Abstract
District hospitals (DHs) care for the majority of surgical patients in Malawi, but data on district hospital surgical capacity are limited. We sought to evaluate the management and outcomes of surgical patients presenting to Salima District Hospital (SDH) in Malawi. Using the SDH surgery registry, we compared patients managed operatively and those non-operatively and performed logistic regression to identify factors associated with operative management. We then compared cases performed at SDH with procedures recommended to be performed at DHs. We included 1374 patients, of whom half were managed operatively. The most common procedures performed were abscess drainage and wound debridement. Logistic regression analysis revealed that patients with abdominal diagnoses were least likely to be treated operatively. Though SDH performs most procedures recommended for the district hospital level, patients requiring laparotomies were most likely to be transferred to a referral hospital. Future studies should assess barriers to performing laparotomies at SDH.
Keywords
Introduction
Surgery has gained recognition as a crucial component of global public health, but an estimated 5 billion people still lack access to safe surgical or anaesthesia care. 1 Though the surgical volume is increasing worldwide, this growth is mainly in high-income countries, and patients in low- and middle-income countries (LMICs) remain disproportionately affected by barriers to care. 2 In Sub-Saharan Africa (SSA) alone, over 20 million DALYs and 300,000 deaths could be averted per year if essential surgical services were widely available. 3
District hospitals (DHs) are the lowest level hospitals that provide major surgery and are theoretically the primary location for providing surgical care for 80% of patients in SSA. 4 According to the Lancet Commission on Global Surgery (LCoGS), DHs should perform 80–90% of all essential surgical procedures. 1 This recommendation is based on the premise that if the Bellwether Procedures (laparotomy, and Caesarean section) can be performed, the hospitals will have the resources to perform most other essential surgery.1,5 However, evidence from SSA suggests that while DHs commonly perform Caesarean sections, they perform few laparotomies.6–9 Limited access to major surgery at DHs results in high transfer rates to referral hospitals, delaying care, and overburdening facilities designed to care for more complex patients.4,9 Moreover, if the transfer cannot be arranged, a patient may simply never receive needed treatment. 4
The combination of significant unmet needs and relatively limited capacity for surgical care at DHs has made scaling up surgery at DHs a priority.1,10 However, evidence of this is broadly lacking.10,11 We sought to describe the surgical scope and volume at Salima District Hospital (SDH) in Malawi and identify factors associated with receiving surgery at SDH.
Methods
Malawi, a low-income country in Sub-Saharan Africa, has 26 DHs and four tertiary hospitals. 12 Salima District Hospital (SDH) is a 100-bed district hospital in Central Malawi with one operating theatre but no intensive care unit (ICU). No consultant general surgeon is present at SDH, and surgical care is available 24 h per day and is provided by trained clinical officers and nurse anesthetists. 9 Clinical Officers complete three years of clinical medicine training followed by two years of surgical training. 9 In theory, surgical patients needing more advanced procedures are transferred to Kamuzu Central Hospital (KCH), a tertiary hospital in Lilongwe, Malawi.
An acute care surgery (ACS) registry was developed at SDH in June 2018. Registry data variables include patient demographics, clinical characteristics, management, and outcomes. All patients presenting to SDH with a general surgical complaint are prospectively entered into the database by trained staff and followed throughout their admission. The registry does not include patients with traumatic injuries.
We performed a retrospective analysis of the SDH ACS registry from June 2018 to June 2021. We recorded baseline demographics, comorbidities, admission vitals, diagnosis, operative intervention, type of operation if performed, and outcome (discharged, transferred to KCH, or died) for each patient, without exclusions, except those who died in the Casualty Department, or were discharged directly from the casualty department, or were missing information on admission or treatment.
We used bivariate analysis to compare patient characteristics by treatment type, stratified into operative or nonoperative management. We used Pearson's chi-squared test or Fisher's exact test to evaluate differences in proportions and Student's t-test to evaluate differences in means. We created a logistic regression model to assess factors associated with operative management at SDH. All variables significantly associated with treatment type were considered for inclusion in the model, and a change in estimate approach was used to build the model. We then performed a subgroup analysis including only patients who had a clear indication for surgery. Patients were deemed to have an indication for surgery if they either underwent surgery at SDH or were transferred to KCH for surgical management.
Finally, we qualitatively compared the procedures performed at SDH with procedures included in three sources that provide differing perspectives on surgical care at DHs: O’Neill et al.'s publication describing the Bellwether Procedures using data from the World Health Organization Emergency and Essential Surgical Care database, 5 a survey on which surgical procedures should be performed at the district hospital level administered to attendees of the 2018 College of Surgeons of East Central and Southern Africa conference, 13 and Volume 1 (Essential Surgery) of Disease Control Priorities, 3rd edition. 14 For our comparison, we only included procedures from these sources if the procedure would be expected to be captured in the SDH ACS registry. We did not evaluate most obstetric, gynaecological, orthopaedic, trauma, burn, or anaesthesia procedures.
We performed all data analysis using STATA (release 17, College Station, TX: StataCorp LLC). The Malawi National Health Research Committee and the University of North Carolina approved our study.
Results
A total of 1714 patients were entered into the SDH ACS database during the study period. We excluded 57 patients discharged from the Casualty Department, 15 patients with missing information on admission, and one patient who died in the Casualty Department. We excluded an additional 267 patients who were missing treatment data (whether surgery was performed or type of surgery performed) and ultimately included 1374 patients in the study.
The mean (SD) age in the overall cohort was 33.9 (22.2) years; 66.4% were male (Table 1). The most common admission diagnoses were skin and soft tissue infections (561, 42.5%), followed by inguinal hernias (196, 14.8%). At least one comorbid condition was present in 14.3%, and 28.5% were transferred to SDH from another facility. About half (689, 50.1%) underwent surgery at SDH. On bivariate analysis, they were younger, less likely to have comorbid conditions, and less likely to be transferred from another facility to SDH. Admission diagnoses associated with non-operative management included intra-abdominal diagnoses, upper GI bleeds, and tumours (Figure 1). A total of 53 patients were missing data on admission diagnosis, and no patients were missing data on operative management.
Patient management by admission diagnosis.
Baseline patient characteristics by treatment type.
Other diagnoses include haemorrhoids, vaginal fistula, hydrocephalus, oesophageal fistula, paraphimosis, urethral bleeding, orchitis, faecal impaction, hypospadias, rectal prolapse, and cirrhosis.
A total of 168 patients (12.6% of the overall cohort) were transferred from SDH to KCH for further management; these included 150 patients who did not undergo surgery at SDH (22.6% of the nonoperative cohort) and 18 patients who did undergo surgery at SDH (2.7% of operative cohort). The mortality rate in the overall cohort was 1.7%, but mortality in the operative cohort was significantly lower than in the nonoperative cohort (0.9% versus 2.6%, p < 0.001).
In the logistic regression analysis, only two variables were significantly associated with the likelihood of operative management at SDH: unsurprisingly, direct admission to SDH (rather than transfer to SDH from another facility) and admission diagnosis (Table 2a). Compared with inguinal hernias, patients with skin and soft tissue infections were significantly more likely to undergo surgery at SDH (OR 2.55, 95% CI 1.78–3.63, p < 0.001). On the other hand, patients with intra-abdominal diagnoses (OR 0.05, 95% CI 0.03–0.10, p < 0.001) and tumours (OR 0.21, 95% CI 0.12–0.38, P < 0.001) were significantly less likely to undergo surgery.
Logistic regression model for predictors of operative management.
There were 847 patients in the subgroup analysis of patients with an indication for surgery. Of these, 689 (81.4%) underwent surgery at SDH, and 158 (18.6%) were transferred to KCH for surgical management. In the subgroup logistic regression model, admission diagnosis was the only variable significantly associated with operative management (Table 2b). Compared to inguinal hernias, patients with skin and soft tissue diagnoses were significantly more likely to undergo surgery at SDH (OR 9.27, 95% CI 3.52–24.41, p < 0.001). Patients with intra-abdominal diagnoses (OR 0.02, 95% CI 0.01–0.04, p < 0.001) and tumours (OR 0.17, 95% CI 0.07–0.41, p < 0.001) were significantly less likely to undergo surgery at SDH.
Logistic regression model for predictors of operative management among subgroup with surgical indication.
The most commonly performed procedures at SDH were incision and drainage of abscess or wound debridement (70.3%), followed by inguinal hernia repair (18.3%) (Table 3). This finding corresponds to skin and soft tissue infections and inguinal hernias being the two most common admission diagnoses. However, though intra-abdominal issues were the third most common diagnosis (13.0% of patients), laparotomies comprised only 1.9% of procedures performed.
Frequency of procedures performed at Salima District Hospital.
Upon comparison with our three chosen sources, we found that SDH performs most essential surgical cases recommended to be performed at DHs (Figure 2). The following procedures were included in all three sources. They were performed at SDH, indicating broad agreement about their performance at the DH level: laparotomy, appendicectomy, hernia repair, hydrocele repair, drainage of osteomyelitis, and major amputation. Procedures included in at least two of the three sources but not performed at SDH were cystostomy, removal of airway foreign body, surgical airway, and biopsy. Procedures performed at SDH but not included in any other lists were haemorrhoidectomy and paraphimosis reduction.
Comparison of procedures performed at SDH with recommended district hospital capacity.
Discussion
Our study found that SDH performs about 230 general surgical procedures per year and a significant association between admission diagnosis and the likelihood of surgical intervention. While SDH performs a range of surgical procedures, the only procedures performed frequently are incision and drainage, wound debridement, and hernia repairs. Patients with acute intra-abdominal pathology are significantly more likely to be transferred to KCH for surgical management. Only 13 laparotomies were performed at SDH during the three-year study period. Interestingly, the postoperative mortality rate of 0.9% in our study is much lower than the 2.1% reported in a large prospective study of surgical outcomes in 25 African countries. 15 The reasons for the lack of consistent performance of laparotomies at SDH may be attributable to facility-or system-level barriers to performing more complex or higher-risk cases at SDH or clinical officer experience and comfort.
Other studies have reported findings similar to ours. A survey of surgical care in DHs in Mozambique, Tanzania, and Uganda noted that the most common procedures performed are caesarean sections, wound-related procedures, and hernia repairs, with laparotomies being performed less frequently. 7 As seen at SDH, there were also very few reports of other procedures such as haemorrhoidectomy, prostatectomy, and vaginal fistula repair. 7 These findings question whether procedures performed so infrequently at the DH level may be more appropriately performed at central hospitals, though this has not been studied.
Another study from South Africa reported that of the nearly 4000 laparotomies performed in the Kwa-Zulu Natal Province during the study period, only 6% were performed at the DH level. 8 On the other hand, in a scoping review of surgical care in DHs in SSA, the three most common procedures reported by included studies were caesarean sections, laparotomies, and hernia repairs, indicating that some DHs perform laparotomies much more frequently than others.
The four procedures included in at least two of our three selected sources on DH capacity but not performed at SDH during the study period were cystostomy, removal of airway foreign body, surgical airway, and biopsy. As discussed in Disease Control Priorities, the most appropriate hospital level for a particular procedure may vary according to multiple systems- or facility-level factors. 14 At SDH specifically, it may be technically possible to perform a biopsy, but there is little point in doing so without adequate pathology facilities. On the other hand, it is likely worth evaluating further the feasibility of expanding surgical care at SDH to include surgical airway, cystostomy, and removal of airway foreign body.
One way to broaden the scope of surgery at SDH and reduce the number of patients transferred to KCH may be through the involvement of general surgeons. However, surgical outcomes appear similar whether surgeons or clinical officers perform procedures. If incentivized by the Ministry of Health, the regular presence of a general surgeon at a district hospital may play a significant role in increasing the volume and diversity of operative cases performed.16,17 In a Rwandan study, for example, patients presenting to a DH staffed by a general surgeon were 75% more likely to receive surgery than patients presenting to a DH staffed by a clinical officer. 16 In addition, surgeons operated on a significantly higher proportion of patients with intra-abdominal diagnoses, complicated hernias, and urological emergencies. In contrast, clinical officers operated primarily on patients with soft tissue infections. 16 Full-time staffing by a general surgeon may not be feasible in many areas due to severe workforce shortages, but intermittent supervision is a promising alternative. 18 A qualitative study of a Zambian surgical supervision programme reported that intermittently supervised clinical officers gained confidence in performing surgical procedures, began performing new operations, and transferred patients to central hospitals less frequently. 18 The programme also improved communication between DHs and central hospitals, and supervising surgeons began remotely consulting on cases in between periods of supervision. 18
Our study has several limitations. The analysis is inherently limited by its retrospective design, and unmeasured confounders may have influenced our findings. For most patients, we lacked information on other treatments that may have been provided, such as IV fluids, antibiotics, nasogastric tube drainage, and blood transfusion. Whether other treatments were administered may have affected management (surgical versus nonoperative) and outcomes. In addition, we excluded 267 patients because of missing treatment data. We also lacked information on specific reasons for non-operative management or transfer to KCH. The clinical officer's comfort level with a procedure is probably only one of many reasons that surgery may not be performed. Specifically, evaluating these reasons is essential to improving surgical capacity at SDH. In addition, we were unable to assess whether each patient included in the study had an indication for surgery. We compensated for this by performing a subgroup analysis that only included patients who underwent surgery at SDH or were transferred to KCH. However, it is possible that some transferred patients had inoperable pathology. Finally, we lacked information on the cause of death and post-discharge outcomes. For patients treated both operatively and nonoperatively, this information could provide important insight into strategies for improving care.
Conclusions
Despite being under-resourced and lacking a general surgeon, SDH can perform most general surgical procedures recommended at DHs, and mortality was low when patients received needed surgical care. Future studies should attempt to clarify why specific procedures are performed infrequently or not performed so that strategies can strengthen surgery at SDH. In particular, supervision of clinical officers by general surgeons has the potential to broaden the scope of surgery at SDH and reduce the need for transfer to KCH.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Fogarty International Center, (grant number D43TW009340).
