Abstract
Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety. We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates. From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs. All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care. None.
Highlights
Surgery is an essential component of a functioning, comprehensive health system, and a high-risk intervention
23 countries, seven Global Burden of Disease (GBD) regions, and four WHO regions; 4329,63–104 articles reporting appendectomy mortality, representing 20 countries, nine GBD regions, and six WHO regions; and 5029,92,105–152 articles reporting groin hernia repair mortality, representing 20 countries, eight GBD regions, and six WHO regions. 80 (65%) of 124 articles were considered high quality; articles of unacceptable quality were removed during our initial screening based on our exclusion criteria
We noted no significant difference in the remaining economic or demographic characteristics for LMICs
Summary
Surgery is an essential component of a functioning, comprehensive health system, and a high-risk intervention. Recent work has estimated that 312·9 million operations occur annually, with most taking place in upper-middleincome and high-income countries.. Countries with more than 35% of the world’s population account for only 6·3% of the total operations, probably indicating a vast unmet need for surgical care in these settings. Many health interventions in low-income and middle-income countries have focused on infectious diseases and maternal and child health. Substantial improvements have been made through programmes developed within growing health systems (eg, developing cadres of skilled birth attendants) or in parallel to poorly functioning ones (eg, vaccination campaigns and directly observed therapy for tuberculosis and HIV).. Populations traditionally affected by infectious diseases and malnutrition are faced with the health problems of industrialisation and ageing.. Substantial improvements have been made through programmes developed within growing health systems (eg, developing cadres of skilled birth attendants) or in parallel to poorly functioning ones (eg, vaccination campaigns and directly observed therapy for tuberculosis and HIV). populations traditionally affected by infectious diseases and malnutrition are faced with the health problems of industrialisation and ageing. Yet the www.thelancet.com/lancetgh Vol 4 March 2016
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