Rech Dino, Bertrand Jane T, Thomas Nicholas, Farrell Margaret, Reed Jason, Frade Sasha, Samkange Christopher, Obiero Walter, Agot Kawango, Mahler Hally, Castor Delivette, Njeuhmeli Emmanuel
The Centre for HIV and AIDS Prevention Studies, Johannesburg, South Africa.
Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America.
PLoS One. 2014 May 6;9(5):e84271. doi: 10.1371/journal.pone.0084271. eCollection 2014.
This analysis explores the association between elements of surgical efficiency in voluntary medical male circumcision (VMMC), quality of surgical technique, and the amount of time required to conduct VMMC procedures in actual field settings. Efficiency outcomes are defined in terms of the primary provider's time with the client (PPTC) and total elapsed operating time (TEOT).
Two serial cross-sectional surveys of VMMC sites were conducted in Kenya, Republic of South Africa, Tanzania and Zimbabwe in 2011 and 2012. Trained clinicians observed quality of surgical technique and timed 9 steps in the VMMC procedure. Four elements of efficiency (task-shifting, task-sharing [of suturing], rotation among multiple surgical beds, and use of electrocautery) and quality of surgical technique were assessed as explanatory variables. Mann Whitney and Kruskal Wallis tests were used in the bivariate analysis and linear regression models for the multivariate analyses to test the relationship between these five explanatory variables and two outcomes: PPTC and TEOT. The VMMC procedure TEOT and PPTC averaged 23-25 minutes and 6-15 minutes, respectively, across the four countries and two years. The data showed time savings from task-sharing in suturing and use of electrocautery in South Africa and Zimbabwe (where task-shifting is not authorized). After adjusting for confounders, results demonstrated that having a secondary provider complete suturing and use of electrocautery reduced PPTC. Factors related to TEOT varied by country and year, but task-sharing of suturing and/or electrocautery were significant in two countries. Quality of surgical technique was not significantly related to PPTC or TEOT, except for South Africa in 2012 where higher quality was associated with lower TEOT.
SYMMACS data confirm the efficiency benefits of task-sharing of suturing and use of electrocautery for decreasing TEOT. Reduced TEOT and PPTC in high volume setting did not result in decreased quality of surgical care.
本分析探讨了自愿男性医学包皮环切术（VMMC）中手术效率要素、手术技术质量与在实际现场环境中进行VMMC手术所需时间之间的关联。效率结果根据主刀医生与患者相处时间（PPTC）和总手术耗时（TEOT）来定义。
2011年和2012年在肯尼亚、南非共和国、坦桑尼亚和津巴布韦对VMMC手术点进行了两次连续横断面调查。经过培训的临床医生观察手术技术质量，并记录VMMC手术中的9个步骤的时间。评估了四项效率要素（任务转移、缝合任务分担、在多个手术床之间轮换以及使用电灼术）和手术技术质量作为解释变量。双变量分析中使用了曼-惠特尼检验和克鲁斯卡尔-沃利斯检验，多变量分析中使用线性回归模型来检验这五个解释变量与两个结果（PPTC和TEOT）之间的关系。在这四个国家和两年期间，VMMC手术的TEOT和PPTC平均分别为23 - 25分钟和6 - 15分钟。数据显示，在南非和津巴布韦（未授权任务转移的地区），缝合任务分担和使用电灼术节省了时间。在对混杂因素进行调整后，结果表明由助理医生完成缝合和使用电灼术可减少PPTC。与TEOT相关的因素因国家和年份而异，但在两个国家中缝合和/或电灼术的任务分担具有显著意义。手术技术质量与PPTC或TEOT无显著关联，但在2012年的南非，较高的质量与较低的TEOT相关。
SYMMACS数据证实了缝合任务分担和使用电灼术在降低TEOT方面的效率优势。在高手术量环境中，TEOT和PPTC的减少并未导致手术护理质量下降。
