Doing More With LessPediatric Neurosurgical Outcomes Following a Neurosurgery Health System Intervention at Mulago National Referral Hospital in Uganda
Introduction
Pediatric global health, including the millennium development goals aimed at children, has predominantly focused on issues such as infectious diseases, premature births, and nutrition.1, 2 Surgical conditions, including neurosurgical conditions, largely have not been a major factor in global health efforts; however, an estimated 85% of children will have a surgically treatable condition by the age of 15 years.3 The landmark The Lancet study on global surgery showed that surgical conditions significantly contribute to the global burden of disease in low-income and middle-income countries (LMICs) and that treating these conditions can be just as, if not more, cost-effective than traditional public health programs, such as immunizations and other interventions considered part of a global health regiment.3, 4, 5 Hence, improving surgical care access and quality of care received is a critical component to improve the health of persons in resource-poor settings.
Pediatric neurosurgical cases have been identified as an important target for impacting health disparities in Uganda, with over 50% of the population being less than 15 years of age.6, 7 The most common type of pediatric neurosurgical case is hydrocephalus, with approximately 80,000–375,000 new cases each year in Sub-Saharan Africa.8 Although CURE Hospital in Uganda specializes in pediatric neurosurgical needs and has made significant progress in developing accessible and affordable treatments for hydrocephalus8, 9, 10 and treating complex pediatric brain tumor cases and other neurosurgical conditions,11, 12, 13, 14 the demand for pediatric neurosurgical treatment far outweighs CURE Hospital's capacity of approximately 1000 cases per year.7 Furthermore, surgeries at CURE Hospital are only accessible to those within a limited catchment area in Uganda, therefore, it is essential for more hospitals to be able to provide critical neurosurgical care for the large pediatric population.
Despite the need for pediatric neurosurgical care, there were only 5 neurosurgeons to serve Uganda's population of 30 million individuals in 2009,15 and even national referral and regional hospitals lack adequate equipment that would allow these neurosurgeons to deliver standard neurosurgical care.16
To overcome the lack of neurosurgeons within Uganda, the Duke University Medical Center and the Duke Global Health Institute established a program, the Duke-Mulago collaboration, in 2007 at Mulago National Referral Hospital in Kampala, Uganda, to address the neurosurgical need with a 2-pronged approach: 1) providing essential equipment to provide basic neurosurgical services, and 2) expanding the neurosurgical training through a twinning approach. In this twinning approach, a multidisciplinary team from Duke University, which included neurosurgeons, anesthesiologists, nurses, biomedical engineers, Certified Registered Nurse Anesthetists, and other health care workers, were paired with their Ugandan counterparts to impart new skills and share best practices during training camps.17 Outcomes data from the pre- and postprogram initiative have shown that this program increased both the number and complexity of cases in Mulago National Referral Hospital.18 However, an analysis focusing on the pediatric patient population at Mulago National Referral Hospital has not been conducted.
Given the large pediatric population in Uganda, it is imperative to understand the effects of this program on pediatric cases. These outcomes data would not only enable us to understand the quality of care patients are receiving, but it would also inform future measures for improving the program. Furthermore, this information would provide insight into the feasibility and efficacy of implementing this program in other hospitals in developing countries. Therefore, the objective of this study was to evaluate the effects of the Duke-Mulago collaboration on pediatric neurosurgical outcomes in Mulago National Referral Hospital.
Section snippets
Setting
Mulago National Referral Hospital serves as a national referral hospital and teaching hospital for Uganda and provides medical care to the largest catchment area of Kampala, the capital city (i.e., 1.5 million people). Likewise, Mulago National Referral Hospital provides the most comprehensive specialty services in the country, and nearly all patients with neurosurgical needs are referred to the hospital for care. Because of the high volume of referrals, limited infrastructure, and human
Overall Descriptive Results
In Mulago National Referral Hospital between FY 2005 and FY 2013, there were 1878 neurosurgical procedures performed, 820 (43.7%) were among children less than 18 years of age. Of the 820 children, outcome data were complete for 374 children. Of the 374 children, 29 died within 30 days, 18 died after 30 days, and 327 were discharged from the hospital. Outcome status by age group was significantly different (P = 0.01). Among children who died within 30 days of a surgical procedure, 45% were less
Discussion
Hospital outcomes of mortality or being discharged after a neurosurgical procedure among pediatric patients differed by age group, length of stay after surgery, and pre- and postprogram periods. Significant predictors of mortality included age and diagnosis type on admission, which were driven mainly be increased treatment of pediatric trauma. Clearly, treating pediatric patients with neurosurgical needs is a complex problem that may differ by the age and condition of the child.
Conclusions
Pediatric surgery in Sub-Saharan Africa is increasingly being recognized as an important public health problem and contributor to the overall global burden of disease. Although this awareness is encouraging, performing more surgeries or providing a higher level of complexity regarding pediatric surgeries alone is not the answer. As our data show, the provision of more complex neurological procedures does not necessitate improved outcomes. Rather, combining these higher-level procedures with
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Conflict of interest statement: Funding was provided by the Duke Global Health Institute.