J. S. Ng-Kamstra1,2, S. Fu1, A. J. Dare1, M. M. Hsiao1,2, P. Rodriguez1, J. Patra1, N. Correa1, P. Jha1 1University of Toronto,Centre For Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital,Toronto, Ontario, Canada 2University of Toronto,Department Of Surgery,Toronto, Ontario, Canada
Introduction: Acute abdominal conditions, including appendicitis, peptic ulcer disease, and incarcerated hernias are associated with high mortality in the absence of timely surgical care. In India, limited country-specific data exists to quantify the burden and distribution of deaths from acute abdomen (DAA) and to guide the development of surgical services. In this study, we describe the spatial and socioeconomic distributions of DAA and quantify potential access to surgical facilities in relation to such deaths.
Methods: Data on DAA throughout India in 2001-2003 were obtained from the Million Death Study (MDS), a nationally representative, population-based mortality survey of 1.1 million Indian households using verbal autopsy methodology. We created a national spatial database of abdominal mortality by integrating data from the MDS with surgical provider and facility data from the District-Level Household and Facility Survey and household socioeconomic data from the Special Fertility and Mortality Survey. The spatial distribution of DAA was calculated using ordinary kriging, and cluster analysis was performed using the Getis-Ord Gi* statistic. This provided ‘hot’ and ‘cold’ clusters of DAA at the postal (PIN) code level. Spatial metrics of access and socioeconomic indicators were then evaluated to compare hot and cold spots of DAA.
Results: 923 of 85388 study deaths in those aged 0-69 years were identified as DAA, representing an estimated 1.1% proportional mortality. The majority of deaths occurred at home (71%) and in rural areas (87%). The mean age-standardized DAA mortality rate was 8.6 times higher in hot than in cold PIN codes. Hot spots were associated with poorer access to district-level hospitals (DH) with a full complement of surgical resources. The median distance to the nearest such hospital was 53 km [IQR 32-85] in hot spots versus 27 km [IQR 17-43] in cold spots. Poverty indicators were also associated with mortality. Median monthly total household expenditure was significantly lower in hot spots versus cold spots, as were adult literacy rates. The proportion of households belonging to a scheduled caste or tribe was significantly higher in hot versus cold spots.
Conclusions: DAA were concentrated in rural India and predominantly occurred outside of a health facility. Mortality was associated with poor geographic access to surgical care, poverty, and belonging to a scheduled caste or tribe. These findings support the need to improve timely access to well-resourced surgical facilities in India to prevent avertable mortality from common surgical conditions. Policies must also address the significant socioeconomic barriers to surgical care, especially for the rural poor in India.
