Should we worry about

surgical outcomes?

Rupert Pearse

Senior Lecturer in Intensive Care Medicine

William Harvey Research Institute

Barts and the London School of Medicine and Dentistry

• 234 million major surgical procedures worldwide

• 4,000 procedures per 100,000 population overall

• 11,000 procedures per 100,000 in high income countries

1989 1990 1992 1993 1994 1995 1996 1997 1998 1999 2001 20020

5000

10000

15000

20000

Year

Nu

mb

er o

f d

eath

s

Number of deaths reported by the National

Confidential Enquiry into Peri-Operative Deaths

The high-risk surgical patient

• Elderly

• Co-morbid disease

• Major surgery

• Emergency surgery

Mortality in selected UK general surgical populations

Pearse et al. Crit Care; 2006; 10 R81.

Overall Standard High-risk0

1

2

3

4

5

0

5

10

15

Size Mortality

Po

pu

lati

on

siz

e (m

illio

ns)

Po

st-op

erative m

orta

lity (%)

Standard and high-risk surgical populations in the UK

Pearse et al. Crit Care; 2006; 10 R81.

Standard risk High risk p

n 3,603,803 513,924 -

Age (years) 54 (38-69) 75 (63-83) <0.0001

Emergency procedures (%)

769,371 (21.3%) 454,924 (88.5%) <0.0001

Duration of hospital stay (days)

3 (1-6) 16 (9-29) <0.0001

Mortality (%) 15,038 (0.42%) 63,340 (12.3%) <0.0001

Mortality following non-cardiac surgery in an NHS TrustJhanji et al Anaesthesia 2008; 63(7): 695-701

Overall Standard High-risk0

10

20

30

0

5

10

15

Size Mortality

Po

pu

lati

on

siz

e (t

ho

usa

nd

s)P

ost-o

perative

mo

rtality (%

)

Less than 1/3 of high-risk patients

are admitted to critical care

Annual figures for the UKhigh-risk surgical population

• 1.4 million in-patient general procedures

• 166,000 high-risk surgical procedures

• 100,000 patients develop complications

• 25,000 deaths

‘Quality and process improvement…. should be directed toward prevention of postoperative complications.’

Khuri et al. Ann Surg 2005; 242: 326–343

Risk prediction for common surgical procedures performed in the UK

Aylin et al. BMJ; 2007(online first)

Colo-rectalUnruptured

AAARuptured

AAACABG

Database size

144,370 31,705 12,781 152,523

Overall mortality

10,424

(7.2%)

3,246

(10.2%)5,987

(46.8%)3,247

(2.1%)

Effect of Urgency

(odds ratio)3.46 2.76 1.38 1.54

High-risk surgery:

Comparison with the cardiac

surgery model

UK Cardiac Surgical Register 1977-2000Society for Cardiothoracic Surgeons of Great Britain & Ireland

0

5

10

15

20

25

30

1977

1978

1979

1980

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1989

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1991

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-95

1995

-96

1996

-97

1997

-98

1998

-99

1999

-00

CA

BG

op

erat

ion

s (t

ho

usa

nd

s)

0%

1%

2%

3%

4%

5%

6%

7%M

ortality

Number Mortality

Why are outcomes so much better

for cardiac surgical patients?

• Younger / Fitter / Elective

• Efficient care pathway for single disease group

• Strong evidence base guides practice

• Post-operative intensive care is standard

• Outcome data influences practice

The high-risk surgical patient:

Just a UK problem?

Predicted

Mortality

Mt Sinai

Observed mortality

Portsmouth

Observed mortality

0-10% 5 (0.6%) 43 (3.8%)

11-20% 6 (5.3%) 25 (14.9%)

>20% 11 (9.7%) 84 (35.9%)

Mortality for common surgical procedures in the USA

Khuri et al. Ann Surg 2005; 242: 326–343.

n30 day

mortalityLong term Mortality

Colectomy 19,895 6.5% 46%

Unruptured AAA 5,300 4.5% 37%

Infra-inguinalvascular

19,117 3.0% 43%

Carotidendarterectomy

16,880 1.2% 34%

LaparoscopicCholecystectomy

14,295 0.6% 17%

Total Hip Replacement 12,184 1% 21%

Placebo: 72 deaths among 459 patients (16%)

Metoprolol: 74 deaths among 462 patients (16%)

Outcomes across the UK:

Comparison of England and Scotland

1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2004 20050

500

1000

1500

2000

Year

Nu

mb

er o

f d

eath

s

Number of deaths following emergency surgery

reported by the Scottish Audit of Surgical Mortality

Critical care resources in Scotland and England

England Scotland

Population (millions) 50.8 5.1

ICU : Acute bed ratio 1.02/100 0.92/100

ICU beds / million population 24.5 31.3

Surgical admissions to Scottish ICUs in 2006Kerssens J SICSAG 2008 unpublished data

Pearse et al. Crit Care; 2006; 10 R81.

ICNARC SICSAG

Elective Emergency Elective Emergency

Mortality 10.4% 30.4% 7.3% 25.3%

APACHE II 13.9 16.6 14.5 17.5

ICU stay (days) 1.0 2.0 1.2 1.9

Hospital stay (days) 15 21 14 19

Urgency 56% 44% 38% 59%

High-risk surgery is an important healthcare problem

• Acknowledge the problem

• Identifying the high-risk patient

• Effective intervention

• Adequate resources

• Quality research

• Reliable outcome data