Elective surgery delays causing an increasing global reliance on emergency systems

Elective surgery is essential to preventing over-reliance on emergency systems and improving outcomes for patients, according to a new study published in The Lancet Global Health.

Using inguinal hernia as a tracer condition for elective care, the researchers assessed access and quality of care in more than 80 countries. They found that low-income countries were more reliant on emergency surgery, which resulted in more complications for patients.

Study co-author Dr Maria Picciochi, from the University of Birmingham, said the study shows that: “Boosting the use of elective surgery for conditions that can be fixed simply and early will reduce the risk of complex, and potentially risky, emergency surgery.”

Increasing reliance on emergency care has resulted in crisis management becoming ‘routine’

Inguinal hernias are a common, global surgical condition. The World Bank Essential Surgery Package identifies inguinal hernia as a condition that leads to substantial global burden, with treatment representing a substantial surgical need.

Repairing inguinal hernias is cost effective and this treatment is offered by health systems worldwide. Ideally, inguinal hernias should be treated with simple day-case surgery, but if neglected, the need for more complex emergency surgery increases substantially, with some patients requiring bowel resection.

The researchers therefore inguinal hernias as a tracer condition for their study to demonstrate how increasing reliance on emergency care has resulted in crisis management becoming routine across a wide range of conditions that respond well to early elective treatment.

Waiting times for elective surgery similar globally but emergency surgery and complications more common in low-income countries

This international, multicentre, prospective cohort study of patients undergoing inguinal hernia surgery (HIPPO) included more than 18,000 patients in 640 hospitals across 83 countries. Countries were categorised into four income groups: high-income, upper-middle-income, lower-middle-income, and low-income countries.

Overall waiting times for elective surgery were similar around the world (median 8 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment.

Of the 18,058 patients included in the study, 1,287 (7%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6.8% in high-income countries vs 14.2% in low-income countries). This was accompanied by an increase in bowel resection rates (1.2% vs 4.2%).

In patients eligible for day-case surgery (12,658), day-case rates were low and variable (50% vs 44.5%). Complications occurred in 2,415 patients (13.4%) and were more common after emergency surgery and bowel resection, and less common after day-case surgery.

As well as increasing rates of emergency surgery and complications in low-income countries, the study also reveals a clear global imbalance in access to mesh repair, with mesh use decreasing from high-income to low-income countries (97.6% vs 61.0%).

Mesh is well proven to reduce long-term hernia recurrence, is simple to place, low-cost and scalable, and the authors say this reflects poor access to simple medical devices in lower-income countries.

Overreliance on emergency surgery can create ‘downward spirals’

The authors acknowledge various limitations to their study, including the sole use of inguinal hernia as a tracer condition, and that they did not capture patients who did not undergo surgery, meaning the societal burden of untreated hernia could be far higher than estimated.

Even so, Dr Picciochi says the study highlights how over reliance on emergency surgery may create a ‘downward spiral’, with patients more susceptible to surgical complications.

“Our study showed multiple weaknesses in access and quality in current healthcare systems, with a particular disadvantage in lower-income settings. As a result, there was higher emergency demand, which further reduced elective capacity and might create downward spirals.

“If weak access and quality persist over several electively treatable conditions, both surgical and non-surgical, multimorbidity can also become established, which makes future elective care harder and emergency care even more complicated,” she said.

The authors have identified various areas of intervention for policymakers, including improving referral systems, increasing the use of mesh repair and educating communities and health workers around the symptoms of hernias.