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

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.

Fig 1.

Countries participating in the International Surgical Outcomes Study. Blue: countries included in the primary analysis. Green: countries with <10 participating hospitals included in the secondary analysis.

Fig 2.

Patients, hospitals, and countries excluded from the study.

Fig 3.

Adjusted risk (odds ratio) of complications with 95% confidence intervals and in-hospital mortality in different surgical procedure categories.