The developing world of pre‐operative optimisation: a systematic review of Cochrane reviews

Abstract

Pre-operative optimisation is a heterogenous group of interventions aimed at improving peri-operative outcomes. To understand the evidence for pre-operative optimisation in the developing world, we systematically reviewed Cochrane reviews on the topic according to the Human Developmental Index (HDI) of the country where patient recruitment occurred. We used summary statistics and cartograms to describe the HDI, year of publication, timing of pre-operative intervention and risk of bias associated with each included trial. We assessed the impact of multinational trials on the risk of bias introduced by countries of differing HDI. Fourhundred and nine trials representing 51 countries and 89,389 randomly allocated participants were summarised in this review. Four-hundred and nineteen out of 451 (93%) trial populations (i.e. a group of study participants from one country) were from high and very high HDI countries. The median (IQR [range]) HDI of countries were 0.862 (0.806-0.892 [0.445-0.949]). Three of the 409 included trials were multinational, representing 32 countries and 37,736 out of 89,389 (42.2%) included participants. Africa was the least represented continent, with only 4 included trials and 566 participants, of which 62.3% were from one multinational trial. The overall risk of bias was high or unclear in 381 out of 409 (93%) trials. Inclusion of multinational trials decreased the proportion of trial populations introducing high or unclear risk of bias by 9.4% (95%CI 5.1-13.7; p < 0.0001). Half of the world's population live in low-and middle-HDI countries. This population is poorly represented in systematically reviewed evidence on pre-operative optimisation. Multinational trials increase the knowledge contribution from low-and middle-HDI countries and decrease risk of bias in systematic reviews. Anaesthesia 2019, 74, 89-99 du Toit et al. | Developing world of pre-operative optimisation

Development of a Clinical Prediction Model for In‐hospital Mortality from the South African Cohort of the African Surgical Outcomes Study

“…A registry of routinely or intermittently collected data can be a valuable resource to clinicians, researchers and administrators for understanding the factors impacting on clinical care. Appropriate use of such data has the potential to greatly impact on efforts to improve access to, and the quality of, perioperative care in South Africa [4].…”

Sensitivity of a preanaesthesia screening and triage tool in identifying high-risk patients attending the preanaesthesia assessment clinic in a tertiary referral hospital in Sub-Saharan Africa: a diagnostic accuracy study

“…Significantly, there is a paucity of data on preoperative evaluation and optimisation in Sub Sahara Africa and little information exists on use of triage questionnaires or systems in the preoperative assessments. 14 One such self-administered questionnaire was shown to have a sensitivity of 95% in identifying high-risk patients in a Western population as part of a triage system that involved a nurse-trained anaesthetist. 9 While this may be adopted in our setting, the differences in language, health literacy and health-seeking behaviour may mean that the results may not be translated to our population.…”

“…While preoperative evaluation questionnaires are now in widespread use, few have been validated particularly in Western populations. Significantly, there is a paucity of data on preoperative evaluation and optimisation in Sub Sahara Africa and little information exists on use of triage questionnaires or systems in the preoperative assessments 14. One such self-administered questionnaire was shown to have a sensitivity of 95% in identifying high-risk patients in a Western population as part of a triage system that involved a nurse-trained anaesthetist 9.…”

Prehabilitation program for African sub-Saharan surgical patients is an unmet need?

“…Perioperative care is a multicomponent intervention implemented by a multidisciplinary team with the purpose to provide safe surgery, accelerate recovery and reduce morbidity and mortality ( Figure 1 ). While the intra- and postoperative care have already received some attention, the potential of the perioperative period remains poorly explored in African countries [ 6 - 11 ]. This time frame represents a major opportunity for decreasing postoperative morbidity and mortality through appropriate surgical risk stratification and patient optimization [ 12 ].…”