The results of a multi-country study on improving outcomes from surgery were recently published in the NEJM. The intervention under study is a simple and as low cost as they get – a standardized check list – but it appears to be effective in both rich and poor countries.
Surgery has become very common around the world, roughly 234 million operations are estimated to take place every year, an occurrence more frequent than childbirth. Clearly the rates of operations per population are not likely to be the same around the world, with higher income countries having more surgeries per capita than poorer countries, but the process remains an uncertain process everywhere, and nearly all surgeries are associated with some related risk of death or complications.
The current thinking is that much of these deaths and complications are preventable, suggesting that they are caused by error or other factors associated with human judgement and the results of this study certainly support this view. The check list is pretty straightforward stuff – did you confirm the patient’s name? did you confirm the reason for surgery? did you confirm the site of surgery? were antibiotics started? did anything go wrong with the equipment that should be checked before its next use? -but seems to make a big difference. Huge.
The authors rolled out the use of the same checklist to 8 sites around the world: from Tanzania to Delhi to Manila to Toronto to London. The list was associated with sizable and significant decreases in death and rates of complications in all sites: the rate of death drop from 1.5% to 0.8% (wow!) and the rate of inpatient complications dropped from 11.0% to 7.0%.
The drops were proportionally higher in lower income countries, where baseline rates of death and complications were higher, but the effects were observed in all sites. The principal investigator of the study – Atul Gawande – used the list in his own practice in Boston and was surprised at how often he and his own team ended up catching something they themselves had missed.
The implications of this study cannot be underestimated. If you believe these results are somewhat generalizable to the rest of the world, even in sites without highly motivated principal investigators like those chosen for this study, the use of such lists could translate into a few million fewer deaths per year, many fewer cases of complications, much less human suffering, and millions of dollars saved from associated medical costs. The costs of implementing the lists? Who knows, but I just downloaded it off the internet, and so could millions of other practitioners. And why stop there, such lists could easily be developed and implemented for dozens of other high risk processes and even those which are much more mundane. Some lament that this translates into boiling the “art” of medicine into some mechanized routine, but when the stakes are so high, I would argue that I would take my chances with the banal.