The Operative Output of District Hospitals in KwaZulu‐Natal Province is Heavily Skewed Toward Obstetrical Care

Abstract

Introduction District hospitals are key to providing universal coverage of essential surgery and for strengthening surgical care in general. This audit set out to quantify the surgical output of all the district hospitals in KwaZulu-Natal Province (KZN) over a 6-month period to see whether district hospitals were delivering the surgical care they are expected to deliver. Results There were a total of 18,871 operations performed at 37 district hospitals in KwaZulu-Natal from July to December 2015. The number of operations per hospital varied widely between 2150 at a single large district hospital and 68 at a small district hospital, respectively. Surgical operations for obstetrical conditions made up by far the majority of operations at 57%, with gynecological operations making up the second highest at 15%. Only 12% of operations were for general surgical conditions. With regards to the bellwether procedures, 96.1% of these were cesarean sections, 2.1% were laparotomies and 1.8% were ORIFs. For almost all the 37 hospitals, the percentage of laparotomies and ORIFs performed was small to negligible, while the percentage of cesarean sections performed was high. The number of bellwether operations performed per 100,000 population was much higher than the number of general surgical or orthopedic operations performed, primarily because of the preponderance of cesarean sections conducted in each hospital. We observed a strong and significant positive correlation (?0.691, 95% CI ?0.538 to ?0.800, p \ 0.001) between increasing distance to nearest regional referral hospital and rate of laparotomies and ORIF procedures performed. Conclusions The surgical output of district hospitals in KZN is heavily skewed toward obstetrics and gynecology. Further work is required to understand the reasons for this, but the current data imply that district hospitals are not delivering surgical and orthopedic care at district hospitals in KwaZulu-Natal.

Bellwether operations in KwaZulu-Natal Province, South Africa, are performed at regional and tertiary rather than district hospitals

“…We have previously shown that the district hospitals of KZN perform CSs, but deliver the other two bellwether procedures to a very limited extent. [6] In that study, we found that a total of 18 871 operations were performed at 37 district hospitals in KZN from July to December 2015. [6] Of the bellwether procedures performed at these institutions, 96.1% were CSs, 2.1% were laparotomies and 1.8% were ORFs.…”

“…[6] In that study, we found that a total of 18 871 operations were performed at 37 district hospitals in KZN from July to December 2015. [6] Of the bellwether procedures performed at these institutions, 96.1% were CSs, 2.1% were laparotomies and 1.8% were ORFs. For almost all these district hospitals, the percentage of laparotomies and ORFs performed was small to negligible, while the percentage of CSs was high.…”

“…[3,4] Surgical services do not easily fit into this approach, however, as it is difficult to prevent surgical illness, and surgical care is by nature complex and reliant on a fairly advanced support infrastructure that must include anaesthesia, postoperative care and radiology services. [5,6] The LCOGS developed the concept of bellwether operations as a metric that uses information on a small number of procedures to provide an overview of the overall state of surgical care in a region. The idea was taken from the concept in politics of using the voting trend in a small geographical region to predict broader voting patterns.…”

“…A recent analysis of operations performed in the district hospitals in KwaZulu-Natal (KZN) Province, SA, showed that while CSs were commonly performed in all the public sector district hospitals in the province, almost no laparotomies or ORFs were being done in these institutions. [6] It was unclear from that original work where the nonobstetric bellwether procedures were being performed.…”

Soft Tissue Sepsis Places a Massive Burden on Regional and Tertiary Surgical Services in KZN Province South Africa

“…In South Africa, most soft tissue sepsis should be managed at the clinic or district hospital level [4,5]. Previous work has, however, suggested that the district surgical system in KZN is not functioning appropriately [10][11][12][13]. The district institutions do not seem to be delivering the so-called Bellwether procedures (laparotomy and ORIF) in a meaningful capacity, and there is evidence that rural patients with acute appendicitis who present to district hospitals have worse outcomes than those who present directly to higher levels of care [10][11][12][13].…”