A reflection of outcomes research and its impact on the practice of hand surgery

‘Outcomes research’ has become a common phrase in hand surgery research. The increasing prevalence of outcomes research is driven by a universal interest to slow down the escalating costs of health care. Everyone recognizes the importance of this topic, and researchers and journals have devoted energy and effort towards outcomes research. But exactly what is outcomes research? Is it randomized controlled trials with clinical outcomes, analysis of large datasets, economic analyses, or case series? Many terms and methodologies are used in association with outcome research, but there is a lack of clarity on what this field includes and its relevance to hand surgery The term outcomes research began with Donabedian’s work in the 1960s. Prior to this, most of the medical literature assessed concrete outcomes such as survival, or functional measures such as grip strength. Donabedian felt that it was important to have a broader view of health care. In his seminal work ‘Evaluating the quality of health care’, he highlighted the need to included economic efficiency, patient satisfaction and examine process measures (Donabedian, 1966). This new paradigm of research (beyond survival and functional measures) formed the foundation for the field of medical outcomes research. The medical specialties rapidly adopted these concepts and developed innovative research methodology such as psychometric measurements of outcomes through patient reported questionnaires. The surgical fields followed by developing a battery of patient-reported outcomes, and hand surgery has lead this movement by embracing the Michigan Hand Outcomes Questionnaire (MHQ), the patient evaluation method (PEM), the disabilities of the arm, shoulder and hand (DASH) questionnaire and many others as standard outcomes tools. In the 1970s, with increasing economic pressures on health care, government and society began to worry about the rising costs of health care. In 1976 the US Congress wrote about the problem of ‘unnecessary surgery’ (Moss and Staggers, 1976). Dr Chase recognized that using Congress’s definitions, much of hand surgery would be considered unnecessary (Chase, 1983). For example surgery was deemed unnecessary if operations were to alleviate endurable symptoms. In Britain, the National Health Service (NHS) recognized the importance of valuing care, and health care benefits were described as direct benefits (decreased health care costs), increased production (decreased disability or death) and intangible benefits (Anonymous, 1978; Ward, 1978). Intangible benefits, such as quality of life, were the hardest to value and are often the area of greatest benefit in hand surgery. In an environment where scarce resources were being allocated and the value of hand surgery was difficult to calculate, Dr Chase wrote a call to arms asking for standardization of hand outcome questionnaires, the recognition of improved quality of life after surgery and an understanding of the total cost of hand injuries, which spurred outcomes research in hand surgery (Chase, 1983). Dr Amadio followed this interest in 1994 with an article that highlighted outcomes research as a discrete field important to hand surgery (Amadio, 1994). Soon thereafter hand surgery entered the outcomes field with the development of standardized validated hand outcome measures, which accounted for patient preferences and function: the DASH in 1996 and the Michigan Hand Outcomes Questionnaire in 1998 (Chung et al., 1998; Hudak et al., 1996). From that time onward, these measures have been extensively used, translated into many languages, and provide uniform measures for our field (Dubert et al., 2001). Since 2000, hand surgery outcomes research publications have become more common and increasingly have health policy implications. For example, studies have looked at the health care system and found barriers to some hand surgery care. These studies highlighted the important role of referring patients to hand specialists in the areas of rheumatoid arthritis and spinal cord injuries (Alderman et al., 2003; Curtin et al., 2007). Without the support of referring physicians, many patients are simply not informed of surgical options. Outcomes research has also attempted to answer some of the burning controversies in hand surgery using sophisticated data pooling techniques, such as systematic review and A reflection of outcomes research and its impact on the practice of hand surgery 524138 JHS0010.1177/1753193414524138The Journal of Hand SurgeryFurther Knowledge/21st Century research: a personal view research-article2014