The quality of surgical care in safety net hospitals: a systematic review.
OBJECTIVE
The quality of surgical care in safety net hospitals (SNHs) is not well understood owing to sparse data that have not yet been analyzed systematically. We hypothesized that on average, SNHs provide a lesser quality of care for surgery patients than non-SNHs.


METHODS
We performed a systematic review of published literature on quality of surgical care in SNHs in accordance with guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched within the PubMed, CINAHL, and Scopus online databases, and included peer-reviewed, English-language, scientific papers published between 1995 and 2013 that analyzed primary or secondary data on ≥1 of the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) of surgical care in a US hospital or system that met the Institute of Medicine definition of a SNH. Each article was reviewed independently by ≥2 co-investigators. A data abstraction tool was used to record the eligibility, purpose, design, results, conclusion, and overall quality of each article reviewed. Disagreements over eligibility and data were resolved by group discussion. The main results and conclusions abstracted from the included articles were then analyzed and presented according to the quality domains addressed most clearly by each article.


RESULTS
Our initial search identified 1,556 citations, of which 86 were potentially eligible for inclusion. After complete review and abstraction, only 19 of these studies met all inclusion criteria. SNHs performed significantly worse than non-SNHs in measures of timeliness and patient centeredness. Surgical care in SNHs tended to be less equitable than in non-SNHs. Data on the safety of surgical care in SNHs were inconsistent.


CONCLUSIONS
Although data are limited, there seems to be need for improvement in particular aspects of the quality of surgical care provided in SNHs. Thus, SNHs should be priority settings for future quality improvement interventions in surgery. Such initiatives could have disproportionately greater impact in these lower-performing settings and would address directly any health care disparities among the poor, underserved, and most vulnerable populations in the United States.
Center for Health Outcomes and Policy, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
Charles A
CA
Mouch
Center for Health Outcomes and Policy, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
Scott E
SE
Regenbogen
Center for Health Outcomes and Policy, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
Sha'Shonda L
SL
Revels
Center for Health Outcomes and Policy, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
Sandra L
SL
Wong
Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI.
Christy H
CH
Lemak
Center for Health Outcomes and Policy, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. Electronic address: ammsurg@umich.edu.
Arden M
AM
Morris
D006801:Humans; D061214:Patient Safety; D018802:Patient-Centered Care; D011787:Quality of Health Care / Q000592:standards*; D064876:Safety-net Providers / Q000592:standards*; D013503:Surgery Department, Hospital / Q000592:standards*; D016896:Treatment Outcome; D014481:United States