Dr KK Aggarwal
Last week I read a Lancet study, which said that 21
lakh people in low and middle-income nations die within 30 days post-
surgery. Around 3.13 crore surgical procedures are performed worldwide
each year. The number of post-operative deaths globally is 42 lakhs and 7.7% of
these deaths occur within 30 days of surgery.
This is a surprising amount of mortality, which
occurs following elective surgery.
Post-surgery deaths are greater in number than
what is attributed to any other cause of death globally, except ischemic heart
disease and stroke. At present, around 4.8 billion people worldwide lack timely
access to safe and affordable surgery. There is an annual unmet need for 143
million procedures in low- and middle-income countries. It is projected
that an expansion of surgical services to address unmet need would increase
total global deaths to 61 lakh annually.
The study took me back to 1976; it was my second
year of MBBS. In that year, in January, doctors in Los Angeles went on
strike in protest over soaring medical malpractice insurance premiums. For five
weeks, approximately 50% of doctors in the county reduced their practice and
withheld care for anything but emergencies. Cunningham and colleagues found the
strike actually prevented more deaths than it caused. Mortality declined
steadily from week one (21 deaths/100,000 population) to weeks six (13) and
seven (14), when mortality rates were lower than the averages of the previous
five years. And, as soon as elective surgery resumed, there was a rise in
deaths. There were 90 more deaths associated with surgery for the two weeks
following the strike in 1976 (i.e. when doctors went back to work) than there
had been during the same period in 1975.
The most comprehensive review of the medical impact
of doctors' strikes was published in the journal Social Science and Medicine in
2008. A team led by Solveig Cunningham and Salim Yusuf at Emory and Georgetown
Universities in the US and McMaster University in Canada, analyzed five
physician strikes around the world, all between 1976 and 2003. Doctors withdrew
their practice in the different strikes analyzed, from between 9 days and 17
weeks. All the different studies report population mortality either stays the
same, or even decreases, during medical strikes. Not a single study found death
rates increased during the weeks of the strikes, compared to other times. It
was concluded “it's a fact that elective, or
non-emergency surgery, tends to stop during a doctors' strike, which seems to
be the key factor”.
But Gruber and Samuel Kleiner who analyzed the
effects of nurses' strikes in hospitals on patient outcomes using nurses' strikes
over the 1984 to 2004 period in New York Stat wrote in a paper entitled,
"Do Strikes Kill? Evidence from New York State," that nurses' strikes
increase in-hospital mortality by 19.4% and 30-day readmission by 6.5% for
patients admitted during a strike. The authors, from MIT and Carnegie Mellon
University, concluded that hospitals during nurses' strikes are providing a
lower quality of patient care.
One of these five studies was an intriguing study,
which analyzed changes in mortality by studying the Jerusalem Post's newspaper
reports of funerals during another Jerusalem doctors' strike, this time between
March and June of 2000. This one arose from the Israel Medical Association's
conflict with the government's proposed wages. The hospitals in the area
cancelled all elective admissions and surgeries, but kept emergency rooms and
other vital departments, such as dialysis units and oncology departments, open.
The funeral study found a decline in the number of funerals during the three
months of the strike, compared with the same months of the previous three
years. One burial society reported 93 funerals during one month of the
strike (May 2000) compared with 153 in May 1999, 133 in May of 1998, and 139 in
May 1997.
How can this be explained?
Firstly, is it the elective or non-emergency
surgery, which is usually most affected in a doctor's strike responsible for
the higher deaths? The answer is yes. You can stay in bed with a fractured leg
for six months and live with a malunited leg throughout your life but if you
like quality and start walking within few days you need to take a risk of 1-2%
by getting an elective surgery.
Elective surgeries including anesthesia are not
risk-free. Lowest risk is 0-1%, moderate risk is 1-5% and high risk is > 5%.
Considering the number of surgeries in India, 1% will be a substantial number.
Sudden or unexpected death in otherwise low risk
population is also responsible for most litigation.
In every elective surgery, the treating surgeon
must define the chances of complications linked mortality during surgery and
anesthesia and the hospitals facilities to manage complications if they occur.
The take home message is that no surgery can be
said to be risk-free. No surgery can be called a
'minor' surgery. Failing to abide by the standards of quality and add
to the mortality.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical
Associations in Asia and Oceania
(CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA
