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Evaluating the Economic Impact of Plastic and Reconstructive Surgical Efforts in the Developing World: The ReSurge Experience

Nasser, Jacob S. B.S.; Billig, Jessica I. M.D.; Sue, Gloria R. M.D.; Chang, James M.D.; Gosain, Arun K. M.D.; Chung, Kevin C. M.D., M.S.

Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 485e-493e
doi: 10.1097/PRS.0000000000005984
Plastic Surgery Focus: Special Topics
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Background: As the global burden of disease continues to rise, it becomes increasingly important to determine the sustainability of specialty surgery in the developing world. The authors aim to (1) evaluate the cost-effectiveness of plastic and reconstructive surgery in the developing world and (2) quantify the economic benefit.

Methods: In this study, the authors performed a retrospective analysis of surgical trips performed by ReSurge International from 2014 to 2017. The organization gathered data on trip information, cost, and clinical characteristics. The authors measured the cost-effectiveness of the interventions using cost per disability-adjusted life-years and defined cost-effectiveness using World Health Organization Choosing Interventions That Are Cost-Effective thresholds. The authors also performed a cost-to-benefit analysis using the human capital approach.

Results: A total of 22 surgical trips from eight different developing countries were included in this study. The authors analyzed a total of 756 surgical interventions. The cost-effectiveness of the surgical trips ranged from $52 to $11,410 per disability-adjusted life-year averted. The economic benefit for the 22 surgical trips was $9,795,384. According to World Health Organization Choosing Interventions That Are Cost-Effective thresholds, 21 of the surgical trips were considered very cost-effective or cost-effective.

Conclusions: Plastic and reconstructive operations performed during short-term surgical trips performed by this organization are economically sustainable. High-volume trips and those treating complex surgical conditions prove to be the most cost-effective. To continue to receive monetary funding, providing fiscally sustainable surgical care to low- and middle-income countries is imperative.

Ann Arbor, Mich.; Palo Alto and Sunnyvale, Calif.; and Chicago, Ill.

From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School; the VA/National Clinician Scholars Program, VA Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System; the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, ReSurge International; and the Division of Pediatric Plastic Surgery, Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine.

Received for publication July 25, 2018; accepted March 4, 2019.

Disclosure:Dr. Chang is a paid consultant of ReSurge International. The remaining authors have no financial disclosures.

Related digital media are available in the full-text version of the article on www.PRSJournal.com.

Kevin C. Chung, M.D., M.S., Section of Plastic Surgery, University of Michigan Health System, 1500 East Medical Center Drive, Taubman Center, SPC 5340, Ann Arbor, Mich. 48109-5340, kecchung@med.umich.edu, Twitter: @kecchung, @jacobsnasser96

Estimates suggest that 5 billion individuals lack access to surgical care worldwide, the majority of whom live in underdeveloped countries.1,2 As a result of this unaddressed surgical burden of disease, low- and middle-income countries will lose approximately $12 trillion in the next 15 years.3 In 2015, the Lancet Commission on Global Surgery was formed to address the surgical burden of disease in low- and middle-income countries through augmenting access and availability of surgical care.4,5 However, subspecialty surgical care access continues to be lacking and is often provided through short-term surgical trips, where high-volume care is performed during a finite period. Despite the efforts of the surgical community, the sustainability of these trips has not been evaluated using a standardized methodology.6

Roughly 66 percent of all disability-adjusted life-years lost worldwide are caused by injury, malignancy, and congenital anomalies.7 To address this need, plastic surgical outreach programs have focused on providing high-volume care for these patients.8 Plastic surgical interventions help to restore movement and function by facilitating the performance of basic activities of daily living. ReSurge International (ReSurge) focuses on delivering plastic surgical care for individuals living in low- and middle-income countries. Although there has been an expanded focus on delivering plastic surgical care, a comprehensive analysis of various plastic and reconstructive interventions has not been conducted.

With charitable organizations striving to offer surgical care in low- and middle-income countries, information on the economic implications of surgical trips can influence policy-making and help us understand the social impact for global health. Given that low- and middle-income countries are limited resource settings, decisions regarding resource allocation and surgical prioritization are necessary for the sustainability of global surgery efforts.9 The purpose of thus study was to (1) calculate the cost-effectiveness of plastic surgical interventions in low- and middle-income countries using World Health Organization Choosing Interventions That Are Cost-Effective methods and (2) determine the economic benefit of these surgical interventions using a cost-to-benefit analysis. Furthermore, we aim to compare the cost-effectiveness of traditional surgical trips to those trips focused on educating physicians in the host country.

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METHODS

Data Source

In this retrospective analysis, we obtained cost and clinical data from ReSurge. ReSurge has performed over 105,000 procedures since 1969, in 15 different low- and middle-income countries, and is one of the largest plastic surgery outreach organizations.10 We compiled data from traditional and visiting educator trips. During visiting educator trips, there is a greater emphasis on training local providers, compared with traditional surgical trips, during which emphasis is placed on completing operations. Patient cases were excluded from the data source if clinical variables required for the cost-effectiveness and/or cost-to-benefit analysis were missing.

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Dependent Variable

The cumulative cost incurred from ReSurge for each surgical trip was calculated. Cumulative cost consisted of lodging, shipping, travel, entertainment, food, medical supplies, and patient expenditure. ReSurge did not provide data regarding the costs borne by the host country, such as labor, supplies, patient recruitment, and operating room time; therefore, these costs were not factored in our analysis. Clinical data included information on patient age, sex, diagnosis, and surgical procedure. All the data were deidentified, and this study received nonregulatory status from our institutional review board.

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Cost-Effectiveness Analysis

The World Health Organization has developed a set of standardized criteria, Choosing Interventions That Are Cost-Effective, for researchers to adhere to when performing cost-effectiveness analyses of medical interventions performed in low- and middle-income countries.11 We quantified the surgical burden using disability-adjusted life-years. A disability-adjusted life-year is defined as a year lost because of morbidity and mortality from the disease state. Cost-effectiveness was reported as cost per disability-adjusted life-years averted. Cost per disability-adjusted life-year averted was calculated by dividing the total cost of the surgical trips by the total number of disability-adjusted life-years averted by performing the surgical intervention. The cost per disability-adjusted life-year averted represents how much it cost to avert 1 year of disability that would have otherwise been lost to the morbidity and mortality of the condition.

We calculated disability-adjusted life-years averted for various medical conditions using (1) disability weights, (2) remaining life expectancy, (3) likelihood of permanent disability, and (4) likelihood of treatment success.12 Two of the researchers (J.S.N. and J.I.B.) assigned parameters individually for each surgical condition, using disability weights from the 2015 Global Burden of Disease study, available from the Institute for Health Metrics and Evaluation.13 Any discrepancies were reviewed collaboratively and resolved. In addition, we determined remaining life expectancy using data from the World Health Organization, which necessitated data on the country of intervention, patient age, and patient sex. When possible, we extrapolated data points for age by assigning patients with a missing age value to the most common age category in the data set. To achieve consistency for the patients with missing data on sex, we assigned half of the patients to the male category and half to the female category. We assigned the likelihood of permanent disability and the likelihood of treatment success using methods described by Tadisina et al. and Gosselin et al.14,15 (See Appendix, Supplemental Digital Content 1, which shows the scoring system for the likelihood of permanent disability and the likelihood of treatment success. Note: This appendix is intended to provide readers with details providing our methodology, http://links.lww.com/PRS/D660.) We matched our values with other studies examining the cost-effectiveness of similar medical conditions.16,17 After we determined the disability weights, remaining life expectancy, likelihood of permanent disability, and likelihood of treatment success, we calculated the number of disability-adjusted life-years averted for each condition using the following equation:

We calculated cost-effectiveness for the interventions performed on each surgical trip by dividing the number of disability-adjusted life-years averted for the entire trip by the cost of the surgical trip.14,18–21 We performed a sensitivity analysis, discounting the health effects from 0 to 6 percent. We reported our results using the 3 percent discounting of the health effects, as recommended by World Health Organization Choosing Interventions That Are Cost-Effective methods. All costs were converted to 2017 U.S. dollars using the Consumer Price Index.

Using World Health Organization Choosing Interventions That Are Cost-Effective thresholds, we compared the cost per disability-adjusted life-year averted with the per-capita gross domestic product for the country of intervention (Fig. 1).22 We used 2017 gross domestic product per-capita estimates from the World Bank.23 If the cost per disability-adjusted life-year averted for the intervention was less than the per-capita gross domestic product, the intervention was considered very cost-effective. Similarly, if the cost per disability-adjusted life-year averted was less than three times the per-capita gross domestic product for the country of intervention, the intervention was considered cost-effective. Finally, any intervention greater than or equal to three times the per-capita gross domestic product was considered not cost-effective.24 In addition, to permit clear comparison, we calculated the cost-effectiveness as a ratio of the cost per disability-adjusted life-year averted to the gross domestic product per capita of the host country (cost-effectiveness ratio).

Fig. 1.

Fig. 1.

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Cost-to-Benefit Analysis

We performed a cost-to-benefit analysis to determine the net economic benefit of these programs. We used the human capital approach, a common method used to evaluate the economic benefit of surgical interventions performed in low- and middle-income countries.25–27 Using the human capital approach, the value is placed on an individual’s ability to contribute to their national economy.25 We extracted data on the gross national income per capita using the Purchasing Power Parity estimates from the World Bank.28 The following equation was used to calculate the economic benefit during of every surgical trip in our analysis:

where GNI/cap is gross national income per capita and DALYs-averted is disability-adjusted life-years averted. In addition, we adjusted the results of the cost-to-benefit analysis to 2017 U.S. dollars, which are reported using 3 percent discounting of the health effects.

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Wilcoxon Rank Sum Test

We used the Wilcoxon rank sum test to examine differences in the cost-effectiveness ratio of traditional and visiting educator trips. This nonparametric test was used because the data comparing educator and traditional trips were not distributed normally. The significance value was set at p < 0.05.

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RESULTS

Surgical Trips

Our analysis included 22 surgical trips performed from 2014 to 2017 by ReSurge (Table 1). The costs of the trips ranged from $2876 to $59,023 (average, $25,054). Of the 22 trips included in our analysis, 14 trips were traditional surgical trips and eight were visiting educator trips. The number of personnel on the trips ranged from two to 14 individuals. Personnel included surgeons, anesthesiologists, pediatricians, nurses, coordinators, translators, and others.

Table 1. - Trip Characteristics
Characteristic No. (%)
Trip type
 Traditional 14 (63.6)
 Visiting educator 8 (36.4)
Country of trip
 Vietnam 10 (45.5)
 India 3 (13.7)
 Cambodia 2 (9.1)
 Tanzania 2 (9.1)
 Zimbabwe 2 (9.1)
 Bhutan 1 (4.5)
 Nicaragua 1 (4.5)
 Ecuador 1 (4.5)
Year of trip
 2014 2 (9.0)
 2015 8 (36.4)
 2016 8 (36.4)
 2017 4 (18.2)
Surgical cases per trip
 0–10 3 (13.6)
 11–20 6 (27.3)
 21–40 4 (18.2)
 41–60 3 (13.6)
 ≥61 6 (27.3)

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Surgical Interventions

A total of 778 patients received surgical treatment during the 22 trips included in our study. We excluded 22 surgical cases from our economic analyses because we were not able to assign a disability weight to these cases, resulting in a final cohort of 756 patients (Table 2). Approximately half of the patients were female (n = 379). A majority of patients were 9 years of age or younger (59 percent). Table 3 depicts the disability weights and the average number of disability-adjusted life-years averted for each categorized surgical condition. The common procedures performed were repair for cleft lip, palate, and/or nose (32 percent); burn contracture release (25 percent); eye ptosis repair (13 percent); and excision of soft-tissue masses (10 percent). Among the categorized medical conditions, the average number of disability-adjusted life-years averted was greatest for patients with malignancy-related surgical conditions (disability-adjusted life-years averted, 8.46), cleft lip and/or palate (disability-adjusted life-years averted, 4.67), and hand conditions (disability-adjusted life-years averted, 1.50).

Table 2. - Patient Characteristics
Characteristic No. (%)
Surgical condition
 Cleft lip, palate, or nose 245 (32.4)
 Burn contracture 190 (25.1)
 Eye ptosis 94 (12.5)
 Soft-tissue mass anomalies 78 (10.3)
 Hand conditions 69 (9.1)
 Foot conditions 18 (2.4)
 Malignancy related 7 (0.9)
 Other 55 (7.3)
Age
 0–3 years 277 (36.6)
 4–9 years 172 (22.7)
 10–18 years 135 (17.9)
 ≥18 years 172 (22.8)
Sex
 Female 379 (50.1)
 Male 377 (49.9)

Table 3. - Surgical Conditions
Surgical Condition No. (%) Disability Weights Average No. of DALYs Averted*
Cleft lip, palate, or nose 245 (32.4) 0.067–0.118 4.67
Burn contracture 190 (25.1) 0.016–0.135 0.92
Eye ptosis 94 (12.5) 0.011–0.022 0.39
Soft-tissue mass anomalies 78 (10.3) 0.011–0.022 0.31
Hand conditions 69 (9.1) 0.016–0.234 1.50
Foot conditions 18 (2.4) 0.006–0.079 0.72
Malignancy related 7 (0.9) 0.288−0.288 8.46
Other 55 (7.3) 0.006–0.067 0.26
D
ALYs, disability-adjusted life-years.
*
Calculated and reported with a 3% discount of health benefits.

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Cost-Effectiveness Analysis

Disability-adjusted life-years averted on the surgical trips ranged from 0.33 to 5.84 (average, 2.07 disability-adjusted life-years averted). The cost-effectiveness of the trips was $52 to $11,410 per disability-adjusted life-year averted (Table 4). The cost per disability-adjusted life-year averted for 21 of the 22 trips was less than one or three times the gross domestic product per capita for the country of intervention, making these trips very cost-effective or cost-effective (Table 4). The cost per disability-adjusted life-year averted for trip 19 was greater than three times the gross domestic product per capita for the country of intervention, classifying this trip as not cost-effective. On trip 19, two patients received surgical treatment and an average 0.33 disability-adjusted life-year were averted. This trip was an educator trip that focused on didactic teaching rather than surgical instructions with patients.

Table 4. - Cost-Effectiveness and Economic Benefit of Surgical Trips
Trip Trip Type Surgical Cases Performed Surgical Cases in Analysis Country Disability Weights Total Adjusted Cost ($)* Average No. of DALYs Averted Cost per DALY Averted ($) Ratio of Cost per DALY Averted to GDP per Capita Economic Benefit ($)*
Raw* 3% Health Benefit Discounting*
1 Traditional 43 41 India 0.016–0.135 33,329 0.72 997 1123 0.58 209,598
2 Traditional 64 64 Vietnam 0.011–0.135 41,879 2.13 281 307 0.13 880,404
3 Traditional 24 23 Cambodia 0.006–0.135 25,007 0.89 1120 1224 0.88 76,828
4 Traditional 66 66 Vietnam 0.011–0.135 36,572 2.64 197 210 0.09 1,125,866
5 Traditional 38 37 India 0.016–0.288 40,375 0.95 1049 1146 0.59 248,740
6 Traditional 24 22 Tanzania 0.006–0.135 26,168 0.52 2164 2296 2.45 33,231
7 Traditional 32 32 Cambodia 0.011–0.135 26,357 1.30 598 635 0.46 156,096
8 Traditional 62 62 Vietnam 0.011–0.118 38,340 3.11 193 199 0.08 1,242,680
9 Traditional 73 69 Vietnam 0.011–0.135 32,890 2.20 210 216 0.09 979,952
10 Traditional 44 44 India 0.006–0.288 59,023 0.95 1375 1417 0.73 294,145
11 Traditional 19 14 Tanzania 0.011–0.135 29,900 1.58 1238 1353 1.45 64,460
12 Traditional 71 70 Vietnam 0.011–0.135 33,548 1.86 243 258 0.11 839,641
13 Traditional 17 17 Vietnam 0.011–0.288 5120 5.84 49 52 0.02 640,846
14 Visiting educator 10 10 Bhutan 0.006–0.135 9030 1.07 817 841 0.27 95,013
15 Visiting educator 12 12 Vietnam 0.011–0.234 5221 2.71 147 161 0.07 209,419
16 Visiting educator 17 17 Zimbabwe 0.016–0.288 7987 3.11 142 151 0.14 97,817
17 Visiting educator 10 10 Nicaragua 0.067–0.118 2876 4.91 55 59 0.03 278,796
18 Visiting educator 15 15 Ecuador 0.011–0.067 13,860 2.79 294 331 0.05 475,849
19 Visiting educator 2 2 Vietnam 0.011–0.011 7592 0.33 10,441 11,410 4.87 4292
20 Visiting educator 18 18 Zimbabwe 0.011–0.135 7696 0.80 488 534 0.49 26,681
21 Traditional 62 59 Vietnam 0.006–0.135 34,206 2.47 215 235 0.10 938,657
22 Traditional 55 52 Vietnam 0.011–0.135 34,206 2.61 230 252 0.11 876,373
D
ALY, disability-adjusted life-years; GDP, gross domestic product.
*
All costs adjusted and reported to the 2017 U.S. dollar value.
Calculated and reported with a 3% discount of health benefits.

In this analysis, we examined the differences between traditional versus visiting educator trips. The cost and number of patients served on visiting educator trips was typically less than that of traditional surgical trips. When comparing cost-effectiveness of traditional and visiting educator trips, we found that the cost-effectiveness ratio of visiting educator trips was comparable to traditional surgical trips, with one exception (Table 4). This one exception, trip 19, had a low surgical volume of two patients. Furthermore, the average number of disability-adjusted life-years averted on this trip was 0.33. When performing the Wilcoxon rank sum test to compare the cost-effectiveness of the traditional and visiting educator trips, the median cost-effectiveness ratio of the traditional surgical trips was 0.13 and the median ratio for the visiting educator trips was 0.14 (p = 0.53).

We found that trips treating more complex and disabling surgical conditions were more cost-effective compared with those treating less complex conditions. The trips averting a higher number of disability-adjusted life-years had a lower cost-effectiveness ratio compared with trips averting a lower number of disability-adjusted life-years (Table 4). In addition, the majority of trips performed in certain regions, such as South America and Southeast Asia, had a lower cost-effectiveness ratio. This may be attributable to the variation in traveling and lodging costs in certain areas of the world.

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Cost-to-Benefit Analysis

Approximately 1720 disability-adjusted life-years were averted by the procedures performed on the 22 surgical trips. This translates to a total economic benefit of $9,795,384 for the surgical trips included in our analysis. The economic benefit of the individual surgical trips ranged from $4292 to $1,242,680 (Table 4). In addition, we found the economic benefit per patient to be $12,957.

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DISCUSSION

Our study demonstrates the fiscal impact of plastic surgery outreach in low- and middle-income countries. By adhering to World Health Organization Choosing Interventions That Are Cost-Effective methodology, we found that almost all the trips performed by ReSurge were either very cost-effective or cost-effective. In addition, our cost-to-benefit analysis determined an economic benefit of these trips and found a substantial return on investment for plastic surgical trips to low- and middle-income countries.

Estimates suggest that 143 million surgical procedures are needed in low- and middle-income countries by 2030 to avert the disability affected by the current surgical burden of disease.4 In our analysis of 22 surgical trips providing plastic surgical care, we found that the conditions treated have a disability weight that ranges from 0.006 to 0.288, indicating a substantial burden placed on these patients and countries because of their surgical disease. According to the Global Burden of Disease study, this disability is comparable to the disability caused by symptomatic human immunodeficiency virus, severe malaria, hearing loss, mild dementia, amputation of one upper limb, and other medical conditions.13 By performing cost-effectiveness and cost-benefit analyses, we found that interventions to amend this disability are economically sustainable in a low-resource setting.

Despite recent evidence that essential surgery in low- and middle-income countries is cost-effective, specialty surgery is not always accepted as a global health intervention.29 Using World Health Organization Choosing Interventions That Are Cost-Effective standards, Shillcutt et al. reported the cost-effectiveness of groin hernia surgery in Ghana to be $13 per disability-adjusted life-year averted, which translates to a cost-effectiveness ratio of 0.02.30 This ratio for groin hernia surgery is similar to that of the plastic and reconstructive surgical trips included in our analysis (trips 4, 8, 9, 13, 15, 17, and 18), highlighting the positive effects of these surgical trips. Similarly, Fitzpatrick and Floyd reviewed the literature on the cost-effectiveness of multidrug-resistant tuberculosis treatment and found the cost-effectiveness ratio for Southeast Asian countries to be 0.18. For plastic surgery efforts, we found the cost-effectiveness ratio for India to range from 0.58 to 0.73.31 Both these ratios are less than 1, indicating that multidrug-resistant tuberculosis treatment and plastic surgical trips are considered cost-effective; therefore, plastic surgery efforts in low- and middle-income countries are comparable to commonly accepted global health interventions.

Findings from this study demonstrate that 21 of the 22 trips were very cost-effective or cost-effective. However, one of these trips was considered not cost-effective (trip 19), perhaps indicating that the surgical conditions treated on these trips were not as debilitating or the cost of these trips was too high for the volume of surgery performed. The surgical trip in our analysis identified as not cost-effective was a visiting educator trip (trip 19). This visiting educator trip was used by ReSurge to develop a team to educate local physicians on surgery for microtia. Because only two cases were performed on this trip, this surgical trip was considered not cost-effective. It is important to note that the visiting educator trips are intentionally designed to have a lower surgical volume for the purpose of teaching local surgeons how to perform the various procedures. Thus, the true impact of these trips occurs after the visiting team leaves the host country and the local surgeons perform the procedure on numerous individuals. Nevertheless, trip 19 had an especially lower number of patients being treated compared with the other visiting educator trips. Although this one visiting educator trip was considered not cost-effective, the local surgeons were being trained on this procedure and may now be able to perform microtia repair independently, permitting the organization to allocate resources to other debilitating conditions. Thus, by providing education to the local providers, the organization is attempting to transition care to the host country and maximize the potential impact. With adequate data, future research may more accurately estimate the impact of visiting educator trips after the visiting organization leaves the host country.

The effort to educate local physicians in low- and middle-income countries has been recognized as an important component of sustainable global health efforts.32–34 If organizations allocate resources to educate local surgeons, less complex surgical interventions can be performed by a surgeon in the host country. This will permit the outreach organizations to transition care to the host organizations and promote the of other surgeons. Furthermore, the surgical trips can then focus on treating patients with complex problems that confer more disability and are unable to be treated by the local surgeons. In contrast, if a surgical trip focuses on providing care for a condition with a low disability weight, there should be efforts to increase surgical volume or perform operations on more complex surgical conditions. Specialty surgical trips should focus on providing surgery for complex conditions that local surgeons are unable to provide. This will help increase both the overall cost-effectiveness and the economic benefit of the interventions performed in the developing world.

In this analysis, we found that trips performed in certain regions of the world were more cost-effective. This may be attributable to a variety of factors, including differences in gross domestic product per capita or a higher cost of traveling to a particular area. For instance, it would cost less for a surgical team from the United States to travel to a country in South America than it would for that same team to travel to a country in West Africa. To make trips more cost-effective in locations that require more resources for travel or lodging, organizations should strive to increase the surgical volumes on such trips. Alternatively, efforts to educate local physicians on the various procedures can aid in the sustainability of these surgical interventions and help increase the cost-effectiveness of these trips that require more resources.

Cost-to-benefit analyses are used to describe the monetary return on investment for charitable organizations.25 Because low cost is a high priority for these entities, a cost-to-benefit analysis can inform policy-makers on the impact of a particular program. If used with a cost variation analysis, researchers can identify areas of improvement, develop a new policy to decrease cost, then finally quantify the effect of that program in monetary terms using a cost-to-benefit analysis. In our analysis, we found that this plastic surgery outreach program provided an economic benefit of roughly $9,795,384, indicating a substantial return on investment. Future cost variation analyses may highlight drivers of cost, which can then be used to implement cost-reduction policy and improve the sustainability of surgical efforts in low- and middle-income countries.

We recognize that our study has limitations. The data provided by ReSurge were not intended for research purposes. We had to exclude multiple patients because of missing data, which may generate unknown confounders or biases. However, we were still able to use this information to model the cost-effectiveness and the economic benefit using established criteria. Furthermore, because the cost data are used for tax purposes, we are confident that the costs reported are accurate. We also recognize that this analysis examined the surgical trips from only one plastic surgery organization. Thus, future analyses examining the economic impact of different surgical trips performed by different global surgery organizations is warranted. The potential impact of training local surgeons through visiting educator trips, which may impact the economic benefit and the cost-effectiveness of the surgical trips, is not taken into account in our analysis, as there is no way to confirm that the surgeons are performing the procedures on their own after the organization leaves the host country. Moreover, we were unable to include certain costs borne by the host country, such as labor, supplies, patient recruitment, and operating room time. Nonetheless, ReSurge is not obligated to compensate for these resources, and thus they do not serve as a burden for the organization. In addition, the lack of these data could have an impact on country-specific analyses, because government support for health care needs varies by country. For example, if India provides costs for operating room and medicines and Vietnam does not, the costs will be difficult to compare between countries but would be more comparable for costs to surgical trips within that country. However, we believe that the underreported costs have only a minor impact on the cost-effectiveness of the surgical trips because the overwhelming majority of trips had a large margin between the cost per disability-adjusted life-year averted and the three-times the gross domestic product per capita value for the host country. Because we did not have access to data regarding follow-up care and postoperative therapy, we did not account for the financial burden of follow-up treatment required after the organization left the country. Nonetheless, almost all surgical trips had a large margin between the cost per disability-adjusted life-year averted and the three times the gross domestic product per capita value, making the addition of follow-up expenditure unlikely to change the results of our study. In addition, we recognize the low power of the Wilcoxon rank sum test used to examined differences. Further analyses with data from multiple organizations are warranted to help confirm the sustainability of educator efforts during surgical trips to low- and middle-income countries.

As the surgical burden of disease continues to grow, implementing sustainable global surgery programs becomes more imperative. We demonstrate that interventions performed by ReSurge are cost-effective and provide an economic benefit to individuals in the host country. Moving forward, other plastic surgery outreach organizations must implement a policy to attempt to alleviate as much disability as possible when performing surgical trips. Such efforts require careful planning regarding the education of local surgeons and consideration of both surgical complexity and volume. Economic analyses will help provide policy-makers with the necessary information to develop an effective strategy to decrease cost and improve the outcomes of the interventions performed in low- and middle-income countries.

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ACKNOWLEDGMENTS

This work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-AR053120-06) (to K.C.C.). We would like to thank Lin Zhong for help with statistical analysis. In addition, we would like to thank ReSurge for assistance in data collection and continued support for this project.

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DISCLAIMER

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

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