Rates, Barriers, and Facilitators of Outcome Collection on Hand Surgery Outreach to Low- and Middle-Income Countries

Abstract

Background:

Global outreach to low- and middle-income countries (LMICs) continues to grow in an effort to improve global health. The practice of quality measurement is empirically lacking from surgical outreach trips to LMICs, which may limit the safety and quality of care provided. Using convergent mixed-methods, we aimed to: (1) identify and evaluate barriers and facilitators to outcome measure collection; and (2) report the sample rate of such collection on hand surgery outreach trips to LMICs.

Methods:

Surgeons and administrators involved in hand surgery outreach trips completed a survey regarding rates of outcome measure collection and a semi-structured interview to explore barriers and facilitators of outcome collection. Survey data were reported descriptively. Interviews were recorded and transcribed, and excerpts were categorized according to the Pettigrew framework for strategic change (content, process, and context). Results were combined through convergent mixed-methods analysis.

Results:

Thirty-three participants completed the survey, and 21 participated in interviews. Rates of collection were the most common for total case number (83%) and patient mortality (65%). Longitudinal outcomes (eg, patient follow-up or time away from work) were less frequently recorded (9% and 4%, respectively). Content analysis revealed barriers related to each domain of the Pettigrew framework.

Conclusions:

This analysis demonstrates low levels of outcome collection on outreach trips and identifies priority areas for improvement. Developing context-specific solutions aimed at addressing barriers (eg, resource/database availability) and promoting facilitators (eg, collaborative relationships) may encourage higher rates of collection, which stands to improve patient safety, quality of care, and accountability when conducting outreach trips to LMICs.

Introduction

It is estimated that 143 million surgical procedures are needed every year, with the greatest need arising from low- and middle-income countries (LMICs). ¹ An estimated $7.9 trillion of cumulative gross domestic product attributable to injury will be lost over the next 15 years, ² making orthopedic trauma among the most burdensome and costly of these surgical conditions. ³ In recent years, short-term surgical outreach trips have become one mechanism to address the growing need for global surgical care. ⁴ To address this need, US-based organizations sponsor more than 6000 short-term medical trips that cost an estimated $250 million annually. ⁵ Although these trips are well-intentioned and help many people, the lack of detailed record-keeping and clinical follow-up prevents comprehensive evaluation of their overall impact.

In health care delivery, measuring outcomes is essential to ensuring patient safety, assessing the clinical and financial impact on an organization, and informing quality improvement efforts.^6-8 While frequently used in high-income countries (HIC), outcome measures are scarcely and inconsistently assessed on surgical outreach trips to LMICs.^9,10 Despite being recognized as a powerful tool for improvement, most quality measurement data from short-term trips are observational and vary significantly across subspecialty. ⁹ Barriers to collect and document outcomes are exacerbated in areas with fewer resources where patient follow-up is a challenge ⁷ and where centralized data collection is limited by resource constraints. ⁶ Despite these challenges, some organizations that prioritize measuring outcomes have succeeded in outcome collection. For example, Operation Smile, an outreach organization focused on craniofacial reconstruction surgery, has been successful in integrating an electronic database for digital documentation of patient outcomes for the purpose of monitoring surgical complications, auditing surgical performance, and planning future treatment.^11,12

Efforts to measure quality of care, including patient outcomes, are increasing in hand surgery outreach. For example, the Data Instrument for Surgical Global Outreach ¹³ and the quality measures validated by the Global Quality in Upper Extremity Surgery and Training (Global-QUEST) investigators ⁶ are 2 tools recently developed to facilitate measurement on outreach trips. Implementation of these tools, however, is predicated on understanding the current landscape of outcome collection in LMICs, as well as the barriers and facilitators to data collection. Identifying these barriers can inform potential solutions, such as technology or efforts toward organizational change, to effectively implement outcome measurement on outreach trips. To this end, the purpose of our investigation was to evaluate and identify barriers and facilitators to outcome measure collection through a convergent mixed-methods (qualitative + quantitative) approach and secondarily to report the rate of such collection.

Methods

Study Design and Participants

A convergent mixed-methods approach was used to investigate the sample rates of outcome collection and barriers and facilitators to such collection as these questions are relatively complex processes best answered by both quantitative and qualitative forms of data by surveying a sample of individuals who have participated in global surgery outreach trips. The quantitative data allow an understanding of the magnitude and generalizability of the issue, and the qualitative data allow an understanding of why or how phenomena occur. The integration of such data forms allows one form to validate, explain, and/or refine the other.

After obtaining institutional review board approval, we recruited surgeons and administrators who have participated in hand surgery outreach trips to LMICs. Because there is no database of organizations leading hand surgery outreach trips, we completed multiple steps to maximize our ability to identify possible participants. First, we contacted leadership within the American Society for Surgery of the Hand to identify partner organizations that lead outreach trips. Second, we reviewed the results of a systematic review of surgical nongovernmental organizations and identified any that conduct hand surgery outreach trips. ¹⁴ Third, we searched Google with the following search terms (“Hand surgery outreach organizations” OR “Global hand surgery trips” OR “Hand surgery outreach” OR “Hand surgery mission trip”) and reviewed the first 10 pages of each search to identify any additional organizations. We contacted leaders of organizations that met the following criteria: hand surgery completed on adults or children during a trip and leads at least 1 international trip per year. We excluded organizations that transported patients to HIC for procedure and those that lacked sufficient publicly available data to verify adherence to inclusion criteria. Leaders of organizations that met our eligibility criteria connected the research team with other members. Finally, we asked participants from organizations that we had identified for the names of any additional potential participants.

Data Collection

Consenting participants were sent a link to our 17-item online survey via Qualtrics (Qualtrics, Provo, Utah), which aimed to assess the collection rate (eg, number of positive responses/total responses) of outcome measures on surgical outreach trips to LMICs. We previously completed a systematic review to identify quality measures addressing orthopedic surgery outreach trips in LMICs. ⁹ Based on these results, our survey queried all measures associated with outcome collection (eg, Do you collect information regarding the number of patients evaluated? Do you collect information regarding patient’s time away from work and activities of daily living?) (Supplemental Appendix A). These measures were classified according to the Agency for Healthcare Research and Quality (AHRQ) National Quality Strategy’s 6 priorities to guide efforts to improve health and health care quality ¹⁵ (Supplemental Appendix B). Responses in each category (yes, no, unsure, other) were calculated and presented as a percent of total responses. Of note, those reporting “other” were encouraged to elaborate in a free text box.

Following completion of the survey, individuals were invited to participate in a semi-structured phone interview to contextualize the barriers and facilitators to outcome measure collection. We used the Pettigrew framework for strategic change to develop a semi-structured interview guide ¹⁶ (Supplemental Appendix C). The Pettigrew framework is composed of 3 interacting domains (content, process, and context, the latter subdivided into external and internal), which provides a model for change and informs implementation efforts in the health care setting^17,18 (Figure 1). This model guided the qualitative portion of our study to investigate barriers and facilitators to outcome collection within 3 domains—what outcomes are organizations measuring (eg, content), how are they collecting them (eg, process), and why are certain measures collected or not collected (eg, context)? The interview questions were open-ended to elicit beliefs across the 3 domains while also allowing for selective probing to obtain rich data to describe the phenomenon. All interviews were conducted by J.M.W. who is trained in qualitative techniques. A constant comparative technique was used (a method in which interviews are analyzed as they are completed), and interviews were completed until saturation was reached (meaning no new beliefs or attitudes were elicited).^19,20 All transcripts were recorded and transcribed for data analysis; patient identifiers were removed, and all records and transcripts were stored in compliance with Health Insurance Portability and Accountability Act policies.

Figure 1.

Pettigrew framework for strategic change with domains used to develop semi-structured interview guide and conduct content analysis.

Adapted from Pettigrew. ¹⁶

Data Reporting and Analysis

Quantitative analysis

Descriptive statistics, including frequency and percentage of responses, were used to assess the distribution, as measured by survey responses, of currently collected outcome measures according to AHRQ quality priorities (Supplemental Appendix A).

Qualitative analysis

The coding team (J.M.W. and M.C.) independently coded the interview transcripts using a combined deductive-inductive approach (content analysis). A codebook was created based on the predetermined, literature-based definitions adapted to the study context from the Pettigrew framework for open coding using Dedoose (version 8.0.35; Dedoose, Los Angeles, California). The 2 coders subsequently coded all transcripts independently and discussed adding or refining codes as new insights emerge. Disagreements were adjudicated by a third researcher experienced in qualitative analysis (L.M.S.). Excerpts associated with open codes or codes added during the coding process were then classified into one of the Pettigrew framework domains. A constant comparative method was used to analyze interviews as they occurred, and the interview guide was revised and probing questions changed based on results. Interviews continued until saturation (when no new codes emerged) was achieved. ²¹ The authors followed the consolidated criteria for reporting qualitative research (Supplemental Appendix D), a 32-item checklist to ensure study rigor and aid in interpretation. ²²

Convergent analysis

We analyzed the 2 data sets (quantitative—descriptive survey statistics + qualitative—interview/content analyses) independently and subsequently conducted a convergent analysis in which the survey responses and interview/content analyses were integrated in a side-by-side manner. ²³ The merged data provided insight that led to a more complete and in-depth understanding of the influences that affect outcome measure collection.

Results

Participant Characteristics

Thirty-three individuals participated in the online survey (30 surgeons, 3 administrators; 23 men and 10 women, representing surgical care experiences in 49 countries) (Figure 2). Twenty-two individuals participated in the qualitative interview (19 surgeons, 3 administrators; 14 men and 8 women). All participant quantitative responses represented unique outreach trips (ie, no 2 participants reported data from the same trip).

Figure 2.

Map illustrating countries in which participants have provided surgical care on outreach trips.

Quantitative Results

Outcome measures collected on outreach trips are described in Table 1. Respondents reported the number of surgeries (82%) and number of patients evaluated (70%) as the most frequently recorded outcome measures on hand surgery outreach trips to LMICs. Functional status, follow-up measures, and outcomes specific to the local context were among the least frequently reported (each less than 10%).

Table 1.

Quantitative Survey Results Displayed as Frequency and Percentage of Responses.

AHRQ priority	Outcome measure	Yes	No	Unsure	Other a
Patient safety	Mortality rates prior to team departure	20 (61%)	8 (24%)	4 (12%)	1 (3%)
	% of patients with postoperative complications	10 (30%)	13 (39%)	7 (21%)	3 (9%)
	% of patients requiring reintervention	8 (24%)	15 (45%)	6 (18%)	4 (12%)
	Long-term mortality rates	8 (24%)	17 (52%)	8 (24%)	0 (0%)
	Follow-up measures	3 (9%)	20 (61%)	10 (30%)	0 (0%)
Person-centered and family-centered care	Patient-reported outcome measures	5 (15%)	23 (70%)	5 (15%)	0 (0%)
	Patient satisfaction	4 (12%)	24 (73%)	4 (12%)	1 (3%)
	Time away from work/ADL	1 (3%)	25 (76%)	5 (15%)	2 (6%)
	Functional status	2 (6%)	22 (67%)	7 (21%)	2 (6%)
Care coordination	Total no. of surgeries performed	27 (82%)	5 (15%)	1 (3%)	0 (0%)
	Total no. of patients evaluated	23 (70%)	7 (21%)	2 (6%)	1 (3%)
Healthy living	Community impact measures	6 (18%)	19 (58%)	8 (24%)	0 (0%)
	Outcomes specific to local context	2 (6%)	25 (76%)	6 (18%)	0 (0%)
Care affordability	Cost per patient/procedure	6 (18%)	19 (58%)	7 (21%)	1 (3%)
AHRQ priority	Process measure	Yes	No	Sometimes
Care coordination	Visiting team database for outcome measure collection	9 (27%)	18 (55%)	6 (18%)
Patient safety	System for reporting adverse outcomes	15 (45%)	13 (39%)	5 (15%)
	System for communication after trip conclusion	24 (73%)	3 (9%)	6 (18%)

Note. AHRQ = Agency for Healthcare Research and Quality; ADL = activities of daily living.

^aParticipants who responded “Other” to questions often cited that measures were documented, as indicated, on paper but not formally collected or reported. Similarly, some measures were only recorded if a patient returned to clinic on subsequent trips. One respondent was on an education-focused trip, so measures related to patient care were not directly applicable.

Qualitative Results

The mean interview duration was 16 minutes (SD = 5) and ranged from 9 to 24 minutes in length. Response topics as characterized by the 3 interacting domains of change (content, process, and context), along with representative excerpts for selected topics, are listed in Table 2. The complete codebook can be found in Supplemental Appendix E.

Table 2.

Topics Discussed in Semi-Structured Interviews Organized by Pettigrew Domain With Representative Quotations.

Domain	Topics	Example statements
Content	Current outcome collection	“Basically, it’s the name, it’s the diagnosis, it’s the surgical procedure, and that’s about it.” “[We have] come up with a metric that looks a lot like how we assess residents in training. We have goals . . . so when we go back, we work with them again and we assess, is this person now capable of doing a procedure on his own . . . We have metrics in terms of educating physicians in other countries as well as outcome measures for patients.” “. . . we do chart our outcomes in the sense of whether its nerve recovery or range of motion, tendon transfer, etc but those are not collected they are just in the charts”
	Motivation for outcome collection	“. . . studying the outcomes can be as important as studying the surgeries when we think to ourselves is this the appropriate surgery for the appropriate patient and did we actually accomplish what we went there to do or have we actually ended up causing some harm that we did not previously anticipate.” “. . . if we see any processes that we feel have led to more complications then we will change the process.” “. . . part of it is to have more robust, well, to really be able to show the impact of our work and to have a more robust set of data that we can show our donors.”
	Target areas of change	“I think what we would really like to collect is not just the impact it has on the patient but how much it has on the family and the community and their ability to work” “I think measures I wish we had more access to was physical exam outcomes; not just patient reported outcomes but also postoperative range of motion, postoperative strength.”
	Lack of data collection	Interviewer: “Generally what outcomes does your organization collect during an outreach trip?” Participant A: “You know what, the answer is none. We are just trying to get the work done.” Participant B: “Um I think probably nothing objective.” Participant C: “None. I mean the answer’s really just none.” Participant D: “I don’t really know of any.” Participant E: “So very seldom, other than the total numbers of operations done and what the specific cases were.”
Process	Data collection methods	“They do written notes—written operative notes, written follow up notes in clinic. They do keep those. They usually can be found but not always, in the clinic” “Sometimes we will get help from the people on the ground if they have an extra nurse or can help us keep track of this excel spreadsheet to try and keep it going.” “I keep a notebook of the exact cases I have done, what I have truly done basically a summary of the procedure and number and this sort of thing.”
	Local site databases	“Many of the hospitals we work in don’t have a good detailed medical records system of its own and they don’t link to any unified system through our organization.” “We certainly collected postop and put them either in, one of the places we go to has a pretty good paper chart, one has a pseudo electric chart, and one basically has nothing.” “The medical records systems are not streamlined and kind of unified, so it is hard to look up information.”
	Visiting organization databases	“[Our organization] has a main database that tracks the patients who have had surgery within the first three months we provide the hospital we work in and will see the patient back in follow-up if there are any problems. So, there is an overall database system that is very general and then there’s specific follow up per patient if there are any issues.”
	Post-trip follow-up	“We send a resident to actually go a year or so after the surgery and track down the patients and provide data on long term follow up.” “We try to follow these patients postoperatively through [the local surgeons] either by Skype or by exchanging photographs and emails. Sometimes that works and sometimes that doesn’t. Again, it depends a lot on the logistics of the area.” “It’s hard for them to collect outcomes data because it requires going and finding patients in the country, because a lot of these people take two days to get there by bus for example, and if they don’t have internet connections, which many of them don’t, it’s really hard to do . . .”
Context (internal and external)	Resource availability (time, money, technology)	“We have limited resources for seeing patients, let alone recording data which takes a fair amount of time on a single day in clinic, on a Sunday where we see about 170 patients or so. And so that’s also a limitation, just in terms of resources.” “The hospital stays pretty much in the red and is just barely getting by. They are interested in providing care to patients and that’s about all they can do.” “I think that the funding is one of the main things. You would almost have to hire somebody to come down with you and do data or pay for them to do it. I mean even if they volunteered you still need to get them there.” “When it’s hard to get your implants, when you don’t know if you’re lights going to work in your OR, you have a lot of other struggles going on. If you have to worry about every single thing about your patient’s care, you are probably going to be too tired at the end of the day to think of a research project, put things into a database, and write a paper.” “If you try to look at outcomes through the lens of the medicine in the United States it just isn’t going to work because there’s such a gap. The needs of the patients and the resources they have to bring to bear on those needs is widely different.”
	Language and cultural barriers	“I think that some kind of ability of the groups to connect from a cultural point is very helpful and makes the trip successful.” “The doctors all speak English but the patients do not and so you don’t end up bringing a translator because you can translate with the doctors easily but then you miss out on getting a more in depth look at baseline characteristics of a patient.” “the differences in terms of the way medicine is practiced is so great and the expectations of the patients were honestly so much less that it’s hard to prepare for that degree of difference.
	Local staff and visiting team interactions and expectations	“. . . understanding what those barriers are on the front side and establishing some trust with the local surgeons as far as rationale for why these things are important and what you’re going to do when you come, I think will go a long way.” “We are doing better with outcome collection since we moved to this educator model as opposed to doing a big group doing 200 cases over two weeks. We do fewer cases and there’s a greater opportunity to educate or try to organize some kind of follow up. If you make personal contact and these folks become your mentees and your friends, then it’s a little bit easier to ask them to spend a little bit of extra time to find a patient and collect the data.”
	Change managers	“Leadership at the hospital and local level, I think really to get into outcomes, they have to want to do it as well and to help motivate changes in treatment. I think a lot of it is going to have to come from within the treating physicians there, the nationals, instead of those of us who come for just a short-term medical mission.” “I think from the [trip] leaders who understand the importance, yes the push to make changes is there- from the average surgeon on the trip, I think the answer is no. They want to go and take care of patients. It’s hard for people who don’t see the big picture.” “. . . the countries or the sites we work with, we have good connections or good relationships where I’m sure if we asked for the help, we can most likely reach a lot of our patients over the last few years or so. I’m thinking maybe just as I say it out loud, a lot of the limitation is us putting the effort into doing that.”

Domain 1: Content

Despite recognizing the importance of outcome measures and their role in delivering quality care, participants noted a lack of data collection beyond basic surgical logs (eg, number/types of surgeries performed). Currently, data are used by organizations to monitor patient safety and assess trip “success”; however, participants expressed desire to collect more robust measurements of community impact, educational development of local staff, and patient functional status. Motivated by the goal of providing high-quality, culture-specific care, participants believed that it is important to identify measures that are both meaningful and useful to the local community.

Domain 2: Process

Data collection is a process often dependent on the presence of a dedicated staff member whose role it is to collect outcome measures and/or digitize paper charts. In addition to staffing needs, insufficient infrastructure, including a lack of a centralized, automated database to collate or report data, is a key barrier. Participants described the use of spreadsheets, emails, paper charts, and personal hand-written logs as the primary data collection systems. Follow-up with local surgeons, although informal, was frequently cited as a way to monitor patients and continue educational efforts for local staff members. Through the use of email, WhatsApp, and Skype, participants respond to questions about patient care and occasionally receive photo documentation of patients’ recovery progression. Participants noted that direct patient follow-up occurred on a few occasions when participants, or members of the organization, conducted repeat trips. This, however, was predicated on the ability to contact the patient and for the patient to return to the clinic.

Domain 3: Context

Both patient follow-up and longitudinal outcome collection are made difficult with limited resource availability (eg, time, money, technology). In addition, the absence of culturally relevant, multilingual outcome measures restricts the ability to assess patient outcomes. Understanding the local customs, culture, and resources; trip continuity; and collaborative relationship-building with local staff were all identified as facilitators of data collection. Participants who made return trips and had built trust with local staff members were better able to elicit their help to collect data and felt better equipped to overcome site-specific barriers. A list of implementable changes to improve outcome collection described by participants is included in Table 3.

Table 3.

Participant Examples of Implementable Changes to Improve Outcome Collection on Hand Surgery Outreach Trips.

Category	Principle	Example actions
Measurement collection
	Use outcome measures that are written in patients’ languages and are culturally relevant	If asking patients about their daily life or function, questions should focus on tasks that are specific to the patient population
	Incorporate thoughtful, patient-centered, and usable measures	• Collect patient experience and patient-reported outcome measures • Take postoperative pictures after reconstruction instead of written description • Document number of people who attended educational lectures
	Avoid outcome measures that are dependent on advanced technology	Avoid imaging/scans as outcome measures
Technology
	Use electronic databases or similar record-keeping systems to document and track outcomes	Implement the use of digital platforms to document patient and trip data and outcomes
	Assess local technology capacity of both medical staff and patients to identify potential follow-up methods	Discuss the prevalence of cell phone use within the local community to communicate with staff members and/or patients after trip conclusion
Trip structure
	Designate staff member/volunteer to conduct data collection efforts	Task shift and delegate tasks to people with fewer but appropriate qualifications
	Have a trip interpreter or liaison to facilitate cross-cultural communication
	Focus on capacity building to ensure bidirectional knowledge transfer and increase time spent collecting outcome measures	Expand educational aspects of outreach trips
Organization
	Implement leadership positions within the organization focused on measuring and assessing outcomes
	Conduct post-trip assessments to inform quality improvement efforts	Survey participants (organization and local providers) after trip conclusion to query successes and challenges in documenting outcomes
Collaborative relationships
	Conduct pretrip needs assessments to evaluate priorities and resources of local community	Use a needs assessment tool or survey to document and guide trip planning
	Maintain ongoing professional relationships with local providers to build trust and improve bidirectional engagement	Return to the same hospital/community for repeat trips
	Engage with local nonphysician staff members within the hospital who may have additional resources to follow up with patients	Engage with medical students, physical therapists, social workers, and so on at the local hospital/community
	Use context-appropriate technology to follow up with local staff members	Use platforms such as WhatsApp, Skype, and email to communicate with local staff

Convergent Analysis Results

Integration of qualitative and quantitative findings yielded both concordant and discordant findings which provided insight that led to a more complete and in-depth understanding of the influences that affect outcome collection. For example, the quantitative results showing infrequent documentation of functional status and follow-up measures were contradicted by participant belief statements expressing the desire to collect these data, indicating barriers to collection are likely not a result of an absence of interest but instead influenced by external factors such as resource limitation. The comparison of results allowed for concrete conclusions about the barriers and facilitators to outcome data collected, which are expanded upon in our discussion (Table 3).

Discussion

Collecting outcome data has become routine in HIC to ensure accountability, quality, and safety. We sought to evaluate the sample rate of outcome measurement on hand surgery outreach trips and to investigate barriers and facilitators to their collection. Our results demonstrate that while the collection of case and patient numbers as well as patient mortality during a trip is high, measurement of other fundamental patient outcome data is low. Through convergent analysis (Figure 3), we identified barriers (eg, resource availability, cultural differences) that are frequently cited as impeding outcome collection. We also identified facilitators (eg, strong relationships with local staff) at both individual and organizational levels that may be leveraged to improve outcome collection. These results can guide efforts toward improving outcome measurement during global surgical outreach.

Figure 3.

Diagram of the convergent analysis allowing integration of the quantitative and qualitative data.

In analyzing AHRQ priorities, we found outcome collection was highest in the domain of care coordination. Through efforts to document number and type of procedures, organizations can measure surgical need and plan future trips. However, these measures are not proxies for the impact that treatment has on the patient and community. To improve quality of care, it is imperative to assess the impact of treatment from the patient’s perspective. The paucity of patient-focused and community-centric measures in LMICs may be largely attributable to a lack of context-specific measures. Components of patient-reported outcome measures (PROMs) commonly used in HIC are often written in English and were derived for patients in Western cultures and thus may not provide meaningful data for patients in LMICs. One participant noted that pain, measured through PROMs in HIC, has variable interpretation across cultures: “. . . pain is something that people use frequently as a gauge of improvement but in some cultures, pain is not necessarily reliably reported by the patient because they value pain in a different way . . .”

Participants also noted that even in resource-poor areas, cell phone use is common and could be leveraged to develop follow-up survey tools. Feasibility of a cell phone–based tool requires it be “simple enough that it could be accomplished but still have enough content that you could draw meaningful conclusions.” Importantly, however, participants also illustrated that when operating in low-resource areas, things like ensuring the lights work and implants are clean take priority over charting data. These sentiments demonstrate the importance of validation and implementation of standardized, simple tools. For example, organizations could use patient-facing mobile phone–based tools for patient follow-up and low-burden tablet-based checklists for surgeons or staff to ensure data collection. ²⁴

Although participants expressed desire to expand the scope of outcome collection, implementation barriers hindered their ability to do so. One main barrier discussed was the absence of a uniform data collection or electronic medical record system to monitor and track patients, a challenge previously addressed in several studies.^6,8,25 Participants called for purposeful development of a tool “created in close conjunction with the local colleagues” so as to ensure usefulness and feasibility within the local system. The goals of a centralized database discussed included the following: (1) promoting consistent outcome collection; and (2) facilitating discussion with local partners following trip conclusion.

Informal communication with local surgeons was commonly discussed, demonstrating that various platforms (eg, email, WhatsApp, Skype) are often used to exchange photographs and information. However, as noted here, “We use a lot of WhatsApp, primarily, to communicate with the local physicians so probably if I went through my phone, I probably have follow up on 10,000 patients—but it’s haphazard”; these platforms do not provide a uniform, regulated system for collating information nor does it provide integration with data that have been previously collected. Future steps for database development should not only focus on tools to promote outcome collection during a trip but also include the capability to share and store information longitudinally.

Direct relationships with local staff, built commonly through repeat trips, were cited as facilitators to data collection. Collaboration was instrumental in developing shared support of outcome collection, an insight best summed up by the following excerpt:

Two of our volunteers went down and did a scouting trip first. I believe in the importance of outcome measures but if that was something you were trying to set up, understanding what those barriers are on the front side and establishing some trust with the local surgeons as far as rationale for why these things are important and what you’re going to do when you come, I think, will go a long way.

Pretrip discussions, in person or virtual, can be critical for facilitating relationships and identifying the resources and needs of a site, thus enabling the selection of cost-effective data collection tools suitable to patient population. Pursuant of the mission to collect quality, context-specific outcome measures, trust and bidirectional trip preparation are vital to implementation of outcome collection.

This study should be viewed in light of its limitations. First, the sampling technique used in this study does not allow for the calculation of an overall response rate. Although we reached saturation in qualitative interviews, the experiences of 33 individuals only represent a portion of stakeholders involved in outreach trips. In addition, we only surveyed surgeons and administrators from the visiting organizations. It is possible that their beliefs may not reflect the views and actions of the larger network of providers and local staff members involved in patient care on outreach trips and may introduce sample and recall bias. In addition, although we developed an interview guide to minimize the presence of leading questions, it is possible that interviewer bias may affect the results of the qualitative analysis. Finally, multiple participants have volunteered on hand and nonhand outreach trips, and while they were asked about their experience specific to hand trips, their recollection of experiences may reflect trips in which hand surgery was not conducted.

Although most agree that outcome collection on hand surgical outreach trips is important, practice of such is rare. As the lack of such collection may impact the safety and quality of care provided, we sought to investigate barriers and facilitators of data collection to inform improvement efforts. The identified barriers and facilitators can be, respectively, mitigated and leveraged through purposeful implementation of context-specific tools to improve outcome collection. We believe that successful implementation of outcome collection for the purpose of improving safety, quality of care, and accountability when conducting outreach trips to LMICs will require addressing these barriers/facilitators.