Elsevier

The Lancet

Volume 374, Issue 9695, 26 September–2 October 2009, Pages 1113-1117
The Lancet

Health Policy
Standardised metrics for global surgical surveillance

https://doi.org/10.1016/S0140-6736(09)61161-2Get rights and content

Summary

Public health surveillance relies on standardised metrics to evaluate disease burden and health system performance. Such metrics have not been developed for surgical services despite increasing volume, substantial cost, and high rates of death and disability associated with surgery. The Safe Surgery Saves Lives initiative of WHO's Patient Safety Programme has developed standardised public health metrics for surgical care that are applicable worldwide. We assembled an international panel of experts to develop and define metrics for measuring the magnitude and effect of surgical care in a population, while taking into account economic feasibility and practicability. This panel recommended six measures for assessing surgical services at a national level: number of operating rooms, number of operations, number of accredited surgeons, number of accredited anaesthesia professionals, day-of-surgery death ratio, and postoperative in-hospital death ratio. We assessed the feasibility of gathering such statistics at eight diverse hospitals in eight countries and incorporated them into the WHO Guidelines for Safe Surgery, in which methods for data collection, analysis, and reporting are outlined.

Introduction

Public health surveillance has long used standardised metrics to quantify disease burden in a population, track mortality rates, and guide health system programming and assessment.1 Maternal mortality, infant mortality, and life expectancy have been important indicators for measuring the efficacy of health services and delivery for more than half a century. Many countries are also incorporating vaccination rates and treatment coverage for specific infectious diseases into surveillance programmes in an effort to identify gaps in resource allocation.2 However, because of the overall worldwide increase in life expectancy and decrease in maternal and infant mortality, other measures are essential for monitoring health system performance.

Surgical care is one important example. An estimated 234 million major operations occur worldwide every year—a previously unrecognised amount that exceeds the global volume of childbirth.3 Evidence suggests that surgical care results in at least 7 million complications every year, including 1 million deaths, which is twice the number of maternal deaths per year.4, 5, 6 However, information on the frequency and safety of operative care is severely limited by gaps in national data and a paucity of standardised definitions for tracking surgical services globally. 70% of countries have no information on frequency of surgical procedures and virtually none attempt to assess distribution of surgical resources or outcomes. Basic metrics for surgical surveillance are needed if public health officials are to engage in effective planning of health system resources, safety, and access.

In 2007, WHO and its Patient Safety Programme launched an initiative called Safe Surgery Saves Lives.7 One aspect of this programme was to develop standardised measures for surveillance of the volume of surgical care and its effect on public health outcomes over time. The aim of these measures is to improve assessment of the magnitude and safety of surgical care while being feasible to gather at a national level by public health agencies in nearly all resource settings. We report the results of this work and describe the rationale for each of the proposed measures. We also tested the practicability of their collection in eight hospitals in eight countries with a broad range of resources and record-keeping practices.

Section snippets

Identification of surgical measures

A technical working group comprised of experts in epidemiology, global health, and research on surgical outcomes from around the world was created to develop standardised metrics for assessing surgery on a global level. Individuals were selected to represent a variety of geographic regions and resource settings, and on the basis of their previous involvement with surgical research and outcomes work. The group reviewed the publications on measuring surgical services, studied the experiences of

Feasibility testing

Once metrics were identified, we assessed the ability of individual facilities to gather the data by requesting such information from one hospital in eight different countries (Toronto General Hospital, Toronto, Canada; St Stephen's Hospital, Delhi, India; Prince Hamzah Hospital, Amman, Jordan; Auckland City Hospital, Auckland, New Zealand; Philippine General Hospital, Manila, Philippines; St Francis Designated District Hospital, Ifakara, Tanzania; St Mary's Hospital, London, UK; and the

Global surgical surveillance

Measurement of the provision and outcomes of surgical care through the use of standardised metrics seems feasible across diverse settings and would provide an important indication of health system performance for these high-risk and complex services. In view of the value of such data, WHO adopted these measures as recommended guidelines for national public health surveillance.10

Facility information, aggregated at a national level, can provide ministries of health and departments of health with

Policy implications

Advances in maternal health have relied on a knowledge built around birth rates and crude maternal and neonatal mortality.11 Such data not only provided a benchmark to measure improvement but also recognition of the enormous effect of unsafe childbirth on global health. Similar to the improvements in maternal health achieved in many parts of the world, a better understanding of the magnitude and outcomes of operative care will allow better research on health services in surgery and provide

Conclusion

Enthusiasm is growing for measuring and improving health systems in a comprehensive way rather than focusing on narrow areas of care.15 Additional metrics are needed for a more complete assessment of health system function. These surgical metrics, including surgical mortality, are one component. Countries can use such information on a national level to identify barriers to access, to assess surgical safety, and to track changes over time. On a broader level, improvements in the capacity of a

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