Elsevier

The Lancet

Volume 391, Issue 10130, 21–27 April 2018, Pages 1589-1598
The Lancet

Articles
Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study

https://doi.org/10.1016/S0140-6736(18)30001-1Get rights and content

Summary

Background

There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa.

Methods

We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899).

Findings

We recruited 11 422 patients (median 29 [IQR 10–70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000–2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2–1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65–578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1–2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4–18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died.

Interpretation

Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective.

Funding

Medical Research Council of South Africa.

Introduction

The surgical population represents a major global health burden, with more than 300 million surgical procedures done annually1 and an early postoperative mortality rate of up to 4%.2, 3 However, it has been estimated that 5 billion people are unable to access safe surgical treatments,4 94% of whom live in low-income and middle-income countries (LMICs).4 Globally, an estimated additional 143 million surgical procedures are required each year, many of which are in Africa.4 Surgery is a cost-effective and core component of universal health coverage,5, 6, 7 but it needs to be safe.4 Known barriers to the provision of safe surgical treatment in Africa include low hospital procedural volumes,8 few hospital beds,9 and a scarce number of operating theatres,10 all of which are compounded by the geographical remoteness of many surgical hospitals and an absence of adequately trained staff.11, 12 The Lancet Commission on Global Surgery13 was established to develop strategies for safe, accessible, and affordable surgical care, but implementation of this strategy requires robust epidemiological data describing patterns of surgical activity and subsequent patient outcomes.7, 13

Data describing surgical outcomes in Africa are scarce, and the findings of international studies are dominated by activity in high-income countries, with little participation from African countries.9, 14 Furthermore, only a few African countries have national registries or audit systems to monitor surgical procedures and subsequent outcomes. Low human-development index countries, many of which are African, are believed to have significantly higher perioperative mortality but this is unconfirmed.14, 15 The effect of population disease burden on the pattern of surgical outcomes in Africa is also unknown. Compared with high-income countries, there is a preponderance of communicable diseases and injuries in Africa,14, 16, 17, 18 of which HIV is the leading cause of life-years lost.18

Research in context

Evidence before this study

Safe, accessible, and affordable surgery is a global health priority. An estimated 5 billion people do not have access to safe and affordable surgery, and an additional 143 million surgeries each year are needed in low-income and middle-income countries (LMICs) to address this need. However, there are few surgical outcome data from LMICs, and particularly few data from Africa. Two observational cohort studies only included a few African countries, with a small range of surgeries reported. Increasing access to surgery is a priority in Africa; however, it is essential to ensure that the surgery is safe, and that unnecessary perioperative morbidity and mortality are prevented. Because of the scarcity of surgical outcomes data in Africa, there is an urgent need for a robust epidemiological study of perioperative patient outcomes to inform the global surgery initiative.

Added value of this study

The African Surgical Outcomes Study provided data from 25 African countries for all in-patient surgeries. Our findings showed that one in five surgical patients in Africa developed a perioperative complication, following which, one in ten patients died. Our findings also showed that, despite being younger with a low-risk profile, and lower occurrences of complications, patients in Africa were twice as likely to die after surgery when compared with outcomes at a global level. African surgical hospitals are under-resourced with a median combined total of specialist surgeons, obstetricians, and anaesthesiologists of 0·7 (IQR 0·2–1·9) per 100 000 population, far below the recommended number identified by the Lancet Commission on Global Surgery. The number of surgical procedures in Africa was also very low at 212 (65–578) per 100 000 population each year. Most surgical procedures were done on an urgent or emergency basis, and a third were caesarean deliveries. Importantly, 95% of deaths occurred after surgery, indicating the need to improve the safety of perioperative care.

Implications of all the available evidence

Previous studies have presented only few data on surgical outcomes in Africa, because of limited country participation and inclusion of selected surgical procedures. The African Surgical Outcomes Study provided a detailed insight into this problem. Our findings suggest a high incidence of potentially avoidable deaths among low-risk patients after surgery, largely caused by a failure to identify and treat life-threatening complications in the perioperative period. Limited availability of human and hospital resources might be a key factor in this problem. Despite the positive effect of the global safe surgery campaign, our findings showed that surgical outcomes will remain poor in Africa unless the perioperative care of patients with deteriorating physiological function is addressed and sufficient resources are available to provide this care. A continent-wide quality improvement strategy to promote effective perioperative care might save many lives after surgery in Africa.

To improve both the provision and quality of surgical treatments in Africa, a detailed understanding is needed about the number of surgical treatments being undertaken, the surgical resources available, and the associated patient outcomes.4 The objective of our African Surgical Outcomes Study (ASOS) was to provide robust epidemiological data describing the volume of surgical activity, perioperative outcomes, and surgical workforce density in Africa, which are similar to published international surgical outcomes data.9

Section snippets

Study design, setting, and participants

We did a 7-day, international, multicentre, prospective observational cohort study of patients aged 18 years and older undergoing any form of inpatient surgery in hospitals in 25 African countries. Our findings are reported in accordance with the STROBE statement.19 A collaborative network of more than 1000 health-care professionals was established across Africa through personal invitations to colleagues, invitations to surgical and anaesthesia societies, a website and a Twitter feed. BMB made

Results

We recruited 11 422 patients (median 29, IQR 10–70) from 247 hospitals in 25 African countries during the national cohort weeks (Figure 1, Figure 2). These countries included 14 low-income countries (Benin, Burundi, Congo, Democratic Republic of the Congo, Ethiopia, The Gambia, Madagascar, Mali, Niger, Senegal, Tanzania, Togo, Uganda, and Zimbabwe) and 11 middle-income countries (Algeria, Cameroon, Egypt, Ghana, Kenya, Libya, Mauritius, Namibia, Nigeria, South Africa, and Zambia).

Discussion

The main finding of this study was that patients receiving surgery in Africa are younger than the global average, with a lower-risk profile and lower complication rates, and yet are twice as likely to die. Approximately one in five surgical patients in our African cohort developed a postoperative complication, and one in ten of these patients died. It is likely that many of these deaths were preventable. This large prospective cohort of surgery in 247 hospitals in 25 African countries revealed

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