Epidemiology and Characteristics of Neurosurgical Conditions at Mbarara Regional Referral Hospital

doi:10.1016/j.wneu.2017.03.019

World Neurosurgery

Volume 102, June 2017, Pages 526-532

https://doi.org/10.1016/j.wneu.2017.03.019 Get rights and content

Background

The unmet surgical need, specifically neurosurgical need, in Uganda is significant, yet only 2 public hospitals currently perform neurosurgery in the country. This study examines the epidemiology and outcomes of neurosurgical conditions presenting to 1 of 12 regional referral hospitals in Uganda, in an effort to understand the neurosurgical needs of this population.

Methods

The study was conducted at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. Demographics, clinical characteristics, and outcomes were retrospectively collected for all patients who presented to MRRH with a neurosurgical condition between January 2012 and September 2015.

Results

During the study period, 1854 patients presented to MRRH with a neurosurgical condition. More than half of the patients were between 19 and 40 years old, and the majority were males (76.1%). The overall median length of stay was 5 days (interquartile range: 2.5–10). The majority of admissions were due to trauma (87%), with almost 60% due to road traffic incidents. The overall mortality rate was 12.8%. A multivariable Cox proportional hazards model revealed that age, closed head injury, and admission Glasgow Coma Scale have a strong positive correlation with mortality while getting a diagnostic image and neurosurgical procedure were negatively correlated with mortality.

Conclusion

Traumatic brain injury represented the majority of neurosurgical admissions at MRRH, disproportionately affecting young males. Age, closed head injury, admission Glasgow Coma Scale, getting a diagnostic image, and neurosurgical procedure were all independent predictors of mortality. Resource appropriate interventions throughout the health system are needed to meet the demand and improve outcomes.

Introduction

The Lancet Commission on Global Surgery estimates that an additional 143 million surgical procedures are needed yearly in order to meet the world's surgical need, with the greatest unmet surgical need in sub-Saharan Africa (SSA).¹ In these areas, the need for neurosurgery is likely substantial given the high incidence of traumatic brain injuries (TBIs) and congenital disorders.2, 3, 4 Despite the need for neurosurgery, few neurosurgeons are currently trained and practicing in SSA. Worldwide, there are 0.4 neurosurgeons per 100,000 people in the world, while the ratio in SSA, other than South Africa, is 0.02 for every 100,000 people.⁵

Uganda has a decentralized health system where health care is provided through a hierarchy of localized health centers, district hospitals, regional referral hospitals, and national referral hospitals. Of all operations, 73% are performed on an emergency basis, reflective of the high burden of trauma and the high proportion of patients who present to a health care provider with advanced pathologies, resulting in a backlog of elective cases.⁶ Currently, neurosurgery is only performed at 2 public hospitals: Mulago National Referral Hospital (MNRH) and Mbarara Regional Referral Hospital (MRRH). Furthermore, there are only 7 neurosurgeons, or 0.02 per 100,000 people in the public hospitals, in Uganda as of 2015.

To overcome the lack of surgical services and build surgical capacity in Uganda, an integrative neurosurgical twinning program was established at MNRH in Kampala Uganda in 2007 through the collaboration among MNRH, Duke University Medical Center, and the Duke Global Health Institute.⁷ The Duke-Mulago twinning program aimed to improve neurosurgical capacity in Uganda through 3 core initiatives: twining, training, and technology. In the years since the program's inception, neurosurgical cases performed at MNRH increased by 180% and 2 neurosurgical residents have successfully completed their residency at MNRH.⁸ On the basis of the success of the twinning program in improving the neurosurgical capacity at MNRH, the Duke-Mulago twinning program will expand to MRRH, the only other public facility in Uganda with a neurosurgery department. Before this expansion, it is critical to know the current neurosurgical case mix and patient outcomes at MRRH. The objective of our study was to describe the epidemiology of neurosurgical conditions at MRRH as part of an effort to understand the neurosurgical needs at MRRH for targeted expansion of the Duke-Mulago twinning program.

Section snippets

Setting

The study was focused in MRRH, a regional 300-bed referral hospital, located in Mbarara, Western Uganda. MRRH is located approximately 260 kilometers from Kampala, the capital of Uganda, and serves as the teaching hospital for Mbarara University of Science and Technology. In 2015, MRRH had 3785 total hospital admissions and 1640 surgeries. In 2012 a neurosurgery department was established, and the hospital currently employs 1 neurosurgeon and several nurses and medical interns who are shared

Patient Demographics

During the study time frame, a total of 1876 charts of patients who were suspected to have a neurosurgical condition were reviewed. Of these, 22 did not have a neurosurgical diagnosis or were not managed by the neurosurgery department and were excluded, resulting in 1854 included in the final analyses. The overall mortality rate among neurosurgery patients admitted into MRRH was 12.8% (230 patients). The median age of all hospitalized neurosurgery patients was 27 years (IQR: 18–39 years). More

Discussion

Knowledge regarding the distribution of neurosurgical conditions in low- and middle-income countries (LMICs) and their associated mortality rates is limited. This study was the first to describe the spectrum of neurosurgical conditions and mortality rates of patients presenting to a referral hospital in Mbarara, Uganda. A majority of the neurosurgical admissions were males, the median length of stay was 5 days, and 13 out of every 100 admissions had an adverse outcome. Age, closed head injury,

Conclusions

Our study provides insights into the distribution and outcomes of neurosurgical conditions in Mbarara. The majority of neurosurgical admissions at MRRH are TBIs, primarily due to RTI, with a large proportion being young males. Younger and mild TBI patients had a higher probability of survival, in addition to those who had a diagnostic image or neurosurgical intervention. Going forward, further exploration of patient characteristics is necessary to fully describe mortality outcomes and implement

Acknowledgments

The authors thank MRRH for the institutional support and the research assistants for their dedication to data quality: Josephine Najjuma, Okiror Noah Emokol. Ethics committee approval was obtained from Mbarara University for Science and Technology Research Ethics Committee and Duke University Health System Institutional Review Board.

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: Role of Funding Sources: Funding was provided by the Duke Global Health Institute, Duke University, Department of Neurosurgery, Division of Global Neurosurgery and Neuroscience. Dr. Staton received salary support funding from the Fogarty International Center, National Institute of Health, US (Staton, K01 TW010000–01A1). Funding sources played no role in study design, data collection, data analysis, or writing of the manuscript. All authors had full access to the data and had final responsibility for the decision to submit for publication.

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Original ArticleEpidemiology and Characteristics of Neurosurgical Conditions at Mbarara Regional Referral Hospital

Background

Methods

Results

Conclusion

Introduction

Section snippets

Setting

Patient Demographics

Discussion

Conclusions

Acknowledgments

World Neurosurg

World Neurosurg

Lancet

World Neurosurg

eNeurologicalSci

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Int J Obstet Anesth

The impact of traumatic brain injuries: a global perspective

NeuroRehabil

Neurosurgery in Africa

Clin Neurosurg

Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda's public hospitals

World J Surg

Surgical capacity building in Uganda through twinning, technology, and training camps

World J Surg

Neurosurgical Outcomes Following Establishment of a Twinning Program at Mulago Hospital in Uganda

StataCorp. 2012. Stata Statistical Software: Release 12

Original Article
Epidemiology and Characteristics of Neurosurgical Conditions at Mbarara Regional Referral Hospital