Background and Objective: Surgical disease increasingly contributes to global mortality and morbidity, particularly in low- and middle-income countries (LMICs). Sub-Saharan Africa as a region has the largest percentage of avertable injury-related surgical disease and surgical digestive diseases; however, estimates suggest that the rate of surgical treatment is lower than the burden of disease. The Lancet Commission on Global Surgery found that global cost-effectiveness data is lacking for a wide range of essential surgical procedures. This study aims to address this gap by defining the cost-effectiveness of exploratory laparotomies in the Ugandan context.
Methods: Over a two-month time period, the costs of patients undergoing emergency exploratory laparotomies at the Soroti Regional Referral Hospital in Soroti, Uganda were collected. A time-and-motion analysis was utilized to calculate operating theatre personnel costs per case. Ward personnel, medication, overhead, and supply costs were recorded and calculated using a micro-costing approach. The cost in USD per disability-adjusted-life-year (DALY) averted was then determined.
Results: Data for 35 exploratory laparotomy patients was collected. The most common cause for laparotomy was small bowel obstruction. The average cost per patient was $95.30, which divided into approximately $27 for ward personnel, $23 for medications, $18 for surgical personnel, $18 for admin/ancillary staff, $7 for operative supplies, and $1.32 for utilities. The post-operative mortality rate was 14%, and the complication rate was 11%. The average number of DALYs averted per patient was 14.44. The cost in USD per DALY averted was $6.60.
Conclusion: This preliminary data provides evidence that emergency exploratory laparotomy is cost-effective compared with other surgical interventions and basic public health interventions, such as bed nets for malaria prevention ($6.48-22.04/DALY averted), and TB, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted). Given that injury-related surgical disease causes more death than TB, HIV, and malaria combined, this indicates that surgery in LMICS is not only a necessary treatment option, but a cost-effective one.