Procedural fairness for radiotherapy priority setting in a low resource context

Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve their populations. This mismatch between demand and supply creates the need for priority setting. There is no widely accepted system to guide patient prioritization for radiotherapy in a low resource context. In the absence of consensus on allocation principles, fair procedures for priority setting should be established. Research is needed to understand what elements of procedural fairness are important to decision makers in diverse settings, assess the feasibility of implementing fair procedures for priority setting in low resource contexts, and improve these processes. This study presents the views of decision makers engaged in everyday radiotherapy priority setting at a cancer center in Rwanda. Semi-structured interviews with 22 oncology physicians, nurses, program leaders, and advisors were conducted. Participants evaluated actual radiotherapy priority setting procedures at the program (meso) and patient (micro) levels, reporting facilitators, barriers, and recommendations. We discuss our findings in relation to the leading Accountability for Reasonableness (AFR) framework. Participants emphasized procedural elements that facilitate adherence to normative principles, such as objective criteria that maximize lives saved. They ascribed fairness to AFR’s substantive requirement of relevance more than transparency, appeals, and enforcement. They identified several challenges unresolved by AFR, such as conflicting relevant rationales and unintended consequences of publicity and appeals. Implementing fair procedure itself is resource intensive, a paradox that calls for innovative, context-appropriate solutions. Finally, socioeconomic and structural barriers to care that undermine procedural fairness must be addressed.

Barriers and facilitators of laparoscopic surgical training in rural north-east India: a qualitative study

Introduction:
Laparoscopic surgery has advantages for treating many abdominal surgical conditions, but its use in low and middle-income countries (LMICs) is limited by many factors, including a lack of training opportunities. The aim of this study was to explore the training experiences of surgeons in rural north-east India to highlight the barriers and facilitators to laparoscopic surgery.

Methods:
Eleven surgeons with experience in laparoscopy in rural north-east India were recruited using purposive and convenience sampling. Ethical approval was obtained from the Institutional Ethics Committee, Maulana Azad Medical College, New Delhi, India and the Leeds Institute of Health Sciences Research Ethics Sub-Committee, West Yorkshire, England. Consenting participants took part in semi-structured interviews, either between May 20 and 25, 2019 in rural north-east India or via Skype or at the University of Leeds in June 2019. Interviews were audio-recorded and transcribed and thematic content analysis performed.

Results:
Exposure to laparoscopy during postgraduate training was common, but training experiences were inconsistent and informal. Alternative training opportunities are limited by availability and cost. There is high demand for a structured curriculum, incorporating formal assessment and credentialing, to include observation and assistance in live surgery and laparoscopic simulation.

Conclusions:
Laparoscopic training experiences are highly variable, with limited training resources and lack of a curriculum. Poor accessibility is consistent with that recorded in literature. Current recommendations include government support and funding to guide development of a standardized curriculum and widen access to training programs for surgeons in rural settings.

A comparison of outcome measures used to report clubfoot treatment with the Ponseti method: results from a cohort in Harare, Zimbabwe.

BACKGROUND:
There are various established scoring systems to assess the outcome of clubfoot treatment after correction with the Ponseti method. We used five measures to compare the results in a cohort of children followed up for between 3.5 to 5 years.

METHODS:
In January 2017 two experienced physiotherapists assessed children who had started treatment between 2011 and 2013 in one clinic in Harare, Zimbabwe. The length of time in treatment was documented. The Roye score, Bangla clubfoot assessment tool, the Assessing Clubfoot Treatment (ACT) tool, proportion of relapsed and of plantigrade feet were used to assess the outcome of treatment in the cohort. Inter-observer variation was calculated for the two physiotherapists. A comparative analysis of the entire cohort, the children who had completed casting and the children who completed more than two years of bracing was undertaken. Diagnostic accuracy was calculated for the five measures and compared to full clinical assessment (gold standard) and whether referral for further intervention was required for re-casting or surgical review.

RESULTS:
31% (68/218) of the cohort attended for examination and were assessed. Of the children who were assessed, 24 (35%) had attended clinic reviews for 4-5 years, and 30 (44%) for less than 2 years. There was good inter-observer agreement between the two expert physiotherapists on all assessment tools. Overall success of treatment varied between 56 and 93% using the different outcome measures. The relapse assessment had the highest unnecessary referrals (19.1%), and the Roye score the highest proportion of missed referrals (22.7%). The ACT and Bangla score missed the fewest number of referrals (7.4%). The Bangla score demonstrated 79.2% (95%CI: 57.8-92.9%) sensitivity and 79.5% (95%CI: 64.7-90.2%) specificity and the ACT score had 79.2% (95%CI: 57.8-92.9%) sensitivity and 100% (95%CI: 92-100%) specificity in predicting the need for referral.

CONCLUSION:
At three to five years of follow up, the Ponseti method has a good success rate that improves if the child has completed casting and at least two years of bracing. The ACT score demonstrates good diagnostic accuracy for the need for referral for further intervention (specialist opinion or further casting). All tools demonstrated good reliability.

Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.

Universal health coverage has been proposed as a strategy to improve health in low-income and middle-income countries (LMICs). However, this is contingent on the provision of good-quality health care. We estimate the excess mortality for conditions targeted in the Sustainable Development Goals (SDG) that are amenable to health care and the portion of this excess mortality due to poor-quality care in 137 LMICs, in which excess mortality refers to deaths that could have been averted in settings with strong health systems.Using data from the 2016 Global Burden of Disease study, we calculated mortality amenable to personal health care for 61 SDG conditions by comparing case fatality between each LMIC with corresponding numbers from 23 high-income reference countries with strong health systems. We used data on health-care utilisation from population surveys to separately estimate the portion of amenable mortality attributable to non-utilisation of health care versus that attributable to receipt of poor-quality care.15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care. Poor quality of health care was a major driver of excess mortality across conditions, from cardiovascular disease and injuries to neonatal and communicable disorders.Universal health coverage for SDG conditions could avert 8·6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems.Bill & Melinda Gates Foundation.

Short Stay Thyroid Surgery: Can We Replicate the Same in Low Resource Setting?

The concept of short stay thyroidectomy has been tested and in practice in the developed world; the same has not been replicated in countries with limited resources due to lack of organized healthcare system. So, in this study, we tried to analyze if short stay thyroid surgery can be performed in a cost-effective way in developing countries and also if the endocrine surgical trainee can deliver these services safely.The study was conducted prospectively from January 2013 to July 2014, at Department of Endocrine Surgery, SGPGIMS, Lucknow, India. Study group included patients undergoing short stay hemithyroidectomy whereas matched patients who qualified for inclusion criteria but did not undergo short stay surgery due to various reasons constituted control group. Outcome in both the groups was compared in terms of complication rates, cost benefit, and patient satisfaction. Subgroup analysis was also done for trainee versus consultant performed short stay thyroid surgery.A total of 439 patients with surgical thyroid disorders were evaluated at our institute during the study period and out of these 110 patients (58 cases and 52 controls) fulfilled the inclusion criteria. Younger patients with low socioeconomic status who were paying out of pocket were found to be more inclined to short stay thyroid surgery. There was no significant difference between the two groups in terms of postanesthetic discharge score (PADS), complication rates, and patients satisfaction; however there was significant reduction (p <0.001) in hospital cost in short stay group. In subgroup analysis, procedure time was more in trainee performed surgeries; however there was no significant difference in terms of mean PADS and complication rates.Short stay thyroidectomy can provide a better cost-effective alternative to conventional thyroidectomy in patients undergoing thyroid surgery and can be safely performed by endocrine surgical trainees even in a low resource setting.

An approach to identify a minimum and rational proportion of caesarean sections in resource-poor settings: a global network study.

Caesarean section prevalence is increasing in Asia and Latin America while remaining low in most African regions. Caesarean section delivery is effective for saving maternal and infant lives when they are provided for medically-indicated reasons. On the basis of ecological studies, caesarean delivery prevalence between 9% and 19% has been associated with better maternal and perinatal outcomes, such as reduced maternal land fetal mortality. However, the specific prevalence of obstetric and medical complications that require caesarean section have not been established, especially in low-income and middle-income countries (LMICs). We sought to provide information to inform the approach to the provision of caesarean section in low-resource settings.We did a literature review to establish the prevalence of obstetric and medical conditions for six potentially life-saving indications for which caesarean section could reduce mortality in LMICs. We then analysed a large, prospective population-based dataset from six LMICs (Argentina, Guatemala, Kenya, India, Pakistan, and Zambia) to determine the prevalence of caesarean section by indication for each site. We considered that an acceptable number of events would be between the 25th and 75th percentile of those found in the literature.Between Jan 1, 2010, and Dec 31, 2013, we enrolled a total of 271 855 deliveries in six LMICs (seven research sites). Caesarean section prevalence ranged from 35% (3467 of 9813 deliveries in Argentina) to 1% (303 of 16 764 deliveries in Zambia). Argentina’s and Guatemala’s sites all met the minimum 25th percentile for five of six indications, whereas sites in Zambia and Kenya did not reach the minimum prevalence for caesarean section for any of the indications. Across all sites, a minimum overall caesarean section of 9% was needed to meet the prevalence of the six indications in the population studied.In the site with high caesarean section prevalence, more than half of the procedures were not done for life-saving conditions, whereas the sites with low proportions of caesarean section (below 9%) had an insufficient number of caesarean procedures to cover those life-threatening causes. Attempts to establish a minimum caesarean prevalence should go together with focusing on the life-threatening causes for the mother and child. Simple methods should be developed to allow timely detection of life-threatening conditions, to explore actions that can remedy those conditions, and the timely transfer of women with those conditions to health centres that could provide adequate care for those conditions.Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Adult Intussusception due to Gastrointestinal Stromal Tumor: A Rare Case Report, Comprehensive Literature Review, and Diagnostic Challenges in Low-Resource Countries.

We present a rare case of gastrogastric intussusception due to gastrointestinal stromal tumor (GIST) and the largest comprehensive literature review of published case reports on gastrointestinal (GI) intussusception due to GIST in the past three decades. We found that the common presenting symptoms were features of gastrointestinal obstruction and melena. We highlight the diagnostic challenges faced in low-resource countries. Our findings emphasize the importance of early clinical diagnosis in low-resource settings in order to guide timely management. In addition, histological analysis of the tumor for macroscopic and microscopic characteristics including mitotic index and c-Kit/CD117 status should be obtained to guide adjuvant therapy with imatinib mesylate. Periodic follow-up to access tumor recurrence is fundamental and should be the standard of care.