July's Paper of the Month looks at a study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition.
Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries
NIHR Global Health Research Unit on Global Surgery
In this study from the Global Surgery Network, they looked at patients undergoing hernia repair across the world. The reason this study is so different, is because they looked beyond the operation, at the pathway of care, the barriers to treatment and the resources available. This whole system approach should be employed for patients undergoing elective colorectal procedures and would be welcomed by policy makers such as the WHO.
HIPPO was undertaken in 83 countries and recruited 18,000 patients over a period of 6 weeks. Patients were recruited prospectively during the recruitment period and followed up for 30 days. However, patients were also questioned as to the duration of symptoms, both before and after attending the hospital clinic. Data was collected on the type of anaesthesia, the use of mesh in the repair, as well as the location and nature of the hospital.
The key findings were that, in low- and middle-income countries, there were greater delays before presentation to hospital and a high rate of emergency presentation and consequential bowel resection. There was also a far higher rate of regional anaesthesia (interestingly spinal rather than local block was prevalent).
There are many lessons from this study that would translate into colorectal practice. The first is that collecting pre-presentation data can inform on the subsequent rate of complications (and promote governments to invest in better access to surgical care). The effective use of regional anaesthesia can deliver safe care to many patients for whom general anaesthesia may not be readily available and besides this, reduce our carbon footprint. Unfortunately, the cost of surgery (and in many countries the patients are charged additionally for mesh) still creates a barrier to timely presentation and best care.
