Global Perioperative Care: From Prioritization to Patient Impact

See Article, page 17 In recent years, there has been increasing emphasis on the importance of teamwork in surgical care.1 The surgical team includes surgeons, anesthesia providers, nurses, and support staff. Each plays an important role in improving teamwork and patient outcomes. Interprofessional courses have been developed to focus on this aspect of surgical care, for example, SAFE OR (Safe operating room) developed by the Association of Anaesthetists and the World Federation of Societies of Anaesthesiologists. We pose the question: why should teamwork not extend into perioperative care research? Prioritization exercises have been conducted globally in surgery and anesthesia.2,3 However, these have only included physicians and researchers, with little representation from nurses, allied health care professionals, and patients. The article by Bedwell et al4from the African PeriOperative Research Group (APORG) Nurses Collaborative, published in this issue of Anesthesia & Analgesia, represents a step change in cross-disciplinary research prioritization. Previously highlighted differences in priorities demonstrate the importance of inclusive research, which involves all stakeholders in the perioperative journey of the patient. In their current Delphi prioritization study, Bedwell et al4 present unique insight into the research priorities of perioperative nurses in Africa. The study steering group included colleagues from 12 African nations. Through a modified Delphi process, the authors generated a shortlist of 10 high-priority perioperative research areas. This effort is likely to strengthen regional health systems in several ways: (1) targeting contextual clinical questions with the greatest public benefit; (2) reducing research waste; (3) fostering collaboration between centers and countries; and (4) advocating for equitable research funding for these highlighted areas. Through a modified Delphi method, the authors were able to reach consensus on key research priorities to guide future research. While, to date, there is no reporting standard for Delphi consensus methods from the Enhancing the Quality and Transparency of Health Research (EQUATOR) network, Bedwell et al present several tenets that suggest both reproducibility and generalizability of this pan-African priority list.5–8 These include a well-defined expertise matrix, predefined dropping rules and number of rounds, and a high retention rate across rounds. Now that a new standard has been established in cross-team prioritization, this model must be reproduced across other settings, with increased scale and even wider stakeholder engagement. Comparing and contrasting priorities of different stakeholders will help to identify shared priorities that will underpin entire health-system level improvement. This currently described study methodology has the potential to transform research in resource-constrained settings and contexts by enabling inclusive research, most relevant to underrepresented stakeholder groups. Patient-level prioritization in less health-literate communities may be supported with qualitative methods to initially generate themes to inform consensus methods.9 The understanding of coproduction of research through community engagement and involvement (CEI) in low- and middle-income countries (LMICs) is still evolving but remains a fundamental component of equitable, contextual, and culturally sensitive research.10–12 Embedding CEI in future prioritization work will help enhance this new standard even further. Perhaps, the most exciting question generated by this research prioritization exercise is: “what next?” Prioritization is nothing without action, and many of the prioritized research areas are multifaceted and complex. “Strategies to translate and implement perioperative research into clinical practice in Africa” (ranked first) will require concepts from implementation science, behavioral science, and iterative complex intervention design.13–15 While delivering such interventions in Africa may be challenging, it presents a compelling opportunity to strengthen local research capacity. Collaboration will be key, as highlighted by the corporate authorship structure adopted by APORG. We encourage the APORG team to continue cultural change in nurse-led research in LMICs by establishing nurse principal investigators and trial management group members in their future work.16 Expanding research capacity among this cadre of health care providers in Africa will support successful, rapid upscaling of future research in global perioperative care. One thing is for certain: research from the growing APORG network will continue to benefit surgical patients and providers in Africa and beyond. Their model for a low-cost, efficient methodology teaches us that high-quality research can be delivered without a high burden for clinicians or patients and provides a global exemplar in pragmatic research.17–20 This example of equitable involvement of historically underrepresented stakeholders will ensure that future research in global perioperative care continues to adopt a contextually appropriate, need-based approach. E DISCLOSURES Name: Adewale Adisa, MD, FWACS, FMCS. Contribution: This author provided intellectual input and revision of the editorial, signed off on the final draft, and took overall accountability for the contents. Conflicts of Interest: None. Name: Gabriella Hyman, MBBCh. Contribution: This author provided intellectual input and revision of the editorial, signed off on the final draft, and took overall accountability for the contents. Conflicts of Interest: None. Name: Angela Enright, MB, FRCPC. Contribution: This author provided intellectual input and revision of the editorial, signed off on the final draft, and took overall accountability for the contents. Conflicts of Interest: A. Enright is an executive section editor of global health, Anesthesia & Analgesia. Name: James Glasbey, MBBCh, MRCS. Contribution: This author wrote the initial draft of the editorial, signed off on the final draft, and took overall accountability for the contents. Conflicts of Interest: None. This manuscript was handled by: Thomas R. Vetter, MD, MPH.