Establishing a National Registry for Hand Surgery

Patient-Derived Framework for Quality in Hand Surgery: A Qualitative Analysis

PURPOSE

Despite the growing attention to evaluating care from the patient perspective, the most common definitions and measurements of quality are currently defined by physicians and health systems. Studies have demonstrated how a lack of patient input can lead to discrepancies between patients' and physicians' assessments of quality and, subsequently, worse patient outcomes. Although quality measures are increasingly used in hand surgery, insufficient work has examined whether these quality measures align with what matters to patients. We completed a qualitative study to assess how patients define high-quality care through the pre-, peri-, and postoperative phases of care in hand surgery.

METHODS

Based on our prior work, we created an open-ended interview guide and conducted semistructured interviews with 43 hand surgery patients at 5 tertiary-care institutions during various phases of care. We completed a thematic analysis to generate subcodes and open codes, to identify themes in high-quality care from the patient perspective.

RESULTS

Patients defined high-quality care as a process of (1) setting and meeting clear expectations; (2) achieving functional goals after surgery; and (3) feeling comfortable with and cared for by the care team. We identified the following 4 patient-centered themes that contributed to high-quality care: (1) communication between the patient and care team through all phases of care; (2) efficient and accurate diagnosis and treatment; (3) satisfactory treatment outcomes and postsurgical experience; and (4) acceptable systemic aspects of care.

CONCLUSIONS

Efforts to improve health care delivery should include areas of care that are important to patients. Our results suggest that measuring aspects of care that often go without assessments, such as communication, can maximize care quality as defined by patients.

CLINICAL RELEVANCE

The themes identified in this study can inform efforts towards patient-centered quality measure development.

Construct validity, floor and ceiling effects, data completeness and magnitude of change for the eight-item HAKIR questionnaire: a patient-reported outcome in the Swedish National Healthcare Quality Registry for hand surgery

Introduction

The aim of this study was to evaluate the construct validity, floor and ceiling effects, data completeness and magnitude of change over time for the eight-item patient questionnaire (HQ-8) in the Swedish Healthcare Quality Registry for hand surgery (HAKIR).

Methods

Construct validity was investigated through predefined hypotheses and correlation statistics between the single items in HQ-8 (pain on load, pain on motion without load, pain at rest, stiffness, weakness, numbness, cold sensitivity and ability to perform daily activities) and QuickDASH. Floor and ceiling effects and data completeness were analysed at preoperative (n = 13,197), three months (n =10,702) and one year (n = 9,986) responses from hand surgery patients. Effect sizes were calculated for pre- and postoperative change scores in elective conditions and postoperative scores for acute conditions.

Results

Correlation coefficients at pre, 3 and 12 months ranged from 0.44 to 0.79 in the total group. No ceiling effect occurred, but a floor effect for the total group was noted for all items at all follow-ups. Missing responses were < 2.6% except for cold sensitivity. The effect sizes varied from small to large for individual items in elective diagnoses. For acute injuries, small effect sizes were found.

Discussion

This study provides evidence of construct validity of HQ-8, lack of ceiling effect, expected floor effect, good data completeness and an ability to detect changes over time. The results indicate that HQ-8 measures unique aspects of disability. The HQ-8 could complement the Quick-DASH in describing patient-reported outcomes after hand surgery.

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.