Effects of Sociodemographic and Child Opportunity Index on Pediatric Plastic and Oral and Maxillofacial Surgical Volume Trends in the COVID-19 Pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused disruptions to pediatric surgical care. Although surgical capacity has returned to the prepandemic state, barriers to surgical access may still exist for children who are medically underserved. We assessed pediatric plastic and oral and maxillofacial surgical volumes by sociodemographic characteristics before and during the COVID-19 pandemic. Methods: A 72-month retrospective cohort analysis of 10,681 pediatric plastic and oral and maxillofacial procedures between 2016 and 2021 was conducted. Multivariable logistic regression and interrupted time series analyses were used to analyze surgical volume trends by sociodemographic groups and Child Opportunity Index (COI). Results: Compared with prepandemic, patients undergoing procedures were more likely to be older than 18 years (P < 0.001) and Hispanic/Latino (adjusted odds ratio 1.38; 95% confidence interval, 1.14-1.68; P < 0.01). Surgical volume trends among patients from the lowest COI levels were lower than where they were estimated to have been if the pandemic did not occur (P = 0.040). Patients who spoke a primary language other than English or Spanish (P = 0.02) and patients with the lowest COI levels (P = 0.04) continued to have unrecovered surgical volumes. Conclusions: There were differences in the sociodemographic case-mix of patients undergoing plastic and oral and maxillofacial surgical procedures before and during the pandemic, and surgical volumes did not recover at the same rate for all patients. Further research can determine why certain sociodemographic groups and patients with low COI levels had decreased surgical access compared with prepandemic trends, and develop interventions focused on equitable pediatric surgical access.

Ecuador’s National Surgical Strengthening Plan: first in Latin America, provides hope for surgical care agenda

Since 2015, there has been a notable increase in global efforts by various stakeholders to promote and advance surgical care policies, as proposed by the Lancet Commission on Global Surgery (LCoGS) namely, the development of the National Surgical Obstetric Anesthesia Planning (NSOAP), a country- driven framework that offers a comprehensive approach to health ministries to enhance their surgical systems. Ecuador has affirmed its position as a leading advocate for surgical care in Latin America. Following a two-year process, Ecuador is the first country in the Region of the Americas to launch an NSSP as a key component of a robust health system, including improving emergency responsiveness and pre- paredness

Hospital Variation and Resource Use for Infants with Craniosynostosis Undergoing Open, Endoscopic, and Distraction Osteogenesis Surgical Techniques.

BACKGROUND: Craniosynostosis is treated with endoscopic, open, and/or distraction surgical techniques. We assessed institutional variation in the use these techniques for craniosynostosis and compared hospital resource use. METHODS: Retrospective analysis of 5249 infants age <18 months old undergoing surgical procedures for all types of craniosynostosis in 2016-2020 in 39 freestanding children's hospitals in the Pediatric Health Information System (PHIS) database. Endoscopic vs. open cranial vault surgery (with and without distraction osteogenesis) was identified using ICD-10-CM codes. Inpatient cost and length of stay (LOS) were compared by surgery type with Wilcoxon Rank Sum. RESULTS: There was significant (p < .001) variation in the percentage of infants who underwent endoscopic repair across hospitals [median 23.6% (interquartile range (IQR): 7.6%-37.5%), range: 0% to 80.4%] and across regions [range: 22.1% (southeast) to 42.5% (northeast)]. For endoscopic procedures, median LOS and inpatient cost were lower (p < .001) without vs. with distraction [1 day (IQR 1-1) vs. 2 days (IQR 2-2); $14,617 (IQR 11,823-22178) vs. $33,599 (IQR 22,800-38,619)]. For open interventions, median LOS and inpatient cost were also lower (p < .001) without vs. with distraction [3 days (IQR 2-4) vs. 5 days (IQR 4-6) and $37,251 (IQR 27,114-50.320) vs. $62,247 (IQR 42,124-91,620)]. CONCLUSIONS: Substantial variation in the surgical approach for craniosynostosis exists across hospitals and regions. Endoscopic repair without distraction had the lowest hospital resource use, while open repair with distraction had the highest hospital resource. Subsequent analysis of short- and long-term outcomes as well as patient-and-family costs is necessary to assess the true cost-effectiveness of each approach.

An introduction to digital determinants of health.

In recent years, technology has been increasingly incorporated within healthcare for the provision of safe and efficient delivery of services. Although this can be attributed to the benefits that can be harnessed, digital technology has the potential to exacerbate and reinforce preexisting health disparities. Previous work has highlighted how sociodemographic, economic, and political factors affect individuals' interactions with digital health systems and are termed social determinants of health [SDOH]. But, there is a paucity of literature addressing how the intrinsic design, implementation, and use of technology interact with SDOH to influence health outcomes. Such interactions are termed digital determinants of health [DDOH]. This paper will, for the first time, propose a definition of DDOH and provide a conceptual model characterizing its influence on healthcare outcomes. Specifically, DDOH is implicit in the design of artificial intelligence systems, mobile phone applications, telemedicine, digital health literacy [DHL], and other forms of digital technology. A better appreciation of DDOH by the various stakeholders at the individual and societal levels can be channeled towards policies that are more digitally inclusive. In tandem with ongoing work to minimize the digital divide caused by existing SDOH, further work is necessary to recognize digital determinants as an important and distinct entity.

A practical tool for managing change: cross-sectional psychometric assessment of the safe surgery organizational readiness tool.

BACKGROUND: Strengthening health systems through planned safety and quality improvement initiatives is an imperative to achieve more equitable, resilient, and effective care. And yet, years of organizational behavior research demonstrate that change initiatives often fall short because managers fail to account for organizational readiness for change. This finding remains true especially among surgical safety and quality improvement initiatives in low-income countries and middle-income countries. In this study, our aim was to psychometrically assess the construct validity and internal consistency of the Safe Surgery Organizational Readiness Tool (SSORT), a short survey tool designed to provide change leaders with insight into facility infrastructure that supports learning and readiness to undertake change. MATERIALS AND METHODS: To demonstrate generalizability and achieve a large sample size ( n =1706) to conduct exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), a collaboration between seven surgical and anesthesia safety and quality improvement initiatives was formed. Collected survey data from health care workers were divided into pilot, exploration, and confirmation samples. The pilot sample was used to assess feasibility. The exploration sample was used to conduct EFA, while the confirmation sample was used to conduct CFA. Factor internal consistency was assessed using Cronbach's alpha coefficient. RESULTS: Results of the EFA retained 9 of the 16 proposed factors associated with readiness to change. CFA results of the identified 9 factor model, measured by 28 survey items, demonstrated excellent fit to data. These factors (appropriateness, resistance to change, team efficacy, team learning orientation, team valence, communication about change, learning environment, vision for sustainability, and facility capacity) were also found to be internally consistent. CONCLUSION: Our findings suggest that communication, team learning, and supportive environment are components of change readiness that can be reliably measured prior to implementation of projects that promote surgical safety and quality improvement in low-income countries and middle-income countries. Future research can link performance on identified factors to outcomes that matter most to patients.

Child Opportunity Index Disparities in Pediatric Surgical Encounters During the Coronavirus 2019 Pandemic.

OBJECTIVE: Surgical encounters decreased during the coronavirus disease (COVID-19) pandemic and may have been deferred more in children with impeded health care access related to social/community risk factors. We compared surgery trends before and during the pandemic by Child Opportunity Index (COI). METHODS: Retrospective analysis of 321,998 elective surgical encounters of children ages 0-to-18 years in 44 US children's hospitals from January 1, 2017 to December 31, 2021. We used auto-regression to compare observed versus predicted encounters by month in 2020-21, modeled from 2017 to 2019 trends. Encounters were compared by COI score (very low, low, moderate, high, very high) based on education, health/environment, and social/economic attributes of the zip code from the children's home residence. RESULTS: Most surgeries were on the musculoskeletal (28.1%), ear/nose/pharynx (17.1%), cardiovascular (15.1%), and digestive (9.1%) systems; 20.6% of encounters were for children with very low COI, 20.8% low COI, 19.8% moderate COI, 18.6% high COI, and 20.1% very high COI. Reductions in observed volume of 2020-21 surgeries compared with predicted varied significantly by COI, ranging from -11.3% (95% confidence interval [CI] -14.1%, -8.7%) for very low COI to -2.6% (95%CI -3.9%, 0.7%) for high COI. Variation by COI emerged in June 2020, as the volume of elective surgery encounters neared baseline. For 12 of the next 18 months, the reduction in volume of elective surgery encounters was the greatest in children with very low COI. CONCLUSIONS: Children from very low COI zip codes experienced the greatest reduction in elective surgery encounters during early COVID-19 without a subsequent increase in encounters over time to counterbalance the reduction.

Estimating access to surgical care: A community centered national household survey from Pakistan.

Pakistan is a lower middle-income country in South Asia with a population of 225 million. No estimate for surgical care access exists for the country. We postulate the estimated access to surgical care is less than the minimum 80% to be achieved by 2030. We conducted a randomized, stratified two-stage cluster household survey. A sample of 770 households was selected using 2017 census frames from the Pakistan Bureau of Statistics. Data was collected on choice of hospital and travel time to the chosen hospital for C-section, laparotomy, open fracture repair (OFR), and specialized surgery. Analysis was conducted using Stata 14. Access to all Bellwether surgeries (C-section, laparotomy, and open fracture repair) in Pakistan is estimated to be 74.8%. However, estimated access in rural areas and the provinces of Balochistan, Khyber Pakhtunkhwa (KP) and Sindh is far less than in urban areas and in Punjab and Islamabad. Estimated access to C-sections is more compared to OFR, laparotomy, and specialized surgery. Health system strengthening efforts should focus on improving surgical care access in rural areas and in Balochistan, KP, and Sindh. More focus is required on standardizing the availability and quality of surgical services in secondary-level hospitals.

Research capacity, motivators and barriers to conducting research among healthcare providers in Tanzania's public health system: a mixed methods study.

BACKGROUND: Building health research capacity in low- and middle-income countries is essential to achieving universal access to safe, high-quality healthcare. It can enable healthcare workers to conduct locally relevant research and apply findings to strengthen their health delivery systems. However, lack of funding, experience, know-how, and weak research infrastructures hinders their ability. Understanding research capacity, engagement, and contextual factors that either promote or obstruct research efforts by healthcare workers can inform national strategies aimed at building research capacity. METHODS: We used a convergent mixed-methods study design to understand research capacity and research engagement of healthcare workers in Tanzania's public health system, including the barriers, motivators, and facilitators to conducting research. Our sample included 462 randomly selected healthcare workers from 45 facilities. We conducted surveys and interviews to capture data in five categories: (1) healthcare workers research capacity; (2) research engagement; (3) barriers, motivators, and facilitators; (4) interest in conducting research; and (5) institutional research capacity. We assessed quantitative and qualitative data using frequency and thematic analysis, respectively; we merged the data to identify recurring and unifying concepts. RESULTS: Respondents reported low experience and confidence in quantitative (34% and 28.7%, respectively) and qualitative research methods (34.5% and 19.6%, respectively). Less than half (44%) of healthcare workers engaged in research. Engagement in research was positively associated with: working at a District Hospital or above (p = 0.006), having a university degree or more (p = 0.007), and previous research experience (p = 0.001); it was negatively associated with female sex (p = 0.033). Barriers to conducting research included lack of research funding, time, skills, opportunities to practice, and research infrastructure. Motivators and facilitators included a desire to address health problems, professional development, and local and international collaborations. Almost all healthcare workers (92%) indicated interest in building their research capacity. CONCLUSION: Individual and institutional research capacity and engagement among healthcare workers in Tanzania is low, despite high interest for capacity building. We propose a fourfold pathway for building research capacity in Tanzania through (1) high-quality research training and mentorship; (2) strengthening research infrastructure, funding, and coordination; (3) implementing policies and strategies that stimulate engagement; and (4) strengthening local and international collaborations.

Environmental Impact of a Pediatric and Young Adult Virtual Medicine Program: A Lesson from the COVID-19 Pandemic.

OBJECTIVES: The Coronavirus Disease 2019 (COVID-19) pandemic led to the expansion of virtual medicine as a method to provide patient care. We aimed to determine the impact of pediatric and young adult virtual medicine use on fossil fuel consumption, greenhouse gas, and nongreenhouse traffic-related air pollutant emissions. METHODS: We conducted a retrospective analysis of all virtual medicine patients at a single quaternary-care children's hospital with a geocoded address in the Commonwealth of Massachusetts prior to (March 16, 2019-March 15, 2020) and during the COVID-19 pandemic (March 16, 2020-March 15, 2021). Primary outcomes included patient travel distance, gasoline consumption, carbon dioxide and fine particulate matter emissions as well as savings in main hospital energy use. RESULTS: There were 3,846 and 307,273 virtual visits performed with valid Massachusetts geocoded addresses prior to and during the COVID-19 pandemic, respectively. During 1 year of the pandemic, virtual medicine services resulted in a total reduction of 620,231 gallons of fossil fuel use and $1,620,002 avoided expenditure as well as 5,492.9 metric tons of carbon dioxide and 186.3 kg of fine particulate matter emitted. There were 3.1 million fewer kilowatt hours used by the hospital intrapandemic compared to the year prior. Accounting for equipment emissions, the combined intrapandemic emission reductions are equivalent to the electricity required by 1,234 homes for 1 year. CONCLUSIONS: Widespread pediatric institutional use of virtual medicine provided environmental benefits. The true potential of virtual medicine for decreasing the environmental footprint of health care lies in scaling this mode of care to patient groups across the state and nation when medically feasible.

Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review.

BACKGROUND: Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality. METHODS: A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated. RESULTS: Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain. CONCLUSIONS: Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.

Comparative Study of Pharyngeal Flap Outcomes between Children With 22q11.2 Deletion Syndrome and Non-Syndromic Cleft Lip and Palate.

BACKGROUND: Management of velopharyngeal insufficiency (VPI) in 22q11.2 deletion syndrome (22q) is challenging. This study compares pharyngeal flap outcomes in children with 22q to those with non-syndromic cleft lip and palate (CLP) to assess risk of poor speech outcomes and negative sequelae. METHODS: Children with 22q or CLP treated with pharyngeal flap through a multidisciplinary VPI clinic between 2009 and 2020 were retrospectively reviewed. Pre- and postoperative speech assessments, perioperative characteristics, and complications were identified. RESULTS: 36 children with ​22q and 40 with CLP were included. Age at surgery (p=0.121), pre-operative velopharyngeal competence score (VPC) (p=0.702), and pre-operative resonance (p=0.999) were similar between groups. Pharyngeal flaps were wider (p=0.038*) and length of stay longer in the 22q group (p=0.031*). On short term follow 4 months after surgery, similar speech outcomes were seen between groups. At long term follow up >12 months after surgery, 86.7% 22q v. 100% CLP (p=0.122) had improvement in velopharyngeal function, however fewer children with 22q (60.0%) achieved a completely "competent" VPC score compared to those with CLP (92.6%) (p=0.016*). Nasal regurgitation improved for both groups, with a greater improvement in those with 22q (p=0.026*). Revision rate (p=0.609) and new onset OSA (0.999) were similar between groups. CONCLUSION: Children with 22q have improved speech after pharyngeal flap, but may be less likely to reach normal velopharyngeal function over the long term than those with CLP; however, negative sequelae do not differ. Improvement in nasal regurgitation is a uniquely positive outcome in this population.

A Financing Strategy to Expand Surgical Health Care.

Despite an evolving need to provide surgical health care globally, few health systems, particularly in low-income and middle-income countries (LMICs), can sufficiently provide such care. The vast majority of the world's people-an estimated 5 billion-are unable to access safe and affordable surgical health care when they need it. This is a significant concern for global public health because the demand for these services is rising with the epidemiological and demographic transitions occurring worldwide. A principal driver of weak surgical health care services is a lack of adequate health system financing for surgical health care. This article examines the financing of surgical health care by analyzing global trends in health system financing, approaches to expand fiscal space for health, and empirical perspectives on the design, introduction, and scale-up of policies to improve surgical systems. We describe a surgical health care financing strategy, together with broader political and economic considerations, to provide policy recommendations to fund the expansion of surgical health care and an essential surgical package as part of universal health coverage in LMICs.

Surgically Correctable Congenital Anomalies: Reducing Morbidity and Mortality in the First 8000 Days of Life.

BACKGROUND: Congenital anomalies are a leading cause of morbidity and mortality worldwide. We aimed to review the common surgically correctable congenital anomalies with recent updates on the global disease burden and identify the factors affecting morbidity and mortality. METHOD: A literature review was done to assess the burden of surgical congenital anomalies with emphasis on those that present within the first 8000 days of life. The various patterns of diseases were analyzed in both low- and middle-income countries (LMIC) and high-income countries (HIC). RESULTS: Surgical problems such as digestive congenital anomalies, congenital heart disease and neural tube defects are now seen more frequently. The burden of disease weighs more heavily on LMIC. Cleft lip and palate has gained attention and appropriate treatment within many countries, and its care has been strengthened by global surgical partnerships. Antenatal scans and timely diagnosis are important factors affecting morbidity and mortality. The frequency of pregnancy termination following prenatal diagnosis of a congenital anomaly is lower in many LMIC than in HIC. CONCLUSION: Congenital heart disease and neural tube defects are the most common congenital surgical diseases; however, easily treatable gastrointestinal anomalies are underdiagnosed due to the invisible nature of the condition. Current healthcare systems in most LMICs are still unprepared to tackle the burden of disease caused by congenital anomalies. Increased investment in surgical services is needed.

Orbital and Eyelid Characteristics, Strabismus, and Intracranial Pressure Control in Apert Children Treated by Endoscopic Strip Craniectomy versus Fronto-Orbital Advancement.

Apert syndrome is characterized by eyelid dysmorphology, V-pattern strabismus, extraocular muscle excyclorotation, and elevated intracranial pressure (ICP). We compare eyelid characteristics, severity of V-pattern strabismus, rectus muscle excyclorotation, and ICP control in Apert syndrome patients initially treated by endoscopic strip craniectomy (ESC) at about 4 months of age versus fronto-orbital advancement (FOA) performed about 1 year of age. Methods: Twenty-five patients treated at Boston Children's Hospital met inclusion criteria for this retrospective cohort study. Primary outcomes were magnitude of palpebral fissure downslanting at 1, 3, and 5 years of age, severity of V-pattern strabismus, rectus muscle excyclorotation, and interventions to control ICP. Results: Before craniofacial repair and through 1 year of age, none of the studied parameters differed for FOA versus ESC treated patients. Palpebral fissure downslanting became statistically greater for those treated by FOA by 3 (P < 0.001) and 5 years of age (P = 0.001). Likewise, severity of palpebral fissure downslanting correlated with severity of V-pattern strabismus at 3 (P = 0.004) and 5 (P = 0.002) years of age. Palpebral fissure downslanting and rectus muscle excyclorotation were typically coexistent (P = 0.053). Secondary interventions to control ICP were required in four of 14 patients treated by ESC (primarily FOA) and in two of 11 patients initially treated by FOA (primarily third ventriculostomy) (P = 0.661). Conclusions: Apert patients initially treated by ESC had less severe palpebral fissure downslanting and V-pattern strabismus, normalizing their appearance. Thirty percent initially treated by ESC required secondary FOA to control ICP.

Assessing the inclusion of children's surgical care in National Surgical, Obstetric and Anaesthesia Plans: a policy content analysis.

OBJECTIVE: While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children's surgery is addressed is not well-known. This study aims to assess the inclusion of children's surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children's surgical care in future policies. DESIGN: We performed two qualitative content analyses to assess the inclusion of children's surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children's Surgery's Optimal Resources for Children's Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia. RESULTS: Our framework for the inclusion of children's surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed 'human resources and training' and 'infrastructure', four addressed 'service delivery', three addressed 'governance and financing', two included 'research, evaluation and quality improvement', and one NSOAP addressed 'equipment and supplies' and 'advocacy and awareness'. CONCLUSIONS: Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children's surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children's surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.

Large Vertex Encephaloceles: Management and Outcomes.

BACKGROUND: Complex vertex and posterior encephaloceles containing brain tissue have uncertain prognosis and high operative risk. Patients may not be offered operative intervention depending on local and regional specialist expertise. The authors present their experience treating 5 such pediatric patients. METHODS: This is a retrospective review of the surgical assessment, planning, and technique of cranial repairs, as well as surgical outcomes and developmental follow-up regarding adaptive functioning for patients presenting for second opinion for encephalocele of the cranial vertex after having been deemed too high risk at another institution. RESULTS: Five consecutive patients presented between January 2014 and June 2016. One patient was not offered repair. Of 4 patients who underwent reconstruction, average age at time of repair was 2.7 months (range, 0.9-6.7). One presented with ruptured encephalocele, whereas the remaining 3 underwent drainage of the encephalocele (average volume of 1200 mL) at time of surgical resection. Operative time averaged 3.7 hours (range, 2.2-5.3). There were no deaths. One patient had a single seizure postoperatively. Two patients required placement of permanent shunt for hydrocephalus. Two patients completed developmental evaluations, both of whom exhibited delays in adaptive functioning relative to same-aged peers. CONCLUSIONS: Patients with large, complex encephalocele warrant evaluation by an experienced high-volume tertiary care pediatric craniofacial center. The decision to proceed with surgical management should include an interdisciplinary team of surgeons, anesthesiologists, neurologists, and social work. Further study of developmental outcomes in both operated and unoperated patients is necessary to better understand risks and benefits of reconstruction.

Association between Surgery, Anesthesia, and Obstetric Workforce and Emergent Surgical and Obstetric Mortality among United States Hospital Referral Regions.

OBJECTIVE: To determine the association between SAO workforce and mortality from emergent surgical and obstetric conditions within US HR Rs. BACKGROUND: SAO workforce per capita has been identified as a core metric of surgical capacity by the Lancet Commission on Global Surgery, but its utility has not been assessed at the subnational level for a high-income country. METHODS: The number of practicing surgeons, anesthesiologists, and obstetricians per capita was estimated for all HRRs using the US Health Resources & Services Administration Area Health Resource File Database. Deaths due to emergent general surgical and obstetric conditions were determined from the Center for Disease Control and Prevention WONDER database. We utilized B-spline quantile regression to model the relationship between SAO workforce and emergent surgical mortality at different quantiles of mortality and calculated the expected change in mortality associated with increases in SAO workforce. RESULTS: The median SAO workforce across all HRRs was 74.2 per 100,000 population (interquartile range 33.3-241.0). All HRRs met the Lancet Commission on Global Surgery lower target of 20 SAO per 100,000, and 97.7% met the upper target of 40 per 100,000. Nearly 2.8 million Americans lived in HRRs with fewer than 40 SAO per 100,000. Increases in SAO workforce were associated with decreases in surgical mortality in HRRs with high mortality, with minimal additional decreases in mortality above 60 to 80 SAO per 100,000. CONCLUSIONS: Increasing SAO workforce capacity may reduce emergent surgical and obstetric mortality in regions with high surgical mortality but diminishing returns may be seen above 60 to 80 SAO per 100,000. Trial Registration: N/A.