Three Observations for Improving Efforts in Surgical Quality Improvement

Ko, Clifford Y.; Martin, Graham; Dixon‐Woods, Mary

doi:10.1001/jamasurg.2022.3122

Cited by 10 publications

(5 citation statements)

References 5 publications

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“…It is reproducible, reduces surveillance bias 13 , 14 and is less vulnerable to changes in coding practice as administrative data is routinely collected independently of individual surgeons or departments 15 . Additionally, development of low-cost composite quality measures is important if publicly funded healthcare systems are to reduce the administrative burden of data collection in surgery 16 and increase the value of surgical care to meet the increasing needs of the population. Despite clear limitations when composite measures are used to compare hospitals treating different populations and case-mix 11 , monitoring of a validated composite quality measure over time may be a useful component of a population-level quality assessment system for surgery, if it can act as a signal to identify impacts of population-level changes or variation that may require deeper evaluation.…”

Section: Introductionmentioning

confidence: 99%

Composite quality measures of abdominal surgery at a population level: systematic review

Rajesh,

Sorensen,

McNamara

2023

BJS Open

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Background Measurement of surgical quality at a population level is challenging. Composite quality measures derived from administrative and clinical information systems could support system-wide surgical quality improvement by providing a simple metric that can be evaluated over time. The aim of this systematic review was to identify published studies of composite measures used to assess the overall quality of abdominal surgical services at a hospital or population level. Methods A search was conducted in PubMed and MEDLINE for references describing measurement instruments evaluating the overall quality of abdominal surgery. Instruments combining multiple process and quality indicators into a single composite quality score were included. The identified instruments were described in terms of transparency, justification, handling of missing data, case-mix adjustment, scale branding and choice of weight and uncertainty to assess their relative strengths and weaknesses (PROSPERO registration: CRD42022345074). Results Of 5234 manuscripts screened, 13 were included. Ten unique composite quality measures were identified, mostly developed within the past decade. Outcome measures such as mortality rate (40 per cent), length of stay (40 per cent), complication rate (60 per cent) and morbidity rate (70 per cent) were consistently included. A major challenge for all instruments is the reliance of valid administrative data and the challenges of assigning appropriate weights to the underlying instrument components. A conceptual framework for composite measures of surgical quality was developed. Conclusion None of the composite quality measures identified demonstrated marked superiority over others. The degree to which administrative and clinical data influences each composite measure differs in important ways. There is a need for further testing and development of these measures.

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Section: Introductionmentioning

confidence: 99%

Composite quality measures of abdominal surgery at a population level: systematic review

Rajesh,

Sorensen,

McNamara

2023

BJS Open

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“…In the first 2 RCTs comparing laparoscopic to taTME, CRM-positive rates varied from 0% to 2.4% with IC TME reported in 0% to 22% 30,31 . The variability in mesorectal grade reported in RCTs raises questions regarding the internal validity of reported TME grades and whether quality control (QC) measures should be systematically implemented in the assessment of this key pathologic endpoint 30,32 . Few RCT protocols describe centralized blinded review of TME specimens, or random audits of pathology reports and TME photographs 6,16,17,20 .…”

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confidence: 99%

“…30,31 The variability in mesorectal grade reported in RCTs raises questions regarding the internal validity of reported TME grades and whether quality control (QC) measures should be systematically implemented in the assessment of this key pathologic endpoint. 30,32 Few RCT protocols describe centralized blinded review of TME specimens, or random audits of pathology reports and TME photographs. 6,16,17,20 However, the incidence of discordance in TME grades between site and central reviewers has not been routinely reported, nor has an action plan to resolve and minimize the occurrence of discordant grades.…”

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confidence: 99%

Discordance in TME Specimen Grading in a Prospective Phase II Multicenter Rectal Cancer Trial

et al. 2023

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Objectives: To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase II trial of transanal TME. Summary Background Data: Grading of TME specimens is based on macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (C/NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described. Methods: A phase II prospective taTME trial was conducted from 2017-2022 across 11 North American centers with TME quality as primary study endpoint. QC measures included training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance prior to trial reporting. Cohen’s Kappa statistic was used to assess agreement in grading. Results: Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ=0.35 (95% CI, 0.10-0.61, P<0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre- versus post-reconciliation rates of C/NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC to NC, N=1) or major downgrade (NC/C to IC, N=4) in 5 cases overall (5%). Conclusions: A 14% rate of major discordance was observed in TME grading between site and central reviewers. Resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through central review of TME photographs and reconciliation of major discordances is strongly recommended.

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“…Scouring the journal landscape in desperation to ensure we have not missed anything, I turned to JAMA Surgery , a high-impact general surgical journal that carries a range of often very technical articles. 1 I was, however, delighted to come across not an orthopaedic article, but an opinion piece on quality improvement (QI) in surgery.…”

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confidence: 99%

Why is QI quite so difficult in surgery in general, and orthopaedics specifically?

Ollivere

2023

Bone & Joint 360

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Three Observations for Improving Efforts in Surgical Quality Improvement

Abstract: This Viewpoint assesses current deficits in surgical quality improvement efforts and describes ways to potentially improve these initiatives for better outcomes.

Cited by 10 publications

References 5 publications

Composite quality measures of abdominal surgery at a population level: systematic review

Composite quality measures of abdominal surgery at a population level: systematic review

Discordance in TME Specimen Grading in a Prospective Phase II Multicenter Rectal Cancer Trial

Why is QI quite so difficult in surgery in general, and orthopaedics specifically?

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