Attitudes Toward Morbidity and Mortality Conferences Among Medical and Surgical Pediatric Specialists in Armenia | Pediatrics | JAMA Surgery | JAMA Network
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Figure 1.  Knowledge, Attitudes, and Perceptions About Morbidity and Mortality Conferences (MMCs) Among All Respondents
Knowledge, Attitudes, and Perceptions About Morbidity and Mortality Conferences (MMCs) Among All Respondents

Respondents include 67 pediatric surgeons or surgical subspecialists and 150 pediatricians or other nonsurgical specialists at 3 children’s hospitals. QI indicates quality improvement.

Figure 2.  Barriers to Implementation of Morbidity and Mortality Conferences Among All Respondents
Barriers to Implementation of Morbidity and Mortality Conferences Among All Respondents

Respondents include 67 pediatric surgeons or surgical subspecialists and 150 pediatricians or other nonsurgical specialists at 3 children’s hospitals.

1.
Stelfox  HT, Joshipura  M, Chadbunchachai  W,  et al.  Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study.  World J Surg. 2012;36(8):1978-1992. doi:10.1007/s00268-012-1593-1PubMedGoogle ScholarCrossref
2.
World Health Organization. Armenia. http://www.who.int/countries/arm/en/. 2017. Accessed February 25, 2017.
3.
Nranyan  A, Petrosyan  A, Hovannisyan  H, et al.  Social Reforms in Armenia. Yerevan, Armenia: Hrayr Maroukhian Foundation; 2011.
4.
Burns  KEA, Duffet  M, Kho  ME,  et al A guide for the design and conduct of self-administered surveys of clinicians.  CMAJ. 2008;179(3):245-252.Google ScholarCrossref
5.
Schwarz  D, Schwarz  R, Gauchan  B,  et al Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement.  BMJ Qual Saf2011;20(12):1082-1088. doi:10.1136/bmjqs-2011-000273Google ScholarCrossref
6.
LaGrone  LN, Fuhs  AK, Egoavil  EH,  et al.  Mixed-methods assessment of trauma and acute care surgical quality improvement programs in Peru.  World J Surg. 2017;41(4):963-969. doi:10.1007/s00268-016-3832-3PubMedGoogle ScholarCrossref
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Research Letter
December 2017

Attitudes Toward Morbidity and Mortality Conferences Among Medical and Surgical Pediatric Specialists in Armenia

Author Affiliations
  • 1Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
  • 2Division of Pediatric Neurology, Arabkir Joint Medical Center, Yerevan, Armenia
JAMA Surg. 2017;152(12):1178-1180. doi:10.1001/jamasurg.2017.2974

Morbidity and mortality conferences (MMCs) are a core component of surgical quality improvement (QI) efforts throughout the developed world. Although MMCs have been adopted in several low-to-middle income countries (LMIC), little is known about their early development and implementation.1

Armenia is an LMIC and former Soviet Republic with a population of nearly 3 million.2 In Armenia, most hospitals have only rudimentary QI programs, and very few institutions conduct MMCs.3 To understand the opportunities and barriers to developing MMCs, we assessed the attitudes and perceptions of hospital-based physicians in Yerevan, the capital of Armenia, and compared these attitudes and perceptions between surgical and nonsurgical clinicians.

Methods

We used evidence-based guidelines for designing and conducting self-administered clinician surveys to develop a 27-question, written survey to assess physicians’ understanding of and willingness to participate in MMCs.4 Our survey contained 6 questions on physicians’ understanding of QI, 5 on understanding of MMCs, 7 on barriers to implementation, 3 on willingness to implement, and 6 on basic demographic characteristics. We distributed our survey to all attending physicians at each of the 3 children’s hospitals in Yerevan. Participation was voluntary, and responses were anonymous. This study was approved and exempted from the need for informed consent by the institutional review board of UCLA (University of California, Los Angeles). Differences between surgical and nonsurgical respondents were calculated using the χ2 test, with P < .05 indicating statistical significance.

Results

Of 260 pediatric physicians approached, 217 agreed to participate (response rate, 83.5%). Sex and age of respondents were not assessed. Sixty-seven respondents (30.9%) were pediatric surgeons or surgical subspecialists, whereas 150 (69.1%) were pediatricians or other nonsurgical specialists. None of the 3 institutions currently have formal MMC programs. Most respondents reported general understanding of MMC principles (201 [92.6%]) and believed that MMCs are an effective tool for education and QI (200 [92.2%]) (Figure 1). However, when asked about implementing MMCs, only 23 physicians (10.6%) reported being comfortable disclosing patient outcomes without fear of negative professional consequences (Figure 1). The most commonly reported barrier to implementation was concern regarding confidentiality of MMC discussions (158 [72.8%]) (Figure 2). Other reported barriers included fear of legal repercussions, job and income security, damage to relationships and referrals, and inadequate time and resources (Figure 2).

We found no difference between medical and surgical physicians in terms of past participation in MMCs (94 of 150 [62.6%] vs 46 of 67 [68.7%]; P = .48) or in the belief that MMCs are an effective means for education and quality improvement (133 of 150 [88.7%] vs 62 of 67 [92.5%]; P = .37). Similarly, surgeons and nonsurgeons reported equal levels of concern regarding professional relationships (141 of 150 [94.0%] vs 58 of 67 [86.6%]; P = .14), confidentiality (109 of 150 [72.7%] vs 48 of 67 [71.6%]; P = .90), and time and resources (63 of 150 [42.0%] vs 21 of 67 [31.3%]; P = .16).

Discussion

Physicians were generally familiar with MMCs and believe them to be useful tools for education and QI. Thus, if physician fears are allayed and legal protections established, MMCs may represent a valuable first step toward establishing more formal and comprehensive QI initiatives. Similar approaches have been successful in other LMICs, where investigators implemented MMCs focusing on process issues rather than clinician-level errors.5 Process-focused, hospitalwide MMCs may be particularly useful in countries, such as Armenia, with a high density of surgeons and where competition among clinicians may be a significant barrier. In addition, collaboration between medical specialists and surgeons may improve systemwide and hospitalwide adoption of MMCs.

This study was limited by the use of a nonvalidated survey and the possibility of an observer effect. Nevertheless, our survey identified significant barriers to implementing MMCs in Armenia, particularly concerns over confidentiality and the legal repercussions of disclosing medical errors.

Conclusions

Although we did not formally assess the medicolegal framework, as a relatively new post-Soviet republic, Armenia has few legal protections for health care professionals. Nevertheless, the health care policy and legal landscape is rapidly evolving, and we hope our results will contribute to the development of an environment that is more conducive to implementing MMCs and other QI processes. Although traditional efforts to address the medical and surgical needs of LMICs have tended to focus on capacity issues, the need to measure and improve the quality of medical care must not be overlooked.6 Similar efforts to understand and document local attitudes and barriers can contribute to the development of local QI programs in LMICs.

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Article Information

Corresponding Author: Shant Shekherdimian, MD, MPH, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, PO Box 709818, Los Angeles, CA 90095 (sshekherdimian@mednet.ucla.edu).

Accepted for Publication: May 14, 2017.

Published Online: August 30, 2017. doi:10.1001/jamasurg.2017.2974

Author Contributions: Dr Rouch had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Rouch, Dawes, Shekherdimian.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rouch, Garber, Shekherdimian.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rouch, Dawes.

Administrative, technical, or material support: Rouch, Shekherdimian.

Study supervision: Shekherdimian.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the UCLA Global Surgery Initiative, which helped to fund travel expenses.

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Stelfox  HT, Joshipura  M, Chadbunchachai  W,  et al.  Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study.  World J Surg. 2012;36(8):1978-1992. doi:10.1007/s00268-012-1593-1PubMedGoogle ScholarCrossref
2.
World Health Organization. Armenia. http://www.who.int/countries/arm/en/. 2017. Accessed February 25, 2017.
3.
Nranyan  A, Petrosyan  A, Hovannisyan  H, et al.  Social Reforms in Armenia. Yerevan, Armenia: Hrayr Maroukhian Foundation; 2011.
4.
Burns  KEA, Duffet  M, Kho  ME,  et al A guide for the design and conduct of self-administered surveys of clinicians.  CMAJ. 2008;179(3):245-252.Google ScholarCrossref
5.
Schwarz  D, Schwarz  R, Gauchan  B,  et al Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement.  BMJ Qual Saf2011;20(12):1082-1088. doi:10.1136/bmjqs-2011-000273Google ScholarCrossref
6.
LaGrone  LN, Fuhs  AK, Egoavil  EH,  et al.  Mixed-methods assessment of trauma and acute care surgical quality improvement programs in Peru.  World J Surg. 2017;41(4):963-969. doi:10.1007/s00268-016-3832-3PubMedGoogle ScholarCrossref
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