Are Surgeons Enough? The Relationship between Increasing Surgical Demand and Access to Surgery in a Resource-Limited...

The relationship between increasing surgical demand and access to operative intervention remains unclear in delivering general surgical care in resource-limited settings, where demand often exceeds capacity. We sought to characterize the association between general surgery patient volume and operative intervention at a tertiary hospital in Malawi, which has an adequate surgical workforce.

We analyzed patients admitted to Kamuzu Central Hospital Lilongwe, Malawi, with a general surgery complaint from 2018-2020. We examined the relationship between the census at the time of admission, the use of operative intervention, and the time to operative intervention. The patient census was defined as low (≤30 patients), medium (31-49 patients), and high (≥50 patients), based on historical patterns.

2,701 patients were included. The mean daily census was 46 patients (SD 10). For the medium and high census, the adjusted risk ratio of undergoing surgery was 0.86 (95% CI 0.78, 0.95) and 0.81 (95% CI 0.73, 0.90), respectively, adjusted for admission diagnosis. For patients requiring urgent abdominal exploration, at a census of 25, the adjusted mean time to operation was 0.8 days (95% CI 0.1, 1.5) compared to 2.8 days (95% CI 2.1, 3.5) at a census of 65 patients.

Despite an adequate surgical workforce, an increasing mean daily census significantly reduced the use of operative intervention and increased time to operation for patients who needed urgent abdominal exploration. Additional improvements in the surgical ecosystem beyond surgeons are necessary to improve surgical access.