Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Agricultural innovation and adaptation to climate change: empirical evidence from diverse agro-ecologies in South Asia

While impacts of climate change on agricultural systems have been widely researched, there is still limited understanding of what agricultural innovations have evolved over time in response to both climatic and non-climatic drivers. Although there has been some progress in formulating national adaptation policies and strategic planning in different countries of South Asia, research to identify local-level adaptive strategies and practices is still limited. Through eight case studies and a survey of 300 households in 15 locations in India, Nepal and Bangladesh, this paper generates empirical evidence on emerging agricultural innovations in contrasting socio-economic, geographical and agro-ecological contexts. The study demonstrates that several farm practices (innovations) have emerged in response to multiple drivers over time, with various forms of institutional and policy support, including incentives to reduce risks in the adoption of innovative practice. It further shows that there is still limited attempt to systematically mainstream adaptation innovations into local, regional and national government structures, policies and planning processes. The paper shows that the process of farm-level adaptation through innovation adoption forms an important avenue for agricultural adaptation in South Asia. A key implication of this finding is that there is a need for stronger collaborations between research institutions, extension systems, civil society and the private sector actors to enhance emerging adaptive innovations at the farm level