Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study
Stephen R Knight, Catherine A. Shaw, Riinu Pius, Thomas M Drake, Lisa Norman, Adesoji Ademuyiwa, Adewale Adisa, María Lorena Aguilera, Sara W Al‐Saqqa, Ibrahim Al‐Slaibi, Aneel Bhangu, Bruce Biccard, Peter Brocklehurst, Ainhoa Costas‐Chavarri, Kathryn Chu, Anna Dare, Muhammed Elhadi, Cameron J. Fairfield, J.E.F. Fitzgerald, Dhruva Ghosh, James Glasbey, Mark I. van Berge Henegouwen, JC Allen Ingabire, T. Peter Kingham, Marie Carmela Lapitan, Ismaïl Lawani, Bettina Lieske, Richard Lilford, Janet Martin, Kenneth A McLean, Rachel Moore, Dion Morton, Dmitri Nepogodiev, Faustin Ntirenganya, Francesco Pata, Thomas Pinkney, Ahmad Uzair Qureshi, Antonio Ramos‐De la Medina, Aya Riad, Hosni Salem, Joana Simões, Richard T. Spence, Neil Smart, Stephen Tabiri, Hannah S. Thomas, Thomas G. Weiser, Malcolm West, John Whitaker, Ewen M. Harrison, Arben Gjata, María Marta Modolo, Sebastian K. King, Erick Chan, Sayeda Nazmun Nahar, Ade Waterman, Dominique Vervoort, Ismaïl Lawani, Alemayehu Ginbo Bedada, Bernardo De Azevedo, Ana Gabriela Figueiredo, M Sokolov, Vénérand Barendegere, Gerald Ekwen, Arnav Agarwal, Anna Dare, Alex Qinyang Liu, Juan Camilo Correa-Cote, Kalisya Luc Malemo, Jacques Fadhili Bake, Jakov Mihanović, K Kunčarová, J Örhalmi, Hosni Salem, Jyri Teras, Aristotelis Kechagias, Alexis Arnaud, Judith Lindert, Stephen Tabiri, Vasileios Kalles, Maria‐Lorena Aguilera‐Arevalo, Gustavo Recinos, Zsolt Baranyai, Basant Kumar, Harish Neelamraju Lakshmi, Sanoop Koshy Zachariah, Philip Alexander, Sunil Kumar Venkatappa, C.S. Pramesh, Radhian Amandito, Christina Fleming, Luca Ansaloni, Francesco Pata, Gianluca Pellino, Ahmed Altibi, Ibrahim Nour, Intisar Hisham Said Hamdun, Muhammed Elhadi, Ali Ghellai, Donatas Venskutonis, Tomas Poškus
Abstract
BACKGROUND: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. METHODS: A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. FINDINGS: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58-5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23-0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. INTERPRETATION: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. FUNDING: National Institute for Health and Care Research.