Disparate outcomes of global emergency surgery - A matched comparison of patients in developed and under-developed healthcare settings

Adil A Shah; Cheryl K Zogg; Abdul Rehman; Asad Latif; Hasnain Zafar; Amarah Shakoor; Nabil Wasif; Alyssa B Chapital; Robert Riviello; Awais Ashfaq; Mallory Williams; Edward E Cornwell 3rd; Adil H Haider

doi:10.1016/j.amjsurg.2018.05.008

Disparate outcomes of global emergency surgery - A matched comparison of patients in developed and under-developed healthcare settings

Am J Surg. 2018 Jun;215(6):1029-1036. doi: 10.1016/j.amjsurg.2018.05.008. Epub 2018 May 12.

Authors

Affiliations

¹ Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA; Division of General Surgery, Mayo Clinic, Phoenix, AZ, USA; Department of Surgery, Aga Khan University, Karachi, Pakistan.
² Yale University, School of Medicine, New-Haven, CT, USA; Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA.
³ Department of Surgery, Aga Khan University, Karachi, Pakistan.
⁴ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁵ Charleston Area Medical Center, West Virginia University, Charleston, WV, USA.
⁶ Division of General Surgery, Mayo Clinic, Phoenix, AZ, USA.
⁷ Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA.
⁸ Department of Cardiothoracic Surgery, Oregon Health Sciences University, Portland, OR, USA.
⁹ Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA.
¹⁰ Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA. Electronic address: ahhaider@partners.org.

PMID: 29807633
DOI: 10.1016/j.amjsurg.2018.05.008

Abstract

Introduction: Access to surgical care is an essential element of health-systems strengthening. This study aims to compare two diverse healthcare settings in South Asia and the United States (US).

Methods: Patients at the Aga Khan University Hospital (AKUH), Pakistan were matched to patients captured in the US Nationwide Inpatient Sample (US-NIS) from 2009 to 2011. Risk-adjusted differences in mortality, major morbidity, and LOS were compared using logistic and generalized-linear (family gamma, link log) models after coarsened-exact matching.

Results: A total of 2,244,486 patients (n = 4867 AKUH; n = 2,239,619 US-NIS) were included. Of those in the US-NIS, 990,963 (42.5%) were treated at urban-teaching hospitals, 332,568 (14.3%) in rural locations. Risk-adjusted odds of reported mortality were higher for Pakistani patients (OR[95%CI]: 3.80[2.68-5.37]), while odds of reported complications were lower (OR[95%CI]: 0.56[0.48-0.65]). No differences were observed in LOS. The difference in outcomes was less pronounced when comparing Pakistani patients to American rural patients.

Conclusion: These results demonstrate significant reported morbidity, mortality differences between healthcare systems. Comparative assessments such as this will inform global health policy development and support.

Keywords: Coarsened-exact matching; Emergency general surgery; Global surgery; Low-middle income; Pakistan.

Publication types

Comparative Study
Multicenter Study

MeSH terms

Adolescent
Adult
Aged
Female
General Surgery / organization & administration*
Hospitals, Teaching
Humans
Inpatients
Male
Middle Aged
Morbidity
Pakistan
Public Health*
Quality of Health Care*
Retrospective Studies
Surgical Procedures, Operative*
United States
Young Adult