Person: Shrime, Mark
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Shrime
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Shrime, Mark
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Publication Evaluation of a countrywide implementation of the world health organisation surgical safety checklist in Madagascar(Public Library of Science, 2018) White, Michelle C.; Baxter, Linden S.; Close, Kristin L.; Ravelojaona, Vaonandianina A.; Rakotoarison, Hasiniaina N.; Bruno, Emily; Herbert, Alison; Andean, Vanessa; Callahan, James; Andriamanjato, Hery H.; Shrime, MarkBackground: The 2009 World Health Organisation (WHO) surgical safety checklist significantly reduces surgical mortality and morbidity (up to 47%). Yet in 2016, only 25% of East African anesthetists regularly use the checklist. Nationwide implementation of the checklist is reported in high-income countries, but in low- and middle-income countries (LMICs) reports of successful implementations are sparse, limited to single institutions and require intensive support. Since checklist use leads to the biggest improvements in outcomes in LMICs, methods of wide-scale implementation are needed. We hypothesized that, using a three-day course, successful wide-scale implementation of the checklist could be achieved, as measured by at least 50% compliance with six basic safety processes at three to four months. We also aimed to determine predictors for checklist utilization. Materials and methods Using a blended educational implementation strategy based on prior pilot studies we designed a three-day dynamic educational course to facilitate widespread implementation of the WHO checklist. The course utilized lectures, film, small group breakouts, participant feedback and simulation to teach the knowledge, skills and behavior changes needed to implement the checklist. In collaboration with the Ministry of Health and local hospital leadership, the course was delivered to 427 multi-disciplinary staff at 21 hospitals located in 19 of 22 regions of Madagascar between September 2015 and March 2016. We evaluated implementation at three to four months using questionnaires (with a 5-point Likert scale) and focus groups. Multivariate linear regression was used to test predictors of checklist utilization. Results: At three to four months, 65% of respondents reported always using the checklist, with another 13% using it in part. Participant’s years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with counting instruments (p< 0.05), but not with verifying: patient identity, difficult intubation risk, risk of blood loss, prophylactic antibiotic administration, or counting needles and sponges. Conclusion: Use of a multi-disciplinary three-day course for checklist implementation resulted in 78% of participants using the checklist, at three months; and an increase in counting surgical instruments. Successful checklist implementation was not predicted by participant length of medical service, hospital size or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.Publication You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda(Public Library of Science, 2018) Albutt, Katherine; Yorlets, Rachel R.; Punchak, Maria; Kayima, Peter; Namanya, Didacus B.; Anderson, Geoffrey A; Shrime, MarkBackground: Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception. Methods: From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis. Results: The Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need. Conclusion: Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda’s surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.Publication Health-system-adapted data envelopment analysis for decision-making in universal health coverage(World Health Organization, 2018) Shrime, Mark; Mukhopadhyay, Swagoto; Alkire, BlakeAbstract Objective: To develop and test a method that allows an objective assessment of the value of any health policy in multiple domains. Methods: We developed a method to assist decision-makers with constrained resources and insufficient knowledge about a society’s preferences to choose between policies with unequal, and at times opposing, effects on multiple outcomes. Our method extends standard data envelopment analysis to address the realities of health policy, such as multiple and adverse outcomes and a lack of information about the population’s preferences over those outcomes. We made four modifications to the standard analysis: (i) treating the policy itself as the object of analysis, (ii) allowing the method to produce a rank-ordering of policies; (iii) allowing any outcome to serve as both an output and input; and (iv) allowing variable return to scale. We tested the method against three previously published analyses of health policies in low-income settings. Results: When applied to previous analyses, our new method performed better than traditional cost–effectiveness analysis and standard data envelopment analysis. The adapted analysis could identify the most efficient policy interventions from among any set of evaluated policies and was able to provide a rank ordering of all interventions. Conclusion: Health-system-adapted data envelopment analysis allows any quantifiable attribute or determinant of health to be included in a calculation. It is easy to perform and, in the absence of evidence about a society’s preferences among multiple policy outcomes, can provide a comprehensive method for health-policy decision-making in the era of sustainable development.Publication Out-of-Pocket Payment for Surgery in Uganda: The Rate of Impoverishing and Catastrophic Expenditure at a Government Hospital(Public Library of Science (PLoS), 2017-10-31) Anderson, Geoffrey; Ilcisin, Lenka; Kayima, Peter; Abesiga, Lenard; Portal Benitez, Noralis; Ngonzi, Joseph; Ronald, Mayanja; Shrime, MarkBackground and objectives It is Ugandan governmental policy that all surgical care delivered at government hospitals in Uganda is to be provided to patients free of charge. In practice, however, frequent stock-outs and broken equipment require patients to pay for large portions of their care out of their own pocket. The purpose of this study was to determine the financial impact on patients who undergo surgery at a government hospital in Uganda. Methods Every surgical patient discharged from a surgical ward at a large regional referral hospital in rural southwestern Uganda over a 3-week period in April 2016 was asked to participate. Patients who agreed were surveyed to determine their baseline level of poverty and to assess the financial impact of the hospitalization. Rates of impoverishment and catastrophic expenditure were then calculated. An “impoverishing expense” is defined as one that pushes a household below published poverty thresholds. A “catastrophic expense” was incurred if the patient spent more than 10% of their average annual expenditures. Results We interviewed 295 out of a possible 320 patients during the study period. 46% (CI 40–52%) of our patients met the World Bank’s definition of extreme poverty (USD 1.90/person/day). After receiving surgical care an additional 10 patients faced extreme poverty, and 5 patients were newly impoverished by the World Bank’s definition (USD 3.10/person/day). 31% of patients faced a catastrophic expenditure of more than 10% of their estimated total yearly expenses. 53% of the households in our study had to borrow money to pay for care, 21% had to sell possessions, and 17% lost a job as a result of the patient’s hospitalization. Only 5% of our patients received some form of charity. Conclusions and relevance Despite the government’s policy to provide “free care,” undergoing an operation at a government hospital in Uganda can result in a severe economic burden to patients and their families. Alternative financing schemes to provide financial protection are critically needed.Publication Funding allocation to surgery in low and middle-income countries: a retrospective analysis of contributions from the USA(BMJ Publishing Group, 2015) Gutnik, Lily; Dieleman, Joseph; Dare, Anna J; Ramos, Margarita S; Riviello, Robert; Meara, John; Yamey, Gavin; Shrime, MarkObjective: The funds available for global surgical delivery, capacity building and research are unknown and presumed to be low. Meanwhile, conditions amenable to surgery are estimated to account for nearly 30% of the global burden of disease. We describe funds given to these efforts from the USA, the world's largest donor nation. Design: Retrospective database review. US Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center and registered US charitable organisations were searched for financial data on any organisation giving exclusively to surgical care in low and middle income countries (LMICs). For USAID, NIH and Foundation Center all available data for all years were included. The five recent years of financial data per charitable organisation were included. All nominal dollars were adjusted for inflation by converting to 2014 US dollars. Setting: USA. Participants: USAID, NIH, Foundation Center, Charitable Organisations. Primary and secondary outcome measures Cumulative funds appropriated to global surgery. Results: 22 NIH funded projects (totalling $31.3 million) were identified, primarily related to injury and trauma. Six relevant USAID projects were identified—all obstetric fistula care totalling $438 million. A total of $105 million was given to universities and charitable organisations by US foundations for 12 different surgical specialties. 95 US charitable organisations representing 14 specialties totalled revenue of $2.67 billion and expenditure of $2.5 billion. Conclusions and relevance Current funding flows to surgical care in LMICs are poorly understood. US funding predominantly comes from private charitable organisations, is often narrowly focused and does not always reflect local needs or support capacity building. Improving surgical care, and embedding it within national health systems in LMICs, will likely require greater financial investment. Tracking funds targeting surgery helps to quantify and clarify current investments and funding gaps, ensures resources materialise from promises and promotes transparency within global health financing.Publication Charitable Platforms in Global Surgery: A Systematic Review of their Effectiveness, Cost-Effectiveness, Sustainability, and Role Training(Springer US, 2014) Shrime, Mark; Sleemi, Ambereen; Ravilla, Thulasiraj D.Objective: This study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed. Methods: A systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included. Results: Surgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited. Conclusions: Because the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.Publication Health, Poverty, and Surgery in the US and Around the World(2015-05-07) Shrime, Mark; Salomon, Joshua A.; Weinstein, Milton C.; Cohen, Jessica L.Health improvement and financial ruin are often inexorably linked. Nearly 30% of the global burden of disease is surgical [1], and over 30 million annual cases of financial ruin are attributable to accessing surgery [2]. In resource-poor countries, where 70% of all healthcare spending is out-of-pocket [3], catastrophic expenditure for medical care is extremely common [4-6]. In the United States, even those with health insurance face financial catastrophe: nearly two-thirds of bankruptcy is medical, and fully 75% of medically bankrupt individuals were insured at the time of their catastrophic medical bill [7]. Financial ruin is most pronounced among the global poor, among patients with life-threatening conditions, and, increasingly, among the elderly [2, 8-10]. As a result, although the World Health Organization [11], the United Nations [12], and the World Bank [13] have all called for financial risk protection in healthcare, medical impoverishment persists, sometimes forcing individuals into a choice between physical health and financial health. Some choose the former and are willing to incur financial ruin to get care: they sell their assets, borrow, decrease consumption, or, catastrophically, face impoverishment in the pursuit of health [4-6, 14-28]. Others respond to a risk of poverty by not complying with physician recommendations, by seeking alternate providers, or by forgoing care altogether [29-34]. In patients with serious conditions, these choices can be lethal [32, 35]. In the US, national health policy has consistently focused on decreasing out-of-pocket medical costs as a mechanism for health improvement—and not always successfully: two years after the initiation of the Oregon Medicaid expansion, for example, health outcomes had not changed dramatically [36]. Globally, policies to improve access to surgical care either mirror this demand-side focus on out-of-pocket cost reduction or address the supply-side dearth of surgical providers through policies such as task shifting [37-39]. The goal of this dissertation, then, is to examine the effects of these policies and platforms for global surgical delivery on health, on impoverishment, and on inequity, and to determine how individuals value tradeoffs among these outcomes. Chapter 1 investigates the role of government policies for increasing surgical access in public hospitals. This extended cost-effectiveness analysis utilizes publicly available data from Ethiopia to evaluate the health, financial, and equity impacts of nine essential surgical procedures on rural patients. Five policies addressing supply- and demand-side barriers to surgical access are examined: 1) universal public financing (UPF), 2) task shifting (TS), 3) UPF with the addition of vouchers (V) to address the nonmedical costs of care, 4) UPF + TS, and 5) UPF + TS + V. I find that, while all policies are likely to improve health, a tradeoff exists: TS averts deaths most dramatically, but does so at the cost of a large increase in financial catastrophe. UPF is more financially risk protective, but has a much smaller impact on health. Only policies that include vouchers for the non-medical costs of accessing care are found to provide an equitable distribution of benefits; the remaining policies continue to impoverish the poor. Chapter 2 compares surgical delivery by charitable organizations with the governmental policies examined in Chapter 1. Using an agent-based model of cancer care in Uganda, the three common charitable platforms for surgical delivery—two-week “mission trips”, mobile surgical units, and free-standing specialty hospitals—are evaluated against combinations of UPF, TS, and V. In addition to health and catastrophic expenditure, two novel metrics are included to 1) incorporate the familial financial impact of a lack of access and 2) formalize the equitable distribution of benefits into a concentration index. I find that mobile surgical delivery platforms by non-governmental organizations can provide health and financial benefits equitably and efficiently and that they perform well when compared to health-system-strengthening policies. Other charitable platforms are equitable but are not efficient when compared with government policies. The results of this analysis also confirm the finding from Chapter 1 that equitable delivery platforms must address the non-medical costs associated with getting to care. Chapter 3 tests the hypothesis that, in the setting of lethal disease, individuals value cure at all costs. A discrete choice experiment is undertaken in a nationally representative US sample of 2359 individuals. Respondents are asked to choose between two hypothetical treatments for a lethal disease, differing only in their chance of cure and their risk of bankruptcy. I find that the resulting indifference curve is multiplicative, and that Americans are less willing to shoulder high risks of bankruptcy to increase their probability of cure than has been previously assumed. Subgroup and sensitivity analyses do not alter this relationship, although, in some groups, the difference in preference between bankruptcy protection and cure is not statistically significant. In no subgroup, however, do I find evidence a significant preference for cure at any cost in the American population.Publication Economic valuation of the impact of a large surgical charity using the value of lost welfare approach(BMJ Publishing Group, 2016) Corlew, Daniel Scott; Alkire, Blake; Poenaru, Dan; Meara, John G; Shrime, MarkBackground: The assessment of the economic burden of surgical disease is integral to determining allocation of resources for health globally. We estimate the economic gain realised over an 11-year period resulting from a vertical surgical programme addressing cleft lip (CL) and cleft palate (CP). Methods: The database from a large non-governmental organisation (Smile Train) over an 11-year period was analysed. Incidence-based disability-adjusted life years (DALYs) averted through the programme were calculated, discounted 3%, using disability weights from the Global Burden of Disease (GBD) study and an effectiveness factor for each surgical intervention. The effectiveness factor allowed for the lack of 100% resolution of the disability from the operation. We used the value of lost welfare approach, based on the concept of the value of a statistical life (VSL), to assess the economic gain associated with each operation. Using income elasticities (IEs) tailored to the income level of each country, a country-specific VSL was calculated and the VSL-year (VSLY) was determined. The VSLY is the economic value of a DALY, and the DALYs averted were converted to economic gain per patient and aggregated to give a total value and an average per patient. Sensitivity analyses were performed based on the variations of IE applied for each country. Results: Each CL operation averted 2.2 DALYs on average and each CP operation 3.3. Total averted DALYs were 1 325 678 (CP 686 577 and CL 639 102). The economic benefit from the programme was between US$7.9 and US$20.7 billion. Per patient, the average benefit was between US$16 133 and US$42 351. Expense per DALY averted was estimated to be $149. Conclusions: Addressing basic surgical needs in developing countries provides a massive economic boost through improved health. Expansion of surgical capacity in the developing world is of significant economic and health value and should be a priority in global health efforts.Publication Global Surgery 2030: a roadmap for high income country actors(BMJ Publishing Group, 2016) Ng-Kamstra, Joshua S; Greenberg, Sarah L M; Abdullah, Fizan; Amado, Vanda; Anderson, Geoffrey A; Cossa, Matchecane; Costas-Chavarri, Ainhoa; Davies, Justine; Debas, Haile T; Dyer, George; Erdene, Sarnai; Farmer, Paul; Gaumnitz, Amber; Hagander, Lars; Haider, Adil; Leather, Andrew J M; Lin, Yihan; Marten, Robert; Marvin, Jeffrey T; McClain, Craig; Meara, John; Meheš, Mira; Mock, Charles; Mukhopadhyay, Swagoto; Orgoi, Sergelen; Prestero, Timothy; Price, Raymond R; Raykar, Nakul; Riesel, Johanna; Riviello, Robert; Rudy, Stephen M; Saluja, Saurabh; Sullivan, Richard; Tarpley, John L; Taylor, Robert H; Telemaque, Louis-Franck; Toma, Gabriel; Varghese, Asha; Walker, Melanie; Yamey, Gavin; Shrime, MarkThe Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.Publication Global economic consequences of selected surgical diseases: a modelling study(Elsevier BV, 2015) Alkire, Blake; Shrime, Mark; Dare, Anna J; Vincent, Jeffrey R; Meara, JohnBackground The surgical burden of disease is substantial, but little is known about the associated economic consequences. We estimate the global macroeconomic impact of the surgical burden of disease due to injury, neoplasm, digestive diseases, and maternal and neonatal disorders from two distinct economic perspectives. Methods The value of lost output (VLO) approach projects annual market economy losses during 2015-2030 by relating disease mortality to changes in the labor force and gross domestic product (GDP). The value of lost welfare (VLW) approach uses a broader measure of nonmarket losses based on a concept termed the value of a statistical life and estimates the present value of long-run welfare losses resulting from mortality and short-run welfare losses resulting from morbidity incurred during 2010. Sensitivity analyses are performed for both approaches. Findings During 2015-2030, the VLO approach projects surgical conditions to result in losses of 1·25%of potential GDP, or $20·7 trillion (2010 USD, PPP). When expressed as a proportion of potential GDP, annual GDP losses are greatest in low- and middle-income countries, with up to a 2·5% loss in output by 2030. When nonmarket losses are assessed (VLW), the present value of economic welfare losses is estimated to be equivalent to 17% of 2010 GDP, or $14.5 trillion (2010 USD, PPP). Neoplasm and injury account for greater than 95% of total economic losses in each approach, but maternal, digestive, and neonatal disorders, which represent only 4% of losses in high-income countries in the VLW approach, contribute to 26% of losses in low-income countries. Interpretation The macroeconomic impact of surgical disease is substantial and inequitably distributed. When paired with the growing number of favorable cost-effectiveness analyses of surgical interventions in low- and middle-income countries, our results suggest that building surgical capacity should be a global health priority.