Outcomes research in hand surgery: where have we been and where should we go?
PURPOSE: The outcomes movement began in response to a national emphasis to control cost and to limit geographic variation in medical services. The impact of the outcomes movement on hand surgery research is unknown. We conducted a systematic review of hand surgery studies to assess the past and current states of outcomes research in this specialty. METHODS: A systematic review of hand surgery outcomes studies was conducted in The Journal of Hand Surgery (American and British volumes) from 1988 to 2004. A Medline search using the 11 Agency for Healthcare Research and Quality categories of outcomes studies was performed. Studies were rated for study design, data endpoints, and level of impact using the Agency for Healthcare Research and Quality-designated impact levels. RESULTS: A total of 2,236 studies were identified, and 1,188 were included in the analysis. Most studies were rated as level 1 impact (N = 1,090, 92%), and a small number of studies were level 4 impact (N = 98, 8%). Thirty-nine percent were prospective and 45% (N = 529) were retrospective descriptive studies. Data gathered in studies included objective clinical measures (N = 672, 57%), quality of life (N = 374, 31%), morbidity (N = 401, 34%), subjective clinical measures (N = 27, 16%), cost (N = 185, 2%), and mortality (N = 11, 1%). CONCLUSIONS: Our systematic review of hand surgery outcomes studies found that much of the research is confined to testing new or existing surgical techniques (level 1 impact). We found a small number of studies that did show improvement in patient outcomes as a result of an intervention (level 4 impact). The future direction of outcomes studies should consider the impact of the research goals to change patient or physician behavior to enhance health parameters. More research on economic analysis needs to be conducted in hand surgery to meet the national goal of containing cost and improving the quality of health care.