Barriers to neurotrauma care in low- to middle-income countries: an international survey of neurotrauma providers

Saniya Mediratta MBBS, MRCS1,2, Jacob R. Lepard MD3,4, Ernest J. Barthélemy MD, MA, MPH4,5, Jacquelyn Corley MD4,6, and Kee B. Park MD, MPH4
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  • 1 Faculty of Medicine, Imperial College London, South Kensington Campus, London;
  • | 2 NIHR Global Health Research Group on Neurotrauma, University of Cambridge, United Kingdom;
  • | 3 Department of Neurosurgery, University of Alabama at Birmingham, Alabama;
  • | 4 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts;
  • | 5 Department of Neurosurgery, Mount Sinai Health System, New York, New York; and
  • | 6 Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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OBJECTIVE

Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers.

METHODS

The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk.

RESULTS

Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region.

CONCLUSIONS

While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.

ABBREVIATIONS

AFR = Africa Region; AMR-L = Region of the Americas–Latin America; AMR-US/Can = Region of the Americas–United States and Canada; EMR = Eastern Mediterranean Region; EUR = Europe Region; GDP = gross domestic product; HIC = high-income country; ICC = intraclass correlation coefficient; LIC = low-income country; LMICs = low- to middle-income countries; MIC = middle-income country; NSOAP = National Surgical, Obstetric, and Anesthesia Plan; SEAR = Southeast Asia Region; TBI = traumatic brain injury; TSI = traumatic spine injury; WHO = World Health Organization; WPR = Western Pacific Region.

Supplementary Materials

    • Supplementary Tables and Figure (PDF 547 KB)

Schematics of transseptal interforniceal resection of a superiorly recessed colloid cyst. ©Mark Souweidane, published with permission. See the article by Tosi et al. (pp 813–819).

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