Surgical Quality in Haiti: The Development of a Quality Assessment for the Emory University School of Medicine and Project Medishare Surgery Trip Open Access

Quinn, Megan Elizabeth (2015)

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Background: Surgical pathology comprises a large portion of the global burden of disease - disproportionately affecting low- and middle-income countries (LMICs). As LMICs currently lack the healthcare infrastructure, healthcare personnel, and training to handle this caseload, an unknown amount of surgery is performed by international organizations. Despite this, there is a paucity of data regarding the quality of care provided by these groups. The Emory University School of Medicine and Project Medishare (EUSOM-PM) surgery trip attempts to increase access to surgical services in the Central Plateau of Haiti, but has yet to establish a system to assess the quality of care provided to patients.

Objective: The goal of this thesis is to define indicators of surgical quality applicable to a low-resource setting and to establish reliable data collection techniques for the EUSOM-PM surgery trip. Methods: Indicators of surgical quality validated in the United States that were transferable to a low-resource setting were included in a data collection instrument. The instrument was used to gather information regarding structural, process, and outcome elements of patient care Results: Quantitative data collected using the data instrument had high response rates and provided complete information regarding patient demographics, processes of care, and outcomes.

Conclusions: A standardized data collection instrument results in more complete data regarding the patient population and the quality of care provided. However, the small quantity of data, particularly the low rates of adverse postoperative outcomes, limits any conclusions regarding the validity of indicators. Continued use of the data instrument will allow for the generation of a multi-year aggregated data set, providing information about shifts in patient demographics, reflect alterations in care processes, and potentially, the impact of these factors on patient outcomes.

Table of Contents

Table of Contents

Chapter 1: Introduction

1.1 Introduction 1

1.2 Statement of the Problem 2

1.3 Purpose 2

1.4 Significance 3

Chapter 2: Literature Review 4

2.1 The Scope of the Problem 5

2.2 Global Disparities in Surgical Services 7

2.2.1 Lack of a Surgical Infrastructure 8

2.2.2 Lack of Trained Healthcare Professionals 10

2.2.3 Lack of Adequate Funding 11

2.3 Surgery and Public Health 12

2.4 Addressing the Gap: Platforms of Surgical Delivery 14

2.4.1 Specialty Surgical Hospitals 15

2.4.2 Temporary Surgical Platforms 16 Self-Contained Surgical Platforms 16 Short-Term Surgical Trips 17

2.4.3 The Emory University School of Medicine - Project Medishare Short-Term Trip 18

2.5 Theories of Healthcare Quality 19

2.5.1 Surgical Quality Assessments 22

2.5.2 Quality Assessments in Global Surgery 24

2.6 The Importance of Quality Assessment 26

Chapter 3: Methods 28

3.1 Sample Population 28

3.2 Research Design 29

3.3 Data Collection and Analysis 31

3.4 Limitations 33

Chapter 4: Results 35

4.1 Findings 35

4.1.1 Data Collection Tool 35

4.1.2 Patient Demographics 36

4.1.3 Structures and Processes 38

4.1.4 Outcomes 39

Chapter 5: Discussion and Conclusions 44

5.1 Overview 44

5.2 Principle Findings 44

5.2.1 Data Collection Tool 44

5.2.2 Assessment of Quality Metrics 46

5.3 Strengths and Weaknesses 48

5.4 Implications of the Study 50

References 51

Appendix 1: Full List of Preoperative NSQIP Variables 56

Appendix 2: Data Collection Tool 58

Appendix 3: Definitions of Variables 67

List of Tables

Table 1: Response Rates of Selected Variables 40

Table 2: Demographics of Patients Evaluated by the EUSOM-PM Surgery Trip 41

Table 3: Operative Variables 42

Table 4: Process Variables 43

Table 5: Outcomes Measures 43

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