The Quality Chasm Viewed Through the Lens of Neurosurgical Treatment of Aneurysmal Subarachnoid Hemorrhage
In this series of socioeconomically disadvantaged patients who survived the initial rupture of SAH and were treated with upfront surgical clipping, we report the late timing of surgery experienced by majority of them, the factors predictive of their poor outcomes, and the causes of delay that are specific in a low-resource setting. While many of these socioeconomic factors would be beyond the scope of usual clinical and neurosurgical practice, an awareness of the context allows the realization of the magnitude of systemic problems10 that are more prevalent in LMICs.11 From such knowledge, solutions could then be formulated. Although by no means exhaustive, we also proffer solutions broadly categorized into either micro-level interventions directed at clinical decision making or macro-level interventions directed at health systems.11,12 The example of our series of patients and the institutional and country contexts will now serve as focal points for our discussion.
Deliberate Upfront Clipping in Low-Resource Settings
Since the publication of long-term outcomes from seminal trials,13,14 patients with ruptured aneurysms ought to be offered the endovascular option for treatment. Emerging recommendations on standards of care, when situated in the context of financial constraints at both the provider and receiver ends of neurosurgical care, pose a negative experience of contrasts. The trend in developed countries is a rise in the use of endovascular treatment option, or at the very least an involvement of a multidisciplinary team for reaching a consensus on the initial course of treatment. This is not the case however in LMICs, where the costs of coils and modern devices are prohibitive—and there are still few specialists who could offer this treatment option.15 Providers of care regardless of specialty therefore commonly apprise the socioeconomically disadvantaged patients with the clipping option only. The socioeconomic context of our patient population does not constitute a justification to be accepted but rather becomes a reflection of the gap between current evidence and actual practice. Despite the realities, it is incumbent for decision makers, on behalf of the recipients of neurosurgical care whom they represent, to have the symmetry of information about the range of treatment options in order to provide the right informed consent. Expanding the workforce of endovascular neurosurgeons and neurointerventionalists—when coupled with systems-level public policy and use of competitive market forces16—also augurs well with increasing accessibility to this treatment option.
Late Timing of Surgical Clipping—A Symptom of Systemic Problems
Peculiar in our study setting would be the late time interval to surgery for the majority of the patients. Although the timing of surgery is not statistically significant—similar to what was found in studies with clipping as the exclusive intervention17,18,19,20,21—this remains a modifiable factor in the institutional or regional catchment setup of our center, partly because the delays are avoidable for the most part.
Variations in surgical care occur on various levels;8 the causes of which are mostly due to the locus of control of either the physician or the patient and relatives. Similar to the literature, several reasons for the delays were physician-related: physician diagnostic problems (37%) and delayed referral policy (23%) from the series of Kassell and colleagues,22 sending patient home or wrong diagnosis for at least one day in the diagnosis of SAH (26%) from the series of Hernesniemi and colleagues.23 Conversely, some of the delays in their series22,23 were patient-related: unstable patient condition, failure of patients to recognize severity of illness, logistical reasons, and untimely decisions by patients and relatives. These reasons are also commonplace in our setting, but the added problem of scarce resources further magnify the causes of delay.
Other than the causes beyond the level of the individual patient, it becomes essential to identify which of those factors might be amenable to modification from the perspective of the provider. For example, we have taken measures to institute an open-line network communication channel24 in order to improve inter-hospital coordination of transfers as well as pre-hospital management. Efforts have been made to address the timeliness of surgery by doing the surgical clipping beyond OR hours, even during the evenings, at which time the OR throughput is usually decreased. Often, when the workforce is adequate, it is the limitation of OR infrastructure that causes the bottleneck. Our data also illustrate the disparities from the expectations for timely and appropriate care of the patient with SAH in LMICs,25 where reasonable timeframes are often unmet especially in our setting. Much work remains to be done in order to improve efficiency and expand the capacity of under-resourced neurosurgical centers in meeting the demands of the increasing surgical volume.
Aside from the fact that many patients from our center’s catchment population live below the poverty threshold, the publicly-funded health system that is supposed to provide an enabling mechanism for them to receive proper neurosurgical care continues to be underfunded.26 This twin problem at both receiving and providing ends of the spectrum remains the perennial limitation in publicly-funded neurosurgical centers such as our setting. Late timing of surgical treatment is also an outward manifestation of a structural problem—it represents the magnitude of the fragmentation of a publicly-funded healthcare system. The financing of hospital-based inpatient services in the public setting are often limited by capitation-based reimbursements from the national social health insurance because the overall scarce resources of the national government are prioritized for population-based health programs.27 From our example of neurosurgical service delivery, the undersupply and depletion of relevant medical supplies such as aneurysm clips, arterial line, bone flap implants, and other surgical implements highlight the inefficiencies inherent in the procurement processes and supply chain management of government-funded centers of any health system.28,29,30 Improving systems-level governance31 and financial arrangements32 by streamlining how common neurosurgical supplies are purchased might improve access to care, and in turn health outcomes.11 Given that hemorrhagic stroke, including SAH, is one of the leading causes of mortality in the country,27 it becomes necessary to make essential neurosurgical care as one of the priorities for long-term capital expenditures and investments by the governing health sector.11
In those patients waiting for their ruptured aneurysm to be clipped, the future risk of poor outcome needs to be understood with respect to both the impact of the cerebral insult they initially had during ictus and the arguably increased likelihood of them avoiding other complications like vasospasm, nosocomial infection, and many other time-dependent factors like rebleeding and even hospitalization costs—some of which may be curtailed or avoided had they undergone an earlier surgery.33,34 While early aneurysm treatment remains to be recommended and is therefore preferred even in low-resource settings, this ideal still remains a daunting task to achieve.
Vasospasm and Intraoperative Rupture—Hardly Modifiable Factors
Our data identify vasospasm as an independent predictor of mortality. Rosengart and colleagues35 pointed out that while there are several studies that examined the factors associated with outcome prior to the era of widespread endovascular use, only 3 studies36,37,38 have sufficient study population to allow analysis of the effect of multiple independent factors. Our findings are consistent with reports from those studies, that vasospasm is an enduring predictor of unfavorable outcomes.35,37,38 Therefore, systems of care have to be responsive in diagnosing and treating this prophylactically and reversibly. This is not the case in our institution, where asymptomatic angiographic vasospasm may have been underdiagnosed and undertreated when compared to global state-of-the-art treatment, partly because of limitations of equipment and infrastructure,3 and the lack of endovascular treatment options.15 Notwithstanding the fact that neurointervention also grants the SAH patient with several options for the diagnosis and novel treatment of vasospasm—a risk factor predictive of mortality in this study—the increase in accessibility and availability of endovascular suites and care providers should fill a huge gap of the long unmet nationwide need for this niche of subspecialty care.
Our data also reveal intraoperative aneurysm rupture at the time of surgery as an independent predictor of mortality. Whereas other studies39,40,41 only identify it as significant factor for poor outcome, Batjer and colleagues41 went further to characterize it as largely dependent on specific microsurgical techniques employed by the aneurysm surgeon. The rapidity of rupture control, which reflects the dexterity of the primary surgeon, may be similarly as important as intraoperative rupture.39,42,43 At the time, the operating microscope for use during microneurosurgery was an old model (Fig. 2) that posed difficulties in maneuverability for quick responses during rupture. Considering that technical proficiency can be enhanced by judicious application of technology to operative imaging and visualization, equipment such as the operating microscope become invaluable tools that aid the neurosurgical procedures to become uneventful.
Regardless, our rates of unfavorable outcomes appear comparable to that of recent studies.44,45 The rates of unfavorable outcomes were 43.3% and 22%, while mortality rates were 18.4% and 5.9% in studies by Roquer et al.44 and Macdonald et al.45, respectively. Factors such as intraoperative rupture and vasospasm were similarly found to be independent predictors of poor outcomes in those studies,44,45,46 despite the fact that their contemporary series of patients had been given the option of treatment by both open surgical and endovascular means. Our experience, however, remains to stand in stark contrast to that of ideal well-resourced settings. The care of the patient with SAH becomes especially difficult when standards of care cannot be offered—often due to inadequate infrastructure and even lack of supply of medicines. Suboptimal pharmacologic treatment often occurs when the supply of nimodipine runs out in the pharmacy, requiring out-of-pocket expenditures from the family of the now unemployed breadwinner-patient with SAH. Other systems-related problems that are commonplace: a postop poor-grade patient who ideally requires ICU admission is instead cared for in the wards with a 1:20 nurse-to-patient ratio; or a neurologically deteriorating post-clipping patient who would have to be transported outside the hospital because the CT scanner has not been repaired for the longest time. These situations are testament to the fact that inadequate funding reduces the quality of care—and that addressing the problem of finite resources for neurosurgery in LMICs can have major effects on improving the outcomes of vulnerable patients.11
The Way Forward
Recognizing that social determinants of health47 can affect the health of a population, a systems approach to the problem-solving of delays, can improve outcomes of interventions to a large extent. Advocacy work for public health and hospital improvement is also needed therefore, in order to lower the barriers to care can address health inequities, particularly in terms of public-private investments in infrastructure and equipment.3,10,11 Preparing the needed workforce entails capacity-building and aligning of payment policies to serve the goal of quality and efficiency. All these must be entrenched in public policy and regulatory frameworks for sustainability and consistency,27 because after all, improvements in care processes result in better quality.
Limitations of the Study
The study excluded patients with presumptive or confirmed diagnosis of aneurysmal SAH but who died before hospital admission or aneurysm treatment. In as far as assessing outcomes of the delayed treatment group, there is also a high likelihood of survival bias. Long-term outcomes after discharge as well as surrogate end points such as post-clipping durability of treatment were not assessed due to lack of postoperative angiography. Additionally, the correlations of our study variables may have been under- or overrepresented because of the retrospective study design. All these constitute a selection bias. Other confounding factors may also be present despite our exhaustive list of variables. For example, we did not have data for potentially clinically-significant variables like duration of brain retraction and temporary occlusion time, due to limitations of data recording. Other variables that have not been found to be statistically significant in this present study, and yet are ordinarily considered to be clinically significant in majority of cases of SAH, remain potential topics for future intensive investigation.
The system-level causes of delay identified in this study were not subjected to statistical analyses. Certainly they have an effect in one way or another,11 but we did not demonstrate how these causes or even potential solutions may be strongly or weakly affective of outcomes. Studies that explore the link of nation-level indicators and indices to patient outcomes are recommended to fill this knowledge gap. We also hope that our experience of neurosurgical care in LMICs—particularly with regard to cerebrovascular treatment—can inform the process of guideline3–6 formulation, in a manner similar to how the living guidelines for the management of traumatic brain injury take into account global experiences.48 Further studies of high-quality evidence in LMIC settings are therefore needed.