Duke Global Children’s Surgery

Duke University Pediatric Surgery/Urology Guatemala Project

A Grand Convergence in Global Health by 2035

“The neglected stepchild of global health”

Global Surgery: The Big Problem • Extent of problem

– 50 million deaths or DALY/year due to lack of basic surgical care

• Pregnancy related complications– ~800 deaths per day– For every woman who dies in childbirth: ~

20 suffer a complication• Injuries

– 5 million deaths/year– 50 million injured

• Inequity of access– 3.5% of operations are performed on

poorest 1/3 of world’s population• Extent of pediatric surgical need

– 85% of children require surgical intervention in LMIC

DALY (Disability-adjusted life years)

• Metric of choice for resource allocation

DALY=YLL+YLD– YLL = Years of Life Lost– YLD = Years of Life lived with Disability

• YLL = years lost through disease-related fatality• YLD requires disability weight (DW) for each

condition, varies between 0 (perfect) and 1 (death)• Combines mortality and morbidity into single metric

Averted DALYs and Effective Coverage

• Impact of interventions measured in “averted DALYs”

• Averted DALYs=YLL*DW*RPD*PST– RPD (Risk of Permanent Disability)– PST (Probability of Successful

Treatment)

• Burden for any condition is “met,” “unmet,” or “unmeetable”

• Effective coverage overall measure of effectiveness

Cost analysis (CA)• Cost of a health intervention

– Most basic cost related analysis• No information on outcomes

– Effectiveness of intervention is uncertain or not under dispute– Difficult to compare interventions

Smoke Alarm Giveaway Program

Cost-benefit analysis (CBA)• CBA measures inputs and outcomes in terms of costs• Decision is easy--if benefits are greater than costs,

then program is worth investing• Direct Costs

– Medical treatment– Laboratory work– Drugs and medication

• Indirect Costs– Work missed (lost wages)– Work missed by caregiver– Value of a statistical life (VSL)

Cost-Effectiveness Analysis• Outcome is effectiveness of intervention• Compares different ways of doing the same thing• Many options for metrics

– Cases detected, lives saved, coverage, etc.

Intervention A $900/8 = $112.5 per life saved

Intervention B $300/2 = $150 per life saved

Incremental CE ratio is (900-300)/(8-2)= 100 per life saved

Intervention A is more cost effective

Intervention A

Intervention B

Total Cost $900 $300

Effectiveness

(# lives saved)

8 2

Cost-utility analysis (CUA)• Type of CEA• Outcome measured by standard index

– QALY - Quality Adjusted Life Years– DALY - Disability Adjusted Life Years

• Dialysis “standard” of $50,000/QALYCost effectiveness and cost–utility of endovascular versus open repair of ruptured abdominal aortic ‐

aneurysm in the Amsterdam Acute Aneurysm Trial

DCP2: Most cost effective interventions

Lay first responders

At other extreme: Coronary artery bypass grafting ($10,000-100,000)

Lancet 2006; 367: 1193–208

Basic ambulance

Surgery at district hospital

Cost-effectiveness of surgery and its policy implications forglobal health: a systematic review and analysis

• What is the big problem they are addressing?– Perception of surgery as expensive may be a barrier to acceptance in global health

• How did they address it?– Systematic review of cost-effectiveness studies that assess surgical interventions in LMIC– 584 articles between 1996-2013, 26 met inclusion criteria– Cost-effectiveness ratios (CERs) and appraised quality using Drummond checklist

• What did they find?– CER of circumcision ($13·78/DALY) similar to vaccines ($12·96–25·93/DALY) and bed nets ($6·48–22·04/DALY)– CERs of cleft lip or palate repair ($47·74/DALY), general surgery ($82·32/DALY), hydrocephalus surgery

($108·74/DALY), and ophthalmic surgery ($136/DALY) similar to BCG vaccine ($51·86–220·39/DALY)– CERs of Caesarean sections ($315·12/DALY) and orthopedic surgery ($381·15/DALY) more favorable than

treatment for ischemic heart disease ($500·41–706·54/DALY) and HIV ARV treatment ($453·74–648·20/DALY)• What is the quality of the literature examined?

– Heterogeneity in techniques to assess costs and outcomes• Some used actual cost data, others used models based on resource use assumptions• Some used WHO-CHOICE or other guidelines to establish costs, others used non-standardized costs

– Measurement of efficacy of intervention not standardized• What are the major conclusions?

– Many essential surgical interventions are cost-effective– Quantification of economic value of surgery is strong argument for expansion of global surgery– Organizational, ethical, and political arguments support expansion of global surgery

Global Burden of Disease (GBD) Study• Original study in 1990, cited >4,000 times• GBD 2010 published in Lancet, over 2,300 pages

– 1 billion estimates of health outcomes– 291 diseases, 67 risk factors, 1,160 sequelae (non-fatal consequences)– 21 regions, 187 countries– Improved methods for the estimation of disability weights

• GBD 2013 reflects 1,000 researchers in more than 100 countries

• BUT…NEED MORE SURGICAL DATA

Figure 5

The Lancet 2012; 380:2095-2028

Global Burden of DiseaseDALYs from 1990 to 2010, all ages, both sexes, combined by cause

Injury/SurgicalIncreased from 9.8% to

11.1%

What is a surgical condition?

• Queried large inpatient database to determine operative rates for GBD 2010• NIS is largest all payer inpatient database in USA (10 mil inpatient

operations, 34.8 mil hospital admissions)• Aggregated admitting diagnosis into GBD categories• Main outcome: Fraction of patients that underwent an operation

• Operations associated with 28.6% of all admissions• In every GBD subcategory (range 0.2%–84.0%)• Highest frequencies in Musculoskeletal (84.0%), Neoplasm

(61.4%), and Transport Injuries (43.2%)

Source: Rose et al, PLOS, 2014.

Priorities for Global Surgical CarePriority 1 surgical conditions are those: That have a large public health burden, and For which there is a surgical procedure that is successful at treating the condition, and

For which the procedure is cost-effective and feasible to promote globally

Priority 1Trauma

Pregnancy-related Hydrocele or hernia repair (umbilical, inguinal, femoral hernias) Appendectomy

Exploratory laparotomy (acute abdominal condition)

Cholecystectomy (acute cholecystitis)

Male circumcision

Incision and drainage (infection)

Repair of isolated cleft lipMock et al., World J Surg, 2010 34:381-385

Duke Global Children’s Surgery

Why Guatemala?• Population exceeds 14 million

– More than half of the population less than 18 years old– High rate of poverty and inequality (Gini index)– Third worst childhood growth rate (Yemen and Bangladesh)

• Civil war, destroyed health care system• Large indigenous population, deeply rooted in rural highlands• Complex, fractionated health care system

Duke Pediatric Surgery/Urology Guatemala Project

• Active since 2010– Service: Provide high-quality care in partnership with

local providers– Learning: Perform and teach safe surgical practice in

collaboration with local providers– Education: Work with local providers on shared

educational opportunities– Development: Build partnerships with medical schools

and health systems– Research: Identify impact areas for research and

education collaborations

Partnerships

Educational Collaborations

• Duke affiliation with Universidad Francisco Marroquin– Medical student, resident exchanges

• Consultation with pediatric surgery fellowship development• Lectures for pediatric residents, nursing staff• CME exchanges with Guatemalan surgeons

Moore Surgical Center

• 12,000 square foot facility, 3 operating rooms, 6 pre-op beds, 21 recovery beds

• Waiting Room, Pre-Op Rooms, Nurses Stations, PACU, Pharmacy

• Staffed by Guatemalan surgeons, nursing staff, administration

• U.S. teams operate in concert with Guatemalan surgeons

Clinical Cases

• Screened 123 children • 48 pediatric general surgery and urology cases• Mean age 8.7 years (range 10 months-17 years)

Condition Procedure Number (Total=48)

Inguinal hernia Inguinal hernia repair 14

Undescended testicle Orchiopexy 7

Phimosis Circumcision 7

Umbilical hernia Umbilical hernia repair 4

Ankyloglossia (tongue-tie) Frenulectomy 2Breast mass Excisional biopsy 2

Scalp mass Excision 2

Skin lesion Excision 2

Back/neck mass Excision 2

Anorectal malformation PSARP (anorectal pull-through) 1

Vesicoureteral reflux Bilateral ureteral reimplantation 1

Hypospadias Hypospadias repair 1

Rectal prolapse Anal circlage 1

Epigastric hernia Epigastric hernia repair 1

Thryoglossal duct cyst Cyst excision (Sistrunk procedure) 1

Research

• Effectiveness and Validity of Subjective vs. Objective Post-Operative Pain Scoring Systems in Guatemala

• Implementing the Universal Protocol in a LMIC • Retrograde Light-Guided Laryngoscopy for Tracheal

Intubation in Children: A Useful Teaching Technique• Effectiveness of Regional Anesthetics in a LMIC• Family Knowledge of Urinary Tract Disease in

Guatemala

Barriers to Surgical Care • Financial (Affordability)

– Direct cost of treatment and related services– Transport costs– Loss of income– Living expenses– Lack of income

• Structural (Accessibility)– Distance to health facility– Lack of transport– Lack of facilities, drugs, equipment, providers– Health worker attitude/poor quality care/poor communication– Lack of coordination among health institutions

• Cultural (Acceptability)– Perceived quality of care– Lack of time, family/work constraints– Preference for traditional remedies– Fear of treatments or distrust of medical community– Religion and cultural beliefs

Grimes et al., World J Surg (2011) 35:941–950

Barriers to Surgical Care

David BoydRachel Hall-Clifford

Eric FinkelsteinLigia Figueroa

Epidemiologic ResearchAccess to Surgical Care

• Pilot study-Address self-reported barriers to surgery• Epidemiologic surveyed 84 families presenting to clinic• Mean duration of symptoms of 3.7 years

Rating and Ranking of Barriers to Care

• For Rating, 46 parents rated importance of barriers– Cost of surgery, distance, waiting time, language,

transportation, time off work, quality of care, and lack of local center

– Likert scale to assess significance of each barrier, rated from 1 (least significant) to 5 (most significant)

• For Ranking, parents ranked significance of barriers– From 1 to 8 (least significant)

Rating and Ranking of Access to Surgical Care

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Applied anthropology study of surgical barriers• Examine parental views of barriers to care• Fieldwork Site

– NAPA-OT Field School, Antigua, Guatemala– Moore Surgical Center, Guatemala City– Hermano Pedro, Antigua

• Methods– Semi-structured interviews with families– Grounded theory analysis– Identify and quantify common themes– Develop codebook, re-analyze transcripts

Grounded theory analysis• Financial barriers/opportunity costs

– Most difficult parts of families’ experiences– Transportation and laboratory testing problematic– Opportunity costs: time off of work

• Systems limitations and quality of care– Limitations in coverage, especially for high-quality care– Distance less restrictive compared to primary care

• Long waits, quality of care, and focus on payment– All motivate to NGO-based care

• Mistrust/fear– Predominance of fear and mistrust– Fear of the unknown single most important barrier to care

Policy Recommendations 1

• Different sectors of health care system should partner together to improve access to surgical care– Collaboration among the MoH, public systems, academic

institutions, NGOs, providers, and families– All stakeholders benefit by unifying common goals

• Economic benefits of investing in pediatric surgical care, including impact on opportunity costs, should be studied– Similar to childhood mortality, investment in surgical programs

should offer value and overall returns– Lancet Commission on Global Surgery should help define the

economic value of surgical care

Policy Recommendations 2• To increase parental confidence, QI systems should be

encouraged– Increasing interest in surgical QI through WHO Guidelines on Safe

Surgery, NSQUP, and global trauma programs – Optimal strategies to support QI are not well defined

• Availability of high quality care should be disseminated to the public– All QI information distributed in a culturally-sensitive manner– Use community resources to publicize accessibility, communication

sensitive to language, education, and culture

To comfort the hurting…