O2158: Predictors of In-Hospital Mortality for Patients with Congenital Surgical Disease at a Tertiary Hospital in Malawi

Background: Mortality associated with surgically correctable congenital disease remains high despite increases in surgical workforce capacity in Malawi. Limited geographic access to adequate pre-referral care and transport to higher levels of care may act as barriers to prompt treatment. We sought to map referral patterns for pediatric surgical evaluation and understand the impact of clinical and access-related factors on in-hospital mortality for admissions with surgically correctable congenital disease to Kamuzu Central Hospital (KCH). This tertiary care facility serves as 1 of 2 pediatric surgical referral centers in Malawi.

Methods: We retrospectively analyzed pediatric surgical admissions ( < 14 years) to KCH from April 1, 2023 to December 1, 2023. Patients admitted to pediatric general surgery, ENT, orthopedics, plastics, and urology services were included. Trauma admissions were excluded. ArcGIS was used to calculate approximate distances traveled to care, and to create district-level choropleths to visualize KCH’s catchment area and in-hospital mortality outcomes. Bivariate and multivariable logistic regression analyses were conducted to identify relevant patient and pre-admission characteristics predictive of in-hospital mortality in the subgroup of patients with surgically correctable congenital disease.

Results: Of 1,044 pediatric surgical admissions over the study period, 60% (n=620) presented from Lilongwe district. Comparatively, 1.2% (n=12) presented from Karonga and Chitipa districts in the Northernmost parts of Malawi. Only 0.3% (n=3) of patients presented from districts in the Southern region, where the second pediatric surgical referral center is located (Figure 1a). 32% percent (n=336) of patients presented with a surgically correctable congenital disease; at the district level, the distribution of in-hospital deaths paralleled admission density for these (Figure 1c and 1b). Multivariable regression (n=311) revealed that patients born prematurely had increased odds of death (OR=3.10, p=0.01) compared to those who were born at term. All patients from tertiary hospitals (n=28) survived during admission to KCH. Increasing distance from home residence to KCH had a protective effect on odds of death (OR=0.23, p=0.02) (Figure 2).

Conclusion: While the catchment area for KCH pediatric surgical services spans Malawi’s Central and Northern regions, most patients present from Lilongwe and immediate neighboring districts. Among patients with congenital disease, premature patients have higher in-hospital mortality compared to those born at term. Furthermore, those presenting from farther distances have lower in-hospital mortality than those closer to KCH. The counterintuitive protective effect of distance on in-hospital mortality suggests that congenital patients presenting from the Northern region are more likely to be clinically robust. There may be an additional burden of pre-referral mortality in Northern Malawi, including children who do not survive to reach KCH or who receive care in non-specialized centers. Improving access to pediatric surgical services for patients in Northern Malawi by increasing timely access to long-distance transport and strengthening healthcare infrastructure and workforce capacity may be beneficial.