The Value of Reporting Perioperative Mortality Rates (POMR)
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INVITED COMMENTARY
The Value of Reporting Perioperative Mortality Rates (POMR) D. A. Watters1
Accepted: 18 September 2020 Ó Socie´te´ Internationale de Chirurgie 2020
The perioperative mortality rate (POMR) is a key performance indicator for global surgery, originally used by the WHO safe surgery saves lives program [1, 2] and then adopted in 2013 through a consensus process by surgeons and anaesthetists in New Zealand, Australia and the Pacific, advocating for global surgery in conjunction with the Alliance for Surgery and Anaesthesia Presence (ASAP) and the International Surgical Society (ISS) [3]. POMR is defined as death following surgery before discharge from hospital or within 30 days, whichever is sooner. Death after surgery before discharge from hospital was regarded as more feasible to collect than 30-day mortality, particularly in LMICs where it may be difficult to follow patients after discharge. POMR was subsequently adopted as one of six recommended surgical metrics by the Lancet Commission of Global Surgery (LCoGS) in 2015 [4]. Malaysia has reported its POMR since 1998 [5], New Zealand since 2011 [6], whilst Tonga was the first Pacific Island nation began to systematically report its POMR in 2013, joined by twelve other countries in the Pacific region [7]. POMR is primarily a safety metric, and its value for safety derives both from the ability of a hospital or health system to know the outcome of patients that undergo procedures, and from the actual rate reported. Death during or after a procedure may be related to preoperative, intraoperative or postoperative factors, so POMR covers much more in terms of the safety and quality of care than just the anaesthesia and surgery provided in the operating room. It is influenced by any of the three delays in accessing surgical care [4], a concept first introduced to inform maternal & D. A. Watters [email protected] 1
Deakin University and Barwon Health Geelong, Victoria 3220, Australia
mortality [8, 9]. It is also related to the surgical anaesthesia and obstetric (SAO) workforce, infrastructure and resources available, as well as to the provision of postoperative care that includes the ability to respond to deterioration. The denominator—all procedures in an operating room requiring some form of anaesthesia—means the actual POMR is heavily influenced by case mix. Many hospitals in LMICs have a higher proportion of emergency to elective procedures than HICs. In LMICs, this may be twothirds to three quarters of cases compared with a third in HICs. In addition to the urgency of a procedure, the major risk factors for perioperative mortality include age, the condition being treated or procedure being performed, and comorbidity, with the American Society of Anesthesiology (ASA) grade being a simple proxy for comorbidity when it is consistently recorded. Little is known about POMR in level 1 or district hospitals in LMICs. Most of the evidence comes from academic hospitals, particularly on acute abdominal surgery [10]. The paper on POMR in the Lake Zone
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