Showing papers by "John G. Meara published in 2015"
Harvard University1, Boston Children's Hospital2, King's College London3, Lund University4, Massachusetts Eye and Ear Infirmary5, University of São Paulo6, University of California, San Diego7, Imperial College London8, Partners In Health9, Brigham and Women's Hospital10, Royal North Shore Hospital11, Medical College of Wisconsin12, Monash University13, Nanyang Technological University14, University of Sierra Leone15, University of Oxford16, Mongolian National University17, University of Malawi18, Flinders University19, Beth Israel Deaconess Medical Center20, Bhabha Atomic Research Centre21, Royal Australasian College of Surgeons22, Stanford University23, University of California, San Francisco24
TL;DR: The need for surgical services in low- and middleincome countries will continue to rise substantially from now until 2030, with a large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs.
2,209 citations
Massachusetts Eye and Ear Infirmary1, Harvard University2, Beth Israel Deaconess Medical Center3, Stanford University4, University of California, San Diego5, Medical College of Wisconsin6, Brigham and Women's Hospital7, University of Washington8, Karolinska Institutet9, Bhabha Atomic Research Centre10, Boston Children's Hospital11, Partners In Health12
TL;DR: The number of individuals worldwide without access to surgical services as defined by the Lancet Commission on Global Surgery is estimated, with findings that the near absence of access in many low-income and middle-income countries represents a crisis.
438 citations
King's College London1, HealthPartners2, Obafemi Awolowo University3, Fred Hutchinson Cancer Research Center4, University of Washington5, University of Liverpool6, Guy's and St Thomas' NHS Foundation Trust7, University of London8, University of Texas Southwestern Medical Center9, Memorial Sloan Kettering Cancer Center10, University of Toronto11, Institut Gustave Roussy12, University of Oxford13, Lund University14, Pontifical Catholic University of Chile15, University of Texas at Austin16, Union for International Cancer Control17, Peking University18, Boston Children's Hospital19, Indiana University20, Harvard University21, Cairo University22, University of Zambia23, University of North Carolina at Chapel Hill24, Leiden University25, European Institute of Oncology26, Amrita Institute of Medical Sciences and Research Centre27, Deakin University28, Barwon Health29, Peking Union Medical College30, Guangdong General Hospital31
TL;DR: To deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning and wide equity and economic gaps are found.
Abstract: Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.
409 citations
226 citations
TL;DR: Half the global population is at risk of financial catastrophe from surgery, with the burden of catastrophic expenditure highest in countries of low and middle income; within any country, it falls on the poor.
208 citations
Harvard University1, Boston Children's Hospital2, King's College London3, Lund University4, Massachusetts Eye and Ear Infirmary5, University of São Paulo6, University of California, San Diego7, Imperial College London8, Brigham and Women's Hospital9, Partners In Health10, Royal North Shore Hospital11, Medical College of Wisconsin12, Nanyang Technological University13, University of Sierra Leone14, University of Oxford15, Mongolian National University16, University of Malawi17, Flinders University18, Beth Israel Deaconess Medical Center19, Bhabha Atomic Research Centre20, Royal Australasian College of Surgeons21, Stanford University22, University of California, San Francisco23
TL;DR: John G Meara*, Andrew J M Leather*, Lars Hagander*, Blake C Alkire, Nivaldo Alonso, Emmanuel A Ameh, Stephen W Bickler, Lesong Conteh, Anna J Dare, Justine Davies, Eunice Dérivois Mérisier, Shenaaz El-Halabi, Paul E Farmer, Atul Gawande, Rowan Gillies, Sarah L M Greenberg, Caris E Grimes, Russell L Gruen,
127 citations
TL;DR: The macroeconomic impact of surgical disease is substantial and inequitably distributed, and the growing number of favourable cost-effectiveness analyses of surgical interventions in low-income and middle-income countries, suggest that building surgical capacity should be a global health priority.
122 citations
TL;DR: A substantial worldwide burden and disparities in femoral shaft fracture incidence between low to middle income and high income countries are demonstrated, and the young are disproportionately affected, underscoring the potential impact of improved access to treatment.
Abstract: Worldwide, road injuries cause over 1.3 million deaths and many more disabilities annually, disproportionately affecting the young and the poor. Approximately one in ten road injuries involves a femoral shaft fracture that is most effectively treated with surgery. Current femoral shaft fracture incidence according to country and age group is unknown and difficult to measure directly but is critical to designing and evaluating interventions.
66 citations
TL;DR: Although the thresholds cannot be interpreted as a minimum standard, they are useful to characterise the global surgical workforce and its deficits and could also be used as markers for health system capacity.
58 citations
TL;DR: Children undergoing craniosynostosis surgery are at increased risk for clinically significant postoperative events requiring ICU admission if they are less than 10 kg body weight, American Society of Anesthesiologists physical status 3 or 4, require intraoperative transfusion of greater than 60 ml/kg of packed erythrocytes, receive hemostatic blood products, or if they develop a significant intraoperative complication.
Abstract: Background: Craniosynostosis surgery is associated with clinically significant postoperative events requiring intensive care unit (ICU) admission. The authors investigate specific variables, which might influence the risk for these events, and thereby make recommendations regarding the need for postoperative ICU admission. Methods: A retrospective review of 225 children undergoing open craniosynostosis repair at a single center during a 10-yr period is reported. The primary outcome measure was the incidence of predefined clinically relevant postoperative cardiorespiratory and hematological events requiring ICU admission. Results: The incidences of postoperative cardiorespiratory and hematological events requiring ICU care were 14.7% (95% CI, 10.5 to 20.1%) and 29.7% (95% CI, 24.0 to 36.3%), respectively. Independent predictors of cardiorespiratory events were body weight less than 10 kg, American Society of Anesthesiologists physical status 3 or 4, intraoperative transfusion of greater than 60 ml/kg packed erythrocytes, and the occurrence of an intraoperative complication. The independent predictors of hematological events were body weight less than 10 kg, American Society of Anesthesiologists physical status 3 or 4, intraoperative transfusion of greater than 60 ml/kg packed erythrocytes, transfusion of hemostatic products (fresh-frozen plasma, platelets, and/or cryoprecipitate), and tranexamic acid not administered. Conclusions: Children undergoing craniosynostosis surgery are at increased risk for clinically significant postoperative events requiring ICU admission if they are less than 10 kg body weight, American Society of Anesthesiologists physical status 3 or 4, require intraoperative transfusion of greater than 60 ml/kg of packed erythrocytes, receive hemostatic blood products, or if they develop a significant intraoperative complication. Tranexamic acid administration was associated with fewer postoperative events. A predictive clinical algorithm for pediatric patients having major craniosynostosis surgery was developed and validated to risk stratify these patients.
55 citations
TL;DR: The results suggest that non-surgeon physicians and non-physician clinicians provide surgical care many in low-resource settings, and it seems likely that task-shifting is far more widespread than is indicated by the medical literature.
TL;DR: The use of task shifting worldwide is documented with an in-depth review of the literature and subsequent confirmation of practices through a provider survey to strengthen strategic planning efforts to bridge the gap between surgical and anaesthetic providers.
TL;DR: Two models were created to show how many providers will need to enter the workforce per year once training is complete to reach targets by 2030, and low-income and lower-middle-income countries show the largest required scale-up.
TL;DR: Surgical access is poor in many low-income and middle-income countries, even when using a narrow definition of surgical access consisting only of timeliness, and Investments in infrastructure and training must be prioritised to address widespread disparity in access to timely surgery.
TL;DR: The state of the blood supply in LMICs is of insufficient quantity and safety, and the reasons for these deficits are multifactorial, and addressing blood supply inadequacies requires focused attention at both local and global levels.
TL;DR: Although some variation exists between countries, the challenges to surgical care provision are largely consistent and based on local resource availability; underfunded rural hospitals faced similar challenges worldwide.
02 Apr 2015
TL;DR: This chapter presents two distinct BCAs: the role of cesarean delivery in the context of obstructed labor, and its associated cost and benefit, has been previously studied by the authors and is presented here with updated results.
Abstract: Since surgery was first included in the second edition of Disease Control Priorities (DCP2, 2006), research examining the cost-effectiveness of surgical interventions in low- and middle-income countries (LMICs) has expanded substantially (see chapter 18). A growing body of evidence suggests that surgical platforms can be cost-effective in these countries, according to the criteria established by the World Health Organization (WHO) (Grimes and others 2013).In parallel, a nascent field of study within global health economics has attempted to expand the application of benefit-cost analysis (BCA) to global health interventions in these countries. In contrast with cost-effectiveness analysis, BCA seeks to estimate the net economic benefit of an intervention in monetary terms. The nature of BCA allows researchers to investigate the potential economic return of an investment in global health; it also allows ministries of health and finance to meaningfully compare health care projects to investments in other governmental sectors, such as education and transportation, which are routinely valued with BCA. The use of BCA in global health has recently become more visible; for example, Jamison, Jha, and Bloom (2008) and Jamison and others (2012) prominently feature BCA in their challenge papers for the 2008 and 2012 Copenhagen Consensus (CC).Within the surgical cost-effectiveness literature, cleft lip and palate (CLP) has been the subject of at least three cost-effectiveness studies in LMICs; all suggest that CLP can be repaired in LMICs in a cost-effective manner (Corlew 2010; Magee, Vander Burg, and Hatcher 2010; Poenaru 2013). A more thorough review of CLP can be found in chapters 8 and 13 of this volume. The role of cesarean delivery in the context of obstructed labor, and its associated cost and benefit, has been previously studied by the authors (Alkire and others 2012a) and is presented here with updated results. This chapter presents two distinct BCAs: An approach for performing BCA using CLP repair as a model surgical intervention using primary data from a subspecialty hospital dedicated to CLP in India A BCA based on secondary data that model the benefit and cost of cesarean delivery for treatment of obstructed labor in 47 LMICs.
TL;DR: This pilot study effectively demonstrates the novel use of time-driven activity-based costing in combination with the value equation as a metric for continuous process improvement programs within the health care setting.
Abstract: BackgroundProcess management within a health care setting is poorly understood and often leads to an incomplete understanding of the true costs of patient care. Using time-driven activity-based costing methods, we evaluated the high-volume, low-complexity diagnosis of plagiocephaly to increase value
TL;DR: A quality assessment checklist for surgical mortality studies could improve mortality reporting and facilitate benchmarking across sites and countries.
TL;DR: The aim of this study was to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency.
TL;DR: The Commission’s key messages mean that, for the first time, global surgery has a strong evidence base to describe the discipline and act as motivation for change, and it will take more than powerful messages and evidence to drive the changes required to help those people who are in need of surgery.
TL;DR: The Global Surgery Fellowship model overcomes many of the traditional challenges to providing adequate surgical care in resource-poor countries and meets the challenge of providing a broad educational experience for many levels of local and foreign physicians, while working within an established locally run health care system.
TL;DR: The launches in London and Boston were the beginning of an education and advocacy campaign intended to highlight the pivotal role of surgical care in health system strengthening, and the greatest volume of academic content published in a synchronised fashion in collaboration with independent journals ever seen in the surgical community.
TL;DR: Tracking funds targeting surgery helps to quantify and clarify current investments and funding gaps, ensures resources materialise from promises and promotes transparency within global health financing.
Abstract: Objective: The funds available for global surgical delivery, capacity building and research are unknown and presumed to be low. Meanwhile, conditions amenable to surgery are estimated to account for nearly 30% of the global burden of disease. We describe funds given to these efforts from the USA, the world’s largest donor nation. Design: Retrospective database review. US Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center and registered US charitable organisations were searched for financial data on any organisation giving exclusively to surgical care in low and middle income countries (LMICs). For USAID, NIH and Foundation Center all available data for all years were included. The five recent years of financial data per charitable organisation were included. All nominal dollars were adjusted for inflation by converting to 2014 US dollars.
TL;DR: Track funds targeting surgery helps not only to quantify and clarify this investment, but also to ultimately serve as a platform to integrate surgical spending within health system strengthening.
Boston Children's Hospital1, King's College London2, Lund University3, Massachusetts Eye and Ear Infirmary4, University of São Paulo5, University of California, San Diego6, Imperial College London7, Brigham and Women's Hospital8, Royal North Shore Hospital9, Medical College of Wisconsin10, Nanyang Technological University11, University of Sierra Leone12, University of Oxford13, Mongolian National University14, University of Malawi15, Beth Israel Deaconess Medical Center16, Harvard University17, Bhabha Atomic Research Centre18, Royal Australasian College of Surgeons19, Stanford University20, National Health Service21, University of California, San Francisco22
TL;DR: John G Meara*, Andrew J M Leather*, Lars Hagander*, Blake C Alkire, Nivaldo Alonso, Emmanuel A Ameh, Stephen W Bickler, Lesong Conteh, Anna J Dare, Justine Davies, Eunice Dérivois Mérisier, Shenaaz El-Halabi, Paul E Farmer, Atul Gawande, Rowan Gillies, Sarah L M Greenberg, Caris E Grimes, Russell L Gruen,
TL;DR: It is the first to show that an ARS improves response rates to allow for better characterization of surgeon needs in the developing world and shows how a CME conference is an effective tool to build surgical capacity and increase confidence level.
TL;DR: This operative log review can be used to identify surgical practice patterns, needs, and deficits in order to inform the growth of surgical capacity at Liberia’s only tertiary medical institution.
Abstract: Situational needs of health care facilities inform the optimal allocation of resources and quality improvement efforts. This study examines surgical care delivery metrics at a tertiary care institution in Liberia. We retrospectively reviewed operative and ward logbooks from January 1 to December 31, 2012. Data parameters included patients’ age, diagnosis, procedure, mortality, and perioperative provider information. In 2012, 1,036 operations were performed. The breakdown of adult surgical cases reveals 452 (45.1 %) general surgery operations, 192 (18.5 %) orthopedic operations, and 180 (17.4 %) ophthalmic operations. Other significant case volume included urologic 53 (5.1 %), ENT 36 (3.5 %), neurosurgical 31 (3.0 %), vascular 24 (2.3 %), and plastic 14 (1.4 %) operations. Pediatric patients accounted for 24.5 % (243) of surgical cases, and 9 % of pediatric surgical cases were for hydrocephalus. General, spinal, and total intravenous anesthesia was provided by non-physician personnel, except when surgeons provided their own anesthesia. Ward logs documented 7.4 % mortality among all patients admitted to the surgical ward, most of which occurred after exploratory laparotomy (44 %), in burn (14 %) patients, and in patients with head/neck emergencies (12 %). This operative log review can be used to identify surgical practice patterns, needs, and deficits in order to inform the growth of surgical capacity at Liberia’s only tertiary medical institution. Using this data to identify critical areas of high-yield operations (e.g., for pediatric hydrocephalus), or excessively high mortality rates (e.g., in burn care), can focus the direction of limited resources toward areas of need. While the heavy reliance on non-consultant surgeons reflects human capacity shortages and a pressing need for postgraduate training programs, identifying the breadth of surgical expertise demonstrated in these operative logs reveals the proficiencies required of surgeons to provide comprehensive surgical care in this setting.
TL;DR: Z-plasty is the preferred surgical method to address tongue-tie due to a greater improvement in mother’s breast pain, pronunciation and speech, tongue movement, and parental satisfaction.
Abstract: Introduction: Ankyloglossia is a congenital anomaly in which the lingual frenulum is unusually short and thick, thus decreasing tongue mobility. In the context of the newborn or young infant it is a subject of ongoing controversy within and between medical specialties. The controversy involves not only the definition but also the management of this anomaly. A tight lingual frenulum is considered a minor malformation by some investigators. Usual treatments for ankyloglossia include speech therapy, as well as simple frenulotomy and frenuloplasty. The aim of this study was to compare the latter two methods with respect to postoperative results and complications. Materials and Methods: A total of 50 patients referred for surgical care were randomly assigned into two groups: simple release (frenulotomy ) or Z-plasty (frenuloplasty), and underwent a pre-surgical assessment. After 3 months, patients were followed with a scheduled interview and questionnaire comparing the outcomes of the two methods. The data were analyzed using SPSS version 18. Results: Surgery had a significant effect on all variables measured in our study (P<0.05). Z-plasty had a greater effect on articulation, breast pain, tongue movement and parent satisfaction than simple release (P<0.05). Z-plasty and simple release had the same effect on breast feeding, latching, and sucking. Conclusion: Z-plasty is the preferred surgical method to address tongue-tie due to a greater improvement in mother’s breast pain, pronunciation and speech, tongue movement, and parental satisfaction.