Health and Economic Benefits of Improved Injury Prevention and Trauma Care Worldwide

Objectives: Injury is a significant source of morbidity and mortality worldwide, and often disproportionately affects younger, more productive members of society. While many have made the case for improved injury prevention and trauma care, health system development in low- and middle-income countries is often limited by resources. This study aims to determine the economic benefit of improved injury prevention and trauma care in low- and middle-income countries. Methods: This study uses existing data on injury mortality worldwide from the 2010 Global Burden of Disease Study to estimate the number of lives that could be saved if injury mortality rates in low- and middle-income countries could be reduced to rates in high-income countries. Using economic modeling – through the human capital approach and the value of a statistical life approach – the study then demonstrates the associated economic benefit of these lives saved. Results: 88 percent of injury-related deaths occur in low- and middle-income countries. If injury mortality rates in low- and middle-income countries were reduced to rates in high-income countries, 2,117,500 lives could be saved per year. This would result in between 49 million and 52 million disability adjusted life years averted per year, with discounting and age weighting. Using the human capital approach, the associated economic benefit of reducing mortality rates ranges from $245 to$261 billion with discounting and age weighting. Using the value of a statistical life approach, the benefit is between 758 and 786 billion dollars per year. Conclusions: Reducing injury mortality in low- and middle-income countries could save over 2 million lives per year and provide significant economic benefit globally. Further investments in trauma care and injury prevention are needed

Global access to surgical care: a modelling study

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, aff ordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defi ned 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 aff ordability. 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 oneway 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 stratifi ed 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

Development of an enhanced recovery after surgery program for pediatric solid tumors

IntroductionEnhanced recovery after surgery (ERAS) is an evidence-based, multi-modal approach to decrease surgical stress, expedite recovery, and improve postoperative outcomes. ERAS is increasingly being utilized in pediatric surgery. Its applicability to pediatric patients undergoing abdominal tumor resections remains unknown.Methods and AnalysisA group of key stakeholders adopted ERAS principles and developed a protocol suitable for the variable complexity of pediatric abdominal solid tumor resections. A multi-center, prospective, propensity-matched case control study was then developed to evaluate the feasibility of the protocol. A pilot-phase was utilized prior to enrollment of all patients older than one month of age undergoing any abdominal, retroperitoneal, or pelvic tumor resections. The primary outcome was 90-day complications per patient. Additional secondary outcomes included: ERAS protocol adherence, length of stay, time to administration of adjuvant chemotherapy, readmissions, reoperations, emergency room visits, pain scores, opioid usage, and differences in Quality of Recovery 9 scores.Ethics and DisseminationInstitutional review board approval was obtained at all participating centers. Informed consent was obtained from each participating patient. The results of this study will be presented at pertinent society meetings and published in peer-reviewed journals. We expect the results will inform peri-operative care for pediatric surgical oncology patients and provide guidance on initiation of ERAS programs. We anticipate this study will take four years to meet accrual targets and complete follow-up.Trial Registration NumberNCT04344899

Net deaths and DALYs averted by income group.

<p>Net deaths are deaths averted if injury mortality rates for each country were to match overall injury mortality rates in HICs (). Net DALYs are reported without discounting or age weighting (<i>Net DALYs [</i>0,0,0]), and with discounting of 3% and age weighting with a peak at 25 years, or β = 0.04 (<i>NetDALYs</i> [3,1,β]). The ranges of reported estimates are from the results of methods 1 and 2 in calculating net DALYs (see Methods). Net DALY values without an asterisk represent DALYs averted if injury mortality rates for each country were to match overall injury mortality rates in HICs in each age group (method 1, ). The values with an asterisk (*) represent DALYs averted if injury mortality and disability matched those of HICs method 2, ).</p

Use and definitions of perioperative mortality rates in low-income and middle-income countries : a systematic review

BACKGROUND: Aggregate and risk-stratified perioperative mortality rates (POMR) are well-documented in high-income countries where surgical databases are common. In many low-income and middle-income country (LMIC) settings, such data are unavailable, compromising efforts to understand and improve surgical outcomes. We undertook a systematic review to determine how POMR is used and defined in LMICs and to inform baseline rates.METHODS: We searched PubMed for all articles published between Jan 1, 2009, and Sept 1, 2014, reporting surgical mortality in LMICs. Search criteria, inclusion and exclusion criteria, and study assessment methodology are reported in the appendix. Titles and abstracts were screened independently by two reviewers. Full-text review and data extraction were completed by four trained clinician coders with regular validation for consistency. We extracted the definition of POMR used, clinical risk scores reported, and strategies for risk adjustment in addition to reported mortality rates.FINDINGS: We screened 2657 abstracts and included 373 full-text articles. 493 409 patients in 68 countries and 12 surgical specialties were represented. The most common definition for the numerator of POMR was in-hospital deaths following surgery (55·3%) and for the denominator it was the number of operative patients (96·2%). Few studies reported preoperative comorbidities (41·8%), ASA status (11·3%), and HIV status (7·8%), with a smaller proportion stratifying on or adjusting mortality for these factors. Studies reporting on planned procedures recorded a median mortality of 1·2% (n=121 [IQR 0·0-4·7]). Median mortality was 10·1% (n=182 [IQR 2·5-16·2) for emergent procedures.INTERPRETATION: POMR is frequently reported in LMICs, but a standardised approach for reporting and risk stratification is absent from the literature. There was wide variation in POMR across procedures and specialties. A quality assessment checklist for surgical mortality studies could improve mortality reporting and facilitate benchmarking across sites and countries.FUNDING: None

Economic benefit of reducing injury mortality.

<p>Economic benefit is reported as a range. Economic benefit calculated by the human capital approach is reported without discounting or age weighting (0,0,0), and with discounting of 3% and age weighting to a peak at age 25 years, or β = 0.04 (3,1, β). The percentage of the total GNI for each income group is reported in parentheses below the range of estimates. Economic benefit calculated by the VSL approach is reported only with discounting of 3% and age weighting to a peak at two-thirds the standard life expectancy at birth, or β = 0.017 [3,1,].</p

Percentage of total injury deaths by income level and injury type.

<p><b>A)</b> Percentage of total injury deaths by income level for each mechanism of injury. The mechanisms of injury are sorted on the x-axis from greatest-to-least by the percentage of deaths occurring in LMICs. <b>B)</b> Percentage of total injury deaths by injury type in each income group. The mechanisms of injury are sorted in the columns from greatest-to-least by the percentage of total deaths occurring worldwide.</p