Articles Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries NIHR Global Health Unit on Global Surgery*, COVIDSurg Collaborative*† Summary Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts Lancet 2022; 400 : 1607–17 of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the Published Online world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a October 31, 2022 https://doi.org/10.1016/ novel index to support local elective surgical system strengthening and address growing backlogs. S0140-6736(22)01846-3 *Members of the NIHR Global Methods First, we performed an international consultation through a four-stage consensus process to develop a Health Unit on Global Surgery multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical and the COVIDSurg Collaborative preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), are listed on appendix (pp 17–69) and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. †Members of the writing Finally, using COVID-19 as an example of an external system shock, we compared hospitals’ SPI to their planned surgical committee are listed at the end volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as of the Article the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the Correspondence to: expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic Mr James Glasbey, NIHR Global baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Health Research Unit on Global Surgery, Institute of Applied Health Research, University of Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective Birmingham, Birmingham, surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six B15 2TH, UK from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on j.glasbey@bham.ac.uk staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points or (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from Mr Aneel Bhangu, 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1–84·9), NIHR Global Health Research Unit on Global Surgery, Institute which varied between HIC (88·5 [89·0–88·0]), MIC (81·8 [82·5–81·1]), and LIC (66·8 [64·9–68·7]) settings. In the of Applied Health Research, third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which University of Birmingham, 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a Birmingham, B15 2TH, UK 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0–4·1; p<0·0001) increase in SVR. This was consistent in a.a.bhangu@bham.ac.uk HIC (4·8% [4·1–5·5]; p<0·0001), MIC (2·8 [2·0–3·7]; p<0·0001), and LIC (3·8 [1·3–6·7%]; p<0·0001) settings. See Online for appendix Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs. Funding National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic. Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Introduction care.3 Some patients might never have accessed the The COVID-19 pandemic highlighted the fragility of surgery they required, with high associated disability elective surgical services around the world, yet global and millions of years of healthy life lost.4,5 With the surgery risks being neglected in pandemic recovery existing challenges in providing accessible and safe planning.1–3 At the start of 2022 an estimated 200 million surgical systems in low-income countries (LICs) and patients worldwide were awaiting surgery.1,2 For time- middle-income countries (MICs) identified by the 2015 critical conditions, such as cancer, one in seven patients Lancet Commission on global surgery, health systems did not have their planned surgery during SARS-CoV-2 and hospitals with less funding for infrastructure, outbreaks and many more had substantial delays to their staffing and equipment were the worst affected, with www.thelancet.com Vol 400 November 5, 2022 1607 Articles Research in context Evidence before this study and multidisciplinary community to identify and prioritise The 2015 Lancet Commission on global surgery identified surgery features of prepared surgery and anaesthesia systems that were and anaesthesia as an indivisible component of holistic health relevant across a wide variety of external system shocks. We systems. The COVID-19 pandemic has revealed ongoing fragility prioritised 23 globally relevant indicators of surgical preparedness in surgery and anaesthesia systems, with more than 200 million across four domains (facilities, staffing, prioritisation, and patients currently awaiting their planned procedures. processes). The SPI was then measured across a range of hospitals We searched PubMed and Embase from the inception of each and settings showing significant variability in preparedness database to March 4, 2022, without date limits for indices, between hospitals, regions, and countries. During the COVID-19 frameworks, or guidelines able to assess a hospital or surgical pandemic, a pressing and globally relevant example of a system system’s ability to deliver planned surgery and anaesthesia stressor, three-quarters of hospitals reported a reduction in during periods of external system stress. Planned surgery planned surgical volume. The SPI score was shown to be strongly included all operations done when a decision for surgery was associated with a hospital’s ability to continue planned surgery, made before hospital admission, whether this was elective validating the concept of preparedness in reducing surgical or expedited. We used search terms related to “preparedness”, cancellations, with a significant and measurable effect. This “resilience”, “pandemic”, or “system stress” in combination with relationship was consistent across different types of hospital and “surgery”, “anaesthesia”, “surgical systems”, “procedures”, or health systems, suggesting that SPI measurement was “non-communicable disease”. External system stressors included generalisable across contexts. airborne pandemics (eg, SARS-CoV-2), non-airborne disease Implications of all the available evidence (eg, Ebola virus), and other system stressors (eg, natural The COVID-19 pandemic highlighted the fragility of surgical disasters, mass trauma, warfare, political instability, and extreme services around the world, yet surgery risks being neglected in weather events). We identified 15 indices and six frameworks for pandemic recovery planning. Without effective, integrated assessing whole-health system preparedness, but none were surgical and anaesthesia systems, non-communicable diseases specific to surgery nor were they validated against a measure of cannot be effectively treated and community health declines, planned surgical volume. We also identified three tools to meaning Sustainable Development Goal 3 cannot be met. quantify essential surgical capacity: WHO Situational Assessment Application of the SPI can identify areas for policy change, Tool, PIPES Tool, and Ethiopian Hospital Assessment Tool. advocacy, and investment at subnational and local levels. However, these were not designed to assess preparedness and Hospitals should urgently implement annual SPI assessment are complex to complete. Together, this shows that the features and create local action plans to strengthen planned surgical of prepared surgery and anaesthesia systems are not yet well services, thus supporting whole-health system resilience. understood or properly implemented. Longitudinal assessment of surgical preparedness can now be Added value of this study incorporated into national surgical, obstetric, and anaesthesia The Surgical Preparedness Index (SPI) is the first tool that planning and considered an essential indicator of surgical specifically assesses elective surgery and anaesthesia system system strength. Future work is required to test the SPI in preparedness. We engaged a diverse, international, low-income countries (4·3% of included hospitals). whole-societal health, economic, social, and political for infrastructure, staffing, and care pathways that can be consequences.3,6 The backlog of patients awaiting applied flexibly across different health systems.10 COVID-19 planned procedures is now one of the most pressing (an airborne pandemic) has been just one form of external challenges to global health for the next 10 years. stress on health systems, but provides an important The SARS-CoV-2 pandemic presented an unprecedented learning opportunity for surgical providers and policy stress on global health systems. Many surgery and makers to strengthen surgical preparedness ahead of anaesthesia services changed their processes for patient future system shocks. selection and reduced their volume of planned procedures, Although several indices of health system preparedness reflecting the high risk to patients planned to receive and surgical capacity have been proposed, these were not surgery of perioperative SARS-CoV-2 infection.7 Different designed to assess preparedness of surgery and models of care have been proposed to support safe anaesthesia services nor have they been validated against a upscaling of planned surgical volume during pandemic measure of surgical capacity.11–13 Whole-health system recovery.8,9 However, shared global learning about the best preparedness indicators are often not applicable to methods to improve preparedness of surgical systems has surgery, and surgical capacity indicators (eg, the WHO not been done. Surgical capacity urgently needs to be Situational Assessment Tool, PIPES Tool, and Ethiopian upscaled to address growing backlogs of patients waiting Hospital Assessment Tool) are not designed to dynamically for their planned procedures and improve preparedness assess the response of services to external system pressure for future system shocks. Solutions need to be identified and are too complex for everyday use. This study describes 1608 www.thelancet.com Vol 400 November 5, 2022 Articles the development and validation of a multinational surgical which the decision for surgery was made before the preparedness index (SPI) and framework to support hospital admission during which the operation took place. elective surgery and anaesthesia services, strengthening Second, measurement of surgical preparedness. A cross- them against future external system shocks. sectional hospital assessment study was done to assess the distribution of the total SPI score at national, subnational, Methods and hospital levels. Third, validation of the multidomain This study was done in three phases (figure 1). First, index SPI against the observed versus expected elective surgical development. An international consultation was done with volume during the COVID-19 pandemic; this was used as a Delphi consensus methodology to develop hospital-level a contempo­raneous example of a globally relevant system preparedness indicators to support surgical service stressor. strengthening. For the purposes of this study, preparedness was defined as the ability of a hospital to maintain capacity Phase 1: development of the SPI for planned surgery during periods of external system The international consultation was done with a diverse, shock. Planned surgery was defined as any operation for multidisciplinary, expert index development group. This Longlisting of candidate indicators through internal consultation 65 front-line perioperative clinicians from 110 candidate indicators proposed by the 32 recommendations across four domains 44 countries invited to participate in the IIDG were shortlisted after iterative thematic longlisting of candidate indicators analysis and combination to reduce redundancy Round 1: online voting with IIDG (rating on a scale of 0 [not important and easy to measure] to 100 [very important and easy to measure]) 15 indicators did not meet predefined The ease of measurement score for dropping criteria of an ease of reporting 17 indicators and the importance score for Phase 1: Development of the SPI or importance score of ≤70 4 indicators was ≤70. These indicators assessed in rounds 2 and 3 Round 2: iterative development and discussion in a virtual meeting of the IIDG Round 3: online voting round with IIDG (overall importance of indicator: essential, desirable, or remove) 6 additional indicators were deemed 9 indicators were suggested to be removed 2 additional indicators were not deemed essential to ≥50% of respondents and were by ≥10% of respondents and were dropped essential by ≥50% of respondents, nor accepted were they suggested to be removed by ≥10% of respondents. They entered round 4 discussion Round 4: Final development and discussion in a virtual meeting of the IIDG Final index of 23 indicators across 4 domains were agreed and entered phase 2 measurement 5375 hospital-level assessment of the SPI (661 ineligible) Measurement Phase 2: 4714 assessments from 1627 hospitals in 119 countries included in the measurement Phase 3: Validation Validation of the SPI using COVID-19 as a case study of external system stress Association of the SPI with observed vs expected planned surgical volume in 1632 hospitals Figure 1: Overview of study design IIDG=international guideline development group. SPI=surgical preparedness index. www.thelancet.com Vol 400 November 5, 2022 1609 Articles included surgeons, anaesthetists, critical-care doctors, promote application and interpretation of the SPI in clinical nurses, and hospital managers involved in the delivery of practice, we calculated global, regional, and national planned surgical care across high-income country (HIC), distributions of SPI. We also disaggregated by hospital MIC, and LIC settings. The range of people included type, country income, COVID-19 burden, and country. across care roles and income setting was designed to Where multiple assessments were made of the same provide breadth of perspectives during consensus rounds hospital, the mean was calculated first by indicator, then an and fulfils typical sample size requirements for Delphi overall mean index score was calculated as an aggregate methodologies.14 A four-stage Delphi process was done mean of these means. Results presented across subgroups within the development group to prioritise hospital-level were calculated as the mean of hospitals’ mean SPI scores SPIs. Consensus definitions were set a priori, and the in each group and presented with a 95% CI. High fidelity process was done in accordance with best practice centre-level SPI data were presented online on a Shiny recommendations: (1) the expertise matrix was predefined, (Boston, MA, USA) application hosted on an Argonaut inclusive, and generalisable; (2) dropping rules were server at the University of Edinburgh, Edinburgh, UK. The predefined; (3) a limit of two voting and two face-to-face inter-rater reliability of SPI assessment was estimated rounds was prespecified; and (4) frequent reminders were again using the ICC(1k) with 95% CIs.17 sent to respondents to maximise the retention rate.15 The We explored the relationship between national mean full methodology for the consultation process is described SPI scores and four relevant global health indicators using in the appendix (pp 70–73). generalised additive modelling fitted with a penalised To explore the relevance of the surgical preparedness cubic spline (with shrinkage). The four selected indicators indicators across other external system shocks, we used a were: (1) the UN’s Human Development Index, which is a consensus ratings exercise with eight international composite index of life expectancy, education, and per development group members (two from high-income capita income (a higher Human Development Index score countries [HICs], four from MICs, and two from LICs). We indicates greater development); (2) global health security defined five different external shocks: airborne pandemic, index, which is an assessment of global health security non-airborne pandemic, warfare and political instability, capabilities (ie, a measure of whole health-system natural disasters, and seasonal pressures. Independent resilience) from the Johns Hopkins Center for Health members were asked to rate the relevance (high, moderate, Security, Baltimore, MD, USA, the Nuclear Threat or low) of each indicator in their local context. Inter-rater Initiative (Washington DC, USA), and the Economist reliability was estimated using intraclass correlation Intelligence Unit (London, UK; a high global health coefficient (ICC[1k]; one-way random effects, average of security score indicates a more resilient health system); k raters) presented with 95% CIs. (3) the WHO Universal Health Coverage (UHC) service coverage index, which combines 14 tracer indicators of Phase 2: preparedness of global surgery and anaesthesia service coverage into a single summary measure (a higher systems UHC index indicates greater coverage); and (4) Gini A hospital-level assessment of the SPI was done between coefficient, which is a measure of population wealth June 6 and Aug 5, 2021, and data were recorded by local inequality (a Gini coefficient of 0 expresses perfect assessors on a centralised, encrypted Research Electronic equality; a coefficient of 1 indicates maximal inequality). Data Capture server hosted by the University of Analyses were done with R Studio (version 4.1.1) packages: Birmingham, Birmingham, UK.16 COVIDSurg is a net­ tidyverse, finalfit, psych, and ggplot2. work of more than 15 000 front-line clinicians from the National Institute for Health Research (NIHR) Global Phase 3: validation of the SPI using planned surgical Health Research Unit on Global Surgery focused on volume during COVID-19 supporting data-driven decision making in perioperative To evaluate the criterion validity of the SPI, we compared a care.7 The network facilitated distribution of the SPI hospital’s self-assessed SPI score with its ability to maintain assessment was sent to local clinicians and managers to planned surgery capacity. This was estimated using the complete for their hospital. Collaborators were observed to expected planned surgical volume ratio (SVR), encouraged to identify other colleagues to complete calculated as the ratio of each hospital’s observed planned multiple assessments of the same hospital to evaluate surgical volume over a 1-month assessment period against inter-rater reliability. Any centre worldwide providing the expected planned surgical volume based on data from planned surgery was eligible to participate. Any post­ the same month in 2019 (the prepandemic baseline) and graduate clinician or manager involved in perioperative expressed as a percentage. Case volume data were care from any specialty background in these centres was measured from routinely collected hospital administrative eligible to participate. Clinicians without a temporary or data, such as theatre logbooks and electronic health-care permanent contract (ie, locum doctors or equivalent) and records. A planned surgery case was defined as any medical students were not eligible to participate. planned admission for a procedure done by a surgeon in Features of hospital assessors and hospitals were an operating theatre under general, regional, or local summarised overall and by country income group. To anaesthesia. This included procedures classified as either 1610 www.thelancet.com Vol 400 November 5, 2022 Articles elective or expedited in the National Confidential Enquiry into Patient Outcome and Death classification system, but Panel: Summary of surgical preparedness index excluded urgent and immediate surgery.18 Patients Hospitals were assessed for each indicator by assessors, scored from 1 (very weak) to undergoing surgery for any indication were eligible for 5 (very strong) with an overall summary surgical preparedness index score calculated inclusion, including benign disease, cancer, trauma, or between 23 and 115. A full description of each indicator to support hospital assessment is obstetrics. This included day-case procedures (ie, provided in the appendix (pp 1–2). discharged same date as operation). Analyses were done using R Studio packages tidyverse, Facilities and consumables finalfit, lmer, and ggplot2. A complete-case analysis was 1. Availability of reserved planned surgery theatres (ring-fenced theatres) preplanned if missing data were both missing at random 2. Availability of reserved planned surgery beds (ring-fenced beds) and in a low number of samples (<5%).19 In the prestudy 3. Availability of reserved critical care beds for planned surgery (ring-fenced critical care) protocol, we planned to impute missing data using multiple 4. Flexibility to rearrange hospital areas to provide a segregated pathway for planned imputation by chained equations based on a missing at surgery (flexible areas) random or missing completely at random assumption if 5. Access to diagnostics and interventions to identify and treat surgical complications data missingness was more than 5%. Centres with no (managing complications) current planned surgery volume estimate were excluded 6. Reliable supply of electricity (electricity supply) from analyses. Generalised additive models were fitted 7. Reliable supply of supplementary oxygen (oxygen supply) using a penalised cubic spline (with shrinkage). Models 8. Reliable supply and management of essential perioperative drugs (drug supply) were initially fitted with a basis dimension of 10 (k). Model 9. Reliable supply and management of devices and implants (device supply) fit was checked using residual plots, convergence 10. Sufficient surgical instrument and local sterilisation processes (sterilisation) confirmed, and basis dimension choice checked. If per 11. Availability of protective measures for theatre teams (protective equipment) group estimated degrees of freedom approached basis Staffing choice minus one (k–1), then the basis dimension was 12. Ability to redistribute staff within and between hospitals to maintain capacity (staff increased. The link function was identify. A random-error redistribution) distribution was assumed and checked on residual plots as 13. Availability of reserved teams to provide planned surgical care (ring-fenced teams) above. To explore whether this association could be explained by confounding we created a mixed-effects linear Prioritisation regression model with country included as a random effect 14. Cross-specialty patient prioritisation for surgery (patient prioritisation) (normal distribution). We checked assumptions by 15. Ability to identify and cancel procedures of limited clinical value (procedure exploring normality and homogeneity of variance of prioritisation) residuals and linearity of quantitative predictors. Systems Model coefficients were adjusted for predefined centre- 16. Formal operational plan to continue planned surgery during external system shocks level and country-level confounders that were identified (formal plan) through a scoping review of published literature and 17. Ability to do preoperative assessment in the community (preoperative assessment) considered a priori by the international development 18. Access to routine preoperative testing for endemic and epidemic diseases group as likely to be clinically and causally linked to both (preoperative testing) exposure and outcome. A proposed casual model was 19. Ability to transfer patients to another hospital with greater capacity (hospital transfer) presented in a directed acyclic graph. Covariables included 20. Ability to facilitate timely discharges (timely discharge) country income—defined according to World Bank 2018 21. Social support system to facilitate safe discharge (social support) definitions and classified as HIC, MIC (including both 22. Capacity to use telephone or video calls for outpatient appointments (remote upper-middle and lower-middle classifications), or LIC on outpatient appointments) the basis of annual gross domestic product per capita 23. Capacity and capability to communicate with family members (family (US$); hospital funding (public, private, or mixed public communication) and private); surgical service provision at the facility (planned only versus planned and unplanned); hospital location (defined by the assessor as primarily an urban, 100 (most stringent restrictions). It has been validated for rural, or mixed urban and rural area); number of hospital use globally by showing associations with planned surgical beds (<50, 50–99, 100–199, 200–499, 500–999, or ≥1000); volume,3 population SARS-CoV-2 infection rates, and and country COVID-19 burden (low, moderate, or high) at Google mobile phone mobility data.20 OxCGRT cutpoint the time of SPI assessment. The Oxford COVID-19 scores used in previous work based on comparisons of Government Response Tracker (OxCGRT) was used as a index scores and national policy sources were used.3 Each surrogate of the overall COVID-19 burden on a local health hospital was given a classification based on the country’s system at the time of the SPI assessment. The OxCGRT is status at the time of assessment: low COVID-19 burden a composite of 19 indicators, including measures and (index <20), moderate COVID-19 burden (20–60), and behavioural interventions associated with containment high COVID-19 burden (>60). The OxCGRT was and closure, economic response, and health systems with preferentially used instead of SARS-CoV-2 case notification an overall score range between 0 (no restrictions) and rates because of global differences in access to testing and www.thelancet.com Vol 400 November 5, 2022 1611 Articles reporting.21,22 Subgroup analyses were presented by country not necessarily those of the National Health Service, the income, COVID-19 burden, hospital financing, and NIHR or the UK Department of Health and Social Care. hospital location, presented in cubic spline curves and with β coefficients generated in mixed-effects models. Results In phase 1, the international consultation to develop the Role of the funding source SPI indicator set involved 69 members (23 [33%] The funders had no role in study design or writing of this women; 46 [67%] men; 41 from HICs, 22 from MICs, and report. The views expressed are those of the authors and six from LICs) from 32 countries. This included front-line surgeons, anaesthetists, and critical-care doctors from the COVIDSurg and NIHR Global Health Unit on Global + High relevance Airborne Non-airborne Warfare and Natural Seasonal pandemic pandemic political disaster pressures Surgery collaborative networks. Of 110 longlisted candidate – Moderate relevance instability (eg, flood and (eg, winter and indicators, the final index included 23 indicators across x Low relevance hurricane) heatwaves) four consensus domains: facilities and consumables, Facilities and consumables staffing, prioriti­ sation, and systems (panel). Detailed Ring-fenced theatres + + + + + descriptions to support hospital assessment are provided in the appendix (pp 1–3). Each indicator was scored using a Ring-fenced beds + + + + + Likert scale between 1 (very weak) and 5 (very strong). The + + + + + scores across all 23 indicators were summed to give a total Ring-fenced critical care SPI score for a hospital with a range between 23 (least Flexible areas + + – – – prepared) and 115 (most prepared). A summary of the Delphi voting rounds is presented in figure 1 and full Managing complications + + + + + results are reported in the appendix (pp 4–5). All eight Electricity supply + + + + + independent raters considered the 23 indicators to have high (20 indicators) or moderate (three indicators) relevance Oxygen supply + + + + + to maintaining volume of planned surgery across all five + + + + + examples of external shocks (figure 2) with high agreement Drug supply between raters (ICC 0·76 [95% CI 0·59–0·89]). Device supply + + + + + In phase 2, 5375 hospital-level assessments were completed, of which 503 did not have an identifiable Sterilisation + + + + + hospital or country or both, 118 did not complete Protective equipment + + + –– – assessment of all indicators, and 40 did not calculate an SVR. Across included facilities, the level of missingness Staffing was less than 5% for all indicators; we did a preplanned Staff redistribution + + + + + complete case analysis without imputation. 4714 complete Ring-fenced teams + + + + + assessments from 1632 hospitals in 119 countries, including 887 (54%) hospitals in 52 (44%) HICs, 675 (41%) Prioritisation hospitals in 56 (47%) MICs, and 70 (4%) hospitals in Patient prioritisation + + + + + 11 (9%) LICs, were eligible for analysis in phase 2 and 3. A summary of included hospitals both overall and by Procedure prioritisation + + + + + World Bank income group and the number of hospitals Systems and assessments by country are reported in the appendix Formal plan + + + + + (pp 6–7). 1217 (74·6%) of 1632 hospitals assessed were public (government) funded, 196 (12·0%) were private Preoperative assessment + + + + + hospitals, and 219 (13·4%) were mixed public and private. Preoperative testing + + – – – 1570 (96·2%) hospitals delivered both planned and unplanned surgery. Hospitals in urban, rural, and mixed Hospital transfer + + + + + settings, with a wide range of hospital bed numbers were included in the assessment. The median number of Timely discharge + + + + + hospitals assessed per country was 6·0 (IQR 2·0–14·5). Social support + + + + + There was a median of 2·0 (1·0–3·0) assessments per hospital, and 764 (46·8%) hospitals had more than one Remote outpatients + + + + + assessment. In hospitals in which more than one Family communication + + + + + assessment was completed, inter-rater reliability of the SPI was moderate (ICC 0·55 [95% CI 0·53–0·57]). A Figure 2: Relevance of the surgical preparedness index to different external shocks summary of features of hospital assessors overall and by Independent development group members were asked to rate the relevance of each surgical preparedness World Bank income group are reported in the appendix indicator following five different external health-care system shocks in their local context. (p 9). The hospital assessors were most commonly 1612 www.thelancet.com Vol 400 November 5, 2022 Articles A Mean SPI index score 100 80 60 40 B High-income countries Middle-income countries Low-income countries 0·03 Smoothed density estimate 0·02 0·01 0 25 50 75 100 25 50 75 100 25 50 75 100 SPI score SPI score SPI score Figure 3: Geographical distribution of SPI score (A) Distribution displayed is centred around the mean value of SPI total score (84·5). Green indicates better prepared surgical systems; red indicates less prepared surgical systems. (B) Distribution of the SPI by country income group. The theoretical score range limits of the SPI were 23–115 points. The lowest mean hospital score was 26 and the highest was 115. These values are displayed at the floor and ceiling values of the x-axis. SPI=surgical preparedness index. surgeons (2845 [60·4%] of 4714 assessors), although outpatient appointments (3·26 [3·21–3·32]), and formal assessments were completed by a range of professionals operational plan (3·28 [3·23–3·32]). The biggest differences from across all surgical disciplines. The mean SPI scores by indicator were seen in device supply (standardised mean per hospital was 84·5 (95% CI 84·1–84·9) out of 115, and difference between HICs and LICs was –1·80 points), global distribution of the SPI are reported in figure 3. remote outpatients (–1·63), and drug supply (–1·62). Hospital scores ranged from 26 to 115. There was variation In the country-level analysis, greater surgical in the mean SPI across subgroups: HICs (88·5 [95% CI prepared­ ness was associated with higher levels of 89·0–88·0]), MICs (81·8 [82·5–81·1]), and LICs (66·8 human develop­ment, health security, and UHC, and [64·9–68·7]); moderate (81·1 [80·4–81·8) and high (87·1 lower levels of wealth inequality (appendix p 12). [86·6–87·6) COVID-19 burden areas; public A suggested framework for assessment of the SPI and (83·0 [82·5–83·5]) and private or mixed (89·8 targeted, local systems strengthening initiatives is [88·9–90·7]) hospitals; and urban (86·1 [85·4–86·8]), reported in the appendix (p 13), and an online application For more on the live hospital rural (77·4 [74·2–80·6]), and mixed (83·7 [83·1–84·3]) to support longitudinal evaluation. SPI assessment tool see spi. surgery settings (appendix p 11). In phase 3, at the time of assessment, 1217 (74·6%) of The mean scores (out of five) for each individual indicator, 1632 hospitals had an SVR of less than 1, suggesting that presented overall and by World Bank income group are they were unable to maintain usual planned sur­gical reported in figure 4. The highest scored indicators were volume during COVID-19. Of these 625 (51·4%) electricity supply (4·38 [95% CI 4·34–4·41]), oxygen supply hospitals were from HICs, 538 (44·2%) from MICs, and (4·33 [4·29–4·36]), and perioperative drugs (4·17 54 (4·4%) from LICs (appendix pp 14–15). The mean [4·34–4·41]). The lowest scored indicators overall were ring- SVR was 79·3% (95% CI 78·1–80·4). This varied fenced critical care beds (3·11 [3·07–3·17]), remote significantly by hospital, ranging from 0·0% (doing no www.thelancet.com Vol 400 November 5, 2022 1613 Articles systems against external shocks. The SPI showed Electricity supply Oxygen supply variability at subnational and hospital levels, identifying Drug supply areas that can improve to create resilience in local Preoperative testing surgical systems. Using COVID-19 as an example, a Sterilisation 10-point increase in the SPI was associated with a Protective equipment 3·6% increase in the planned surgical volume ratio. This Managing complications Preoperative assessment relationship was robust across income settings, hospital Surgical preparedness indicator Device supply types, and COVID-19 burdens. Hospitals with private Procedure prioritisation versus public financing and in HICs were able to Timely discharge maintain a higher SVR than those in MICs or LICs, Family communication indicating the importance of hospital resourcing as a Ring-fenced theatres Patient prioritisation mediator of planned surgical throughput. Our findings Ring-fenced beds suggest that the under-resourced surgical systems, Staff redistribution identified as at risk by the Lancet Commission on global Ring-fenced teams surgery,23 will also be at greatest risk of secondary effects Hospital transfer and delayed recovery from COVID-19. Routine SPI Flexible areas Social support Overall assessment might help to identify actionable targets for Formal plan High-income countries local policy, advocacy, and investment in surgery and Remote outpatients Middle-income countries anaesthesia service strengthening that complement Ring-fenced critical care Low-income countries existing frameworks for global health security.24,25 Focused 2 3 4 5 efforts to address surgical preparedness will be essential Mean point score (overall) in addressing growing backlogs and mitigating against Figure 4: Mean ratings of hospitals across surgical preparedness indicators harm for patients awaiting surgery. Scores are a mean following ratings from 1632 participants. Indicators are ordered from highest to lowest mean The 23 surgical preparedness indicators are easy to score (out of 5) overall by indicator. measure without additional resources, with moderate ICC values, and they allow local hospital teams to identify planned surgery) to 200·0% (doing twice as many targets that are relevant to them and are actionable. planned surgeries than the pre-pandemic baseline). A There was significant variability in performance across histogram of SVR across World Bank income groups is indicators and across resource settings. For example, reported in the appendix (p 14). The proposed causal ring-fenced critical care beds was rated as being model is reported in the appendix (p 16), and figure 5 challenging in HIC, MIC, and LIC settings, suggesting a shows the SPI score against the SVR, overall and across challenge that might be hard to surmount. Conversely, key subgroups. A linear association was observed between device supply, drug supply, and remote outpatients SPI score and SVR with a ten-point total SPI score increase appointments were scored lower in lower-income associated with a 3·6% (95% CI 3·0 to 4·1; p<0·0001) settings, perhaps highlighting important areas for increase in SVR in the mixed-effects model. Hospitals in advocacy and service investment. Public hospitals and MICs (–8·37% [95% CI –8·45 to –8·29]; p<0·0001) and those in rural settings had lower SPI scores, highlighting LICs (–10·56% [–14·89 to –6·2]; p<0·0001) versus HICs vulnerable hospital types that warrant future focus.26 The were associated with a reduced SVR. Private (3·01% finding that better resourced surgical services were more [0·12 to 5·91]; p<0·0001) and mixed public and private resilient to system stress during SARS-CoV-2, with a (3·20% [1·02 to 5·37]; p=0·0002) hospitals were both more rapid recovery, aligns with other research in this associated with increased SVR versus public hospitals. No area.27 Country-level analysis showed consistency of the significant associations between hospital location (urban SPI with other measures of health system resilience, vs rural or mixed) and SVR were observed (appendix p 10). such as the Global Health Security index, and strong On subgroup analysis, association between SPI score and correlation with UHC service coverage and other SVR was observed in HICs (4·8% [4·1 to 5·5]; p<0·0001), measures of wealth equality and development. However, MICs (2·8% [2·0 to 3·7]; p<0·0001), and LICs the SPI has strong clinical use beyond these population- (3·8 [1·3 to 6·7]; p<0·0001); moderate (3·5 [2·7 to 4·2%]; level measures by allowing hospital benchmarking and p<0·0001) and high (4·1 [3·3 to 4·8]; p<0·0001) COVID-19 highlighting areas for targeted action. burden areas; public (3·6% [3·0 to 4·2]; p<0·0001) and Other indices exist to address both health system private hospitals (4·1% [3·1 to 5·2]; p<0·0001); and in preparedness and surgical capacity separately, but they do urban (4·2% [3·3 to 5·1]; p<0·0001), rural (4·9 [1·6 to 8·2]; not combine the immediate need to focus on surgery at a p=0·0046), and mixed locations (3·4 [2·7 to 4·1]; p<0·0001). subnational or hospital level and preparedness for external shocks.28,29 In a review of whole-health system preparedness Discussion indicators, no index was meaningfully associated with We have developed, measured, and validated a hospital- clinical outcomes, and no surgery-specific indices were level SPI to support strengthening of elective surgery found.11 Other frameworks exist to evaluate surgical 1614 www.thelancet.com Vol 400 November 5, 2022 Articles capacity in isolation (the PIPES checklist,12 WHO A B Situational Assessment tool,13 and Ethiopian Hospital Assessment tool30). However, these are not designed to 100 dynamically assess preparedness (ie, the response of services to external system pressure). They are also 80 80 complex, long, and not feasible for regular application. Planned SVR Our index was validated in the context of the SARS-CoV-2 pandemic, but it is likely to be generalisable beyond this 60 setting. In a consensus exercise, independent international 60 raters considered the indicators all to have high or High-income countries 40 moderate relevance across five example scenarios. Middle-income countries However, the index might not have full content validity Low-income countries 40 across every external shock recorded. For example, in the case of seasonal pressures (heatwaves or winter pressures) C D adequate temperature control in clinical areas through air 100 100 conditioning or heating might be considered an important additional indicator. In addition, the relative importance of SPI indicators might change from system stressor to 80 80 stressor and from country to country; for example, during Planned SVR the COVID-19 recovery period, staff shortages might be the primary limiting factor for delivery of planned surgery. 60 This has been compounded over time due to burnout and 60 staff sickness. Therefore, we consider the SPI to be a minimum core indicator set to underpin elective surgical Moderate COVID-19 burden 40 Public funded hospitals High COVID-19 burden Private or mixed funded hospitals system preparedness with relevance across a variety of 40 scenarios. However, the SPI requires validation and a potential need for adaptation for other external stressors E F 110 exists, highlighting an important area for ongoing research. Surgery has been neglected from planning for pandemic 90 90 recovery, despite being a core component of functioning Planned SVR health-care systems.23,31 The SPI presents a consensus response by the international community to tackle the 70 70 issue of neglect of surgery from planning. However, our <50 hospital beds 50–99 hospital beds study has limitations. First, this cross-sectional assessment 100–199 hospital beds 50 50 of preparedness does not account for hospitals at different 200–499 hospital beds Urban 500–999 hospital beds Rural stages of the readiness–response–recovery cycle.32 Second, ≥1000 hospital beds Mixed urban and rural the index does not inform the net benefit of restoring 25 50 75 100 25 50 75 100 surgery versus other hospital activities; however, surgical SPI score SPI score service preparedness is an essential component of holistic health system resilience: it strengthens other health-care Figure 5: Association between SPI scores and hospitals’ planned surgical volume ratio processes (eg, readiness to provide oxygen)33 and Association between SPI scores and hospitals’ planned surgical volume ratio overall (A) and by country income status (B), COVID-19 burden (C), hospital funding mechanism (D), number of hospital beds (E), and hospital transparent priori­­tisation will be key in competition for location (F). The planned surgical volume ratio was calculated as the ratio of each hospital’s observed planned restricted resources.34 Third, 868 (53%) of the 1632 hospitals surgical volume over a 1-month assessment period against the expected planned surgical volume based on data had only one assessor. Differences in preparedness might from the same month in 2019 (the prepandemic baseline) and expressed as a percentage. Shaded areas are exist between specialties or operating theatres that are not 95% CIs. SPI=surgical preparedness index. SVR=surgical volume ratio. reflected here, and we were unable to assess variability between subgroups of assessors in more details. Fourth, confounding due to COVID-19 pressures, we adjusted for there was some imbalance in represen­ tation between this in modelling and did a subgroup analysis in high and HICs, MICs, and LICs in both indicator development and moderate COVID-19 burden areas; no countries were the cross-sectional assessment. However, data were classified as low COVID-19 burden. Sixth, barriers and collected from a large sample of 744 (46·6%) hospitals in facilitators to implementation of the SPI framework are not MICs and LICs indicating generalisability. Fifth, data yet fully understood; we include an online assessment tool For more on COVID-19 burdens suggest that some hospitals in countries with lower to support future imple­mentation and evaluation. Seventh, at the time of our assessment see https://ourworldindata.org/ COVID-19 burden at the time of assessment (eg, Australia our surrogate measure of COVID-19 burden (OxCGRT) did coronavirus and China) had a lower SPI score, but still were able to not account for government mandates to pause planned maintain their planned surgical volume. To address surgical care, which might have led to unmeasured www.thelancet.com Vol 400 November 5, 2022 1615 Articles confounding. Eighth, we included several plau­ sible response to these stressors in minimising suffering and confoun­ ders in mixed-effects modelling support­ ed by loss of life.40,41 Although the SPI has been developed during causal relationships presented in a directed acyclic graph. the COVID-19 pandemic, it has been specifically designed However, there might be residual unmeasured to be applicable to any context of health system pressure. confounding or measure­ ment error that has been Other context-specific modifications (eg, to incorporate unaccounted for. Ninth, our primary outcome measure sustainable measures for climate resilience) might become was data driven and pragmatic, but represented a single necessary as use of the index expands into global surgical cross-sectional assessment, calculated as a relative measure practice.42 Best processes for imple­mentation of the SPI for of surgical volume. This should be considered when longitudinal assessment of a hospital’s preparedness is an applying the index to national health policy in which urgent research area for ongoing development. absolute measures of outcomes and effects might be Writing group important. Tenth, interpretation of composite measures, James C Glasbey, Tom EF Abbott, Adesoji Ademuyiwa, Adewale Adisa, such as the SPI, is challenging, and we have only explored Ehab AlAmeer, Sattar Alshryda, Alexis P Arnaud, Brittany Bankhead-Kendall, MK Abou Chaar, Daoud Chaudhry, the relationship between the total index score and SVR. We Ainhoa Costas-Chavarri, Miguel F Cunha, Justine I Davies, Anant Desai, are unable to judge the relative importance of individual Muhammed Elhadi, Marco Fiore, J Edward Fitzgerald, indicators, which might vary across specialties, hospitals, Maria Fourtounas, Alex James Fowler, Kay Futaba, Gaetano Gallo, and resource contexts. Future exploration of the scaling Dhruva Ghosh, Rohan R Gujjuri, Rebecca Hamilton, Parvez Haque, Ewen M Harrison, Peter Hutchinson, Gabriella Hyman, Arda Isik, and measurement properties of the index and differential Umesh Jayarajah, Haytham MA Kaafarani, Bryar Kadir, Ismail Lawani, functioning of the indicators is required during future Hans Lederhuber, Elizabeth Li, Markus W Löffler, development. Future iterations of the SPI could consider Maria Aguilera Lorena, Harvinder Mann, Janet Martin, Dennis Mazingi, normalising or transforming the scale to make its Craig D McClain, Kenneth A McLean, John G Meara, Antonio Ramos-De La Medina, Mengistu Mengesha, Ana Minaya, minimum and maximum values more intuitive (eg, 0–100), María Marta Modolo, Rachel Moore, Dion Morton, Dmitri Nepogodiev, but this should be balanced with clinical use and Faustin Ntirenganya, Francesco Pata, Rupert Pearse, Maria Picciochi, interpretability of the output for local assessors. Eleventh, Thomas Pinkney, Peter Pockney, Gabrielle H van Ramshorst, unplanned surgery is an important component of surgical Toby Richards, April Camilla Roslani, Sohei Satoi, Raza Sayyed, Richard Shaw, Joana Filipa Ferreira Simões, Neil Smart, Richard Sulliva, systems, especially in LMICs in which a larger proportion Malin Sund, Sudha Sundar, Stephen Tabiri, Elliott H Taylor, of patients present to care services requiring emergency or Mary L Venn, Dakshitha Wickramasinghe, Naomi Wright, immediate care.35 The SPI has been developed and validated Sebastian Bernardo Shu Yip, and Aneel Bhangu. in planned surgery only and is not designed to be applied Contributors in emergency systems. Finally, we have not considered the The writing group and the statistical analysis group (JCG, KAM, OO, BK, EH, AAB) contributed to writing, data interpretation, and critical revision safety and efficacy of the surgeries. There are likely to be of the manuscript. The writing group, operations committee, and differences across resource settings that might be dissemination committee contributed to study conception, protocol exacerbated by the whole-health system effect of COVID-19 development, study delivery, and management. The collaborators and should be considered in future work.3,35 contributed to data collection and study governance across included sites. All members of the writing group had full access to the data in the study. As the recovery following the COVID-19 pandemic JCG, KAM, OO, BK, EH, and AAB verified the underlying data in the continues to gather pace there is a need for urgent and study. JCG, AAB, and the writing committee had final responsibility for regular (eg, annual) hospital self-assessment using the SPI. the decision to submit for publication. Detailed role descriptions of all When possible, this assessment should be integrated with contributing collaborating authors are shown in the appendix (pp 28–54). existing quality and safety programmes and national Declaration of interests surgical, obstetric, and anaesthesia plan­ning. SPI imple­ RP has received research grants or consultancy fees or both from Edwards Lifesciences, Intersurgical, and GlaxoSmithKline. JM has consulted for mentation alongside national surgical, obstetric, and WHO on projects related to perioperative preparedness. TA has received anaesthesia planning will add resilience to national capacity consultancy fees from MSD unrelated to this work. All other members of building that is aleady under­way. Improving preparedness the writing group declare no competing interests. is likely to strengthen planned surgical services against Data sharing future external shocks and support upscaling of surgery to Anonymised data are available upon request from the writing group, address growing demands. Therefore, the SPI supports a and successful completion of a data sharing agreement through an Application Programming Interface linked to the REDCap data server major priority area for WHO for ongoing progress towards hosted at Birmingham Clinical Trials Unit, University of Birmingham, Sustainable Development Goal 3: Health and Wellbeing.36–38 Birmingham, UK. Summary data and a self-assessment tool are available COVID-19 is just one form of external shock that puts online. additional pressure on planned surgical care pathways. Acknowledgments Other epidemics, such as influenzas and Ebola virus, have This work was supported by a National Institute for Health Research had significant effects on surgical services over the past (NIHR) Global Health Research Unit Grant (NIHR 16.136.79), the Association of Coloproctology of Great Britain and Ireland, Bowel decade.39 Natural phenomena associated with climate Research UK, British Association of Surgical Oncology, British change, stresses from geopolitical insta­bility, and conflict Gynaecological Cancer Society, and Medtronic. JG was supported by an have also already had a substantial effect and continue NIHR Doctoral Research Fellowship (NIHR300175). The views expressed are those of the authors and not necessarily those of the National Health to pose a substantial future threat to surgical system Service, the NIHR, or the UK Department of Health and Social Care. functioning. 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