Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar

Over two-thirds of the world’s population lack access to surgical care. Non-governmental organisation’s providing free surgeries may overcome financial barriers, but other barriers to care still exist. This analysis paper discusses two different case-finding strategies in Madagascar that aimed to increase the proportion of poor patients, women and those for whom multiple barriers to care exist. From October 2014 to June 2015, we used a centralised selection strategy, aiming to find 70% of patients from the port city, Toamasina, and 30% from the national capital and two remote cities. From August 2015 to June 2016, a decentralised strategy was used, aiming to find 30% of patients from Toamasina and 70% from 11 remote locations, including the capital. Demographic information and self-reported barriers to care were collected. Wealth quintile was calculated for each patient using a combination of participant responses to asset-related and demographic questions, and publicly available data. A total of 2971 patients were assessed. The change from centralised to decentralised selection resulted in significantly poorer patients undergoing surgery. All reported barriers to prior care, except for lack of transportation, were significantly more likely to be identified in the decentralised group. Patients who identified multiple barriers to prior surgical care were less likely to be from the richest quintile (p=0.037) and more likely to be in the decentralised group (p=0.046). Our country-specific analysis shows that decentralised patient selection strategies may be used to overcome barriers to care and allow patients in greatest need to access surgical care

Effect of removing the barrier of transportation costs on surgical utilisation in Guinea, Madagascar and the Republic of Congo

Background: 81 million people face impoverishment from surgical costs every year. The majority of this impoverishment is attributable to the non-medical costs of care—for transportation, for food and for lodging. Of these, transportation is the largest, but because it is not viewed as an actual medical cost, it is frequently unaddressed. This paper examines the effect on surgical utilisation of paying for transportation. Methods: A hierarchical logistic regression was performed on 2692 patients presenting for surgical care to a non-governmental organisation operating in the Republic of the Congo, Guinea and Madagascar. Controlling for distance from the hospital, age, gender, the need for air travel and time between appointments, the effect of payment for transportation on the surgical no-show rate was evaluated. Results: After adjustment for observed confounders, paying for transportation drops the surgical no-show rate by 45% (OR 0.55; 95% CI 0.40 to 0.77; p<0.001). Age, delay between appointments and the number of hours travelled for surgery also predict surgical no-show. For 28% of no-show patients, the cost of transportation from their homes to a nearby predetermined pick-up point remained a barrier, even when transportation from the pick-up point to the hospital was free. Conclusion: Transportation costs are a significant barrier to surgical care in low-resource settings, and paying for it halves the no-show rate. This finding highlights that decreasing demand-side barriers to surgical care cannot be limited only to the removal of user fees

The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK.

In this paper, we describe the potential of simulation to improve hospital responses to the COVID-19 crisis. We provide tools which can be used to analyse the current needs of the situation, explain how simulation can help to improve responses to the crisis, what the key issues are with integrating simulation into organisations, and what to focus on when conducting simulations. We provide an overview of helpful resources and a collection of scenarios and support for centre-based and in situ simulations

The dispute between Carlini-Plana and Laplace on the theory of the Moon

In 1820 a prize was awarded to Carlini-Plana and Damoiseau for their memoirs on the lunar tables based solely on the law of universal gravity, as the Acad\ue9mie des Sciences in Paris required. Laplace had proposed in 1818 the setting up of the prize and he was member of the committee who examined the memoirs. But Laplace, unexpectedly, strongly criticised Carlini-Plana's approach to the lunar theory. A dispute ensued: although he understood the importance of the criticisms of Carlini and Plana, addressing them punctiliously, Laplace had a precise objective in mind: to prove that his lunar theory, premised in the M\ue9canique C\ue9leste on the theory of universal gravity, could, with the help of able calculating astronomers, give rise eventually to good Lunar tables. After the exchanges, public and private, Laplace recognised that Carlini and Plana had advanced the theory: the decisive step towards compiling lunar tables deduced solely from theory could thus be said to have been substantially accomplished

The (Non) Spread of Innovations : The Mediating Role of Professionals

Two qualitative studies in the U.K. health care sector trace eight purposefully selected innovations. Complex, contested, and nonlinear innovation careers emerged. Developing the nonlinear perspective on innovation spread further, we theorize that multiprofessionalization shapes “nonspread.” Social and cognitive boundaries between different professions retard spread, as individual professionals operate within unidisciplinary communities of practice. This new theory helps explain barriers to the spread of innovation in multiprofessional organizations in both health care and other settings

Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study

Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported. To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid. A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites