Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries

Robertson, Faith C.; Esene, Ignatius; Kolias, Angelos G.; Kamalo, Patrick; Fieggen, Graham; Gormley, William B.; Broekman, Marike L D; Park, Kee B.; Rosenfeld, Jeffrey V.; Ammar, Ahmed; Tisel, Magnus; Fuller, Anthony T.; Smith, Timothy R.; Mendez, Ivar; Brennum, Jannick; Honeybul, Stephen; Matsumara, Akira; Muneza, Sévérien; Rubiano, Andrés M.; Rosseau, Gail; Misra, Basant K.; Bolles, Gene; Adelson, David L.; Dempsey, Robert J.; Hutchinson, Peter J.; Aklilu, Abenezer Tirsit; Javier-Lizan, Abigail; Belhachmi, Adil; Khizar, Ahtesham; Taşcu, A.; Yalçınkaya, Ali; Ndajiwo, Aliyu Baba; Ukacjukwu, Alvan-Emeka; Agrawal, Amit; Thapa, Amit; Silva, Ana C.V.; Gretschel, Armin; Sukumaran, Arvind; Vats, Atul; Jarad, Bakr Abo; Karmacharya, Balgopal; Chaurasia, Bipin; Liew, B S; Arias, Carlos A. Rodriguez; Karekezi, Claire; Cohen-Inbar, Or; Sale, Danjuma; Kanesen, Davendran; Djilvesi, Djula; Nwaribe, Evarsitus; Mahmoud, MadihaR; Awais, Mian Muhammad; Kumar, Sanjay; Adeleye, Amos Olufemi; Agarwal, Manoj K.; Nkeshimana, Menelas; Achebe, Sunday David Ndubuisi; Gaddafi, Walid El; Uysal, Ece; Morgan, Eghosa; Buno, Elubabor; Sunday, Emmanuel; Adefris, Esayas; Alelyani, Fayez; Constanzo, Felipe; Longo, Gabriel S.; Farooq, Ghulam; Dunia, Goertz Mirenge; Bot, Gyang Markus; Shabani, Hamisi K.; Deora, Harsh; Almenshawy, Hassan; Kuheil, Hazem; Maldonado, Igor Lima; Negoi, Ionuț; Yousaf, Irfan; Abdullah, Jafri Malin; Golubović, Jagoš; Ayadi, Khalil; Limpastan, Kriengsak; Jokonya, Luxwell; Hodzic, Mirsad; Kassem, Mohamed; Al-Rawi, Mohammed; Tariq, Muhammad; Mykola, Vyval; Balak, Naci; Abuhadrous, Nidal; Syrmos, Nikolaos; Alser, Osaid; Young, Paul H.; Wahjoepramono, Petra Octavian Perdana; Sriram, Prabu Rau; Ouchetati, Rafik; Basaran, Recep; Bhoot, Ritesh; Amorim, Robson Luís Oliveira de; Iliƒá, Rosanda; Wadanamby, Saman; Fetene, Samuel M.; Behari, Sanjay; Babu, Satish; Khan, Tariq; Duong, Trung Kien; Laeke, Tsegazeab; Kanmounye, Ulrick Sidney; Komar, Vladimir; George, Ipe Vazheeparambil; Hussain, Zahid; Lucena, Lynne Lourdes N.; Mbaki, Hugues Brieux Ekouélé; Kumwenda, Ken-Keller; Bah, Djvnaba; Efe, Ibrahim E.; Bandoh, Dickson; Aji, Yunus Kuntawi; Dakurah, Thomas

doi:10.1016/j.wnsx.2019.100059

Cited by 27 publications

(17 citation statements)

References 19 publications

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“…It is highly likely that the vast majority of neurosurgical procedures performed by general surgeons in low-and middle-income countries go unreported in the literature. This is emphasised by results of a survey published in 2020 finding ''task-sharing'' or ''task-shifting'' for neurosurgery occurred in at least 20 low-and middle-income countries, especially in emergency situations [22]. Nevertheless, this review provides the most up to date and complete summary of the literature.…”

Section: Discussionmentioning

confidence: 97%

Emergency Neurosurgery Performed by General Surgeons: A Systematic Review

et al. 2021

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Background In under-resourced settings, general surgeons may be called upon to perform emergency operations within other specialties. Accordingly, we aimed to characterise patient outcomes after emergency neurosurgery performed by a general surgeon or general surgery trainee. Methods PubMed, Embase and the Cochrane Library were searched to 30 May 2021 for observational studies reporting outcomes after emergency neurosurgery performed by a general surgeon. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, mortality rates and complications were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42021258097. Results From 632 records, 14 retrospective observational studies were included, covering a total sample of 1,988 operations. Four studies were from Australia, and the remaining 10 were, respectively, from 10 other countries. Most common operations performed were decompressive surgery with burr holes or craniectomy for head trauma and insertion of intracranial pressure monitors. Rural hospitals were the most common settings. Mortality rates for procedures performed by general surgeons at latest follow-up were heterogenous, ranging from 5% for evacuation of chronic subdural haematoma in Kenya to 81% in head injured patients in a Hong Kong study. Conclusions This is the first systematic review that synthesises the literature to characterise patient outcomes after neurosurgical operations performed by a general surgeon. Findings from this study may benefit global surgery performed in rural, remote, military or humanitarian settings.

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Section: Discussionmentioning

confidence: 97%

Emergency Neurosurgery Performed by General Surgeons: A Systematic Review

et al. 2021

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“…The low economic impact is of great importance since this device could be particularly useful in low- and middle-income countries (LMICs), in which EVD placement is performed by non-neurosurgeons, mostly general surgeons, in remote areas where referral to neurosurgeons is time-consuming or impossible or the patients’ clinical conditions are worsening rapidly ( Robertson et al, 2019a , b , c ; Fuller et al, 2020 ). The aid of a simple guide for EVD placement could be of great benefit in those contexts, helping surgeons and improving outcomes.…”

Section: Discussionmentioning

confidence: 99%

Multimodal Simulation of a Novel Device for a Safe and Effective External Ventricular Drain Placement

et al. 2021

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BackgroundExternal ventricular drain (EVD) placement is mandatory for several pathologies. The misplacement rate of the EVD varies widely in literature, ranging from 12.3 to 60%. The purpose of this simulation study is to provide preliminary data about the possibility of increasing the safety of one of the most common life-saving procedures in neurosurgery by testing a new device for EVD placement.MethodsWe used a novel guide for positioning the ventricular catheter (patent RM2014A000376). The trajectory was assessed using 25 anonymized head CT scans. The data sets were used to conduct three-dimensional computer-based and combined navigation and augmented reality-based simulations using plaster models. The data set inclusion criteria were volumetric head CT scan, without midline shift, of patients older than 18. Evans’ index was used to quantify the ventricle’s size. We excluded patients with slit ventricles, midline shift, skull fractures, or complex skull malformations. The proximal end of the device was tested on the cadaver.ResultsThe cadaveric tests proved that a surgeon could use the device without any external help. The multimodal simulation showed Kakarla grade 1 in all cases but one (grade 2) on both sides, after right and left EVD placement. The mean Evans’ index was 0.28. The geometric principles that explain the device’s efficacy can be summarized by studying the properties of circumference and chord. The contact occurs, for each section considered, at the extreme points of the chord. Its axis, perpendicular to the plane tangent to the spherical surface at the entry point, corresponds to the direction of entry of the catheter guided by the instrument.ConclusionAccording to our multimodal simulation on cadavers, 3D computer-based simulation, 3D plaster modeling, 3D neuronavigation, and augmented reality, the device promises to offer safer and effective EVD placement. Further validation in future clinical studies is recommended.

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“…9,11 Because of this, underserved provinces in LMICs like the Philippines have resorted to task-sharing as a way to increase access to neurosurgical care. 44,45 While Japan boasts the best statistics with regard to the ratio of neurosurgeons to patients in the population, it is interesting to note that 28.9% of Japanese board-certified neurosurgeons consider the number of neurosurgeons in their country to be too low. 52 This is due to the fact that the care provided by Japanese neurosurgeons covers a broad range of services not limited to surgery, including disease prevention, neurointervention, radiation therapy, subacuteand chronic-phase treatment, and rehabilitation.…”

Section: In-service Residency and Fellowship Training For Improving Amentioning

confidence: 99%

“…13,19 It is imperative to convince governments through their health agencies and ministries that the neurosurgical disease burden has societal costs and leads to economic losses, and that investments for infrastructure development are therefore worthwhile. 43,45 Additionally, many of the leading causes of mortality in the populations of the region are relevant to the neurosurgeon. 15,16 Regardless of demographic differences, wherein HICs tend to have aging populations while LMICs have greater proportions of youth and children, certain subsets of the population will require neurosurgical care at some point.…”

Section: Health System Strengthening Increased Funding and Related mentioning

confidence: 99%

The state of neurosurgical training and education in East Asia: analysis and strategy development for this frontier of the world

Ferraris

Matsumura

Wardhana

et al. 2020

Neurosurgical Focus

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OBJECTIVEThe authors, who are from Indonesia, Japan, Malaysia, the Philippines, and Taiwan, sought to illustrate the processes of training neurosurgeons in their respective settings by presenting data and analyses of the current state of neurosurgical education across the East Asian region.METHODSThe authors obtained quantitative data as key indicators of the neurosurgical workforce from each country. Qualitative data analysis was also done to provide a description of the current state of neurosurgical training and education in the region. A strengths, weaknesses, opportunities, and threats (SWOT) analysis was also done to identify strategies for improvement.RESULTSThe number of neurosurgeons in each country is as follows: 370 in Indonesia, 10,014 in Japan, 152 in Malaysia, 134 in the Philippines, and 639 in Taiwan. With a large neurosurgical workforce, the high-income countries Japan and Taiwan have relatively high neurosurgeon to population ratios of 1 per 13,000 and 1 per 37,000, respectively. In contrast, the low- to middle-income countries Indonesia, Malaysia, and the Philippines have low neurosurgeon to population ratios of 1 per 731,000, 1 per 210,000, and 1 per 807,000, respectively. In terms of the number of training centers, Japan has 857, Taiwan 30, Indonesia 7, Malaysia 5, and the Philippines 10. In terms of the number of neurosurgical residents, Japan has 1000, Taiwan 170, Indonesia 199, Malaysia 53, and the Philippines 51. The average number of yearly additions to the neurosurgical workforce is as follows: Japan 180, Taiwan 27, Indonesia 10, Malaysia 4, and the Philippines 3. The different countries included in this report have many similarities and differences in their models and systems of neurosurgical education. Certain important strategies have been formulated in order for the system to be responsive to the needs of the catchment population: 1) establishment of a robust network of international collaboration for reciprocal certification, skills sharing, and subspecialty training; 2) incorporation of in-service residency and fellowship training within the framework of improving access to neurosurgical care; and 3) strengthening health systems, increasing funding, and developing related policies for infrastructure development.CONCLUSIONSThe varied situations of neurosurgical education in the East Asian region require strategies that take into account the different contexts in which programs are structured. Improving the education of current and future neurosurgeons becomes an important consideration in addressing the health inequalities in terms of access and quality of care afflicting the growing population in this region of the world.

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Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries

Cited by 27 publications

References 19 publications

Emergency Neurosurgery Performed by General Surgeons: A Systematic Review

Emergency Neurosurgery Performed by General Surgeons: A Systematic Review

Multimodal Simulation of a Novel Device for a Safe and Effective External Ventricular Drain Placement

The state of neurosurgical training and education in East Asia: analysis and strategy development for this frontier of the world

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