Essential surgery at the district hospital: a retrospective descriptive analysis in three African countries.
Essential surgery at the district hospital: a retrospective descriptive analysis in three African countries.
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DOI：
10.1371/journal.pmed.1000243
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发表时间：
2010-03-09
期刊：
影响因子：
15.8
通讯作者：
Macfarlane SB
中科院分区：
文献类型：
--
作者：
Galukande M;von Schreeb J;Wladis A;Mbembati N;de Miranda H;Kruk ME;Luboga S;Matovu A;McCord C;Ndao-Brumblay SK;Ozgediz D;Rockers PC;Quiñones AR;Vaz F;Debas HT;Macfarlane SB
在两篇调查撒哈拉非洲国家八家地区医院手术供应情况的论文的第一篇中，Margaret Kruk和她的同事发现，低水平的手术护理供应表明对手术服务的需求未得到满足。手术条件是撒哈拉以南非洲疾病负担的重要因素。然而，人们显然忽视了外科治疗作为一种公共卫生干预措施来应对这一负担。人们越来越热衷于扭转这一趋势，促进地区医院的基本外科服务，因为地区医院是农村人口在危急情况下的第一个接触点。本研究调查了撒哈拉以南三个非洲国家地区医院的手术范围。在一项回顾性描述性研究中，使用标准化表格和对关键举报人的访谈，从乌干达、坦桑尼亚和莫桑比克的八家地区医院收集了现场数据。总的来说，外科手术的范围很窄，主要包括必要和挽救生命的紧急手术。各医院的手术量各不相同，从5到45个主要手术/10,000人不等。产科手术最为常见，包括剖宫产和子宫引流术。疝修补和伤口护理占普通外科手术的65%。所研究医院的床位数量为每1,000人0.2至1.0张。本研究的结果清楚地表明，所研究的医院在地区一级提供的外科护理水平较低。这在多大程度上转化为未满足的需求仍不清楚，尽管在这八家医院的集水区，通过剖宫产出生的活产比例非常低，这表明对外科服务的需求有很大的未满足。撒哈拉以南非洲地区目前卫生系统中的地区医院有助于将基本手术纳入综合初级保健服务的范围。因此，显著扩大地区医院的手术能力至关重要；这将导致可持续的、可预防的发病率和死亡率。每年，全球约有2.34亿例大型外科手术。在这些手术中，只有四分之一是在占世界人口近四分之三的低收入和中等收入国家进行的。换句话说，在高收入国家，平均每年每10万人中有10110人接受手术，而在低收入和中等收入国家，每10万人中只有295人接受手术。然而，需要手术的病症（包括分娩并发症和创伤性损伤）在发展中国家很常见，并大大增加了这些国家的疾病负担。各组织正在努力通过改善发展中国家的急诊和基本外科护理来减轻这一负担。例如，贝拉吉奥基本外科小组（BESG）包括来自几个非洲国家、世界卫生组织（世卫组织）和美国的外科、麻醉、产科（照顾怀孕和分娩妇女的医学分支）和卫生政策方面的专家，旨在增加撒哈拉以南非洲地区获得外科服务的机会。改善撒哈拉以南非洲地区获得手术服务的一种方法是促进在地区医院提供基本手术服务。这些医院是生活在农村地区的人的第一个转诊设施。传统上，病人在这些设施接受大部分初级保健，但要获得更专业的护理，则转到二级和三级保健设施（分别是地区和国家转诊医院）。然而，如果要挽救生命，许多外科疾病，特别是产科急诊，需要在地区医院进行治疗。不幸的是，人们对撒哈拉以南非洲地区地区医院目前进行的外科手术的范围和数量知之甚少，在制定方案以增加这些设施的外科服务之前，需要这些信息。在这项回顾性描述性研究中，研究人员（其中一些是BESG的一部分）调查了三个撒哈拉以南非洲国家的地区医院进行的手术范围。研究人员通过检查医院记录和采访管理人员，获得了坦桑尼亚和莫桑比克两家代表性地区医院以及乌干达四家代表性地区医院的外科手术的最新数据。他们报告说，观察到在这些医院进行的外科手术范围很窄，主要包括必要的挽救生命的紧急手术，如为分娩婴儿进行的剖宫产手术和与伤口有关的手术。除一家乌干达医院外，产科手术约占所有医院外科手术的一半。疝修补和伤口护理占普通外科手术的近三分之二。各医院的外科手术量从每1万人中5到45例大手术不等（平均每1万人25例手术）。在所有医院中，每1万人中进行1至17次剖宫产手术和0.5至7次疝气修补手术。最后，研究人员利用他们的数据和世卫组织对剖宫产手术人口需求的估计估计，在坦桑尼亚的两家地区医院，需要剖宫产手术的妇女中有一半到三分之二无法获得这一拯救生命的手术。这些发现表明，坦桑尼亚、莫桑比克和乌干达的地区医院提供的外科护理水平较低。需要进一步的研究来证实这些发现可以推广到撒哈拉以南非洲其他地区的地区医院，并量化这种低水平的外科护理在多大程度上转化为未满足的需求。该研究的局限性包括缺乏关于结果、患者转诊到更高级别设施的信息，以及在这些医院进行的外科手术中有多少是处理创伤性损伤的信息。然而，本研究收集的信息，以及调查这三个国家地区医院保健工作者的可用性和提供基本手术的资金的另一篇论文所收集的信息表明，撒哈拉以南非洲地区地区医院的手术能力需要改进。研究人员建议，如果这个目标能够实现，它应该可以避免世界上这个贫穷地区的许多疾病和死亡。请通过本摘要的在线版本http://dx.doi.org/10.1371/journal.pmed.1000243访问这些网站。Margaret E. Kruk等人在PLoS医学研究文章中调查了同一家医院中卫生工作者的可用性和手术资金。世卫组织的紧急和基本外科护理全球行动计划提供了关于贝拉吉奥基本外科小组的信息，该计划旨在向世界各地低收入和中等收入国家的卫生保健人员传授基本的紧急、基本手术和麻醉技能；世卫组织还有一个页面描述急诊和基本手术在初级卫生保健中的重要性
In the first of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues find low levels of surgical care provision suggesting unmet need for surgical services. Surgical conditions contribute significantly to the disease burden in sub-Saharan Africa. Yet there is an apparent neglect of surgical care as a public health intervention to counter this burden. There is increasing enthusiasm to reverse this trend, by promoting essential surgical services at the district hospital, the first point of contact for critical conditions for rural populations. This study investigated the scope of surgery conducted at district hospitals in three sub-Saharan African countries. In a retrospective descriptive study, field data were collected from eight district hospitals in Uganda, Tanzania, and Mozambique using a standardized form and interviews with key informants. Overall, the scope of surgical procedures performed was narrow and included mainly essential and life-saving emergency procedures. Surgical output varied across hospitals from five to 45 major procedures/10,000 people. Obstetric operations were most common and included cesarean sections and uterine evacuations. Hernia repair and wound care accounted for 65% of general surgical procedures. The number of beds in the studied hospitals ranged from 0.2 to 1.0 per 1,000 population. The findings of this study clearly indicate low levels of surgical care provision at the district level for the hospitals studied. The extent to which this translates into unmet need remains unknown although the very low proportions of live births in the catchment areas of these eight hospitals that are born by cesarean section suggest that there is a substantial unmet need for surgical services. The district hospital in the current health system in sub-Saharan Africa lends itself to feasible integration of essential surgery into the spectrum of comprehensive primary care services. It is therefore critical that the surgical capacity of the district hospital is significantly expanded; this will result in sustainable preventable morbidity and mortality. Please see later in the article for the Editors' Summary Every year, about 234 million major surgical procedures take place globally. Of these procedures, only a quarter are performed in low- and middle-income countries where nearly three-quarters of the world's population lives. Put another way, in high-income countries, 10,110 people out of every 100,000 have surgery each year on average compared to only 295 people out of every 100,000 in low- and middle-income countries. Yet conditions that need surgery (including complications of childbirth and traumatic injuries) are common in developing countries and contribute significantly to the burden of disease in these countries. Various organizations are working to reduce this burden by improving emergency and essential surgical care in developing countries. For example, the Bellagio Essential Surgery Group (BESG), which includes experts in surgery, anesthesia, obstetrics (the branch of medicine that cares for women during pregnancy and childbirth), and health policy from several African countries, the World Health Organization (WHO), and the US, aims to increase access to surgical services in sub-Saharan Africa. One way to improve access to surgical services in sub-Saharan Africa would be to promote the provision of essential surgical services at district hospitals. These hospitals are the first referral facilities for people living in rural areas. Traditionally, patients receive much of their primary health care at these facilities but are referred to secondary and tertiary health care facilities (regional and national referral hospitals, respectively) for more specialized care. However, many surgical conditions—in particular, obstetric emergencies—need to be treated at district hospitals if lives are to be saved. Unfortunately, very little is known about the range and volume of surgical procedures currently undertaken in district hospitals in sub-Saharan Africa and such information is needed before programs can be developed to increase access to surgical services at these facilities. In this retrospective, descriptive study, the researchers (some of whom are part of the BESG) investigate the scope of surgery undertaken in district hospitals in three sub-Saharan African countries. The researchers obtained recent data on the surgical procedures done at two representative district hospitals each in Tanzania and in Mozambique and four representative district hospitals in Uganda by examining hospital records and by interviewing administrators. The observed range of surgical procedures performed in these hospitals was narrow, they report, consisting mainly of essential and life-saving emergency procedures such as cesarean sections for the delivery of babies and wound-related procedures. Obstetric procedures accounted for around half of all surgical procedures in all the hospitals except one Ugandan hospital. Hernia repair and wound care accounted for nearly two-thirds of general surgical procedures. The surgical output across the hospitals varied from five to 45 major procedures per 10,000 people in the population (average 25 operations per 10,000 people). Across the hospitals, between one and 17 cesarean sections and between 0.5 and seven hernia repairs were performed per 10,000 people in the population. Finally, the researchers used their data and WHO estimates of the population need for cesarean sections to estimate that in the two Tanzanian district hospitals, between half and two-thirds of women that needed a cesarean section did not have access to this life-saving procedure. These findings suggest that there are low levels of provision of surgical care in district hospitals in Tanzania, Mozambique, and Uganda. Further studies are needed to confirm that these findings are generalizable to district hospitals elsewhere in sub-Saharan Africa and to quantify the extent to which this low level of surgical care translates into unmet needs. Limitations of the study include a lack of information on outcomes, on referral of patients to higher-level facilities, and on how many of the surgical procedures undertaken at these hospitals dealt with traumatic injuries. Nevertheless, the information collected in this study, together with that in a separate paper that investigates the availability of health workers and funding for the provision of essential surgery in district hospitals in these three countries, suggests that the surgical capacity of district hospitals in sub-Saharan Africa needs to be improved. If this goal can be achieved, suggest the researchers, it should avert many illnesses and deaths in this poor region of the world. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000243. The availability of health workers and funding for surgery in the same hospitals is investigated in a PLoS Medicine Research Article by Margaret E. Kruk et al. Information on the Bellagio Essential Surgery Group is available WHO's Global initiative for Emergency and Essential Surgical Care plans to take essential emergency, basic surgery and anesthesia skills to health care staff in low- and middle-income countries around the world; WHO also has a page describing the importance of emergency and essential surgery in primary health care
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影响因子：
0.6
作者：
Bickler, SW;Telfer, ML;Sanno-Duanda, B
通讯作者：
Sanno-Duanda, B
DOI：
10.1308/003588407x209329
发表时间：
2007-10-01
影响因子：
1.4
作者：
Lavy, Chris;Tindall, Alistair;Chimangeni, Sandy
通讯作者：
Chimangeni, Sandy
DOI：
10.1097/00005373-200003000-00022
发表时间：
2000-03-01
影响因子：
--
作者：
Kobusingye, OC;Lett, RR
通讯作者：
Lett, RR
影响因子：
12.7
作者：
BLANCHARD, RJW;BLANCHARD, MEE;SMYTHE, CM
通讯作者：
SMYTHE, CM
影响因子：
15.8
作者：
Luboga S;Macfarlane SB;von Schreeb J;Kruk ME;Cherian MN;Bergström S;Bossyns PB;Denerville E;Dovlo D;Galukande M;Hsia RY;Jayaraman SP;Lubbock LA;Mock C;Ozgediz D;Sekimpi P;Wladis A;Zakariah A;Dade NB;Donkor P;Gatumbu JK;Hoekman P;Ijsselmuiden CB;Jamison DT;Jessani N;Jiskoot P;Kakande I;Mabweijano JR;Mbembati N;McCord C;Mijumbi C;de Miranda H;Mkony CA;Mocumbi P;Ndihokubwayo JB;Ngueumachi P;Ogbaselassie G;Okitombahe EL;Toure CT;Vaz F;Zikusooka CM;Debas HT;Bellagio Essential Surgery Group (BESG)
通讯作者：
Bellagio Essential Surgery Group (BESG)