Low cost quality initiatives for management of neurosurgical patients in developing nations: Perspective from a tertiary care centre in Pakistan
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
Muhammad S. Shamim
Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
DOI:10.4103/sni.sni_352_16Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Hamid H. Rai, Muhammad Waqas, Muhammad S. Shamim. Low cost quality initiatives for management of neurosurgical patients in developing nations: Perspective from a tertiary care centre in Pakistan. 14-Mar-2017;8:35
How to cite this URL: Hamid H. Rai, Muhammad Waqas, Muhammad S. Shamim. Low cost quality initiatives for management of neurosurgical patients in developing nations: Perspective from a tertiary care centre in Pakistan. 14-Mar-2017;8:35. Available from: http://surgicalneurologyint.com/surgicalint_articles/low-cost-quality-initiatives-for-management-of-neurosurgical-patients-in-developing-nations-perspective-from-a-tertiary-care-centre-in-pakistan/
Background:Targeting resources on cost-effective care strategies is pertinent for developing nations, specifically for already burdened specialties such as neurosurgery, where without state support and insurance companies, expenses are borne by the patient themselves.
Methods:This was a descriptive review of literary work published by the section of neurosurgery at Aga Khan University Hospital, Pakistan. We searched PubMed and CiNAHL databases to identify articles, which were then critically analyzed and discussed from a perspective of low-cost quality care.
Results:We demonstrate the cost effectiveness of three initiatives, namely, blood ordering protocol for elective spine arthrodesis, nonoperative management being superior to surgical stabilization in spine injury patients with complete neurological deficits, and early tracheostomy in patients with isolated severe traumatic brain injury.
Conclusion:Initiation and implementation of such cost-effective strategies without compromising quality health standards must be emphasized by neurosurgical centers throughout the developing world for smart allocation and utilization of funds.
Keywords: Blood transfusion protocol, cost effectiveness, early tracheostomy, spinal cord injury
With a per capita income of PKR 153,060 (2015), Pakistan is classified by the World Health Organization as a low middle-income country. Cost is a serious consideration for our patients, especially in the private health sector, where without state support and insurance companies, expenses are borne by the patients themselves.[
We searched PubMed and CiNAHL databases for articles published by the department of neurosurgery at Aga Khan University Hospital, Pakistan. The terms “Aga Khan University Hospital,” “Neurosurgery,” or “Research” were used to run search on two separate occasions, i.e., 8 May and 20 May 2016. We selected all the articles in which the studies were carried out at the Aga Khan University Hospital, irrespective of date of publication. The articles were then critically analyzed and discussed from a perspective of low cost quality care, with reference to the available international literature.
The prospective validation of blood ordering protocol was a cross-sectional study conducted during the year 2012. All adult patients who underwent elective spinal arthrodesis were included and prospectively observed. The actual transfusion index was calculated for individual patients with the formula C1/T, where C1 is the number of units of packed red blood cells (RBCs) cross matched and T is the number of actual transfusions. C1/T was then compared with a theoretical transfusion index C2/T for the same group of patients; C2 being the number derived from calculating the number of units of packed RBCs that would have been ordered for individual patient according to the protocol. The cost difference between C1/T and C2/T was analyzed.
A detailed retrospective analysis of all patients admitted from 2004 to 2010 with “complete injury,” i.e., patients with either complete spinal cord injury (SCI) or complete deficits following traumatic spine injury presenting within 14 days of injury were included. Complete SCI was defined as patients having no motor or sensory function below the neurological level, no preserved function in sacral segments S4-S5, and confirmed on the basis of MRI of affected region showing complete disruption of the spinal canal. Included patients were divided into two groups, those who underwent stabilization procedures and those who were managed nonoperatively. Both groups were compared with the outcome parameters being time to rehabilitation, length of hospital stay, 30-day morbidity/mortality, cost of treatment, and status at follow-up. Rehabilitation was defined as mobilization from bed up to the chair or wheelchair, and status at follow-up was measured in terms of axial pain or mobilization at follow-up.
Patients with isolated severe traumatic brain injury (TBI), defined as a Glasgow Coma Scale (GCS) score <8, requiring airway control and ventilation were included in a 7-year review. Early tracheostomy (ET) was defined as tracheostomy within 7 days of TBI, and prolonged endotracheal intubation (EI) as EI exceeding 7 days of TBI. All patients were comparable in terms of age and initial GCS, and both groups were evaluated regarding clinical outcome in terms of ventilator-associated pneumonia (VAP), intensive care unit (ICU) stay, and Glasgow Outcome Scale (GOS).
A total of 125 patients were included for the blood ordering protocol and a total of 435 units of packed RBCs were ordered (C1), out of which only 108 units were transfused (T), yielding a C1/T of 4.02. The C2 for the same group of patients was 188 units of packed RBCs, and the C2/T was thus calculated to be 1.74. Implementation of the protocol would reduce per patient cost from Pakistani Rupees (PKR) 6676.8 ± 4125.8 to 4700.8 ± 1712.86 (P < 0.001), with an overall cost reduction of 30%.
Fifty-four patients fulfilled the inclusion criteria for complete SCI, and half of these patients were operated. On comparing endpoints, patients in the operative group took longer time to rehabilitation (P = 0.002); had longer hospital stay (P = 0.006), which included longer length of stay in special care unit (P = 0.002) as well as intensive care unit (P = 0.004); and were associated with more complications, especially those related to infections (P = 0.0027). The mean cost of treatment was also significantly higher in the operative group, being USD 6500 compared to that of the nonoperative group of USD 1490 (P < 0.001).
Of the 100 patients with severe TBI, 49 underwent ET and 51 remained on prolonged EI for ventilation. Evaluation of both the groups regarding clinical outcome in terms of VAP showed higher frequency in the EI group relative to the ET group (63% vs. 45%; P = 0.09). ET group showed significantly less ventilator days (10 days vs. 13 days; P = 0.031), ICU stay (11 days vs. 13 days; P = 0.030), complication rate (14% vs. 18%), and mortality (8.2% vs. 17.6%). Clinical outcome assessed on the basis of GOS was also better in the ET group, and most importantly, total inpatient cost of USD 8027 in the ET group was considerably less compared with USD 9961 of the EI group.
With innovations regarding the safety and efficacy of spinal arthrodesis, the number of complex reconstructive fusion procedures is increasing.[
Surgical stabilization of patients with “complete” SCI is a common procedure in most spine centers of the world, despite the deficits being irreversible.[
ET has shown to provide a relatively stable and well-tolerated airway, with access for good pulmonary toilet, making oral feeding possible, permitting early ambulation, and in turn preventing orthostatic and ventilator-associated pneumonia (VAP).[
For low-middle income developing countries such as Pakistan, where without state support and insurance companies, expenses are borne by the patient themselves, especially in the private sector. Low cost initiatives without compromising health quality, as discussed, must be sought after by neurosurgical centers in developing countries, where financial and manpower constraints emphasize the need for implementation of smartly allocating funds.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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