TY - JOUR
T1 - Access to and quality of elective care
T2 - a prospective cohort study using hernia surgery as a tracer condition in 83 countries
AU - Dönmez, A. Eylül
AU - Goswami, Aakansha Giri
AU - Raheja, Aashna
AU - Bhadani, Aayush
AU - El Kady, Abd Elrahman Safwat
AU - Alniemi, Abdalaziz
AU - Awad, Abdalkarim
AU - Aladl, Abdalla
AU - Younis, Abdalla
AU - Alwali, Abdallah
AU - Khalil, Abdallah
AU - Mansour, Abdallah
AU - Elkhouly, Abdallah Mohamed
AU - Rashad Temerik, Abdallah
AU - Hasan, Abdallatef
AU - Chied, Abdelhafid
AU - Abdraba, Abdelhamid
AU - Hrora, Abdelmalek
AU - Abdelshafi, Abdelrahman
AU - Alwali, Abdelrahman
AU - Maraqa, Abdelrahman
AU - Ghaffar, Abdul
AU - Chekfa, Abdul Jabar
AU - Al Balushi, Abdul Majeed
AU - Quddus, Abdul
AU - Hammadieh, Abdul Rahman
AU - Muntaka, Abdul Jalilu Mohammed
AU - Asekun, Abdulazeez
AU - Alshahrani, Abdulaziz
AU - Jowharji, Abdulaziz
AU - Alshukre, Abdulbaset
AU - Khair Etareig, Abdulhafid
AU - Abubakar Abdulkarim, Abdulhafiz
AU - Ashiru, Abdulhafiz
AU - Alailesh, Abdulhamid
AU - Al-Mallah, Abdullah
AU - Baydoun, Abdullah
AU - Chaudhry, Abdullah
AU - Askin, Abdullah Emre
AU - Almutairi, Abdulmjeed
AU - Belkhair, Abdulmunem
AU - Abdllah, Abdulrahman
AU - Alhammali, Abdulrahman
AU - Basalim, Abdulrahman
AU - Abouelnagah, Abdulrahman Galal Mohamed Mostafa
AU - Ghazal, Abdulrahman
AU - Mohammed, Abdulrahman
AU - Nikolaou, Angelos I.
AU - Pellino, Gianluca
AU - Martin Fernandez, Jose
N1 - Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
PY - 2024/7
Y1 - 2024/7
N2 - Background: Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. Methods: This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. Findings: 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72–2·46) and bowel resection (1·85, 1·31–2·63), and less common after day-case surgery (0·39, 0·34–0·44). Interpretation: This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. Funding: NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).
AB - Background: Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. Methods: This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. Findings: 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72–2·46) and bowel resection (1·85, 1·31–2·63), and less common after day-case surgery (0·39, 0·34–0·44). Interpretation: This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. Funding: NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).
KW - Humans
KW - Prospective Studies
KW - Elective Surgical Procedures/statistics & numerical data
KW - Female
KW - Male
KW - Middle Aged
KW - Adult
KW - Quality of Health Care/statistics & numerical data
KW - Health Services Accessibility/statistics & numerical data
KW - Herniorrhaphy/statistics & numerical data
KW - Aged
KW - Hernia, Inguinal/surgery
KW - Adolescent
KW - Young Adult
KW - Global Health
KW - Postoperative Complications/epidemiology
KW - Child
UR - http://www.scopus.com/inward/record.url?scp=85195427180&partnerID=8YFLogxK
U2 - 10.1016/S2214-109X(24)00142-6
DO - 10.1016/S2214-109X(24)00142-6
M3 - Article
C2 - 38797188
AN - SCOPUS:85195427180
SN - 2214-109X
VL - 12
SP - e1094-e1103
JO - The Lancet Global Health
JF - The Lancet Global Health
IS - 7
ER -