Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis.

Background
Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure.

Methods
As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure.

Results
Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001).

Conclusions
The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

Ponseti clubfoot management: Experience with the Steenbeek foot abduction brace.

Clubfoot is one of the most common congenital deformities, with an incidence of one in 1000 live births worldwide. In Kenya, approximately 1200 infants are born with clubfoot every year. Left untreated, clubfoot leads to painful, disabling deformity and social stigmatization. Bracing is an integral part of the internationally accepted standard of care, and the Ponseti method of clubfoot management with compliance with bracing is considered to be the key to a successful outcome (1). This has brought the type of brace under scrutiny, with newer ‘child-friendly’ braces recommended over the traditional Dennis Brown brace (Figure 1), which has been associated with high rates of noncompliance. However, these child-friendly braces are expensive (USD$300) and out of reach for most families of affected children in Kenya and other developing countries. The Steenbeek foot abduction brace (SFAB) is made locally in Kenya at a cost of <USD$10 (Figure 2). The SFAB has been in use since the inception of the Clubfoot Care for Kenya (CCK) program in 2005. Therefore, we performed a study investigating SFAB acceptance, tolerability, compliance, complications and outcomes in the CCK program.

Establishing a children’s orthopaedic hospital for Malawi: A review after 10 years.

BEIT CURE International Hospital (BCIH) opened in 2002 providing orthopaedic surgical services to children in Malawi. This study reviews the hospital’s progress 10 years after establishment of operational services. In addition we assess the impact of the hospital’s Malawi national clubfoot programme (MNCP) and influence on orthopaedic training.All operative paediatric procedures performed by BCIH services in the 10th operative year were included. Data on clubfoot clinic locations and number of patients treated were obtained from the MNCP. BCIH records were reviewed to identify the number of healthcare professionals who have received training at the BCIH.609 new patients were operated on in the 10th year of hospital service. Patients were treated from all regions; however 60% came from Southern regions compared with the 48% in the 5th year. Clubfoot, burn contracture and angular lower limb deformities were the three most common pathologies treated surgically. In total BCIH managed 9,842 patients surgically over a 10-year period. BCIH helped to establish and co-ordinate the MNCP since 2007. At present the program has a total of 29 clinics, which have treated 5748 patients. Furthermore, BCIH has overseen the full or partial training of 5 orthopaedic surgeons and 82 orthopaedic clinical officers in Malawi.The BCIH has improved the care of paediatric patients in a country that prior to its establishment had no dedicated paediatric orthopaedic service, treating almost 10,000 patients surgically and 6,000 patients in the MNCP. This service has remained consistent over a 10-year period despite times of global austerity. Whilst the type of training placement offered at BCIH has changed in the last 10 years, the priority placed on training has remained paramount. The strategic impact of long-term training commitments are now being realised, in particular by the addition of Orthopaedic surgeons serving the nation.

Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia. A prospective study of 22 children (32 feet) from 2 to 10 years of age.

Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti’s technique in neglected clubfoot in children in a rural setting in Ethiopia.A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2-10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years.A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot.This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.

Provision of surgical care in Ethiopia: Challenges and solutions.

With the lowest measured rate of surgery in the world, Ethiopia is faced with a number of challenges in providing surgical care. The aim of this study was to elucidate challenges in providing safe surgical care in Ethiopia, and solutions providers have created to overcome them. Semi-structured interviews were conducted with 10 practicing surgeons in Ethiopia. Following de-identification and immersion into field notes, topical coding was completed with an existing coding manual. Codes were adapted and expanded as necessary, and the primary data analyst confirmed reproducibility with a secondary analyst. Qualitative analysis revealed topics in access to care, in-hospital care delivery, and health policy. Patient financial constraints were identified as a challenge to accessing care. Surgeons were overwhelmed by patient volume and frustrated by lack of material resources and equipment. Numerous surgeons commented on the inadequacy of training and felt that medical education is not a government priority. They reported an insufficient number of anaesthesiologists, nurses, and support staff. Perceived inadequate financial compensation and high workload led to low morale among surgeons. Our study describes specific challenges surgeons encounter in Ethiopia and demonstrates the need for prioritisation of surgical care in the Ethiopian health agenda. LCoGS: The Lancet Commission on Global Surgery; LMIC: low- and middle-income country.

Competency-Based Education in Low Resource Settings: Development of a Novel Surgical Training Program.

BACKGROUND:
The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Competency-based training has been advanced in high-income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low- and middle-income countries. We describe the development of a competency-based program to accelerate specialty training of in-country providers in cleft surgery techniques.

METHODS:
The program was designed and piloted among eight trainees at five international cleft lip and palate surgical mission sites in Latin America and Africa. A competency-based evaluation form, designed for the program, was utilized to grade general technical and procedure-specific competencies, and pre- and post-training scores were analyzed using a paired t test.

RESULTS:
Trainees demonstrated improvement in average procedure-specific competency scores for both lip repairs (60.4-71.0%, p < 0.01) and palate (50.6-66.0%, p < 0.01). General technical competency scores also improved (63.6-72.0%, p < 0.01). Among the procedural competencies assessed, surgical markings showed the greatest improvement (19.0 and 22.8% for lip and palate, respectively), followed by nasal floor/mucosal approximation (15.0%) and hard palate dissection (17.1%).

CONCLUSION:
Surgical delivery models in LMICs are varied, and trade-offs often exist between goals of case throughput, quality and training. Pilot program results show that procedure-specific and general technical competencies can be improved over a relatively short time and demonstrate the feasibility of incorporating such a training program into surgical outreach missions.

Towards effective Ponseti clubfoot care: the Uganda Sustainable Clubfoot Care Project.

Neglected clubfoot is common, disabling, and contributes to poverty in developing nations. The Ponseti clubfoot treatment has high efficacy in correcting the clubfoot deformity in ideal conditions but is demanding on parents and on developing nations’ healthcare systems. Its effectiveness and the best method of care delivery remain unknown in this context. The 6-year Uganda Sustainable Clubfoot Care Project (USCCP) aims to build the Ugandan healthcare system’s capacity to treat children with the Ponseti method and assess its effectiveness. We describe the Project and its achievements to date (March 2008). The Ugandan Ministry of Health has approved the Ponseti method as the preferred treatment for congenital clubfoot in all its hospitals. USCCP has trained 798 healthcare professionals to identify and treat foot deformities at birth. Ponseti clubfoot care is now available in 21 hospitals; in 2006-2007, 872 children with clubfeet were seen. USCCP-designed teaching modules on clubfoot and the Ponseti method are in use at two medical and three paramedical schools. 1152 students in various health disciplines have benefited. USCCP surveys have (1) determined the incidence of clubfoot in Uganda as 1.2 per 1000 live births, (2) gained knowledge surrounding attitudes, beliefs, and practices about clubfoot across different regions, and (3) identified barriers to adherence to Ponseti treatment protocols. USCCP is now following a cohort of treated children to evaluate its effectiveness in the Ugandan context.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Musculoskeletal trauma services in Uganda.

Approximately 2000 lives are lost in Uganda annually through road traffic accidents. In Kampala, they account for 39% of all injuries, primarily in males aged 16-44 years. They are a result of rapid motorization and urbanization in a country with a poor economy. Uganda’s population is an estimated 28 million with a growth rate of 3.4% per year. Motorcycles and omnibuses, the main taxi vehicles, are the primary contributors to the accidents. Poor roads and drivers compound the situation. Twenty-three orthopaedic surgeons (one for every 1,300,000 people) provide specialist services that are available only at three regional hospitals and the National Referral Hospital in Kampala. The majority of musculoskeletal injuries are managed nonoperatively by 200 orthopaedic officers distributed at the district, regional and national referral hospitals. Because of the poor economy, 9% of the national budget is allocated to the health sector. Patients with musculoskeletal injuries in Uganda frequently fail to receive immediate care due to inadequate resources and most are treated by traditional bonesetters. Neglected injuries typically result in poor outcomes. Possible solutions include a public health approach for prevention of road traffic injuries, training of adequate human resources, and infrastructure development.

Patterns and Causes of Amputation in Ayder Referral Hospital, Mekelle, Ethiopia: A Three-Year Experience

BACKGROUND:
Amputation is a surgical procedure for the removal of a limb which is indicated when limb recovery is impossible. There are different types of amputation, and their causes can vary from one area to the other. Therefor, the aim of this study is to find out the patterns and causes of amputations in patients presented to Ayder Referral Hospital, Mekelle, Ethiopia.

METHODS:
the record of 87 patients who had amputation at different sites after admission to Ayder referral hospital, Mekelle, Ethiopia in three years period were reviewed retrospectively.

RESULT:
A total of 87 patients had amputation of which 78.2% were males. The age range was from 3 to 95 years, and the mean age was 40.6 in years. The most common indications were trauma (37.7%), tumor (24.1%), and peripheral arterial disease (PAD) (20.7%). The commonest type of amputation was major lower limb amputation (58.6%) which includes above knee amputation (35.6%)and below knee amputation (23%) followed by digital amputation (17.2%). There was 11.4% major upper limb amputation of which there was one patient who had re-amputation.

CONCLUSION:
Most of the indications for amputations in our setup are potentially preventable by increasing awareness in the society on safety measures both at home and at work and early presentation to health facilities.

A Prospective Observational Study of Anesthesia-Related Adverse Events and Postoperative Complications Occurring During a Surgical Mission in Madagascar

BACKGROUND:
Two-thirds of the world’s population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined. Little is known concerning the incidence of anesthesia complications. Mercy Ships uses fully trained staff, and infrastructure and equipment resources similar to that of high-income countries, allowing the influence of these factors to be disentangled from patient factors when evaluating anesthesia and surgical outcomes after NGO sponsored surgery. We aimed to estimate the incidence of anesthesia-related and postoperative complications during a 2-year surgical mission in Madagascar.

METHODS:
As part of quality assurance and participation in a new American Society of Anesthesiologists Anesthesia Quality Institute sponsored NGO Outcomes registry, Mercy Ships prospectively recorded anesthesia-related adverse events. Adverse events were grouped into 6 categories: airway, cardiac, medication, regional, neurological, and equipment. Postoperative complications were predefined as 16 adverse events and graded for patient impact using the Dindo-Clavien classification.

RESULTS:
Data were evaluated for 2037 episodes of surgical care. The overall anesthesia adverse event rate was 2.0% (confidence interval [CI], 1.4-2.6). The majority (85% CI, 74-96) of adverse events occurred intraoperatively with 15% (CI, 3-26) occurring in postanesthesia care unit. The most common intraoperative adverse event, occurring 7 times, was failed regional (spinal) anesthesia that was due to unexpectedly long surgery in 6 cases; bronchospasm and arrhythmias were the second most common, occurring 5 times each. There were 217 postoperative complications in 191 patients giving an overall complication rate of 10.7% (CI, 9.3-12.0) per surgery and 9.4% (CI, 8.1-10.7) per patient. The most common postoperative complication was unexpected return to the operating room and the second most common was surgical site infection (39.2%; CI, 37.0-41.3 and 33.2%; CI, 31.1-35.3 of all complications, respectively). The most common (42.9%; CI, 40.7-45.1) grade of complication was grade II. There was 1 death.

CONCLUSIONS:
This study adds to the scarce literature on anesthesia outcomes after mission surgery in low- and middle-income countries. We join others in calling for an international NGO anesthesia and surgical outcome registry and for all surgical NGOs to adopt international standards for the safe practice of anesthesia.