Surgical outcomes research ensuring safer surgery
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1 Surgical outcomes research ensuring safer surgery Auckland POMRC meeting 15 June 2015 Professor David A Watters Royal Australasian College of Surgeons
2 Acknowledgments Commissioners, authors and collaborators of Lancet Commission on Global Surgery Co-workers: Russell Gruen, Phil Hider, Roshan Ariyaratnam, Damian Clarke, Leona Wilson, Douglas Stupart Mar 14: Consensus meeting at RACS on POMR held with RACS Global Health, ANZCA, Pacific Island Surgeons, and regional Public Health physicians with an interest in Global Health ANZASM Andreas Kiermeier, Wendy Babidge, Claudia Retegan, Barry Beiles and Glen McCulloch
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4 A common vision Universal access to safe, affordable surgical and anesthesia care when needed
5 K M1 5 BILLION cannot access safe surgery when needed
6 The three delays First delay Second delay Third delay
7 K M2 143 million more procedures needed annually at minimum.
8 K M3 33 million Individuals face catastrophic expenditures paying for surgery & anaesthesia annually.
9 K M4 Investing in surgery is affordable, saves lives, & promotes economic growth.
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14 K M5 Surgery is an indivisible, indispensable part of health care. World Bank President Jim Kim Launch of the Lancet Commission in Global Surgery, Jan 2014.
15 Incidence of surgery in GBD disease categories
16 Lancet Commission: core indicators for global surgery: April
17 Perioperative mortality rates (POMR) A safety and quality indicator for global health What are the rates globally? When do we measure POMR? How do we risk adjust to compare like with like? RACS study with AIHW data POMR Australia Using Dr Foster to benchmark surgical outcomes
18 New Zealand POMRC Leona Wilson (Chair) Cathy Ferguson (Deputy Chair) Phil Hider (Clinical Epidemiologist) Jonathan Koea FRACS Jean Claude Theis FRACS Digby Ngan Kee (O&G) Michael Kluger (Anaes) Tony William (ICU) Rosaleen Robertson (Clinical Safety) Teena Robinson (Periop Nursing) Established 2010
19 POMR WHO metric POMR 24 death on the same calendar day as surgery (or within 24 hours) POMR 30 death before discharge from hospital or within 30 days whichever is sooner Numerator = number of postoperative deaths Denominator = number of patients who have had a procedure in an operating room Use at population level (cf MMR, IMR) Clinical interpretation depends on casemix and requires risk stratification Inserted into the WHO list of 100 health indicators in November 2014
20 POMR the credible indicator for global surgery Adopted for study of surgical safety checklist Introduced to 100 Health Indicators by WHO in November 2014 Included as safety and outcome measure in Resolution to strengthen emergency and essential surgery by 136 th Executive Board of WHO in January 2015 Recommended for use at health system level Provides context for audits of surgical mortalities as has the denominators (number of procedures or patients having at least one procedure)
21 WHO Safety Checklist (2008) 8 hospitals In-hospital mortality fell from 1.5 to 0.8% ( %) Complications reduced from 11 to 7% Netherlands hospital mortality 1.5 to 0.8% Complications 15.4 to 10.8% Haynes et al NEJM 2009 De Vries et al Qual Saf Health Care 2008
22 Methodology with POMR
23 Time to in-hospital death Roshan Ariyaratnam, R Gruen et al
24 POMR (cumulative) P O M R No of Days Post Procedure
25 7 Day POMR correlates with POMR Days Correlation > Days Data from Barwon health and New Zealand POMRC Roshan Ariyaratnam et al, ASC 2014
26 Barry Beiles & VASM
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28 7,728,232 2,363,724 1,953,767 1, , , , ,434 54,076 Source: AIHW/RACS
29 Source AIHW and RACS
30 0.25% 0.26% 0.19%
31 Interpreting perioperative mortality what are the risk factors? Urgency Age ASA (Comorbidities) Condition/procedure group [Gender] [Public or private hospital] Understanding and interpreting POMR at a hospital/service level in Australia and New Zealand
32 Urgency of procedure
33 The influence of age on mortality
34 Age and urgency
35 Roshan Ariyaratnam, R Gruen et al In-hospital POMR by age and urgency NZ, Barwon Health, Pietermaritzburg, SA, and Port Moresby, PNG
36 Does gender affect mortality?
37 Procedure: NZ cumulative mortality
38 Dr Foster comparing outcomes
39 Condition: In-hospital mortality #NOF Barwon Dr Foster [Victoria]: #NOF in hospital mortality %
40 Benchmarking #NOF mortality July June 2014 Dr Foster [Victoria]: #NOF in hospital mortality %
41 Fractured neck of femur in-hospital mortality July 2011 June ,122 separations Barwon Health
42 Acute admissions for diverticulitis, peritonitis, intestinal obstruction
43 Hospital mortality from acute diverticular disease 13,197 admissions July 2011 to June 2014
44 Mortality from peritonitis 653 admissions (557 acute) July 2011 June 2014
45 Intestinal obstruction
46 Mortality from intestinal obstruction admissions as emergencies 653 at Barwon Health 6.58% mortality
47 Predicting surgical mortality probability ASA PS (1-5) Procedure Risk (1-3) Urgency (Non emergent/emergency) Barry Beiles - VASM SCORE - VASM Mean Standard Error Median 7 Mode 7 Standard Deviation Sample Variance Kurtosis Skewness Range 9 Minimum 0 Maximum 9 Sum Count 5412 Scoring System: Glance et al Ann Surg 2012
48 Victorian Audit of Surgical Mortality B Beiles, C Retegan et al 2014
49 Risk Adjustment of Outcomes NSQIP Predicting Mortality and Complications ASA Albumin Wound classification Functional status Urgency Age Alkaline Phosphatase Anderson et al WJS 2014
50 HIC: POMR30 by specialty group Source Year Procedure Gp Rate per 100 ANZ Acute # Hip Boston NSQIP Colon 3.2 Netherlands 2010 Colon Boston NSQIP 2004 Gen/Vasc 1.2 US NSQIP Non-cardiac 1.34 US NSQIP Colon GB hernia pancreas NZ POMRC Elective 2.1 NZ POMRC Emergency 9.8 NZ POMRC Knee replacement 0.2 Australia Elecitve Hip arthroplasty Risk Stratification: Urgency and Procedure Group
51 POMR 30 LMIC s Source Year Rate/100 Rate/10,000 Reference Zambia Watters et al Alotau, PNG Stokes et al Port Moresby PNG W M Kaptigau Tonga W Tangi et al Suva, Fiji J Turagawa Mendi, PNG B Dagam PNG/ TongaRates Expressed for All Surgery Performed in Hospital or Health Service Kaptigau, Port Moresby rate for all surgery in audited unit Mendi: rate excludes O&G Zambia: Rate for all surgery in audited unit (one of 5) over each of 10 years. Fiji: rates for all surgery at CWM
52 POMR 24 within 24 hours Country Years Surgical type Rate/100 Rate/100,00 NZ POMRC Emergency General NZ POMRC Elective General MSF teams General and Obstetric Malawi 1999 Elective and Emergency Togo 2006 All surgery Zimbabwe 1992 All surgery PNG (48h) 2002 All surgery (New Zealand) Review of 939 deaths in NSW ( ) Less than 20% of deaths related to anaesthesia
53 Progress Oceania NZ POMRC reporting POMR (since 2011) POMR has been agreed in the Pacific Tonga have two years of data Fiji collecting data Advocacy with health departments in Australia and New Zealand to report POMR ANZASM audits of surgical mortality to report denominators
54 POMR progress global surgery Safe Surgery Saves Lives program (2008) Lancet Commission adoption of POMR Review published by WJS on POMR POMR included in WHO s list of 100 health indicators Advocate for a metric such as POMR to be included in WHA resolution on surgery
55 POMR progress Oceania NZ POMRC reporting POMR (since 2011) POMR has been agreed in the Pacific Tonga and Fiji have two years of data Lancet Commission has adopted POMR as Credible Indicator (launch in April 2015) Advocacy with health departments in Australia and New Zealand to report POMR ANZASM Audits of surgical mortality to report denominators (AIHW-RACS data) WHA likely to pass resolution on surgery in May 2015
56 Surgical outcomes research Perioperative mortality 30, 90, 365 days Unplanned return to theatre Unplanned ICU admission Unplanned readmissions Prolonged length of stay Wound infection or other complication rates Patient reported surgical outcomes return to work or to normal activity quality of life
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