title: Proposed minimum rates of surgery to support desirable health outcomes: an observational study based on four strategies.
abstract: BACKGROUND
  The global volume of surgery in 2012 is estimated at 312·9 million operations per year, but rates of surgery vary substantially. Maternal health advocates proposed minimum caesarean delivery rates for benchmarking and to improve perinatal outcomes; however, this has not been done for surgery because the association between rates of surgical care provision as a whole and population health outcomes have not been well described. We use available data to estimate minimum rates of surgery that are associated with important health indicators.
  
  
  METHODS
  We defined surgical operations as procedures done in operating theatres that need general or regional anaesthesia or profound sedation to control pain. We used four strategies to identify rates of surgery based on estimated rates of surgery per country for 2012 associated with life expectancy of 74-75 years; estimated rates of surgery associated with a maternal mortality ratio of less than or equal to 100 per 100 000 live births; estimated minimum need for surgery in the 21 Global Burden of Disease (GBD) regions based on the prevalence of disorders; and surgical rates from the so-called 4C countries (Chile, China, Costa Rica, and Cuba) identified in The Lancet Commission on Global Surgery as exemplary for their achievement of high health status, despite resource limitations.
  
  
  RESULTS
  Based on 2012 national surgical rates, countries with reported life expectancy of 74-75 years (n=17) had a median surgical rate of 4392 (IQR 2897-4873) operations per 100 000 population annually. The median surgical rate associated with maternal mortality ratio lower than 100 (n=109) is 5028 (IQR 4139-6778) operations per 100 000 population annually. The median surgical rate estimated for all 21 GBD regions was 4669 (IQR 4339-5291) operations per 100 000 population annually. The 4C countries had a mean surgical rate of 4344 (95% CI 2620-6068) operations per 100 000 population annually. 13 of the 21 GBD regions, accounting for 78% of the world's population, do not achieve the lowest end of the surgical rate range.
  
  
  CONCLUSIONS
  We identified a surprisingly narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health-care systems and surgical capacity.
  
  
  BACKGROUND
  None.
authors: Department of Surgery, Stanford University, School of Medicine, CA, USA. Electronic address: mesquive@stanford.edu.
authors: Micaela M
authors: MM
authors: Esquivel
authors: Ariadne Labs at Brigham and Women's Hospital and the Harvard T H Chan School of Public Health, Boston, MA, USA.
authors: George
authors: G
authors: Molina
authors: Department of Surgery, Stanford University, School of Medicine, CA, USA.
authors: Tarsicio
authors: T
authors: Uribe-Leitz
authors: Ariadne Labs at Brigham and Women's Hospital and the Harvard T H Chan School of Public Health, Boston, MA, USA.
authors: Stuart R
authors: SR
authors: Lipsitz
authors: Division of Pediatric Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA.
authors: John
authors: J
authors: Rose
authors: Division of Pediatric Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA.
authors: Stephen W
authors: SW
authors: Bickler
authors: Ariadne Labs at Brigham and Women's Hospital and the Harvard T H Chan School of Public Health, Boston, MA, USA.
authors: Atul A
authors: AA
authors: Gawande
authors: Ariadne Labs at Brigham and Women's Hospital and the Harvard T H Chan School of Public Health, Boston, MA, USA.
authors: Alex B
authors: AB
authors: Haynes
authors: Department of Surgery, Stanford University, School of Medicine, CA, USA.
authors: Thomas G
authors: TG
authors: Weiser