When patients call their surgeon's office: an opportunity to improve the quality of surgical care and prevent readmissions

Emergency department use after outpatient thyroidectomy across three states

BACKGROUND

Although outpatient thyroidectomy has become common, few large-scale studies have examined post-thyroidectomy emergency department use, readmission, and encounters not resulting in readmission, known as "treat-and-release" encounters. We evaluated post-outpatient thyroidectomy emergency department use and readmission and characterized associated factors.

METHODS

Using the Healthcare Cost and Utilization Project databases, we identified adult outpatient (same-day or <24-hour discharge) thyroidectomies performed in Florida, Maryland, and New York from 2016 to 2017. We identified the procedures linked with emergency department treat-and-release encounters and readmissions within 30 days postoperatively and the factors associated with post-thyroidectomy emergency department use and readmission.

RESULTS

Of the 17,046 patients who underwent outpatient thyroidectomy at 374 facilities, 7.5% had emergency department treat-and-release encounters and 2.3% readmissions. The most common reasons for emergency department treat-and-release encounters (9.9%) and readmissions (22.2%) were hypocalcemia-related diagnoses. Greater odds of treat-and-release were associated with identifying as non-Hispanic Black (adjusted odds ratio: 1.5, 95% confidence interval: 1.3-1.8) or Hispanic race/ethnicity (adjusted odds ratio: 1.4, 95% CI: 1.1-1.6), having Medicaid insurance (adjusted odds ratio: 2.7, 95% CI: 2.3-3.2), and living in non-metropolitan areas (adjusted odds ratio: 1.6, 95% CI: 1.1-2.2). We observed no associations between these factors and the odds of readmission.

CONCLUSION

Emergency department use after outpatient thyroidectomy is common. Racial, ethnic, socioeconomic, and geographic disparities are associated with treat-and-release encounters but not readmissions. Standardization of perioperative care pathways, focusing on identifying and addressing specific issues in vulnerable populations, could improve care, reduce disparities, and improve patient experience by avoiding unnecessary emergency department visits after outpatient thyroidectomy.

Patients Have Poor Postoperative Recall of Information Provided the Day of Surgery but Report Satisfaction With and High Use of an E-mailed Postoperative Digital Media Package

Purpose

To understand what portions of the surgical day patients remember, what parts of an e-mailed media package regarding their surgery patients are used, and how that information affects their surgical experience.

Methods

Patients undergoing an outpatient arthroscopic procedure were approached in the preoperative area and asked to remember 3 words. Postoperatively, they were seen by the surgeon to discuss surgical findings and instructions. They were then e-mailed a multimedia package containing a thank you letter, postoperative instructions, annotated arthroscopy images, and a personalized video from the surgeon. Patients were called 2 to 5 days after surgery to answer survey questions and recall the 3 words they were told on the day of surgery.

Results

Of the 160 patients, 100% received and accessed the e-mail. When asked if they remembered the postoperative conversation, 125 (78.1%) patients responded yes and 35 (21.9%) responded no. When asked to rate how well they remembered the postoperative conversation, 75.2% patients rated their memory very poor (48, 38.4%) or poor (46, 36.8%). Similarly, 129 (80.6%) patients were unable to remember the 3 surgeon-related words. One hundred percent of patients strongly agreed (145, 90.6%) or agreed (15, 9.4%) the e-mail package enhanced their experience. In addition, 100% of patients strongly agreed (150, 93.8%) or agreed (10, 6.2%) the surgeon video enhanced their experience. The average e-mail shares per patient was 2.5, with 158 (98.7%) of patients sharing the e-mail at least once.

Conclusions

This study shows that patients had poor memory of in-person conversations on the day of surgery. However, patients were satisfied with a postoperative multimedia package provided via e-mail after surgery. Patients interacted with the e-mail primarily on their cell phones, liked the surgeon video, and shared the e-mail with others.

Level of evidence

Level IV, therapeutic case series.

Impact of Surgical Wait Time to Hysterectomy for Benign Gynecologic Disease

STUDY OBJECTIVE

To determine the impact of surgical wait time on healthcare use and surgical outcomes for patients undergoing hysterectomy for benign gynecologic indications.

DESIGN

Retrospective cohort study.

SETTING

Urban, academic tertiary care center.

PATIENTS

Patients who underwent hysterectomy for benign disease between 2012 and 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were categorized into 2 groups, dichotomized by surgical wait times >30 days or ≤30 days. Healthcare use was measured by the number of discrete patient interactions with the healthcare system through phone calls, secure electronic messaging, and office and emergency room visits. Univariate and multivariable logistic regression models were performed to assess the association between surgical wait time and healthcare use and perioperative outcomes while controlling for confounders. A total of 277 patients were included in our analysis: 106 (38.3%) had surgical wait times >30 days (median 47 days, range 24-68 days), and 171 (67.1%) had surgical wait times ≤30 days (median 19 days; range 12-26 days). The groups did not differ by age, insurance status, substance use, or comorbid conditions. Patients in the group with surgical wait times >30 days were more likely to have increased healthcare use (69 of 106, 65% vs 43 of 171, 25%; odds ratio 5.55; 95% confidence interval, 3.27-9.41). There were no differences in intraoperative complications (9 of 106, 8% vs 19 of 171, 11%; p = .482) or postoperative complications (28 of 106, 26% vs 32 of 171, 19%; p = .13) between the groups; however, after controlling for potential confounders, patients with surgical wait times >30 days were 3.22 times more likely to be readmitted than patients with surgical wait times ≤30 days (95% confidence interval, 1.27-8.19).

CONCLUSION

A surgical wait time >30 days in patients undergoing a hysterectomy for benign disease is associated with increased healthcare use in the interim. Although patients who experience longer surgical wait times do not experience worse surgical outcomes, they may be at higher risk for readmission after surgery. Targeted interventions to optimize perioperative coordination of care for patients undergoing a hysterectomy for benign disease, especially those within vulnerable populations, are needed to improve quality of care, decrease any redundant or inefficient healthcare use, and reduce any unnecessary delays.

Perioperative Telephone Encounters Should Be Included in the Relative Value Scale Update Committee Review of Time Spent on Total Hip and Knee Arthroplasty

BACKGROUND

Providing care for patients undergoing hip and knee arthroplasty requires substantial effort beyond the actual replacement surgery to ensure a safe, clinical, and economically effective outcome. Recently, the Centers for Medicare and Medicaid Services has stated that the procedural codes for total hip (THA) and total knee arthroplasty (TKA) are potentially misvalued and has asked for a review by the Relative Value Scale Update Committee (RUC). The purpose of this study is to quantify one of the additional work efforts associated with telephone encounters during the perioperative episode of care.

METHODS

We retrospectively reviewed all 47,841 telephone calls from patients to our office from 2015 to 2017 in a consecutive series of 3309 patients who underwent TKA and 3651 patients who underwent THA. We recorded reasons for communication, amount of communication, and the caller identity for both 30 days preoperatively and 90 days postoperatively. We then used the RUC Building Block Method to calculate the preservice and postservice work included in a review of the time and intensity of the codes for THA and TKA.

RESULTS

The average number of preoperative patient calls per patient was 2.31 for TKA and 2.44 for THA, and the average number of postoperative calls was 5.01 for TKA and 4.00 for THA. The most common reasons for patient calls were perioperative care instructions, medications, medical clearance, paperwork/insurance, and complications. Using the RUC-approved work relative value units (wRVUs) assigned to each telephone encounter, an additional 1.83 wRVUs for perioperative telephone encounters for TKA and 1.61 for THA should be assigned.

CONCLUSIONS

Providing patients with appropriate support during the arthroplasty episode of care requires substantial telephonic support, which should be acknowledged. As the RUC considers reviewing the time and intensity spent on perioperative care for patients undergoing THA and TKA, they should consider appropriately documenting the amount of work required for telephone communication.

Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery

BACKGROUND

Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS).

OBJECTIVE

We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS.

MATERIALS AND METHODS

A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls.

RESULTS

Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure.

CONCLUSION

This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.