Defining Quality in Health Care and Measuring Quality in Surgery:

Insurance Status and Disparities in Outpatient Care after Traumatic Injuries of the Hand: A Retrospective Cohort Study

BACKGROUND

Hand-injured patients seen in the emergency department can often be followed as outpatients for definitive care and rehabilitation. Many face barriers to continuing care in the outpatient setting that impact quality of care delivery. The authors aimed to evaluate patterns of outpatient follow-up after initial emergency department evaluation of traumatic hand injuries, identify factors associated with poor follow-up, and suggest areas for improvement.

METHODS

In this retrospective cohort study, the authors reviewed records of adult patients with acute hand injuries referred for outpatient follow-up after initial plastic surgery consultation in the emergency department of a single urban Level I trauma center over a 12-month period (n = 300). Patients were grouped by insurance (i.e., no insurance, Medicaid, Medicare, or private). Outcomes included completion of outpatient follow-up, hand therapy participation, and emergency department return visits.

RESULTS

Factors significantly associated with failure to follow up included male sex (OR, 3.58; 95 percent CI, 1.57 to 8.16), uninsured status (OR, 3.47; 95 percent CI, 1.48 to 8.16), Medicaid insurance (OR, 4.46; 95 percent CI, 1.31 to 15.25), and lack of a driver's license (OR, 3.35; 95 percent CI, 1.53 to 7.34). Hand therapy attendance and unexpected emergency department return visits also varied significantly by insurance type (p < 0.001).

CONCLUSIONS

There is a significant disparity in the use of outpatient care after emergency department visits for acute hand injuries. Uninsured and Medicaid-insured patients are significantly less likely to initiate recommended hand specialty follow-up, and significantly less likely to complete follow-up even when established with an outpatient clinic. Future research should evaluate targeted interventions for at-risk patients.

Applying the British Association of Oral and Maxillofacial Surgeons quality outcomes metrics to a UK oncology and reconstructive surgery service - benchmarking the data

The British Association of Oral and Maxillofacial Surgery is soon to implement the Quality Outcomes in Oral in Maxillofacial Surgery (QOMS) to provide a platform for quality management across the specialty in the UK. The initial oncology and reconstruction audits for QOMS involves data collection on specific procedures and metrics. The aim of this report is to determine their appropriateness using extant audit datasets in our institution that overlap substantially with the QOMS audits. Pre-existing datasets comprising information on patients treated for oral cavity SCC with curative intent were analysed. Data on surgical margins, lymphadenectomy lymph node yield, delay between surgery and adjuvant radiotherapy, duration of hospital stay, and complications including flap failures were analysed. All statistical analyses were performed with SPSS 25. Run charts describing longitudinal data were generated using SPC for Excel version 6. Twenty three patients (3.1%) of 701 resections had a positive surgical margin reported. Seventeen (4.3%) of patients had less than 18 LNs in the ND specimen analysed. Mean time to start date of adjuvant therapy was 62 days. Only 9% of patients commenced adjuvant therapy within 6 weeks. The median duration of stay was 18 days. In 1153 free flaps a failure rate of 4.3% was identified. A total of 1349 complications (CD I-V) were recorded in the 1111 patients undergoing major surgery with free flap reconstruction. The QOMS selected metrics for oncology and reconstruction are clinically relevant, readily measurable, and likely to be actionable by the surgical team.

Standardization for oncologic head and neck surgery

The inherent variability in performing specific surgical procedures for head and neck cancer remains a barrier for accurately assessing treatment outcomes, particularly in clinical trials. While non-surgical modalities for cancer therapeutics have evolved to become far more uniform, there remains the challenge to standardize surgery. The purpose of this review is to identify the barriers in achieving uniformity and to highlight efforts by surgical groups to standardize selected operations and nomenclature. While further improvements in standardization will remain a challenge, we must encourage surgical groups to focus on strategies that provide such a level.

Quality management in surgery: improving clinical and surgical outcomes

Quality is a term used by various specialists, from different perspectives, having as a common point to identify focuses that promote their development in institutional management. Quality processes allow us to improve assistance, reducing complication and death rates and reducing costs. Currently, the positive experience of the patient is highly valued and should be sought by all institutions. The benefits of quality procedures are extensive. There is evidence of lower complication and mortality rates, cost reduction, uniformity of care, improved communication and opportunity for health education. There is a need for financial investment by the institutions, but they can be converted in the future. The idea that these are just bureaucratic steps must be fought because individualistic attitudes are no longer part of safe medicine. The success of a quality process requires interdisciplinarity, integration with quality offices for effective communication. The implementation of feasible attitudes should be sought, with a high adherence rate to seek patient satisfaction and safety. We will address historical aspects, the requirements for the implementation of a quality program, the concepts of indicators and the aspects that influence the quality in surgery, in addition to presenting benefits that such a program can offer to the surgeon and the institution.

Outcomes Measurement in Global Hand Surgery

The global burden of musculoskeletal trauma is high. There is a need to improve access to safe, high-quality surgery in many low- and middle-income countries (LMICs). Numerous initiatives have taken aim at solving this underlying shortage in surgical care, including mission trips, academic programs, and international collaborations. However, much work remains to be done in LMICs compared with high-income countries (HICs). In HICs, the field of hand surgery has grown partially owing to the rigorous application of clinical research to examine outcomes and determine best practices. Patient-reported outcome measures (PROMs) have a key role as a valid patient-centered method of capturing symptoms and well-being. They have substantial promise in LMICs to understand patient symptom severity and quality of life better, monitor treatment success or failure, determine cost-effectiveness of procedures, and guide capacity building. Contextually appropriate PROMs can improve routine follow-up in LMICs and advance the practice and study of hand surgery worldwide.

Treating Hand Trauma in Low-Resource Setting: A Challenge for Low- and Middle-Income Countries

Hand trauma surgical treatment and perioperative therapy are often lacking in low- and middle-income countries resulting in high rates of patient morbidity following injury. Providing education through a multifaceted approach including in-person teaching, written resources, videos, and Internet and social media platforms and facilitating skill acquisition through simulation permits local providers to gain expertise in hand trauma care and thus benefits patients. This article outlines challenges faced by low- and middle-income countries in caring for hand trauma patients and possible implementable solutions.

Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions

BACKGROUND

In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality.

OBJECTIVE

The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures.

MATERIALS AND METHODS

An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures.

RESULTS

Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements.

CONCLUSION

Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.