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Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries
The Lancet ( IF 168.9 ) Pub Date : 2022-10-31 , DOI: 10.1016/s0140-6736(22)01846-3
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Background

The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs.

Methods

First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score.

Findings

In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1–84·9), which varied between HIC (88·5 [89·0–88·0]), MIC (81·8 [82·5–81·1]), and LIC (66·8 [64·9–68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0–4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1–5·5]; p<0·0001), MIC (2·8 [2·0–3·7]; p<0·0001), and LIC (3·8 [1·3–6·7%]; p<0·0001) settings.

Interpretation

The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Funding

National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic.



中文翻译:

择期手术系统强化:119 个国家 1632 家医院手术准备指数的开发、测量和验证

背景

2015 年柳叶刀全球外科委员会将手术和麻醉确定为整体医疗保健系统不可或缺的组成部分。然而,COVID-19 暴露了世界各地计划的外科服务的脆弱性,这在大流行恢复计划中也被忽视了。本研究旨在开发和验证一种新指数,以支持加强当地择期手术系统并解决日益增多的积压问题。

方法

首先,我们通过四阶段共识过程进行了国际咨询,以制定用于医院级评估的多领域指数(手术准备指数;SPI)。其次,我们测量了高收入国家 (HIC)、中等收入国家 (MIC) 和低收入国家 (LIC) 的全球医院网络的手术准备情况,以探索 SPI 在国家、国家以下和地区的分布情况。医院水平。最后,以 COVID-19 作为外部系统冲击的示例,我们将医院的 SPI 与其计划的手术体积比(SVR;即入院前决定手术的手术)进行了比较,计算为在 2021 年 6 月 6 日至 8 月 5 日的 1 个月评估期内观察到的手术量,与基于 2019 年同期医院管理数据(即大流行前基线)的预期手术量相比。使用线性混合效应回归模型来确定增加 SPI 分数的效果。

发现

在第一阶段,从 103 个候选指标的长名单中,23 个被 69 名临床医生(23 [33%] 女性;46 [67%] 男性;41 名来自高收入国家,22 名来自中等收入国家,和 6 个来自低收入国家)来自 32 个国家。多领域 SPI 包括 11 个设施和消耗品指标,两个人员配置指标,两个优先级指标,八个系统指标。医院的得分从 23 分(准备最少)到 115 分(准备最多)。在第二阶段,来自 119 个国家的 4714 名临床医生对 1632 家医院的手术准备情况进行了评估。1632 家医院中有 745 家 (45·6%) 位于中等收入国家或低收入国家。平均 SPI 得分为 84·5 (95% CI 84·1–84·9),在 HIC (88·5 [89·0–88·0])、MIC (81·8 [82·5– 81·1]) 和 LIC (66·8 [64·9–68·7]) 设置。在第三阶段,1217 (74·6%) 家医院在 COVID-19 大流行期间没有保持预期的 SVR,其中 625 (51·4%) 来自 HIC,538 (44·2%) 来自 MIC,54 (4·4) %) 来自 LIC 设置。在混合效应模型中,SPI 增加 10 点对应于 SVR 增加 3·6%(95% CI 3·0–4·1;p<0·0001)。这在 HIC (4·8% [4·1–5·5]; p<0·0001)、MIC (2·8 [2·0–3·7]; p<0·0001) 和LIC (3·8 [1·3–6·7%]; p<0·0001) 设置。

解释

SPI 包含 23 个指标,这些指标在全球范围内适用,与不同的系统压力源相关,在地方层面有所不同,并且可由一线团队收集。在 COVID-19 的案例研究中,较高的 SPI 与增加的计划手术量比率相关,与国家收入状况、COVID-19 负担和医院类型无关。医院应每年对其手术准备情况进行自我评估,以确定可以改进的领域,在当地手术系统中建立弹性,并提高解决择期手术积压的能力。

资金

美国国立卫生研究院 (NIHR) 全球外科全球健康研究组、NIHR 学院、大不列颠及爱尔兰结肠直肠协会、英国肠道研究协会、英国肿瘤外科协会、英国妇科癌症协会和美敦力。

更新日期:2022-11-04
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