234 million surgeries occur globally each year. Such a volume has never been previously estimated or recognised and shows that safety of surgical care should be an urgent public health priority. And high-income countries undertake many more surgeries each year than low-income countries in relation to their population sizes. This disproportionate absence of surgical access in low-income settings suggests a large unaddressed disease burden worldwide. These are the conclusions of authors of an Article published early Online and in an upcoming edition of The Lancet.
While surgery occurs in every setting from the most resource rich to the most resource limited, little is known about the actual worldwide volume and availability of surgical care since only anecdotal evidence exists. Dr Thomas Weiser, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA, and colleagues estimated the number of operations undertaken worldwide, described their distribution, and assessed the importance of surgical care in global public-health policy.
The researchers gathered surgical data from 56 (29%) of the 192 WHO member states, and from this used a model to estimate that 234.2 million major surgical procedures are undertaken every year worldwide. Major operations were defined as any incision, excision, manipulation or suturing of tissue occurring in an operation room and requiring regional or general anaesthesia or profound sedation to control pain. Countries spending less than US$100 per head on health care have an estimated mean rate of major surgery of 295 procedures per 100,000 population per year, whereas those spending more than $1000 have a mean rate of 11 110 -- more than 37 times higher. Middle-expenditure ($400-$1000) and high-expenditure (>$1000) countries, accounting for just 30.2% of the world's population, provided 73.5% (172.3 million) of operations worldwide in 2004. By contrast, poor expenditure (<$100) countries account for 34.8% of the global population yet only undertook 3.5% (8.1 million) of all surgical procedures in 2004.
The study stems from a new program by the World Health Organization to address surgical safety on a global level. The Safe Surgery Saves initiative is a product of the World Alliance for Patient Safety, a branch of WHO that is evaluating harm patients experience as they interact with the health system. Major complication rates following inpatient surgery in developed countries have been previously estimated to occur in 3-16% of inpatient operations, including death rates of 0.4%-0.8%. In the developing world, studies suggest that death following major inpatient surgery occurs at a rate of 5-10%, with mortality rates from anaesthesia alone as high as 1 in 150. The researchers postulate that even using conservative estimates, 7 million patients suffer complications following surgery, half of which are likely to be preventable. The authors say that the volume of surgery undertaken suggests that surgical safety has now emerged as a substantial global public-health concern. They propose that just as public-health interventions and educational projects have greatly improved maternal and neonatal survival, so might analogous efforts in surgical safety and quality of care.
In addition, a clear disparity between rich and poor countries emerged. The authors say:"Although less than a third of the world's people reside in countries with yearly per-head expenditures on health exceeding $4000, roughly three-quarters of the operations occur in this population. Conversely, the poorest third of the world's population -- residing in countries in which per-head expenditure on health is $100 or less -- receive just 3% of the operations that are undertaken worldwide. This finding strongly suggests the existence of a large unaddressed disease burden globally."
They conclude:"Our findings suggest that surgery now occurs at a tremendous volume worldwide, in settings both rich and poor. The implications are substantial. This unappreciated worldwide growth shows a great need for public-health efforts to improve the monitoring, safety, and availability of surgical services, especially in view of their high risk and expense. A public-health strategy for surgical care is paramount."
In an accompanying Comment, Dr Stephen Bickler, University of California, San Diego, CA, USA and Dr David Spiegel, University of Pennsylvania School of Medicine, Philadelphia, PA, USA, say:"As initiatives to improve surgical care move forward, there is an urgent need to identify the best strategies for instituting surgical services in settings of limited resources."
Dr Thomas Weiser, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA T) +1 617 432 4894 / +1 916 833 2140 E) tweiser@hsph.harvard.edu
Dr Stephen Bickler, University of California, San Diego, CA, USA T) contact by e-mail only E) sbickler@ucsd.edu
http://www.eurekalert.org/jrnls/lance/pdfs/surgeryfinal.pdf
Journal
The Lancet