Acta Anaesthesiologica Taiwanica 54 (2016) 41e43
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Editorial View
Measuring and reducing perioperative anesthetic-related mortality:
View from East Asia
Keywords:
anesthesia;
editorial;
Far East;
mortality;
perioperative
Florence Nightingale, the social reformer and founder of modern
nursing, pioneered the application of medical statistics to improve
patient outcomes in hospitals. She took measurements in British
field hospitals during the Crimean War and used calculations to
determine that more soldiers died from infectious diseases exacer-
bated by unsanitary conditions than died from battle injuries. Night-
ingale invented compelling data visualization formats and used
them to convince Queen Victoria to order systematic improvements
in military and later civilian hospital management standards and
practices. Ultimately, Nightingale's work resulted in modernizing
hospital policies and procedures that continue to save lives and
improve healthcare outcomes globally to the present day, helping
to transform the hospital, in the minds of many around the world,
into a place to go for healing rather than a place to go to die.1,2
But how reliably, in this present day, do we capture medical and
public health information? How effectively is it leveraged to moti-
vate advances in policy development and outcomes? We concern
ourselves with such questions particularly with respect to perioper-
ative anesthesia, especially in East Asia, and precisely on quantifying
adverse events, risk management, and outcome improvement. We
embark by reviewing some fundamentals on the impact of surgery
and anesthesia on public health around the world.
While opinion on the relative value of surgery has remained
controversial from its inception, a developing consensus tenders
it as impacting vitally and positively on global public health.3 Ex-
perts are asserting that operative interventions are a boon as a fac-
tor influencing disability-adjusted life years and in terms of more
fundamental constructs such as economic and psychological well-
being; further, they assert that this value has been underesti-
mated.4,5 However, it is also recognized that 5 billion people around
the world lack access to necessary surgical and anesthesia care,
http://dx.doi.org/10.1016/j.aat.2016.06.004
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://
creativecommons.org/licenses/by-nc-nd/4.0/).
with the problem most seriously affecting the peoples of impover-
ished regions in South Asia and sub-Saharan Africa.6 Where surgi-
cal and anesthesia services are accessible, researchers have
engaged in efforts to quantify their safety and efficacy, but firm con-
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
by anesthesia or where anesthesia was deemed a contributing
factor. The study compared pre-1970s data with that from
1970se1980s, 1990se2000s, and 2000se2010. When analyzed
separately by human development index level groups, the
decline was found to hold true only for more highly developed
countries.8
Only one nationwide investigation of anesthesia-related mortal-
ity in Taiwan has been published since the establishment of the Na-
tional Health Insurance Plan in 1995. It found an average
anesthetic-caused mortality rate of 11.9/100,000 cases over the
years 1995e1998 and 2002e2008 (sufficient data were not
collected in the intervening years), which compares poorly with
other developed countries cited in the study.9 Table 1 summarizes
that data.
The findings suggest that Taiwan suffers an anesthetic-related
mortality rate ten times higher or more than those reported for
other developed countries. We pause today to reflect on this infor-
mation and its implications, to consider how well we can assume
that the research, in Taiwan or elsewhere, has been able to capture
reality and then we turn our gaze. We look backward in time, from
the publication of the Taiwanese study 6 years ago, to the present
day, and onward into the future, and we look outward, to other
countries in East Asia: China (including Hong Kong), Mongolia,
Japan, North Korea, and South Korea; to other neighbors in South-
east Asia and the Asian Pacific region. Finally, we anticipate
whether and how we might liaise between Taiwan and other coun-
tries in East Asia, where we may enjoy cultural and language con-
nections and possess relevant knowledge about clinical and
bureaucratic practices, and researchers elsewhere who specialize
in international assessment of anesthetic and surgical risk and
safety.
42
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-
opment of a project to analyze and report on that data. We also
welcome East Asian and other Asia-Pacific area researchers and
policymakers to contact the corresponding author and exchange
with us information on anesthetic-related mortality and safety
improvement, and to collaborate with us on advancing our knowl-
edge and practice in the future.
Obtaining clear, valid, and useful data on the safety of anesthesia
is a challenge. An entry point for the introduction of misinforma-
tion lies at the place and time where adverse events occur and
are labelled (or mislabeled), categorized (or miscategorized),
recorded (or misrecorded), reported (or misreported), and made
accessible (or not). Incorrect, incomplete, or misleading informa-
tion can be communicated, missed, or lost, due to conscious or un-
conscious bias, to medicolegal concerns, to desires to cast people or
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.
A cautionary story recently appeared in the form of a study pub-
lished in the BMJ which stirred international headlines: The authors
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
were more than 2.5 times greater than most currently-cited figures.
The corrected estimate lists medical error as the third leading cause
of death in the US after heart disease and cancer.10
A 2002 review of the literature on anesthesia safety sharply
called into question the validity of contemporary studies on the
issue, pointing to concerns with operational definitions, and
concluded that “wide variations based on methodological differ-
ences reported in the literature make it impossible to detect trends
in anesthesia safety”.11 Such problems continue to be cited in more
recent studies and reviews, with one major 2009 review describing
findings on anesthetic safety trends as “controversial”.12
Researchers treating anesthetic-related safety, risk, and mortal-
ity should carefully lay the appropriate groundwork before under-
taking projects in this area. It appears sensible to believe that
anesthesiology has come a long way and is safer today in more
areas of the world than in past decades, while being administered
to a population that is increasingly older and presents with more
complex and fragile clinical situations. However, we pay heed to
the warnings sounded by experts in much or most of the recent
literature, and we conclude that little is known for sure about mor-
tality and the safety profile associated with anesthesia within na-
tions across the Far East, across Asia, or around the world.
Communication and collaboration with experts in the field inter-
nationally should occur at every stage of the research undertaking,
so that information collection processes, operational definitions,
and research methodologies can become increasingly
J.L. Reynolds et al.
Figure 1. Crimean War: Florence Nightingale going around the wards at Scutari Hos-
pital. Image title: M0003645. Wood engraving. Note. From 1855 Illustrated London
News Published: 24 February 1855. Wellcome Library, London, UK. Wellcome Images
http://wellcomeimages.org. Copyrighted work available under Creative Commons Attri-
bution only license CC BY 4.0 http://creativecommons.org/licenses/by/4.0/. Reprinted
with permission.
standardized, therefore reliable, and allow for valid international
comparisons.
Florence Nightingale lives on in the popular imagination, partic-
ularly in the West, symbolized as “the lady with the lamp”
(Figure 1) making hospital rounds and tending to the sick.13 Let
us raise our own lights high and use the power of transparent
and reliable information to illuminate a better way forward for sur-
gical teams, policymakers, and for the public, around the Far East
and throughout the global healthcare enterprise.
Conflicts of interest
All authors declare no conflicts of interest.
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Anesthetic-related mortality 43

James L. Reynoldsy Yang Chen-Hsien

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

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