A Critical Assessment of Surveys in Plastic and Reconstructive Surgery: A Systematic Review

Purpose: Surveys are one of the fundamental approaches used to assess patient preferences and current practice patterns in plastic surgery.¹ In contrast with other surgical specialties, plastic surgery procedures emphasize quality of life outcomes. Therefore, understanding factors that influence the attitudes of patients and physicians are important to achieve successful outcomes. Despite the prevalent use of surveys in Medicine, researchers have identified inherent biases in surveys used in medical research.² It is uncertain how prevalent and the magnitude of these problems in plastic surgery surveys. Our specific aims are to (1) determine the extent to which survey instruments in plastic and reconstructive surgery contain inherent biases and (2) identify areas of improvement for developing survey instruments.

Methods: We searched four databases (Embase, PsycInfo, Medline and PubMed) for articles in plastic surgery that contain a survey. We identified studies published from 1997 to 2017 that had some measurement of physician/patient attitudes as a key theme. Validated or outcome instruments were excluded. Two trained reviewers assessed the articles using specific inclusion and exclusion criteria. A modified checklist from Choi et al. was used to examine the biases in these surveys.³

Results: Of the 4,768 articles captured by the search, 200 articles were included in the final review. The number of questions in a survey ranged from 2 to 82 (mean, 14 questions). The mean percentage of biased questions in a survey questionnaire was 19%. Flaws that could have a considerable impact on responses, such as leading questions (0.3%) and double-barreled questions (0.7%), were negligible. Conversely, relatively minor flaws, such as forced choice (8.9%) and end-aversion (4.3%), were more common. When performing a multivariable analysis, we observed no significant differences in the percentage of bias among later years or longer surveys.

Conclusions: Overall, surveys in plastic surgery do not contain inherent flaws that impact survey results. This critical review revealed areas of improvement for survey research in this specialty. Given the policy implications of data collected with surveys in measuring physician/patient attitudes, the Plastic Surgery specialty has performed remarkably well in delivering carefully structured surveys that captured attitudes of plastic surgery practices. Alerting Plastic Surgery researchers in the biases in past surveys assures an even more robust application of this essential survey tool.  

References:

1. Phillips AW, Friedman BT, Utrankar A, Ta AQ, Reddy ST, Durning SJ. Surveys of Health Professions Trainees: Prevalence, Response Rates, and Predictive Factors to Guide Researchers. Academic medicine : Journal of the Association of American Medical Colleges. Feb 2017;92(2):222-228.
2. Sullivan GM, Artino AR, Jr. How to Create a Bad Survey Instrument. Journal of Graduate Medical Education. Aug 2017;9(4):411-415.
3. Choi BCK, Pak AWP. A Catalog of Biases in Questionnaires. Preventing Chronic Disease. 2005;2(1):A13.