Biccard, B.M.

Nejthardt, M.B.

English

AJOL - African Journals Online

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojaa 3 EditorialChallenging barriers to surgical access in lower and middle-income countriesThe Lancet Commission on Global Surgery suggests that five billion people do not have access to safe, affordable surgical and anaesthesia care when needed.1 This is most evident in lower- and middle-income countries where 9 out of 10 people do not have access to basic surgical care.1Sub-Saharan Africa is one area singled out as having one of the greatest unmet surgical needs globally.2 Barriers to surgical access lead to delayed presentation of disease. As a consequence, disease progression increases the burden of disease. Elective surgery becomes semi-urgent and increases perioperative risk for adverse outcomes. This is well documented in the South African Surgical Outcomes Study (SASOS),3 and in the African Surgical Outcomes Study (ASOS),4 where elective surgery constitutes less than 50% of all surgeries, in comparison to Europe where elective surgery makes up 75% of all surgeries.5Barriers to surgical access are complex and multifactorial, and have been described by the ‘Three Delays’ framework.6 Determinants of safe and timely surgery centre around accessibility and availability. Delay in seeking care may be due to financial, geographic, cultural and educational constraints (First Delay). Once the decision to seek care is made, patients experience a delay in getting to hospital (Second Delay); predominantly governed by transport difficulties and scarcity of available surgical facilities. Finally, a patient arriving at an appropriate healthcare facility is not guaranteed the needed surgery (Third Delay). This Third Delay is highlighted in this edition of the Journal by Lankoande et al. who showed that elective day of surgery cancellation rates in an 800-bed tertiary hospital in Burkina Faso were in excess of 20%, of which 90% were deemed avoidable by the authors.7 Day of surgery cancellations have implications in both high- and low-income countries. They are associated with a loss of revenue and waste of resources, as well as significant psychological, social and financial implications for patients and their families. Furthermore, they result in a significant loss of training opportunities for surgical trainees.8 Additionally in lower-income countries where direct remuneration per procedure may not occur, same day surgical cancellations undermine the cost-effectiveness of the healthcare system; where fewer cases are performed for the same fixed human resource cost, resulting in a higher average cost per operation.Of greater concern, is that same day surgical cancellation has the potential to increase the burden of disease. In Lankoande and colleagues’ study, 60% of the cancelled procedures were rescheduled and the average waiting time for these patients was almost three weeks. Additionally, 10% of cases were cancelled more than once.7 These delays may have a significant effect on outcome. Closer scrutiny is also needed to explain why 40% of the cancellations were indefinitely postponed. A possible reason, which needs to be explored, is whether disease progression resulted in advanced pathology obviating the need for further surgery. Rescheduling of cases has another knock-on effect, which is not limited to the individual patient but rather to the community, where waiting-list times increase, and others are therefore denied timely surgical access. Surgical disease progression may therefore also compromise the outcomes of these patients.Published cancellation rates vary significantly, anything from 2% to 30%, hence it is important to bench mark against loco-regionally and internationally accepted standards.8–14 Observationally, it appears that cancellation rates tend to be higher in lower and middle-income countries as compared to higher-income countries. Cancellation rates reflect one component of efficiency. High efficiency units which are considered as high performance hospitals aim for cancellation rates less than 5%; and poor performance is deemed as cancellation rates > 10%.15 Same day surgery cancellation rate is seen as a quality assurance measure, which can be targeted to improve cost-effective healthcare delivery. Encouragingly, these high efficiency and performance benchmarks are potentially achievable in Burkina Faso, where if the factors assessed as ‘avoidable cancellations’ were addressed, the cancellation rate would fall below 5%.7Root cause analysis of inefficient utilisation of a scarce resource has to start with data collection of practices to firstly identify what the loco-regional standard is. Secondly and more importantly, we need to implement intervention strategies to make lasting improvements. Collaborative research on the African continent, such as the recently undertaken African Surgical Outcomes Study, has highlighted that despite enormous challenges, meaningful collaboration is possible.4 This collaborative group has the capacity to identify barriers and point to strategies that may require healthcare practitioners, managers, government and non-governmental bodies with context-specific insight to engage in a more accountable practice.Surgical access is not only a human right needed to decrease pain and suffering and promote dignity, but is also fundamental to enhance social and economic empowerment.MB Nejthardt, BM BiccardDepartment of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, South AfricaReferences1.  Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. doi: 10.1016/S0140-6736(15)60160-X2.  Grimes CE, Law RS, Borgstein ES, et al. Systematic review of met and unmet need of surgical disease in rural sub-Saharan Africa. World J Surg. 2012;36(1):8-23. doi: 10.1007/s00268-011-1330-1 [published Online First: 2011/11/08]3.  Biccard BM, Madiba TE, South African Surgical Outcomes Study I. The South African Surgical Outcomes Study: A 7-day prospective observational cohort study. S Afr Med J. 2015;105(6):465-75. doi: 10.7196/SAMJ.94354.  Biccard BM, Madiba TE, Kluyts HL, et al. Perioperative patient outcomes in The African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet. 2017: in press.5.  Pearse RM, Moreno RP, Bauer P, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380(9847):1059-65. doi: 10.1016/S0140-6736(12)61148-9 [published Online First: 2012/09/25]The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojaa 46.  Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social science & medicine (1982). 1994;38(8):1091-110. [published Online First: 1994/04/01]7.  Lankoandé M, Bonkoungou P, Ki BK, et al. Economic and psychologic burden of scheduled surgery cancellation in a Sub-Saharan country (Burkina Faso). South Afr J Anaesth Analg. 2017;23(6).8.  Dimitriadis PA, Iyer S, Evgeniou E. The challenge of cancellations on the day of surgery. Int J Surg. 2013;11(10):1126-30. doi: 10.1016/j.ijsu.2013.09.002 [published Online First: 2013/09/17]9.  Chalya PL, Gilyoma JM, Mabula JB, et al. Incidence, causes and pattern of cancellation of elective surgical operations in a university teaching hospital in the Lake Zone, Tanzania. Afr Health Sci. 2011;11(3):438-43. [published Online First: 2012/01/26]10.  Appavu ST, Al-Shekaili SM, Al-Sharif AM, et al. The Burden of Surgical Cancellations and No-Shows: Quality management study from a large regional hospital in Oman. Sultan Qaboos University medical journal. 2016;16(3):e298-302. doi: 10.18295/squmj.2016.16.03.006 [published Online First: 2016/09/09]11.  Cihoda JH, Alves JR, Fernandes LA, et al. The analysis for the causes of surgical cancellations in a Brazilian university hospital. Care management journals : Journal of case management ; J  Long Term Home Health Care. 2015;16(1):41-7. [published Online First: 2015/04/29]12.  Schuster M, Neumann C, Neumann K, et al. The effect of hospital size and surgical service on case cancellation in elective surgery: results from a prospective multicenter study. Anesth Analg. 2011;113(3):578-85. doi: 10.1213/ANE.0b013e318222be4d [published Online First: 2011/06/18]13.  Schofield WN, Rubin GL, Piza M, et al. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust. 2005;182(12):612-5. [published Online First: 2005/06/21]14.  Kaye AD, McDowell JL, Diaz JH, et al. Effective strategies in improving operating room case delays and cancellations at an academic medical center. J Med Pract Manag: MPM. 2015;30(6 Spec No):24-9. [published Online First: 2015/06/13]15.  Macario A. Are your hospital operating rooms “efficient”? A scoring system with eight performance indicators. Anesthesiology. 2006;105(2):237-40. [published Online First: 2006/07/28]

Editorial: Challenging barriers to surgical access in lower and middle-income countries

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Editorial: Challenging barriers to surgical access in lower and middle-income countries

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