What are some potential surgical research topics that can improve patient outcomes?

Surgical Research Topics to Improve Patient Outcomes

The highest priority surgical research topics that demonstrably improve patient outcomes are: (1) implementation and compliance with Enhanced Recovery After Surgery (ERAS) protocols, (2) standardization of outcome measurement using core outcome sets, and (3) failure-to-rescue prevention systems, particularly in high-risk and elderly populations. 1, 2

Priority Research Area 1: Enhanced Recovery After Surgery (ERAS) Implementation

ERAS protocols are proven to reduce hospital length of stay and complications across multiple surgical specialties, making implementation research the highest priority. 1

• ERAS guidelines decrease hospital length of stay by 30-50% and reduce postoperative complications, with meta-analysis of 74 randomized trials involving 9,076 participants demonstrating these benefits 1, 2
• The number of ERAS elements implemented directly correlates with the magnitude of benefit, suggesting research should focus on maximizing protocol adherence rather than selective implementation 1
• Future research must prioritize improving implementation strategies and measuring compliance rates, as approximately 50% of surgical complications are preventable through evidence-based protocols 1
• Multimodal opioid-sparing analgesia within ERAS frameworks specifically reduces postoperative delirium in elderly patients with cognitive impairment 2

Priority Research Area 2: Standardized Outcome Measurement

Developing and implementing core outcome sets (COS) across surgical specialties is critical, as inconsistent outcome reporting currently prevents meaningful comparison between studies and meta-analysis. 1

Essential Components of Surgical Outcome Assessment

• All surgical trials must measure and report at minimum: mortality (30-day and long-term), complications classified by Clavien-Dindo and Comprehensive Complication Index (CCI), quality of life using validated PROMs, and re-operation/re-intervention rates 1
• Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) must be routinely collected in clinical care, not just research, as they capture outcomes that matter most to patients 1
• Outcomes should be recorded at standardized time points across studies to enable cross-study comparison 1
• Research is needed to develop condition-specific and intervention-specific PROMs jointly with patients, as current tools often fail to capture patient priorities 1

Bariatric Surgery Model

The bariatric surgery field provides a template for other specialties, having established a core outcome set including: weight, diabetes status, overall quality of life, mortality, technical complications, re-operations with severity classification, dysphagia/regurgitation, micronutrient status, and cardiovascular risk 1

Priority Research Area 3: Failure-to-Rescue Prevention

The difference between high and low mortality hospitals is not complication rates but effective rescue once complications occur, making failure-to-rescue prevention systems a critical research priority. 2

• Failure-to-rescue rates are significantly higher in frail elderly patients, yet this represents a modifiable system-level factor 2
• Implementing physiological track-and-trigger systems with specific activation thresholds (such as Modified Early Warning Score with lower thresholds for elderly: heart rate >90 bpm, systolic BP <110 mmHg) reduces failure-to-rescue mortality 2
• Rapid response teams including intensivists experienced in postoperative surgical management improve outcomes when complications are detected early 2
• Research should evaluate optimal team composition, activation criteria, and response protocols specific to surgical populations 2

Priority Research Area 4: Prehabilitation in High-Risk Populations

Prehabilitation research must shift from measuring exercise capacity changes to clinically relevant postoperative outcomes, with standardized measurement intervals. 1

Critical Research Gaps

• Current prehabilitation studies lack consensus on which outcomes to measure, with variable assessment of complications, mortality, length of stay, and readmission rates 1
• Only 2 of 10 reviewed studies comprehensively measured and reported adherence (prescribed minutes, repetitions, and achieved intensity), making it impossible to determine intervention effectiveness 1
• Future studies must measure postoperative outcomes (complications, mortality, length of stay, readmission) at standardized intervals rather than focusing solely on fitness metrics like 6-minute walk test or VO2 max 1
• Research should identify which patient populations benefit most from prehabilitation, as younger prostate cancer patients with short hospital stays may benefit more from quality-of-life focused outcomes than length-of-stay reduction 1

Priority Research Area 5: Surgical Safety and Quality Improvement

Implementation of surgical safety checklists reduces mortality from 1.5% to 0.8% and complications from 11.0% to 7.0%, yet adoption remains incomplete. 3

• The WHO Surgical Safety Checklist demonstrated mortality reduction across diverse economic settings and patient populations in 8 countries 3
• Research should focus on barriers to checklist adoption and strategies to improve compliance, as the intervention is proven but underutilized 3
• Every institution must appoint a "data quality guarantor" to ensure accurate outcome recording and reporting 1
• Routine interdisciplinary mortality and morbidity conferences following standardized formats should be mandatory, with research defining minimum standards for these conferences 1

Priority Research Area 6: Geriatric Surgical Optimization

Frailty assessment provides unique prognostic information beyond traditional risk scores and shows dose-dependent effects on failure-to-rescue, complications, reoperation, and mortality. 2

Essential Research Directions

• All patients ≥65 years require frailty screening using validated tools, yet optimal screening instruments and intervention strategies remain unclear 2
• Proactive geriatric co-management beginning preoperatively or immediately postoperatively significantly reduces mortality, length of stay, and discharge to higher care levels, but implementation models need refinement 2
• Research must develop tools for holistic risk assessment quantifying all risk and protective factors, including socio-demographic determinants of health 1
• Combining NSQIP Surgical Risk Calculator with frailty assessment and nutritional status provides optimal mortality prediction, but this approach requires validation across surgical specialties 2

Priority Research Area 7: Surgical Disparities

African American individuals have increased mortality risk across multiple surgical procedures, with gender, sexual orientation, age, and geographic disparities also well-documented, requiring urgent research attention. 4

Key Research Priorities

• Improving patient-clinician communication through evidence-based interventions and decision aids 4
• Evaluating care quality at facilities serving higher proportions of minority patients to identify and address systematic deficiencies 4
• Fostering community engagement and outreach using technology to improve access 4
• Workforce diversification and training to reduce implicit bias and improve cultural competency 4
• Systematic evaluation of health technologies to reduce disparities rather than exacerbate them 4

Priority Research Area 8: Low and Middle-Income Country (LMIC) Surgical Care

Three priority areas for LMIC surgical research are: access to surgery, outcomes of cancer surgery, and perioperative care. 5, 6

• District hospitals should prioritize developing surgical services for low-complexity, high-volume conditions 6
• Emergency and essential surgical care must be integrated within national Universal Health Coverage frameworks 6
• Evidence-based interventions for reducing surgical site infections, improving trauma systems, and reducing maternal/perinatal mortality require implementation research in LMIC settings 6
• Research must be driven by front-line LMIC clinicians, patients, and stakeholders rather than imposed by high-income country researchers 5

Critical Research Methodology Considerations

Artificial intelligence applications in surgical outcome assessment require rigorous evaluation, as current evidence for clinical benefit is lacking. 1

• The precise benefit of AI in clinical practice and research remains unmeasured despite widespread discussion 1
• Socio-demographic and cultural factors influencing surgical outcomes are only now being recognized, requiring specialized measurement tools that do not yet exist 1
• Benchmarking tools to compare healthcare systems within and across countries and demonstrate impact on individual health outcomes need development 1

Common Pitfalls to Avoid

• Never ration surgical or critical care based solely on chronological age—biological age and frailty status are far more predictive of outcomes 2
• Avoid conducting surgical research without patient involvement in outcome selection, as researcher-selected outcomes often fail to capture what matters most to patients 1
• Do not implement prehabilitation programs without measuring clinically relevant postoperative outcomes and comprehensive adherence data 1
• Avoid using non-standardized outcome measurement intervals, as this prevents cross-study comparison and meta-analysis 1