L Lancet Commission on Global Surgery

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1 The Lancet Commission on Global Surgery Information management and global surgery metrics Russell Gruen MBBS PhD FRACS Professor of Surgery & Public Health, Monash University, Australia, & Nanyang Technological University, Singapore. Chair, LCoGS Information Management Working Group. The Lancet Commission on Global Surgery

2 Quality Cycle Surgery & Anaesthesia Health & Produc/vity

3 Poli4cal Economy Problem Defini4on Key- stakeholders Decision- makers Quality Cycle Surgery & Anaesthesia Health & Produc/vity

4 Universal access to safe, affordable surgical and anesthesia care when needed How can we drive progress? & How will we know if progress is being made?

5 Information Management Working Group Commissioners/Authors: Russell Gruen, Sarah Greenberg, Chris Lavy, Iain Wilson, Richard Sullivan, TB Kamara, Andy Leather, John Meara, Lars Hagander, Steve Bickler, David Watters, Tom Weiser. Collaborators: Ties Boerma, Ed Kelley, Meena Cherian, Melanie Walker, Emmanuel Makasa, Meera Kotagal, Rebecca Maine, John Rose, Joshua Ng-Kamstra, Phil Hider, Leona Wilson, Douglas Stupart, Grant Laing, Damian Clarke, Roshan Aryaratnam, Charlotta Palmqvist, Kathleen O Neill, Ainhoa Costas. The Lancet Commission on Global Surgery

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7 1. Surgical metrics are lacking

8 2. Surgical data is not systema/cally collected Popula/on- based Data Household surveys Verbal autopsies Facility- based Data Infrastructure surveys Health service ac/vity

9 3. No standard surgical taxonomy exists and exis8ng classifica8ons are of limited usefulness

10 Focus on health system strengthening: Credible Indicators Time- bound targets level

11 Global Surgery Indicator Framework Preparedness for surgery Whether services are appropriately planned and sufficiently developed Delivery of surgery Effec/veness of coverage and quality of care being provided Impact of surgery Effects on health, well- being, and produc/vity.

12 Core Indicators for Global Surgery Access to /mely essen/al surgery Financial protec/on Specialist surgical workforce density Postopera/ve mortality Surgical volume 12

13 Access to timely essential surgery Definition: Percentage of the population that can access, within 2 hours, a facility that can do caesarian section, laparotomy, and treat an open fracture (the Bellwether Procedures) Rationale: All people should have timely access to emergency surgical services; Doing the Bellwether Procedures infers performance of most essential surgical procedures; 2 hours is a threshold of death from complications of childbirth Target: Minimum 80% coverage of essential surgical and anaesthesia services, per country, by 2030 The Lancet Commission on Global Surgery

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15 Specialist surgical workforce density Definition: Number of specialist surgical, anaesthetic and obstetric physicians who are working per 100,000 population Rationale: The availability and accessibility of human resources for health is a crucial component of surgical and anaesthetic care delivery. Target: 100% of countries with at least 20 surgical, anaesthetic, and obstetric physicians per 100,000 population by 2030 The Lancet Commission on Global Surgery

16 Number'of'Surgeons,'Anaesthesiologists'and'Obstetricians'' per'100,000'popula;on' 100! 90! 80! 70! 60! 50! 40! 30! 20! 10! WHO'Regions!(p<0.001)! World'Bank'Class!(p<0.001)! Health'Expenditure'Quintile'(p<0.001)! 0! Europe!! Americas! Western!Pacific! Eastern!Mediterranean! South!East!Asia! Africa! High!Income! Upper!Middle!Income! Lower!Middle!Income! Low!Income! 5th! 4th! 3rd! 2nd! 1st! The Lancet Commission on Global Surgery

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18 Value >19 0 Figure 10: Change in surgical workforce density needed for specialist SAO-only model to meet 20 SAO providers per population by Assumes retirement is at a rate of 1% per year. SAO=surgical, anaesthetic, and obstetric. be coupled to increases in the The number Lancet of Commission trainees. on Global Surgery 50 Cost Time Training programmes should aim to train committed SAO SAO

19 Surgical volume Definition: Procedures done in an operating theatre, per 100,000 population per year Rationale: The number of surgical procedures done per year is an indicator of met need Target: 80% of countries by 2020 and 100% of countries by 2030 tracking surgical volume; 5000 procedures per 100,000 population by 2030 The Lancet Commission on Global Surgery

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21 Perioperative Mortality Definition: All-cause death rate before discharge in patients who have had a procedure in an operating theatre, divided by the total number of procedures, presented as a percentage Rationale: Surgical and anaesthesia safety is an integral component of care delivery Perioperative mortality encompasses deaths in the operating theatre and in the hospital after the procedure Procedures chosen as denominator because most feasible Target: 80% of countries by 2020 and 100% of countries by 2030 tracking perioperative mortality; (in 2020 assess global data and set national targets for 2030) The Lancet Commission on Global Surgery

22 80 POMR by Case Urgency POMR (%) reported, by emergency status (Systema4c review) Emergency Procedures Mixed Urgency Planned Procedures

23 Risk Adjustment of POMR (Systema4c review)

24 POMR by age and emergency status (4 country analysis) The Lancet Commission on Global Surgery

25 Low volume (<2000/ ) Mid-level volume ( / ) High volume (>10 000/ ) High perioperative mortality rate Vo w Vo quality Vo quality Mid-level perioperative mortality rate Vo w Vo quality Vo quality Low perioperative mortality rate Vo w Vo quality Vo quality Figure 15: National surgical volume and perioperative mortality analysis matrix Red shows areas of high concern, yellow shows areas of moderate concern, and green shows areas of desired targets. Selection bias can be identified with country level data collection that includes risk stratification and surgical procedure coding. This is important and will require enhanced information management capabilities, but should not preclude the immediate collection of perioperative mortality rate and surgical volume. The Lancet Commission on Global Surgery

26 Protection against impoverishing expenditure Definition: Proportion of households protected against impoverishment from direct out-of-pocket payments for surgical and anaesthesia care Rationale: Billions of people each year at risk of financial ruin because they have accessed surgical services; this is a surgery-specific version of a World Bank universal health coverage target Target: 100% protection against impoverishment from out-ofpocket payments for surgical and anaesthesia care by 2030 The Lancet Commission on Global Surgery

27 Protection against catastrophic expenditure Definition: Proportion of households protected against catastrophic expenditure from direct out-of-pocket payments for surgical and anaesthesia care Rationale: Billions of people each year at risk of financial ruin because they have accessed surgical services; this is a surgery-specific version of a World Bank universal health coverage target Target: 100% protection against catastrophic expenditure from out-of-pocket payments for surgical and anaesthesia care by 2030 The Lancet Commission on Global Surgery

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29 Core Indicators for Global Surgery 29

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Performance Management. Ch. 9 The Performance Measurement. Mechanism. Chiara Demar8ni UNIVERSITY OF PAVIA. mariachiara.demar8ni@unipv.

Performance Management. Ch. 9 The Performance Measurement. Mechanism. Chiara Demar8ni UNIVERSITY OF PAVIA. mariachiara.demar8ni@unipv. UNIVERSITY OF PAVIA Performance Management Ch. 9 The Performance Measurement Mechanism Chiara Demar8ni mariachiara.demar8ni@unipv.it Master in Interna+onal Business and Economics Defini8on Performance