Summary Background 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. Methods 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. Findings 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. Interpretation 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. Funding None.
Summary Background Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non-medical costs of accessing care increase that number. ...The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery. Methods To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non-medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model. Findings 3·7 billion people (posterior credible interval 3·2–4·2 billion) risk catastrophic expenditure if they need surgery. Each year, 81·3 million people (80·8–81·7 million) worldwide are driven to financial catastrophe—32·8 million (32·4–33·1 million) from the costs of surgery alone and 48·5 million (47·7–49·3) from associated non-medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions. Interpretation Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health-system design. Funding MGS received partial funding from NIH/NCI R25CA92203.
The Healthcare Access and Quality (HAQ) index, developed by the Institute for Health Metrics and Evaluation, uses estimates of amenable mortality to quantify health system performance over time. ...While much is known about general health system performance globally, few studies have portrayed the performance of surgical systems. In order to quantify access to quality surgical care, evaluate changes over time, and link these changes to health care investments, surgical and non-surgical Health Access and Quality sub-indices were developed.
We categorized 32 amenable mortality causes as either surgical or non-surgical conditions. Using principal components analysis and scaled amenable mortality rates, we constructed a surgical and non-surgical Health Access and Quality sub-index. Using these sub-indices, relative improvement over time was compared. An expenditure model with country fixed effects was built to explore drivers of differences in relative improvement of sub-indices.
Compared to low-income countries, high-income countries have been 2.77 times more effective at improving surgical care (p < .05). Government expenditure on healthcare has a larger effect on improving surgical Health Access and Quality (p < 0.05) while development assistance for health has a larger effect on improving non-surgical Health Access and Quality (p < 0.05).
Global health investment must prioritize strengthening health systems as opposed to the historically favored vertical programming. In order to achieve health equity in low-income countries, more focus should be placed on domestic financing of surgical systems. Health Access and Quality sub-indices can be used by countries to identify targets, monitor progress, and evaluate interventions aimed at improving access to quality surgical healthcare.
Summary Background The surgical burden of disease is substantial, but little is known about the associated economic consequences. We estimate the global macroeconomic impact of the surgical burden of ...disease due to injury, neoplasm, digestive diseases, and maternal and neonatal disorders from two distinct economic perspectives. Methods We obtained mortality rate estimates for each disease for the years 2000 and 2010 from the Institute of Health Metrics and Evaluation Global Burden of Disease 2010 study, and estimates of the proportion of the burden of the selected diseases that is surgical from a paper by Shrime and colleagues. We first used the value of lost output (VLO) approach, based on the WHO's Projecting the Economic Cost of Ill-Health (EPIC) model, to project annual market economy losses due to these surgical diseases during 2015–30. EPIC attempts to model how disease affects a country's projected labour force and capital stock, which in turn are related to losses in economic output, or gross domestic product (GDP). We then used the value of lost welfare (VLW) approach, which is conceptually based on the value of a statistical life and is inclusive of non-market losses, to estimate the present value of long-run welfare losses resulting from mortality and short-run welfare losses resulting from morbidity incurred during 2010. Sensitivity analyses were performed for both approaches. Findings During 2015–30, the VLO approach projected that surgical conditions would result in losses of 1·25% of potential GDP, or $20·7 trillion (2010 US$, purchasing power parity) in the 128 countries with data available. When expressed as a proportion of potential GDP, annual GDP losses were greatest in low-income and middle-income countries, with up to a 2·5% loss in output by 2030. When total welfare losses are assessed (VLW), the present value of economic losses is estimated to be equivalent to 17% of 2010 GDP, or $14·5 trillion in the 175 countries assessed with this approach. Neoplasm and injury account for greater than 95% of total economic losses with each approach, but maternal, digestive, and neonatal disorders, which represent only 4% of losses in high-income countries with the VLW approach, contribute to 26% of losses in low-income countries. Interpretation The macroeconomic impact of surgical disease is substantial and inequitably distributed. When paired with the growing number of favourable cost-effectiveness analyses of surgical interventions in low-income and middle-income countries, our results suggest that building surgical capacity should be a global health priority. Funding US National Institutes of Health/National Cancer Institute.
Although advances in the reduction of maternal mortality have been made, up to 273,000 women will die this year from obstetric etiologies. Obstructed labor (OL), most commonly treated with Caesarean ...delivery, has been identified as a major contributor to global maternal morbidity and mortality. We used economic and epidemiological modeling to estimate the cost per disability-adjusted life-year (DALY) averted and benefit-cost ratio of treating OL with Caesarean delivery for 49 countries identified as providing an insufficient number of Caesarean deliveries to meet demand.
Using publicly available data and explicit economic assumptions, we estimated that the cost per DALY (3,0,0) averted for providing Caesarean delivery for OL ranged widely, from $251 per DALY averted in Madagascar to $3,462 in Oman. The median cost per DALY averted was $304. Benefit-cost ratios also varied, from 0.6 in Zimbabwe to 69.9 in Gabon. The median benefit-cost ratio calculated was 6.0. The main limitation of this study is an assumption that lack of surgical capacity is the main factor responsible for DALYs from OL.
Using the World Health Organization's cost-effectiveness standards, investing in Caesarean delivery can be considered "highly cost-effective" for 48 of the 49 countries included in this study. Furthermore, in 46 of the 49 included countries, the benefit-cost ratio was greater than 1.0, implying that investment in Caesarean delivery is a viable economic proposition. While Caesarean delivery alone is not sufficient for combating OL, it is necessary, cost-effective by WHO standards, and ultimately economically favorable in the vast majority of countries included in this study.
Objectives/Hypothesis:
To examine sinonasal anatomic variants that may predispose toward recurrent acute rhinosinusitis (RARS).
Study Design:
Retrospective case‐control.
Methods:
Sinus computed ...tomography (CT) scans from a consecutive series of adult patients meeting strict diagnostic criteria for RARS were retrospectively reviewed. A control group was assembled from patients who underwent pituitary or temporal bone CT for a nonrhinosinusitis indication. CT scans were scored for the presence of Haller cells, concha bullosa, and impinging septal spurs. Maximal septal deviation (degrees), infundibular widths, and Lund staging were also assessed. The prevalence of these anatomic variants was statistically compared between the RARS and control groups.
Results:
Thirty‐six patients met diagnostic criteria for RARS (mean age, 47.2 years; 2:1 female preponderance); 42 control patients were identified. The mean Lund score for patients with RARS was 2.25 versus 1.27 for the control group (P < .001). Although RARS patients were more likely to manifest concha bullosa (41.7% vs. 28.6%) or impinging septal spurs (27.8% vs. 19.0%), these differences were not statistically significant (P = .165 and P = .260, respectively). However, patients with RARS were significantly more likely to radiographically demonstrate Haller cells (39.9% vs. 11.9%, respectively, P = .006). Finally, patients with RARS had significantly smaller mean infundibular widths when compared with control patients (0.591 mm vs. 0.823 mm, respectively, P < .001).
Conclusions:
The presence of Haller cells and smaller infundibular widths were statistically associated with RARS when compared to control patients. Our data suggest that anatomy could play a role in the pathogenesis of RARS. Further prospective study is warranted. Laryngoscope, 2010
We estimated deaths amenable to high-quality health care globally and then modeled the macroeconomic impact in low- and middle-income countries using two macroeconomic perspectives: a ...value-of-lost-output approach to project gross domestic product (GDP) losses annually for the period 2015-30, and a value-of-lost-welfare approach to estimate the present value of total economic welfare losses in 2015. We estimated that eight million amenable deaths occurred in 2015, 96 percent of them in low- and middle-income countries. The value of lost output resulted in a projected cumulative loss of $11.2 trillion in these countries during 2015-30, with a potential economic output loss of up to 2.6 percent of GDP in low-income countries by 2030, compared to 0.9 percent in upper-middle-income countries. The value-of-lost-welfare approach estimated welfare losses of $6.0 trillion in 2015. Inadequate access to high-quality health care results in significant mortality and imposes a macroeconomic burden that is inequitably distributed, with the largest relative burden falling on low-income countries. Given that these deaths are unnecessary and the projected GDP losses are avoidable, there is a strong ethical and economic case for promoting high-quality health care as an essential component of universal health coverage.
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