Patients in Africa twice as likely to die after an operation than global average, report shows

Nicola Davis | Wed 3 Jan ‘18  | The Guardian

Higher mortality rate occurs despite patients usually being younger and fitter and is likely due to lack of medical staff, say scientists

Patients undergoing surgery in Africa are more than twice as likely to die following an operation than the global average, despite generally being younger, healthier and the surgery they are undergoing being more minor, research has revealed.

The study, which covered 25 countries, revealed that just over 18% of in-patients developed complications following surgery, while 1% of elective in-patients died in hospital within 30 days of their operation – twice the global average.

Prof Bruce Biccard, a co-author of the latest study from the University of Cape Town, said that one of the major problems is likely to be an insufficient number of medical staff, resulting in difficulties in spotting or tackling complications following operations. “[The reason] that people do so terribly in Africa from a surgical point of view is that there are just no human resources,” he said.

The research, Biccard added, offers a crucial snapshot of issues around surgery in low and middle income countries. “Data from Africa is almost non existent,” he said.

Writing in journal the Lancet, the international team of researchers describe how they collected data from 11,422 adult patients at 247 hospitals spread over 25 countries – including Ethiopia, Egypt, Nigeria and Zambia – to assess patient outcomes following surgical procedures which required an overnight stay. Each hospital collected data during one week of their choosing between February and May 2016, although data on complications and death were not available for every patient.

The results reveal that 2.1% of those who underwent any surgery, and 1% of those who had elective surgery, died in hospital within 30 days of their operation. Only a minority of deaths occurred on the day of the operation itself.

Just over 18% of all patients developed complications, ranging from stroke to pneumonia, almost one in 10 of whom died. “It is likely that many of these deaths were preventable,” the authors note.
However the study also revealed that the number of operations across the continent was very low and fewer than 43% of surgeries in Africa were elective, with the majority of patients instead undergoing urgent or emergency operations. Meanwhile, caesarean deliveries accounted for 33% of surgeries across Africa – a remarkably high proportion.

Together, says Biccard, that highlights another problem: that many individuals who need surgery might not have access to it. “The real sad thing is that there is a lot of surgery obviously that is not happening,” he said. “That is probably a huge killer in Africa,” he added.

The authors suggest that the findings are probably a reflection of a scanty workforce, limited numbers of hospital beds, and poor systems to check up on patients follow surgery, noting that there are only about 0.7 specialist surgeons, obstetricians and anaesthesiologists per 100,000 population. The recommended figure to decrease the risk of death following surgery is 20–40 such specialists per 100,000 population. “There is no way we are going to be able to train enough physicians to fill this deficit in human resources,” said Biccard, suggesting that either systems for focusing care on high-risk patients need to be developed, or non-physicians would need to be helped to identify patients who might be at risk.

The authors also note that 14 African countries did not take part in the study, but that with some of those politically unstable, in conflict, or having few doctors, surgical outcomes could be even worse.

Dr David Walker, a consultant in anaesthesia and critical care medicine at University College London Hospitals, who was not involved in the study, said that issues of care of patients around the time of surgery was a global issue.

“It seems to be, no matter where in the world you have surgery, complications for many are an inevitable consequence of hospitalisation,” he said. “Importantly, when complications occur there may be considerable disparity in patient outcomes after those complications: so it [often] isn’t the complication that kills you, it is the failure to rescue – how [the patient is looked after following the complication].”

The latest study, he adds, suggests that poor access to timely surgery is a “forgotten epidemic” in Africa. “It reminds us also about the importance of the surgical journey – looking after patients from the minute they present in hospital, through surgery and, really importantly, the ability to care for patients in the post-operative period,” he said.