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• W2894370113 abstract "Postoperative complications are now a major, but under-recognised, cause of morbidity and mortality in patients undergoing elective and emergency surgery. The impact of population change, such as increasing age and co-morbidities, on future healthcare requirements is substantial. In anaesthesia and surgery, postoperative events identified from large databases, such as the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP), allow some future projections of the impact of these changes on population outcomes and resource requirements.1Cohen M.E. Bilimoria K.Y. Ko C.Y. Hall B.L. Development of an American College of Surgeons National Surgery Quality Improvement Program: morbidity and mortality risk calculator for colorectal surgery.J Am Coll Surg. 2009; 208: 1009-1016Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar Despite the known limitations of the risk calculation for individuals,2Keller D.S. Ho J.W. Mercadel A.J. Ogola G.O. Steele S.R. Are we taking a risk with risk assessment tools? Evaluating the relationship between NSQIP and the ACS risk calculator in colorectal surgery.Am J Surg. 2018; (Advance Access published on July 19, 2018)https://doi.org/10.1016/j.amjsurg.2018.07.015Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar the high weighting on postoperative complications of specific patient factors such as age, diabetes mellitus, body mass index, and the American Association of Anesthesiologists physical status classification (ASA status), provides a concerning picture for the future. Indeed, postoperative complications can now be reasonably considered a pandemic, if defined as ‘the worldwide spread of a (relatively) new disease’. Cancer can also be considered a pandemic3Hume T. Christensen J. CNN WHO: imminent global cancer ‘disaster’ reflects aging, lifestyle factors.https://edition.cnn.com/2014/02/04/health/who-world-cancer-report/index.htmlDate: February 5, 2014Google Scholar; however, although both ‘diseases’ probably share a similar impact on population mortality, an aetiology in part related to aging and lifestyle factors, and preventable and treatable elements, cancer receives substantially more public and research attention. This situation is gradually changing as the impact on patient outcomes and health budgets of postoperative complications becomes more apparent, and as large data sets provide better insights into the nature and potential aetiology of the problems4Sessler D.I. Meyhoff C.S. Zimmerman N.M. et al.Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial.Anesthesiology. 2018; 128: 317-327Crossref PubMed Scopus (142) Google Scholar, 5Beattie W.S. Wijeysundera D.N. Chan M.T.V. et al.Implication of major adverse postoperative events and myocardial injury on disability and survival: a planned subanalysis of the ENIGMA-II Trial.Anesth Analg. 2018; (Advance Access published on March 12, 2018)https://doi.org/10.1213/ANE.0000000000003310Crossref Scopus (26) Google Scholar and the impact of specific therapeutic interventions.6Vester-Andersen M. Lundstrøm L.H. Møller M.H. et al.Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study.Br J Anaesth. 2014; 112: 860-870Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 7POISE Study Group Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.Lancet. 2008; 371: 1839-1847Abstract Full Text Full Text PDF PubMed Scopus (1723) Google Scholar, 8Devereaux P.J. Mrkobrada M. Sessler D.I. et al.Aspirin in patients undergoing noncardiac surgery.N Engl J Med. 2014; 370: 1494-1503Crossref PubMed Scopus (589) Google Scholar The analysis of the National Emergency Laparotomy Audit (NELA) data presented in this issue of British Journal of Anaesthesia9Oliver C.M. Basset M. Poulton T. et al.Organisational factors and mortality after emergency laparotomy: multilevel analysis of 39,903 National Emergency Laparotomy Audit patients.Br J Anaesth. 2018; 121: 1346-1356Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar examines another critical aspect of healthcare—how the organisation and structure of health systems, rather than medicines and medical devices, might impact on outcome. System elements can include aspects such as hospital size and nature, internal structures (such as emergency surgical or geriatrics units), and processes and pathways (such as perioperative care pathways, or checklists).6Vester-Andersen M. Lundstrøm L.H. Møller M.H. et al.Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study.Br J Anaesth. 2014; 112: 860-870Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 10Haynes A.B. Weiser T.G. Berry W.R. et al.A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med. 2009; 360: 491-499Crossref PubMed Scopus (3811) Google Scholar It examines specific elements in the hierarchy of health systems, and finds significant between-institution associations with positive outcomes, such as postoperative geriatric review and the presence of an emergency surgical unit. Of note, it also finds associations between poorer outcomes and seemingly logical benefits, such as direct intensive care unit or critical care unit admission and hospitals with cardiothoracic surgical capacity, or equivocal benefits of elements such consultant level experience in the operating room. There are important messages from this type of analysis, and these findings. Firstly, these data highlight some of the limitations and benefits of large database analysis. As pointed out by the authors, associations do not determine causation, although they can generate hypotheses. After all, we should not be surprised that patients who are sent for intensive or high acuity care because of a clinician's assessment of need have poorer outcomes than those considered suitable for general ward care, but it is very plausible that postoperative geriatric input into elderly patients improves outcomes. However, we need to consider what other unmeasured elements might contribute to any improvement, such as whether the 6% of institutions with access to such specialist geriatric care might also have had other beneficial aspects. Although multivariate analysis can attempt to tease out co-associations with other factors such as patient co-morbidities, the sometimes modest performance of risk prediction tools2Keller D.S. Ho J.W. Mercadel A.J. Ogola G.O. Steele S.R. Are we taking a risk with risk assessment tools? Evaluating the relationship between NSQIP and the ACS risk calculator in colorectal surgery.Am J Surg. 2018; (Advance Access published on July 19, 2018)https://doi.org/10.1016/j.amjsurg.2018.07.015Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar suggests this cannot necessarily be accounted for with precision. Secondly, the data showing potential benefits from specialised units postoperatively highlight the impact of health systems, separately to the specific application of medicines and medical devices. This impact can be large. A simple example of high relevance to anaesthesia is the availability of high acuity care in the very early postoperative period. A benefit has been suggested for even moderate risk patients in both a retrospective analysis of the impact of reduced access to high acuity care,11Swart M. Carlisle J.B. Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.Br J Anaesth. 2017; 118: 100-104Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar and a prospective analysis of the introduction of an anaesthesia-led enhanced recovery service.12Eichenberger A.S. Haller G. Cheseaux N. et al.A clinical pathway in a post-anaesthesia care unit to reduce length of stay, mortality and unplanned intensive care unit admission.Eur J Anaesthesiol. 2011; 28: 859-866Crossref PubMed Scopus (41) Google Scholar Of note, both studies suggested decreases in both mortality and length of stay that were much greater than many specific therapeutic interventions.4Sessler D.I. Meyhoff C.S. Zimmerman N.M. et al.Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial.Anesthesiology. 2018; 128: 317-327Crossref PubMed Scopus (142) Google Scholar, 5Beattie W.S. Wijeysundera D.N. Chan M.T.V. et al.Implication of major adverse postoperative events and myocardial injury on disability and survival: a planned subanalysis of the ENIGMA-II Trial.Anesth Analg. 2018; (Advance Access published on March 12, 2018)https://doi.org/10.1213/ANE.0000000000003310Crossref Scopus (26) Google Scholar These two studies also highlight the need to consider a range of outcomes. Mortality is relatively uncommon, but measurable and more frequent events include medical emergency response calls,13Seglenieks R. Painter T.W. Ludbrook G.L. Predicting patients at risk of early postoperative adverse events.Anaesth Intensive Care. 2014; 42: 649-656Crossref PubMed Google Scholar hypotension,4Sessler D.I. Meyhoff C.S. Zimmerman N.M. et al.Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial.Anesthesiology. 2018; 128: 317-327Crossref PubMed Scopus (142) Google Scholar length of stay,11Swart M. Carlisle J.B. Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.Br J Anaesth. 2017; 118: 100-104Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 12Eichenberger A.S. Haller G. Cheseaux N. et al.A clinical pathway in a post-anaesthesia care unit to reduce length of stay, mortality and unplanned intensive care unit admission.Eur J Anaesthesiol. 2011; 28: 859-866Crossref PubMed Scopus (41) Google Scholar and events after hospital discharge.14Dexter F. Epstein R.H. Dexter E.U. Lubarsky D.A. Sun E.C. Hospitals with briefer than average lengths of stays for common surgical procedures do not have greater odds of either re-admission or use of short-term care facilities.Anaesth Intensive Care. 2017; 45: 210-219Crossref PubMed Google Scholar All are important safety, efficacy, and efficiency components of the Baylor STEEEP™ definition of quality of care,15Ballard D.J. Interview: achieving STEEEP healthcare: a journey supported by comparative effectiveness research.Comp Eff Res. 2013; 2: 523-527Crossref PubMed Scopus (3) Google Scholar and are very relevant to the health economic and value creation challenges facing most hospitals and healthcare providers.16Porter M.E. What is value in health care?.N Engl J Med. 2010; 363: 2477-2481Crossref PubMed Scopus (3257) Google Scholar In light of these findings, it is interesting to reflect on the future role of recovery rooms. These were originally designed as places for the provision of short-term high acuity care of patients temporarily unsuitable for the low acuity ward environment.17Zuck D. Anaesthetic and postoperative recovery rooms. Some notes on their early history.Anaesthesia. 1995; 50: 435-438Crossref PubMed Scopus (16) Google Scholar Patient complexity has changed substantially since the 1960s, yet recovery room capacity has not necessarily followed, and might no longer be fit for purpose. This can go unrecognised. For example, in Australia, prolonged stay in recovery for medical reasons has not been considered a positive indicator of quality,18The Australian Council on Healthcare Standards. Australasian clinical indicator report 13th edition 2004–2011. Available from: https://www.achs.org.au/media/50245/achs_clinical_indicators_report_web.pdf (accessed 7 September 2018)Google Scholar despite the fact that, in some institutions, prolonged stay can be frequently indicated.13Seglenieks R. Painter T.W. Ludbrook G.L. Predicting patients at risk of early postoperative adverse events.Anaesth Intensive Care. 2014; 42: 649-656Crossref PubMed Google Scholar Internal analysis of the impact of more advanced recovery capacity suggests substantial impacts on hospital capacity, outcomes and costs, and large financial returns on investment (unpublished analysis by the author). Although costs and impacts vary substantially internationally, simple costs analysis from the UK11Swart M. Carlisle J.B. Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.Br J Anaesth. 2017; 118: 100-104Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar suggests these principles apply across at least the developed world. Lastly, the data presented demonstrate the potential confounding effect of institution health system differences on outcomes from multi-centre trials. Although this can, to a degree, be accounted for by stratified randomisation by site, it still requires consideration of the potential cause of between-site differences. For example, if the presence of a postoperative geriatric service alone were responsible for a two-thirds reduction in mortality, inter-institutional variance in this service might swamp the benefits of other changes, such as beta blockers7POISE Study Group Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.Lancet. 2008; 371: 1839-1847Abstract Full Text Full Text PDF PubMed Scopus (1723) Google Scholar or depth of anaesthesia monitoring.19Monk T.G. Weldon B.C. Does depth of anesthesia monitoring improve postoperative outcomes?.Curr Opin Anaesthesiol. 2011; 24: 665-669Crossref PubMed Scopus (25) Google Scholar Influences of potentially confounding health systems elements are evident elsewhere. For example, the benefit of the preoperative surgical checklist on patient outcomes has been well described,10Haynes A.B. Weiser T.G. Berry W.R. et al.A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med. 2009; 360: 491-499Crossref PubMed Scopus (3811) Google Scholar but was accompanied by differences in impact depending on the health system or institution in which it was used. Whilst factors such as how the checklist was applied are no doubt relevant, what else in these health systems did, or did not, confer postoperative benefit? The same might apply to other multicentre clinical trials, especially those where outcomes differed to those demonstrated in small or single-site pilot studies. The failure of benefits of tight glucose control in a single centre of predominantly surgical patients20Berghe G. Wouters P. Weekers F. et al.Intensive insulin therapy in the critically ill patients.N Engl J Med. 2001; 345: 1359-1367Crossref PubMed Scopus (8186) Google Scholar to translate into benefits in a multicentre trial21NICE-SUGAR Study Investigators Finfer S. Chittock D.R. et al.Intensive versus conventional glucose control in critically ill patients.N Engl J Med. 2009; 360: 1346-1349Crossref PubMed Scopus (123) Google Scholar might be one example. Although there are a number of potential causes, ‘a lower “commitment” to TGCIIT by centres other than Leuven’ has been suggested.22Preiser J.C. NICE-SUGAR: the end of a sweet dream?.Crit Care. 2009; 13: 143Crossref PubMed Scopus (31) Google Scholar Should we be enquiring as to what at the original site, such as staffing, appeared to provide a site benefit, and could it practically or economically be reproduced elsewhere? Even for multi-centre trials with positive outcomes, such as RELIEF,23Myles P.S. Bellomo R. Corcoran T. et al.Restrictive versus liberal fluid therapy for major abdominal surgery.N Engl J Med. 2018; 378: 2263-2274Crossref PubMed Scopus (392) Google Scholar are there lessons to be learned about health systems from inter-institution and cross-country variances, rather than attributing these to chance variation? In this sense, large trials and databases can act to generate hypotheses about health systems, but well-designed prospective trials, with research including health services elements, are required to prove benefit. This is not to say such change, or such research, is easy. A change in prescribing of fluids or medicines is relatively easy and does not usually disrupt the fabric of the health system. In contrast, fundamental changes in systems require significant planning, and can have substantial financial, industrial, and logistical implications. As pointed out Oliver and colleagues,9Oliver C.M. Basset M. Poulton T. et al.Organisational factors and mortality after emergency laparotomy: multilevel analysis of 39,903 National Emergency Laparotomy Audit patients.Br J Anaesth. 2018; 121: 1346-1356Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar these types of solutions can in some ways be considered low technology, but personnel costs contribute to the majority of most hospital budgets, and change can require large upfront investment. Nevertheless, their impact is potentially large, and perhaps it is time we made this area a major, rather than a hidden, health priority. GL is the sole contributor to this article. GL is the director of a commercial and academic clinical trials unit, PARC Clinical Research, and a member of the Advisory Committee on Medical Devices, Therapeutic Goods Administration, Australia. Funding for research into recovery capacity has been provided by grants from the Australian and New Zealand College of Anaesthetists, and the Royal Adelaide Hospital, and PARC Clinical Research." @default.
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• W2894370113 title "Hidden pandemic of postoperative complications—time to turn our focus to health systems analysis" @default.
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