Amber Caldwell

Surgical Care and Health Systems

BackgroundWhile surgical care impacts a wide variety of diseases and conditions with non-operative and operative services, both preventive and curative, there has been little discussion concerning how surgery might be integrated within the health system of a low and middle-income country (LMIC), nor how strengthening surgical services may improve health systems and population health.MethodsWe reviewed reports from several meetings of the working group on health systems strengthening of the Global Initiative for Emergency and Essential Surgical Care, and also performed a review of the literature including the search terms “surgery,” “health system,” “developing country,” “health systems strengthening,” “health information system,” “financing,” “governance,” and “integration.”ResultsThe literature search revealed no reports which focused on the integration of surgical services within a health system or as a component of health system strengthening. A conceptual model of how surgical care might be integrated within a health system is proposed, based on the discussions of our working group, combined with sources from the medical literature, and utilizing the World Health Organization’s conceptual model of a health system.ConclusionsStrengthening the delivery of surgical services in LMICs will require inputs at multiple levels within a health system, and this effort will require the coalescence of committed individuals and organizations, supported by civil society.

Time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems

OBJECTIVE To investigate the use of time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems. METHODS Time intervals from injury to admission, admission to surgery and surgery to discharge for patients with isolated femur fractures in four low- and middle-income countries were compared with the corresponding values from one German hospital, an Israeli hospital and the National Trauma Data Bank of the United States of America by means of Students t-tests. The correlations between the time intervals recorded in a country and that countrys expenditure on health and gross domestic product (GDP) were also evaluated using Pearsons product moment correlation coefficient. FINDINGS Relative to patients from high-income countries, those from low- and middle-income countries were significantly more likely to be male and to have been treated by open femoral nailing, and their intervals from injury to admission, admission to surgery and surgery to discharge were significantly longer. Strong negative correlations were detected between the interval from injury to admission and government expenditure on health, and between the interval from admission to surgery and the per capita values for total expenditure on health, government expenditure on health and GDP. Strong positive correlations were detected between the interval from surgery to discharge and general government expenditure on health. CONCLUSION The time intervals for the treatment of femur fractures are relatively long in low- and middle-income countries, can easily be measured, and are highly correlated with accessible and quantifiable country data on health and economics.

Impact of academic collaboration and quality of clinical orthopaedic research conducted in low- and middle-income countries

Background: Little is known about the quality of orthopaedic investigations conducted in low- and middle-income countries (LMICs). Academic collaboration is one model to build research capacity and improve research quality. Our study aimed to determine (1) the quality of clinical orthopaedic research conducted in LMICs, (2) the World Bank Regions and LMICs that publish the highest quality studies, (3) the pattern of collaboration among investigators and (4) whether academic collaboration between LMIC and non-LMIC investigators is associated with studies that have higher levels of evidence. Methods: Orthopaedic studies from 2004 to 2014 conducted in LMICs were extracted from multiple electronic databases. The World Bank Region, level of evidence and author country-affiliation were recorded. Collaboration was defined as a study that included an LMIC with non-LMIC investigator. Results: There were 958 studies that met inclusion criteria of 22,714 searched. Ninety-seven (10.1%) of included studies achieved Level 1 or 2 evidence, but case series (52.3%) were the most common. Collaboration occurred in 14.4% of studies and the vast majority of these (88.4%) were among academic institutions. Collaborative studies were more likely to be Level 1 or 2 (20.3% vs. 8.4%, p < 0.01), prospective (34.8% vs. 22.9% p = 0.04) and controlled (29.7% vs. 14.4%, p < 0.01) compared to non-collaborative studies. Conclusions: Although orthopaedic studies in LMICs rarely reach Level 1 or 2 evidence, studies published through academic collaboration between LMIC and non-LMIC investigators are associated with higher levels of evidence and more prospective, controlled designs.

Building Orthopaedic Trauma Capacity: IGOT International SMART Course.

Summary: Orthopaedic injuries from trauma are increasingly common in Low to Middle Income Countries secondary to the increase in road traffic. These injuries commonly contain a soft tissue component, which complicates treatment of bony injuries and increases amputation rate. Specialized care using plastic surgery techniques is required to effectively treat these injuries. Historically medical mission models have been used to provide specialists to help provide soft tissue coverage where plastic surgeons are not available. This type of care is inherently unsustainable. We present an approach where a course was designed to teach soft tissue coverage techniques to orthopaedic surgeons. The course was given annually over 5 years, serving approximately 300 participants. Data collected from participants demonstrated that they found the course useful, learned techniques that allowed them to care for patients, and disseminate the knowledge further. Participants endorsed that they had performed 594 flaps with a 93% success rate at 1 year of follow-up from the course. We find that this type of intervention has the potential to address the need for soft tissue coverage in countries where this need is present, and resources are unavailable.

The Institute for Global Orthopedics and Traumatology: A Model for Academic Collaboration in Orthopedic Surgery

In 2006, surgeons at the University of California, San Francisco (UCSF) established the Institute for Global Orthopedics and Traumatology (IGOT), an initiative within the department of orthopedic surgery. The principal aim of IGOT is to create long-term, sustainable solutions to the growing burden of musculoskeletal injury in low- and middle-income countries (LMICs) through academic partnership. IGOT currently has relationships with teaching hospitals in Ghana, Malawi, Tanzania, Nicaragua, and Nepal. The organizational structure of IGOT is built on four pillars: Global Surgical Education (GSE), Global Knowledge Exchange (GKE), Global Research Initiative (GRI), and Global Leadership and Advocacy. GSE focuses on increasing surgical knowledge and technical proficiency through hands-on educational courses. The GKE facilitates the mutual exchange of surgeons and trainees among IGOT and its partners. This includes a global resident elective that allows UCSF residents to complete an international rotation at one of IGOT’s partner sites. The GRI strives to build research capacity and sponsor high-quality clinical research projects that address questions relevant to local partners. The fourth pillar, Global Leadership and Advocacy aims to increase awareness of the global impact of musculoskeletal injury through national and international courses and events, such as the Bay Area Global Health Film Festival. At the core of each tenet is the collaboration among IGOT and its international partners. Over the last decade, IGOT has experienced tremendous growth and maturation in its partnership model based on cumulative experience and the needs of its partners.

Surgical Management and Reconstruction Training (SMART) Course for International Orthopedic Surgeons.

BACKGROUND The burden of complex orthopedic trauma in low- and middle-income countries (LMICs) is exacerbated by soft-tissue injuries, which can often lead to amputations. This studys purpose was to create and evaluate the Surgical Management and Reconstruction Training (SMART) course to help orthopedic surgeons from LMICs manage soft-tissue defects and reduce the rate of amputations. METHODS In this prospective observational study, orthopedic surgeons from LMICs were recruited to attend a 2-day SMART course taught by plastic surgery faculty in San Francisco. Before the course, participants were asked to assess the burden of soft-tissue injury and amputation encountered at their respective sites of practice. A survey was then given immediately and 1-year postcourse to evaluate the quality of instructional materials and the courses effect in reducing the burden of amputation, respectively. RESULTS Fifty-one practicing orthopedic surgeons from 25 countries attended the course. No participant reported previously attempting a flap reconstruction procedure to treat a soft-tissue defect. Before the course, participants cumulatively reported 580-970 amputations performed annually as a result of soft-tissue defects. Immediately after the course, participants rated the quality and effectiveness of training materials to be a mean of ≥4.4 on a Likert scale of 5 (Excellent) in all 14 instructional criteria. Of the 34 (66.7%) orthopedic surgeons who completed the 1-year postcourse survey, 34 (100%, P < 0.01) reported performing flaps learned at the course to treat soft-tissue defects. Flap procedures prevented 116 patients from undergoing amputation; 554 (93.3%) of the cumulative 594 flaps performed by participants 1 year after the course were reported to be successful. Ninety-seven percent of course participants taught flap reconstruction techniques to colleagues or residents, and a self-reported estimate of 28 other surgeons undertook flap reconstruction as a result of information dissemination by 1 year postcourse. CONCLUSION The SMART Course can give orthopedic surgeons in LMICs the skills and knowledge to successfully perform flaps, reducing the self-reported incidence of amputations. Course participants were able to disseminate flap reconstructive techniques to colleagues at their home institution. While this course offers a collaborative, sustainable approach to reduce global surgical disparities in amputation, future investigation into the viability of teaching the SMART course in LMICs is warranted.

Reply to letter to the editor: Critically assessing the Haiti earthquake response and the barriers to quality orthopaedic care.

We thank Dr. Moyad for his constructive criticism and service to the Haitian people. His positive experience providing care in the wake of this natural disaster is testament to the power of volunteerism in resource-poor countries. After the earthquake, many medical and surgical volunteers sacrificed to provide the highest quality care to disaster casualties. These stories and tremendous worldwide response should give all of us hope regarding our international capacity for relief. Nevertheless, the intention of the publication was to provide our readership with a perspective that has remained largely elusive. Although many publications regarding the orthopaedic response to the Haiti earthquake document the quantity of procedures performed and the personal stories of the volunteers, there are few systematic documentations of the failures. Our systematic method of data collection and analysis has many weaknesses highlighted in the publication, but it provides an important window into potential ways in which we can improve and devise measures of disaster care. Many of the anecdotes associated with poor-quality care, we believe, were preventable with training. From our interviews, for example, we discovered that ill-prepared physicians such as ophthalmologists and pediatricians were performing orthopaedic surgeries without adequate training. In addition, to address Dr. Moyad’s specific point regarding fasciotomies, there is documentation to suggest that this procedure should be reconsidered in the acute muscle-crush compartment syndromes commonly found in earthquake zones. The muscle in these limbs usually is already dead and in these resource-poor settings, when damage-control orthopaedics is necessary, there is limited time for repeated operations that risk limb-threatening infection [2]. Although we will never know the specific nature of every injury treated, there clearly is room for debate and greater need for better documentation and further study of disaster response. A substantial report from the Pan American Health Organization (PAHO) discusses the overall lack of organization and chaotic pattern of the relief effort [1]. The foreword of the report states that the response, “included a number of wholly unprepared or even incompetent health actors who bypassed the overburdened coordination mechanisms”. For these reasons, the PAHO report highlights the need for accreditation and training in disaster response, a matter about which we disagree with Dr. Moyad. Regardless of the outcome, training courses provide volunteers with the opportunity to share stories, exchange knowledge, build expert opinion, and prepare for a variety of patient-care possibilities. We hope that formal training courses are cultivated to continue to improve the care provided to patients most in need.