Post-operative morbidity and mortality in Indigenous Peoples: A scoping review and meta-analysis

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Abstract
Indigenous Peoples across North America and Oceania experience worse health outcomes compared to non-Indigenous people, including increased post-operative morbidity and mortality. No data is available on global differences in surgical morbidity and mortality between geographic locations and across surgical specialties. The aim of this study is to evaluate disparities in post-operative morbidity and mortality between Indigenous and non-Indigenous populations. This scoping review and meta-analysis was conducted in accordance with PRISMA-ScR and MOOSE guidelines. Eight electronic databases were searched with no language restriction. Studies reporting on Indigenous populations outside of Canada, the USA, New Zealand, or Australia, or on interventional procedures were excluded. Primary outcomes were post-operative morbidity and mortality. Secondary outcomes included reoperations, readmission rates, and length of hospital stay. The Newcastle Ottawa Scale was used for quality assessment. Eighty-four unique observational studies were included in this review. Of these, 67 studies were included in the meta-analysis (Oceania n=31, North America n=36). Extensive heterogeneity existed among studies and 50% were of poor quality. Indigenous patients worldwide had 1.26 times higher odds of post-operative morbidity (OR=1.26, 95% CI: 1.10-1.44, p<0.01) and 1.34 times higher odds of post-operative infection (OR=1.34, 95% CI: 1.12-1.59, p<0.01) than non-Indigenous patients. Indigenous patients also had 1.33 times higher odds of reoperation (OR=1.33, 95% CI: 1.02-1.74, p=0.04) and longer hospital stays (SMD=0.09; 95% CI: 0.02-1.08; p=0.05). In conclusion, we found that Indigenous patients experience significantly poorer surgical outcomes than their non-Indigenous counterparts. Additionally, there remains a paucity of high-quality research focusing on assessing and improving surgical equity for Indigenous patients worldwide, despite multiple international and national calls to action for reconciliation and decolonization to improve access to quality surgical care for Indigenous populations.

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