Thomas G Weiser, MD, MPH

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
Cec and You Shall Find: Cecal Perforation in a Patient with COVID-19. Digestive diseases and sciences Baiu, I., Forgo, E., Kin, C., Weiser, T. G. 2021
View details for DOI 10.1007/s10620-020-06810-5

View details for PubMedID 33492532
We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations. World journal of surgery Panda, N., Etheridge, J. C., Singh, T., Sonnay, Y., Molina, G., Burian, B. K., Capo-Chichi, N., Cauley, C. E., de Beer, D. A., Derbew, M., Dias, R. D., Fearon, M. C., Feyssa, M. D., Hagen, K., Kumar, M., Mammo, T. N., Mariano, E. R., Merry, A., Mushayandebvu, B., Nabukenya, M. T., Shah, M., Spruce, L., Weiser, T. G., Brindle, M. E. 2021
Abstract

As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic.18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus.From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation.This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

View details for DOI 10.1007/s00268-021-06000-y

View details for PubMedID 33638023
Pulse oximetry in low-resource settings during the COVID-19 pandemic. The Lancet. Global health Starr, N., Rebollo, D., Asemu, Y. M., Akalu, L., Mohammed, H. A., Menchamo, M. W., Melese, E., Bitew, S., Wilson, I., Tadesse, M., Weiser, T. G. 2020
View details for DOI 10.1016/S2214-109X(20)30287-4

View details for PubMedID 32628910
Correction to: Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers. World journal of surgery Panda, N., Koritsanszky, L., Delisle, M., Anyomih, T. T., Desai, E. V., Sonnay, Y., Molina, G., Madani, K., Vervoort, D., Weiser, T. G., Benjamin, E. M., Haynes, A. B. 2020
Abstract

In the original version of the article, Dominique Vervoort's last name was misspelled. It is correct as reflected here. The original article has been updated.

View details for DOI 10.1007/s00268-020-05550-x

View details for PubMedID 32347349
Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers. World journal of surgery Panda, N., Koritsanszky, L., Delisle, M., Anyomih, T. T., Desai, E. V., Sonnay, Y., Molina, G., Madani, K., Vervoot, D., Weiser, T. G., Benjamin, E. M., Haynes, A. B. 2020
Abstract

BACKGROUND: The Surgical Safety Checklist (SSC) has been shown to reduce perioperative complications across global health systems. We sought to assess perceptions of the SSC and suggestions for its improvement among medical students, trainees, and early career providers.METHODS: From July to September 2019, a survey assessing perceptions of the SSC was disseminated through InciSioN, the International Student Surgical Network comprising medical students, trainees, and early career providers pursuing surgery. Individuals with ≥2years of independent practice after training were excluded. Respondents were categorized according to any clinical versus solely non-clinical SSC exposure. Logistic regression was used to evaluate associations between clinical/non-clinical exposure and promoting future use of the SSC, adjusting for potential confounders/mediators: training level, human development index, and first perceptions of the SSC. Thematic analysis was conducted on suggestions for SSC improvement.RESULTS: Respondent participation rate was 24%. Three hundred and eighteen respondents were included in final analyses; 215 (67%) reported clinical exposure and 190 (60%) were promoters of future SSC use. Clinical exposure was associated with greater odds of promoting future SSC use (aOR 1.81 95% CI [1.03-3.19], p=0.039). A greater proportion of promoters reported "Improved Operating Room Communication" as a goal of the SSC (0.21 95% CI [0.15-0.27]-vs.-0.12 [0.06-0.17], p=0.031), while non-promoters reported the SSC goals were "Not Well Understood" (0.08 95% CI [0.03-0.12]-vs.-0.03 [0.01-0.05], p=0.032). Suggestions for SSC improvement emphasized context-specific adaptability and earlier formal training.CONCLUSIONS: Clinical exposure to the SSC was associated with promoting its future use. Earlier formal clinical training may improve perceptions and future use among medical students, trainees, and early career providers.

View details for DOI 10.1007/s00268-020-05518-x

View details for PubMedID 32307554
Value and Feasibility of Telephone Follow-Up in Ethiopian Surgical Patients. Surgical infections Starr, N., Gebeyehu, N., Tesfaye, A., Forrester, J. A., Bekele, A., Bitew, S., Wayessa, E., Weiser, T. G., Negussie, T. 2020
Abstract

Background: Surgical site infections (SSIs) represent a major cause of morbidity and mortality in Ethiopia. Lack of post-discharge follow-up, including identification of SSIs, is a barrier to continued patient care, often because of financial and travel constraints. As part of a surgical quality improvement initiative, we aimed to assess patient outcomes at 30 days post-operative with a telephone call. Patients and Methods: We conducted mobile telephone follow-up as part of Lifebox's ongoing Clean Cut program, which aims to improve compliance with intra-operative infection prevention standards. One urban tertiary referral hospital and one rural district general hospital in Ethiopia were included in this phase of the study; hospital nursing staff called patients at 30 days post-operative inquiring about signs of SSIs, health-care-seeking behavior, and treatments provided if patients had any healthcare encounters since discharge. Results: A total of 701 patients were included; overall 77% of patients were reached by telephone call after discharge. The rural study site reached 362 patients (87%) by telephone; the urban site reached 176 patients (62%) (p<0.001). Of the 39 SSIs identified, 19 (49%) were captured as outpatient during the telephone follow-up (p<0.001); 22 (34%) of all complications were captured following discharge (p<0.001). Telephone follow-up improved from 65%-78% in the first half of project implementation to 77%-89% in the second half of project implementation. Conclusion: Telephone follow-up after surgery in Ethiopia is feasible and valuable, and identified nearly half of all SSIs and one-third of total complications in our cohort. Follow-up improved over the course of the program, likely indicating a learning curve that, once overcome, is a more accurate marker of its practicability. Given the increasing use of mobile telephones in Ethiopia and ease of implementation, this model could be practical in other low-resource surgical settings.

View details for DOI 10.1089/sur.2020.054

View details for PubMedID 32301651
COVID-19 Preparedness within the Surgical, Obstetric and Anesthetic Ecosystem in Sub Saharan Africa. Annals of surgery Ademuyiwa, A. O., Bekele, A., Berhea, A. B., Borgstein, E., Capo-Chichi, N., Derbew, M., Evans, F. M., Feyssa, M. D., Galukande, M., Gawande, A. A., Gueye, S. M., Harrison, E., Jani, P., Kaseje, N., Litswa, L., Mammo, T. N., Mellin-Olsen, J., Muguti, G., Nabukenya, M. T., Ngoga, E., Ntirenganya, F., Rulisa, S., Starr, N., Tabiri, S., Tadesse, M., Walker, I., Weiser, T. G., Wren, S. M. 2020
View details for DOI 10.1097/SLA.0000000000003964

View details for PubMedID 32301806
Impact of the Affordable Care Act Insurance Marketplaces on Out-of-Pocket Spending Among Surgical Patients. Annals of surgery Liu, C., Maggard-Gibbons, M., Weiser, T. G., Morris, A. M., Tsugawa, Y. 2020
Abstract

OBJECTIVE: To evaluate the association between the introduction of the Affordable Care Act (ACA) Health Insurance Marketplaces ("Marketplaces") and financial protection for patients undergoing surgery.BACKGROUND: The ACA established Marketplaces through which individuals could purchase subsidized insurance coverage. However, the effect of these Marketplaces on surgical patients' healthcare spending remains largely unknown.METHODS: We analyzed a nationally representative sample of adults aged 19-64 who underwent surgery in 2010-2017, using the Medical Expenditure Panel Survey. Low-income patients eligible for cost-sharing and premium subsidies in the Marketplaces [income 139%-250% federal poverty level (FPL)] and middle-income patients eligible only for premium subsidies (251%-400% FPL) were compared to high-income controls ineligible for subsidies (>400% FPL) using a quasi-experimental difference-in-differences approach. We evaluated 3 main outcomes: (1) out-of-pocket spending, (2) premium contributions, and (3) likelihood of experiencing catastrophic expenditures, defined as out-of-pocket plus premium spending exceeding 19.5% of family income.RESULTS: Our sample included 5450 patients undergoing surgery, representing approximately 69 million US adults. Among low-income patients, Marketplace implementation was associated with $601 lower [95% confidence interval (CI): -$1169 to -$33; P = 0.04) out-of-pocket spending; $968 lower (95% CI: -$1652 to -$285; P = 0.006) premium spending; and 34.6% lower probability (absolute change: -8.3 percentage points; 95% CI: -14.9 to -1.7; P = 0.01) of catastrophic expenditures. We found no evidence that health expenditures changed for middle-income surgical patients.CONCLUSIONS: The ACA's insurance Marketplaces were associated with improved financial protection among low-income surgical patients eligible for both cost-sharing and premium subsidies, but not in middle-income patients eligible for only premium subsidies.

View details for DOI 10.1097/SLA.0000000000003823

View details for PubMedID 32221119
Safety of Foregoing Operation for Small Bowel Obstruction in the Virgin Abdomen: Systematic Review and Meta-Analysis. Journal of the American College of Surgeons Choi, J., Fisher, A. T., Mulaney, B., Anand, A., Carlos, G., Stave, C. D., Spain, D. A., Weiser, T. G. 2020
Abstract

Our objective was to assess the safety of foregoing surgery in patients without abdominopelvic surgery history presenting with small bowel obstruction (SBO). Classic dogma has counseled early surgical intervention for small bowel obstruction (SBO) in the virgin abdomen - patients without abdominopelvic surgery history - given their presumed higher risk of malignant or potentially catastrophic etiologies compared to those who underwent prior abdominal operations. The term virgin abdomen was coined before widespread use of computed tomography, which now elucidates many SBO etiologies. Despite recent efforts to re-evaluate clinical management standards, the prevalence of SBO etiologies in the virgin abdomen and the current management landscape (non-operative vs operative) in these patients remain unclear. Our random-effects meta-analysis of six studies including 442 patients found the prevalence of malignant etiologies in patients without abdominopelvic surgery history presenting with SBO varied from 7.7% [95% CI:3.0-14.1] to 13.4% [95% CI:7.6-20.3] on sensitivity analysis. Most malignant etiologies were not suspected prior to surgery. De novo adhesions (54%) were the most common etiology. Over half of patients underwent a trial of non-operative management, which often failed. Subgroups of patients likely have variable risk profiles for underlying malignant etiologies, yet no study had consistent follow-up data and we did not find convincing evidence that foregoing operative management altogether in this population can be generally recommended.

View details for DOI 10.1016/j.jamcollsurg.2020.06.010

View details for PubMedID 32574687
Comment on "COVID-19 Preparedness Within the Surgical, Obstetric, and Anesthetic Ecosystem in Sub Saharan Africa". Annals of surgery Starr, N., Weiser, T. G. 2020
View details for DOI 10.1097/SLA.0000000000004096

View details for PubMedID 32433299
What constitutes a 'successful' recovery? Patient perceptions of the recovery process after a traumatic injury. Trauma surgery & acute care open Rosenberg, G., Zion, S. R., Shearer, E., Bereknyei Merrell, S., Abadilla, N., Spain, D. A., Crum, A. J., Weiser, T. G. 2020; 5 (1): e000427
Abstract

Background: As the number of patients surviving traumatic injuries has grown, understanding the factors that shape the recovery process has become increasingly important. However, the psychosocial factors affecting recovery from trauma have received limited attention. We conducted an exploratory qualitative study to better understand how patients view recovery after traumatic injury.Methods: This qualitative, descriptive study was conducted at a Level One university trauma center. Participants 1-3years postinjury were purposefully sampled to include common blunt-force mechanisms of injuries and a range of ages, socioeconomic backgrounds and injury severities. Semi-structured interviews explored participants' perceptions of self and the recovery process after traumatic injury. Interviews were transcribed verbatim; the data were inductively coded and thematically analyzed.Results: We conducted 15 interviews, 13 of which were with male participants (87%); average hospital length of stay was 8.9 days and mean injury severity score was 18.3. An essential aspect of the patient experience centered around the recovery of both the body and the 'self', a composite of one's roles, values, identities and beliefs. The process of regaining a sound sense of self was essential to achieving favorable subjective outcomes. Participants expressed varying levels of engagement in their recovery process, with those on the high end of the engagement spectrum tending to speak more positively about their outcomes. Participants described their own subjective interpretations of their recovery as most important, which was primarily influenced by their engagement in the recovery process and ability to recover their sense of self.Discussion: Patients who are able to maintain or regain a cohesive sense of self after injury and who are highly engaged in the recovery process have more positive assessments of their outcomes. Our findings offer a novel framework for healthcare providers and researchers to use as they approach the issue of recovery after injury with patients.Level of evidence: III-descriptive, exploratory study.

View details for DOI 10.1136/tsaco-2019-000427

View details for PubMedID 32154383
Survey of National Surgical Site Infection Surveillance Programs in Low- and Middle-Income Countries. Surgical infections Forrester, J. D., Berndtson, A. E., Santorelli, J., Raschke, E., Weiser, T. G., Coombs, A. V., Sawyer, R. G., Chou, J., Knight, H. P., Valenzuela, J. Y., Rickard, J. 2020
Abstract

Background: Surgical site infection (SSI) surveillance programs are strongly recommended as a core component of effective national infection prevention and control (IPC) programs. Participation in national SSI surveillance (nSSIS) programs has been shown to decrease reported SSIs among high-income countries (HICs), and it is expected that the same is possible among low- and middle-income countries (LMICs). We sought to determine what, if any nSSIS programs exist among LMICs. Methods: A cross-sectional survey was performed to evaluate existence of nSSIS of World Bank-defined LMICs. A digital survey assessment for presence of national IPC and nSSIS programs was delivered to persons capable of identifying the presence of such a program. Statistical analysis was performed using STATA. Institutional Review Board approval was obtained for this study. Results: Of the 137 countries identified, 55 (40%) were upper middle income (UMI), 47 (34%) were lower middle income (LMI), and 34 (25%) were low income. Representatives from 39 (28%) LMICs completed the survey. Of these respondent countries, 13 (33%) reported the presence of a national IPC program. There was no difference between countries with IPC programs and those without with respect to country income designation, population size, World Health Organization region, or conflict status. Only five (13% of all respondents) reported presence of a nSSIS program. Conclusions: National surgical site infection surveillance programs are an integral component of a country's ability to provide safe surgical procedures. Presence of nSSIS was reported infrequently in LMICs. International governing bodies should be encouraged to guide LMIC leadership in establishing a nSSIS infrastructure that will help enable safe surgical procedures.

View details for DOI 10.1089/sur.2020.053

View details for PubMedID 32397833
Bellwethers versus Baskets: Operative Capacity and the Metrics of Global Surgery. World journal of surgery Weiser, T. G. 2020
View details for DOI 10.1007/s00268-020-05615-x

View details for PubMedID 32529464
The effects of physical distancing on population mobility during the COVID-19 pandemic in the UK. The Lancet. Digital health Drake, T. M., Docherty, A. B., Weiser, T. G., Yule, S., Sheikh, A., Harrison, E. M. 2020; 2 (8): e385–e387
View details for DOI 10.1016/S2589-7500(20)30134-5

View details for PubMedID 32835195

View details for PubMedCentralID PMC7292602
Association of the US Affordable Care Act With Out-of-Pocket Spending and Catastrophic Health Expenditures Among Adult Patients With Traumatic Injury. JAMA network open Liu, C., Tsugawa, Y., Weiser, T. G., Scott, J. W., Spain, D. A., Maggard-Gibbons, M. 2020; 3 (2): e200157
Abstract

Trauma is an expensive and unpredictable source of out-of-pocket spending for American families. The Patient Protection and Affordable Care Act (ACA) sought to improve financial protection by expanding health insurance coverage, but its association with health care spending for patients with traumatic injury remains largely unknown.To evaluate the association of ACA implementation with out-of-pocket spending, premiums, and catastrophic health expenditures (CHE) among adult patients with traumatic injury.Data from a nationally representative sample of US adults aged 19 to 64 years who had a hospital stay or emergency department visit for a traumatic injury from January 2010 to December 2017 were analyzed using the Medical Expenditure Panel Survey. Multivariable generalized linear models were used to evaluate changes in spending after ACA implementation. Additionally, 4 income subgroups were evaluated based on ACA thresholds for program eligibility: lowest-income patients (earning 138% or less of the federal poverty level [FPL]), low-income patients (earning 139% to 250% of the FPL), middle-income patients (earning 251% to 400% of the FPL), and high-income patients (earning more than 400% of the FPL). Data were analyzed from February to December 2019.Implementation of the ACA, beginning January 1, 2014.Out-of-pocket spending, premium spending, out-of-pocket plus premium spending, and likelihood of experiencing CHE, defined as out-of-pocket plus premium spending exceeding 19.5% of family income.Of the 6288 included patients, 2995 (weighted percentage, 51.3%) were male, and the mean (SD) age was 41.4 (12.8) years. Implementation of the ACA was associated with 31% lower odds of CHE (adjusted odds ratio, 0.69; 95% CI, 0.54 to 0.87; P = .002). Changes were greatest in lowest-income patients, who experienced 30% lower out-of-pocket spending (adjusted percentage change, -30.4%; 95% CI, -46.6% to -9.4%; P = .01), 26% lower out-of-pocket plus premium spending (adjusted percentage change, -26.3%; 95% CI, -41.0% to -8.1%; P = .01), and 39% lower odds of CHE (adjusted odds ratio, 0.61; 95% CI, 0.44 to 0.84; P = .002). Low-income patients experienced decreased out-of-pocket spending and out-of-pocket plus premium spending but no changes in CHE, while middle-income and high-income patients experienced no significant changes in any spending outcome. In the post-ACA period, 1 in 11 of all patients with traumatic injury and 1 in 5 with the lowest incomes continued to experience CHE each year.Implementation of the ACA was associated with improved financial protection for US adults with traumatic injury, especially lowest-income individuals targeted by the law's Medicaid expansions. Despite these gains, injured patients remain at risk of financial strain.

View details for DOI 10.1001/jamanetworkopen.2020.0157

View details for PubMedID 32108892
Evidenced-Based Practice Among Trainees: A Survey on Facial Trauma Wound Management. Journal of surgical education Choi, J., Traboulsi, A. A., Okland, T. S., Sadauskas, V., Perrault, D., Spain, D. A., Lorenz, H. P., Weiser, T. G. 2020
Abstract

Assess whether facial trauma wound care and antibiotic use recommendations are guided by evidence-based practice (EBP) or practice patterns, and investigate strategies to improve EBP adoption among surgical trainees.We conducted a survey of all trainees who manage facial trauma (general surgery, emergency medicine, plastic surgery, otolaryngology) to assess clinical knowledge and sources of treatment recommendations. Clinical questions were based on Oxford Center for Evidence-Based Medicine Level 1 or 2 evidence. We measured internal validity of questions using Cronbach's α. Results were weight-adjusted for nonresponse and then analyzed using Welch t test and descriptive statistics.Stanford Hospital and Clinics, a Level I trauma center.Response rate was 50.3% overall (78/155). For recommendations on facial trauma wound and antibiotic use, nonspecialty junior residents most frequently relied on their own senior or specialty residents (79.1%); nonspecialty senior residents relied on specialty residents (67.9%). Specialty junior residents most often relied on their own senior residents (51.0%), the majority of whom made recommendations based on their own knowledge (73.2%). Questions assessing EBP knowledge had Cronbach's α of 0.98; response accuracy was similar between specialty and nonspecialty residents (54.6% vs 55.5%, p = 0.96). When provided recommendations that conflict with EBP, both nonspecialty and specialty residents more frequently followed recommendations rather than EBP; junior residents reported doing so to avoid conflict with superiors. Total 92.6% of surveyed residents felt cross-departmental EBP guidelines would improve patient care.Facial trauma wound care and antibiotic recommendations disseminate down seniority and from craniofacial specialty to nonspecialty residents, yet knowledge of EBP among senior specialty and nonspecialty residents was weak. EBP may be difficult to adopt in the absence of consensus society guidelines. To address this gap, we published a review of EBP for facial trauma and plan to update our trauma manual with cross-departmental guidelines to facilitate EBP adoption among trainees.

View details for DOI 10.1016/j.jsurg.2020.03.015

View details for PubMedID 32461098
Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs. Surgical infections Rickard, J., Beilman, G., Forrester, J., Sawyer, R., Stephen, A., Weiser, T. G., Valenzuela, J. 2019
Abstract

Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.

View details for DOI 10.1089/sur.2019.142

View details for PubMedID 31816263
Out-of-Pocket Spending by Surgical Patients after Implementation of the Affordable Care Act Insurance Marketplaces Liu, C., Maggard-Gibbons, M., Weiser, T., Morris, A., Tsugawa, Y. ELSEVIER SCIENCE INC. 2019: S158
View details for Web of Science ID 000492740900294
Improvement of WHO Surgical Safety Checklist Use in Emergency Operations in a Low Human Development Index Setting Starr, N. E., Gebeyehu, N., Tesfaye, A., Alemu, S. B., Habteyohannes, T., Wayessa, E., Forrester, J. A., Mammo, T. N., Weiser, T. G. ELSEVIER SCIENCE INC. 2019: S133
View details for Web of Science ID 000492740900242
Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury JOURNAL OF SURGICAL RESEARCH Rosenberg, G. M., Shearer, E. J., Zion, S. R., Mackey, S. C., Morris, A. M., Spain, D. A., Weiser, T. G. 2019; 241: 277–84
View details for DOI 10.1016/j.jss.2019.04.008

View details for Web of Science ID 000471137000039
Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia. BMC health services research Mattingly, A. S., Starr, N., Bitew, S., Forrester, J. A., Negussie, T., Bereknyei Merrell, S., Weiser, T. G. 2019; 19 (1): 579
Abstract

BACKGROUND: Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals.METHODS: We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results.RESULTS: The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine.CONCLUSIONS: The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.

View details for DOI 10.1186/s12913-019-4383-8

View details for PubMedID 31419972
Tactics to Prevent Intra-Abdominal Infections in General Surgery SURGICAL INFECTIONS Weiser, T. G., Forrester, J. D., Forrester, J. A. 2019; 20 (2): 139–45
View details for DOI 10.1089/sur.2018.282

View details for Web of Science ID 000463924600009
Readmission risk and costs of firearm injuries in the United States, 2010-2015 PLOS ONE Spitzer, S. A., Vail, D., Tennakoon, L., Rajasingh, C., Spain, D. A., Weiser, T. G. 2019; 14 (1)
View details for DOI 10.1371/journal.pone.0209896

View details for Web of Science ID 000456700400008
Tactics to Prevent Intra-Abdominal Infections in General Surgery. Surgical infections Weiser, T. G., Forrester, J. D., Forrester, J. A. 2019
Abstract

BACKGROUND: Abdominal infections following surgery have many severe consequences. Several effective, well-evaluated infection prevention and control processes exist to avoid these infections.METHODS: This manuscript reviews and provides supporting evidence for common management strategies useful to avoid postoperative abdominal infection.RESULTS: Prevention of abdominal infection begins with preparation of the environment using standard infection control practices. Peri-operative use of systemic antibiotics, an antibiotic bowel preparation in colorectal surgery, and effective antiseptic preparation of the surgical site all reduce infection rates. Peri-operative supplemental oxygenation, maintenance of core body temperature, and physiologic euglycemia will reduce both incisional and organ-space infections in the abdominal surgery patient. Strategic use of irrigation and drain placement may be useful in some circumstances.CONCLUSION: Specific methods of prevention are documented to reduce intra-abdominal infections. Prevention requires a multi-disciplinary team including the surgeon, anesthesiologist, and all operating room personnel.

View details for PubMedID 30628859
Cougar (Puma concolor) Injury in the United States. Wilderness & environmental medicine Wang, Y. Y., Weiser, T. G., Forrester, J. D. 2019
Abstract

Human encounters with the cougar (Puma concolor) are rare in the United States but may be fatal.We performed a retrospective analysis of cougar attacks in the United States. We asked Fish and Wildlife Department officials from the 16 states in which cougars are known to live to identify all verified cougar attacks recorded in state history. Variables describing the human victim, cougar, and conditions surrounding the attack were recorded. The Fisher exact test was used for comparison.Ten states reported 74 cougar attacks from 1924 to 2018. Persons less than 18 y of age were heavily represented among victims; 48% were <18 y old, and 35% were less than 10 y old. Attacks were more common in the summer and fall months. Most attacks occurred during daylight hours. The head, neck, and chest were the most common anatomic sites of injury. Sixteen (46%) victims were hospitalized after being attacked, among the 35 victims with these data available. Eleven (15%) attacks were fatal among 71 reports with this information. None of the hospitalized victims died (P=0.02). No victim variables were predictive of death.Cougar attacks are uncommon but can be fatal. Attacks commonly affect children and young adults, although all age groups are at risk of attack and death. Most attacks occur during the daytime in the summer and fall. As development and recreational activities put humans in closer contact with cougars, establishing validated public health messaging is critical to minimize injurious encounters.

View details for DOI 10.1016/j.wem.2019.04.002

View details for PubMedID 31248816
Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury. The Journal of surgical research Rosenberg, G. M., Shearer, E. J., Zion, S. R., Mackey, S. C., Morris, A. M., Spain, D. A., Weiser, T. G. 2019; 241: 277–84
Abstract

Monitoring longitudinal patient-reported outcomes after injury is important for comprehensive trauma care. Current methodologies are resource-intensive and struggle to engage patients.Patients ≥18 y old admitted to the trauma service were prospectively enrolled. The following inclusion criteria were used: emergency operation, ICU length of stay ≥2 midnights, or hospital length of stay ≥4 d. Validated and customized questionnaires were administered using a novel internet-based survey platform. Three-month follow-up surveys were administered. Contextual field notes regarding barriers to enrollment/completion of surveys and challenges faced by participants were recorded.Forty-seven patients were eligible; 26 of 47 (55%) enrolled and 19 of 26 (73%) completed initial surveys. The final sample included 14 (74%) men and 5 (26%) women. Primary barriers to enrollment included technological constraints and declined participation. Contextual field notes revealed three major issues: competing hospital tasks, problems with technology, and poor engagement. The average survey completion time was 43 ± 27 min-21% found this too long. Seventy-four percent reported the system "easy to use" and 95% reported they would "very likely" or "definitely" respond to future surveys. However, 10 of 26 (38%) patients completed 3-mo follow-up.Despite a well-rated internet-based survey platform, study participation remained challenging. Lack of email access and technological issues decreased enrollment and the busy hospitalization posed barriers to completion. Despite a thoughtful operational design and implementation plan, the trauma population presented a challenging group to engage. Next steps will focus on optimizing engagement, broadening access to survey reminders, and enhancing integration into clinical workflows.

View details for PubMedID 31042606
Minimum Specifications for a Lifebox Surgical Headlight for Resource-Constrained Settings JAMA SURGERY Forrester, J. A., Torgeson, K., Weiser, T. G. 2019; 154 (1): 80–82
View details for DOI 10.1001/jamasurg.2018.4205

View details for Web of Science ID 000456039900020
Readmission risk and costs of firearm injuries in the United States, 2010-2015. PloS one Spitzer, S. A., Vail, D., Tennakoon, L., Rajasingh, C., Spain, D. A., Weiser, T. G. 2019; 14 (1): e0209896
Abstract

BACKGROUND: In 2015 there were 36,252 firearm-related deaths and 84,997 nonfatal injuries in the United States. The longitudinal burden of these injuries through readmissions is currently underestimated. We aimed to determine the 6-month readmission risk and hospital costs for patients injured by firearms.METHODS: We used the Nationwide Readmission Database 2010-2015 to assess the frequency of readmissions at 6 months, and hospital costs associated with readmissions for patients with firearm-related injuries. We produced nationally representative estimates of readmission risks and costs.RESULTS: Of patients discharged following a firearm injury, 15.6% were readmitted within 6 months. The average annual cost of inpatient hospitalizations for firearm injury was over $911 million, 9.5% of which was due to readmissions. Medicare and Medicaid covered 45.2% of total costs for the 5 years, and uninsured patients were responsible for 20.1%.CONCLUSIONS: From 2010-2015, the average total cost of hospitalization for firearm injuries per patient was $32,700, almost 10% of which was due to readmissions within 6 months. Government insurance programs and the uninsured shouldered most of this.

View details for PubMedID 30677032
Acute severe iatrogenic hyponatremia. Trauma surgery & acute care open Baiu, I., Kang, M., Weiser, T. G. 2019; 4 (1): e000388
View details for DOI 10.1136/tsaco-2019-000388

View details for PubMedID 31750400
Clinical update on management of pancreatic trauma HPB Soreide, K., Weiser, T. G., Parks, R. W. 2018; 20 (12): 1099–1108
Abstract

Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma.Systematic literature review until May 2018.Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries.Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.

View details for PubMedID 30005994
Letter to the Editor ANNALS OF SURGERY Spitzer, S. A., Vail, D., Rajasingh, C. M., Tennakoon, L., Spain, D. A., Weiser, T. G. 2018; 268 (6): E77–E78
View details for Web of Science ID 000452668900043
Minimum Specifications for a Lifebox Surgical Headlight for Resource-Constrained Settings. JAMA surgery Forrester, J. A., Torgeson, K., Weiser, T. G. 2018
View details for PubMedID 30427987
Implementing a Standardized Nurse-driven Rounding Protocol in a Trauma-surgical Intensive Care Unit: A Single Institution Experience. Cureus Marshall, C. D., Fay, M. E., Phillips, B., Faurote, R., Kustudia, J., Ransom, R. C., Henley, C., DiConstanzo, L., Jopling, J. K., Sang, A. X., Spain, D. A., Tisnado, J. A., Weiser, T. G. 2018; 10 (10): e3422
Abstract

Introduction Patient care in the trauma-surgical intensive care unit (SICU) requires trust and effective communication between nurses and physicians. Our SICU suffered from poor communication and trust between nurses and physicians, negatively impacting the working environment and, potentially, patient care. Methods A SICU Task Force studied communication practices and identified areas for improvement, leading to several interventions. The daily physician rounding was altered to improve communication and to enhance the role of the registered nurses (RN) inrounds. Additionally, a formal night resident rounding time was implemented. Results A post-intervention survey focusing on cooperation, teamwork, and appreciation between nurses and physicians revealed improvement in these domains. Informal feedback from nurses and physicians indicated improved working relationships and satisfaction with the SICU environment. However, results of a national survey performed after the intervention did not show the same level of improvement. Conclusions A Task Force consisting of SICU nurses and physicians can effectively study a widespread communication issue and implement targeted interventions. While informal feedback may indicate improvement, it can be difficult to demonstrate improvement using formal surveys.

View details for DOI 10.7759/cureus.3422

View details for PubMedID 30546974
Scoring System to Aid Implementation of a Surgical Infection Prevention Quality Improvement Program in Resource-Constrained Settings Forrester, J. A., Negussie, T., Beyene, A., Haynes, A. B., Berry, W., Weiser, T. G., Bekele, A. ELSEVIER SCIENCE INC. 2018: S132–S133
View details for Web of Science ID 000447760600254
The association between angioembolization and splenic salvage for isolated splenic injuries. The Journal of surgical research Rosenberg, G. M., Weiser, T. G., Maggio, P. M., Browder, T. D., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. 2018; 229: 150–55
Abstract

BACKGROUND: Recent data suggest improved splenic salvage rates when angioembolization (AE) is routinely employed for high-grade splenic injuries; however, protocols and salvage rates vary among centers.MATERIALS/METHODS: Adult patients with isolated splenic injuries were identified using the National Trauma Data Bank, 2013-2014. Patients were excluded if they underwent immediate splenectomy or died in the emergency department. To characterize patterns of AE, trauma centers were grouped into quartiles based on frequency of AE use. Unadjusted analyses and mixed-effects logistical regression controlling for center effects were performed.RESULTS: Five thousand and ninety three adult patients were identified. Overall, 705 (13.8%) underwent AE and 290 (5.7%) required a splenectomy. In unadjusted comparisons, splenectomy rates were lower for patients with severe spleen injuries who underwent AE (7% versus 11%, P=0.02). In mixed-effect logistical regression patients with severe splenic injuries undergoing AE had a lower odds ratio (OR) for splenectomy (OR = 0.67, P=0.04). Patients treated at centers in the highest quartile of AE use had a lower OR for splenectomy (OR = 0.58, P=0.02).CONCLUSIONS: The use of AE in patients with isolated severe splenic injuries is associated with decreased splenectomy rates. There is an association between centers that perform AE frequently and reduced splenectomy rates.

View details for PubMedID 29936983
The association between angioembolization and splenic salvage for isolated splenic injuries Rosenberg, G. M., Weiser, T. G., Maggio, P. M., Browder, T. D., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2018: 150–55
View details for DOI 10.1016/j.jss.2018.03.013

View details for Web of Science ID 000436501300021
Surgical Instrument Reprocessing in Resource-Constrained Countries: A Scoping Review of Existing Methods, Policies, and Barriers. Surgical infections Forrester, J. A., Powell, B. L., Forrester, J. D., Fast, C., Weiser, T. G. 2018; 19 (6): 593–602
Abstract

BACKGROUND: Surgical infections are a major cause of morbidity and mortality in low- and middle-income countries (LMICs). Inadequately reprocessed surgical instruments can be a vector for pathogens. Little has been published on the current state of surgical instrument reprocessing in LMICs.METHODS: We performed a scoping review of English-language articles in PubMed, Web of Science, and Google Scholar databases describing current methods, policies, and barriers to surgical instrument reprocessing in LMICs. We conducted qualitative analysis of all studies to categorize existing practices and barriers to successful surgical instrument reprocessing. Barriers were non-exclusively categorized by theme: training/education, resource availability, environment, and policies/procedures. Studies associating surgical infections with existing practices were separately evaluated to assess this relationship.RESULTS: Nine hundred seventy-two abstracts were identified. Forty studies met criteria for qualitative analysis and three studies associated patient outcomes with surgical instrument reprocessing. Most studies (n=28, 70%) discussed institution-specific policies/procedures; half discussed shortcomings in staff training. Sterilization (n=38, 95%), verification of sterilization (n=19, 48%), and instrument cleaning and decontamination (n=16, 40%) were the most common instrument reprocessing practices examined. Poor resource availability and the lack of effective education/training and appropriate policies/procedures were cited as the common barriers. Of the case series investigating surgical instrument reprocessing with patient outcomes, improperly cleaned and sterilized neurosurgical instruments and contaminated rinse water were linked to Pseudomonas aeruginosa ventriculitis and Mycobacterium port site infections, respectively.CONCLUSIONS: Large gaps exist between instrument reprocessing practices in LMICs and recommended policies/procedures. Identified areas for improvement include instrument cleaning and decontamination, sterilization aspects of instrument reprocessing, and verification of sterilization. Education and training of staff responsible for reprocessing instruments and realistic, defined policies and procedures are critical, and lend themselves to improvement interventions.

View details for PubMedID 30156997
Surgical Instrument Reprocessing in Resource-Constrained Countries: A Scoping Review of Existing Methods, Policies, and Barriers SURGICAL INFECTIONS Forrester, J. A., Powell, B., Forrester, J. D., Fast, C., Weiser, T. G. 2018; 19 (6): 593–602
View details for DOI 10.1089/sur.2018.078

View details for Web of Science ID 000443033500006
Developing Process Maps as a Tool for a Surgical Infection Prevention Quality Improvement Initiative in Resource-Constrained Settings JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Forrester, J. A., Koritsanszky, L. A., Amenu, D., Haynes, A. B., Berry, W. R., Alemu, S., Jiru, F., Weiser, T. G. 2018; 226 (6): 1103-+
Abstract

Surgical infections cause substantial morbidity and mortality in low-and middle-income countries (LMICs). To improve adherence to critical perioperative infection prevention standards, we developed Clean Cut, a checklist-based quality improvement program to improve compliance with best practices. We hypothesized that process mapping infection prevention activities can help clinicians identify strategies for improving surgical safety.We introduced Clean Cut at a tertiary hospital in Ethiopia. Infection prevention standards included skin antisepsis, ensuring a sterile field, instrument decontamination/sterilization, prophylactic antibiotic administration, routine swab/gauze counting, and use of a surgical safety checklist. Processes were mapped by a visiting surgical fellow and local operating theater staff to facilitate the development of contextually relevant solutions; processes were reassessed for improvements.Process mapping helped identify barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. Compliance with most processes improved significantly following organizational changes to align tasks with specific process goals.Enumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. Simplifying these process maps into an adaptable tool could be a powerful strategy for improving safe surgery delivery in LMICs.

View details for PubMedID 29574175
Trauma-induced insurance instability: Variation in insurance coverage for patients who experience readmission after injury Rajasingh, C., Weiser, T. G., Knowlton, L. M., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. LIPPINCOTT WILLIAMS & WILKINS. 2018: 876–84
View details for DOI 10.1097/TA.0000000000001832

View details for Web of Science ID 000435351800006
Cold steel might cure, but it takes a village to prevent surgical infections LANCET INFECTIOUS DISEASES Chu, K., Weiser, T. G. 2018; 18 (5): 476–77
View details for PubMedID 29519765
Surgical deserts in California: an analysis of access to surgical care JOURNAL OF SURGICAL RESEARCH Uribe-Leitz, T., Esquivel, M. M., Garland, N. Y., Staudenmayer, K. L., Spain, D. A., Weiser, T. G. 2018; 223: 102–8
Abstract

Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties.We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis.There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty.Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.

View details for PubMedID 29433860
Guide to research in academic global surgery: A statement of the Society of University Surgeons Global Academic Surgery Committee SURGERY Saluja, S., Nwomeh, B., Finlayson, S. G., Holterman, A. L., Jawa, R. S., Jayaraman, S., Juillard, C., Krishnaswami, S., Mukhopadhyay, S., Rickard, J., Weiser, T. G., Yang, G. P., Shrime, M. G., Soc Univ Surg Global Acad Surg 2018; 163 (2): 463–66
Abstract

Global surgery is an emerging academic discipline that is developing in tandem with numerous policy and advocacy initiatives. In this regard, academic global surgery will be crucial for measuring the progress toward improving surgical care worldwide. However, as a nascent academic discipline, there must be rigorous standards for the quality of work that emerges from this field. In this white paper, which reflects the opinion of the Global Academic Surgery Committee of the Society for University Surgeons, we discuss the importance of research in global surgery, the methodologies that can be used in such research, and the challenges and benefits associated with carrying out this research. In each of these topics, we draw on existing examples from the literature to demonstrate our points. We conclude with a call for continued, high-quality research that will strengthen the discipline's academic standing and help us move toward improved access to and quality of surgical care worldwide.

View details for PubMedID 29221877
Patient-reported outcomes in trauma: a scoping study of published research. Trauma surgery & acute care open Rosenberg, G. M., Stave, C., Spain, D. A., Weiser, T. G. 2018; 3 (1): e000202
Abstract

More people are surviving traumatic injury, but disability and reduced quality of life are frequent. Investigators are now focusing on patient-reported outcomes (PROs) to better understand this problem. We performed a scoping study of the literature to explore trends in the study of PROs after injury. The volume of published literature on PROs after injury has consistently increased, but use of measurement tool and categorization of publications are inconsistent. Journal keyword patterns are inconsistent and likely limit the effective dissemination of important findings. In studies of hospitalized trauma patients, more than 100 unique measurement tools were used, and trauma-specific measures were used in fewer than 5% of studies. International investigators are more consistent than those in the USAin the use of validated, classic measurement tools such as the Short-Form 36 and the EuroQoL Five-Dimension tools. Uniform use of measurement tools would help improve the quality and comparability of research on PROs, and trauma-specific measures would enhance the study of long-term injury outcomes.

View details for PubMedID 30234168
Tio ar med WHO:s checklista for saker kirurgi - Checklistan - nu viktig del av operationssjukvarden globalt. Lakartidningen Haynes, A., Weiser, T., Gustafson, P. 2018; 115
View details for PubMedID 29917171
An Update on Fatalities Due to Venomous and Nonvenomous Animals in the United States (2008-2015). Wilderness & environmental medicine Forrester, J. A., Weiser, T. G., Forrester, J. D. 2018
Abstract

To review recent (2008-2015) United States mortality data from deaths caused by nonvenomous and venomous animals and compare with historical data.The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database was queried to return all animal-related fatalities between 2008 and 2015. Mortality frequencies for animal-related fatalities were calculated using the estimated 2011 United States population. Inclusion criteria included all mortalities that were a consequence of bite, contact, attack, or envenomation (International Classification of Diseases 10th revision codes W53-W59 and X20-X29).There were 1610 animal-related fatalities, with the majority from nonvenomous animals (2.8 deaths per 10 million persons). The largest proportion of animal-related fatalities was due to "other mammals," largely composed of horses and cattle. Deaths attributable to Hymenoptera (hornets, wasps, and bees) account for 29.7% of the overall animal-related fatalities and have been steady over the last 20 years. Dog-related fatality frequencies are stable, although the fatality frequency of 4.6 deaths per 10 million persons among children 4 years of age or younger was nearly 4-fold greater than in the other age groups.Appropriate education and prevention measures aimed at decreasing injury from animals should be directed at the high-risk groups of agricultural workers and young children with dogs. Public policy and treatment pricing should align to ensure adequate available medication for those at risk of anaphylaxis from stings from Hymenoptera.

View details for PubMedID 29373216
Development of a Surgical Infection Surveillance Program at a Tertiary Hospital in Ethiopia: Lessons Learned from Two Surveillance Strategies. Surgical infections Forrester, J. A., Koritsanszky, L., Parsons, B. D., Hailu, M., Amenu, D., Alemu, S., Jiru, F., Weiser, T. G. 2018; 19 (1): 25–32
Abstract

Surgical site infections (SSIs) are a leading cause of post-operative morbidity and mortality. We developed Clean Cut, a surgical infection prevention program, with two goals: (1) Increase adherence to evidence-based peri-operative infection prevention standards and (2) establish sustainable surgical infection surveillance. Here we describe our infection surveillance strategy.Clean Cut was piloted and evaluated at a 523 bed tertiary hospital in Ethiopia. Infection prevention standards included: (1) Hand and surgical site decontamination; (2) integrity of gowns, drapes, and gloves; (3) instrument sterility; (4) prophylactic antibiotic administration; (5) surgical gauze tracking; and (6) checklist compliance. Primary outcome measure was SSI, with secondary outcomes including other infection, re-operation, and length of stay. We prospectively observed all post-surgical wounds in obstetrics over a 12 day period and separately recorded post-operative complications using chart review. Simultaneously, we reviewed the written hospital charts after patient discharge for all patients whose peri-operative adherence to infection prevention standards was captured.Fifty obstetric patients were followed prospectively with recorded rates of SSI 14%, re-operation 6%, and death 2%. Compared with direct observation, chart review alone had a high loss to follow-up (28%) and decreased capture of infectious complications (SSI [n = 2], endometritis [n = 3], re-operations [n = 2], death [n = 1]); further, documentation inconsistencies failed to capture two complications (SSI [n = 1], mastitis [n = 1]). Concurrently, 137 patients were observed for peri-operative infection prevention standard adherence. Of these, we were able to successfully review 95 (69%) patient charts with recorded rates of SSI 5%, re-operation 1%, and death 1%.Patient loss to follow-up and poor documentation of infections underestimated overall infectious complications. Direct, prospective follow-up is possible but requires increased time, clinical skill, and training. For accurate surgical infection surveillance, direct follow-up of patients during hospitalization is essential, because chart review does not accurately reflect post-operative complications.

View details for PubMedID 29135348
Trauma-induced insurance instability: Variation in insurance coverage for patients who experience readmission after injury. The journal of trauma and acute care surgery Rajasingh, C. M., Weiser, T. G., Knowlton, L. M., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. 2018; 84 (6): 876–84
Abstract

Traumatic injuries result in a significant disruption to patients' lives, including their ability to work, which may place patients at risk of losing insurance coverage. Our objective was to evaluate the impact of injury on insurance status. We hypothesized that trauma patients with ongoing health needs experience changes in coverage.We used the Nationwide Readmission Database (2013-2014), a nationally representative sample of readmissions in the United States. We included patients aged 27 years to 64 years admitted with any diagnosis of trauma with at least one readmission within 6 months. Patients on Medicare and with missing payer information were excluded. The primary outcome was payer status.57,281 patients met inclusion criteria, 11,006 (19%) changed insurance payer at readmission. Of these, 21% (n = 2,288) became uninsured, 25% (n = 2,773) gained coverage, and 54% (n = 5,945) switched insurance. Medicaid and Medicare gained the largest fraction of patients (from 16% to 30% and 0% to 18%, respectively), with a decrease in private payer coverage (37% to 17%). In multivariate analysis, patients who were younger (27-35 years vs. 56-64 years; odds ratio [OR], 1.30; p < 0.001); lived in a zip code with average income in the lowest quartile (vs. the highest quartile; OR, 1.37; p < 0.001); and had three or more comorbidities (vs. none; OR, 1.61; p < 0.001) were more likely to experience a change in insurance.Approximately one fifth of trauma patients who are readmitted within 6 months of their injury experience a change in insurance coverage. Most switch between insurers, but nearly a quarter lose their insurance. The government adopts a large fraction of these patients, indicating a growing reliance on government programs like Medicaid. Trauma patients face challenges after injury, and a change in insurance may add to this burden. Future policy and quality improvement initiatives should consider addressing this challenge.Epidemiologic, level III.

View details for PubMedID 29443863
Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review. Surgical infections McQuillan, T. J., Cai, L. Z., Corcoran-Schwartz, I., Weiser, T. G., Forrester, J. D. 2018
Abstract

Musculoskeletal trauma represents a large source of morbidity in low and middle human development index countries (LMHDICs). Open reduction and internal fixation (ORIF) of traumatic long bone fractures definitively manages these injuries and restores function when conducted safely and effectively. Surgical site infections (SSIs) are a common complication of operative fracture fixation, although the risks of infection are ill-defined in LMHDIC.This study reviewed systematically all studies describing SSI after ORIF in LMDHICs. Studies were reviewed based on their qualitative characteristics, after which a quantitative synthesis of weighted pooled infection rates based on available patient-level data was performed to estimate published incidence of SSI.Forty-two studies met criteria for qualitative review and 32 studies comprising 3,084 operations were included in the quantitative analysis. Among 3,084 operations, the weighted pooled SSI rate was 6.4 infections per 100 procedures (95% confidence interval [CI] 4.6-8.2 infections per 100 procedures). Higher rates of infection were noted among the sub-group of open fractures (95% CI 13.9-23.0 infections per 100 procedures). Lower extremity injuries and procedures utilizing intra-medullary nails also had slightly higher rates of infection versus upper extremity procedures and other fixation devices.Reported rates of SSI after ORIF are higher in LMHDICs, and may be driven by high rates of infection in the sub-group of open fractures. This study provides a baseline SSI rate obtained from literature produced from LMHDICs. Infection rates are highly dependent on fracture sub-types.

View details for PubMedID 29341840
Letter to the Editor. Annals of surgery Spitzer, S. A., Vail, D., Rajasingh, C. M., Tennakoon, L., Spain, D. A., Weiser, T. G. 2017
View details for PubMedID 29266006
SERIOUS, NONLETHAL FIREARM-RELATED INJURIES IN THE UNITED STATES: COMPILING THE EVIDENCE RESPONSE AMERICAN JOURNAL OF PUBLIC HEALTH Spitzer, S. A., Staudenmayer, K. L., Weiser, T. G. 2017; 107 (8): E25
View details for PubMedID 28700309
Why do patients receive care from a short-term medicalmission? Survey study from rural Guatemala JOURNAL OF SURGICAL RESEARCH Esquivel, M. M., Chen, J. C., Woo, R. K., Siegler, N., Maldonado-Sifuentes, F. A., Carlos-Ochoa, J. S., Cardona-Diaz, A. R., Uribe-Leitz, T., Siegler, D., Weiser, T. G., Yang, G. P. 2017; 215: 160–66
Abstract

Hospital de la Familia was established to serve the indigent population in the western highlands of Guatemala and has a full-time staff of Guatemalan primary care providers supplemented by short-term missions of surgical specialists. The reasons for patients seeking surgical care in this setting, as opposed to more consistent care from local institutions, are unclear. We sought to better understand motivations of patients seeking mission-based surgical care.Patients presenting to the obstetric and gynecologic, plastic, ophthalmologic, general, and pediatric surgical clinics at the Hospital de la Familia from July 27 to August 6, 2015 were surveyed. The surveys assessed patient demographics, surgical diagnosis, location of home, mode of travel, and reasons for seeking care at this facility.Of 252 patients surveyed, 144 (59.3%) were female. Most patients reported no other medical condition (67.9%, n = 169) and no consistent income (83.9%, n = 209). Almost half (44.9%, n = 109) traveled >50 km to receive care. The most common reasons for choosing care at this facility were reputation of high quality (51.8%, n = 130) and affordability (42.6%, n = 102); the least common reason was a lack of other options (6.4%, n = 16).Despite long travel distances and the availability of other options, reputation and affordability were primarily cited as the most common reasons for choosing to receive care at this short-term surgical mission site. Our results highlight that although other surgical options may be closer and more readily available, reputation and cost play a large role in choice of patients seeking care.

View details for PubMedID 28688642
Clinical phenotypes of US level I trauma centers: use of clustering methodology Forrester, J. D., Weiser, T. G., Maggio, P., Browder, T., Tennakoon, L., Spain, D. A., Staudenmayer, K. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2017: 146–52
Abstract

American College of Surgeons Level I Trauma Centers (ACSL1TCs) meet the same personnel and structural requirements but serve different populations. We hypothesized that these nuanced differences may amenable to description through mathematical clustering methodology.The National Trauma Data Bank 2014 was used to derive information on ACSL1TCs. Explorative cluster hypothesis generation was performed using Ward's linkage to determine expected number of clusters based on patient and injury characteristics. Subsequent k-means clustering was applied for analysis. Comparison between clusters was performed using the Kruskal-Wallis or chi-square test.In 2014, 113 ACSL1TCs admitted 267,808 patients (median = 2220 patients, range: 928-6643 patients). Three clusters emerged. Cluster I centers (n = 53, 47%) were more likely to admit older, Caucasian patients who suffered from falls (P < 0.05) and had higher proportions of private (31%) and Medicare payers (29%) (P = 0.001). Cluster II centers (n = 18, 16%) were more likely to admit younger, minority males who suffered from penetrating trauma (P < 0.05) and had higher proportions of Medicaid (24%) or self-pay patients (19%) (P = 0.001). Cluster III centers (n = 42, 37%) were similar to cluster I with respect to racial demographic and payer status but resembled cluster II centers with respect to injury patterns (P < 0.05).Our analysis identified three unique, mathematically definable clusters of ACSL1TCs serving three broadly different patient populations. Understanding these mathematically definable clusters should have utility when assessing an institution's financial risk profile, directing prevention and outreach programs, and performing needs and resource assessments. Ultimately, clustering allows for more meaningful direct comparisons between phenotypically similar trauma centers.

View details for PubMedID 28688640
The prevalence of psychiatric diagnoses and associated mortality in hospitalized US trauma patients JOURNAL OF SURGICAL RESEARCH Townsend, L. L., Esquivel, M. M., Uribe-Leitz, T., Weiser, T. G., Maggio, P. M., Spain, D. A., Tennakoon, L., Staudenmayer, K. 2017; 213: 171–76
Abstract

We hypothesized that psychiatric diagnoses would be common in hospitalized trauma patients in the United States and when present, would be associated with worse outcomes.The Nationwide Inpatient Sample (NIS, 2012) was used to determine national estimates for the number of patients admitted with an injury. Psychiatric diagnoses were identified using diagnosis codes according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.A total of 36.5 million patients were admitted to hospitals in the United States in 2012. Of these, 1.3 million (4%) were due to trauma. Psychiatric conditions were more common in patients admitted for trauma versus those admitted for other reasons (44% versus 34%, P < 0.001). Trauma patients who had a psychiatric diagnosis compared to trauma patients without a psychiatric diagnosis were older (mean age: 61 versus 56 y, P < 0.001), more often female (52% versus 50%, P < 0.001), and more often white (73% versus 68%, P < 0.001). For ages 18-64, drug and alcohol abuse predominated (41%), whereas dementia and related disorders (48%) were the most common in adults ≥65 y. Mortality was lower for trauma patients with a psychiatric diagnosis compared to those who did not in both unadjusted and adjusted analysis (1.9% versus 2.8%; odds ratio: 0.56, P < 0.001).Psychiatric conditions are present in almost half of all hospitalized trauma patients in the United States; however, the types of conditions varied with age. The frequency of psychiatric conditions in the trauma population suggests efforts should be made to address this component of patient health.

View details for PubMedID 28601311
A geospatial evaluation of timely access to surgical care in seven countries BULLETIN OF THE WORLD HEALTH ORGANIZATION Knowlton, L. M., Banguti, P., Chackungal, S., Chanthasiri, T., Chao, T. E., Dahn, B., Derbew, M., Dhar, D., Esquivel, M. M., Evans, F., Hendel, S., LeBrun, D. G., Notrica, M., Saavedra-Pozo, I., Shockley, R., Uribe-Leitz, T., Vannavong, B., McQueen, K. A., Spain, D. A., Weiser, T. G. 2017; 95 (6): 437–44
Abstract

To assess the consistent availability of basic surgical resources at selected facilities in seven countries.In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available.Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh.Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

View details for PubMedID 28603310

View details for PubMedCentralID PMC5463808
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
New global surgical and anaesthesia indicators in the World Development Indicators dataset BMJ GLOBAL HEALTH Raykar, N. P., Ng-Kamstra, J. S., Bickler, S., Davies, J., Greenberg, S. M., Hagander, L., Johnson, W., Leather, A. M., McQueen, K., Mukhopadhyay, S., Suzuki, E., Weiser, T., Shrime, M. G., Meara, J. G. 2017; 2 (2): e000265
View details for PubMedID 29225929
Surgical Site Infections after Tissue Flaps Performed in Low and Middle Human Development Index Countries: A Systematic Review. Surgical infections Cai, L. Z., Chang, J., Weiser, T. G., Forrester, J. D. 2017
Abstract

Surgical site infections (SSIs) affect the safety of surgical care and are particularly problematic and prevalent in low and middle Human Development Index Countries (LMHDICs).We performed a systematic review of the existing literature on SSIs after tissue flap procedures in LMHDICs through the PubMed, Ovid, and Web of Science databases. Of the 405 abstracts identified, 79 were selected for full text review, and 30 studies met inclusion criteria for analysis.In the pooled analysis, the SSI rate was 5.8 infections per 100 flap procedures (95% confidence interval [CI] 2%-10%, range: 0-40%). The most common indication for tissue flap was pilonidal sinus repair, which had a pooled SSI rate of 5.6 infections per 100 flap procedures (95% CI 2%-10%, range: 0-15%). No fatalities from an infection were noted. The reporting of infection epidemiology, prevention, and treatment was poor, with few studies reporting antibiotic agent use (37%), responsible pathogens (13%), infection comorbidities (13%), or time to infection (7%); none reported cost.Our review highlights the need for more work to develop standardized hospital-based reporting for surgical outcomes and complications, as well as future studies by large, multi-national groups to establish baseline incidence rates for SSIs and best practice guidelines to monitor SSI rates.

View details for PubMedID 28915094
Impact of Surgical Lighting on Intraoperative Safety in Low-Resource Settings: A Cross-Sectional Survey of Surgical Providers. World journal of surgery Forrester, J. A., Boyd, N. J., Fitzgerald, J. E., Wilson, I. H., Bekele, A., Weiser, T. G. 2017
Abstract

Safe surgery requires high-quality, reliable lighting of the surgical field. Little is reported on the quality or potential safety impact of surgical lighting in low-resource settings, where power failures are common and equipment and resources are limited.Members of the Lifebox Foundation created a novel, non-mandatory, 18-item survey tool using an iterative process. This was distributed to surgical providers practicing in low-resource settings through surgical societies and mailing lists.We received 100 complete responses, representing a range of surgical centres from 39 countries. Poor-quality surgical field lighting was reported by 40% of respondents, with 32% reporting delayed or cancelled operations due to poor lighting and 48% reporting electrical power failures at least once per week. Eighty per cent reported the quality of their surgical lighting presents a patient safety risk with 18% having direct experience of poor-quality lighting leading to negative patient outcomes. When power outages occur, 58% of surgeons rely on a backup generator and 29% operate by mobile phone light. Only 9% of respondents regularly use a surgical headlight, with the most common barriers reported as unaffordability and poor in-country suppliers.In our survey of surgeons working in low-resource settings, a majority report poor surgical lighting as a major risk to patient safety and nearly one-third report delayed or cancelled operations due to poor lighting. Developing and distributing robust, affordable, high-quality surgical headlights could provide an ideal solution to this significant surgical safety issue.

View details for PubMedID 29051968
Using the WHO Surgical Safety Checklist to Direct Perioperative Quality Improvement at a Surgical Hospital in Cambodia: The Importance of Objective Confirmation of Process Completion. World journal of surgery Garland, N. Y., Kheng, S., De Leon, M., Eap, H., Forrester, J. A., Hay, J., Oum, P., Sam Ath, S., Stock, S., Yem, S., Lucas, G., Weiser, T. G. 2017
Abstract

The WHO surgical safety checklist (SSC) is known to prevent postoperative complications; however, strategies for effective implementation are unclear. In addition to cultural and organizational barriers faced by high-income countries, resource-constrained settings face scarcity of durable and consumable goods. We used the SSC to better understand barriers to improvement at a trauma hospital in Battambang, Cambodia.We introduced the SSC and trained data collectors to observe surgical staff performing the checklist. Members of the research team observed cases and data collection. After 3 months, we modified the data collection tool to focus on infection prevention and elicit more accurate responses.Over 16 months we recorded data on 695 operations (304 cases using the first tool and 391 cases with the modified tool). The first tool identified five items as being in high compliance, which were then excluded from further assessment. Two items-instrument sterility confirmation and sponge counting-were identified as being misinterpreted by the data collectors' tool. These items were reworded to capture objective assessment of task completion. Confirmation of instrument sterility was initially never performed but rectified to >95% compliance; sponge counting and prophylactic antibiotic administration were consistently underperformed.Staff complied with communication elements of the SSC and quickly adopted process improvements. The wording of our data collection tool affected interpretation of compliance with standards. Material resources are not the primary barrier to checklist implementation in this setting, and future work should focus on clarification of protocols and objective confirmation of tasks.

View details for PubMedID 29038828
Surgical Site Infections after Appendectomy Performed in Low and Middle Human Development-Index Countries: A Systematic Review. Surgical infections Foster, D., Kethman, W., Cai, L. Z., Weiser, T. G., Forrester, J. D. 2017
Abstract

Acute appendicitis is a common surgical emergency worldwide. Early intervention is associated with better outcomes. In low and middle Human Development-Index Countries (LMHDICs), late presentation and poor access to healthcare facilities can contribute to greater illness severity and higher complication rates, such as post-operative surgical site infections (SSIs). The current rate of SSIs post-appendectomy in low- and middle-index settings has yet to be described.We performed a systemic review of the literature describing the incidence and management of SSIs after appendectomy in LMHDICs. We conducted qualitative and quantitative analysis of the data in manuscripts describing patients undergoing appendectomy to establish a baseline SSI rate for this procedure in these settings.Four hundred twenty-three abstracts were initially identified. Of these, 35 studies met the criteria for qualitative and quantitative analysis. The overall weighted, pooled SSI rated were 17.9 infections/100 open appendectomies (95% confidence interval [CI] 10.4-25.3 infections/100 open appendectomies) and 8.8 infections/100 laparoscopic appendectomies (95% CI 4.5-13.2 infections/100 laparoscopic appendectomies). The SSI rates were higher in complicated appendicitis and when pre-operative antibiotic use was not specified.Observed SSI rates after appendectomy in LMHDICs are dramatically higher than rates in high Human Development-Index Countries. This is particularly true in cases of open appendectomy, which remains the most common surgical approach in LMHDICs. These findings highlight the need for SSI prevention in LMHDICs, including prompt access to medical and surgical care, routine pre-operative antibiotic use, and implementation of bundled care packages and checklists.

View details for PubMedID 29058569
Surgical Site Infections after Inguinal Hernia Repairs Performed in Low and Middle Human Development Index Countries: A Systematic Review. Surgical infections Cai, L. Z., Foster, D., Kethman, W. C., Weiser, T. G., Forrester, J. D. 2017
Abstract

Inguinal hernias are a common disorder in low- and middle-human development index countries (LMHDICs). Poor access to surgical care and lack of patient awareness often lead to delayed presentations of incarcerated or strangulated hernias and their associated morbidities. There is a scarcity of data on the baseline incidence of surgical site infections (SSIs) after hernia repair procedures in LMHDICs.We performed a systematic review of the literature describing the incidence and management of SSIs after inguinal hernia repair in LMHDICs. We conducted qualitative and quantitative analyses of manuscripts describing patients undergoing hernia repair to establish a baseline SSI rate for this procedure in these settings.Three hundred twenty-three abstracts were identified after applying search criteria, and 31 were suitable for the quantitative analysis. The overall pooled SSI rate was 4.1 infections/100 open hernia repairs (95% confidence interval [CI] 3.0-5.3 infections/100 open repairs), which is consistent with infection rates from high-human development index countries. A separate subgroup analysis of laparoscopic hernia repairs found a weighted pooled SSI rate of 0.4 infections/100 laparoscopic repairs (95% CI 0-2.4 infections/100 laparoscopic repairs).As surgical access continues to expand in LMHDIC settings, it is imperative to monitor surgical outcomes and ensure that care is provided safely. Establishing a baseline SSI rate for inguinal hernia repairs offers a useful benchmark for future studies and surgical programs in these countries.

View details for PubMedID 29048997
Surgical Site Infection after Sternotomy in Low- and Middle-Human Development Index Countries: A Systematic Review. Surgical infections Forrester, J. D., Cai, L. Z., Zeigler, S., Weiser, T. G. 2017; 18 (7): 774–79
Abstract

The burden of cardiovascular disease is increasing in low- and middle-human development index (LMHDI) countries, and cardiac operations are an important component of a comprehensive cardiovascular care package. Little is known about the baseline incidence of surgical site infections (SSIs) among patients undergoing sternotomy in LMHDI countries.A prospectively registered, systematic literature review of articles in the PubMed, Ovid, and Web of Science databases describing the epidemiology and management of SSIs among persons undergoing sternotomy in LMHDI countries was performed. We performed a quantitative synthesis of patients undergoing sternotomy for CABG to estimate published sternotomy SSI rates.Of the 423 abstracts identified after applying search criteria, 14 studies were reviewed in detail. The pooled SSI rate after sternotomy among reviewed studies was 4.3 infections per 100 sternotomies (95% confidence interval [CI] 1.3-6.0 infections per 100 sternotomies), which is comparable to infection rates in high-human development index countries.As the burden of cardiovascular disease in LMHDI settings increases, the ability to provide safe cardiac surgical care is paramount. Describing the baseline SSI rate after sternotomy in LMHDI countries is an important first step in creating baseline expectations for SSI rates in cardiac surgical programs in these settings.

View details for PubMedID 28949848
Cerebral Fat Embolism in a Trauma Patient with Captured Imaging of Echogenic Emboli in the Inferior Vena Cava JOURNAL OF MEDICAL ULTRASOUND Wang, N. N., Panda, N., Hyun, J. S., Barounis, D., Weiser, T. G. 2016; 24 (4): 162–65
View details for DOI 10.1016/j.jmu.2016.08.006

View details for Web of Science ID 000391124800008
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
Nontraumatic Clostridium septicum Myonecrosis in Adults Case Report and a 15-Year Systematic Literature Review INFECTIOUS DISEASES IN CLINICAL PRACTICE Forrester, J. D., Shkolyar, E., Gregg, D., Spain, D. A., Weiser, T. G. 2016; 24 (6): 318–23
View details for DOI 10.1097/IPC.0000000000000400

View details for Web of Science ID 000387468200024
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
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
A Multinational Evaluation of Timely Access to Basic Surgical Services Using Geospatial Analyses Knowlton, L., Esquivel, M., Uribe-Leitz, T., Mcqueen, K., Chackungal, S., LeBrun, D. G., Chao, T. E., Weiser, T. G., Spain, D. A. ELSEVIER SCIENCE INC. 2016: E118
View details for DOI 10.1016/j.jamcollsurg.2016.08.296

View details for Web of Science ID 000395825100255
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 PubMedID 27229108
Maternal and Neonatal Mortality After Cesarean Delivery In Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Molina, G., Weiser, T. G., Haynes, A. B. 2016; 315 (18): 2017
View details for PubMedID 27163993
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
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 Web of Science ID 000372774200017

View details for PubMedCentralID PMC4773932
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

View details for PubMedCentralID PMC4698055
Uninsured status may be more predictive of outcomes among the severely injured than minority race. Injury 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 PubMedID 26396045
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
Improving perioperative outcomes in low-resource countries: It can't be fixed without data CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Weiser, T. G., Makasa, E. M., Gelb, A. W. 2015; 62 (12): 1239–43
View details for PubMedID 26391794
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
Abstract

Fungal mesh infections are a rare complication of hernia repairs with mesh. The first case of Coccidioides spp. mesh infection is described, and a systematic literature review of all known fungal mesh infections was performed. Nine cases of fungal mesh infection are reviewed. Female and male patients are equally represented, median age is 49.5 years, and critical illness and preinfection antibiotic use were common. Fungal mesh infections are rare, but potentially fatal, complications of hernias repaired with mesh.

View details for DOI 10.1111/myc.12364

View details for PubMedID 26293423
Trauma center verification and a more inclusive system: identifying unnecessary criteria for level III/IV centers Forrester, J., Weiser, T. G., Maggio, P. M., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. ELSEVIER SCIENCE INC. 2015: E31
View details for DOI 10.1016/j.jamcollsurg.2015.08.379

View details for Web of Science ID 000386899000071
Surgical deserts in California: an analysis of access to surgical care Uribe-Leitz, T., Esquivel, M. M., Staudenmayer, K. L., Spain, D. A., Weiser, T. G. ELSEVIER SCIENCE INC. 2015: E29
View details for DOI 10.1016/j.jamcollsurg.2015.08.375

View details for Web of Science ID 000386899000067
Analysis of a Hospital-Based Trauma Registry in Rural Cameroon: Description of Initial Results and Recommendations Esquivel, M. M., Long, C., Kaggya, K. M., Uribe-Leitz, T., Weiser, T. G., Wren, S. M. ELSEVIER SCIENCE INC. 2015: S86–S87
View details for DOI 10.1016/j.jamcollsurg.2015.07.196

View details for Web of Science ID 000361119700168
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
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 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
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 Hider, P., Wilson, L., Rose, J., Weiser, T. G., Gruen, R., Bickler, S. W. ELSEVIER SCIENCE INC. 2015: 25
View details for Web of Science ID 000360573400026
Projections to achieve minimum surgical rate threshold: an observational study 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. ELSEVIER SCIENCE INC. 2015: 14
View details for Web of Science ID 000360573400015
Proposed minimum rates of surgery to support desirable health outcomes: an observational study based on four strategies 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. ELSEVIER SCIENCE INC. 2015: 12
View details for Web of Science ID 000360573400013
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
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
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
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
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 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
Abdominal Trauma GLOBAL SURGERY AND ANESTHESIA MANUAL: PROVIDING CARE IN RESOURCE-LIMITED SETTINGS Matousek, A. C., Weiser, T. G., Rogers, S. O., Meara, J. G. 2015: 501–11
View details for Web of Science ID 000484041100103
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

View details for PubMedCentralID PMC4273085
Surgical Safety Checklists in Ontario, Canada NEW ENGLAND JOURNAL OF MEDICINE Weiser, T. G., Krummel, T. M. 2014; 370 (24): 2349–50
View details for Web of Science ID 000337033700023

View details for PubMedID 24918387
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
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 Web of Science ID 000336425200017
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
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

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