Trends in neurosurgical care in Western Uganda: an interrupted time series analysis

Neurosurg Focus. 2018 Oct;45(4):E15. doi: 10.3171/2018.7.FOCUS18270.


Objective: In addition to the rising burden of surgical disease globally, infrastructure and human resources for health remain a great challenge for low- and middle-income countries, especially in Uganda. In this study, the authors aim to explore the trends of neurosurgical care at a regional referral hospital in Uganda and assess the long-term impact of the institutional collaboration between Mulago National Referral Hospital and Duke University.

Methods: An interrupted time series is a quasi-experimental design used to evaluate the effects of an intervention on longitudinal data. The authors applied this design to evaluate the trends in monthly mortality rates for neurosurgery patients at Mbarara Regional Referral Hospital (MRRH) from March 2013 to October 2015. They used segmented regression and autoregressive integrated moving average models for the analysis.

Results: Over the study timeframe, MRRH experienced significant increases in referrals received (from 117 in 2013 to 211 in 2015), neurosurgery patients treated (from 337 in 2013 to 625 in 2015), and operations performed (from 61 in 2013 to 173 in 2015). Despite increasing patient volumes, the hospital achieved a significant reduction in hospital mortality during 2015 compared to prior years (p value = 0.0039).

Conclusions: This interrupted time series analysis study showed improving trends of neurosurgical care in Western Uganda. There is a steady increase in volume accompanied by a sharp decrease in mortality through the years. Multiple factors are implicated in the significant increase in volume and decrease in mortality, including the addition of a part-time neurosurgeon, improvement in infrastructure, and increased experience. Further in-depth prospective studies exploring seasonality and long-term outcomes are warranted.

Keywords: ARIMA = autoregressive integrated moving average; DGHI = Duke Global Health Institute; DUMC = Duke University Medical Center; GCS = Glasgow Coma Scale; ITS = interrupted time series; LMICs; MNRH = Mulago National Referral Hospital; MRRH = Mbarara Regional Referral Hospital; SSA = Sub-Saharan Africa; global neurosurgery; global surgery; low- and middle-income countries.

MeSH terms

  • Hospital Mortality / trends
  • Hospitals
  • Humans
  • International Educational Exchange
  • Internship and Residency*
  • Interrupted Time Series Analysis
  • Neurosurgery / education
  • Neurosurgical Procedures / education
  • Neurosurgical Procedures / mortality
  • Neurosurgical Procedures / trends*
  • North Carolina
  • Referral and Consultation / trends*
  • Retrospective Studies
  • Surgery Department, Hospital / trends
  • Uganda