Joint Replacement Medical Mission Trips Can Provide High Quality Care in Developing Countries: Assessing Quality Using the Structure, Process, and Outcomes Paradigm

Abstract

Background: Medical mission trips that go to developing countries are becoming more popular worldwide and there is need for rigorous quality assessment of the care that these trips provide. Current scrutiny of these trips stems from the lack of established metrics to assess these programs’ quality and from the dearth of literature that attempts to evaluate these trips’ care quality. In developed countries, however, the structure, process, and outcomes paradigm is commonly used to comprehensively assess care quality and many tools exist to evaluate each of these respective quality categories. In this study, we apply these assessment tools to evaluate the structure, processes, and outcomes of Operation Walk (Op-Walk) Boston’s medical mission joint replacement trips to the Dominican Republic (D.R.). Methods: For Op-Walk Boston’s medical mission trip to the D.R., the structure and process elements of care quality were assessed using the Blue Cross/Blue Shield’s (BCBS) Blue Distinction criteria. Full points were given for criteria that the program replicates entirely and zero points were given for criteria that are not replicated entirely. For non-replicated criteria, Op-Walk Boston’s clinical and administrative teams were asked if they compensate for failure to meet the criterion, and they were also asked to identify barriers that prevent them from meeting the criterion. To assess the outcomes quality category, Op-Walk Boston’s patients completed Western Ontario and McMaster Universities’ Arthritis Indexes (WOMAC) and Short Form (36) Health Surveys (SF-36) preoperatively and at 12-month follow-up. Patients were stratified into low, medium, and high scoring preoperative groups based on their preoperative WOMAC function scores. We then examined the associations between these groups’ baseline functional status and two outcomes—improvement in functional status over 12 months and absolute functional status at 12 months—using ANOVA with multivariable linear regression. Results: The structure and process assessment revealed that Op-Walk Boston’s program scored 71 out of 100 possible points, exceeding the 60-point threshold needed to qualify for Blue Distinction. The program met five out of eight “required” criteria and 11 out of 19 “informational” criteria. It scored 14/27 in the “general” category, 30/36 in the “structure” category, 17/20 in the “process” category, and 10/17 in the “outcomes and volume” category. The outcomes assessment revealed that patients’ functional status and pain levels improved greatly after surgery and that those with the lowest WOMAC functional scores preoperatively made the greatest gains in function and pain relief following their joint replacement. Conclusion: Our analysis shows that Op-Walk Boston’s medical mission trip provides high quality care across all care quality categories. An analysis of the program’s structure and processes reveals that Op-Walk Boston scores well on the Blue Distinction criteria’s structure and process categories. In addition to demonstrating high quality structure and processes, the Blue Distinction analysis identifies areas of programmatic improvement and identifies targets for future quality improvement initiatives. Furthermore, the analysis shows that many Blue Distinction criteria can only be met by hospitals operating in the United States (U.S.), so future work should focus on creating criteria that are applicable to total joint replacement (TJR) mission trips in the context of developing countries. Our analysis of the program’s outcomes shows that all tertiles in the Dominican cohort exhibited substantial improvements and high absolute scores at one-year follow-up, demonstrating that the program achieves high quality outcomes. Similar to cohorts from developed countries, Op-Walk patients with poorer preoperative functional statuses improve more than patients who had a higher preoperative level of function. Contrasting developed country cohorts, however, all Dominican tertiles had similar one-year follow-up outcomes regardless of their baseline WOMAC function status, suggesting that poor preoperative function may not limit absolute scores at one-year follow-up. Additional research is needed to confirm these findings in other developing countries and to understand why these associations vary between patients in the D.R. and patients from developed countries.