Colleen Aldous

Global and country underestimation of hepatocellular carcinoma (HCC) in 2012 and its implications

PURPOSE The problems of screening costs, as well as poor data, potentially lead to the underestimation of the incidence of hepatocellular carcinoma (HCC). In particular, this is problematic in developing countries with limited resources and poor data. The study develops a model to inform policy makers of the true incidence and potential extra cost of HCC in a developing country context. METHODS Using Globocan 2012 data, we employed an ecological correlation design at country level to associate HCC incidence data with relevant determinant data like HBV-HCV and other exposure factors. A Poisson regression model was used to estimate potentially missed incident cases of HCC by country and region based on the country risk factor covariate values. RESULTS The results indicated that HBV and HCV prevalence were significantly associated with HCC incidence (p<0.001) and potentially accounted for 94%% of incident HCC in 2012. We estimated a total of 120,772 potentially missed incident HCC cases in 2012. These cases are largely predicted for South Asia (>21,000), North Asia (>15,000), Western Africa (14,500) and Eastern Africa (12,500). CONCLUSIONS Developing countries, with poorer quality data and a high historical burden of hepatitis, were predicted to have the majority of missed HCC cases in 2012 based on our model. These countries are, therefore, less able to detect, budget for or manage HCC. The high cost of HCC treatment, as well as its economic implications, poses a challenge in resource poor settings.

The design, construction and implementation of a computerised trauma registry in a developing South African metropolitan trauma service

INTRODUCTION The Pietermaritzburg Metropolitan Trauma Service formerly lacked a robust computerised trauma registry. This made surgical audit difficult for the purpose of quality of care improvement and development. We aimed to design, construct and implement a computerised trauma registry within our service. Twelve months following its implementation, we sought to examine and report on the quality of the registry. METHODOLOGY Formal ethical approval to maintain a computerised trauma registry was obtained prior to undertaking any design and development. Appropriate commercial software was sourced to develop this project. The registry was designed as a flat file. A flat file is a plain text or mixed text and binary file which usually contains one record per line or physical record. Thereafter the registry file was launched onto a secure server. This provided the benefits of access security and automated backups. Registry training was provided to clients by the developer. The exercise of data capture was then integrated into the process of service delivery, taking place at the endpoint of patient care (discharge, transfer or death). Twelve months following its implementation, the compliance rates of data entry were measured. RESULTS The developer of this project managed to design, construct and implement an electronic trauma registry into the service. Twelve months following its implementation the data were extracted and audited to assess the quality. A total of 2640 patient entries were captured onto the registry. Compliance rates were in the order of eighty percent and client satisfaction rates were high. A number of deficits were identified. These included the omission of weekend discharges and underreporting of deaths. CONCLUSION The construction and implementation of the computerised trauma registry was the beginning of an endeavour to continue improvements in the quality of care within our service. The registry provided a reliable audit at twelve months post implementation. Deficits and limitations were identified and new strategies have been planned to overcome these problems and integrate the trauma registry into the process of clinical care.

Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital.

BACKGROUND Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings. METHODS A structured template was developed for each morbidity and mortality meeting. We used a grid to analyse mortality and classify the death as: (i) death expected/death unexpected; and (ii) death unpreventable/death preventable. Individual cases were then analysed using a combination of error taxonomies. RESULTS During the period June - December 2011, a total of 400 acute admissions (195 trauma and 205 non-trauma) were managed at Edendale Hospital, Pietermaritzburg, South Africa. During this period, 20 morbidity and mortality meetings were held, at which 30 patients were discussed. There were 10 deaths, of which 5 were unexpected and potentially avoidable. A total of 43 errors were recognised, all in the domain of the acute admissions ward. There were 33 assessment failures, 5 logistical failures, 5 resuscitation failures, 16 errors of execution and 27 errors of planning. Seven patients experienced a number of errors, of whom 5 died. CONCLUSION Error theory successfully dissected out the contribution of error to adverse events in our institution. Translating this insight into effective strategies to reduce the incidence of error remains a challenge. Using the examples of error identified at the meetings as educational cases may help with initiatives that directly target human error in trauma care.

The hospital cost of road traffic accidents at a South African regional trauma centre: A micro-costing study

BACKGROUND Road traffic crashes are responsible for a vast amount of death and disability in developing countries. This study uses a bottom up, micro-costing approach to determine the cost of road traffic related crashes in South Africa. METHODS Using the data from one hundred consecutive RTC related admissions to a regional hospital in South Africa we performed a bottom up costing study. To calculate costs patients were reviewed every 48 h and all interventions were recorded for each individual patient. Prices of interventions were obtained from hospital pricelists. A total cost was calculated on an individual basis. RESULTS The total cost of in-patient care for these patients was US

The implications of the patterns of error associated with acute trauma care in rural hospitals in South Africa for quality improvement programs and trauma education.

6,98,850. Upper limb injuries were the most expensive, and the total cost increased with the number of body regions injured. The biggest expenditure was on ward overheads (

The cost effectiveness of early management of acute appendicitis underlies the importance of curative surgical services to a primary healthcare programme.

2,81,681). Ninety operations were performed - the total cost of theatre time was

A concept paper: Using the outcomes of common surgical conditions as quality metrics to benchmark district surgical services in South Africa as part of a systematic quality improvement programme

1,48,230 and the cost of orthopaedic implants was

A deadly combination - HIV and diabetes mellitus: Where are we now?

1,26,487. CONCLUSION The cost of care of a RTC victim is significant. In light of the high numbers of RTC victims admitted over the course of the year this is a significant cost burden for a regional hospital to bear. This cost must be taken into account when allocating hospital budgets.

Diabetic patients served at a regional level hospital: what is their clinical picture?

INTRODUCTION This audit uses error theory to analyze inappropriate trauma referrals from rural district hospitals in South Africa. The objective of the study is to inform the design of quality improvement programs and trauma educational programs. METHODS At a weekly metropolitan morbidity and mortality meeting all trauma admissions to the Pietermaritzburg Metropolitan Trauma Service are reviewed. At the meeting problematic and inappropriate referrals and cases of error are identified. We used the (JCAHO) taxonomy to analyze these errors. RESULTS During the period July 2009-2011 we received 1512 trauma referrals from our rural hospitals. Of these referrals we judged 116 (13%) to be problematic. This group sustained a total of 142 errors. This equates to 1.2 errors per patient. There were 87 males and 29 females in this group. The mechanism of injury was as follows, blunt trauma (66), stabs (32), gunshot wounds (GSW) (13) and miscellaneous five. The types of error consisted of assessment errors (85), resuscitation errors (26), logistics errors (14) and combination errors (17). The cause of the errors was planning failure in 68% of cases and execution failure in the remaining 32% of cases. The assessment errors involved the abdomen (50), chest (9), vascular system (8) and miscellaneous (18). The resuscitation errors involved airway (4), chest (11), vascular access (8) and cervical spine immobilization (3). CONCLUSIONS Rural areas are error prone environments. Errors of execution revolve around the resuscitation process and current trauma courses specifically address these resuscitation deficits. However planning or assessment failure is the most common cause of error with blunt trauma being more prone to error of assessment than penetrating trauma.

Patterns of injury seen in road crash victims in a South African trauma centre

INTRODUCTION Appendicitis in the developing world is a cause of significant preventable morbidity. This prospective study from a regional hospital in South Africa constructs a robust cost model that demonstrates the cost effectiveness of an efficient curative surgical service in a primary healthcare-orientated system. METHODS A prospective audit of all patients with acute appendicitis admitted to Edendale Hospital was undertaken from September 2010 to September 2011. A microcosting approach was used to construct a cost model based on the estimated cost of operative and perioperative interventions together with the associated hospital stay. For cost analysis, patients were divided into the following cohorts: uncomplicated appendicitis, complicated appendicitis with localised intra-abdominal sepsis, complicated appendicitis with generalised intra-abdominal sepsis, with and without intensive care unit admission. RESULTS Two hundred patients were operated on for acute appendicitis. Of these, 36% (71/200) had uncomplicated appendicitis and 57% (114/200) had perforation. Pathologies other than appendicitis were present in 8% (15/200) and these patients were excluded. Of the perforated appendices, 45% (51/114) had intra-abdominal contamination that was localised while 55% (63/114) generalised sepsis. The mean cost for each patient was: 6,578 ZAR (£566) for uncomplicated appendicitis; 14,791 ZAR (£1,272) for perforation with localised intra-abdominal sepsis and 34,773 ZAR (£2,990) for perforation with generalised intra-abdominal sepsis without intensive care admission. With intensive care admission it was 77,816 ZAR (£6,692). The total cost of managing acute appendicitis was 4,272,871 ZAR (£367,467). Almost 90% of this total cost was owing to advanced disease with abdominal sepsis and therefore potentially preventable. CONCLUSIONS Early uncomplicated appendicitis treated appropriately carries little morbidity and is relatively inexpensive to treat. As the pathology progresses, the cost rises exponentially. An efficient curative surgical service must be regarded as a cost effective component of a primary healthcare orientated system.