title: Acute care surgery in Rwanda: Operative epidemiology and geographic variations in access to care.
abstract: BACKGROUND
  Surgical management of emergent, life-threatening diseases is an important public health priority. The objectives of this study were to (1) describe acute care general surgery procedures performed at the largest referral hospital in Rwanda and (2) understand the geographic distribution of disease presentations and referral patterns.
  
  
  METHODS
  We performed a retrospective review of prospectively collected acute care surgery cases performed at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda between June 1 and December 1, 2011. Using Pearson's χ(2) test and the Fisher exact test, we compared cases originating from within Kigali and transfers from other provinces. Geospatial analyses also were used to further describe transfer patterns.
  
  
  RESULTS
  During the study period, 2,758 surgical interventions were performed, of which 25.6% (707/2,758) were general surgery operations. Of these, 45.4% (321/707) met the definition of acute care surgery. Only about one-third-32.3% (92/285)-of patients resided within Kigali, whereas about two-thirds-67.7% (193/285)-were transferred from other provinces. Most patients transferred from other provinces were younger than 18 years of age (40.4%; 78/193), and 83.0% (39/47) of patients older than 50 years of age originated from outside of Kigali. Specific operative indications and surgical procedures varied substantially between patients from Kigali and patients transferred from other provinces.
  
  
  CONCLUSIONS
  Emergency surgical conditions remain important contributors to the global burden of disease, particularly in low- and middle-income countries. Geographic variations exist in terms of operative diagnoses and procedures, which implies a need for improved access to surgical care at the district level with defined transfer mechanisms to greater-level care facilities when needed.
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada; Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada; Surgeons Overseas, New York, NY. Electronic address: evan.wong@mail.mcgill.ca.
authors.forename: Evan G
authors.initials: EG
authors.lastname: Wong
authors.affiliation: Department of Surgery, University of Rwanda, Kigali, Rwanda.
authors.forename: Georges
authors.initials: G
authors.lastname: Ntakiyiruta
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada; Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Mathieu C
authors.initials: MC
authors.lastname: Rousseau
authors.affiliation: Department of Surgery, University of Rwanda, Kigali, Rwanda.
authors.forename: Landouald
authors.initials: L
authors.lastname: Ruhungande
authors.affiliation: Surgeons Overseas, New York, NY; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Surgery, Columbia University, New York, NY.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Kushner
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada.
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Liberman
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada.
authors.forename: Kosar
authors.initials: K
authors.lastname: Khwaja
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: Dakermandji
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada.
authors.forename: Marnie
authors.initials: M
authors.lastname: Wilson
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada; Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Tarek
authors.initials: T
authors.lastname: Razek
authors.affiliation: Department of Surgery, University of Rwanda, Kigali, Rwanda.
authors.forename: Patrick
authors.initials: P
authors.lastname: Kyamanywa
authors.affiliation: Department of Surgery, McGill University, Montreal, Quebec, Canada; Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Dan L
authors.initials: DL
authors.lastname: Deckelbaum
mesh_terms: D000208:Acute Disease / Q000453:epidemiology / Q000628:therapy*; D003906:Developing Countries; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012432:Rwanda / Q000453:epidemiology; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*