Surgical Care Delivered by International Organizations: An Initial Questionnaire

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Surgical Care Delivered by International
OrganizationsAn Initial Questionnaire

• K A Kelly McQueen, MD, MPH
• Kathleen Casey, MD, FACS

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Follow-up to BoSD WG 2008 Meeting

• Delivery Breakout Group
• Premise International organizations (IOs)
  contribute to decreasing unmet surgical need
• Little data describing magnitude of contributions
• Many IOs collect data for internal review,
  planning and logistics

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Basis for Survey

• We believe surgery plays an integral role in
  global public health
• Data lacking on unmet surgical needs and impact
• Humanitarian contributions in the global surgical
  realm understudied
• While anecdotal and single entity reports
  relatively plentiful more comprehensive analysis
  across agencies is rare

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NGO Survey

• Basic assessment of data collection practices
  with regard to scope, scale and quality measures
  educational programming and interaction with
  local health systems
• Stated Goal evaluate the role NGOs and relief
  organizations play in delivery of surgical care
  and services
• To inform more in-depth study in future

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Methodology

• Survey sent to 100 organizations involved in
  provision of humanitarian surgical care -
  identified by Operation Giving Back (ACS),
  Society for Pediatric Anesthesia (ASA), and the
  US State Department Registry for PVOs
• E-mail based survey
• Responses collected between Oct Dec 2008
• 12 questions (1 page)
• Check boxes and open text

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Questionnaire

• Organization name (optional)
• Regions of operation
• Provision of Surgery (yes/no)
• Type of Surgery
• Tracking
• Annual surgical volume
• Infection Rate (yes/no)
• Mortality Rate (yes/no)
• Emergencies (percentage of total cases)
• Number and type of providers
• Surgical Follow up (degree)
• Provision of Education and Training
• Interaction with Local Health Systems

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Survey Cohort

• Wide range of size and organizational scope
  represented in this cohort
• Based upon
• surgical cases / year
• countries where care is delivered
• Spectrum of care delivered

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Results

• 46 response rate (46/99)
• Total reported annual surgical volume 223,425
  cases
• Most were organizations reporting lt500 cases
  annually, and many provided specialized surgical
  care

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Volume of Surgery Delivered - Caveats

• Surgical volumes in several cases are only
  estimates or in some cases unknown
• Depends upon who is asked parent organization,
  site of care delivery, etc.
• Future queries might consider identifying role of
  person providing data and where they are based

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Where are Surgical Services Provided?
N52
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WHO (2006) World Health Report working together
for health
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Geographic Scope of NGOs
Number of regions where surgery is provided
N 54
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Nature of Surgical Services Provided
N52
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Providers used other than surgeons
anesthesiologists
N53
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Number of Procedures
Most organizations were able to report or
estimate the annual volume of surgical care
delivered. Some did not have centralized access
to such data may have been at individual
hospitals or a central headquarters.
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Types of Procedures
For numbers and types of surgery, future study
may involve basic definitions of surgical
procedures.
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Mortality
Definitions may play a role with these measures
immediate post-op mortality versus late, impact
of length of follow-up, etc. Factors that may
influence decision not to track post op mortality
rates . . .
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General Complications
Not specified further
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Infection

• Least frequently measured.
• Possible considerations When infections manifest
  . . .
• Patients lost to f/u?
• Teams not present long enough to see infection?
• Lack of feedback loop with post-op care provided
  by local provider partners?

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Does your organization provide education and/or
training?
N 54
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Interaction with Local Health Systems
N53
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Observations on quality measures in Humanitarian
Surgery

• IOs knowledgeable and committed
• No defined standards, measures, reporting
• Implementation in resource poor settings
• Issues of follow up in rural and poor areas
• It remains to be seen what to measure, how to
  measure, how to report, who to report to
  (internally, host country, a US group,
  stakeholders, all of above?)

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Considerations for further study

• Methodology of data collection -
• Who, What, How, How often?
• Deterrents to data collection?
• Impact of setting (rural, urban, etc)?
• Provide definitions of surgical case?

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Considerations for further study

• Whether the following correlate with provision of
  follow up care and related data collection
• Size of organization
• Budget of organization
• Age/Maturity of organization
• Schedule (time and frequency in country)
• Integration with local systems
• Feedback loops with local systems/partners

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Potential Selection Bias

• 77 of responding organizations are included
  within the Operation Giving Back (ACS) database
  of surgical NGOs

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Comments

• Data documenting the surgical burden of
  disease and existing surgical delivery is needed
  for defining intervention strategies and
  priorities.
• IOs play an important role in surgical delivery
  in developing countries and are a ready resource
  that might be engaged for data collection on
  unmet surgical need, cost analyses, quality
  measures, and resources needed for scalability
  and sustainability efforts.

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• This study represents a small sample size in
  light of the number of IOs involved in
  international surgical care
• Cohort surveyed includes a nice distribution of
  organization size, broad spectrum of surgical
  care provided, and wide geographic impact
• Serves as a preliminary snapshot

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• Surgical IOs demonstrate interest in
• Quality
• Safety
• Measures
• Reporting
• (despite relative paucity of resources)
• (despite lack of standard definitions and
  reporting mechanisms)

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What is needed?

• Standard definitions
• Standard measures (Quality measures appropriate
  to resource limited settings still not well
  defined)
• Creation of open source resources (free or
  inexpensive) that NGOs can access for reporting
  quality and safety measures
• Communication for sharing ideas / models/
  resources / tools / limitations / frustrations
• Incentives for collecting quality measures
• Support for areas where improvement is desired
  based on benchmarking

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• Thank you

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