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.

An Online Calculator for Predicting Academic Career Trajectory in Neurosurgery in the United States.

OBJECTIVE: Determining factors that predict a career in academic neurosurgery can help to improve neurosurgical training and faculty mentoring efforts. Although many academic career predictors have been established in the literature, no method has yet been developed to allow for individualized predictions of an academic career trajectory. The objective of the present study was to develop a Web-based calculator for predicting the probability of a career in academic neurosurgery. METHODS: The present study used data from neurosurgeons listed in the American Association of Neurological Surgeons database. A logistic regression model was used to predict probability of an academic career, and bootstrapping with 2000 samples was used to calculate an optimism-corrected C-statistic. P < 0.05 was considered statistically significant. RESULTS: A total of 1818 neurosurgeons were included in our analysis. Most surgeons were male (89.7%) and employed in nonacademic positions (60.2%). Factors independently associated with an academic career were female sex, attending a residency program affiliated with a top 10 U.S. News medical school, attaining a Doctor of Philosophy (PhD) degree, attaining a Master of Science (MS) degree, higher h-index during residency, more months of protected research time during residency, and completing a clinical fellowship. Our final model had an optimism-corrected C-statistic of 0.74. This model was incorporated into a Web-based calculator (https://neurooncsurgery.shinyapps.io/academic_calculator/). CONCLUSIONS: The present study consolidates previous research investigating neurosurgery career predictors into a simple, open-access tool. Our work may serve to better clarify the many factors influencing trainees' likelihood of pursuing a career in academic neurosurgery.

Regional, Racial, and Mortality Disparities Associated With Neurosurgeon Staffing at Level I Trauma Centers.

BACKGROUND: Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because neurosurgeons hold expertise in treating TBI, increased neurosurgical staffing may improve patient outcomes. We hypothesized that TBI patients treated at level I trauma centers (L1TCs) with ≥3 neurosurgeons have a decreased risk of mortality vs. those treated at L1TCs with <3 neurosurgeons. METHODS: The Trauma Quality Improvement Program database (2010-2016) was queried for patients ≥18 years with TBI. Patient characteristics and mortality were compared between ≥3 and <3 neurosurgeon-staffed L1TCs. A multivariable logistic regression analysis was used to identify risk factors associated with mortality. RESULTS: Traumatic brain injury occurred in 243 438 patients with 5188 (2%) presenting to L1TCs with <3 neurosurgeons and 238 250 (98%) to L1TCs with ≥3 neurosurgeons. Median injury severity score (ISS) was similar between both groups (17, P = .09). There were more Black (37% vs. 12%, P < .001) and Hispanic (18% vs. 12%, P < .001) patients in the <3 neurosurgeon group. Nearly 60% of L1TCs with <3 neurosurgeons are found in the South. Mortality was higher in the <3 vs. the ≥3 group (12% vs. 10%, P < .001). Patients treated in the <3 neurosurgeon group had a higher risk for mortality than those treated in the ≥3 neurosurgeon group (odds ratio (OR) 1.13, 95% confidence intervals (CI) 1.01-1.26, P = .028). DISCUSSION: There exists a significant racial disparity in access to neurosurgeon staffing with additional disparities in outcomes based on staffing. Future efforts are needed to improve this chasm of care that exists for trauma patients of color.

Current Workforce Status of the Neurosurgery Societies Belonging to the Latin American Federation of Neurosurgical Societies: A Survey of the Presidents of These Neurosurgery Societies.

BACKGROUND: The Latin American Federation of Neurosurgical Societies (FLANC) is a nongovernmental, nonprofit civil association, founded to promote neurosurgery in the Latin American countries. The American College of Surgeons and American Association of Neurological Surgeons has recommended a ratio of 1 neurosurgeon/100,000 inhabitants. We aimed to estimate the neurosurgical workforce of the FLANC in 2020. METHODS: We performed an internet-based survey of the presidents of the societies of the FLANC to obtain the neurosurgical workforce characteristics and demographics in their countries. We coded and blindly analyzed the information for dispersion measures and graphics using SPSS, version 25, and Microsoft Excel for map density building. We obtained ratios for the number of neurosurgeons/100,000 inhabitants and the inverse ratio (the number of inhabitants/1 neurosurgeon). RESULTS: We obtained information from 19 countries. The population totaled 650,008,765 inhabitants. The workforce included 9100 neurosurgeons for a composite within the FLANC of 1.4 neurosurgeons/100,000 inhabitants. The mean ratio among individual countries was 1.17, with as many as 9 countries having a ratio of <1 neurosurgeon/100,000 inhabitants. The proportion of female neurosurgeons in the FLANC was 9.54%. Seven countries had no neurosurgeons in a range of subspecialty fields. CONCLUSIONS: The FLANC has significant disparities in neurosurgical workforce ratios among the member countries. Central American countries probably have the greatest needs. Gender equity should also be improved among the training institutions. We encourage readers to develop future research into the local geographical distribution of neurosurgeons among the countries to better understand their needs and barriers to providing high-quality standards of care.

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.

An Analysis of Publication Productivity During Residency for 1506 Neurosurgical Residents and 117 Residency Departments in North America.

BACKGROUND: Bibliometrics is defined as the study of statistical and mathematical methods used to quantitatively analyze scientific literature. The application of bibliometrics in neurosurgery continues to evolve. OBJECTIVE: To calculate a number of publication productivity measures for almost all neurosurgical residents and departments within North America. These measures were correlated with survey results on the educational environment within residency programs. METHODS: During May to June 2017, data were collected from departmental websites and Scopus to compose a bibliometric database of neurosurgical residents and residency programs. Data related to authorship value and study content were collected on all articles published by residents. A survey of residency program research and educational environment was administered to program directors and coordinators; results were compared with resident academic productivity. RESULTS: The median number of publications in residency was 3; median h-index and Resident index were 1 and 0.17 during residency, respectively. There was a statistically significant difference in academic productivity among male neurosurgical residents compared with females. The majority of articles published were tier 1 clinical articles. Residency program research support was significantly associated with increased resident productivity (P < .001). Scholarly activity requirements were not associated with increased resident academic productivity. CONCLUSION: This study represents the most comprehensive bibliometric assessment of neurosurgical resident academic productivity during training to date. New benchmarks for individual and department academic productivity are provided. A supportive research environment for neurosurgical residents is associated with increased academic productivity, but a scholarly activity requirement was, surprisingly, not shown to have a positive effect.

Italian census on neurosciences: the ICoNe2 study.

BACKGROUND: The growing impact of the emergency neurology of trauma centers and of mechanical thrombectomy for the treatment of acute ischemic stroke is revolutionizing the domain of eurosciences. METHODS: A census focused on the demographic distribution of the three main cohorts of neurosciences (neurologists, neuroradiologists, and neurosurgeons) was conducted in Italy between December 2015 and February 2017, and results were compared to the estimated retirement rates and loss for other reasons. RESULTS: The total number of neurosciences specialists active in Italy was 4394 at the end of the period of the survey. The estimated retirement rates and losses seem not be supplied by the physicians in training in the same period. CONCLUSIONS: A proper redistribution of the resources and the modification of the training programs seem to be mandatory to maintain acceptable standards of care for the Italian neurosciences during the next decade.

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.

Neurosurgical Care: Availability and Access in Low-Income and Middle-Income Countries.

BACKGROUND: An estimated 5 billion people worldwide lack access to basic surgical care. In particular, the vast majority of low-income and middle-income countries (LMICs) currently struggle to provide adequate neurosurgical services. Significant barriers exist, including limited access to trained medical, nursing, and allied health staff; lack of equipment; and availability of services at reasonable distance and at reasonable cost to patients. An accurate assessment of current neurosurgical capacity in LIMCs is an essential first step in tackling this deficit. OBJECTIVE: To quantify the neurosurgical operational capacity and assess access to neurosurgical services in LMICs, by taking into account the location of workforce and services. METHODS: A total of 141 LMICs were contacted and asked to report the number of currently practicing neurosurgeons, access to computed tomographic and magnetic resonance imaging, and availability of neurosurgical equipment (microscope, endoscope, bipolar diathermy, high-speed neurosurgical drill). A proposed World Federation of Neurosurgeons classification was used to stratify cities based on the level of neurosurgical care that could be provided. The data were geocoded and analyzed in Redivis (Redivis Inc.) to assess the percentage of the population covered within a 2-hour travel time of a city offering differing levels of neurosurgical care. RESULTS: 68 countries provided complete data (response rate, 48.2%). Eleven countries reported having no practicing neurosurgeons. The average percentage of the population with access to neurosurgical services within a 2-hour window is 25.26% in sub-Saharan Africa, 62.3% in Latin America and the Caribbean, 29.64% in East Asia and the Pacific, 52.83% in South Asia, 79.65% in the Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia. CONCLUSIONS: There are several challenges to the provision of adequate neurosurgical services in low-resource settings. This study used mapping techniques to determine the current global neurosurgical workforce capacity and distribution. We have used our findings to identify areas for improvement. These include increasing and improving neurosurgical training programs worldwide, recruiting students and young physicians into the field, and retaining existing neurosurgeons within their home countries.

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.