Publications by authors named "Mark G Shrime"

130 Publications

The Macroeconomic Consequences Of Firearm-Related Fatalities In OECD Countries, 2018-30: A Value-Of-Lost-Output Analysis.

Health Aff (Millwood) 2020 11;39(11):1961-1969

Blake C. Alkire is an instructor in the Program in Global Surgery and Social Change at Harvard Medical School and an instructor in otolaryngology at the Massachusetts Eye and Ear Infirmary, in Boston, Massachusetts.

We modeled gross domestic product (GDP) losses attributable to firearm-related fatalities in each of thirty-six Organization for Economic Cooperation and Development (OECD) countries using the value-of-lost-output approach from 2018 to 2030. There are three categories of firearm-related fatalities: physical violence, self-harm, and unintentional injury. We project that the thirty-six OECD countries will lose $239.0 billion in cumulative GDP from 2018 to 2030 from firearm-related fatalities. Most of these losses ($152.5 billion) will occur as a result of fatalities in the US. In 2030 alone, the OECD countries will collectively lose $30.4 billion (0.04 percent) of their estimated annual GDP from firearm-related fatalities. The highest relative losses will occur in Mexico and the US; the lowest will occur in Japan. Firearm-related fatalities are expected to disproportionately affect the US and Mexican economies. Across the OECD, 48.5 percent of economic losses will be attributable to physical violence, 47.0 percent to self-harm, and 4.6 percent to unintentional injury. These findings provide a more complete picture of the toll of firearm-related fatalities, a global public health crisis that, without intervention, will continue to impose significant economic losses across OECD countries.
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http://dx.doi.org/10.1377/hlthaff.2019.01701DOI Listing
November 2020

Top 10 Resources in Global Surgery.

Glob Health Sci Pract 2020 09 30;8(3):606-611. Epub 2020 Sep 30.

Cabinet Office, Government of the Republic of Zambia, Lusaka, Zambia.

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http://dx.doi.org/10.9745/GHSP-D-20-00050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541111PMC
September 2020

Money down the drain: predatory publishing in the COVID-19 era.

Can J Public Health 2020 10 4;111(5):665-666. Epub 2020 Sep 4.

Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland.

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http://dx.doi.org/10.17269/s41997-020-00411-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7472937PMC
October 2020

Identifying essential components of surgical care delivery through quality improvement: An updated surgical assessment tool.

Int J Surg 2020 Oct 15;82:103-107. Epub 2020 Aug 15.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.

Background: Surgical care is a cost-effective intervention with major public health impact. Yet, five billion people do not have access to surgical and anesthesia care. This overwhelming unmet need has generated a rising interest in scale-up of these services globally. The purpose of this research was to aggregate available guidelines and create a synthesized tool that could provide valuable information at the local, national, and international health system levels.

Methods: A systematic review identified current documents cataloging elements for surgical care provision. Items with a reported frequency of >30% were included in the initial draft of the Surgical Assessment Tool. This underwent two cycles of Delphi-method expert opinion elicitation from providers working in low- and middle-income settings. Finally, the tool underwent vetting by the World Health Organization to create an expert-endorsed survey.

Results: Fifteen surgical tools were identified, containing a total of 216 unique elements in the following domains: infrastructure (n = 152), service delivery (n = 49), and workforce (n = 15). The final tool consisted of 169 items in the following domains: infrastructure (n = 35), service delivery (n = 92), workforce (n = 20), information management (n = 10), and financing (n = 12).

Conclusion: Informed planning is critical to ensure successful expansion of surgical services. Our analysis of current tools shows varying agreement on the essential components of surgical care delivery. This updated tool serves as a crucial method to systematically assess surgical systems as well as monitor, modify, and strengthen in a scalable fashion. Importantly, it has the potential to be used in all settings after adaptation to local context.
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http://dx.doi.org/10.1016/j.ijsu.2020.08.002DOI Listing
October 2020

Is AJCC/UICC Staging Still Appropriate for Head and Neck Cancers in Developing Countries?

OTO Open 2020 Jul-Sep;4(3):2473974X20938313. Epub 2020 Jul 6.

Program in Global Surgery and Social Change, Harvard Medical School and Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

By 2030, 70% of cancers will occur in developing countries. Head and neck cancers are primarily a developing world disease. While anatomical location and the extent of cancers are central to defining prognosis and staging, the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) have incorporated nonanatomic factors that correlate with prognosis into staging (eg, p16 status of oropharyngeal cancers). However, 16 of 17 head and neck surgeons from 13 African countries cannot routinely test for p16 status and hence can no longer apply AJCC/UICC staging to oropharyngeal cancer. While the AJCC/UICC should continue to refine staging that best reflects treatment outcomes and prognosis by incorporating new nonanatomical factors, they should also retain and refine anatomically based staging to serve the needs of clinicians and their patients in resource-constrained settings. Not to do so would diminish their global relevance and in so doing also disadvantage most of the world's cancer patients.
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http://dx.doi.org/10.1177/2473974X20938313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338737PMC
July 2020

How much is enough? Exploring the dose-response relationship between cash transfers and surgical utilization in a resource-poor setting.

PLoS One 2020 14;15(5):e0232761. Epub 2020 May 14.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America.

Objective: Cash transfers are a common intervention to incentivize salutary behavior in resource-constrained settings. Many cash transfer studies do not, however, account for the effect of the size of the cash transfer in design or analysis. A randomized, controlled trial of a cash-transfer intervention is planned to incentivize appropriate surgical utilization in Guinea. The aim of the current study is to determine the size of that cash transfer so as to maximize compliance while minimizing cost.

Methods: Data were collected from nine coastal Guinean hospitals on their surgical capabilities and the cost of receiving surgery. These data were combined with publicly available data about the general Guinean population to create an agent-based model predicting surgical utilization. The model was validated to the available literature on surgical utilization. Cash transfer sizes from 0 to 1,000,000 Guinean francs were evaluated, with surgical compliance as the primary outcome.

Results: Compliance with scheduled surgery increases as the size of a cash transfer increases. This increase is asymptotic, with a leveling in utilization occurring when the cash transfer pays for all the costs associated with surgical care. Below that cash transfer size, no other optima are found. Once a cash transfer completely covers the costs of surgery, other barriers to care such as distance and hospital quality dominate.

Conclusion: Cash transfers to incentivize health-promoting behavior appear to be dose-dependent. Maximal impact is likely only to occur when full patient costs are eliminated. These findings should be incorporated in the design of future cash transfer studies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232761PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7224483PMC
July 2020

Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps.

Laryngoscope 2021 01 3;131(1):E26-E33. Epub 2020 Apr 3.

Department of Otolaryngology, University of Louisville School of Medicine, Louisville, Kentucky, U.S.A.

Objective: Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP.

Study Design: Cohort-style Markov decision-tree economic model with a 36-year time horizon.

Methods: A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed.

Results: The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855.

Conclusions: The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner.

Level Of Evidence: 2C Laryngoscope, 131:E26-E33, 2021.
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http://dx.doi.org/10.1002/lary.28648DOI Listing
January 2021

The impact of physician migration on mortality in low and middle-income countries: an economic modelling study.

BMJ Glob Health 2020 7;5(1):e001535. Epub 2020 Jan 7.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.

Background: The WHO estimates a global shortage of 2.8 million physicians, with severe deficiencies especially in low and middle-income countries (LMIC). The unequitable distribution of physicians worldwide is further exacerbated by the migration of physicians from LMICs to high-income countries (HIC). This large-scale migration has numerous economic consequences which include increased mortality associated with inadequate physician supply in LMICs.

Methods: We estimate the economic cost for LMICs due to excess mortality associated with physician migration. To do so, we use the concept of a value of statistical life and marginal mortality benefit provided by physicians. Uncertainty of our estimates is evaluated with Monte Carlo analysis.

Results: We estimate that LMICs lose US$15.86 billion (95% CI $3.4 to $38.2) annually due to physician migration to HICs. The greatest total costs are incurred by India, Nigeria, Pakistan and South Africa. When these costs are considered as a per cent of gross national income, the cost is greatest in the WHO African region and in low-income countries.

Conclusion: The movement of physicians from lower to higher income settings has substantial economic consequences. These are not simply the result of the movement of human capital, but also due to excess mortality associated with loss of physicians. Valuing these costs can inform international and domestic policy discussions that are meant to address this issue.
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http://dx.doi.org/10.1136/bmjgh-2019-001535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042584PMC
January 2021

Global Burden of Head and Neck Cancer: Economic Consequences, Health, and the Role of Surgery.

Otolaryngol Head Neck Surg 2020 Mar 7;162(3):296-303. Epub 2020 Jan 7.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.

Objective: We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes.

Study Design: Statistical and economic analysis.

Setting: Research group.

Subjects And Methods: We conducted a statistical analysis on data from the World Development Indicators and the 2016 Global Burden of Disease study to describe the relationship between surgical workforce and global head and neck cancer mortality-to-incidence ratios. A value of lost output model was used to project the global macroeconomic effects of head and neck cancer.

Results: Significant differences in mortality-to-incidence ratios existed between Global Burden of Disease study superregions. An increase of surgical, anesthetic, and obstetric provider density by 10% significantly correlated with a reduction of 0.76% in mortality-to-incidence ratio ( < .0001; adjusted = 0.84). There will be a projected global cumulative loss of $535 billion US dollars (USD) in economic output due to head and neck cancer between 2018 and 2030. Southeast Asia, East Asia, and Oceania will suffer the greatest gross domestic product (GDP) losses at $180 billion USD, and South Asia will lose $133 billion USD.

Conclusion: The mortality burden of head and neck cancer is increasing and disproportionately affects those in low- and middle-income countries and regions with limited surgical workforces. This imbalance results in large and growing economic losses in countries that already face significant resource constraints. Urgent investment in the surgical workforce is necessary to ensure access to timely surgical services and reverse these negative trends.
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http://dx.doi.org/10.1177/0194599819897265DOI Listing
March 2020

The Scale-Up of the Global Surgical Workforce: Can Estimates be Achieved by 2030?

World J Surg 2020 04;44(4):1053-1061

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.

Background: The Lancet Commission on Global Surgery showed that countries with surgeon, anesthetist, and obstetrician (SAO) densities of 20-40 SAO/100,000 population were associated with improved health outcomes and recommended a global surgical workforce scale-up by 2030. Whether countries would be able to achieve such scale-up efforts in that time-frame is unknown.

Methods: A differential equation model was used to estimate the growth rate and number of SAO necessary for each country to reach the aforementioned SAO densities. Workforce data from Mexico and India were used to estimate achievable rates of SAO scale-up for middle- and low-income countries, respectively. Secular surgical growth rates were estimated to demonstrate what might occur without dedicated scale-up efforts.

Results: To reach at least 20 SAO/100,000 population in all countries by 2030, over 808 thousand SAO need to be trained by 2030. To reach at least 40 SAO/100,000 population, over 2.1 million SAO need to be trained. If countries adopt a scale-up rate similar to Mexico's previously achieved rate of scale-up, 66% of countries would have 20 SAO/100,000 population by 2030. If countries adopt a scale-up rate similar to India's previously achieved rate of scale-up, 56% would have 20 SAO/100,000 population by 2030.

Conclusion: With dedicated efforts in surgical workforce scale-up, significant gains in SAO density can be made worldwide. However, without intervention, many countries are unlikely to improve their current workforce densities. Investments in workforce scale-up are likely to yield workforce gains that mirror current resource states.
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http://dx.doi.org/10.1007/s00268-019-05329-9DOI Listing
April 2020

Cost-Effectiveness Analysis of Screening for Hepatitis B Virus Infection in Patients With Solid Tumors Before Initiating Chemotherapy.

Clin Gastroenterol Hepatol 2020 06 31;18(7):1600-1608.e4. Epub 2019 Oct 31.

Division of Gastroenterology, University of California, San Diego, La Jolla, California. Electronic address:

Background & Aims: Patients with solid tumors who undergo chemotherapy have an increased risk of hepatitis B virus (HBV) reactivation, but a low proportion of these patients are screened for HBV infection and guidelines make conflicting recommendations. Further, the cost-effectiveness of newer treatments for HBV prophylaxis has not been examined for this population. We aimed to analyze the cost-effectiveness of HBV screening before chemotherapy for patients with solid tumors.

Methods: We compared 3 HBV screening strategies (screen all, screen only high-risk patients, or screen none) using a Markov model of a population of adults in the United States who initiated chemotherapy for a solid tumor. We modeled use of entecavir prophylaxis for HB surface antigen (HBsAg)-positive patients and surveillance for HBsAg-negative patients who are positive for HBV core antibody. The Markov cycle length was 1 year, with model simulation for up to 5 years.

Results: The screen all strategy was the most cost effective, with an incremental cost-effectiveness ratio of $42,761 compared to screening only high-risk patients. The screen none strategy was less effective and less costly than screening all patients or only high-risk patients. The screen-all strategy was the most cost effective for all estimates of prevalence of HBsAg-positive patients and estimates of HBV reactivation in HBsAg-positive patients. Screening only high-risk patients was the most cost-effective strategy when more than 25% of high-risk patients were screened for HBV infection.

Conclusions: In a Markov model analysis, we found screening all patients with solid tumors for HBV infection before chemotherapy to be the most cost-effective strategy. Guidelines should consider recommending HBV tests for patients initiating chemotherapy.
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http://dx.doi.org/10.1016/j.cgh.2019.10.039DOI Listing
June 2020

Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries.

Int J Health Policy Manag 2019 09 1;8(9):521-537. Epub 2019 Sep 1.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.

Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services.

Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities' (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates.

Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study.

Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.
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http://dx.doi.org/10.15171/ijhpm.2019.43DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815989PMC
September 2019

'We are all serving the same Ugandans': A nationwide mixed-methods evaluation of private sector surgical capacity in Uganda.

PLoS One 2019 24;14(10):e0224215. Epub 2019 Oct 24.

Mbarara University of Science and Technology (MUST), Mbarara, Uganda.

Introduction: Half of all Ugandans (49%) turn to the private or private-not-for-profit (PNFP) sectors when faced with illness, yet little is known about the capacity of these sectors to deliver surgical services. We partnered with the Ministry of Health to conduct a nationwide mixed-methods evaluation of private and PNFP surgical capacity in Uganda.

Methods: A standardized validated facility assessment tool was utilized to assess facility infrastructure, service delivery, workforce, information management, and financing at a randomized nationally representative sample of 16 private and PNFP hospitals. Semi-structured interviews were conducted to qualitatively explore facilitating factors and barriers to surgical, obstetric and anaesthesia (SOA) care. Hospitals walk-throughs and retrospective reviews of operative logbooks were completed.

Results: Hospitals had a median of 177 beds and two operating rooms. Ten hospitals (62.5%) were able to perform all Bellwether procedures (cesarean section, laparotomy and open fracture treatment). Thirty-day surgical volume averaged 102 cases per facility. While most hospitals had electricity, oxygen, running water, and necessary equipment, many reported pervasive shortages of blood, surgical consumables, and anesthetic drugs. Several themes emerged from the qualitative analysis: (1) geographic distance and limited transportation options delay reaching care; (2) workforce shortages impede the delivery of surgical care; (3) emergency and obstetric volume overwhelm the surgical system; (4) medical and non-medical costs delay seeking, reaching, and receiving care; and (5) there is poor coordination of care with insufficient support systems.

Conclusion: As in Uganda's public sector, barriers to surgery in private and PNFP hospitals in Uganda are cross-cutting and closely tied to resource availability. Critical policy and programmatic developments are essential to build and strengthen Ugandan surgical capacity across all sectors.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224215PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812829PMC
March 2020

Lifting the burden: State Medicaid expansion reduces financial risk for the injured.

J Trauma Acute Care Surg 2020 01;88(1):51-58

From the Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery (J.W.S., B.T.S., S.A., E.M.B., J.C., R.V.M., B.R.H.R.), Harborview Medical Center, University of Washington, Seattle, Washington; Center for Global Surgery Evaluation (M.G.S.), Massachusetts Eye and Ear; and Program in Global Surgery and Social Change (M.G.S.), Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.

Background: Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain because of high out-of-pocket (OOP) health care costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington (WA) state, which extended coverage to more than 600,000 WA residents, was associated with a reduction in financial risk among trauma patients.

Methods: We analyzed all trauma patients aged 18 to 64 years admitted to the sole level 1 trauma center in WA from 2012 to 2017. We defined 2012 to 2013 as the prepolicy period and 2014 to 2017 as the postpolicy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate postsubsistence income and OOP expenses for our sample and then applied these two estimates to determine catastrophic health expenditure (CHE) risk as defined by the World Health Organization (OOP health expenses ≥40% of estimated household postsubsistence income).

Results: A total of 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0%, and the uninsured rate decreased from 19.2% to 3.7% (p < 0.001 for both). There was no significant change in private insurance coverage. Medicaid expansion was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and less than 0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p < 0.01).

Conclusion: State ME led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers.

Level Of Evidence: Economic analysis, level II.
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http://dx.doi.org/10.1097/TA.0000000000002493DOI Listing
January 2020

The health utility of mild and severe dysphonia.

Laryngoscope 2020 05 5;130(5):1256-1262. Epub 2019 Aug 5.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.

Objectives/hypothesis: The impact of disease states can be measured using health state utilities, which are values that reflect economic preferences for health outcomes. Utilities for dysphonia have not been studied using direct methods. The objective of this project was to establish the baseline health utilities of mild and severe dysphonia from a societal perspective.

Study Design: Direct utility elicitation survey.

Methods: Four health states (monocular blindness, binocular blindness, mild dysphonia, and severe dysphonia) were evaluated by a convenience sample of adults recruited from the general public with three computer-aided estimation techniques (visual analog scale [VAS], standard gamble [SG], and time trade-off [TTO]). Standardized descriptions and voice recordings from multiple dysphonic patients were employed. Perfect health was defined as a utility of 1, with death 0. Analysis of variance with post hoc pairwise comparison was used to calculate significant differences between health states.

Results: Three hundred participants were surveyed, and 225 (75.0%) responses met quality thresholds. Severe dysphonia (VAS = 48.3, SG = 0.810, TTO = 0.798) was valued significantly worse than monocular blindness (VAS = 56.2, SG = 0.834, TTO = 0.839) on the VAS (P < .001) and equivalent on SG and TTO; it was preferred over binocular blindness (VAS = 25.7, SG = 0.631, TTO = 0.622; P < .001) with all methods. Mild dysphonia evaluated favorably with all methods to the other health states (VAS = 78.5, SG = 0.902, TTO = 0.908; P < .001).

Conclusions: Voice disorders may have a measurable impact on utility, with severe dysphonia valued equivalently to monocular blindness. Mild dysphonia has a utility decrement from perfect health. These estimates are critical for quality-of-life assessment and could be used to assess cost-effectiveness of treatments for voice disorders.

Level Of Evidence: NA Laryngoscope, 130:1256-1262, 2020.
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http://dx.doi.org/10.1002/lary.28216DOI Listing
May 2020

Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis.

Lancet Glob Health 2019 07;7(7):e932-e939

Department of Nursing, Michigan State University, East Lansing, MI, USA; Malawi University of Science and Technology, Limbe, Malawi.

Background: Health-care regionalisation, in which selected services are concentrated in higher-level facilities, has successfully improved the quality of complex medical care. However, the effectiveness of this strategy in routine maternal care is unknown. Malawi has established a national goal of halving its neonatal mortality by 2030. In this study, we aimed to assess the effect of obstetric service regionalisation in pregnant women and their newborn babies in Malawi.

Methods: In this analysis, we assessed regionalisation through the use of an agent-based simulation model. We used a previously estimated utilisation function, incorporating both patient-specific and health-facility-specific characteristics, to inform patient choice. The model was validated against known utilisation patterns in Malawi. Four regionalisation scenarios were compared with the status quo: scenario 1 restricted deliveries to facilities currently capable of providing caesarean sections; scenario 2 had the same restrictions as scenario 1, but with selected facilities upgraded to provide caesarean sections; scenario 3 restricted delivery to facilities that provided five or more basic emergency obstetric and neonatal care services in the preceding 3 months; and scenario 4 had the same restrictions as scenario 3, but with selected facilities upgraded to provide at least five basic emergency obstetric and neonatal care services. We assessed neonatal mortality, utilisation, travel distance, median out-of-pocket expenditure, and proportion of women facing catastrophic expenditure. The effects of upgrading the obstetric readiness of all facilities, of removing all user fees, and of upgrading without restriction were considered in scenario analyses. Heterogeneity and parameter uncertainty were incorporated to create 95% posterior credible intervals (PCIs).

Findings: Scenarios restricting women to give birth in facilities with caesarean section capabilities reduced neonatal mortality by 11·4 deaths per 1000 livebirths (scenario 1; 95% PCI 9·8-13·1) and 11·6 deaths per 1000 livebirths (scenario 2; 10·2-13·1), whereas scenarios restricting women to facilities that provided five or more basic emergency obstetric and neonatal care services did not affect neonatal mortality. Similarly, the caesarean section rate in Malawi, which is 4·6% under the status quo, was predicted to rise significantly in scenario 1 (14·7%, 95% PCI 14·5-14·9; p<0·0001) and scenario 2 (10·4%, 10·2-10·6; p<0·0001), but not in scenarios 3 and 4. Women were required to travel longer distances in scenario 1 (increase of 7·2 km, 95% PCI 4·5-9·9) and in scenario 2 (4·4 km, 1·5-7·2) than in the status quo (p<0·0001). Out-of-pocket costs tripled (p<0·0001; status quo vs scenario 1 and scenario 2), and the risk of catastrophic expenditure significantly increased from a baseline of 6·4% (95% PCI 6·1-6·6) to 14·7% (14·5-14·9) in scenario 1 and 11·3% (11·0-11·5) in scenario 2. This increase was especially pronounced among the poor (p<0·0001; status quo vs scenario 1 and scenario 2).

Interpretation: Policies restricting women to give birth in facilities with caesarean section capabilities is likely to result in significant decreases in neonatal mortality and might allow Malawi to meet its goal of halving its neonatal mortality by 2030. However, this improvement comes at the cost of increased distances to care and worsening financial risks among women.

Funding: Bill & Melinda Gates Foundation, Damon Runyon Cancer Research Foundation.
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http://dx.doi.org/10.1016/S2214-109X(19)30170-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581692PMC
July 2019

Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi.

BMJ Glob Health 2019 30;4(2):e000930. Epub 2019 Mar 30.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.

Introduction: In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility.

Methods: A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion.

Results: Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women.

Conclusion: For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.
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http://dx.doi.org/10.1136/bmjgh-2018-000930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441245PMC
March 2019

Predictors of Obstetric Fistula Repair Outcomes in Lubango, Angola.

J Obstet Gynaecol Can 2019 Dec 12;41(12):1726-1733. Epub 2019 Apr 12.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA; Center for Surgery and Public Health,(,) Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Objective: Obstetric fistulas have a significant physical and social impact on many women in Angola. The majority of the population of this sub-Saharan African nation does not have access to high-quality obstetric care, and this is associated with a risk of prolonged labour and formation of obstetric fistulas. Fistulas are challenging to correct surgically and may require repeated operations. The objective of the study was to determine predictors of successful obstetric fistula repair.

Methods: In this retrospective study, data from all recorded cases of fistula repair performed between July 2011 and December 2016 at the Centro Evangélico de Medicina do Lubango (CEML) hospital located in Lubango, Angola, were reviewed. Analysis of the data was carried out to determine factors affecting the success of fistula repair; parametric and non-parametric tests were used for group comparisons and logistic regression for outcome prediction (Canadian Task Force classification II-2).

Results: A total of 407 operations were performed on 243 women. Of these, 224 women were diagnosed with a vesicovaginal fistula and 19 with a combined vesicovaginal and rectovaginal fistula. The success rate for the attempted repairs was 42%. On multivariate analysis, the success of first surgery was negatively affected by the difficulty of repair (odds ratio 0.28; P < 0.01). For patients requiring repeat surgery, the odds of success were increased with each subsequent operation (odds ratio 5.32; P < 0.01).

Conclusion: Although fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.
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http://dx.doi.org/10.1016/j.jogc.2019.01.025DOI Listing
December 2019

Operative volume and surgical case distribution in Uganda's public sector: a stratified randomized evaluation of nationwide surgical capacity.

BMC Health Serv Res 2019 Feb 6;19(1):104. Epub 2019 Feb 6.

Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.

Background: Little is known about operative volume, distribution of cases, or capacity of the public sector to deliver essential surgical services in Uganda.

Methods: A standardized mixed-methods surgical assessment and retrospective operative logbook review were completed at 16 randomly selected public hospitals serving 64·0% of Uganda's population.

Results: A total of 3014 operations were recorded, annualizing to a surgical volume of 36,670 cases/year or 144·5 operations/100,000people/year. Absolute surgical volume was greater at regional referral than general hospitals (p < 0·001); but, relative surgical volume/catchment population was greater at the general versus regional level (p = 0·03). Most patients undergoing operations were women (78·3%) with a mean age of 26·9 years. The overall case distribution was 69·0% obstetrics/gynecology, 23·7% general surgery, 4·0% orthopedics, and 3·3% other subspecialties. Cesarean sections were the most common operation (55·8%). Monthly operative volume was strongly predicted by number of surgical, anesthetic, and obstetric physician providers (훽=10·72, p = 0·005, R = 0·94) when controlling for confounders. Notably, operative volume was not correlated with availability of electricity, oxygen, light source, suction, blood, instruments, suture, gloves, intravenous fluid, or antibiotics.

Conclusion: An understanding of operative case volume and distribution is essential in facilitating targeted interventions to strengthen surgical capacity. These data suggest that surgical workforce is the critical driver of operative volume in the Ugandan public sector. Investment in the surgical workforce is imperative to ensure access to safe, timely, and affordable surgical and anaesthesia care.
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http://dx.doi.org/10.1186/s12913-019-3920-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366061PMC
February 2019

Morbidity and mortality among patients with head and neck cancer in the emergency department: A national perspective.

Head Neck 2019 04 24;41(4):1007-1015. Epub 2019 Jan 24.

Center for Global Surgery Evaluation, Massachusetts Eye and Ear, Boston, Massachusetts.

Background: Emergency departments are playing an increasing role in cancer management. Emergency department utilization by patients with head and neck cancer, however, is unknown.

Methods: The 2009-2011 Nationwide Emergency Department Sample was queried for patients with a principle diagnosis of head and neck cancer. Descriptive analysis was performed to characterize patient and hospital characteristics, outcomes, and charges. Logistic regression identified predictors of admission and mortality.

Results: A total of 31 390 patients were seen in the emergency department with head and neck cancer: 72.8% were admitted, 0.5% died in the emergency department, and 5.0% died during admission. Patients with cancer of unknown primary site had the greatest odds of admission (odds ration [OR]: 2.83; P < 0.0001). Privately insured patients (OR: 1.78; P = 0.001), those from higher income zip codes (OR: 1.56; P = 0.008), and those with oropharyngeal cancer (OR: 2.02; P = 0.0003) had the greatest odds of death.

Conclusion: These findings have direct implications for preventing unnecessary and costly emergency department visits, improving hospital and physician preparedness, and improving patient outcomes.
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http://dx.doi.org/10.1002/hed.25534DOI Listing
April 2019

Sustainability of using the WHO surgical safety checklist: a mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar.

BMJ Glob Health 2018 20;3(6):e001104. Epub 2018 Dec 20.

Centre for Implementation Science, King's College London, London, UK.

Background: The WHO Surgical Safety Checklist reduces postoperative complications by up to 50% with the biggest gains in low-income and middle-income countries (LMICs). However in LMICs, checklist use is sporadic and widespread implementation has hitherto been unsuccessful. In 2015/2016, we partnered with the Madagascar Ministry of Health to undertake nationwide implementation of the checklist. We report a longitudinal evaluation of checklist use at 12-18 months postimplementation.

Methods: Hospitals were identified from the original cohort using purposive sampling. Using a concurrent triangulation mixed-methods design, the primary outcome was self-reported checklist use. Secondary outcomes included use of basic safety processes, assessment of team behaviour, predictors of checklist use, impact on individuals and organisational culture and identification of barriers. Data were collected during 1-day hospital visits using validated questionnaires, WHO Behaviourally Adjusted Rating Scale (WHOBARS) assessment tool and focus groups and analysed using descriptive statistics, multivariate linear regression and thematic analysis.

Results: 175 individuals from 14 hospitals participated. 74% reported sustained checklist use after 15 months. Mean WHOBARS scores were high, indicating good team engagement. Sustained checklist use was associated with an improved overall understanding of patient safety but not with WHOBARS, hospital size or surgical volume. 87% reported improved understanding of patient safety and 83% increased job satisfaction. Thematic analysis identified improvements in hospital culture (teamwork and communication, preparation and organisation, trust and confidence) and hospital practice (pulse oximetry, timing of antibiotic prophylaxis, introduction of a surgical count). Lack of time in an emergency and obstructive leadership were the greatest implementation barriers.

Conclusion: 74% of participants reported sustained checklist use 12-18 months following nationwide implementation in Madagascar, with associated improvements in job satisfaction, culture and compliance with safety procedures. Further work is required to examine this implementation model in other countries.
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http://dx.doi.org/10.1136/bmjgh-2018-001104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307586PMC
December 2018

Degenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume.

Global Spine J 2018 Dec 24;8(8):784-794. Epub 2018 Apr 24.

Harvard Medical School, Boston, MA, USA.

Study Design: Meta-analysis-based calculation.

Objectives: Lumbar degenerative spine disease (DSD) is a common cause of disability, yet a reliable measure of its global burden does not exist. We sought to quantify the incidence of lumbar DSD to determine the overall worldwide burden of symptomatic lumbar DSD across World Health Organization regions and World Bank income groups.

Methods: We used a meta-analysis to create a single proportion of cases of DSD in patients with low back pain (LBP). Using this information in conjunction with LBP incidence rates, we calculated the global incidence of individuals who have DSD and LBP (ie, their DSD has neurosurgical relevance) based on the Global Burden of Disease 2015 database.

Results: We found that 266 million individuals (3.63%) worldwide have DSD and LBP each year; the highest and lowest estimated incidences were found in Europe (5.7%) and Africa (2.4%), respectively. Based on population sizes, low- and middle-income countries have 4 times as many cases as high-income countries. Thirty-nine million individuals (0.53%) worldwide were found to have spondylolisthesis, 403 million (5.5%) individuals worldwide with symptomatic disc degeneration, and 103 million (1.41%) individuals worldwide with spinal stenosis annually.

Conclusions: A total of 266 million individuals (3.63%) worldwide were found to have DSD and LBP annually. Significantly, data quality is higher in high-income countries, making overall quantification in low- and middle-income countries less complete. A global effort to address degenerative conditions of the lumbar spine in regions with high demand is important to reduce disability.
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http://dx.doi.org/10.1177/2192568218770769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293435PMC
December 2018

Quality of essential surgical care in low- and middle-income countries: a systematic review of the literature.

Int J Qual Health Care 2019 Apr;31(3):166-172

Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.

Purpose: Quality of care is an emerging area of focus in the surgical disciplines. However, much of the emphasis on quality is limited to high-income countries. To address this gap, we conducted a systematic review of the literature on the quality of essential surgical care in low- and middle- income countries (LMIC).

Data Sources: We searched PubMed, Cinahl, Embase and CAB Abstracts using three domains: quality of care, surgery and LMIC.

Study Selection: We limited our review to studies of essential surgeries that pertained to all three search domains.

Data Extraction: We extracted data on study characteristics, type of surgery and the way in which quality was studied.

Results Of Data Synthesis: 354 studies were included. 281 (79.4%) were single-center studies and nearly half (n = 169, 46.9%) did not specify the level of facility. 207 studies reported on mortality (58.47%) and 325 reported on a morbidity (91.81%), most commonly surgical site infection (n = 190, 53.67%). Of the Institute of Medicine domains of quality, studies were most commonly of safety (n = 310, 87.57%) and effectiveness (n = 180, 50.85%) and least commonly of equity (n = 21, 5.93%).

Conclusion: We find that while there are numerous studies that report on some aspects of quality of care, much of the data is single center and observational. Additionally, there is variability on which outcomes are reported both within and across specialties. Finally, we find under-reporting of parameters of equity and timeliness, which may be critical areas for research moving forward.
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http://dx.doi.org/10.1093/intqhc/mzy141DOI Listing
April 2019

Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis.

BMJ Glob Health 2018 22;3(3):e000810. Epub 2018 Jun 22.

Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.

Introduction: Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country's surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings.

Methods: We did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances.

Results: We included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1% for appendectomy, cholecystectomy and caesarean delivery to 20%-27% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2% of studies explicitly defined the time frame during which deaths accrued.

Conclusions: Efforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.
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http://dx.doi.org/10.1136/bmjgh-2018-000810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6035511PMC
June 2018

Health-system-adapted data envelopment analysis for decision-making in universal health coverage.

Bull World Health Organ 2018 Jun 23;96(6):393-401. Epub 2018 Apr 23.

Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave #411, Boston, Massachusetts, 02115, United States of America (USA).

Objective: To develop and test a method that allows an objective assessment of the value of any health policy in multiple domains.

Methods: We developed a method to assist decision-makers with constrained resources and insufficient knowledge about a society's preferences to choose between policies with unequal, and at times opposing, effects on multiple outcomes. Our method extends standard data envelopment analysis to address the realities of health policy, such as multiple and adverse outcomes and a lack of information about the population's preferences over those outcomes. We made four modifications to the standard analysis: (i) treating the policy itself as the object of analysis, (ii) allowing the method to produce a rank-ordering of policies; (iii) allowing any outcome to serve as both an output and input; and (iv) allowing variable return to scale. We tested the method against three previously published analyses of health policies in low-income settings.

Results: When applied to previous analyses, our new method performed better than traditional cost-effectiveness analysis and standard data envelopment analysis. The adapted analysis could identify the most efficient policy interventions from among any set of evaluated policies and was able to provide a rank ordering of all interventions.

Conclusion: Health-system-adapted data envelopment analysis allows any quantifiable attribute or determinant of health to be included in a calculation. It is easy to perform and, in the absence of evidence about a society's preferences among multiple policy outcomes, can provide a comprehensive method for health-policy decision-making in the era of sustainable development.
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http://dx.doi.org/10.2471/BLT.17.191817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5996217PMC
June 2018

Response to: "Reducing the Burden of Catastrophic Health Expenditures in the United States".

Ann Surg 2018 07;268(1):e21-e22

Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, Department of Otolaryngology and Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA.

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http://dx.doi.org/10.1097/SLA.0000000000002463DOI Listing
July 2018

The Economic Consequences Of Mortality Amenable To High-Quality Health Care In Low- And Middle-Income Countries.

Health Aff (Millwood) 2018 06;37(6):988-996

John G. Meara is the Kletjian Professor of Global Surgery and director of the Program in Global Surgery and Social Change, Harvard Medical School, and plastic surgeon-in-chief, Department of Plastic and Oral Surgery, Boston Children's Hospital.

We estimated deaths amenable to high-quality health care globally and then modeled the macroeconomic impact in low- and middle-income countries using two macroeconomic perspectives: a value-of-lost-output approach to project gross domestic product (GDP) losses annually for the period 2015-30, and a value-of-lost-welfare approach to estimate the present value of total economic welfare losses in 2015. We estimated that eight million amenable deaths occurred in 2015, 96 percent of them in low- and middle-income countries. The value of lost output resulted in a projected cumulative loss of $11.2 trillion in these countries during 2015-30, with a potential economic output loss of up to 2.6 percent of GDP in low-income countries by 2030, compared to 0.9 percent in upper-middle-income countries. The value-of-lost-welfare approach estimated welfare losses of $6.0 trillion in 2015. Inadequate access to high-quality health care results in significant mortality and imposes a macroeconomic burden that is inequitably distributed, with the largest relative burden falling on low-income countries. Given that these deaths are unnecessary and the projected GDP losses are avoidable, there is a strong ethical and economic case for promoting high-quality health care as an essential component of universal health coverage.
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http://dx.doi.org/10.1377/hlthaff.2017.1233DOI Listing
June 2018

Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-Years for 29 Cancer Groups, 1990 to 2016: A Systematic Analysis for the Global Burden of Disease Study.

JAMA Oncol 2018 11;4(11):1553-1568

The Farr Institute of Health Informatics Research, Institute of Health Informatics, University College London, London, England.

Importance: The increasing burden due to cancer and other noncommunicable diseases poses a threat to human development, which has resulted in global political commitments reflected in the Sustainable Development Goals as well as the World Health Organization (WHO) Global Action Plan on Non-Communicable Diseases. To determine if these commitments have resulted in improved cancer control, quantitative assessments of the cancer burden are required.

Objective: To assess the burden for 29 cancer groups over time to provide a framework for policy discussion, resource allocation, and research focus.

Evidence Review: Cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs) were evaluated for 195 countries and territories by age and sex using the Global Burden of Disease study estimation methods. Levels and trends were analyzed over time, as well as by the Sociodemographic Index (SDI). Changes in incident cases were categorized by changes due to epidemiological vs demographic transition.

Findings: In 2016, there were 17.2 million cancer cases worldwide and 8.9 million deaths. Cancer cases increased by 28% between 2006 and 2016. The smallest increase was seen in high SDI countries. Globally, population aging contributed 17%; population growth, 12%; and changes in age-specific rates, -1% to this change. The most common incident cancer globally for men was prostate cancer (1.4 million cases). The leading cause of cancer deaths and DALYs was tracheal, bronchus, and lung cancer (1.2 million deaths and 25.4 million DALYs). For women, the most common incident cancer and the leading cause of cancer deaths and DALYs was breast cancer (1.7 million incident cases, 535 000 deaths, and 14.9 million DALYs). In 2016, cancer caused 213.2 million DALYs globally for both sexes combined. Between 2006 and 2016, the average annual age-standardized incidence rates for all cancers combined increased in 130 of 195 countries or territories, and the average annual age-standardized death rates decreased within that timeframe in 143 of 195 countries or territories.

Conclusions And Relevance: Large disparities exist between countries in cancer incidence, deaths, and associated disability. Scaling up cancer prevention and ensuring universal access to cancer care are required for health equity and to fulfill the global commitments for noncommunicable disease and cancer control.
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http://dx.doi.org/10.1001/jamaoncol.2018.2706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248091PMC
November 2018
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