Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines

Abstract

Objective: The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden.

Methods: Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes.

Results: Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P = 0.01).

Conclusions: This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons.

Keywords: BMC, Bicol Medical Center; CI, Confidence interval; CT, Computed tomography; GCS, Glasgow Coma Scale; Global health; Global neurosurgery; HIC, High-income country; ICU, Intensive care unit; LMIC; LMIC, Low- and middle-income country; MS, Mother Seton Hospital; Neurotrauma; OR, Odds ratio; TBI, Traumatic brain injury; TS, Task-sharing; TS/S, Task-shifting and task-sharing; Task-sharing; Task-shifting; Workforce.

Figure 1

Craniotomy kit at Bicol Medical Center. In many low- and middle-income countries, a hand-crank Hudson-Brace is used with a Gigli saw (not pictured) to make burr holes to complete the craniotomy, compared with a power drill in high-income countries.

Figure 2

Emergency craniotomy for an emergency epidural hematoma evacuation. A general surgery resident uses a Gigli saw to complete the craniotomy after consulting with the local neurosurgeon, who was concurrently resecting a brain tumor.

Figure 3

A theoretical task-sharing model. Ideally, task-sharing would involve structure in the 3 phases of training, practice, and maintenance of providers.

Figure 4

The Bicol Region task-sharing model. The program is depicted in the 3-phase format of training, practice, and maintenance of providers provided in Figure 1. Green text indicates consistency with an ideal task-sharing model, whereas yellow is partially consistent and red is missing or can be improved.