- Email: [email protected]
Barriers to Surgical Care at a Tertiary Hospital in Kigali, Rwanda
j o u r n a l o f s u r g i c a l r e s e a r c h j u n e 2 0 2 0 ( 2 5 0 ) 1 4 8 e1 5 5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Barriers to Surgical Care at a Tertiary Hospital in Kigali, Rwanda Myles Dworkin, MPH,a,1,* Thierry Cyuzuzo, MD,b,1 Jean de Dieu Hategekimana, MD,b Jean Katabogama, MD,b Faustin Ntirenganya, MD,b,c and Jennifer Rickard, MD, MPHc,d a
Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania The College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda c Department of Surgery, University Teaching Hospital of Kigali, Department of Surgery, Kigali, Rwanda d Department of Surgery, University of Minnesota, Department of Surgery, Minneapolis, Minnesota b
article info
abstract
Article history:
Background: The disproportionate distribution of surgical resources across the globe has left
Received 14 July 2019
many in low- and middle-income countries without proper care. Patients often have
Received in revised form
complex surgical problems that are worsened by delayed presentation. We aim to describe
2 December 2019
barriers to surgical care at a tertiary hospital in Kigali, Rwanda.
Accepted 29 December 2019
Materials and methods: A prospective review of all patients undergoing general and ortho-
Available online xxx
pedic surgery was performed at a tertiary hospital in Rwanda. Patients completed a questionnaire regarding their presurgical interactions with the health-care system.
Keywords:
Results: Over a 3-wk period, there were 24 (33%) general and 49 (67%) orthopedic surgery
Delivery of health care
patients. Patients reported delays seeking care (n ¼ 21, 29%), reaching care (n ¼ 28, 38.5%),
Rwanda
and receiving care (n ¼ 44, 60%). The median number of days from first symptom to surgery
Referral and consultation
was 7.3 d and was significantly longer for patients reporting at least 1 barrier to care
Global surgery
(P < 0.001). Barriers reported during the care-seeking time period had the largest impact on time to surgery (51.5 d versus 5.7 d, P ¼ 0.01). Meanwhile, the most frequently reported barriers included not knowing care was needed (n ¼ 17, 23%), transportation issues (n ¼ 25, 34%), and surgical staff availability (n ¼ 23, 32.5%). Conclusions: Initiatives are needed to address common barriers to surgical care in Rwanda. Educational programs designed to help patients identify key symptoms could encourage earlier presentation to health-care providers. System-based projects to improve transportation could facilitate patient transfers within the health-care system. Finally, increasing surgical staff at hospitals throughout the country would reduce delays and improve access. ª 2020 Elsevier Inc. All rights reserved.
This study was presented as a poster presentation at Consortium of Universities of Global Health in Chicago, IL, on March 8, 2019. * Corresponding author. Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street , Philadelphi, PA 19107. Tel.: þ1 610 547 3312; fax: þ1 215-955-6983. E-mail address: [email protected] (M. Dworkin). 1 Co-first authors. 0022-4804/$ e see front matter ª 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.12.045
dworkin et al barriers to surgical care in kigali, rwanda
Introduction While the international effects of communicable diseases have received attention in the past, the burden of surgical disease has only recently been identified as a growing public health crisis.1,2 In Rwanda, as many as 33% of deaths can be averted with proper access to surgical care.3 A study found that 41% of the population has at least one operative procedure during their lifetime, with 15% requiring surgery over the past year and 6.5% currently in need of surgery.4 As of 2012, there were 50 surgeons located in Rwanda responsible for a population of 12 million.4 Most surgeons are located in urban centers, with general practitioners serving local needs at district hospitals. General practitioners perform some procedures such as cesarean sections, but most major surgeries require care at a tertiary referral center.4 Approximately, 90% of surgical procedure relate to either general or orthopedic surgery.5 Barriers to care in Rwanda included transportation, high costs, education, and lack of trust in the health-care system.4,6 Although several studies have characterized the surgical disease burden, few have examined patient interaction with the system regarding obstacles to care.3,4,7 A model for studying interactions within health-care systems is the three delays model. Studying maternal health outcomes, Thaddeus and Maine8 created a framework to analyze delays in care. The three delays model stratifies barriers to care into the following: (1) delays in the decision to seek care, (2) delays in arrival at an appropriate health-care facility, and (3) delays in the provision of care.8 This framework has since been adopted by many global health fields.1,9-11 Questionnaires have been designed based on this model to explore and quantify barriers to pediatric surgery in Uganda, finding that the major contributing factors were delays in seeking care and cost of intervention.10 A similar study was conducted in Rwanda to assess delays reported by general surgery patients referred from a district hospital. They found that the most frequently reported delays related to the cost of transfer and laboratory or radiology issues.11 This study, however, did not report which barriers had the largest impact on overall time to surgery and only assessed potential delays in general surgery patients referred from a district hospital. The purpose of this study was to determine the most frequently reported barriers to care in surgical patients at a tertiary referral hospital in Kigali, Rwanda, and to assess which delays had the largest impact on time to surgical treatment. Based on previous work, we hypothesized that care-seeking delays would have the largest impact on time from first symptom to surgery and that the most common barriers would be related to the cost of management.
Methods Setting This study was conducted at the University Teaching Hospital of Kigali (CHUK) in Rwanda. CHUK is the largest referral hospital in Rwanda with 565 beds and a catchment area of 6.2
149
million people. It has six operating rooms (ORs) in the main surgical block.12
Survey development Questionnaires were developed based on prior studies and modified using input from physicians in Rwanda.10,11 Questions pertained to demographics, barriers to care, hospital stay, and postdischarge readmission rates (Appendix A). Questions were written in English, then translated into Kinyarwanda, and back translated into English by authors. Questionnaires were tested by Rwandan medical students and patients to confirm content and validity. Surveys were administered by three trained research assistants (RAs). RAs underwent a 2-wk training program to review the data collection tool and study goals. Biweekly meetings were used to resolve discrepancies in reporting. Interviews for the first 10% of participants were reviewed among RAs to ensure uniformity.
Eligibility and enrollment Patients undergoing surgery were enrolled between August 19, 2018, and September 8, 2018. This time period was selected as the time needed to obtain our sample size of 70 patients which was based on a power analysis and previous work on barriers to care in Rwanda.10 Patients were eligible for enrollment if they were older than 18 y, were admitted to either general surgery or orthopedic departments, were capable of answering questions, and spoke English or Kinyarwanda. Orthopedics and general surgery patients were included as these two patient populations make up 90% of surgical patients in Rwanda.5 Patients were excluded if they had previously received a surgery for their chief complaint. Patients with symptoms starting before January 1, 2018, were excluded to limit the effect of recall bias. Patients were enrolled in the study on postoperative day 1. Questionnaires were provided at the initial time of consent. Enrolled patients were followed by RAs for the duration of their hospital stay to record any complications that occurred. Patients also completed 30-d postdischarge questionnaires via phone.
Data collection Data were collected using Research Electronic Data Capture (REDCap).13 Delays were defined as any patient-reported factor that negatively impacted their ability to access surgical care. Patients reported their perceptions on whether there was a delay in care and what the specific barrier to care was at that level. We excluded delays attributed to nonoperative management at a health-care facility because it was not possible to determine if this was truly a delay or the correct form of management at the time. We also excluded delays because of a functional impairment such as patients who sustained an orthopedic trauma that limited their ability to reach a health-care facility. Delays were classified in accordance with the three delays model. Delays seeking care involved factors from time of first symptom to the decision to seek help from a health-care
150
j o u r n a l o f s u r g i c a l r e s e a r c h j u n e 2 0 2 0 ( 2 5 0 ) 1 4 8 e1 5 5
facility. This included recognition of need for health care and visiting traditional healers. Delays reaching care involved factors from the decision to seek help from a health-care facility to arrival at CHUK. This included transportation time and cost. Delays receiving care involved factors from arrival at CHUK to time of surgery. This included the availability of ORs and surgical staff, defined as any health professional involved in providing surgical care to patients. Primary outcomes included the number and frequency of patients perceiving delays to seeking, reaching, or receiving care as well as symptom duration. Symptom duration was defined as the interval between symptom recognition and surgery. Secondary outcomes included surgical outcomes such as length of hospital stay, reoperations, surgical site infections, mortality, and readmission. Readmission included patients admitted to any health-care facility after discharge from CHUK.
Data analysis Data were analyzed using SPSS-25. Descriptive statistics were provided for demographics, barriers, and outcomes. Variables were compared using the Mann-Whitney U-Test, chi-square test, and Fischer exact tests. Multiple linear regressions were used to determine the effect of delays on outcomes. Significance was defined at the a < 0.05 level.
less than a secondary school education (n ¼ 55, 75%). There were 24 (33%) patients who presented to CHUK directly while 49 (66%) first presented to other facilities. The most common insurance was Rwanda Social Security Board (RSSB) category III (n ¼ 32, 44%). The Rwanda Social Security Board is a national health insurance plan based on a sliding income with a scale ranging from category I to IV.14 There were 57 (78%) patients who reported at least 1 delay in care.
Delays in seeking care Delays seeking care were reported by 21 (29%) patients: 16 general surgery and five orthopedic patients. More general surgery patients reported delays seeking care than orthopedic patients (62.5% versus 39%, P < 0.001). Common causes for delays seeking care were not believing symptoms required care (n ¼ 17) and use of traditional medicine (n ¼ 10) (Table 3). The median number of days from first symptom to the decision to seeking care for all patients was 0.5 d (interquartile range [IQR]: 0-1.5) (Table 4). This differed between patients reporting barriers to care and those who did not (5 d versus 0 d, P < 0.001) as well as between general and orthopedic surgery patients (2 d versus 0 d, P < 0.001).
Delays in reaching care Ethical considerations Ethical clearance was obtained from the CHUK Ethics Committee. All patients provided informed consent. Patients had the ability to agree to study participation while deferring postdischarge follow-up phone calls. A total of 81 patients were approached with 73 consenting and 8 declining or unable to provide consent (Figure).
Results Over the study period, 81 patients underwent surgery and 73 were enrolled in the study (Table 1). A list of procedures may be found in Table 2. There were 49 (67%) orthopedic and 24 (33%) general surgery patients. Most patients (n ¼ 58, 79.5%) presented through the emergency department (ED) and had
Patients receiving surgery at CHUK (n = 81)
Patients included in study (n = 73)
Patients declined consent or excluded based on criteria (n = 8)
Completed 30-day postdischarge follow up survey (n = 40)
Incomplete 30-day postdischarge follow up survey due to no response upon calling (n = 33)
Fig e Flow diagram of patients included in the study.
Delays reaching care were reported by 28 (38.5%) patients: eight general surgery and 20 orthopedic patients. Common causes were transportation issues, (n ¼ 25), which commonly occurred during transfer from a district hospital to CHUK (n ¼ 8). Transportation issues included transport availability, travel time, and travel cost (Table 3). The median number of days from the decision to seek care to arrival at CHUK was 1.6 d (IQR: 0.8-11.9) (Table 4). The number of days was significantly greater for patients reporting barriers to reaching care (3.3 d versus 0.9 d, P ¼ 0.002). General surgery patients had longer times reaching care than orthopedic patients (4 d versus 1.4 d, P ¼ 0.03).
Delays in receiving care Delays receiving care were encountered by 44 (60%) patients: 17 general surgery and 27 orthopedic patients. Of 58 patients presenting to the ED, 32 reported delays receiving care. Of the 15 patients who were directly admitted, 12 reported delays receiving care. Common causes were surgical staff availability (n ¼ 23), OR availability (n ¼ 18), or laboratory challenges (n ¼ 14). Laboratory challenges included cost of tests, unavailable tests, or unavailable staff (Table 3). The median number of days from arrival at CHUK to surgery was 2.25 d (IQR: 1.0-5.4) (Table 4). This was significantly different for patients reporting a delay receiving care (3.4 d versus 1.4 d, P ¼ 0.02). There was no difference in time receiving care between general surgery and orthopedic patients (1.5 d versus 2.8, P ¼ 0.9). Similarly, there was no difference in time receiving care between patients presenting to the ED and those directly admitted (2.3 d versus 2.0 d, P ¼ 0.8).
151
dworkin et al barriers to surgical care in kigali, rwanda
Table 1 e Characteristics of patients receiving either general or orthopedic procedures at a tertiary referral hospital over a 3-wk period. Patient characteristics Age, years (median, interquartile range)
Table 2 e List of general and orthopedic procedures undergone by study patients. Surgery
n (%) 33 (27.5-44.5)
Sex
Number of patients, n (%)
Incision and drainage
20 (25)
Open reduction and internal fixation
17 (21)
Male
61 (83.5)
Exploratory laparotomy
8 (10)
Female
12 (16.5)
External fixation
8 (10)
Hemiarthroplasty
6 (7)
Service Orthopedic surgery
49 (67)
Ostomy procedure of the bowel
5 (6)
General surgery
24 (33)
Intramedullary nail insertion
4 (5)
Amputation
4 (5) 2 (2)
Mode of presentation Emergency department
58 (79.5)
Gastrectomy
Direct admit
15 (20.5)
Gastroenterol anastomosis
1 (1)
Biopsy
1 (1)
Province Southern
24 (33)
Cholecystectomy
1 (1)
Kigali
21 (29)
Skin graft
1 (1)
Northern
15 (20)
Nephrectomy
1 (1)
Eastern
7 (10)
Appendectomy
1 (1)
Western
6 (8)
Tendon repair
1 (1)
Insurance No insurance
1 (1.5)
RSSB I
9 (13)
RSSB II
26 (37)
RSSB III
32 (46)
RSSB IV
1 (1.5)
Private
1 (1.5)
Education No education
20 (27.5)
Primary school
35 (48)
Secondary school (ordinary level) Secondary school (advance level) University
3 (4) 12 (16.5) 3 (4)
Presenting health-care facility Community health worker
The median length of hospital stay was 9.5 d (IQR: 6-18.25) (Table 5). Six patients developed surgical site infections, and one patient died in the hospital. Follow-up interviews were completed by 40 patients, and the 30-d readmission rate was 12.5% (n ¼ 5). There were no differences in the length of hospital stay; requirement of multiple procedures; rates of infection; or mortality based on barriers, admitting service, or mode of presentation. Patients reporting no delays were more likely to be readmitted than patients reporting at least 1 delay (37.5% versus 5%, P ¼ 0.03) (Table 5).
3 (4)
Health center
34 (46.5)
Private clinic
1 (1.5)
District hospital
11 (15)
Referral hospital
24 (33)
RSSB ¼ Rwanda Social Security Board.
Outcomes The median number of days from first symptom to surgery was 7.3 d (IQR: 3.7-49.0). There was a significant difference between patients reporting at least 1 delay and those who did not report a delay (11.4 d versus 3.4 d, P < 0.001) (Table 4). The number of days was greater for general surgery patients than orthopedic patients (47.2 d, versus 6.0 d, P < 0.001). Based on a multiple linear regression, patients reporting barriers to seeking care had longer symptom duration than patients who did not report barriers when controlling for delays in reaching and receiving care (51.5 d, versus 5.7 d, P ¼ 0.01).
Discussion The present study examines patient-reported barriers to care and analyzes delays for patients undergoing orthopedic and general surgery procedures at a major referral hospital in Rwanda. It provides a new insight into patient pathways to surgical treatment that can help direct future initiatives. The most frequently reported barriers included patients not knowing care was needed, transportation issues, and surgical staff availability while delays seeking care had the largest impact on time from first symptom to surgery. General surgery patients had longer times from first symptom to surgery than orthopedic patients. This was similar to prior findings from Kenya that suggest general surgery was associated with longer disease durations than other specialties.15 A possible reason for this is the impact of care-seeking delays. Orthopedic injures often relate to easily identifiable external trauma, whereas general surgery patients exhibit ambiguous abdominal symptoms. This is supported by the fact that general surgery patients reported significantly more care-seeking barriers than orthopedic patients, with the most common barrier related to not knowing
152
j o u r n a l o f s u r g i c a l r e s e a r c h j u n e 2 0 2 0 ( 2 5 0 ) 1 4 8 e1 5 5
Table 3 e List of specific delays cited by patients. Delays Delays seeking care
Table 4 e Time to seek, reach, and receive care. N*
17
Traditional healer
10
Did not think doctor could help
6
Cost
6
Delay caused by family or friends
4
Thought it would take too long to get help
2
Travel issues
28 25
Travel not available
16
Travel cost
12
Travel time
7
Wanted second opinion
3
Didn’t think transfer was required
2
Cost of medical care
2
No caretaker to accompany patient
2
Insecurity
1
Delays receiving care Unavailable surgical staff
n
21
Did not think it was required
Delays reaching care
Time period
44 23
Total, median (IQR)
Seeking care Total time to seek care, days
73
0.5 (0, 1.5)
Patients with reported delays in seeking care, days
21
5 (1, 38)
Patients without reported delays in seeking care, days
52
0.0 (0, 0)
Reaching care Total time reaching care, days
73
1.6 (0.8, 11.9)
Patients with reported delays in reaching care, days
28
3.3 (1.5, 79.7)
Patients without reported delays in reaching care, days
45
0.9 (0.7, 6.1)
Receiving care Total time to receive care, days
73
2.25 (1, 5.2)
Patients with reported delays in receiving care, days
44
3.4 (1.4, 7.6)
Patients without reported delay in receiving care, days
29
1.4 (1, 3.3)
Total time from symptoms to surgery, days
73
7.3 (3.7, 46.7)
Unavailable surgical infrastructure
18
Patients with any reported delay, days
57
11.4 (4.7, 79.7)
Unable to access test or lab
14
Patients without any reported delay, days
16
3.4 (2.3, 4.9)
Cost
4
Unavailable test or lab
6
No staff available
5
No hospital bed available
6
Cost of surgery
5
Unable to purchase medications
5
Unknown
4
No caretaker to accompany patient
1
Patients reporting one or more delays
57
* Patients were counted as having experienced a delay at the given level based on presence of one or more delays during the time interval. Multiple delays may have been encountered by a single patient at any individual level.
care was needed. Furthermore, our findings support previously published results that delays seeking care have the largest impact on time to surgery when compared with delays reaching or receiving care.9,15-17 Programs focused on patient identification of dangerous physical symptoms and risk factors have been shown to encourage patients to seek care more promptly.18 Villages in Rwanda contain at least one community health worker who can provide basic nursing and health education. These community workers could be trained to provide additional educational programs. Other initiatives that may reduce barriers to seeking care include the use of mobile health applications to promote earlier and easier presentation to physicians.19,20 The mobile network coverage reaches 90% of the Rwandan population and mobile health applications have been used in prior initiatives.21,22 Efforts focused on reducing care-seeking delays have potential to have the largest impact on reducing time from first symptom to surgery.
IQR ¼ interquartile range.
Similar to other studies, travel availability and cost were noted as frequent barriers to reaching care.11,23-26 Patients spent a median of 1.6 d reaching the referral hospital and 38.5% reported a delay during this process. This is similar to previous findings from Rwanda.11 Improved transfer systems have been shown to provide a survival benefit for patients.24 To achieve these survival benefits, the Rwandan National Surgical, Obstetrics, and Anesthesia Plan (NSOAP) proposes several strategies focused on improving transfer pathways.27 A part of that plan is to create designated patient transfer pathways based on province and specific surgical need. The NSOAP also seeks to reduce delays in emergent surgical referrals. A prospective study in India suggests that this may be carried out by developing context-specific transfer protocols or checklist and processes for prioritizing patients.25 Another strategy to help Rwanda achieve its NSOAP goals is providing free interhospital transfers.23 Rwanda offers prehospital and interhospital transfer services with plans to have at least two ambulances per hospital, but cost remains a barrier to widespread utilization.11 The price for transfer depends on insurance type with patients responsible for a percentage of total fees. Studies are needed to develop cost-efficient and contextspecific protocols in order for Rwanda to achieve its NSOAP goals of reducing transfer delays. Another frequently referenced delay was the lack of available surgical staff emphasizing the need for improved surgical capacity.28-30 This barrier was not as frequently reported in a previous study.11 The discrepancy in findings may be explained by variations in staffing at referral hospitals
7 Readmission rates were based on follow-up interviews which were completed by n ¼ 40 patients. Length of hospital stay provided in median number of days. y
*
0 5
10 8
4 1
11 9
3
9.5 Length of hospital stayy
2 5 Readmission*
10
0
0 6
1 0
3 3
1 0
2 4
Mortality
1
6
1
Surgical site infection
0 14 10 4 2 12 14 Requirement of multiple procedures
General surgery, n ¼ 24 Patients reporting no delays in care, n ¼ 16 Patients reporting at least 1 delay in care, n ¼ 57 Total, n ¼ 73 Quality of care metrics
Table 5 e Quality of care metrics by reporting of delays, service, and mode of presentation.
Orthopedic surgery, n ¼ 49
Presented to the ED, n ¼ 58
Directly admitted, n ¼ 15
dworkin et al barriers to surgical care in kigali, rwanda
153
throughout the year and within different departments. The present study was performed during August and September, a common time for government-sponsored surgical outreach to district hospitals. This outreach is needed because most surgical staff in Rwanda work in referral hospitals.4 This, however, reduces staffing and may have contributed to delays noted in the study. The objectives of the Rwandan NSOAP include redistribution of surgical staff among district and referral hospitals as well as increasing the volume of outreach surgery.27 Our findings suggest that this may result in increased delays at referral centers. This could be prevented by increasing surgical staff in parallel with the NSOAP objectives. The Human Resources for Health (HRH) program, which partners the Ministry of Health with several U.S.-based institutions, addresses this need by assisting in surgical training.31,32 Human Resources for Health has helped train an estimated 4600 students in health careerelated fields including surgery.33 Increasing surgical staff will allow for additional support at district hospitals while preventing delays at referral centers. The secondary aim of this study was to determine the impact of delays on surgical outcomes. While reported barriers to care significantly prolonged time from first symptom to surgery, they were not associated with surgical outcomes. This is in contrast to previous studies that have found delays increase mortality and lead to poor outcomes for patients.34,35 The discrepancy may be related to the relatively small sample size and short follow-up used in this study. Future research specifically focused on surgical outcomes is needed to determine the impact of delays. This study contained a number of limitations. First, the survey examined patient-referenced delays, but self-reported surveys are subject to biases and incomplete knowledge.36 For example, patients were aware of delays due to OR availability, but not what factor specifically prevented treatment. Patientreported barriers to care are subjective findings which may vary based on the individual and additional barriers may exist. In addition, the scope of this study was limited to patients undergoing general and orthopedic surgical care at CHUK over a 3-wk period resulting in a limited sample size. It excluded patients waiting for surgery, unable to reach CHUK, and receiving surgical care elsewhere or at other times of the year. As such, variations due to seasonal factors were not considered and barriers to care at other health-care facilities were not investigated. Furthermore, differences between emergent and elective surgeries were not considered because the majority of cases were emergent. Finally, the study was subject to recall bias as patients were asked to think retrospectively about their pathway to surgery. To limit this, we excluded patients with symptoms before January 1, 2018. In conclusion, reported barriers in surgical care were associated with prolonged time to surgery with delays seeking care having the largest impact. Initiatives using community health workers to educate individuals could reduce these delays, especially among general surgery patients, and should be prioritized. Delays to reaching and receiving care were also frequently referenced. The Rwandan NSOAP has identified these as important areas for improvement. Our findings suggest that improved patient transfer pathways are necessary and may be achieved through the development of cost-
154
j o u r n a l o f s u r g i c a l r e s e a r c h j u n e 2 0 2 0 ( 2 5 0 ) 1 4 8 e1 5 5
efficient specialized protocols. In addition, while NSOAP objectives to redistribute surgical staff and increase district outreach are important, they would benefit from enhanced training capacity to avoid unintended delays. Further studies applying this survey tool to both district and referral hospitals in Rwanda should be conducted to improve generalizability and help optimize targeted interventions.
Acknowledgment This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution: D.M., C.T., and R.J. conceptualized the study and conducted literature reviews as well as prepared all necessary documents for institutional review board with input from N.F. All authors contributed to study design. D.M., C.T., H.J., and K.J. participated in collecting data with analysis and interpretation performed by D.M., C.T., and R.J. All authors contributed to writing the manuscript and production of figures and tables with edits provided by N.F. and R.J.All authors approved the final version.
Disclosure The authors have no disclosures or conflicts of interest to report.
Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jss.2019.12.045.
references
1. Meara JG, Andrew JM, Leather, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569e624. 2. Bickler SW, Weiser TG, Kassebaum N, et al. Global burden of surgical conditions. In: Essential surgery: disease control priorities. Washington, DC: World Bank; 2015. 3. Wong EG, Georges N, Mathieu CR, et al. Acute care surgery in Rwanda: operative epidemiology and geographic variations in access to care. Surgery. 2015;158:37e43. 4. Petroze RT, Reinou SG, Francine N, et al. Estimating operative disease prevalence in a low-income country: results of a Nationwide population survey in Rwanda. Surgery. 2013;153:457e464. 5. Rickard JL, Ntakiyiruta G, Chu KM. Identifying gaps in the surgical training curriculum in Rwanda through evaluation of operative activity at a teaching hospital. J Surg Educ. 2015;72:73e81. 6. Forrester JD, Forrester JA, Kamara TB, et al. Self-reported determinants of access to surgical care in 3 developing countries. JAMA Surg. 2016;151:257e263. 7. Ndayizeye L, Ngarambe C, Smart B, et al. Peritonitis in Rwanda: epidemiology and risk factors for morbidity and mortality. Surgery. 2016;160:1645e1656.
8. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38:1091e1110. 9. Calvello E, Skog A, Tenner A, et al. Applying the lessons of maternal mortality reduction to global emergency health. Bull World Health Organ. 2015;93:361e440. 10. Pilkington M, Situma M, Winthrop A, Poenaru D. Quantifying delays and self-identified barriers to timely access to pediatric surgery at Mbarara Regional referral hospital, Uganda. J Pediatr Surg. 2018;53:1073e1079. 11. Mpirimbanyi C, Abahuje E, Hirwa A, et al. Defining the three delays in referral of surgical emergencies from district hospitals to University teaching hospital of Kigali, Rwanda. World J Surg. 2019;43:1e9. 12. Petroze R, Nzayisenga A, Rusanganwa V, et al. Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg. 2012;158:37e43. 13. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)ea metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377e381. 14. Rwanda Social Security Board. 2019. Available at: http://www. rssb.rw/. Accessed February 6, 2019. 15. Poenaru D, Pemberton J, Cameron BH. The burden of waiting: DALYs accrued from delayed access to pediatric surgery in Kenya and Canada. J Pediatr Surg. 2015;50:765e770. 16. Kong VY, ChB M, Aldous C, et al. Understanding the reasons for delay to definitive surgical care of patients with acute appendicitis in rural South Africa. S Afr J Surg. 2014;52:2e5. 17. Gebrehiwot T, San Sebastian M, Edin K, Goicolea I. Health workers’ perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia. BMC Pregnancy Childbirth. 2014;14:137. 18. Snow J. Reducing the Burden of the Three Delays on Maternal Health in Timor-Leste. Presented at the health improvement projects, Timor-Leste. 2015. 19. Mechael P. Exploring Health Related Uses of Mobile Phones: An Egyptian Case Study. Public Health & Policy. London: London School of Hygiene and Tropical Medicine 264; 2006. 20. Bastawrous A, Armstrong MJ. Mobile health use in low- and high-income countries: an overview of the peer-reviewed literature. J R Soc Med. 2013;106:130e142. 21. Ruton H, Musabyimana A, Gaju E, et al. The impact of an mHealth monitoring system on health care utilization by mothers and children: an evaluation using routine health information in Rwanda. Health Policy Plan. 2018;33:920e927. 22. Musabyimana A, Ruton H, Gaju E, et al. Assessing the perspectives of users and beneficiaries of a community health worker mHealth tracking system for mothers and children in Rwanda. PLoS One. 2018;13:1e12. 23. Stewart BT, Gyedu A, Giannou C, et al. Consensus recommendations for essential vascular care in low- and middle-income countries. J Vasc Surg. 2016;64:1770e1779. 24. Boschini LP, Lu-Myers Y, Msiska N, et al. Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa. Injury. 2016;47:1118e1122. 25. Dye TD, Bogale S, Hobden C, et al. Complex care systems in developing countries: breast cancer patient navigation in Ethiopia. Cancer. 2010;116:577e585. 26. Kumar V, Khajanchi M, Raykar NP, et al. Waiting at the hospital door: a prospective, multicentre assessment of third delay in four tertiary hospitals in India. Lancet. 2015;385:S24. 27. The Rwandan Ministry of Health. National Surgical, Obstetrics, and Anesthesia Plan 2018e2024. Kigali, Rwanda: The Rwandan Ministry of Health; 2018. 28. Rickard J, Ntakiyiruta G, Chu K. Associations with perioperative mortality rate at a major referral hospital in Rwanda. World J Surg. 2016;40:784e790.
dworkin et al barriers to surgical care in kigali, rwanda
29. Caesar U, Karlsson J, Hansson E. Incidence and root causes of delays in emergency orthopaedic procedures: a single-centre experience of 36,017 consecutive cases over seven years. Patient Saf Surg. 2018;12:2. 30. Norton I, von Schreeb J, Aitken P, et al. Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters. Geneva, Switzerland: World Health Organization; 2013. 31. Rickard J, Ssebuufu R, Kyamanywa P, et al. Scaling up a surgical residency program in Rwanda. East Cent Afr J Surg. 2016;21:11e23. 32. Binagwaho A, Kyamanywa P, Farmer PE, et al. The human resources for health program in Rwandada new partnership. N Engl J Med. 2013;369:2054e2059.
155
33. Cancedda C, Cotton P, Shema J, et al. Health professional training and capacity strengthening through international academic partnerships: the first five years of the human resources for health program in Rwanda. Int J Health Policy Manag. 2018;7:1024e1039. 34. Ifesanya A, Ogundele O, Ifesanya J. Orthopaedic surgical treatment delays at a tertiary hospital in sub saharan Africa: communication gaps and implications for clinical outcomes. Niger Med J. 2013;54:420e425. 35. Maine RG, Kajombo C, Purcell L, et al. Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi. BJS Open. 2019;3:367e375. 36. Rosenman R, Tennekoon V, Hill L. Measuring bias in selfreported data. Int J Behav Healthc Res. 2014;2:320e332.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Barriers to Surgical Care at a Tertiary Hospital in Kigali, Rwanda Myles Dworkin, MPH,a,1,* Thierry Cyuzuzo, MD,b,1 Jean de Dieu Hategekimana, MD,b Jean Katabogama, MD,b Faustin Ntirenganya, MD,b,c and Jennifer Rickard, MD, MPHc,d a
Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania The College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda c Department of Surgery, University Teaching Hospital of Kigali, Department of Surgery, Kigali, Rwanda d Department of Surgery, University of Minnesota, Department of Surgery, Minneapolis, Minnesota b
article info
abstract
Article history:
Background: The disproportionate distribution of surgical resources across the globe has left
Received 14 July 2019
many in low- and middle-income countries without proper care. Patients often have
Received in revised form
complex surgical problems that are worsened by delayed presentation. We aim to describe
2 December 2019
barriers to surgical care at a tertiary hospital in Kigali, Rwanda.
Accepted 29 December 2019
Materials and methods: A prospective review of all patients undergoing general and ortho-
Available online xxx
pedic surgery was performed at a tertiary hospital in Rwanda. Patients completed a questionnaire regarding their presurgical interactions with the health-care system.
Keywords:
Results: Over a 3-wk period, there were 24 (33%) general and 49 (67%) orthopedic surgery
Delivery of health care
patients. Patients reported delays seeking care (n ¼ 21, 29%), reaching care (n ¼ 28, 38.5%),
Rwanda
and receiving care (n ¼ 44, 60%). The median number of days from first symptom to surgery
Referral and consultation
was 7.3 d and was significantly longer for patients reporting at least 1 barrier to care
Global surgery
(P < 0.001). Barriers reported during the care-seeking time period had the largest impact on time to surgery (51.5 d versus 5.7 d, P ¼ 0.01). Meanwhile, the most frequently reported barriers included not knowing care was needed (n ¼ 17, 23%), transportation issues (n ¼ 25, 34%), and surgical staff availability (n ¼ 23, 32.5%). Conclusions: Initiatives are needed to address common barriers to surgical care in Rwanda. Educational programs designed to help patients identify key symptoms could encourage earlier presentation to health-care providers. System-based projects to improve transportation could facilitate patient transfers within the health-care system. Finally, increasing surgical staff at hospitals throughout the country would reduce delays and improve access. ª 2020 Elsevier Inc. All rights reserved.
This study was presented as a poster presentation at Consortium of Universities of Global Health in Chicago, IL, on March 8, 2019. * Corresponding author. Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street , Philadelphi, PA 19107. Tel.: þ1 610 547 3312; fax: þ1 215-955-6983. E-mail address: [email protected] (M. Dworkin). 1 Co-first authors. 0022-4804/$ e see front matter ª 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.12.045
dworkin et al barriers to surgical care in kigali, rwanda
Introduction While the international effects of communicable diseases have received attention in the past, the burden of surgical disease has only recently been identified as a growing public health crisis.1,2 In Rwanda, as many as 33% of deaths can be averted with proper access to surgical care.3 A study found that 41% of the population has at least one operative procedure during their lifetime, with 15% requiring surgery over the past year and 6.5% currently in need of surgery.4 As of 2012, there were 50 surgeons located in Rwanda responsible for a population of 12 million.4 Most surgeons are located in urban centers, with general practitioners serving local needs at district hospitals. General practitioners perform some procedures such as cesarean sections, but most major surgeries require care at a tertiary referral center.4 Approximately, 90% of surgical procedure relate to either general or orthopedic surgery.5 Barriers to care in Rwanda included transportation, high costs, education, and lack of trust in the health-care system.4,6 Although several studies have characterized the surgical disease burden, few have examined patient interaction with the system regarding obstacles to care.3,4,7 A model for studying interactions within health-care systems is the three delays model. Studying maternal health outcomes, Thaddeus and Maine8 created a framework to analyze delays in care. The three delays model stratifies barriers to care into the following: (1) delays in the decision to seek care, (2) delays in arrival at an appropriate health-care facility, and (3) delays in the provision of care.8 This framework has since been adopted by many global health fields.1,9-11 Questionnaires have been designed based on this model to explore and quantify barriers to pediatric surgery in Uganda, finding that the major contributing factors were delays in seeking care and cost of intervention.10 A similar study was conducted in Rwanda to assess delays reported by general surgery patients referred from a district hospital. They found that the most frequently reported delays related to the cost of transfer and laboratory or radiology issues.11 This study, however, did not report which barriers had the largest impact on overall time to surgery and only assessed potential delays in general surgery patients referred from a district hospital. The purpose of this study was to determine the most frequently reported barriers to care in surgical patients at a tertiary referral hospital in Kigali, Rwanda, and to assess which delays had the largest impact on time to surgical treatment. Based on previous work, we hypothesized that care-seeking delays would have the largest impact on time from first symptom to surgery and that the most common barriers would be related to the cost of management.
Methods Setting This study was conducted at the University Teaching Hospital of Kigali (CHUK) in Rwanda. CHUK is the largest referral hospital in Rwanda with 565 beds and a catchment area of 6.2
149
million people. It has six operating rooms (ORs) in the main surgical block.12
Survey development Questionnaires were developed based on prior studies and modified using input from physicians in Rwanda.10,11 Questions pertained to demographics, barriers to care, hospital stay, and postdischarge readmission rates (Appendix A). Questions were written in English, then translated into Kinyarwanda, and back translated into English by authors. Questionnaires were tested by Rwandan medical students and patients to confirm content and validity. Surveys were administered by three trained research assistants (RAs). RAs underwent a 2-wk training program to review the data collection tool and study goals. Biweekly meetings were used to resolve discrepancies in reporting. Interviews for the first 10% of participants were reviewed among RAs to ensure uniformity.
Eligibility and enrollment Patients undergoing surgery were enrolled between August 19, 2018, and September 8, 2018. This time period was selected as the time needed to obtain our sample size of 70 patients which was based on a power analysis and previous work on barriers to care in Rwanda.10 Patients were eligible for enrollment if they were older than 18 y, were admitted to either general surgery or orthopedic departments, were capable of answering questions, and spoke English or Kinyarwanda. Orthopedics and general surgery patients were included as these two patient populations make up 90% of surgical patients in Rwanda.5 Patients were excluded if they had previously received a surgery for their chief complaint. Patients with symptoms starting before January 1, 2018, were excluded to limit the effect of recall bias. Patients were enrolled in the study on postoperative day 1. Questionnaires were provided at the initial time of consent. Enrolled patients were followed by RAs for the duration of their hospital stay to record any complications that occurred. Patients also completed 30-d postdischarge questionnaires via phone.
Data collection Data were collected using Research Electronic Data Capture (REDCap).13 Delays were defined as any patient-reported factor that negatively impacted their ability to access surgical care. Patients reported their perceptions on whether there was a delay in care and what the specific barrier to care was at that level. We excluded delays attributed to nonoperative management at a health-care facility because it was not possible to determine if this was truly a delay or the correct form of management at the time. We also excluded delays because of a functional impairment such as patients who sustained an orthopedic trauma that limited their ability to reach a health-care facility. Delays were classified in accordance with the three delays model. Delays seeking care involved factors from time of first symptom to the decision to seek help from a health-care
150
j o u r n a l o f s u r g i c a l r e s e a r c h j u n e 2 0 2 0 ( 2 5 0 ) 1 4 8 e1 5 5
facility. This included recognition of need for health care and visiting traditional healers. Delays reaching care involved factors from the decision to seek help from a health-care facility to arrival at CHUK. This included transportation time and cost. Delays receiving care involved factors from arrival at CHUK to time of surgery. This included the availability of ORs and surgical staff, defined as any health professional involved in providing surgical care to patients. Primary outcomes included the number and frequency of patients perceiving delays to seeking, reaching, or receiving care as well as symptom duration. Symptom duration was defined as the interval between symptom recognition and surgery. Secondary outcomes included surgical outcomes such as length of hospital stay, reoperations, surgical site infections, mortality, and readmission. Readmission included patients admitted to any health-care facility after discharge from CHUK.
Data analysis Data were analyzed using SPSS-25. Descriptive statistics were provided for demographics, barriers, and outcomes. Variables were compared using the Mann-Whitney U-Test, chi-square test, and Fischer exact tests. Multiple linear regressions were used to determine the effect of delays on outcomes. Significance was defined at the a < 0.05 level.
less than a secondary school education (n ¼ 55, 75%). There were 24 (33%) patients who presented to CHUK directly while 49 (66%) first presented to other facilities. The most common insurance was Rwanda Social Security Board (RSSB) category III (n ¼ 32, 44%). The Rwanda Social Security Board is a national health insurance plan based on a sliding income with a scale ranging from category I to IV.14 There were 57 (78%) patients who reported at least 1 delay in care.
Delays in seeking care Delays seeking care were reported by 21 (29%) patients: 16 general surgery and five orthopedic patients. More general surgery patients reported delays seeking care than orthopedic patients (62.5% versus 39%, P < 0.001). Common causes for delays seeking care were not believing symptoms required care (n ¼ 17) and use of traditional medicine (n ¼ 10) (Table 3). The median number of days from first symptom to the decision to seeking care for all patients was 0.5 d (interquartile range [IQR]: 0-1.5) (Table 4). This differed between patients reporting barriers to care and those who did not (5 d versus 0 d, P < 0.001) as well as between general and orthopedic surgery patients (2 d versus 0 d, P < 0.001).
Delays in reaching care Ethical considerations Ethical clearance was obtained from the CHUK Ethics Committee. All patients provided informed consent. Patients had the ability to agree to study participation while deferring postdischarge follow-up phone calls. A total of 81 patients were approached with 73 consenting and 8 declining or unable to provide consent (Figure).
Results Over the study period, 81 patients underwent surgery and 73 were enrolled in the study (Table 1). A list of procedures may be found in Table 2. There were 49 (67%) orthopedic and 24 (33%) general surgery patients. Most patients (n ¼ 58, 79.5%) presented through the emergency department (ED) and had
Patients receiving surgery at CHUK (n = 81)
Patients included in study (n = 73)
Patients declined consent or excluded based on criteria (n = 8)
Completed 30-day postdischarge follow up survey (n = 40)
Incomplete 30-day postdischarge follow up survey due to no response upon calling (n = 33)
Fig e Flow diagram of patients included in the study.
Delays reaching care were reported by 28 (38.5%) patients: eight general surgery and 20 orthopedic patients. Common causes were transportation issues, (n ¼ 25), which commonly occurred during transfer from a district hospital to CHUK (n ¼ 8). Transportation issues included transport availability, travel time, and travel cost (Table 3). The median number of days from the decision to seek care to arrival at CHUK was 1.6 d (IQR: 0.8-11.9) (Table 4). The number of days was significantly greater for patients reporting barriers to reaching care (3.3 d versus 0.9 d, P ¼ 0.002). General surgery patients had longer times reaching care than orthopedic patients (4 d versus 1.4 d, P ¼ 0.03).
Delays in receiving care Delays receiving care were encountered by 44 (60%) patients: 17 general surgery and 27 orthopedic patients. Of 58 patients presenting to the ED, 32 reported delays receiving care. Of the 15 patients who were directly admitted, 12 reported delays receiving care. Common causes were surgical staff availability (n ¼ 23), OR availability (n ¼ 18), or laboratory challenges (n ¼ 14). Laboratory challenges included cost of tests, unavailable tests, or unavailable staff (Table 3). The median number of days from arrival at CHUK to surgery was 2.25 d (IQR: 1.0-5.4) (Table 4). This was significantly different for patients reporting a delay receiving care (3.4 d versus 1.4 d, P ¼ 0.02). There was no difference in time receiving care between general surgery and orthopedic patients (1.5 d versus 2.8, P ¼ 0.9). Similarly, there was no difference in time receiving care between patients presenting to the ED and those directly admitted (2.3 d versus 2.0 d, P ¼ 0.8).
151
dworkin et al barriers to surgical care in kigali, rwanda
Table 1 e Characteristics of patients receiving either general or orthopedic procedures at a tertiary referral hospital over a 3-wk period. Patient characteristics Age, years (median, interquartile range)
Table 2 e List of general and orthopedic procedures undergone by study patients. Surgery
n (%) 33 (27.5-44.5)
Sex
Number of patients, n (%)
Incision and drainage
20 (25)
Open reduction and internal fixation
17 (21)
Male
61 (83.5)
Exploratory laparotomy
8 (10)
Female
12 (16.5)
External fixation
8 (10)
Hemiarthroplasty
6 (7)
Service Orthopedic surgery
49 (67)
Ostomy procedure of the bowel
5 (6)
General surgery
24 (33)
Intramedullary nail insertion
4 (5)
Amputation
4 (5) 2 (2)
Mode of presentation Emergency department
58 (79.5)
Gastrectomy
Direct admit
15 (20.5)
Gastroenterol anastomosis
1 (1)
Biopsy
1 (1)
Province Southern
24 (33)
Cholecystectomy
1 (1)
Kigali
21 (29)
Skin graft
1 (1)
Northern
15 (20)
Nephrectomy
1 (1)
Eastern
7 (10)
Appendectomy
1 (1)
Western
6 (8)
Tendon repair
1 (1)
Insurance No insurance
1 (1.5)
RSSB I
9 (13)
RSSB II
26 (37)
RSSB III
32 (46)
RSSB IV
1 (1.5)
Private
1 (1.5)
Education No education
20 (27.5)
Primary school
35 (48)
Secondary school (ordinary level) Secondary school (advance level) University
3 (4) 12 (16.5) 3 (4)
Presenting health-care facility Community health worker
The median length of hospital stay was 9.5 d (IQR: 6-18.25) (Table 5). Six patients developed surgical site infections, and one patient died in the hospital. Follow-up interviews were completed by 40 patients, and the 30-d readmission rate was 12.5% (n ¼ 5). There were no differences in the length of hospital stay; requirement of multiple procedures; rates of infection; or mortality based on barriers, admitting service, or mode of presentation. Patients reporting no delays were more likely to be readmitted than patients reporting at least 1 delay (37.5% versus 5%, P ¼ 0.03) (Table 5).
3 (4)
Health center
34 (46.5)
Private clinic
1 (1.5)
District hospital
11 (15)
Referral hospital
24 (33)
RSSB ¼ Rwanda Social Security Board.
Outcomes The median number of days from first symptom to surgery was 7.3 d (IQR: 3.7-49.0). There was a significant difference between patients reporting at least 1 delay and those who did not report a delay (11.4 d versus 3.4 d, P < 0.001) (Table 4). The number of days was greater for general surgery patients than orthopedic patients (47.2 d, versus 6.0 d, P < 0.001). Based on a multiple linear regression, patients reporting barriers to seeking care had longer symptom duration than patients who did not report barriers when controlling for delays in reaching and receiving care (51.5 d, versus 5.7 d, P ¼ 0.01).
Discussion The present study examines patient-reported barriers to care and analyzes delays for patients undergoing orthopedic and general surgery procedures at a major referral hospital in Rwanda. It provides a new insight into patient pathways to surgical treatment that can help direct future initiatives. The most frequently reported barriers included patients not knowing care was needed, transportation issues, and surgical staff availability while delays seeking care had the largest impact on time from first symptom to surgery. General surgery patients had longer times from first symptom to surgery than orthopedic patients. This was similar to prior findings from Kenya that suggest general surgery was associated with longer disease durations than other specialties.15 A possible reason for this is the impact of care-seeking delays. Orthopedic injures often relate to easily identifiable external trauma, whereas general surgery patients exhibit ambiguous abdominal symptoms. This is supported by the fact that general surgery patients reported significantly more care-seeking barriers than orthopedic patients, with the most common barrier related to not knowing
152
j o u r n a l o f s u r g i c a l r e s e a r c h j u n e 2 0 2 0 ( 2 5 0 ) 1 4 8 e1 5 5
Table 3 e List of specific delays cited by patients. Delays Delays seeking care
Table 4 e Time to seek, reach, and receive care. N*
17
Traditional healer
10
Did not think doctor could help
6
Cost
6
Delay caused by family or friends
4
Thought it would take too long to get help
2
Travel issues
28 25
Travel not available
16
Travel cost
12
Travel time
7
Wanted second opinion
3
Didn’t think transfer was required
2
Cost of medical care
2
No caretaker to accompany patient
2
Insecurity
1
Delays receiving care Unavailable surgical staff
n
21
Did not think it was required
Delays reaching care
Time period
44 23
Total, median (IQR)
Seeking care Total time to seek care, days
73
0.5 (0, 1.5)
Patients with reported delays in seeking care, days
21
5 (1, 38)
Patients without reported delays in seeking care, days
52
0.0 (0, 0)
Reaching care Total time reaching care, days
73
1.6 (0.8, 11.9)
Patients with reported delays in reaching care, days
28
3.3 (1.5, 79.7)
Patients without reported delays in reaching care, days
45
0.9 (0.7, 6.1)
Receiving care Total time to receive care, days
73
2.25 (1, 5.2)
Patients with reported delays in receiving care, days
44
3.4 (1.4, 7.6)
Patients without reported delay in receiving care, days
29
1.4 (1, 3.3)
Total time from symptoms to surgery, days
73
7.3 (3.7, 46.7)
Unavailable surgical infrastructure
18
Patients with any reported delay, days
57
11.4 (4.7, 79.7)
Unable to access test or lab
14
Patients without any reported delay, days
16
3.4 (2.3, 4.9)
Cost
4
Unavailable test or lab
6
No staff available
5
No hospital bed available
6
Cost of surgery
5
Unable to purchase medications
5
Unknown
4
No caretaker to accompany patient
1
Patients reporting one or more delays
57
* Patients were counted as having experienced a delay at the given level based on presence of one or more delays during the time interval. Multiple delays may have been encountered by a single patient at any individual level.
care was needed. Furthermore, our findings support previously published results that delays seeking care have the largest impact on time to surgery when compared with delays reaching or receiving care.9,15-17 Programs focused on patient identification of dangerous physical symptoms and risk factors have been shown to encourage patients to seek care more promptly.18 Villages in Rwanda contain at least one community health worker who can provide basic nursing and health education. These community workers could be trained to provide additional educational programs. Other initiatives that may reduce barriers to seeking care include the use of mobile health applications to promote earlier and easier presentation to physicians.19,20 The mobile network coverage reaches 90% of the Rwandan population and mobile health applications have been used in prior initiatives.21,22 Efforts focused on reducing care-seeking delays have potential to have the largest impact on reducing time from first symptom to surgery.
IQR ¼ interquartile range.
Similar to other studies, travel availability and cost were noted as frequent barriers to reaching care.11,23-26 Patients spent a median of 1.6 d reaching the referral hospital and 38.5% reported a delay during this process. This is similar to previous findings from Rwanda.11 Improved transfer systems have been shown to provide a survival benefit for patients.24 To achieve these survival benefits, the Rwandan National Surgical, Obstetrics, and Anesthesia Plan (NSOAP) proposes several strategies focused on improving transfer pathways.27 A part of that plan is to create designated patient transfer pathways based on province and specific surgical need. The NSOAP also seeks to reduce delays in emergent surgical referrals. A prospective study in India suggests that this may be carried out by developing context-specific transfer protocols or checklist and processes for prioritizing patients.25 Another strategy to help Rwanda achieve its NSOAP goals is providing free interhospital transfers.23 Rwanda offers prehospital and interhospital transfer services with plans to have at least two ambulances per hospital, but cost remains a barrier to widespread utilization.11 The price for transfer depends on insurance type with patients responsible for a percentage of total fees. Studies are needed to develop cost-efficient and contextspecific protocols in order for Rwanda to achieve its NSOAP goals of reducing transfer delays. Another frequently referenced delay was the lack of available surgical staff emphasizing the need for improved surgical capacity.28-30 This barrier was not as frequently reported in a previous study.11 The discrepancy in findings may be explained by variations in staffing at referral hospitals
7 Readmission rates were based on follow-up interviews which were completed by n ¼ 40 patients. Length of hospital stay provided in median number of days. y
*
0 5
10 8
4 1
11 9
3
9.5 Length of hospital stayy
2 5 Readmission*
10
0
0 6
1 0
3 3
1 0
2 4
Mortality
1
6
1
Surgical site infection
0 14 10 4 2 12 14 Requirement of multiple procedures
General surgery, n ¼ 24 Patients reporting no delays in care, n ¼ 16 Patients reporting at least 1 delay in care, n ¼ 57 Total, n ¼ 73 Quality of care metrics
Table 5 e Quality of care metrics by reporting of delays, service, and mode of presentation.
Orthopedic surgery, n ¼ 49
Presented to the ED, n ¼ 58
Directly admitted, n ¼ 15
dworkin et al barriers to surgical care in kigali, rwanda
153
throughout the year and within different departments. The present study was performed during August and September, a common time for government-sponsored surgical outreach to district hospitals. This outreach is needed because most surgical staff in Rwanda work in referral hospitals.4 This, however, reduces staffing and may have contributed to delays noted in the study. The objectives of the Rwandan NSOAP include redistribution of surgical staff among district and referral hospitals as well as increasing the volume of outreach surgery.27 Our findings suggest that this may result in increased delays at referral centers. This could be prevented by increasing surgical staff in parallel with the NSOAP objectives. The Human Resources for Health (HRH) program, which partners the Ministry of Health with several U.S.-based institutions, addresses this need by assisting in surgical training.31,32 Human Resources for Health has helped train an estimated 4600 students in health careerelated fields including surgery.33 Increasing surgical staff will allow for additional support at district hospitals while preventing delays at referral centers. The secondary aim of this study was to determine the impact of delays on surgical outcomes. While reported barriers to care significantly prolonged time from first symptom to surgery, they were not associated with surgical outcomes. This is in contrast to previous studies that have found delays increase mortality and lead to poor outcomes for patients.34,35 The discrepancy may be related to the relatively small sample size and short follow-up used in this study. Future research specifically focused on surgical outcomes is needed to determine the impact of delays. This study contained a number of limitations. First, the survey examined patient-referenced delays, but self-reported surveys are subject to biases and incomplete knowledge.36 For example, patients were aware of delays due to OR availability, but not what factor specifically prevented treatment. Patientreported barriers to care are subjective findings which may vary based on the individual and additional barriers may exist. In addition, the scope of this study was limited to patients undergoing general and orthopedic surgical care at CHUK over a 3-wk period resulting in a limited sample size. It excluded patients waiting for surgery, unable to reach CHUK, and receiving surgical care elsewhere or at other times of the year. As such, variations due to seasonal factors were not considered and barriers to care at other health-care facilities were not investigated. Furthermore, differences between emergent and elective surgeries were not considered because the majority of cases were emergent. Finally, the study was subject to recall bias as patients were asked to think retrospectively about their pathway to surgery. To limit this, we excluded patients with symptoms before January 1, 2018. In conclusion, reported barriers in surgical care were associated with prolonged time to surgery with delays seeking care having the largest impact. Initiatives using community health workers to educate individuals could reduce these delays, especially among general surgery patients, and should be prioritized. Delays to reaching and receiving care were also frequently referenced. The Rwandan NSOAP has identified these as important areas for improvement. Our findings suggest that improved patient transfer pathways are necessary and may be achieved through the development of cost-
154
j o u r n a l o f s u r g i c a l r e s e a r c h j u n e 2 0 2 0 ( 2 5 0 ) 1 4 8 e1 5 5
efficient specialized protocols. In addition, while NSOAP objectives to redistribute surgical staff and increase district outreach are important, they would benefit from enhanced training capacity to avoid unintended delays. Further studies applying this survey tool to both district and referral hospitals in Rwanda should be conducted to improve generalizability and help optimize targeted interventions.
Acknowledgment This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution: D.M., C.T., and R.J. conceptualized the study and conducted literature reviews as well as prepared all necessary documents for institutional review board with input from N.F. All authors contributed to study design. D.M., C.T., H.J., and K.J. participated in collecting data with analysis and interpretation performed by D.M., C.T., and R.J. All authors contributed to writing the manuscript and production of figures and tables with edits provided by N.F. and R.J.All authors approved the final version.
Disclosure The authors have no disclosures or conflicts of interest to report.
Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jss.2019.12.045.
references
1. Meara JG, Andrew JM, Leather, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569e624. 2. Bickler SW, Weiser TG, Kassebaum N, et al. Global burden of surgical conditions. In: Essential surgery: disease control priorities. Washington, DC: World Bank; 2015. 3. Wong EG, Georges N, Mathieu CR, et al. Acute care surgery in Rwanda: operative epidemiology and geographic variations in access to care. Surgery. 2015;158:37e43. 4. Petroze RT, Reinou SG, Francine N, et al. Estimating operative disease prevalence in a low-income country: results of a Nationwide population survey in Rwanda. Surgery. 2013;153:457e464. 5. Rickard JL, Ntakiyiruta G, Chu KM. Identifying gaps in the surgical training curriculum in Rwanda through evaluation of operative activity at a teaching hospital. J Surg Educ. 2015;72:73e81. 6. Forrester JD, Forrester JA, Kamara TB, et al. Self-reported determinants of access to surgical care in 3 developing countries. JAMA Surg. 2016;151:257e263. 7. Ndayizeye L, Ngarambe C, Smart B, et al. Peritonitis in Rwanda: epidemiology and risk factors for morbidity and mortality. Surgery. 2016;160:1645e1656.
8. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38:1091e1110. 9. Calvello E, Skog A, Tenner A, et al. Applying the lessons of maternal mortality reduction to global emergency health. Bull World Health Organ. 2015;93:361e440. 10. Pilkington M, Situma M, Winthrop A, Poenaru D. Quantifying delays and self-identified barriers to timely access to pediatric surgery at Mbarara Regional referral hospital, Uganda. J Pediatr Surg. 2018;53:1073e1079. 11. Mpirimbanyi C, Abahuje E, Hirwa A, et al. Defining the three delays in referral of surgical emergencies from district hospitals to University teaching hospital of Kigali, Rwanda. World J Surg. 2019;43:1e9. 12. Petroze R, Nzayisenga A, Rusanganwa V, et al. Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg. 2012;158:37e43. 13. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)ea metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377e381. 14. Rwanda Social Security Board. 2019. Available at: http://www. rssb.rw/. Accessed February 6, 2019. 15. Poenaru D, Pemberton J, Cameron BH. The burden of waiting: DALYs accrued from delayed access to pediatric surgery in Kenya and Canada. J Pediatr Surg. 2015;50:765e770. 16. Kong VY, ChB M, Aldous C, et al. Understanding the reasons for delay to definitive surgical care of patients with acute appendicitis in rural South Africa. S Afr J Surg. 2014;52:2e5. 17. Gebrehiwot T, San Sebastian M, Edin K, Goicolea I. Health workers’ perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia. BMC Pregnancy Childbirth. 2014;14:137. 18. Snow J. Reducing the Burden of the Three Delays on Maternal Health in Timor-Leste. Presented at the health improvement projects, Timor-Leste. 2015. 19. Mechael P. Exploring Health Related Uses of Mobile Phones: An Egyptian Case Study. Public Health & Policy. London: London School of Hygiene and Tropical Medicine 264; 2006. 20. Bastawrous A, Armstrong MJ. Mobile health use in low- and high-income countries: an overview of the peer-reviewed literature. J R Soc Med. 2013;106:130e142. 21. Ruton H, Musabyimana A, Gaju E, et al. The impact of an mHealth monitoring system on health care utilization by mothers and children: an evaluation using routine health information in Rwanda. Health Policy Plan. 2018;33:920e927. 22. Musabyimana A, Ruton H, Gaju E, et al. Assessing the perspectives of users and beneficiaries of a community health worker mHealth tracking system for mothers and children in Rwanda. PLoS One. 2018;13:1e12. 23. Stewart BT, Gyedu A, Giannou C, et al. Consensus recommendations for essential vascular care in low- and middle-income countries. J Vasc Surg. 2016;64:1770e1779. 24. Boschini LP, Lu-Myers Y, Msiska N, et al. Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa. Injury. 2016;47:1118e1122. 25. Dye TD, Bogale S, Hobden C, et al. Complex care systems in developing countries: breast cancer patient navigation in Ethiopia. Cancer. 2010;116:577e585. 26. Kumar V, Khajanchi M, Raykar NP, et al. Waiting at the hospital door: a prospective, multicentre assessment of third delay in four tertiary hospitals in India. Lancet. 2015;385:S24. 27. The Rwandan Ministry of Health. National Surgical, Obstetrics, and Anesthesia Plan 2018e2024. Kigali, Rwanda: The Rwandan Ministry of Health; 2018. 28. Rickard J, Ntakiyiruta G, Chu K. Associations with perioperative mortality rate at a major referral hospital in Rwanda. World J Surg. 2016;40:784e790.
dworkin et al barriers to surgical care in kigali, rwanda
29. Caesar U, Karlsson J, Hansson E. Incidence and root causes of delays in emergency orthopaedic procedures: a single-centre experience of 36,017 consecutive cases over seven years. Patient Saf Surg. 2018;12:2. 30. Norton I, von Schreeb J, Aitken P, et al. Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters. Geneva, Switzerland: World Health Organization; 2013. 31. Rickard J, Ssebuufu R, Kyamanywa P, et al. Scaling up a surgical residency program in Rwanda. East Cent Afr J Surg. 2016;21:11e23. 32. Binagwaho A, Kyamanywa P, Farmer PE, et al. The human resources for health program in Rwandada new partnership. N Engl J Med. 2013;369:2054e2059.
155
33. Cancedda C, Cotton P, Shema J, et al. Health professional training and capacity strengthening through international academic partnerships: the first five years of the human resources for health program in Rwanda. Int J Health Policy Manag. 2018;7:1024e1039. 34. Ifesanya A, Ogundele O, Ifesanya J. Orthopaedic surgical treatment delays at a tertiary hospital in sub saharan Africa: communication gaps and implications for clinical outcomes. Niger Med J. 2013;54:420e425. 35. Maine RG, Kajombo C, Purcell L, et al. Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi. BJS Open. 2019;3:367e375. 36. Rosenman R, Tennekoon V, Hill L. Measuring bias in selfreported data. Int J Behav Healthc Res. 2014;2:320e332.