Plastic Surgery International

Plastic Surgery International / 2014 / Article

Research Article | Open Access

Volume 2014 |Article ID 921625 | 12 pages | https://doi.org/10.1155/2014/921625

Helping Hands: A Cost-Effectiveness Study of a Humanitarian Hand Surgery Mission

Academic Editor: Bishara S. Atiyeh
Received15 May 2014
Accepted01 Aug 2014
Published20 Aug 2014

Abstract

Purpose. Congenital anomalies and injuries of the hand are often undertreated in low-middle income countries (LMICs). Humanitarian missions to LMICs are commonplace, but few exclusively hand surgery missions have been reported and none have attempted to demonstrate their cost-effectiveness. We present the first study evaluating the cost-effectiveness of a humanitarian hand surgery mission to Honduras as a method of reducing the global burden of surgically treatable disease. Methods. Data were collected from a hand surgery mission to San Pedro Sula, Honduras. Costs were estimated for local and volunteer services. The total burden of disease averted from patients receiving surgical reconstruction was derived using the previously described disability-adjusted life years (DALYs) system. Results. After adjusting for likelihood of disability associated with the diagnosis and likelihood of the surgery’s success, DALYs averted totaled 104.6. The total cost for the mission was $45,779 (USD). The cost per DALY averted was calculated to be $437.80 (USD), which is significantly below the accepted threshold of two times the per capita gross national income of Honduras. Conclusions. This hand surgery humanitarian mission trip to Honduras was found to be cost-effective. This model and analysis should help in guiding healthcare professionals to organize future plastic surgery humanitarian missions.

1. Introduction

Humanitarian missions to low-middle income countries (LMICs) have become a major source of medical care for underserved populations, particularly in plastic surgery. Teams consist of a variety of healthcare professionals who travel to the country in need, with all required supplies and equipment. On location, surgeons perform life-changing procedures for patients with congenital deformities, trauma, or burns, all of which cause significant disease burden on the local population [1, 2]. This service is provided free of charge to the patients. All expenses are paid by charitable donations, usually without religious, financial, cultural, or political agendas [3].

Honduras is a democratic nation in Central America with a population of approximately 7.5 million. Over half of the population lives below the poverty line and an estimated 30% are unemployed [4]. Like many LMICs, Honduras lacks both resources and an adequate health care infrastructure to provide the care for its citizens. According to the World Health Organization, “roughly 30.1% of the population receives no healthcare, 83% are uninsured, and there is marked exclusion of ethnic minorities and rural populations.” Further, there are only 8.8 physicians and 3 nurses per 10,000 citizens, compared to 26 physicians and 94 nurses per 10,000 in the United States [5]. In 2005, the per capita total expenditure on healthcare in Honduras was $91 versus $6,350 in the United States [4]. Furthermore, patients’ access to hospitals can be limited geographically and by a lack of transportation means. At the same time, medical technology and surgical techniques in developed countries continue to advance rapidly. This has created a growing dichotomy in healthcare between rich and poor countries [6, 7]. In particular, areas of subspecialty surgery, such as reconstructive plastic surgery and hand surgery, which are increasingly specialized in countries like the United States, are all but absent in some developing nations [8, 9]. Because of this, humanitarian missions to the developing world are becoming more and more relevant as a way to provide direct aid and training to local surgeons. Many medical and surgical mission trips throughout the world have been reported in the literature with plastic surgery volunteer trips being especially common, and the majority of which involve cleft lip and palate repair [10]. Some reported mission trips involve treatment of both hand anomalies and craniofacial defects. However, very few of the reported humanitarian mission trips have focused solely on hand surgery. Further, the cost-effectiveness of such trips has not been previously reported. In the present paper, we present a report on the cost-effectiveness of a mission trip to Honduras in May 2006 that exclusively focused on hand surgery.

2. Methods

2.1. Study Population

In May 2006, our group of 20 healthcare professionals traveled to San Pedro Sula, Honduras. Our local sponsor, the Ruth Paz Foundation, a nonprofit charitable group, assisted on site with organization, logistics, and advertising. We worked out of a local public hospital called Leonardo Martinez, which hosts a variety of medical and surgical humanitarian mission trips. Team personnel consisted of 3 hand/microsurgery trained surgeons, 1 plastic surgery trained surgeon, 1 hand/microsurgery fellow, 1 plastic surgery resident, 3 anesthesiologists, 1 pediatrician, 1 nurse anesthetist, 5 operating room nurses, 1 recovery room nurse, 1 hand therapist, 1 team administrator, and 1 photographer. All surgical supplies (including gowns, drapes, sponges, sutures, dressings, and plaster) and surgical instruments were brought with the team for the trip.

Members of the Ruth Paz Foundation set up the screening clinic and organized the follow-up visits. Potential patients were alerted about the available services, through radio announcements and fliers. The majority of the patients were screened for surgery on the primary screening day with additional patients, who missed the main screening day, screened each day. The operating schedule for the next five days was created based on the patients seen on the main screening day. Those screened for surgery were then immediately referred to waiting anesthesiologists and pediatrician for same day medical clearance. Patients were then instructed when to return for surgery before they left.

Many minor procedures were performed with local surgeons present in order to provide training for their future practice. Ganglion cysts and masses were removed for extreme size, intractable pain, or functional limitation. Because of the team’s yearly trip to Honduras, we were also able to perform more complex two-staged procedures. All surgeries were performed by either a board certified plastic surgeon or orthopedic surgeon. Each day, the team would round on all postoperative patients in the morning and in the evening. The patients were seen in follow-up clinic by local physicians, who removed splints, dressings, sutures, and k-wires, as necessary. Patients were also seen by local physical and occupational therapists that provided assistance with splints as well as therapy.

2.2. Costs

The team’s costs for the trip were calculated by adding the team’s travel expenses, which included transportation, lodging, and donated supplies that were brought with them (Table 1(a)). The team’s 2006 costs were then adjusted for inflation to present day based on data obtained from World Bank’s data [4]. Weekly hospital personnel salaries and preoperative, intraoperative, and postoperative medication costs were obtained from the Ruth Paz Foundation (Tables 1(b) and 1(c)). We were unable to obtain operative room cost or daily hospital stay costs. Other fixed costs, such as utilities and building costs, were not included as we were not able to obtain this information. Patients were charged a symbolic fee based on their household income by the local hospital for services, but due to the nominal nature of the fee (ranging from $0 to $50), this was not included for analysis.

(a) Team costs

Value (USD) in 2006Cumulative inflation rate (2006 to 2013)Inflation adjusted value (USD) in 2013% of total costs

Transportation and lodging$23,00015.90%$26,650.3462.2%
Donated supplies$14,00015.90%$16,226.0037.8%
Total cost$37,00015.90%$42,876.34

(b) Local personnel salary

Weekly salary (USD) in 2013NumberWeekly cost (USD)% of total costs

Local surgeon$3452$69045.3%
Surgical tech.$1852$37024.3%
Nurse$1852$37024.3%
Cleaning$921$926.0%
Total cost$1,522

(c) Hospital costs

Weekly cost (USD) in 2013

Pre- and postoperative medications$448.84
Intraoperative medications$932
Total costs$1,380.84

(d) Overall mission cost

Cost (USD)% of total costs

Team costs$42,876.34 93.7%
Local personnel costs$1,522.00 3.3%
Hospital costs$1,380.84 3.0%
Total overall costs$45,779.18

(e) Cost-effectiveness metrics

If 2 × TC (i.e., doubled)If 5 × TC

Total cost (TC)$45,779.18$91,558.36$228,895.90
Cost per patient$572.24$1,144.48$2,861.20
Cost per DALY averted$437.80$875.32$2,188.30*
*Still below $3,890 (2 × PCGNI)

PCGNI: per capita gross national income.
2.3. Outcome

The total burden of musculoskeletal disease was calculated for each patient that underwent surgery using disability-adjusted life years (DALYs) format. As no surgery performed was life-saving, all of the DALYs attributed were from years lost to disability (YLD) and none from years of life lost (YLL). YLD is calculated using disability weight and the remaining life expectancy. In previous calculations of YLD, age weighting factors and discount rate were also incorporated in the calculation; however, the recently published Global Burden of Disease 2010 study has moved away from those adjustments [11]. Every patient’s diagnosis and associated disability was matched as closely as possible to a health state based on each state’s lay description as described in Global Burden of Disease 2010 study. Each patient was then assigned a disability weight based on the closest available health state (Table 2). For each patient, the potential years lived with disability value was calculated using the patient’s age and life expectancy chart found in the Global Burden of Disease 2010 study. For each patient, the DALY value represents the burden of an untreated condition. This value has been subsequently adjusted for likelihood of permanent disability and likelihood of treatment success as described in the literature by McCord and Chowdry and modified by Gosselin et al. [1216] and represents the DALYs averted with surgery (Table 3). To err on side of overestimating cost per DALY averted, we chose conservative weights for disability, likelihood of permanent disability, and effectiveness of treatment. The scoring system used in assigning likelihood of permanent disability and likelihood of treatment success is shown in Table 4.


AgeSexDiagnosisAvailable disability weightDisability weight

9FTendon adhesionMusculoskeletal problems: arms, mild0.024
16MFinger flexor tendon injuryMusculoskeletal problems: arms, mild0.024
26MFinger flexor tendon injury and nerve lacerationInjured nerves: long term0.136
60MPosttraumatic joint contractureMusculoskeletal problems: arms, mild0.024
68FTrigger fingerMusculoskeletal problems: arms, mild0.024
3FFinger flexor tendon injuryMusculoskeletal problems: arms, mild0.024
13MCubitus varusDisfigurement: level 10.013
14MPolydactylyDisfigurement: level 10.013
47MLipomaDisfigurement: level 1, with itch or pain0.029
57FTrigger fingerMusculoskeletal problems: arms, mild0.024
11MBurn scar contractureBurns of <20% total surface area or <10% total surface area if head or neck or hands or wrist involved: long term, with or without treatment0.018
12MBurn scar contractureMusculoskeletal problems: arms, mild0.024
21FPartial traumatic amputationAmputation of finger(s), excluding thumb: long term, with treatment0.03
30FNerve lacerationInjured nerves: long term0.136
34MSkin contractureMusculoskeletal problems: arms, mild0.024
47MRadius and ulna fractureFracture of radius or ulna: short term, with or without treatment0.065
8MMetacarpal fractureMusculoskeletal problems: arms, mild0.024
11MCubitus varusDisfigurement: level 10.013
21MBurn scar contractureBurns of <20% total surface area or <10% total surface area if head or neck or hands or wrist involved: long term, with or without treatment0.018
45MPosttraumatic joint contractureMusculoskeletal problems: arms, mild0.024
48MCarpal tunnel syndromeInjured nerves: short term0.065
51FGanglion cystDisfigurement: level 1, with itch or pain0.029
67MDupuytren’s contractureMusculoskeletal problems: arms, moderate0.114
5MBurn scar contractureBurns of <20% total surface area or <10% total surface area if head or neck or hands or wrist involved: long term, with or without treatment0.018
7MPolydactylyDisfigurement: level 10.013
19FTumorDisfigurement: level 1, with itch or pain0.029
21MTumorDisfigurement: level 1, with itch or pain0.029
31MDorsal ganglion cystDisfigurement: level 1, with itch or pain0.029
42FNonunion radiusFracture of radius or ulna: long term, without treatment0.05
56FDe Quervain's syndromeMusculoskeletal problems: arms, moderate0.114
11 moMThumb hypoplasiaAmputation of thumb: long term0.013
23MBurn scar contractureMusculoskeletal problems: arms, mild0.024
33MBurn scar contractureMusculoskeletal problems: arms, moderate0.114
37FHook nail deformityDisfigurement: level 10.013
48MDupuytren's contractureMusculoskeletal problems: arms, mild0.024
8MFlexor tendon injuryMusculoskeletal problems: arms, mild0.024
10FScar contractureMusculoskeletal problems: arms, mild0.024
20MFlexor tendon injury with nerve lacerationInjured nerves: long term0.136
55MCarpal tunnel syndromeInjured nerve: short term0.065
5MSyndactylyMusculoskeletal problems: arms, mild0.024
17MThumb hypoplasiaMusculoskeletal problems: arms, moderate0.114
18MForeign body with ulnar neuropathyInjured nerves: short term0.065
23MForeign bodyMusculoskeletal problems: arms, mild0.024
34MRadial head fractureFracture of radius or ulna: short term, with or without treatment0.065
44MPosttraumatic joint contractureMusculoskeletal problems: arms, mild0.024
49MExtensor tendon lacerationMusculoskeletal problems: arms, mild0.024
20MFlexor tendon injuryMusculoskeletal problems: arms, moderate0.114
22FPosttraumatic joint contractureMusculoskeletal problems: arms, mild0.024
22MPosttraumatic joint contractureMusculoskeletal problems: arms, mild0.024
47MShoulder lipomaDisfigurement: level 1, with itch or pain0.029
61FGanglion cyst and ulnocarpal abutmentMusculoskeletal problems: arms, moderate0.114
5MBurn scar contractureBurns of <20% total surface area or <10% total surface area if head or neck or hands or wrist involved: long term, with or without treatment0.018
32MFlexor tendon injuryMusculoskeletal problems: arms, moderate0.114
60FGanglion cystDisfigurement: level 1, with itch or pain0.029
61MFinger flexor tendon injuryMusculoskeletal problems: arms, moderate0.114
65FL ulna nonunionFracture of radius or ulna: long term, without treatment0.05
10MSyndactylyMusculoskeletal problems: arms, mild0.024
24MMalunionMusculoskeletal problems: arms, moderate0.114
35FNerve lacerationInjured nerves: long term0.136
38MNerve lacerationInjured nerves: long term0.136
10 moML MF-RF syndactylyMusculoskeletal problems: arms, mild0.024
17MMalunionFracture of hand: long term, without treatment0.016
18MFlexor tendon injuryMusculoskeletal problems: arms, moderate0.114
28MRadial nerve lacerationInjured nerves: long term0.136
42FCarpal tunnel syndromeInjured nerve: short term0.065
14MFlexor tendon injury with nerve lacerationMusculoskeletal problems: arms, moderate0.114
23FBurn scar contractureBurns of <20% total surface area or <10% total surface area if head or neck or hands or wrist involved: long term, with or without treatment0.018
50MRadial nerve lacerationInjured nerves: long term0.136
9FBurn scar contractureBurns of <20% total surface area or <10% total surface area if head or neck or hands or wrist involved: long term, with or without treatment0.018
16FMalunionMusculoskeletal problems: arms, mild0.024
31FGanglion cystDisfigurement: level 1, with itch or pain0.029
47FUlnocarpal abutmentMusculoskeletal problems: arms, moderate0.114
55FCarpal tunnel syndromeInjured nerve: short term0.065
14FBurn scar contractureMusculoskeletal problems: arms, moderate0.114
39FGanglion cystDisfigurement: level 1, with itch or pain0.029
42MPosttraumatic joint contractureMusculoskeletal problems: arms, mild0.024
46MPosttraumatic joint contractureMusculoskeletal problems: arms, mild0.024
57FCarpal tunnel syndromeInjured nerve: short term0.065
23MFinger massDisfigurement: level 1, with itch or pain0.029
62MSkin lesionDisfigurement: level 1, with itch or pain0.029


Case
#
AgeRemaining life expectancySexDiagnosisProcedureDisability Wt.DALYLikelihood of permanent disabilityLikelihood of treatment successDALY averted

Day 1
1977.27FTendon adhesionL wrist exploration w/tenolysis FDP0.0241.854480.70.70.9086952
21670.3MFinger flexor tendon injuryR index finger Hunter rod placement0.0241.68720.70.70.826728
32660.41MFinger flexor tendon injury and nerve lacerationR FPL repair w/tendon grafts; nerve repair with sural nerve graft0.1368.215760.70.74.0257224
46027.81MPosttraumatic joint contractureR long finger PIP joint arthrodesis0.0240.667440.70.70.3270456
56820.68FTrigger fingerR LF trigger finger release0.0240.496320.70.70.2431968
6383.23FFinger flexor tendon injuryL ring finger FDS/FDP-Hunter rod implant0.0241.997520.70.70.9787848
71373.29MCubitus varusL lateral closing wedge osteotomy of supracondylar for cubitus varus0.0130.952770.70.70.4668573
81472.29MPolydactylyB/l thumb partial duplication repair; anlage excision0.0130.939770.70.70.4604873
94739.9MLipomaExcision of L forearm mass 0.0291.15710.70.70.566979
105730.55FTrigger fingerR IF and LF trigger finger release0.0240.73320.70.70.359268
111175.28MBurn scar contractureL forearm excision of burn scar; STSG0.0181.355040.30.70.2845584
121274.28MBurn scar contractureR hand thumb webs space deepening with split thickness skin graft 0.0241.782720.30.70.3743712
132165.36FPartial traumatic amputationL RF amputation completion0.031.96080.70.70.960792
143056.46FNerve lacerationNerve graft L ulnar nerve; anticlaw tendon transfer0.1367.678560.70.73.7624944
153452.52MSkin contractureL middle PIP contracture release and skin graft0.0241.260480.70.70.6176352
164739.9MRadius and ulna fractureORIF L radius/ulna0.0652.59350.30.70.544635

Day 2
17878.26MMetacarpal fractureR LF pinning of metacarpal fracture0.0241.878240.70.70.9203376
181175.28MCubitus varusR supracondylar osteotomy0.0130.978640.70.70.4795336
192165.36MBurn scar contractureR IF burn contracture release; FTSG0.0181.176480.70.70.5764752
204541.8MPosttraumatic joint contractureL index and long finger PIP fusion0.0241.00320.70.70.491568
214838.95MCarpal tunnel syndromeL carpal tunnel release0.0652.531750.70.71.2405575
225136.12FGanglion cystExcision of R wrist mass0.0291.047480.70.70.5132652
236721.55MDupuytren's contractureL hand excision of Dupuytren's contracture0.1142.45670.70.71.203783
24581.25MBurn scar contractureR hand burn contracture release0.0181.46250.70.70.716625
25779.26MPolydactylyReconstruction of R thumb polydactyly0.0131.030380.70.70.5048862
261967.34FTumorExcision of L hand mass0.0291.952860.70.70.9569014
272165.36MTumorExcision of bony tumor ×2 of L humerus0.0291.895440.70.70.9287656
283155.48MDorsal ganglion cystExcision of ganglion cyst0.0291.608920.70.70.7883708
294244.71FNonunion radiusRepair nonunion radius0.052.23550.70.71.095395
305631.47FDe Quervain's syndromeDe Quervain’s release0.1143.587580.70.71.7579142
3111 mo85.21MThumb hypoplasiaR thumb amp, and pollicization0.0131.107730.70.70.5427877
322363.38MBurn scar contracturePIP arthrodesis; debulk flap0.0241.521120.70.70.7453488
333353.5MBurn scar contractureContracture release of all fingers R hand; flexor tendon division0.1146.0990.70.72.98851
343749.58FHook nail deformityV-Y advancement L index fingertip 0.0130.644540.70.70.3158246
354838.95MDupuytren's contractureL little finger arthrodesis and k-wire for palmar scar revision w/FTSG0.0240.93480.70.70.458052

Day 3
36878.26MFlexor tendon injury2nd stage flexor tendon reconstruction; removal hunter rod and tendon graft from leg to finger0.0241.878240.70.70.9203376
371076.27FScar contractureL hand scar revision; tenolysis; removal of k-wire0.0241.830480.70.70.8969352
382066.35MFlexor tendon injury with nerve lacerationRepair flexor tendons wrist with tendon grafts, ulnar nerve repair with sural nerve graft0.1369.02360.70.74.421564
395532.38MCarpal tunnel syndromeR carpal tunnel release0.0652.10470.70.71.031303
40581.25MSyndactylySyndactyly release L 4th web space0.0241.950.70.70.9555
411769.32MThumb hypoplasiaR thumb opponensplasty; R 1st web deepening; R thumb UCL reconstruction0.1147.902480.70.73.8722152
421868.33MForeign body with ulnar neuropathyExcision of foreign body L hypothenar eminence; neurolysis ulnar nerve0.0654.441450.70.72.1763105
432363.38MForeign bodyBullet removal ×2 R hand0.0241.521120.70.70.7453488
443452.52MRadial head fractureL radial head excision0.0653.41380.70.71.672762
454442.77MPosttraumatic joint contractureL LF, RF, and SF PIP joint fusion0.0241.026480.70.70.5029752
464938MExtensor tendon lacerationTendon transfer for thumb extension PL → EPL0.0240.9120.70.70.44688
472066.35MFlexor tendon injuryZone II IF, MF, and RF hunter rods0.1147.56390.70.73.706311
482264.37FPosttraumatic joint contractureL LF PIP joint arthrodesis0.0241.544880.70.70.7569912
492264.37MPosttraumatic joint contractureL thumb IP fusion0.0241.544880.70.70.7569912
504739.9MShoulder lipomaExcision of R shoulder lipoma0.0291.15710.70.70.566979
516126.91FGanglion cyst and ulnocarpal abutmentR dorsal ganglion/L matched ulnar arthroplasty0.1143.067740.70.71.5031926

Day 4
52581.25MBurn scar contractureR hand burn scar contracture release; FTSG0.0181.46250.70.70.716625
533254.49MFlexor tendon injuryR FDS → FDP transfer 2–50.1146.211860.70.73.0438114
546027.81FGanglion cystL dorsal wrist excision of ganglion cyst0.0290.806490.70.70.3951801
556126.91MFinger flexor tendon injuryL wrist ECRL to FDP; transfer of w/palmaris graft0.1143.067740.70.71.5031926
566523.29FL ulna nonunionORIF with iliac crest bone graft0.051.16450.70.70.570605
571076.27MSyndactylyRelease syndactyly 2nd and 4th web spaces with flaps and grafts0.0241.830480.70.70.8969352
582462.39MMalunionR thumb MCP joint arthrodesis0.1147.112460.70.73.4851054
593551.53FNerve lacerationTendon transfer for L wrist extension and thumb extension; FCU → ECRB, PL → EPL0.1367.008080.70.73.4339592
603848.6MNerve lacerationR forearm sural nerve graft0.1366.60960.70.31.388016
6110 mo85.21ML MF-RF syndactylyL MF-RF syndactyly release0.0242.045040.70.71.0020696
621769.32MMalunionThumb osteotomy and alignment-ORIF; removal of foreign body thumb0.0161.109120.70.70.5434688
631868.33MFlexor tendon injuryL forearm FDS → FDP tendon transfer0.1147.789620.70.73.8169138
642858.44MRadial nerve lacerationTendon transfer radial nerve palsy; FCR → EDC; PT → ECRB; ring sublimis → EPL0.1367.947840.70.73.8944416
654244.71FCarpal tunnel syndromeL carpal tunnel release0.0652.906150.70.71.4240135

Day 5
661472.29MFlexor tendon injury with nerve lacerationR FDS/FDP ring and small finger tenorrhaphy and digital nerve repair0.1148.241060.70.74.0381194
672363.38FBurn scar contractureL hand burn scar contracture release0.0181.140840.70.70.5590116
685037.05MRadial nerve lacerationTendon transfer of radial nerve palsy; FCR → EDC; PT → ECRB; ring sublimis → EPL0.1365.03880.70.72.469012
69977.27FBurn scar contractureWeb space deepening and scar revision0.0181.390860.70.70.6815214
701670.3FMalunionR RF MCP arthrodesis0.0241.68720.70.70.826728
713155.48FGanglion cystExcision of R wrist dorsal ganglion0.0291.608920.70.70.7883708
724739.9FUlnocarpal abutmentL ulnar shortening0.1144.54860.70.72.228814
735532.38FCarpal tunnel syndromeR carpal tunnel release0.0652.10470.70.71.031303
741472.29FBurn scar contractureL LF PIP burn contracture release and fusion; FTSG; Z plasty L elbow burn scar0.1148.241060.70.74.0381194
753947.62FGanglion cystExcision of R volar wrist ganglion cyst0.0291.380980.70.70.6766802
764244.71MPosttraumatic joint contractureL thumb MCP arthrodesis0.0241.073040.70.70.5257896
774640.85MPosttraumatic joint contractureL long finger PIP joint arthrodesis0.0240.98040.70.70.480396
785730.55FCarpal tunnel syndromeL carpal tunnel release0.0651.985750.70.70.9730175
792363.38MFinger massExcision of L ring finger mass0.0291.838020.70.70.9006298
806226MSkin lesionExcision of L hand skin lesion0.0290.7540.70.70.36946

Mean:30.75955.938Total:220.009Total:104.349028

R = right; L = left; IF= index finger; LF = long finger; RF = ring finger; SF = small finger; PIP = proximal interphalangeal; MCP = metacarpal phalangeal; FPL = flexor pollicis longs; FDS = flexor digitorum superficialis; FDP = flexor digitorum profundus; FCR = flexor carpi radials; FCU = flexor carpi ulnaris; PL = palmaris longus; EPL = extensor pollicis longus; ECRL = extensor carpi radialis longus; ECRB = extensor; carpi radialis brevis; EDC = extensor digitorum communis; FCU = flexor carpi ulnaris; UCL = ulnar collateral ligament; STSG = split thickness skin graft; FTSG = full thickness skin graft; ORIF = open reduction internal fixation.

Weight

Likelihood of permanent disability
 >95% go on to disability1.0
 <95 and >50%0.7
 <50 and >5%0.3
 <5%0
Effectiveness of treatment
 >95% chance for cure1.0
 <95 and >50%0.7
 <50 and >5%0.3
 <5%0

3. Results

In total, 120 patients were screened and 80 patients were found to be candidates for surgery. Over the week, 128 total procedures were performed on 54 adults (68%) and 26 children (32%). The average age of the patient undergoing surgery was 31 years with ages ranging from 10 months to 68 years. Of these patients, 27 were female (34%) and 53 were male (66%). Table 4 includes the procedures performed on each patient, as well as their age and gender. Operative time for the entire trip totaled 93 hours and 50 minutes over 5 days. Average operative time was 18 hours and 46 minutes per day and 6 hours and 15 minutes per operative table per day. Most of the procedures were very short in duration, with 43 cases (53%) lasting less than 1 hour. 25 cases (31%) took 1-2 hours, 9 cases (11%) lasted 2-3 hours, and only 4 cases (5%) were longer than 3 hours in duration. No immediate complications, such as ischemic loss or early wound infection, were noted. There were no anesthetic complications and no mortalities.

As shown in Table 4, the total number of DALYs potentially avertable totaled 220.5. Adjusting for likelihood of disability associated with the diagnosis and likelihood of the surgery’s success, DALYs averted totaled 104.6. The total cost (in current USD) for the volunteer trip including the team’s travel and lodging cost of $45,779.18 and local hospital’s cost of $2,903 (USD) is detailed in Table 1. On average, it costs $572.24 (USD) per patient that was surgically treated. Cost-effectiveness was measured using cost per DALY averted and, for this trip, the cost for each DALY averted was conservatively estimated to be $437.80 (USD), which is significantly less than the accepted threshold of two times the per capita gross national income of Honduras, $3,890 (USD). Further, a brief sensitivity analysis provided in Table 1(e) displays that even if total costs were to increase by 500%, the cost per DALY averted would still be below the threshold of $3,890 (USD).

4. Discussion

This study demonstrates that hand surgery mission trips are a cost-effective means of providing surgical care at HNQCP in San Pedro Sula, Honduras, using an established economic evaluation model. We also inherently validate the effectiveness of the DALY system as a useful and versatile method of evaluating surgical mission trips. While it is one of the first quantitative systems of evaluating such trips, it is also only one of the many possible ways to analyze mission trips. However, this analysis also represents an important step in standardizing the evaluation of such trips to better optimize foreign intervention by surgical teams, as proposed by McCord [13].

The $437.80 per DALY averted for this week long surgical mission trip is similar to those previously reported in the literature that have ranged between $343 and $362 per DALY [14, 15]. Our cost per DALY is well within the two times per capita gross national income, an accepted metric for program cost-effectiveness as suggested by earlier studies [15]. We believe our slightly higher cost per DALY averted can be attributed to multiple factors. First, we have used conservative estimations for all DALY and disability weight. Second, previous studies did not use the 2010 version of the Global Burden of Disease (GBD) system to evaluate cost-effectiveness and consequently may have contributed to differences in the cost per DALY averted value. Third, bringing more staff, such as residents, anesthesiologists/anesthetist, pediatrician, nurses, and hand therapist, may have added to travel and lodging cost. As the availability of more locally trained medical professionals is available in Honduras, fewer anesthesiologists, or nurses, and therapists from the United States will be needed for each trip thus making each subsequent mission trip more cost-effective than the previous. With local capacity to care for simple cases like ganglion cyst removal, trigger finger release, and arthrodesis, subsequent trips can focus on more disabling complex conditions such as nerve injuries which require advance surgical training. Since a volunteer mission trip’s costs are relatively fixed, focusing on these conditions can contribute to more DALYs averted lowering the trip’s cost per DALY averted.

In addition to providing direct care, our team has been able to lecture at the medical school in San Pedro Sula and invite local surgeons to come and learn how to manage surgical hand cases. Our nurses and therapists have also worked with local staff to improve pre-, peri-, and postoperative care of patients. Such training and educational efforts are often difficult to quantify and are not reflected in the cost per DALY averted, but they are important in the long-term development of adequately trained local health care professionals and healthcare infrastructure. While the capacity to care for these surgical conditions is being developed in Honduras, surgical mission trips such as ours serve as an important bridge until that day arrives.

The limitations of this study include the inability to include certain costs, such as operating room, hospital stay, utilities, and building costs; however, given the large margin between the cost per DALY averted and the twice per capita gross national income (PCGNI) of Honduras ($3890 in 2012) [4], we believe that the underreported costs have only a minor impact on the cost per DALY averted. Even if total costs (TC) were five times higher, the cost per DALY averted would still be the threshold value of $3890 (2*PCGNI), as illustrated in Table 1(e). As in previous cost-effectiveness studies, a rough trade-off is used to assign hand conditions with disability weights as the Global Burden of Disease 2010 study does not have many specific disability weights for various hand conditions. There are also instances where disability weights make little sense from a functional standpoint: amputation of finger(s) excluding thumb has a disability weight of 0.030 which compares poorly to disability weight of 0.013 for amputation of thumb, long term. One can argue that the loss of a thumb is more functionally debilitating than the loss of a finger as opposition-apposition function is lost in a thumb amputation and grip maybe minimally affected with a finger amputation [11]. The nature of short volunteer mission trip makes obtaining long-term outcomes data difficult. However, with greater capacity in host countries, prospective studies that assess patient outcomes will enable us to more objectively determine patient outcomes without relying on assumptions. Until then, we feel that using the correctional factor “probability of successful treatment” is needed to account for treatment success/failures as there is a lack of follow-up data. Imperfect as it maybe, the DALY method for assessing cost-effectiveness has been used in a number of previous studies in LMICs and offers a more objective and standardized way to assess the impact of surgical mission trips, cost-effectiveness and serves as a benchmark for future trips.

Conflict of Interests

The authors have no conflict of interests to report.

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Copyright © 2014 Kashyap K. Tadisina et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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