Frugal innovation for global surgery: leveraging lessons from low- and middle-income countries to optimise resource use and promote value-based care

Limited or inconsistent access to necessary resources creates many challenges for delivering quality medical care in low- and middle-income countries (LMICs). These include funding and revenue, skilled clinical and allied health professionals, administrative expertise, reliable community infrastructure (eg water, electricity), functioning capital equipment and sufficient surgical supplies. Despite these challenges, some surgical care providers manage to provide cost effective, high quality care, offering lessons not only for other LMICs but also for high-income countries (HICs) that are working towards increasing value-based care. Examples would be how to optimise the consumption of resources, and reduce the environmental and public health burden of surgical care.

Owing to the liberal utilisation of capital equipment and single-use supplies, surgical care in HICs is increasingly recognised as a significant source of greenhouse gases and other environmental impacts that adversely affect human health. Regulations require many potentially reusable supplies and drugs to be discarded after single use. Supply manufacturers may label drugs or products as single-use to increase profit, reduce liability or facilitate regulatory approval. Many HICs struggle to increase the value of care while maximising quality and outcomes, and minimising cost and resource use.

Salome Maswime: dynamic leader in global surgery

As Associate Professor and Head of Global Surgery at the University of Cape Town (UCT), South Africa, Salome Maswime is aware of the scale of the job in front of her. “For me the big problem is the disconnect between health systems and clinical care in low and middle income countries, especially concerning surgical care. Outcomes are often poor, there being not enough focus on the quality of surgery, and how it relates to integrated health care and overarching health systems performance”, she explains. Maswime saw such shortcomings first hand in her clinical career in obstetrics and gynaecology, before she took up the new post as Head of Global Surgery at UCT in July, 2019.

Usability of Mobile Health Apps for Postoperative Care: Systematic Review

Background: Mobile health (mHealth) apps are increasingly used postoperatively to monitor, educate, and rehabilitate. The usability of mHealth apps is critical to their implementation.

Objective: This systematic review evaluates the (1) methodology of usability analyses, (2) domains of usability being assessed, and (3) results of usability analyses.

Methods: The A Measurement Tool to Assess Systematic Reviews checklist was consulted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was adhered to. Screening was undertaken by 2 independent reviewers. All included studies were assessed for risk of bias. Domains of usability were compared with the gold-standard mHealth App Usability Questionnaire (MAUQ).

Results: A total of 33 of 720 identified studies were included for data extraction. Of the 5 included randomized controlled trials (RCTs), usability was never the primary end point. Methodology of usability analyses included interview (10/33), self-created questionnaire (18/33), and validated questionnaire (9/33). Of the 3 domains of usability proposed in the MAUQ, satisfaction was assessed in 28 of the 33 studies, system information arrangement was assessed in 11 of the 33 studies, and usefulness was assessed in 18 of the 33 studies. Usability of mHealth apps was above industry average, with median System Usability Scale scores ranging from 76 to 95 out of 100.

Conclusions: Current analyses of mHealth app usability are substandard. RCTs are rare, and validated questionnaires are infrequently consulted. Of the 3 domains of usability, only satisfaction is regularly assessed. There is significant bias throughout the literature, particularly with regards to conflicts of interest. Future studies should adhere to the MAUQ to assess usability and improve the utility of mHealth apps.

Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa—a scoping review

Background
Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries.

Methods
We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks.

Results
Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties.

Conclusion
A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.

Hashtag Global Surgery: The Role of Social Media in Advancing the Field of Global Surgery

Introduction: Surgery is increasingly recognized as an indispensable part of healthcare, but lack of awareness about its cost-effectiveness and cross-cutting impact remain. Social media has become an important resource for healthcare professionals in a variety of settings due to its instant global reach in a non-discriminatory and low-threshold manner. In 2010, #globalsurgery was first used on Twitter to spread awareness, foster international collaborations, and raise voices of advocates around the world. Here, we examine the role of social media in the field of global surgery.

Methods: The use of #globalsurgery on Twitter was analyzed through Tweetreach from July 31 to December 31, 2018. Additional analysis of hashtags in Spanish, Japanese, Malay, and Portuguese was done to determine the number of tweets, retweets, impressions, and users using #globalsurgery or translated hashtags. Sentiment analysis was performed to determine the affective state of tweets.

Results: A total of 4,519 tweets and 15,861 retweets were posted by 4,449 different contributors. Tweets totalled 58,733,406 potential direct impressions and 46,560,293 potential amplified impressions, with potential reach of 11,272,014. English was the major language (99.47%), followed by Spanish (0.49%) and Japanese (0.04%). Portuguese and Malay hashtags were not used during the study period.

Conclusion: #globalsurgery provides an innovative way to overcome barriers and strengthen collaboration among advocates, and more effectively raise awareness about global surgery.

Oxygen availability in sub-Saharan African countries: a call for data to inform service delivery

Oxygen is central to the management of patients admitted to hospital with severe COVID-19. Furthermore, the availability of oxygen therapy is just as important for the management of other patients who are acutely ill. However, despite recognition from most health-care providers that oxygen is a fundamental component of a health-care system, it has not been a focus of health-care delivery in sub-Saharan African countries, as shown by the lack of data collected on oxygen availability.

Psychological Status of Surgical Staff During the COVID-19 Outbreak

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which appeared in early December 2019, had an atypical viral pneumonia outbreak in Wuhan, Hubei, China. And there is a high risk of global proliferation and impact. The sudden increase in confirmed cases has brought tremendous stress and anxiety to frontline surgical staff. The results showed that the anxiety and depression of surgical staff during the outbreak period were significantly higher and mental health problems appeared, so psychological interventions are essential.

Doctor-patient Communication in Surgical Practice During the Coronavirus (COVID-19) Pandemic

COVID‐19 is a new respiratory disease that has become a pandemic, involving whole world. Hospitals are now a hub for this disease and patients are advised to avoid hospitals as far as possible. Many healthcare workers are infected with SARS‐CoV‐2. This virus can spread from an infected doctor to patients or colleagues and does not respect any boundaries. Moreover, immunocompromized patients are at a greater risk of this potentially life‐threatening contagious disease. Recommendations of social distancing and home isolation to limit the spread of coronavirus are major factors limiting patients’ communication with doctors regarding their disease.

Surgical Site Infection and Costs in Low- And Middle-Income Countries: A Systematic Review of the Economic Burden

Background: Surgical site infection (SSI) is a worldwide problem which has morbidity, mortality and financial consequences. The incidence rate of SSI is high in Low- and Middle-Income countries (LMICs) compared to high income countries, and the costly surgical complication can raise the potential risk of financial catastrophe.

Objective: The aim of the study is to critically appraise studies on the cost of SSI in a range of LMIC studies and compare these estimates with a reference standard of high income European studies who have explored similar SSI costs.

Methods: A systematic review was undertaken using searches of two electronic databases, EMBASE and MEDLINE In-Process & Other Non-Indexed Citations, up to February 2019. Study characteristics, comparator group, methods and results were extracted by using a standard template.

Results: Studies from 15 LMIC and 16 European countries were identified and reviewed in full. The additional cost of SSI range (presented in 2017 international dollars) was similar in the LMIC ($174-$29,610) and European countries ($21-$34,000). Huge study design heterogeneity was encountered across the two settings.

Discussion: SSIs were revealed to have a significant cost burden in both LMICs and High Income Countries in Europe. The magnitude of the costs depends on the SSI definition used, severity of SSI, patient population, choice of comparator, hospital setting, and cost items included. Differences in study design affected the comparability across studies. There is need for multicentre studies with standardized data collection methods to capture relevant costs and consequences of the infection across income settings.

Management Strategies and Role of Telemedicine in a Surgery Unit During COVID-19 Outbreak

At the end of 2019, in Wuhan, the capital of Hubei (China) were reported 27 cases of death caused by “severe acute respiratory virus coronavirus 2” (SARS-CoV-2) [1]. The World Health Organization (WHO) on March 11, 2020, has declared the COVID-19 outbreak a global pandemic [2]. Officially, Italian lockdown started on March 10th and ended on May 3rd, 2020. From 4 May a new phase of coexistence with the coronavirus began. This is characterized by a gradual reopening of commercial activities and by persistence of some important rules such as social distancing and use of masks in public transport. At the 20/05/2020 in Italy there are 226.699 total cases and 32.169 deaths, while in Campania region, total cases are 4.707 with 400 deaths [3]. In this situation, there was a rapid reorganization of public health system and hospitals. Also, for surgery there have been several changes. As part of COVID-19 containment strategy and with Intensive Care Unit (ICU) near collapse, elective operations were suspended while emergency surgery and the operative therapy of oncological patients continued. Moreover, have been deleted all non-urgent outpatients visits and endoscopic procedures.