A critical threshold for global pediatric surgical workforce density

Pediatric Surgery International (2021) 37:1303–1309 https://doi.org/10.1007/s00383-021-04939-6 ORIGINAL ARTICLE A critical threshold for global pediatric surgical workforce density Megan E. Bouchard1 Monica Langer1 · Yao Tian1 · Jeanine Justiniano2 · Samuel Linton1 · Christopher DeBoer1 · Fizan Abdullah1 · Accepted: 31 May 2021 / Published online: 9 June 2021 © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021 Abstract Purpose 1.7 billion children lack access to surgical care, particularly in low- and middle-income countries (LMIC). The pediatric surgical workforce density (PSWD), an indicator of surgical access, correlates with survival of complex pediatric surgical problems. To determine if PSWD also correlates with population-level health outcomes for children, we compared PSWD with pediatric-specific mortality rates and determined the PSWD associated with improved survival. Methods Using medical licensing registries, pediatric surgeons practicing in 26 countries between 2015 and 2019 were identified. Countries’ PSWD was calculated as the ratio of pediatric surgeons per 100,000 children. The correlation between neonatal, infant and under 5 mortality rates and PSWD was assessed using Spearman’s correlations and piecewise linear regression models. Results Four LIC, eight L-MIC, ten UMIC and four HIC countries, containing 420 million children, were analyzed. The median PSWD by income group was 0.03 (LIC), 0.12 (L-MIC), 1.34 (UMIC) and 2.13 (HIC). PSWD strongly correlated with neonatal (0.78, p < 0.001), infant (0.82, p < 0.001) and under 5 (0.83, p < 0.001) mortality rates. Survival improved with increasing PSWD to a threshold of 0.37. Conclusion PSWD correlates with pediatric population mortality rates, with significant improvements in survival with PSWD > 0.37. Currently, PSWD in LMICs is inadequate to meet UN Sustainable Development Goal 3.2 for child mortality. Keywords Workforce density · Pediatric surgery · Childhood mortality · National surgical planning Introduction Despite major improvements in childhood survival in lowand middle-income countries (LMICs), the 2015 Millennium Developmental Goals for neonatal, infant, and child mortality were not met, thus prompting inclusion in the United Nation’s Sustainable Developmental Goal (SDG) 3.2: to end preventable deaths of children under 5 years of age by 2030 [1]. Surgery is now unanimously recognized as an essential component of universal health coverage by the 2015 World Health Assembly; access to pediatric * Megan E. Bouchard 1 Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL 60611, USA 2 Loyola University Chicago Stritch School of Medicine, 2160 S. First Ave, Maywood, IL 60153, USA surgical services, specifically, is critical to effectively care for congenital conditions and trauma, which disproportionately affect children in LMICs and contribute to preventable morbidity and mortality [2, 3]. With nearly one-fifth of surgical disability-adjusted life-years (DALYs) caused by congenital or perinatal conditions and the known lack of surgical access in LMICs, access to pediatric surgical care remains paramount [4]. However, an estimated 1.7 billion children worldwide lack access to surgical care, including 1.1 billion in low- and middle-income countries (LMICs) where children comprise nearly 50% of the population [5, 6]. Among other indicators of surgical access, the Lancet Commission on Global Surgery (LCoGS) identified the density of surgical providers as a marker of sufficient workforce capacity [7]. The LCoGS demonstrated a strong correlation between surgical workforce density and adult population health outcomes, specifically maternal mortality rate, with a critical threshold of 20 surgical providers per 100,000 people correlating with significant reductions in mortality [7]. This threshold has served as a benchmark 13 Vol.:(0123456789) 1304 for surgical access and a target for national surgical planning for scale-up of the surgical workforce in LMICs. While it is well recognized that specific pediatric surgery workforce goals are needed for national strategic planning to improve pediatric care, none currently exist [5, 8]. Specialist pediatric surgeons are needed for treatment of congenital and complex pediatric problems, thus the pediatric surgical workforce density (PSWD) is an important indicator of access to comprehensive pediatric care [9]. Outcomes for specific pediatric surgical conditions in LMICs correlate with PSWD as evidenced by a recent systematic review demonstrating that a PSWD of 0.4 per 100,000 children significantly correlated with increased odds of survival in gastroschisis, esophageal atresia, intestinal atresia, and typhoid perforation [9]. While it makes sense that outcomes from surgical conditions correlate with PSWD, it is unknown if PSWD correlates with pediatric-specific population mortality rates. Therefore, we aimed (1) to assess for a correlation between PSWD and neonatal, infant, and under 5 childhood mortality rates and (2) to identify the critical PSWD threshold associated with significant mortality reduction for national strategic surgical planning. Methods Study design and data sources We conducted a retrospective, cross-sectional study of pediatric surgeons’ workforce density (PSWD) using publicly available medical licensing registries and the WHO Global Surgical Workforce Database [10]. Only countries with publicly available data on the subspecialty classification of physicians were included. A convenience sample of 26 geographically and economically diverse countries between 2015 and 2018 was identified. Countries included in the analysis were classified by the World Bank income brackets including low income (LIC), lower-middle income (L-MIC), upper-middle income (UMIC) and high income (HIC). For each country, the most recent publicly available medical licensing data were used to identify the number of practicing pediatric surgeons with an active license. Pediatric surgeons were defined by country-specific certification as specialist pediatric surgeons. Given most countries define pediatric care as care delivered to patients less than 15 years old, each country’s population less than 15 years old was retrieved from the World Bank [6, 9]. Additionally, the under 5-year old, infant and neonatal mortality rates for each country were obtained [6]. 13 Pediatric Surgery International (2021) 37:1303–1309 Outcomes and analysis The primary outcome was each country’s respective PSWD, calculated as the number of pediatric surgeons per 100,000 children less than 15 years old. Then for each income bracket, the median PSWD and mean proportion of less than 15-year-old population were determined. The under 5, infant, and neonatal mortality rates were converted to survival rate (...truncated)