Quality Measures in Postmastectomy Breast Reconstruction: Identifying Metrics to Improve Care

Textbook outcomes in DIEP flap breast reconstruction: a Delphi study to establish consensus

PURPOSE

Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction.

METHODS

A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of ≥ 70% agreement among respondents established consensus among the tested statements.

RESULTS

Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration ≤ 12 h for bilateral and ≤ 10 h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay < 5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI > 40, HgbA1c > 7) and case-volume cut-offs for providers (≥ 21) and institutions (≥ 44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%).

CONCLUSION

This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.

Quality Metrics in Hand Surgery: A Systematic Review

PURPOSE

The enactment of the Patient Protection and Affordable Care Act in 2010 placed an emphasis on measuring the quality of care. However, the issue of how best to measure quality remains in question. Although some surgical specialties frequently rely on quality measures such as the mortality rate, measuring quality in hand surgery necessitates the use of metrics beyond this traditional scope. A review was performed of the potential quality metrics used in the hand surgery literature published after the Affordable Care Act was enacted, to identify current trends in quality measurement and guide efforts to improve the quality of care in hand surgery.

METHODS

We searched the PubMed and EMBASE databases to identify original research articles within hand surgery to assess how care is being measured. Data extracted from the articles included study characteristics, quality metrics, and the domain(s) of quality.

RESULTS

A total of 7,308 articles were identified, and 63 prospective and retrospective articles were included in the analysis. The most common quality measure reported in the hand surgery literature was an outcome measure (100%) and the least common was a structure measure (30.2%). The most common metrics were pain (44.4%) and patient-reported measures (41.3%). Effectiveness (42.9%) was the most frequently assessed domain of quality, whereas efficiency (3.2%) was the least studied.

CONCLUSIONS

We identified quality measures used in contemporary hand surgery literature and found a substantial variation in the representation of quality metrics. Structure and process measures can be leveraged to provide a more holistic assessment of the quality of care in hand surgery.

CLINICAL RELEVANCE

Although outcome measurements are critical to understanding effectiveness, structure and process measures should be considered and reported as necessary, because these metrics may influence treatment outcomes and the development of quality measures.