A. Godier-Furnemont1, M. Cheung2, N. Kakembo3, A. Nabirye3, H. Nambooze3, A. Yap1, P. Kisa3, A. Muzira3, J. Sekabira3, D. Ozgediz2 1Yale University,Medical School,New Haven, CT, USA 2Yale University,Department Of Surgery,New Haven, CT, USA 3Makerere University, Mulago Hospital,Department of Surgery,Kampala, Uganda
Introduction: The substantial backlog of pediatric surgery in resource-limited settings and associated economic consequences have not been measured but have been proposed as metrics for unmet need to aid capacity-building programs. We analyzed surgical conditions and access to definitive care at the national referral hospital, one of two centers with a dedicated pediatric surgery unit in Uganda. Secondarily we assessed economic burden of access to care on families.
Methods: A survey tool was designed, piloted, and validated. This was used to conduct a prospective study of children age 0-18 years presenting to the Mulago Hospital Pediatric Surgery Outpatient Clinic (PSOPC) and Ward June 1- August 31 2016 using convenience sampling.
Results: 313 PSOPC visits represented 263 unique patients (pts), and 81 inpatient visits were recorded. Median age of PSOPC pts was 1.5 yrs. 51% of pts previously visited another facility (Table 1). 36% of these made ≥2 visits before being referred to Mulago. 75% of PSOPC pts and 28% of Ward pts came from 2 surrounding districts. Median round-trip costs, travel time, and burden costs for pts are summarized in Table 1.
80% of PSOPC pts presented with a new concern; 12% for the next part of a staged surgery; 9% for post-operative follow-up. The most frequently seen conditions in the PSOPC were umbilical and inguinal hernias (13.7% and 12.9%, respectively), anorectal malformations (10.6%), masses (9.1%) and Hirschsprung’s disease (6.1%). Median time caregivers were aware of an inguinal hernia at the time of PSOPC presentation was 18 months. Median age of pts with inguinal hernias was 2.5 yrs; of pts awaiting anoplasty: 1 yr; awaiting colostomy closure: 1.8 yrs.
Of 240 PSOPC pts with a new issue or scheduled for surgery, 10% were admitted and 54% of these pts recovered or received surgery; surgery was postponed for 37.5%. The most cited reason for denial of admission from PSOPC was full ward capacity; pts were instructed to return to the PSOPC in a median of 4 wks.
Ward pts travelled further than PSOPC (median 1 vs. 2.5 hrs, p=0.003). 18% and 53% of PSOPC and ward pts, respectively, borrowed money for transport; 6% and 28%, respectively, sold assets for transport.
Conclusion: A minority of outpatients receive needed surgery at their first presentation to the PSOPC. Ward pts have a significantly higher transport cost burden and come from significantly farther away than outpts. Age at first presentation to the PSOPC, and at the time of surgery represent significant delays in accessing and receiving definitive care. Resource shortages such as limited operating space for elective cases contribute to significant backlogs. Infrastructure and capacity development are necessary to make progress in these areas.
