Subscribe to RSS
DOI: 10.1055/s-0043-1770769
From Art to Science: Patient-Reported Outcomes in Hand Surgery
![](https://www.thieme-connect.de/media/10.1055-s-00031417/202303/lookinside/thumbnails/10-1055-s-0043-1770769_v15n3editorial-1.jpg)
A Brief History of Outcomes
Medicine has historically been viewed as an art rather than a science, and the outcome of an intervention is often reported without solid evidence to back up assertions. The history of bloodletting is a good example of this. Hippocrates believed that the basic elements of life (earth, fire, water, and air) were represented in humans by the four humors of blood, bile, black bile, and phlegm. Of these, blood was considered the dominant humor. Since the disease was thought to arise from an imbalance of these humors, bloodletting became popularized to restore harmony and thus cure disease. This belief prevailed until the mid-19th century when, in Edinburgh, Dr. Hughes Bennett observed that patients who were not subjected to bloodletting developed milder diseases than those who were. The practice slowly receded over the following years and is now considered the cause of death of many patients, including the American President George Washington, who died the day after bloodletting from shock.[1]
This early story of observing outcomes influencing practice has been paralleled over the years in medicine. Doctors have traditionally been slow to follow and change practices. One hundred years later, John Charnley developed his hip replacement and began implanting it in patients at the orthopaedic hospital in Wrightington in 1962. His early results were far superior to previous implants and the natural history of hip osteoarthritis. Over the following years, Charnley trained selected surgeons to implant his device. Within 20 years, hip replacement became the country's most-performed orthopaedic operation despite the lack of randomized controlled trials (RCTs) comparing total hip joint replacement to conservative management.[2]
In Scotland, the Scottish Arthroplasty project was established in the 1990s. Although patient-reported outcome measures (PROMs) are not recorded nationally, outcome measures such as death, revision, and readmission with complication are allowing surgeons to benchmark against their peers.
Hand surgery developed as a subspecialty of both Orthopaedic and Plastic Surgical practice after the Second World War, necessitated by the need for reconstructive surgery in mutilated or severely burned patients. In 1952, a group of surgeons in the United Kingdom interested in hand surgery formed the “Hand Club,” meeting regularly to discuss cases and socialize. This club, however, was exclusive and refused to admit new members. In 1956, the “Second Hand Club” became the current British Society for Surgery of the Hand (BSSH).
With the growth of the BSSH, interest in clinical outcomes developed, and in 1995 a conference was held to examine outcomes in hand surgery specifically. This discussion is documented in a paper outlining the conclusions of a working group.[3] The outcomes were broadly categorized as subjective or objective. The subjective outcomes were based on a series of questions on the patient regarding function and symptom level, with objective data assessed by the physician using measurement. These concepts were very quickly and widely adopted. Over the next 10 years, many sites and disease-specific outcome measures were developed in multiple centers. Data collection, however, remained a significant issue. Around 2010, most of these data were imputed by hand, and only some clinicians had the resources to collect patient outcome data.
In recent years, published research in hand surgery has grown exponentially, driven by the technology of the Internet, communications, and readily accessible statistics packages.
We have, therefore, seen a massive shift in how we define and measure a successful outcome as hand surgeons, moving from the art of the 20th century to the science of the 21st century, and how we rate our strength of evidence that becomes important if we are to interpret published scientific studies effectively.
Publication History
Article published online:
29 June 2023
© 2023. Society of Indian Hand Surgery & Microsurgeons. All rights reserved.
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
-
References
- 1 Thomas DP. The demise of bloodletting. J R Coll Physicians Edinb 2014; 44 (01) 72-77
- 2 Blom AW, Donovan RL, Beswick AD, Whitehouse MR, Kunutsor SK. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021; 374 (1511): n1511
- 3 Macey AC, Burke FD, Abbott K. et al; British Society for Surgery of the Hand. Outcomes of hand surgery. J Hand Surg [Br] 1995; 20 (06) 841-855
- 4 Smith GCS, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003; 327 (7429): 1459-1461
- 5 Wouters RM, Jobi-Odeneye AO, de la Torre A, Joseph A, Hovius SER. ICHOM Hand and Wrist Working Group. A standard set for outcome measurement in patients with hand and wrist conditions: consensus by the International Consortium for Health Outcomes Measurement Hand and Wrist Working Group. J Hand Surg Am 2021; 46 (10) 841-855.e7
- 6 Lloyd-Hughes H, Geoghegan L, Rodrigues J. et al. Systematic review of the use of patient reported outcome measures in studies of electively-managed hand conditions. J Hand Surg Asian Pac Vol 2019; 24 (03) 329-341
- 7 Jerome JTJ, Malshikare VA. Fingertip injuries outcome score. Plast Reconstr Surg Glob Open 2022; 10 (06) e4386
- 8 Stirling PHC, McEachan JE, Rodrigues JN, Harrison CJ. Improving the structural validity of the QuickDASH questionnaire: exploratory factor analysis and structural equation modelling in 1798 patients with carpal tunnel syndrome. J Hand Ther 2023; (e-pub ahead of print) DOI: 10.1016/j.jht.2022.09.004.
- 9 Stirling P, Jenkins PJ, Clement ND, Duckworth AD, McEachan JE. The net promoter scores with friends and family test after four hand surgery procedures. J Hand Surg Eur Vol 2019; 44 (03) 290-295
- 10 Stirling PHC, Jenkins PJ, Clement ND, Duckworth AD, McEachan JE. Self-perceived hand normality before and after surgical treatment of Dupuytren contracture. J Hand Surg Am 2021; 46 (05) 403-408