title: Monitoring and evaluating surgical care: defining perioperative mortality rate and standardising data collection.
abstract: BACKGROUND
  Case volume per 100 000 population and perioperative mortality rate (POMR) are key indicators to monitor and strengthen surgical services. However, comparisons of POMR have been restricted by absence of standardised approaches to when it is measured, the ideal denominator, need for risk adjustment, and whether data are available. We aimed to address these issues and recommend a minimum dataset by analysing four large mixed surgical datasets, two from well-resourced settings with sophisticated electronic patient information systems and two from resource-limited settings where clinicians maintain locally developed databases.
  
  
  METHODS
  We obtained data from the New Zealand (NZ) National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa (PMZ) and Port Moresby, Papua New Guinea (PNG). Information was sought on inclusion and exclusion criteria, coding criteria, and completeness of patient identifiers, admission, procedure, discharge and death dates, operation details, urgency of admission, and American Society of Anesthesiologists (ASA) score. Date-related errors were defined as missing dates and impossible discrepancies. For every site, we then calculated the POMR, the effect of admission episodes or procedures as denominator, and the difference between in-hospital POMR and 30-day POMR. To determine the need for risk adjustment, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site of age, admission urgency, ASA score, and procedure type.
  
  
  RESULTS
  1 365 773 patient admissions involving 1 514 242 procedures were included, among which 8655 deaths were recorded within 30 days. Database inclusion and exclusion criteria differed substantially. NZ and Geelong records had less than 0·1% date-related errors and greater than 99·9% completeness. PMZ databases had 99·9% or greater completeness of all data except date-related items (94·0%). PNG had 99·9% or greater completeness for date of birth or age and admission date and operative procedure, but 80-83% completeness of patient identifiers and date related items. Coding of procedures was not standardised, and only NZ recorded ASA status and complete post-discharge mortality. In-hospital POMR range was 0·38% in NZ to 3·44% in PMZ, and in NZ it underestimated 30-day POMR by roughly a third. The difference in POMR by procedures instead of admission episodes as denominator ranged from 10% to 70%. Age older than 65 years and emergency admission had large independent effects on POMR, but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site.
  
  
  CONCLUSIONS
  Hospitals can collect and provide data for case volume and POMR without sophisticated electronic information systems. POMR should initially be defined by in-hospital mortality because post-discharge deaths are not usually recorded, and with procedures as denominator because details allowing linkage of several operations within one patient's admission are not always present. Although age and admission urgency are independently associated with POMR, and ASA and case mix were not included, risk adjustment might not be essential because the relative odds between sites persisted. Standardisation of inclusion criteria and definitions is needed, as is attention to accuracy and completeness of dates of procedures, discharge and death. A one-page, paper-based form, or alternatively a simple electronic data collection form, containing a minimum dataset commenced in the operating theatre could facilitate this process.
  
  
  BACKGROUND
  None.
authors: Department of Clinical Sciences in Lund, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Lund, Sweden; The Alfred Hospital and Monash University, Melbourne, VIC, Australia.
authors: Charlotta L
authors: CL
authors: Palmqvist
authors: Deakin University, Burwood, VIC, Australia; Barwon Health, Geelong, VIC, Australia.
authors: Roshan
authors: R
authors: Ariyaratnam
authors: Deakin University, Burwood, VIC, Australia; Barwon Health, Geelong, VIC, Australia; Royal Australasian College of Surgeons, East Melbourne, VIC, Australia.
authors: David A
authors: DA
authors: Watters
authors: Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZuluNathal, Pietermaritzburg, South Africa.
authors: Grant L
authors: GL
authors: Laing
authors: Barwon Health, Geelong, VIC, Australia.
authors: Douglas
authors: D
authors: Stupart
authors: Perioperative Mortality Review Committee, Health Quality and Safety Commission, Wellington, New Zealand; Department of Population Health, University of Otago, Christchurch, New Zealand.
authors: Phil
authors: P
authors: Hider
authors: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
authors: Joshua S
authors: JS
authors: Ng-Kamstra
authors: Perioperative Mortality Review Committee, Health Quality and Safety Commission, Wellington, New Zealand; Department of Anaesthesia, Hutt Valley District Health Board, Lower Hutt, New Zealand.
authors: Leona
authors: L
authors: Wilson
authors: Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZuluNathal, Pietermaritzburg, South Africa.
authors: Damian L
authors: DL
authors: Clarke
authors: Department of Clinical Sciences in Lund, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Lund, Sweden.
authors: Lars
authors: L
authors: Hagander
authors: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
authors: Sarah L M
authors: SL
authors: Greenberg
authors: The Alfred Hospital and Monash University, Melbourne, VIC, Australia; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore. Electronic address: rgruen@ntu.edu.sg.
authors: Russell L
authors: RL
authors: Gruen