August 9, 2022
Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Ko C, Shah T, Nathens A, et al. How Well Is Surgical Improvement Being Conducted? Evaluation of 50 Local Surgery-Related Improvement Efforts. J Am Coll Surg. 2022, in press.
The National Academy of Medicine has defined high-quality care as that which is safe, effective, patient-centered, timely, efficient, and equitable. The authors, including Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director of the ACS Division of Research and Optimal Patient Care, cite data that indicate efforts to achieve high-quality care frequently fall short of achieving their goals. Surgical quality problems usually are identified based on the recognition of preventable mortality and morbidity, inefficient care, and patient harms. Additional research cited in the article demonstrate that quality problems resulting in patient harm may be present in up to 40% of surgical care episodes.
To quantify the local effectiveness of surgical quality improvement efforts, the authors evaluated 50 projects conducted at the hospital/unit level in 10 institutions that participate in the ACS Continuous Quality Improvement programs. Success of the quality improvement (QI) initiative was judged based on 39 criteria grouped into eight component areas. The mean percentage of criteria fulfilled for the 50 efforts was 39%, and only 24% of the QI efforts reported full achievement of the criteria. Potential reasons for failure to achieve QI goals included lack of resources, inadequate monitoring of progress, and competing priorities that interfered with participation by surgeons and other healthcare professionals. The authors concluded that a considerable proportion of surgical QI efforts do not achieve preset goals, suggesting that continued efforts to improve the success rates are needed.
Noorduyn JCA, van de Graaf VA, Willigenburg NW, et al. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People with Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open. 2022;5(7):e2220394. doi:10.1001/jamanetworkopen.2022.20394
A scarcity of quality evidence is available supporting the long-term effectiveness of arthroscopic meniscectomy versus physical therapy for patients with partial tears of the knee meniscus. The authors presented data on 5-year outcomes of a randomized trial comparing the two treatment modalities. The trial was a multicenter, randomized, non-inferiority study.
The study cohort consisted of 321 patients ages 45 to 70 years old. Each participant was diagnosed with a degenerative meniscus tear. The primary outcome of interest was patient-reported knee function based on an internationally accepted grading scale. The secondary outcome was progression of knee osteoarthritis based on radiological imaging. Complete 5-year data were available for 278 of the 321 patients.
The mean improvement in knee function scores was 29.6 for patients undergoing arthroscopy and 25.1 for patients treated with physical therapy. This difference was not statistically significant. Rates of knee osteoarthritis progression were similar in both groups. The authors concluded that physical therapy was not inferior to arthroscopic meniscectomy.
Hallstrom B, Meremikwu R. Arthroscopic Treatment of Degenerative Meniscal Tears and Sham Surgery or Physical Therapy—An Update on the ESCAPE Trial. JAMA Netw Open. 2022;5(7):e2220405. doi:10.1001/jamanetworkopen.2022.2040
In the editorial that accompanied the article, Brian Hallstrom, MD, and Ramzy Meremikwu, MD, noted that despite the substantial number of high-quality studies that have shown no benefit for surgical treatment of this condition, including this report, surgeons continue to perform this operation. Although the risk of mortality and morbidity is extremely low with this procedure, patients are at risk for a decline in quality of life, and these operations are associated with significant financial costs to healthcare systems. It is worth noting that the data presented in the article and the perspectives offered in the editorial primarily came from orthopaedic surgeons. Whether these data will stimulate a change in surgical practice is unknown at this time.