Anju Ranjit

Surgical needs of Nepal: pilot study of population based survey in Pokhara, Nepal.

AbstractBackgroundThe Surgeons OverSeas assessment of surgical need (SOSAS) tool, a population-based survey on surgical conditions in low- and middle-income countries (LMICs), was performed in Sierra Leone and Rwanda. This pilot study in Nepal is the initial implementation of the SOSAS survey in South Asia.MethodsA pilot study of SOSAS, modified for Nepal’s needs and reprogrammed using mobile data collection software, was undertaken in Pokhara in January 2014. Cluster randomized sampling was utilized to interview 100 individuals in 50 households within two wards of Pokhara, one rural and one urban. The first portion of the survey retrieved demographic data, including household members and time to nearest health facilities. The second portion interviewed two randomly selected individuals from each household, inquiring about surgical conditions covering six anatomical regions.ResultsThe pilot SOSAS in Nepal was easily completed over 3xa0days, including training of 18 Nepali interns over 2xa0days. The response rate was 100xa0%. A total of 13 respondents had a current surgical need (face 4, chest 1, back 1, abdomen 1, groin 3, extremity 3), although eight reported there was no need for surgical care. Five respondents (5xa0%) had a current unmet surgical need.ConclusionnThe SOSAS pilot study in Nepal was successfully conducted, demonstrating the feasibility of performing SOSAS in South Asia. The estimated 5xa0% current unmet surgical need will be used for sample size calculation for the full country survey. Utilizing and improving on the SOSAS tool to measure the prevalence of surgical conditions in Nepal will help enumerate the global surgical burden of disease.

Outcomes of Mothers and Children at Five Years After Cesarean Versus Vaginal Delivery [22E]

INTRODUCTION:The objective of this study was to determine whether outcomes of mothers and children at five years vary after cesarean versus vaginal delivery.METHODS:TRICARE (universal insurance coverage to all members of US Armed Services and their dependents) data was used to identify mother-infant

Obstetric Care in the U.S. Military: Comparison of Direct and Purchased Care System Within TRICARE [11R]

INTRODUCTION: Pregnant women with TRICARE (universal insurance coverage to members of US Armed Services and their dependents) can receive obstetric care under direct care/salary-based (DC) or purchased care/fee-for-service (PC) system. The objective of this study was to compare intra-partum obstetric care between direct and purchased care systems in TRICARE. METHODS: TRICARE (2006–2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (normal vaginal, cesarean and instrumental vaginal) and co-morbid conditions (gestational diabetes and hypertension) along with complications, including post-partum hemorrhage (PPH), lacerations, infection and thrombotic events were compared between two systems of care. RESULTS: A total of 440,138 deliveries were identified. The mean age of mothers in DC and PC was 26.7 years and 27.3 years, respectively (P<.001). A higher proportion of mothers in DC had gestational diabetes (6.9% vs 4.9%, P<.001) and gestational hypertension (5.8% vs 4.7%, P<.001). Proportion of cesarean delivery (25.8% vs 30.9%, P<.001) and instrumental vaginal delivery (5.3% vs 6.4%, P<.001) was lower in DC compared to PC. Complications such as PPH (4.9% vs 3.4%, P<.001) and perineal lacerations (8.3% vs 6.4%, P<.001) were significantly higher in DC as compared to PC. CONCLUSION: We found that the direct/military (salary-based) system had fewer interventions (such as operative deliveries) and higher complication rates. Study of the direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the US.

Variation in Ultrasound Utilization by Region and System of Care in the U.S. Military [30M]

INTRODUCTION: ACOG recommends up to two ultrasounds (USGs) in low-risk pregnancies. We sought to examine the proportion of women using TRICARE (insurance for US Armed Services members and their dependents) who received more than 2 USGs per pregnancy and variation across geographical regions and systems of care (direct/salary-based vs purchased/fee-for-service). METHODS: We used TRICARE (2006–2010) claims data to identify deliveries and created a low-risk cohort by excluding women aged 35 and above, twin and preterm deliveries, and women with prior cesarean or co-morbidities. CPT codes were used to determine the number of USGs per pregnancy for all women and low-risk women. The proportion of women who received more than 2 USGs/pregnancy were compared across four US regions and between two systems of care. RESULTS: Among 268,975 total deliveries, 50.94% were in the direct system, 49.06% were in the purchased system and 49.1% were identified as low-risk pregnancies. Overall, 137,168 (51%) received more than 2 USGs/pregnancy. Higher proportion of low-risk deliveries in the Northeast (48.67%) received more than 2 USGs screening during pregnancy compared to South (43.59%), Mid-west (36.54%) and West (39.58%) (P=.001). The purchased system had a higher proportion of low-risk women receiving more than 2 USGs/pregnancy compared to the direct system (46.05% vs. 37.93%; P<.001). CONCLUSION: There was wide variation in frequency of USG screening during pregnancy across regions and systems of care. Low-risk pregnancies in the direct/salary-based system received fewer ultrasounds than in the purchased/fee-for-service system. These findings suggest that reimbursement structures may impact USG utilization.

Untreated breast masses: A cross sectional countrywide survey of Nepal

Adequate access to healthcare is crucial to deliver a comprehensive, systematic diagnostic evaluation of a breast mass. Though the etiology of breast masses is vast, including both benign and malignant causes, a missed diagnosis of breast cancer should never occur in any part of the world. Globally, breast cancer is the most frequently diagnosed malignancy, accounting for about 10% of all malignancies detected in both men and women; 45% of the more than 1 million incident cases of breast care annually and 55% of breast-cancer related deaths occur in low and middle-income countries (LMICs).1,2 Case fatality rates from breast cancer are higher in LMICs than in high-income countries, perhaps from scarcity of preventive care facilities and lack of awareness.3