umu.sePublications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Groin hernias and unmet need for surgery in Uganda: Epidemiology, mosquito nets and cost-effectiveness
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.ORCID iD: 0000-0001-5884-0369
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Surgery has traditionally been considered more expensive than many other health care interventions and with little impact on the burden of disease in a global perspective. One of the reasons behind this misconception is that the effects of surgical conditions and their treatment have not been factored into the equation. Cost-effectiveness analyses of surgical interventions have largely been missing.

An estimated 20 million herniorrhaphies are carried out annually but over 200 million people suffer from groin hernias. Herniorrhaphy is one of the most commonly performed surgical procedures also in Low and Middle Income Countries (LMIC). However, the surgical repair method is not the same due to financial constraints. In high income countries a synthetic mesh is used and has reduced the risk of recurrence. This 125 USD mesh is too costly for the majority in LMIC. Mosquito mesh, which is cheaper but very similar to commercial meshes, is used in several settings but outcomes need to be investigated more extensively before this practice can be recommended in routine surgical service.

The Aims of this thesis were to define the prevalence of groin hernia, to relate it to the surgical capacity, outcomes and costs of surgery in eastern Uganda and to investigate the feasibility and difference in cost and cost-effectiveness of replacing a commercial mesh with a mosquito mesh in groin hernia surgery.

Methods Three studies (1-3) were carried out in eastern Uganda. 1: A cross sectional study investigating the prevalence of groin hernia in adult males in the Health and Demographic Surveillance Site (HDSS) in Iganga and Mayuge districts. 2: A facility based study with prospective data collection of all surgeries undertaken in the two hospitals providing surgery for the HDSS population. 3: A double blinded, randomised controlled trial comparing the outcomes of using a mosquito mesh relative using a commercial mesh in groin hernia surgery.

Results 1: the prevalence of untreated groin hernia among the study participants was 6.6%. 2: the rate of groin hernia surgery was 17 per 100 000 population. Thus, less than 1% of the estimated number of cases of groin hernia in the catchment area of the two hospitals are operated per year. A herniorrhaphy costs around 60 USD to perform. This corresponds to a third of the cost of TB treatment and a 15th of the cost of HIV/AIDS treatment per year in Uganda. 3: No significant differences in terms of recurrence rates, post operative and chronic complications and patient satisfaction were demonstrated between the patients operated using the mosquito mesh and the commercial mesh. Cost-effectiveness was very high for both materials but total cost in the mosquito mesh group was 124 USD lower per surgery than in the commercial mesh group.

Conclusion There is a vast unmet need for groin hernia surgery. Cost of surgery compares favourably with other health care interventions prioritised by the international organisations and funders. A superior technique can be used in groin hernia surgery at low cost, with high cost-effectiveness in a Low Income Country. 

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2015. , 78 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1740
Keyword [en]
Global surgery, groin hernia, groin hernia surgery, hernia epidemiology, low cost surgery, cost-effectiveness
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-107659ISBN: 978-91-7601-316-8 (print)OAI: oai:DiVA.org:umu-107659DiVA: diva2:848805
Public defence
2015-09-17, Hörsalen, Östersunds Sjukhus, Kyrkgatan 16, Östersund, 09:00 (English)
Opponent
Supervisors
Available from: 2015-08-27 Created: 2015-08-25 Last updated: 2015-08-26Bibliographically approved
List of papers
1. Prevalence of treated and untreated groin hernia in eastern Uganda
Open this publication in new window or tab >>Prevalence of treated and untreated groin hernia in eastern Uganda
Show others...
2014 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 6, 728-734 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Hernia repair is the most commonly performed general surgical procedure worldwide. The prevalence is poorly described in many areas, and access to surgery may not be met in low- and middle-income countries. The objectives of this study were to investigate the prevalence of groin hernia and the surgical repair rate in a defined sub-Saharan region of Africa. METHODS: A two-part study on hernia prevalence was carried out in eastern Uganda. The first was a population-based prevalence study with 900 randomly selected men in a Health and Demographic Surveillance Site. The second was a prospective facility-based study of all surgical procedures performed in the two hospitals providing surgical care in the region. RESULTS: The overall prevalence of groin hernia (current hernia or scar after groin hernia surgery) in men was 9·4 per cent. Less than one-third of men with a hernia had been operated on. More than half had no pain symptoms. The youngest age group had an overall prevalence of 2·4 per cent, which increased to 7·9 per cent in the age range 35-54 years, and to 37 per cent among those aged 55 years and above. The groin hernia surgery rate at the hospitals investigated was 17 per 100 000 population per year, which corresponds to a surgical correction rate of less than 1 per cent per year. Based on hospital records, a considerable number of patients having surgery for groin hernia were women (20 of 84 patients, 24 per cent). CONCLUSION: Groin hernia is a common condition in men in this east Ugandan cohort and the annual surgical correction rate is low. Investment is needed to increase surgical capacity in this healthcare system.

Place, publisher, year, edition, pages
John Wiley & Sons, 2014
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-87715 (URN)10.1002/bjs.9457 (DOI)24652681 (PubMedID)
Available from: 2014-04-07 Created: 2014-04-07 Last updated: 2017-12-05Bibliographically approved
2. Cost of surgery in a low-income setting in eastern Uganda
Open this publication in new window or tab >>Cost of surgery in a low-income setting in eastern Uganda
Show others...
2015 (English)In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 157, no 6, 983-991 p.Article in journal (Refereed) Published
Abstract [en]

Background. Operative interventions have traditionally been seen as expensive; therefore, surgery has been given low priority in global health care planning in low-income countries. A growing body of evidence indicates that surgery can also be highly cost effective in low-income settings, but our current knowledge of the actual cost of surgery in such settings is limited. This study was carried out to obtain data on the costs of commonly performed operative procedures in a rural/semiurban setting in eastern Uganda. Methods. A prospective, facility-based study carried out at a general district hospital (public) and a mission hospital (private, not-for-profit) in the Iganga and Mayuge districts in eastern Uganda. Items included in the cost calculations were staff time, materials and medicines, overhead costs, and capital costs. Results. The cost of surgery was higher at the mission hospital, with higher expenditure and lower productivity than the public hospital. The most commonly performed major procedures were caesarean section, uterine evacuation, and herniorrhaphy for groin hernia. The costs for these interventions varied between $68.4 and $74.4, $25.0 and $32.6, and $58.6 and $66.0, respectively. The most commonly performed minor procedures were circumcision, suture of cuts and lacerations, and incision and drainage of abscess. The costs for these interventions varied between $16.2 and $24.6, $15.8 and $24.3, and $10.1 and $18.6, respectively. Conclusion. The cost of surgery in the study setting compares favorably with other prioritized health care interventions, such as treatment for tuberculosis, human immunodeficiency virus/AIDS, and childhood immunization. Surgery in low-income settings can be made more cost effective, leading to increased quantity and improved quality of surgical services.

Place, publisher, year, edition, pages
Elsevier, 2015
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-106127 (URN)10.1016/j.surg.2015.01.026 (DOI)000354910600003 ()25934080 (PubMedID)
Available from: 2015-07-14 Created: 2015-07-09 Last updated: 2017-12-04Bibliographically approved
3. District-level surgery in Uganda: Indications, interventions and perioperative mortality
Open this publication in new window or tab >>District-level surgery in Uganda: Indications, interventions and perioperative mortality
Show others...
2015 (English)In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 158, no 1, 7-16 p.Article in journal (Refereed) Published
Abstract [en]

Background: The world's poorest 2 billion people, benefit from no more than about 3.5% of the world's operative procedures. The burden of surgical disease is greatest in Africa, where operations could save many lives. Previous facility-based studies have described operative procedure caseloads, but prospective studies investigating interventions, indications and perioperative mortality rates (POMR), are rare.

Methods: A prospective, questionnaire-based collection of data on all major and minor operative procedures was undertaken at 2 hospitals in rural Uganda covering 4 and 3 months in 2011, respectively. Data included patient characteristics, indications for the interventions performed, and outcome after surgery.

Results: We recorded 2,790 operative procedures on 2,701 patients. The rate of major operative procedures per 100,000 population per year was 225. Patients undergoing major operative procedures (n = 1,051) were mostly women (n = 923; 88%) because most interventions were performed owing to pregnancy-related complications (n = 747; 67%) or gynecologic conditions (n = 114; 10%). General operative interventions registered included herniorrhaphy (n = 103; 9%), exploratory laparotomy (n = 60; 5%), and appendectomy (n = 31; 3%). The POMR for major operative procedures was 1 % (n = 14) and was greatest after exploratory laparotomy (13%; n = 8) and caesarean delivery (1%; n = 4). Most deaths = 16) were a result of sepsis (n = 10-11) or hemorrhage (n = 3-5).

Conclusion: The volume of surgery was low relative to the size of the catchment population. The POMR was high. Exploratory laparotomy and caesarean section were identified as high-risk procedures. Increased availability of blood, improved pen operative monitoring, and early intervention could be part of a solution to reduce the POMR

National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-106319 (URN)10.1016/j.surg.2015.03.022 (DOI)000356320400003 ()25958070 (PubMedID)
Available from: 2015-07-17 Created: 2015-07-10 Last updated: 2017-05-22Bibliographically approved
4. A Randomized Trial of Low-Cost Mesh in Groin Hernia Repair
Open this publication in new window or tab >>A Randomized Trial of Low-Cost Mesh in Groin Hernia Repair
Show others...
2016 (English)In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 374, no 2, 146-153 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The most effective method for repair of a groin hernia involves the use of a syn-thetic mesh, but this type of mesh is unaffordable for many patients in low- and middle-income countries. Sterilized mosquito meshes have been used as a lower-cost alternative but have not been rigorously studied.METHODS: We performed a double-blind, randomized, controlled trial comparing low-cost mesh with commercial mesh (both lightweight) for the repair of a groin hernia in adult men in eastern Uganda who had primary, unilateral, reducible groin hernias. Surgery was performed by four qualified surgeons. The primary outcomes were hernia recurrence at 1 year and postoperative complications.RESULTS: A total of 302 patients were included in the study. The follow-up rate was 97.3% after 2 weeks and 95.6% after 1 year. Hernia recurred in 1 patient (0.7%) assigned to the low-cost mesh and in no patients assigned to the commercial mesh (abso-lute risk difference, 0.7 percentage points; 95% confidence interval [CI], −1.2 to 2.6; P = 1.0). Postoperative complications occurred in 44 patients (30.8%) assigned to the low-cost mesh and in 44 patients (29.7%) assigned to the commercial mesh (absolute risk difference, 1.0 percentage point; 95% CI, −9.5 to 11.6; P = 1.0).CONCLUSIONS: Rates of hernia recurrence and postoperative complications did not differ signifi-cantly between men undergoing hernia repair with low-cost mesh and those un-dergoing hernia repair with commercial mesh.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-107657 (URN)10.1056/NEJMoa1505126 (DOI)000367996700009 ()26760085 (PubMedID)
Note

Originally published in manuscript form with title "Low cost mesh in groin hernia repair - A double-blinded, randomized trial"

Available from: 2015-08-25 Created: 2015-08-25 Last updated: 2017-12-04Bibliographically approved
5. Cost-effectiveness of groin hernia surgery using a low-cost versus a commercial mesh
Open this publication in new window or tab >>Cost-effectiveness of groin hernia surgery using a low-cost versus a commercial mesh
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-107658 (URN)
Available from: 2015-08-25 Created: 2015-08-25 Last updated: 2015-08-26Bibliographically approved

Open Access in DiVA

fulltext(29272 kB)557 downloads
File information
File name FULLTEXT01.pdfFile size 29272 kBChecksum SHA-512
f604445c88e65bd5797e67a6e37f75e223cc6fc31abc62210c0e1fa13e55ddf750d36d6aae8dec69e40257df8d5241661da452e24b01b9fdb5ff0b49e14c416c
Type fulltextMimetype application/pdf
spikblad(68 kB)33 downloads
File information
File name SPIKBLAD01.pdfFile size 68 kBChecksum SHA-512
f0362ba128844e8425d28a011a6722b3aabde8c671b06c19d9f9a23363be38ca0c3d98c6040c715a197593a456bea8ef1b5327720f979b1dcf8119e1eb0eafc8
Type spikbladMimetype application/pdf

Search in DiVA

By author/editor
Löfgren, Jenny
By organisation
Surgery
Surgery

Search outside of DiVA

GoogleGoogle Scholar
Total: 557 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 1719 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf