title: Mortality of emergency abdominal surgery in high-, middle- and low-income countries.
abstract: BACKGROUND
  Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI).
  
  
  METHODS
  This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression.
  
  
  RESULTS
  Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1·6 per cent at 24 h (high 1·1 per cent, middle 1·9 per cent, low 3·4 per cent; P < 0·001), increasing to 5·4 per cent by 30 days (high 4·5 per cent, middle 6·0 per cent, low 8·6 per cent; P < 0·001). Of the 578 patients who died, 404 (69·9 per cent) did so between 24 h and 30 days following surgery (high 74·2 per cent, middle 68·8 per cent, low 60·5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2·78, 95 per cent c.i. 1·84 to 4·20) and low-income (OR 2·97, 1·84 to 4·81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days.
  
  
  CONCLUSIONS
  Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role.
  
  
  BACKGROUND
  NCT02179112 (http://www.clinicaltrials.gov).
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000328:Adult; D057189:Checklist; D015331:Cohort Studies; D019049:Developed Countries; D003906:Developing Countries; D013505:Digestive System Surgical Procedures / Q000401:mortality*; D004630:Emergencies; D005260:Female; D005767:Gastrointestinal Diseases / Q000601:surgery; D006801:Humans; D008297:Male; D061214:Patient Safety; D011785:Quality Assurance, Health Care