By Will Boggs MD
NEW YORK (Reuters Health) – Despite having lower risk profiles and fewer postoperative complications, patients in Africa are nearly twice as likely to die after surgery as patients elsewhere, according to the African Surgical Outcomes Study (ASOS).
“Although the message of the study is startling, I do believe that the message is important as it has flagged an area where I believe we can potentially modify our practice and thus improve surgical outcomes,” Dr. Bruce M. Biccard from the University of Cape Town, in South Africa, told Reuters Health by email.
Previous reports have highlighted the undersupply of safe surgical treatment in Africa, but even these studies have given scant attention to lower-income countries there.
Dr. Biccard and colleagues in the ASOS undertook a seven-day prospective observational study of more than 11,400 patients aged 18 years and older undergoing any inpatient surgery in 247 hospitals in 14 low-income and 11 middle-income countries in Africa.
Each hospital served a median population of 810,000 people with a median of 300 beds, four operating rooms, and three critical care beds providing invasive ventilation. Hospitals were staffed by a median three specialist surgeons, one specialist anesthetist and two specialist obstetricians, with a median 0.7 of any specialist per 100,000 population.
Most patients had a low perioperative risk profile, but most surgeries were urgent or emergent, the researchers report in The Lancet, online January 3.
Postoperative complications developed in 18.2% of patients, of whom 9.5% died.
The mortality rate after surgery was 2.1%, with 5.9% of these deaths occurring on the day of surgery.
Compared with the International Surgical Outcomes Study (ISOS) of elective surgery, the elective surgical patients in ASOS were younger, had a lower risk profile, underwent more minor surgery and had fewer postoperative complications, but their mortality was twice the global average of that in ISOS.
Dr. Biccard stressed the limited human resources available in Africa to provide perioperative care.
“We need to focus postoperative attention on the patients at risk of postoperative complications,” he said. “If we can identify and manage complications earlier in Africa, we can potentially make a large difference to surgical outcomes.”
Dr. Biccard added that “we need to look at the potential role of nonphysician providers in postoperative surveillance.”
Dr. Anna J. Dare from the University of Toronto, Canada, who co-authored an accompanying editorial, told Reuters Health by email, “Unfortunately, this study shows that the volume of surgery performed is even lower than we thought; in the 25 African countries sampled, the number of operations performed was 20 times lower than the minimum volume required to meet a country’s basic surgical needs. That’s shocking, because it means each year there are literally hundreds of thousands of people who need surgery – often to save their life – who simply never make it to a hospital.”
“Lack of access to surgery is a silent killer: silent because it isn’t counted when we look at hospital deaths, and because it is missing from the discourse on health care in many low- and middle-income countries,” she added.
“To reduce post-operative deaths and improve the quality and safety of surgery in the near term, we need to ensure there are adequate staff to care for patients; that they are trained to recognize and treat complications after surgery; and that they have the equipment and resources to do so,” Dr. Dare said. “Improving the processes of care, including developing early warning systems for health staff caring for patients who aren’t doing as well as expected after surgery, and ensuring early communication of concerns, are low-cost, simple interventions that may reduce post-operative deaths.”
“African countries bear the greatest burden of conditions that require surgical care worldwide, and yet as this study brings into stark relief, they have shockingly low access to safe surgical care,” Dr. Dare concluded. “To save lives and improve health outcomes, governments, development agencies, and other stakeholders must invest in improving access to safe, timely, and affordable surgical care for Africans.”
SOURCE: http://bit.ly/2mmXvcd and http://bit.ly/2D7IZzB
Lancet 2018.
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