Outcomes for the Journal: Introduction of Four Subdomains

This past January, an editorial in the Journal described a brief history of the outcomes movement and emphasized the expanding role of outcomes research in our field; Lin, Chung, and Rohrich delineated the need to better define criteria for “outcomes designation” in the Journal and considered its implications for the readership.1 Outcomes research has the ability to drive a research agenda forward and influence current policy and care delivery practices.1–4 As this research continues to gain traction, Plastic and Reconstructive Surgery and Plastic and Reconstructive Surgery – Global Open remain dedicated to providing readers with high-quality, evidence-based research through a rigorous review process. Plastic and Reconstructive Surgery has just categorized all the Outcomes articles from 2011 onward as the Plastic and Reconstructive Surgery Outcomes collection, available at: https://journals.lww.com/plasreconsurg/pages/collectiondetails.aspx?TopicalCollectionId=121. In this article, we propose new, reader-friendly, subcategorization outcomes criteria based on the 11 previously defined Agency for Health Care Research and Quality domains of (1) comparative effectiveness, (2) descriptive epidemiology, (3) economic assessment, (4) legislation or regulation, (5) methodologic development, (6) modeling, (7) patient-reported outcomes, (8) practice variation, (9) quality of health care, (10) sociology of health care, and (11) systematic review or meta-analysis (Table 1).1,5Table 1.: Eleven Agency for Health Care Research and Quality Categories and Definitions*BACKGROUND AND HISTORY Plastic and Reconstructive Surgery has the highest impact factor across all plastic surgery–specific journals (3.784). In addition, it currently ranks twenty-third across all surgery journals worldwide, further validating its role as one of the most innovative and trusted journals that adheres to the core principles of evidence-based medicine and emphasizes the importance of patient safety.6 Outcomes articles themselves have outperformed other journal topics and the Journal itself with respect to impact factor.7 To date, there has been no published literature investigating the application of the specifier “outcomes” to journal articles in Plastic and Reconstructive Surgery. The importance of health outcomes research is reflected by recent evidence that outcomes-designated articles had an overall impact factor of 4.457 in 20157 (outperforming all other subtopics and Plastic and Reconstructive Surgery). After reviewing all “outcomes-designated” articles published in Plastic and Reconstructive Surgery from 2009 to 2017, certain criteria included the following: use of a validated instrument, fidelity to a rigorous methodologic design, and evaluation of bias and quality-assessment tools. These studies consistently used validated methodologies, which facilitated more uniform data reporting. Improved standardization of outcomes criteria may facilitate a better understanding of the findings and clinical translation of outcomes-designated articles and increase Journal transparency regarding criteria needed for acceptance. In addition, use of criteria consistent with the practices of evidence-based medicine may allow for comparative analyses across studies.8 INTRODUCTION OF FOUR OUTCOMES SUBDOMAINS The designation of four new outcomes subdomains may allow for more defined article categorization as an Outcomes article. The image for this designation is shown in Figure 1. It will further specify outcomes designation using a simplified framework (Table 2). As these domains become more familiar and recognizable, they may become more easily understood by the reader and can influence provider practices to optimize patient care. This schema would align with and reinforce the Journal’s commitment to “chronicling the present and laying the experimental and clinical foundations for future advances in clinical and plastic surgery.”6 In addition, specification of type of outcome evaluated provides context for the article and informs the reading population of its potential impact in one of the four defined domains. Plastic and Reconstructive Surgery currently bases outcomes designation using the 11 Agency for Health Care Research and Quality criteria. It is our belief that the 11 Agency for Health Care Research and Quality domains may be distilled into the following four subdomains: prevention, quality of care, patient-reported health, and cost (Fig. 2). These simplified domain criteria may help contextualize research findings and promote reader engagement. We acknowledge that inevitable overlap exists between domains. However, review of all Plastic and Reconstructive Surgery outcomes articles published from 2009 to 2017 was consistent with their categorization into four distinct domains.Table 2.: Four Outcomes Subdomain CriteriaFig. 1.: Outcomes symbol.Fig. 2.: Four proposed outcome subdomains: prevention, quality of care, patient-reported health, and cost.Outcomes Prevention Ensuring patient safety in preventative medicine is a cornerstone of high-quality health care delivery. Patient safety practices have been defined as those that “reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.”9 Although this was not explicitly stated, definition underscores the need to evaluate current practices that have not been studied with respect to their ability to avoid or to prevent harm. In our analysis, the majority of articles in Plastic and Reconstructive Surgery evaluating patient safety as an endpoint were either systematic reviews/meta-analyses or organizational guidelines. These reviews provide readers with a critique of available literature for techniques and procedures. The criteria for designation of a systematic review as an outcomes article have been described by Kelley and Chung.10 Safety guidelines (often proposed by surgical societies) are included in this domain, as they may directly influence provider care delivery based on new findings and/or newly defined care standards. Quality of Care Quality of health care delivery has been historically difficult to define, as there are many factors that can influence care quality. Multiple outcome endpoints are often needed to ensure comprehensive evaluation of this domain. The Agency for Health Care Research and Quality defines health care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes which are consistent with current professional knowledge.”11 Studies that receive this outcomes specifier thoroughly evaluate an intervention, technique, practice variation, methodologic design, or modeling process by applying multiple validated outcome instruments. Ideally, this should include both patient and provider perspectives. This, in turn, allows the reader to evaluate whether or not a new technique meets criteria. Patient-Reported Health Patient-reported health outcome measures have revolutionized our ability to appreciate health care outcomes by providing insight into patient perception of health status and satisfaction with interventions.2,3,8 Traditional measures of survival, disease, and physiologic outcomes preclude a holistic appreciation of patient experience with disease and treatment process.8,12 An understanding of patient quality of life and function is vital for evaluating a chosen treatment strategy. Patient-reported outcome measures have been emphasized in the Journal as the gold standard for assessing these domains.8 In addition, the use of patient-reported outcome measures continues to extend its reach beyond the strictly clinical realm by influencing quality of care standards and legislation.4 The importance of patient-reported outcome measuring tools has gained widespread acceptance in medicine.13,14 Their importance in the field of plastic and reconstructive surgery has been previously described in multiple articles.1,2,8,14,15 As new surgical techniques emerge, it is of paramount importance that refinement of existing or validation of new patient-reported outcome measures keep pace with advances in treatment. Cost Our current health care environment emphasizes the importance of delivery of cost-effective, high-quality care. Evaluation of surgical techniques using economic tools to compare the costs and outcomes of different interventions can allow for the identification of techniques that emphasize safety, objectify quality of care, and optimize patient-perceived outcomes of care. Plastic and reconstructive surgery is a rapidly growing field and new (and often more expensive) technologies and innovations outpace our ability to economically assess their value early on. The methodology for conducting cost studies has been outlined by Kotsis and Chung, and uniformity of outcome reporting has been emphasized to allow for comparison across techniques.16 However, these studies should be combined with other outcome measures (including patient quality of life) to provide a more complete picture of ultimate outcome.17 Studies classified into this domain will provide readers with the evidence needed to evaluate interventions and their utility from an economic perspective. Better quality research in this subdomain must become available to best use scarse health care dollars to determine the most cost-effective outcomes. CONCLUSIONS Health outcomes research allows for evaluation of the end results of care delivery through a more inclusive approach that honors patient preferences. It is our task to ensure that outcomes research is conducted and reported in an understandable, standardized fashion. Since 2009, articles in Plastic and Reconstructive Surgery have been given an outcomes designation based on Agency for Health Care Research and Quality criteria. We have proposed four new outcome subdomains, which provide a framework for understanding outcomes research in the Journal. These domains may promote journal transparency of outcomes classification. In addition, they will provide readers with the ability to critically evaluate articles and make informed decisions regarding health care.