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Robertson FC, Esene IN, Kolias AG, Kamalo P, Fieggen G, Gormley WB, Broekman ML, Park KB. Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries. World Neurosurg X 2020; 6:100059. [PMID: 32309800 PMCID: PMC7154228 DOI: 10.1016/j.wnsx.2019.100059] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs. METHODS The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics. RESULTS The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%). CONCLUSIONS TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.
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Affiliation(s)
- Faith C. Robertson
- Harvard Medical School, Boston, Massachusetts, USA
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ignatius N. Esene
- Neurosurgery Division, Department of Surgery, University of Bamenda, Cameroon
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Patrick Kamalo
- University of Malawi, College of Medicine, Department of Surgery, Blantyre, Malawi
- Stellenbosch University, Centre for Medical Ethics and Law, Cape Town, South Africa
| | - Graham Fieggen
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - William B. Gormley
- Harvard Medical School, Boston, Massachusetts, USA
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marike L.D. Broekman
- Leiden University Medical Center, Neurosurgery, Leiden, Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Kee B. Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Robertson FC, Esene IN, Kolias AG, Kamalo P, Fieggen G, Gormley WB, Broekman ML, Park KB. Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries. World Neurosurg X 2019. [PMID: 32309800 PMCID: PMC7154228 DOI: 10.1016/j.wnsx.2019.100059;] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs. METHODS The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics. RESULTS The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%). CONCLUSIONS TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.
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Affiliation(s)
- Faith C. Robertson
- Harvard Medical School, Boston, Massachusetts, USA,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA,To whom correspondence should be addressed: Faith C. Robertson, M.D., M.Sc.
| | - Ignatius N. Esene
- Neurosurgery Division, Department of Surgery, University of Bamenda, Cameroon
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Patrick Kamalo
- University of Malawi, College of Medicine, Department of Surgery, Blantyre, Malawi,Stellenbosch University, Centre for Medical Ethics and Law, Cape Town, South Africa
| | - Graham Fieggen
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - William B. Gormley
- Harvard Medical School, Boston, Massachusetts, USA,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA,Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marike L.D. Broekman
- Leiden University Medical Center, Neurosurgery, Leiden, Netherlands,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Kee B. Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Robertson FC, Briones R, Mekary RA, Baticulon RE, Jimenez MA, Leather AJM, Broekman MLD, Park KB, Gormley WB, Lucena LL. Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines. World Neurosurg X 2019; 6:100058. [PMID: 32309799 PMCID: PMC7154225 DOI: 10.1016/j.wnsx.2019.100058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/18/2022] Open
Abstract
Objective The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden. Methods Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes. Results Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P = 0.01). Conclusions This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons.
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Key Words
- BMC, Bicol Medical Center
- CI, Confidence interval
- CT, Computed tomography
- GCS, Glasgow Coma Scale
- Global health
- Global neurosurgery
- HIC, High-income country
- ICU, Intensive care unit
- LMIC
- LMIC, Low- and middle-income country
- MS, Mother Seton Hospital
- Neurotrauma
- OR, Odds ratio
- TBI, Traumatic brain injury
- TS, Task-sharing
- TS/S, Task-shifting and task-sharing
- Task-sharing
- Task-shifting
- Workforce
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Affiliation(s)
- Faith C Robertson
- Harvard Medical School, Boston, Massachusetts, USA.,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Richard Briones
- Department of Surgery, Bicol Medical Center, Naga City, Philippines
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA.,MCPHS University, Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, Boston, Massachusetts, USA
| | - Ronnie E Baticulon
- Departments of Anatomy and Neurosciences, University of the Philippines-Philippines General Hospital, Manila, Philippines
| | - Miguel A Jimenez
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew J M Leather
- King's Centre for Global Health & Health Partnerships, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Marike L D Broekman
- Leiden University Medical Center, Neurosurgery, Leiden, the Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts, USA.,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynne L Lucena
- Department of Surgery, Bicol Medical Center, Naga City, Philippines.,Bicol Regional Teaching and Training Hospital, Legazpi, Bicol, Philippines
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