Sources of delayed provision of neurosurgical care in a rural kenyan setting.
BACKGROUND
Delay to neurosurgical care can result in significant morbidity and mortality. In this study, we aim to identify and quantify the sources of delay to neurosurgical consultation and care at a rural setting in Kenya.


METHODS
A mixed-methods, cross-sectional analysis of all patients admitted to the neurosurgical department at Kijabe Hospital (KH) was conducted: A retrospective analysis of admissions from October 1 to December 31, 2013 and a prospective analysis from June 2 to June 20, 2014. Sources of delay were categorized and quantified. The Kruskal-Wallis test was used to identify an overall significant difference among diagnoses. The Mann-Whitney U test was used for pairwise comparisons within groups; the Bonferroni correction was applied to the alpha level of significance (0.05) according to the number of comparisons conducted. IBM SPSS version 22.0 (SPSS, Chicago, IL) was used for statistical analyses.


RESULTS
A total of 332 admissions were reviewed (237 retrospective, 95 prospective). The majority was pediatric admissions (median age: 3 months). Hydrocephalus (35%) and neural tube defects (NTDs; 27%) were most common. At least one source of delay was identified in 192 cases (58%); 39 (12%) were affected by multiple sources. Delay in primary care (PCPs), in isolation or combined with other sources, comprised 137 of total (71%); misdiagnosis or incorrect management comprised 46 (34%) of these. Finances contributed to delays in 25 of 95 prospective cases. At a median delay of 49 and 200.5 days, the diagnoses of hydrocephalus and tumors were associated with a significantly longer delay compared with NTDs (P < 0.001).


CONCLUSIONS
A substantial proportion of patients experienced delays in procuring pediatric neurosurgical care. Improvement in PCP knowledge base, implementation of a triage and referral process, and development of community-based funding strategies can potentially reduce these delays.
Division of Neurosurgery, Toronto Western Hospital, University Health Network, Hamilton, Canada ; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Hamilton, Canada ; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
Alireza
A
Mansouri
Division of Neurosurgery, Toronto Western Hospital, University Health Network, Hamilton, Canada.
Vivien
V
Chan
Department of Neurosurgery, AIC Kijabe Hospital, Kijabe, Kenya.
Veronica
V
Njaramba
Division of Neurosurgery, Toronto Western Hospital, University Health Network, Hamilton, Canada ; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Hamilton, Canada.
David W
DW
Cadotte
Department of Neurosurgery, AIC Kijabe Hospital, Kijabe, Kenya ; University of Wisconsin Health Center, Wisconsin, USA.
A Leland
AL
Albright
Division of Neurosurgery, Toronto Western Hospital, University Health Network, Hamilton, Canada ; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Hamilton, Canada ; The Greg Wilkins-Barrick Chair in International Surgery, Canada.
Mark
M
Bernstein
Delay; developing nations; neurosurgery; outcome; rural