Table 3. Revised LCoGS indicators and basic data points.
| Indicator 1: Geospatial access | |
| LCoGS indicator definition | Proportion of the population that can access, within 2 hours, a facility that can do cesarean delivery, laparotomy, and treatment of open fracture (the Bellwether procedures) |
| Utstein revised definition | Proportion of a country’s population with geographic access (within 2 hours) to a facility capable of providing surgical and anaesthesia care for the Bellwether procedures (cesarean section, laparotomy, and surgical management of open long bone fracture) |
| Overall summary of data elements | • Population estimates • Facility locations • Capacity of health facilities to do Bellwether procedures • Distance and travel time of population to facilities |
| Basic data points needed to construct the indicator (<2 years) |
Population - Population data or modelled estimates at resolution of 1 × 1 km (disaggregated by 5-year age groupings and sex, if available) Facility location/capability - Location of health facilities offering Bellwether procedures Distance/travel time3.1 - Estimated time to travel to facilities from population locations |
| Indicator 2: Workforce | |
| LCoGS indicator definition | Number of specialist surgical, obstetric, and anaesthetic physicians who are working per 100 000 population. |
| Utstein revised definition | Number of each of surgery, obstetric, or anaesthesia providers who are actively practicing, per 100 000 population |
| Overall summary of data elements | • Provider3.2
numbers as: - Number of nationally certified3.3 specialist physician3.4 practitioners for each of surgery, obstetric, or anaesthesia care, excluding trainees - Number of nationally certified nonspecialist physician practitioners of surgery, obstetric, or anaesthesia care, excluding trainees - Number of nationally certified nonphysician practitioners of surgery, obstetric, or anaesthesia care, excluding trainees - Number of other practitioners (“other practitioners”) of surgery, obstetric, or anaesthesia care who do not fit into aforementioned categories (includes physician trainees and noncertified nonphysician providers—note this is not used in the basic data) • Total country population |
| Basic data points needed to construct the indicator (<2 years) |
Providers - Total number of nationally certified specialist physician practitioners for each of surgery, anaesthesia, or obstetric care Disaggregated by cadre (surgery, obstetric, or anaesthesia providers) - Total number of other nationally certified providers of surgery, obstetric, or anaesthesia care Disaggregated by cadre (surgery, obstetric, or anaesthesia providers) Population - Total country population |
| Indicator 3: Volume | |
| LCoGS indicator definition | Number of procedures done in an operating theatre, per 100 000 population per year |
| Utstein revised definition | Number of surgical procedures done in an operating theatre using any form of anaesthesia 3.5 , per 100,000 population per year |
| Overall summary of data elements | • Number of surgical procedures done in an operating theatre, using any anaesthesia, per year • Total country population |
| Basic data points needed to construct the indicator (<2 years) |
Procedures - Total number of procedures done in an operating theatre using any form of anaesthesia, per year3.5 Population - Total country population |
| Indicator 4: POMR | |
| LCoGS indicator definition | All-cause death rate before discharge in patients who have undergone a procedure in an operating theatre using any form of anaesthesia, divided by the total number of procedures, presented as a percentage, per year |
| Utstein revised definition | Deaths from all causes, before discharge (up to 30 days), in all patients who have received any anaesthesia for a procedure done in an operating theatre 3.5 , divided by the total number of procedures, per year, expressed as a percentage |
| Overall summary of data elements | • Number of patients undergoing a surgical procedure in an operating theatre using any form of anaesthesia who died before hospital discharge (up to 30 days), per year • Number of procedures done in an operating theatre, using any anaesthesia, per year (from Indicator 3: Volume) |
| Basic data points needed to construct the indicator (<2 years) |
Deaths - Number of in-hospital deaths (up to 30 days) in all patients who received any anaesthesia for a surgical procedure performed in an operating theatre3.5, per year Procedures - Number of surgical procedures done in an operating theatre using any form of anaesthesia, per year3.5 Time point: - Deaths before discharge (up to 30 days) |
| Indicator 5: FRP | |
| LCoGS indicator definition | FRP: Risk of Catastrophic Expenditure from Surgical Care |
| Utstein revised definition | Percentage of the population at risk of catastrophic expenditure if they were to require a surgical procedure 3.6 |
| Overall summary of data elements | • OOP3.7 OOP is the direct medical costs incurred from receiving surgical care from time of admission to a facility capable of providing surgical and anaesthesia care to the time of discharge. • Household expenditure Total household expenditure (Y) is defined as “the sum of the monetary values of all items (goods and services) consumed by each household” over 12 months. Catastrophic expenditure threshold • The catastrophic expenditure threshold should be set at 10% of total household expenditure3.8. If (OOP/Y) × 100 >10, catastrophic expenditure has occurred |
| Basic data points needed to construct the indicator (<2 years) |
OOP expenditure for access to surgical care - Nationally representative survey of direct OOP expenditure Household expenditure - National total household expenditure (per individual household) |
The basic data sets are for use for global reporting at the macrolevel only since they provide insufficient granularity to inform national planning or service refinement at the meso- or microlevel. For example, the basic data set does not provide meaningful comparison of POMR across settings since the results are not adjusted for baseline patient risk or type of procedure.
3.1For comparability, travel time means ideal time to travel between a location and a facility. It does not mean experienced travel time from recognition of the need for surgery to arriving at a facility, which may incorporate delays in seeking care or delays in obtaining transport.
3.2We have not provided a definition of what a surgery, anaesthetic, or obstetric provider is; we agreed that these should be defined by each country, with recognition that the definitions are likely to vary locally. Providers are persons directly involved in delivering the surgery, obstetric, or anaesthetic care, i.e., the person doing the operation or giving the anaesthetic.
3.3Certified means completion of a government and/or professionally approved advanced education program that leads to a nationally recognised qualification to provide surgery, anaesthesia, or obstetric care.
3.4Specialist physicians are providers who have obtained a medical degree (physician) and undergone specialty postgraduate training (certification).
3.5This recognises that, at the current time, definitions of procedures that constitute surgery differ between countries and data sources. We have therefore agreed upon a broad definition of procedures for the basic data set (<2-year time frame), without defining a list. This definition includes incision, excision, or manipulation of tissue needing anaesthesia in an operating theatre. This includes day-cases but excludes procedures in other locations, i.e., outside of the operating theatre. Definition of anaesthesia is regional or general anaesthesia, or profound sedation to control pain. Number of surgical codes in a single anaesthesia procedure are counted as one case. If only a subset of procedures is feasible to collect for this indicator, then the type of procedures included should be transparently reported.
3.6Catastrophic expenditure is usually calculated at the individual level (with data collected on OOP and household expenditure for each individual undergoing a medical admission episode). However, many people do not access surgery care because of fear of catastrophic expenditure. This indicator thus uses individual OOP expenditure for those who seek surgery in combination with national average level household expenditure to estimate the proportion of people who would suffer catastrophic expenditure if they were to need surgery.
3.7Direct OOP costs could, in reality, include prehospital direct medical costs. However, they are not included here as they are small relative to the hospitalisation episode and patients may not recall these as readily as hospitalisation costs. This does not include direct nonmedical costs (lodging, food, transport to and from facility). This does not include indirect costs (e.g., loss of earnings).
3.8We note as per SDG Target 3.8.2, there are 2 recognised thresholds, >10% and > 25%; however, we have chosen 10%.
FRP, financial risk protection; LCoGS, The Lancet Commission on Global Surgery; OOP, out-of-pocket expenditure; POMR, perioperative mortality rate.