Mortality After Surgery in Europe: A 7 Day Cohort Study

Study Questions:

What are the mortality rates and patterns of critical care use for general surgery patients at the national level across Europe, and what can we learn from these data?


The authors sought to identify opportunities for improvement in general surgical outcomes by documenting outcomes at the national level, using a European cohort study between April 4, 2011 and April 11, 2011. During this time, all adult patients admitted for nonelective or elective inpatient surgery at participating centers, including 498 hospitals across 28 nations, were entered into a registry, capturing data on demographics, operation, and critical care, using prospective data entry at the patient level. Follow-up was a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures included length of stay, and admission to the critical care unit. Multilevel logistic regression models were used to adjust for differences in mortality rates between countries.


During this 1-week period, 46,539 patients undergoing surgery were included, of whom 1,855 (4%) died in the hospital, and 3,599 (8%) were admitted to the intensive care unit after surgery (median length of stay, 1.2 days [interquartile range, 0.9-3.6]). Mortality rates for noncardiac surgery varied widely by nation from a low of 1.2% (95% confidence interval [CI], 0.0-3.0) for Iceland, to a high of 21.5% (95% CI, 16.9-26.2) for Latvia. Using the United Kingdom as a reference, and after adjusting for confounding variables, the mortality rate ranged from a low in Finland (OR, 0.44; 95% CI, 0.19-1.05; p = 0.06) to a high for Poland (OR, 6.92; 95% CI, 2.37-20.27; p = 0.0004). It was also observed that 1,358 (73%) of patients who died were not admitted to the intensive care unit at any time.


The authors concluded that the mortality rate for patients undergoing inpatient noncardiac surgery was higher than anticipated. They also opined that variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.


This study is a very important and welcome analysis of national-level data for surgical in-hospital mortality. The Dartmouth Atlas has offered very important insights into variations in care and outcomes for medical care and procedures across the United States. Up until now, such data—which highlight opportunities for quality improvement—have been lacking at the national level. The current study, funded by the European Society of Intensive Care Medicine, and the European Society of Anesthesiology, represents a big step forward in identifying opportunities for quality improvement. The study also demonstrates the importance and potential impact of well-run observational registry research. Randomized clinical trials may be the gold standard for comparing one treatment or procedure to another. But we need more and better observational studies to inform and improve health care delivery and health care policy. It behooves us not to identify the best treatment in a randomized trial, and then fail to properly implement it.

Keywords: Iceland, Intensive Care Units, Hospital Mortality, Intensive Care, Poland, Finland, Europe, Critical Care

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