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• W2945573852 abstract "Stanislaw Krawczyk refers to the director Patryk Vega and his film Botoks, which provides a fictional account of the experiences of individuals receiving health care in Poland. The film, which has been widely viewed, caused outrage among health-care workers in Poland, who are depicted in an extremely negative way, perhaps the most striking example being the serious sexual assault of a patient by a member of hospital staff. The film is provocative to say the least, and some consider it deliberately misleading. I understand from colleagues in Poland that the film director was subject to legal action by several organisations relating to misrepresentation of various statistics about the Polish health-care system. The film does include a statistic regarding postoperative mortality but does not cite our Article1Pearse RM Moreno RP Bauer P et al.Mortality after surgery in Europe: a 7 day cohort study.Lancet. 2012; 380: 1059-1065Summary Full Text Full Text PDF PubMed Scopus (819) Google Scholar as a source. As with any epidemiological research, we can only describe patterns in the data collected. We must be cautious in making any generalisation to the wider population we sample from. In our Article,1Pearse RM Moreno RP Bauer P et al.Mortality after surgery in Europe: a 7 day cohort study.Lancet. 2012; 380: 1059-1065Summary Full Text Full Text PDF PubMed Scopus (819) Google Scholar we recognised that our overall mortality figure was at the higher end of published estimates, and we made it clear that readers should not draw conclusions about outcomes in individual countries, especially those with a small number of participating hospitals. These mortality estimates cannot be considered representative of the entirety of the health-care systems in question. Our focus was instead placed on the variation in outcomes between countries that sampled their surgical populations in the same way. In the 5 years since the publication of this work, epidemiological studies2Abbott TEF Fowler AJ Dobbs TD Harrison EM Gillies MA Pearse RM Frequency of surgical treatment and related hospital procedures in the UK: a national ecological study using hospital episode statistics.Br J Anaesth. 2017; 119: 249-257Summary Full Text Full Text PDF PubMed Scopus (106) Google Scholar, 3The International Surgical Outcomes Study groupGlobal patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.Br J Anaesth. 2016; 117: 601-609Summary Full Text Full Text PDF PubMed Scopus (295) Google Scholar, 4Writing Committee for the VISION Study InvestigatorsAssociation of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery.JAMA. 2017; 317: 1642-1651Crossref PubMed Scopus (403) Google Scholar, 5Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study InvestigatorsAssociation between postoperative troponin levels and 30-day mortality among patients undergoing non-cardiac surgery.JAMA. 2012; 307: 2295-2304Crossref PubMed Scopus (715) Google Scholar from several international groups have revealed more about outcomes after surgery. The consistent message is that a high-risk subpopulation of surgical patients exists that accounts for about 10–15% of inpatient procedures. High-risk patients are typically older with severe chronic disease. In a technical sense, surgery and anaesthesia are safe throughout Europe, yet high-risk patients still frequently develop medical complications, such as pneumonia or myocardial infarction, in the days following surgery. Postoperative complications in high-risk patients are widely agreed to be the primary cause of preventable deaths after surgery in high-income countries. The proportion of such patients included in any epidemiological sample has a considerable effect on the overall mortality estimate. It is now clear that the findings of large epidemiological studies of surgical populations are very susceptible to this source of bias. We studied all surgical procedures (ie, the entire population, not a sample) performed in UK National Health Service hospitals in a 5-year period from 2009 to 2014.2Abbott TEF Fowler AJ Dobbs TD Harrison EM Gillies MA Pearse RM Frequency of surgical treatment and related hospital procedures in the UK: a national ecological study using hospital episode statistics.Br J Anaesth. 2017; 119: 249-257Summary Full Text Full Text PDF PubMed Scopus (106) Google Scholar Among the 39 million procedures performed, the overall 30-day mortality was 1·1% (twice the mortality quoted for Poland by Krawczyk), increasing to 2·3% after 90 days. Importantly, these findings were very sensitive to how surgery was defined and categorised. Using the broadest definition of which procedures count as surgery, 12 500 procedures are performed per 100 000 population, but this falls to just 2 400 procedures for the strictest definition. Confusion is caused by the large volume of very minor procedures, which might or might not take place in an operating theatre, sometimes under anaesthesia and sometimes not. The inclusion or exclusion of low-risk day-case surgery or high-risk emergency surgery has a considerable effect on both the apparent number of procedures and the apparent mortality. This is highly relevant to our 2012 Article1Pearse RM Moreno RP Bauer P et al.Mortality after surgery in Europe: a 7 day cohort study.Lancet. 2012; 380: 1059-1065Summary Full Text Full Text PDF PubMed Scopus (819) Google Scholar because we excluded day-case surgery but included emergency surgery. Furthermore, we now believe that local investigators in Poland and elsewhere took much more trouble to collect data describing major surgeries at the expense of omitting minor (low-risk) procedures. This explains the face validity of numerous secondary analyses of these data for risk factors such as anaemia and serum sodium,6Baron D Hochrieser H Posch M et al.Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients.Br J Anaesth. 2014; 113: 416-423Summary Full Text Full Text PDF PubMed Scopus (261) Google Scholar, 7Cecconi M Hochrieser H Chew M et al.Preoperative abnormalities in serum sodium concentrations are associated with higher in-hospital mortality in patients undergoing major surgery.Br J Anaesth. 2016; 116: 63-69Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar through to standards of care such as use of the WHO safe surgery checklist.8Jammer T Ahmad C Aldecoa D et al.Point prevalence of surgical checklist use in Europe: relationship with hospital mortality.Br J Anaesth. 2015; 114: 801-807Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar In a subsequent international study of elective surgery only,3The International Surgical Outcomes Study groupGlobal patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.Br J Anaesth. 2016; 117: 601-609Summary Full Text Full Text PDF PubMed Scopus (295) Google Scholar we did not identify such high mortality. Despite offering assurances of complete data control, we were unable to persuade societies in Poland and Ireland to participate in this comparative study, and an opportunity for clarification was missed. It has been my continued personal career aim to promote better perioperative care in order to improve outcomes for high-risk surgical patients. This is embodied in the concept of perioperative medicine, which is now being widely adopted throughout the world as an approach to improving short-term and long-term patient outcomes, and hence the success of surgery as a treatment. Epidemiological research provides essential information by describing which patients experience poor outcomes, thus guiding subsequent interventional trials and quality improvement programmes. Among numerous examples of positive international effects, the aforementioned work has driven a major national campaign to promote perioperative medicine led by the Royal College of Anaesthetists in the UK, and was used to make the case to the Romanian Ministry for Health for more investment in perioperative care resources. In these examples, discussion of the research did not centre on specific mortality estimates, nor on technical error by surgeons and anaesthetists, but on whether the paper provided evidence of a need to improve the quality of perioperative care. I share Krawczyk's frustration with the way these research findings have been misrepresented. However, I feel I must also emphasise the considerable positive effects the work has had in many countries. I hold various grants from public and commercial funders for research into better ways to care for high-risk surgical patients. Post-surgery mortality in PolandIn 2012, The Lancet published the results of a 7 day cohort study on mortality after surgery in Europe (Sept 22, 2012, p 1059).1 The Article contained information that was inappropriately used in Poland to promote a film, Botoks, which was watched by more than 2 million people. I am concerned that these data could still be used in similar ways. Full-Text PDF" @default.
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• W2945573852 title "Post-surgery mortality in Poland – Author's reply" @default.
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