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Mortality after surgery in Europe: a 7 day cohort study.
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MedLine Citation:
PMID:  22998715     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.
METHODS: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ(2) and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries.
FINDINGS: We included 46,539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9-3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0-3·0] for Iceland to 21·5% [16·9-26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19-1·05; p=0·06] for Finland to 6·92 [2·37-20·27; p=0·0004] for Poland).
INTERPRETATION: The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.
FUNDING: European Society of Intensive Care Medicine, European Society of Anaesthesiology.
Authors:
Rupert M Pearse; Rui P Moreno; Peter Bauer; Paolo Pelosi; Philipp Metnitz; Claudia Spies; Benoit Vallet; Jean-Louis Vincent; Andreas Hoeft; Andrew Rhodes;
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Publication Detail:
Type:  Journal Article; Multicenter Study; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Lancet     Volume:  380     ISSN:  1474-547X     ISO Abbreviation:  Lancet     Publication Date:  2012 Sep 
Date Detail:
Created Date:  2012-09-24     Completed Date:  2012-10-23     Revised Date:  2014-03-19    
Medline Journal Info:
Nlm Unique ID:  2985213R     Medline TA:  Lancet     Country:  England    
Other Details:
Languages:  eng     Pagination:  1059-65     Citation Subset:  AIM; IM    
Copyright Information:
Copyright © 2012 Elsevier Ltd. All rights reserved.
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MeSH Terms
Descriptor/Qualifier:
Adult
Aged
Cohort Studies
Critical Care / utilization
Europe / epidemiology
Female
Hospital Mortality
Hospitalization / statistics & numerical data
Humans
Length of Stay / statistics & numerical data
Male
Middle Aged
Postoperative Care / methods,  statistics & numerical data
Surgical Procedures, Operative / mortality*
Treatment Outcome
Grant Support
ID/Acronym/Agency:
CS/08/08/17//Department of Health
Investigator
Investigator/Affiliation:
Peter Bauer / ; Andreas Hoeft / ; Philipp Metnitz / ; Rui Moreno / ; Rupert Pearse / ; Paolo Pelosi / ; Andrew Rhodes / ; Claudia Spies / ; Benoit Vallet / ; Jean-Louis Vincent / ; Sandrine Damster / ; Kim Golder / ; Russell Hewson / ; Marta Januszewska / ; Brigitte Leva / ; Rui Moreno / ; Rupert Pearse / ; Vasco Ramos / ; Andrew Rhodes / ; Eric Hoste / ; Luc Huyghens / ; Rita Jacobs / ; Veerle Van Mossevelde / ; Godelieve Opdenacker / ; Jan Poelaert / ; Herbert Spapen / ; Kris Leleu / ; Dirk Rijckaert / ; Koen De Decker / ; Luc Foubert / ; Nikolaas De Neve / ; Patrick Biston / ; Michael Piagnerelli / ; Vincent Collin / ; Nadia den Blauwen / ; Charlotte Clauwaert / ; Luc De Crop / ; An Verbeke / ; Heilige Hartziekenhuis Roeselare / ; Pieter Derumeaux / ; Christophe Gardin / ; Sebastiaan Kindt / ; Sofie Louage / ; Bruno Verhamme / ; Patrick Druwé / ; Ingrid Lahaye / ; Francis Rosseel / ; Robert Rutsaert / ; Luc Vanlinthout / ; Marc De Kock / ; Patrice Forget / ; Pascal Georges / ; Irina Grosu / ; David Kahn / ; Fernande Lois / ; Mona Momeni / ; Audrey Pospiech / ; Bernadette Yemnga / ; Jean-Luc Jadoul / ; Manu Malbrain / ; Dana Bosinceanu / ; Edith Collard / ; Philippe Jorens / ; Dirk Reyntiens / ; Carine Smitz / ; Marcel Vercauteren / ; David Fagnoul / ; Luc van Obbergh / ; Jean-Louis Vincent / ; Tatjana Goranović / ; Branka Mazul-Sunko / ; Krapinske Toplice / ; Krešimir Oremuš / ; Gabrijela Bešlić / ; Viktor Duzel / ; Ada Hauptman / ; Sanja Peremin / ; Andrej Šribar / ; Miroslav Župčić / ; Slavonski Brod / ; Ivan Mirković / ; Zlata Šarić Bauer / ; Matija Belavić / ; Božidar Blažanin / ; Mirjana Lončarić Katušin / ; Antonija Brozović Krijan / ; Petar Mišković / ; Nataša Šimić-Korać / ; Jasna Topić / ; Antonio Žilić / ; Josip Žuni / ; Ivana Acan / ; Mirta Adanić / ; Nikola Ivanov / ; Jadranka Pavičić Šarić / ; Katarina Tomulić / ; Nataša Visković / ; Silvana Bošnjak / ; Ivana Haršanji Drenjančevic / ; Gordana Kristek / ; Slavica Kvolik / ; Stela Markić / ; Andreja Stojanovic Rakipovic / ; Ozana Katarina Tot / ; Darija Venzera- Azenic / ; Lada Kalagac Fabris / ; Iva Bačak-Kocman / ; Igor Balenović / ; Daniela Bandić / ; Patricia Adrianne Judith Deutsch / ; Loredana Divjak / ; Ina Grčić Filipović / ; Zvonka Gužvinec / ; Zrinka Krznarić / ; Yvonne Lončarić / ; Jelena Vadlja Magaš / ; Marek Mitrović / ; Marija Okić / ; Mario Pavlek / ; Elza Ramov / ; Karolina Rezek / ; Ante Sekulić / ; Boris Tomasevic / ; Mirjana Mirić / ; Anita Tomašević / ; Tina Tomić Mahečić / ; Vilena Vrbanović / ; Mirna Bobinac / ; Alfred Božić / ; Danijela Debelic / ; Vedran Frkovic / ; Inga Mladić Batinica / ; Senka Baranović / ; Željka Gavranović / ; Mirna Kikec / ; Branka Maldini / ; Stela Marić / ; Ivan Agnić / ; Nikola Delić / ; Nataša Dropulić / ; Toni Kljaković Gašpić / ; Darko Ilić / ; Božena Ivančev / ; Nenad Karanović / ; Dorjan Kuščević / ; Zlatko Marović / ; Matija Milić / ; Ana Nevešćanin / ; Tatjana Petković / ; Mario Smoje / ; Gordana Brozović / ; Tatjana Goranović / ; Milana Jelisavac / ; Martina Matolić / ; Branka Mazul-Sunko / ; Dagmar Oberhofer / ; Ana Marija Pavičić / ; Kata Šakić / ; Margarita Delija Bozovic / ; Zvjezdana Kotorac Krecek / ; Renata Krobot / ; Tatjana Andabaka / ; Mislav Bratanić / ; Orjana Dzepina / ; Martina Kraljev / ; Julija Šeric / ; Tatjana Šimurina / ; Rosa Grujić / ; Biljana Nacevski-Bulaja / ; Mirna Barižon / ; Vrančić Danira / ; Bulaja Dražen / ; Kimer Dušanka / ; Marijana Bašić Halužan / ; Žaja Joško / ; Roca Katica / ; Magda Labor / ; Tea Grgurević Marinković / ; Danči Mihovilčević / ; Bego Marija / ; Marinković Srečko / ; Srđan Vranković / ; Theodoros Kyprianou / ; Kyriakos Neophytou / ; Vladimir Cerny / ; Karel Cvachovec / ; Barbora Belikova / ; Michal Drab / ; Kamil Hudacek / ; Ivo Krikava / ; Petr Stourac / ; Katarina Zadrazilova / ; Vladimír Bicek / ; Milena Brabcová / ; Radka Klozová / ; Jaromír Vajter / ; Tomáš Vymazal / ; Palle Toft / ; Louise Blichfeldt / ; Bo Dilling Hansen / ; Kirsten Moller / ; Jeppe Sylvest Nielsen / ; Joachim Frederiksen / ; 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Nils Stegmann / ; Uwe Erkens / ; Jens Kopcke / ; Andreas Meyer / ; Hartmut Brestrich / ; Sandra Ernst / ; Stella Merkel / ; Lena Krieger / ; Frank Luers / ; Andreas Weyland / ; Gabriele Noeldge-Schomburg / ; Thomas Menckie / ; Christina Wasmund / ; Ralph-Dieter Bredtmann / ; Ines Erler / ; Carsten Raufhake / ; Christine Haumann / ; Angela Möllemann / ; Uwe Oehmichen / ; Olga Sergejewa / ; Brigitte Lehning / ; Elke Czeslick / ; Michaela Geyer / ; Michael Malcharek / ; Armin Sablotzki / ; Marina Stier / ; Florian Feld / ; Gernot Marx / ; Rolf Rossaint / ; Verena Simon / ; Apostolos Armaganidis / ; Despoina Koulenti / ; Anastasia Kotanidou / ; Serafim Nanas / ; Androula Papastylianou / ; Aikaterini Psevdi / ; Anastasios Stathopoulos / ; Asklepieion Voulas / ; Efthymia Kanna / ; Anastasia Koutsikou / ; Alexandra Moustaka / ; Achilleas Chovas / ; Apostolos Komnos / ; Tilemachos Zafiridis / ; Josef Franses / ; Athena Lavrentieva / ; Eleni Koraki / ; Chrysostomos Katsenos / ; Maria Flora Kasianidou / ; Pantelia Nasopoulou / ; Eleni Spyropoulou / ; Chrysoula Gousia / ; Constantine Katsanoulas / ; Dimitrios Lathyris / ; George Kyriazopoulos / ; Dimitrios Sfyras / ; Athanasia Tsirogianni / ; Apostolos Armaganidis / ; Georgia Kostopanagiotou / ; Despoina Koulenti / ; Mihail Lignos / ; Paraskevi Matsota / ; Christos Christopoulos / ; Alexandra Mouratidou / ; Efstratia Vrettou / ; Spyros Boufidis / ; Eleni Moka / ; Eleni Arnaoutoglou / ; Vasileios Koulouras / ; George Nakos / ; Georgios Papathanakos / ; Georgios Anthopoulos / ; Georgios Choutas / ; Dimitrios Karapanos / ; Vaso Tzani / ; Georgios Gkiokas / ; Konstantinos Nastos / ; Fotios Nikolakopoulos / ; Christos Dragoumanis / ; Nikos Nikitidis / ; Ioannis Pneumatikos / ; Vassiliki Theodorou / ; Danai Zacharouli / ; Stella Kandi / ; Konstantinos Tasopoulos / ; Kostoula Arvaniti / ; Dimitrios Matamis / ; Eva Mplougoura / ; Polixeni Petropoulou / ; Ioannis Soumpasis / ; Ekaterini Amaniti / ; Maria Giannakou-Peftoulidou / ; Eleni Gkeka / ; Ioanna Soultati / ; Maria Kokinou / ; Lambrini Papatheodorou / ; Maria Stafylaraki / ; Tatiana Giasnetsova / ; Nikoleta Gritsi-Gerogianni / ; Christina Kydona / ; Olga Kiskira / ; Ioannis Koulentis / ; Alexandros Apsokardos / ; Konstantinos Dimitropoulos / ; Ourania Soldatou / ; Christodoulos Nathanail / ; Alexios Papazotos / ; Pirros Tsakas / ; Phyllis-Maria Clouva-Molyvdas / ; Athina Kolotoura / ; Monika Sartzi / ; Spiros Papanikolaou / ; Pavlos Polakis / ; Stylianos Karatzas / ; Aikaterini Kyparissi / ; Theonymfi Papavasilopoulou / ; Triantafillia Koukoubani / ; Evangelia Mastora / ; Kyriaki Spyropoulou-Pagdatoglou / ; Vasileia Nyktari / ; Polychronis Malliotakis / ; Alexandra Papaioannou / ; Vasileios Bekos / ; Elisavet Maragkou / ; Anna Spring / ; Stavros Evagelatos / ; Aikaterini Ioakeimidou / ; Nikos Noulas / ; Zsolt Molnár / ; Emese Csüllög / ; Enikő Elekes / ; Tamás Molnár / ; Zsuzsana Katona / ; Ildiko Kremer / ; Angela Miko / ; Akos Csomos / ; Zsuzsanna Galambos / ; Akos Szucs / ; Gyorgy Nyikos / ; Gabor Szekeres / ; Ervin Szabo / ; Katalin Kranitz / ; Melinda Simon / ; Janos Szigeti / ; Emánuel Gaál / ; Attila Havas / ; Alexandru Ille / ; Krisztina Bráz / ; Geza Nagy / ; Gisli Sigurdsson / ; Fridrik T Sigurbjörnsson / ; Gisli H Sigurdsson / ; Sigurbergur Kárason / ; Elin Edda Sigurdardottir / ; Ásbjörn Blöndal / ; Björn Gunnarsson / ; Andrew Westbrook / ; Alan Broderick / ; Parvaiz Hafeez / ; Deepak Hanumanthaiah / ; Janette Brohan / ; Donal O'Chroinin / ; Kevin Bailey / ; Karthik Ramamoorthy / ; Yvonne Doyle / ; Noelle Freir / ; James O'Rourke / ; Philip Jonson / ; Sabir Saeed / ; Ivan Hayes / ; John Loughrey / ; Stephen Frohlich / ; Nuala McCauley / ; Donal Ryan / ; Gerry Fitzpatrick / ; Leo Kevin / ; Jubil Thomas / ; Barry Warde / ; Alan Woolhead / ; Michelle Duggan / ; Cara Egan / ; Seamus Crowley / ; Soloman Lebese / ; Anne Bergin / ; Andrew Westbrook / ; Rory Page / ; Daniel Collins / ; Michael McKenny / ; Giorgio Della Rocca / ; Salvatore Grasso / ; Anna Bresciani / ; Livio Carmino / ; Silvia Ghelfi / ; Laura Lorenzelli / ; Maria Teresa Novelli / ; Chiara Pescarmona / ; Agostino Roasio / ; Alessandro Gatta / ; Mauro Nastasi / ; Manlio Sanseverino / ; Carla Tinti / ; Andrea Bianchin / ; Maria Tormena / ; Antonio Franco / ; Federica Marini / ; Piero Di Mauro / ; Francesca Rapido / ; Concezione Tommasino / ; Ferdinando Bellotti / ; Daniele Boninsegna / ; Gianluca Castellani / ; Daniele Sances / ; Gianluca Spano / ; Stefano Tredici / ; Dario Vezzoli / ; Igneo Fucecchio / ; Alessandro Bacci / ; Roberta Coppini / ; Sandro Dell'unto / ; Emanuele Mori / ; Maria Rosa Stanzani / ; Monica Tosi / ; Michele Collareta / ; Francesco Forfori / ; Matteo Franchi / ; Giuseppe Mancino / ; Massimo Battistella / ; Elisa Baricocchi / ; Francesco Bona / ; Felicino Debernardi / ; Gianmarco Giacoletto / ; Antonio Iacobellis / ; Paolo Massucco / ; Nora Moselli / ; Andrea Muratore / ; Graziella Palomba / ; Elena Sardo / ; Michele De Simone / ; Luisa Suita / ; Edoardo Zocca / ; Barbara Bucci / ; Francesco Della Corte / ; Tiziana Piciucco / ; Valeria Viarengo / ; Gabriella Bettelli / ; Eugenia Cantarini / ; Marina Giampieri / ; Alessandra Tanfani / ; Eugenio Recchia / ; S Raffaele Milano / ; Elena Bignami / ; Giovanna Bruno / ; Roberto Costagliola / ; Azzurra Gandolfi / ; Massimiliano Greco / ; Rosalba Lembo / ; Giacomo Monti / ; Elisa Nicelli / ; Nicola Pasculli / ; Stefano Turi / ; Giorgio Della Rocca / ; Antonio Baroselli / ; Marcella Brazzoni / ; Mattia Buttazzoni / ; Stefania Buttera / ; Carlo Centonze / ; Giovanni Serena / ; Lorenzo Spagnesi / ; Ilaria Toretti / ; Anna Vilardi / ; Ester Zearo / ; Ines Arpino / ; Sara Baraldi / ; Chiara Guarnerio / ; Vincenzo Molene / ; Maria Concetta Monea / ; Enrico Vaccarisi / ; Luigi Vicari / ; Alida Albante / ; Marco Aversano / ; Cinzia Loiacono / ; Maurizio Marandola / ; Maurizio Fusari / ; Nicola Petrucci / ; Amerigo Galla / ; Antonio Mascia / ; Paolo Primieri / ; Anna Di Noto / ; Angelo Gratarola / ; Alessandro Molin / ; 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Ben van der Hoven / ; Patricia Ormskerk / ; Oliver Beck / ; Sjouke Schiere / ; Auke Reidinga / ; Allart Venema / ; Marga Hoogendoorn / ; Kees Olthof / ; Hans Flaatten / ; Ib Jammer / ; Vegard Dokka / ; Svein Arne Monsen / ; Lars Marius Ytrebo / ; Mostafa Noursadeghi / ; Ahmed Shahzad / ; Ola Dagfinn Boksasp / ; Christoph Roiss / ; Hans Frank Strietzel / ; Anne Gina / ; Schie Berntsen / ; Helge Haugland / ; Svein Ove Vingsnes / ; Patric Axelsson / ; Thomas Olsen / ; Sanjay Katre / ; Kristin Aakeroey / ; Adam Mikstacki / ; Barbara Tamowicz / ; Dominika Bożiłow / ; Robert Goch / ; Piotr Grabowski / ; Jacek Kupisiak / ; Małgorzata Małłek / ; Robert Szyca / ; Włodzimierz Kostyrka / ; Robert Choma / ; Grzegorz Jankowski / ; Władysław Kościelniak / ; Paweł Pietraszek / ; Bartosz Szarowar / ; Ricardo Matos / ; Carlos França / ; António Pais Lacerda / ; Lucindo Ormonde / ; Rosário Rosa / ; Inês Pereira / ; Paula Vitor / ; Henrique Completo Bento / ; Maria Raquel Lopes / ; Marques Carvalho / ; Manuela Faria / ; Ana Cláudia de Sousa / ; Pereira de Freitas / ; Eduardo Almeida / ; Rui Mealha / ; Rachel Vicente / ; Raquel Monte / ; Fernando Rua / ; Nelson Barros / ; Francisco Esteves / ; Célia Maria Gouveia Pinheiro / ; Vila Real / ; Vítor Miguel Oliveira / ; Maria Fátima Oliveira / ; Isabel Martins / ; José Pedro Saraiva / ; José Pedro Assunção / ; Anabela Bártolo / ; Anabela Carvalho / ; Carlos Correia / ; Salomé Martins / ; Ruth Milheiro / ; Alejandro Diaz / ; Maria Imelda Gonçalves / ; Rosa Ribeiro / ; Joana Estilita / ; Carlos Glória / ; José de Almeida / ; Filipa Barros / ; Armindo Ramos / ; Margarida Camara / ; Edward Richard Maul / ; Julio Nobrega / ; Anuscka Langner / ; Dionísio Maia / ; Ofélia Afonso / ; Filomena Faria / ; Sofia Serra / ; Maria Manuela Botelho / ; Pedro Ferreira / ; Luís Mourão / ; Ana Vintém Oliveira / ; Margarida Resende / ; Miguel Aleman / ; Jorge Fonseca / ; Marta Isidoro / ; Helena de Meneses / ; António Pêgas / ; José Pereira / ; Luis Pereira / ; Bárbara Ramos / ; Francisco Matos / ; Ricardo Matos / ; Maria de Lurdes Gonçalves Castro / ; Ana Martins / ; Cristina Ramos / ; Manuel de Sousa / ; Luís Bento / ; Conceição Botas / ; Vitor Lopes / ; Rosa Mendes / ; Ioana Grigoras / ; Mihaela Blaj / ; Mihaela Damian / ; Andreea Lupusoru / ; Irina Ristescu / ; Monica Codreanu / ; Ciresica Diaconescu / ; Alina Nistor / ; Dorin Stanescu Stelian / ; Livia Streanga / ; Maria Berneanu / ; Cristina Bordeianu / ; Calarasu Florenta / ; Alina Iacob / ; Mary Nicoleta Lupu / ; Iulian Mocanu / ; Coca Moraru / ; Carleta Meran / ; Bacalbasa Nicolae / ; Madalina Sandu / ; Roxana Turcanu / ; Florina Epure / ; Monica Grigore / ; Cristina Hotaranu / ; Nicoleta Popescu / ; Oleg Baban / ; Manuela Baciu / ; Aurica Ciobanu / ; Catalin Ioan Denciu / ; Vitalie Gurau / ; Ion Maftei / ; Ion Moldovan / ; Liviu Ungureanu / ; Prodan Bogdan / ; Dan Corneci / ; Melania Dinu / ; Dutu Madalina / ; Manolescu Rely / ; Negoita Silvius / ; Dana Tomescu / ; Droc Gabriela / ; Stelian Adrian Dinescu / ; Mitre Calin / ; Daniela Ionescu / ; Simona Margarit / ; Horatiu Vasian / ; Corina Albu / ; Carmen Balasa / ; Alina Cadrigati / ; Dorian Dragulescu / ; Loredana Gavra / ; Ciprian Hentia / ; Claudiu Macarie / ; Mihaela Manescu / ; Ioan Nediglea / ; Dana Ocica / ; Bedreag Ovidiu / ; Marius Papurica / ; Cosmin Plavat / ; Claudia Popa / ; Mihaela Ramneantu / ; Dorel Sandesc / ; Zoran Sandici / ; Mihaela Sarandan / ; Ioana Belciu / ; Eugen Tincu / ; Irina Ursu / ; Mariana Aignatoaie / ; Mariana Huzuneanu / ; Simona Cocu / ; Natalia Hagau / ; Roxana Ciubotaru / ; Sanda-Maria Copotoiu / ; Ruxandra Copotoiu / ; Ghitescu Ioana / ; Judit Kovacs / ; Azamfirei Leonard / ; Ianos Szederjesi / ; Vanvu Genoveva / ; Simona Mosnegutu / ; Maja Surbatovic / ; Dragan Djordjevic / ; Biljana Djordjevic / ; Krasimirka Grujic / ; Dusko Jovanovic / ; Ivana Krstic-Lecic / ; Jovana Obradovic / ; Snjezana Zeba / ; Jasna Jevdjic / ; Milos Miletic / ; Filip Zunic / ; Aleksandra Bulasevic / ; Radoslava Brko / ; Narcisa Gazibegovic / ; Mirjana Kendrisic / ; Radisa Vojinovic / ; Jozef Firment / ; Roman Zahorec / ; Judita Capková / ; Jozef Firment / ; Monika Grochova / ; Stefan Trenkler / ; Martin Griger / ; Roman Zahorec / ; Erika Bakosova / ; Martin Kvasnica / ; Beata Saniova / ; Miroslav Sulaj / ; Andrea Zacharovska / ; Alexandra Simkova / ; Andrea Číková / ; Andrea Gebhardtova / ; Slávka Hanuljaková / ; Juraj Koutun / ; Andrea Martonová / ; Veronika Žilinčárová / ; Katarína Galkova / ; Stefan Krbila / ; Viliam Sobona / ; Marieta Ocenasova / ; Vesna Novak-Jankovic / ; Vesna Novak-Jankovic / ; Adela Stecher / ; Feri Stivan / ; Andriy Grynyuk / ; Marija Damjanovska / ; Ivan Kostadinov / ; Mile Knezevic / ; Marko Malivojevic / ; Zvonko Borovsak / ; Mirt Kamenik / ; Dušan Mekiš / ; Irena Osojnik / ; Lučka Kosec / ; Silva Ostojič Kapš / ; Dragoslav Aleksic / ; Božena Gerjevič / ; Katja Kalan / ; Tomaz Ursic / ; Cesar Aldecoa / ; Juan Montejo González / ; Anna Artigas / ; Andres Garcia / ; Alberto Lisi / ; Isabel Perez / ; Gisela Perez / ; Nuria Poch / ; Sergi Vaquer / ; Goiatz Balciscueta / ; Helena Barrasa / ; Sara Cabanes / ; Javier Maynar / ; Yolanda Poveda / ; Amaia Quintano Rodero / ; Ana Vallejo / ; Patricia Duque / ; Beatriz Garcia-Bunger / ; Maria Adoracion Elvira / ; Ana María Lajara / ; María Palencia / ; Rafael Ramos / ; Ana Saez Fernandez / ; Juan Tirapu León / ; Jaione Iza López / ; Francisco Yoldi Murillo / ; Eva Turumbay Ramirez / ; Patricia Unzué Rico / ; Marta Patricia / ; Martín Vizcaíno / ; Maria José Bernat Álvarez / ; Kenneth Planas Real / ; Arantxa Mas Serra / ; Norma Aracil / ; Begoña Menendez Bodega / ; Raquel Fernández García / ; Marivi Álvarez García / ; Borja de la Quintana Gordon / ; Alicia Gutiérrez Jodrá / ; Angela De Santos López / ; Juan José Llavador Ros / ; Rocío Ayala Soto / ; Isabel Sepúlveda / ; Esperanza Pascual Díez / ; Luisa Fernández Fernández / ; Carlos Soria Gulina / ; Laura Pérez Arviza / ; Lorena Mouriz Fernandez / ; Antía Río Gómez / ; Concepción Alonso Martínez / ; Ana Belén Rodríguez Rodríguez / ; Carmen Lopez Soto / ; Cesar Aldecoa / ; Clara Garcia / ; Mario Lorenzo / ; Elena Pinilla / ; Jesus Rico / ; Irene Ruperez / ; Eduardo Alonso / ; Fernando Leira / ; David Pestaña Emilio Maseda / ; Concepcion Royo / ; Jose Villagran / ; Giralt Murillo Candi / ; Garcia Eduardo Esteva / ; Raquel Mansilla Folgado / ; Nadal Joan Fornaguera / ; Pijoan Calonge Montse / ; Anna Sape Prat / ; Dolores Sintes / ; Donaldo Arteta Arteta / ; Horacio García Delgado / ; Juan Fajardo López-Cuervo / ; Mikel Celaya López / ; Alejandro Ramírez / ; Francisco José Saldaña / ; Pilar Aliste / ; Ana Hermira Anchuelo / ; Ascensión García Campos / ; Mercedes Catalán / ; Mónica García Gómez / ; Olga Gonzalez Gonzalaez / ; Eloísa López López / ; Isabel Real Navacerrada / ; Sara Arlanzón de Quevedo / ; Matilde Gonzalez Serrano / ; Francisco Perez-Cerdá Silvestre / ; Francisco Martinez Torrente / ; Blanca Arocas / ; Ernesto Pastor Martinez / ; Marina Soro / ; Fernando Maroto / ; Ruth Robledo Algarra / ; Inés Silla Aleixandre / ; Gemma Rodriguez Argente / ; Ana Broseta Lleó / ; Antonio Vela Rubio / ; José Luis Vicente Sánchez / ; Irene Enríquez Valcárcel / ; Clara Balust / ; Jaume Balust / ; Xavier Borrat / ; Maria Jose Carretero / ; Isabel Gracia / ; Purificacion Matute / ; Jordi Mercadal / ; Roger Pujol / ; Beatriz Tena / ; Marta Ubre / ; Dolores Dorda Albalad / ; Concepción Muñoz Alcaide / ; Jesus Caballero / ; Angels Camps Cervantes / ; Miriam de Nadal Clanchet / ; Nuria Montferrer Estruch / ; Mercè Ballvé Ferrer / ; Albert Lacasta Fornells / ; Eduard Terrer Galera / ; Irene Garcia Martinez / ; Susana Manrique Muñoz / ; Andres Pelavski / ; Pilar Tormos Perez / ; Miguel Angel Gonzalez Posada / ; Ivette Chocron de Prat / ; Jordi Rello / ; Llum García Serrano / ; José Manuel Naya Sieiro / ; Lorena Silva / ; Maria Jose Colomina Sole / ; Alfons Biarnes Suñé / ; Isabel Rochera Villach / ; José Ignacio Gómez Herreras / ; Rodrigo Poves / ; Beatriz Martinez Rafael / ; Icier Martinez Almeida / ; Angel Fernandez Collates / ; Maria Jose Bartolomé / ; Bonifacio Cimadevilla / ; Antonio Manuel González González / ; Jose Manuel Rabanal Llevot / ; Juan Carlos Diaz de Terán Mira / ; Begoña González Molina / ; Sara Pardo / ; Carlos López Sánchez / ; Monica Williams / ; Estibaliz Zaldibar / ; Lourdes Muñoz Corsini / ; José Ramón Rodríguez Fraile / ; Maria de la Lastra / ; Monir Kabiri Sacramento / ; Francisco Javier López Saña / ; Josep Trenado Ålvarez / ; Maria Luisa Cantón Bulnes / ; Violeta Gándara Carrasco / ; María del Rocío Míguez Crespo / ; Diana Narváez Cubillos / ; Enrique Laza Laza / ; María del Pino Heredia Pérez / ; Ángel Arenzana Seisdedos / ; Bartolomé Fernández Torres / ; Marian Santos Ampuero / ; Marta Chicot Llano / ; Esperanza Mata / ; Manuel Munoz / ; Mar Orts / ; Antonio Planas / ; Fernando Ramasco / ; Carlos Roman / ; Marina Varela Durán / ; Sabela del Río Fernandez / ; Yolanda Sanduende Otero / ; Susana Lopez Pineiro / ; Cristina Barreiro Pardal / ; Jesús Fernández Alcantud / ; Mercedes Ayuso Antolinos / ; Francisco Barrios / ; Ana Collantes Casanova / ; Manuel Ruiz Castro / ; Beatriz Infantes Crespo / ; Uzuri Lancha Felipe / ; Marta Liceras Fuster / ; Máximo Sanz García / ; Begoña Herrero Garrote / ; Ricardo Moreno Gonzalez / ; Maria José Montes Granero / ; Carlos Lloreda de la Guía / ; Raquel Chaves López / ; Santiago de Frutos López / ; Jose Javier Marco Martinez / ; Angel Garcia Mostaza / ; Antonio Jiménez Moreno / ; Irene Riquelme Osado / ; Ana Bardina Pastor / ; Rosa Peña / ; Mónica Rustarazo Pérez / ; María Aliaño Piña / ; Carlos Aranda Romero / ; Elena Rodríguez Rodríguez / ; Vicente Pedroviejo Sáez / ; Fernando Safatle / ; Javier Hernández Salvan / ; Mar Galán Sampedro / ; Patricia Alfaro de la Torre / ; Jonatan Pérez Toro / ; Crsitina Lasa Unzúe / ; Maria José Vargas / ; David Garcia Bernal / ; Mercedes Echevarria / ; Alejandro Ubeda Iglesias / ; Ana Loza / ; Araceli Rodriguez Morillo / ; Pedro Diaz Serrano / ; Fernando Caba Barrientos Sevilla / ; Elena Cacho / ; Ricardo Calderón / ; Mercedes Dufur / ; Carolina Marginet / ; Pablo Monedero / ; Maria José Yepes / ; Luzdivina Rellán Alvarez / ; Francisca Fernández Carballal / ; Alberto Pensado Castiñeiras / ; Paula Dieguez García / ; Lorena Ramos López / ; Pablo Rama Maceiras / ; María Socorro Martínez Puente / ; Maria Teresa Rey Rilo / ; Ana Esther Trujillo Alonso / ; Sonia Rodríguez Fernández / ; Rafael Omaña García / ; Aníbal Pérez García / ; Rafael Bello Puentes / ; Domingo Nunez Aguado / ; Carlos Lopez Carballo / ; Ricardo Fernandez Fernandez / ; Amadeo Toledo Presedo / ; Ricardo Bermejo Diaz de Rabago / ; Ana Rodriguez Velasco / ; Yolanda Jiménez Capel / ; Ana Fernández Cortés / ; Esther Martínez García / ; Laura Martinez Gimeno / ; Jordi Klamburg / ; Rosa Castillo Omedas / ; Miriam González Núñez / ; Clara Llubià Maristany / ; Enrique Moret Ruiz / ; Xavier Artigas / ; Sebastian Castrillón / ; Nieves Espinosa / ; Ana María Gomez-Caro / ; Susana Illa / ; Inmaculada India / ; Beatriz Martín-Huerta / ; Victoria Moral / ; Marisa Moreno / ; Cristina Iglesias Fernández / ; Violeta Fernández García / ; Pedro Picatto Hernández / ; Angel Alberto Honrubia Checa / ; David Salvatierra Diaz / ; Manuel Linero Noguera / ; Ignacio Pujol Varela / ; Miguel González Gallego / ; Oscar Martínez García / ; José Javier Ariño Irujo / ; Carlos González Perrino / ; Julio Rey Picazo / ; Francisco López Timoneda / ; María Manzanero Arroyo / ; Isabel Albalá Blanco / ; Marcos Martínez Borja / ; Sara Martín Burcio / ; Nilda Martinez Castro / ; Aránzazu Puente Cerdeiriña / ; Marta de la Torre Concostrina / ; Medrano Viñas Cristina / ; Trinidad Dorado Díaz / ; Juan Avellanosa Esteruelas / ; Ildefonso Ingelmo Ingelmo / ; Paco Duran Insuga / ; Elisabeth Claros Llamas / ; Jose Juan Martín Lopez / ; María Beltran Martín / ; Elena Elías Martín / ; Eva Ureta Mesa / ; Manuela Loren Monterde / ; Paloma Alonso Montoiro / ; Maria Luisa Gonzalez Móstoles / ; Eva Velasco Olarte / ; Adolfo Martínez Pérez / ; Fernando Domínguez Perez / ; Ana Serrano Romero / ; Diego Parise Rous / ; Nuria Mané Ruiz / ; Jose Angel Palomo Ruiz / ; Alvaro Ruigomez Saiz / ; Alvaro de la Vega Terol / ; Angel Candela Toha / ; Fernando Alvarez Utrera / ; Fermín Alberdi / ; Itxaso Elósegui / ; Javier García / ; Pilar Marco Garde / ; Escudero Itziar Mintegui / ; Iker García Sáez / ; Estibaliz Salas / ; Mercedes Zabarte / ; Rosa-Maria Diaz-Boladeras / ; Emilio Mora-Guevara / ; Julia Ferreras Zamora / ; Alfons Bonet / ; Lidia Salo / ; Unai Salinas / ; Juan Zaballos / ; Ana Abella Alvarez / ; Carlos Jimenez Garrido / ; Juan Ramón Hita Roa / ; Federico Gordo Vidal / ; Jorge Garcia-Egea / ; Monica Zamora Elson / ; Carlos Seron-Arbeloa / ; Miguel Angel Mendiola Asensio / ; Rosa Gastaldo Simeón / ; Luis Enrique Muñoz Alameda / ; Guillermo Oeding Angulo / ; Monserrat Aranzubia / ; Jose Juan Arcas / ; Julian Arevalo / ; Belén Quesada Belvert / ; César Pérez Calvo / ; Marta Cremades / ; Pascual Crespo / ; Ana Cuarental / ; Mercedes Del Olmo / ; Pablo Turrión Fernández / ; José Luis Franqueza García Isabel Garcia Vega / ; Elena Herrera / ; Miguel Angel Alcala Llorente / ; Cecilia Martin Rabes / ; Ana Gamo de Maeyer / ; Manuel Pérez Marquez / ; Diego López Mendoza / ; José María Milicua Muñoz / ; Natividad Arias Martínez / ; Arnoldo Santos Oviedo / ; Pau Benavent Garrigues / ; José Alonso Íñigo / ; Sergi Tormo Ferrandiz / ; Silvia Sanchez-Morcillo / ; Matilde Lafuente Sánchez / ; Asunción Marqués Parra / ; Sonia Gomar Vidal / ; Raquel Montoiro Allué / ; Begoña Zalba Etayo / ; Raquel Bustamante Rodriguez / ; Luis Martin Villen / ; Cristina Molla Jimenez / ; Ricardo Salas de Zayas / ; Cristina Dolera Moreno / ; Fernando SanJose Pacheco / ; Jose Luis Anton Pascual / ; Fernando Tejera Gude / ; Eva Manteiga Riestra / ; Francisco Cota Delgado / ; Maria Victoria de la Torre Prados / ; Javier Barrios / ; Manuel Cervera-Montes / ; Mercedes García-Sanz / ; Vicente García / ; Guillermo Sanmiguel / ; Julian López Álvaro / ; Beatriz Bornay Barrachima / ; Francisco Jose Romero Bermejo / ; Alberto Garcia Fernandez Pilar / ; Martinez Garcia / ; Carolina Navarro Ramírez / ; Jorge Gómez Ramos / ; Luis Angel Samaniego / ; Alberto Belenguer-Muncharaz / ; Amparo Ferrándiz-Selles / ; Maria-Lidon Mateu-Campos / ; David Domínguez / ; Elena Espinosa / ; Teresa León / ; Nazario Ojeda Betancor / ; Javier Garcia Cortes / ; Juan José Díaz Díaz / ; Ana Manzano Canalechevarria / ; Beatriz Fores Novales / ; Jose Manuel Garcia Peña / ; Tomas Rodriguez Delgado / ; Beatriz Santamaria Roquerio / ; Juan Jose Gomez Sainz / ; Teresa Tebar Soto / ; Michelle Chew / ; Heléne Seeman-Lodding / ; Peter Dahm / ; Helena Odenstedt Hergès / ; Christoffer Lundborg / ; Heléne Seeman-Lodding / ; Sören Söndergaard / ; Christian Rylander / ; Ferenc Sari / ; Anna Oscarsson Tibblin / ; Anne Adolfsson / ; Bengt Klarin / ; Susann Schrey / ; Edyta Merisson / ; Jörgen Rydén / ; Mona Britt Divander / ; Annika Hedin / ; Daniel Hedlund / ; Mikael Axelsson Lindkvist / ; Monir Jawad / ; Lona Layous / ; Jan Wernerman / ; Håkan Björne / ; Olof Brattström / ; Staffan Olheden / ; Anders Oldner / ; Eva Sellden / ; Bernhard Walder / ; Nadine Wickboldt / ; Ariane Rossi / ; Luzius Steiner / ; Mirjana Djurdjevic / ; Roger Lussmann / ; Martin Geisen / ; Christoph Hofer / ; Matthias Turina / ; Mike Grocott / ; David Goldhill / ; Lynn Everett / ; Katy Harris / ; Maggie Wright / ; David Adams / ; Lorraine Alderson / ; Julie Baker / ; Iain Christie / ; Colin Ferguson / ; Matthew Hill / ; Kate Holmes / ; Andrew Hutton / ; Gary Minto / ; Paul Moor / ; Andrew Porter / ; Richard Struthers / ; Niven Akotia / ; Alaa Belhaj / ; Serene Chang / ; Enrique Collantes / ; Katrin Eigener / ; Michael Husband / ; Ahsun Khan / ; Ming-Li Kong / ; Eleanor Jane McAlees / ; Neil MacDonald / ; Edyta Niebrzegowska / ; Wendy Parnell / ; Amanda Smith / ; Rupert Pearse / ; Ally Chhatwal / ; Smriti Jhingan / ; Richard Muswell / ; Yoyo Poon / ; Nidhita Singh / ; Robert Stephens / ; Robin Vasan / ; Nicola Waife / ; Tahmina Weda / ; Adrian Clarke / ; Tamas Szakmany / ; Simon Fletcher / ; Melissa Rosbergen / ; Mark Blunt / ; Liz Prince / ; Kate Wong / ; David Goldhill / ; Ram Kumar / ; Sarah Stilwell / ; Keith Couper / ; Neil Crooks / ; Fang Gao-Smith / ; Teresa Melody / ; Catherine Snaith / ; Jaimin Patel / ; Dhruv Parekh / ; Joyce Yeung / ; Bernadette Loughnan / ; Vas Moosajee / ; Tamsin Rope / ; Lliam Edger / ; Julie Dawson / ; Daniel Hadfield / ; Phil Hopkins / ; Lisa McDonald / ; Chris Willars / ; Gillian Campbell / ; Jayne Craig / ; Andrew Smith / ; Karleen Ladipo / ; Geoff Lockwood / ; Juan Moreno / ; Ruth Ballington / ; Sibongilele Hamandishe / ; David Rogerson / ; Sarah Cowman / ; Paul Hayden / ; Nuno Pinto / ; Taj Sandhar / ; Dilshan Arawwawala / ; Lauren Brotherston / ; Christine Mitchell-Inwang / ; Helena Walsh / ; Famila Alagarsamy / ; Serena Goon / ; Sylvia Karcheva / ; Amy Krepska / ; Brian McKinney / ; Vishal Patil / ; Nicholas Batchelor / ; Christopher Day / ; Louise Finch / ; Charlie Gibson / ; Matthew Grayling / ; Sheena Hubble / ; William Key / ; Thomas Knight / ; Alexander Loosley / ; Paul Margetts / ; Hannah Stewart / ; Jeremy Bewley / ; Katrina Hurley / ; Ruth Murphy / ; Catherine Philpott / ; Kathryn Pollock / ; Katie Sweet / ; Matthew Thomas / ; Katy Tucker / ; David Windsor / ; Daniel Conway / ; Steve Gold / ; Tanviha Quraishi / ; Jason Cupitt / ; Sally Baddeley / ; John David Brown / ; Irwin Foo / ; Damien Mantle / ; Peter Carvalho / ; Sam Huddart / ; Justin Kirk-Bayley / ; Rebecca Smith / ; Lisa Milligan / ; Sonia Poulose / ; Som Sarkar / ; Jerry Nolan / ; Emma Pedley / ; Andrew Padkin / ; Siamak Pesian / ; Satish Rajamanickam / ; Konnur Ramkumar / ; Jerry Thomas / ; Alison Crayford / ; Angus Turner / ; Fiona Bottrill / ; Stephen Webb / ; Shaman Jhanji / ; Niall MacCallum / ; Kate Wessels / ; Tim Wigmore / ; Alistair Meikle / ; Stephen Wilson / ; Stuart White / ; Andrew Bonnett / ; Andrew Rushton / ; Colin Williams / ; Oliver Zuzan / ; Andrew Hall / ; Jane Montgomery / ; Ailie Piggot / ; Richard Read / ; Mary Stocker / ; Tiina Tamm / ; Banwari Agarwal / ; Stephen Ward / ; Lucy Brown / ; Manju Joy / ; Suresh Venkatesh / ; Thomas Hughes / ; Christine Mitchell-Inwang / ; Lajos Zsisku / ; Alistair Roy / ; Victoria Hooper / ; Johanna Mouland / ; Jeremy Nightingale / ; Steve Rose / ; Patrick Chiam / ; Harnita Chohan / ; Chris Dickson / ; Sarah Gibb / ; Charley Higham / ; Caroline Harvey / ; Chandra Janarthanan / ; Laura Jones / ; Avinash Kapoor / ; Mark Moll / ; Louise Roberts / ; David Saunders / ; Glenn Arnold / ; Claire Gibbs / ; Mhairi Jhurgursing / ; Dena Pierro / ; Frances Pritchard / ; Patrick Doyle / ; Maie Templeton / ; Robert Wilson / ; Kim Zantua / ; Thomas Collyer / ; James Featherstone / ; Rachael Worton / ; Jane Bruce / ; Kate McGuigan / ; Grant Price / ; Sarah Moreton / ; Mark Pulletz / ; Helen Anderson / ; Ian Baxter / ; Alex Beckingsale / ; Mark Callaghan / ; Ansu Datta / ; Jo Dawson / ; Jackit Gollogly / ; Chris Izod / ; Steve Lobaz / ; Caroline MacFie / ; Manju Patel / ; Heather Payne / ; Raj Singh / ; Gemma Timms / ; Shaun McLeod / ; Peter O'Brian / ; Elspeth Horner / ; Vivekananda Joshi / ; Karen Stuart-Smith / ; Tania Seale / ; Clare Bolger / ; Hannah Collins / ; Emma Ekins / ; Kim Golder / ; Lesley Hawkins / ; Max Jonas / ; Karen Linford / ; Beverley Wadams / ; Madeleine Beach / ; Marcela Vizcaychipi / ; William Jewsbury / ; Simon Davies / ; Packianathaswamy Balaji / ; Muthuraj Kangaraj / ; Nagesh Pissay / ; Neil Smith / ; Senthilkumar Gopalakrishnan / ; John MacKinnon / ; Gustav Strandvik / ; Ruth Francis / ; Adrian Jennings / ; Matthew Keating / ; Sajith Kumar / ; Sarah Leese / ; Cliona Magee / ; Jane Pilsbury / ; James Ralph / ; David Riddington / ; Rajneesh Sachdeva / ; Catherine Snelson / ; Suresh Vasanth / ; Judith Wilde / ; Beth Lavender / ; Rachel Lyons / ; Malcolm Watters / ; Tim Adams / ; Simon Dyer / ; Lucy Tindall / ; Andrew Claxton / ; Meenu Netke / ; Esam Akouds / ; Debrah Bates / ; Heather Gallagher / ; Jonathan Hatton / ; William Holroyd / ; Atideb Mitra / ; Trudy Nurse / ; Deborah Reed / ; Somi Desikan / ; Russell Barber / ; Sophie Childs / ; Britta O'Carroll-Kuehn / ; Mark Wyldbore / ; Ayad Al-Abdaly / ; Suman Amatya / ; Sherly Bhaskaran / ; Garud Chandan / ; Suman Chaudhry / ; Moses Chikungwa / ; Greg Earnshaw / ; Moni Grewal / ; Shamimul Haque / ; John Hawkins / ; Ahmed Javaid / ; Clare Jackson / ; Miriam Kamel / ; Ruchira Marla / ; Dori-Ann Mculloch / ; Tom Parker / ; Yussof Salib / ; Ramesh Saravanmuthu / ; Chris Secker / ; Siva Sockalingam / ; Anne Taylor / ; Pauline Austine / ; Vrushali Kanade / ; Dora Paal / ; May Un Sam Mok / ; Andrew Burtenshaw / ; Laura Davis / ; Parvez Ellahee / ; David Freeman / ; Richard Pierson / ; Julie Wollaston / ; Amara Karmarkar / ; Clare Ball / ; Emily Calton / ; Louise Maxwell / ; Rachel Walker / ; Martin Bland / ; Lynne Bullock / ; Donna Harrison-Briggs / ; Paul Hodge / ; Anton Krige / ; Ged Dempsey / ; Claire Hammell / ; Robert Loveridge / ; Robert Parker / ; Jane Snell / ; Carl Wright / ; Andy Baker / ; Katharine Barr / ; Alex Belcher / ; Sam Bonnington / ; Anne-Marie Bougeard / ; Emma Fitzgerald / ; Rachael Ford / ; Chantal Gillard / ; Liz Griffiths / ; Lizzie Greenberg / ; Jonathan Huber / ; Steve Mathieu / ; Neil Richardson / ; Laura Tompsett / ; Nigel White / ; Santosh Patel / ; Victoria Corner / ; Richard Thomas / ; Dawn Trodd / ; Jennifer Wilson / ; Ed Copley / ; Laura Flutter / ; Jonathan Hulme / ; Jay Susarla / ; Alison Thwaites / ; Suraj Jayasundera / ; Sean McAfee / ; Jonathan Chantler / ; Stuart McKechnie / ; Julia Neely / ; Ronelle Mouton / ; Edward Scarth / ; Jasmeet Soar / ; Joanne Buss / ; Vicki Currie / ; Mansoor Sange / ; Anja Kuttler / ; Fiona Power / ; David Alexander / ; Kevin Dunne / ; Guy Shinner / ; Euan Black / ; Grant Haldane / ; Jennie Kerr / ; Taj Saran / ; Geraldine Ward / ; Fiona Jefferies / ; Peter Alexander / ; Alison Royle / ; Farid Nahla / ; Tim Bowles / ; Maggie Gregory / ; Rebecca Ahern / ; David Cartlidge / ; Lloyd Craker / ; Christopher Thompson / ; Heena Bidd / ; Julian Giles / ; Amanda Manser / ; Gareth Parry / ; Peter Chan / ; Dinesh Das / ; Nisreen Fahmy / ; David Higgins / ; Ahmed Khader / ; Alex Stone / ; Silvia Leonardi / ; Oliver Rose / ; Elizabeth Bright / ; Ari Ercole / ; Muhammed Amir Rafi / ; Radhika Ramasamy / ; Bengeri Sheshgiri / ; Colin Merrill / ; Valerie Page / ; Elaine Walker / ; Stephen Harris / ; Sarah Hughes / ; Alan Morrison / ; Khaled Razouk / ; Mustafa Ayman / ; Nawaf Al-Subaie / ; Fuhazia Arif / ; Jeremy Cashman / ; Maurizio Cecconi / ; Mark Edsell / ; Nicoletta Fossati / ; Sarah Jane Hammond / ; Mark Hamilton / ; Dagan Lonsdale / ; Carl Moran / ; Andrew Rhodes / ; Claas Siegmueller / ; Freya Velzeboer / ; Patrick Wong / ; Alicia Jakeman / ; Chris Mowatt /
Comments/Corrections
Comment In:
Lancet. 2013 Feb 2;381(9864):369-70   [PMID:  23374466 ]
Lancet. 2013 Feb 2;381(9864):370   [PMID:  23374470 ]
Lancet. 2013 Feb 2;381(9864):369   [PMID:  23374467 ]
Lancet. 2013 Feb 2;381(9864):369   [PMID:  23374468 ]
Lancet. 2013 Feb 2;381(9864):370-1   [PMID:  23374469 ]
Lancet. 2013 Feb 2;381(9864):370   [PMID:  23374471 ]
Lancet. 2013 Dec 21;382(9910):2063   [PMID:  24360379 ]
Lancet. 2012 Sep 22;380(9847):1034-6   [PMID:  22998699 ]
Orthopade. 2013 Aug;42(8):663   [PMID:  23912306 ]
Lancet. 2013 Dec 21;382(9910):2063-4   [PMID:  24360378 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Lancet
Journal ID (iso-abbrev): Lancet
ISSN: 0140-6736
ISSN: 1474-547X
Publisher: Lancet Publishing Group
Article Information
© 2012 Elsevier Ltd. All rights reserved.
License:
pmc-release publication date: Day: 22 Month: 9 Year: 2012
Print publication date: Day: 22 Month: 9 Year: 2012
Volume: 380 Issue: 9847
First Page: 1059 Last Page: 1065
PubMed Id: 22998715
ID: 3493988
Publisher Id: LANCET61148
DOI: 10.1016/S0140-6736(12)61148-9

Mortality after surgery in Europe: a 7 day cohort study
Rupert M Pearsea* Email: r.pearse@qmul.ac.uk
Rui P Morenob
Peter Bauerc
Paolo Pelosie
Philipp Metnitzd
Claudia Spiesf
Benoit Valletg
Jean-Louis Vincenth
Andreas Hoefti
Andrew Rhodesjk
for the European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology
aBarts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
bUCINC, Hospital de São José, Centro Hospitalar de Lisboa Central, EPE, Lisbon, Portugal
cSection of Medical Statistics, Medical University of Vienna, Vienna, Austria
dDepartment of Anaesthesia and General Intensive Care, Medical University of Vienna, Vienna, Austria
eIRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
fCharité-Universitaetsmedizin, Berlin, Germany
gAnaesthesiology and Critical Care, University Hospital, Lille, France
hErasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
iDepartment of Anaesthesiology, University of Bonn, Bonn, Germany
jSt George's Healthcare NHS Trust, London, UK
kSt George's University of London, London, UK
*Correspondence to: Dr Rupert Pearse, Adult Critical Care Unit, Royal London Hospital, London E1 1BB, UK r.pearse@qmul.ac.uk
Members listed in appendix

Introduction

More than 230 million major surgical procedures are undertaken worldwide each year.1 For most patients, risks of surgery are low and yet evidence increasingly suggests that complications after surgery are an important cause of death.2–5 About 10% of patients undergoing surgery in the UK are at high risk of complications, accounting for 80% of postoperative deaths.2–4 If this rate is applicable worldwide, up to 25 million patients undergo high-risk surgical procedures each year, of whom 3 million do not survive until hospital discharge. Patients who develop complications but survive to leave hospital often have reduced functional independence and long-term survival.5–8

Despite obvious differences in procedure-related and patient-related mortality risks, most surgical patients use one care pathway, sharing standard facilities for preoperative assessment, anaesthesia, operating rooms, post-anaesthetic recovery, and hospital wards. This approach is adequate for most patients but might not meet the needs of the small number of patients at high risk of complications and death. In the USA, evidence of variations in postoperative mortality within health-care systems suggest the potential to implement measures that improve patient outcomes.9 Low rates of admission to critical care for patients at high risk of complications undergoing non-cardiac surgery are of particular concern,2–4 and might be affected by international differences in the provision of critical care.10,11 With high volumes of surgery undertaken, even a low rate of avoidable harm will be associated with many preventable deaths.

International comparative data might provide important insights into delivery of health care for surgical patients. However, little or no data are available describing provision of care or outcomes for unselected surgical patients. The objective of the European Surgical Outcomes Study (EuSOS) was to describe mortality rates and patterns of critical care resource use for patients undergoing non-cardiac surgery across several European nations.


Methods
Study design and participants

We did this European cohort study between 0900 h (local time) on April 4, 2011, and 0859 h on April 11, 2011. All adult patients (older than 16 years) admitted to participating centres for elective or non-elective inpatient surgery commencing during the 7 day cohort period were eligible for inclusion. Patients undergoing planned day-case surgery, cardiac surgery, neurosurgery, radiological, or obstetric procedures were excluded because these patients receive care within separate, dedicated pathways. Participating hospitals (appendix pp 11–68) were a voluntary convenience sample, identified through membership of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology and by direct approach from national study coordinators. Ethics requirements differed by country. In Denmark, centres were exempt from ethics approval because this study was deemed to be a clinical audit. In all other nations formal ethics approval was applied for and given. In Finland alone we were required to obtain written informed consent from individual patients.

Procedures

Local investigators were supported by national coordinators and via a website that provided key documentation, including the protocol and guidance on study procedures. We obtained data describing perioperative care facilities once for each hospital at the beginning of the study. We collected data describing consecutive patients with paper case record forms, which we made anonymous before entering the information onto a secure internet-based electronic case record form (OpenClinica, Boston, MA, USA). We completed an operating theatre case report form for each eligible patient who we then followed up until hospital discharge for data describing hospital stay, admission to critical care, and in-hospital mortality. We completed a critical care case record form to capture data describing the first admission to critical care for any individual patient at any time during the follow-up period. Example case record forms are available from the study website.

We selected patient-level variables on the basis that they were objective, routinely collected for clinical reasons, could be transcribed with a high level of accuracy, and would be relevant to a risk adjustment model in most patients. We censored critical care and hospital discharge data at 60 days after surgery. We assessed data for completeness and then checked for plausibility and consistency with prospectively defined ranges.12

The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care.

Statistical analysis

Our aim was to recruit as many participating hospitals as possible and to recruit every eligible patient in those hospitals. We anticipated that a minimum sample size of 20 000 patients would enable a precise estimate of mortality. This sample size was also expected to provide a sufficient number of events (>200) for construction of a robust logistic regression model for mortality.

We used SPSS (version 19.0) for data analysis. Categorical variables are presented as number (%) and continuous variables as mean (SD) when normally distributed or median (IQR) when not. We used χ2 and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed several binary logistic regression models to identify factors independently associated with hospital mortality and to adjust for differences in confounding factors between countries. These included a one-level model and a hierarchical two-level generalised linear mixed model, with patients being at the first level and hospital at the second. Factors were entered into the model based on their univariate relation to outcome (p<0·05). All factors were biologically plausible with a sound scientific rationale and a low rate of missing data. The results of the model are reported as adjusted odds ratios (OR) with 95% CI. We assessed the models through sensitivity analyses with three random (disjoint) subsamples of countries and a fourth sample removing all patients from the largest country in the dataset (the UK). We explored all possible interacting factors and examined how they might have affected the final results.

This study is registered with ClinicalTrials.gov, number NCT01203605.

Role of the funding source

The study was funded by the European Society of Intensive Care Medicine and the European Society of Anaesthesiology who appointed an independent steering committee (appendix p 11), who were responsible for study design, conduct, and data analysis. Members of the steering committee had full access to the study data and were solely responsible for interpretation of the data, drafting and critical revision of the report, and the decision to submit for publication.


Results

We collected data describing patients undergoing in-patient surgery in 498 hospitals across 28 European nations. Median number of operating theatres in each hospital was 15 (IQR 10–22) and median number of critical care beds was 19 (9–40). Data were returned for 46 985 cases of which 446 were removed having been identified as duplicates or having missing critical care or mortality data, leaving 46 539 for analysis (figure 1). A median number of 83 (39–125) patients were included per hospital and 1045 (455–1732) per country. 281 (56%) hospitals were affiliated to a university, recruiting 31 132 patients (68% of total, appendix p 2).

Table 1 shows baseline data for all patients. Overall crude mortality was 4·0% and the median duration of hospital stay was 3·0 days (IQR 1·0–7·0). Prevalence of comorbid disease, grade of surgery, crude mortality rates, duration of hospital stay, and number of critical care admissions differed substantially between countries (table 2, appendix p 2). Table 2 shows unadjusted OR for hospital mortality by country. 3599 patients (8%) were admitted to critical care at some point during hospital stay, of whom 2555 (71%) had planned admissions (figure 2). Median stay in critical care was 1·2 days (0·9–3·6). 1358 patients who died were not admitted to critical care at any stage after surgery (73% of all deaths). 506 patients (14%) admitted to critical care died before hospital discharge, of whom 218 (43%) died after the first admission to critical care was complete.

We explored variables associated with hospital mortality in a univariate analysis, the findings of which were much the same as for a sensitivity analysis of different subsets of the database (table 1, appendix pp 3–4). We then constructed several binary logistic regression models to adjust for baseline differences that might explain the unadjusted OR for individual countries (table 2). We developed both single-level and multilevel models (appendix pp 5–8) with variables that were significant in the univariate analysis. The point estimates for the OR did not differ greatly between the one-level and two-level models, but the hierarchical model consistently provided a more conservative estimate of country effects across the sensitivity tests (appendix p 9).

We constructed a further model including all significant interacting factors (appendix p 10). Since this increased model complexity did not substantially change the country-level estimates, we report results of the more parsimonious two-level model without interactions (figure 3). Factors that were independently associated with mortality and that we therefore used to adjust for baseline confounders were: country where surgery was done, urgency of surgery, grade of surgery, surgical procedure category, age, American Society of Anesthesiologists (ASA) score, metastatic disease, and cirrhosis (appendix pp 7–8). We entered ASA score rather than the Lee Revised Cardiac Index because, although the two were highly correlated, less data describing ASA score were missing.

With the UK study population as the reference category, we identified higher unexplained rates of mortality in Poland, Romania, Latvia, and Ireland (table 2, figure 3).


Discussion

This international prospective study has provided data for a population of more than 46 000 unselected patients undergoing inpatient surgery from 28 European countries. 4% of included patients died before hospital discharge, which was a higher mortality rate than expected.2,3,6,13–16 We identified substantial differences in crude and risk adjusted mortality rates between countries. When compared with the UK, the recorded mortality rates for Poland, Latvia, Romania, and Ireland were higher even after adjustment for all identified confounding variables. This pattern could relate to cultural, demographic, socioeconomic, and political differences between nations, which might affect population health and health-care outcomes.

A major strength of our study was the large number of consecutive unselected patients enrolled in a multicentre and multinational setting. A vigorous approach to follow-up for missing and incomplete data provided a high-quality dataset for analysis. The dataset allowed us to explore probable prognostic factors and to adjust crude mortality rates to describe differences in outcomes between countries. Our analysis identified several factors associated with increased mortality. These findings suggest that surgery-related and patient-related factors interact to increase mortality risk. Only two comorbid disease categories were identified as independent variables. This finding probably arose because the ASA score was designed to describe the severity of coexisting medical disease.

Evidence suggests that critical-care-based cardiorespiratory interventions can improve outcomes among high-risk surgical patients.17–21 However, in our study, only 5% of patients underwent a planned admission to critical care with a median stay of about 1 day. Unplanned admissions to critical care were associated with higher mortality rates than were planned admissions. Remarkably, most patients who died (73%) were not admitted to critical care at any stage after surgery. Of patients who died after admission to critical care, 43% did so after the initial episode was complete and the patient had been discharged to a standard ward. These findings suggest a systematic failure in the process of allocation of critical care resources. This notion is consistent with previous reports of a failure to rescue deteriorating surgical patients with a detrimental effect on patient outcomes22 and the high incidence of myocardial injury in the days after surgery.23 For some patients with a poor prognosis, postoperative admission to critical care might have been deemed inappropriate—eg, after palliative surgery for disseminated malignancy. However, our data suggest these cases are few in number (<5% of patients had malignancy, table 1). Meanwhile other investigators have challenged the suggestion that patients should be offered surgery when the standard of postoperative care is unlikely to be adequate for their needs.2 The low rate of admission to critical care prevents any detailed comparison of this resource between nations. Further research is needed to better understand whether early admission to critical care can improve survival after major surgery.

Despite the large sample size, our study might not be truly representative of current practice across Europe because only a small proportion of European hospitals took part. Although in some countries the patient sample was large enough to show national practice, the high proportion of patients enrolled in university hospitals in other countries suggests a degree of selection bias. In particular, our data might not show the true surgical case-mix and standards of care in countries with a small number of participating hospitals. Although we planned to enrol every eligible patient undergoing surgery during the study period, we cannot be sure of the exact proportion of eligible patients included. Nonetheless, assuming the volume of surgery during the cohort week is typical of the participating hospitals, these centres undertake more than 2·3 million inpatient surgical procedures each year, which is 1% of the estimated volume of surgery taking place worldwide.1 Whether truly representative or not, our findings clearly describe a large cross-section of health care in Europe.

Some of our findings might be indicative of limitations of commonly used risk-adjustment variables with unexpected patterns of survival across categories for both ASA score and grade of surgery. This finding could result from the poor ability of clinicians to discriminate between the less severe categories of these variables. Random partitioning of the countries into three equal groups and repetition of the modelling exercise showed much the same results with regards to the OR of the relevant effect factors, showing some stability of the risk adjustment in subsets of countries. This stability was further confirmed in more complex models that included interactions between variables for which none of the interactions with the country factor contributed significantly to prediction. We identified other interactions that did significantly contribute to prediction but we did not record a substantial change in country effects when estimated from the extended model including these interactions. We therefore decided to use the simpler of the hierarchical models for the final analysis because our aim had been to construct a parsimonious model that practising clinicians would easily understand.

As far as we are aware, this was the first large, prospective, international assessment of surgical outcomes (panel). In some countries, data are available that describe survival after specific procedures such as vascular, joint replacement, or bowel cancer surgery.24–26 However, these audits are poorly representative of overall national surgical populations because high-risk patients are under-represented. The few previous estimates suggest an overall mortality for unselected inpatient surgery of between 1% and 2%,2,3,6,13–16 but these values are representative of only a few health-care systems. In a previous study13 of national registry data from the Netherlands, 30 day mortality was reported as 1·85%, which is much the same as the crude hospital mortality of 2% for this country in the EuSOS study. In the UK, a prospective investigation2 with a very similar methods to EuSOS identified a postoperative critical care admission rate of 6·7%, which is much the same as to the value of 6% for EuSOS in the UK.2 However, 30 day mortality was 1·6% compared with 3·6% for 60 day in-hospital mortality for UK patients in EuSOS. Reports from nations outside Europe describe 30 day mortality rates from 1·3% to 2·0%.6,14,15

Previous investigators have described the differences in provision of health services across Europe, in particular numbers of critical care beds.10,11 The reported seven-times greater provision of critical care beds for Germany than for the UK is likely to affect rates of admission to critical care and postoperative outcomes.10,11,27 This finding is in keeping with our present data that show a greater rate of admission to critical care after surgery in Germany than in the UK. Other studies have shown that fewer than a third of high-risk non-cardiac surgical patients are admitted to critical care after surgery in the UK despite high mortality rates,2–4 which is consistent with the results of our study; across Europe 73% of surgical patients who died were never admitted to critical care. This situation contrasts with perioperative care for cardiac surgical patients who by definition have severe comorbid disease and undergo major body cavity surgery followed by routine admission to critical care with mortality rates of less than 2%.28 Several reasons could explain why outcomes for cardiac and non-cardiac surgical patients differ but the quality of perioperative care is likely to be among the most important. The heath-care community increasingly recognises the importance of the entire perioperative care pathway including preoperative assessment, optimisation of coexisting medical disease, integrated care pathways relevant to the surgical procedure, WHO surgical checklists, advanced haemodynamic monitoring during surgery, early admission to critical care, acute pain management and critical-care outreach services, and hospital discharge planning together with the primary care physician.20,21 Routine audit and reporting of data for clinical outcomes has also proved a highly effective instrument for improvement of the quality of perioperative care.29

Our findings suggest both the need and potential to implement measures to improve postoperative outcomes. In addition to further research in this discipline, the root causes of this problem could be better understood through increased use of high-quality registries designed to capture robust data describing quality of care and clinical outcomes for surgical patients. This step would require increased funding for this specific area of health services research. The high mortality rate after surgery might be modified by changes in the organisation of care.20


References
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Supplementary Material

Supplementary appendix


Acknowledgments

This study was funded by the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. RP is a National Institute for Health Research (UK) Clinician Scientist.


Contributors

All authors were involved in the design and conduct of the study. Data collection and collation was done by the members of the EuSOS study group. AR, RM, and PB did the data analysis with input from RP. The report was drafted by RP and AR and revised following critical review by all authors.


Conflicts of interest

We declare that we have no conflicts of interest.


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