What factors influence follow-up in orthopedic trauma surgery?

Travel barriers, unemployment, and external fixation predict loss to follow-up after surgical management of lower extremity fractures in Dar es Salaam, Tanzania

Objective:

Predict loss to follow-up in prospective clinical investigations of lower extremity fracture surgery.

Design:

Secondary analysis of 2 prospective clinical trials.

Setting:

National public orthopaedic and neurologic trauma tertiary referral hospital in Dar es Salaam, Tanzania, a low-income country in sub-Saharan Africa.

Patients/Participants:

Three hundred twenty-nine femoral shaft and 240 open tibial shaft fracture patients prospectively enrolled in prospective controlled trials of surgical fracture management by external fixation, plating, or intramedullary nailing between June 2015 and March 2017.

Intervention:

Telephone contact for failure to attend scheduled 1-year clinic visit.

Main Outcome Measurements:

Ascertainment of primary trial outcome at 1-year from surgery; post-hoc telephone questionnaire for reasons patient did not attend the 1-year clinic visit.

Results:

One hundred twenty-seven femur fracture (39%) and 68 open tibia fracture (28%) patients did not attend the 1-year clinic visit. Telephone contact significantly improved ascertainment of the primary study outcome by 20% between 6-month and 1-year clinic visits to 82% and 92% respectively at study completion. Multivariable analysis associated unemployment (OR = 2.5 [1.7–3.9], P < .001), treatment with an external fixator (OR = 1.7 [1.0–2.8], P = .033), and each additional 20 km between residence and clinic (OR = 1.03 [1.00–1.06], P = .047] with clinic nonattendance. One hundred eight (55%) nonattending patients completed the telephone questionnaire, reporting travel distance to the hospital (49%), and travel costs to the hospital (46%) as the most prevalent reasons for nonattendance. Sixty-five percent of patients with open tibia fractures cited relocation after surgery as a contributing factor.

Conclusions:

Relocation during recovery, travel distance, travel cost, unemployment, and use of an external fixator are associated with loss to clinical follow-up in prospective investigations of femur and open tibia fracture surgery in this population. Telephone contact is an effective means to assess outcome.

Correlation of Appointment Times and Subspecialty With the No-Show Rates in an Orthopedic Ambulatory Clinic

EXECUTIVE SUMMARY

Unexpectedly missed appointments ("no-shows") cause clinic inefficiency, lost time and revenue, wasted healthcare resources, and provider dissatisfaction. No-shows can be associated with miscommunication, transportation difficulties, employment status, age, race, and socioeconomic status. This study investigates the association between no-show rates and patient, appointment time, and provider characteristics. Data for all scheduled appointments in a single orthopedic multispecialty institution during calendar year 2016 were obtained. Data points included patient age, gender, and race; hour; month; and subspecialty. Chi-square testing was used to compare no-show and kept appointments with respect to patient and appointment characteristics. Logistic regression was used to calculate differences in no-show rates between orthopedic subspecialties. The overall no-show rate was 11.5%. Race, age, and subspecialties were all found to be associated with higher no-show rates. No significant differences were observed for gender, appointment time, or month of appointment. The authors suggest that patients at higher risk of not showing up for scheduled appointments may need extra effort from providers to accommodate the patients' schedules when making appointments, to confirm their appointments a few days before, and/or to incentivize patients to minimize no-shows.

Factors associated with early postoperative survey completion in orthopaedic surgery patients

PURPOSE

To determine factors associated with survey compliance 2-weeks postoperatively.

METHODS

1269 patients age 17-years and older participating in the Maryland Orthopaedic Registry from August 2015-March 2018 were administered a baseline questionnaire preoperatively and emailed a follow-up questionnaire 10-days postoperatively. Demographics were self-reported and medical records reviewed for relevant medical history.

RESULTS

609 patients (48.0%) completed both the baseline and 2-week surveys. A decreased likelihood of 2-week survey completion was seen in patients who identified as black, smokers, patients without a college education, patients who were unmarried, unemployed, had a lower income, or covered by government-sponsored insurance (p < 0.05). Other preoperative variables significantly associated with decreased likelihood of completion included surgery on the right side, upper extremity surgery, preoperative opioid use, no specific injury leading to surgery, lower preoperative expectations, depression and fatigue symptoms, and worse pain, function, and activity scores (p < 0.05). Multivariable analysis confirmed race, operative extremity, education, insurance status, smoking, activity level, and pain scores were independent predictors of survey completion.

CONCLUSION

Several demographic and preoperative variables are associated with survey completion 2-weeks post-orthopaedic surgery. The results provide insight into patient populations that may be targeted in order to assure higher survey compliance and improve analysis of patient-reported outcomes.

Predicting completion of follow-up in prospective orthopaedic trauma research

Objective:

Orthopaedic trauma studies that collect long-term outcomes are expensive and maintaining high rates of follow-up can be challenging. Knowing what factors influence completion of follow-up could allow interventions to improve this. We aimed to assess which factors influence completion of follow-up in the 12 months following surgery in prospective orthopaedic trauma research.

Design:

Prospective Cohort Study.

Setting:

Level 1 Trauma Center, Vancouver, Canada.

Participants:

Eight hundred seventy patients recruited to 4 prospective studies investigating the outcomes of operatively treated lower extremity fractures.

Main outcome measurements:

Completion of follow-up defined as completion of all outcome measures at all time points up to 12 months following injury.

Results:

Univariate analysis and subsequent analysis by building a reductive multivariate regression model allowed for estimation of the influence of factors in completion of follow-up.

Eight hundred seventy patients with complete data had previously been recruited and were included in the analysis. Seven hundred seven patients (81.2%) completed follow-up to 12 months. Factors associated with completion of follow up included higher physical component score of SF-36 at baseline, not being on social assistance at the time of injury, being married and having a higher level of educational attainment.

Conclusions:

Our study has demonstrated several important factors identifiable at baseline which are associated with a failure to complete follow-up. Although these factors are not modifiable themselves, we advocate that researchers designing studies should plan for additional follow-up resources and interventions for at risk patients.

Level of Evidence:

Level IV

Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries

BACKGROUND

Currently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers.

METHODS

We identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae.

RESULTS

After reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization.

CONCLUSIONS

Our findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients.

LEVEL OF EVIDENCE

Level IV.

Mapping recovery in simple and complex tibial plateau fracture fixation

Aims

The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures.

Patients and Methods

Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86).

Results

Mean SF-36 PCS improved significantly in both groups from six to 12 months (p < 0.001) and one to five years (simple, p = 0.008; complex, p = 0.007). In both groups, the baseline scores were not reached at five years. The SF-36 PCS was significantly higher in the simple group compared with the complex group at both six months (p = 0.007) and 12 months (p = 0.01), but not at five years (p = 0.17). Between each timepoint, approximately 50% or more of the patients in each group achieved an MCID in their score change, indicating a significant clinical change in condition. The complex group had a much larger drop off in the first six months, with comparable proportions achieving MCID at the subsequent time intervals.

Conclusion

Tibial plateau fracture recovery was characterized overall by an initial decline in functional outcome from baseline, followed by a steep improvement from six to 12 months, and ongoing recovery up to five years. In simple patterns, patients tended to achieve a higher functional score by six months compared with the complex patterns. However, comparable functional scores between the groups achieved only at the five-year point suggest later recovery in the complex group. Function does not improve to baseline by five years in either group. This information is useful in counselling patients about the course of prospective recovery. Cite this article: Bone Joint J 2019;101-B:1009–1014.

Improved Outcomes in Patients with Retinal Detachment after Implementation of a Silicone Oil Registry and Phone Call Reminder System

PURPOSE

This retrospective study was performed to assess the clinical impact in reducing silicone oil (SO)-related complications such as keratopathy of a registry and appointment reminder system for patients with complicated retinal detachment (RD) who underwent pars plana vitrectomy (PPV) with SO tamponade.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 87 eyes of 87 patients who received SO tamponade were included.

METHODS

The study was carried out at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG). Patients were divided into those who received SO before (control group, n = 48) or after (treatment group, n = 39) implementation of an SO registry and patient reminder system in 2014. Patient records were reviewed to identify clinical characteristics and outcomes.

MAIN OUTCOME MEASURES

The primary outcome measure was the difference in the rate of loss to follow-up before versus after the implementation of the registry and reminder system. Secondary outcomes were the duration of SO tamponade, keratopathy rate, and intraocular pressure (IOP) at the last visit before SO removal.

RESULTS

Forty-eight patients were included in the control group, and 39 patients were included in the treatment group. The number of patients lost to follow-up was 23 (47.9%) in the control group versus 6 (15.4%) in the treatment group (P = 0.0015). The mean duration before SO removal was 79.6±91.7 weeks in the control group and 36.3±31.5 weeks in the treatment group (mean±standard deviation [SD]) (P = 0.015). Keratopathy developed in 33.3% of patients in the control group and 12.8% of patients in the treatment group (P = 0.0425). Mean IOP at the last visit before SO removal was 13.0±5.2 mmHg (mean±SD) in the control group and 13.3±7 mmHg (mean±SD) in the treatment group (P > 0.05).

CONCLUSIONS

A phone call appointment reminder system for patients with complicated RD who underwent PPV and SO tamponade reduced the rate of loss to follow-up and the duration of SO tamponade, correlating with a reduction in the rate of keratopathy.

Reducing routine laboratory tests in patients with isolated extremity fractures: a prospective safety and feasibility study in 246 patients

Background

Daily routine laboratory testing is unnecessary in most admitted patients. The opportunity to reduce daily laboratory testing in orthopaedic trauma patients has not been previously investigated.

Methods

A prospective observational study was performed based on a new laboratory testing reduction protocol for 12 months at two tertiary care trauma centers. Admitted patients with surgically treated isolated upper or lower extremity fractures were included (n = 246). The testing protocol consisted of a complete blood count (CBC) and basic metabolic panel (BMP) on postoperative day 2. Thereafter, tests were obtained at individual providers' discretion. Patients were followed for 30 days postoperatively. The primary outcome was number of laboratory tests reduced. Secondary outcomes included provider protocol compliance, and adverse patient outcomes. Chi-squared tests were used to compare differences in categorical variables among the cohorts. Analysis of variance tests were used for continuous variables. The relative reductions in testing utilization were calculated using our division's standard-of-care before program implementation (1 CBC and 1 BMP per patient per inpatient day). Significance was defined as P < 0.05.

Results

Of the 246 patients, there were 45 protocol fall outs due to provider deviation (n = 24) or medically justified necessity for additional testing (n = 21). Across all groups, a total of 778 CBC or BMP tests were avoided, amounting to a 69% reduction in testing compared to the pre-implementation baseline. Ninety-five percent of protocol group patients were safely discharged either without laboratory testing or with one set of tests obtained on postoperative day 2. There were no 30-day readmissions or reported complications associated with the new laboratory testing protocol.

Conclusions

In patients with surgically treated fractures about the elbow and knee, obtaining a single set of laboratory tests on postoperative day 2 is safe and efficacious in terms of reducing inappropriate resource utilization.

Trial registration

retrospectively registered.

Understanding the surgical care needs and use of outpatient surgical care services among homeless patients at the Ottawa Hospital

Background

The use of outpatient health care services by homeless people is low compared to their high level of need; however, it is unclear whether this applies to surgical care. We sought to describe surgical care access among homeless patients in a Canadian tertiary care setting.

Methods

We reviewed the medical records of adult (age > 18 yr) patients with no fixed address or a shelter address who presented to The Ottawa Hospital Emergency Department from Jan. 1, 2013, to Dec. 31, 2014, and required surgical referral. We analyzed the data using descriptive statistics.

Results

A surgical referral was initiated in 129 emergency department visits for 97 patients (77 men [79%], mean age 46.7 yr). Most patients lived in shelters (77 [79%]) and had provincial health insurance (82 [84%]), but only 35 (36%) had a primary care physician. The mean number visits for any reason was 7.9 (standard deviation 13.7) (range 1–106). The majority of surgical referrals (83 [64.3%]) were for traumatic injuries, and the most frequently consulted service (52 [40.3%]) was orthopedic surgery. Just under half (48 [49%]) of referred patients attended at least 1 outpatient appointment, and only a third (33 [34%]) completed full follow-up.

Conclusion

Homeless patients presenting to an emergency department and requiring surgical care were predominantly men living in shelters, most frequently seeking care for traumatic injuries. Current outpatient services may not meet the surgical care needs of these patients, as many do not access them. Alternative approaches to outpatient care must be considered, particularly among high-need services such as orthopedics, to support surgical care access among this population.

Disparities in follow-up care for ballistic and non-ballistic long bone lower extremity fractures

OBJECTIVES

To describe differences in follow-up compliance and emergency department (ED) visits between ballistic and non-ballistic operative lower extremity fracture patients.

DESIGN

Retrospective study.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

Patients age ≥18 years with ≥1 tibia or femur fractures treated with ORIF or intramedullary nailing (IMN) between September 1, 2013 and August 31, 2015.

MAIN OUTCOME MEASURE

A compliance fraction calculated as ([number of attended follow-up visits] / [number of attended follow-up visits + number of missed follow-up visits]) and ED visits in the post-operative period.

RESULTS

612 patients were studied. Patients with ballistic lower extremity fractures had a younger mean age (30.8 years v. 41.6 years; p < 0.0001); a shorter length of stay (5.00 days v. 8.00 days; p < 0.0001); and were more likely to be male (92.6% v. 68%; p < 0.0001) and African-American (90.1% v. 63.1%; p < 0.0001) when compared to non-ballistic long bone injuries. Increased follow-up compliance (defined as a compliance fraction ≥0.75) was associated with having a non-ballistic fracture (OR 1.73, 1.13-2.64; p = 0.01), not having an ED visit (OR 2.08, 1.30-3.33; p = 0.002), and being female (OR 1.82, 1.27-2.61; p = 0.001). Increased ED utilization (≥ 1 ED visit) was associated with ballistic mechanism (OR 1.95, 1.20-3.16; p = 0.006), a low follow-up compliance fraction (OR 2.08, 1.30-3.33; p = 0.0019), homelessness (OR 3.91, 1.53-9.98; p = 0.006), and African-American race (OR 2.26, 1.26-4.05; p = 0.05). Scheduling a specific follow-up visit on the discharge summary did not predict higher compliance (OR 1.51, 0.98-2.33; p = 0.06). Conversely, the lack of a specific follow-up visit scheduled on the discharge summary did not predict ED utilization (OR 0.63, 0.34-1.17; p = 0.14).

CONCLUSION

The results of this study demonstrate that increased utilization of the ED was associated with ballistic fractures, homelessness, decreased clinic compliance, and African American race. Furthermore, patients with non-ballistic injuries, women, and those without any ED visit were more likely to have higher outpatient clinic compliance.

Patient preferences for nutritional supplementation to improve fracture healing: a discrete choice experiment

OBJECTIVE

Vitamin D is often prescribed as an adjuvant therapy to aid fracture healing due to its biological role in bone health. However, the optimal frequency, dosage and duration of vitamin D supplementation for non-osteoporotic fracture healing has not been established. The objective of this study was to determine patient preferences for fracture healing relative to hypothetical vitamin D supplementation dosing options.

DESIGN

Discrete choice experiment.

SETTING

Level 1 trauma centre in Baltimore, Maryland, USA.

PARTICIPANTS

199 adult (18-60 years) patients with a fracture.

PRIMARY OUTCOME MEASURES

Parameter estimates of utility for fracture healing relative to dosing regimens were analysed using hierarchical Bayesian modelling.

RESULTS

A reduced risk of reoperation (34.3%) and reduced healing time (24.4%) were the attributes of greatest relative importance. The highest mean utility estimates were for a one-time supplementation dose (ß=0.71, 95% CI 0.41 to 1.00) followed by a reduced risk of reoperation (ß=0.41 per absolute % reduction, 95% CI 0.0.36 to 0.46). Supplementation for 24 weeks in duration (ß=-0.83, 95% CI -1.00 to -0.67) and a daily supplement (ß=-0.29, 95% CI -0.47 to -0.11) had the lowest mean utilities. The 'no supplement' option had a large negative value suggesting supplementation was generally desirable in this sample population. Among other possible clinical scenarios, patients expected a 2% reduction in the absolute risk of reoperation or a 3.1-week reduction in healing time from the baseline to accept a treatment regimen requiring two separate doses of supplementation, two blood tests and a cost of $20 within 3 months of injury.

CONCLUSIONS

Patients with orthopaedic trauma demonstrated strong willingness to take a vitamin D supplement that would decrease risk of reoperation and reduce healing time. Furthermore, these findings specify the required decrease in reoperation risk and reduction in healing time patients would expect to adhere to possible vitamin D dosing regimens.

No-shows in appointment scheduling - a systematic literature review

No-show appointments significantly impact the functioning of healthcare institutions, and much research has been performed to uncover and analyze the factors that influence no-show behavior. In spite of the growing body of literature on this issue, no synthesis of the state-of-the-art is presently available and no systematic literature review (SLR) exists that encompasses all medical specialties. This paper provides a SLR of no-shows in appointment scheduling in which the characteristics of existing studies are analyzed, results regarding which factors have a higher impact on missed appointment rates are synthetized, and comparisons with previous findings are performed. A total of 727 articles and review papers were retrieved from the Scopus database (which includes MEDLINE), 105 of which were selected for identification and analysis. The results indicate that the average no-show rate is of the order of 23%, being highest in the African continent (43.0%) and lowest in Oceania (13.2%). Our analysis also identified patient characteristics that were more frequently associated with no-show behavior: adults of younger age; lower socioeconomic status; place of residence is distant from the clinic; no private insurance. Furthermore, the most commonly reported significant determinants of no-show were high lead time and prior no-show history.

Communication with Orthopedic Trauma Patients via an Automated Mobile Phone Messaging Robot

BACKGROUND

Communication with orthopedic trauma patients is traditionally problematic with low response rates (RRs). The purpose of this investigation was to (1) evaluate the feasibility of communicating with orthopedic trauma patients postoperatively, utilizing an automated mobile phone messaging platform; and (2) assess the first 2 weeks of postoperative patient-reported pain and opioid use after lower extremity orthopedic trauma procedures.

MATERIALS AND METHODS

This was a prospective investigation at a Level 1 trauma center in the United States. Adult patients who were capable of mobile phone messaging and were undergoing common, lower extremity orthopedic trauma procedures were enrolled in the study. Patients received a daily mobile phone message protocol inquiring about their current pain level and amount of opioid medication they had taken in the past 24 h starting on postoperative day (POD) 3 and continuing through POD 17. Our analysis considered (1) Patient completion rate of mobile phone questions, (2) Patient-reported pain level (0-10 scale), and (3) Number and percentage of daily prescribed opioid medication patients reported taking.

RESULTS

Twenty-five patients were enrolled in this investigation. Patients responded to 87.5% of the pain and opioid medication inquiries they received over the 2-week study period. There were no differences in RRs by patient age, sex, or educational attainment. Patient-reported pain decreased over the initial 2-week study period from an average of 4.9 ± 1.7 on POD 3 to 3 ± 2.2 on POD 16-17. Patients took an average of 68% of their maximum daily narcotic prescription on POD 3 compared with 35% of their prescribed pain medication on POD 16-17.

CONCLUSIONS

We found that in orthopedic trauma patients, an automated mobile phone messaging platform elicited a high patient RR that improved upon prior methods in the literature. This method may be used to reliably obtain pain and medication utilization data after trauma procedures.

Delayed follow-up in patients with diabetic retinopathy in South India: Social factors and impact on disease progression

Purpose:

To identify social factors associated with delayed follow-up in South Indian patients with diabetic retinopathy (DR) and to study DR progression during the delayed follow-up period.

Materials and Methods:

In this cross-sectional study, 500 consecutive patients with DR returning after greater than twice the advised follow-up period were identified from a tertiary referral center in South India. A previously validated 19-item questionnaire was administered to study patients to assess causes for the follow-up delay. Patient demographics, DR status, and treatment plan were recorded at the study visit and the visit immediately before the delay. The eye with the most severe disease was included in the analysis.

Results:

Complete data were available for 491 (98.2%) patients. Among these, 248 (50.5%) cited “my eyes were okay at the time,” 201 (41.0%) cited “no attender to accompany me,” and 190 (38.6%) cited “financial cost” as causes of the follow-up delay. Those with vision-threatening DR (VTDR, n = 233) predominantly reported “financial cost” (47% vs. 32%, P = 0.001), whereas those with non-VTDR more frequently reported “my eyes were okay at the time” (58% vs. 42%, P = 0.001). Evidence of disease progression from non-VTDR to VTDR was seen in 67 (26%) patients. Almost 1/3^rd (29%) of patients who were previously advised regular examination required additional intervention.

Conclusion:

Many patient-level factors affect poor compliance with follow-up in DR, and these factors vary by disease severity. Targeting these barriers to care through patient education and clinic procedures may promote timely follow-up and better outcomes in these patients.

Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty

BACKGROUND

Shoulder arthroplasty is an effective procedure for managing patients with shoulder pain secondary to end-stage arthritis. Insurance status has been shown to be a predictor of patient morbidity and mortality. The current study evaluated the effect of patient insurance status on perioperative outcomes after shoulder replacement surgery.

METHODS

Data between 2004 and 2011 were obtained from the Nationwide Inpatient Sample. Analysis included patients undergoing shoulder arthroplasty (partial, total, and reverse) procedures determined by International Classification of Disease, 9th Revision procedure codes. The primary outcome was medical and surgical complications occurring during the same hospitalization, with secondary analyses of mortality and hospital charges. Additional analyses using the coarsened exact matching algorithm were performed to assess the influence of insurance type in predicting outcomes.

RESULTS

A data inquiry identified 103,290 shoulder replacement patients (68,578 Medicare, 27,159 private insurance, 3544 Medicaid/uninsured, 4009 other). The overall complication rate was 17.2% (n = 17,810) and the mortality rate was 0.20% (n = 208). Medicare and Medicaid/uninsured patients had a significantly higher rate of medical, surgical, and overall complications compared with private insurance using the controlled match data. Multivariate regression analysis found that having private insurance was associated with fewer overall medical complications.

CONCLUSION

Private insurance payer status is associated with a lower risk of perioperative medical and surgical complications compared with an age- and sex-matched Medicare and Medicaid/uninsured payer status. Mortality was not statistically associated with payer status. Primary insurance payer status should be considered as an independent risk factor during preoperative risk stratification for shoulder arthroplasty procedures.

Predicting and Preventing Loss to Follow-up of Adult Trauma Patients in Randomized Controlled Trials: An Example from the FLOW Trial

BACKGROUND

High loss-to-follow-up rates are a risk in even the most rigorously designed randomized controlled trials (RCTs). Consequently, predicting and preventing loss to follow-up are important methodological considerations. We hypothesized that certain baseline characteristics are associated with a greater likelihood of patients being lost to follow-up. Our primary objective was to determine which baseline characteristics are associated with loss to follow-up within 12 months after an open fracture in adult patients participating in the Fluid Lavage of Open Wounds (FLOW) trial. We also present strategies to reduce loss to follow-up in trauma trials.

METHODS

Data for this study were derived from the FLOW trial, a funded trial in which payments to clinical sites were tied to participant retention. We conducted a binary logistic regression analysis with loss to follow-up as the dependent variable to determine participant characteristics associated with a higher risk of loss to follow-up.

RESULTS

Complete data were available for 2,381 of 2,447 participants. One hundred and sixty-three participants (6.7%) were lost to follow-up. Participants who received treatment in the U.S. were more likely to be lost to follow-up than those who received treatment in other countries (odds ratio [OR] = 3.56, 95% confidence interval [CI]: 2.46 to 5.17, p < 0.001). Male sex (OR = 1.75, 95% CI: 1.15 to 2.67, p = 0.009), current smoking (OR = 1.82, 95% CI: 1.28 to 2.58, p = 0.001), high-risk alcohol consumption (OR = 1.88, 95% CI: 1.16 to 3.05, p = 0.010), and an age of <30 years (OR = 2.16, 95% CI: 1.19 to 3.95, p = 0.012) all significantly increased the odds of a patient being lost to follow-up. Conversely, participants who had sustained polytrauma (OR = 0.52, 95% CI: 0.37 to 0.73, p < 0.001) or had a Gustilo-Anderson type-IIIA, B, or C fracture (OR = 0.60, 95% CI: 0.38 to 0.94, p = 0.024) had lower odds of being lost to follow-up.

CONCLUSIONS

Using a number of strategies, we were able to reduce the loss-to-follow-up rate to <7%. Males, current smokers, young participants, participants who consumed a high-risk amount of alcohol, and participants in the U.S. were more likely to be lost to follow-up even after these strategies had been employed; therefore, additional strategies should be developed to target these high-risk participants.

CLINICAL RELEVANCE

This study highlights an important need to develop additional strategies to minimize loss to follow-up, including targeted participant-retention strategies. Male sex, an age of <30 years, current smoking, high-risk alcohol consumption, and treatment in a developed country with a predominantly privately funded health-care system increased the likelihood of participants being lost to follow-up. Therefore, strategies should be targeted to these participants. Use of the planning and prevention strategies outlined in the current study can minimize loss to follow-up in orthopaedic trials.

Impact of Distance to Treatment Center on Care Seeking for Pelvic Floor Disorders

OBJECTIVE

The aim of this study was to evaluate the impact of distance from residence to treatment center on access to care for female pelvic floor disorders at an academic institution.

METHODS

A retrospective cross-sectional study was conducted of women seen for pelvic floor disorders at an academic institution from 2008 to 2014. Patient characteristics were extracted from charts. Geographical and US census data was obtained from public records and used to calculate distance from patient residence to physician office. Statistical analysis was performed using R Software (Version 0.98.1102) and Microsoft Excel (Version 14.4.7). Statistical significance was defined as a 2-sided P value of less than 0.05, and the χ test was used to determine associations of categorical variables.

RESULTS

A total of 3015 patients were included in the analysis. The mean distance traveled was 93 miles. Thirty percent of patients traveled more than 50 miles. Many patients (43%) reported having the symptoms for more than 2 years. Patients who traveled farther were significantly more likely to be white, English-speaking, and with pelvic organ prolapse as primary complaint. These patients were more likely to plan surgery at the first visit than patients who traveled less far (29% vs 14%). Patients who traveled farther were also more likely to live in counties with a low percentage of persons older than 65 years and low percentage of female inhabitants.

CONCLUSIONS

Women who travel the farthest for treatment of pelvic floor disorders have experienced the symptoms for longer duration and are more willing to plan surgery at presentation. These women also come from counties with fewer elderly women, suggesting future outreach care should focus on similar geographic areas.

Patient Attitudes Toward Telemedicine for Diabetic Retinopathy

INTRODUCTION

Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is a validated, cost-effective method to improve monitoring. However, little is known of patients' attitudes toward telemedicine for DR. Our study explores factors that influence patients' attitudes toward participating in telemedicine.

MATERIALS AND METHODS

Ninety seven participants in a university and the Veterans Administration setting completed a survey. Only people with diabetes mellitus (DM) were included. The main outcome was willingness to participate in telemedicine. The other outcomes were perceived convenience and impact on the patient-physician relationship. Participants reported demographic information, comorbidities, and access to healthcare. Analysis was performed with t-tests and multivariable logistic regression.

RESULTS

Demographic factors were not associated with the outcomes (all p > 0.05). Patients had decreased odds of willingness if they valued the patient-physician relationship (adjusted odds ratio [OR] = 0.08, confidence interval [CI] = 0.02-0.35, p = 0.001) or had a longer duration of diabetes (adjusted OR = 0.93, CI = 0.88-0.99, p = 0.02). Patients had increased odds of willingness if they perceived increased convenience (adjusted OR = 8.10, CI = 1.77-36.97, p = 0.01) or had more systemic comorbidities (adjusted OR = 1.85, CI = 1.10-3.11, p = 0.02).

DISCUSSION

It is critical to understand the attitudes of people with DM where telemedicine shows promise for disease management and end-organ damage prevention. Patients' attitudes are influenced by their health and perceptions, but not by their demographics. Receptive patients focus on convenience, whereas unreceptive patients strongly value their patient-physician relationships or have long-standing DM. Telemedicine monitoring should be designed for people who are in need and receptive to telemedicine.

The health belief model and factors associated with adherence to treatment recommendations for positional plagiocephaly

OBJECTIVE This study aimed to examine factors associated with adherence to recommended treatment among pediatric patients with positional skull deformity by reviewing a single-institution experience (2007-2014) with the treatment of positional plagiocephaly. METHODS A retrospective chart review was conducted. Risk factors, treatment for positional head shape deformity, and parent-reported adherence were recorded. Univariate and multivariate analyses were used to assess the impact of patient clinical and demographic characteristics on adherence. RESULTS A total of 991 patients under age 12 months were evaluated for positional skull deformity at the Texas Children's Hospital Cranial Deformity Clinic between 2007 and 2014. According to an age- and risk factor-based treatment algorithm, patients were recommended for repositioning, physical therapy, or cranial orthosis therapy or crossover from repositioning/physical therapy into cranial orthosis therapy. The patients' average chronological age at presentation was 6.2 months; 69.3% were male. The majority were white (40.7%) or Hispanic (32.6%); 38.7% had commercial insurance and 37.9% had Medicaid. The most common initial recommended treatment was repositioning or physical therapy; 85.7% of patients were adherent to the initial recommended treatment. Univariate analysis showed differences in adherence rates among subgroups. Children's families with Medicaid were less likely to be adherent to treatment recommendations (adherence rate, 80.2%). Families with commercial insurance were more likely to be adherent to the recommended treatment (89.6%). Multivariate logistic regression confirmed that factors associated with parent-reported adherence to recommended treatment included primary insurance payer, diagnosis (plagiocephaly vs brachycephaly), and the nature of the recommended treatment. Families were less likely to be adherent if they had Medicaid, a child with a diagnosis of brachycephaly, or were initially recommended for cranial orthosis therapy than families with commercial insurance, a child with a diagnosis of plagiocephaly, or an initial recommendation for repositioning or physical therapy. Factors associated with treatment completion included corrected age, insurance, diagnosis, recommended treatment, and distance to provider from patient's residence. Patients with commercial insurance (OR 1.49, 95% CI 1.10-2.02, p = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment. CONCLUSIONS Insurance type, degree of head shape deformity, and types of recommended treatment appear to affect rates of adherence to recommended treatments for positional skull deformation.

Evaluation of Orthopedic Trauma Surgery Follow-up and Impact of a Routine Callback Program

A high rate of patients lost to follow-up is a common problem in orthopedic trauma surgery. This adversely affects the ability to produce accurate clinical outcomes research. The purpose of this project was to (1) evaluate the rate of loss to follow-up at an academic level I trauma center; (2) identify the patient-reported reasons for loss to follow-up; and (3) evaluate the efficacy of a routine patient callback program. All patients who underwent surgery in the orthopedic trauma division of the University of Virginia Medical Center from April 1, 2014, to September 30, 2014, and did not complete their postoperative clinic follow-up were analyzed. The characteristics of these patients were evaluated, and the primary reason for not completing the recommended follow-up was identified. All patients were then offered additional orthopedic follow-up at the time of contact. Of the 480 patients who met the inclusion criteria, 41 (8.5%) failed to complete the recommended postoperative follow-up course. The most common reason for being lost to follow-up was feeling well and not having the need to be seen (46.3%). Only 6 (14.6%) of the 41 patients requested follow-up care at the time of contact. The lost to follow-up rate in this study, 8.5%, was considerably lower than that previously reported, but patient characteristics were consistent with those of prior studies on this subject. The low lost to follow-up rate may reflect a difference in geographic location or patient population. The patient callback program had a low yield of patients requesting additional follow-up after being contacted. [Orthopedics. 2017; 40(2):e312-e316.].

Factors Associated with Patient-Initiated Telephone Calls After Spine Surgery

BACKGROUND

Telephone calls play a significant role in the follow-up care of postoperative patients. However, further data are needed to identify the determinants of patient-initiated telephone calls after surgery because these factors may also highlight potential areas of improvement in patient satisfaction and during the hospital discharge process. Therefore, the goal of this study is to determine the number of postoperative patient telephone calls within 14 days after surgery and establish the factors associated with patient-initiated calls and reasons for calling.

METHODS

A retrospective chart review of all spine surgeries performed at our institution from January 1, 2014, through January 2, 2015, was completed. Patient demographics, perioperative and operative variables, and telephone encounter data were collected. The primary outcome was a patient-initiated telephone call within 14 days after surgery. Secondary outcomes included reporting and analyzing the reasons for patient phone calls, analyzing which procedures were associated with the most telephone calls, and conducting a multivariate analysis to determine independent risk factors for patient calls.

RESULTS

Of the 488 patients who underwent surgical procedures, 222 patients (45.7%) made a telephone call within 14 days after surgery. There were 61 patients (27.48%) who called regarding pain control and 54 patients (23.87%) who called with bathing/dressing/wound questions. Other common categories include the following: other (21.17%), medication problems (15.77%), weight-bearing status/activity restrictions (5.14%), fever (3.15%), bowel management (1.35%), work notes (1.35%), and anticoagulation questions (0.45%). Factors associated with a telephone call within 14 days postoperatively included increased body mass index (P = 0.031), lower number of comorbidities (P = 0.043), telephone call within 2 weeks prior to surgery (P = 0.027), American Society of Anesthesiologists (ASA) score of 2 (P = 0.036), discharge disposition to home (P = 0.003), and elective procedure (P = 0.006). Multivariate analysis revealed that fusion procedures (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.05-4.45; P = 0.037) and ASA score of 3-4 (OR, 0.55; 95% CI, 0.31-0.96, P = 0.036) were independently associated with increased and decreased propensity, respectively, toward making a phone call within 2 weeks.

CONCLUSIONS

Postoperative patient-initiated telephone calls within 14 days after spine surgery are very common, occurring after almost one half of all procedures. By evaluating such determinants, patient care can be improved by better addressing patient needs during and prior to discharge to prevent potential unnecessary postoperative calls and improve patient satisfaction.

Lost to follow-up: reasons and outcomes following tibial plateau fractures

INTRODUCTION

Different reasons for lost to follow-up are assumed. Besides "objective" reasons, "subjective" reasons and satisfaction contribute to treatment adherence. Retrospective studies usually lack the possibility of acquisition of additional outcome information. Purpose of this study was to determine outcome and factors for patients not returning for follow-up.

METHODS

Between 2002 and 2009, 380 patients underwent internal fixation for tibial plateau fractures. Short Musculoskeletal Function Assessment (SMFA) was collected at 6, 12, and 24 months as long as patients returned for follow-up. Pain and range of motion were measured. Records were studied for reasons of termination of follow-up. Statistical analysis was performed comparing lost to follow-up versus continued office visits regarding demographics, contributing factors, and SMFA.

RESULTS

Two hundred fifty-nine patients were followed until treatment was completed (PRN), while 120 patients (32 %) terminated further follow-up. Patients in the 12- and 24-month follow-up groups were older (p = 0.02; p < 0.01, respectively). Pain (VAS ≥ 3) was noticed in 22 % of the patients terminating follow-up before the 6-month survey and 41 % of the patients returning for the 24-month SMFA survey (χ ² = 0.06). Improvements were found with time in SMFA subscores but arm and hand. No differences in SMFA subscores at 6 or 12 months were found between those leaving treatment untimely and those being released from office visits.

CONCLUSION

Follow-up remains important to obtain as much up-to-date information as possible. The current study does not support the assumption that patients lost to follow-up have a different SMFA outcome than patients returning until PRN.

LEVEL OF EVIDENCE

III.

Tertiary survey in polytrauma patients should be an ongoing process

INTRODUCTION

Due to prioritisation in the initial trauma care, non-life threatening injuries can be overlooked or temporally neglected. Polytrauma patients in particular might be at risk for delayed diagnosed injuries (DDI). Studies that solely focus on DDI in polytrauma patients are not available. Therefore the aim of this study was to analyze DDI and determine risk factors associated with DDI in polytrauma patients.

METHODS

In this single centre retrospective cohort study, patients were considered polytrauma when the Injury Severity Score was ≥ 16 as a result of injury in at least 2 body regions. Adult polytrauma patients admitted from 2007 until 2012 were identified. Hospital charts were reviewed to identify DDI.

RESULTS

1416 polytrauma patients were analyzed of which 12% had DDI. Most DDI were found during initial hospital admission after tertiary survey (63%). Extremities were the most affected regions for all types of DDI (78%) with the highest intervention rate (35%). Most prevalent DDI were fractures of the hand (54%) and foot (38%). In 2% of all patients a DDI was found after discharge, consisting mainly of injuries other than a fracture. High energy trauma mechanism (OR 1.8, 95% CI 1.2-2.7), abdominal injury (OR 1.5, 95% CI 1.1-2.1) and extremity injuries found during initial assessment (OR 2.3, 95% CI 1.6-3.3) were independent risk factors for DDI.

CONCLUSION

In polytrauma patients, most DDI were found during hospital admission but after tertiary survey. This demonstrates that the tertiary survey should be an ongoing process and thus repeated daily in polytrauma patients. Most frequent DDI were extremity injuries, especially injuries of the hand and foot.