Volume 75, Issue S1 p. e28-e33
Original Article
Free Access

Priorities for peri-operative research in Africa

B.M. Biccard

Corresponding Author

B.M. Biccard

Correspondence to: B.M. Biccard

Email: [email protected]

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The African Peri-operative Research Group (APORG) working group

The African Peri-operative Research Group (APORG) working group

See Appendix  S1 for the APORG list of collaborators.Search for more papers by this author
First published: 05 January 2020
Citations: 15

Summary

Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri-operative research agenda to ensure co-ordinated, collaborative research efforts across Africa in order to decrease peri-operative mortality. The objective was to determine the top 10 research priorities for peri-operative research in Africa. A Delphi technique was used to establish consensus on the top research priorities. The top 10 research priorities identified were (1) Develop training standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri-operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri-operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri-operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence-based practice guidelines for peri-operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri-operative outcomes associated with emergency surgery. These peri-operative research priorities provide the structure for an intermediate-term research agenda to improve peri-operative outcomes across Africa.

Introduction

Deaths following surgery are the third largest contributor to deaths globally 1. In Africa, nearly a billion people do not have access to safe and affordable surgery 2. The recent collaborative African Surgical Outcomes Study (ASOS) highlighted the limited human resources available to provide surgical care, and the resultant ‘failure to rescue’ which was associated with a peri-operative mortality twice the global average 3. The distribution of surgeries in Africa differs from that of high-income countries, with one-third of all surgeries in Africa being caesarean sections, which is associated with a mortality rate 50 times higher than that reported in high-income countries 4. These startling peri-operative outcomes have forged a large, informal collaborative across Africa, known as the African Peri-operative Research Group (APORG). These clinician investigators have a desire to provide pragmatic solutions to improve peri-operative outcomes in Africa, despite difficult resource-limited environments 5.

In order to provide a ‘context-sensitive’ approach to improving peri-operative outcomes in Africa, it is necessary to provide agreed peri-operative research priorities. National leaders from the African Surgical Outcomes (ASOS) trials collaborated under the auspices of the APORG to achieve this objective. This initiative was undertaken because this group, which represents over 30 countries and 500 hospitals across Africa, believes that it has the capacity to drive this research agenda to improve peri-operative outcomes across Africa despite limited research resources.

The objective of this study was to determine the top 10 priorities for peri-operative research in Africa, using a priority setting process.

Methods

Ethical approval was obtained from the ethics committee of the University of Cape Town, South Africa. A Delphi technique 6 was used for this African peri-operative research priority setting project, which was conducted as an electronic survey over four rounds between July 2019 and September 2019. This approach to consensus development for priorities was modelled on a previous priority setting process used in South Africa 7. In the first round, an email invitation was sent to all ASOS 3 and ASOS-2 national leaders across Africa (a convenience sample) (see also Appendix S2). This was a closed survey within this group and was not advertised openly. Participation was voluntary and all respondents gave consent. In the first round, respondents were asked to submit potential peri-operative research priorities. The responses were collated and, where appropriate, similar research priorities were amalgamated into a single priority by AT, LT, UP and BB.

In the second round, these potential research priorities were circulated to all the respondents, with each receiving the potential priorities in a different order due to randomisation. Respondents were asked to rank the top 10 research priorities, and where possible to provide justifications for inclusion or exclusion of priorities. In the third round, adaptive questioning was used, with only the top 20 research priorities from round two being presented in rank order, with all submitted justifications attached. In this round, the respondents were asked to consider re-ranking their previous submission from round two, based on the priorities ranking and justifications of the group. If the respondents preferred not to change their previous rankings, they were encouraged to provide justifications for their decision. For the second and third rounds of the Delphi process, the respondents were encouraged not to discuss their submissions with other colleagues in order to minimise bias.

The survey was conducted in English and French, and all communications, responses and proposed priorities were communicated in both languages during the Delphi process. All priorities were visible on a single screen in the second and third rounds, and all responses were captured electronically. If a response was incomplete, or the respondent wanted to change the response, they could resubmit a response during that round of the Delphi process. If a respondent had submitted more than one electronic survey in a round, then the last and most complete response was used in the ranking. To ensure that the electronic survey was only completed by the ASOS and ASOS-2 national leaders, and to prevent completion of multiple e-surveys per round by a single participant, all submissions were identifiable to TM who collated the final responses per round for analysis. Following collation of these responses, the database was then de-identified. There were no incentives for participation. The fourth and final Delphi round was held at a workshop on 28 September 2019 in Durban, South Africa, which was live streamed to allow for open participation in the final stage. At the workshop, a discussion of the top 15 research priorities from the third round was held, in order to determine the final top 10 priorities.

The rank order of the research priorities from rounds two and three was calculated using a reverse scoring system. Therefore, a rank of one was assigned 10 points, with a descending point allocation down to a rank of 10, which was allocated one point. The scores of the respondents for each proposed priority were combined to present the research priority rank order. Incomplete responses (< 10 priorities ranked) were analysed, and no adjustment was made for incomplete responses.

Results

This electronic survey is reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines in Appendix S3 8. Fifty-two national or co-national African leaders were invited to participate in the research priority setting process from 37 African countries: Algeria; Angola; Bénin; Botswana; Burkina Faso; Burundi; Cameroon; Central African Republic; Congo; Democratic Republic of the Congo; Djibouti; Egypt; Ethiopia; Gambia; Ghana; Ivory Coast; Kenya; Liberia; Libya; Madagascar; Malawi; Mali; Mauritius; Mozambique; Namibia; Niger; Nigeria; Rwanda; Senegal; Sierra Leone; South Africa; Swaziland; Tanzania, Togo; Uganda; Zambia; and Zimbabwe. Thirty-two of the invited national leaders participated in the priority setting process and submitted 158 potential research priorities; these were amalgamated into 60 unique potential research priorities. These potential research priorities covered a broad range of fields including anaesthesia; communication and teamwork; critical care; economics; surgery; geriatrics; obstetrics; paediatrics; pain; patient outcomes; peri-operative medicine; registries; resources and guidelines; quality improvement; social context; trauma; and wellness. In the fourth round, it was agreed that the top 10 priorities from round three should remain as the top 10 priorities for the priority setting process. The agreed top 10 priorities for peri-operative research in Africa are shown in Table 1.

Table 1. Top 10 priorities for peri-operative research in Africa
1. Develop training standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa
2. Develop minimum provision of care standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa
3. Early identification and management of mothers at risk from peripartum haemorrhage in the peri-operative period
4. The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri-operative care
5. A facility audit/African World Health Organization situational analysis tool (WHO-SAT) audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and the level of training and knowledge of peri-operative healthcare providers (surgeons, anaesthetists and nurses)
6. Establishing evidence-based practice guidelines for peri-operative physicians in Africa
7. Economic analysis of strategies to finance access to surgery in Africa
8. Establishment of a minimum dataset surgical registry
9. A quality improvement programme to improve implementation of the surgical safety checklist
10. Peri-operative outcomes associated with emergency surgery

Discussion

A Delphi process is a well-established approach to determine clinical research priorities 9. Ten research priorities have been identified for peri-operative research in Africa. These priorities provide the structure for an intermediate-term, African, collaborative peri-operative research programme. These priorities represent the consensus of peri-operative clinician scientists from over 30 African countries, and cover a broad range of topics which are context-sensitive to the challenges and needs of peri-operative research in Africa 5.

Priority number 1. Develop training standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa

Standards for training of surgical 10, anaesthesia 11, 12 and peri-operative nurses have been proposed previously. As this is the highest ranked priority, it would suggest that these training models do not yet adequately address the needs for providing peri-operative care in a limited resource environment, particularly where the number of surgical, anaesthesia and obstetric specialists is < 1 per 100,000 3; this figure is 50 times below the recommended minimum number of specialists needed to provide a safe surgical service 2.

Priority number 2. Develop minimum provision of care standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa

There are numerous examples demonstrating the difficulty in providing safe peri-operative care in Africa. In the peri-operative period, neither oximetry 13 nor capnography 14 are ubiquitous, yet they may improve outcomes 13, 14. There is a clear signal of ‘failure to rescue’ being a key driver of peri-operative mortality in Africa 3. Following adult surgery, it is estimated that ‘failure to rescue’ is twice the global average in Africa 3, and it may be as high as 17 times the global average when considering maternal mortality following caesarean section 4. There has been a previous call for monitoring standards to prevent mortality 15. This priority is a clear statement that there is a need to establish minimum care standards for Africa, to facilitate early identification of patients at risk, and thereby decrease ‘failure to rescue’ and peri-operative mortality.

Priority number 3. Early identification and management of mothers at risk from peripartum haemorrhage in the peri-operative period

Caesarean section is the most commonly performed surgical procedure in Africa, contributing to one third of all adult surgeries 4. Peripartum haemorrhage is the leading cause of maternal mortality following caesarean section in Africa, where one in four mothers die if they suffer a peripartum haemorrhage 11. Decreasing peripartum haemorrhage is the priority to be addressed in the third APORG research network project, which will be known as the African Surgical Outcomes-3 (ASOS-3) study.

Priority number 4. The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri-operative care

It is estimated that nearly 60% of excess deaths globally are due to low-quality care 16 and excess mortality due to low-quality healthcare systems are particularly high in Africa 17. Besides identifying and improving training standards (priority 1) and monitoring standards (priority 2), improvements in team communication may be an important component to improve patient safety and peri-operative outcomes 18.

Priority number 5. A facility audit/African World Health Organization situational analysis tool (WHO-SAT) audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and the level of training and knowledge of peri-operative healthcare providers (surgeons, anaesthetists and nurses)

A facility and situational analysis audit is needed in order to document the current dire conditions in which a number of peri-operative healthcare providers work in Africa. It is hoped that this will provide the impetus needed to improve these peri-operative clinical environments, and to ensure these efforts are focussed on documented deficiencies. In the longer term, this may lead to improvements in the clinical environment, resulting in better quality care 17 and improved patient outcomes.

Priority number 6. Establishing evidence-based practice guidelines for peri-operative physicians in Africa

There is a growing awareness that ‘peri-operative care’ or ‘peri-operative medicine’ in a low-resource environment is fundamentally different to that of a well-resourced environment. The prevalence of undiagnosed diseases 19 or poorly managed chronic comorbidities 20 in elective surgical patients reflects limited access to a functional primary healthcare system. Patient comorbidities that are not identified and/or optimised before surgery adversely affect surgical outcomes. In low-resource environments, the need for surgery provides an important opportunity to provide simple public health interventions, which may improve surgical outcomes. In addition, there may also be improvements in public health by flagging co-existing diseases and ensuring initiation or optimisation of therapy with integration into the primary healthcare system.

Priority number 7. Economic analysis of strategies to finance access to surgery in Africa

It is estimated that 95% of patients in Africa do not have access to safe and affordable surgery 2. Access to surgery is worse in low- and middle-income countries 2. Access to timely essential surgery is defined as the proportion of the population that can access a facility that can perform caesarean delivery, laparotomy and treat open fractures (known as Bellwether procedures 2) within 2 h. The low number of surgical procedures per 100,000 population conducted in Africa 3 would suggest that there is a substantial number of patients who cannot access surgery. A prolonged time to accessing surgery is associated with increased postoperative morbidity 21. This priority addresses the need to increase access to surgery in Africa.

Priority number 8. Establishment of a minimum dataset surgical registry

The adage ‘If you can't measure it, you cannot improve it’ is attributed to Peter Drucker. Establishing a benchmark for surgical outcomes across hospitals in Africa will allow for a documentation of success and failures associated with addressing some of these priorities, and the intervention implementation strategies considered to be of possible benefit in ensuring a higher quality healthcare system 17. Tracking outcomes in a minimum dataset will ensure that resources will not be wasted on futile projects.

Priority number 9. A quality improvement programme to improve implementation of the surgical safety checklist

Observational data have shown that the use of a safe surgery checklist improves patient outcomes after surgery and possibly decreases mortality 22-25. Randomised controlled trials appear to show the beneficial effects associated with the use of the safe surgery checklist 26-28. Implementation of the safe surgery checklist may be a simple way to improve the quality of peri-operative care in Africa, particularly as the safe surgery checklist is only used in 57% of surgical procedures 3.

Priority number 10. Peri-operative outcomes associated with emergency surgery

Emergency surgery accounts for nearly 60% of all adult surgeries in Africa 3; this is of importance given that urgent and emergent surgery is an independent predictor of mortality and severe postoperative complications in Africa 29. As a large proportion of the burden of peri-operative mortality in Africa can be attributed to urgent and emergency surgery, strategies are needed to identify these patients earlier, decrease the time to access surgery and ensure adequate peri-operative care to minimise ‘failure to rescue’. In order to improve peri-operative outcomes, a simple and appropriate low-resource environment quality improvement programme 30, 31 would be desirable for these patients.

Although the priorities are ranked, simultaneous and complimentary implementation of the 10 priorities should be considered. Importantly, the priorities are interlinked and clearly build across and upon each other. For example, establishing a minimum dataset surgical registry (priority 8), has the potential to document the successes of a number of other priorities, for example, implementing the safe surgery checklist (priority 9), and implementing training standards (priority 1), monitoring standards (priority 2), improving communication and team work (priority 4) and establishing evidence-based practice guidelines for peri-operative medicine (priority 6). Furthermore, a facility and situational audit (priority 5) will inform which training standards (priority 1) and monitoring standards (priority 2) need to be addressed in different centres. Different groups addressing various priorities simultaneously would, therefore, be recommended.

The strength of this priority setting exercise is that APORG is the largest clinical network in Africa conducting continental peri-operative research 3 and these research priorities represent the consensus of peri-operative clinician scientists from over 30 African countries. However, as this was the first peri-operative research priority setting process undertaken in Africa, it is likely that the other peri-operative clinician scientists from Africa were not included. Furthermore, the response rate was just over 60% for this priority setting exercise. It is hoped that this work will create an awareness which will increase the participation of other African clinician scientists in future priority setting processes. Furthermore, patients did not participate in this research priority setting process. A patient-centred approach to healthcare is important, and patient participation should be an objective for future research priority settings in Africa 9.

In summary, the top 10 priorities for peri-operative research in Africa have been identified following a research priority setting process using the Delphi technique. These research priorities provide the structure for an intermediate-term research agenda for peri-operative research in Africa. It is hoped that addressing these priorities will significantly improve peri-operative outcomes in Africa.

Acknowledgements

The final Delphi workshop was funded by the Discipline of Anaesthesiology and Critical Care, University of KwaZulu-Natal. They had no role in the study design, data acquisition, data analysis or writing of the paper. No other competing interests declared.