This is an excerpt of the publication below, with the title above.
Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study
The Lancet
Global Surg Collaborative and
NIHR Global Health Research Unit on Global Surgery †
May 24, 2022
opengovasia
Key messages
by Joaquim Cardoso MSc.
The Health Strategist — Institute
May 31st, 2022
- 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 availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist.
- Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised.
- The centralisation of services into comprehensive cancer centres, supported…, is likely to improve quality of care, particularly in resource-constrained environments.
- However, centralisation can unintentionally reduce access to safe and effective cancer care, secondary to geographical and financial barriers for patients, particularly in the absence of robust referral mechanisms.
Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study
The Lancet
Global Surg Collaborative and
NIHR Global Health Research Unit on Global Surgery †
May 24, 2022
SUMMARY
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.
ORIGINAL PUBLICATION (excerpt)
Introduction
Of the 15·2 million individuals diagnosed with cancer in 2015, 80% required surgery. 1
Of the 15·2 million individuals diagnosed with cancer in 2015, 80% required surgery
For many common, high-burden cancers, including breast, colorectal, and gastric cancers, surgery often offers the best chance of cure, particularly in early-stage disease.
45 million surgical procedures are estimated to be needed worldwide each year to treat cancer, yet fewer than 25% of patients with cancer have access to safe, affordable, and timely surgery. 2
45 million surgical procedures are estimated to be needed worldwide each year to treat cancer, yet fewer than 25% of patients with cancer have access to safe, affordable, and timely surgery.
To address the growing cancer burden in low-income and middle-income countries (LMICs), investments will need to be made in the entire cancer care continuum.
This includes surgical treatment for cancer and the services that support high-quality surgical care, such as diagnostic imaging, pathology, perioperative care, and the training of personnel.
To address the growing cancer burden in low-income and middle-income countries (LMICs), investments will need to be made in the entire cancer care continuum.
This includes surgical treatment for cancer and the services that support high-quality surgical care, such as diagnostic imaging, pathology, perioperative care, and the training of personnel.
Investing in cancer care can yield substantial health and economic benefits if investments are closely aligned with country needs.3
Although a compelling rationale for investing in the global scale-up of cancer care exists, these data are predominantly based on simulation and extrapolation. 1 , 3 , 4
Little is known about the type or quality of surgical care that patients with cancer receive for common, high-burden cancers around the world, nor the impact of surgical care on survival outcomes.
These knowledge gaps make it difficult for countries to identify areas of need and make informed investments in their cancer systems in order to maximise health gains.
We previously showed 5 that patients in LMICs have higher mortality after cancer surgery compared with those in high-income countries, but the impact of hospital facilities on patient outcomes was not explored.
Structural characteristics such as case volume, facility availability, and the presence of specialised services are known to affect surgical outcomes in high-income settings. 6 , 7 , 8
… patients in LMICs have higher mortality after cancer surgery compared with those in high-income countries …
Structural characteristics such as case volume, facility availability, and the presence of specialised services are known to affect surgical outcomes in high-income settings …
Improving hospital facilities through additional infrastructure and resources, translating to greater capacity, is thought to affect clinical outcomes in lower-income settings.
Estimates suggest that poor-quality health systems cause 8 million deaths per year in LMICs. 9
Using a systems-based approach, we aimed to describe critical surgical oncology services available worldwide and to investigate whether hospital facilities are associated with improved outcomes after cancer surgery worldwide, particularly in low-income settings, and the potential effects of improving these resources.
Methods
See the original publication
Results
See the original publication
Discussion
In this prospective study of patients undergoing cancer surgery in 238 hospitals from 66 countries, higher availability of specific hospital infrastructure and resources was associated with improved outcomes.
Hospitals that were well resourced had less than half the postoperative mortality rate, showing an improved ability to prevent death after the development of postoperative complications, with up to three fewer deaths per 100 operations performed. Of note, these findings were independent of country income group.
The availability of hospital resources has long been thought to affect clinical outcomes in lower-income settings; the magnitude of this effect is now clear.
Despite the overall mortality benefit seen in hospitals with more resources and strong processes, many patients do not have access to such hospital infrastructure, particularly in low-income settings.24
Improvements to hospital facilities are known to be cost-effective,3 but the absence of high-quality data limits interpretability, and the effects of specific hospital facilities on outcomes and cancer surgery worldwide were previously unclear.
Strategic planning requires detailed and accurate information to allocate appropriate resources, prioritise quality improvement, and evaluate effects. Determining the effectiveness of hospital infrastructure can guide future investment and provide a platform for continued assessment of hospital performance.
Our results offer a concrete approach by focusing on specific infrastructure and resources in hospitals worldwide.
Such hospitals perform significantly better than others without them; in the 62 hospitals with three or fewer facilities, mortality rates were three times higher than in the 113 hospitals with all five facilities present.
This difference is likely to be explained by a 50% increase in the capacity to rescue patients after the development of a major complication.
These findings were robust in a sensitivity analysis and a similar trend was identified when all 11 hospital facilities were included.
These results show that a strategy of expanding system capabilities at hospitals, particularly in low-income and middle-income settings, could markedly improve outcomes and patient access to safe, effective surgical care.
Such hospitals perform significantly better than others without them; …
This difference is likely to be explained by a 50% increase in the capacity to rescue patients after the development of a major complication.
Previous studies have reported similar associations between key hospital facilities and mortality.
Funk and colleagues 6 found that the presence of complex medical oncology services and specific radiology services were important for lowering mortality in patients undergoing oesophagectomy.
Similarly, Joseph and colleagues 25 found that several institutional characteristics had a stronger effect on operative mortality after pancreatic resection than hospital volume.
However, differences in major morbidity after surgery are often undescribed. 6, 21
To our knowledge, this is the first global analysis to assess the impact of hospital facilities on short-term outcomes in cancer surgery.
The synergistic effect of scaling up of imaging, treatment modalities, and quality in low-income settings on oncological outcomes has been shown in studies from 2021.3,4
In particular, investments in imaging modality availability are a critical component for comprehensive improvement in global cancer survival.3
In particular, investments in imaging modality availability are a critical component for comprehensive improvement in global cancer survival
However, our results must be interpreted with caution.
We suspect that these facilities are proxies for the expertise, resources, and complex processes of care required to facilitate surgery, including the optimisation of preoperative, intraoperative, and postoperative care for patients undergoing surgery for cancer.
However, our results must be interpreted with caution.
We suspect that these facilities are proxies for the expertise, resources, and complex processes of care required to facilitate surgery, including the optimisation of preoperative, intraoperative, and postoperative care for patients undergoing surgery for cancer.
The presence of a CT scanner is unlikely to directly improve patient outcomes without associated investment in additional supportive capacity, such as health-care workers and technical support.
The presence of a CT scanner is unlikely to directly improve patient outcomes without associated investment in additional supportive capacity, such as health-care workers and technical support.
The five key facilities that were included in our multivariable models are likely to be indirect markers for other structural and process measures that are also closely related to outcomes after cancer surgery.
For example, we found that hospitals with more resources were more likely to use the WHO surgical safety checklist and have negative resection margins, potentially reflecting related organisational processes associated with these facilities.
… hospitals with more resources were more likely to use the WHO surgical safety checklist and have negative resection margins, potentially reflecting related organisational processes associated with these facilities.
A similar pattern in outcomes was shown in models including all 11 of the hospital facilities originally assessed, suggesting that the five facilities identified in our analysis might also reflect further development of additional hospital services.
Higher levels of hospital facility were also associated with increased access to surgical care for a broad range of cancer types.
The majority of hospitals with all five facilities present were able to perform elective operations for 11 different cancers, which represent 60% of all incident cancers and 70% of cancer deaths worldwide over the next 10 years.3
Patients also presented with earlier stage disease, suggesting hospital facility improvement could be associated with concurrent investment in early detection programmes and strengthening of health-care systems.
Similar outcomes were found between hospitals with four or five key facilities, which could suggest a ceiling effect between expanding system capabilities and outcome improvement.
Centres providing cancer care worldwide vary in size, scale, and structure. Designated cancer centres, referral networks, and standardised cancer pathways are underdeveloped or absent in many LMICs.26
Designated cancer centres, referral networks, and standardised cancer pathways are underdeveloped or absent in many LMICs
The centralisation of services into comprehensive cancer centres, supported by our analysis, is likely to improve quality of care, particularly in resource-constrained environments.
However, centralisation can unintentionally reduce access to safe and effective cancer care, secondary to geographical and financial barriers for patients, particularly in the absence of robust referral mechanisms.12
The centralisation of services into comprehensive cancer centres, supported by our analysis, is likely to improve quality of care, particularly in resource-constrained environments.
However, centralisation can unintentionally reduce access to safe and effective cancer care, secondary to geographical and financial barriers for patients, particularly in the absence of robust referral mechanisms.
Therefore, selection of a geographical location to serve the greatest number of patients, while defining the minimum requirements of a comprehensive cancer centre, is crucial.26
Efforts to improve the quality of cancer care must occur alongside efforts to increase access to care, to maximise health gains and develop equitable cancer systems.
Our study has important limitations.
We have detailed hospital-level data for 55% of hospitals within the primary study, with a lower response rate from high-income hospitals. However, we covered 87% of patients in LMIC settings, where the majority of all cancer deaths occur.27
Furthermore, case volume and adjusted mortality rates of non-included hospitals were similar, and a sensitivity analysis indicated robust findings across all measured outcomes.
Therefore, an association between missing responses and measured outcomes is unlikely.
Despite including validated measures of overall patient health, we were unable to account for detailed patient comorbidity across income group within the adjusted models due to the burden of additional data collection, particularly in low-resource settings.
The five hospital facilities identified could represent additional, unmeasured structural and complex care processes. Despite capturing a broad range of hospital infrastructure and resources, we are unable to extrapolate our results to all the additional resources that a hospital might contain. However, as the number of hospital facilities increased, an increase in the capacity to rescue patients was shown.
Therefore, investment and improvement in overall hospital capability is likely to greatly improve early patient outcomes after cancer surgery.
However, in countries without universal health care, additional investment in hospital facilities must avoid unaffordable increases in total costs to patients for safe surgical care.
Further work validating our findings and exploring the effect of specific combinations, particularly in LMIC settings, is required.
Additionally, we were unable to follow up patients beyond 30 days after surgery. Little is known about longer-term outcomes, such as cancer-free survival, in resource-limited settings.1,3
Nevertheless, postoperative complications after major surgery can affect longer-term outcomes, including patient survival and disability.22
Longer-term disease and overall survival after surgery might be lower in LMICs, particularly because patients presented with later stage disease. The impact of delayed surgery in life-years lost for stage I–III disease is well described in high-income countries,28 but knowledge gaps exist globally.
Furthermore, only patients undergoing primary surgery for breast, colorectal, and gastric cancers were included, and therefore our conclusions might not translate across other globally prevalent cancers.
The current study will be extended to capture longer-term outcomes and other cancers in the future, which should add substantially to knowledge of the impact of hospital infrastructure and resources on global surgical outcomes.
Finally, we did not have information on surgeon volume or nurse-to-bed ratio, which are both known mediators in the association between hospital facilities and mortality.25
Debates are ongoing as to whether hospital volume versus hospital process is the primary reason for lower perioperative mortality in cancer surgery,25,29 particularly because available clinical resources often increase with hospital volume.25
Additional studies are required to determine their effects on hospital mortality globally.
The centralisation of services into comprehensive cancer centres, supported by our analysis, is likely to improve quality of care, particularly in resource-constrained environments.
However, centralisation can unintentionally reduce access to safe and effective cancer care, secondary to geographical and financial barriers for patients, particularly in the absence of robust referral mechanisms.12
The centralisation of services into comprehensive cancer centres, supported by our analysis, is likely to improve quality of care, particularly in resource-constrained environments.
However, centralisation can unintentionally reduce access to safe and effective cancer care, secondary to geographical and financial barriers for patients, particularly in the absence of robust referral mechanisms.12
In conclusion, the number of patients undergoing surgery in hospitals with reduced resources and weak processes of care is higher in low-income and middle-income settings, putting these patients at additional risk.
Although early mortality after cancer surgery is known to be increased in LMICs, the improvement of facilities, processes, and quality of care can dramatically reduce perioperative mortality in these settings.
A more comprehensive study of systems strengthening and improvement interventions to reduce postoperative mortality would provide important information on mechanisms to improve cancer surgery outcomes for the large numbers of patients who receive care at these institutions.
Correspondence to:
Prof Ewen M Harrison,
NIHR Global Health Research Unit on Global Surgery,
Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK
Writing group
Stephen R Knight, Kathryn Chu, Marie Carmela Lapitan, Anna J Dare, Riinu Pius, Catherine A Shaw, Thomas M Drake, Lisa Norman, Adesoji O Ademuyiwa, Adewale O Adisa, Maria Lorena Aguilera, Sara W Al-Saqqa, Ibrahim Al-Slaibi, Aneel Bhangu, Bruce M Biccard, Peter Brocklehurst, Ainhoa Costas-Chavarri, Muhammed Elhadi, Cameron J Fairfield, J Edward Fitzgerald, Dhruv Ghosh, James Glasbey, Mark I van Berge Henegouwen, J C Allen Ingabire, T Peter Kingham, 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 Khairy Salem, Joana Simões, Richard Spence, Neil Smart, Stephen Tabiri, Hannah Thomas, Malcolm West, John Whitaker, Thomas G Weiser, Ewen M Harrison.
References and additional information
See the original publication
Originally published at https://www.thelancet.com
