- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Hamilton, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Hamilton, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Department of Neurosurgery, AIC Kijabe Hospital, Kijabe, Kenya
- University of Wisconsin Health Center, Wisconsin, USA
- The Greg Wilkins-Barrick Chair in International Surgery, Canada
Division of Neurosurgery, Toronto Western Hospital, University Health Network, Hamilton, Canada
Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Hamilton, Canada
The Greg Wilkins-Barrick Chair in International Surgery, Canada
DOI:10.4103/2152-7806.152141Copyright: © 2015 Mansouri A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Mansouri A, Chan V, Njaramba V, Cadotte DW, Albright AL, Bernstein M. Sources of delayed provision of neurosurgical care in a rural kenyan setting. Surg Neurol Int 25-Feb-2015;6:32
How to cite this URL: Mansouri A, Chan V, Njaramba V, Cadotte DW, Albright AL, Bernstein M. Sources of delayed provision of neurosurgical care in a rural kenyan setting. Surg Neurol Int 25-Feb-2015;6:32. Available from: http://sni.wpengine.com/surgicalint_articles/sources-of-delayed-provision-of-neurosurgical-care-in-a-rural-kenyan-setting/
Background:Delay to neurosurgical care can result in significant morbidity and mortality. In this study, we aim to identify and quantify the sources of delay to neurosurgical consultation and care at a rural setting in Kenya.
Methods:A mixed-methods, cross-sectional analysis of all patients admitted to the neurosurgical department at Kijabe Hospital (KH) was conducted: A retrospective analysis of admissions from October 1 to December 31, 2013 and a prospective analysis from June 2 to June 20, 2014. Sources of delay were categorized and quantified. The Kruskal–Wallis test was used to identify an overall significant difference among diagnoses. The Mann–Whitney U test was used for pairwise comparisons within groups; the Bonferroni correction was applied to the alpha level of significance (0.05) according to the number of comparisons conducted. IBM SPSS version 22.0 (SPSS, Chicago, IL) was used for statistical analyses.
Results:A total of 332 admissions were reviewed (237 retrospective, 95 prospective). The majority was pediatric admissions (median age: 3 months). Hydrocephalus (35%) and neural tube defects (NTDs; 27%) were most common. At least one source of delay was identified in 192 cases (58%); 39 (12%) were affected by multiple sources. Delay in primary care (PCPs), in isolation or combined with other sources, comprised 137 of total (71%); misdiagnosis or incorrect management comprised 46 (34%) of these. Finances contributed to delays in 25 of 95 prospective cases. At a median delay of 49 and 200.5 days, the diagnoses of hydrocephalus and tumors were associated with a significantly longer delay compared with NTDs (P
Conclusion:A substantial proportion of patients experienced delays in procuring pediatric neurosurgical care. Improvement in PCP knowledge base, implementation of a triage and referral process, and development of community-based funding strategies can potentially reduce these delays.
Keywords: Delay, developing nations, neurosurgery, outcome, rural
Although the provision of medical care in Sub-Saharan Africa has improved significantly in the past few decades, there remain significant deficiencies with regard to accessibility of care, resulting in potentially serious and irreversible consequences for patients.[
While consequences of delay pertain to virtually all medical specialties, the field of neurosurgery is particularly time-sensitive and minutes to hours may mean the difference between life and death and/or disability. Access to timely neurosurgical care is problematic in many low and middle-income nations but few studies have been devoted to its characterization and quantification.[
The dearth of access to neurosurgical care in Sub-Saharan nations such as Kenya is a serious issue. In Kenya, there is one neurosurgeon for every 3.2 million residents; for comparison, there is 1 per 60,000 in the United States.[
In this cross-sectional study, a combination of a retrospective and prospective chart review analysis of patient admissions was undertaken. For the retrospective component, an arbitrary time frame of October–December, 2013 was selected. This was based on prior knowledge regarding the average volume of admissions to the neurosurgical department at KH. For the prospective component, admissions during an arbitrary time frame of June 2–20, 2014 were recorded and analyzed. Prior admissions for the same patient (applicable to the retrospective part of the study) were also collected and analyzed. These repeat admissions were not used in the calculation of distances travelled by patients.
Demographic information, details with regard to presenting pathology, and management timing and strategy were recorded. Categories of pathologies managed were as follows: Hydrocephalus – or procedures related to its management – (HCP); isolated neural tube defects (NTD); combined HCP + NTD; tumor; trauma; infections; and other miscellaneous categories (e.g. scalp lesions).
With regard to the identification and quantification of sources of delay, the following time periods were recorded (median values):
Time Frame #1: Time period between recognition of symptoms to seeking medical attention (days) [prehospital delay] Time Frame #2: Time period between seeking medical attention to neurosurgical consultation (days) [delay at primary care] Time Frame #3: Time to procurement of neurosurgical care upon admission (or diagnosis in cases where conservative/medical management was selected) (days) [neurosurgical in-service delay] Time Frame #4: Length of stay (days).
Time Frame #1: Time period between recognition of symptoms to seeking medical attention (days) [prehospital delay]
Time Frame #2: Time period between seeking medical attention to neurosurgical consultation (days) [delay at primary care]
Time Frame #3: Time to procurement of neurosurgical care upon admission (or diagnosis in cases where conservative/medical management was selected) (days) [neurosurgical in-service delay]
Time Frame #4: Length of stay (days).
In cases where the chart data were not clear with regard to time frame #1 (prehospital delay), this field was left blank. Accurate documentation of these time frames was limited by the values entered on the initial consultation upon admission to KH.
In the prospective component of the investigation, a more comprehensive assessment of the patient's social and medical history was attained. As a result, additional information such as method (s) of travel and data regarding time of travel from the patient's initial starting point to KH were recorded.
Data regarding the causes of delay to KH and subsequent disposition were categorized as follows:
Source #1: Patient/caregiver-related factors such as lack of recognition of symptoms Source #2: Financial issues – delay in seeking medical attention in order to gather finances Source #3: Medical-related factors such as a misdiagnosis, incorrect management of the correct diagnosis, or the limited availability of resources at outside institutions Source #4: Delays in the provision of neurosurgical care (e.g., availability of operating room time).
Source #1: Patient/caregiver-related factors such as lack of recognition of symptoms
Source #2: Financial issues – delay in seeking medical attention in order to gather finances
Source #3: Medical-related factors such as a misdiagnosis, incorrect management of the correct diagnosis, or the limited availability of resources at outside institutions
Source #4: Delays in the provision of neurosurgical care (e.g., availability of operating room time).
In cases of difficulty determining whether a time period would be classified as a source of delay, discussions were held between authors to reach a resolution. For example, if the parents of a child born at home noticed a myelomeningocele at birth but sought medical attention 2–3 days later, this was considered a Source #1 delay. Meanwhile, a prolonged admission to the local hospital for the management of sepsis in a patient with a nonleaking myelomeningocele was not considered as a source of delay. A Source #4 delay would be a case in which the delay to procurement of neurosurgical care was attributed to resource limitations (e.g. OR time) or a delay in diagnosis.
Average distances from KH were estimated based on the patient's city/town of origin and Google Maps™.
Description of center
KH is situated in Kijabe, a small town located just over an hour by road north-west of Nairobi, Kenya. The neurosurgical department at the center has been developed only recently and is headed by an American academic neurosurgeon formerly practicing in the United States (ALA). It currently offers neurosurgical care primarily to the pediatric patients from various locations across Kenya and some neighboring countries. Adult neurosurgical care is provided on an emergent or a limited elective basis.
All patients admitted to the neurosurgical department at KH (adult or pediatric), within the selected time intervals, and regardless of whether operative or medical/conservative intervention was selected.
Descriptive statistics were used for assessment of demographics and epidemiology of pathologies. The Kruskal–Wallis test for nonparametric variables was used to determine whether an overall significant difference with regard to the amount of delay was present among the various diagnoses. Should this be the case, the Mann–Whitney U test would be used as a post-hoc test to conduct pairwise comparisons within groups. Based on the availability of prior data regarding the extent of delay with congenital anomalies and intracranial tumors (adults),[
This study was approved by the Institutional Research Ethics Board at KH.
As part of the retrospective component of this study, a total of 197 patient charts were obtained by the health records department at KH. Nine charts did not belong to neurosurgical patients and were erroneously selected, resulting in 188 charts available for review. Thirty-one patients admitted during this 3-month period had been previously admitted to KH; inclusion of these records yielded an additional 49 records for a total of 237 admissions. A total of 95 admissions over a period of 3 weeks (June 2–20, 2014) were available for analysis in the prospective segment of the study.
Patient demographics, both in the retrospective and prospective segments of the study, have been summarized in
From the retrospective component of the study, documentation of the length of time for Frame #1 (prehospital delay) was not available in 130 of the admission records, which affected the estimations for both Frame #1 and Frame #2 (delay at primary care). Similarly, it was not possible to accurately determine whether financial barriers or means of transportation contributed to the delay in presentation from this retrospective component of the study (
A total of seven cases (2%) were affected by delay secondary to factors influenced by the neurosurgical service affecting the time to the procurement of neurosurgical care [
Combining the data from the two components of the study, it was found that patients experiencing the longest period of delay were primarily those with CNS tumors, followed by HCP [
This cross-sectional, mixed-methods study is the first of its kind to be conducted with the purpose of assessing and quantifying the sources of delay to the provision of primarily pediatric neurosurgical care with a broad range of presenting pathologies in the developing world. While the focal point of this study was based in KH, the principal findings of this study may be applicable to the needs of other rural neurosurgical centers as well. Strengthened by the relatively large sample size analyzed, we have identified areas of deficiency in the regional healthcare and local administrative system, which can be improved in order to decrease delay and improve the delivery of patient care.
Seldom were patients admitted on an elective basis at KH. This not only reflects the urgent nature of neurosurgical pathologies but also the fact that many out of hospital cases are not recognized in time and present at an advanced stage of the pathology. The majority of admissions (76%) were attributable to HCP and NTDs. In a prospective study conducted during the year 2005 at a neurosurgical center in Ikeja, Nigeria, 64% of the pediatric patients were found to be affected by congenital anomalies.[
Although previous epidemiological studies assessing the burden of surgical disease in developing nations have found trauma to be one of the most common reasons for admission,[
While a great proportion of delays were attributable to patients/parents not recognizing the signs and symptoms of the pathology, delays faced within the health care system represented the highest incidence and time quantity within our study. This is in contrast to our original hypothesis and the findings of the study by Idowu and Apemiye in which patient-related matters contributed to 62% of the delays.[
In seeking medical attention, possible factors for delay include lack of patient awareness about signs and symptoms, geographical accessibility, and resource-related barriers.[
The cost of transportation and hospitalization are a major deterrent for patients.[
Many cases of HCP or malignancy were wrongfully diagnosed and managed as infectious diseases such as malaria, typhoid, and brucellosis. This was reflected in the significantly prolonged period of delay in presentation of patients with these diagnoses compared with NTD. Furthermore, several cases were noted in which a patient with a myelomeningocele was managed at the outside institution with daily dressing changes with no definitive intervention planned. While inadequate knowledge on behalf of the local physicians regarding the pathology is a likely factor,[
The role of nongovernmental organizations as the missing link
The importance of nongovernmental organizations (NGOs) in developing nations cannot be underestimated. The mandate of most NGOs is typically focused on a specific field within a specific cohort of the community. Successful NGOs possess proficiency of knowledge and/or technical expertise in their field of focus, along with a good rapport with the community they serve.[
As an adjunct to the aforementioned community-based measures of financial support, NGOs can participate in fundraising activities and coordinating medical insurance foundations serving the local community.[
This study was limited by several factors that prevented a comprehensive quantification and analysis of factors resulting in delay. The subjective nature of classifying cases of delay introduces a source of bias. The retrospective component of the study was in some cases limited by inaccurate chart retrieval and inconsistent documentation of history. These deficiencies have been previously identified as substantial barriers to instituting standardized measures of success in developing nations, which prevent progress at the institution and in the field in general.[
With these limitations considered, the current study represents the first of its kind to assess and quantify the sources of delay to the provision of primarily pediatric neurosurgical care, assessing a variety of diagnoses, in a high-volume rural setting in the developing world. In addition, we have also identified and analyzed various cultural, academic, infrastructural, and administrative factors that contribute to the overall delay to care. Furthermore, we have provided an outline of steps that can be taken to improve upon these issues. Future prospective studies, conducted over a longer time period and sampling neurosurgical settings from a diverse set of developing nations, would assist in better identifying and quantifying additional sources of delay; findings from such multi-centric studies would be of particular value given their improved external validity. Studies such as the current one help initiate the drive toward devising strategies that can be used to decrease delays in a field in which time is of the essence. A strong and ethically sound partnership between NGOs, government organizations, and corporate sponsors can provide the means necessary for the development and success of initiatives aimed at reducing these delays.
Public health outreach efforts, particularly targeting rural regions, need to be expanded as preventative strategies for some of the most common pediatric nervous system disorders. Such efforts would include education about the importance of folic acid and its cost-free distribution within local governmental health centers Community-based strategies can be effective means of addressing many financial and logistic issues with regard to accessing timely medical care; these need to be explored and developed further Formal triage guidelines and referral protocols are needed, both at the local hospital level and at the level of the ministry of health, in order to create a safer and more efficient strategy that would ensure access to timely medical care for all patients Strategies aimed at improving data collection and storage are necessary to increase the efficiency of the work flow and to enable self-evaluation and improvements by hospitals A transparent and ethical collaboration between NGOs, governmental organizations, and corporate partners has great potential for advancing these efforts.
Public health outreach efforts, particularly targeting rural regions, need to be expanded as preventative strategies for some of the most common pediatric nervous system disorders. Such efforts would include education about the importance of folic acid and its cost-free distribution within local governmental health centers
Community-based strategies can be effective means of addressing many financial and logistic issues with regard to accessing timely medical care; these need to be explored and developed further
Formal triage guidelines and referral protocols are needed, both at the local hospital level and at the level of the ministry of health, in order to create a safer and more efficient strategy that would ensure access to timely medical care for all patients
Strategies aimed at improving data collection and storage are necessary to increase the efficiency of the work flow and to enable self-evaluation and improvements by hospitals
A transparent and ethical collaboration between NGOs, governmental organizations, and corporate partners has great potential for advancing these efforts.
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