In Response

In reviewing the Letter to the Editor, “Anesthetic Resources Do Not Always Correlate With Quality of Care in Resource Limited Settings,”1 concerns—including the lack of equipment, knowledge on the part of health care providers, and the lack of quality of health care services provided—are mentioned as ongoing issues for providers in low and middle-income countries (LMICs). In the article, Dr Raiten1 described examples of high-quality surgical procedures, high degree of flexible provider intuition and creativity to ensure quality, and utilization issues of high-cost equipment in spite of challenges. While these are present in all spectrums of health care systems, meeting minimum standards of country-level surgical and anesthesia metrics is important for assurance of high-quality anesthesia care for all persons within a political region. It provides the best chance to ensure that all persons undergoing an emergent or elective surgical procedure with anesthesia have safe care.2 The efforts of the original article were to provide intermittent benchmarks to reach the global target of safe surgical and anesthesia care for 80% of the world by 2030. This would allow the goals to be met of having emergency and essential surgical care and anesthesia as part of universal health coverage globally (embodied in the World Health Assembly [WHA] resolution 68.15).2,3 The original publication addresses only one of many factors of anesthesia quality improvement: assessment of resources within a health care system as a part of systems thinking.4 The article by Raiten1 does not assess professional anesthesia practice, patterns, or preferences. There is a need to perform research with qualitative method to evaluate this facet of quality improvement and is being performed across disciplines.5 Additionally, the original article illustrates quantitative measurement gaps (eg, the perioperative mortality rate [POMR] and the POMR on operative day [an anesthesia]), and its importance is noted in literature.2 This illustrates the need to implement critical institutional and country-level metrics, which can be used to correlate to other metrics such as the number of physician anesthesia providers (PAPs) required to reach a ideal maternal mortality ratio (MMR) thresholds.6 Gratitude and thanks are given to Raiten1 for the issues illustrated as a call for more research and consideration for triangulating data when assessing anesthesia quality of care. To reach the goals set forth by the WHA to ensure safe surgical and anesthesia care for 80% of the world by 2030, every county should have monitoring and evaluation systems that incorporate the aggregated key indicators as set forth by working groups such as the G4 Alliance, the Lancet Commission on Global Surgery, and the World Bank to meet the United Nations (UN) Post-2015 Sustainable Development Goals (SDGs) for emergency and essential surgical care and anesthesia, and the original article continues to justify its implementation and advocacy.2,3 Jonathan Meadows, DO, MS, MPH, CPH, CPhT, PHAP CertDepartment of Emergency MedicineMerit Health WesleyHattiesburg, Mississippi[email protected]