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1.  Use of social audits to examine unofficial payments in government health services: experience in South Asia, Africa, and Europe 
BMC Health Services Research  2011;11(Suppl 2):S12.
Background
Unofficial payments in health services around the world are widespread and as varied as the health systems in which they occur. We reviewed the main lessons from social audits of petty corruption in health services in South Asia (Bangladesh, Pakistan), Africa (Uganda and South Africa) and Europe (Baltic States).
Methods
The social audits varied in purpose and scope. All covered representative sample communities and involved household interviews, focus group discussions, institutional reviews of health facilities, interviews with service providers and discussions with health authorities. Most audits questioned households about views on health services, perceived corruption in the services, and use of government and other health services. Questions to service users asked about making official and unofficial payments, amounts paid, service delivery indicators, and satisfaction with the service.
Results
Contextual differences between the countries affected the forms of petty corruption and factors related to it. Most households in all countries held negative views about government health services and many perceived these services as corrupt. There was little evidence that better off service users were more likely to make an unofficial payment, or that making such a payment was associated with better or quicker service; those who paid unofficially to health care workers were not more satisfied with the service. In South Asia, where we conducted repeated social audits, only a minority of households chose to use government health services and their use declined over time in favour of other providers. Focus groups indicated that reasons for avoiding government health services included the need to pay for supposedly free services and the non-availability of medicines in facilities, often perceived as due to diversion of the supplied medicines.
Conclusions
Unofficial expenses for medical care represent a disproportionate cost for vulnerable families; the very people who need to make use of supposedly free government services, and are a barrier to the use of these services. Patient dissatisfaction due to petty corruption may contribute to abandonment of government health services. The social audits informed plans for tackling corruption in health services.
doi:10.1186/1472-6963-11-S2-S12
PMCID: PMC3332556  PMID: 22376233
2.  A population-based study of ambulatory and surgical services provided by orthopaedic surgeons for musculoskeletal conditions 
Background
The ongoing process of population aging is associated with an increase in prevalence of musculoskeletal conditions with a concomitant increase in the demand of orthopaedic services. Shortages of orthopaedic services have been documented in Canada and elsewhere. This population-based study describes the number of patients seen by orthopaedic surgeons in office and hospital settings to set the scene for the development of strategies that could maximize the availability of orthopaedic resources.
Methods
Administrative data from the Ontario Health Insurance Plan and Canadian Institute for Health Information hospital separation databases for the 2005/06 fiscal year were used to identify individuals accessing orthopaedic services in Ontario, Canada. The number of patients with encounters with orthopaedic surgeons, the number of encounters and the number of surgeries carried out by orthopaedic surgeons were estimated according to condition groups, service location, patient's age and sex.
Results
In 2005/06, over 520,000 Ontarians (41 per 1,000 population) had over 1.3 million encounters with orthopaedic surgeons. Of those 86% were ambulatory encounters and 14% were in hospital encounters. The majority of ambulatory encounters were for an injury or related condition (44%) followed by arthritis and related conditions (37%). Osteoarthritis accounted for 16% of all ambulatory encounters. Orthopaedic surgeons carried out over 140,000 surgeries in 2005/06: joint replacement accounted for 25% of all orthopaedic surgeries, whereas closed repair accounted for 16% and reductions accounted for 21%. Half of the orthopaedic surgeries were for arthritis and related conditions.
Conclusion
The large volume of ambulatory care points to the significant contribution of orthopaedic surgeons to the medical management of chronic musculoskeletal conditions including arthritis and injuries. The findings highlight that surgery is only one component of the work of orthopaedic surgeons in the management of these conditions. Policy makers and orthopaedic surgeons need to be creative in developing strategies to accommodate the growing workload of orthopaedic surgeons without sacrificing quality of care of patients with musculoskeletal conditions.
doi:10.1186/1472-6963-9-56
PMCID: PMC2682488  PMID: 19335904
3.  Experiences with Policing among People Who Inject Drugs in Bangkok, Thailand: A Qualitative Study 
PLoS Medicine  2013;10(12):e1001570.
Using thematic analysis, Kerr and colleagues document the experiences of policing among people who inject drugs in Bangkok and examine how interactions with police can affect drug-using behaviors and health care access.
Please see later in the article for the Editors' Summary
Background
Despite Thailand's commitment to treating people who use drugs as “patients” not “criminals,” Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012.
Methods and Findings
Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample.
Conclusions
This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In many countries, the dominant strategy used to control illegal drugs such as heroin and methamphetamine is criminal law enforcement, a strategy that sometimes results in human rights abuses such as ill-treatment by police, extrajudicial killings, and arbitrary detention. Moreover, growing evidence suggests that aggressive policing of illicit drug use can have adverse public-health consequences. For example, the fear engendered by intensive policing may cause people who inject drugs (PWID) to avoid services such as needle exchanges, thereby contributing to the HIV/AIDS epidemic. One country with major epidemics of illicit drug use and of HIV/AIDS among PWID is Thailand. Although Thailand reclassified drug users as “patients” instead of “criminals” in 2002, possession and consumption of illicit drugs remain criminal offenses. The 2002 legislation also created a system of compulsory drug detention centers, most of which lack evidence-based addiction treatment services. In 2003, the Thai government launched a campaign to suppress drug trafficking and to enrol 300,000 people who use drugs into treatment. This campaign received international criticism because it involved extensive human rights violations, including more than 2,800 extrajudicial killings of suspected drug users and dealers.
Why Was This Study Done?
Drug-related arrests and compulsory detention of drug users are increasing in Thailand but what is the impact of current policing practices on drug users and on public health? In this qualitative study (a study that aims for an in-depth understanding of human behavior), the researchers use thematic analysis informed by the Rhodes' Risk Environment Framework to document the social and structural factors that led to encounters with the police among PWID in Bangkok between 2008 and 2012, the policing tactics employed during these encounters, and the associated health consequences of these encounters. The Risk Environment Framework posits that a range of social, political, economic, and physical environmental factors interact with each other and shape the production of drug-related harm.
What Did the Researchers Do and Find?
Between July 2011 and June 2012, the researchers conducted in-depth interviews with a convenience sample (a non-random sample from a nearby population) of 42 participants in the Mitsampan Community Research Project, an investigation of drug-using behavior, health care access, and drug-related harms among PWID in Bangkok. Respondents reported that policing activities had intensified since rapid urine toxicology screening became widely available and since the initiation of a crackdown on drug users in 2011. They described various forms of violence and misconduct that they had experienced during confrontations with police, including false accusations, degrading stop and search procedures, and excessive use of force. Urine drug testing was identified as a key tool used by the police, with some respondents describing how police caused unnecessary humiliation by requesting urine samples in public places. It was also reported that the police used positive test results as a means of extortion. Finally, some respondents reported feeling powerless in relation to the police and cited fear of retaliation as an important barrier to obtaining redress for police corruption. Others reported that they had adopted strategies to avoid the police such as staying indoors, a strategy likely to impede access to health care, or changing their drug-using behavior by, for example, injecting midazolam rather than methamphetamine, a practice associated with an increased risk of injection-related complications.
What Do These Findings Mean?
These findings suggest that the policing of PWID in Bangkok between 2008 and 2012 involved injustices, human rights abuses, and corruption and highlight the potential for widespread misuse of urine drug testing. Moreover, they suggest that policing practices in this setting may have increased the vulnerability of PWID to poor health by impeding their access to health care and by increasing the occurrence of risky drug-using behaviors. Because this study involved a small convenience sample of PWID, these findings may not be generalizable to other areas of Bangkok or Thailand and do not indicate whether police misconduct and corruption is highly prevalent across the all police departments in Bangkok. Nevertheless, these findings suggest that multilevel structural changes and interventions are needed to mitigate the harm associated with policing of illicit drug use in Bangkok. These changes will need to ensure full accountability for police misconduct and access to legal services for victims of this misconduct. They will also need to include ethical guidelines for urine drug testing and the reform of policies that promote repressive policing and compulsory detention.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001570.
This study is further discussed in a PLOS Medicine Perspective by Burris and Koester
Human Rights Watch, a global organization dedicated to defending and protecting human rights, has information about drug policy and human rights, which includes information on Thailand
The Global Commission on Drug Policy published a report in June 2012 entitled “The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic” (available in several languages)
The Global Commission on HIV and the Law published a report in July 2012 entitled “HIV and the Law: Risk, Rights and Health” (available in several languages), the Open Society Foundations have prepared a briefing on this report
More information about the Mitsampan Community Research Project is available
doi:10.1371/journal.pmed.1001570
PMCID: PMC3858231  PMID: 24339753
4.  The Orthopaedic Trauma Patient Experience: A Qualitative Case Study of Orthopaedic Trauma Patients in Uganda 
PLoS ONE  2014;9(10):e110940.
The disability adjusted life years (DALYs) associated with injuries have increased by 34% from 1990 to 2010, making it the 10th leading cause of disability worldwide, with most of the burden affecting low-income countries. Although disability from injuries is often preventable, limited access to essential surgical services contributes to these increasing DALY rates. Similar to many other low- and middle-income countries (LMIC), Uganda is plagued by a growing volume of traumatic injuries. The aim of this study is to explore the orthopaedic trauma patient's experience in accessing medical care in Uganda and what affects the injury might have on the socioeconomic status for the patient and their dependents. We also evaluate the factors that impact an individual's ability to access an appropriate treatment facility for their traumatic injury. Semi-structured interviews were conducted with patients 18 year of age or older admitted with a fractured tibia or femur at Mulago National Referral Hospital in Kampala, Uganda. As limited literature exists on the socioeconomic impacts of disability from trauma, we designed a descriptive qualitative case study, using thematic analysis, to extract unique information for which little has been previously been documented. This methodology is subject to less bias than other qualitative methods as it imposes fewer preconceptions. Data analysis of the patient interviews (n = 35) produced over one hundred codes, nine sub-themes and three overarching themes. The three overarching categories revealed by the data were: 1) the importance of social supports; 2) the impact of and on economic resources; and 3) navigating the healthcare system. Limited resources to fund the treatment of orthopaedic trauma patients in Uganda leads to reliance of patients on their friends, family, and hospital connections, and a tremendous economic burden that falls on the patient and their dependents.
doi:10.1371/journal.pone.0110940
PMCID: PMC4215992  PMID: 25360815
5.  Barriers to and facilitators for screening women for intimate partner violence in surgical fracture clinics: a qualitative descriptive approach 
Background
Intimate Partner Violence (IPV) is a major health issue that involves any physical, sexual or psychological harm inflicted by a current or former partner. Musculoskeletal injuries represent the second most prevalent clinical manifestation of IPV. Health care professionals, however, rarely screen women for IPV. Using qualitative methods, this study aimed to explore the perceived barriers to IPV screening and potential facilitators for overcoming these barriers among orthopaedic surgeons and surgical trainees.
Methods
We conducted three focus groups with orthopaedic surgeons, senior surgical trainees, and junior surgical trainees. A semi-structured focus group guide was used to structure the discussions. Transcripts and field notes from the focus groups were analyzed using the qualitative software program N’Vivo (version 10.0; QSR International, Melbourne, Australia). To further inform our focus group findings and discuss policy changes, we conducted interviews with two opinion leaders in the field of orthopaedics. Similar to the focus groups, the interviews were digitally recorded and transcribed, and then analyzed.
Results
In the analysis, four categories of barriers were identified: surgeon perception barriers; perceived patient barriers; fracture clinic barriers and orthopaedic health care professional barriers. Some of the facilitators identified included availability of a crisis team; development of a screening form; presence of IPV posters or buttons in the fracture clinic; and the need for established policy or government support for IPV screening. The interviewees identified the need for: the introduction of evidence-based policy aiming to increase awareness about IPV among health care professionals working within the fracture clinic setting, fostering local and national champions for IPV screening, and the need to generate change on a local level.
Conclusions
There are a number of perceived barriers to screening women in the fracture clinic for IPV, many of which can be addressed through increased education and training, and additional resources in the fracture clinic. Orthopaedic health care professionals are supportive of implementing an IPV screening program in the orthopaedic fracture clinic.
doi:10.1186/1471-2474-14-122
PMCID: PMC3635968  PMID: 23560744
Intimate partner violence (IPV); Musculoskeletal injuries; Barriers; Screening
6.  Auditing Nicaragua’s anti-corruption struggle, 1998 to 2009 
BMC Health Services Research  2011;11(Suppl 2):S3.
Background
Four social audits in 1998, 2003, 2006 and 2009 identified actions that Nicaragua could take to reduce corruption and public perception in primary health care and other key services.
Methods
In a 71-cluster sample, weighted according to the 1995 census and stratified by geographic region and settlement type, we audited the same five public services: health centres and health posts, public primary schools, municipal government, transit police and the courts. Some 6,000 households answered questions about perception and personal experience of unofficial and involuntary payments, payments without obtaining receipts or to the wrong person, and payments "to facilitate" services in municipal offices or courts. Additional questions covered complaints about corruption and confidence in the country's anti-corruption struggle. Logistic regression analyses helped clarify local variations and explanatory variables. Feedback to participants and the services at both national and local levels followed each social audit.
Results
Users' experience of corruption in health services, education and municipal government decreased. The wider population's perception of corruption in these sectors decreased also, but not as quickly. Progress among traffic police faltered between 2006 and 2009 and public perception of police corruption ticked upwards in parallel with drivers' experience. Users' experience of corruption in the courts worsened over the study period -- with the possible exception of Managua between 2006 and 2009 -- but public perception of judicial corruption, after peaking in 2003, declined from then on. Confidence in the anti-corruption struggle grew from 50% to 60% between 2003 and 2009. Never more than 8% of respondents registered complaints about corruption.
Factors associated with public perception of corruption were: personal experience of corruption, quality of the service itself, and the perception that municipal government takes community opinion into account and keeps people informed about how it uses public funds.
Conclusions
Lowering citizens' perception of corruption in public services depends on reducing their experience of it, on improving service quality and access and -- perhaps most importantly -- on making citizens feel they are well-informed participants in the work of government.
doi:10.1186/1472-6963-11-S2-S3
PMCID: PMC3332562  PMID: 22375610
7.  P24 - Geriatric Medicine: An Innovative Care Strategy in Orthopaedics and Traumatology 
For many years, the administration of the Careggi University Hospital (CUH), in agreement with the Faculty of Medicine and Surgery of the University of Florence, has pressed for the creation of a department of general medicine within its othopaedic traumatology centre. In its decision n.243 of May 5, 2009, the administration of the CUH, along the lines of similar experiences already in place, set up a simple departmental unit (SDU) of geriatric medicine (GM) within the hospital’s department of orthopaedics.
The aim of this unit is to guarantee continuity of care to orthopaedics inpatients, through the identification of a specific care pathway for clinically unstable patients. The clinical activity carried out, mainly in the context of the provision of continuity of care, takes the form of daily consultancy. The SDU has a series of objectives, organisational (less postponement of surgery due to medical problems, better integration of healthcare through a multidisciplinary team, provision of internal medicine and geriatric consultancy to guarantee continuity of care), clinical (reduction of peri-operative medical complications and adverse events) and strategic (improvement of the quality of geriatric and internal medicine care, better communication with patients and families). The unit strives to exploit to the full the multi-professional (doctors, rehabilitation therapists, registered nurses, social workers) and interdisciplinary (internal medicine, geriatrics, orthopaedics, physical medicine, anaesthesiology, cardiology, angiology etc.) intervention and, in the fragile elderly, applies a multi-dimensional geriatric assessment instrument.
Clinical activity:
The physicians working in the GM SDU provide daily consultancy, including Saturday mornings. Constant telephone contact is available, also on Sundays and holidays.
In the period from 1/9/2009 to 31/7/2010, a total of 1867 consultancies were provided, spread over 268 days, which corresponds to a mean of 6.97 examinations/day. Of these, 652 (34.92%) were first visits and 1215 (65.08%) were follow ups. The assessments were always conducted in a spirit of multi-professional and multidisciplinary collaboration.
The assessments were carried out in the following departments: general orthopaedics II (25.98%), general orthopaedics I (21.26%), general orthopaedics III (18.26%), traumatology-orthopaedics (13.55%), orthopaedic oncology and reconstruction (11.25%) as well as, in smaller percentages, in all the other SDUs of the orthopaedics department, in the neurosurgery department, the plastic surgery department and the spinal unit.
In particular, internal and geriatric medicine consultancy for patients was requested in connection with high levels of co-morbidity, polypharmacy regimens, acute confusional state, dehydration, hydro-electrolytic disorders, uncompensated type 2 diabetes mellitus, pulmonary embolism, chronic liver disease and cirrhosis, pneumonia and bronchitis causing respiratory insufficiency, decompensated congestive heart failure, targeted antibiotic therapy, chronic renal insufficiency, and management of anti-aggregant and anticoagulant therapies.
Positive aspects: the clinical assessments were made using a multidisciplinary approach, based on the fundamental collaboration of specialists in orthopaedics, anaesthesiology-resuscitation, angiology, cardiology, radiology and physical medicine; excellent collaboration with services (radiology, neuroradiology, angiology, cardiology, etc.).
Negative aspects: constant difficulties transferring clinically unstable patients to the hospital’s medical specialty SDUs due to lack of beds; lack of intermediate care beds as a sort of “buffer” between the intensive care and inpatient departments; scope for improving the internal medicine skills of the nursing staff.
Research projects:
In synergy the hospital’s other SDUs, the GM SDU takes part in projects aiming to improve care and clinical management. It currently has collaborations with the geriatrics clinic, regional centre of reference for haemostasis and thrombosis, the bone metabolism clinic, the orthopaedics clinics, the geriatrics agency, the radiology service, the continuity-of-care agency, the clinical management, and the general affairs unit. Furthermore, on the instigation of the regional health council, a working group has recently been set up on the reorganisation of the “Care pathway of elderly patients with proximal femur fracture (orthogeriatrics)”.
Prospects for implementation and improvement:
The aims of the “Project to reorganise and upgrade the orthopaedics and traumatology centre of the Careggi University Hospital” include: the institution of a medical geriatrics department providing medium and high intensity of care; the presence, 24 hours/day, of a specialist from the medical area in the traumatology open space; the involvement of the internal medicine specialist in pre-hospitalisation procedures.
PMCID: PMC3213796
8.  International patients on operation vacation – perspectives of patients travelling to Hungary for orthopaedic treatments 
Background: The importance of cross-border healthcare, medical and health tourism plays a significant role in the European health policy and health management. After dentistry, orthopaedic treatments are the leading motivation for seeking care in Hungary, as patients with rheumatic and motion diseases are drawn to the thermal spas and well-established orthopaedic centres. This paper aims to gain insight into foreign patients’ perspectives on their experience of having sought medical tourism in orthopaedic care in Hungary.
Methods: A patient survey was conducted in 2012 on motivations for seeking treatment abroad, orthopaedic care received and overall satisfaction. In addition, health professionals’ interviews, and 17 phone interviews were conducted in 2013 with Romanian patients who had orthopaedic treatment in Hungary. Finally, medical records of foreign patients were analysed.
Results: The survey was completed by 115 participants – 61.1% females, mean age= 41.9, 87% Romanian origin. Most of the patients came to Hungary for orthopaedic surgeries, e.g. arthroscopy, knee/hip prosthesis or spinal surgery. 72.6% chose Hungary because of related to perceived better quality and longstanding culture of Hungarian orthopaedic care. Over 57% of patients reported being ‘very satisfied’ with care received and 41.6% ‘satisfied’. The follow-up interviews further reflected this level of satisfaction, therefore many respondents stating they have already recommended the Hungarian healthcare to others.
Conclusion: Based on the findings, patients from neighbouring regions are increasingly seeking orthopaedic care in Hungary. Patients having orthopaedic care are highly satisfied with the quality of care, the whole treatment process from the availability of information to discharge summaries and would consider returning for further treatments.
doi:10.15171/ijhpm.2014.113
PMCID: PMC4226623  PMID: 25396209
Patient Satisfaction; Cross-Border Patient Care; Access; Orthopaedic Treatments
9.  Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries 
PLoS Medicine  2010;7(3):e1000243.
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.
Background
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.
Methods and Findings
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.
Conclusion
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
Editors' Summary
Background
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.
Why Was This Study Done?
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.
What Did the Researchers Do and Find?
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.
What Do These Findings Mean?
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.
Additional Information
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
doi:10.1371/journal.pmed.1000243
PMCID: PMC2834708  PMID: 20231871
10.  The Evolution of Advocacy and Orthopaedic Surgery 
Background
The future direction of American health care has become increasingly controversial during the last decade. As healthcare costs, quality, and delivery have come under intense scrutiny, physicians play evolving roles as “advocates” for both their profession and patients via healthcare policy. Hospital-physician alignment is critical to the future success of advocacy among orthopaedic surgeons, as both hospitals and physicians are key stakeholders in health care and can work together to influence major health policy decisions.
Questions/purposes
We (1) define the role of advocacy in medicine, specifically within orthopaedic surgery; (2) explore the history of physician advocacy and its evolution; (3) examine the various avenues of involvement for orthopaedic surgeons interested in advocacy; and (4) reflect on the impact of such activities on the future of orthopaedic surgery as it relates to hospital-physician alignment.
Methods
We performed a comprehensive review of the literature through a bibliographic search of MEDLINE® and Google Scholar databases from January 2000 to December 2010 to identify articles related to advocacy and orthopaedic surgery.
Results
Advocacy among orthopaedic surgeons is critical in guiding the future of the American healthcare system. In today’s world, advocacy necessitates a wider effort to improve healthcare access, quality, and delivery for patients on a larger scale. The nature of physician advocacy among orthopaedic surgeons is grounded in the desire to serve patients and alleviate their suffering. Participation in medical societies and political campaigns are two avenues of involvement.
Conclusions
The increasing role of government in American health care will require a renewed commitment to advocacy efforts from orthopaedic surgeons. The role of advocacy is rapidly redefining the continuum of care to a trinity of clinical excellence, innovative research, and effective advocacy. Failure to recognize this growing role of advocacy limits the impact we can have for our patients.
doi:10.1007/s11999-013-2900-3
PMCID: PMC3706663  PMID: 23479232
11.  Musculoskeletal Trauma Services in Serbia 
Serbia, a middle-income country, is located in southeastern Europe, with territory of 88,361 km2 and 9,400,000 inhabitants. Average month salary is US$542 and the registered unemployment rate is 22%. The country is administratively divided into 30 districts (193 municipalities). The healthcare system is territorially organized. In the state capital there are five clinical hospitals with musculoskeletal traumatology departments, as well as one in each of the four university centers. In addition, there are orthopaedic departments in 40 smaller hospitals throughout the country and in three military hospitals, along with several pediatric surgical departments involved in managing musculoskeletal trauma. There are 524 orthopaedic trauma surgeons (1:18,000 people), with a minor number of additionally trained general and pediatric surgeons who care for musculoskeletal problems. Bonesetters are neither recognized nor included in the healthcare system. Orthopaedic traumatology services are well organized, with variable accessibility depending on the distance between injury site and nearest medical facility. Preventive strategies are well developed and mainly consider agricultural, industrial, and traffic injuries. Distribution of medical institutions is satisfactory. Future activities should include continuing medical education of specialists, exclusion of inappropriate specialists, improvement of preventive strategies and medical transport facilities, as well as standardization of medical equipment, diagnostics, and treatment protocols.
doi:10.1007/s11999-008-0364-7
PMCID: PMC2584292  PMID: 18622666
12.  Musculoskeletal Training for Orthopaedists and Nonorthopaedists: Experiences in India 
In India, health policies, services, health indices, and medical education are improving despite the country’s enormous population and limited resources. Orthopaedic training in India should be geared to serve the predominantly rural population (72% of total population) living in some 550,000 villages, but unless the basic amenities improve in villages and towns, orthopaedists will remain averse to serving in these areas. Traditional practitioners play an important role in musculoskeletal trauma care in villages and even some town and city areas, and hence cannot be ignored. We suggest a stratified system of orthopaedic training for medical graduates, postgraduates, and paramedics with a well-defined need-based curriculum, and a clear cut division of labor, terms, and conditions to suit the stratified social and demographic structure of India. This stratified system is intended to provide appropriate musculoskeletal trauma care services to the rural population, reduce neglected and mismanaged trauma, consequently avoiding subsequent orthopaedic disability, and reduce the financial burden of managing these cases. This system also intends to prevent overloading of teaching hospitals and apex institutes and ensure availability of subspecialized orthopaedic services in the country at designated centers. Traditional practitioners shall be periodically educated regarding safe orthopaedic practices, which are anticipated to yield improved trauma care services.
doi:10.1007/s11999-008-0410-5
PMCID: PMC2584295  PMID: 18683015
13.  Early Active Motion in Joint Pain and Stiffness 
E. Bishop (“Bish”) Mumford was born in 1879 in Indiana [2] (most likely in or near New Harmony, the birthplace of both of his parents, who were committed to Robert Owen’s concept of that socialistic community established by Owen in 1826 [4]). He graduated from the University of Wisconsin in 1901 and Johns Hopkins in 1905. He obtained postgraduate training at Boston Children’s Hospital and Gouverneur’s Hospital (a hospital originally established to provide care for low income patients of color) in New York. He returned to Indiana to establish a practice in children’s orthopaedics. His practice was interrupted by WW I, where he served as a captain in a base hospital in France. He returned after the war and in 1920 opened the Indianapolis Industrial Clinic with Dr. Jay Reed. He later was appointed to the faculty at the Medical College of Indiana and was one of the first surgeons appointed to the James Whitcomb Riley Hospital for Crippled Children and the first surgeon appointed to the Veteran’s Administration Hospital of Indiana. He continued his appointments at these and other hospitals until his death.
Dr. Mumford was one of the founding members of the AAOS, and was one of eight members listed as attending the business meeting of the Clinical Orthopaedic Society, October 30, 1931, where the concept of a new national organization was discussed [1]. While the record is not entirely clear, Mumford apparently served on the Executive Committee of the AAOS from 1931 (when according to Heck the AAOS was chartered [3]) until 1944, then as President-Elect, President from 1945–1946, and continued on the Executive Committee until 1950 [2]; that being the case, he would have served on the Executive longer than any of the original founders (and perhaps longer than anyone since). He is the only AAOS President to have served two terms: at the written request of the Office of Defense Transportation in 1944, the January, 1945 meeting was canceled, and he remained President during the subsequent year, presiding over the 1946 meeting. He was active in the AOA and the Clinical Orthopaedic Society (he served as Secretary-Treasurer, Vice-President, and President in 1933, the year of the first meeting of the AAOS), as well as the Indianapolis Board of Health, the American College of Surgeons and other organizations. Among all of his many clinical responsibilities and activities in the 1930s, he found time to assume from his father the management of his family’s 5800 acre farm in Indiana.
The article we reproduce here expresses Mumford’s belief in early mobilization of injured joints. “The motion you gain through early mobilization of the joint,” he maintained, “you do not lose. The motion you lose through long fixation of the joint may be permanent.” This article, published in 1960, undoubtedly reflected concepts he developed through his long experience with industrial injuries.Dr. E. Bishop Mumford is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
References
Brown T. The American Orthopaedic Association: A Centennial History. Chicago, IL: The American Orthopaedic Association; 1987.E. Bishop Mumford. J Bone Joint Surg Am. 1962;44:579–581.Heck CV. Fifty Years of Progress: In Recognition of the 50th Anniversary of the American Academy of Orthopaedic Surgeons. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Robert Owen. Wikipedia Web site. Available at: http://www.en.wikipedia.org/wiki/Robert_Owen. Accessed August 29, 2007.
doi:10.1007/s11999-007-0022-5
PMCID: PMC2505291  PMID: 18196380
14.  Transparency in Nigeria's public pharmaceutical sector: perceptions from policy makers 
Background
Pharmaceuticals are an integral component of health care systems worldwide, thus, regulatory weaknesses in governance of the pharmaceutical system negatively impact health outcomes especially in developing countries [1]. Nigeria is one of a number of countries whose pharmaceutical system has been impacted by corruption and has struggled to curtail the production and trafficking of substandard drugs. In 2001, the National Agency for Food and Drug Administration and Control (NAFDAC) underwent an organizational restructuring resulting in reforms to reduce counterfeit drugs and better regulate pharmaceuticals [2]. Despite these changes, there is still room for improvement. This study assessed the perceived level of transparency and potential vulnerability to corruption that exists in four essential areas of Nigeria's pharmaceutical sector: registration, procurement, inspection (divided into inspection of ports and of establishments), and distribution.
Methods
Standardized questionnaires were adapted from the World Health Organization assessment tool and used in semi-structured interviews with key stakeholders in the public and private pharmaceutical system. The responses to the questions were tallied and converted to scores on a numerical scale where lower scores suggested greater vulnerability to corruption and higher scores suggested lower vulnerability.
Results
The overall score for Nigeria's pharmaceutical system was 7.4 out of 10, indicating a system that is marginally vulnerable to corruption. The weakest links were the areas of drug registration and inspection of ports. Analysis of the qualitative results revealed that the perceived level of corruption did not always match the qualitative evidence.
Conclusion
Despite the many reported reforms instituted by NAFDAC, the study findings suggest that facets of the pharmaceutical system in Nigeria remain fairly vulnerable to corruption. The most glaring deficiency seems to be the absence of conflict of interest guidelines which, if present and consistently administered, limit the promulgation of corrupt practices. Other major contributing factors are the inconsistency in documentation of procedures, lack of public availability of such documentation, and inadequacies in monitoring and evaluation. What is most critical from this study is the identification of areas that still remain permeable to corruption and, perhaps, where more appropriate checks and balances are needed from the Nigerian government and the international community.
doi:10.1186/1744-8603-5-14
PMCID: PMC2775729  PMID: 19874613
15.  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
16.  What Is the Current Status of Global Health Activities and Opportunities in US Orthopaedic Residency Programs? 
Background
Interest in developing national health care has been increasing in many fields of medicine, including orthopaedics. One manifestation of this interest has been the development of global health opportunities during residency training.
Questions/purposes
We assessed global health activities and opportunities in orthopaedic residency in terms of resident involvement, program characteristics, sources of funding and support, partner site relationships and geography, and program director opinions on global health participation and the associated barriers.
Methods
An anonymous 24-question survey was circulated to all US orthopaedic surgery residency program directors (n = 153) by email. Five reminder emails were distributed over the next 7 weeks. A total of 59% (n = 90) program directors responded.
Results
Sixty-one percent of responding orthopaedic residencies facilitated clinical experiences in developing countries. Program characteristics varied, but most used clinical rotation or elective time for travel (76%), which most frequently occurred during Postgraduate Year 4 (57%) and was used to provide pediatric (66%) or trauma (60%) care. The majority of programs (59%) provided at least some funding to traveling residents and sent accompanying attendings on all ventures (56%). Travel was most commonly within North America (85%), and 51% of participating programs have established international partner sites although only 11% have hosted surgeons from those partnerships. Sixty-nine percent of residency directors believed global health experiences during residency shape future volunteer efforts, 39% believed such opportunities help attract residents to a training program, and the major perceived challenges were funding (73%), faculty time (53%), and logistical planning (43%).
Conclusions
Global health interest and activity are common among orthopaedic residency programs. There is diversity in the characteristics and geographical locations of such activity, although some consensus does exist among program directors around funding and faculty time as the largest challenges.
doi:10.1007/s11999-013-3184-3
PMCID: PMC3792241  PMID: 23893360
17.  The case for orthopaedic medicine in Israel 
Background
Musculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists.
Methods
In order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel’s large non-profit HMO’s, and the domains of the visits to an orthopaedic surgeon.
Results
Orthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO’s. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training.
Discussion
While orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the “Orthopaedic Medicine Lacuna” is responsible for inadequate treatment of non-surgical problems of the musculoskeletal system with immense financial implications. We present a preliminary probe into possible solutions which could be relevant to many developed countries.
doi:10.1186/2045-4015-2-42
PMCID: PMC3834558  PMID: 24245773
Orthopaedic medicine; Musculoskeletal pain; Pain management
18.  Acute Pyogenic Arthritis of the Hip: An Operation Giving Free Access and Effective Drainage 
Dr. Gathorne R. Girdlestone is shown at a Wingfield Hospital fête. Figure reprinted with permission of the Oxfordshire Health Archives, Oxfordshire, UK.
Gathorne Robert Girdlestone was born in 1881, the son of the Rev. R.B. Girdlestone, Honorary Canon of Christ Church, Oxford [3]. His early education was at Charterhouse, then he read medicine at New College, Oxford. Girdlestone received his subsequent medical training at St. Thomas’ Hospital, London, completing his house appointment there. He subsequently went to Oswestry, where he was influenced by Sir Robert Jones. During WW I he returned to Oxford to assume charge of a military hospital that eventually had over 400 beds. The Wingfield Convalescent Home, an “old fashioned institution,” [3] was located in Headington, then a village near Oxford, and Girdlestone’s initial military hospital consisted largely of open air huts on the Wingfield grounds. Girdlestone continued to work there and at the Radcliffe Infirmary after the war. These huts were, through the benefaction of Sir William Morris (the founder of Morris Motors and later elevated to Lord Nuffield), replaced with modern buildings beginning in 1930 with a bequest of £70,000 [4]. These new buildings, initially named the Wingfield-Morris Orthopaedic Hospital, were opened by the Prince of Wales in 1933. As a result of his work and stature and perhaps his relationship with Lord Nuffield, Girdlestone was appointed in 1937 the first British Professor of Orthopaedic Surgery. (Oxford Medical School eventually received £2,000,000 from Lord Nuffield [3].) The Wingfield-Morris Orthopaedic Hospital became part of the National Health Service in 1948, then was renamed the Nuffield Orthopaedic Centre in 1950, the year of Girdlestone’s death. It is fair to say that Girdlestone was among the primary and most influential individuals creating a specialty of orthopaedic surgery in the first half of the 20th century.
Girdlestone wrote at least two articles describing excision arthroplasty of the hip. The first, from 1928, described a radical excision for draining tuberculous hips [1] and the second (reprinted here), from 1942, a related and perhaps at times even more radical operation for pyogenic infections [2]. Girdlestone emphasized these radical operations were intended only for severe infections, and readers are reminded these were both published in the preantibiotic era, when radical surgery was often required to save a patient’s life. In the first article, he also emphasized the principle of “removal of diseased and devitalized tissues, flattening down of dead spaces, and leaving drainage so complete and lasting as will allow the wound to heal from the bottom” [1]. He excised the greater trochanter and all involved muscles, suturing skin edges deep into the wound so as to achieve effective drainage. When necessary, he also “flattened” the edges of the acetabulum. In the second article he suggested less radical operations were often ineffective in pyogenic infections owing to the “miniature rabbit-warren of sinuses and cavities” [2]. The techniques were fundamentally similar to those he had earlier described for tuberculosis. He used a wide transverse incision (Fig. 2) to access the hip, excising all lateral musculature along with the trochanter and the lateral margin of the acetabulum (Fig. 1). In the presence of infection in the intermuscular planes, he avoided suturing the skin deeply, and rather packed the wound with Vaseline gauze and rubber drains (Fig. 4). The postoperative care included splinting either on a frame (if good nursing care was available) or spica casting with a large window. Readers familiar with operations for infected total hip arthroplasties will immediately recognize current procedures are far less radical than those typically used in Girdlestone’s time. Rarely would an infected arthroplasty be treated with such radical excision of bone and muscle, open packing, and secondary healing. For that reason, I suggest the name Girdlestone not be used for contemporary operations except as they apply to what he described: excision arthroplasty more accurately describes current procedures.
References
Girdlestone GR. Arthrodesis and other operations for tuberculosis of the hip. In: Milford H, ed. The Robert Jones Birthday Volume. London, UK: Oxford University Press; 1928:347–374.Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. Lancet. 1943;241:419–421.In Memorium: Gathorne Robert Girdlestone. J Bone Joint Surg Br. 1951;33:130–133.Nuffield Orthopaedic Centre National Health Service Web site. Available at: http://www.noc.nhs.uk/. Accessed October 4, 2007.
doi:10.1007/s11999-007-0082-6
PMCID: PMC2505144  PMID: 18196404
19.  Evaluating the outcomes of a podiatry-led assessment service in a public hospital orthopaedic unit 
Background
In Australia, the demand for foot and ankle orthopaedic services in public health settings currently outweighs capacity. Introducing experienced allied health professionals into orthopaedic units to initiate the triage, assessment and management of patients has been proposed to help meet demand. The aim of this study was to evaluate the effect of introducing a podiatry-led assessment service in a public hospital orthopaedic unit. The outcomes of interest were determining: the proportion of patients discharged without requiring an orthopaedic appointment, agreement in diagnosis between the patient referral and the assessing podiatrist, the proportion of foot and ankle conditions presenting to the service, and the proportion of each condition to require an orthopaedic appointment.
Methods
This study audited the first 100 patients to receive an appointment at a new podiatry-led assessment service. The podiatrist triaged ‘Category 3’ referrals consisting of musculoskeletal foot and ankle conditions and appointments were provided for those considered likely to benefit from non-surgical management. Following assessment, patients were referred to an appropriate healthcare professional or were discharged. At the initial appointment or following a period of care, patients were discharged if non-surgical management was successful, surgery was not indicated, patients did not want surgery, and if patient’s failed to attend their appointments. All other patients were referred for an orthopaedic consultation as indicated.
Results
Ninety-five of the 100 patients (69 females and 31 males; mean age 51.9, SD 16.4 years) attended their appointment at the podiatry-led assessment service. The 95 referrals contained a total of 107 diagnoses, of which the podiatrist agreed with the diagnosis stated on the referral in 56 cases (Kappa =0.49, SE = 0.05). Overall, 34 of the 100 patients were referred to an orthopaedic surgeon and the remaining 66 patients were discharged from the orthopaedic waiting list without requiring an orthopaedic consultation.
Conclusions
Two-thirds of patients who had an appointment at the podiatry-led assessment service were discharged without requiring a surgical consultation. The introduction of a podiatry-led service assists with timely provision of patient care and ensures those with the greatest need for orthopaedic surgery have improved access to specialist care.
doi:10.1186/s13047-014-0045-6
PMCID: PMC4240809  PMID: 25419238
20.  Low-income Countries’ Orthopaedic Information Needs: Challenges and Opportunities 
Background
The Internet should, in theory, facilitate access to peer-reviewed scientific articles for orthopaedic surgeons in low-income countries (LIC). However, there are major barriers to access, and most full-text journal articles are available only on a subscription basis, which many in LIC cannot afford. Various models exist to remove such barriers. We set out to examine the potential, and reality, of journal article access for surgeons in LIC by studying readership patterns and journal access through a number of Internet-based initiatives, including an open access journal (“PLoS Medicine”), and programs from the University of Toronto (The Ptolemy Project) and World Health Organization (WHO) (Health InterNetwork Access to Research Initiative [HINARI]).
Questions/purposes
Do Internet-based initiatives that focus on peer-reviewed journal articles deliver clinically relevant information to those who need it? More specifically: (1) Can the WHO’s program meet the information needs of practicing surgeons in Africa? (2) Are healthcare workers across the globe aware of, and using, open access journals in a manner that reflects global burden of disease (GBD)?
Methods
We compared actual Ptolemy use to HINARI holdings. We also compared “PLoS Medicine” readership patterns among low-, middle-, and high-income regions.
Results
Many of the electronic resources used through Ptolemy are not available through HINARI. In contrast to higher-income regions, “PLoS Medicine” readership in Africa is proportional to both the density of healthcare workers and the GBD there.
Conclusions
Free or low-cost Internet-based initiatives can improve access to the medical literature in LIC. Open access journals are a key component to providing clinically relevant literature to the regions and healthcare workers who need it most.
doi:10.1007/s11999-010-1365-x
PMCID: PMC3049618  PMID: 20431972
21.  PRevalence of Abuse and Intimate Partner Violence Surgical Evaluation (P.R.A.I.S.E.): rationale and design of a multi-center cross-sectional study.  
Background
Intimate partner violence (IPV) is described by the American Medical Association as "a pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, deprivation, and intimidation." The long-term consequences of IPV include health risks, posttraumatic stress disorder, depression, and staggering economic costs for health care of victims. Intimate partner violence is often underreported among women who seek medical attention. The current study seeks to address the issue of possible underreporting of IPV in orthopaedic fracture clinics by establishing prevalence rates of IPV among women seeking treatment for musculoskeletal injuries.
Methods/Design
We propose a cross-sectional multicenter study wherein 3,600 women will complete a self-reported written questionnaire across clinical sites in North America, Europe, and Australia. Recruitment of participants will take place at orthopaedic fracture clinics at each clinical site. The questionnaire will contain a validated set of questions used to screen for IPV, as well as questions that pertain to the participant's demographic, injury characteristics, and experiences with health care utilization. Female patients presenting to the orthopaedic fracture clinics will complete two validated self-reported written questionnaires (Woman Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS)) to determine the prevalence of IPV in the past 12 months and in their lifetime. The two questionnaires were designed for rapid assessment of IPV status in emergency departments, family practice, and women's health clinics that we believe are similar to our intended setting of an orthopaedic clinic.
Discussion
If the prevalence of IPV among women attending orthopaedic clinics is greater than the current perceptions of orthopaedic surgeons, this study will serve to advocate for the continued education of medical professionals to better recognize probable IPV cases and offer existing services to enhance the care of these patients.
doi:10.1186/1471-2474-11-77
PMCID: PMC2883954  PMID: 20416039
22.  Morbidity Pattern and Impact of Rehabilitative Services in Earth Quake Victims of Kashmir, India. 
Background:
The Kashmir earthquake also known as South Asia earthquake, hit both sides of Jammu & Kashmir on October 8th 2005 and was quite devastating with official toll of deaths being 73,276 in Pakistan Administered Kashmir (POK) and 1,360 deaths in the Indian administered Kashmir. The injured registering on the two sides were around 100,000 and 6,300 respectively. This was followed by a series of aftershocks on both sides for another 3 weeks
Method:
A follow up (retrospective) survey was conducted by the Department of Community Medicine SKIMS, Srinagar in collaboration with National Institute of Orthopedically Handicapped (NIOH), Kolkata, immediately after the devastating earthquake of October 2008 that hit Kashmir (Jammu & Kashmir- India) and northern parts of India with the objectives to know the nature of the injuries, magnitude of disabilities, rehabilitative services provided, and service satisfaction. Addresses of earthquake victims registered with various health institutions, Tertiary Care Centre, orthopaedic hospital, district hospital and Composite Regional Centre (CRC)(through which rehabilitative services were provided initially) were collected and referral details, if any, to various health institutions. They were visited at their residence and interviewed for the desired information as per proforma by a team comprising of a doctor, physiotherapist, prosthetist and orthotist by making house to house survey in the earthquake areas. An effort for non registered injured victims, if any in the locality, was also made with health or district authorities to trace non registered injured persons
Results:
The study shows that majority of injured were young adults and adolescent females, and primarily upper extremities, cervical spine and head were injured. The severely injured were shifted within 12–24 hrs to referral hospitals. In 2/3rd of affected families, single member was injured, whereas in 1/3rd at least two were injured. The case fatality rate was <1% because of low prevalence of crush injuries, and quick medical relief/management of the injured. A significant number of seriously injured victims (40%) required rehabilitative services and assistive devices. Probably a quick intervention by medical rehabilitative services, including facility of assistive aids and necessary customised prosthetics and orthotics first time in such disaster, has resulted in high client satisfaction, early restoration of functional and psychological status of the injured victims.
Conclusion:
A collective effort by various public and private agencies with timely response at referral hospitals to various injuries reduced the frequency and chances of major disabling conditions. Intervention by CRC for providing assistive devices has also significantly helped in bringing back the functional and psychological status of the injured victims. Proper inter-sectorial coordination, better managerial skills, training of community volunteers (NGOs), and professionals on disaster management may further reduce the injury related disability and its impact. There is need of updating medico-surgical disaster management training for health care workers on continuous basis at various levels
PMCID: PMC3068802  PMID: 21475527
Earthquake; injuries; victims; rehabilitative services; satisfaction
23.  Global Relevance of Literature on Trauma 
The trauma pandemic disproportionately kills and maims citizens of low-income countries although the immediate cause of the trauma is often an industrial export of a high-income country, such as a motor vehicle. Addressing the trauma pandemic in low-income countries requires access to relevant research information regarding prevention and treatment of injuries. Such information is also generally produced in high-income countries. We reviewed two years’ worth of articles from leading orthopaedic and general medical journals to determine whether the scientific literature appropriately reflects the global burden of musculoskeletal disease, particularly that due to trauma. General medical journals underrepresented musculoskeletal disease, but within musculoskeletal disease an appropriate majority of papers were regarding trauma, in particular the epidemiology and prevention of injury. Orthopaedic journals, while focusing on musculoskeletal conditions, substantially underrepresented the global burden of disease due to trauma and hardly consider injury epidemiology and prevention. If orthopaedic surgeons want to maximize their global impact, they should focus on writing about trauma questions relevant to their colleagues in low-income countries and ensuring these same colleagues have access to the literature.
doi:10.1007/s11999-008-0397-y
PMCID: PMC2584287  PMID: 18685910
24.  Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review 
PLoS Medicine  2012;9(6):e1001244.
A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries.
Introduction
Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.
Methods and Findings
Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.
Conclusions
Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Health care can be provided through public and private providers. Public health care is usually provided by the government through national healthcare systems. Private health care can be provided through “for profit” hospitals and self-employed practitioners, and “not for profit” non-government providers, including faith-based organizations.
There is considerable ideological debate around whether low- and middle-income countries should strengthen public versus private healthcare services, but in reality, most low- and middle-income countries use both types of healthcare provision. Recently, as the global economic recession has put major constraints on government budgets—the major funding source for healthcare expenditures in most countries—disputes between the proponents of private and public systems have escalated, further fuelled by the recommendation of International Monetary Fund (an international finance institution) that countries increase the scope of private sector provision in health care as part of loan conditions to reduce government debt. However, critics of the private health sector believe that public healthcare provision is of most benefit to poor people and is the only way to achieve universal and equitable access to health care.
Why Was This Study Done?
Both sides of the public versus private healthcare debate draw on selected case reports to defend their viewpoints, but there is a widely held view that the private health system is more efficient than the public health system. Therefore, in order to inform policy, there is an urgent need for robust evidence to evaluate the quality and effectiveness of the health care provided through both systems. In this study, the authors reviewed all of the evidence in a systematic way to evaluate available data on public and private sector performance.
What Did the Researchers Do and Find?
The researchers used eight databases and a comprehensive key word search to identify and review appropriate published data and studies of private and public sector performance in low- and middle-income countries. They assessed selected studies against the World Health Organization's six essential themes of health systems—accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency—and conducted a narrative review of each theme.
Out of the 102 relevant studies included in their comparative analysis, 59 studies were research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. The researchers found that study findings varied considerably across countries studied (one-third of studies were conducted in Africa and a third in Southeast Asia) and by the methods used.
Financial barriers to care (such as user fees) were reported for both public and private systems. Although studies report that patients in the private sector experience better timeliness and hospitality, studies suggest that providers in the private sector more frequently violate accepted medical standards and have lower reported efficiency.
What Do These Findings Mean?
This systematic review did not support previous views that private sector delivery of health care in low- and middle-income settings is more efficient, accountable, or effective than public sector delivery. Each system has its strengths and weaknesses, but importantly, in both sectors, there were financial barriers to care, and each had poor accountability and transparency. This systematic review highlights a limited and poor-quality evidence base regarding the comparative performance of the two systems.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001244.
A previous PLoS Medicine study examined the outpatient care provided by the public and private sector in low-income countries
The WHO website provides more information on healthcare systems
The World Bank website provides information on health system financing
Oxfam provides an argument against increased private health care in poor countries
doi:10.1371/journal.pmed.1001244
PMCID: PMC3378609  PMID: 22723748
25.  Few Insurance-Based Differences in Upper Extremity Elective Surgery Rates After Healthcare Reform 
Background
Before the US Patient Protection and Affordable Care Act of 2010, there were documented insurance-based disparities in access to orthopaedic surgeons and care of orthopaedic conditions. While Massachusetts passed healthcare reform in 2007 with many similar provisions, it is unknown whether the disparities were present during the period of the law’s enactment.
Questions/purposes
We asked whether differences in rates of surgery between patients with novel government-subsidized healthcare plans and other forms of insurance, and between uninsured and insured patients, were similar after institution of the Massachusetts reform laws.
Methods
We identified 7577 patients diagnosed with upper extremity injuries between January 1, 2007 and October 1, 2010. From an institutional administrative database, we extracted demographics, insurance status, and plan of care. Insurance categories included government-subsidized healthcare plan (Commonwealth Care), private insurance, workers compensation, military-related (TriCare), Medicare, Medicaid (MassHealth), non-Commonwealth Care, and other insured and uninsured. After adjusting for age, gender, and diagnosis, we compared the proportions of patients who underwent elective surgery.
Results
Of 7577 patients, 1685 (22%) underwent elective upper extremity surgery. The adjusted rates of surgery were similar across most insurance categories, with higher rates in the workers compensation and TriCare categories compared with Commonwealth Care. Uninsured patients were as likely to undergo surgery as insured patients.
Conclusion
In a population with near-universal health insurance, a government-run health insurance exchange, and novel, government-subsidized, managed care plans, we found few insurance-based differences in rates of elective upper extremity orthopaedic surgery in a cohort of patients after healthcare reform.
Level of Evidence
Level IV, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2305-8
PMCID: PMC3369096  PMID: 22451335

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