title: Surgical efficiencies and quality in the performance of voluntary medical male circumcision (VMMC) procedures in Kenya, South Africa, Tanzania, and Zimbabwe.
abstract: BACKGROUND
  This analysis explores the association between elements of surgical efficiency in voluntary medical male circumcision (VMMC), quality of surgical technique, and the amount of time required to conduct VMMC procedures in actual field settings. Efficiency outcomes are defined in terms of the primary provider's time with the client (PPTC) and total elapsed operating time (TEOT).
  
  
  METHODS
  Two serial cross-sectional surveys of VMMC sites were conducted in Kenya, Republic of South Africa, Tanzania and Zimbabwe in 2011 and 2012. Trained clinicians observed quality of surgical technique and timed 9 steps in the VMMC procedure. Four elements of efficiency (task-shifting, task-sharing [of suturing], rotation among multiple surgical beds, and use of electrocautery) and quality of surgical technique were assessed as explanatory variables. Mann Whitney and Kruskal Wallis tests were used in the bivariate analysis and linear regression models for the multivariate analyses to test the relationship between these five explanatory variables and two outcomes: PPTC and TEOT. The VMMC procedure TEOT and PPTC averaged 23-25 minutes and 6-15 minutes, respectively, across the four countries and two years. The data showed time savings from task-sharing in suturing and use of electrocautery in South Africa and Zimbabwe (where task-shifting is not authorized). After adjusting for confounders, results demonstrated that having a secondary provider complete suturing and use of electrocautery reduced PPTC. Factors related to TEOT varied by country and year, but task-sharing of suturing and/or electrocautery were significant in two countries. Quality of surgical technique was not significantly related to PPTC or TEOT, except for South Africa in 2012 where higher quality was associated with lower TEOT.
  
  
  CONCLUSIONS
  SYMMACS data confirm the efficiency benefits of task-sharing of suturing and use of electrocautery for decreasing TEOT. Reduced TEOT and PPTC in high volume setting did not result in decreased quality of surgical care.
authors.affiliation: The Centre for HIV and AIDS Prevention Studies, Johannesburg, South Africa.
authors.forename: Dino
authors.initials: D
authors.lastname: Rech
authors.affiliation: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
authors.forename: Jane T
authors.initials: JT
authors.lastname: Bertrand
authors.affiliation: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Thomas
authors.affiliation: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
authors.forename: Margaret
authors.initials: M
authors.lastname: Farrell
authors.affiliation: U.S. Department of State, President's Emergency Plan for AIDS Relief, Washington, D.C, United States of America.
authors.forename: Jason
authors.initials: J
authors.lastname: Reed
authors.affiliation: The Centre for HIV and AIDS Prevention Studies, Johannesburg, South Africa.
authors.forename: Sasha
authors.initials: S
authors.lastname: Frade
authors.affiliation: Institute of Continuing Health Education, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe.
authors.forename: Christopher
authors.initials: C
authors.lastname: Samkange
authors.affiliation: National Reproductive Health Society, Kisumu, Kenya.
authors.forename: Walter
authors.initials: W
authors.lastname: Obiero
authors.affiliation: Impact Research and Development Organization, Kisumu, Kenya.
authors.forename: Kawango
authors.initials: K
authors.lastname: Agot
authors.affiliation: Jhpiego, Dar es Salaam, Tanzania.
authors.forename: Hally
authors.initials: H
authors.lastname: Mahler
authors.affiliation: United States Agency for International Development, Washington D.C., United States of America.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: United States Agency for International Development, Washington D.C., United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D002944:Circumcision, Male / Q000592:standards* / Q000706:statistics & numerical data; D017598:Efficiency, Organizational / Q000592:standards*; D006801:Humans; D007630:Kenya; D008297:Male; D013019:South Africa; D013636:Tanzania; D015030:Zimbabwe