Disparate outcomes of global emergency surgery: A matched comparison of patients in developed and under-developed healthcare settings

Adil A. Shah, Aga Khan University
Chery K. Zogg, Yale University, School of Medicine, USA
Abdul Rehman Alvi, Aga Khan University
Asad Lafif, Johns Hopkins University School of Medicine, USA
Hasnain Zafar, Aga Khan University
Amarah Shakoor, West Virginia University, USA
Nabil Wasif, Yale University, School of Medicine, USA
Alyssa B. Chapita, Mayo Clinic, USA
Robert Riviello, Brigham & Women's Hospital, USA
Awais Ashfaq, Oregon Health Sciences University, USA
Mallory Williams, Howard University Hospital and College of Medicine, USA
Edward E. Cornwell, Howard University Hospital and College of Medicine, USA
Adil H. Haider, Brigham & Women's Hospital, USA


Introduction: Access to surgical care is an essential element of health-systems strengthening. This study aims to compare two diverse healthcare settings in South Asia and the United States (US).
Methods: Patients at the Aga Khan University Hospital (AKUH), Pakistan were matched to patients captured in the US Nationwide Inpatient Sample (US-NIS) from 2009 to 2011. Risk-adjusted differences in mortality, major morbidity, and LOS were compared using logistic and generalized-linear (family gamma, link log) models after coarsened-exact matching.
Results: A total of 2,244,486 patients (n = 4867 AKUH; n = 2,239,619 US-NIS) were included. Of those in the US-NIS, 990,963 (42.5%) were treated at urban-teaching hospitals, 332,568 (14.3%) in rural locations. Risk-adjusted odds of reported mortality were higher for Pakistani patients (OR[95%CI]: 3.80[2.68-5.37]), while odds of reported complications were lower (OR[95%CI]: 0.56[0.48-0.65]). No differences were observed in LOS. The difference in outcomes was less pronounced when comparing Pakistani patients to American rural patients.
Conclusion: These results demonstrate significant reported morbidity, mortality differences between healthcare systems. Comparative assessments such as this will inform global health policy development and support