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Designing a novel program for emergency neurosurgical task-sharing in Indonesia: Evidence base from a meta-analysis
Bryan Gervais de Liyis1, Muhammad Kusdiansah1, Aryandhito Widhi Nugroho2
1Division of Neurosurgery, Department of Surgery, National Brain Center Hospital Mahar Mardjono, East Jakarta, Indonesia.
Background:
The Ministry of Health of Indonesia recognized a need for a structured emergency neurosurgical task-sharing program to expand time-critical access in neurosurgeon-deficient districts while maintaining patient safety. We synthesized global outcomes of emergency cranial procedures performed by general surgeons without on-site neurosurgeons and evaluated determinants relevant to program design.
Methods:
A comprehensive search of ScienceDirect, Scopus, PubMed, Google Scholar, and Cochrane databases was conducted through January 2026 to identify studies reporting mortality, reoperation rates, and functional outcomes after emergency neurosurgical procedures performed by general surgeons. Random effects models were applied to pooled proportions.
Results:
Fifteen studies with a total of 1,195 patients were analyzed (mean age 35.05 ± 11.85 years; 75.94% male). Pooled ≤ 1-month mortality was 14% (95%CI: 9%-20%) and last follow-up mortality was 17% (95%CI: 12%-24%). Reoperation occurred in 13% (95%CI: 7%-22%). Unfavorable outcomes occurred in 23% (95%CI: 12%-39%), while favorable outcomes were 73% (95%CI: 52%-87%). Heterogeneity was substantial for several outcomes, reflecting differences in pathology, procedures, supervision, training, and health system context. Limited comparative data did not show a consistent direction of excess early harm under supervised task sharing models, but the evidence was very low certainty and was not suitable for non-inferiority inference. Subgroup analyses suggested directionally lower mortality in cohorts with prior dedicated training and perioperative or intraoperative neurosurgeon consultation, and lower early mortality in cohorts excluding hydrocephalus.
Conclusion:
Available evidence supports a cautious implementation framework in which emergency neurosurgical task sharing is restricted to selected life-threatening cranial conditions, embedded within structured training, mandatory neurosurgeon consultation, explicit referral criteria, and prospective outcome monitoring. For Indonesia, the most defensible initial scope is non hydrocephalus emergency cranial decompression in neurosurgeon deficient districts where referral delay would exceed the therapeutic window.