Mark Shrime

Mark Shrime
Harvard Medical School | HMS · Program in Global Surgery and Social Change

MD, MPH, PhD, FACS

About

173
Publications
98,375
Reads
How we measure 'reads'
A 'read' is counted each time someone views a publication summary (such as the title, abstract, and list of authors), clicks on a figure, or views or downloads the full-text. Learn more
49,579
Citations

Publications

Publications (173)
Article
Background The largest proportion of people at risk of catastrophic expenditures for surgical care live in low‐ and middle‐income countries. This study aims to evaluate the financial impact among surgical patients at Kibuye Hope Hospital (KHH) in Burundi. Methods Data were collected from patients undergoing a surgical procedure at KHH from January...
Article
Full-text available
The delivery of healthcare in conflict-affected regions places tremendous strains to health systems, and the economic value of surgical care in conflict settings remains poorly understood. Our aims were to evaluate the cost-effectiveness, societal economic benefits, and return on investment (ROI) for surgical care in a conflict-affected region in S...
Article
There are marked barriers to research and publishing for low- and middle- income country (LMIC) ENT researchers. This could be reflected in LMIC journal characteristics and research, which has never been investigated. We aim to characterize differences in the number, geographic distribution, publishing costs, reach, number of articles, citations, a...
Article
Objective Patient preferences regarding thyroid nodules are poorly understood. Our objective is to (1) employ a discrete choice experiment (DCE) to explore risk tradeoffs in thyroid nodule management, and (2) segment respondents into preference phenotypes. Study Design DCE. Setting Thyroid surgery clinic, online survey. Methods A DCE including 5...
Article
Full-text available
The Declaration of Geneva serves as a guide to ethical medical practice. It primarily addresses the duties of the physician in relation to an individual physician–patient relationship and implicitly advocates a ‘first come, first served’ model. It assumes the availability of adequate resources to treat all patients. However, no health system can me...
Article
Full-text available
Over 1.7 billion children lack access to surgical care, mostly in low- and middle-income countries (LMICs), with substantial risks of catastrophic health expenditures (CHE) and impoverishment. Increasing interest in reducing out-of-pocket (OOP) expenditures as a tool to reduce the rate of poverty is growing. However, the impact of reducing OOP expe...
Article
Full-text available
Objectives An estimated 1.7 billion children around the world do not have access to safe, affordable and timely surgical care, with the financing through out-of-pocket (OOP) expenses being one of the main barriers to care. Our study modelled the impact of reducing OOP costs related to surgical care for children in Somaliland on the risk of catastro...
Article
Full-text available
Knowing the target oxygen saturation (SpO2) range that results in the best outcomes for acutely hypoxemic adults is important for clinical care, training, and research in low-income and lower-middle income countries (collectively LMICs). The evidence we have for SpO2 targets emanates from high-income countries (HICs), and therefore may miss importa...
Article
Full-text available
Background: The shortage of trained surgeons, anesthesiologists, and obstetricians is a major contributor to the unmet need for surgical care in low- and middle-income countries, and the shortage is aggravated by migration to higher-income countries. Methods: We performed a cross-sectional observational study, combining individual-level data of...
Article
Purpose of review: Open access articles are more frequently read and cited, and hence promote access to knowledge and new advances in healthcare. Unaffordability of open access article processing charges (APCs) may create a barrier to sharing research. We set out to assess the affordability of APCs and impact on publishing for otolaryngology train...
Article
Full-text available
Objective To qualitatively explore the broad set of preferences and attitudes patients have about thyroid nodules, which influence the decision‐making process. Study Design A descriptive survey design was administered as interviews. Setting Outpatient thyroid surgery clinic. Methods Semistructured interviews were conducted with 20 patients prese...
Article
Full-text available
Introduction Efficient utilisation of surgical resources is essential when providing surgical care in low-resources settings. Countries are developing plans to scale up surgery, though insufficiently based on empirical evidence. This paper investigates the determinants of hospital efficiency in district hospitals in three African countries. Method...
Article
Background The financial burden of surgery is substantial worldwide. Postoperative complications increase costs in high-resource settings, but this is not well studied in other settings. Our objective was to review the financial impact of postoperative complications. Method Patients undergoing emergency gastrointestinal operations at a center in K...
Article
Background: Over two-thirds of the world's population cannot access surgery when needed. Interventions to address this gap have primarily focused on surgical training and ministry-level surgical planning. However, patients more commonly cite cost-rather than governance or surgeon availability-as their primary access barrier. We undertook a randomi...
Article
Full-text available
Objective Open access (OA) publishing makes research more accessible but is associated with steep article processing charges (APCs). The study objective was to characterize the APCs of OA publishing in otolaryngology‐head and neck surgery (OHNS) journals. Methods We conducted a cross‐sectional analysis of published policies of 110 OHNS journals co...
Article
Full-text available
Background The implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10...
Article
Background: Worldwide, 3.7 billion people risk financial catastrophe if they require surgery, mostly affecting the poorest populations. Surgical care associated with catastrophic health expenditure (CHE) has not been well-described in the South African context. The objectives of this study were to determine: (1) the proportion of surgical patients...
Article
Full-text available
Background: While primary data on the unmet need for surgery in low- and middle-income countries is lacking, household surveys could provide an entry point to collect such data. We describe the first development and inclusion of questions on surgery in a nationally representative Demographic and Health Survey (DHS) in Zambia. Method: Questions r...
Preprint
Full-text available
Background The implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the >79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%...
Article
Full-text available
Background Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impov...
Article
Full-text available
Objective This study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA). Setting Surgical and anaesthesia services across all levels of care—primary, secondary and tertiary. Design We performed a scoping review of scientific databases (PubMed, EMBASE,...
Article
Full-text available
Background Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequen...
Preprint
Full-text available
Background Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. Despite being rapidly taken up by practitioners, datapoints from which to derive them were not defined, limiting comparability across time or settings. We convened...
Preprint
Background: Over two-thirds of the world's population cannot access surgery when needed. Interventions to address this gap have primarily focused on surgical training and ministry-level surgical planning. However, patients more commonly cite cost--rather than governance or surgeon availability--as their primary access barrier. We undertook a random...
Article
We modeled gross domestic product (GDP) losses attributable to firearm-related fatalities in each of thirty-six Organization for Economic Cooperation and Development (OECD) countries using the value-of-lost-output approach from 2018 to 2030. There are three categories of firearm-related fatalities: physical violence, self-harm, and unintentional in...
Article
Full-text available
Key Messages The most useful resource reported was Global Surgery 2030, along with other publications, data collection tools, books and training manuals, and a documentary. This list could serve as a starting point for individuals interested in global surgery and be supplemented with resources advocating for global surgery from clinical, population...
Article
Background Surgical care is a cost-effective intervention with major public health impact. Yet, five billion people do not have access to surgical and anesthesia care. This overwhelming unmet need has generated a rising interest in scale-up of these services globally. The purpose of this research was to aggregate available guidelines and create a s...
Article
Full-text available
By 2030, 70% of cancers will occur in developing countries. Head and neck cancers are primarily a developing world disease. While anatomical location and the extent of cancers are central to defining prognosis and staging, the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) have incorporated nonanatomic factors t...
Article
Full-text available
Objective Cash transfers are a common intervention to incentivize salutary behavior in resource-constrained settings. Many cash transfer studies do not, however, account for the effect of the size of the cash transfer in design or analysis. A randomized, controlled trial of a cash-transfer intervention is planned to incentivize appropriate surgical...
Article
Objective Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically‐refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost‐effectiveness of dupilumab versus ESS for patients with CRSwNP. Study Design Cohort‐style Markov decision‐tree economic mo...
Article
Full-text available
Background A baseline assessment of surgical capacity is recommended as a first-step to surgical system strengthening in order to inform national policy. In Ethiopia, the World Health Organization’s Tool for Situational Analysis (WHO SAT) was adapted to assess surgical, obstetric, and anesthesia capacity as part of a national initiative: Saving Liv...
Article
Objective We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes. Study Design Statistical and economic analysis. Setting Research group. Subjects and Methods We conducted a statistical analysis on data from the Wor...
Article
Full-text available
Background The WHO estimates a global shortage of 2.8 million physicians, with severe deficiencies especially in low and middle-income countries (LMIC). The unequitable distribution of physicians worldwide is further exacerbated by the migration of physicians from LMICs to high-income countries (HIC). This large-scale migration has numerous economi...
Article
Background: The Lancet Commission on Global Surgery showed that countries with surgeon, anesthetist, and obstetrician (SAO) densities of 20-40 SAO/100,000 population were associated with improved health outcomes and recommended a global surgical workforce scale-up by 2030. Whether countries would be able to achieve such scale-up efforts in that ti...
Article
Full-text available
Introduction Half of all Ugandans (49%) turn to the private or private-not-for-profit (PNFP) sectors when faced with illness, yet little is known about the capacity of these sectors to deliver surgical services. We partnered with the Ministry of Health to conduct a nationwide mixed-methods evaluation of private and PNFP surgical capacity in Uganda....
Article
Background Delayed access to surgical care for congenital conditions in low- and middle-income countries is associated with increased risk of death and life-long disabilities, although the actual burden of delayed access to care is unknown. Our goal was to quantify the burden of disease related to delays to surgical care for children with congenita...
Article
Background: Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain due to high out-of-pocket healthcare costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington state-which extended coverage to >600,000 WA residents-was assoc...
Article
Full-text available
Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on pur...
Article
In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening e...
Article
Full-text available
Background In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the i...
Article
Background: Metrics to measure the burden of surgical conditions, such as disability weights (DWs), are poorly defined, particularly for pediatric conditions. To summarize the literature on DWs of children's surgical conditions, we performed a systematic review of disability weights of pediatric surgical conditions in low- and middle-income countr...
Article
Background: The aim of this study was to describe the national epidemiology of burns in Brazil and evaluate regional access to care by defining the contribution of out-of-hospital mortality to total burn deaths. Methods: We reviewed admissions data for Brazil's single-payer, free-at-point-of-care, public-sector provider and national death regist...
Article
Full-text available
Recognizing the unmet need for surgical care in Ethiopia, the Federal Ministry of Health (FMOH) has pioneered innovative methodologies for surgical system development with Saving Lives through Safe Surgery (SaLTS). SaLTS is a national flagship initiative designed to improve access to safe, essential and emergency surgical and anaesthesia care acros...
Article
Background Although nearly two-third of bankruptcy in the United States is medical in origin, a common assumption is that individuals facing a potentially lethal disease opt for cure at any cost. This assumption has never been tested, and knowledge of how the American population values a trade-off between cure and bankruptcy is unknown. Objectives...
Article
Full-text available
Objectives To estimate incidence, mortality, and disability- adjusted life years (DALYs) caused by cancer in the Eastern Mediterranean Region (EMR) between 2005 and 2015. Methods Vital registration system and cancer registry data from the EMR region were analyzed for 29 cancer groups in 22 EMR countries using the Global Burden of Disease Study 2015...
Article
Full-text available
Abstract OBJECTIVES: To estimate incidence, mortality, and disability-adjusted life years (DALYs) caused by cancer in the Eastern Mediterranean Region (EMR) between 2005 and 2015. METHODS: Vital registration system and cancer registry data from the EMR region were analyzed for 29 cancer groups in 22 EMR countries using the Global Burden of Disease...
Article
As the US health care economy continues the painstaking transformation from a volume-based to a value-based system, it becomes increasingly important to define what constitutes value to patients. Over the past 2 decades, the patient perspective of value has often been accounted for using quality of life (QOL) metrics.¹ Quality-of-life measures inco...
Article
Background: The global lack of anesthesia capacity is well described, but country-specific data are needed to provide country-specific solutions. We aimed to assess anesthesia capacity in Madagascar as part of the development of a Ministry of Health national surgical plan. Methods: As part of a nationwide surgical safety quality improvement proj...
Article
Objectives Patient preferences are crucial for the delivery of patient-centered care. Discrete choice experiments (DCEs) are an emerging quantitative methodology used for understanding these preferences. In this study, we employed DCE techniques to understand the preferences of patients presenting for an ear, nose, and throat clinic visit. Study D...
Article
Full-text available
Background: An adequate amount of prepaid resources for health is important to ensure access to health services and for the pursuit of universal health coverage. Previous studies on global health financing have described the relationship between economic development and health financing. In this study, we further explore global health financing tr...
Article
Full-text available
Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological...
Chapter
Research over the past 15 years has dramatically changed how surgical care is viewed within global health. Once thought as too expensive and inappropriate for settings of limited resources, surgical care is now recognized as an essential component of strong health systems and capable of treating a wide spectrum of important clinical problems in a h...
Article
Full-text available
IMPORTANCE Cancer is the second leading cause of death worldwide. Current estimates on the burden of cancer are needed for cancer control planning. OBJECTIVE To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 32 cancers in 195 countries and territories from...
Article
Objective: To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk. Background: Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measure...
Article
Full-text available
Background Brazil boasts a health scheme that aspires to provide universal coverage, but its surgical system has rarely been analysed. In an effort to strengthen surgical systems worldwide, the Lancet Commission on Global Surgery proposed a collection of 6 standardised indicators: 2-hour access to surgery, surgical workforce density, surgical volum...
Article
Background: The Lancet Commission on Global Surgery recommends that every country report its surgical volume and postoperative mortality rate. Little is known, however, about the numbers of operations performed and the associated postoperative mortality rate in low-income countries or how to best collect these data. Methods: For one month, every...
Article
Background: Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect. Methods: We abstracted nonelderly adults (...
Article
Introduction: Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in...
Article
Full-text available
Background: The recently adopted Sustainable Development Goals call for the end of poverty and the equitable provision of healthcare. These goals are often at odds, however: health seeking can lead to catastrophic spending, an outcome for which cancer patients and the poor in resource-limited settings are at particularly high risk. How various hea...
Data
Supplemental methods, results, and figures. (DOCX)
Article
Full-text available
Background The non-profit and volunteer sector has made notable contributions to delivering surgical services in low-and middle-income countries (LMICs). As an estimated 55 % of surgical care delivered in some LMICs is via charitable organizations; the financial contributions of this sector provides valuable insight into understanding financing pri...
Article
Full-text available
Background The assessment of the economic burden of surgical disease is integral to determining allocation of resources for health globally. We estimate the economic gain realised over an 11-year period resulting from a vertical surgical programme addressing cleft lip (CL) and cleft palate (CP). Methods The database from a large non-governmental o...
Article
Background The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and publish...
Article
Background Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income cou...
Article
Importance: Specialty emergency departments (EDs) provide a unique mechanism of health care delivery, but the value that they add to the medical system is not known. Evaluation of patient preferences to determine value can have a direct impact on resource allocation and direct-to-specialist care. Objective: To assess the feasibility of contingen...
Article
When Sambany, a farmer in his 60s from rural Madagascar, arrived for surgery, he had spent 30 years with a 16-lb tumor on the left side of his face (Figure). In those decades, he had traveled to 10 hospitals, only 3 of which actually had surgeons; none agreed to take his case. Because his mass was removed by volunteer surgeons with Mercy Ships, the...