Kimberly M. Daniels

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

Prenatal Features Predictive of Robin Sequence Identified by Fetal Magnetic Resonance Imaging

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

Cost-Benefit Analysis of Three-Dimensional Craniofacial Models for Midfacial Distraction: A Pilot Study.

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

Palatal fistula risk after primary palatoplasty: a retrospective comparison of humanitarian operations and tertiary hospitals

7·57 per capita and take 20 472 person years. When accounting for the delay of entry to the workforce due to training in these countries, the median rate of entry to meet the goal density will have to increase 10·9 times after a 10 year delay in an SAO only model as opposed to 4·98 times with a 5 year delay in the hybrid 4:1 associate clinician-to-SAO model. INTERPRETATION Although low-income countries, lower-middle-income countries, and upper-middle-income countries will require a surgical workforce scale-up, lower-middle-income countries will require the largest scale-up. In these countries, implementing a system of task shifting can decrease costs and training times by 40%. Meeting densities of 20 per 100 000 will not guarantee quality care or improved access in rural areas, and equal attention must be paid to the provision of safe, affordable, accessible surgical care to all who need it. FUNDING None.

Physician Courtesy and Patient Satisfaction in a Pediatric Plastic and Oral Surgery Department

Background: Prenatal magnetic resonance imaging is increasingly used to detect congenital anomalies. The purpose of this study was to determine whether prenatal magnetic resonance imaging accurately characterizes features predictive of postnatal Robin sequence so that possible airway compromise and feeding difficulty at birth can be anticipated. Methods: The authors retrospectively identified pregnant women who underwent fetal magnetic resonance imaging between 2002 and 2014 and were found to be carrying a fetus with micrognathia. Micrognathia was subjectively categorized as minor, moderate, or severe. Pregnancy outcome was determined as follows: intrauterine fetal demise, elective termination, early neonatal death, or viable infant. Postnatal findings of micrognathia, Robin sequence, and associated anomalies were compared to prenatal findings. Results: Micrognathia was identified in 123 fetuses. Fifty-two pregnancies (42.3 percent) produced a viable infant. The remainder resulted in termination in the fetal period or death shortly after birth resulting from unrelated causes. For infants who lived, prenatal micrognathia was categorized as minor (55.1 percent), moderate (30.6 percent), or severe (14.3 percent). Forty-two percent of neonates with minor prenatal micrognathia had postnatal micrognathia; however, only 11.1 percent had Robin sequence. All neonates with moderate fetal micrognathia had postnatal micrognathia, and the majority had Robin sequence (86.7 percent). All newborns with severe micrognathia had Robin sequence and all prenatally diagnosed with glossoptosis had Robin sequence. Conclusions: Prenatal findings of moderate or severe micrognathia or glossoptosis are predictive of postnatal Robin sequence, thus expediting appropriate perinatal management of airway and feeding problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Assessing the Cost of Prophylactic Antibiotic Use after Cleft Lip and Lip Adhesion Procedures/PRACTITIONER APPLICATION

Objective Patient-specific three-dimensional (3D) models are increasingly used to virtually plan rare surgical procedures, providing opportunity for preoperative preparation, better understanding of individual anatomy, and implant prefabrication. The purpose of this study was to assess the benefit of 3D models related to patient safety, operative time, and cost. Design Retrospective review. Setting Academic, tertiary care hospital. Patients, Participants Midfacial distraction was studied as a representative craniofacial operation. A consecutive series of 29 patients who underwent a single type of midfacial distraction was included. Intervention For a subset of patients, computed tomography-derived 3D models were used to study patient-specific anatomy and precontour hardware. Main Outcome Measures Complications, operative time, blood loss, and estimated cost. Results Twenty patients underwent midfacial distraction without and nine with preoperative use of a 3D model. Seven complications occurred in six patients without model use, including premature consolidation (3), cerebrospinal fluid leak (2), and hardware malfunction (2). No complications were reported in the model group. Controlling for surgeon variation, model use resulted in a 31.3-minute (7.8%) reduction in operative time. Time-based cost savings were estimated to be

How much surgery is enough? Aligning surgical delivery with best-performing health systems

1036. Conclusions Three-dimensional models are valuable for preoperative planning and hardware precontouring in craniofacial surgery, with potential positive effects on complications and operative time. Savings related to operative time and complications may offset much of the cost of the model.

Otologic Disease Following Palatoplasty In International Cleft Palate Cohort

BACKGROUND Humanitarian surgical organisations provide cleft palate repair for patients without access to surgical care. Despite decades of experience, very little research has assessed the outcomes of these trips. This study investigates the fistula rate in patients from two cohorts in rural China and one in the USA. METHODS This retrospective study compared the odds of fistula presentation among three cohorts whose palates were repaired between April, 2005, and November, 2009. The primary cohort included 97 Chinese patients operated on in China by surgeons from ReSurge International. A second Chinese cohort of 250 patients was operated on at Huaxi University Hospital by Chinese surgeons. The third cohort of 120 patients from the University of California San Francisco (UCSF) was included for comparison over the same time period; data was taken from medical records. Age, fistula presentation, and Veau Class were compared between the three cohorts with χ(2) tests. Logistic regression was used to analyse predictors of fistula presentation among the three cohorts. This study received institutional review board approval from the UCSF, the Harvard School of Public Health, and physicians at Huaxi University Hospital, and written consent was obtained from study participants in China. FINDINGS The fistula risk was 35·4% in ReSurge patients, 12·8% for patients at Huaxi University Hospital, and 2·5% for patients at UCSF (p<0·001). At the time of surgery 15·5% of the ReSurge patients were younger than 2 years old, whereas 90·8% of the UCSF children and 41·6% of the Huaxi children were (p<0·001). In the ReSurge cohort, 20·6% of patients had a Veau class of I or II, wheras 40·8% and 58·9% of UCSF and Huaxi patients, respectively, were in class I or II (p<0·001). Age and Veau Class were associated with fistula formation in a univariate analysis. (Veau Class III or IV vs I or II, odds ratio [OR] 6·399 [95% CI 3·182-12·871]; age, OR 1·071 [95% CI 1·024-1·122]). A multivariate model controlling for the surgical group, age at palatoplasty, and sex showed an association between Veau Class and the odds of fistula presentation (Class III or IV vs I or II, OR 5·630 [95% CI 2·677-11·837). In this model, UCSF patients and Huaxi patients had 0·064 and 0·451 times the odds of developing a fistula, respectively, compared with ReSurge patients (p<0·001 both). INTERPRETATION Chinese children undergoing palatoplasty on surgical missions have higher post-operative odds of palatal fistula than do children treated by local physicians. Children in low-resource settings have higher complication rates than do children in high-resource settings. Older age at palatoplasty and a Veau class III and IV are associated with post-palatoplasty fistula. Furthermore demographic, socioeconomic, and cultural differences could play a part in palatoplasty fistula outcomes between these three populations. More research is needed to determine the effects of post-operative care, the skill of the providers, and the technique used in the surgery that play a role on fistula outcomes after primary palatoplasty, particularly in low-resource environments. FUNDING None.

Palatal Fistula Risk after Primary Palatoplasty: A Retrospective Comparison of a Humanitarian Organization and Tertiary Hospitals

EXECUTIVE SUMMARY Hospitals in the United States have started collecting information related to the patient experience with the objective of improving overall patient satisfaction. Between 2012 and 2015, the authors collected data from 2,875 patient satisfaction surveys. The purpose of this study was to analyze the effects of several variables—wait time, physician courtesy, administrative staff courtesy, patients’ opportunity to ask questions, and patients’ understanding of the answers—on a patient satisfaction score. A linear regression model was used to analyze the effects of these variables on patient satisfaction. All variables but one were significantly associated with patient satisfaction in the multivariable model. Healthcare provider courtesy was the strongest predictor of patient satisfaction; a score of “excellent” was associated with a 2.63-point (95% confidence interval [2.36, 2.90]) increase on a 5-point scale for patient satisfaction compared with a courtesy score of “poor.” These findings suggest that patients had a positive experience when physicians and staff members were courteous.

Ear Disease following Cleft Lip and Palate Surgery without Tympanostomy Tube Placement

EXECUTIVE SUMMARY The purpose of this study was to understand the true cost of administering prophylactic antibiotics postoperatively to patients undergoing cleft lip and lip adhesion procedures for which the rate of infection is historically low. Using time‐driven activity‐based costing (TDABC) methodologies, the plastic surgery department of one hospital created a process map with related time intervals and personnel cost rates for administering the antibiotic. The cost for each provider, based on standard salary information, was multiplied by the time required to complete his or her stage of the process, and this outcome was added to the supply costs. Overall cost was determined by summing the cost of all the steps. The cost of administering four doses of ampicillin/sulbactam to a patient during an inpatient stay ranged from