Introduction

Article Outline

• Copyright

In editing this volume of Seminars in Colon and Rectal Surgery, we have tried to illustrate the impact that outcomes research has had in colorectal surgery and forecast the future role of this type of research for our subspecialty. The Agency for Healthcare Research and Quality defines outcome research as “research to understand the end results of particular health care practices and interventions”—the scope of outcomes research is therefore broad and includes evaluation of the effectiveness of specific medical treatments, interventions, public health strategies and policies, and practice patterns and quality of care through an understanding of structure, process, and outcome. It is important to note that outcomes research does not stand alone but rather should be viewed as a complement to basic science, clinical trials, and other forms of clinical research. In this regard, outcomes research is an important scientific endeavor that can be used to assess various treatments, health patterns and policies, and health care systems.

Historically, Avedis Donabedian, a health care researcher and physician, first used the term “outcomes” in defining results following medical therapy. He was one of the first to address the wide range of measurable outcomes—simply definable variables such as morbidity and mortality as well as less easily defined outcomes such as social restoration, patient satisfaction, physical disability, functional impairment, and long-term outcomes. In addition, while determining follow-up of chronically ill patients from acute care hospitals, Donabedian first made the connection between outcomes and quality assurance. Thus, at an early stage, Donabedian recognized that outcomes are intimately related to quality in health care and should be viewed as complementary. Given that these two concepts are so closely linked, we will try to highlight their interaction where possible in each article.

Quality assessment and performance measurement have become daily concerns for colorectal surgeons. The Institute of Medicine recently launched the Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Project to accelerate the diffusion and pace of quality improvement efforts in the United States. Institute of Medicine reports to the Centers for Medicare and Medicaid Services have subsequently focused on specific policies to improve the quality of health care through the following: (1) measurement and reporting of performance data; (2) payment incentives, and (3) quality improvement initiatives. With this mandate, the Centers for Medicare and Medicaid Services recently launched the Physician Voluntary Reporting Program, in which participating physicians capture data about the quality of care provided to Medicare beneficiaries. Well-designed outcomes studies are essential to the development of meaningful and fair quality metrics and are instrumental in the design and evaluation of quality improvement strategies. The influence of outcomes research on our practice is therefore likely to increase.

In colon and rectal surgery, outcomes research has already made a significant impact on our daily patient management and we have therefore chosen to focus this edition on the most clinically relevant outcomes research rather than providing the theoretical basis, statistical models, or metrics of measurement. In March 2003, Dr. Clifford Ko provided readers of this journal a thorough and concise review of the theoretical foundation for outcomes research. His thoughtful volume included topics detailing fundamental theory and methodological considerations in this area. To build on this foundation and not duplicate this work, our more clinical emphasis takes advantage of a list of authors who are leaders in their respective fields. Many of the authors have been formerly trained in health services research, epidemiology, or clinical outcomes, and each has made significant contributions in their area of interest.

Our outcomes issue includes topics that have incited great interest and controversy in the field of colon and rectal surgery. We begin by addressing the impact of bowel preparations, analgesia, and enhanced recovery programs on perioperative outcomes. Next we address the relationship between lymph node recovery, surgical technique, anastomotic method, pelvic reconstruction, and laparoscopy and outcomes. Last, scoring systems used to predict outcomes are described to provide a detailed understanding of risk adjustment, an area of increasing importance in the era of performance measurement. These articles represent only a small select sample of subject matter; however, each builds on the preceding article to provide a rich understanding of outcomes research in the field of colon and rectal surgery.

In summary, this issue of Seminars in Colon and Rectal Surgery provides an overview of outcomes research in several important areas of investigation that should satisfy the active clinician and researcher. Our particular emphasis for this volume is the impact of outcomes research in colorectal surgery and the role of outcomes on quality measurement and assurance—included, where possible, is information regarding potential quality metrics in each area of research. This is critical as quality metrics and measurement become more and more important to the individual practitioner. We hope that the reader enjoys the well-written articles included in our carefully selected list of authors and gains valuable insight into the world of outcomes research.