Barriers to Quality Perioperative Care and Postoperative Mortality Variations in Elective Abdominal Surgery: A Mixed-Methods Study

BACKGROUND: Perioperative morbidity and mortality significantly affect the healthcare system. Patients undergoing surgical procedures in Latin America have an increased risk of postoperative mortality. METHODS: We used a mixed-methods design to identify barriers to quality perioperative care for elective abdominal surgery in Brazil. We used secondary data from a cohort of 107,372 patients (ExCareBR) to examine postoperative mortality risk factors revealing significant variations in the mortality rates across different hospitals. Using a rapid qualitative assessment method, data were collected through semistructured interviews, direct observations, and perioperative pathway mapping. These data were triangulated to identify process-related barriers associated with mortality variations. An analytical comparison matrix was used to compare barriers between hospitals associated with higher and lower mortality. RESULTS: Data from patients who underwent surgery at 10 hospitals across various regions were analyzed, focusing on elective abdominal surgeries. A model was used to assess the association between the surgical procedure and 30-day postoperative mortality, adjusting for patient and procedure factors (fixed factors, first level) and hospital-specific effects (second level). The median odds ratio (MOR) of 1.58 (interquartile range [IQR], 1.47-1.70) indicated significant variability attributable to hospital effects, suggesting that patients with similar characteristics in fixed factors are up to 58% more likely to experience mortality in higher-risk hospitals. Qualitative data provided context to the quantitative results and our analytical framework revealed four main barriers to quality care that collectively distinguish hospitals associated with higher mortality from those that are not: (1) lack of standardized organizational structures for postoperative care, which impedes the escalation of care; (2) nurse understaffing in surgical wards; (3) communication deficiencies across perioperative phases; and (4) fragmented perioperative patient pathways within the public health system. CONCLUSIONS: The primary challenges in delivering high-quality care were identified during the postoperative period, significantly affecting patient outcomes. Future research should focus on enhancing postoperative care processes, with particular attention to the organization of care, human resources, and communication. These components are crucial for strengthening the surgical health system in low-resource settings.