Surgery now occurs at a tremendous volume worldwide, resulting in a great need for public health efforts to improve the safety and availability of surgical services, according to the results of a study reported in The Lancet, published online June 25.
"Little is known about the amount and availability of surgical care globally," write Thomas G. Weiser, from the Harvard School of Public Health in Boston, Massachusetts, and colleagues. "We estimated the number of major operations undertaken worldwide, described their distribution, and assessed the importance of surgical care in global public-health policy."
The investigators collected demographic, health, and economic data, as well as per capita total healthcare costs from analyses performed in 2004 for 192 member states of the World Health Organization (WHO).
Major surgery was defined as any procedure taking place in a hospital operating room in which tissue was incised, excised, manipulated, or sutured, generally requiring regional or general anesthesia or sedation. The investigators used several sources to gather data regarding the rate of surgery, including government agencies, statistical and epidemiological organizations, published literature, and experts involved in surgical policy initiatives. For countries lacking such data, the investigators created a model to estimate rates of major surgery and then used demographic data to calculate the total worldwide volume of surgery.
Of 192 WHO member states, surgical data were available for 56 (29%). The estimated annual rate of major surgical procedures worldwide was 234.2 million (95% confidence interval, 187.2 – 281.2 million). Estimated mean rate of major surgery was 295 ± 53 procedures per 100,000 population per year for countries spending US$100 or less per capita on healthcare compared with 11,110 ± 1300 procedures for those countries spending more than $1000 (P < .0001).
Although middle-expenditure ($401 – $1000 per capita on healthcare) and high-expenditure (>$1000 per capita on healthcare) countries account for 30.2% of the world's population, they performed 73.6% (172.3 million) of operations worldwide in 2004. In contrast, low-expenditure (≤$100 per capita on healthcare) countries account for 34.8% of the global population, but they performed only 3.5% (8.1 million) of all surgical procedures in 2004.
"Worldwide volume of surgery is large," the study authors write. "In view of the high death and complication rates of major surgical procedures, surgical safety should now be a substantial global public-health concern. The disproportionate scarcity of surgical access in low-income settings suggests a large unaddressed disease burden worldwide."
Limitations of this study include that less than a third of countries were able to offer data for surgical volume, lack of reliable information about inpatient death rates or other measures of adverse outcome, absence of standardization in data collection, that few countries reported outpatient surgical procedures, a blurred distinction between major and minor surgical procedures, and that estimates for some low-income and middle-income countries required extrapolation from regional data.
"Our findings suggest that surgery now occurs at a tremendous volume worldwide, in settings both rich and poor," the study authors conclude. "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."
The authors have disclosed no relevant financial relationships.
The Lancet. Published online June 25, 2008.
Reviewed by Ramaz Mitaishvili, MD
