Rates of surgical deaths and infections at district hospitals in Malawi and Zambia: a prospective multicentre cohort study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Surgical patients undergoing major operations (obstetric, general, trauma, and other surgery) at district hospitals (n=15103). Intervention: Patient characteristics (ASA physical status score II) and surgical provider cadre (medical doctor vs non-physician clinician) vs. ASA physical status score I; Non-physician clinician (NPC)-led surgery. Primary outcome: In-hospital perioperative mortality and postoperative infection (OR 6.658, 95% CI 2.363 to 18.762, p=<0.01).

Q: What does this research mean for the field?

At district hospitals in Malawi and Zambia, poorer preoperative physical status significantly increases perioperative mortality, whereas the cadre of the lead surgeon (medical doctor vs non-physician clinician) does not significantly affect surgical outcomes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Jakub Gajewski; Mengyang Zhang; Leon Bijlmakers; Chiara Pittalis; Eric Borgstein; Gerald Mwapasa; John Kachimba; Mweene Cheelo; Kristen Waterman; Ruairı́ Brugha

doi:10.1136/bmjopen-2021-049126

December 1, 2021BMJ OpenOpen Access

Rates of surgical deaths and infections at district hospitals in Malawi and Zambia: a prospective multicentre cohort study

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Why the study?

Perioperative mortality, postoperative infection rates, and their associations with patient characteristics among surgical patients at district-level hospitals in Malawi and Zambia needed to be evaluated using routinely available data.

Are patient characteristics and the cadre of the lead surgeon (medical doctor vs non-physician clinician) associated with in-hospital perioperative mortality and postoperative infection at district hospitals in Malawi and Zambia?

Key Points

To report perioperative mortality and postoperative infection rates among surgical patients at district-level hospitals in Malawi and Zambia and examine associations with patient characteristics using routine clinical data.
Multicentre study conducted across 8 government district hospitals in Malawi and 9 mission and government district hospitals in Zambia (ISRCTN66099597).
Analyzed routinely recorded surgical outcomes using standard logistic regression and penalised maximum likelihood logistic regression to assess predictors of perioperative mortality and postoperative infection.
Average perioperative mortality rates were 0.19% in Malawi and 0.43% in Zambia; increased mortality was significantly associated with older age (OR=1.046, 95% CI 1.016 to 1.078), ASA physical status score II (OR=6.658, 95% CI 2.363 to 18.762), and general surgery compared to obstetrical procedures (OR=3.821, 95% CI 1.226 to 11.908).
Average postoperative infection rates were 2.69% in Malawi and 2.24% in Zambia; infections were significantly associated with age (OR=1.010, 95% CI 1.000 to 1.020), male sex (OR=0.407, 95% CI 0.260 to 0.637), general procedures (OR=2.319, 95% CI 1.397 to 3.850), and trauma-related procedures (OR=5.490, 95% CI 2.632 to 11.449).
There was no significant correlation between surgical outcomes and the cadre of the lead surgeon performing the operation (non-physician clinician versus medical doctor).

Study Design

Type

Cohort (n=15,103)

Multicenter

Yes

Structured PICO

Are patient characteristics and the cadre of the lead surgeon (medical doctor vs non-physician clinician) associated with in-hospital perioperative mortality and postoperative infection at district hospitals in Malawi and Zambia?

P

Population

15,103 surgical operations (mean patient age 27.18 years, 84.5% female) performed under anaesthesia requiring at least one overnight stay across 17 district hospitals in Malawi and Zambia, followed from operation start until hospital discharge.

E

Exposure

Major surgery performed at district hospitals evaluated by patient risk factors (age, sex, ASA physical status score II or III-V, procedure category, emergency status) and surgical provider cadre (medical doctor [MD]-led vs non-physician clinician [NPC]-led surgical teams).

C

Comparator

Reference categories in multivariable regression: ASA physical status score I, obstetric surgery, elective surgery, and non-physician clinician (NPC)-led surgical team.

O

Outcome

Co-primary outcomes: In-hospital perioperative mortality (any death from start of operation up to hospital discharge) and postoperative infection (combined wound infection and pulmonary infection prior to hospital discharge).hard clinical

Main Result

Odds Ratio: 6.658 (95% CI 2.363–18.762)

p-value: p=<0.01

Major surgical procedures at district hospitals in Malawi and Zambia had relatively low perioperative mortality and infection rates, and outcomes did not differ between medical doctors and trained non-physician clinicians, supporting task-shifting models in rural sub-Saharan Africa.

Limitations

Data on surgical site infections and surgical deaths were self-reported by staff from participating hospitals, which might have led to under-reporting
Potential selection bias and Hawthorne effect as participating hospitals were part of the COST-Africa surgical training programme, limiting generalisability
Lack of assessment of complications in the long term after hospital discharge
Self-reported data on surgical site infections and surgical deaths by participating hospital staff could have potential reporting bias/under-reporting
Potential selection bias and Hawthorne effect because hospitals were participating in the COST-Africa surgical training and supervision programme, limiting generalisability
Lack of assessment of complications in the long term following discharge

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Preoperative ASA status warrants heightened vigilance in district hospitals; observational data leaves open non-physician clinician equivalence pending prospective trials.

Abstract

Objective This paper reports perioperative mortality and postoperative infection rates of surgical patients who underwent operations at district-level hospitals in Malawi and Zambia, and the associations of these outcomes with patient characteristics based on routinely available data. Design Prospective cohort study. Setting Eight government district hospitals in Malawi and nine mission and government district hospitals in Zambia. Outcome measures Perioperative mortality and postoperative infection were used as primary outcome measures in this study. Logistic regression and penalised maximum likelihood logistic regression were used to examine the factors correlated with surgical outcomes. Results The average perioperative mortality rates were 0.19% and 0.43% in Malawi and Zambia, respectively. Penalised maximum likelihood logistic regression showed that age (OR=1.046, 95% CI 1.016 to 1.078) and American Society of Anesthesiologists physical status score II (OR=6.658, 95% CI 2.363 to 18.762) were significantly associated with perioperative deaths. General surgery procedures were significantly more likely than obstetrical procedures to result in perioperative deaths (OR=3.821, 95% CI 1.226 to 11.908). The average rates of postoperative infections in Malawi and Zambia were 2.69% and 2.24%, respectively. Age (OR=1.010, 95% CI 1.000 to 1.020) and male sex (OR=0.407, 95% CI 0.260 to 0.637) were significantly associated with postoperative infections. Additional factors, general procedures (OR=2.319, 95% CI 1.397 to 3.850) and trauma-related procedure (OR=5.490, 95% CI 2.632 to 11.449) were significantly associated with infection rates. There was no significant correlation between surgical outcomes and cadre of lead surgeon (a non-physician clinician or doctor). Conclusion Rates of mortality and postoperative infections in this sample of district-level hospitals in Malawi and Zambia were relatively low, with poorer preoperative physical status as the main predictor of both greater postoperative infection and mortality. The study demonstrates that outcomes of major surgical cases do not depend on the cadre (type) of surgeon performing it, and outcomes can be monitored using routine data, at district level in these countries. Trial registration number ISRCTN66099597 .

Discussion

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Cite This Study

Gajewski et al. (2021) conducted a cohort in Surgical patients undergoing major operations (obstetric, general, trauma, and other surgery) at district hospitals (n=15,103). Patient characteristics (ASA physical status score II) and surgical provider cadre (medical doctor vs non-physician clinician) vs. ASA physical status score I; Non-physician clinician (NPC)-led surgery was evaluated on In-hospital perioperative mortality and postoperative infection (OR 6.658, 95% CI 2.363 to 18.762, p=<0.01).

synapsesocial.com/papers/6a8082210300245a6192a34a https://doi.org/10.1136/bmjopen-2021-049126

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Rates of surgical deaths and infections at district hospitals in Malawi and Zambia: a prospective multicentre cohort study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Rates of surgical deaths and infections at district hospitals in Malawi and Zambia: a prospective multicentre cohort study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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