The Laryngoscope C 2014 The American Laryngological, V

Rhinological and Otological Society, Inc.

Global Health-Related Publications in Otolaryngology Are Increasing Kyle J. Chambers, MD; Francis Creighton, MD; Dunia Abdul-Aziz, MD; Mack Cheney, MD; Gregory W. Randolph, MD Objectives/Hypothesis: Determine trends in global health-related publication in otolaryngology. Study Design: A review of research databases. Methods: A search of publications available on PubMed and nine additional databases was undertaken reviewing two time periods 10 years apart for the timeframes 1998 to 2002 (early time period) and 2008 to 2012 (recent time period) using specific search terms to identify global health-related publications in otolaryngology. Publications were examined for region of origin, subspecialty, type of publication, and evidence of international collaboration. v2 and t test analyses were used to identify trends. Results: In the 1998 to 2002 time period, a total of 26 publications met inclusion criteria for the study, with a mean of 5.2 6 2.8 publications per year. In the 2008 to 2012 time period, a total of 61 publications met inclusion criteria, with a mean of 12.3 6 5.6 publications per year. The 235% increase in global health-related publications identified between the two study periods was statistically significant (P 5.02). The absolute number of publications in which collaboration occurred between countries increased from three in the early time period to nine the recent time period. Conclusions: There has been a significant increase in the volume of global health-related publications in English language otolaryngology journals over the past decade, providing strong evidence of the increasing trend of global health as an academic pursuit within the field of otolaryngology. Key Words: Global health, global health research, otolaryngology, international otolaryngology. Level of Evidence: NA Laryngoscope, 00:000–000, 2014

INTRODUCTION Seventy percent of the world’s population lives in low- or middle-income countries, yet only 26% of surgical procedures worldwide occur in these countries.1,2 Otolaryngologists have long been involved in global humanitarian surgical efforts to supplement patient care and training in low-resource regions without access to specialists trained in otolaryngology head and neck surgery.3–6 These efforts have mainly come in the form of short-term medical/surgical mission trips or global health initiatives, often organized by disparate nongovernmental organizations, academic institutions, and faith-based or charitable groups. Within the Academy of Otolaryngology Head and Neck Surgery, there has been significant expansion of international activities with the development of a broad-based international program,

From the Department of Otolaryngology (K.J.C., F.C., D.A.-A., M.C., Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Department of Otology and Laryngology (K.J.C., F.C., D.A.-A., M.C., G.W.R.), Harvard Medical School, Boston, Massachusetts; and the Division of Surgical Oncology, Department of Surgery (G.W.R.), Massachusetts General Hospital, Boston, Massachusetts, U.S.A. Editor’s Note: This Manuscript was accepted for publication August 5, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Kyle J. Chambers, MD, Department of Otolaryngology, 243 Charles Street, Boston, MA 02114, E-mail: [email protected] G.W.R.),

DOI: 10.1002/lary.24906

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which now includes 16 regional directors for defined global regional activities.7 Recently, in addition to continued global humanitarian efforts, there exists an increasing awareness that global otolaryngology may be evolving to become a more established academic pursuit, with an increasing focus on incorporation of global health-related and educational research in global otolaryngologic surgical activities. The term global health may be used to refer to the health of specific geographic regions, specific populations, or even specific types of diseases. More often, the term refers to an analysis of health encompassing the entire population of the world, with a focus on understanding the relationships between social and medical organizations that affect health.8 Using this definition, global health-related research in the field of otolaryngology may include descriptive research focused on heath needs, health assessment, burden of disease, or surgical capacity in low-income countries, but it may also include evaluation of broader topics such as health disparities across nation borders, geographic workforce variations, surgical volunteerism, international training and academic partnerships, the application of technology to new regions, and other endeavors.9 In otolaryngology, as in many surgical fields, there is a perception of an increasing awareness of and interest in global heath as an academic pursuit, especially as it relates to surgical education and research in delivery of care models. The purpose of this article was to assess whether there has been an increase in publications in Chambers et al.: Academic Global Otolaryngology

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TABLE I. lobal Otolaryngology Search Terms. Column A

Column B

World health, OR global health, OR developing country, OR international medicine, OR global medicine, OR tropical medicine, OR middle income country, OR low income country, OR third world, OR medical mission, OR international cooperation, OR developing world, OR medically underserved area, OR United Nations, OR World Health Organization, OR international agencies, OR unmet need

Otolaryngology, OR otorhinolaryngology, OR ENT, OR laryngology, OR otology, OR otologic, OR nose, OR nasal, OR ear, OR throat, OR paranasal sinuses, OR pharynx, OR pharyngeal, OR larynx, OR laryngeal, OR mouth, OR oral cavity, OR palatine tonsil, OR adenoid, OR trachea, OR oesophagus, OR esophagus, OR esophageal, OR audiology, OR speech, OR neurotology, OR nasopharynx, OR nasopharyngeal, OR skull, OR skull base, OR thyroid gland, OR thyroid, OR parathyroid, OR parathyroid glands, OR face, OR facial, OR neck, OR temporal bone, OR salivary glands, OR parotid glands, OR parotid, OR eustachian tube, OR acoustic, OR inner ear, OR cochlea, OR voice, OR vocal, OR hearing loss, OR hearing, OR otorhinolaryngologic disease, OR nasal surgical procedures, OR craniofacial abnormalities, OR head and neck neoplasms, OR head and neck, OR neck, OR otolaryngologic neoplasms, OR pharyngeal, OR vestibular

Search included any combination of column A and any combination of column B. For PubMed search, terms were entered both as Medical Subject Headings and title/abstract terms. ENT 5ear, nose, and throat.

the field of otolaryngology related to global health over time that may reflect an evolving interest in global otolaryngology as an academic pursuit.

MATERIALS AND METHODS This study was deemed exempt from review by the institutional review board. A search of publications related to global otolaryngology was undertaken reviewing two time periods 10 years apart for the timeframes 1998 to 2002 (early time period) and 2008 to 2012 (recent time period). A broad search was performed using international and regional databases to access a complete list of publications. The databases accessed for the search included: 1) PubMed/Medline (National Center for Biotechnology Information), 2) Embase (Elsevier), 3) African Index Medicus, 4) Literatura Latino Americana em Ci^ encias da Sa ude (LILACS), 5) IndMed, 6) BIOSIS Previews, 7) Korean Med, 8) Index Medicus for the Eastern Mediterranean Region, 9) Index Medicus for the Southeast Asian Region, and 10) Western Pacific Region Index Medicus. Search terms used are shown in Table I. Publications were limited to the English language. Animal studies were excluded. Duplicate publications or publications pertaining only to a high income country were also excluded. The publications identified by the search were

Fig. 1. Publications by year.

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reviewed, and information regarding the region of origin, region of interest, subspecialty involved, and type of article was assigned. v2 and t test analyses were used to identify trends.

RESULTS In the 1998 to 2002 time period, a total of 26 publications met inclusion criteria for the study, with a mean of 5.2 6 2.8 publications per year. In the 2008 to 2012 time period, a total of 61 publications met inclusion criteria, with a mean of 12.2 6 5.6 publications per year. The number of publications for each year is demonstrated in Figure 1. There was a 235% increase in global health-related publications identified between the early and recent time periods (P 5.02). North America was the most common region of origin for publications in both the early time period and recent time period, with seven (26.9%) and 20 (33.6%) publications, respectively (Fig. 2). North America, Western Europe, South East Asia, India, Australia, and Africa each demonstrated an increasing number of publications from the early to recent time period; however,

Fig. 2. Publications by country/region of origin.

Chambers et al.: Academic Global Otolaryngology

increase in total number from the early to recent time period, with the exception of validation studies, of which there were none identified in the recent time period (Fig. 4). There was a trend toward an increasing proportion of retrospective reviews from the early time period (7.7%) to the recent time period (21.3%) (P 5.12).

DISCUSSION

Fig. 3. Publications by subspecialty.

this finding was not statistically significant. The absolute number of publications in which collaboration occurred between countries (defined as a publication with authors from institutions in separate countries) increased from the early time period (three) to the recent time period (nine); however, no difference was identified between the proportion of collaboration in the early time period (11.5%) and the recent time period (14.8%) (P 5.69). Otology was the most common subspecialty field in the early time period, with 19 publications, and did not change significantly in the recent time period, with 17 publications (Fig. 3). Head and neck surgery, general otolaryngology, pediatric otolaryngology, and facial plastic surgery had 3, 3, 1, and 0 publications in the early time period, and 15, 18, 8, and 3 in the recent time period, respectively, with each demonstrating and absolute increase in publications between time periods. There was a trend toward increase in proportion of publications in the general otolaryngology category from the early time period (11.5%) to the recent time period (29.5%), but this was not statistically significant (p50.07). Each type of publication also saw an absolute

Fig. 4. Publications by type.

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This study demonstrates a 235% increase in global health-related publications in the field of otolaryngology within the past decade, a trend seen in similar medical specialties.10,11 The most common region of origin was North America for both the early and recent time periods. North America, Western Europe, South East Asia, India, Australia, and Africa each demonstrated an increasing number of publications from the early to recent time period. Among subspecialties, the number of otology publications saw a slight decrease from the early to recent time periods. General otolaryngology, head and neck, laryngology, facial plastics, and pediatric otolaryngology each saw increases in publications over time. Additionally, there was a three-fold increase in the number of publications with authors working across nation borders in collaboration; however, the overall proportion of collaborative projects remained unchanged at roughly 15% of the early to recent time period publications. In the United States and in other high-income countries, academic institutions are partnering more and more with institutions in low- and middle-income countries in surgical fields to develop collaborative training programs and research partnerships in surgical specialties.12,13 These partnerships can improve access and quality of care, decrease the disparities in access to surgical care, and strengthen health systems.12,14 There has also been a call in the field of otolaryngology for building collaborative research and training programs across nation borders that can be mutually beneficial,15 a notion the authors of this article fully support. The findings in our study suggest these programs are resulting in increasing academic productivity. As global health-related research becomes more widespread within otolaryngology, there will be a need to determine what type of research questions to prioritize. Some have argued that the most pressing questions relate to the global burden of surgical disease, the ability of surgical treatment to prevent disability and death, and the best strategies for improving surgical care in settings of limited resources.16 For research carried out in resource-poor settings, ethical considerations to ensure that the research is both responsive to the health needs of that community and a priority set by the community is paramount.11,17 Although this study evaluated published research, the findings may reflect a larger trend toward global otolaryngology increasingly becoming an academic pursuit. As further evidence, many residency training programs have developed opportunities for residents to work internationally. In one recent survey, 25% of US otolaryngology residency programs were found to participate in global health volunteer projects.18 Global health Chambers et al.: Academic Global Otolaryngology

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initiatives and electives have also become available for many Canadian otolaryngology residents.19 These opportunities to work abroad have in part been driven by the growing interest of medical students and residents. One recent survey of medical students entering otolaryngology found 93% of respondents with “strong” or “very strong” interest in international electives.20 Recently, the Academy of Otolaryngology Head and Neck Surgery has developed a Global Resident Exchange Program, whereby five international and five US-based otolaryngology residency programs have entered into a collaborative agreement for resident exchange and training. A recent comprehensive survey among general surgery residents, a group thought to be comparable, found a similar 94% of respondents interested in an international elective.21 Several medical and surgical specialties have also begun to explore developing academic global health subspecialties.12,22 Most notably, several authors in the field of general surgery have promoted the development an academic track in global surgery.13,23 Additionally, general surgeons at several academic centers have negotiated time and salary support for academic positions, with global surgery as a major component of their job description.24 Finally, several global surgery fellowship positions have also been created for surgical trainees at well-known academic institutions as a way to foster academic success within global surgery.10,13 Whether the development of a similar academic track in global otolaryngology will occur is unknown; however, the authors of this article would support such a development as a way to accommodate the growing interest among future otolaryngologists and to better grow and define the field. An academic track for otolaryngology may involve a number of different components either built into residency or as a separate fellowship, some of which may include formal coursework in global health already in existence at many institutions, faculty mentorship, collaborative experiences with institutions abroad, and research projects within the field. To our knowledge, although such an academic track does not yet exist for global otolaryngology, several steps have been taken in this direction at several institutions. The Massachusetts Eye and Ear Infirmary, for example, has recently established an Office of Global Surgery, with a mission to support global outreach and academic collaboration in otolaryngology and ophthalmology. Other academic institutions have well-established centers for global health that appear to be increasingly collaborating with otolaryngologists as well; however, limited information is currently published regarding the extent and effectiveness of academic collaborations in global otolaryngology through these centers.

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CONCLUSION There has been a significantly increased volume of global health-related publications in otolaryngology journals over the past decade, providing evidence of the increasing trend of global health as an academic pursuit within otolaryngology.

BIBLIOGRAPHY 1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet 2008;372:139–144. 2. Tollefson TT, Larrabee WF. Global surgical initiatives to reduce the surgical burden of disease. JAMA 2012;307:667–668. 3. Boon DA. Medical adventure in Nepal. J Otolaryngol 1980;9:526–533. 4. Parson DS, Mair EA. Volunteer otolaryngology practice in rural Mexico. Int J Pediatr Otorhinolaryngol 1991;22:19–27. 5. Pham AM, Tollefson TT. Cleft deformities in Zimbabwe, Africa: socioeconomic factors, epidemiology, and surgical reconstruction. Arch Facial Plast Surg 2007;9:385–391. 6. Crockett DJ. Operation Restore Hope: Cebu, Philippines. AAO-HNS Bull 2013;32:47. 7. International Steering Committee (including regional advisors). AAO-HNS Bull 2014;33:42. 8. Frenk J, Moon S. Governance challenges in global health. N Engl J Med 2013;368:936–942. 9. Fagan JJ, Jacobs M. Survey of ENT services in Africa: need for a comprehensive intervention. Glob Health Action 2009;19:2–4. 10. Finlayson S. How should surgeons respond to enthusiasts of global surgery? Surgery 2013;153:871–872. 11. Lavery JV, Green SK, Bandewar SV, et al. Addressing ethical, social, and cultural issues in global health research. PLoS Negl Trop Dis 2013;7: e2227. 12. Riviello R, Ozgediz D, Hsia R, Azzie G, Newton M, Tarpley J. Role of collaborative academic partnerships in surgical training, education, and provision. World J Surg 2010;34:459–465. 13. Farmer PE, Meara JG. Commentary: the agenda for academic excellence in “global” surgery. Surgery 2013;153:321–322. 14. Ozgediz D, Wang J, Jayaraman S, et al. Surgical training in global health: initial results of a 5-year partnership with a surgical training program in a low-income country. Arch Surg 2008;143:860–865. 15. Aswani J, Baidoo K, Otiti J. Establishing a head and neck unit in a developing country. J Laryngol Otol 2012;126:552–555. 16. Bickter SW, Spiegel DA. Global surgery—defining a research agenda. Lancet 2008;372:90–92. 17. Lairumbi GM, Michael P, Fitzpatrick R, English M. Ethics in practice: the state of the debate on promoting the social value of global health research in resource poor settings particularly Africa. BMC Med Ethics 2011;12:22. 18. Volsky, PG, Sinacori, JT. Global health initiatives of US otolaryngology residency programs: 2011 global health initiatives surgery results. Laryngoscope 2012;122:2422–2427. 19. Javidnia H, McLean, L. Global health initiatives and electives: a survey of interest among canadian otolaryngology residents. J Otolaryngol Head Neck Surg 2011;40:81–85. 20. Boyd NH, Cruz RM. The importance of international medical rotations in selection of an otolaryngology residency. J Grad Med Educ 2011:414– 416. 21. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg 2009;208:304– 312. 22. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008;32:533–536. 23. Calland JF, Petroze RT, Abelson J, Kraus E. Engaging academic surgery in global health: Challenges and opportunities in the development of an academic track in global surgery. Surgery 2013;153:316–320. 24. Tarpley JL. Commentary: an academic track in global surgery. Surgery 2013;153:322–324.

Chambers et al.: Academic Global Otolaryngology

Global health-related publications in otolaryngology are increasing.

Determine trends in global health-related publication in otolaryngology...
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