What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure

Objectives: To measure the financial burden associated with accessing surgical care in Sierra Leone. Design: A cross-sectional survey conducted with patients at the time of discharge from tertiary level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical, and indirect costs for surgical care, and summary household assets. Missing data were imputed.Setting: The main tertiary level hospital in Freetown, Sierra Leone. Participants: 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards.Outcome measures: Rates of catastrophic expenditure (CE) (a cost > 10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs, and means used to meet these costs were derived. Results: Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10$138 (63%) and US$34 (16$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (6 patients) had health insurance. Conclusion: Obtaining surgical care has substantial economic impacts on households which pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy.

Peer reviewe

What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure

ObjectivesTo measure the financial burden associated with accessing surgical care in Sierra Leone.DesignA cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed.SettingThe main tertiary-level hospital in Freetown, Sierra Leone.Participants335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards.Outcome measuresRates of catastrophic expenditure (a cost &gt;10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived.ResultsOf 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10$138 (63%) and US$34 (16$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance.ConclusionObtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.</jats:sec

Perspectives on technology: All STEPS count – an integrated framework for net zero urological care

Objective: To present a narrative review of evidence to guide the delivery of high‐quality, low‐carbon urological care using a structured framework. Methods: Academic and policy papers which outline actions focused on decarbonising urological care and surgical care more broadly were identified and reviewed. The ‘STEPS to Low‐Carbon Care’ framework (an acronym for low‐carbon care across ‘Settings and Treatments, Efficiency, Prevention and System change’) was then used to categorise and present the evidence‐based decarbonisation actions, using the National Health Service in England as a case study. Results: Across all STEPS framework elements, tangible actions were identified alongside opportunities for future research and innovation. The evidence‐based actions that were identified to transition to low‐carbon care settings and treatments included tackling known carbon hotspots in operating theatres: anaesthetic gases, consumables and electricity use. Outside the operating theatre, urology pathway transformation through one‐stop clinics, day‐case surgery, appropriate use of virtual appointments and streamlined pathways demonstrated opportunities to reduce carbon emissions, with potential additional benefits in terms of cost, efficiencies, and patient outcome improvements. Key climate mitigation actions that support keeping people healthy were identified. There was a paucity of evidence demonstrating the implementation of climate change action as part of routine service delivery. Embedding sustainability across organisational processes and ways of working requires actions to upskill, engage and enable the workforce to deliver and to establish clinical leadership. Conclusion: This review identified a range of interventions to decarbonise urological care, whilst highlighting a need for further research. Categorising the evidence according to components of the STEPS framework indicated the potential utility of this framework when determining unrealised decarbonisation opportunities in urology and more widely across healthcare. Delivering sustained and system‐wide low‐carbon urological care will require the collective action of all who design, deliver and influence patient care across the specialty and all urology patient pathways

Correction to: Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy (Surgical Endoscopy, (2018), 10.1007/s00464-018-6281-2)

BackgroundA reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets.MethodsPatient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall's tau for dichotomous variables, or Jonckheere-Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis.ResultsA higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p ConclusionWe have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty