Risk Factors for Mortality and Adverse Outcomes after General Surgery Procedures in Sub-Saharan Africa Include Malaria and Type-2 Diabetes

Abstract

Introduction: In sub-Saharan Africa, mortality, prolonged length of stay (LOS), and readmission after elective and emergency surgical procedures represent a major global health burden. In order to identify predictors of such adverse outcomes, we analyzed records of 4851 patients undergoing surgical procedures in a rural referral hospital serving 26 districts in Ghana. Methods: Hospital records (January 2015 to December 2017) were retrospectively analyzed to delineate independent risk factors of mortality, prolonged LOS ≥5 days, and 90-day readmission. Multivariable logistic regression based on 10 attributes (age, sex, insurance status, hemoglobin, leukocyte count, hypertension, admission serum glucose, Type-2 Diabetes (T2D), HIV status, malaria status) was utilized for modeling, which was cross-validated by using leave-one-out cross validation. Results: Of 4,851 patients, 66% were male, average age was 46±22 years (mean±SD). Critical attributes of this patient population included T2D in 9%, admission hyperglycemia (glucose ≥140 mg/dl) in 48%, malaria in 14% and HIV in 2%. Cumulative mortality was 6% after emergency or elective operations. Admission hyperglycemia and malaria were independent predictors of readmission: area under the curve (AUC)=0.70. Elder status, T2D, and leukocytosis (leukocyte count>11,000/microliter) were independent predictors of mortality (AUC=0.69) and leukocytosis and hemoglobin concentration independently predicted prolonged LOS (AUC=0.66). Conclusion: Patients are 6 times more likely to die after surgery in sub-Saharan Africa when compared to global averages. Potentially actionable risk factors for mortality and adverse outcomes include poorly controlled T2D, admission hyperglycemia, malaria and anemia.