Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda

Nkurunziza, Theoneste; Toma, Gabriel; Odhiambo, Jackline; Maine, Rebecca; Riviello, Robert; Gupta, Neil; Habiyakare, Caste; Mpunga, Tharcisse; Bonane, Alex; Hedt‐Gauthier, Bethany

doi:10.1016/j.surg.2016.08.006

Cited by 41 publications

(62 citation statements)

References 22 publications

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“…Studies on health seeking behavior in sub-Saharan Africa have noted that delays to reaching definitive care can stem both from where and when patients seek care and challenges in systems of care [13]. These initial delays when combined with referral delays in reaching tertiary hospitals [14] can worsen patient outcomes. Because the majority of patients in our study had health insurance (95% of those with insurance information), which should facilitate access to care, sensitizing communities on the importance of early care seeking behavior, as well as implementing pro-active policies on health system strengthening that support travel to health facilities can minimize these delays [15].…”

Section: Discussionmentioning

confidence: 99%

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes

et al. 2017

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BackgroundManagement of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda.MethodsThis retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes.ResultsIn 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15–60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p < 0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p < 0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p < 0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died.ConclusionWhile acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients.

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Section: Discussionmentioning

confidence: 99%

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes

et al. 2017

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“…Additional challenges to identifying the burden of critical illness include vague and sometimes varying working definitions of ICUs and critically ill patients [1,39] and inconsistent ICU admission criteria across different settings, usually primarily driven by availability of ICU beds [37,40]. Moreover, the need for critical care is usually substantially underestimated due to barriers to access related to distance, lack of transportation, and cost [22,41]. Population-based estimates of the burden of critical illness in resource-limited settings are lacking [9].…”

Section: Challenges To Critical Care In Resource-limited Settings Gapmentioning

confidence: 99%

Global Critical Care: Moving Forward in Resource-Limited Settings

Dı́az

Riviello

Papali

et al. 2019

Annals of Global Health

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IntroductionCritical care is an important component of health care systems around the world (Figure 1). Caring for critically ill patients in resource-rich settings typically involves treatment in intensive care units (ICUs) staffed with highly specialized health care professionals, systematic monitoring and use of high-cost technology [1]. Unfortunately, these components are not always available in resource-limited settings [2, 3], where the burden of disease is greater [4], outcomes are poorer [5, 6], and local characteristics require context-specific approaches to the organization of critical care services.Critical care delivery, education, and research require a global perspective based on epidemiologic considerations. The burden of critical illness in resource-limited settings is not well described, but the best available estimates suggest that it may be greater than in resource-rich settings [7, 8] due to deficiencies in access to health care, emergency triage, and lack of early recognition [9][10][11]. Mortality for adults with sepsis [5, 12, 13] and acute respiratory distress syndrome (ARDS) [14][15][16] in resource-limited settings is higher than in resource-rich settings, and decedents are usually young (mean age 35 years vs. 61 years in United States) [12,17], which contributes to a greater negative downstream social and economic impact. Similarly, there is a higher burden of sepsis and respiratory infection mortality among children [18][19][20][21]. Recent epidemiological changes in global health have created a ' double burden of disease' to resource-limited settings [9,22] due to an increase in the prevalence of non-communicable diseases combined with lack of improvement in the long-recognized higher burden of communicable diseases, maternal and child mortality, malnutrition, and human immunodeficiency virus (HIV)-related complications.Health care professionals from resource-rich and resource-limited settings should take a global perspective on critical care for both ethical and practical reasons. Ethically, health care professionals, trainees, professional societies, non-governmental organizations (NGOs), and international organizations from resource-rich settings have the capacity of deploying resources to improve outcomes for critically ill patients in resource-limited settings [11,23,24]. Assistance can include financial help, knowledge exchange in the form of research and educational partnerships, and capacity building in operations and implementation science. From a practical point of view, supporting resource-limited settings is also important given that inter-related economies, Caring for critically ill patients is challenging in resource-limited settings, where the burden of disease and mortality from potentially treatable illnesses is higher than in resource-rich areas. Barriers to delivering quality critical care in these settings include lack of epidemiologic data and context-specific evidence for medical decision-making, deficiencies in health systems organization and resources, and in...

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“…Given similar inpatient services, the cost per bed‐day at tertiary hospitals is estimated to be two to five times higher than the equivalent at a district hospital22. In addition, the cost of patient transfers to tertiary hospitals can impoverish families22 or lead to delays in reaching care23 that can jeopardize patient outcomes. Although more expensive than anticipated, providing laparotomy at the district hospital is still likely to be the least costly option.…”

Section: Discussionmentioning

confidence: 99%

Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing

et al. 2018

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BackgroundIn low‐ and middle‐income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings.MethodsThis costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time‐driven activity‐based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices.ResultsOf 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent).ConclusionThe intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale‐up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location‐related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.

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Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda

Cited by 41 publications

References 22 publications

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes

Global Critical Care: Moving Forward in Resource-Limited Settings

Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing

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