Improving Anesthesia Capacity for Ambulatory Surgery in Low- and Middle-Income Countries: Current Scenario and Future Prospects

Anesthesia for ambulatory or day-case surgery (DCS) is the provision of anesthesia services to a patient for a diagnostic or operative procedure, which require facilities for postanesthesia recovery but do not require an overnight stay in a hospital bed.1 With the rates of DCS having increased by over 200% to 300% in the last decade, DCS constitute a significant proportion of elective surgeries performed in the developed world.2 Performing surgeries on a day-case basis has several advantages that benefit the patient, the hospital, and the health care system. In addition to allowing patients to recuperate in a familiar home environment, DCS has shown to mitigate complications of prolonged hospitalization, resulting in higher patient satisfaction and better perioperative outcomes.3,4 However, DCS remains rudimentary in low- and middle-income countries (LMICs), despite its widely recognized benefits. Literature from LMICs regarding the organization and delivery of successful anesthesia services for DCS is limited, as is data regarding outcome measures after DCS in these countries.5 There are several hurdles that patients, clinicians, hospital administrators, and health care policymakers of LMICs face in their efforts to make anesthesia for DCS safe and effective, with a less than satisfactory primary health care infrastructure only further compounding the problem. Several international organizations have developed guidelines regarding the organization and delivery of anesthesia for DCS.1 However, we opine that such recommendations are from, and for, health settings in high-income countries and that their applicability to LMICs is limited. In this article, we aim to highlight some of the constraints that resource-strapped LMICs face in the organization and delivery of anesthesia for DCS. Our article expands on the ethnic and cultural factors that affect provision of anesthesia for DCS, cautioning clinicians against the assumption of the universality of even well-researched international recommendations. Performing successful and safe DCS mandates unique requisites in the form of proper patient selection, adherence to specific perioperative anesthesia principles, and planning for postoperative discharge. Generic efforts to improve basic surgical health care in LMICs may not necessarily translate to increased capacity for DCS, which require more targeted interventions and solutions. Key focus areas for future prospects to improve capacity for anesthesia for DCS in LMICs, and a roadmap for change would be addressed as well. ANESTHESIA FOR DCS IN LMICS: EXISTING ROADBLOCKS LMICs face numerous challenges in the provision of safe anesthesia services, which include financial constraints, limited access to surgery and anesthesia, poor health infrastructure, and chronic deficiencies of trained anesthesia workforce.6 Access to DCS, in particular, is a significant concern in LMICs and is a result of a combination of patient-, anesthesia-, surgery-, and system-related barriers. Patient-Related Barriers: Challenging Patient Demographics Patients undergoing DCS go home after successful surgery and are expected to take care of themselves or be taken care of by their family. The importance of adequate information sharing regarding anesthesia, surgery, and postoperative recuperation cannot be overemphasized. Clear instructions regarding how and when to contact emergency hospital services, if needed, are routinely provided. In addition, DCS requires the patient to be living within a certain distance from the hospital.3 These prerequisites, which for an anesthesiologist practicing in the developed world would seem obvious, do not necessarily hold true for clinicians practicing in LMICs. The patients’ literacy level is often low, with the resultant limited ability to understand pertinent perioperative information.7 This is further compounded by myriad cultural and religious beliefs that significantly affect how information is processed by patients and their families. Preoperative information is also usually available online on hospital websites that patients and caregivers are encouraged to look up in the days preceding surgery. However, with limited availability of Internet facilities and smartphone technology and lower literacy, these practices are often challenging in LMICs. With a huge disparity between rural and urban health care provisions in LMICs, rural patients often need to travel long distances using unreliable public transport to reach hospitals in cities for their surgery.8 Discharging these patients, who live in faraway villages and towns on the same day after surgery, is impractical and unsafe, as well. In addition, various social obstacles (eg, patients living in temporary and unsuitable accommodations, lack of electricity and water supply, limited support from the family for postsurgical care) hamper same-day discharge after DCS, sometimes forcing clinicians to admit patients overnight. Anesthesia-Related Barriers: Shortage of Relevant Drugs and Equipment The safe and successful performance of anesthesia for DCS requires an in-depth understanding of the principles of anesthetic pharmacology, with particular attention to the onset and offset times, postoperative side-effects, and recovery profiles. The use of drugs with a rapid onset and short duration of action (eg, remifentanil, fentanyl, propofol, sevoflurane, desflurane), regional anesthesia techniques including short-acting central neuraxial blockade, and less invasive airway devices (eg, supraglottic airway devices) are some of the cornerstones in the practice of anesthesia for DCS.3 However, anesthesia providers in LMICs face chronic shortages and unreliable availability of potent intravenous opioids and anesthetic induction drugs. Central neuraxial blocks often cannot be administered due to frequent shortages of spinal needles.9 Anesthesia workstations capable of delivering volatile anesthetic agents are limited, as are ultrasound machines and nerve stimulator needles for the administration of regional blocks.10 In such challenging and often frustrating circumstances, anesthesiologists in LMICs frequently rely on drugs (eg, pentazocine, morphine, thiopental sodium, ketamine, halothane) that have much poorer recovery profiles, precluding same-day discharge. Effective management of postoperative pain is a key aspect of DCS that has direct implications in determining timely discharge from health care facilities and preventing unanticipated readmissions after otherwise uncomplicated surgery.1 Despite the extensive use of nonopioids for postoperative analgesia, many patients might still require some form of opioids for postdischarge use. In the developed world, most patients are prescribed opioids (eg, codeine, hydrocodone, oxycodone) in addition to paracetamol (ie, acetaminophen) and nonsteroidal anti-inflammatory drugs to manage pain after discharge from the hospital.11,12 However, oral preparations of these opioids are usually not available in LMICs. Their availability and use are further limited by high costs and strict regulatory restrictions regarding the prescription and distribution of opioids on an outpatient basis.13,14 Surgery-Related Barriers: Deficient Technique and Expertise Performing DCS requires dedicated surgeons trained in specific aspects of ambulatory procedures, including the use of minimally invasive techniques. Hospitals and surgical centers in LMICs often face chronic shortages of trained surgical staff, with nonphysicians and nurses being responsible for preoperative and postoperative care. This is further compounded by limited opportunities for continued professional development, which often restricts the kind of surgeries that can be conducted on a day-case basis. Even when sufficient knowledge and technical skills exist, hospitals in LMICs face shortage of minimal invasive surgical equipment like laparoscopic carts, arthroscopy units, and phacoemulsification machines, among others. In addition, surgical groups in LMICs are constrained by the absence of validated and published models that can prospectively determine work flow and criteria for safe and early discharge. Challenges in performing day-case laparoscopic surgeries in LMICs have been described, with deficiencies in technique and equipment cited as important contributory factors.15 System-Related Barriers: Organizational Deficiencies In the Western world, DCS is usually performed in free-standing ambulatory surgery facilities or in hospitals with a separate day-procedure unit having its own administrative infrastructure, dedicated staff, and recovery areas to manage scheduling and patient flow.16 These are difficult to set up and operate in LMICs, which already face severe shortages of resources and manpower in providing even basic hospital-based inpatient care. Hospital administrators face significant challenges related to staffing, scheduling, and smooth functioning of perioperative services, and cancellations are frequent due to patients failing to turn up to the health care facility, nonavailability of beds in the recovery wards, and unanticipated delays or complications in inpatient surgeries. Furthermore, several LMICs have a skewed dual system of health care with an inadequately funded government sector catering to a large majority of the population and a significantly larger privatized sector providing health care concentrated to larger towns and cities. Health care systems in LMICs are financed through a combination of direct taxation, social security insurance contributions (eg, the Employees’ State Insurance scheme in India), private health insurance, out-of-pocket payments, and external sources (eg, financial aids, international loans). The contribution from each of these mentioned sources vary significantly across LMICs. Patients in LMICs often have limited options for insurance coverage, and most pay out-of-pocket to avail health care facilities in the private sector. In general, the lower the country’s income level is, the greater is the share of out-of-pocket payments in financing the health care systems. Such out-of-pocket payments have shown to represent >50% of the total health expenditure in countries like India, Bangladesh, and the Philippines.17 Further complicating this scenario is the fact that some surgeries are not covered by insurance companies, unless the patients are admitted overnight. Also, insurance reimbursement to hospitals for procedures performed is substantially higher when they include a prospectively approved overnight hospital stay. These economic and financial issues have a significant effect on the availability and accessibility of DCS services in LMICs. DEVELOPING ANESTHESIA CAPACITY FOR DCS: THE WAY FORWARD It is undeniable that there is a critical need to overhaul the existing system in LMICs if their people could benefit from surgeries done on a day-case basis, and coordinated efforts to overcome the existing barriers is the need of the hour. Currently, most efforts to improve anesthesia for DCS are spearheaded by academic institutions and organizations with a strong interest in global health. However, we believe that involvement of health care managers, policy makers, government agencies, international organizations, and other stakeholders could be a crucial step in accelerating progress toward better anesthesia for DCS, that is also long-term sustainable. We wish to highlight some considerations that are important to improve and consolidate future prospects of anesthesia for DCS in LMICs.Figure.: Monitoring and evaluation framework for ambulatory surgery in low- and middle-income countries. i. Improve teaching and training in DCS during anesthesiology and surgery residency in LMICs via curriculum development and structured training programs. Trainee anesthesiologists and surgeons could benefit from dedicated rotations in day-case procedure units to familiarize them with the unique challenges in providing anesthesia and surgery in a day-case setting. In addition, having “clinical lead” consultants in anesthesia and surgery for training and implementation of services could streamline the provision of DCS services in tertiary centers and academic institutions, thereby setting up a precedent for trainee doctors. ii. Improve information sharing with the patient in the perioperative period with patient information leaflets and infographics in local languages. The dissemination of preoperative information with cognizance to prevailing cultural and religious factors, during their visit to the surgical clinic, could improve the accessibility and acceptability of DCS services. In addition, empowering patients with relevant knowledge could change the paternalistic culture prevalent in several LMIC societies to one where patients exercise autonomy and decision making regarding their health. iii. Increase the efficiency of the process of preanesthetic evaluation. The unbalanced physician-patient ratio in LMICs often makes it difficult for every patient planned for DCS to undergo prior evaluation by an anesthesiologist. An initial protocol-based patient selection and preanesthetic evaluation by trained nurses could streamline the process helping to avoid last minute cancellations. The need for any consultation by an anesthesiologist can subsequently be guided based on the nurse’s assessment. Such a nurse-led protocol-based preoperative patient evaluation has been previously adopted with promising results.18 iv. Sustained efforts to improve availability of drugs and equipment that are particularly important for the conduct of DCS. This includes, but is not limited to, short-acting intravenous anesthetic drugs, modern anesthesia workstations, supraglottic airway devices, and equipment for safe performance of regional anesthesia techniques. Instead of accounting available drugs and equipment at any single point of time, conducting regular and timely audits on the consumption of anesthetic drugs and equipment during DCS procedures could provide better information regarding the supply chain and system performance. This would also enable hospital administrators streamline the process of allotting appropriate funds for DCS. v. Greater involvement of primary and community health care centers in the delivery of anesthesia for DCS and using a “bundled” integrated approach might improve the ease of access and utilization of DCS services by the community. Moreover, governmental health policies across multiple LMICs dedicate a significant proportion of funds for strengthening primary health care centers so that comprehensive and universal health care can be provided. The location of these primary health centers close to the community could be an added advantage in ensuring same-day discharge. vi. Continued collaboration with international organizations (eg, the World Federation of Society of Anesthesiologists, Medecins Sans Frontieres, CapaCare [Capacity Building and Training of Medical Staff], Operation Smile) could provide unavailable surgical treatment while improving teaching and training capacity at the local community level till the time that LMICs are self-sufficient and self-reliant in providing safe anesthesia for DCS. Data from these organizations are seldom included in national registries, and thus, their impact in addressing the “unmet” surgical needs is probably underestimated. vii. Using objective outcome measures like health care costs, case-cancellation rates, and patient satisfaction surveys for anesthesia services for DCS and maintaining a regional/national registry could potentially help compare the quality of services provided across hospitals and regions.19 Based on such yearly performance reviews, local/locoregional audits and quality improvement projects could be initiated by hospitals, leading to monetary incentives for well-performing centers. Financial incentives from the government to hospitals providing successful anesthesia for DCS and formal accreditation of these centers by “deemed” accrediting organizations and professional bodies could help encourage stakeholders to invest in and improve the quality of anesthesia services for DCS provided. MONITORING AND EVALUATION: FRAMEWORK FOR CHANGE In contrast to major public health issues, surgical services in general and DCS in particular have received only modest attention in LMICs. DCS is resource intensive, requires an uninterrupted supply of skilled workforce and consumables, and sustained investment in governance and infrastructure development. In this context, it is crucial to evaluate how anesthesia for DCS could be effectively integrated into the existing health systems. The World Health Organization (WHO) has provided frameworks for monitoring and evaluation (M&E) to assess functioning of health systems in LMICs.20 We propose an M&E framework based on the WHO model to plan, organize, and evaluate efforts to improve capacity of anesthesia for DCS in LMICs. The framework is described in the Figure and includes indicators in 4 categories: inputs, outputs, outcomes, and impact. SUMMARY AND CONCLUSIONS Thus, there is a pressing need to specifically address critical lacunae in the provisions, and the lack thereof, of anesthesia for DCS in LMICs. Guidelines from international organizations regarding anesthesia for DCS are impractical in the challenging scenarios encountered in LMICs in the absence of a basic framework to provide ambulatory perioperative care. Improving anesthesia capacity for DCS in LMICs requires significant investment in terms of skilled labor and is technologically and logistically challenging. However, with good planning and sustained efforts to integrate DCS into the country’s health care system, the return in quality life years for patients and resultant savings in health expenditure could potentially exceed the initial efforts and investment. The M&E framework described would need to be validated in varied clinical settings and modified to region-specific needs in LMICs to facilitate the implementation of the proposed interventions. This is something that clinicians, hospital administrators, health care policymakers, and governmental institutions in LMICs need to be cognizant of now more than ever. DISCLOSURES Name: Sunaakshi Puri, MD. Contribution: This author helped search the literature and review and draft the manuscript. Name: Anjishnujit Bandyopadhyay, MD. Contribution: This author helped search the literature and review and draft the manuscript. Name: Vighnesh Ashok, FRCA. Contribution: This author helped with the conceptualization, design, and critical revision of the manuscript. This manuscript was handled by: Girish P. Joshi, MBBS, MD, FFARCSI.