Surgical Care in Liberia and Implications for Capacity Building

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Surgical Care in Liberia and Implications for Capacity Building

Article in World Journal of Surgery ? December 2014

DOI: 10.1007/s00268-014-2905-4

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World J Surg DOI 10.1007/s00268-014-2905-4

ORIGINAL SCIENTIFIC REPORT

Surgical Care in Liberia and Implications for Capacity Building

Tiffany E. Chao ? Pratik B. Patel ? Michael Kikubaire ? Michelle Niescierenko ? Lars Hagander ? John G. Meara

? Socie?te? Internationale de Chirurgie 2014

Abstract Background Situational needs of health care facilities inform the optimal allocation of resources and quality improvement efforts. This study examines surgical care delivery metrics at a tertiary care institution in Liberia. Methods We retrospectively reviewed operative and ward logbooks from January 1 to December 31, 2012. Data parameters included patients' age, diagnosis, procedure, mortality, and perioperative provider information. Results In 2012, 1,036 operations were performed. The breakdown of adult surgical cases reveals 452 (45.1 %) general surgery operations, 192 (18.5 %) orthopedic operations, and 180 (17.4 %) ophthalmic operations. Other significant case volume included urologic 53 (5.1 %), ENT 36 (3.5 %), neurosurgical 31 (3.0 %), vascular 24 (2.3 %), and plastic 14 (1.4 %) operations. Pediatric patients accounted for 24.5 % (243) of surgical cases, and 9 % of pediatric surgical cases were for hydrocephalus. General, spinal, and total intravenous anesthesia was provided by non-physician personnel, except when surgeons provided their own anesthesia. Ward logs documented 7.4 % mortality among all patients admitted to the surgical ward, most of which occurred after exploratory laparotomy (44 %), in burn (14 %) patients, and in patients with head/neck emergencies (12 %). Conclusions This operative log review can be used to identify surgical practice patterns, needs, and deficits in order to inform the growth of surgical capacity at Liberia's only tertiary medical institution. Using this data to identify critical areas of high-yield operations (e.g., for pediatric hydrocephalus), or excessively high mortality rates (e.g., in burn care), can focus the direction of limited resources toward areas of need. While the heavy reliance on nonconsultant surgeons reflects human capacity shortages and a pressing need for postgraduate training programs, identifying the breadth of surgical expertise demonstrated in these operative logs reveals the proficiencies required of surgeons to provide comprehensive surgical care in this setting.

T. E. Chao ? P. B. Patel ? L. Hagander ? J. G. Meara Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA

T. E. Chao ? P. B. Patel ? L. Hagander ? J. G. Meara Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA

T. E. Chao (&) Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB 425, Boston, MA 02115, USA e-mail: tchao@

M. Kikubaire Department of Surgery, John F. Kennedy Medical Center, Monrovia, Republic of Liberia

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Introduction

In recent years, surgical care has been widely accepted as a cost-effective and integral, yet traditionally neglected, cornerstone of basic healthcare delivery in resource-limited settings [1?5]. Global surgical disease burden, estimated at 11 % of total disability-adjusted life years (DALYs) lost worldwide, is known to disproportionately affect low- and middle-income countries (LMICs), where the inadequacy of surgical and anesthetic capacity is well documented [2, 5, 6]. While these data apply broadly to LMICs, particularly in sub-Saharan Africa, it is important to recognize the specific situations and needs of individual countries to optimally tailor resources and interventions at the country level [4, 7, 8]. Though data is often available regarding the frequency of different procedures performed in highincome countries, there is very little published data regarding the distribution of surgical procedures in LMICs. Data regarding the scope of surgical procedures performed in LMICs must be communicated to the international surgery community to adequately prepare potential human resources and infrastructural investments in these settings. The disease-specific burden and intervention outcomes evaluation are of particular interest [9].

Liberia, a small West African nation with a population of 4.1 million, at once demonstrates real health care capacity needs and the potential for considerable progress [10]. A post-conflict nation recovering from a devastating 14-year civil war (1989?2003), Liberia is in the midst of a critical period of stabilization and reconstruction. Identifying shortcomings in surgical and anesthetic care, followed by strengthening of these systems, can help a country in its achievement of the Millennium Development Goals [11].

As an important first step to improve the surgical care delivery system of Liberia, studies have begun to address the longstanding dearth of data regarding Liberian surgical capacity and surgical health indicators. The WHO Situational Analysis Tool and other systematic methods for surgical capacity assessment in LMICs have been applied to survey sixteen Liberian district hospitals [10, 12] varying in size from 11 to 200 beds, which comprise all of the major health facilities outside the capital city, Monrovia. These studies demonstrated essentially uniform shortcomings in

M. Niescierenko Department of Medicine, Boston Children's Hospital, Boston, MA, USA

L. Hagander Department of Pediatric Surgery, Lund Children's Hospital, Lund, Sweden

L. Hagander Department of Clinical Sciences in Lund, International Pediatrics, Faculty of Medicine, Lund University, Lund, Sweden

surgical capacity, particularly in areas of infrastructure and human capital [10, 12?14]. Kruk and colleagues showed that in 2008, 5 years after the Liberian Civil War, rural Liberians still had limited access to life-saving health care [13]. In 2011, Knowlton et al. used a comprehensive survey tool to collect data from 11 hospitals. It was noted that only three fully trained Liberian surgeons and two obstetrics?gynecology surgeons worked in Liberia in 2011, with twenty-one physicians performing the majority of operations. No physician anesthesiologists worked in the country at that time. Their study revealed a critical shortage of surgical and anesthesia care providers, as well as a strong need for continued development of emergency and essential surgical services and improved outcome tracking across Liberia [14].

In order to advance Liberia's commitment to improved healthcare, we performed a comprehensive operative log review at the major tertiary referral center in Liberia to evaluate surgical demographics and operative capacity. Analysis of operative logbook data is intended to identify surgical practice patterns, needs, and deficits by identifying surgical interventions performed, describing anesthesia practice, and assessing in-hospital mortality after surgery. The goals of this review are to optimize use of local human and infrastructural resources in Liberia and to inform the international community regarding the scope of surgical practice required in this setting.

Materials and methods

Study design

This study is a retrospective case series review of operative, surgical ward, and payment logs that are routinely maintained by the tertiary hospital John F. Kennedy Medical Center (JFKMC) for patient care and outcome monitoring.

Study location and staff

This study was conducted at JFKMC in Monrovia, Liberia in 2013. Located in the capital, Monrovia, JFKMC is the national medical center of Liberia and the only tertiary medical institution in the country, and therefore reflects the highest level of care available domestically. The Medical Center is composed of four separate institutions, including John F. Kennedy Memorial Hospital, the Liberian-Japanese Friendship Maternity Hospital, the Tubman National Institute of Medical Arts, and Catherine Mills Rehabilitation Hospital. The researchers participating in this study are involved in a partnership between the Harvard Program in Global Surgery and Social Change and JFKMC, including physicians from both institutions.

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Data collection

The operative, ward, and payment logs from January 1, 2012 to December 31, 2012 were retrospectively reviewed. Data extracted from the operative logs included age, gender, diagnosis, procedure performed, date of surgical procedure, surgeon provider, anesthesia provider, anesthesia type, elective versus emergent procedure, and mortality. Operative log data included surgery performed at JFK's main hospital and excluded obstetric procedures, which were performed at an adjacent facility. Data extracted from the surgical ward logs included date of admission, preoperative diagnosis, date of surgical procedure, procedure performed, length of stay, and mortality. The surgical ward log included patients admitted with surgical diagnoses regardless of whether they received an operation during their hospitalization. Deaths that occurred in patients who had received an operation were considered postoperative mortality if death occurred within 30 days. Data extracted from the payment logs included whether payment was received, amount paid, and self-pay versus insurance. In the cases where handwritten data was difficult to interpret, data was extrapolated through medical record numbers cross-reference and/or consensus was researched through consultation between researchers.

Data storage

All data were extracted through digital photographs of original logs, as Internet access is limited onsite. Photographs were stored on password-protected, hospitalencrypted laptops. Data were then entered into RedCapTM, the firewall-protected Harvard Catalyst supported data management and analysis platform.

Data analysis

Descriptive statistics, including demographics of the patient and medical provider population, frequency of procedures, and mortality rates, were generated in RedCapTM. Missing or incomplete data resulted in denominator adjustments, all of which are presented. Patients under the age of 18 were considered pediatric.

Ethical considerations

Internal Review Board (IRB) approval was obtained through both the Harvard Program in Global Surgery and Social Change at Boston Children's Hospital and JFKMC. Study staff met respective country and university guidelines for human subject training to conduct research were provided. No official follow-up protocol was followed, although informal follow-up took place between

researchers and local surgeons. Continuing review and updates on preliminary data findings and analysis were provided to both institutions.

Results

Patient demographic information is presented in Table 1. Of 1,036 cases performed in 2012, only 992 had complete information with both gender and age. The age of patients ranged from days to 98 years, with a median value of 36 years. There were 749 (75.5 %) adult and 243 (24.5 %) pediatric patients. Male patients numbered 688 (69.5 %).

The breakdown of adult surgical cases reveals 452 (45.1 %) general surgery operations, 192 (18.5 %) orthopedic operations, and 180 (17.4 %) ophthalmic operations. Other significant case volume included urologic 53 (5.1 %), ENT 36 (3.5 %), neurosurgical 31 (3.0 %), vascular 24 (2.3 %), and plastic 14 (1.4 %) surgical procedures. In the 826 cases where such information was recorded, 169 (20.5 %) involved some form of trauma. Of the neurosurgical cases, 32 (97 %) took place within the pediatric population for hydrocephalus. All pediatric neurosurgical cases were temporizing CSF drainage procedures without shunt placement, comprising 9 % of the overall pediatric surgical case volume. Nearly a quarter of cases were performed emergently (22.7 %). Of the 235 emergent cases, 170 (72.3 %) were performed for general surgery emergencies. Emergencies comprised 23 % of operations on adults and 30 % of operations on children. Further details about operative case distribution are presented in Tables 2 and 3.

Operations were performed by 24 different doctors listed as primary surgeons. Table 4 shows the breakdown of 1,036 cases by primary surgeon, which included 6 JFK consultant surgeons (including one orthopedic and two ophthalmic), 4 JFK medical officers, and 14 visiting international surgeons. All six JFK consultant surgeons and five other surgeons performed over 20 operations each. Ten surgeons performed fewer than 10 operations each.

Table 1 Patient demographics for all procedures at JFK Medical Center, 2012

Adults (n = 749)

Children (n = 243) (%)

Overall (n = 992*) (%)

Gender

Male 511 71.0 % 177 29.0 688 69.5

Female 238 79.1

66 20.9 304 30.5

Overall* 749 75.5 % 243 24.5 992 100

* Includes only procedures for patients with documented age and gender. Of 1,036 records, only 992 were complete with both gender and age information

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Anesthesia was administered by 17 different providers. Of those, five represented surgeons providing their own local anesthesia. All other anesthetists listed were nonphysician personnel. Of 1,015 cases where such information was provided, anesthesia type was almost equally split between general anesthesia, used in 374 cases (36.8 %), and spinal anesthesia, used in 344 cases (33.9 %). Local anesthesia was administered as the sole anesthetic in 214 cases (21 %). Of note, total intravenous anesthesia (TIVA) was used in 67 surgical cases (7 %).

Postoperative status was recorded in 689 cases, and intheater mortality revealed two intraoperative deaths, or a 0.3 % intraoperative mortality rate. Of 584 patients entered into the surgical ward log, there were 43 deaths, representing a ward mortality rate of 7.4 %. Surgical diagnoses associated with ward deaths included 19 abdominal emergencies (44 %), 6 burns (14 %), and 5 head/neck emergencies (12 %). Ward log data were insufficient to distinguish which patients were postoperative versus

waiting for an operation versus simply admitted with a surgical diagnosis. (See Table 5).

According to payment logbooks, procedure charge to patients varied from US$27 for herniorrhaphy to US$255 for open prostatectomy. Median cost to patient was US$60, with a range of US$7?255. Most patients (60 %) paid their own costs out of pocket, though 35 % of patients received free care either due to their emergency presentation or age \5 years. Another 4 % had their costs paid for with health insurance or state funding agencies.

Table 4 Primary surgeon

JFK consultant surgeon (6) JFK medical officer (4) Visiting surgeon (14) None listed Total

546 (52.7 %) 338 (32.6 %) 134 (12.9 %) 18 (1.7 %) 1,036

Table 2 Surgical care delivery at JFK Medical Center during 1 year (n = 1,036)

Adults

Children Total

(C18 years) (\18 years)

n% n % n%

General surgery Orthopedics Ophthalmology Urology ENT Neurosurgery Vascular surgery Plastic and reconstructive

surgery Gynecology Other/unknown Heme/Lymph

323 71.5 129 28.5 452 45.1

149 77.6 43 22.4 192 18.5

163 90.6 17 9.4 180 17.4

46 86.8 7 13.2 53 5.1

29 80.6 7 19.4 36 3.5

1 3.2 30 96.8 31 3.0

24 100

0 0 24 2.3

8 57.1 6 42.9 14 1.4

3 100 1 100 2 100

00 00 00

3 0.3 1 0.1 2 0.2

Table 5 Top causes of surgical ward mortality (out of 584 patients entered into the surgical ward log)

Cause

# Deaths

Abdominal emergencies

19

Acute abdomen

10

Bowel perforation

6

Hernia

1

Abdominal mass

1

Ingestion

1

Burns

6

Head and neck emergencies

5

Orthopedic emergencies

2

Urologic emergencies

2

Infection

2

Diabetic causes

1

Breast cancer

1

Unknown

5

Total

43

Table 3 Breakdown of cases by emergent versus elective (n = 1,036)

Elective

Emergent

General surgery ENT Orthopedic surgery Urology Neurosurgery Vascular surgery Other Total

289 24 171 50 29 17 198 778 (75.1 %)

37.10 % 3.10 %

22.00 % 6.40 % 3.70 % 2.20 %

25.40 %

170 12 33 5 3 6 6 235 (22.7 %)

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72.30 % 5.10 %

14.00 % 2.10 % 1.30 % 2.60 % 2.60 %

Not recorded

8 3 1 1 1 1 8 23 (2.2 %)

34.80 % 13.00 % 4.30 % 4.30 % 4.30 % 4.30 % 34.80 %

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