Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countrie

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Résumé

Background Timely and safe elective health care facilitates return to normal activities for patients and prevents
emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to
take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia
as a tracer condition.
Methods This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which
any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing
primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO’s Health System
Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times)
and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank
income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for
hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel
logistic regression model.
Findings 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency
surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%),
accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective
surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays
between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults,
mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible
for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications
occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds
ratio 2·06, 95% CI 1·72–2·46) and bowel resection (1·85, 1·31–2·63), and less common after day-case surgery (0·39,
0·34–0·44).
Interpretation This study demonstrates that elective health care is essential to preventing over-reliance on emergency
systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh
repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might
strengthen non-surgical pathways too, reducing the burden on society and health services.

Mots-clés

quality ,elective care, hernia surgery