A Geospatial Analysis of the Availability, Distribution, and Accessibility of Neurosurgical Facilities, Workforce, and Infrastructure in Nigeria; and Projection Towards 2050.

OBJECTIVE: There has been a modest but progressive increase in the neurosurgical workforce, training, and service delivery in Nigeria in the last 2 decades. However, these resources are unevenly distributed. This study aimed to quantitatively assess the availability and distribution of neurosurgical resources in Nigeria while projecting the needed workforce capacity up to 2050. METHODS: An online survey of Nigerian neurosurgeons and residents assessed the country's neurosurgical infrastructure, workforce, and resources. The results were analyzed descriptively, and geospatial analysis was used to map their distribution. A projection model was fitted to predict workforce targets for 2022-2050. RESULTS: Out of 86 neurosurgery-capable health facilities, 65.1% were public hospitals, with only 17.4% accredited for residency training. Dedicated hospital beds and operating rooms for neurosurgery make up only 4.0% and 15.4% of the total, respectively. The population disease burden is estimated at 50.2 per 100,000, while the operative coverage was 153.2 cases per neurosurgeon. There are currently 132 neurosurgeons and 114 neurosurgery residents for a population of 218 million (ratio 1:1.65 million). There is an annual growth rate of 8.3%, resulting in a projected deficit of 1113 neurosurgeons by 2030 and 1104 by 2050. Timely access to neurosurgical care ranges from 21.6% to 86.7% of the population within different timeframes. CONCLUSIONS: Collaborative interventions are needed to address gaps in Nigeria's neurosurgical capacity. Investments in training, infrastructure, and funding are necessary for sustainable development and optimized outcomes.

Locum Tenens Neurosurgery in the United States: A Medicare Claims Analysis of Outcomes, Complications, and Cost of Care.

BACKGROUND: The utilization of locum tenens physicians in the United States has risen significantly as a stopgap for clinical practice needs, particularly in rural and other underserved areas. The difficulty in hiring new physicians to remote hospitals has resulted in the dependence of these institutions on locum tenens coverage. Here, we assess the quality and cost of neurosurgical care between locum and non-locum neurosurgeons in the United States, the first study in our knowledge to do so. METHODS: A 5% random sample of the Medicare claims limited data set was queried for 2005-2011 for neurosurgical cases using International Classification of Diseases, Clinical Modification, 9th edition (ICD-9-CM) procedure codes for common cranial and spine procedures. Cases were divided into locum and non-locum groups using ICD modifier Q6. The association between locum care and 30-day surgical complications, disposition, and cost of care was evaluated. RESULTS: A total of 112,397 patients met inclusion criteria, with locum tenens practitioners involved in 164 (0.15%) cases. Locum and non-locum cohorts were statistically and clinically similar at baseline, with respect to comorbidity and case type. Mortality (0.00% vs. 0.19%; P=0.739), discharge disposition (P=0.739), surgical complication rates, and length of stay (8.74 ± 12.24 vs. 10.54 ± 15.51 days; P = 0.117) did not appear to differ significantly between the 2 groups. Hospitalization costs were also similar (158,780.20 ± 223,735.50 vs. 168,104.40 ± 308,074.90 USD; P = 0.698), as were amounts paid by patients (39,197.70 ± 14,144.75 vs. 39,234.36 ± 15,467.63 USD, P = 0.976). CONCLUSIONS: Among Medicare beneficiaries, there exists no difference in short-term complication rates, lengths of hospitalization, or costs between locum and non-locum neurosurgeons.

Reappraising Neurosurgical Residency in Nepal-Stepping Stone for Paradigm Shift from Its Current Perspectives.

BACKGROUND: Nepal has a critical shortage of health workers for achieving its projected sustainable development goals pertaining to its health sector. METHODS: To counteract this crisis and reduce the morbidity and mortality associated with untreated brain injuries secondary to inadequate access, it is pivotal to generate solutions through the establishment of improved educational and training objectives. Objectives must align themselves with achieving equitable access to neurologic health. To that end, the cadre of health professionals able to treat neurologic disease should be sharply skilled and increased in number. We outline potential sustainable solutions at the training level to address this public health problem. RESULTS: Demanding and limitless working hours, burnout, social stressors, and minimal monthly stipend likely contribute to limited applications for neurosurgery residency programs. Measures should be taken to improve participation and access to extracurricular nonwork activities so as to improve resident well-being and avoid burnout. Moreover, gender inequality has also become a matter of concern as there were no females among 31 new specialist registrations in neurosurgery in 2017 and only 5 female neurosurgeons in practice to date in Nepal as per the NMC registration. CONCLUSIONS: Every effort should be directed toward honing the "value of neurosurgeon" among residents and promoting and nurturing their capabilities thereby maximizing sustainability in our health care system.

Takeoff of African Neurosurgery and the World Federation of Neurosurgical Societies Rabat Training Center Alumni.

The World Federation of Neurosurgical Societies (WFNS) Rabat Training Center was established in 2002 following the efforts of Dr. Abdeslam El Khamlichi. This institution has paved the way to guide tremendous change and to improve neurosurgery training in Africa, especially Sub-Saharan Africa (SSA). The center has enabled so far the training of more than 58 neurosurgical candidates, from approximately 18 countries in SSA, including 30 neurosurgeons who are already back in their respective countries, establishing and improving neurosurgical care. It is clear that this is the first successful example of the WFNS in increasing the neurosurgical workforce in SSA by well-trained and competent neurosurgeons. Consequently, this experience is worth depicting. We reviewed the profile of the neurosurgeons trained in this center and shortly summarized their reestablishment in their respective countries and their challenges to provide neurosurgical care in such source-limited countries.

Essential Neurosurgical Workforce Needed to Address Neurotrauma in Low- and Middle-Income Countries.

BACKGROUND: Among all trauma-related injuries globally, traumatic brain injury (TBI) and traumatic spine injury (TSI) account for the largest proportion of cases. Where previously data was lacking, recent efforts have been initiated to better quantify the extent of neurotrauma in low- and middle-income countries (LMICs). This information is vital to understand the current neurosurgical deficit so that resources and efforts can be focused on where they are needed most. The purpose of this study is to determine the minimum number of neurosurgeons to address the neurotrauma demand in LMICs and evaluate current evidence to support facility needs so that policy-based recommendations can be made to prioritize development initiatives to scale up neurosurgical services. METHODS: Using existing data regarding the incidence of TBI and TSI in LMICs and current neurosurgical workforce and estimates of case load capacity, the minimum number of neurosurgeons needed to address neurotrauma per population was calculated. Evidence was gathered regarding necessary hospital facilities and disbursement patterns based on time needed to intervene effectively for neurotrauma. RESULTS: There are 4,897,139 total operative cases of TBI and TSI combined in LMICs annually. At minimum, there needs to be 1 neurosurgeon only performing neurotrauma cases per approximately 212,000 people. Evidence suggests that patients should be within 4 hours of a neurosurgical facility at the very least. CONCLUSIONS: The development of neurotrauma systems is essential to address the large burden of neurotrauma in LMICs. The minimum requirements for neurosurgical workforce is 1 neurotrauma surgeon per 212,000 people.

Pediatric neurosurgical workforce, access to care, equipment and training needs worldwide.

OBJECTIVE: The presence and capability of existing pediatric neurosurgical care worldwide is unknown. The objective of this study was to solicit the expertise of specialists to quantify the geographic representation of pediatric neurosurgeons, access to specialist care, and equipment and training needs globally. METHODS: A mixed-question survey was sent to surgeon members of several international neurosurgical and general pediatric surgical societies via a web-based platform. Respondents answered questions on 5 categories: surgeon demographics and training, hospital and practice details, surgical workforce and access to neurosurgical care, training and equipment needs, and desire for international collaboration. Responses were anonymized and analyzed using Stata software. RESULTS: A total of 459 surgeons from 76 countries responded. Pediatric neurosurgeons in high-income and upper-middle-income countries underwent formal pediatric training at a greater rate than surgeons in low- and lower-middle-income countries (89.5% vs 54.4%). There are an estimated 2297 pediatric neurosurgeons in practice globally, with 85.6% operating in high-income and upper-middle-income countries. In low- and lower-middle-income countries, roughly 330 pediatric neurosurgeons care for a total child population of 1.2 billion. In low-income countries in Africa, the density of pediatric neurosurgeons is roughly 1 per 30 million children. A higher proportion of patients in low- and lower-middle-income countries must travel > 2 hours to seek emergency neurosurgical care, relative to high-income countries (75.6% vs 33.6%, p < 0.001). Vast basic and essential training and equipment needs exist, particularly low- and lower-middle-income countries within Africa, South America, the Eastern Mediterranean, and South-East Asia. Eighty-nine percent of respondents demonstrated an interest in international collaboration for the purposes of pediatric neurosurgical capacity building. CONCLUSIONS: Wide disparity in the access to pediatric neurosurgical care exists globally. In low- and lower-middle-income countries, wherein there exists the greatest burden of pediatric neurosurgical disease, there is a grossly insufficient presence of capable providers and equipped facilities. Neurosurgeons across income groups and geographic regions share a desire for collaboration and partnership.

Geographic proximity to specialized pediatric neurosurgical care in the contiguous United States.

OBJECTIVE Absent from an analysis of supply is consideration of the geographic distribution of pediatric neurosurgeons. Several patient socioeconomic metrics are known to be associated with outcome in pediatric neurosurgical diseases, such as hydrocephalus. The purpose of this study was to determine current geographic proximity to pediatric neurosurgical care using professional society databases. This study also sought to establish how socioeconomic factors are related to distance to care, using federal government-collected data. METHODS A list of currently practicing American Board of Pediatric Neurological Surgery (ABPNS)-certified neurosurgeons was compiled (ABPNS group). A separate list of practicing members of the Joint Pediatric Section (JPS) of the American Association of Neurological Surgeons/Congress of Neurological Surgeons was prepared (JPS group). Current primary practice locations were collected from each professional society database for each ABPNS or JPS neurosurgeon and were charted using ArcGIS mapping software (ESRI, version 10.3) on a United States Census Bureau map. The straight distance from the centroid of each zip code tabulation area (ZCTA) to the nearest neurosurgeon was determined by group type of neurosurgeon (ABPNS vs ABPNS + JPS). ZCTA-level data on demographic and socioeconomic factors were acquired from the American Community Survey, including data in children and young adults (0-18 or 0-24 years old) and the general population. These data were compared by distance to care and by groups of neurosurgeons (Pearson's chi-square analysis; the threshold of significance was set at 0.05). RESULTS Three hundred fifty-five practicing neurosurgeons providing pediatric care were located, of whom 215 surgeons were certified by the ABPNS and 140 were JPS members only. The analysis showed that 1 pediatric neurosurgeon is in practice for every 289,799 persons up to the age of 24 years. The average distance between a ZCTA and the nearest pediatric neurosurgeon is 63.3 miles (SE 0.3, range 0.0-499.7 miles). Geographic analysis showed that 27.1% of children live farther than 60 miles from an ABPNS-certified neurosurgeon and 19.7% from either an ABPNS-certified neurosurgeon or a JPS member. ZCTAs with children who live farther than 60 miles from a neurosurgeon providing pediatric care had a marginally higher rate of uninsured children, a higher percentage of families with children living below the federal poverty level, and a higher proportion of persons living in rural areas compared with ZCTAs with children who live within 60 miles of care (p < 0.005 for each finding). CONCLUSIONS The results of this study indicate that there is considerable variation in proximity to pediatric neurosurgical subspecialty care by geographic region. In addition, there is a relationship between distance to neurosurgical care and socioeconomic indicators. Optimization of access to pediatric neurosurgical care may involve strategies to overcome long geographic distances, particularly in rural and underserved areas. Such areas may have disproportionately lower socioeconomic levels, which may further limit access to care and affect outcomes. Both the total number of pediatric neurosurgeons per pediatric population and their geographic distribution could be important in determining appropriate subspecialty supply factors (e.g., the number of accredited pediatric neurosurgical fellowship training programs), as well as being important drivers of neurosurgical patient outcomes.

Epilepsy services in Saudi Arabia. Quantitative assessment and identification of challenges.

OBJECTIVE: To assess the epilepsy services and identify the challenges in hospitals without epilepsy monitoring units (EMUs). In addition, comparisons between governmental and private sectors, as well as between regions, are to be performed. METHODS: A cross sectional study conducted using an online questionnaire distributed to the secondary and tertiary hospitals without EMUs throughout the Kingdom of Saudi Arabia (KSA). The study was conducted from September 2013 to September 2015 and regular updates from all respondents were constantly made. Items in the questionnaire included the region of the institution, the number of pediatric and adult neurologists and neurosurgeons along with their subspecialties, the number of beds in the Neurology Department, whether they provide educational services and have epilepsy clinics and if they refer patients to an EMU or intend to establish one in the future. RESULTS: Forty-three institutions throughout the Kingdom responded, representing a response rate of 54%. The majority of hospitals (58.1%) had no adult epileptologists. A complete lack of pediatric epileptologists was observed in 72.1% of hospitals. Around 39.5% were utilizing beds from internal medicine. Hospitals with an epilepsy clinic represented 34.9% across all regions and sectors. Hospitals with no intention of establishing an EMU represented 53.5%. Hospitals that did not refer their epileptic patients to an EMU represented 30.2%. CONCLUSION: Epilepsy services in KSA hospitals without EMUs are underdeveloped.

Global Neurosurgery: The Unmet Need.

Globally, the lack of access to basic surgical care causes 3 times as much deaths as HIV/AIDS, tuberculosis, and malaria combined. The magnitude of this unmet need has been described recently, and the numbers are startling. Major shifts in global health agenda have highlighted access to essential and emergency surgery as a high priority. A broad examination of the current global neurosurgical efforts to improve access has revealed some strengths, particularly in the realm of training; however, the demand grossly outstrips the supply; most people in low-income countries do not have access to basic surgical care, either due to lack of availability or affordability. Projects that help create a robust and resilient health system within low- and middle-income countries require urgent implementation. In this context, concurrent scale-up of human resources, investments in capacity building, local data collection, and analysis for accurate assessment are essential. In addition, through process of collaboration and consensus building within the neurosurgical community, a unified voice of neurosurgery is necessary to effectively advocate for all those who need neurosurgical care wherever, whenever.