Introduction
The proportion of patients who die during or after surgery, otherwise known as the
perioperative mortality rate (POMR), is a credible indicator of the safety and quality
of operative care. Its accuracy and usefulness as a metric, however, particularly
one that enables valid comparisons over time or between jurisdictions, has been limited
by lack of a standardized approach to measurement and calculation, poor understanding
of when in relation to surgery it is best measured, and whether risk-adjustment is
needed. Our aim was to evaluate the value of POMR as a global surgery metric by addressing
these issues using 4, large, mixed, surgical datasets that represent high-, middle-,
and low-income countries.
Methods
We obtained data from the New Zealand National Minimum Dataset, the Geelong Hospital
patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg,
South Africa, and Port Moresby, Papua New Guinea. For each site, we calculated the
POMR overall as well as for nonemergency and emergency admissions. We assessed the
effect of admission episodes and procedures as the denominator and the difference
between in-hospital POMR and POMR, including postdischarge deaths up to 30 days. To
determine the need for risk-adjustment for age and admission urgency, we used univariate
and multivariate logistic regression to assess the effect on relative POMR for each
site.
Results
A total of 1,362,635 patient admissions involving 1,514,242 procedures were included.
More than 60% of admissions in Pietermaritzburg and Port Moresby were emergencies,
compared with less than 30% in New Zealand and Geelong. Also, Pietermaritzburg and
Port Moresby had much younger patient populations (P < .001). A total of 8,655 deaths were recorded within 30 days, and 8–20% of in-hospital
deaths occurred on the same day as the first operation. In-hospital POMR ranged approximately
9-fold, from 0.38 per 100 admissions in New Zealand to 3.44 per 100 admissions in
Pietermaritzburg. In New Zealand, in-hospital 30-day POMR underestimated total 30-day
POMR by approximately one third. The difference in POMR if procedures were used instead
of admission episodes ranged from 7 to 70%, although this difference was less when
central line and pacemaker insertions were excluded. Age older than 65 years and emergency
admission had large, independent effects on POMR but relatively little effect in multivariate
analysis on the relative odds of in-hospital death at each site.
Conclusion
It is possible to collect POMR in countries at all level of development. Although
age and admission urgency are strong, independent associations with POMR, a substantial
amount of its variance is site-specific and may reflect the safety of operative and
anesthetic facilities and processes. Risk-adjustment is desirable but not essential
for monitoring system performance. POMR varies depending on the choice of denominator,
and in-hospital deaths appear to underestimate 30-day mortality by up to one third.
Standardized approaches to reporting and analysis will strengthen the validity of
POMR as the principal indicator of the safety of surgery and anesthesia care.
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Article info
Publication history
Published online: May 06, 2015
Accepted:
March 18,
2015
Footnotes
This work was supported by the Lancet Commission on Global Surgery. The authors acknowledge the assistance of the Perioperative Mortality Review Committee and Health Quality and Safety Commission, Wellington, in provision of New Zealand data. R.L.G. is supported by a Practitioner Fellowship from the Australian National Health and Medical Research Council. No funding was received for this work. Study design: D.A.W. and R.L.G.; data collection: R.A., P.H., G.L.L., D.S., L.W., D.L.C., and D.A.W.; data analysis: C.L.P., P.H., and R.L.G.; data interpretation: all authors; writing and editing: all authors.
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© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
