INTRODUCTION:Globally, over 4.8 billion people lack access to safe, timely, and affordable surgical care, with the burden falling heaviest on low- and middle-income countries. In Ethiopia, where surgical services are urban-centered and out-of-pocket (OOP) health spending is among the highest globally, financial barriers often deter care-seeking. This study provides the first nationally representative assessment of catastrophic health expenditure (CHE) among surgical patients in Ethiopia to quantify financial risk and inform future equitable health financing reforms. METHOD:This national cross-sectional survey was conducted as part of the Ethio-SOS study, which includes 32 hospitals across Ethiopia. A total of 412 surgical patients were enrolled. Data were collected on direct and indirect costs, sociodemographic characteristics, and surgical indication. CHE was defined as OOP medical expenditure exceeding 10% of annual household expenditure. RESULTS:Of 412 participants (53.6% female, 46.4% male), 103 (25.0%) experienced catastrophic health expenditure (CHE). Key cost drivers included medications (37%), laboratory tests (14%), and surgical fees (14%). Non-medical expenses, such as food, transportation, and caregiver support, accounted for 20% of total spending. Risk factors for CHE included smaller household size (OR = 0.52, p = 0.046), unmarried status (OR = 0.38, p = 0.002), greater distance from the hospital, and trauma-related surgery (OR = 1.95, p = 0.042). Coping mechanisms included borrowing money (16.6%) and selling assets (13.9%). CONCLUSIONS:One in four surgical patients in Ethiopia experiences CHE, with increased vulnerability among unmarried individuals, smaller households, and those undergoing trauma-related procedures. Medication and non-medical costs, such as transportation, remain significant financial burdens. These findings highlight urgent gaps in financial protection and underscore the need for targeted policy reforms, such as improved access to medicine, transportation support, and expanded safety nets, to reduce out-of-pocket surgical costs and promote equitable access to care.

Background:Surgical outcomes research is sparse in low- and middle-income countries (LMICs). This is due to poor funding, lack of human resources, and inadequate infrastructure. However, a growing number of collaborative small collection of large multinational and multicentered studies have been successfully performed. These studies have overcome regulatory and logistical hurdles and have shown that collecting such data in the LMIC setting is possible.underscore the drive and capabilities of LMIC researchers. Methods:A review of the literature using PubMed was performed for multicenter and multinational studies on surgical outcomes in LMICs. Results:All studies collected a diverse array of postoperative outcomes including complications and mortality. Multiple studies performed adjusted analyses to allow for identification of independent risk factors of surgical outcomes. Each study reinforced that outcomes in LMICs are markedly worse than in HICs. Conclusion:These studies showed that outcomes research is feasible and needed in LMICs. In this review we summarize each of these impactful studies and present strengths, weaknesses, commonalities and gaps that remain.

BACKGROUND:A systematic analysis of how essential surgery developed worldwide throughout the COVID-19 pandemic remains absent. This scoping review aims to define essential surgery by comparing definitions between high-income countries and low- and middle-income countries during COVID-19. METHODS:We conducted a scoping review of Ovid, PubMed, Scopus, and Web of Science databases for articles published January 2020 to December 2022 that defined essential surgery during COVID-19. Articles referencing pediatric populations or exclusively elective surgery were excluded. This review was registered with PROSPERO (CRD42024495318). Articles were categorized by country income status, surgical specialty, and methodology. Procedures were classified into 8 surgical systems (neurosurgery, breast/gynecology, etc) and deemed to have strong (≥75%), moderate (50-74%), or limited (<50%) consensus as essential on the basis of how many articles mentioned the procedure. RESULTS:We analyzed 85 articles (61 high-income countries, 24 low- and middle-income countries) from 4,247 screened. Essential surgery comprises procedures needed within 30 days that prevent mortality, are time-sensitive, preserve function, prevent altered prognosis, or have no medical alternatives. Neurosurgery was most represented, with strong consensus for immediate life-threatening conditions needing intervention within 24 hours. Although high-income countries and low- and middle-income countries agreed on procedures addressing immediate threats to life, significant disparities existed in urology, gynecology, and colorectal surgery. CONCLUSION:Our findings highlight the need for resource-stratified, specialty-specific guidelines that can be adapted to different health care contexts, while maintaining the core principles of surgical prioritization. Future frameworks should incorporate timeframes for safe surgical delay, risk of disease progression, resource requirements, and expected outcomes to guide ethical surgical triage.

Postdischarge venous thromboembolism (pdVTE) is a life-threatening complication following resection for pancreatic cancer (PC). While national guidelines recommend extended chemoprophylaxis for all, adherence is low and ranges from 1.5 to 44

BACKGROUND:Perioperative morbidity and mortality remain disproportionately high in low- and middle-income countries (LMICs). Quality improvement (QI) has shown effectiveness in improving health outcomes and patient safety across healthcare systems globally and is often a mandatory part of training in high income countries. However, QI education in LMICs remains decentralized and limited in scope. Aiming to address this gap, we designed and delivered perioperative QI education in three LMIC settings. This study aims to summarize methodology and experiences across the three settings and outline the factors leading to success and challenges experienced to inform future QI education efforts in LMICs. METHODS:We designed and implemented a perioperative QI curriculum that included online didactic content, course assessments, and a two to three day in-person course featuring both didactic and QI project development training. Descriptive statistics were reported for course features and participant pre- and post-course survey results. Qualitative course feedback from participants and administrators is summarized in a narrative format. RESULTS:Five courses were conducted, training a total of 90 participants. Of those who completed pre-course surveys, most participants were nurses (35.5%) or residents (43.6%), and the majority (71.1%) had no prior experience with QI. Self-assessed comfort significantly improved across several domains, including understanding QI concepts, developing aim statements, and designing projects. Qualitatively, participants enjoyed the course's interactive format and recommended future offerings be longer, more frequent, and include expanded content on data analysis and project implementation. Course administrators recommend involving local partners throughout course development, forming structured plans to sustain QI initiatives started as part of the course, and ensuring any pre-course materials use context-specific examples. CONCLUSION:Implementation of a perioperative QI curriculum across three LMIC settings was feasible and associated with significant improvements in participant-reported comfort with core QI skills and knowledge. Success was driven by the inclusion of local faculty, interactive project development, and adaptation of course content to local context. Future efforts should focus on building local QI mentorship capacity, integrating QI education into residency training, and developing contextually appropriate resources to support scalable, sustainable QI training in LMICs.

Background Clinicians use Cancer Antigen 19 − 9 (CA19-9) to assess treatment response and inform clinical decisions for patients with pancreatic ductal adenocarcinoma (PDAC). However, nearly 30% of patients with PDAC do not have an elevated CA19-9. Methods Using electronic health data, an artificial intelligence-based electronic tumor marker (e19-9) was created using common serum laboratory values to predict the expected CA19-9 level. The association between e19-9 and clinical outcomes was then measured in patients with PDAC who did not have an elevated CA19-9. Results The value of e19-9 was informative for predicting both completion of treatment and metastatic progression. Post-treatment e19-9 was independently associated with overall survival. A decline in e19-9 of at least 50% over treatment (AUC 0.79), and a post-treatment e19-9 of < 100 (AUC 0.84), mirror the clinical utility of CA19-9 for predicting the same outcomes. Conclusions The e19-9 correlates with important clinical outcomes among patients that do not have an elevated CA19-9 biomarker and has potential to guide clinical decisions.

Background: The rising burden of cancer significantly influences the global economy and healthcare systems. While local and contextual cancer research is crucial, it is often limited by the availability of funds. In South Asia, with 1.7 million new cancer cases and 1.1 million deaths due to cancer in 2020, understanding cancer research funding trends is pivotal. Methods: We reviewed funded cancer studies conducted between January 1, 2003, and Dec 31, 2022, using ClinicalTrials.gov, International Cancer Research Partnership (ICRP) Database, NIH World RePORT, and WHO International Clinical Trials Registry Platform (ICTRP). We included funded studies related to all cancer types, conducted in South Asian countries, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. Results: We identified 6561 funded cancer studies from South Asia between 2003 and 2022, increasing from 400 studies in 2003-2007 to 3909 studies in 2018-2022. India had the highest number of funded cancer studies, while Afghanistan, Bhutan, and the Maldives had minimal or no funded cancer research output. Interventional studies (67.3%) were the most common study type funded. The most common cancer sites funded were breast (17.8%), lung (9.9%), oropharyngeal (6.2%), and cervical (5.0%) cancers. On the WHO ICTRP, international funding agencies contributed to a majority of studies (57.5%), except in India where local funding agencies (58.2%) funded more studies. Conclusion: This study identified gaps in research funding distribution across cancer types and geographic areas in South Asia. This data can be used to optimize the distribution of cancer research funding in South Asia, fostering equitable advancement in cancer research.

Background: Perioperative data are essential to improve the safety of surgical care. However, surgical outcome research (SOR) from low- and middle-income countries (LMICs) is disproportionately sparse. We aimed to assess practices, barriers, facilitators, and perceptions influencing the collection and use of surgical outcome data (SOD) in LMICs. Methods: An internet-based survey was developed and disseminated to stakeholders involved in the care of surgical patients in LMICs. The Performance of Routine Information Systems Management framework was used to explore the frequency and relative importance of organizational, technical, and behavioral barriers. Associations were determined using χ 2 and ANOVA analyses. Results: Final analysis included 229 surgeons, anesthesia providers, nurses, and administrators from 36 separate LMICs. A total of 58.1% of individuals reported that their institution had experience with collection of SOD and 73% of these reported a positive impact on patient care. Mentorship and research training was available in <50% of respondent’s institutions; however, those who had these were more likely to publish SOD ( P = 0.02). Sixteen barriers met the threshold for significance of which the top 3 were the burden of clinical responsibility, research costs, and accuracy of medical documentation. The most frequently proposed solutions were the availability of an electronic data collection platform (95.3%), dedicated research personnel (93.2%), and access to research training (93.2%). Conclusions: There are several barriers and facilitators to collection of SOD that are common across LMICs. Most of these can be addressed through targeted interventions and are highlighted in this study. We provide a path towards advancing SOR in LMICs.

BACKGROUND:Despite a glaring need and proven efficacy, prospective surgical registries are lacking in low- and middle-income countries. The objective of this study was to design and implement a comprehensive prospective perioperative registry in a low-income country. METHODS:This study was conducted at Hawassa University Comprehensive Specialized Hospital in Hawassa, Ethiopia. Design of the registry occurred from June 2021 to May 2022 and pilot implementation from May 2022 to May 2023. All patients undergoing elective or emergent general surgery were included. Following one year, operability and fidelity of the registry were analyzed by assessing capture rate, incidence of missing data, and accuracy. RESULTS:A total of 67 variables were included in the registry including demographics, preoperative, operative, post-operative, and 30-day data. Of 440 eligible patients, 226 (51.4%) were successfully captured. Overall incidence of missing data and accuracy was 5.4% and 90.2% respectively. Post pilot modifications enhanced capture rate to 70.5% and further optimized data collection processes. CONCLUSION:The establishment of a low-cost electronic prospective perioperative registry in a low-income country represents a significant step forward in enhancing surgical care in under-resourced settings. The initial success of this registry highlights the feasibility of such endeavors when strong partnerships and local context are at the center of implementation. Continuous efforts to refine this registry are ongoing, which will ultimately lead to enhanced surgical quality, research output, and expansion to other sites.

In 2015, the Ethiopian Federal Ministry of Health (FMOH) developed the Saving Lives through Safe Surgery (SaLTS) initiative to improve national surgical care. Previous work led to development and implementation of 15 surgical key performance indicators (KPIs) to standardize surgical data practices. The objective of this project is to investigate current practices of KPI data collection and assess quality to improve data management and strengthen surgical systems. The first portion of the study documented the surgical data collection process including methods, instruments, and effectiveness at 10 hospitals across 2 regions in Ethiopia. Secondly, data for KPIs of focus [1. Surgical Volume, 2. Perioperative Mortality Rate (POMR), 3. Adverse Anesthetic Outcome (AAO), 4. Surgical Site Infection (SSI), and 5. Safe Surgery Checklist (SSC) Utilization] were compared between registries, KPI reporting forms, and the DHIS2 (district health information system) electronic database for a 6-month period (January - June 2022). Quality was assessed based on data completeness and consistency. The data collection process involved hospital staff recording data elements in registries, quality officers calculating KPIs, completing monthly KPI reporting forms, and submitting data into DHIS2 for the national and regional health bureaus. Data quality verifications revealed discrepancies in consistency at all hospitals, ranging from 1-3 indicators. For all hospitals, average monthly surgical volume was 57 cases, POMR was 0.38% (13/3399), inpatient SSI rate was 0.79% (27/3399), AAO rate was 0.15% (5/3399), and mean SSC utilization monthly was 93% (100% median). Half of the hospitals had incomplete data within the registries, ranging from 2-5 indicators. AAO, SSC, and SSI were commonly missing data in registries. Non-standardized KPI reporting forms contributed significantly to the findings. Facilitators to quality data collection included continued use of registries from previous interventions and use of a separate logbook to document specific KPIs. Delayed rollout of these indicators in each region contributed to issues in data quality. Barriers involved variable indicator recording from different personnel, data collection tools that generate false positives (i.e. completeness of SSC defined as paper form filled out prior to patient discharge) or missing data because of reporting time period (i.e. monthly SSI may miss infections outside of one month), inadequate data elements in registries, and lack of standardized monthly KPI reporting forms. As the FMOH introduces new indicators and changes, we recommend continuous and consistent quality checks and data capacity building, including the use of routinely generated health information for quality improvement projects at the department level.

Background: Studies have linked bibliometric indices with the academic level of plastic surgeons, but this relationship has not been explored with residency program directors (PDs). As teachers of the next generation, PDs’ academic performance is an important component of residency program success. We sought to identify distinguishing characteristics of integrated plastic surgery programs, focusing on their PD bibliometric indices. Methods: We identified plastic surgery programs based on 2021 Doximity reputation and research output rankings, respectively, and then divided them into four quartiles (Q1–Q4). PD academic history and bibliometric indices (h-index, the number of publications, and citations) were collected through Doximity profiles and program websites: PubMed, Scopus, Google Scholar, American Society of Plastic Surgeons, and Accreditation Council for Graduate Medical Education. Results: Eighty-four programs were identified. There was a significant positive relationship between h-index, the number of publications, and type of research with reputation ranking ( P < 0.05). After adjusting for years of experience post-training, h-index (OR = 1.24; P < 0.001) and the number of publications (OR = 1.05, P < 0.001) were significantly associated with reputation ranking. There was a statistically significant relationship between PD research fellowship completion and research output ranking ( P < 0.01). After adjusting for years of experience post-training, h-index (OR = 1.05; P = 0.047) and the number of publications (OR = 1.01; P = 0.04) were significantly associated with research output ranking. Conclusion: Higher ranked programs tend to have PDs who have a strong record of scholarly activity, as evidenced by certain bibliometric indices.

Journal of Surgical OncologyVolume 128, Issue 6 p. 943-946 EDITORIAL Teaming with artificial intelligence to support global cancer surgical care Taylor J. Jaraczewski MD, Taylor J. Jaraczewski MD Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorGopika SenthilKumar BS, Gopika SenthilKumar BS Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Department of Physiology and Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorAdhitya Ramamurthi MD, Adhitya Ramamurthi MD Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorKaitlyn Nimmer BA, Kaitlyn Nimmer BA Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorXin Yang PhD, Xin Yang PhD Clinical and Translational Science Institute of Southeast Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorAnai N. Kothari MD, MS, FSSO, Corresponding Author Anai N. Kothari MD, MS, FSSO [email protected] orcid.org/0000-0001-6544-8832 Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Clinical and Translational Science Institute of Southeast Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Correspondence Anai N. Kothari, MD, MS, FSSO, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA. Email: [email protected]Search for more papers by this author Taylor J. Jaraczewski MD, Taylor J. Jaraczewski MD Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorGopika SenthilKumar BS, Gopika SenthilKumar BS Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Department of Physiology and Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorAdhitya Ramamurthi MD, Adhitya Ramamurthi MD Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorKaitlyn Nimmer BA, Kaitlyn Nimmer BA Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorXin Yang PhD, Xin Yang PhD Clinical and Translational Science Institute of Southeast Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USASearch for more papers by this authorAnai N. Kothari MD, MS, FSSO, Corresponding Author Anai N. Kothari MD, MS, FSSO [email protected] orcid.org/0000-0001-6544-8832 Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Clinical and Translational Science Institute of Southeast Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Correspondence Anai N. Kothari, MD, MS, FSSO, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA. Email: [email protected]Search for more papers by this author First published: 11 October 2023 https://doi.org/10.1002/jso.27442Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat REFERENCES 1Kotagal M, Horvath K. Surgical delivery in under-resourced settings: building systems and capacity around the corner and far away. JAMA Surg. 2015; 150: 100-102. 2Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. 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OBJECTIVE:To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery. BACKGROUND:Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19. METHODS:Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models. RESULTS:This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure. CONCLUSIONS:Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status.