An article published in The Lancet calls attention to the lack of surgical access in low-income countries and the disproportionate absence of surgical access in low-income countries compared to high-income ones. Dr Thomas Weiser (Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA) find that in relation to population size, richer countries perform more surgeries than poorer ones, and this suggests a potentially large disease burden that has yet to be addressed.

Since 234 million surgeries occur each year around the world, surgical safety should be a public health priority. There is little data, apart from anecdotal evidence, about the actual volume and availability of surgery around the world even though the practice occurs in most resource rich and resource poor societies. Weiser and colleagues sought to address this knowledge gap by estimating the number of operations undertaken worldwide, describing their distribution, and analyzing the importance of surgical care in global public-health policy.

Data from 56 of 192 WHO member states were entered into a model to reach an estimate of 234.2 million major surgical procedures each year in the world. The researchers defined surgery as, “Any intervention occurring in a hospital operating theatre involving the incision, excision, manipulation, or suturing of tissue, and that usually requires regional or general anaesthesia or profound sedation to control pain.” Poorer countries – those spending less than US$100 per person on health care – perform about 295 procedures per 100,000 people each year, whereas richer countries – those spending more than $1000 perform about 11,110 procedures per 100,000 people each year.  In other words, the rate in high-expenditure countries is over 37 times higher than the rate in low-expenditure countries. Although 30.2% of the population lived in middle-expenditure and high-expenditure countries in 2004 (those spending $400 – $1000 and over $1000 per person, respectively), the countries were responsible for 73.5% of surgeries. The poor-expenditure countries, on the other hand, had 24.8% of the population and 3.5% of surgical procedures in 2004.

An additional finding regarding surgical procedures is that 0.4% to 0.8% of inpatient operation result in death in the developed world, compared to 5% to 10% in the developing world. Death rates from anesthesia alone are about 1 in 150 in the developing world, and some 7 million patients suffer major complications during surgery. According to the authors, the number of surgeries require a global public health concern about surgical safety. To aid surgical safety and the quality of care, they propose public health interventions and educational projects.

On the notable differences between richer and poorer countries, the authors write: “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.”

“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,” conclude the authors.

Dr Stephen Bickler (University of California, San Diego, CA, USA) and Dr David Spiegel (University of Pennsylvania School of Medicine, Philadelphia, PA, USA) write in an accompanying comment: “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.”

An estimation of the global volume of surgery: a modelling strategy based on available data
Thomas G Weiser, Scott E Regenbogen, Katherine D Thompson, Alex B Haynes, Stuart R Lipsitz, William R Berry, Atul A Gawande
The Lancet
(2008).
DOI:10.1016/S0140-6736(08)60878-8
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Written by: Peter M Crosta