The notion of “reverse innovation”--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.

BACKGROUND: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient’s care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. METHODS: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen’s kappa. RESULTS: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. CONCLUSIONS: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Background Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists. Approach We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearing house for all federal performance measures, and classified all measures as follows: 1) anesthesia-specific; 2) surgery-specific; 3) jointly attributable; or 4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome or efficiency; (2) patients; disease and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream. National Quality Forum Measures Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. “Anesthesia-specific” measures addressed preoperative antibiotic timing (n=4), normothermia (n=1), and protocol use for placement of central venous catheter (n=1). Jointly attributable measures included outcome measures (n=49/67, 73.1%) which were weighted towards mortality alone (n=24) and cardiac surgery (n=14). Other jointly attributable measures addressed orthopedic surgery (n=4), general surgical oncologic resections (n=12) or nonspecified surgeries (n=15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n=33/67, 47%) were frequent measure stewards. Summary and Ways Forward Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcomes-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented as well as procedural and sedation care provided in non-operating room settings.

The purpose of this questionnaire is to create a data set to help evaluate capacity for anaesthesia care at a national level, and to provide guidance for improving or maintaining standards for the safe practice of anaesthesia. Completion of this survey is voluntary and optional. This form is intended to be completed by an anaesthesia provider. Ideally, this provider should have first-hand knowledge of the facility that is being reviewed. Data collection must be done in accordance with local protocols and laws, and must not include any patient health information. Providing your personal contact information is optional and would only be used if clarification of your responses is needed.Data may be entered electronically using an online version of this survey form. Data are stored in a secure RedCap database, jointly maintained by the WFSA and the UCSF Anesthesia Division of Global Health Equity. If you enter data electronically, you will be provided a copy of your survey responses as a pdf and as a raw database file. More information on the electronic survey tool can be found at the WFSA website.This survey should take approximately 45 minutes. If you are unsure of the answer to any question or choose not to answer, please leave it blank. You may stop the survey at any time. GENERAL QUESTIONSDate of data collection (dd/mm/yy): Contact information of staff completing this assessment (Name, phone and email):Country (location of healthcare facility being surveyed):

Purpose of Review This review summarizes the history and scope of physician burnout, and explores recent advances in its understanding. With a particular focus on physicians who have completed their training, it also explores the present and future of interventions designed to alleviate the symptoms and sequelae of burnout. Recent Findings Nearly 50 years since first described, burnout continues to remain a pervasive issue within anesthesia and medicine as a whole. Recent work has continued to outline risk factors and specialty-specific prevalence, and explore individual and institutional interventions to prevent and treat symptoms. Summary Burnout continues to impact all who work in healthcare, at all levels of training. This review highlights recent advances in our understanding of the scope, causes, and management of burnout. In light of the current COVID-19 pandemic, we hope that the national and international focus on preventing and remediating burnout will continue to expand and strengthen.

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Purpose of reviewThe SARS-CoV-2 (COVID-19) pandemic has highlighted the inequities in access to healthcare while also revealing our global connectivity. These inequities are emblematic of decades of underinvestment in healthcare systems, education, and research in low-middle income countries (LMICs), especially in surgery and anesthesiology. Five billion people remain without access to safe surgery, and we must take appropriate action now. Recent findingsThe pediatric perioperative mortality in low-resourced settings may be as high as 100 times greater than in high-resourced settings, and a pediatric surgery workforce density benchmark of 4/1 million population could increase survivability to over 80%. Delay in treatment for congenital surgically correctable issues dramatically increases disability-adjusted life years. Appropriate academic partnerships which promote education are desired but the lack of authorship position priority for LMIC-based researchers must be addressed. Five perioperative benchmark indicators have been published including: geospatial access to care within 2 h of location; workforce/100,000 population; volume of surgery/100,000 population; perioperative mortality within 30 days of surgery or until discharged; and risks for catastrophic expenditure from surgical care. SummaryResearch that determines ethical and acceptable partnership development between high-and low-resourced settings focusing on education and capacity building needs to be standardized and followed.

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