Johanna N. Riesel

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anesthesia care in low- and middleincome countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labor, congenital anomalies, and breast and cervical cancer. Although the term, low- and middleincome countries (LMICs), has been used throughout the report for brevity, the Commission realizes that tremendous income diversity exists between and within this group of countries. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, noncommunicable diseases, and injuries. Surgical and anesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anesthesiacare,whichshouldbeavailable, affordable,timely,andsafetoensuregood coverage, uptake, and outcomes. Despite a growing need, the develop

Global access to surgical care: a modelling study

BACKGROUND More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commissions vision. METHODS We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis. FINDINGS At least 4·8 billion people (95% posterior credible interval 4·6-5·0 [67%, 64-70]) of the worlds population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access. INTERPRETATION Most of the worlds population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all. FUNDING None.

Prevalence and Implications of Preinjury Warfarin Use An Analysis of the National Trauma Databank

OBJECTIVES To describe the prevalence of preinjury warfarin use in a large national sample of trauma patients and to define the relationship between preinjury warfarin use and mortality. DESIGN Retrospective cohort study. SETTING The National Trauma Databank (7.1). PATIENTS All patients admitted to eligible trauma centers during the study period; 1,230,422 patients (36,270 warfarin users) from 402 centers were eligible for analysis. MAIN OUTCOME MEASURES Prevalence of warfarin use and all-cause in-hospital mortality. Multivariate logistic regression was used to estimate the odds ratio (OR) for mortality associated with preinjury warfarin use. RESULTS Warfarin use increased among all patients from 2.3% in 2002 to 4.0% in 2006 (P < .001), and in patients older than 65 years, use increased from 7.3% in 2002 to 12.8% in 2006 (P < .001). Among all patients, 9.3% of warfarin users died compared with only 4.8% of nonusers (OR, 2.02; 95% confidence interval [CI], 1.95-2.10; P < .001). After adjusting for important covariates, warfarin use was associated with increased mortality among all patients (OR, 1.72; 95% CI, 1.63-1.81; P < .001) and patients 65 years and older (OR, 1.38; 95% CI, 1.30-1.47; P < .001). CONCLUSIONS Warfarin use is common among injured patients and its prevalence has increased each year since 2002. Its use is a powerful marker of mortality risk, and even after adjusting for confounding comorbidities, it is associated with a significant increase in death.

Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development

John G Meara*, Andrew J M Leather*, Lars Hagander*, Blake C Alkire, Nivaldo Alonso, Emmanuel A Ameh, Stephen W Bickler, Lesong Conteh, Anna J Dare, Justine Davies, Eunice Dérivois Mérisier, Shenaaz El-Halabi, Paul E Farmer, Atul Gawande, Rowan Gillies, Sarah L M Greenberg, Caris E Grimes, Russell L Gruen, Edna Adan Ismail, Thaim Buya Kamara, Chris Lavy, Ganbold Lundeg, Nyengo C Mkandawire, Nakul P Raykar, Johanna N Riesel, Edgar Rodas‡, John Rose, Nobhojit Roy, Mark G Shrime, Richard Sullivan, Stéphane Verguet, David Watters, Thomas G Weiser, Iain H Wilson, Gavin Yamey, Winnie Yip

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.

Global Surgery 2030: a roadmap for high income country actors

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the worlds new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

Towards closing the gap of the global surgeon, anaesthesiologist, and obstetrician workforce: thresholds and projections towards 2030.

BACKGROUND Billions of people are without access to surgical care, in part because of the inequitable distribution of the surgical workforce. Drawing on recently collected data for the number of surgeons, anaesthesiologists, and obstetricians worldwide, we sought to show their global maldistribution by identifying thresholds of surgical workforce densities, and by calculating the number of additional providers needed to reach those thresholds. METHODS From the WHO Global Surgical Workforce Database, national data for the number of specialist surgeons, anaesthesiologists, and obstetricians per 100 000 population (density) were compared with the number of maternal deaths per 100 000 live births (maternal mortality ratio; MMR) in WHO member countries. A regression line was fit between density of specialist surgeons, anaesthesiologists, and obstetricians and the logarithm of MMR, and we explored the correlation for an upper and a lower density threshold. Based on previous estimates of the global volume of surgical procedures, a global average productivity per specialist was derived. We then multiplied the average productivity with the derived upper and lower threshold densities, and compared these numbers to previously estimated global need of surgical procedures (4664 procedures per 100 000 population). Finally, the numbers of additional providers needed to reach the thresholds in countries with a density below the respective threshold were calculated. FINDINGS Each 10-unit increase in density of surgeons, anaesthesiologists, and obstetricians, corresponded to a 13·1% decrease in MMR (95% CI 11·3-14·8). We saw particularly steep improvements in MMR from 0 to roughly 20 per 100 000 population. Above roughly 40 per 100 000 population, higher density was associated with relatively smaller improvements in MMR. These arbitrary thresholds of 20 and 40 specialists per 100 000 corresponded with a volume of surgery of 2917 and 5834 procedures per 100 000 population, respectively, and were symmetrically distributed around the estimated global need of 4664 surgical procedures per 100 000 population. Our density thresholds are slightly higher than the current average in lower-middle income countries (16 per 100 000) and upper-middle-income countries (38 per 100 000), respectively. To reach the threshold of at least 20 per 100 000 in each country today, another 440 231 (IQR 438 900-443 245) providers would be needed. To reach 40 per 100 000, 1 110 610 (IQR 1 095 376-1 183 525) providers would be needed. INTERPRETATION Assuming uniform productivity, a global surgical workforce between 20 and 40 per 100 000 would suffice to provide the worlds missing surgical procedures. We concede that causality cannot be implied, but our results suggest that countries with a workforce density above certain thresholds have better health outcomes. Although the thresholds cannot be interpreted as a minimum standard, they are useful to characterise the global surgical workforce and its deficits. Such thresholds could also be used as markers for health system capacity. FUNDING None.

The scale-up of the surgical workforce

BACKGROUND Countries with fewer than 20 specialist surgeons, anaesthetists, and obstetricians (SAO) per 100 000 population have worse health outcomes. To achieve surgical workforce densities of 20 per 100 000 by 2030, a scale up of the surgical workforce is required. No previous study has shown what this will cost, how many providers will be required, or how long it will take to increase the global surgical workforce. We aim to identify these answers for health-care systems that employ SAO alone and for those that use a hybrid model of SAO and task shifting to inform strategic planning. METHODS Data for the density of SAO per country were obtained from the WHO Global Surgical Workforce Database. To find the total number of SAO that need to enter the workforce by 2030 to achieve surgical workforce thresholds of 20 per 100 000, the population growth formula (P=0e(rt)) was used and we assumed exponential surgical workforce growth and two potential retirement rates of either 1% or 10%. We did not account for migration. The same calculations were used for associate clinicians needed to enter the workforce in either a 2:1 or 4:1 associate clinicians-to-SAO ratio. The costs to train SAO and associate clinicians were estimated with data for training costs imputed into a regression analysis with health-care expenditure per capita for each country. We assumed training costs will remain constant, and we did not account for inflation. The time needed to train new surgical and anaesthetic providers was estimated with average length of training for SAO and associate clinicians and was measured in person years. Two models (one for a system of SAO only and one for a hybrid of SAO and associate clinicians) were created to show how many providers will need to enter the workforce per year once training is complete to reach targets by 2030. The model did not involve the scale-up of the surgical workforce needed to address unmet needs of essential surgical services. FINDINGS By 2030, the world will need 1 272 586 new surgical workforce providers to meet a surgical workforce density of 20 per 100 000 assuming a 1% retirement rate. This will cost US

Global surgical and anaesthetic task shifting: a systematic literature review and survey

71-146 billion depending on the model used. Low-income and lower-middle-income countries show the largest required scale-up. An additional 806 352 (median 3412 [IQR 691-6851]) providers are needed in those countries. In the SAO only model, this will cost a median of US

Building a global surgery initiative through evaluation, collaboration, and training: the Massachusetts General Hospital experience.

19·66 per 2013 capita (IQR 15·79-25·07) and will take a median of 34 121 person years (IQR 6911-68 509). In the 4:1 associate clinician-to-SAO ratio, it will cost a median of US