Rowan Gillies

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

Correlation of Quantitative EEG in Acute Ischemic Stroke With 30-Day NIHSS Score Comparison With Diffusion and Perfusion MRI

Background and Purpose— Magnetic resonance imaging (MRI) methods such as diffusion- (DWI) and perfusion-weighted (PWI) imaging have been widely studied as surrogate markers to monitor stroke evolution and predict clinical outcome. The utility of quantitative electroencephalography (qEEG) as such a marker in acute stroke has not been intensively studied. The aim of the present study was to correlate ischemic cortical stroke patients’ clinical outcomes with acute qEEG, DWI, and PWI data. Materials and Methods— DWI and PWI data were acquired from 11 patients within 7 and 16 hours after onset of symptoms. Sixty-four channel EEG data were obtained within 2 hours after the initial MRI scan and 1 hour before the second MRI scan. The acute delta change index (aDCI), a measure of the rate of change of average scalp delta power, was compared with the National Institutes of Health Stroke Scale scores (NIHSSS) at 30 days, as were MRI lesion volumes. Results— The aDCI was significantly correlated with the 30-day NIHSSS, as was the initial mean transit time (MTT) abnormality volume (&rgr;=0.80, P <0.01 and &rgr;=0.79, P <0.01, respectively). Modest correlations were obtained between the 15-hour DWI lesion volume and both the aDCI and 30-day NIHSSS (&rgr;=0.62, P <0.05 and &rgr;=0.73, P <0.05, respectively). Conclusions— In this small sample the significant correlation between 30-day NIHSSS and acute qEEG data (aDCI) was equivalent to that between the former and MTT abnormality volume. Both were greater than the modest correlation between acute DWI lesion volume and 30-day NIHSSS. These preliminary results indicate that acute qEEG data might be used to monitor and predict stroke evolution.

Global surgery: defining an emerging global health field

Global health is one of the defi ning issues of the 21st century, attracting unprecedented levels of interest and propelling health and disease from a biomedical process to a social, economic, political, and environmental concern. Surgery, however, has not been considered an integral component of global health and has remained largely absent from the discipline’s discourse. After much inattention, surgery is now gaining recognition as a legitimate component of global health. In January, 2014, Jim Kim, President of the World Bank, urged the global health community to challenge the injustice of global inequity in surgical care, stating that “surgery is an indivisible, indispensable part of health care and of progress towards universal health coverage”. However, defi ning a place for surgery within the current global health paradigm of disease-based care and issue-specifi c advocacy remains a challenge—surgery is not a distinct disease entity such as HIV/AIDS, nor does it target a specifi c demographic such as reproductive, maternal, neonatal, and child health. Rather, surgery plays a part in addressing a diverse set of cross-cutting health challenges within a health system and is crucial to the full attainment of global health goals. Individuals and groups committed to addressing global inequity in access to surgery and improving the status of surgical care within global health have started to come together under the umbrella of global surgery. Although the term global surgery has rapidly entered the vernacular, a defi nition has not been provided. Here, we discuss the importance of defi ning global surgery to advance its role as an indivisible component of global health and propose a working defi nition that can serve as a focal point around which both the surgical and wider global health community can unite. Increased awareness of the place for surgery within global health will benefi t not only the surgical community, but all those working to improve health outcomes, strengthen health systems, and reduce health inequities at a local and global scale. Common defi nitions in global health are central to the setting of objectives, priorities, and strategies, communication of goals and vision, and channelling of resources. They can also act as a rallying point, to unify diff erent actors and create strong community cohesion, which is key to generation of political priority. The nascent global surgery movement would do well to learn from global health’s mistakes. Failure to defi ne global health early in its own development allowed and even encouraged several, competing, and sometimes contradictory frames of reference to emerge. The confusion was damaging and created silos and factions among groups instead of cohesion and cooperation. Although global surgery has not been defi ned formally, defi nitions for various related terms including surgical care, surgical conditions, and surgical providers have been proposed (appendix). These defi nitions take a broad, inclusive approach to the defi nition of surgery, recognising that surgical care is usually delivered within multidisciplinary teams. Such care does not always involve an operation or procedure and can be delivered at primary care level and in the hospital setting. Underpinning the emergence of the term global surgery has been a desire to link surgical need with the overall global health agenda. To defi ne global surgery conceptually, the central tenets of global health therefore need to be incorporated. These tenets have themselves been the subject of much analysis and debate, but are broadly considered to include the global conceptualisation of health, the synthesis of population-based approaches with individual level clinical care, the central concept of equity in health, and the cross-sectoral, interdisciplinary approach to the understanding of ill health and its solutions. The term global in global health refers to health issues that are worldwide or universally present, that transcend national boundaries, and are supraterritorial—such as, for example, climate change. The key commonality is that global is used to refer to the scope of the problems not their physical location. So too for global surgery. In the absence of a clear defi nition, global surgery has been increasingly used to refer to surgery within geographical boundaries, and particularly within low-income and middle-income countries. A focus on these countries is appropriate because inequity is greatest in these regions. However, defi nition of the specialty as referring only to the problems of specifi c countries or regions would be incorrect. Concentration on the scope of the problems and the processes driving them rather than the geographical boundaries in which they are contained allows for greater insight into determinants and solutions. A global approach to surgery will mean a change in the way responsibility and accountability for surgical care are approached. Because the causes of inadequate or inequitable surgical care and the solutions are often interconnected or interdependent, the burden and responsibility for improving care is collective and needs to extend beyond sovereign borders. Identifi cation of successful strategies for increasing collective responsibility, action, and accountability at a global level, which are also locally grounded, will be crucial to meaningful progress in global surgery. The emergence of several transnational initiatives that address globally relevant issues in surgery such as patient safety, hospitalacquired infection, and international organ traffi cking are examples of strategies that have been conceived at a global level, developed on the basis of collective responsibility, and adopted within countries and local institutions. Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60237-3

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.

The global met need for emergency obstetric care: a systematic review.

Of the 287 000 maternal deaths every year, 99% happen in low‐ and middle‐income countries. The vast majority could be averted with timely access to appropriate emergency obstetric care (EmOC). The proportion of women with complications of pregnancy or childbirth who actually receive treatment is reported as ‘Met need for EmOC’.

Geospatial mapping to estimate timely access to surgical care in nine low-income and middle-income countries

BACKGROUND The Lancet Commission on Global Surgery calls for universal access to safe, affordable, and timely surgical care. Two requisite components of timely access are (1) the ability to reach a surgical provider in a given timeframe, and (2) the ability to receive appropriately prompt care from that provider. We chose a threshold of 2 h in view of its relevance in time-to-death in post-partum haemorrhage. Here, we use geospatial mapping to enumerate the percentage of a nations population living within 2 h of a surgeon and the surgeon-to-population ratio for each provider. METHODS Geospatial mapping was used to identify the population living within a 2-h driving distance (access zone) of a health-care facility staffed by a surgeon. Surgeon locations were extracted from Ministries of Health, professional society databases, and published literature for countries which had available data. Data were reviewed by individuals knowledgeable of in-country distribution. Spatial distribution of providers was mapped with Google Maps engine. Access zones were constructed around every provider through estimation of driving times in Google Maps. The number of people living within zones was estimated with the Socioeconomic Data and Applications Center Population Estimation Service. Surgeon-to-population ratios were constructed for every individual access zone and averaged to report a single ratio. FINDINGS Results (% countrys population living within an access zone; average surgeon:population ratio within all access zones) are reported for nine countries with available data: Somaliland (16·9%; 1:118 306), Botswana (31·0%; 1:64 635), Ethiopia (39·6%; 1:229 696), Rwanda (41·3%; 1:158 484), Namibia (43·4%; 1:69 385), Zimbabwe (54%; 1:148 292), Mongolia (55·5%; 1:10 500), Sierra Leone (70·3%; 1:106 742), and Pakistan (84·4%, 1:139 299). Surgeon-to-population ratios vary substantially even within countries; in Sierra Leone, urban access zones have a ratio of 1:45 058 and rural access zones have a ratio of 1:467 929. INTERPRETATION Surgical access is poor in many low-income and middle-income countries, even when using a narrow definition of surgical access consisting only of timeliness. Living outside of an access zone makes timely access to surgical care highly unlikely, and in view of low surgeon-to-population ratios and poor prehospital transport, even living within a 2-h access zone might not confer 2-h access. Investments in infrastructure and training must be prioritised to address widespread disparity in access to timely surgery. FUNDING None.

A time-driven activity-based costing model to improve health-care resource use in Mirebalais, Haiti

BACKGROUND In resource-limited settings, efficiency is crucial to maximise resources available for patient care. Time driven activity-based costing (TDABC) estimates costs directly from clinical and administrative processes used in patient care, thereby providing valuable information for process improvements. TDABC is more accurate and simpler than traditional activity-based costing because it assigns resource costs to patients based on the amount of time clinical and staff resources are used in patient encounters. Other costing approaches use somewhat arbitrary allocations that provide little transparency into the actual clinical processes used to treat medical conditions. TDABC has been successfully applied in European and US health-care settings to facilitate process improvements and new reimbursement approaches, but it has not been used in resource-limited settings. We aimed to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency. METHODS A multidisciplinary team used TDABC to map clinical processes for obstetric care (vaginal and caesarean deliveries, from triage to post-partum discharge) and breast cancer care (diagnosis, chemotherapy, surgery, and support services, such as pharmacy, radiology, laboratory, and counselling) at Hôpital Universitaire de Mirebalais (HUM) in Haiti. The team estimated the direct costs of personnel, equipment, and facilities used in patient care based on the amount of time each of these resources was used. We calculated inpatient personnel costs by allocating provider costs per staffed bed, and assigned indirect costs (administration, facility maintenance and operations, education, procurement and warehouse, bloodbank, and morgue) to various subgroups of the patient population. This study was approved by the Partners in Health/Zanmi Lasante Research Committee. FINDINGS The direct cost of an uncomplicated vaginal delivery at HUM was US

Surgical care by non-surgeons in low-income and middle-income countries: a systematic review

62 and the direct cost of a caesarean delivery was US

The How Project: understanding contextual challenges to global surgical care provision in low-resource settings

249. The direct costs of breast cancer care (including diagnostics, chemotherapy, and mastectomy) totalled US