Perspective: Identifying and Addressing Disparities in Surgical Access

As surgical quality improvement programs proliferate, we must return to 1 of the central tenets of the National Institute of Health—American College of Surgeons (ACS) Symposium on Surgical Disparities Research: “No quality without access.” Disparities across the continuum of surgical care also extend to access to surgical care. A 2019 systematic literature review of studies conducted in the United States identified 223 surgical access study outcomes with demonstrated disparities across a surgical access framework: Provider Access, Surgical Indication Detection, Progression to Surgery, or Optimal Care Capacity.¹ To compare these potential quality measures with existing surgical performance measures, this framework was applied to an environmental scan of measure repositories and survey of quality experts, returning only 16 validated measures of surgical access. This critical gap is a clear charge for health systems to mitigate population-level disparities in surgical care by incorporating surgical access measures.

SURGICAL QUALITY MEASUREMENT AND DISPARITIES

Surgical quality measures are widely used to assess health system performance and identify areas for quality improvement. Postoperative outcomes, such as 30-day mortality and readmission, and process measures such as intraoperative normothermia and preoperative antibiotic prophylaxis are hallmark measures of surgical quality. These indicators have been used by nationwide performance measurement programs, such as the Veterans Affairs Surgical Quality Improvement Program, the ACS National Surgical Quality Improvement Program, the Surgical Care Improvement Project, and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators. Before widespread use, quality measures undergo specification and rigorous testing to ensure they produce reliable and credible results about the quality of care provided. Validated measures are paramount to successful quality improvement initiatives, as they enable hospitals to compare their performance against national benchmarks; to accurately identify areas of improvement; and to reliably track changes over time.

Contemporary understandings of surgical care broaden the continuum of quality measures to include surgical access indicators. Defined as “the timely use of personal health services to achieve the best possible outcome,”² access to care is an underemphasized driver of healthcare outcomes. Disruptions along the continuum of care can negatively impact surgical patients’ health, and increasing access improves surgical outcomes.^3,4 Just as surgical outcome and process measures are used by hospitals and health systems to assess the impact of quality improvement efforts, developing validated measures of surgical access would allow hospitals to identify gaps in access to care and facilitate pre/post evaluations of quality improvement interventions. A myopic focus on process and outcome measurement is a disservice to patients with limited access to timely, appropriate surgical services and to those who never make it into the operating room.

Increasing demand for quality performance reporting has unearthed disparities in the quality of care patients receive. In parallel with other medical specialties, surgical disparities research has thus become a burgeoning field of study. Disparities based on race/ethnicity, socioeconomic status, and other demographic factors have been reported in processes of care and outcomes after surgery. Many of the contributing factors to surgical disparities are actionable at the provider and system level, including workforce capacity and competency, and surgical management protocols and strategies.⁵ Quality measurement can be used to systematically capture disparities and identify intervention targets, as exemplified by the 2017 AHRQ National Healthcare Quality and Disparities reports. Given demonstrated disparities in access to surgical care,⁵ quality measurement at the hospital and health system level should incorporate surgery-specific access measures to identify and mitigate disparities.

MEASURING ACCESS TO HEALTH CARE: LESSONS LEARNED

The aforementioned AHRQ report demonstrated racial/ethnic, and socioeconomic disparities in access to care, defined by access measures such as past 12 months routine care appointment and ongoing source of care.⁶ These broad measures of access do not translate seamlessly to the surgical realm. For example, not all surgeries are routine (elective), and the need for emergent versus elective general surgery operations does not completely explain disparities in surgical outcomes.⁷ Further, the appropriateness of ongoing surgical care varies widely based on clinical and patient factors; the same measure of access cannot be applied to conditions where revisions are expected, such as burn management, and to those where ongoing surgery is not performed, for example, permanent ileostomies and internal fixation for fractures. Several frameworks for healthcare access have elucidated determinants of disparate access, but not how these factors manifest within the breadth of medical specialties.^8,9 It is therefore difficult to extrapolate actionable quality measures from these behemoth models to specific surgical specialties. Operationalizing access to surgical health care in the United States is a nascent field, and surgeons might adapt more granular models developed in primary care¹⁰ and in the Veterans Health Administration.¹¹

Access to and quality of surgical care has been modeled and operationalized on a global scale, leading to the development of several access measures such as 2-hour access to essential surgeries and specialist surgical workforce density per 100,000 population.^12,13 The appropriateness of these quality indicators has not been assessed in the United States, likely due to presumed differences between low/middle-income countries and the United States in facility infrastructure, healthcare financing, and the volume of surgical procedures performed. Resolving disparities in access to surgical care in the United States requires the development of surgical access measures specific to our sociodemographic and health systems context.

IDENTIFYING VALIDATED SURGICAL ACCESS MEASURES

Eradicating surgical disparities requires bridging the gap between potential and developed surgical access measures. To determine the number existing quality metrics which incorporate surgical access, the ACS Metrics for Equitable Access and care in SURgery (MEASUR) project conducted an environmental scan comprised of peer-reviewed and gray literature, the National Quality Forum’s portfolio of endorsed measures, AHRQ’s National Quality Measures Clearinghouse and National Guidelines Clearinghouse, and the Centers for Medicare and Medicaid Services Measures Inventory. A survey was subsequently administered to 12 surgical specialty societies to elicit additional existing performance measures. Of the 341 existing quality measures, just 16 fell within the surgical access framework¹ of Provider Access, Surgical Indication Detection, Progression to Surgery, or Optimal Care Capacity (Table 1).

TABLE 1.

Existing Validated Measures of Access to Surgery by Surgical Access Domain

Measure Title	Measure Steward
Provider access
Under 1500g infant Not Delivered at Appropriate Level of Care: The number per 1000 live births of <1500g infants delivered at hospitals not appropriate for that size infant.	California Maternal Quality Care Collaborative
Progression to surgery
Suspension of scheduled surgery: Percentage of scheduled surgical interventions suspended due to unavailability of previously reserved intensive care unit (ICU) beds.	Spanish Society of Intensive and Critical Care and Units Coronary
Hip fracture surgery within 48 h: the risk-adjusted proportion of hip fractures that were surgically treated within 48h of patient’s initial admission to hospital, among patients aged 65 years and older.	Canadian Institute for Health Information
Time between needle biopsy and initial breast cancer surgery: the time in business days required between the day of the needle biopsy which identifies the presence of a breast cancer and the day of the initial cancer surgery of that lesion.	National Consortium of Breast Centers
Surgical resection in nonsmall cell lung cancer: The proportion of patients with non-small cell lung cancer (NSCLC) who undergo surgical resection; and the proportion of patients with stage I to II (T1aN0 to T2bN1, or T3N0) NSCLC who undergo surgical resection	Scottish Cancer Taskforce
Primary PCI received within 90 min of Hospital Arrival
Percentage of acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary percutaneous coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 min or less.	Centers for Medicare and Medicaid Services
Receipt of optimal care
Salpingo-oophorectomy with omentectomy, debulking; cytoreductive surgery, or pelvic exenteration in stages I to IIIC ovarian cancer	Society of Gynecologic Oncology
Chemotherapy and/or radiation therapy offered to patients with stage IIIC/IV endometrial cancer: Percentage of women ≥18 years of age with stage IIIC/IV endometrial cancer undergoing primary surgery to remove the uterus for whom there is documentation that chemotherapy and/or radiation therapy was discussed with and offered to the patient*	Society of Gynecologic Oncology
Intraperitoneal chemotherapy offered within 42 d of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer	Society of Gynecological Oncology
Endoscopic, laparoscopic, or robotic surgery performed for all
Endometrial cancer (excluding sarcoma and lymphoma), for all stages except stage IV	Society of Gynecologic Oncology
Intraperitoneal chemotherapy administered within 42 d of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer	Society of Gynecological Oncology
Minimally invasive surgery discussed and performed for treatment of endometrial carcinoma*	Society of Gynecological Oncology
Performance of radical hysterectomy in patients with
IB1-IIA cervical cancer who undergo hysterectomy	Society of Gynecological Oncology
Percent of newly diagnosed invasive and ductal carcinoma in situ (DCIS) breast cancer patients (stage 0-stage 4) seen by surgeon that undergo risk assessment for a hereditary cause of breast cancer.	American Society of Breast Surgeons
Postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy with (or without) brachytherapy for patients with positive pelvic nodes, positive surgical margin, and/or positive parametrium	Society of Gynecological Oncology
The proportion of patients (invasive cancer only) who received a single (breast) operation for the primary tumor (excluding reconstruction).	European Society of Breast Cancer Specialists

^*Measure specifications not accessible.

Existing validated measures of surgical access are not comprehensive or representative of the breadth of disparities in access to surgery. Cancer surgery specialties are heavily represented, whereas less than 10% (15/223) of access indicators found through literature review were gynecological oncology and half (8/16) of existing validated measures of surgical access fall within this specialty. Similarly, 20% (3/16) of existing metrics describe breast cancer surgery, despite comprising only 10% (20/223) of all unique access disparities indicators. Notably, the measure specifications of 3 of these 16 validated measures were not accessible online; proprietary measures pose implementation issues for under-resourced and safety net hospitals and health systems. Both existing and potential access measures are skewed towards the domains of Progression to Surgery and Optimal Care Capacity. The relative dearth of validated measures of Provider Access and Surgical Indication Detection suggests that measure development in these areas is warranted, for example, accessibility of high-volume surgeons or the severity of disease upon presentation for surgery.

THE ROLE OF HOSPITALS AND HEALTH SYSTEMS

Surgical process and outcome measures are frequently measured at a hospital level, and this approach is also appropriate for assessing access to surgical care. Though population-level needs are often addressed through policy-level interventions, for example, Medicaid expansion has been shown to reduce racial, ethnic, and income disparities in performance on surgical access indicators,⁵ hospitals and health systems are better equipped to act expediently in addressing population-level disparities in surgical access. Furthermore, only hospitals and health systems can address factors contributing to surgical disparities, including provider, system, clinical care/ quality, postoperative care, and rehabilitation factors.⁵ Patient navigation programs have been shown to increase access to kidney transplant services and receipt of surgery,¹⁴ and decrease time to surgeon evaluation for breast cancer patients.¹⁵ Multidisciplinary team approaches are another tool to increase timeliness to surgical care for vulnerable populations.¹⁶ Given the demonstrated relationship between delayed presentation for common surgeries and post-operative morbidity and mortality,^17,18 using hospital-level measures to identify opportunities for quality improvement could ultimately reduce costs associated with complications, reoperations, and readmissions. Before quality improvement activities can be implemented, however, more performance measures must be developed to appropriately prioritize areas of intervention.

PROPOSALS

Assess and Address Performance on Current Surgical Access Measures

Hospitals and health systems are well positioned to track performance on existing surgical access measures, especially those serving breast and gynecological cancer patients. Existing structural and process measures related to timeliness and appropriateness of care are proxies for surgical access and may already be collected through quality collaboratives. If disparities are detected, targeted quality improvement activities should be considered based on patient demographic factors, mechanisms of disparate access, and health system capacity.

Determine Applicability of Global Surgical and Domestic Medical Access Measures

Global surgery access measures and medical access measures could be adapted to reflect access to surgery in the United States. Surgical access in rural and under-resources areas of the United States may mirror trends in low and middle-income countries, warranting assessment of the validity of The Lancet Commission on Global Surgery Indicators for use in the United States. Existing patient experience measures of timeliness of care and availability of acute care could also be adapted for use in surgery.

Develop Additional Surgical Access Measures

Using extant literature, surgical access study outcomes should be translated into specified performance measures. This begs the question: how should the field of surgical quality measurement prioritize these development efforts? Established consensus development processes including expert panel review, feasibility testing, and/or Delphi methodology could be utilized. Professional societies are often at the forefront of measure stewardship and are well positioned develop relevant, subspecialty-specific measures of access to surgical care. Given the importance of access measure development to reducing disparities, including both patient and health system perspectives will be crucial to this effort. Patients, surgeons, researchers, measure developers, hospital administrators, and policymakers must unite to specify, test, and implement new surgical access measures.

CONCLUSIONS

Mounting evidence exists for disparities in access to surgical care in the United States, yet few specified surgical access performance measures exist. Hospitals and health systems are crucial stakeholders and must track performance on existing surgical access measures to identify opportunities to increase health equity while decreasing costs. Using surgical access performance measures holds potential for downstream improvements in disparities in commonly accepted outcome measures, such as postoperative morbidity and mortality. Additional surgical access measures should be developed to guide and assess needed quality improvement efforts.