum was delivered to third-year medical students (MS3s) during the 2-day orientation phase of each rotation of an 8-week surgery clerkship from August 2018 to May 2019. The course targeted approximately 30 students per session in the preclinical orientation at Rutgers-New Jersey Medical School. Upon completion of the 8-week clerkship rotation, a paper survey was administered to evaluate student's exposure to previous content, attitudes toward global health, interest and engagement in course materials, and applicability of learned course content to local environments. SETTING: Rutgers-New Jersey Medical School, an urban medical school located in Newark, New Jersey. PARTICIPANTS: A total of 191 students attended the global surgery and health equity course; 146 participants participated in the postcourse survey. RESULTS: When asked about baseline interest in global or public health, the majority (51%) were extremely interested or very interested. Nearly all participants found the course to be valuable (94%). When asked which educational modality was preferred, 23% of participants favored the traditional lecture component and 29% favored case-based discussions. Nearly half (48%) the respondents found both modalities to be valuable. Fifty students (34% of respondents) reported encounters with patients affected by barriers in access to surgical care during their clerkships. CONCLUSIONS: Medical students responded favorably to this health inequity and global surgery pilot course and requested supplemental lectures. Additionally, course content was applicable to local clinical experiences. Therefore, 1 modality of integrating global surgery to the established curriculum is under the framework of health inequity and social determinants of health during surgical clerkships. This study demonstrates that meaningful inclusion of global surgery and health inequity can be implemented within the existing curricular structure.

Use of the six core surgical indicators from the Lancet Commission on Global Surgery in Colombia: a situational analysis.

BACKGROUND: Surgical, anaesthetic, and obstetric (SAO) health-care system strengthening is needed to address the emergency and essential surgical care that approximately 5 billion individuals lack globally. To our knowledge, a complete, non-modelled national situational analysis based on the Lancet Commission on Global Surgery surgical indicators has not been done. We aimed to undertake a complete situation analysis of SAO system preparedness, service delivery, and financial risk protection using the core surgical indicators proposed by the Commission in Colombia, an upper-middle-income country. METHODS: Data to inform the six core surgical system indicators were abstracted from the Colombian national health information system and the most recent national health survey done in 2007. Geographical access to a Bellwether hospital (defined as a hospital capable of providing essential and emergency surgery) within 2 h was assessed by determining 2 h drive time boundaries around Bellwether facilities and the population within and outside these boundaries. Physical 2 h access to a Bellwether was determined by the presence of a motor vehicle suitable for individual transportation. The Department Administrativo Nacional de Estadística population projection for 2016 and 2018 was used to calculate the SAO provider density. Total operative volume was calculated for 2016 and expressed nationally per 100 000 population. The total number of postoperative deaths that occurred within 30 days of a procedure was divided by the total operative volume to calculate the all-cause, non-risk-adjusted postoperative mortality. The proportion of the population subject to impoverishing costs was calculated by subtracting the baseline number of impoverished individuals from those who fell below the poverty line once out-of-pocket payments were accounted for. Individuals who incurred out-of-pocket payments that were more than 10% of their annual household income were considered to have experienced catastrophic expenditure. Using GIS mapping, SAO system preparedness, service delivery, and cost protection were also contextualised by socioeconomic status. FINDINGS: In 2016, at least 7·1 million people (15·1% of the population) in Colombia did not have geographical access to SAO services within a 2 h driving distance. SAO provider density falls short of the Commission's minimum target of 20 providers per 100 000 population, at an estimated density of 13·7 essential SAO health-care providers per 100 000 population in 2018. Lower socioeconomic status of a municipality, as indicated by proportion of people enrolled in the subsidised insurance regime, was associated with a smaller proportion of the population in the municipality being within 2 h of a Bellwether facility, and the most socioeconomically disadvantaged municipalities often had no SAO providers. Furthermore, Colombian providers appear to be working at or beyond capacity, doing 2690-3090 procedures per 100 000 population annually, but they have maintained a relatively low median postoperative mortality of 0·74% (IQR 0·48-0·84). Finally, out-of-pocket expenses for indirect health-care costs were a key barrier to accessing surgical care, prompting 3·1 million (6·4% of the population) individuals to become impoverished and 9·5 million (19·4% of the population) individuals to incur catastrophic expenditures in 2007. INTERPRETATION: We did a non-modelled, indicator-based situation analysis of the Colombian SAO system, finding that it has not yet met, but is working towards achieving, the targets set by the Lancet Commission on Global Surgery. The observed interdependence of these indicators and correlation with socioeconomic status are consistent with well recognised factors and outcomes of social, health, and health-care inequity. The internal consistency observed in Colombia's situation analysis validates the use of the indicators and has now informed development of an early national SAO plan in Colombia, to set a data-informed stage for implementation and evaluation of timely, safe, and affordable SAO health care, within the National Public Health Decennial Plan, which is due in 2022. FUNDING: Zoll Medical.

Next Generation of Global Surgeons: Aligning Interest With Early Access to Global Surgery Education.

BACKGROUND: Although interest in global surgery is increasing among medical students,1 several questions remain unanswered such as: the association of demographics with said interest, the extent that global surgical burden education has been integrated into medical education, and the availability of global surgery electives. This study aimed to assess the current state of global surgery education in the United States (U.S.) to support recommendations for future curriculum development. MATERIALS AND METHODS: An anonymous online survey was distributed to medical students currently enrolled in the U.S. Descriptive data were compiled regarding interest in and access to global surgery programs; demographic data were analyzed using chi-squared testing for categorical variables. RESULTS: A total of 754 students from 18 medical schools throughout the U.S. responded to the survey. Only complete responses were included in final analysis (n = 658). Most of the respondents (66%) reported interest in global surgery, with a higher proportion of those interested being in their preclinical years. However, the majority (79%) reported that global surgery issues are rarely or never addressed in their required curriculum. Over half of respondents were unaware of whether their school even offers such programs. CONCLUSIONS: Although interest in global surgery is on the rise among medical students, results suggest that many currently lack exposure to global surgery concepts in their medical education. To that end, early exposure may be most effective during the preclinical years, so that the next generation may align global surgery participation with clinical aspirations, with the ultimate goal of addressing global disparities.

Exploring residents' interest and career aspirations in global surgery.

BACKGROUND: Surgical residents increasingly seek global surgery (GS) experiences during training. Understanding their motives and goals is important to develop the optimal educational programs. A survey for surgical residents was developed to explore this interest. MATERIALS AND METHODS: A survey administered in 2016 to residents in three surgical programs within the same academic institution assessed interest, prior global health experience, preferred training opportunities, and career goals in GS. RESULTS: Seventy-four surgical residents responded (78%) with 82% expressing interest in GS and 86% motivated by a desire for volunteerism. International electives (65%) and volunteer missions (49%) were the preferred experiences during residency over longer commitments such as advanced degrees. A majority of residents planned to incorporate GS into their career (76%) most commonly by volunteering on missions (70%) with a smaller group aiming for a career in GS (13%). Residents with prior global health experience (n = 27, 36%) showed greater interest in GS (96% versus 72%, P = 0.02) and a commitment after residency (93% versus 68%, P = 0.02), and trended toward greater interest in GS careers (22% versus 6%, P = 0.06). CONCLUSIONS: Institutional interest in GS remains high among surgical residents, motivated primarily by a desire for volunteerism. Following training, most residents plan to participate in short-term volunteer commitments, though a small group envisions GS as part of their long-term career goals. Prior global health experience is associated with interest in GS both in the present and long term. Providing these experiences early may be a strategy to support academic interest.

The National Surgical, Obstetric, and Anesthesia Plan (NSOAP): Recognition and Definition of an Empirically Evolving Global Surgery Systems Science Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa".

In 2015, the Lancet Commission on Global Surgery (LCoGS) working groups developed a National Surgical, Obstetric, and Anesthesia Plan (NSOAP) framework to guide national surgical system development globally predicated on six data points (indicators) which can assess surgical systems. Zambia as well as other subSaharan Africa (SSA) countries have forged ahead in designing and implementing interventions based on LCoGS indicators collected to inform NSOAP. Concurrently, the Zambian team and others have recognized the need for rigorous scientific inquiry to assess and iteratively improve upon the NSOAP process and outputs. Based on the Zambian experience, as well as that of ours in Colombia, we have identified "core principles" through convergent works which inform a scientific framework through which NSOAP can be evaluated. We propose that when contextualized, participatory action research (PAR) and dissemination and implementation science are methodologies upon which a robust framework can be developed to achieving objective and iterative NSOAP evaluation, and ultimately universal health coverage as envisioned by the World Health Organization (WHO).

Preparing Global Trauma Nurses for Leadership Roles in Global Trauma Systems.

Trauma leads to 5.7 million annual deaths globally, accounting for 25%-33% of global unintentional deaths and 90% of the global trauma burden in low- and middle-income countries. The Lancet Commission on Global Surgery and the World Health Organization assert that emergent and essential surgical capacity building and trauma system improvement are essential to address the global burden of trauma. In response, the Rutgers Global Surgery program, the School of Nursing and Medicine, and the Robert Wood Johnson University Hospital faculty collaborated in the first Interprofessional Models in Global Injury Care and Education Symposium in June 2016. This 2-week symposium combined lectures, high-fidelity simulation, small group workshops, site visits to Level I trauma centers, and a 1-day training course from the Panamerican Trauma Society. The aim was to introduce global trauma nurses to trauma leadership and trauma system development. After completing the symposium, 10 nurses from China, Colombia, Kenya, Puerto Rico, and Uruguay were surveyed. Overall, 88.8% of participants reported high levels of satisfaction with the program and 100% stated being very satisfied with trauma lectures. Symposia, such as that developed and offered by Rutgers University, prepare nurses to address trauma within system-based care and facilitate trauma nursing leadership in their respective countries.

A Comprehensive Framework for International Medical Programs: A 2017 consensus statement from the American College of Academic International Medicine.

The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM's mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations.