Evalua&ng Orthopaedic Access for a Ter&ary Referral Hospital in Sub-‐Saharan Africa
SUMR Scholar: Sharonya Vadaka2u SUMR Mentor: Neil Sheth, MD and
Ajay Premkumar, MD/MPH candidate
Overall Project: Assess Poten&al Benefit of Building an Orthopaedic Center in Tanzania
1. QuanCfy the Burden of Musculoskeletal Disease in Tanzania • PresenCng at TerCary Referral Hospital in N. Tanzania (KCMC)
2. Assess Current Level of Access to Orthopaedic Surgery in N. Tanzania • Helping determine capacity & safety to provide surgery in region’s hospitals • Determining the number of people lacking access to surgical services • Determine the unmet burden of musculoskeletal surgical disease
3. Feasibility of an Orthopaedic Center to address unmet burden • Cost • Direct & indirect benefit of meeCng burden of musculoskeletal surgical disease
Defining the Problem • 35% of people live in developing countries • 3.5% of surgical procedures performed in LMICs • 30% of global disease burden is surgical
The Lancet Commission on Global Surgery, 2015 Spiegel DA, et al., Global IniCaCve for
Emergency and EssenCal Surgical Care: 2011 and beyond, 2013
Impact of Inadequate Surgery in LMICs
• 95% of injury-‐related deaths occur in LMICs • Rate will remain high • Compounded by disproporConate rise in injuries
• Surgery alleviates burden (DALYs) of injuries • Mortality and morbidity
• Mortality 10X higher in LMICs • Lack of proper surgical care
Mock CN, et al. EssenCal surgery: key messages from Disease Control PrioriCes, 3rd ediCon, 2015
How does orthopaedics fit into this?
• Conforms to overall trend and dispariCes
• Musculoskeletal damage frequent in injury vicCms
• Injury rate rising in LMICs, decreasing elsewhere
• Training and equipment severely lacking in LMICs
Mock, C. et.al. The Global Burden of Musculoskeletal Injuries: Challenges and SoluCons, 2008
Lavy, C.B.D. et al. Orthopaedic Training in Developing Countries, 2005
What is being done to address the problem?
• “Blitz” surgeries • Quickly treaCng large number of paCents
• Mission (service and teaching) trips • Over 250 million dollars raised per year • 6,000+ trips per year • Number is rising
All raise ethical dilemmas: -‐ Las9ng Impact vs. Personal Sa9sfac9on -‐ Just because we can operate, should we? -‐ Adequate consent
Kushner A.L, et al. Addressing the millennium development goals from a surgical perspecCve, 2010
Nthumba P.M. et al. “Blitz Surgery”: Redefining Surgical Needs, Training, and PracCce in Sub-‐Saharan Africa, 2010.
Defining capacity, safety, & access to care
• Capacity directly related to safety
• Previous assessment methods are inadequate • # of Surgeons or ORs / populaCon • Resource Inventory, eg. pulse oximeters
• RaCo of procedures : disease prevalence • Tanzania to New Zealand, United States
What is the problem in Tanzania?
• Severe lack of providers • 15 orthopaedic surgeons for 46 million people in Tanzania (1: 3,000,000) • 28,000+ surgeons for 319 million people in United States (1: 11,400) • Unequal concentraCon in rural vs. urban areas • Brain drain
• Increase in Road Traffic Accidents • 40%+ of all injuries presenCng in Tanzanian hospitals • Third leading cause of DALYs by 2020
Spiegel D.A. et al. The burden of musculoskeletal disease in LMICs, 2008. Casey E.R, et al. Analysis of traumaCc injuries presenCng to a referral hospital emergency department in Moshi, Tanzania, 2012.
How do we define orthopaedic access in Tanzania ?
Using four dimensions of surgical access:
4meliness surgical capacity
safety affordability
-‐ The Lancet Commission on Global Surgery
Alkire B.C. et al. Global access to surgical care: a modelling study, 2015
A More Comprehensive Metric for Access• Includes measures to fully quanCfy Safety
• Scoring safety: WHO’s tool • Tool for situaConal analysis to assess emergency and essenCal surgical care (TSAAEESC)
• TSAAEESC scoring method used in Sierra Leone, Liberia, and Solomon Islands
• Four components: infrastructure, human resources, intervenCons, and equipment • Focused on procedures for orthopaedic surgery
World Health OrganizaCon, Tool for SituaConal Analysis to Assess Emergency and EssenCal Surgical Care Kwon et al. Development of a Surgical Capacity Index: OpportuniCes for Assessment and Improvement, 2011.
Needs Assessment Form Infrastructure & Supplies at FaciliCes
New Safety Scoring Method = More Accurate Picture
• Adapts a previously used metric for use in orthopaedic surgery (TSAAEESC) • Will allow us to quanCfy the unmet need in a more comprehensive manner
• Provides way to incorporate various dimensions of safety into access
• Assess feasibility and quanCfy safety benefit of building an orthopaedic center
Next Steps• Score 5 hospitals and develop a weighted safety score for N. Tanzania
• Determine cost of reducing burden of disease and improving safety & access • Orthopedic center in Moshi, Tanzania • Inter and intra-‐insCtuConal collaboraCon led by Penn
• QuanCfy ulCmate benefit of meeCng the currently unmet burden in Tanzania • Increased economic producCvity • ReducCon in disability (DALYs)
Proposal: Orthopaedic Center for
Excellence in Moshi, Tanzania
Acknowledgments
• Neil Sheth, MD • Ajay Premkumar • Joanne Levy, MBA & MCP • Safa Browne • The Leonard Davis InsCtute
Thank you!