Options chirurgicales quand il n'y a pas de chirurgien

Surgery where there is no surgeon Whats are the options?

Johan von Schreeb MD. PhD, specialist general surgery Centre for research on health care in disasters

Outline 1.

2.

3.

4.

5.

Global burden of surgical needs Cost effectiveness of surgery Unmet surgical needs in low income countries Task shifting of surgery to reduce the unmet needs Task shifting in Sierra Leone

1. Global burden of surgical conditions  10% of deaths (4,7 millions) in low and middle countries (LMIC) are due to surgically treatable conditions  injuries (38%), malignancies (19%), congenital anomalies (9%), complications of pregnancy (6%), cataracts (5%) and perinatal conditions (4%)  Provision of essential surgical procedures would avert about 1.5 million deaths a year or 6-7% of all avertable deaths in LMICs with “44 Essential surgical procedures” Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2013;380(9859):2095-128. Epub 2012/12/19.

Forthcoming Lancet publication” Essential surgery: key messages from Disease Control Priorities, 3rd edition ”

2. Cost effective?  Surgical treatment as cost effective as vaccination programs and 10-15 times more than antiretroviral medication for HIV  Hernia repair ($US 10–$100/DALY averted), Emergency C- sectio ($US15–$380)  Oral rehydration solution (over $US1,000), and anti-retroviral therapy for HIV/AIDS (around $US 900/DALY averted).

 First-level hospital has been found to be especially cost-effective $US10–$220 per DALY  28 of the 44 essential procedures  1:10 cost-benefit ratio Alkire B, Vincent J, Meara J. Chapter 21. Benefit-Cost Analysis for Selected Surgical Interventions in Low and Middle Income Countries. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds.

Disease Control Priorities: Third Edition Volume 1 Essential Surgery (IN PRESS): World Bank; 2015

2. Cost-effectiveness of surgical interventions

Anti Retrovirals

Cost/DALY (2012 USD)

Range

3. Unmet surgical need in low and middle income countries  2 billion people lack access to basic surgery*  Only 3·5% of surgeries in low-income countries where 35% of the world’s people live  In 2012 survey of all surgeries in Sierra Leone found 500 surgeries /100 000/pop (Need =10 times higher)  Unmet country need= 90%

*Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372(9633): 139–44 Bolkan, von Schreeb et al. Met and unmet need for surgery in Sierra Leone , re-submitted following revision Surgery 2014

4. Task shifting  Delegation of certain responsibilities to less specialized workers  Examples of medical task-shifting • Ophthalmic nurses doing cataract operations • Anesthesia nurses providing general anesthesia

 Surgical task-shifting • Shifting of tasks from surgeons to non-specialists • Shifting tasks from doctors to non-doctors (NPC)

4. Task shifting  In Tanzania 84% of C-sections done by Non Physician Clinician (NPC)  Outcomes such as maternal and neonatal mortality rates after C-section were similar for (NPC) compared with doctors.

 In Mozambique 92% of C-sections by NPC  NPC were three times more cost-effective to train and deploy. In Burkina Faso EOC by general practitioners was more cost-effective than that trained obstetricians

• Six non-randomized controlled studies caesarean section

NPCs vs MD -

• Results: No significant difference in maternal nor perinatal deaths  

McCord C, Mbaruku G, Pereira C, Nzabuhakwa C, Bergstrom S. The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Affairs (Millwood) 2009; 28: w876–85.

Pereira C, Mbaruku G, Nzabuhakwa C, Bergstrom S, McCord C. Emergency obstetric surgery by non-physician clinicians in Tanzania. International Journal of Gynecology and Obstetrics 2011; 114: 180–3

Sierra Leone    

6 million people Long history of conflict Significant unmet surgical needs (90%) Study found that 25% of all deaths could have been averted by surgery*  Significant health care staff shortage

‘ Groen RS, Samai M, Stewart KA, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 2012; 380(9847): 1082–7.

Surgical workforce Freetown Provinces Surgeons 12 2 Obstetrician/gynaecolog 6 1 ist MD practising surgery 1 3.5 Surgical Technician 10 4

Total 14 7 4.5 14

Kingham 2009 - Quantifying Surgical Capacity in Sierra Leone; Arch Surg. 2009;144(2):122-127

Surgical Training Program: Increasing access to essential surgical care in Sierra Leone by training Community Health Officers +MDs

 Joint program Capa Care and Ministry of Health  Focus on surgical conditions that  1) Are common 2) constitutes significant burden of disease 3) could be averted by “essential surgery”

 Students selected from communities Training (2 years)

Practical training

Basics Masanga

Partner hospitals (2-3)

Theoretical / Skills training

Visiting consultant specialists in: - Surgery and orthopedics - Obstetrics and gynaecology - Radiology (Ultrasound) - Anesthisiology

Ex a m

Houseman ships (1 year) Conaught and/or PCMH

Teaching Facilities Primary Training Center 1.

Masanga Hospital Partner Hospitals 3.

Magbenteh, Makeni 4.

Holy Spirit, Makeni 5.

St John of God, Lunsar 6.

Kamakwie Weslian Hospital 11.

Lion Hearth Medical Center, Yele 12.

Gundama Refferal Center, Bo 13.

Serabu Catholic Hospital 14.

Aberdeen Womens Center, Freetown Housemanship Hospitals 19.

Canaught University Hospital, Freetown 20.

PCMH Maternity Hospital, Freetown

Students in the program 30 25 20 student housemanship

15 10 5 0 first half 2011

first half 2012

first half 2013

first half 2014

Top 10 procedures (as by 1st July 2014) Procedure

Number

Percentage

1. Inguinal hernia repair

3895

26.1%

2. Cesarean section

3144

21.1%

3. Explorative laparotomy

672

4.5%

4. Appendectomy

497

3.3%

5. Scrotal hydrocele

494

3.3%

6. Tubal ligation

489

3.3%

7. Hysterectomy

443

3.0%

8. Dilation and curettage

437

2.9%

9. Incision and drainage 10. Obstetrics and gynecology other

431 400

2.9% 2.7%

Ebola in Sierra Leone  + 7 000 infected, 140 health care staff  Currently 70-90 new cases per day  Two students in the program has died from Ebola  No new admissions to the program  Expat doctors evacuated

 Indirect effects on the health service ?

Surgical procedures / Ebola cases

students

housemanship

finished

Ebola cases

Admission and surgical rates following Ebola outbreak in Sierra Leone Bolkan, BashTaqi, Samai, Gerdin, von Schreeb, Resubmitted following revision PloS Outbreaks Dec 2014

Conclusion     

Surgical conditions cause significant burden of disease Surgery is cost effective in averting morbidity and mortality Significant unmet needs of surgery in low income countries Surgery neglected public health priority!

New and innovative strategies are needed to reduce the unmet need of surgery  Task shifting has been showed to be safe and cost effective  MSF and task shifting?