Editorial Perspective: Global Surgery: Measuring the Impact

Abstract

Surgery and safe anesthesia are important contributors toglobal public health. This recent recognition occurs as non-communicable disease is growing and surpassing the roleof communicable disease [1], including HIV/AIDS, incontributing to disability and premature death in low-income countries (LICs.) Surgical intervention for trauma,cancer, obstetric emergencies, and other essential surgicalconditions [2] is required to affect the global burden ofdisease (GBD). Prioritizing surgical interventions for theconditions in LICs contributing most greatly to the GBDand for which the surgery is cost-effective and proven [3]has created a focus on treating trauma, some cancers, cat-aracts, simple congenital defects, and obstetric emergen-cies. However, without safe anesthesia, even the mosthighly prioritized procedures may not have the intendedimpact if anesthesia outcomes are poor [4–6].The provision of surgery and safe anesthesia is not theend point. The impact of surgery and verification of safeanesthesia must be evaluated through complication rates,follow-up, and outcome measures. These data are surpris-ingly difficult to collect in LICs. In a majority of LICs,patients are cared for in the hospital by family members,and there is little follow-up or documentation followingprocedures or treatments. A patient’s condition after hos-pital discharge is rarely known in LICs, and complicationsare not often reported to the doctors providing services inthese settings. Even death is most often unrecorded, asmost patients die at home, and death certificates in LICs arenot issued [7].Measuring the impact of surgical intervention and theoutcomes related to surgery and anesthesia in LICs is achallenge. Surgical and anesthesia-related morality ratesmay reflect the current state of surgical care by country,and are generally recorded in LICs. With this in mind, thereis consensus among surgeons and anesthesiologists com-mitted to global health that perioperative death divided bytotal surgical interventions, the perioperative mortality rate(POMR), is an initial health indicator for surgical care. ThePOMR is a generally available, reportable data point thatcould serve as a starting point toward comparing surgicalservices at a population level [8].Defining the POMR, defined as death occurring in theoperating room or within the first 24 h (POMR 24) dividedby total interventions performed is an endpoint of value,potentially similar to the maternal mortality rate (MMR).Since its introduction the MMR has transformed supportfor improving outcomes in the perinatal period. Like theMMR, the POMR is nonspecific and requires thoughtfulapplication. It is important to note that the POMR is sug-gested as a surgical health indicator, which provides basicpopulation level information and reveals no specificinformation for stratification or analysis. However, healthindicators, especially mortality rates, are powerful sum-mary statistics within global health, and following theirtrends has provided valuable feedback on interventions forimprovement. Therefore recording the POMR has thepotential to provide an initial benchmark for the quality ofsurgery and anesthesia in a country or region. In LICs, theoperating logbook is omnipresent, and therefore collectingthe POMR 24 will be a simple matter and is unlikely toburden a system stretched thin in most LICs. Reporting thePOMR will require support from Ministries of Health andthe World Health Organization to insure appropriatecomparison and analysis.