Advertisement

World Journal of Surgery

, Volume 43, Issue 2, pp 353–359 | Cite as

Cost Analysis of the Mongolian ATLS© Program: A Framework for Low- and Middle-Income Countries

  • Jack E. Kornfeld
  • Micah G. Katz
  • James R. Cardinal
  • Batsaikhan Bat-Erdene
  • Gerelmaa Jargalsaikhan
  • Jade NunezEmail author
Original Scientific Report

Abstract

Background

Trauma is the leading cause of death among Mongolians aged 24–44. To improve initial management of injured patients, the Mongolian National University of Medical Sciences (MNUMS) implemented the American College of Surgeons’ (ACS) Advanced Trauma Life Support (ATLS) training program in 2015. Cost analysis demonstrates that such programs can have clear pathways to self-sufficiency.

Methods

Costs associated with an ACS Mongolian ATLS program were quantified based on discussions with the Mongolian government, MNUMS, ATLS Australasia headquarters, and existing pricing data. Costs were then classified as either essential or contingencies. These classifications determined budgetary items for each program. Savings projections for contingencies included training Mongolian instructors and educators. Scenarios for funding the budget were then assessed.

Results

The minimum annual cost of ATLS in Mongolia, which includes 3 ATLS student courses/1 instructor course, is $10,709. A budget of $19,900 includes additional contingencies. The scenario that involves foreign instructors is the most expensive one. An initial investment of $85,000 to train Mongolian instructors reduces annual costs by $48,305 (71% reduction). An investment of $4050 to train a Mongolian educator will reduce costs by $1750 annually. ATLS can be sustained with 0.04% of Mongolia’s current spending on public health and preventative services.

Conclusions

Initial investment to train Mongolian ATLS instructors leads to substantial savings. Training a Mongolian educator lowers long-term costs. When minimum costs for ATLS courses are understood, these can be scaled up and supported with different contingencies and minimal funding by government or third-party stakeholders.

Notes

Acknowledgements

We thank Anudari Zorigtbaatar, Hannah Pioli, Dr. Sergelen Orgoi, Dr. Raymond Price, Dr. Michael Hollands, Lesley Dunstall and Jonathan Nellermoe for expert advice and help with reviewing the manuscript. The study was funded by the Dartmouth Center for Health Equity.

Compliance with ethical standards

Conflict of interest

The authors report no conflict of interest in the publication of this manuscript.

References

  1. 1.
    World Health Organization (WHO) (2010) Mongolian STEPS survey on the prevalence of noncommunicable disease and injury risk factors 2009. WHO Libr, GenevaGoogle Scholar
  2. 2.
    Lombardo S, Unurbileg B, Gerelmaa J, Bayarbaatar L, Sarnai E, Price R (2017) Trauma system assessment in Mongolia: INTACT evaluation and recommendations for improvement. In: Academic surgical congressGoogle Scholar
  3. 3.
    Spiegel DA, Choo S, Cherian M et al (2011) Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J Surg 35:272–279.  https://doi.org/10.1007/s00268-010-0904-7 CrossRefGoogle Scholar
  4. 4.
    Amitai A, Lundeg G Emergency medicine in Mongolia. AAEM Resident and Student Association. https://www.aaem.org/UserFiles/file/julyaug06_em-mongolia.pdf
  5. 5.
    Cherian M, Noel L, Buyanjargal Y, Salik G (2004) Essential emergency surgical procedures in resource-limited facilities: a WHO workshop in Mongolia. World Hosp Heal Serv 40:24–29Google Scholar
  6. 6.
    Henry JA, Orgoi S, Govind S et al (2012) Strengthening surgical services at the Soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia. World J Surg 36:2359–2370.  https://doi.org/10.1007/s00268-012-1668-z CrossRefGoogle Scholar
  7. 7.
    Price R, Sergelen O, Unursaikhan C (2013) Improving surgical care in Mongolia: a model for sustainable development. World J Surg 37:1492–1499.  https://doi.org/10.1007/s00268-012-1763-1 CrossRefGoogle Scholar
  8. 8.
    Ali J, Naraynsingh V (1987) Potential impact of the advanced trauma life support (ATLS). Program in a Third World country. Int Surg 72:179–184Google Scholar
  9. 9.
    van Olden GDJ, Dik Meeuwis J, Bolhuis HW et al (2004) Clinical impact of advanced trauma life support. Am J Emerg Med 22:522–525.  https://doi.org/10.1016/j.ajem.2004.08.013 CrossRefGoogle Scholar
  10. 10.
    Navarro S, Montmany S, Rebasa P et al (2014) Impact of ATLS training on preventable and potentially preventable deaths. World J Surg 38:2273–2278.  https://doi.org/10.1007/S00268-014-2587-Y CrossRefGoogle Scholar
  11. 11.
    Vestrup JA, Stormorken A, Wood V (1988) Impact of advanced trauma life support training on early trauma management. Am J Surg 155:704–707CrossRefGoogle Scholar
  12. 12.
    Mohammad A, Branicki F, Abu-Zidan FM (2014) Educational and clinical impact of advanced trauma life support (ATLS) courses: a systematic review. World J Surg 38:322–329.  https://doi.org/10.1007/S00268-013-2294-0 CrossRefGoogle Scholar
  13. 13.
    Ali J, Adam R, Stedman M et al (1994) Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country. J Trauma 36:391–394CrossRefGoogle Scholar
  14. 14.
    Drimousis PG (2011) Advanced trauma life support certified physicians in a non trauma system setting: is it enough? Resuscitation 82:180–184.  https://doi.org/10.1016/j.resuscitation.2010.10.005 CrossRefGoogle Scholar
  15. 15.
    Adam R, Stedman M, Winn J et al (1994) Improving trauma care in Trinidad and Tobago. West Indian Med J 43:36–38Google Scholar
  16. 16.
    Billmann FG, Burnett C, Welke S, Bokor-Billmann T (2013) Effect of advanced trauma life support (ATLS) on the time needed for treatment in simulated mountain medicine emergencies. Wilderness Environ Med 24:407–411.  https://doi.org/10.1016/j.wem.2013.04.006 CrossRefGoogle Scholar
  17. 17.
    Jayaraman S, Sethi D, Chinnock P, Wong R (2014) Advanced trauma life support training for hospital staff. Cochrane Database Syst Rev 8:CD004173.  https://doi.org/10.1002/14651858.CD004173.pub4 Google Scholar
  18. 18.
    The American College of Surgeons (2013) Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg 74:1–392.  https://doi.org/10.1097/ta.0b013e31828b82f5 CrossRefGoogle Scholar
  19. 19.
    Ali J, Adam RU, Josa D et al (1999) Comparison of performance of interns completing the old (1993) and new interactive (1997) advanced trauma life support courses. J Trauma 46:80–86.  https://doi.org/10.1097/00005373-199901000-00013 CrossRefGoogle Scholar
  20. 20.
    Luedi MM, Wölfl CC, Wieferich K et al (2017) Teaching advanced trauma life support (ATLS): a nationwide retrospective analysis of 8202 lessons taught in Germany. J Surg Educ 74:161–166.  https://doi.org/10.1016/j.jsurg.2016.06.010 CrossRefGoogle Scholar
  21. 21.
    Milasius S (2017) Experience of implementation of standardized trauma treatment methodology advanced trauma life support courses (ATLS) in Lithuania. http://www.pitt.edu/~super1/lecture/lec21941/001.htm. Accessed 22 Nov 2017
  22. 22.
    Dredge R (2004) Hospital global bugeting. https://mpra.ub.uni-muenchen.de/38681/1/MPRA_paper_38678.pdf
  23. 23.
    Lkhagvadorj A (2012) An analysis of the new budget law of Mongolia of 2011. http://www.swiss-cooperation.admin.ch/mongolia/en/Home/Governance
  24. 24.
    Cashin C, Somanathan A (2015) Assessment of systems for paying health care providers in Mongolia: implications for equity, efficiency and universal health coverage. World Bank Group. http://documents.worldbank.org/curated/en/711891467991004186/Assessment-of-systems-for-paying-health-care-providers-in-Mongolia-implications-for-equity-efficiency-and-universal-health-coverage
  25. 25.
    Abdullah F, Troedsson H, Cherian M (2011) The world health organization program for emergency surgical, obstetric, and anesthetic care. Arch Surg 146:620.  https://doi.org/10.1001/archsurg.2011.84 CrossRefGoogle Scholar
  26. 26.
    Hipsher SA (2013) Central Asia: Afghanistan, Kazakhstan, Kyrgyz Republic, Mongolia, Tajikistan, Turkmenistan and Uzbekistan. In: The private sector’s role in poverty reduction in Asia. Elsevier, pp 227–244Google Scholar
  27. 27.
    Neumann N, Warburton D (2015) A review of the modern mongolian healthcare system. Cent Asian J Med Sci 1:16–21Google Scholar
  28. 28.
    Tsilaajav T, Ser-Od E, Baasai B, Byambaa G, Shagdarsuren O (2013) Mongolia health system review, vol 3, no 2. World Health Organization, Regional Office for the Western Pacific, ManilaGoogle Scholar
  29. 29.
    WHO (2017) Global health expenditure database. http://apps.who.int/nha/database. Accessed 22 Nov 2017
  30. 30.
    The American College of Surgeons Advanced Trauma Life Support. https://www.facs.org/quality-programs/trauma/atls. Accessed 21 Aug 2018
  31. 31.
    Abu-Zidan FM (2016) Advanced trauma life support training: how useful it is? World J Crit care Med 5:12–16.  https://doi.org/10.5492/wjccm.v5.i1.12 CrossRefGoogle Scholar
  32. 32.
    Ali J, Adam R, Stedman M et al (1994) Cognitive and attitudinal impact of the advanced trauma life support program in a developing country. J Trauma 36:695–702CrossRefGoogle Scholar
  33. 33.
    Santora TA, Trooskin SZ, Blank CA et al (1996) Video assessment of trauma response: adherence to ATLS protocols. Am J Emerg Med 14:564–569.  https://doi.org/10.1016/S0735-6757(96)90100-X CrossRefGoogle Scholar
  34. 34.
    (2017) Mongolia—mining. export.gov. https://www.export.gov/article?id=Mongolia-Mining. Accessed 22 Nov 2017

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Jack E. Kornfeld
    • 1
  • Micah G. Katz
    • 2
  • James R. Cardinal
    • 3
  • Batsaikhan Bat-Erdene
    • 4
  • Gerelmaa Jargalsaikhan
    • 4
  • Jade Nunez
    • 2
    • 5
    Email author
  1. 1.Dartmouth Medical SchoolLebanonUSA
  2. 2.Center for Global SurgeryUniversity of UtahSalt Lake CityUSA
  3. 3.School of MedicineUniversity of UtahSalt Lake CityUSA
  4. 4.Department of SurgeryMongolian National University of Medical SciencesUlaanbaatarMongolia
  5. 5.University of UtahSalt Lake CityUSA

Personalised recommendations