This publication describes the development, piloting, and construction validation of the GAPS, an evidence-based pediatric surgical CAT designed for low-resource settings. A systematic review, published by our group, describing existing CATs and surgical resource guidelines [12] served as the basis for the development of GAPS. A 37-person multidisciplinary expert panel collaborated to establish consensus about the data items in the tool.
The development of GAPS was an intensive endeavor, highlighting the complexities associated with research in low-resources settings. The OU and AC sections in the piloted GAPS Version 2 garnered a limited response rate, likely attributable to the persistent challenges in data collection inherent to research in the developing world [18, 19]. Low- and middle-income countries often lack the infrastructure for consistent outcome reporting, complicating proof of intervention for quality improvement [20, 21]. Outcome reporting in HICs is often burdensome due to the multitude of variables in data collection tools such as the American College ofSurgeons National Surgical Quality Improvement Program (ACS NSQIP) with over 130 variables. Dimick demonstrated that five variables sufficiently risk-adjust procedure-specific quality measures for core general surgery operations [22]. Subsequently, Ullrich identified a minimal dataset for predicting pediatric surgical perioperative mortality in low-resource settings [19].
Comparatively, ED was the section most successful at discriminating between levels of surgical care. Unlike outcomes, there is an aspect of positive validation that accompanies the presence of training programs and external collaborations that may lead to a reporting bias [23, 24]. Historically, individual partnerships between low and high resource institutions have been the most common method of furthering the quality of care and access to surgical services [25]. The global focus on enhancing medical education may accentuate the disparity in educational resources between basic and advanced care settings, potentially introducing reporting bias due to the direct observation and reporting of educational activities.
As described, GAPS successfully discerns between levels of surgical care, the first CAT tool of its kind to do so. Complex data does not necessarily translate to granularity and can come at the expense of utility [26]. There exist simplified models for robust scoring systems and quality-outcome databases such as the American Society of Anesthesiologists scoring system and the ACS NSQIP respectively [26, 27]. To facilitate and streamline the use of GAPS, we abridged GAPS to include only itemsthat significantly discriminated between levels of care (GAPS Version 3; Appendix C). The GRM IRT further supports the choice of items in GAPS Version 3.
Though GAPS is a step forward in the development of an all-encompassing evidence-based CAT, it is not without its limitations. The pilot study and validation were confined to a narrow set of countries, with a significant emphasis on the DRC, due to availability of local advocates and our operational reach. Despite these constraints, the diversity of participating countries and income levels suggests our results have a broad applicability. Perhaps the most important limitations of GAPS is that assessment of internal consistency of responses were not feasible. Furthermore, as suggested by Stewart et al, previous assessments of surgical capacity have not translated to surgical output[28]. However, Stewart et al’s study, focused on 25 essential surgical resources as proxies for broader surgical capacity, primarily emphasizing material resources [28]. We concur that traditional measures of surgical capacity, focusing on material resources, are insufficient surrogates for surgical output. Consequently, in devising the GAPS tool, we incorporated elements beyond material resources. The integration of further capacity metrics – human resources, accessibility, outcomes, and education – in GAPS represents our effort to transcend an inventory approach. However, though GAPS may be more comprehensive, its ability to directly measure surgical output remains untested. Accurately measuring surgical output necessitates a comprehensive evaluation of surgical procedures and their respective outcomes, a topic that extends beyond the scope of this current paper. This limitation reflects a crucial area for future investigations. Nevertheless, it is essential to initially address factors such as human and material resources, accessibility, education, and basic outcomes to create a foundation for objectively evaluating surgical output. Our hope is that GAPS will serve as a valuable tool in future research aimed at assessing surgical output in addition to surgical capacity.