Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries

International Surgical Outcomes Study group

Abstract

Background: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care.

Methods: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries.

Results: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries.

Conclusions: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care.

Study registration: ISRCTN51817007

Keywords: cohort studies; critical care/utilisation; operative/mortality; postoperative care/methods; postoperative care/statistics and numerical data; surgery; surgical procedures.

© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

Figures

Fig 1.
Fig 1.
Countries participating in the International Surgical Outcomes Study. Blue: countries included in the primary analysis. Green: countries with

Fig 2.

Patients, hospitals, and countries excluded…

Fig 2.

Patients, hospitals, and countries excluded from the study.

Fig 2.
Patients, hospitals, and countries excluded from the study.

Fig 3.

Adjusted risk (odds ratio) of…

Fig 3.

Adjusted risk (odds ratio) of complications with 95% confidence intervals and in-hospital mortality…

Fig 3.
Adjusted risk (odds ratio) of complications with 95% confidence intervals and in-hospital mortality in different surgical procedure categories.
Fig 2.
Fig 2.
Patients, hospitals, and countries excluded from the study.
Fig 3.
Fig 3.
Adjusted risk (odds ratio) of complications with 95% confidence intervals and in-hospital mortality in different surgical procedure categories.

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