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Acta Anaesthesiologica Taiwanica 54 (2016) 41e43

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Editorial View

Measuring and reducing perioperative anesthetic-related mortality:

View from East Asia

with the problem most seriously affecting the peoples of impover-

anesthesia; ished regions in South Asia and sub-Saharan Africa.6 Where surgi-
editorial; cal and anesthesia services are accessible, researchers have
Far East; engaged in efforts to quantify their safety and efficacy, but firm con-
mortality; clusions remain elusive at best.
A recent major review and meta-analysis on anesthetic-related
mortality and anesthetic-related cardiac arrest found a significant
reduction over time in anesthetic-related perioperative cardiac ar-
rest in more highly developed countries, when comparing data
from the pre-1990s to that from the years 1990e2010.7
Another study found reduced perioperative mortality over the
decades, where deaths were deemed to have been caused solely
Florence Nightingale, the social reformer and founder of modern by anesthesia or where anesthesia was deemed a contributing
nursing, pioneered the application of medical statistics to improve factor. The study compared pre-1970s data with that from
patient outcomes in hospitals. She took measurements in British 1970se1980s, 1990se2000s, and 2000se2010. When analyzed
field hospitals during the Crimean War and used calculations to separately by human development index level groups, the
determine that more soldiers died from infectious diseases exacer- decline was found to hold true only for more highly developed
bated by unsanitary conditions than died from battle injuries. Night- countries.8
ingale invented compelling data visualization formats and used Only one nationwide investigation of anesthesia-related mortal-
them to convince Queen Victoria to order systematic improvements ity in Taiwan has been published since the establishment of the Na-
in military and later civilian hospital management standards and tional Health Insurance Plan in 1995. It found an average
practices. Ultimately, Nightingale's work resulted in modernizing anesthetic-caused mortality rate of 11.9/100,000 cases over the
hospital policies and procedures that continue to save lives and years 1995e1998 and 2002e2008 (sufficient data were not
improve healthcare outcomes globally to the present day, helping collected in the intervening years), which compares poorly with
to transform the hospital, in the minds of many around the world, other developed countries cited in the study.9 Table 1 summarizes
into a place to go for healing rather than a place to go to die.1,2 that data.
But how reliably, in this present day, do we capture medical and The findings suggest that Taiwan suffers an anesthetic-related
public health information? How effectively is it leveraged to moti- mortality rate ten times higher or more than those reported for
vate advances in policy development and outcomes? We concern other developed countries. We pause today to reflect on this infor-
ourselves with such questions particularly with respect to perioper- mation and its implications, to consider how well we can assume
ative anesthesia, especially in East Asia, and precisely on quantifying that the research, in Taiwan or elsewhere, has been able to capture
adverse events, risk management, and outcome improvement. We reality and then we turn our gaze. We look backward in time, from
embark by reviewing some fundamentals on the impact of surgery the publication of the Taiwanese study 6 years ago, to the present
and anesthesia on public health around the world. day, and onward into the future, and we look outward, to other
While opinion on the relative value of surgery has remained countries in East Asia: China (including Hong Kong), Mongolia,
controversial from its inception, a developing consensus tenders Japan, North Korea, and South Korea; to other neighbors in South-
it as impacting vitally and positively on global public health.3 Ex- east Asia and the Asian Pacific region. Finally, we anticipate
perts are asserting that operative interventions are a boon as a fac- whether and how we might liaise between Taiwan and other coun-
tor influencing disability-adjusted life years and in terms of more tries in East Asia, where we may enjoy cultural and language con-
fundamental constructs such as economic and psychological well- nections and possess relevant knowledge about clinical and
being; further, they assert that this value has been underesti- bureaucratic practices, and researchers elsewhere who specialize
mated.4,5 However, it is also recognized that 5 billion people around in international assessment of anesthetic and surgical risk and
the world lack access to necessary surgical and anesthesia care, safety.

1875-4597/Copyright © 2016, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
42 J.L. Reynolds et al.

Table 1
Reported estimates of anesthesia-related mortality in Taiwan and key
developed countries.

Deaths/100,000 anesthetic cases

USA 0.5e1 (1989, 2005)

UK 0.556 (1987)
Japan 1 (2002)
Taiwan 11.9 (2008)

Note. From “Survey of 11-year anesthesia-related mortality and analysis

of its associated factors in Taiwan,” by T.-C. Liu et al., 2010, Acta Anaes-
thesiology Taiwanica, 48, p. 56e61. Copyright 2010, Elsevier. Adapted
with permission.

We know that an additional dataset exists for nationwide

anesthetic-related mortality in Taiwan for the years subsequent
to those analyzed by Liu et al,9 and we are encouraging the devel-
Figure 1. Crimean War: Florence Nightingale going around the wards at Scutari Hos-
opment of a project to analyze and report on that data. We also pital. Image title: M0003645. Wood engraving. Note. From 1855 Illustrated London
welcome East Asian and other Asia-Pacific area researchers and News Published: 24 February 1855. Wellcome Library, London, UK. Wellcome Images
policymakers to contact the corresponding author and exchange http://wellcomeimages.org. Copyrighted work available under Creative Commons Attri-
with us information on anesthetic-related mortality and safety bution only license CC BY 4.0 http://creativecommons.org/licenses/by/4.0/. Reprinted
with permission.
improvement, and to collaborate with us on advancing our knowl-
edge and practice in the future.
standardized, therefore reliable, and allow for valid international
Obtaining clear, valid, and useful data on the safety of anesthesia
is a challenge. An entry point for the introduction of misinforma-
Florence Nightingale lives on in the popular imagination, partic-
tion lies at the place and time where adverse events occur and
ularly in the West, symbolized as “the lady with the lamp”
are labelled (or mislabeled), categorized (or miscategorized),
(Figure 1) making hospital rounds and tending to the sick.13 Let
recorded (or misrecorded), reported (or misreported), and made
us raise our own lights high and use the power of transparent
accessible (or not). Incorrect, incomplete, or misleading informa-
and reliable information to illuminate a better way forward for sur-
tion can be communicated, missed, or lost, due to conscious or un-
gical teams, policymakers, and for the public, around the Far East
conscious bias, to medicolegal concerns, to desires to cast people or
and throughout the global healthcare enterprise.
groups in this or that light, to exaggerate a problem in order to gain
attention or funding, due to corruption, or due to lack of a well-
developed statistical recording and reporting infrastructure. Conflicts of interest
A cautionary story recently appeared in the form of a study pub-
lished in the BMJ which stirred international headlines: The authors All authors declare no conflicts of interest.
noted that death certificate reporting procedures in the United
States obscured medical error as a cause of death. Using more care-
ful methods, they estimated that deaths caused by medical error References
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Anesthetic-related mortality 43

James L. Reynoldsy Yang Chen-Hsien

Acta Anaesthesiologica Taiwanica, Taipei, Taiwan Department of Anesthesiology, Taipei Tzu Chi Hospital, New Taipei
City, Taiwan
Wei-Zen Sun*,y
Acta Anaesthesiologica Taiwanica, Taipei, Taiwan *
Corresponding author. Department of Anesthesiology, College of
Department of Anesthesiology, College of Medicine, National Taiwan Medicine, National Taiwan University, 7 Chungshan South Road,
University, Taipei, Taiwan 10002 Taipei, Taiwan.
E-mail address: wzsun@ntu.edu.tw (W.-Z. Sun).

Globalization Editor (J.L.R.) and Editor-in-Chief (W.-Z.S.), Acta Anaesthesiologica