Health PolicyStandardised metrics for global surgical surveillance
Introduction
Public health surveillance has long used standardised metrics to quantify disease burden in a population, track mortality rates, and guide health system programming and assessment.1 Maternal mortality, infant mortality, and life expectancy have been important indicators for measuring the efficacy of health services and delivery for more than half a century. Many countries are also incorporating vaccination rates and treatment coverage for specific infectious diseases into surveillance programmes in an effort to identify gaps in resource allocation.2 However, because of the overall worldwide increase in life expectancy and decrease in maternal and infant mortality, other measures are essential for monitoring health system performance.
Surgical care is one important example. An estimated 234 million major operations occur worldwide every year—a previously unrecognised amount that exceeds the global volume of childbirth.3 Evidence suggests that surgical care results in at least 7 million complications every year, including 1 million deaths, which is twice the number of maternal deaths per year.4, 5, 6 However, information on the frequency and safety of operative care is severely limited by gaps in national data and a paucity of standardised definitions for tracking surgical services globally. 70% of countries have no information on frequency of surgical procedures and virtually none attempt to assess distribution of surgical resources or outcomes. Basic metrics for surgical surveillance are needed if public health officials are to engage in effective planning of health system resources, safety, and access.
In 2007, WHO and its Patient Safety Programme launched an initiative called Safe Surgery Saves Lives.7 One aspect of this programme was to develop standardised measures for surveillance of the volume of surgical care and its effect on public health outcomes over time. The aim of these measures is to improve assessment of the magnitude and safety of surgical care while being feasible to gather at a national level by public health agencies in nearly all resource settings. We report the results of this work and describe the rationale for each of the proposed measures. We also tested the practicability of their collection in eight hospitals in eight countries with a broad range of resources and record-keeping practices.
Section snippets
Identification of surgical measures
A technical working group comprised of experts in epidemiology, global health, and research on surgical outcomes from around the world was created to develop standardised metrics for assessing surgery on a global level. Individuals were selected to represent a variety of geographic regions and resource settings, and on the basis of their previous involvement with surgical research and outcomes work. The group reviewed the publications on measuring surgical services, studied the experiences of
Feasibility testing
Once metrics were identified, we assessed the ability of individual facilities to gather the data by requesting such information from one hospital in eight different countries (Toronto General Hospital, Toronto, Canada; St Stephen's Hospital, Delhi, India; Prince Hamzah Hospital, Amman, Jordan; Auckland City Hospital, Auckland, New Zealand; Philippine General Hospital, Manila, Philippines; St Francis Designated District Hospital, Ifakara, Tanzania; St Mary's Hospital, London, UK; and the
Global surgical surveillance
Measurement of the provision and outcomes of surgical care through the use of standardised metrics seems feasible across diverse settings and would provide an important indication of health system performance for these high-risk and complex services. In view of the value of such data, WHO adopted these measures as recommended guidelines for national public health surveillance.10
Facility information, aggregated at a national level, can provide ministries of health and departments of health with
Policy implications
Advances in maternal health have relied on a knowledge built around birth rates and crude maternal and neonatal mortality.11 Such data not only provided a benchmark to measure improvement but also recognition of the enormous effect of unsafe childbirth on global health. Similar to the improvements in maternal health achieved in many parts of the world, a better understanding of the magnitude and outcomes of operative care will allow better research on health services in surgery and provide
Conclusion
Enthusiasm is growing for measuring and improving health systems in a comprehensive way rather than focusing on narrow areas of care.15 Additional metrics are needed for a more complete assessment of health system function. These surgical metrics, including surgical mortality, are one component. Countries can use such information on a national level to identify barriers to access, to assess surgical safety, and to track changes over time. On a broader level, improvements in the capacity of a
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