Measuring the quality of surgical care provision to Aboriginal and Torres Strait Islander patients

Aboriginal and/or Torres Strait Islander Australians have a life expectancy 8 years less than other Australians.1 Access to equitable high-quality surgical care may be a contributing factor to this disparity. Aboriginal and Torres Strait Islander patients have a higher emergency to elective surgery ratio,2, 3 a global indicator of access to surgical care.4 When Aboriginal and/or Torres Strait Islander Australians do access surgical care, they may experience higher rates of post-operative morbidity and mortality.5-11 The focus must now shift from simply reporting disparities in surgical outcomes for Aboriginal and/or Torres Strait Islander Australians to identifying, measuring and addressing the process measures involved in these poor surgical outcomes. Process measures are the specific steps that lead, positively or negatively, to a particular outcome. In surgery, examples of process measures are the percentage of eligible patients receiving preoperative anaemia screening, the percentage of patients receiving appropriate venous thromboembolism prophylaxis or the percentage of patients receiving appropriate antibiotic prophylaxis. Process measures allow us to pinpoint opportunities for healthcare improvement by highlighting what is being done well and what needs improvement.12, 13 Similar to an outcome measure, a process measure is essentially a rate of an event with a specified numerator and denominator. For surgical outcome measures the numerator is typically small, for example rates of surgical site infection (SSI) may be 5%. For process measures the numerators are relatively larger, for example rates of prophylactic antibiotic prescription may be 95%. Thus, a smaller sample size is needed for process measures compared to outcome measures to show a significant difference. In addition, data for outcome measures are typically captured over a specified time period (typically 30 days for post-operative adverse events), whereas data for a process measure are collected at the time when process of care occurs. Data for calculating process measures can thus be collected in a more expedient fashion, with smaller sample sizes needed than for outcome measures. This is particularly important when disparity research involving patients in minority groups is conducted, where small sample sizes are an inherent problem for researchers. Despite this, the measurement of disparities in processes of surgical care is relatively rare. The majority of current surgical health outcome research examining disparities in surgical care utilizes existing administrative databases. This limits authors to the variables included in these data sets. Surgical outcomes are collected in these data sets, process measures are typically not. With the adoption of electronic health records, a new generation of health service researchers now have access to data recording processes of care. Hence, we should focus more on studying processes of care. At present, even when prospectively conducted studies do include the necessary data to study and report process measures, authors may not do so. A recent publication by Thong et al. examined the variation in antibiotic prescription and complications for emergency appendicectomy in Australia.10 Antibiotic prophylaxis was provided to 92% of all patients. Aboriginal and/or Torres Strait Islander patients were 5.8 times more likely to develop an SSI compared to other patients. Despite having the data to do so, the authors do not report the process measure (antibiotic prescription rates for Aboriginal and Torres Strait Islander patients) that may have contributed to the disparity in rates of SSI. This analysis would lead to an actionable result. There may be a disparity in antibiotic prophylaxis for Aboriginal and/or Torres Strait patients and this can be addressed directly. Alternately, the receipt of antibiotic prophylaxis may be equivalent and despite this Aboriginal and/or Torres Strait Islander patients still experience higher rates of SSI. The focus can then shift to alternate process measures to ensure the equitable receipt of high-quality surgical care. Henman et al. conducted a prospective study of SSIs following caesarean section at the Royal Darwin Hospital.9 The rate of SSI was five times higher in Aboriginal and/or Torres Strait Islander women compared to other women. The authors then examined process measures that may have contributed to this disparity in surgical outcomes. The hospital implemented a quality improvement bundle; altering the surgical skin preparation, adjusting antibiotic prophylaxis guidelines to suit local bacterial pathogens and providing an educational bundle to staff. Six months after the implementation of these initiatives, the overall rate of SSI had reduced from to 6.9% to 3.3%.9 By improving processes of care, the hospital was able to provide more equitable high quality of care that achieved better surgical outcomes for all patients. There are documented disparities in surgical outcomes for Aboriginal and/or Torres Strait Islander patients. To make surgical care more equitable for all Australians, there must be a larger emphasis on studying modifiable process measures that lead to these poor health outcomes. By identifying, measuring and addressing disparities in processes of care, Australians can better close the gap in surgical outcomes for Aboriginal and/or Torres Strait Islander patients. EdJ is a Doctor of Philosophy candidate at an Australian institution. This research degree is supported by the Australian Government Research Training Program (RTP) Scholarship.