LAUSR

A core concept promoted by health services researchers interested in the impact of surgical and anesthesia care on global health programs is that of ‘‘bellwether’’ procedures: that is, a select set of well-defined operations that represents the capacity of a facility or health ecosystem to provide surgical care. The Lancet Commission on Global Surgery (LCoGS) developed and proposed this concept by using three conditions—the acute abdomen, obstetric complications, and open fracture—that, if appropriately treated, collectively represented the capacity of a facility to deliver over 90% of emergency and essential surgical care [1, 2]. Treatment of these conditions became known as ‘‘Bellwether procedures’’, defined as cesarean delivery, laparotomy, and treatment of open fracture, and were proposed as archetype operations to evaluate surgical delivery and the capacity of a health system to deliver complex but critically essential operative care. The limitations of the Bellwethers as articulated by the LCoGS are immediately apparent. Laparotomy is too generic to interpret, impossible to compare across countries and settings, and does not provide enough detail of what was done, what the possible indication might have been, or how complex the operations actually was. Treatment of open fracture, while clear in its indication, is not an operation as it does not provide any indication of the procedure performed. Only c-section is narrow enough in its description, delivery and relatively finite list of indications to be useful. Because of these limitations, there has been an argument made to identify a set of operations that are clearly defined, are performed for a relatively narrow set of indications, and treat disease categories amenable to surgical intervention: trauma, emergency obstetric conditions, solid organ cancers, congenital malformations, certain types of infections (e.g., appendicitis), and certain diseases of aging (e.g., coronary artery disease, osteoarthritis of the knee). In fact, a Delphi process has recently concluded and will report on the concept of a ‘‘basket’’ of proposed operations predictably targeted toward specific diseases that affect large numbers of patients and whose successful execution typically results in substantial clinical benefit. The concept of a basket of operations is akin to the use of a ‘‘shopping basket’’ of goods and services that reflect spending habits and patterns of consumers as a means of calculating the Consumer Price Index. ‘‘Goods’’ can be added or removed over time as habits change, but representative goods and services are kept fairly constant. Instead of the Bellwether procedures, a basket of procedures can be simultaneously more expansive and more discrete, and represent treatment capacity for a host of global disease entities such as cancers, injuries, infections, congenital anomalies, and emergency maternal conditions. In this issue of the Journal, Truche and colleagues report on the postoperative mortality rate, or POMR, of the emergency Bellwether procedures in Brazil, and whether using a smaller sampling of operations can inform our understanding of postoperative mortality throughout the country [3]. They used a national database called DATASUS, representing 60–70% of hospital admissions to estimate POMR for all procedures captured by this system as well as POMR for emergency laparotomy, open fracture & Thomas G. Weiser [email protected]