Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. National Institute for Health and Care Research.

Objectives To compare the Portsmouth (P) Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and specialized colorectal (Cr) POSSUM scoring systems in the prediction of mortality after resection of colorectal cancer. Design Retrospective study of patients after resection of colorectal cancer. Setting University hospital. Patients One hundred twenty patients with complete medical records who underwent resection of colorectal cancer between January 1, 1996, and December 31, 2004, at our institution were enrolled in the study. Main Outcome Measures P-POSSUM and Cr-POSSUM scores were calculated for each patient. In-hospital mortality rate and number of deaths within 30 days after surgery were recorded. The ratio of observed to expected deaths was calculated for each analysis. Results The P-POSSUM system underpredicted mortality by 25%, with no significant difference between the predicted and observed values (P = .96). The observed to expected ratio for Cr-POSSUM was 1.11, with no significant difference between the observed and predicted values (P = .19). Area under the receiver operating curve for P-POSSUM was 0.70 and for Cr-POSSUM was 0.59. Conclusions Both P-POSSUM and Cr-POSSUM perform well in predicting mortality after colorectal cancer surgery, but the Cr-POSSUM is more accurate. There is a constant need for reevaluation of existing and any new scoring systems outside original development and validation populations. The Cr-POSSUM score is a promising specialized tool for monitoring surgical outcomes in colorectal cancer surgery.