Plastic surgeons prove their worth with outcomes
Patients’ self-images, quality of life improve
When you strip away the complexities of clinical outcomes measurement, one question remains: Did the patient get better?
Yet in the delicate area of plastic and reconstructive surgery, proving quality and value calls for further questions. Did the patient’s self-image improve? Did the patient’s quality of life increase?
Measure by patients’ perceptions
Reconstructive surgeons can measure success objectively, by comparing symmetry of reconstructed breasts after mastectomy and independent observers’ ratings of aesthetics. "But what’s really important is what the patient feels about it," says Mark Schusterman, MD, a Houston plastic surgeon and chairman of the Medical Effectiveness Research Committee of the Arlington Heights, IL-based American Society of Plastic and Reconstructive Surgeons.
Patient functioning and self-image are core aspects of a new outcomes measurement tool being developed by the society. Plastic surgeons will be able to use the data collection instrument to assess their outcomes, compare themselves to a national database and market their value to managed care, says Bruce Cunningham, MD. Cunningham is a professor of plastic surgery at the University of Minnesota in Minneapolis and chairman of the Outcomes Research Committee of the Plastic Surgery Educational Foundation in Arlington Heights, IL. The educational foundation has funded outcomes studies related to explantation of breast implants and breast reduction.
The ASPRS data collection tool is designed for clinician use with all types of plastic and reconstructive surgery and includes questions about the impact of surgery on quality of life. (See sample questionnaire, p. 93.) After further testing, it will be released in its final form later this year. Specific modules, such as for breast reconstruction and rhinoplasty, also may be developed.
Psychological factors, such as body image, affect the patient’s overall health status, says Cunningham. In measuring outcomes, he says reconstructive surgeons are asking: "What is there about someone’s appearance that either enhances or degrades his or her functioning ability?"
Some payers reject claims
Proving quality is more than academic to plastic and reconstructive surgeons. The surgery increasingly falls into a gray area, with some payers asserting that it is cosmetic and not medically necessary.
Suppose, for example, a patient suffers a traumatic facial injury, and in an emergency procedure, surgeons correct facial fractures.
"Suppose there is something that needs to be revised," says Schusterman. "Can you live without that being revised?"
What about reconstruction for a cleft lip or palate? Or breast reconstruction after a mastectomy?
"In their zeal to cut costs, [payers] oftentimes make it very difficult for patients to have these procedures," Schusterman says of reconstructive surgery. "If they don’t completely deny it, they make it difficult for patients to get coverage."
The plastic and reconstructive surgeons hope outcomes management will help them prove their value. The society plans to create a national database with reports available for physicians as well as managed care organizations.
"We’re trying to demonstrate what the role is of plastic surgery in health care in America," says Schusterman.
"You have a more productive and psychologically sound person," he says. "That is money well-spent. That provides some positive health benefits. We hope this instrument and project will document that in a way that will demonstrate to the purchasers that they are getting good value for their money."
While plastic surgeons await completion of a specialized measurement tool, surgeons have assessed the outcomes of breast implantation and explantation (removal of implants) using widely recognized questionnaires, such as the SF-36, a measure of functional health status developed by the Medical Outcomes Trust in Boston.
In a study at 17 medical centers, surgeons are following the cases of women for two years following breast reconstruction after mastectomy.
They are monitoring complications, aesthetics, physical functioning, psychosocial results, and costs with preoperative assessment and follow-up at one year and two years postoperatively. The general health status questionnaires were altered to include questions about shoulder and abdominal wall function, body image, and practical concerns about clothes, exercise, and work activities.
One aspect of the study compares the choice of implants vs. transverse rectus abdominis musculocutaneous (TRAM) or natural tissue reconstruction.
"Do implant patients have more somatic complaints, more aches and pains, than natural tissue transplants? That has not turned out to be the case," says Ed Wilkins, MD, associate professor of surgery at the University of Michigan in Ann Arbor and research investigator for the Veterans Administration Health Services Research and Development program. The research is funded by a U.S. Army medical research grant.
Yet TRAM patients have better outcomes in terms of body image and other psychosocial issues, says Wilkins.
"Implants cost less," he says. "But if patients have better outcomes with TRAMs, the cost benefit ratio may be better.
"One of the things I’ve noticed is that patients who have TRAMs tend to incorporate that reconstruction into their body image more readily," he says. "Patients who have TRAMs tend to refer to their reconstruction as my breasts’"
Wilkins says the outcomes research helps define choices for patients who need breast reconstruction, and it documents the procedure’s benefits to payers.
"We want to demonstrate clearly, once and for all, that breast reconstruction develops very definite benefits in psychosocial outcomes for our patients," he says.
[Editor’s note: For more information on the plastic surgery outcomes measurement instrument, contact Mary-Patricia McKeever, Research Associate, American Society of Plastic and Reconstructive Surgeons, 444 East Algonquin Road, Arlington Heights, IL 60005. Telephone: (847) 228-9900.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content