Thomas G Weiser, MD

All Publications

• Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Mérisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L., Grimes, C. E., Gruen, R. L., Ismail, E. A., Kamara, T. B., Lavy, C., Lundeg, G., Mkandawire, N. C., Raykar, N. P., Riesel, J. N., Rodas, E., Rose, J., Roy, N., Shrime, M. G., Sullivan, R., Verguet, S., Watters, D., Weiser, T. G., Wilson, I. H., Yamey, G., Yip, W. 2015; 386 (9993): 569-624

  View details for DOI 10.1016/S0140-6736(15)60160-X

  View details for PubMedID 25924834

• Global operating theatre distribution and pulse oximetry supply: an estimation from reported data LANCET Funk, L. M., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Merry, A. F., Enright, A. C., Wilson, I. H., Dziekan, G., Gawande, A. A. 2010; 376 (9746): 1055-1061

  Abstract

  Surgery is an essential part of health care, but resources to ensure the availability of surgical services are often inadequate. We estimated the global distribution of operating theatres and quantified the availability of pulse oximetry, which is an essential monitoring device during surgery and a potential measure of operating theatre resources.We calculated ratios of the number of operating theatres to hospital beds in seven geographical regions worldwide on the basis of profiles from 769 hospitals in 92 countries that participated in WHO's safe surgery saves lives initiative. We used hospital bed figures from 190 WHO member states to estimate the number of operating theatres per 100,000 people in 21 subregions throughout the world. To estimate availability of pulse oximetry, we sent surveys to anaesthesia providers in 72 countries selected to ensure a geographically and demographically diverse sample. A predictive regression model was used to estimate the pulse oximetry need for countries that did not provide data.The estimated number of operating theatres ranged from 1·0 (95% CI 0·9-1·2) per 100,000 people in west sub-Saharan Africa to 25·1 (20·9-30·1) per 100,000 in eastern Europe. High-income subregions all averaged more than 14 per 100,000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100,000. Pulse oximetry data from 54 countries suggested that around 77,700 (63,195-95,533) theatres worldwide (19·2% [15·2-23·9]) were not equipped with pulse oximeters.Improvements in public-health strategies and monitoring are needed to reduce disparities for more than 2 billion people without adequate access to surgical care.WHO.

  View details for DOI 10.1016/S0140-6736(10)60392-3

  View details for Web of Science ID 000282411600032

  View details for PubMedID 20598365

• Standardised metrics for global surgical surveillance LANCET Weiser, T. G., Makary, M. A., Haynes, A. B., Dziekan, G., Berry, W. R., Gawande, A. A. 2009; 374 (9695): 1113-1117

  Abstract

  Public health surveillance relies on standardised metrics to evaluate disease burden and health system performance. Such metrics have not been developed for surgical services despite increasing volume, substantial cost, and high rates of death and disability associated with surgery. The Safe Surgery Saves Lives initiative of WHO's Patient Safety Programme has developed standardised public health metrics for surgical care that are applicable worldwide. We assembled an international panel of experts to develop and define metrics for measuring the magnitude and effect of surgical care in a population, while taking into account economic feasibility and practicability. This panel recommended six measures for assessing surgical services at a national level: number of operating rooms, number of operations, number of accredited surgeons, number of accredited anaesthesia professionals, day-of-surgery death ratio, and postoperative in-hospital death ratio. We assessed the feasibility of gathering such statistics at eight diverse hospitals in eight countries and incorporated them into the WHO Guidelines for Safe Surgery, in which methods for data collection, analysis, and reporting are outlined.

  View details for Web of Science ID 000270370900034

  View details for PubMedID 19782877

• A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEW ENGLAND JOURNAL OF MEDICINE Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., Gawande, A. A. 2009; 360 (5): 491-499

  Abstract

  Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation.The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

  View details for Web of Science ID 000262812400008

  View details for PubMedID 19144931

• An estimation of the global volume of surgery: a modelling strategy based on available data LANCET Weiser, T. G., Regenbogen, S. E., Thompson, K. D., Haynes, A. B., Lipsitz, S. R., Berry, W. R., Gawande, A. A. 2008; 372 (9633): 139-144

  Abstract

  Little is known about the amount and availability of surgical care globally. We estimated the number of major operations undertaken worldwide, described their distribution, and assessed the importance of surgical care in global public-health policy.We gathered demographic, health, and economic data for 192 member states of WHO. Data for the rate of surgery were sought from several sources including governmental agencies, statistical and epidemiological organisations, published studies, and individuals involved in surgical policy initiatives. We also obtained per-head total expenditure on health from analyses done in 2004. Major surgery was defined as any intervention occurring in a hospital operating theatre involving the incision, excision, manipulation, or suturing of tissue, usually requiring regional or general anaesthesia or sedation. We created a model to estimate rates of major surgery for countries for which such data were unavailable, then used demographic information to calculate the total worldwide volume of surgery.We obtained surgical data for 56 (29%) of 192 WHO member states. We estimated that 234.2 (95% CI 187.2-281.2) million major surgical procedures are undertaken every year worldwide. Countries spending US$100 or less per head on health care have an estimated mean rate of major surgery of 295 (SE 53) procedures per 100 000 population per year, whereas those spending more than $1000 have a mean rate of 11 110 (SE 1300; p<0.0001). Middle-expenditure ($401-1000) and high-expenditure (>$1000) countries, accounting for 30.2% of the world's population, provided 73.6% (172.3 million) of operations worldwide in 2004, whereas poor-expenditure (

  View details for Web of Science ID 000257552400028

  View details for PubMedID 18582931

• Costs and Financial Burden of Initial Hospitalizations for Firearm Injuries in the United States, 2006-2014. American journal of public health Spitzer, S. A., Staudenmayer, K. L., Tennakoon, L., Spain, D. A., Weiser, T. G. 2017; 107 (5): 770-774

  Abstract

  To quantify the inflation-adjusted costs associated with initial hospitalizations for firearm-related injuries in the United States.We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2006 to 2014. We converted charges from hospitalization to costs, which we inflation-adjusted to 2014 dollars. We used survey weights to create national estimates.Costs for the initial inpatient hospitalization totaled $6.61 billion. The largest proportion was for patients with governmental insurance coverage, totaling $2.70 billion (40.8%) and was divided between Medicaid ($2.30 billion) and Medicare ($0.40 billion). Self-pay individuals accounted for $1.56 billion (23.6%) in costs.From 2006 to 2014, the cost of initial hospitalizations for firearm-related injuries averaged $734.6 million per year. Medicaid paid one third and self-pay patients one quarter of the financial burden. These figures substantially underestimate true health care costs. Public health implications. Firearm-related injuries are costly to the US health care system and are particularly burdensome to government insurance and the self-paying poor.

  View details for DOI 10.2105/AJPH.2017.303684

  View details for PubMedID 28323465

• Population-based estimate of trauma-related deaths for law enforcement personnel: Risks for death are higher and increasing over time. journal of trauma and acute care surgery Eastman, A. L., Cripps, M. W., AbdelFattah, K. R., Inaba, K., Weiser, T. G., Spain, D. A., Staudenmayer, K. L. 2017

  Abstract

  Trauma-related deaths remain an important public health problem. One group susceptible to death due to traumatic mechanisms is U.S. Law Enforcement (LE). We hypothesized that LE officers experienced a higher chance of violent death compared to the general U.S. population and that risks have increased over time.The National Institute on Occupational Safety and Health (NIOSH) National Occupational Mortality Surveillance (NOMS) is a population-based survey of occupational deaths. It includes data for workers who died during 1985-1998 in one of 30 U.S states (EARLY period). Additional deaths were added from 23 U.S. states in 1999, 2003-2004, 2007-2010 (LATE period). Mortality rates are estimated by calculating proportionate mortality ratios (PMR). A PMR above 100 is considered to exceed the average background risk for all occupations. All adults >18 years of age whose primary occupation was listed as "Law Enforcement Worker" were included in the analysis.Law enforcement personnel were more likely to die from an injury compared to the general population (Figure 1). The overall PMR for injury in EARLY was 111 (95% Confidence Interval [CI] 108-114, p<0.01), and for LATE was 118 (95% CI 110-127, p<0.01). Four mechanisms of death reached statistical significance: motor vehicle traffic (MVT)-driver, MVT-other, intentional self-harm, and assault/homicide. The highest PMR in EARLY was associated with firearms (PMR 272, 95% CI 207-350, p<0.01). The highest PMR in LATE was associated with death due to being a driver in an MVT (PMR 194, 95% CI 169-222, p<0.01). There were differences in risk of death by race and gender. White females had the highest PMR due to Assault and Homicide (PMR 317, 95% CI 164-554, p<0.01). All groups had similar risks of death due to Intentional Self-Harm (PMR 130-171).The risk of death for US LEOs is high and increasing over time, suggesting an at-risk population that requires further interventions. Targeted efforts based on risk factors, such as gender and race, may assist with the development of prevention programs for this population.

  View details for DOI 10.1097/TA.0000000000001528

  View details for PubMedID 28422921

• Mapping Disparities in Access to Safe, Timely, and Essential Surgical Care in Zambia JAMA SURGERY Esquivel, M. M., Uribe-Leitz, T., Makasa, E., Lishimpi, K., Mwaba, P., Bowman, K., Weiser, T. G. 2016; 151 (11): 1064-1069

  Abstract

  Surgical care is widely unavailable in developing countries; advocates recommend that countries evaluate and report on access to surgical care to improve availability and aid health planners in decision making.To analyze the infrastructure, capacity, and availability of surgical care in Zambia to inform health policy priorities.In this observational study, all hospitals providing surgical care were identified in cooperation with the Zambian Ministry of Health. On-site data collection was conducted from February 1 through August 30, 2011, with an adapted World Health Organization Global Initiative for Emergency and Essential Surgical Care survey. Data collection at each facility included interviews with hospital personnel and assessment of material resources. Data were geocoded and analyzed in a data visualization platform from March 1 to December 1, 2015. We analyzed time and distance to surgical services, as well as the proportion of the population living within 2 hours from a facility providing surgical care.Surgical capacity, supplies, human resources, and infrastructure at each surgical facility, as well as the population living within 2 hours from a hospital providing surgical care.Data were collected from all 103 surgical facilities identified as providing surgical care. When including all surgical facilities (regardless of human resources and supplies), 14.9% of the population (2 166 460 of 14 500 000 people) lived more than 2 hours from surgical care. However, only 17 hospitals (16.5%) met the World Health Organization minimum standards of surgical safety; when limiting the analysis to these hospitals, 65.9% of the population (9 552 780 people) lived in an area that was more than 2 hours from a surgical facility. Geographic analysis of emergency and essential surgical care, defined as access to trauma care, obstetric care, and care of common abdominal emergencies, found that 80.7% of the population (11 704 700 people) lived in an area that was more than 2 hours from these surgical facilities.A large proportion of the population in Zambia does not have access to safe and timely surgical care; this percentage would change substantially if all surgical hospitals were adequately resourced. Geospatial visualization tools assist in the evaluation of surgical infrastructure in Zambia and can identify key areas for improvement.

  View details for DOI 10.1001/jamasurg.2016.2303

  View details for Web of Science ID 000388404500020

  View details for PubMedID 27580500

  View details for PubMedCentralID PMC5179136

• Coccidioidomycosis: Surgical Issues and Implications. Surgical infections Forrester, J. D., Guo, H. H., Weiser, T. G. 2016: -?

  Abstract

  Coccidioidomycosis, commonly called "valley fever," "San Joaquin fever," "desert fever," or "desert rheumatism," is a multi-system illness caused by infection with Coccidioides fungi (C. immitis or C. posadasii). This organism is endemic to the desert Southwest regions of the United States and Mexico and to parts of South America. The manifestations of infection occur along a spectrum from asymptomatic to mild self-limited fever to severe disseminated disease.Review of the English-language literature.There are five broad indications for surgical intervention in patients with coccidioidomycosis: Tissue diagnosis in patients at risk for co-existing pathology, perforation, bleeding, impingement on critical organs, and failure to resolve with medical management. As part of a multidisciplinary team, surgeons may be responsible for the care of infected patients, particularly those with severe disease.This review discusses the history, microbiology, epidemiology, pathology, diagnosis, and treatment of coccidioidomycosis, focusing on situations that may be encountered by surgeons.

  View details for PubMedID 27740893

• Trends in open vascular surgery for trauma: implications for the future of acute care surgery. journal of surgical research Forrester, J. D., Weiser, T. G., Maggio, P., Browder, T., Tennakoon, L., Spain, D., Staudenmayer, K. 2016; 205 (1): 208-212

  Abstract

  Trauma patients with vascular injuries have historically been within a general surgeon's operative ability. Changes in training and decline in operative trauma have decreased trainees' exposure to these injuries. We sought to determine how frequently vascular procedures are performed at US trauma centers to quantify the need for general surgeons trained to manage vascular injuries.We conducted a retrospective analysis of the National Trauma Data Base (NTDB) from 2012 compared with 2002. Patients with general surgical and vascular procedures were identified using International Classification of Diseases, Ninth Revision, procedure codes 38.0-39.99, excluding 38.9-38.99.General surgery or vascular operations were performed on 12,099 (24%) of 50,248 severely injured adult patients in 2002 and 21,854 (16%) of 138,009 injured patients in 2012. Nineteen percent to 26% of all patients underwent vascular procedures. Patients with combined general surgery and vascular procedures were less likely to be discharged home and more likely to die. In 2002, 6% of severely injured adult trauma patients underwent open vascular procedures at level III/IV trauma centers; by 2012, only 1% of vascular surgery procedures were performed at level III/IV centers (P < 0.001).Need for emergent vascular surgery remains common for severely injured patients. Future trauma systems and surgical training programs will need to account for the need for open vascular skills. The findings suggest that there is already a trend away from open vascular procedures at level III/IV trauma centers, which may be a sign of system compensation for changes in the workforce.

  View details for DOI 10.1016/j.jss.2016.06.032

  View details for PubMedID 27621021

• Trends in the management of pelvic fractures, 2008-2010 JOURNAL OF SURGICAL RESEARCH Chu, C. H., Tennakoon, L., Maggio, P. M., Weiser, T. G., Spain, D. A., Staudenmayer, K. L. 2016; 202 (2): 335-340

  Abstract

  Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time.The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality.A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001).AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.

  View details for DOI 10.1016/j.jss.2015.12.052

  View details for Web of Science ID 000376334700014

  View details for PubMedID 27229108

• The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination AMERICAN SURGEON Staudenmayer, K., Wang, N. E., Weiser, T. G., Maggio, P., Mackersie, R. C., Spain, D., Hsia, R. Y. 2016; 82 (4): 356-361

  Abstract

  The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.

  View details for Web of Science ID 000377853800022

  View details for PubMedID 27097630

• Trauma center care is associated with reduced readmissions after injury. journal of trauma and acute care surgery Staudenmayer, K., Weiser, T. G., Maggio, P. M., Spain, D. A., Hsia, R. Y. 2016; 80 (3): 412-418

  Abstract

  Trauma center care has been associated with improved mortality. It is not known if access to trauma center care is also associated with reduced readmissions. We hypothesized that receiving treatment at a trauma center would be associated with improved care and therefore would be associated with reduced readmission rates.We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from 2007-2008. All hospital admissions and emergency department visits associated with injury were longitudinally linked. Regions were categorized by whether or not they had trauma centers. We excluded all patients younger than 18 years of age. We performed univariate and multivariate regression analyses to determine if readmissions were associated with patient characteristics, length of stay for initial hospitalization, trauma center access, and triage patterns.A total of 211,504 patients were included in the analysis. Of these, 5,094 (2%) died during the index hospitalization. Of those who survived their initial hospitalization, 79,123 (38%) experienced one or more readmissions to any hospital within one year. The majority of these were one-time readmissions (62%) but 38% experienced multiple readmissions. Over 67% of readmissions were unplanned and 8% of readmissions were for a trauma. After controlling for patient variables known to be associated with readmissions, primary triage to a trauma center was associated with a lower odds of readmission (OR 0.89, p<0.001). The effect of transport to a trauma center remained significantly associated with decreased odds of readmission at one year (OR 0.96, p<0.001).Readmissions after injury are common and are often unscheduled. While patient factors play a role in this, care at a trauma center is also associated with decreased odds for re-admission, even when controlling for severity of injury. This suggests that the benefits of trauma center care extend beyond improvements in mortality to improved long-term outcomes.Economic/Decision LEVEL OF EVIDENCE: Level IV.

  View details for DOI 10.1097/TA.0000000000000956

  View details for PubMedID 26713975

• Size and distribution of the global volume of surgery in 2012 BULLETIN OF THE WORLD HEALTH ORGANIZATION Weiser, T. G., Haynes, A. B., Molina, G., Lipsitz, S. R., Esquiye, M. M., Uribe-Leitz, T., Fu, R., Azad, T., Chao, T. E., Berry, W. R., Gawande, A. A. 2016; 94 (3): 201-209

  View details for DOI 10.2471/BLT.15.159293

  View details for Web of Science ID 000372774200017

• Size and distribution of the global volume of surgery in 2012. Bulletin of the World Health Organization Weiser, T. G., Haynes, A. B., Molina, G., Lipsitz, S. R., Esquivel, M. M., Uribe-Leitz, T., Fu, R., Azad, T., Chao, T. E., Berry, W. R., Gawande, A. A. 2016; 94 (3): 201-209F

  Abstract

  To estimate global surgical volume in 2012 and compare it with estimates from 2004.For the 194 Member States of the World Health Organization, we searched PubMed for studies and contacted key informants for reports on surgical volumes between 2005 and 2012. We obtained data on population and total health expenditure per capita for 2012 and categorized Member States as very-low, low, middle and high expenditure. Data on caesarean delivery were obtained from validated statistical reports. For Member States without recorded surgical data, we estimated volumes by multiple imputation using data on total health expenditure. We estimated caesarean deliveries as a proportion of all surgery.We identified 66 Member States reporting surgical data. We estimated that 312.9 million operations (95% confidence interval, CI: 266.2-359.5) took place in 2012, an increase from the 2004 estimate of 226.4 million operations. Only 6.3% (95% CI: 1.7-22.9) and 23.1% (95% CI: 14.8-36.7) of operations took place in very-low- and low-expenditure Member States representing 36.8% (2573 million people) and 34.2% (2393 million people) of the global population of 7001 million people, respectively. Caesarean deliveries comprised 29.6% (5.8/19.6 million operations; 95% CI: 9.7-91.7) of the total surgical volume in very-low-expenditure Member States, but only 2.7% (5.1/187.0 million operations; 95% CI: 2.2-3.4) in high-expenditure Member States.Surgical volume is large and growing, with caesarean delivery comprising nearly a third of operations in most resource-poor settings. Nonetheless, there remains disparity in the provision of surgical services globally.

  View details for DOI 10.2471/BLT.15.159293

  View details for PubMedID 26966331

  View details for PubMedCentralID PMC4773932

• Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data LANCET GLOBAL HEALTH Uribe-Leitz, T., Jaramillo, J., Maurer, L., Fu, R., Esquivel, M. M., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2016; 4 (3): E165-E174

  Abstract

  Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures-caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair-to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.None.

  View details for Web of Science ID 000370675000019

  View details for PubMedID 26916818

• Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. International journal of obstetric anesthesia Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Mérisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L., Grimes, C. E., Gruen, R. L., Ismail, E. A., Kamara, T. B., Lavy, C., Lundeg, G., Mkandawire, N. C., Raykar, N. P., Riesel, J. N., Rodas, E., Rose, J., Roy, N., Shrime, M. G., Sullivan, R., Verguet, S., Watters, D., Weiser, T. G., Wilson, I. H., Yamey, G., Yip, W. 2016; 25: 75-78

  View details for DOI 10.1016/j.ijoa.2015.09.006

  View details for PubMedID 26597405

• Uninsured status may be more predictive of outcomes among the severely injured than minority race INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Gerry, J. M., Weiser, T. G., Spain, D. A., Staudenmayer, K. L. 2016; 47 (1): 197-202

  Abstract

  Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.We performed a retrospective analysis of the 2010-2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18-64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29-1.98, p<0.001) and black race (OR 1.24, 1.04-1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36-0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29-2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32-0.63, p<0.001).Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.

  View details for DOI 10.1016/j.injury.2015.09.003

  View details for Web of Science ID 000367339900036

• Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. JAMA Molina, G., Weiser, T. G., Lipsitz, S. R., Esquivel, M. M., Uribe-Leitz, T., Azad, T., Shah, N., Semrau, K., Berry, W. R., Gawande, A. A., Haynes, A. B. 2015; 314 (21): 2263-2270

  Abstract

  Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes.To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality.Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. The year of analysis was 2012. Cesarean delivery rates were available for 54 countries for 2012. For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years. For the 22 countries for which no cesarean rate data were available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percent of urban population, and geographic region.Cesarean delivery rate.The relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100,000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births).The estimated number of cesarean deliveries in 2012 was 22.9 million (95% CI, 22.5 million to 23.2 million). At a country-level, cesarean delivery rate estimates up to 19.1 per 100 live births (95% CI, 16.3 to 21.9) and 19.4 per 100 live births (95% CI, 18.6 to 20.3) were inversely correlated with maternal mortality ratio (adjusted slope coefficient, -10.1; 95% CI, -16.8 to -3.4; P = .003) and neonatal mortality rate (adjusted slope coefficient, -0.8; 95% CI, -1.1 to -0.5; P < .001), respectively (adjusted for total health expenditure per capita, population, percent of urban population, fertility rate, and region). Higher cesarean delivery rates were not correlated with maternal or neonatal mortality at a country level. A sensitivity analysis including only 76 countries with the highest-quality cesarean delivery rate information had a similar result: cesarean delivery rates greater than 6.9 to 20.1 per 100 live births were inversely correlated with the maternal mortality ratio (slope coefficient, -21.3; 95% CI, -32.2 to -10.5, P < .001). Cesarean delivery rates of 12.6 to 24.0 per 100 live births were inversely correlated with neonatal mortality (slope coefficient, -1.4; 95% CI, -2.3 to -0.4; P = .004).National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

  View details for DOI 10.1001/jama.2015.15553

  View details for PubMedID 26624825

• First case of mesh infection due to Coccidioides spp. and literature review of fungal mesh infections after hernia repair. Mycoses Forrester, J. D., Gomez, C. A., Forrester, J. A., Nguyen, M., Gregg, D., Deresinski, S., Banaei, N., Weiser, T. G. 2015; 58 (10): 582-587

  View details for DOI 10.1111/myc.12364

  View details for PubMedID 26293423

• Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. American journal of obstetrics and gynecology Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Mérisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L., Grimes, C. E., Gruen, R. L., Ismail, E. A., Kamara, T. B., Lavy, C., Lundeg, G., Mkandawire, N. C., Raykar, N. P., Riesel, J. N., Rodas, E., Rose, J., Roy, N., Shrime, M. G., Sullivan, R., Verguet, S., Watters, D., Weiser, T. G., Wilson, I. H., Yamey, G., Yip, W. 2015; 213 (3): 338-340

  View details for DOI 10.1016/j.ajog.2015.04.010

  View details for PubMedID 25985722

• Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Merisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L., Grimes, C. E., Gruen, R. L., Ismail, E. A., Kamara, T. B., Lavy, C., Lundeg, G., Mkandawire, N. C., Raykar, N. P., Riesel, J. N., Rodas, E., Rose, J., Roy, N., Shrime, M. G., Sullivan, R., Verguet, S., Watters, D., Weiser, T. G., Wilson, I. H., Yamey, G., Yip, W. 2015; 213 (3): 338-340

  View details for DOI 10.1016/j.ajog.2015.04.010

  View details for Web of Science ID 000360551700011

• Projections for Achieving the Lancet Commission Recommended Surgical Rate of 5000 Operations per 100,000 Population by Region-Specific Surgical Rate Estimates WORLD JOURNAL OF SURGERY Uribe-Leitz, T., Esquivel, M. M., Molina, G., Lipsitz, S. R., Verguet, S., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 39 (9): 2168-2172

  Abstract

  We previously identified a range of 4344-5028 annual operations per 100,000 people to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100,000 people. We evaluate rates of growth and estimate the time it will take to reach this minimum surgical rate threshold.We aggregated country-level surgical rate estimates from 2004 to 2012 into the twenty-one Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size for each year and assessed the rate of growth over time. We then extrapolated the time it will take each region to reach a surgical rate of 5000 operations per 100,000 population based on linear rates of change.All but two regions experienced growth in their surgical rates during the past 8 years. Fourteen regions did not meet the recommended threshold in 2012. If surgical capacity continues to grow at current rates, seven regions will not meet the threshold by 2035. Eastern Sub-Saharan Africa will not reach the recommended threshold until 2124.The rates of growth in surgical service delivery are exceedingly variable. At current rates of surgical and population growth, 6.2 billion people (73 % of the world's population) will be living in countries below the minimum recommended rate of surgical care in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met in a timely fashion as part of the integrated health system development.

  View details for DOI 10.1007/s00268-015-3113-6

  View details for Web of Science ID 000359447800010

  View details for PubMedID 26067635

• Proposed Minimum Rates of Surgery to Support Desirable Health Outcomes: An Observational Study Based on Three Strategies WORLD JOURNAL OF SURGERY Esquivel, M. M., Molina, G., Uribe-Leitz, T., Lipsitz, S. R., Rose, J., Bickler, S., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 39 (9): 2126-2131

  Abstract

  The global volume of surgery is estimated at 312.9 million operations annually, but rates of surgery vary dramatically. Identifying surgical rates associated with improved health outcomes would be useful for benchmarking and targeted health system strengthening.We identified rates of surgery associated with a life expectancy (LE) of 74-75 years, a maternal mortality ratio (MMR) of less than or equal to 100 per 100,000 live births, and the estimated need for surgery in the seven global burden of disease (GBD) super-regions based on the prevalence of surgical conditions. We compared our findings to surgical rates from Chile, China, Costa Rica, and Cuba ("4C"), countries with moderate resources but high health outcomes.The median surgical rates associated with LE of 74-75 years (N = 17) and MMR below 100 (N = 109) are 4392 (IQR 2897-4873) and 5028 (IQR 4139-6778) operations per 100,000 people annually, respectively. The mean surgical rate estimated for the seven super-regions was 4723 (95 % CI 3967-5478) operations per 100,000 people annually. The "4C" countries had a mean surgical rate of 4344 (95 % CI 2620-6068) operations per 100,000 people annually. Thirteen of the twenty-one GBD regions, accounting for 78 % of the world's population, do not achieve rates of surgery at the lowest end of this range.We identified a narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health care systems and surgical capacity.

  View details for DOI 10.1007/s00268-015-3092-7

  View details for Web of Science ID 000359447800004

  View details for PubMedID 25968342

• Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development LANCET Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Merisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L., Grimes, C. E., Gruen, R. L., Ismail, E. A., Kamara, T. B., Lavy, C., Lundeg, G., Mkandawire, N. C., Raykar, N. P., Riesel, J. N., Rodas, E., Rose, J., Roy, N., Shrime, M. G., Sullivan, R., Verguet, S., Watters, D., Weiser, T. G., Wilson, I. H., Yamey, G., Yip, W. 2015; 386 (9993): 569-624

  View details for DOI 10.1016/S0140-6736(15)60160-X

  View details for Web of Science ID 000359431900031

• The role of facility-based surgical services in addressing the national burden of disease in New Zealand: An index of surgical incidence based on country-specific disease prevalence SURGERY Hider, P., Wilson, L., Rose, J., Weiser, T. G., Gruen, R., Bickler, S. W. 2015; 158 (1): 44-54

  Abstract

  Surgery is a crucial component of health systems, yet its contribution has been difficult to define. We linked national hospital service utilization with national epidemiologic data to describe the use of surgical procedures in the management of a broad spectrum of conditions.We compiled International Classification of Diseases-10-Australian Modification codes from the New Zealand National Minimum Dataset, 2008-2011. Using primary cause of admission, we aggregated hospitalizations into 119 disease states and 22 disease subcategories of the World Health Organization Global Health Estimate (GHE). We queried each hospitalization for any surgical procedure in a binary manner to determine the volume of surgery for each disease state. Surgical procedures were defined as requiring general or neuroaxial anesthesia. We then divided the volume of surgical cases by counts of disease prevalence from the Global Burden of Disease Study 2010 to determine annual surgical incidence.Between 2008 and 2011, there were 1,108,653 hospital admissions with 275,570 associated surgical procedures per year. Surgical procedures were associated with admissions for all 22 GHE disease subcategories and 116 of 119 GHE disease states. The sub-categories with the largest surgical case volumes were Unintentional Injuries (48,073), Musculoskeletal Diseases (38,030), and Digestive Diseases (27,640). Surgical incidence ranged widely by individual disease states with the highest in: Other Neurological Conditions, Abortion, Appendicitis, Obstructed Labor, and Maternal Sepsis.This study confirms that surgical care is required across the entire spectrum of GHE disease subcategories, illustrating a critical role in health systems. Surgical incidence might be useful as an index to estimate the need for surgical procedures in other populations.

  View details for DOI 10.1016/j.surg.2015.04.005

  View details for Web of Science ID 000356320400008

  View details for PubMedID 25979439

• Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development SURGERY Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Merisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gullies, R., Greenberg, S. L., Grimes, C. E., Gruen, R. L., Ismail, E. A., Kamara, T. B., Lavy, C., Ganbold, L., Mkandawire, N. C., Raykar, N. P., Riesel, J. N., Rodas, E., Rose, J., Roy, N., Shrime, M. G., Sullivan, R., Verguet, S., Watters, D., Weiser, T. G., Wilson, I. H., Yamey, G., Yip, W. 2015; 158 (1): 3-6

  View details for DOI 10.1016/j.surg.2015.04.011

  View details for Web of Science ID 000356320400002

  View details for PubMedID 25987187

• Global access to surgical care: a modelling study. The Lancet. Global health Alkire, B. C., Raykar, N. P., Shrime, M. G., Weiser, T. G., Bickler, S. W., Rose, J. A., Nutt, C. T., Greenberg, S. L., Kotagal, M., Riesel, J. N., Esquivel, M., Uribe-Leitz, T., Molina, G., Roy, N., Meara, J. G., Farmer, P. E. 2015; 3 (6): e316-23

  Abstract

  More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission's vision.We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis.At least 4·8 billion people (95% posterior credible interval 4·6-5·0 [67%, 64-70]) of the world's population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access.Most of the world's population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.None.

  View details for DOI 10.1016/S2214-109X(15)70115-4

  View details for PubMedID 25926087

• Global access to surgical care: a modelling study LANCET GLOBAL HEALTH Alkire, B. C., Raykar, N. P., Shrime, M. G., Weiser, T. G., Bickler, S. W., Rose, J. A., Nutt, C. T., Greenberg, S. L., Kotagal, M., Riesel, J. N., Esquivel, M., Uribe-Leitz, T., Molina, G., Roy, N., Meara, J. G., Farmer, P. E. 2015; 3 (6): E316-E323

  View details for DOI 10.1016/S2214-109X(15)70115-4

  View details for Web of Science ID 000354827300012

  View details for PubMedID 25926087

• The role of facility-based surgical services in addressing the national burden of disease in New Zealand: an index of surgical incidence based on country-specific disease prevalence. Lancet Hider, P., Wilson, L., Rose, J., Weiser, T. G., Gruen, R., Bickler, S. W. 2015; 385: S25-?

  Abstract

  Surgery is a crucial component of health systems, yet its actual contribution has been difficult to define. We aimed to link use of national hospital service with national epidemiological surveillance data to describe the use of surgical procedures in the management of a broad spectrum of conditions.We compiled Australian Modification-International Classification of Diseases-10 codes from the New Zealand National Minimum Dataset, 2008-11. Using primary cause of admission, we aggregated admissions to 91 hospitals into 119 disease states and 22 disease subcategories of the WHO Global Health Estimate (GHE). We queried each admission for any surgical procedure in a binary manner to determine the frequency of admitted patients whose care required surgery. Surgical procedures were defined as requiring general or neuroaxial anaesthesia. We then divided the volume of surgical cases by counts of disease prevalence from the GBD 2010 to determine surgical incidence. This study was approved by the University of Otago Human Ethics Committee (Health; Reference Number HD14/42). Raw data was only handled by coauthors with direct affiliation with the New Zealand Ministry of Health.Between 2008 and 2011, there were 1 108 653 hospital admissions with 275 570 associated surgical procedures per year. Surgical procedures were associated with admissions for all 22 GHE disease subcategories and 116 of 119 GHE disease states (excluding intestinal nematode infections, iodine deficiency, and vitamin A deficiency). The subcategories with the largest surgical case volumes were unintentional injuries (48 073), musculoskeletal diseases (38 030), and digestive diseases (27 640), and the subcategories with the smallest surgical case volumes were nutritional deficiencies (13), neonatal conditions (204), and infectious and parasitic diseases (982). Surgical incidence ranged widely by individual disease states with the highest in other neurological conditions, abortion, appendicitis, obstructed labour, and maternal sepsis.This study confirms previous research that surgical care is required across the entire spectrum of GHE disease subcategories, showing the crucial role of operative intervention in health systems. Surgical incidence might be useful as an index to estimate the need for surgical procedures in other populations.None.

  View details for DOI 10.1016/S0140-6736(15)60820-0

  View details for PubMedID 26313072

• Variability in mortality after caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: implications for expanding surgical services. Lancet Weiser, T. G., Uribe-Leitz, T., Fu, R., Jaramillo, J., Maurer, L., Esquivel, M. M., Gawande, A. A., Haynes, A. B. 2015; 385: S34-?

  Abstract

  While surgical interventions occur at lower rates in resource-poor settings, rates of complication and death after surgery are substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that quality accompanies increased global access to surgical care. We aimed to assess mortality following surgery to assess the risks of such interventions in these environments.We collected the most recent demographic, health, and economic data from WHO for 114 countries classified as low-income or lower-middle-income according to the World Bank in 2005. We searched OVID, MedLine, PubMed, and SCOPUS to identify studies in these countries reporting all-cause mortality after three commonly performed operations: caesarean delivery, appendectomy, and groin hernia repair. Reports from governmental and other agencies were also identified. We modelled surgical mortality rates for countries without reported data with the lasso technique that performs continuous variable subset selection to avoid model overfitting. We validated our model against known case fatality rates for caesarean delivery. We aggregated mortality results by subregion to account for variability in data availability. We then created collective surgical case fatality rates by WHO region.We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality rates were 7·7 per 1000 operations for caesarean delivery (IQR 3-14), 4·0 per 1000 operations for appendectomy (IQR 0-17), and 4·7 per 1000 operations for hernia groin (IQR 0-13); all recorded deaths occurred during the same admission to hospital as the operation. Based on our model, case fatality rate estimates by subregion ranged from 0·7 (central Europe) to 13·9 (central sub-Saharan Africa) per 1000 caesarean deliveries, 5·6 (central Asia) to 6·4 (central sub-Saharan Africa) per 1000 appendectomies, and 3·5 (tropical Latin America) to 33·9 (central sub-Saharan Africa) per 1000 hernia repairs.All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments, and substantially higher than those in middle-income and high-income settings. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.None.

  View details for DOI 10.1016/S0140-6736(15)60829-7

  View details for PubMedID 26313082

• Proposed minimum rates of surgery to support desirable health outcomes: an observational study based on four strategies. Lancet Esquivel, M. M., Molina, G., Uribe-Leitz, T., Lipsitz, S. R., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 385: S12-?

  Abstract

  The global volume of surgery in 2012 is estimated at 312·9 million operations per year, but rates of surgery vary substantially. Maternal health advocates proposed minimum caesarean delivery rates for benchmarking and to improve perinatal outcomes; however, this has not been done for surgery because the association between rates of surgical care provision as a whole and population health outcomes have not been well described. We use available data to estimate minimum rates of surgery that are associated with important health indicators.We defined surgical operations as procedures done in operating theatres that need general or regional anaesthesia or profound sedation to control pain. We used four strategies to identify rates of surgery based on estimated rates of surgery per country for 2012 associated with life expectancy of 74-75 years; estimated rates of surgery associated with a maternal mortality ratio of less than or equal to 100 per 100 000 live births; estimated minimum need for surgery in the 21 Global Burden of Disease (GBD) regions based on the prevalence of disorders; and surgical rates from the so-called 4C countries (Chile, China, Costa Rica, and Cuba) identified in The Lancet Commission on Global Surgery as exemplary for their achievement of high health status, despite resource limitations.Based on 2012 national surgical rates, countries with reported life expectancy of 74-75 years (n=17) had a median surgical rate of 4392 (IQR 2897-4873) operations per 100 000 population annually. The median surgical rate associated with maternal mortality ratio lower than 100 (n=109) is 5028 (IQR 4139-6778) operations per 100 000 population annually. The median surgical rate estimated for all 21 GBD regions was 4669 (IQR 4339-5291) operations per 100 000 population annually. The 4C countries had a mean surgical rate of 4344 (95% CI 2620-6068) operations per 100 000 population annually. 13 of the 21 GBD regions, accounting for 78% of the world's population, do not achieve the lowest end of the surgical rate range.We identified a surprisingly narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health-care systems and surgical capacity.None.

  View details for DOI 10.1016/S0140-6736(15)60807-8

  View details for PubMedID 26313058

• Projections to achieve minimum surgical rate threshold: an observational study. Lancet Uribe-Leitz, T., Esquivel, M. M., Molina, G., Lipsitz, S. R., Verguet, S., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 385: S14-?

  Abstract

  Recent work has indicated an increase in surgical services, especially in resource poor settings. However, the rate of growth is poorly understood and likely insufficient to meet public health needs. We previously identified a range of 4344 to 5028 operations per 100 000 population annually to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100 000 population. We evaluate rates of growth in surgery and estimate the time it will take to reach this minimum surgical rate threshold.We aggregated 2004 and 2012 country-level surgical rate estimates into the 21 Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size and estimate rate of growth between these years. We then extrapolated the time it will take to reach a surgical rate of 5000 operations per 100 000 population based on linear rates of change.All but two regions (central Europe and southern Latin America) experienced growth in their surgical rates during the past 8 years; the fastest growth occurred in regions with the lowest surgical rates. 14 regions representing 79% of the world's population (5·5 billion people) did not meet the recommended surgical rate threshold in 2012. If surgical capacity grows at current rates, seven regions (central sub-Saharan Africa, east Asia, eastern sub-Saharan Africa, north Africa and middle east, south Asia, southeast Asia, and western sub-Saharan Africa) will not meet the recommended surgical rate threshold by 2035; Eastern Sub-Saharan Africa will not reach this level until 2124.The rates of growth in surgical service delivery are exceedingly variable, but the largest growth rates were noted in the poorest regions. Although this study does not address the quality of care, and rates of surgery are unlikely to change linearly, this exercise is useful to project how many years it could take regions to reach specific surgical rates. At current rates of growth, 4·9 billion people (70% of the world's population) will still be living in countries below the minimum recommended rate of surgery in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met as part of integrated health system development.None.

  View details for DOI 10.1016/S0140-6736(15)60809-1

  View details for PubMedID 26313060

• Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet Weiser, T. G., Haynes, A. B., Molina, G., Lipsitz, S. R., Esquivel, M. M., Uribe-Leitz, T., Fu, R., Azad, T., Chao, T. E., Berry, W. R., Gawande, A. A. 2015; 385: S11-?

  Abstract

  It was previously estimated that 234·2 million operations were performed worldwide in 2004. The association between surgical rates and population health outcomes is not clear. We re-estimated global surgical volume to track changes over time and assess rates associated with healthy populations.We gathered demographic, health, and economic data for 194 WHO member states. Surgical volumes were obtained from published studies and other reports from 2005 onwards. We estimated rates of surgery for all countries without available data based on health expenditure in 2012 and assessed the proportion of surgery comprised by caesarean delivery. The rate of surgery was plotted against life expectancy to describe the association between surgical care and this health indicator.We identified 66 countries reporting surgical data between 2005 and 2013. We estimate that 312·9 million operations (95% CI 266·2-359·5) took place in 2012-a 33·6% increase over 8 years; the largest proportional increase occurred in countries spending US$400 or less per capita on health care. Caesarean delivery comprised 29·8% (5·8 million operations) of the total surgical volume in poor health expenditure countries compared with 10·8% (7·8 million operations) in low health expenditure countries and 2·7% (5·1 million operations) in high health expenditure countries. We noted a correlation between increased life expectancy and increased surgical rates up to 1533 operations per 100 000 people, with significant but less dramatic improvement above this rate.Surgical volume is large and continues to grow in all economic environments. A single procedure-caesarean delivery-comprised almost a third of surgical volume in the most resource-limited settings. Surgical care is an essential part of health care and is associated with increased life expectancy, yet many low-income countries fail to achieve basic levels of service. Improvements in capacity and delivery of surgical services must be a major component of health system strengthening.None.

  View details for DOI 10.1016/S0140-6736(15)60806-6

  View details for PubMedID 26313057

• Avoidable maternal and neonatal deaths associated with improving access to caesarean delivery in countries with low caesarean delivery rates: an ecological modelling analysis. Lancet Molina, G., Esquivel, M. M., Uribe-Leitz, T., Lipsitz, S. R., Azad, T., Shah, N., Semrau, K., Berry, W. R., Gwande, A. A., Weiser, T. G., Haynes, A. B. 2015; 385: S33-?

  Abstract

  Reducing maternal and neonatal deaths are important global health priorities. We have previously shown that up to a country-level caesarean delivery rate (CDRs) of roughly 19·0%, cesarean delivery rates and maternal mortality ratio (MMR) and neonatal mortality rate (NMR) were inversely correlated. We investigated the absolute reductions in maternal and neonatal deaths if countries with low CDR increased their rates to a range of greater than 7·2% but less than or equal to 19·1%.We calculated maternal and neonatal deaths in 2013 and 2012, respectively, for countries with CDR 7·2% or less (N=45) with available data from the World Bank Development Indicators. We modelled the expected reduction in deaths in these countries if they had the 25th and 75th MMR and NMR percentiles observed for countries (N=48) with CDRs ranging from greater than 7·2% but less than or equal to 19·1%. This model assumes that if countries with low CDRs increased their rates of caesarean delivery to greater than 7·2% but less than or equal to 19·1%, they would achieve levels of MMR and NMR observed in countries with those CDRs.We estimate 176 078 (95% CI 163 258-188 898) maternal and 1 117 257 (95% CI 1 033 611-1 200 902) neonatal deaths occurred in 45 countries with low CDRs in 2013 and 2012, respectively. If these countries had the 25th and 75th MMR and NMR percentiles (MMR, IQR 36-190; NMR, 9-24) observed in countries (N=48) with a CDR ranging from greater than 7·2% but less than or equal to 19·1%, there would be a potential reduction of 109 762-163 513 and 279 584-803 129 maternal and neonatal deaths, respectively.Increasing caesarean delivery in countries with low CDRs could avert as many as 163 513 maternal deaths and 803 129 neonatal deaths annually. These findings assume that as health systems develop the capacity to deliver surgical care, there is a concurrent improvement in the quality of care and in the ability to rescue women and neonates who would otherwise die. Improving access to safe caesarean delivery should be a central focus in surgical care globally.None.

  View details for DOI 10.1016/S0140-6736(15)60828-5

  View details for PubMedID 26313081

• Beyond the hospital doors: Improving long-term outcomes for elderly trauma patients JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Ayoung-Chee, P. R., Rivara, F. P., Weiser, T., Maier, R. V., Arbabi, S. 2015; 78 (4): 837-843

  Abstract

  Elderly trauma patients (TPs) are the fastest growing trauma population, increasing the need for postacute care rehabilitation. For TP, discharge to skilled nursing facilities (SNFs) has been associated with higher 1-year mortality compared with discharge to inpatient rehabilitation facilities (IRFs) or home. The availability of IRF beds has been decreasing, but the proportion occupied by non-TPs, specifically stroke patients (SPs), has increased. We wanted to better characterize trends in trauma discharges and compare them with a population that is equally dependent on postdischarge rehabilitation. We hypothesized that discharge to SNF is rapidly increasing, while discharge to IRF is declining for trauma, but not for SPs.This is retrospective cohort study of adult trauma and SPs discharged from 2003 to 2009. The National Trauma Data Bank and National Inpatient Sample were used to study TPs and SPs, respectively.Falls became the leading cause of injury, and the proportion of older TPs increased from 23% to 30%. Older TPs discharged to SNF increased from 30.7% in 2003 to 40.8% in 2009 (p < 0.001). TPs were 34% (adjusted relative risk [RR], 1.34; 95% confidence interval [CI], 1.15-1.57) more likely to be discharged to an SNF and 36% (adjusted RR, 0.64; 95% CI, 0.48-0.85) less likely to be discharged to an IRF. From 2003 to 2009, SPs were 78% more likely to be discharged to an IRF (adjusted RR, 1.78; 95% CI, 1.74-1.82). The largest absolute increase in SP discharges to IRFs occurred the year following implementation of the stroke center certification program.For TPs, there was a significant increase in SNF discharges and a decrease in IRF discharges. During the same period, after implementation of stroke center certification, SPs were more likely to be discharged to an IRF. Future research should focus on evaluating which postacute care setting is most effective in providing rehabilitation for TPs and adjusting our discharge efforts to improve long-term outcomes.Prognostic and epidemiologic study, level III.

  View details for DOI 10.1097/TA.0000000000000567

  View details for Web of Science ID 000352074000025

  View details for PubMedID 25742250

• Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate LANCET GLOBAL HEALTH Rose, J., Weiser, T. G., Hider, P., Wilson, L., Gruen, R. L., Bickler, S. W. 2015; 3: S13-S20

  Abstract

  Surgery is a foundational component of health-care systems. However, previous efforts to integrate surgical services into global health initiatives do not reflect the scope of surgical need and many health systems do not provide essential interventions. We estimate the minimum global volume of surgical need to address prevalent diseases in 21 epidemiological regions from the Global Burden of Disease Study 2010 (GBD).Prevalence data were obtained from GBD 2010 and organised into 119 disease states according to the WHO's Global Health Estimate (GHE). These data, representing 187 countries, were then apportioned into the 21 GBD epidemiological regions. Using previously defined values for the incident need for surgery for each of the 119 GHE disease states, we calculate minimum global need for surgery based on the prevalence of each condition in each region.We estimate that at least 321·5 million surgical procedures would be needed to address the burden of disease for a global population of 6·9 billion in 2010. Minimum rates of surgical need vary across regions, ranging from 3383 operations per 100 000 in central Latin America to 6495 operations per 100 000 in western sub-Saharan Africa. Global surgical need also varied across subcategories of disease, ranging from 131 412 procedures for nutritional deficiencies to 45·8 million procedures for unintentional injuries.The estimated need for surgical procedures worldwide is large and addresses a broad spectrum of disease states. Surgical need varies between regions of the world according to disease prevalence and many countries do not meet the basic needs of their populations. These estimates could be useful for policy makers, funders, and ministries of health as they consider how to incorporate surgical capacity into health systems.US National Institutes of Health.

  View details for Web of Science ID 000353624100008

  View details for PubMedID 25926315

• Gastrointestinal Mucormycosis Requiring Surgery in Adults with Hematologic Malignant Tumors: Literature Review SURGICAL INFECTIONS Forrester, J. D., Chandra, V., Shelton, A. A., Weiser, T. G. 2015; 16 (2): 194-202

  Abstract

  Gastrointestinal mucormycosis is associated with high mortality rates. Appropriate and early antifungal therapy and prompt surgical intervention are essential.Case report and literature review.Nineteen case reports were reviewed describing adults with hematologic malignant tumors who developed intestinal mucormycosis and underwent surgery. The overall survival rate was 50%.Intestinal mucormycosis is an infection associated with a high mortality rate although adults with underlying hematologic malignant have improved outcomes compared with other groups.

  View details for DOI 10.1089/sur.2013.232

  View details for Web of Science ID 000352360400015

  View details for PubMedID 25405775

• Timing and cost of scaling up surgical services in low-income and middle-income countries from 2012 to 2030: a modelling study LANCET GLOBAL HEALTH Verguet, S., Alkire, B. C., Bickler, S. W., Lauer, J. A., Uribe-Leitz, T., Molina, G., Weiser, T. G., Yamey, G., Shrime, M. G. 2015; 3: S28-S37

  Abstract

  Given the large burden of surgical conditions and the crosscutting nature of surgery, scale-up of basic surgical services is crucial to health-system strengthening. The Lancet Commission on Global Surgery proposed that, to meet populations' needs, countries should achieve 5000 major operations per 100 000 population per year. We modelled the possible scale-up of surgical services in 88 low-income and middle-income countries with a population greater than 1 million from 2012 to 2030 at various rates and quantified the associated costs.Major surgery includes any intervention within an operating room involving tissue manipulation and anaesthesia. We used estimates for the number of major operations achieved per country annually and the number of operating rooms per region, and data from Mongolia and Mexico for trends in the number of operations. Unit costs included a cost per operation, proxied by caesarean section cost estimates; hospital construction data were used to estimate cost per operating room construction. We determined the year by which each country would achieve the Commission's target. We modelled three scenarios for the scale-up rate: actual rates (5·1% per year) and two "aspirational" rates, the rates achieved by Mongolia (8·9% annual) and Mexico (22·5% annual). We subsequently estimated the associated costs.About half of the 88 countries would achieve the target by 2030 at actual rates of improvements, with up to two-thirds if the rate were increased to Mongolian rates. We estimate the total costs of achieving scale-up at US$300-420 billion (95% UI 190-600 billion) over 2012-30, which represents 4-8% of total annual health expenditures among low-income and lower middle-income countries and 1% among upper middle-income countries.Scale-up of surgical services will not reach the target of 5000 operations per 100 000 by 2030 in about half of low-income and middle-income countries without increased funding, which countries and the international community must seek to achieve expansion of quality surgical services.None.

  View details for Web of Science ID 000353624100010

  View details for PubMedID 25926318

• The burden of selected congenital anomalies amenable to surgery in low and middle-income regions: cleft lip and palate, congenital heart anomalies and neural tube defects. Archives of disease in childhood Higashi, H., Barendregt, J. J., Kassebaum, N. J., Weiser, T. G., Bickler, S. W., Vos, T. 2015; 100 (3): 233-238

  Abstract

  To quantify the burden of selected congenital anomalies in low and middle-income countries (LMICs) that could be reduced should surgical programmes cover the entire population with access to quality care.Burden of disease and epidemiological modelling.LMICs from all global regions.All prevalent cases of selected congenital anomalies at birth in 2010.Disability-adjusted life years (DALYs).Surgical programmes for three congenital conditions were analysed: clefts (lip and palate); congenital heart anomalies; and neural tube defects. Data from the Global Burden of Disease 2010 Study were used to estimate the combination of fatal burden that could be addressed by surgical care and the additional long-term non-fatal burden associated with increased survival.Of the estimated 21.6 million DALYs caused by these three conditions in LMICs, 12.4 million DALYs (57%) are potentially addressable by surgical care among the population born with such conditions. Neural tube defects have the largest potential with 76% of burden amenable by surgery, followed by clefts (59%) and congenital heart anomalies (49%). Sub-Saharan Africa and South Asia have the greatest proportion of surgically addressable burden for clefts (68%), North Africa and Middle East for congenital heart anomalies (73%), and South Asia for neural tube defects (81%).There is an important and neglected role surgical programmes can play in reducing the burden of congenital anomalies in LMICs.

  View details for DOI 10.1136/archdischild-2014-306175

  View details for PubMedID 25260520

• Surgically avertable burden of digestive diseases at first-level hospitals in low and middle-income regions. Surgery Higashi, H., Barendregt, J. J., Kassebaum, N. J., Weiser, T. G., Bickler, S. W., Vos, T. 2015; 157 (3): 411-419

  Abstract

  To quantify the burden of digestive diseases avertable by surgical care at first-level hospitals in low- and middle-income countries (LMICs).We examined 4 digestive diseases from the Global Burden of Disease (GBD) 2010 STUDY: Appendicitis, intestinal obstruction, inguinal and femoral hernia, and gallbladder and bile duct disease. Using demographic and epidemiologic data from the GBD 2010 STUDY, we calculated the potential decrease in burden of digestive diseases if quality surgical services were available universally and accessible at first-level hospitals. The lowest case fatality rates for each age and sex grouping from all GBD regions were assumed to reflect the best possible state of full surgical coverage and treatment. These best scenario rates were applied to the GBD 2010 results from all LMIC regions to estimate surgically avertable burden.Overall, 4.8 million disability-adjusted life-years (DALYs) or 65% of burden related to the 4 digestive diseases are avertable potentially with first-level surgical care in LMICs. Sub-Saharan Africa has the greatest avertable burden in absolute DALYs (1.7 million) and avertable proportion (83%). Intestinal obstruction accounted for the largest portion of avertable burden among the 4 digestive diseases (2.2 million DALYs; 64% avertable).Improving the capacity of surgical services at first-level hospitals is essential for averting the burden of digestive diseases in LMICs. Practicable strategies for scaling up surgical capacities in rural districts are available potentially, which must be given due attention.

  View details for DOI 10.1016/j.surg.2014.07.009

  View details for PubMedID 25444219

• Adding insult to injury: discontinuous insurance following spine trauma. journal of bone and joint surgery. American volume Kastenberg, Z. J., Hurley, M. P., Weiser, T. G., Cole, T. S., Staudenmayer, K. L., Spain, D. A., Ratliff, J. K. 2015; 97 (2): 141-146

  Abstract

  Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

  View details for DOI 10.2106/JBJS.N.00148

  View details for PubMedID 25609441

• Adding Insult to Injury: Discontinuous Insurance Following Spine Trauma JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Kastenberg, Z. J., Hurley, M. P., Weiser, T. G., Cole, T. S., Staudenmayer, K. L., Spain, D. A., Ratliff, J. K. 2015; 97A (2): 141-146

  View details for DOI 10.2106/JBJS.N.00148

  View details for Web of Science ID 000348217200012

• Surgically avertable burden of obstetric conditions in low- and middle-income regions: a modelled analysis BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY Higashi, H., Barendregt, J. J., Kassebaum, N. J., Weiser, T. G., Bickler, S. W., Vos, T. 2015; 122 (2): 228-236

  Abstract

  To quantify the burden of maternal and neonatal conditions in low- and middle-income countries (LMICs) that could be averted by full access to quality first-level obstetric surgical procedures.Burden of disease and epidemiological modelling.LMICs from all global regions.The entire population in 2010.We included five conditions in our analysis: maternal haemorrhage; obstructed labour; obstetric fistula; abortion(1) ; and neonatal encephalopathy. Demographic and epidemiological data were obtained from the Global Burden of Disease 2010 study. We split the disability-adjusted life years (DALYs) of these conditions into surgically 'avertable' and 'non-avertable' burdens. We applied the lowest age-specific fatality rates from all global regions to each LMIC region to estimate the avertable deaths, assuming that the differences of death rates between each region and the lowest rates reflect the gap in surgical care.Deaths and DALYs avertable.Of the estimated 56.6 million DALYs (i.e. 56.6 million years of healthy life lost) of the selected five conditions, 21.1 million DALYs (37%) are avertable by full coverage of quality obstetric surgery in LMICs. The avertable burden in absolute term is substantial given the size of burden of these conditions in LMICs. Neonatal encephalopathy constitutes the largest portion of avertable burden (16.2 million DALYs) among the five conditions, followed by abortion (2.1 million DALYs).Improving access to quality surgical care at first-level hospitals could reduce a tremendous burden of maternal and neonatal conditions in LMICs.

  View details for DOI 10.1111/1471-0528.13198

  View details for Web of Science ID 000346915800021

  View details for PubMedID 25546047

• Burden of Injuries Avertable By a Basic Surgical Package in Low- and Middle-Income Regions: A Systematic Analysis From the Global Burden of Disease 2010 Study WORLD JOURNAL OF SURGERY Higashi, H., Barendregt, J. J., Kassebaum, N. J., Weiser, T. G., Bickler, S. W., Vos, T. 2015; 39 (1): 1-9

  Abstract

  Injuries accounted for 11 % of the global burden of disease in 2010. This study aimed to quantify the burden of injury in low- and middle-income countries (LMICs) that could be averted if basic surgical services were made available and accessible to the entire population.We examined all causes of injury from the Global Burden of Disease 2010 Study. We split the disability-adjusted life years (DALYs) for these conditions between surgically "avertable" and "nonavertable" burdens. For estimating the avertable fatal burden, we applied the lowest fatality rates among the 21 epidemiologic regions to each LMIC region, assuming that the differences in death rates between each region and the lowest rates reflect the gap in surgical care. We adjusted for fatal cases that occur prior to reaching hospitals as they are not surgically avertable. Similarly, we applied the lowest nonfatal burden per case to each LMIC region.Overall, 21 % of the injury burden in LMICs was potentially avertable by basic surgical care (52.3 million DALYs). The avertable proportion was greater for deaths than for nonfatal burden (23 vs. 20 %), suggesting that surgical services for injuries more effectively save lives than ameliorate disability. Sub-Saharan Africa had the largest proportion of potentially avertable burden (25 %). South Asia had the highest total avertable DALYs (17.4 million). Road injury comprised the largest total avertable burden in LMICs (16.1 million DALYs).Basic surgical care has the potential to play a major role in reducing the injury-related burden in LMICs.

  View details for DOI 10.1007/s00268-014-2685-x

  View details for Web of Science ID 000346789500001

  View details for PubMedID 25008243

• Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. The Lancet. Global health Chao, T. E., Sharma, K., Mandigo, M., Hagander, L., Resch, S. C., Weiser, T. G., Meara, J. G. 2014; 2 (6): e334-45

  Abstract

  The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health efforts. We did a systematic review and analysis of cost-effectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery.We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-effectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist.Of the 584 identified studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13·78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12·96-25·93 per DALY) and bednets for malaria prevention ($6·48-22·04 per DALY). Median CERs of cleft lip or palate repair ($47·74 per DALY), general surgery ($82·32 per DALY), hydrocephalus surgery ($108·74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51·86-220·39 per DALY). Median CERs of caesarean sections ($315·12 per DALY) and orthopaedic surgery ($381·15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500·41-706·54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453·74-648·20 per DALY).Our findings suggest that many essential surgical interventions are cost-effective or very cost-effective in resource-poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery's role in the global health movement. However, economic value should not be the only argument for resource allocation--other organisational, ethical, and political arguments can also be made for its inclusion.

  View details for DOI 10.1016/S2214-109X(14)70213-X

  View details for PubMedID 25103302

• Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis LANCET GLOBAL HEALTH Chao, T. E., Sharma, K., Mandigo, M., Hagander, L., Resch, S. C., Weiser, T. G., Meara, J. G. 2014; 2 (6): E334-E345

  View details for Web of Science ID 000336425200017

• Evaluation of a large-scale donation of Lifebox pulse oximeters to non-physician anaesthetists in Uganda ANAESTHESIA Finch, L. C., Kim, R. Y., Ttendo, S., Kiwanuka, J. K., Walker, I. A., Wilson, I. H., Weiser, T. G., Berry, W. R., Gawande, A. A. 2014; 69 (5): 445-451

  Abstract

  Pulse oximetry is widely accepted as essential monitoring for safe anaesthesia, yet is frequently unavailable in resource-limited settings. The Lifebox pulse oximeter, and associated management training programme, was delivered to 79 non-physician anaesthetists attending the 2011 Uganda Society of Anaesthesia Annual Conference. Using a standardised assessment, recipients were tested for their knowledge of oximetry use and hypoxia management before, immediately following and 3-5 months after the training. Before the course, the median (IQR [range]) test score for the anaesthetists was 36 (34-39 [26-44]) out of a maximum of 50 points. Immediately following the course, the test score increased to 41 (38-43 [25-47]); p < 0.0001 and at the follow-up visit at 3-5 months it was 41 (39-44 [33-49]); p = 0.001 compared with immediate post-training test scores, and 75/79 (95%) oximeters were in routine clinical use. This method of introduction resulted in a high rate of uptake of oximeters into clinical practice and a demonstrable retention of knowledge in a resource-limited setting.

  View details for DOI 10.1111/anae.12632

  View details for Web of Science ID 000334368300009

  View details for PubMedID 24738801

• The epidemiology of trauma-related mortality in the United States from 2002 to 2010. journal of trauma and acute care surgery Sise, R. G., Calvo, R. Y., Spain, D. A., Weiser, T. G., Staudenmayer, K. L. 2014; 76 (4): 913-920

  Abstract

  Epidemiologic trends in trauma-related mortality in the United States require updating and characterization. We hypothesized that during the past decade, there have been changing trends in mortality that are associated with multiple public health and health care-related factors.Multiple sources were queried for the period of 2002 to 2010: the National Trauma Data Bank, the National Centers for Disease Control, the National Highway Traffic Safety Administration, the Nationwide Emergency Department Sample, and the US Census Bureau. The incidence of injury and mortality for motor vehicle traffic (MVT) collisions, firearms, and falls were determined using National Centers for Disease Control data. National Highway Traffic Safety Administration data were used to determine motor vehicle collision information. Injury severity data were derived from the Nationwide Emergency Department Sample and National Trauma Data Bank. Analysis of mortality trends by year was performed using the Cochran-Armitage test for trend. Time-trend multivariable Poisson regression was used to determine risk-adjusted mortality over time.From 2002 to 2010, the total trauma-related mortality decreased by 6% (p < 0.01). However, mortality trends differed by mechanism. There was a 27% decrease in the MVT death rate associated with a 20% decrease in motor vehicle collisions, 19% decrease in the number of occupant injuries per collision, lower injury severity, and improved outcomes at trauma centers. While firearm-related mortality remained relatively unchanged, mortality caused by firearm suicides increased, whereas homicide-associated mortality decreased (p < 0.001 for both). In contrast, fall-related mortality increased by 46% (5.95-8.70, p < 0.01).MVT mortality rates have decreased during the last decade, owing in part to decreases in the number and severity of injuries. Conversely, fall-related mortality is increasing and is projected to exceed both MVT and firearm mortality rates should current trends continue. Trauma systems and injury prevention programs will need to take into account these changing trends to best accommodate the needs of the injured population.Epidemiologic study, level III.

  View details for DOI 10.1097/TA.0000000000000169

  View details for PubMedID 24662852

• The role of surgery in global health: analysis of United States inpatient procedure frequency by condition using the global burden of disease 2010 framework. PloS one Rose, J., Chang, D. C., Weiser, T. G., Kassebaum, N. J., Bickler, S. W. 2014; 9 (2)

  Abstract

  The role of surgical care in promoting global health is the subject of much debate. The Global Burden of Disease 2010 study (GBD 2010) offers a new opportunity to consider where surgery fits amongst global health priorities. The GBD 2010 reinforces the DALY as the preferred methodology for determining the relative contribution of disease categories to overall global burden of disease without reference to the likelihood of each category requiring surgery. As such, we hypothesize that the GBD framework underestimates the role of surgery in addressing the global burden of disease.We compiled International Classification of Diseases, Version 9, codes from the United States Nationwide Inpatient Sample from 2010. Using the primary diagnosis code for each hospital admission, we aggregated admissions into GBD 2010 disease sub-categories. We queried each hospitalization for a major operation to determine the frequency of admitted patients whose care required surgery. Major operation was defined according to the Agency for Healthcare Research and Quality (AHRQ). In 2010, 10 million major inpatient operations were performed in the United States, associated with 28.6% of all admissions. Major operations were performed in every GBD disease subcategory (range 0.2%-84.0%). The highest frequencies of operation were in the subcategories of Musculoskeletal (84.0%), Neoplasm (61.4%), and Transport Injuries (43.2%). There was no disease subcategory that always required an operation; nor was there any disease subcategory that never required an operation.Surgical care cuts across the entire spectrum of GBD disease categories, challenging dichotomous traditional classifications of 'surgical' versus 'nonsurgical' diseases. Current methods of measuring global burden of disease do not reflect the fundamental role operative intervention plays in the delivery of healthcare services. Novel methodologies should be aimed at understanding the integration of surgical services into health systems to address the global burden of disease.

  View details for DOI 10.1371/journal.pone.0089693

  View details for PubMedID 24586967

• Thyroid surgery in a district hospital: a vertical program embedded in a rural hospital. World journal of surgery Weiser, T. G. 2013; 37 (7): 1574-1575

  View details for DOI 10.1007/s00268-013-2098-2

  View details for PubMedID 23649532

• Safety in the operating theatre-a transition to systems-based care NATURE REVIEWS UROLOGY Weiser, T. G., Porter, M. P., Maier, R. V. 2013; 10 (3): 161-173

  Abstract

  All surgeons want the best, safest care for their patients, but providing this requires the complex coordination of multiple disciplines to ensure that all elements of care are timely, appropriate, and well organized. Quality-improvement initiatives are beginning to lead to improvements in the quality of care and coordination amongst teams in the operating room. As the population ages and patients present with more complex disease pathology, the demands for efficient systematization will increase. Although evidence suggests that postoperative mortality rates are declining, there is substantial room for improvement. Multiple quality metrics are used as surrogates for safe care, but surgical teams--including surgeons, anaesthetists, and nurses--must think beyond these simple interventions if they are to effectively communicate and coordinate in the face of increasing demands.

  View details for DOI 10.1038/nrurol.2013.13

  View details for Web of Science ID 000316712500007

  View details for PubMedID 23419492

• Review article: Perioperative checklist methodologies CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Weiser, T. G., Berry, W. R. 2013; 60 (2): 136-142

  Abstract

  Checklists are increasingly being used by surgical teams in the perioperative period to improve clinical care and increase patient safety. In this article, we review some of the mechanisms by which checklists work and evaluate evidence supporting their use.There is a growing body of evidence showing the importance of team-based checklists in clinical care. In multiple complex clinical environments, from the operating room to the intensive care unit, checklists can help ensure adherence to known standards of care and improve communication amongst team members. In addition, the efficacy of checklists is being shown in both developed and developing settings.Checklists can aid clinicians involved in complex processes and multidisciplinary team interactions to improve the quality and safety of care by prompting dialogue and exchange of information.

  View details for DOI 10.1007/s12630-012-9854-x

  View details for Web of Science ID 000315579500006

  View details for PubMedID 23233394

• Mass casualty incident training in a resource-limited environment (Br J Surg 2012; 99: 356-361) BRITISH JOURNAL OF SURGERY Weiser, T. G. 2012; 99 (3): 361-361

  View details for DOI 10.1002/bjs.7774

  View details for Web of Science ID 000303148800010

  View details for PubMedID 22287072

• Rates and patterns of death after surgery in the United States, 1996 and 2006 SURGERY Semel, M. E., Lipsitz, S. R., Funk, L. M., Bader, A. M., Weiser, T. G., Gawande, A. A. 2012; 151 (2): 171-182

  Abstract

  Nationwide rates and patterns of death after surgery are unknown.Using the Nationwide Inpatient Sample, we compared deaths within 30 days of admission for patients undergoing surgery in 1996 and 2006. International Classification of Diseases codes were used to identify 2,520 procedures for analysis. We examined the inpatient 30-day death rate for all procedures, procedures with the most deaths, high-risk cardiovascular and cancer procedures, and patients who suffered a recorded complication. We used logistic regression modeling to adjust 1996 mortality rates to the age and gender distributions for patients undergoing surgery in 2006.In 1996, there were 12,573,331 admissions with a surgical procedure (95% confidence interval [CI], 12,560,171-12,586,491) and 224,111 inpatient deaths within 30 days of admission (95% CI, 221,912-226,310). In 2006, there were 14,333,993 admissions with a surgical procedure (95% CI, 14,320,983-14,347,002) and 189,690 deaths (95% CI, 187,802-191,578). Inpatient 30-day mortality declined from 1.68% in 1996 to 1.32% in 2006 (P < .001). Of the 21 procedures with the most deaths in 1996, 15 had significant declines in adjusted mortality in 2006. Among these 15 procedures, 8 had significant declines in operative volume. The inpatient 30-day mortality rate for patients who suffered a complication decreased from 12.10% to 9.84% (P < .001).Nationwide reporting on surgical mortality suggests that the number of inpatient deaths within 30 days of surgery has declined. Additional research to determine the underlying causes for decreased mortality is warranted.

  View details for DOI 10.1016/j.surg.2011.07.021

  View details for Web of Science ID 000299607800005

  View details for PubMedID 21975292

• Postgame Analysis: Using Video-Based Coaching for Continuous Professional Development JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Hu, Y., Peyre, S. E., Arriaga, A. F., Osteen, R. T., Corso, K. A., Weiser, T. G., Swanson, R. S., Ashley, S. W., Raut, C. P., Zinner, M. J., Gawande, A. A., Greenberg, C. C. 2012; 214 (1): 115-124

  Abstract

  The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance.Four complex operations performed by surgeons of varying experience--a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience--were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded.The sessions focused on operative technique--both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident's technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings.Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development.

  View details for DOI 10.1016/j.jamcollsurg.2011.10.009

  View details for Web of Science ID 000299054400017

  View details for PubMedID 22192924

• In-hospital Death following Inpatient Surgical Procedures in the United States, 1996-2006 WORLD JOURNAL OF SURGERY Weiser, T. G., Semel, M. E., Simon, A. E., Lipsitz, S. R., Haynes, A. B., Funk, L. M., Berry, W. R., Gawande, A. A. 2011; 35 (9): 1950-1956

  Abstract

  Over the past decade, improvements in perioperative care have been widely introduced throughout the United States, yet there is no clear indication that the death rate following surgery has improved. We sought to evaluate the number of deaths after surgery in the United States over a 10-year period and to evaluate trends in postoperative mortality.Using the National Hospital Discharge Survey, we identified patients who underwent a surgical procedure and subsequently died in the hospital within 30 days of admission.In 1996 there were 12,250,000 hospitalizations involving surgery, rising to 13,668,000 in 2006. Postoperative deaths, however, declined during this same period, from 201,000 to 156,000 (P < 0.01), giving a postoperative in-hospital death ratio (death per hospitalization) of 1.64 and 1.14% (P < 0.001), respectively, for the two time frames.The death rate following surgery is substantial but appears to have improved. Such mortality statistics provide an essential measure of the public health impact of surgical care. Incorporating mortality statistics following therapeutic intervention is an essential strategy for regional and national surveillance of care delivery.

  View details for DOI 10.1007/s00268-011-1169-5

  View details for Web of Science ID 000293705500002

  View details for PubMedID 21732207

• Surgical outcome measurement for a global patient population: Validation of the Surgical Apgar Score in 8 countries SURGERY Haynes, A. B., Regenbogen, S. E., Weiser, T. G., Lipsitz, S. R., Dziekan, G., Berry, W. R., Gawande, A. A. 2011; 149 (4): 519-524

  Abstract

  Surgical care is a vital component of health care worldwide, yet there is no clinically meaningful measure of operative outcomes that could be applied globally. The Surgical Apgar Score, a simple metric derived from 3 intraoperative parameters, has been shown in U.S. academic medical centers to predict 30-day patient outcomes after operation, but has not been validated more broadly.We collected the components of the Surgical Apgar Score at the time of operation for 5,909 adult patients undergoing noncardiac operative procedures under general anesthesia at 8 hospitals in diverse international settings and evaluated the relationship between patients' scores and the incidence of inpatient postoperative morbidity and mortality, using generalized estimating equations to adjust for clustering within sites.During the first 30 days of postoperative hospitalization, 544 patients (9.2%) experienced ≥ 1 complications. Compared with patients with the median score of 7--whose complication rate was 9.1%-those with a Surgical Apgar Score <5 (n = 302) had an adjusted complication rate of 32.9% (relative risk [RR],3.6; 95% CI, 2.9-4.5), whereas those with a score of 10 (n = 238) had a 3.0% adjusted complication rate (RR, 0.3; 95% CI, 0.1-1.1). The score's c-statistic for prediction of any complication is 0.70; for death it is 0.77.The Surgical Apgar Score is easily calculated, predictive, and moderately discriminative for major complications among adults undergoing inpatient noncardiac operative procedures. Such a score could provide objective indication of relative postoperative risk for inpatients and provide a potential target for quality improvement efforts, particularly in resource-limited settings.

  View details for DOI 10.1016/j.surg.2010.10.019

  View details for Web of Science ID 000289017500007

  View details for PubMedID 21216419

• Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention BMJ QUALITY & SAFETY Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. S., Dellinger, E. P., Dziekan, G., Herbosa, T., Kibatala, P. L., Lapitan, M. C., Merry, A. F., Reznick, R. K., Taylor, B., Vats, A., Gawande, A. A. 2011; 20 (1): 102-107

  Abstract

  To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention.Pre- and post intervention survey.Eight hospitals participating in a trial of a WHO surgical safety checklist.Clinicians actively working in the designated study operating rooms at the eight hospitals. SURVEY INSTRUMENT: Modified operating-room version Safety Attitudes Questionnaire (SAQ).Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability.Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation.Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.

  View details for DOI 10.1136/bmjqs.2009.040022

  View details for Web of Science ID 000289726400014

  View details for PubMedID 21228082

• HEALTH POLICY All-or-none compliance is the best determinant of quality of care NATURE REVIEWS UROLOGY Weiser, T. G. 2010; 7 (10): 541-542

  View details for DOI 10.1038/nrurol.2010.155

  View details for Web of Science ID 000282679500005

  View details for PubMedID 20930866

• Perspectives in quality: designing the WHO Surgical Safety Checklist INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Weiser, T. G., Haynes, A. B., Lashoher, A., Dziekan, G., Boorman, D. J., Berry, W. R., Gawande, A. A. 2010; 22 (5): 365-370

  Abstract

  The World Health Organization's Patient Safety Programme created an initiative to improve the safety of surgery around the world. In order to accomplish this goal the programme team developed a checklist with items that could and, if at all possible, should be practised in all settings where surgery takes place. There is little guidance in the literature regarding methods for creating a medical checklist. The airline industry, however, has more than 70 years of experience in developing and using checklists. The authors of the WHO Surgical Safety Checklist drew lessons from the aviation experience to create a safety tool that supports essential clinical practice. In order to inform the methodology for development of future checklists in health care, we review how we applied lessons learned from the aviation experience in checklist development to the development of the Surgical Safety Checklist and also discuss the differences that exist between aviation and medicine that impact the use of checklists in health care.

  View details for DOI 10.1093/intqhc/mzq039

  View details for Web of Science ID 000281958200020

  View details for PubMedID 20702569

• Adopting A Surgical Safety Checklist Could Save Money And Improve The Quality Of Care In U.S. Hospitals HEALTH AFFAIRS Semel, M. E., Resch, S., Haynes, A. B., Funk, L. M., Bader, A., Berry, W. R., Weiser, T. G., Gawande, A. A. 2010; 29 (9): 1593-1599

  Abstract

  Use of the World Health Organization's Surgical Safety Checklist has been associated with a significant reduction in major postoperative complications after inpatient surgery. We hypothesized that implementing the checklist in the United States would generate cost savings for hospitals. We performed a decision analysis comparing implementation of the checklist to existing practice in U.S. hospitals. In a hospital with a baseline major complication rate after surgery of at least 3 percent, the checklist generates cost savings once it prevents at least five major complications. Using the checklist would both save money and improve the quality of care in hospitals throughout the United States.

  View details for DOI 10.1377/hlthaff.2009.0709

  View details for Web of Science ID 000281601300006

  View details for PubMedID 20820013

• Effect of A 19-Item Surgical Safety Checklist During Urgent Operations in A Global Patient Population ANNALS OF SURGERY Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz, S. R., Gawande, A. A. 2010; 251 (5): 976-980

  Abstract

  To assess whether implementation of a 19-item World Health Organization (WHO) Surgical Safety Checklist in urgent surgical cases would improve compliance with basic standards of care and reduce rates of deaths and complications.Use of the WHO Surgical Safety Checklist has been shown to be associated with significant reductions in complications and deaths. Before evaluation of this safety tool, concern was raised about whether its use would be practical or beneficial during urgent surgical procedures.We prospectively collected clinical process and outcome data for 1750 consecutively enrolled patients 16 years of age or older undergoing urgent noncardiac surgery before and after introduction of the WHO Surgical Safety Checklist in 8 diverse hospitals around the world; 842 underwent urgent surgery-defined as an operation required within 24 hours of assessment to be beneficial-before introduction of the checklist and 908 after introduction of the checklist. The primary end point was the rate of complications, including death, during hospitalization up to 30 days following surgery.The complication rate was 18.4% (n=151) at baseline and 11.7% (n=102) after the checklist was introduced (P=0.0001). Death rates dropped from 3.7% to 1.4% following checklist introduction (P=0.0067). Adherence to 6 measured safety steps improved from 18.6% to 50.7% (P<0.0001).Implementation of the checklist was associated with a greater than one-third reduction in complications among adult patients undergoing urgent noncardiac surgery in a diverse group of hospitals. Use of the WHO Surgical Safety Checklist in urgent operations is feasible and should be considered.

  View details for DOI 10.1097/SLA.0b013e3181d970e3

  View details for Web of Science ID 000277101200028

  View details for PubMedID 20395848

• Key Concepts for Estimating the Burden of Surgical Conditions and the Unmet Need for Surgical Care WORLD JOURNAL OF SURGERY Bickler, S., Ozgediz, D., Gosselin, R., Weiser, T., Spiegel, D., Hsia, R., Dunbar, P., McQueen, K., Jamison, D. 2010; 34 (3): 374-380

  Abstract

  Surgical care is emerging as a crucial issue in global public health. Methodology is needed to assess the impact of surgical care from a public health perspective.A consensus opinion of a group of surgeons, anesthesiologists, and public health experts was established regarding the methodology for estimating the burden of surgical conditions and the unmet need for surgical care.For purposes of analysis, we define surgical conditions as any disease state requiring the expertise of a surgically trained provider. Abnormalities resulting from a surgical condition or its treatment are termed surgical sequelae. Surgical care is defined as any measure that reduces the rates of physical disability or premature death associated with a surgical condition. To measure the burden of surgical conditions and unmet need for surgical care we propose using cumulative disability-adjusted life-year (DALY) curves generated from age-specific population-based data. This conceptual framework is based on the premise that surgically associated disability and death is determined by the incidence of surgical conditions and the quantity and quality of surgical care. The burden of surgical conditions is defined as the total disability and premature deaths that would occur in a population should there be no surgical care; the unmet need for surgical care is defined as the potentially treatable disability and premature deaths due to surgical conditions. Burden of surgical conditions should be expressed as DALYs and unmet need as potential DALYs avertable.Methodology is described for estimating the burden of surgical conditions and unmet need for surgical care. Using this approach it will be feasible to estimate the global burden of surgical conditions and help clarify where surgery fits among other global health priorities. These methods need to be validated using population-based data.

  View details for DOI 10.1007/s00268-009-0261-6

  View details for Web of Science ID 000274328200002

  View details for PubMedID 19862570

• Population Health Metrics for Surgery: Effective Coverage of Surgical Services in Low-Income and Middle-Income Countries WORLD JOURNAL OF SURGERY Ozgediz, D., Hsia, R., Weiser, T., Gosselin, R., Spiegel, D., Bickler, S., Dunbar, P., McQueen, K. 2009; 33 (1): 1-5

  Abstract

  Access to surgical services is emerging as a crucial issue in global public health. "Effective coverage" is a health metric used to evaluate essential health services in low- and middle-income countries. It measures the fraction of potential health gained that is actually realized for a given intervention by integrating the concepts of need, use, and quality.This study applies the concept of effective coverage to surgical services by considering injuries and obstetric complications as high-priority surgical conditions in low- and middle-income countries.Effective coverage for both is poor, but it is less well defined for traumatic conditions compared to obstetric conditions owing to a lack of data.More primary and secondary data are critical to measure effective coverage and to estimate the resources required to improve access to surgical services in low- and middle-income countries.

  View details for DOI 10.1007/s00268-008-9799-y

  View details for Web of Science ID 000261657300001

  View details for PubMedID 18958518