Hillary Jenny

Barriers to Cleft Lip and Palate Repair Around the World.

Background:Cleft lip and/or palate (CLP) is estimated to occur in 1 out of every 700 births, but for many people residing in low- and middle-income countries this deformity may be repaired late in life or not at all. This study aims to analyze worldwide provider-perceived barriers to the surgical repair of CLP in low- and middle-income countries. Methods:From 2011 to 2014, Smile Train distributed a multiple-choice, voluntary survey to healthcare providers to identify areas of need in CLP care worldwide. Data on provider-reported barriers to care were aggregated by year, country, and larger world regions. Results:A total of 1997 surveys were completed by surgeons and healthcare providers (60.7% response rate). The most commonly reported barriers were “patient travel costs” (60.7%), “lack of patient awareness” (54.1%), and “lack of financial support” (52.8%). “Patient travel costs” was the most commonly reported barrier in sub-Saharan Africa, the Middle East and North Africa, and South and Southeast Asia. “Lack of financial support” was the most commonly reported barrier in the Americas, Eastern Europe, and East Asia. Conclusions:This is the largest intercontinental study on healthcare provider-identified barriers to care, representing the limitations experienced by healthcare professionals in providing corrective surgery for CLP around the world. Financial risk protection from hidden costs, such as patient travel costs, is essential. Community health workers and nurses are critical for communication and linking CLP care to the rest of the community. Recognition of these barriers can inform future policy decisions, targeted by region, for surgical systems delivering care for patients with CLP worldwide.

Assessing the Brazilian surgical system with six surgical indicators: a descriptive and modelling study

Background Brazil boasts a health scheme that aspires to provide universal coverage, but its surgical system has rarely been analysed. In an effort to strengthen surgical systems worldwide, the Lancet Commission on Global Surgery proposed a collection of 6 standardised indicators: 2-hour access to surgery, surgical workforce density, surgical volume, perioperative mortality rate (POMR) and protection against impoverishing and catastrophic expenditure. This study aims to characterise the Brazilian surgical health system with these newly devised indicators while gaining understanding on the complexity of the indicators themselves. Methods Using Brazils national healthcare database, commonly reported healthcare variables were used to calculate or simulate the 6 surgical indicators. Access to surgery was calculated using hospital locations, surgical workforce density was calculated using locations of surgeons, anaesthesiologists and obstetricians (SAO), and surgical volume and POMR were identified with surgical procedure codes. The rates of protection against impoverishing and catastrophic expenditure were modelled using cost of surgical inpatient hospitalisations and a γ distribution of incomes based on Gini and gross domestic product/capita. Findings In 2014, SAO density was 34.7/100 000 population, surgical volume was 4433 procedures/100 000 people and POMR was 1.71%. 79.4% of surgical patients were protected against impoverishing expenditure and 84.6% were protected against catastrophic expenditure due to surgery each year. 2-hour access to surgery was not able to be calculated from national health data, but a proxy measure suggested that 97.2% of the population has 2-hour access to a hospital that may be able to provide surgery. Geographic disparities were seen in all indicators. Interpretation Brazils public surgical system meets several key benchmarks. Geographic disparities, however, are substantial and raise concerns of equity. Policies should focus on stimulating appropriate geographic allocation of the surgical workforce and better distribution of surgical volume. In some cases, where benchmarks for each indicator are met, supplemental analysis can further inform our understanding of health systems. This measured and systematic evaluation should be encouraged for all nations seeking to better understand their surgical systems.

The Role of Plastic Surgeons in Advancing Global Development.

I n September 2015, the international community came together to agree on the Sustainable Development Goals. These 17 goals are part of the 2030 Agenda for Sustainable Development, a plan of action for people, the planet, and prosperity. Ambitious and far-reaching as they are, they are built on three keystones: the elimination of extreme poverty, fighting climate change, and a commitment to fighting injustice and inequality. In that context, there is an increasing need to acknowledge the linkage between universal delivery of and access to safe and affordable surgical care, global health and development. Critical to the achievement of the Sustainable Development Goals is the global realization of access to safe affordable surgical and anesthesia care when needed. As a community of care providers dedicated to the restoration of the form and function of the human body, plastics surgeons have a collective opportunity to contribute to global development, making the world more equitable and helping to reduce extreme poverty. In 2008, Drs. Paul Farmer and JimKim identified surgery as the “neglected stepchild of global health” referring to the relative underfunding and lack of priority accorded surgical care. The landmark report by the Lancet Commission on Global Surgery “Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare and Economic Development” estimated that between 28% and 32% of the global burden of disease is amenable to surgical treatment. However, as many as 5 billion people of a total world population of 7.4 billion lack access to safe, timely, and affordable surgical care, a burden felt most severely in lowandmiddle-income countries (LMICs). Untreated, these conditions cause premature mortality and are a source of lifetime disability—surgical conditions claim an estimated 16.9 million lives per year. The Lancet Commission estimates that an additional 143 million surgeries would be necessary every year to save lives and prevent disability from surgical conditions. Building surgical capacity is not just important for preventing morbidity and mortality—lack of access to surgery impedes human freedoms and impacts global development and economic growth. Without the growth of surgical systems, LMICs are estimated to sacrifice up to 2% of annual gross domestic product growth by 2030. These losses correspond to 12.3 trillion USDollars (USD) of lost economic output in LMICs alone. Even when surgical care is available, it may not be financially accessible to the entire population: 33 million individuals face catastrophic expenditure due to the direct medical costs of surgery and anesthesia each year, with an additional 48 million facing catastrophic expenditure due to nonmedical costs, such as travel. This burden falls most heavily on the poorest people in LMICs. The myth of surgery as a luxury for the rich has been dispelled: it is a right for all, and a cost-effective means of treating disease. As a treatment modality, surgery demonstrates cost-effectiveness on par with other interventions, such as vaccinations and bed nets for malaria prevention. This holds true for plastic surgery, and, in particular, cleft lip and palate repair: the cost-effectiveness of this intervention is a mere US

Quality of essential surgical care in low- and middle-income countries: a systematic review of the literature

47.74 (2012 US

Access to safe blood in low-income and middle-income countries: lessons from India

) per disability-adjusted life year averted.

Patient-Perceived Barriers to Accessing Cleft Care at a Tertiary Referral Center in São Paulo, Brazil

PURPOSE Quality of care is an emerging area of focus in the surgical disciplines. However, much of the emphasis on quality is limited to high-income countries. To address this gap, we conducted a systematic review of the literature on the quality of essential surgical care in low- and middle- income countries (LMIC). DATA SOURCES We searched PubMed, Cinahl, Embase and CAB Abstracts using three domains: quality of care, surgery and LMIC. STUDY SELECTION We limited our review to studies of essential surgeries that pertained to all three search domains. DATA EXTRACTION We extracted data on study characteristics, type of surgery and the way in which quality was studied. RESULTS OF DATA SYNTHESIS 354 studies were included. 281 (79.4%) were single-center studies and nearly half (n = 169, 46.9%) did not specify the level of facility. 207 studies reported on mortality (58.47%) and 325 reported on a morbidity (91.81%), most commonly surgical site infection (n = 190, 53.67%). Of the Institute of Medicine domains of quality, studies were most commonly of safety (n = 310, 87.57%) and effectiveness (n = 180, 50.85%) and least commonly of equity (n = 21, 5.93%). CONCLUSION We find that while there are numerous studies that report on some aspects of quality of care, much of the data is single center and observational. Additionally, there is variability on which outcomes are reported both within and across specialties. Finally, we find under-reporting of parameters of equity and timeliness, which may be critical areas for research moving forward.

Assessing burn care in Brazil: An epidemiologic, cross-sectional, nationwide study

Timely, affordable access to screened blood is essential to the provision of safe surgical care and depends on three key aspects: adequate volume of blood supply, safe protocols for blood donation and transfusion, and appropriate regulation to ensure safe, equitable and sustainable distribution. Many low-income and middle-income countries experience a deficit in these categories, particularly in rural areas. We draw on the experience of rural surgical practitioners in India and summarise the existing literature to evaluate India’s blood banking system and discuss its major barriers to the safe and equitable provision of blood. Many low-income and middle-income countries struggle with accruing a sufficient voluntary, unpaid blood donation base to meet the need. Efforts to increase blood supply through mandatory family replacement donations can lead to dangerous delays in care provision. Additionally, prohibition of unbanked, directed blood transfusion restricts the options of health practitioners, particularly in rural areas. Blood safety is also a significant concern, and efforts must be taken to decrease the risk of transfusion-transmitted infections and inform and treat donors who test positive. Lastly, blood banking systems need a centralised governing body to ensure fair prices for blood, promote comprehensive transfusion reporting and increase system-wide transparency and accountability.

Pediatric surgical capacity building - a pathway to improving access to pediatric surgical care in Haiti

Background: In low- and middle-income countries, poor access to care can result in delayed surgical repair of orofacial clefts leading to poor functional outcomes. Even in Brazil, an upper middle-income country with free comprehensive cleft care, delayed repair of orofacial clefts commonly occurs. This study aims to assess patient-perceived barriers to cleft care at a referral center in São Paulo. Methods: A 29-item questionnaire assessing the barriers to care was administered to 101 consecutive patients (or their guardians) undergoing orofacial cleft surgery in the Plastic Surgery Department in Hospital das Clínicas, in São Paulo, Brazil, between February 2016 and January 2017. Results: A total of 54.4% of patients had their first surgery beyond the recommended time frame of 6 months for a cleft lip or cleft lip and palate and 18 months for a cleft palate. There was a greater proportion of isolated cleft palates in the delayed group (66.7% vs 33.3%). Almost all patients had a timely diagnosis, but delays occurred from diagnosis to repair. The mean number of barriers reported for each patient was 3.8. The most frequently cited barriers related to lack of access to care include (1) lack of hospitals available to perform the surgery (54%) and (2) lack of availability of doctors (51%). Conclusion: Delays from diagnosis to treatment result in patients receiving delayed primary repairs. The commonest patient-perceived barriers are related to a lack of access to cleft care, which may represent a lack of awareness of available services.

Efficacy of Facilitated Capacity Building in Providing Cleft Lip and Palate Care in Low- and Middle-Income Countries

Background: The aim of this study was to describe the national epidemiology of burns in Brazil and evaluate regional access to care by defining the contribution of out‐of‐hospital mortality to total burn deaths. Methods: We reviewed admissions data for Brazils single‐payer, free‐at‐point‐of‐care, public‐sector provider and national death registry data abstracted from DATASUS for 2008–2014. Admissions, in‐hospital mortality, hospital reimbursement, and total deaths from the death registry were assessed for records coded under ICD‐10 codes corresponding to flame, scald, contact, and electrical burns. Results: A total of 17,264 burn deaths occurred between 2008–2014 (mean annual 2,466 [SD 202]). Of all burns deaths 79.1% occurred out of hospital, with marked regional differences in the proportion of out‐of‐hospital deaths (P < 0.001), the greatest being in the North region. The mean annual number of admissions >24 hours was 18,551 (SD 1,504) with the greatest prevalence of flame burns overall (43.98%) and scalds prevailing in < 5 years (57.8%). Regional differences were found in per‐capita admissions (P < 0.001) with the greatest number in the Central‐West region. A mean of

Abstract: Assessing Quality in Systematic Reviews

1,022 (SD