1 Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study Bruce M Biccard, Thandinkosi E Madiba, Hyla-Louise Kluyts, Dolly M Munlemvo, Farai Madzimbamuto, Apollo Basenero, Christina S Gordon, Coulibaly Youssouf, Sylvia Rakotoarison, Veekash Gobin, Ahmadou L Samateh, Chaibou M Sani, Akinyinka O Omigbodun, Simbo D Amanor-Boadu, Janat Tumukunde, Tonya M Esterhuizen, Yannick Le Manach, Patrice Forget, Abdulaziz M Elkhogia, Ryad M Mehyaoui, Eugene Zoumeno, Gabriel Ndayisaba, Henry Ndasi, Andrew Ndonga, Zipporah Ngumi, Ushmah Patel, Daniel Zemenfes Ashebir, Akwasi Antwi-Kusi, Bernard Mbwele, Hamza Doles Sama, Mahmoud Elfiky, Maher Fawzy, Rupert M Pearse, on behalf of the African Surgical Outcomes Study (ASOS) investigators. Supplementary material
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Perioperative patient outcomes in the African Surgical Outcomes
Study: a 7-day prospective observational cohort study
Bruce M Biccard, Thandinkosi E Madiba, Hyla-Louise Kluyts, Dolly M Munlemvo, Farai Madzimbamuto,
Apollo Basenero, Christina S Gordon, Coulibaly Youssouf, Sylvia Rakotoarison, Veekash Gobin, Ahmadou L
Samateh, Chaibou M Sani, Akinyinka O Omigbodun, Simbo D Amanor-Boadu, Janat Tumukunde, Tonya M
Esterhuizen, Yannick Le Manach, Patrice Forget, Abdulaziz M Elkhogia, Ryad M Mehyaoui, Eugene Zoumeno,
Gabriel Ndayisaba, Henry Ndasi, Andrew Ndonga, Zipporah Ngumi, Ushmah Patel, Daniel Zemenfes Ashebir,
Akwasi Antwi-Kusi, Bernard Mbwele, Hamza Doles Sama, Mahmoud Elfiky, Maher Fawzy, Rupert M Pearse,
on behalf of the African Surgical Outcomes Study (ASOS) investigators.
Supplementary material
2
Appendix. Members of the African Surgical Outcomes Study (ASOS) group
ASOS Writing Committee. Bruce M Biccard, Thandinkosi E Madiba, Hyla-Louise Kluyts, Dolly M
Munlemvo, Farai Madzimbamuto, Apollo Basenero, Christina S Gordon, Coulibaly Youssouf, Sylvia
Rakotoarison, Veekash Gobin, Ahmadou L Samateh, Chaibou M Sani, Akinyinka O Omigbodun, Simbo D
Amanor-Boadu, Janat Tumukunde, Tonya M Esterhuizen, Yannick Le Manach, Patrice Forget, Abdulaziz M
Elkhogia, Ryad M Mehyaoui, Eugene Zoumeno, Gabriel Ndayisaba, Henry Ndasi, Andrew Ndonga, Zipporah
Ngumi, Ushmah Patel, Daniel Zemenfes Ashebir, Akwasi Antwi-Kusi, Bernard Mbwele, Hamza Doles Sama,
Mahmoud Elfiky, Maher Fawzy, Rupert M Pearse, on behalf of the African Surgical Outcomes Study (ASOS)
investigators.
ASOS Steering Committee. B M Biccard, T E Madiba, R M Pearse, on behalf of the African Surgical
Outcomes Study (ASOS) investigators.
ASOS investigators
Algeria: National Leader: R Mehyaoui
Établissement hospitalier spécialisé en chirurgie cardio-vasculaire Dr M.A Maouche ex CNMS Alger:
R Mehyaoui*, H Kanoun, L Chelbi, A Alghazali, A Metali
Centre Hospitalo Universitaire Issad Hassani, Beni-messous Alger:
R Mokretar*, F Ouanes
Centre Hospitalo Universitaire Mustapha Pacha: Alger
Z Imessaoudene, Khalfallah
Centre Hospitalo Universitaire Salim Zemirli Alger:
M Guenane*, S Sadat
Etablissement Hospitalo Universitaire d'Oran:
B Gadi*, D Benali, N Chikh
Centre Hospitalo Universitaire Hassani Abdelkader, Sidi belabess:
M Laksari *
Etablissement Public Hospitalier Mostaganem:
F Boufas*
Benin. National Leader: E Zoumenou
Abomey-Calavi Hospital:
Joseph Akodjenou.
Centre Hospitalier Départemental de l'Atacora:
Oswald Gbéhadé
Centre National Hospitalier Universitaire Hubert Koutoukou MAGA:
Serge Mewanou
Centre Hospitalier Départemental de Mono/Couffo:
Edith Djessouho
Centre Hospitalier Départemental de l’Ouémé-Plateau:
Rene Ahossi.
Centre Hospitalier Départemental Zou:
Hippolyte Abadagan
Centre Hospitalier Départemental-Donga:
3
Ambroise Guegni
Hôpital de zone Sounon Séro de Nikki:
Guy Assoum
Hôpital de la Mère et de l’Enfant Lagune de Cotonou:
Lidwine Zomahoun.
Hôpital de zone Aplahoue:
Kpatinvo Oscar.
Hôpital de zone de Boko:
Rosalie Souhe.
Hôpital de zone de Kandi:
Hubert Dewanou
Hôpital de zone Menontin:
Rodrigue Nascimento
Hôpital de zone Djougou (ordre de malte):
Marius Guezo
Hôpital de zone Malanville Karimama:
Sèhivè Valéry Adjignon.
Hôpital de zone sanitaire Kouandé:
Felix Anani
Hôpital de zone d'Adjohoun:
Thomas Allaye.
Hôpital d'Instruction des Armées, Parakou:
Charles Tchegnonsi.
Hôpital d'Instruction des Armées de Cotonou:
Lionelle Fanou.
Hôpital de zone Banikoara:
Rodrigue Hadecon
Hôpital de zone de Ouidah:
Anatole Atomabe
University Departmental Hospital Borgou-Alibori, Parakou:
Blaise Tchaou
Burundi. National Leader: G Ndayisaba
Bururi Hôpital:
E Horugavye.
Clinique Prince Louis Rwagasore:
L Habimana.
Hôpital Prince Regent Charles:
T Nkesha.
Ngozi Hospital:
C Manirimbere.
4
Kamenge Military Hospital:
R Ndikumana.
King Khaled Hospital of Bujumbura (CHUK):
JC Niyondiko.
Kirundo Hospital:
P Minani.
Regional Hospital of Gitega:
F Bigirimana
Ruyigi Hospital:
JdD Uwiteyimbabazi.
Cameroon. National Leader: H Ndasi
Banso Baptist Hospital:
MA Degaulle.
Baptist Hospital Mutengene:
ND Konwuoh, G Ekwen, H Ndasi
Mbingo Baptist Hospital:
M Kaggya, N Constance, N Samuel, S Akanyun, T Freeman.
Mboppi Baptist Hospital, Douala:
L Royas
Regional Hospital, Limbe:
M Tchoupa*, WAG Simo, D Ngouane
Saint Elizabeth Catholic General Hospital, Shisong:
BN Tanjong
Congo. National Leaders: AP Bouya, PDG Mawandza
Clinique Louise Michel, Pointe Noire:
MD Sedekounou, F Carlos, PD Gallou, A Prosper.
Democratic Republic of Congo. National Leader: Munlemvo DM
Biamba Marie Mutombo Hospital:
Athombo JS*
Centre de Sante Mater Dei:
Sanduku DK*, Mampangula Y
Centre Hospitalier et de Diagnostic Medical:
Munlemvo DM *, Nziene VN
Centre Hospitalier Grâce à Dieu :
Odia PK*
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Centre Hospitalier, Monkole:
Mbombo WD*, Mbuyi WMS
Centre Medico-Chirurgical de Pigeon:
Mukuna PM*
Centre Mère et Enfant de Barumbu:
Boloko PM*, Mvwama NM, Ikuku JJN
Clinique Bondeko:
Mwamba JD*
Clinique Ngaliema:
Manzombi JK, Mvwala KR*
Les cliniques universitaires de Kinshasa:
Ilunga JP.M, Mukenga MM, Mawisa T, Kilembe AM*, Bikuelo CJ , Mwepu IM.
El Rapha Clinic:
Mwepu IM*, Mwaluka CN, HN Sarah
Masi-Manimba Hospital:
Kukembila AM*
Hôpital de L'amitie Sino-Congolaise, Njili:
Diyoyo MP*, Ngalala AM, Kabango R.
Hôpital Dipumba:
Kongolo M*, Mbayabu M.
Hôpital Général de Référence de N'djili:
Namegabe ES*, Bula Bula IM.
Hôpital Général de Référence : Institut Médical Evangélique/kimpese:
Denominators vary with the completeness of the data. DRC Democratic Republic of the Congo; CI confidence interval
*The country specific crude mortality rates and complication rates are particularly unstable as the study was not powered to accurately determine the country specific
mortality and complication rates. A country sample size of at least 3000 patients would be required for a relatively stable estimate of mortality and 1400 patients for a
relatively stable estimate of postoperative complications.
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Supplementary Table 2. Multivariable model of in-hospital mortality per-protocol analysis. Odds ratio (OR) 95% confidence interval (CI) P-value
Intercept 0·002 0·000-0·046 <0·0001
Patient factors
Age spline 1 0·990 0·869-1·129 0·89
Age spline 2 1·125 0·133-9·503 0·91
Age spline 3 0·985 0·005-185·709 1·00
Age spline 4 0·773 0·017-34·282 0·89
ASA 1 Reference
ASA 2 1·438 0·910-2·273 0·12
ASA 3 3·627 2·269-5·799 <0·0001
ASA 4 or 5 10·153 5·986-17·222 <0·0001
Surgical factors
Elective surgery Reference
Urgent surgery 3·296 2·155-5·041 <0·0001
Emergent surgery 4·397 2·864-6·752 <0·0001
Minor surgery Reference
Intermediate surgery 1·699 1·038-2·782 0·04
Major surgery 2·595 1·536-4·385 0·0004
Cardiothoracic and vascular surgery 1·773 0·983-3·197 0·06
Ear nose and throat 2·279 1·062-4·892 0·03
Gastrointestinal and hepatobiliary 2·599 1·572-4·296 0·0002
Gynaecology and obstetrics 0·329 0·170-0·634 0·0009
Neurosurgery 2·794 1·378-5·663 0·0044
Other 1·133 0·508-2·528 0·76
Plastics and breast 1·576 0·773-3·212 0·21
Urology 1·684 0·803-3·535 0·17
Countries
A 2·006 1·029-3·913 0·04
B 1·080 0·301-3·875 0·91
3
C 0·387 0·090-1·665 0·20
D 1·892 0·952-3·761 0·07
E 1·062 0·491-2·295 0·88
F 2·525 1·292-4·933 0·0067
G 0·407 0·094-1·765 0·23
H 0·667 0·307-1·446 0·31
I 0·821 0·361-1·867 0·64
J 0·614 0·270-1·397 0·25
ASA American Society of Anesthesiologists; A-J anonymised countries
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Supplementary Table 3. Comparison between the elective surgery patients of the African Surgical Outcomes Study (per-protocol,
representative sample) and the International Surgical Outcomes Study
ASOS (n=3868) ISOS (n=44814)
Risk factors
Age 44·6 (17·0) 55·3 (17·1)
ASA 1 1737 (44·9) 11 227 (25·1)
Minor surgery 1140 (29·5) 672 (8·0)
Outcomes
Mortality 42 (1·1) 207 (0·5)
Complications 468 (12·1) 7508 (16·8)
Mortality following complications 26/468 (5·6) 207/7508 (2·8)
Data are mean (SD) or n (proportion). ASOS= African Surgical Outcomes Study. ISOS= International Surgical Outcomes Study. ASA=American Society of
Anesthesiologists.
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Supplementary Table 4. Hospital facilities and resources data (n=166) of the per-protocol representative country sample analysis. Data
presented as n (%) or median [25th/75th centile]
Hospital facilities and resources n (%) or median [25th/75th centile]
Population served by the hospital 881 500 [200 000-2000 000]
University affiliated hospital 70/162 (43·2)
Government funding/ private funding/ government and private funding 129 (77·7) / 26 (15·7) / 11 (6·6)
Type of hospital
Primary-level hospital 36 (21·7)
Secondary-level hospital 59 (35·5)
Tertiary-level hospital 71 (42·3)
Hospital resources
Hospital beds 300 [135-525]
Operating rooms 4 [2-7]
Critical care beds allowing invasive ventilation 3 [0-6]
Full time specialist surgeons 3 [1-7]
Full time specialist anaesthesiologists 1 [1-5]
Full time specialist obstetricians 2 [0-5]
Combined number of specialist surgeons, anaesthesiologists and obstetricians 7 [2-16]
Combined number of specialist surgeons, anaesthesiologists and obstetricians/100,000 population 0·7 [0·2-1·9]
6
Supplementary Table 5. Description of the per-protocol representative sample of the African Surgical Outcomes Study (ASOS) patient
Data are mean (SD), median (25th/75th percentile) or n (proportion). Denominators vary with the completeness of the data. Odds ratios were constructed for in-hospital
complications and mortality with univariate binary logistic regression analysis. The denominator for each group is shown. CI= confidence interval. ASA=American Society
Critical care admission to treat complications 91/467 (19·5) 50/91* (54·9) 14/376† (3·7)
Death following a postoperative complication 26/467 (5·6) 8/91* (8·8) 18/376† (4·8)
Denominators vary with the completeness of the data. *total number admitted to critical care immediately following surgery; †total number not admitted to critical care
immediately after surgery
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Supplementary Table 7. Postoperative complications (per-protocol, representative sample analysis) in the African Surgical Outcomes
Denominators vary with the completeness of the data. CI confidence interval; IQR interquartile range
13
Supplementary Table 11. Multivariable model of in-hospital mortality using a per-protocol analysis of DCP3 hospital category
compliant data.
Odds ratio (OR) 95% confidence interval (CI) P-value
Intercept 0·002 0·000-0·049 0·0001
Patient factors
Age spline 1 0·988 0·864-1·130 0·86
Age spline 2 1·111 0·125-9·900 0·93
Age spline 3 1·062 0·005-228·722 0·98
Age spline 4 0·702 0·014-34·248 0·86
ASA 1 Reference
ASA 2 1·529 0·955-2·447 0·08
ASA 3 3·690 2·277-5·981 <0·0001
ASA 4 or 5 10·121 5·872-17·446 <0·0001
Surgical factors
Elective surgery Reference
Urgent surgery 3·512 2·278-5·416 <0·0001
Emergent surgery 4·638 2·992-7·191 <0·0001
Minor surgery Reference
Intermediate surgery 1·620 0·987-2·660 0·06
Major surgery 2·444 1·441-4·146 0·0009
Cardiothoracic and vascular surgery 1·833 1·011-3·324 0·05
Ear nose and throat 2·381 1·103-5·137 0·03
Gastrointestinal and hepatobiliary 2·686 1·609-4·482 0·0002
Gynaecology and obstetrics 0·337 0·172-0·660 0·0015
Neurosurgery 3·028 1·481-6·191 0·0024
Other 1·158 0·517-2·593 0·72
Plastics and breast 1·377 0·649-2·921 0·41
Urology 1·771 0·839-3·738 0·13
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Countries
A 2·025 1·036-3·960 0·04
B 1·098 0·305-3·962 0·89
C 0·190 0·025-1·433 0·11
D 1·903 0·955-3·791 0·07
E 1·060 0·489-2·295 0·88
F 2·523 1·288-4·942 0·0070
G N/A
H 0·682 0·314-1·483 0·33
I 0·831 0·365-1·893 0·66
J 0·623 0·273-1·419 0·26
DCP3 Disease Control Priorities in Developing Countries classification; ASA American Society of Anesthesiologists; A-J anonymised countries; N/A not applicable as no
outcome reported
15
Supplementary Table 12. Multivariable logistic regression with multiple imputation for missing data
Main analysis odds ratio without
imputation for missing data
Minimum odds ratio obtained with multiple
imputation for missing data
Maximum odds ratio obtained with multiple
imputation for missing data
Intercept 0·002 0·002 0·002
Patient factors
Age spline 1 0·990 0·990 0·991
Age spline 2 1·125 1·114 1·141
Age spline 3 0·985 0·951 1·008
Age spline 4 0·773 0·763 0·795
ASA 1 Reference Reference Reference
ASA 2 1·438 1·422 1·438
ASA 3 3·627 3·584 3·621
ASA 4 or 5 10·153 10·061 10·158
Surgical factors
Elective surgery Reference Reference Reference
Urgent surgery 3·296 3·289 3·306
Emergent surgery 4·397 4·379 4·403
Minor surgery Reference Reference Reference
Intermediate surgery 1·699 1·696 1·704
Major surgery 2·595 2·591 2·606
Cardiothoracic and
vascular surgery 1·773 1·782 1·791
Ear nose and throat 2·279 2·290 2·298
Gastrointestinal and
hepatobiliary 2·599 2·607 2·619
Gynaecology and
obstetrics 0·329 0·329 0·331
Neurosurgery 2·794 2·803 2·819
Other 1·133 1·134 1·150
Plastics and breast 1·576 1·579 1·588
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Urology 1·684 1·673 1·697
Countries
A 2·006 1·993 2·018
B 1·080 1·080 1·085
C 0·387 0·384 0·387
D 1·892 1·855 1·892
E 1·062 1·063 1·065
F 2·525 2·525 2·530
G 0·407 0·407 0·408
H 0·667 0·666 0·668
I 0·821 0·809 0·822
J 0·614 0·611 0·615
ASA American Society of Anesthesiologists; A-J anonymised countries; N/A not applicable as no outcome reported
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Supplementary Table 13. Multivariable model of in-hospital mortality per-protocol analysis of DCP3 hospital category compliant data,
with DCP3 hospital categories forced into multivariable analysis.
Odds ratio (OR) 95% confidence interval (CI) P-value
Intercept 0·001 0·000-0·026 <0·0001
Patient factors
Age spline 1 0·984 0·861-1·126 0·82
Age spline 2 1·182 0·132-10·582 0·88
Age spline 3 0·923 0·004-200·849 0·98
Age spline 4 0·768 0·016-37·733 0·89
ASA 1 Reference
ASA 2 1·521 0·950-2·435 0·08
ASA 3 3·598 2·220-5·832 <0·0001
ASA 4 or 5 10·205 5·913-17·614 <0·0001
Surgical factors
Elective surgery Reference
Urgent surgery 3·568 2·314-5·500 <0·0001
Emergent surgery 4·779 3·078-7·420 <0·0001
Minor surgery Reference
Intermediate surgery 1·599 0·973-2·626 0·06
Major surgery 2·373 1·398-4·029 0·0014
Cardiothoracic and vascular surgery 1·752 0·964-3·185 0·07
Ear nose and throat 2·192 1·013-4·746 0·05
Gastrointestinal and hepatobiliary 2·693 1·612-4·500 0·0002
Gynaecology and obstetrics 0·346 0·176-0·681 0·0021
DCP3 Disease Control Priorities in Developing Countries classification; ASA American Society of Anesthesiologists; A-J anonymised countries; N/A not applicable as no
outcome reported
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Supplementary Table 14. Multivariable model of in-hospital mortality per-protocol analysis and DCP3 hospital category compliant,
with university affiliation forced into multivariable analysis.
Odds ratio (OR) 95% confidence interval (CI) P-value
Intercept 0·004 0·000-0·101 0·0008
Patient factors
Age spline 1 0·973 0·850-1·113 0·69
Age spline 2 1·495 0·164-13·597 0·72
Age spline 3 0·487 0·002-110·182 0·80
Age spline 4 1·298 0·026-65·569 0·90
ASA 1 Reference
ASA 2 1·496 0·931-2·402 0·10
ASA 3 3·585 2·201-5·838 <0·0001
ASA 4 or 5 9·702 5·594-16·825 <0·0001
Surgical factors
Elective surgery Reference
Urgent surgery 3·545 2·292-5·481 <0·0001
Emergent surgery 4·594 2·942-7·173 <0·0001
Minor surgery Reference
Intermediate surgery 1·613 0·981-2·650 0·06
Major surgery 2·440 1·435-4·150 0·0010
Cardiothoracic and vascular surgery 1·919 1·050-3·506 0·03
Ear nose and throat 2·430 1·118-5·280 0·03
Gastrointestinal and hepatobiliary 2·756 1·638-4·639 0·0001
Gynaecology and obstetrics 0·314 0·157-0·630 0·0011
Neurosurgery 3·159 1·533-6·508 0·0018
Other 1·188 0·529-2·669 0·68
Plastics and breast 1·459 0·684-3·112 0·33
Urology 1·872 0·883-3·967 0·10
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Countries
A 2·257 1·117-4·562 0·0234
B 1·132 0·312-4·113 0·85
C 0·184 0·024-1·392 0·10
D 2·037 1·006-4·123 0·0481
E 1·303 0·546-3·111 0·55
F 2·520 1·286-4·941 0·0071
G N/A
H 0·434 0·150-1·255 0·12
I 0·865 0·379-1·975 0·73
J 0·693 0·299-1·608 0·39
University-affiliation 0·791 0·499-1·255 0·32
DCP3 Disease Control Priorities in Developing Countries; ASA American Society of Anesthesiologists; A-J anonymised countries; N/A not applicable as no outcome
reported
21
Supplementary Figure 1. Per-protocol calibration plot for the in-hospital mortality multivariable model
22
Supplementary Figure 2. Per-protocol sample analysis of surgical mortality following elective surgery in high-income, low-middle income, and African countries
ISOS International Surgical Outcomes Study, ASOS African Surgical Outcomes Study, HIC high income countries, LMIC low-middle income countries
0%
1%
2%
3%
4%
5%
6%
All-cause postoperative mortality Mortality following postoperative complications
HIC ISOS LMIC ISOS ASOS
23
Supplementary Figure 3. African regional participation of countries in the African Surgical Outcomes Study
Regions include central, eastern, northern, southern, western Africa, and Indian Ocean Islands
1
Supplementary material: Patient outcomes definition guide for the African
Surgical Outcomes Study (ASOS)
Table of Contents Definitions of anaesthetic complications ............................................................................................ 2