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• W2954688410 abstract "Postoperative death is not unheard of, yet patients hope that such an outcome is unlikely when they require surgery themselves. Dmitri Nepogodiev and colleagues1Nepogodiev D Martin J Biccard B et al.Global burden of postoperative death.Lancet. 2019; 393: 401Summary Full Text Full Text PDF PubMed Scopus (177) Google Scholar estimate that, globally, at least 4·2 million people die each year within 30 days of a surgical procedure—a cause of death known as perioperative mortality, which was a focus of the Lancet Commission on Global Surgery.2Meara JG Leather AJ Hagander L et al.Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1850) Google Scholar Nepogodiev and colleagues used a complex model for perioperative mortality in different economic regions, making numerous assumptions and calculations since little data on perioperative mortality exists in any setting. The Article was considered controversial, receiving both criticism and praise on social media immediately after publication. Criticisms included the lack of risk adjustment, modeling methodology, and the absence of a link to cause of death. Although most of these criticisms were scientifically valid, critics uniformly missed the point. Early in the 20th century, Ernest Amory Codman, a surgeon from Boston, began to use end result cards for each patient to record outcomes, including morbidity and mortality.3Hicks C Makary M A prophet to modern medicine: Ernest Amory Codman.Br Med J. 2013; 347Crossref Scopus (10) Google Scholar In 1911, the Massachusetts General Hospital (Boston, MA, USA) refused to accept his suggestions about the need for morbidity and mortality conferences and his outcome tracking system, thus Codman resigned.3Hicks C Makary M A prophet to modern medicine: Ernest Amory Codman.Br Med J. 2013; 347Crossref Scopus (10) Google Scholar Subsequently, morbidity and mortality conferences became standard procedure in all surgery units in high-income countries and have become an integral part of surgical culture. At the department, hospital, or facility level, risk adjustment is meaningful to understand the possible factors that might have led to morbidity and mortality. These discussions then form the basis of a root cause analysis and hopefully lead to improvements in surgical quality and safety. To be clear, we believe that risk adjustment is meaningful at the facility level in the context of quality and safety improvement and to allow for fair benchmarking given the diverse spectrum of surgical disease presentation. The view of mortality at the national level differs from that at the facility level. National mortality data is used to assess the reality of the situation—ie, how many patients are dying. This concept is supported by the fact that maternal mortality, infant mortality, and under-5 mortality estimates are not risk-adjusted. In areas where perioperative mortality is high, the reality of death after surgery should be acknowledged and action should be taken to improve systems; people who have died should not be blamed for presenting to health care late, and researchers should not dismiss their deaths through risk adjustment. National data should be used to illustrate the realities of the human condition, rather than ignoring what makes us uncomfortable. Perioperative mortality in many countries is very high and should not be ignored. Three changes are needed if universal health coverage and the Sustainable Development Goals are to be achieved. First, surgical facilities should record perioperative mortality and use this information for regular morbidity and mortality conferences and quality improvement processes. Second, perioperative mortality data that has not been risk-adjusted should be aggregated by ministries of health tracking progress on surgical, obstetric, and anaesthesia system strengthening to make strategic and tactical decisions about their national surgical, obstetric and anaesthesia plans.4Albutt K Sonderman K Citron I et al.Healthcare leaders develop strategies for expanding national surgical, obstetric, and anaesthesia plans in WHO AFRO and EMRO regions.World J Surg. 2019; 43: 360-367Crossref PubMed Scopus (27) Google Scholar Third, ministries of health should send this national data to WHO and the World Bank for transparent reporting in the World Bank World Development Indicators. We must first count the dead, then account for their death; only then can we improve care. We declare no competing interests. Making all deaths after surgery countWe welcome the important focus that Dmitri Nepogodiev and colleagues1 bring to surgical safety. The authors estimate that globally, postoperative deaths account for 4·2 million deaths per year (7·7% of total deaths). Nepogodiev and colleagues project an expansion of surgical services in low-income and middle-income countries (LMICs) will result in an additional 1·9 million postoperative deaths per year, assuming that the postoperative mortality rate in LMICs remains constant while surgical services in these countries expand. Full-Text PDF Global burden of postoperative deathThe Lancet Commission on Global Surgery1 identified that 313 million surgical procedures are performed worldwide each year. Little is known about the quality of surgery globally because robust reports of postoperative death rates are available for only 29 countries.2 The rate of postoperative deaths is a measure of the success of surgical care systems, and improving this metric is a global priority. Full-Text PDF Making all deaths after surgery count – Authors' replySafe surgery saves lives and is a cost-effective public health intervention, but it is associated with risks.1 We estimated that, worldwide, more people die within 30 days of surgery than of any disease-specific category of death, with the exception of stroke and ischaemic heart disease.2 Globally, disparities in postoperative death exist, with the majority of deaths occurring in low-income and middle-income countries (LMICs), despite only a minority of global surgeries being done there. High postoperative mortality rates indicate system failures, which are prevalent in LMICs. Full-Text PDF Making all deaths after surgery countWe read with interest the estimated global postoperative death rates by by Dmitri Nepogodiev and colleagues.1 The authors highlighted the importance of routinely measuring surgical outcomes and expanding surgical services, together with initiatives to reduce postoperative death. Additionally, permanent disability should be considered when addressing the burden of surgical procedures. Permanent disability is particularly relevant with regard to neurosurgery, in which postoperative neurological changes could have important consequences in the patient's daily life. Full-Text PDF" @default.
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• W2954688410 title "Making all deaths after surgery count" @default.
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