title: Development of a ratio of emergent to total hernia repairs as a surgical capacity metric.
abstract: BACKGROUND
  Non-communicable diseases including surgical conditions are gaining attention in developing countries. Despite this there are few metrics for surgical capacity. We hypothesized that (a) the ratio of emergent to total hernia repairs (E/TH) would correlate with per capita health care expenditures for any given country, and (b) the E/TH is easy to obtain in resource-poor settings.
  
  
  METHODS
  We performed a systematic review to identify the E/TH for as many countries as possible (Prospero registry CRD42013004645). We screened 1285 English language publications since 1990; 23 met inclusion criteria. Primary data was also collected from Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. A total of 13 countries were represented. Regression analysis was used to determine the correlation between per capita health care spending and the E/TH.
  
  
  RESULTS
  There is a strong correlation between the log values of the ratio emergent to total groin hernias and the per capita health care spending that is robust across country income levels (R(2) = 0.823). Primary data from KCH was easily obtained and demonstrated a similar correlation.
  
  
  CONCLUSIONS
  The ratio of emergent to total groin hernias is a potential measure of surgical capacity using data that is easily attainable. Further studies should validate this metric against other accepted health care capacity indicators. Systematic review registered with Prospero (CRD42013004645).
authors.affiliation: NC Jaycee Burn Center, Department of Surgery, University of North Carolina, 101 Manning Drive CB 7600, Chapel Hill, NC 27759, USA. Electronic address: jcsamuel@med.unc.edu.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Samuel
authors.affiliation: Department of Surgery, University of North Carolina, 4001 Burnett Womack Bldg CB 7050, Chapel Hill, NC 27599, USA.
authors.forename: Anna F
authors.initials: AF
authors.lastname: Tyson
authors.affiliation: Department of Surgery, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi.
authors.forename: Charles
authors.initials: C
authors.lastname: Mabedi
authors.affiliation: Department of Surgery, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi.
authors.forename: Gift
authors.initials: G
authors.lastname: Mulima
authors.affiliation: NC Jaycee Burn Center, Department of Surgery, University of North Carolina, 101 Manning Drive CB 7600, Chapel Hill, NC 27759, USA.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Cairns
authors.affiliation: Department of Surgery, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi.
authors.forename: Carlos
authors.initials: C
authors.lastname: Varela
authors.affiliation: Department of Surgery, University of North Carolina, 4001 Burnett Womack Bldg CB 7050, Chapel Hill, NC 27599, USA.
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Charles
mesh_terms: D003906:Developing Countries; D017558:Elective Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data; D004630:Emergencies / Q000191:economics / Q000453:epidemiology; D005102:Health Expenditures / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand / Q000191:economics / Q000706:statistics & numerical data*; D006552:Hernia, Inguinal / Q000191:economics / Q000453:epidemiology / Q000601:surgery*; D059685:Herniorrhaphy / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008295:Malawi
keywords: Developing countries; Hernia, inguinal; Malawi; Surgery; World health
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