The built and social neighborhood environment and child obesity: A systematic review of longitudinal studies.

The built and social neighborhood environment where a child lives has been increasingly studied as an exposure that may affect child weight long term. We conducted a systematic review of primary research articles published in 2011 through 2019 that reported results from longitudinal analyses of associations between neighborhood environment characteristics and child obesity or weight. Neighborhood environment measures included proximity to food stores, parks, and recreational facilities, walkability, crime, perceived safety, and social cohesion. Information on study population, exposure and outcome measures, and main results were extracted from 39 studies and results were presented for full cohorts and stratified by sex. Most studies were prospective cohorts (90%) with a median follow-up time of six years. Studies analyzing changes in the neighborhood versus changes in weight were less common than approaches analyzing baseline measures of the neighborhood environment in relation to obesity incidence or weight trajectories. Associations varied by sex, race/ethnicity, and age group. Within the food environment domain, the strongest evidence of adverse impact was for fast food restaurants but the effect was only apparent among girls. Results suggested green space, parks, and recreational facilities may have a beneficial effect on weight. Increased crime and low perceived safety may be risk factors for increased weight although not all studies were consistent. Standardization of measures across studies, investigation of multiple social and physical environment measures simultaneously, effect modification by demographic characteristics, and change in the environment vs change in weight analyses are needed to strengthen conclusions.

Cross-Sectional Associations of Built and Social Neighborhood Environment Variables with Body Mass Index in a Large Sample of Urban Predominantly African American Children.

Background and Objectives: Neighborhood environments may play a role in the development of child obesity by providing or limiting opportunities for children to be physically active and access healthy food near the home. This study quantifies associations between the neighborhood built and social environment and age- and sex- standardized body mass index (BMI) z-scores in a predominantly African American urban sample. Methods: Electronic health record data from a pediatric integrated delivery system (N = 26,460 children, 6 to 19 years old in Philadelphia in 2014) were linked to eight built and social neighborhood environment characteristics. Generalized estimating equations were used to obtain adjusted associations between neighborhood features and age- and sex-adjusted BMI Z-score. Interactions between built and social exposures were examined, as well as effect modification by age, sex, neighborhood socioeconomic status, and population density. Results: Of 26,460 children, 17% were overweight and 21% were obese. After adjustment for individual- and neighborhood-level confounders, higher neighborhood greenness and higher walkability were associated with lower BMI z-score [mean difference per standard deviation (SD): -0.069 (95% confidence interval: [-0.108 to -0.031] and -0.051 [-0.085, -0.017], respectively)]. Higher levels of neighborhood food and physical activity resources were associated with higher BMI z-score [mean difference per SD 0.031 (0.012 and 0.050)]. We observed no interaction between the built and social neighborhood measures. Conclusion: Policies to promote walkability and greening of urban neighborhoods may contribute to preventing obesity in children.

The Scale-Up of the Global Surgical Workforce: Can Estimates be Achieved by 2030?

BACKGROUND: The Lancet Commission on Global Surgery showed that countries with surgeon, anesthetist, and obstetrician (SAO) densities of 20-40 SAO/100,000 population were associated with improved health outcomes and recommended a global surgical workforce scale-up by 2030. Whether countries would be able to achieve such scale-up efforts in that time-frame is unknown. METHODS: A differential equation model was used to estimate the growth rate and number of SAO necessary for each country to reach the aforementioned SAO densities. Workforce data from Mexico and India were used to estimate achievable rates of SAO scale-up for middle- and low-income countries, respectively. Secular surgical growth rates were estimated to demonstrate what might occur without dedicated scale-up efforts. RESULTS: To reach at least 20 SAO/100,000 population in all countries by 2030, over 808 thousand SAO need to be trained by 2030. To reach at least 40 SAO/100,000 population, over 2.1 million SAO need to be trained. If countries adopt a scale-up rate similar to Mexico's previously achieved rate of scale-up, 66% of countries would have 20 SAO/100,000 population by 2030. If countries adopt a scale-up rate similar to India's previously achieved rate of scale-up, 56% would have 20 SAO/100,000 population by 2030. CONCLUSION: With dedicated efforts in surgical workforce scale-up, significant gains in SAO density can be made worldwide. However, without intervention, many countries are unlikely to improve their current workforce densities. Investments in workforce scale-up are likely to yield workforce gains that mirror current resource states.

Does Andrews facial analysis predict esthetic sagittal maxillary position?

OBJECTIVE: Cephalometric analyses have limited utility in planning maxillary sagittal position for orthognathic surgery. In Six Elements of Orofacial Harmony, Andrews quantified maxillary position relative to forehead projection and angulation and proposed an ideal relationship. The purpose of this study was to investigate the ability of this technique to predict esthetic sagittal maxillary position. STUDY DESIGN: Survey study including a male and female with straight facial profiles, normal maxillary incisor angulations, and Angle's Class I. Maxillary position was modified on lateral photographs to create 5 images for each participant with incisor-goal anterior limit line (GALL) distances of -4, -2, 0, +2, and +4 mm. A series of health care professionals and laypeople were asked to rate each photo in order of attractiveness. RESULTS: A total of 100 complete responses were received. Incisor-GALL distances of +4 mm (41%) and +2 mm (40%) were most commonly considered "most esthetic" for the female volunteer (P < .001). For the male volunteer, there were 2 peak "most esthetic" responses: incisor-GALL distances of 0 mm (37%) and -4 mm (32%) (P < .001). CONCLUSION: Respondents considered maxillary incisor position 2 to 4 mm anterior to GALL most attractive in a woman and 0 to 4 mm posterior to GALL most esthetic in a man. Using these modified target distances, this analysis may be useful for orthognathic surgery planning.

Palatal Fistula Risk after Primary Palatoplasty: A Retrospective Comparison of a Humanitarian Organization and Tertiary Hospitals.

BACKGROUND: Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States. METHODS: This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation. RESULTS: The fistula risk was 35.4% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF ( P < 0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P < 0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients ( P < 0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation. CONCLUSIONS: Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.

Physician Courtesy and Patient Satisfaction in a Pediatric Plastic and Oral Surgery Department.

EXECUTIVE SUMMARY: Hospitals in the United States have started collecting information related to the patient experience with the objective of improving overall patient satisfaction. Between 2012 and 2015, the authors collected data from 2,875 patient satisfaction surveys. The purpose of this study was to analyze the effects of several variables-wait time, physician courtesy, administrative staff courtesy, patients' opportunity to ask questions, and patients' understanding of the answers-on a patient satisfaction score. A linear regression model was used to analyze the effects of these variables on patient satisfaction. All variables but one were significantly associated with patient satisfaction in the multivariable model. Healthcare provider courtesy was the strongest predictor of patient satisfaction; a score of "excellent" was associated with a 2.63-point (95% confidence interval [2.36, 2.90]) increase on a 5-point scale for patient satisfaction compared with a courtesy score of "poor." These findings suggest that patients had a positive experience when physicians and staff members were courteous.

Frequency and Morbidity of Temporomandibular Joint Involvement in Adult Patients With a History of Juvenile Idiopathic Arthritis.

PURPOSE: Most patients with juvenile idiopathic arthritis (JIA) have temporomandibular joint (TMJ) involvement, but little is known about the natural history of TMJ disease as these children enter adulthood. The purpose of this study was to evaluate adults with a history of JIA to document the frequency and severity of TMJ abnormalities and morbidity. The authors hypothesized that most would have persistent TMJ disease as adults. MATERIALS AND METHODS: This cross-sectional study included adults (>19 years of age) with JIA who were managed at Boston Children's Hospital (BCH) as children and at Brigham and Women's Hospital (BWH) as adults. History of a TMJ problem was not considered for enrollment. Patients completed a questionnaire and underwent physical examination and maxillofacial cone-beam computed tomography (CBCT). Additional data were obtained from medical records. Associations between TMJ abnormalities at CBCT and arthritis history, TMJ pain and function, facial asymmetry, malocclusion, and cephalometric analysis were examined. RESULTS: Of 129 eligible patients contacted, 21 (42 TMJs) were enrolled. Mean age was 26.0 ± 6.1 years and mean duration of care for JIA at the BCH and BWH was 13.7 ± 6.5 years. TMJ pain was present in 62% of patients (n = 13); 43% (n = 9) had a TMJ functional limitation and 76% (n = 16) had lower facial asymmetry. Abnormalities were found in the TMJs on 55% of CBCT scans, with 79% showing bilateral deformities. There was at least 1 cephalometric measurement of mandibular size or position that was more than 1 standard deviation beyond normal in 81% of patients (n = 17). Only 4 patients (19%) had previously been evaluated for a TMJ problem. CONCLUSION: TMJ abnormalities and related morbidity are common in adult patients with a history of JIA. Therefore, an early screening protocol for TMJ involvement in children with a new diagnosis of JIA would be beneficial and long-term follow-up into adulthood should be routine.

Cost-Benefit Analysis of Three-Dimensional Craniofacial Models for Midfacial Distraction: A Pilot Study.

OBJECTIVE: Patient-specific three-dimensional (3D) models are increasingly used to virtually plan rare surgical procedures, providing opportunity for preoperative preparation, better understanding of individual anatomy, and implant prefabrication. The purpose of this study was to assess the benefit of 3D models related to patient safety, operative time, and cost. DESIGN: Retrospective review. SETTING: Academic, tertiary care hospital. PATIENTS, PARTICIPANTS: Midfacial distraction was studied as a representative craniofacial operation. A consecutive series of 29 patients who underwent a single type of midfacial distraction was included. INTERVENTION: For a subset of patients, computed tomography-derived 3D models were used to study patient-specific anatomy and precontour hardware. MAIN OUTCOME MEASURES: Complications, operative time, blood loss, and estimated cost. RESULTS: Twenty patients underwent midfacial distraction without and nine with preoperative use of a 3D model. Seven complications occurred in six patients without model use, including premature consolidation (3), cerebrospinal fluid leak (2), and hardware malfunction (2). No complications were reported in the model group. Controlling for surgeon variation, model use resulted in a 31.3-minute (7.8%) reduction in operative time. Time-based cost savings were estimated to be $1036. CONCLUSIONS: Three-dimensional models are valuable for preoperative planning and hardware precontouring in craniofacial surgery, with potential positive effects on complications and operative time. Savings related to operative time and complications may offset much of the cost of the model.

Physician Assistants Improve Efficiency and Decrease Costs in Outpatient Oral and Maxillofacial Surgery.

PURPOSE: To determine the effects on time, cost, and complication rates of integrating physician assistants (PAs) into the procedural components of an outpatient oral and maxillofacial surgery practice. MATERIALS AND METHODS: This is a prospective cohort study of patients from the Department of Plastic and Oral Surgery at Boston Children's Hospital who underwent removal of 4 impacted third molars with intravenous sedation in our outpatient facility. Patients were separated into the "no PA group" and PA group. Process maps were created to capture all activities from room preparation to patient discharge, and all activities were timed for each case. A time-driven activity-based costing method was used to calculate the average times and costs from the provider's perspective for each group. Complication rates were calculated during the periods for both groups. Descriptive statistics were calculated, and significance was set at P < .05. RESULTS: The total process time did not differ significantly between groups, but the average total procedure cost decreased by $75.08 after the introduction of PAs (P < .001). The time that the oral and maxillofacial surgeon was directly involved in the procedure decreased by an average of 19.2 minutes after the introduction of PAs (P < .001). No significant differences in postoperative complications were found. CONCLUSIONS: The addition of PAs into the procedural components of an outpatient oral and maxillofacial surgery practice resulted in decreased costs whereas complication rates remained constant. The increased availability of the oral and maxillofacial surgeon after the incorporation of PAs allows for more patients to be seen during a clinic session, which has the potential to further increase efficiency and revenue.

Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures.

BACKGROUND: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. METHODS: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures. FINDINGS: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. INTERPRETATION: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Prenatal Features Predictive of Robin Sequence Identified by Fetal Magnetic Resonance Imaging.

BACKGROUND: Prenatal magnetic resonance imaging is increasingly used to detect congenital anomalies. The purpose of this study was to determine whether prenatal magnetic resonance imaging accurately characterizes features predictive of postnatal Robin sequence so that possible airway compromise and feeding difficulty at birth can be anticipated. METHODS: The authors retrospectively identified pregnant women who underwent fetal magnetic resonance imaging between 2002 and 2014 and were found to be carrying a fetus with micrognathia. Micrognathia was subjectively categorized as minor, moderate, or severe. Pregnancy outcome was determined as follows: intrauterine fetal demise, elective termination, early neonatal death, or viable infant. Postnatal findings of micrognathia, Robin sequence, and associated anomalies were compared to prenatal findings. RESULTS: Micrognathia was identified in 123 fetuses. Fifty-two pregnancies (42.3 percent) produced a viable infant. The remainder resulted in termination in the fetal period or death shortly after birth resulting from unrelated causes. For infants who lived, prenatal micrognathia was categorized as minor (55.1 percent), moderate (30.6 percent), or severe (14.3 percent). Forty-two percent of neonates with minor prenatal micrognathia had postnatal micrognathia; however, only 11.1 percent had Robin sequence. All neonates with moderate fetal micrognathia had postnatal micrognathia, and the majority had Robin sequence (86.7 percent). All newborns with severe micrognathia had Robin sequence and all prenatally diagnosed with glossoptosis had Robin sequence. CONCLUSIONS: Prenatal findings of moderate or severe micrognathia or glossoptosis are predictive of postnatal Robin sequence, thus expediting appropriate perinatal management of airway and feeding problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Assessing the Cost of Prophylactic Antibiotic Use After Cleft Lip and Lip Adhesion Procedures.

EXECUTIVE SUMMARY: The purpose of this study was to understand the true cost of administering prophylactic antibiotics postoperatively to patients undergoing cleft lip and lip adhesion procedures for which the rate of infection is historically low. Using time-driven activity-based costing (TDABC) methodologies, the plastic surgery department of one hospital created a process map with related time intervals and personnel cost rates for administering the antibiotic. The cost for each provider, based on standard salary information, was multiplied by the time required to complete his or her stage of the process, and this outcome was added to the supply costs. Overall cost was determined by summing the cost of all the steps. The cost of administering four doses of ampicillin/sulbactam to a patient during an inpatient stay ranged from $61.91 to $81.83. The total cost included all steps, from the initial antibiotic prescription through the final administration by a nurse. We attributed variations in cost to the staff member's level of familiarity with the antibiotic and dosing protocols for that patient. Over the course of a year, the cost of administering prophylactic antibiotics for this patient population was between $3,281.23 and $4,336.99. The results of this study effectively demonstrate the use of TDABC to determine the cost of administering prophylactic postoperative antibiotics. If we assume that antibiotics are of limited value for all clean-contaminated plastic surgery procedures, the plastic surgery department can expect to save $18,000 to $22,000 each year by forgoing their use. Furthermore, when clinically supported, reducing the use of prophylactic antibiotics not only diminishes the cost of care but also reduces the complexity of postoperative care.

How much surgery is enough? Aligning surgical delivery with best-performing health systems.

BACKGROUND: Surgical delivery varies 150-fold across countries. However, no direct correlation exists between surgical delivery and health outcomes, making it difficult to pinpoint a goal for surgical scale-up. We attempted to determine the amount of surgery that would be delivered worldwide, if the world aligned itself with countries providing the best health outcomes. METHODS: The number of cases performed annually has previously been published for 55 countries, which we stratified by World Bank income group. Life expectancy, maternal mortality, under-5 mortality, adult mortality, and a composite outcome of the four were plotted against reported surgical delivery. Univariate and multivariate polynomial regression curves were fit, and the optimum point on each regression curve was determined by solving for first-order conditions. The country closest to the optimum for each health outcome was taken as representative of the best-performing health system. Monetary inputs to, and surgical procedures provided by, these health systems were scaled to the global population. FINDINGS: For the five health outcomes, four countries (Sweden, Germany, Singapore, and Canada) performed at the optimum. Currently, 318 million procedures are provided annually around the world. If global surgical delivery mirrored delivery in the four best-performing countries, however, between 630 million (maternal survival) and 870 million cases (composite outcome) would be provided annually. With population growth, this will increase to between 750 million and 1 billion annual cases, respectively, by 2030. The best-performing health systems spend roughly 10% of their gross domestic product on health-care, providing 9000-12 000 cases per 100 000 individuals in the population. INTERPRETATION: To the best of our knowledge this is the first study to provide empirical evidence for the surgical output that an ideal health system would provide. The findings in this study provide a potential goal for surgical scale-up around the world. FUNDING: National Institutes of Health/National Cancer Institute.

Palatal fistula risk after primary palatoplasty: a retrospective comparison of humanitarian operations and tertiary hospitals.

BACKGROUND: Humanitarian surgical organisations provide cleft palate repair for patients without access to surgical care. Despite decades of experience, very little research has assessed the outcomes of these trips. This study investigates the fistula rate in patients from two cohorts in rural China and one in the USA. METHODS: This retrospective study compared the odds of fistula presentation among three cohorts whose palates were repaired between April, 2005, and November, 2009. The primary cohort included 97 Chinese patients operated on in China by surgeons from ReSurge International. A second Chinese cohort of 250 patients was operated on at Huaxi University Hospital by Chinese surgeons. The third cohort of 120 patients from the University of California San Francisco (UCSF) was included for comparison over the same time period; data was taken from medical records. Age, fistula presentation, and Veau Class were compared between the three cohorts with χ(2) tests. Logistic regression was used to analyse predictors of fistula presentation among the three cohorts. This study received institutional review board approval from the UCSF, the Harvard School of Public Health, and physicians at Huaxi University Hospital, and written consent was obtained from study participants in China. FINDINGS: The fistula risk was 35·4% in ReSurge patients, 12·8% for patients at Huaxi University Hospital, and 2·5% for patients at UCSF (p<0·001). At the time of surgery 15·5% of the ReSurge patients were younger than 2 years old, whereas 90·8% of the UCSF children and 41·6% of the Huaxi children were (p<0·001). In the ReSurge cohort, 20·6% of patients had a Veau class of I or II, wheras 40·8% and 58·9% of UCSF and Huaxi patients, respectively, were in class I or II (p<0·001). Age and Veau Class were associated with fistula formation in a univariate analysis. (Veau Class III or IV vs I or II, odds ratio [OR] 6·399 [95% CI 3·182-12·871]; age, OR 1·071 [95% CI 1·024-1·122]). A multivariate model controlling for the surgical group, age at palatoplasty, and sex showed an association between Veau Class and the odds of fistula presentation (Class III or IV vs I or II, OR 5·630 [95% CI 2·677-11·837). In this model, UCSF patients and Huaxi patients had 0·064 and 0·451 times the odds of developing a fistula, respectively, compared with ReSurge patients (p<0·001 both). INTERPRETATION: Chinese children undergoing palatoplasty on surgical missions have higher post-operative odds of palatal fistula than do children treated by local physicians. Children in low-resource settings have higher complication rates than do children in high-resource settings. Older age at palatoplasty and a Veau class III and IV are associated with post-palatoplasty fistula. Furthermore demographic, socioeconomic, and cultural differences could play a part in palatoplasty fistula outcomes between these three populations. More research is needed to determine the effects of post-operative care, the skill of the providers, and the technique used in the surgery that play a role on fistula outcomes after primary palatoplasty, particularly in low-resource environments. FUNDING: None.

The scale-up of the surgical workforce.

BACKGROUND: Countries with fewer than 20 specialist surgeons, anaesthetists, and obstetricians (SAO) per 100 000 population have worse health outcomes. To achieve surgical workforce densities of 20 per 100 000 by 2030, a scale up of the surgical workforce is required. No previous study has shown what this will cost, how many providers will be required, or how long it will take to increase the global surgical workforce. We aim to identify these answers for health-care systems that employ SAO alone and for those that use a hybrid model of SAO and task shifting to inform strategic planning. METHODS: Data for the density of SAO per country were obtained from the WHO Global Surgical Workforce Database. To find the total number of SAO that need to enter the workforce by 2030 to achieve surgical workforce thresholds of 20 per 100 000, the population growth formula (P=0e(rt)) was used and we assumed exponential surgical workforce growth and two potential retirement rates of either 1% or 10%. We did not account for migration. The same calculations were used for associate clinicians needed to enter the workforce in either a 2:1 or 4:1 associate clinicians-to-SAO ratio. The costs to train SAO and associate clinicians were estimated with data for training costs imputed into a regression analysis with health-care expenditure per capita for each country. We assumed training costs will remain constant, and we did not account for inflation. The time needed to train new surgical and anaesthetic providers was estimated with average length of training for SAO and associate clinicians and was measured in person years. Two models (one for a system of SAO only and one for a hybrid of SAO and associate clinicians) were created to show how many providers will need to enter the workforce per year once training is complete to reach targets by 2030. The model did not involve the scale-up of the surgical workforce needed to address unmet needs of essential surgical services. FINDINGS: By 2030, the world will need 1 272 586 new surgical workforce providers to meet a surgical workforce density of 20 per 100 000 assuming a 1% retirement rate. This will cost US$71-146 billion depending on the model used. Low-income and lower-middle-income countries show the largest required scale-up. An additional 806 352 (median 3412 [IQR 691-6851]) providers are needed in those countries. In the SAO only model, this will cost a median of US$19·66 per 2013 capita (IQR 15·79-25·07) and will take a median of 34 121 person years (IQR 6911-68 509). In the 4:1 associate clinician-to-SAO ratio, it will cost a median of US$7·57 per capita and take 20 472 person years. When accounting for the delay of entry to the workforce due to training in these countries, the median rate of entry to meet the goal density will have to increase 10·9 times after a 10 year delay in an SAO only model as opposed to 4·98 times with a 5 year delay in the hybrid 4:1 associate clinician-to-SAO model. INTERPRETATION: Although low-income countries, lower-middle-income countries, and upper-middle-income countries will require a surgical workforce scale-up, lower-middle-income countries will require the largest scale-up. In these countries, implementing a system of task shifting can decrease costs and training times by 40%. Meeting densities of 20 per 100 000 will not guarantee quality care or improved access in rural areas, and equal attention must be paid to the provision of safe, affordable, accessible surgical care to all who need it. FUNDING: None.

Half a billion surgical cases: Aligning surgical delivery with best-performing health systems.

BACKGROUND: Surgical delivery varies 200-fold across countries. No direct correlation exists, however, between surgical delivery and health outcomes, making it difficult to pinpoint a goal for surgical scale-up. This report determines the amount of surgery that would be delivered worldwide if the world aligned itself with countries providing the best health outcomes. METHODS: Annual rates of surgical delivery have been published previously for 129 countries. Five health outcomes were plotted against reported surgical delivery. Univariate and multivariate polynomial regression curves were fit, and the optimal point on each regression curve was determined by solving for first-order conditions. The country closest to the optimum for each health outcome was taken as representative of the best-performing health system. Monetary inputs to and surgical procedures provided by these systems were scaled to the global population. RESULTS: For 3 of the 5 health outcomes, optima could be found. Globally, 315 million procedures currently are provided annually. If global delivery mirrored the 3 best-performing countries, between 360 million and 460 million cases would be provided annually. With population growth, this will increase to approximately half a billion cases by 2030. Health systems delivering these outcomes spend approximately 10% of their GDP on health. CONCLUSION: This is the first study to provide empirical evidence for the surgical output that an ideal health system would provide. Our results project ideal delivery worldwide of approximately 550 million annual surgical cases by 2030.