Economic Impact of surgery on households and individuals in low income countries: A systematic review

Background
Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) – the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com).

Methods
We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines.

Results
31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs.

Conclusion
Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspectiv

SURGE: Survey of Undergraduate Respondents on Global surgery Education

Introduction
It is estimated that over 10% of the global burden of disease can be treated with surgery, most of which is located in low and middle-income countries (LMICs), underpinning the importance of the topic of global surgery (GS). The multidisciplinary principles of GS are increasingly recognised as being key to modern practice and as such, must be fostered at early stages of medical training. However, it is unclear whether medical students are being exposed to GS. This study aimed to assess the importance of GS and its presence in medical curricula.

Methods
A novel, 22-item online questionnaire was developed and disseminated to medical students and faculty members using social media. Data collection was conducted by a collaboration of medical students, who acted as regional leads at their institutions.

Results
795 medical students and 141 faculty members representing 38/42 of UK medical schools (90.4%) completed the questionnaire. Only 84 students (10.6%) were previously exposed to GS. Most students (66.3%) and faculty (60.6%) agreed that GS should be an integral part of the curriculum. Only 20 students (2.5%) were or familiar with what a career in GS means.

Conclusion
Approximately 2/3 of students and faculty agree that global surgery should be an integral part of the mandatory curriculum. Findings of this study should underpin further incorporation of GS into curricula, as high-income countries can decisively contribute to achieving the global surgery 2030 targets, by training a new generation of clinicians who are ready for the challenges of the 21st century.

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background
Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling.

Methods
The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty.

Results
NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year.

Conclusion
As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.

Anastomotic leak following oesophagectomy: research priorities from an international Delphi consensus study

Background
The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks.

Methods
A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three‐stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income.

Results
In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis.

Conclusion
Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.

A global country-level comparison of the financial burden of surgery.

Abstract
Background
Approximately 30 per cent of the global burden of disease is surgical, and nearly one‐quarter of individuals who undergo surgery each year face financial hardship because of its cost. The Lancet Commission on Global Surgery has proposed the elimination of impoverishment due to surgery by 2030, but no country‐level estimates exist of the financial burden of surgical access.

Methods
Using publicly available data, the incidence and risk of financial hardship owing to surgery was estimated for each country. Four measures of financial catastrophe were examined: catastrophic expenditure, and impoverishment at the national poverty line, at 2 international dollars (I$) per day and at I$1·25 per day. Stochastic models of income and surgical costs were built for each country. Results were validated against available primary data.

Results
Direct medical costs of surgery put 43·9 (95 per cent posterior credible interval 2·2 to 87·1) per cent of the examined population at risk of catastrophic expenditure, and 57·0 (21·8 to 85·1) per cent at risk of being pushed below I$2 per day. The risk of financial hardship from surgery was highest in sub‐Saharan Africa. Correlations were found between the risk of financial catastrophe and external financing of healthcare (positive correlation), national measures of well‐being (negative correlation) and the percentage of a country’s gross domestic product spent on healthcare (negative correlation). The model performed well against primary data on the costs of surgery.

Conclusion
Country‐specific estimates of financial catastrophe owing to surgical care are presented. The economic benefits projected to occur with the scale‐up of surgery are placed at risk if the financial burden of accessing surgery is not addressed in national policies.