Health policy will be an integral component of research publications accepted in Plastic and Reconstructive Surgery. What is health policy research and why should we care? Health policy research includes analysis of population data, health care legislation, and global health care initiatives to inform and influence patient care and health care policy. The emphasis on health policy publications stems from the seismic changes affecting health care delivery both in the United States and across the globe. These changes impact all surgical patients, including plastic surgery patients. To promote health policy research, an Editorial in the September of 2020 edition of Plastic and Reconstructive Surgery shared the relevance of this type of work, and a subsequent Editor’s Perspective from January of 2022 discussed how to approach health policy research.1,2 Only through critical examination of population databases can we understand the impact of health policy on our practice and our patients. Conducting health policy research demands the use of administrative data sets, which are fraught with inadequate precision. As highlighted by Scott et al., although there are challenges to performing this type of research, pitfalls may be overcome through several strategies.3 Methods using quasi-experimental design, including difference-in-difference analyses, propensity score matching, and instrumental variables, are among the novel statistical techniques that are much needed to evaluate health policy in our field.
Health policy initiatives have global impact. Although surgical checklists are now a cornerstone of surgical practice in the United States, this was not always the case. In 2007, the World Health Organization sponsored a study on surgical safety to identify and mitigate complication risk attributed to a lack of standardization in surgical care. A 19-item surgical checklist was implemented at eight hospitals in eight countries within North America, the Middle East, Africa, and the Pacific Rim. The checklist included steps such as confirming patient identity, marking surgical sites, reconciling allergies, a standard preoperative timeout, and intraoperative use of pulse oximetry. The authors found a reduction in mortality from 1.5% to 0.8%, and a complication reduction of 11% to 7% following the introduction of the checklist.4 These reductions in morbidity and mortality amount to substantial impact on patient safety and well-being in the context of an annual worldwide surgical volume of over 234 million cases. This is the type of influential health policy research that we want to receive at Plastic and Reconstructive Surgery.
Although studies may inform policy, critical assessments of enacted legislation affecting plastic surgery practice are also critical. As an example, a study by Gooch et al. assessed a piece of New York State legislation passed in 2011 that required discussion of reconstruction options for all mastectomy patients.5 Interestingly, despite the appropriateness and patient-centeredness by which this legislation had been crafted, the authors found that postmastectomy reconstruction rates in New York State were increasing before the 2011 legislation. No significant increase in postmastectomy reconstruction was attributable to this policy. This work fosters discussion and further investigation into barriers women may face following mastectomy, given underuse of reconstruction overall. This further informs future policy initiatives, both in New York and in other states, to promote equity.
Health policy research is not just limited to patient care. In a highly relevant study on the effect of intern work hours on serious medical errors in intensive care units, the authors conducted a randomized controlled trial by assigning interns to 24-hour shifts or a reduced schedule. The authors found that interns made significantly more medical errors when working 24-hour shifts when compared to reduced shifts.6 Lengthy, high-intensity shifts are an aberrancy for professions in the United States. To work continuously for 24 hours, particularly under such stressful conditions as in the intensive care unit, is detrimental to the health of both our patients and our trainees. From a patient perspective, this work substantiates policy interventions aimed at improving work conditions for graduate medical education to reduce preventable medical errors. For trainees, creating a work environment that reduces exhaustion and fosters enjoyment will improve patient outcomes and reduce burnout, a phenomenon that many physicians and nursing staff experience today.
On the population level, health policy research publications have broader implications on the quality of health care delivered to adults in the United States. Using a random sample of adults living in 12 metropolitan areas in the United States, McGlynn et al. investigated quality of care delivered to adult patients in the United States. Not surprisingly, the authors found a wide variation in quality.7 These deficits in quality influence the health of the American public and, perhaps more importantly, serve as the basis by which future interventions may be measured. In effect, this work serves as an impetus to improve health equity for all Americans, regardless of baseline socioeconomic status.
To encourage health policy research in our specialty, a special logo (Fig. 1) will be included on Plastic and Reconstructive Surgery articles pertaining to this topic starting in the February of 2023 issue. These articles will be presented in an ever-growing collection on PRSJournal.com: https://bit.ly/PRSHealthPolicy. We wish to sponsor tutorials and guides on how to conduct health policy research in plastic surgery. We are confident that health policy research can—and will—be an integral component of plastic surgeons advocating for our specialty and for our patients. Thoughtful analyses of population studies, legislative efforts, and quality and safety initiatives will influence our specialty and the care we deliver.
The authors thank Angela Burch, American Society of Plastic Surgeons staff editor of production and design, for creating the new Plastic and Reconstructive Surgery Health Policy logo. They also thank Aaron Weinstein, editorial director, and Anna Wojtul, copy editor, for assistance with this editorial.
1. Byrd JN, Chung KC. Conducting health policy research. Plast Reconstr Surg. 2022;150:1–3.
2. Chung KC, Baxter NB, Rohrich RJ. Promoting health policy research in plastic surgery. Plast Reconstr Surg. 2021;147:1242–1244.
3. Scott JW, Schwartz TA, Dimick JB. Practical guide to health policy evaluation using observational data. JAMA Surg. 2020;155:353–354.
4. Haynes AB, Weiser TG, Berry WR, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499.
5. Gooch JC, Guth A, Yang J, et al. Increases in postmastectomy reconstruction in New York State are not related to changes in state law. Plast Reconstr Surg. 2019;144:159e–166e.
6. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–1848.
7. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–2645.