Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

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

Segmental speckle tracking strain and strain rate in stable coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Northern Norway Regional Health Authority Background It is known that patients with coronary artery disease (CAD) display reduced global and regional strain and strain rate (SR). However, knowledge about segmental strain and SR in stable CAD patients is still limited. Purpose The purpose of this study was to explore whether segmental strain and SR analyses are different between patients with normal and stenotic coronary arteries among individuals with chest-pain. Methods A total of 510 patients with chest pain, referred to coronary computed tomography angiography (CCTA) and additional 102 patients with myocardial infarction (MI) were prospectively included. All patients underwent transthoracic echocardiography (TTE) with strain-rate analysis. All patients with CCTA-suspected CAD subsequently underwent invasive CAG, as well as in all MI patients. Global longitudinal strain (GLS) and average for segmental peak longitudinal strain during systole (PLS), peak systolic strain rate (PLSR S), peak early diastolic strain rate (PLSR E), post systolic shortening (PSS) measurements were analysed. Further, different cut-off values for reduced strain and SR were used to define the percentage of functionally reduced segments between patients with normal CAD (no CAD), MI, and stable CAD patients who were further treated by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Results As shown in the table 1,  all average segmental strain and SR parameters differed significantly between no CAD and MI groups. However, only PLSR E showed significant differences between no CAD and PCI groups .  PLSR E, PLS and GLS showed significant differences between no CAD and CABG groups. The percentage of reduced segmental strain and SR showed similar results. Regarding the percentage of pathological segments at different cut-off values, PLSR E showed the most significant difference between these four groups at a cut-off value 1.5 (p &amp;lt; 0.001) (Figure 1). Conclusion Patients with MI or CABG display clearly reduced segmental strain and SR values. However, in patients with chest-pain, segmental PLSR E seemed to be the only indicator revealing subtle differences between patients with no CAD or those assigned to PCI. The diagnostic value of PLSR E needs to be investigated in further studies. Abstract Table 1  Abstract Figure 1 </jats:sec

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit