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Bellwether Procedures for Monitoring Subnational Variation of All-cause Perioperative Mortality in Brazil

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Abstract

Background

All-cause perioperative mortality rate (POMR) is a commonly reported metric to assess surgical quality. Benchmarking POMR remains difficult due to differences in surgical volume and case mix combined with the burden of reporting and leveraging this complex and high-volume data. We seek to determine whether the pooled and individual procedure POMR of each bellwether (cesarean section, laparotomy, management of open fracture) correlate with state-level all-cause POMR in the interest of identifying benchmark procedures that can be used to make standardized regional comparisons of surgical quality.

Methods

The Brazilian National Healthcare Database (DATASUS) was queried to identify unadjusted all-cause POMR for all patient admissions among public hospitals in Brazil in 2018. Bellwether procedures were identified as any procedure involving laparotomy, cesarean section, or treatment of open long bone fracture and then classified as emergent or elective. The pooled POMR of all bellwether procedures as well as for each individual bellwether procedure was compared with the all-cause POMR in each of the 26 states, and one federal district and correlations were calculated. Funnel plots were used to compare surgical volume to perioperative mortality for each bellwether procedure.

Results

4,756,642 surgical procedures were reported to DATASUS in 2018: 237,727 emergent procedures requiring laparotomy, 852,821 emergent cesarean sections, and 210,657 open, long bone fracture repairs. Pooled perioperative mortality for all of the bellwether procedures was correlated with all-procedure POMR among states (r = 0.77, p < 0.001). POMR for emergency procedures (2.4%) correlated with the all-procedure (emergent and elective) POMR (1.6%, r = 0.93, p < .001), while POMR for elective procedures (0.4%) did not (p = .247). POMR for emergency laparotomy (4.4%) correlated with all-procedure POMR (1.6%, r = 0.52, p = .005), as did the POMR for open, long bone fractures (0.8%, r = 0.61, p < .001). POMR for emergency cesarean section (0.05%) did not correlate with all-procedure POMR (p = 0.400). There was a correlation between surgical volume and emergency laparotomy POMR (r = − 0.53, p = .004), but not for emergency cesarean section or open, long bone fractures POMR.

Conclusion

Procedure-specific POMR for laparotomy and open long bone fracture correlates modestly with all-procedure POMR among Brazilian states which is primarily driven by emergency procedure POMR. Selective reporting of emergency laparotomy and open fracture POMR may be a useful surrogate to guide subnational surgical policy decisions.

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Authors and Affiliations

  1. Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA

    Paul Truche, Lina Roa, Isabelle Citron, Luke Caddell & Matheus Reis

  2. Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada

    Lina Roa

  3. Faculty of Medicine of University of Sao Paulo, FMUSP, São Paulo, Brazil

    Joao Neto

  4. Department of Surgery, Deakin University and Barwon Health, Melbourne, Australia

    Eileen Moore

  5. Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

    Fabio Botelho

  6. Division of Plastic Surgery, University of São Paulo, São Paulo, Brazil

    Nivaldo Alonso

  7. Deakin University and Barwon Health, Melbourne, Australia

    David Watters

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  1. Paul Truche
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Appendices

Appendix 1

See Table 3.

Table 3 DATASUS codes used for each bellwether procedure
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Appendix 2

See Table 4.

Table 4 2018 perioperative mortality per 100 bellwether procedures by state
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Truche, P., Roa, L., Citron, I. et al. Bellwether Procedures for Monitoring Subnational Variation of All-cause Perioperative Mortality in Brazil. World J Surg 44, 3299–3309 (2020). https://doi.org/10.1007/s00268-020-05607-x

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