.UKZN Assists in Assessing POMR Globally
UKZN staff based in the Pietermaritzburg Metropolitan Trauma Unit, recently participated in a study supported by the Lancet Commission on Global Surgery entitled, “Toward a standard approach to measurement and reporting of perioperative mortality rates (POMR) a global indicator for surgery”. Assessing POMR within a country provides valuable information and is regarded by many clinicians and governments as a credible indicator of quality.
Public health surveillance methods rely on standardised metrics to evaluate the burden of diseases and the health performance system. Such metrics have not been developed for surgical services despite an increasing volume, substantial cost and high rates of death and disability related to surgical procedures.
The Lancet commission on global surgery aims to analyse a range of metrics that could be included as a core global surgery metric with POMR being one of them. POMR is defined as the proportion of patients that die either during or immediately after surgery. This particular study focused on analysing the collection of total annual surgical volume and all-cause mortality rate before discharge among post-operative patients as an indicator of realised access and surgical safety.
This study analysed datasets from two high-income countries namely New Zealand and Australia as well as a low-income country, Papua New Guinea and middle-income South Africa. The datasets analysed included 1.362.635 patient admissions involving 1.514.242 procedures. A total of 8 655 deaths were recorded within a 30 day period and results indicated that 8-20% of in-hospital deaths occurred on the same day as the first operation.
POMR varied by both age and urgency. Among emergency cases, POMR was two-three fold greater than non-emergency cases. The study also found that emergency cases in patients over the age of 65 had greater POMR. Adjusting for variables such as increasing the hospital stay of patients had little effect on the POMR between the sites as well as high income and low income countries. The study also found that the procedures varied between the sites with Pietermaritzburg admitting 38.1% of patients for emergency laparotomies which only accounted for 0.1% of admissions in New Zealand.
The introduction of a safety checklist in participating centres resulted in a decrease in POMR from 1.5 to 0.8 deaths per 100 procedures. However, the researchers suggested that in order for POMR to be adopted as a core global surgery metric, a better understanding is needed on how various measurement and analytic issues affect its accuracy and usefulness for monitoring and guiding improvements in resource-poor settings.
The feasibility of data collection varied as in first referral hospitals in resource-poor countries, written entries are made in logbooks of the operating theatre and are often the only source of information.
Research suggests that as much as 11–30% of the global burden of disease requires surgical care as a core indicator. Reporting on POMR will essentially assist to strengthen health systems through the delivery of safe, effective, and accessible surgical care.
Commenting on the study, Dr Damian Clarke, president of the Surgical Research Society of Southern Africa and Lead Trauma Surgeon and Academic Head of the Area 2 Trauma Service in the Pietermaritzburg Metropolitan area said: ‘Global surgery is an exciting new field of research. It takes as a starting point the realization that surgery is an integral cost effective part of a public health strategy. The initial area on which global surgery research focused was in quantifying the burden of surgical disease in the developing world and the resources available to deal with this burden.’
‘Recently the focus has moved on to developing a metric which can be used to quantify the quality of a surgical service. This has been difficult as surgical disease is often diverse. The use of POMR has been suggested as a useful marker? global surgery movement is trying to get this metric to be adopted by the WHO.
‘The current study arose out of a meeting between staff from Pietermaritzburg and Professor Gruen from Monash University in Australia. The Pietermaritzburg hospital complex has developed a Hybrid Electronic Medical Registry (HEMR) which captures data on all surgical patients. The HEMR has accrued a great deal of data and the obvious thought was to use our data to see if POMR could be collected and used as a research tool in our environment. This data was then compared to data from a number of other registries in the Southern Hemisphere. The data provided by the HEMR was of sufficient quality to allow for meaningful comparison and it is hoped that data from the HEMR will continue to be used in the future for ongoing research both locally and internationally.’
MaryAnn Francis