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1.  Children's surgery: a national survey of consultant clinical practice 
BMJ Open  2012;2(5):e001639.
Objectives
To survey clinical practice and opinions of consultant surgeons and anaesthetists caring for children to inform the needs for training, commissioning and management of children's surgery in the UK.
Design
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) hosted an online survey to gather data on current clinical practice of UK consultant surgeons and anaesthetists caring for children.
Setting
The questionnaire was circulated to all hospitals and to Anaesthetic and Surgical Royal Colleges, and relevant specialist societies covering the UK and the Channel Islands and was mainly completed by consultants in District General Hospitals.
Participants
555 surgeons and 1561 anaesthetists completed the questionnaire.
Results
32.6% of surgeons and 43.5% of anaesthetists considered that there were deficiencies in their hospital's facilities that potentially compromised delivery of a safe children's surgical service. Almost 10% of all consultants considered that their postgraduate training was insufficient for current paediatric practice and 20% felt that recent Continued Professional Development failed to maintain paediatric expertise. 45.4% of surgeons and 39.2% of anaesthetists considered that the current specialty curriculum should have a larger paediatric component. Consultants in non-specialist paediatric centres were prepared to care for younger children admitted for surgery as emergencies than those admitted electively. Many of the surgeons and anaesthetists had <4 h/week in paediatric practice. Only 55.3% of surgeons and 42.8% of anaesthetists participated in any form of regular multidisciplinary review of children undergoing surgery.
Conclusions
There are significant obstacles to consultant surgeons and anaesthetists providing a competent surgical service for children. Postgraduate curricula must meet the needs of trainees who will be expected to include children in their caseload as consultants. Trusts must ensure appropriate support for consultants to maintain paediatric skills and provide the necessary facilities for a high-quality local surgical service.
doi:10.1136/bmjopen-2012-001639
PMCID: PMC3488724  PMID: 23075572
Paediatric Surgery
2.  ‘I'd like to know what causes it, you know, anything I've done?’ Are we meeting the information and support needs of patients with macular degeneration? A qualitative study 
BMJ Open  2013;3(11):e003306.
Objective
To examine patients’ experiences of information and support provision for age-related macular degeneration (AMD) in the UK.
Study design
Exploratory qualitative study investigating patient experiences of healthcare consultations and living with AMD over 18 months.
Setting
Specialist eye clinics at a Birmingham hospital.
Participants
13 patients diagnosed with AMD.
Main outcome measures
Analysis of patients’ narratives to identify key themes and issues relating to information and support needs.
Results
Information was accessed from a variety of sources. There was evidence of clear information deficits prior to diagnosis, following diagnosis and ongoing across the course of the condition. Patients were often ill informed and therefore unable to self-advocate and recognise when support was needed, what support was available and how to access support.
Conclusions
AMD patients have a variety of information needs that are variable across the course of the condition. Further research is needed to determine whether these experiences are typical and identify ways of translating the guidelines into practice. Methods of providing information need to be investigated and improved for this patient group.
doi:10.1136/bmjopen-2013-003306
PMCID: PMC3822314  PMID: 24202055
Qualitative Research; Ophthalmology
3.  Does it matter where you go for breast surgery?: Attending Surgeon’s Influence on Variation in Receipt of Mastectomy for Breast Cancer 
Medical care  2010;48(10):892-899.
Background
Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeon’s influence on the variation in receipt of these procedures.
Objectives
To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer.
Methods
Attending surgeons (n=419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during 6/05 − 2/07 (n=2290) were surveyed. Respondent surgeons (n=291) and patients (n=1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment.
Results
Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median 29%, 5th–95th percentile 9%–65%) than for mastectomy (median 18%, 5th–95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, one surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%).
Conclusion
Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.
doi:10.1097/MLR.0b013e3181ef97df
PMCID: PMC3176679  PMID: 20808256
4.  A survey of emergency vascular service provision. 
Recommendations exist for the optimal management of vascular surgical emergency patients. A telephone survey of on-call surgical registrars was performed to assess the current state of emergency vascular service provision across the Wessex and South West regions in the UK. Of the 24 hospitals surveyed, 10 had formal on-call arrangements for vascular surgical cover, 14 had informal arrangements where the general surgical consultant on-call provided cover and could contact a vascular surgeon if they were available and 3 hospitals had no such arrangements. No difficulties had been experienced by the on-call staff surveyed with any of the existing arrangements. Only 5 of the hospitals had formal on-call arrangements for interventional radiologists. We conclude that current emergency vascular service provision is suboptimal compared to national guidelines and patients may be subject to unequitable access to services. This may not be tenable in the new era of clinical governance.
PMCID: PMC2503788  PMID: 11995749
5.  The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon 
Midwifery  2010;26(5-2):549-557.
Objective
to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes.
Design
a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health.
Setting
childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon.
Participants
in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected.
Measurements
the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008.
Findings
the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries.
Key conclusions and implications for practice
there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.
doi:10.1016/j.midw.2010.06.012
PMCID: PMC2989442  PMID: 20691519
Maternal health; Safety; Health system
6.  Consultant Surgeons and Vasectomy 
British Medical Journal  1973;2(5867):629-634.
In late 1971 410 consultant general surgeons and urologists—74% of a national random sample—responded to a postal survey about vasectomy. Probably about 50,000 vasectomies were performed by surgeons in England and Wales in 1970. The service was largely a private one: 60% of consultants' hospital vasectomies were not done under the National Health Service, and, in addition, 26% of the consultants who worked in relevant specialties performed vasectomies elsewhere than in hospital (usually in private nursing homes). Based again on consultants' estimates, probably 6,000 men in 1970 had their requests for vasectomy turned down by surgeons, or more than one turned down for every 10 done. The most common reason was that patients were “too young.”
About 90% of the consultants thought vasectomy could normally be performed safely and adequately as an outpatient procedure, yet only 64% said that 90% or more of their hospital vasectomies were done on this basis. While 69% regarded services in their areas as adequate, most were in favour of more special vasectomy clinics.
PMCID: PMC1589651  PMID: 4714846
7.  Evaluation of Immunization Knowledge, Practices, and Service-delivery in the Private Sector in Cambodia 
A study of private-sector immunization services was undertaken to assess scope of practice and quality of care and to identify opportunities for the development of models of collaboration between the public and the private health sector. A questionnaire survey was conducted with health providers at 127 private facilities; clinical practices were directly observed; and a policy forum was held for government representatives, private healthcare providers, and international partners. In terms of prevalence of private-sector provision of immunization services, 93% of the private inpatient clinics surveyed provided immunization services. The private sector demonstrated a lack of quality of care and management in terms of health workers’ knowledge of immunization schedules, waste and vaccine management practices, and exchange of health information with the public sector. Policy and operational guidelines are required for private-sector immunization practices that address critical subject areas, such as setting of standards, capacity-building, public-sector monitoring, and exchange of health information between the public and the private sector. Such public/private collaborations will keep pace with the trends towards the development of private-sector provision of health services in developing countries.
PMCID: PMC2740687  PMID: 18637533
Evaluation studies; Health services; Health-sector reforms; Health systems; Immunization; Private sector; Quality of care; Standards; Cambodia
8.  Surgeons’ opinions and practice of informed consent in Nigeria 
Journal of Medical Ethics  2010;36(12):741-745.
Background
Informed consent is perhaps more relevant to surgical specialties than to other clinical disciplines. Fundamental to this concept is the provision of relevant information for the patient to make an informed choice about a surgical intervention. The opinions of surgeons in Nigeria about informed consent in their practice were surveyed.
Methods
A cross-sectional survey of surgeons in Nigeria was undertaken in 2004/5 using self-administered semistructured questionnaires.
Results
There were 102 respondents, 85.3% of whom were men and 58.8% were aged 31–40 years. 43.1% were consultants and 54.0% were surgical trainees. 27.4% were in surgical subspecialties, 26.5% in general surgery and 21.6% were obstetricians and gynaecologists. 54.9% agreed that sufficient information is not provided to patients while obtaining their consent for surgical procedures. They listed medicolegal reasons (70.6%), informing patients about benefits, risks and alternatives (64.7%) and hospital policy (50.0%) as some reasons for obtaining consent for surgical procedures. When patients decline to give consent for surgery, 84.3% of them thought that poor communication between surgeons and patients may be contributory. They identified taking a course in bioethics during surgical training and compulsory communication skills course as some ways to improve communication between surgeons and patients.
Conclusion
Most Nigerian surgeons seemed to have a good knowledge of the informed consent requirements and process but fall short in practice. There is a need to improve the surgeon–patient relationship in line with modern exigencies to provide interactive environments for fruitful patient communication and involvement.
doi:10.1136/jme.2010.037440
PMCID: PMC3332031  PMID: 20940174
9.  Driving to Contract Management in Health Care Institutes of Developing Countries 
Background
Public hospitals can privatize management activities by contracting with a private organization or person to perform the work. Management contract is a method which uses private sector for major government projects like hospitals. This study evaluates contract management in health care institutes of developing countries.
Methods
Information has been collected by reviewing the management contract condition of selected countries. Different forms of public private partnership for private participation in hospitals were surveyed.
Results
The effects of management contract is expanding market opportunities to include public sector clients, capturing a market to be protected from competitors and providing a reliable and timely source of revenue.
Conclusion
Contracting with non-governmental entities will provide better results than government provision of the same services. Contracting initiatives must be regulated and monitored at the highest level of government by experienced and astute policy makers, economists and operational personnel.
PMCID: PMC3385803  PMID: 22754687
Contract management; Developing country; Public; Private; Hospital; Government
10.  Observance of Patient’s Rights: A Survey on the Views of Patients, Nurses, and Physicians 
Assessment of patients’ views about the observance of patients’ rights in the health system is of great importance for evaluation of such systems. Comparing views of patients (recipients of health services) and physicians and nurses (health care providers) regarding the observance of various aspects of patients’ rights at three hospitals representing three models of medical service provision (teaching, private, and public) is the main objective of this study.
This was a cross-sectional descriptive and analytical study, and the information needed was gathered through questionnaires. They were filled out by an interviewer for patients, but self administered by physicians and nurses. The field of study consisted of three hospitals including a general teaching hospital, a private hospital, and a public hospital, all located in Tehran. The questionnaires contained some general questions regarding demographic information and 21 questions concerning the necessity of observing patient’s rights. The questionnaires were initially filled out by a total of 143 patients, and then consigned to 143 nurses (response rate = 61.3%) and 82 physicians (response rate = 27.5%) to be completed. The rate of observance of each right was measured on a Likert scale ranging from zero (non-observance) to 10 (full observance). Considering abnormal distribution of the information, it was analyzed with non-parametrical tests using SPSS 11.5 software package.
The results of this study showed that the study groups had different views about how well different aspects of patients’ rights were observed. The highest level of disagreement was related to the right of choosing and deciding by the patients, which was not satisfactory in the teaching hospital.
According to the results, it seems that healthcare providers, especially physicians, should be better informed of patients’ right of access to information and right of choosing and deciding. Based on the observed disagreement between the views of the patients and those of the physicians in the present study, it can be asserted that the patients thought that the level of observance of these rights was lower in comparison with what the physicians thought.
PMCID: PMC3713914  PMID: 23908758
patient’s rights; medical ethics; views; Iran
11.  Calculation of Costs of Pregnancy- and Puerperium-related Care: Experience from a Hospital in a Low-income Country 
Calculation of costs of different medical and surgical services has numerous uses, which include monitoring the performance of service-delivery, setting the efficiency target, benchmarking of services across all sectors, considering investment decisions, commissioning to meet health needs, and negotiating revised levels of funding. The role of private-sector healthcare facilities has been increasing rapidly over the last decade. Despite the overall improvement in the public and private healthcare sectors in Bangladesh, lack of price benchmarking leads to patients facing unexplained price discrimination when receiving healthcare services. The aim of the study was to calculate the hospital-care cost of disease-specific cases, specifically pregnancy- and puerperium-related cases, and to indentify the practical challenges of conducting costing studies in the hospital setting in Bangladesh. A combination of micro-costing and step-down cost allocation was used for collecting information on the cost items and, ultimately, for calculating the unit cost for each diagnostic case. Data were collected from the hospital records of 162 patients having 11 different clinical diagnoses. Caesarean section due to maternal and foetal complications was the most expensive type of case whereas the length of stay due to complications was the major driver of cost. Some constraints in keeping hospital medical records and accounting practices were observed. Despite these constraints, the findings of the study indicate that it is feasible to carry out a large-scale study to further explore the costs of different hospital-care services.
PMCID: PMC2980891  PMID: 20635637
Cost calculation; Costs and cost analysis; Health expenditure; Healthcare cost; Hospital cost; Maternal health; Micro-costing; Bangladesh
12.  How do you tell if a change in surgical technique leads to a change in outcome? 
The Journal of urology  2010;183(4):1510-1514.
Purpose
Surgeons routinely evaluate and modify their surgical technique in order to improve patient outcome. It is also common for surgeons to analyze results before and after a change in technique to determine whether the change did indeed lead to better results. A simple comparison of results before and after a surgical modification may be confounded by the surgical learning curve. Here, we aim to develop a statistical method applicable to the analysis of before / after studies in surgery.
Materials and Methods
We used simulation studies to compare different statistical analyses of before / after studies. We evaluated a simple two group comparison of results before and after the modification by chi squared, and a novel bootstrap method that adjusts for the surgical learning curve.
Results
In the presence of the learning curve, a simple two group comparison almost always found an ineffective surgical modification to be of benefit. If the surgical modification was harmful, leading to a 10% reduction in success rates, a two group comparison nonetheless reported a statistically significant improvement in outcome about 80% of the time. The bootstrap method had only moderate power, but did not find ineffective surgical modifications of benefit more than would be expected by chance.
Conclusions
Simplistic approaches to the analysis of before / after studies in surgery can lead to grossly erroneous results under a surgical learning curve. A straightforward alternative statistical method allows investigators to separate the effects of the learning curve from those of the surgical modification.
doi:10.1016/j.juro.2009.12.034
PMCID: PMC2859681  PMID: 20172569
research design; surgery; evaluation studies
13.  Reducing Referral Delays in Colorectal Cancer Diagnosis: Is It about How You Ask? 
Objectives
Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. We tested whether certain details of information transmitted through computerized provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed colorectal cancer (CRC).
Methods
We studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees, and other specialists. From the colonoscopy referral preceding CRC diagnosis, we determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. We compared distributions of proportions of diagnostic clues between patients with > 60 and ≤ 60 day lag and examined predictors of lag time.
Results
Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had lag > 60 days. Referrals associated with longer lag times included those with “positive fecal occult blood test” (92 days, P<0.0001), “hematochezia” (75 days, P=0.02), “history of polyps” (221 days, P=0.0006), and when “screening” (versus specific symptoms) was given as reason for diagnostic colonoscopy (203 days, P=0.002). Independent predictors of shorter wait times included 3 diagnostic clues, notation of urgency, and documentation of verbal contact.
Conclusions
Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.
doi:10.1136/qshc.2009.033712
PMCID: PMC2965264  PMID: 20584706
delayed cancer diagnosis; colorectal cancer; colonoscopy referrals; computerized order entry; electronic medical records; primary care
14.  Public and private providers’ quality of care for tuberculosis patients in Kampala, Uganda 
SUMMARY
SETTING
The role of the private sector in tuberculosis treatment in developing countries in sub-Saharan Africa is largely unknown. In recent years, many fee-for-service clinics have opened up in Kampala, Uganda. Little is known about the tuberculosis caseload seen in private clinics or the standard of care provided to the patients.
OBJECTIVE
To compare the appropriateness of tuberculosis care in private and public clinics, and the extent of the tuberculosis burden handled in the private sector.
DESIGN
Cross-sectional survey in private and public clinics treating tuberculosis patients in Kampala, Uganda, during June to August 1999.
MEASUREMENTS
Clinics were evaluated for appropriateness of care. This was defined as provision of proper diagnosis (sputum smear microscopy as the primary means of diagnosis), treatment (short-course chemotherapy, with or without directly observed therapy), outcome evaluation (smear microscopy at 6 or 7 months) and case notification in accordance with the Uganda National Tuberculosis and Leprosy Programme.
RESULTS
A total of 114 clinics (104 private, 10 public) were surveyed. Forty-one per cent of the private clinics saw three or more new tuberculosis patients each month. None of the public or private clinics met all standards for appropriate tuberculosis care. Only 24% of all clinics adhered to WHO-recommended treatment guidelines. Public clinics, younger practitioners and practitioners with advanced degrees were most likely to provide appropriate care for tuberculosis.
CONCLUSION
The private sector cares for many tuberculosis cases in Kampala; however, a new programme that offers continuing medical education is needed to improve tuberculosis care and to increase awareness of national guidelines for tuberculosis care.
PMCID: PMC3419472  PMID: 11716336
tuberculosis; quality of care; diagnosis; treatment; private provider
15.  High Satisfaction Rating by Users of Private-for-profit Healthcare Providers—evidence from a Cross-sectional Survey Among Inpatients of a Private Tertiary Level Hospital of North India 
Background:
Evaluation of outcomes can help improve the quality of provision of services within a healthcare setting. There is limited report on patient satisfaction in private-sector in India although they provide three-quarters of healthcare services.
Aim:
The study was designed to report the level of satisfaction among inpatients of a private tertiary care hospital in India.
Materials and Methods:
A total of 102 participants were recruited and their socio-demographic, health-seeking behavior, and satisfaction rating on various aspects of healthcare were elicited. A five item Likert scale was used to obtain the satisfaction rating. Data analysis was done with the help of Stata version-9. Proportions for the discrete variables and means with Standard Deviation for the continuous variables were obtained.
Results:
All the participants were urban and from upper-middle or upper socio-economic strata. The participants reported a high level of overall satisfaction (93%) as well as high satisfaction with physicians (95%), the doctor's interpersonal skills (99%), nursing-care (93%), general services (94%), and pharmacy (88.1%).
Conclusion:
There was a high level of satisfaction reported by the participants at this tertiary level hospital. This might reflect the actual good quality services being provided by the provider or the nonannoying response, which cannot be ruled out.
doi:10.4103/1947-2714.100991
PMCID: PMC3456482  PMID: 23050252
Client satisfaction; patient satisfaction; private hospital; tertiary care
16.  Internet use by orthopaedic outpatients – current trends and practices 
The Australasian Medical Journal  2012;5(12):633-638.
Background
The e-patient revolution increasingly enables patients to self diagnose and self educate, influencing decisions affecting their health. This poses a challenge for both patients and health care professionals due to the highly variable and often poor quality information available on the internet.
Aims
This study aims to measure the current internet usage in patients attending outpatient clinics, in both a public and private setting. All patients were recruited whilst consulting orthopaedic surgeons.
Method
We developed a 29 question survey which asked questions related to patient demographics, general internet usage and internet usage related to the patient’s orthopaedic condition. Patients were recruited for the public cohort during Western Health outpatient clinics and for the private cohort during private surgical consults in the waiting rooms of eight surgeons’ clinics.
Results
A total of 400 surveys were completed; 200 in both the private and public cohorts of the study. Of all surveyed participants, 79% (n = 316) had access to the internet. Of people who had access to the internet 65.2% (n = 206) used the internet to investigate their orthopaedic condition. 29.6% (n = 61) of participants asked their surgeon questions related to information they had read on the internet. Of patients that had access to the internet 36.1% (n = 114) used the internet to research their surgeon.
Conclusion
Patients are commonly using the internet as an information resource, in spite of the highly variable quality of this information. This highlights the need for patient information websites which reflect the current standards of clinical practice.
doi:10.4066/AMJ.2012.1530
PMCID: PMC3561591  PMID: 23382767
Online medical information; Internet use; Patient’s awareness; orthopaedics
17.  Reasons against referral to the psychiatrist 
Postgraduate Medical Journal  1971;47(548):315-319.
Consultants practising clinical specialties other than psychiatry in six general hospitals were asked by questionnaire about reasons which might prevent the referral of patients to a psychiatrist. The purpose of the enquiry was to find out the causes of the discrepancy between the prevalence of psychiatric disorder among medical and surgical patients and the low rate of referral.
Forty-five per cent of the consultants were influenced by the patient's dislike of referral; there was also evidence of marked dissatisfaction with existing psychiatric services at certain hospitals, felt chiefly by the younger consultants. Part-time consultants gave more reasons for non-referral, but there was no significant difference between medical and surgical specialties despite reported variations in referral practice.
It is concluded that general hospital psychiatric units have a role to play in improving the relationship between psychiatrists and other specialties so that referral practice can meet the needs of the patient.
PMCID: PMC2466916  PMID: 5580936
18.  Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey 
PLoS Medicine  2010;7(3):e1000242.
In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.
Background
There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.
Methods and Findings
We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.
Conclusion
African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Infectious diseases remain the major killers in developing countries, but traumatic injuries, complications of childbirth, and other conditions that need surgery are important contributors to the overall burden of disease in these countries. Unfortunately, the provision of surgical services in low- and middle-income countries is often insufficient. There are many fewer operations per a head of population in developing countries than in developed countries, essential operations such as cesarean sections for complicated deliveries are not always available, and elective operations such as male and female sterilization can be difficult to obtain. Lack of funding for surgical procedures and shortages of trained health workers have often been blamed for the low rates of surgery in developing countries. For example, anesthesiologists (doctors who are trained to give anesthetics and other pain-relieving agents) and trained anesthetists (usually nurses and technicians) are rare in many African countries, as are surgeons and obstetricians (doctors who look after women during pregnancy and childbirth). To make matters worse, these specialists often work in tertiary referral hospitals in large cities. In district hospitals, which provide most of the primary health care needs of rural populations, basic surgical care is usually provided by “mid-level health care providers” (MLPs)—individuals with a level of training between that of nurses and physicians.
Why Was This Study Done?
Various organizations are currently working to improve emergency and essential surgical care in developing countries. For example, the Bellagio Essential Surgery Group (BESG) seeks to define, quantify, and address the problem of unmet surgical needs in sub-Saharan Africa. Importantly, however, before any programs can be introduced to improve access to surgical services in developing countries, better baseline data on existing surgical services needs to be collected—most of the available information on these services is anecdotal. In this study, the researchers (most of whom are members of the BESG) investigate the provision of surgical procedures and anesthesia in district hospitals in three sub-Saharan African countries and estimate the costs of surgery performed in the same hospitals.
What Did the Researchers Do and Find?
The researchers collected recent data on the number of doctors, MLPs, and nurses in two district hospitals in Tanzania and in Mozambique, and from four district hospitals in Uganda and information on each hospital's expenditure. Most of the health workers in these hospitals (which care for 3 million people between them) were nurses (77.5%), followed by MLPs not trained to provide surgical care (7.8%), and MLPs trained to provide surgical care (3.8%). The hospitals had between one and six medical doctors each (28 across all the hospitals), but there were no trained surgeons or anesthesiologists posted at any of the hospitals. About half of the major surgical procedures undertaken at these hospitals were performed by doctors but more than a third were done by MLPs although the exact pattern of personnel involved in surgery varied among the three countries. Anesthesia was mostly provided by nurses and doctors; again the pattern of anesthesia provision varied among countries and hospitals. Only 7%–14% of overall hospital expenditure was allocated to surgical care and most of this allocation was used for obstetric services. Finally, the researchers estimate that, on the basis of district populations, the district hospitals spent between US$0.05 and US$0.14 per head on surgical services.
What Do These Findings Mean?
These findings indicate that, in the district hospitals investigated in this study, physicians, MLPs, and nurses provide most of the surgical care. Furthermore, although all the hospitals in the study provide some surgical care, it accounts for a small part of the hospitals' overall operating costs. These findings may not be generalizable to other district hospitals in sub-Saharan Africa and provide no information about the unmet needs for surgical care. Nevertheless, these findings and those of a separate paper that investigates the range and volume of surgical procedures undertaken in the same district hospitals provide a valuable baseline for planning the expansion of health care services in Africa. They also suggest that increasing the funds allocated to surgery and formalizing the training of MLPs might be a cost-effective way of increasing access to surgical care in sub-Saharan Africa and other developing regions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000242.
The range and volume of surgery in the same hospitals is investigated in a PLoS Medicine Research Article by Moses Galukande 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
doi:10.1371/journal.pmed.1000242
PMCID: PMC2834706  PMID: 20231869
19.  Community care: the independent sector. 
BMJ : British Medical Journal  1996;313(7059):740-743.
The independent sector, which consists of the voluntary and private sectors, is a vital element in supporting older people in the community. The voluntary sector, coordinated by the Council for Voluntary Service and the National Council for Voluntary Organisations, provides a variety of services, including practical help, reassurance and companionship, and advice, information, campaigning, and advocacy. The private sector owns all of the nursing homes and most of the residential homes and is gradually becoming more involved with the provision of services to help support older people in their own homes. With this increase in size and importance of the independent sector over recent years, there is now a real need for greater communication between the private, voluntary, and statutory agencies in any one region. In some areas, forums made up of representatives of these various sectors meet to discuss relevant issues and construct local policies, thus allowing a more coordinated approach to the delivery of services.
Images
PMCID: PMC2352092  PMID: 8819449
20.  Surgeons Underestimate Their Patients’ Desire for Preoperative Information 
World Journal of Surgery  2008;32(6):964-970.
Background
Provision of adequate patient information may contribute to a “satisfying” surgical treatment. The patient’s views on successful transfer of information concerning operative characteristics may not be in concert with the surgeon’s. The aim of the present study was to determine opinions of both surgeons and patients about issues of surgical information.
Methods
A group of surgeons (n = 24) and surgical patients (n = 125) responded to a questionnaire that included 80 topics involving domains of information on disease, physical examination, preoperative period, anesthesia, operation, postoperative period, self care, and general hospital issues. Both groups were asked for their opinion on what they considered important and useful preoperative information for patients. Questions were scored with a visual analog scale. The reliability of the questionnaire was calculated with Cronbach’s alpha. Differences in opinions between surgeons and patients were analyzed with Student’s t-test.
Results
The Cronbach’s alpha of the questionnaire was high (0.91), indicating its high reliability. Patients scored significantly higher (p < 0.001) in most domains, including preoperative period, anaesthesia, operation, postoperative period, self care, and general hospital information. Women demonstrated a significantly higher need for information than men did. These findings were independent of patient age or complexity of operation. In contrast, surgeons thought that their patients desired more extensive information on cause, effect, and prognosis of the disease itself (p < 0.001).
Conclusion
Surgeons generally underestimate their patients’ desire for receiving extensive information prior to a surgical procedure of any complexity. Surgeons should develop strategies to bridge this informational mismatch.
doi:10.1007/s00268-008-9581-1
PMCID: PMC2386849  PMID: 18408963
21.  “Until the trial is complete you can’t really say whether it helped you or not, can you?”: exploring cancer patients’ perceptions of taking part in a trial of acupressure wristbands 
Background
Nested qualitative studies within clinical trials provide data on patients’ experiences of receiving trial interventions and can inform and improve trial designs. The present study explored patients’ experiences of participating in a randomised controlled trial of acupressure wristbands for chemotherapy related nausea.
Methods
A randomised three-group sham-controlled trial was carried out to evaluate the effectiveness of acupressure wristbands in the management of chemotherapy-related nausea. A convenience sample of 26 patients volunteered to participate in a qualitative study to explore their experiences of using acupressure wristbands, and taking part in the clinical trial. Participants were recruited from each of the three UK geographical sites from which the trial was conducted: Manchester, Liverpool and Plymouth. In-depth semi-structured interviews were conducted with the participants in their own homes or other location convenient for participating patients. Interviews were audio-taped, transcribed verbatim and analysed using Framework methodology.
Results
The main motivational factors influencing participants to take part in the trial were a desire to 'give something back’ and limit their own experience of nausea. Participants were largely satisfied with the organisation and running of the acupressure wristband trial. Many participants experienced positive outcomes as a result of taking part in the trial. Lapses in memory, or poor health as a result of their chemotherapy treatment, led to some participants failing to complete trial paperwork on designated days. Two sham wristband participants reported wearing the bands inappropriately resulting in pressure being applied to the acupoint. Almost all of the participants interviewed had only experienced mild nausea or vomiting during the trial. Participants were pragmatic on the extent to which the wristbands were responsible for this lack of nausea and vomiting during the trial. However, many participants, including some patients receiving sham acupressure, believed the wristbands to have had a positive impact on their nausea and vomiting; there was a perception that the wristbands were, at least in part, responsible for the lack of nausea and vomiting they had experienced.
Conclusions
Participants perceive acupressure wristbands as reducing the level of nausea and vomiting experienced during chemotherapy treatment. Reports that some participants wore wristbands inappropriately, and/or delayed completion of trial paperwork could represent confounding variables and have implications for the trial results, and the design of clinical trials within the field of cancer.
doi:10.1186/1472-6882-13-260
PMCID: PMC3851943  PMID: 24103725
Cancer; Chemotherapy; Nausea; Vomiting; Acupressure; Acupressure Wristbands; Qualitative research
22.  Waiting times for carotid endarterectomy in UK: observational study 
Objectives To assess timeliness of carotid endarterectomy services in the United Kingdom.
Design Observational study with follow-up to March 2008.
Setting UK hospitals performing carotid endarterectomy.
Participants UK surgeons undertaking carotid endarterectomy from December 2005 to December 2007.
Main outcome measures Provision and speed of delivery of appropriate assessments of patients; carotid endarterectomy and operative mortality; 30 day postoperative mortality.
Results 240 (61% of those eligible) consultant surgeons took part from 102 (76%) hospitals and trusts. Of 9913 carotid endarterectomies recorded on hospital episode statistics, 5513 (56%) were included. Of the patients who underwent endarterectomy, 83% had a history of transient ischaemic attack or stroke. Of these recently symptomatic patients, 20% had their operation within two weeks of onset of symptoms and 30% waited more than 12 weeks. Operative mortality was 0.5% during the inpatient stay and 1.0% (95% confidence interval 0.7% to 1.3%) by 30 days.
Conclusion Only 20% of symptomatic patients had surgery within the two week target time set by the National Institute for Health and Clinical Excellence (NICE). Although operative mortality rates are comparable with those in other countries, some patients might experience disabling or fatal stroke while waiting for surgery and hence not be included in operative statistics. Major improvements in services are necessary to enable early surgery in appropriate patients in order to prevent strokes.
doi:10.1136/bmj.b1847
PMCID: PMC2691453  PMID: 19502220
23.  Effect of surgical training on outcome and hospital costs in coronary surgery 
Heart  2001;85(4):454-457.
BACKGROUND—There is a perceived conflict between the need for service provision and surgical training within the National Health Service (NHS). Trainee surgeons tend to be slower (thereby reducing theatre throughput), and may have more complications (increasing hospital stay and costs).
OBJECTIVE—To quantify the effect of training on outcome and costs.
DESIGN—Data on 2740 consecutive isolated coronary artery bypass (CABG) operations were analysed retrospectively. Redo and emergency procedures were excluded. The seniority of the operating surgeon was related to operating times, risk stratified outcome, and overall hospital costs.
SETTING—Regional cardiothoracic surgery unit.
MAIN OUTCOME MEASURES—Postoperative mortality; hospital costs.
RESULTS—Consultants, senior trainees, intermediate trainees, and junior trainees performed 1524, 759, 434, and 23 procedures, respectively. Trainees at the three different levels were directly supervised by a consultant in 55%, 95%, and 100% of cases. The unadjusted mortalities were 3.2%, 2.0%, 2.3%, and 4.3%, respectively (NS). There were no significant differences between the groups with respect to time in the intensive care unit and length of hospital stay. The mean cost per patient was £6619, £6572, £6494, and £6404 (NS).
CONCLUSIONS—Trainees performed 44.4% of all CABG operations. There was no detrimental effect on patient outcome, length of hospital stay, or overall hospital costs. There need be little conflict between service and training needs, even in hospitals with extensive training programmes.


Keywords: coronary artery bypass surgery; training; costs
doi:10.1136/heart.85.4.454
PMCID: PMC1729696  PMID: 11250976
24.  Private Hospital Sector Development: An Exploratory Study on Providers Perspective in Addis Ababa, Ethiopia 
Ethiopian Journal of Health Sciences  2011;21(Suppl 1):59-64.
Background
Over the past decade there is a trend of fast development in the private hospital sector in Ethiopia. This important component of the health care system has received policy attention and federal government is a promoter for private health care. Yet lack of basic data on the factors affecting the growth of private health care provision in the country and no studies are available on this issue in Ethiopia. The aim of this study is to get some preliminary insights on the factors affecting the growth and development of private hospital sector in Addis Ababa, Ethiopia with perspective of provider.
Methods
A hospital based qualitative study was conducted in 25 for-profit hospitals in Addis Ababa using key informant in-depth interviews and secondary data was collected from Federal Ministry of Health and Addis Ababa City Health Administration and private hospital providers.
Results
The findings of the study suggest that private hospital sector is expanding significantly in recent years in Ethiopia. The active role of government is a catalyst for the growth of private facilities in the country. Factors outside the health are growing disposable income, improvements in literacy, road networks, population growth and long standing diseases, all contribute to the trend. But private providers are facing many problems, like availability of trained manpower, escalation of costs, availability and quality of drugs and financing mechanisms.
Conclusion
Private hospital sector is expanding in Ethiopia. But private providers are vulnerable to imperfections in the existing market structure. Government and professional bodies need to make a concerted effort to address these issues and design appropriate strategies to promote and regulate this sector effectively.
PMCID: PMC3275879  PMID: 22435009
Private hospital sector; Development; Providers
25.  A One-Stop Carpal Tunnel Clinic 
INTRODUCTION
By December 2008, 90% of referrals requiring hospital admission will need to be seen and treated within the 18-week patient pathway. Previously, patients within our trust with suspected carpal tunnel syndrome had to wait 3 months to see a specialist in clinic and, once assessed, would have to wait up to a further 6 months for an open carpal tunnel decompression under local anaesthetic (OCTD/LA). We set up a one-stop clinic, where patients would have their out-patient consultation and surgery on the same day. We evaluated the clinic in order to assess whether it led to reduced waiting times whilst maintaining good clinical outcome and patient satisfaction.
PATIENTS AND METHODS
Patients were selected on the basis of the standard referral letter alone. Those selected were then assessed by a single surgeon in the clinic. The patients deemed appropriate underwent an OCTD/LA and were discharged the same day. Patients were followed up with a patient satisfaction and Boston questionnaire.
RESULTS
Forty-six patients underwent 63 OCTD/LA, waiting an average of 2.2 months (9 weeks) from referral. There was high patient satisfaction and improvement in symptoms following treatment in the clinic.
CONCLUSIONS
We believe a one-stop carpal tunnel clinic can be an efficient and cost-effective way of treating this common condition.
doi:10.1308/003588409X391910
PMCID: PMC2749392  PMID: 19220947
Carpal tunnel syndrome; Carpal tunnel decompression

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