(Reuters Health) – Only limited evidence exists regarding patient outcomes from short-term missions that provide reconstructive surgery in lower-income countries, a new systematic review has found.
Because higher complication rates were reported in studies with better information on follow-up, “Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions,” researchers write in BMJ Global Surgery, online April 3.
They recommend that short-term reconstructive-surgery missions work toward sustainable partnerships that would “provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems.”
“Our study attempted to summarize what we currently know about these types of missions. By doing so, it also identified what we don’t know, and what we could do in the near future to improve our understanding of missions,” Dr. Thom C.C. Hendriks of VU Medisch Centrum and Global Surgery Amsterdam told Reuters Health by email.
He and his coauthors say theirs was the first systematic review to assess the quality of available data on short-term reconstructive surgical missions.
Such missions are a common and well-established model for providing specialized care in lower- and middle-income countries, where they “have a tendency to work outside the local healthcare system,” according to the report.
Despite the ubiquity of such missions, the authors note, their results are poorly documented. This in turn raises issues about the accountability of missions, whether they are a rational use of resources, and the ethical implications of “surgical volunteerism.”
The authors identified 41 studies of missions to address such conditions as cleft lip, post-burn contractures and noma (an orofacial gangrene). Missions to conflict zones were excluded.
Most of the 41 studies were case series, and 37 were graded as Oxford CEBM Level IV evidence. Twenty-eight related to cleft care.
The studies encompassed more than 48,000 patients (mean age 13) in Africa, Southeast Asia, Eastern Europe and South and Central America. Average mission length was 10 days.
Nine studies (22%) did not report on complications, and 12 (29%) reported a complication rate only, without specifying a follow-up length or rate. The overall complication rate in these 12 studies was 1.2%.
Ten studies (24%) reported follow-up lengths under 180 days, with a mean follow-up rate of 81.3% and a 7.1% complication rate. Another 10 studies provided follow-ups of longer than 180 days, with a mean follow-up rate of 56.0% and a 22.3% complication rate.
Their findings, the authors conclude, “showed that reported complication rates were considerably higher when the quality and length of follow-up increased. This suggests that without data on quality of follow-up, there is a high risk of reporting bias due to under-reporting of complications.
They recommend, among other approaches, that organizations implement “diagonal development” missions, in which short-term specialized missions are combined with longer-term investments in developing sustainable local healthcare systems. The authors also call for better, longer-term reporting of complication rates from surgical missions.
Dr. Josh Ng-Kamstra, a fellow in critical-care medicine at the University of Calgary, Canada, and lead author of a 2016 report on surgical non-governmental organizations, told Reuters Health by email that the authors’ recommendations, while not new, are important.
“Long-term outcomes are especially relevant to reconstructive surgery, often required in younger populations with a long post-surgical life expectancy. Complications can occur well after surgery and can have lasting implications for quality of life.”
Dr. Mark G. Shrime, director of the Center for Global Surgery Evaluation and faculty member in the Program in Global Surgery and Social Change at Harvard Medical School, in Boston, said there are “scads of evidence that these ‘surgical safaris’ are inappropriate (yet) they continue because … they fit our schedules, despite the detrimental effects these missions have on the people we’re ostensibly helping.”
“Short-term trips may have a role, but that role should really only be as a small part of existing, longer-term sustainable partnerships,” he concluded. “Otherwise, we fly in, feel like heroes, and leave our local surgical colleagues to deal with the messes we might just be leaving behind.”
Neither Dr. Ng-Kamstra nor Dr. Shrime was involved in the new report.
[Source: Reuters Health]