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

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.


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.

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.

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. [12][13][14][15][16] 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.

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. Costeffectiveness 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).

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 6 Plastic Surgery International        [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 costeffectiveness 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.