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!