title: Surgical need in an ageing population: a cluster-based household survey in Nepal.
abstract: BACKGROUND
  With an ageing global population comes major non-communicable disease burden, especially in low-income and middle-income countries. An unknown proportion of this burden is treatable or palliated with surgery. This study aimed to estimate the surgical needs of individuals aged 50 years or older in Nepal.
  
  
  METHODS
  A two-stage, 30 randomised cluster by 30 households, community-based survey was performed in Nepal with the validated Surgeons OverSeas Assessment of Surgical Need (SOSAS). Respondents aged older than 50 years were included. After verbal informed consent was obtained, SOSAS collected household demographics, completed a verbal autopsy, and randomly selected household members for verbal head-to-toe examinations for surgical conditions. The Nepal Health Research Council in Kathmandu and the Nationwide Children's Hospital in Columbus, OH, USA, granted ethical approval.
  
  
  RESULTS
  The survey sampled 1350 households, totalling 2695 individuals (97% response rate); 49% were aged 50-59 years, 33% were 60-69 years, and 17% were 70 years and older. Of these, 273 surgical conditions were reported by 507 individuals. A growth or mass (including hernias and goiters) was the most commonly reported potentially surgical condition (25%), injuries and fractures were also common and had the greatest disability. Acquired deformities (13%), incontinence (11%), non-injury wounds (9%), and pelvic organ prolapse were also prevalent. Together, head and neck (24%) and back and extremity conditions (32%) were responsible for more than half of the conditions potentially treatable with surgery. These were followed by genitourinary (28%), abdominal (14%) and chest and breast conditions (2%). Extrapolated nationwide, roughly 1·25 million elderly individuals have a surgically treatable condition (32 150 per 100 000 people). There were 108 deaths in the year before to the survey. 20 (19%) were potentially preventable with surgery. Half of the deaths were due to a growth or mass, 20% to injury, 20% to abdominal pain or distension, and 10% to a non-injury wound. The age-standardised death rate of those with a potentially surgical condition was 24 per 1000 persons for individuals in their 6th decadte, 60 per 1000 for those in their 7th, and 44 per 1000 for those in their 8th. One in five deaths were potentially treatable or palliated by surgery. Literacy and distance to secondary and tertiary health facilities were associated with not receiving care for surgical conditions (p<0·05).
  
  
  CONCLUSIONS
  Surgical need is largely unmet among elderly individuals in Nepal. Literacy and distance from a capable health facility are the greatest barriers to care. Although verbal examination findings were used as proxies for surgical conditions, the survey tool has been previously validated. Also, there is potential for recall bias with overestimation of tragic deaths and underestimation of unknown or forgotten surgical causes of death and disease. However, this is the most comprehensive evaluation of surgical need in a developing country among the elderly. As the global population ages, there is an increasing need to improve access to surgical services and strengthen health systems to care for this group.
  
  
  BACKGROUND
  The Association for Academic Surgery, Surgeons OverSeas, and the Fogarty International Center.
authors: Department of Surgery, University of Washington, Seattle, Washington DC, USA. Electronic address: stewarb@uw.edu.
authors: Barclay T
authors: BT
authors: Stewart
authors: Surgeons OverSeas (SOS), New York, NY, USA; Centre for Global Surgery, McGill University Health Centre, Montreal, QC, Canada.
authors: Even
authors: E
authors: Wong
authors: Surgeons OverSeas (SOS), New York, NY, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors: Shailvi
authors: S
authors: Gupta
authors: Manipal College of Medical Sciences, Pokhara, Nepal.
authors: Santosh
authors: S
authors: Bastola
authors: Department of Surgery, Nepal Medical College, Kathmandu, Nepal.
authors: Sunil
authors: S
authors: Shrestha
authors: Surgeons OverSeas (SOS), New York, NY, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Surgery, Columbia University, New York, NY, USA.
authors: Adam L
authors: AL
authors: Kushner
authors: Surgeons OverSeas (SOS), New York, NY, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
authors: Benedict C
authors: BC
authors: Nwomeh