Evaluation of indications for and outcomes of elective surgery

Abstract

Background: Wide small-area variations in the rates of elective surgical procedures and lack of systematic outcome measurement have raised questions about the appropriateness of such surgery. Our objective was to determine the feasibility of routine evaluation of indications for and outcomes of elective surgery.

Methods: Participants consisted of 138 surgeons and 5313 patients who underwent 1 or more of 6 specific surgical procedures (for a total of 6274 operations). Surgical indications were evaluated according to published guidelines. Patients' self-reported health-related quality of life (HRQOL) before and at appropriate intervals after surgery was measured with standard, validated generic and disease-specific instruments. Patient-specific results were routinely sent to the surgeons, from whom feedback was requested.

Results: Surgeons provided information on the indications for surgery for 44% to 95% of the 6 procedures, and the indications matched the guidelines in 73% to 99% of cases. Completed HRQOL questionnaires were returned by 58% of the patients. Postoperative HRQOL scores were markedly improved in most patients, but in 2% to 26% of the various procedures, there was either no change or a deterioration in HRQOL. In most of the procedure groups a small proportion of patients had relatively minor symptoms and disability preoperatively, but in the cataract surgery group this proportion was large. Opinion among the participating surgeons was divided as to the potential value of this method of evaluation. The cost of the outcome evaluation program was about $12/patient.

Interpretation: Evaluation of indications for and outcomes of elective surgery could be implemented systematically at reasonable cost and could be included in an accountability framework for health services. Most surgeons were not enthusiastic about this kind of evaluation.

Fig. 1: Cataract surgery. Distribution of preoperative Visual Function Assessment scores. A score of 100 indicates that the patient has no visual complaints whatever; a score of 0 indicates virtual blindness. Data were missing for 1% of patients.

Fig. 2: Cataract surgery. Distribution of postoperative changes in Visual Function Assessment score. Data were missing for 3% of patients.

Fig. 3: Total hip replacement. Distribution of postoperative changes in score on the Western Ontario and McMaster Universities Osteoarthritis Index. Data were missing for 4% of patients.