Pediatric neurosurgery in Ukraine in 2001-2020. Availability, workforce, performance indicators

Objective: to analyze the development dynamics of pediatric neurosurgical care in Ukraine in 2001-2020. Materials and methods . The number of pediatric neurosurgical beds, pediatric neurosurgeons, hospitalization rates and surgical treatment of children in neurosurgical departments of Ukraine in 2001‒2020 were analyzed. Data for the years 2014-2020 were unavailable for departments located in temporarily non-government-controlled territories. Results. In 2020, there were 22 pediatric neurosurgery departments in Ukraine, with a total of 290 pediatric neurosurgical beds, representing a 26.6% increase compared to 2001. Pediatric neurosurgical departments or pediatric units with neurosurgical beds were operational in almost all regions. The distribution of pediatric neurosurgical beds in Ukraine did not statistically differ from countries with high-income levels (p=0.9987). The increased number of beds contributed to more than doubling the provision of neurosurgical beds per child population. In 2001, there were 17 beds per 1 million


Introduction
The first pediatric neurosurgery department in Ukraine began providing assistance in 1950 as part of the newly established Kyiv Institute of Neurosurgery.The department was entrusted with organizational and methodical work on the creation and development of pediatric neurosurgical service in the country.Initial research focused on studying the clinical course and surgical treatment of brain tumors in children as well as the surgical treatment of congenital malformations of the central and peripheral nervous system.The treatment of cholesteatomas, craniostenoses, hydrocephalus, birth-related craniocerebral injuries, spinal cord tumors and chronic subdural hematomas in infants has been successfully studied.Technological advances allowed for the expansion of surgical interventions for critical cases of hydrocephalus and brain tumors in infants.Emergency care for newborns with ruptured spinal cord hernias was organized and distributed in Ukraine.The number of patients with such pathologies as neurorachischisis, intramedullary tumors, tumors of the brainstem, III ventricle, and pineal area has increased significantly [1,2].
The pediatric neurosurgical service of Ukraine actually began to be formed in accordance with the order of the Ministry of Health of Ukraine No.360 dated December 19, 1997 "On complementing the list of medical positions with the position of "pediatric neurosurgeon".At that time, there were 4 pediatric neurosurgical departments (111 beds) and 2 departments of a different profile with pediatric neurosurgical beds (20 beds) in the country.Subsequently, orders No.224 dated September 10, 1999 "On the improvement of neurosurgical care for children in Ukraine" and No.33 dated February 23, 2000 "On staff standards and typical staffing of health care institutions" were issued.Specialization and advanced training courses in the field of "pediatric neurosurgery" have been held in the departments of neurosurgery, specialists have been cer tified and re-cer tified, regional pediatric neurosurgical departments and pediatric neurosurgical beds in departments of other specialties have been opened, the service of the main pediatric neurosurgeons of the country was established, standards for the provision of pediatric neurosurgical beds and by specialists of the country's population, the workload on the specialist and surgical activity have been determined.
Currently, Ukraine has a power ful pediatric neurosurgical service training highly qualified specialists.The range of pathologies that are subject to neurosurgical treatment has been significantly expanded, and the capabilities and quality of neurosurgical care for children have been enhanced.Pediatric neurosurgeons are proficient in treating the entire spectrum of pediatric pathologies including congenital central nervous system defects, hydrocephalus, brain and spinal cord tumors, inflammatory and vascular diseases of the central nervous system, brain and spinal cord injuries.
Objective: to analyze the development dynamics of pediatric neurosurgical care in Ukraine in 2001-2020.

Study object
The number of pediatric neurosurgical beds, pediatric neurosurgeons, hospitalization rates and surgical treatment of children in neurosurgical departments of Ukraine in 2001-2020 were analyzed.Data from departments located in temporarily uncontrollable territories are missing for the years 2014-2020.

Inclusion criteria
Data from pediatric neurosurgical departments and departments of a different profile, which include pediatric neurosurgical beds, were included in the study.

Study design
Accounting of neurosurgical units (beds) in Ukraine was carried out according to the form approved by the order of the Ministry of Health of Ukraine No. 295 dated November 24, 1994.The form regulates the accounting of neurosurgical beds, staff, hospitalized, operated on and deceased children according to the main nosological forms, according to which neurosurgical treatment is carried out.
From the neurosurgical departments and departments of another profile providing neurosurgical care were selected, which contain pediatric neurosurgical beds and pediatric neurosurgeons providing neurosurgical care to children.
From the array of statistical data on the provision of neurosurgical care, data on children who were hospitalized, operated on, and died as a result of neurosurgical pathology were selected.
The pediatric population includes children under 18 years of age.
Data on the number of pediatric population were obtained partly from the source [3] and from the website of the Institute of Youth https://inmol.org/stat/children-count-ua/.Based on these data, the trend line y= 0,0172x2-0,06902x+14,429 was determined.Missing data for some years were calculated with R-squared value R2=0,9993.

Statistical analysis
Relative indicators were calculated: surgical activity, overall and postoperative lethality.Statistical processing of data was carried out using the analysis of dynamic series using the grouping method.Prognostic models were constructed.To compare the distribution of pediatric beds in Ukraine with high-income countries, the chi-square criterion was used.The critical level of statistical significance (p) for hypothesis testing was considered to be ≤0.05.Microsoft Excel software was used for calculations.

Beds and workforce
In 2001, 6 pediatric neurosurgical departments (153 beds) and 10 other pediatric units (76 pediatric neurosurgical beds) provided neurosurgical care to children in Ukraine.The establishment of pediatric neurosurgery as a separate profession in 1997 and the Ministry of Health of Ukraine's directive to improve the provision of pediatric neurosurgical care contributed to the expansion of the pediatric neurosurgical hospital stock.In 2013, there http://theunj.org were already 8 pediatric neurosurgery departments (189 beds) and 14 departments of other profiles with pediatric neurosurgery beds (114 beds) operating in the country.The total number of pediatric neurosurgical beds was 2.3 times higher than in 1997 and 32.3% higher than in 2001.In the following years, the hospital stock of the pediatric neurosurgical network was influenced by political and epidemiological factors.In 2014, a decrease in almost all indicators was recorded by 8.3-16.2%,with the exception of the level of workload for 1 pediatric neurosurgeon, which increased by 14.3% (Fig. 1, Table 1).In the next 6 years, an increase in the hospital stock was noted, but due to the quarantine in 2020, part of the pediatric neurosurgical stock was repurposed for covid beds.In 2020, Ukraine had 22 pediatric neurosurgery departments with a total of 290 pediatric neurosurgery beds (26.6% more than in 2001) (see Fig. 1, Table 1).
J.T. Roach et al. conducted a study based on an online survey of members of the International Society for Pediatric Neurosurgery, aiming to access the availability of pediatric neurosurgical care in different countries.The dependence of available resources on the country's income level has been established.Low-and middle-income countries tend to concentrate pediatric neurosurgical beds in large cities, while high-income countries tend to have more units, but with fewer beds, which are evenly distributed throughout the country, making neurosurgical care for children more accessible.Thus, out of 96 pediatric neurosurgical departments in high-income countries, 42 (43.8%)had less than 10 beds, 37 (38.5%) had 10-20 beds, 13 (13.5%)had 21-40 beds, 4 (4.2%)-more than 40 beds [4].
Ukraine is a country with high availability of pediatric neurosurgical care.Pediatric neurosurgical departments or pediatric units of a different profile, which include pediatric neurosurgical beds, operate in almost all regions, with 10 (45.5%) having fewer than 10 beds, 8 (36.4%) having 10-20 beds, 3 (13.6%)having 21-40 beds and 1 (4.5%) having more than 40.The distribution of pediatric neurosurgical beds in Ukraine is not statistically different from that in high-income countries (p=0.9987).
The expansion of bed capacity led to more than a doubling of the indicator measuring the availability of neurosurgical beds for children.In 2001, there were 17 beds per million children, compared to 38 in 2020.In the literature, neither global standards nor indicators of the availability of pediatric neurosurgical beds in other countries have been found, so it is impossible to find out the level of their sufficiency.According to the standard of the Ministry of Health of Ukraine (75 beds per 1 million child population), which has not been in effect since 2016, the child population of Ukraine is provided with pediatric neurosurgical beds by half (see Fig. 1, Table 1).
Over the first 13 years of the 21st century, the number of pediatric neurosurgeons and their availability to the pediatric population of Ukraine varied with a clear upward trend.The events of 2013-2014 had a negative impact on child neurosurgical personnel, with the number of doctors decreasing by 16.2% (from 68 to 57 individuals).Over the following 6 years, the number of pediatric neurosurgeons and their provision to the pediatric population remained stable (Fig. 2).In 2020, the number of pediatric neurosurgeons in Ukraine doubled compared to 2001, reaching 58 (9.2% of the total number of neurosurgeons in Ukraine and 2.5% of the total number of pediatric neurosurgeons globally).Currently, there are 2297 pediatric neurosurgeons working in the world, 85.6% of whom work in highincome and upper-middle-income countries [5].According to the standards of the Ministry of Health of Ukraine, 7.5 child neurosurgeon rates are required for 1 million children, i.e. for 1 pediatric neurosurgeonabout 120,000 children.In 2020, the number of pediatric neurosurgeons met the standard (7.7 per 1 million children) and was more than 3 times higher than in 2001 (see Table 1, Fig. 2).Accordingly, the workload of 1 pediatric neurosurgeon decreased almost 4 times -1298,95 children.In low-income African countries, the number of pediatric neurosurgeons is about 1 per 30 million children [5], in the USA -1 per 289,799 people under the age of 24 [6].

Pediatric neurosurgery training
In the 1950s-1990s, there was no separate specialty "pediatric neurosurgery", and training the basics of neurosurgical care for children was conducted as a part of the general training of neurosurgeons.The clinical residency program of the Institute of Neurosurgery provided that each resident medical practitioner should undergo practical training in all clinics of the institute (oncology, vascular pathology, neurotrauma, spinal pathology, pediatric neurosurgery), as well as in other divisions of the institute (morphology, radiology, etc.).In clinical divisions, training was not regulated by terms.In the pediatric clinic, residents worked with future employment in mind, there were no separate programs.During the 5-month specialization courses in neurosurgery, lectures on the peculiarities of pediatric pathology were delivered.In Europe, there is no "pediatric neurosurgery" specialty, it is a subspecialty.Training and improvement of technologies and techniques of pediatric neurosurgery are recommended to be carried out in specialized centers.

Pediatric neurosurgical care
In the pediatric neurosurgical depar tments, assistance was provided to children with craniocerebral and spinal injuries, brain and spinal cord tumors, vascular diseases of the nervous system, hydrocephalus, congenital malformations of the central nervous system.The emergence of new technologies and diagnostic and treatment methods contributes to the rapid development of pediatric neurosurgery.The use of new developments improves the outcomes of surgical interventions and reduces the number of adverse and fatal consequences.
In the first 13 years of the 21st century a clear trend towards an increase in the number of hospitalized and operated patients was noted.Thus, compared to 2001, the number of hospitalized children increased by 33.9% (per 1 million child population -2.2 times), the number of operated on by 66.4% (per 1 million child population -2.7 times).The annexation of Crimea and the occupation of Donbass in 2014 led to a decrease in the number of hospitalized patients by 14.7% (per 1 million child population -by 11%), and operated on -by 17.4% (per 1 million child population -by 13.8%).The following five years, fluctuations in indicators with a slight upward trend were recorded, but the quarantine announced in 2020 resulted in a significant decrease in the number of hospitalizations and neurosurgical care for children -by 24.8% (per 1 million child population -by 24.3 %) and 18.4% (per 1 million child population -18.1%), respectively (Table 2, Figs. 3 and 4).
The COVID-19 pandemic has led to a decrease in the number of neurosurgical operations worldwide [7][8][9].This concerned many nosologies, but most of alltraumatic injuries of the nervous system, hydrocephalus, epilepsy.This pattern has been attributed to travel restrictions and stay-at-home orders, reducing the likelihood of traumatic injuries such as car accidents and sports injuries, people's attempts to avoid hospitals, postponing elective surgeries due to limited hospital resources as a result of the repurposing of hospital beds to COVID ones.
Analyzing the dynamics as a whole for 20 years, only the absolute number of hospitalized patients decreased (by 15.8%), while the absolute number of operated patients increased by 3.3%.Regarding the relative indicators (per 1 million children), the hospitalization rate increased by 53.8%, and the surgical rate increased by 88.7% (see Table 2, Figs. 3 and 4).Analysis of hospital morbidity (HM) was conducted, calculated as the number of hospitalized patients with pediatric neurosurgical pathology per year, divided by the number of pediatric population and multiplied by 1 million.The HM indicator can to some extent assess the prevalence of pathology and determine its development dynamics [10].
Over 20 years, the HM for pediatric neurosurgical pathology, both overall and for specific types of pathology, has changed.Until 2014, a significant increase in HM was recorded, in subsequent years, due to military actions in eastern Ukraine, the annexation of Crimea, and the COVID-19 pandemic, HM varied.
The total HM for a child with neurosurgical pathology has reached its peak in 2013 and was 1692 cases per 1 million child population, which is 2.2 times higher than in 2001.Over the next 5 years, the rate ranged from 1500-1600 before dropping sharply to 1201 in 2020 (Fig. 5).http://theunj.orgFig. 6.Hospital incidence by major types of pediatric neurosurgical pathology Fig. 5 demonstrates that other types of pediatric neurosurgical pathology are much less frequently r ec or ded.T he sec ond mos t c ommon pediatr ic neurosurgical pathology is hydrocephalus (see Fig. 7).

Fig. 3. Hospitalization rates for children with neurosurgical pathology
Over 20 years, the proportion of this pathology in the overall structure has increased from 3.7 to 10.0%, leading to an increase in HM from 29 to 149 per 1 million child population (Fig. 6).This A significant increase in HM for neuro-oncological diseases was also noted.From 2001 to 2013, the annual growth rate of this indicator was 4 cases per 1 million population (from 31 to 83).In subsequent years, the relative stability of the indicator (79-81 cases) was observed with a significant increase in 2019 to 110 and a further decrease to 100 due to the COVID-19 pandemic in 2020 (see Fig. 6).In the overall structure of pediatric neurosurgical pathology, the proportion of neuro-oncological diseases increased from 3.9 to 8.3% ranking the 3rd (see Fig. 7).
Congenital anomalies of the nervous system rank 4th in the structure of the pediatric population hospitalized in neurosurgical departments (see Fig. 7).Over 20 years, their proportion increased from 1.9 to 5.0.Over this period, the HM varied with a distinct upward trend.In 2019, it amounted to 78 cases per 1 million population, which is 5.2 times higher than in 2001 (see Fig. 6).This is probably due to an increase in the survival rate of newborns with severe pathology.
Vascular lesions of the ner vous system are extremely rare in children (see Fig. 7).Their proportion in the structure of neurosurgical pathology for which children were hospitalized was 2.8%.In 2001, the prevalence of this pathology was 5 cases per 1 million children.Within 17 years, this rate increased to 46 (9.2 times), and decreased in 2019-2020, reaching 2011 level in 2020 (26 cases) (see Fig. 6).In relation to HM for this pathology, the value of the indicator varied in different years with a slight tendency to double in general (see Fig. 6).
One of the indicators of surgical service efficiency is surgical activity -the ratio of the number of operated on and hospitalized patients (%).Despite the 20-year decrease in the number of operated patients, surgical activity increased from 28.3% in 2001 to 34.8% in 2020 (see Table 2, Fig. 8).
The main requirement for the development of any medical field, particularly pediatric neurosurgery, is the widespread implementation of modern diagnostic and treatment methods into practice.Accurate diagnosis, which significantly affects the thoroughness of patients selection for surgery, and constantly improving methods of surgical inter ventions, improve the treatment outcomes, in particular, reducing postoperative lethality.Thus, in the first 15 years of the studied period, postoperative lethality varied without a definite trend, whereas over the past 5 years, a twofold decrease in the indicator has been recorded.Even quarantine measures had a slight effect on postoperative lethality (see Fig. 8).
The structure of pediatric neurosurgical pathology has changed over the last 20 years.Acute cerebrocranial trauma was and still is the main pathology in the structure of neurosurgical interventions.However, the absolute number of children operated on with acute craniocerebral trauma decreased over time from 1954 to 1269 (by 35%), and its proportion of the total pathology decreased from 64.2% in 2001 to 40.4% in 2020 (Fig. 9).In our opinion, this trend is associated with a 45.3% decrease in the number of children in Ukraine.If the number of children remained unchanged (standardization by the number of children in 2001), the number of children operated on for craniocerebral trauma in 2020 would be 2,317, i.e.
18.6% more than in 2001, i.e. when the indicator was standardised, an increase in the number of cases of pediatric acute craniocerebral trauma was noted.
Advances in hydrocephalus treatment technologies in children have led to an increase in both the absolute number and the proportion of structure of neurosurgical pathology.Thus, in 2001, 281 children were operated on (9.2% of the total number of those operated on), in 2020 -693 (22.8% of the total number of operations, an increase of 2.5 times) (see Fig. 9).The standardised figure for the number of children in 2020 is 1,265 people (i.e.4.5 times more than in 2001).
Neuro-oncological diseases rank third in the structure of pediatric neurosurgical pathology, accounting for 8.4% in 2001 and 13.6% in 2020.The absolute number of patients operated on for neuro-oncological pathology in 2020 was 428, standardised by the number of pediatric population in 2001 -781, which is 67.2% and 3 times higher than in 2001 (see Fig. 9).The main reason for this increase is unclear.It may be both a banal increase in oncological pathology of the nervous system in children and the development of In 2001, 109 children with congenital malformations of the nervous system were operated on (3.6% of all neurosurgical pathology), in 2021 there were already 220 (7%) of such patients (see Fig. 9), standardized by the number of children in 2001 -402, so it is safe to say that the number of children with congenital malformations of the nervous system is increasing.Conclusions 1. Ukraine is a country with high availability of pediatric neurosurgical care.There is no statistically significant difference between Ukraine and high-income countries in the distribution of pediatric neurosurgical beds (p=0.9987).
2. For 20 years the availability of neurosurgical beds for child population has more than doubled, from 17 beds per 1 million children in 2001 to 38 in 2020.
3. The availability of pediatric neurosurgeons for the pediatric population has increased more than 3 times over the past 20 years and currently meets the standard of the Ministry of Health of Ukraine (7.7 per 1 million children).

Fig. 1 .
Fig. 1.The total number of pediatric neurosurgical beds and density of pediatric neurosurgical beds (standardized to per 1 mln child population) Note.* Hereinafter in the text excluding the data of departments located in temporarily uncontrolled territories.
The lecturers of the Department of Neurosurgery at Kyiv Institute of Postgraduate Education (now P.L. Shupyk National Healthcare University of Ukraine) introduced the pediatric department, and sometimes the trainees were involved in the department's work.With the introduction of internship in 1993 (3 years of training in neurosurgery), the principle remained the same, but the number of lectures increased and interns had more opportunities to familiarize themselves with the work of the departments, particularly the pediatric one.Since 1996, the training period for neurosurgeons has been reduced to one and a half years.At the end of 1997, the list of medical positions was supplemented with the position of "pediatric neurosurgeon".The training program for pediatric neurosurgeons included 9 months of general specialization in neurosurgery and 6 months of pediatric neurosurgery.In 2005, by the decision of the Ministry of Health of Ukraine, internship in neurosurgery and all surgical disciplines became 3-year internship.The principle of training has not changed.Students could focus on the areas they identified after the second year of training.Since 2010, constant work has been carried out to increase the terms and principles of neurosurgeon training according to the standards of the European Association of Neurosurgeons (5-7 years), depending on the direction and involvement in scientific work.The Ministry of Health of Ukraine issued an order on the 5-year training of neurosurgeons: internship, upon completion of which a specialist certificate was issued, and a recommended 2-year residency with the opportunity to improve knowledge in a particular area (pediatric neurosurgery, vascular, spinal, etc.).This principle lasted for a year, since almost all of them having received a certificate, were employed because they had good training.In 2020-2023, unclear changes occurred in postgraduate training in neurosurgery, particularly in pediatric neurosurgery.According to the orders of the Ministry of Health of Ukraine, specialization in adult neurosurgery requires 9 months with a certificate of trauma surgeon, and specialization in pediatric neurosurgery -6 months with a certificate of pediatric surgeon.

Fig. 2 .
Fig. 2. The total number of pediatric neurosurgeons and density of pediatric neurosurgeons (standardized to per 1 mln child population)

Fig. 4 .
Fig. 4. Rates of operated children with neurosurgical pathology

Fig. 7 .
Fig. 7. Absolute and calculated per 1 million child population, the number of children treated and operated on for neurosurgical pathology in 2019.Notes.TBI-traumatic brain injury.2019 was chosen to demonstrate the indicators, since the indicators of 2020 were significantly influenced by quarantine measures, altering the established trends

Fig. 9 .
Fig. 9. Structure of neurosurgical pathology for which children were underwent surgery on

4 .
Established in 2001-2013, the trend towards a significant increase in both absolute and relative rates of hospitalization and surgery for children with neurosurgical pathology in subsequent years due to the annexation of Crimea, military actions in Donbas and the COVID-19 pandemic changed to a decreasing trend.5.The most common neurosurgical pathology in children is acute traumatic brain injury (according to 2019 data, 966 cases per 1 million child population

Table 1 .
Pediatric neurosurgical hospital stock, number of pediatric neurosurgeons and availability of pediatric neurosurgeons in the pediatric population http://theunj.org

Table 2 .
Indicators of pediatric neurosurgical care, utilization of hospital stock and workload of pediatric neurosurgeons http://theunj.org