Dataset Information

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries.

ABSTRACT:

Background

This study assessed the potential cost-effectiveness of high (80-100%) vs low (21-35%) fraction of inspired oxygen (FiO₂) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa.

Methods

Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO₂, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($).

Results

High FiO₂ may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO₂ was $216 compared with $222 for low FiO₂ leading to a -$6 (95% confidence interval [CI]: -$13 to -$1) difference in costs. In India, the average cost for high FiO₂ was $184 compared with $195 for low FiO₂ leading to a -$11 (95% CI: -$15 to -$6) difference in costs. In South Africa, the average cost for high FiO₂ was $1164 compared with $1257 for low FiO₂ leading to a -$93 (95% CI: -$132 to -$65) difference in costs. The high FiO₂ arm had few SSIs, 7.33% compared with 8.38% for low FiO_2, leading to a -1.05 (95% CI: -1.14 to -0.90) percentage point reduction in SSIs.

Conclusion

High FiO₂ could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this.

SUBMITTER: NIHR Global Health Research Unit on Global Surgery Collaborators

PROVIDER: S-EPMC10457493 | biostudies-literature | 2023 Sep

REPOSITORIES: biostudies-literature

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Publications

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries.

BJA open 20230715

<h4>Background</h4>This study assessed the potential cost-effectiveness of high (80-100%) <i>vs</i> low (21-35%) fraction of inspired oxygen (FiO<sub>2</sub>) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa.<h4>Methods</h4>Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO<sub>2</sub>, published literature, and a cost survey ...[more]

PMID: 37655933

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Project description:ImportanceOveruse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.ObjectivesTo assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.Evidence reviewWe searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.FindingsOf 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.Conclusions and relevanceThis systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

Project description:BackgroundAccess to timely and quality surgical care is limited in low- and middle-income countries (LMICs). Telemedicine, defined as the remote provision of health care using information, communication and telecommunication platforms have the potential to address some of the barriers to surgical care. However, synthesis of evidence on telemedicine use in surgical care in LMICs is lacking.AimTo describe the current state of evidence on the use and distribution of telemedicine for surgical care in LMICs.MethodsThis was a scoping review of published and relevant grey literature on telemedicine use for surgical care in LMICs, following the PRISMA extension for scoping reviews guideline. PubMed-Medline, Web of Science, Scopus and African Journals Online databases were searched using a comprehensive search strategy from 1 January 2010 to 28 February 2021.ResultsA total of 178 articles from 53 (38.7%) LMICs across 11 surgical specialties were included. The number of published articles increased from 2 in 2010 to 44 in 2020. The highest number of studies was from the World Health Organization Western Pacific region (n = 73; 41.0%) and of these, most were from China (n = 69; 94.5%). The most common telemedicine platforms used were telephone call (n = 71, 39.9%), video chat (n = 42, 23.6%) and WhatsApp/WeChat (n = 31, 17.4%). Telemedicine was mostly used for post-operative follow-up (n = 71, 39.9%), patient education (n = 32, 18.0%), provider training (n = 28, 15.7%) and provider-provider consultation (n = 16, 9.0%). Less than a third (n = 51, 29.1%) of the studies used a randomised controlled trial design, and only 23 (12.9%) reported effects on clinical outcomes.ConclusionTelemedicine use for surgical care is emerging in LMICs, especially for post-operative visits. Basic platforms such as telephone calls and 2-way texting were successfully used for post-operative follow-up and education. In addition, file sharing and video chatting options were added when a physical assessment was required. Telephone calls and 2-way texting platforms should be leveraged to reduce loss to follow-up of surgical patients in LMICs and their use for pre-operative visits should be further explored. Despite these telemedicine potentials, there remains an uneven adoption across several LMICs. Also, up to two-thirds of the studies were of low-to-moderate quality with only a few focusing on clinical effectiveness. There is a need to further adopt, develop, and validate telemedicine use for surgical care in LMICs, particularly its impact on clinical outcomes.

Project description:IntroductionTelemedicine is being adopted for postoperative surveillance but requires evaluation for efficacy. This study tested a telephone Wound Healing Questionnaire (WHQ) to diagnose surgical site infection (SSI) after abdominal surgery in low- and middle-income countries.MethodA multi-centre, international, prospective study was embedded in the FALCON trial; a factorial RCT testing measures to reduce SSI in seven low- and middle-income countries (NCT03700749). It was conducted according to a pre-registered protocol (SWAT126) and reported according to STARD guidelines. The reference test was in-person review by a trained clinician at 30 postoperative days according to US Centres for Disease Control criteria. The index test was telephone administration of an adapted WHQ at 27 to 30 postoperative days by a researcher blinded to the outcome of in-person review. The sum of item response scores generated an overall score between 0 and 29. The primary outcome was the diagnostic accuracy of the WHQ, defined as the proportion of SSI correctly identified by the telephone WHQ, and summarized using the area under the receiving operator characteristic curve (AUROC) and diagnostic test accuracy statistics.ResultsPatients were included from three upper-middle income (396 patients, 13 hospitals), three lower-middle income (746 patients, 19 hospitals), and one low-income country (54 patients, 4 hospitals). 90.3% (1088 of 1196) patients were successfully contacted. Those with non-midline incisions (adjusted odds ratio: 0.36, 95% c.i. 0.17 to 0.73, P=0.005) or a confirmed diagnosis of SSI on in-person assessment (odds ratio: 0.42, 95% c.i. 0.20 to 0.92, P=0.006) were harder to reach. The questionnaire correctly discriminated between most patients with and without SSI (AUROC 0.869, 95% c.i. 0.824 to 0.914), which was consistent across subgroups. A representative cut-off score of ≥4 displayed a sensitivity of 0.701 (0.610-0.792), specificity of 0.911 (0.878-0.943), positive predictive value of 0.723 (0.633-0.814) and negative predictive value of 0.901 (0.867-0.935).ConclusionSSI can be diagnosed using a telephone questionnaire (obviating in-person assessment) in low resource settings.

Project description:BACKGROUND:Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions. METHODS:MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach. RESULTS:Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities. DISCUSSION:The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.

Project description:ObjectivesStudies indicate that many types of surgical care are cost-effective compared with other health interventions in low-income and middle-income countries (LMICs). However, global health investments to support these interventions remain limited. This study undertakes a scoping review of research on the economic impact of surgical interventions in LMICs to determine the methodologies used in measuring economic benefits.DesignThe Arksey and O'Malley methodological framework for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist were used to review the data systematically. Online databases were used to identify papers published between 2005 and 2020, from which we selected 19 publications that quantitatively examined the economic benefits of surgical interventions in LMICs.ResultsMajority of publications (79%) reported the use of disability-adjusted life-years (DALYs) to assess economic impact. In comparison, 21% used other measures, such as the value of statistical life or cost-effectiveness ratios, or no measure at all. 31% were systematic or retrospective reviews of the literature on surgical procedures in LMICs, while 69% either directly assessed economic impact in a specific area or evaluated the need for surgical procedures in LMICs. All studies reviewed related to the economic impact of surgical procedures in LMICs, with most about paediatric surgical procedures or a specific surgical specialty.ConclusionTo make informed policy decisions regarding global health investments, the economic impact must be accurately measured. Researchers employ a range of techniques to quantify the economic benefit of surgeries in LMICs, which limits understanding of overall economic value. We conclude that the literature would benefit from a careful selection of methods, incorporating age and disability weights based on the Global Burden of Disease weights, and converting DALYs to dollars using the value of statistical life approach and the human capital approach, reporting both estimates.

Dataset Information

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries.

Background

Methods

Results

Conclusion

Publications

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries.

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