Physician anesthesiologists are leaders in patient safety in the developed world. The technology, vigilance and protocols that our specialty embrace have saved countless lives in the O.R. and everywhere that sedation takes place. It would be easy to believe that this is normative. But in low-income countries across the globe, anesthesia-related mortality rates are shockingly high, and most of them occur in healthy patients (ASA Physical Status 1-2). Most of these patient deaths would be considered preventable in a higher-income environment.
This reality is not a global secret. In fact, the global anesthesia crisis has been reported before,1,2 but without action until recently. Non-communicable and chronic diseases now eclipse infectious disease as factors contributing to global mortality rates.3 With this disease transition, the role of safe anesthesia and surgery has emerged as an important strategy for global health. This evolution in health care will require new global metrics to evaluate safety and demonstrate effectiveness. A quantitative, reliable, reproducible health indicator is needed – one that does not impose excessive costs on overburdened systems.
Of the health indicators routinely tracked by the World Health Organization (WHO), mortality rates are the most powerful. Even when non-specific, they provide tractable information that can be benchmarked and used as a measure of improvement. Maternal mortality rates (MMR) and under-5 mortality rates4 have been particularly successful in revealing disparities in health across populations. These rates are routinely cited when describing national health outcomes and when discussing the cost effectiveness of interventions.
The perioperative mortality rate (POMR) is the proposed new indicator of safe anesthesia and surgery in low-income countries. POMR is defined as the all-cause mortality of ASA Physical Status 1, 2 or 3 patients within 24 hours of a surgical intervention with anesthesia. Like MMR and other mortality rates, the POMR is not specific to any service and will not reveal important aspects of causality. But it will reveal the shocking reality of anesthesia- and surgery-related mortality in the poorest countries.
Recently, ASA reached out to support the WHO and United Nations in releasing a World Health Assembly resolution for the prioritization of safe anesthesia and surgery. This endorsement was shared by the American College of Surgeons, the World Federation of Societies of Anaesthesiologists and the International College of Surgeons. An important next step in this global process is the mandatory collection and reporting of the POMR.
Figure 1: World Health Report 2008, accessed online at http://www.who.int/whr/2008/en/index.html, May 28, 2013. Permission received from the WHO for reprinting.
ASA and its members, in collaboration with our international partners, must demand that the WHO and its member states adopt and endorse the POMR as a descriptor of global health care effectiveness. Perioperative death in low-risk individuals is a sentinel event, and mandating the reporting of POMR will enable improvements in surgical safety.
Collection of the POMR in low-income countries will begin a quality management cycle that identifies the patients and situations of greatest risk. This will inspire ongoing and future efforts at mitigation. Loss of life due to respiratory depression and difficulties with airway management, for example, will motivate the efforts of the Lifebox Campaign to put a pulse oximeter in every operating room. Mortality related to hemorrhage will inform surgical triage, referral of high-risk patients and development of blood banks. Failures of judgment will lead to better educational programs and certification standards for local anesthesia providers.
Figure 2: Perioperative Mortality Rates and National Resources (Dutton R. 2013)
In summary, collection and reporting of POMR will be the first, and most important, metric for a true understanding of surgical mortality worldwide. As hypothesized in Figure 2, it is likely that the most substantial gains in mortality will be achieved in countries with the lowest human development index. As suggested by the figure, continued improvements in health care infrastructure will continue to lower mortality, but at a slower rate. This occurs because gains in safety and outcome are often “reinvested” in operating on sicker patients. Global collection and reporting of the POMR will provide the data needed to test this theory over time, and will track our ability to improve anesthesia and surgical care in the developing world.
K.A. Kelly McQueen, M.D., M.P.H., Associate Professor of Anesthesiology, Affiliate Faculty, Vanderbilt Institute for Global Health; Director, Vanderbilt Anesthesia Global Health and Development, Vanderbilt University and Medical Center, Nashville.
Richard P. Dutton, M.D., M.B.A. is a Clinical Associate Anesthesiologist at the University of Chicago. He is Executive Director of the Anesthesia Quality Institute.
1. McQueen KA. Anesthesia and the global burden of surgical disease. Int Anesthesiol Clin. 2010;48(2):91-107.
2. Dubowitz G, Detlefs S, McQueen KA. Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices. World J Surg. 2010;34(3):438-444.
3. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197-2223.
4. The World Health Organization. World Health Statistics 2012. Geneva, Switzerland: World Health Organization; 2012. http://www.who.int/gho/publications/world_health_statistics/2012/en. Accessed March 11, 2013.