Post-operative telephone review is safe and effective: prospective study - Monash outpatient review by phone trial

In-Person Clinic Visits After Laparoscopic Cholecystectomy: Lessons Learned From COVID-19 Pandemic

INTRODUCTION

The utility of routine in-person clinic appointments after laparoscopic cholecystectomy (LC) is uncertain, especially after the increase of telehealth visits during the COVID-19 pandemic. The purpose of this study was to evaluate the utility of routine in-person follow-up for patients undergoing LC prior to changes implemented during the pandemic and to determine whether a return to routine in-person follow-up is warranted.

METHODS

We retrospectively reviewed follow-up encounters for all patients undergoing LC from April 2018 to February 2020. All patients were routinely scheduled for in-person postoperative clinic follow-up 2-4 wk after discharge. Follow-up was considered nonroutine if new studies or medications were ordered, the patient was referred to the emergency department or readmitted, or malignancy was identified on pathology review.

RESULTS

Of 661 patients undergoing LC, 449 (68%) attended their scheduled in-person postoperative appointment and 212 (32%) did not. The postoperative appointment was nonroutine for 39 patients (9% of clinic attenders). Readmission occurred in 42 patients, with no differences between clinic attenders and nonattenders (P = 0.12). Furthermore, attending a postoperative clinic visit did not affect odds of readmission (odds ratio: 0.705, 95% confidence interval: 0.368, 1.351; P = 0.29). Readmission occurred on median day 9 after discharge in both groups.

CONCLUSIONS

The incidence of nonroutine follow-up after LC is low, and attendance at follow-up clinic was not associated with reduced readmissions. A return to routinely scheduling in-person follow-up 2-4 wk after discharge may not be warranted. Telehealth visits within 1 wk of discharge after LC should be considered.

The efficiency of quick response code versus telephone contact for post-discharge follow-up after ophthalmic day surgery: a randomized controlled trial

PURPOSE

To assess and compare the efficiency of quick response (QR) code versus telephone contact for post-discharge follow-up in patients receiving low-risk ophthalmic day surgery.

METHODS

One hundred and sixty patients undergoing strabismus day-care surgery with general anesthesia were randomly allocated to either the intervention group using QR code (QR group) or the control group receiving telephone call (TEL group) for post-discharge follow-up. The primary outcome was the follow-up overall attendance rate on the second postoperative day. Secondary outcomes included attendance rate at the first scheduled follow-up, number of text message reminders, elapsed time and estimated cost for follow-up, omission rate of follow-up responses, and patient satisfaction.

RESULTS

The overall attendance rate of follow-up was significantly higher in the QR group than that in the TEL group (97.5% vs. 87.5%, p = 0.016). As compared with the TEL group, the QR group significantly reduced the number of text message reminders with higher attendances at the first scheduled follow-up (p < 0.001, p =  0.001). Besides, the TEL group cost a median time of 258 s and a median cost of RMB 5.8 yuan to complete a follow-up consultant, but was associated with a significantly high omission rate of follow-up responses comparing to the QR group (p = 0.002). Patient satisfaction was comparable between two groups.

CONCLUSION

QR code follow-up can be more efficient than traditional telephone contact in assessing the post-discharge recovery after strabismus day surgery, which provides a safe and intuitively alternative follow-up pathway for identifying issues that may necessitate further clinical care for more low-risk ophthalmic day surgeries.

Using an E-Health Application for Post-operative Monitoring After Inguinal Hernia Repair: A Feasibility Study

BACKGROUND

E-Health care is already well established in some (non-) surgical specialties and is considered as a means of improving patient-centred care. Considering the demand of remote health care changes, especially in the COVID-19 pandemic, it is essential to investigate the feasibility of e-Health care within one of the most performed surgery procedures: inguinal hernia repair.

METHODS

A total of 60 patients used the e-Health application in this study compliant. Primary objectives were to investigate the accuracy of the "deviating post-operative course" alerting by the e-Health application. Secondary objectives included patient perspective and e-Health costs analysis.

RESULTS

Forty-four patients reported no deviation in the post-operative course using the e-Health application of which 93.2% (n = 41) was in concordance with the findings during standard follow-up. Within 16 patients reporting a deviating post-operative course, a true complication was found in 25% (n = 4). Based on in-hospital costs, a hypothetical e-Health follow-up scenario was more expensive (€59.5 per patient) than current standard follow-up care (€28.2 per patient). Usage of the e-Health application showed a high perceived overall patient satisfaction: 4.2 (on a Likert-scale of 1-5).

CONCLUSION

An e-Health application is a promising tool for identifying patients who require in-person or phone follow-up assessment. Patients' perspectives surveys revealed high potential and willingness of using this application. A hypothetical e-Health follow-up scenario showed to be more expensive compared to current standard follow-up. If the identified (dis)advantages can be improved, e-Health follow-up care appears to be promising in terms of safety and feasibility. Future studies can leverage on this study and further investigate the use of e-Health within the field of general surgery.

Innovations and Implementation of Telemedicine in Surgical Clinics Beyond COVID-19: A Narrative Review

Introduction: Telemedicine has emerged as a powerful tool in the delivery of health care to surgical patients and innovations are developing to address challenges in the technology, enhancing consumer-provider encounters while located remotely. Our study aims at collating and commenting on the published evidence for how current challenges in telemedicine for surgical clinics are met by innovations currently in development. We also comment on the implementation and monitoring strategies for telemedicine. Methods: Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science, and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient"; and "surgical clinic." For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting, and if they had a focus during the COVID-19 pandemic. Results: Three hundred forty-five articles were identified and screened, so that 73 articles were included in the review. Almost all articles were from Western countries (n = 69), mostly in surgical journals (n = 39) and from a range of sub-specialties, but pre-dominantly orthopedics (n = 12) and general surgery (n = 9). The majority were original comparative studies, with 31 studies directly comparing telemedicine with in-person appointments and 22 articles focused on implementation during COVID-19. Discussion/Conclusion: Advanced telecommunication technology has enabled telemedicine to become an effective and safe form of health care delivery, with high consumer and provider satisfaction. Innovative protocol and technology developments have addressed the limitations of telemedicine. Sophisticated and familiar medical software integrates with electronic medical records to automate and streamline documentation, consent, and billing processes. Surgical clinics are investing in telehealth workflow co-ordination and information technology support to troubleshoot any technical difficulties as well as education for providers and consumers to address technology illiteracy. As health care services continue to transition their systems to an online network, further research is required to understand the ability and assess the feasibility of telemedicine to fully integrate.

Utilization and Adequacy of Telemedicine for Outpatient Pediatric Surgical Care

INTRODUCTION

Telemedicine (TM) use accelerated out of necessity during the COVID-19 pandemic, but the utility of TM within the pediatric surgery population is unclear. This study measured utilization, adequacy, and disparities in uptake of TM in pediatric surgery during the COVID-19 pandemic.

METHODS

Scheduled outpatient pediatric surgery clinic encounters at a large academic children's hospital from January 2020 through March 2021 were reviewed. Sub-group analysis examined post-operative (PO) visits after appendectomy and umbilical, epigastric, and inguinal hernia repairs.

RESULTS

Of 9149 scheduled visits, 87.9% were in-person and 12.1% were TM. TM visits were scheduled for PO care (76.9%), new consultations (7.1%), and established patients (16.0%). Although TM visits were more frequently canceled or no shows (P < 0.001), most canceled TM visits were PO visits, of which 41.7% were canceled via electronic communication reporting the absence of any PO concerns. TM visits were adequate for accomplishing visit goals in 98.2%, 95.5%, and 96.2% of PO, new, and established patient visits, respectively. Patients utilizing TM visits were more frequently of white race, privately-insured, from less disadvantaged neighborhoods, and living a greater distance from clinic (P < 0.001 for all comparisons).

CONCLUSIONS

TM was adequate for the majority of visits in which it was utilized, including the basic PO visits that occurred via TM. TM was used more by patients with greater travel and less by those of minority race, with public insurance, and from more disadvantaged neighborhoods. Future work is necessary to ensure broad access to this useful tool for all children requiring surgical care.

Telemedicine versus face-to-face follow up in general surgery: a randomized controlled trial

BACKGROUND

Telemedicine provides healthcare to patients at a distance from their treating clinician. There is a lack of high-quality evidence to support the safety and acceptability of telemedicine for postoperative outpatient follow-up. This randomized controlled trial-conducted before the COVID-19 pandemic-aimed to assess patient satisfaction and safety (as determined by readmission, reoperation and complication rates) by telephone compared to face-to-face follow-up after uncomplicated general surgical procedures.

METHODS

Patients following laparoscopic appendicectomy or cholecystectomy and laparoscopic or open umbilical or inguinal hernia repairs were randomized to a telephone or face-to-face outpatient clinic. Patient demographics, perioperative details and postoperative outcomes were compared. Patient satisfaction was assessed via a standardized Likert-style scale.

RESULTS

One hundred and twenty-three patients were randomized over 12 months. Mean consultation times were significantly shorter for telemedicine than face-to-face clinics (telemedicine 10.52 ± 7.2 min, face-to-face 15.95 ± 9.96 min, P = 0.0021). There was no difference between groups in the attendance rates, nor the incidence or detection of postoperative complications. Of the 58 patients randomized to the telemedicine arm, 40% reported high, and 60% reported very high satisfaction with the method of clinic follow-up.

CONCLUSION

Telemedicine postoperative follow-up is safe and acceptable to patients and could be considered in patients undergoing uncomplicated benign general surgery.

Laparoscopic Appendectomy Translates into Less Analgesics and Faster Return to Work in Asia

Background:

Laparoscopic appendectomy (LA) is claimed to require less analgesic and allow for a faster return to work. This study examines whether these benefits hold true in Asian patient populations.

Methods:

A retrospective audit of emergency appendectomies over one year was conducted to study outcomes of postoperative pain, length of stay (LOS), duration of analgesia, and hospitalization leave (HL). A telephone questionnaire evaluated post-discharge analgesic intake, residual symptoms at follow-up, adequacy of HL and opinion on teleconsult reviews.

Results:

Of the 201 patients, 187 (93%) underwent LA. Presurgery symptoms were significantly longer in the open appendectomy (OA) group (mean: OA 3.79, LA 1.81 days; p = 0.026) which also had a higher frequency of perforation (71.4%). LA patients reported less pain compared to OA (LA 3.60 vs. OA 4.14; p = 0.068) but were prescribed the same 2 weeks of analgesics as OA. LOS was significantly less for LA (mean LA 3.09, OA 6.93 days; p = 0.006). Mean HL for LA and OA were 17.9 and 21.8 days respectively (p = 0.05). Nearly 83% patients did not complete the prescribed course of analgesics and 47% patients felt that HL was more than adequate. Seventy-five percent of patients were asymptomatic at hospital follow-up and nearly 41% agreed to teleconsult reviews.

Conclusion:

Majority of LA patients do not need 2 weeks of analgesics and their HL can be shortened for faster return to work thereby realizing the true benefits of minimally invasive surgery. Selected cases can be offered postoperative teleconsultation.

Routine in-person post-operative follow-up for uncomplicated laparoscopic appendectomy does not change management

INTRODUCTION

Eliminating points in the continuum of care that do not change management is a safe strategy for cost containment and workflow efficiency in health systems. As a process improvement initiative, we sought to identify whether routine, outpatient follow-up changes management in laparoscopic appendectomy in a military hospital.

METHODS

We performed a retrospective chart review of adult patients undergoing laparoscopic appendectomy during a one-year period. The primary outcome was identification of a change in management during routine in person follow-up. Secondary outcomes included location of patient presentation with a post-operative event (clinic, emergency department, primary care provider), and if those visits changed management. Events were defined as any deviation from the typical post-operative course within 6 weeks of surgery, including abnormal specimen pathology.

RESULTS

One-hundred and seventy-six appendectomies were performed over one year, and 148 patients met inclusion criteria (median age = 27, 66.9% male). Perforation was identified in 10.1% of patients. Seventeen-point-five percent of patients had a post-operative event, of which persistent pain was the most common. Only 2.0% of all patients saw a change in management at their routine in person follow-up appointment. Eighty percent of patients with any post-operative events sought care outside of their routine in person follow up appointments. No variable was independently associated with a change in management.

CONCLUSION

Routine in-person clinical follow-up for laparoscopic appendectomy almost never changes management. Perforated appendicitis may be an indication for in-person follow-up. Considering a telemedicine model for post-operative follow-up of laparoscopic appendectomy patients will provide a safe and effective alternative to in-person clinic visits, while saving patients time and allowing providers the clinic freedom to prioritize more urgent and new patients.

Improving patient care in neurosurgery through postoperative telephone calls: a systematic review and lessons from all surgical specialties

OBJECTIVE

Postoperative telephone calls are a simple intervention that can be used to improve communication with patients, potentially affecting patient safety and satisfaction. Few studies in the neurosurgical literature have examined the effect of a postoperative telephone call on patient outcomes, although several exist across all surgical specialties. The authors performed a systematic review and analyzed studies published since 2000 to assess the effect of a postoperative telephone call or text message on patient safety and satisfaction across all surgical specialties.

METHODS

A search of PubMed-indexed articles was performed on June 12, 2021, and was narrowed by the inclusion criteria of studies from surgical specialties with > 50 adult patients published after 1999, in which a postoperative telephone call was made and its effects on safety and satisfaction were assessed. Exclusion criteria included dental, medical, and pediatric specialties; systematic reviews; meta-analyses; and non-English-language articles. Dual review was utilized.

RESULTS

Overall, 24 articles met inclusion criteria. The majority reported an increase in patient satisfaction scores after a postoperative telephone call was implemented, and half of the studies demonstrated an improvement in safety or outcomes.

CONCLUSIONS

Taken together, these studies demonstrate that implementation of a postoperative telephone call in a neurosurgical practice is a feasible way to enhance patient care. The major limitations of this study were the heterogeneous group of studies and the limited neurosurgery-specific studies.

Are Surgical Patients Satisfied With Remote Consultations? A Comparison of Remote Versus Conventional Outpatient Clinic Follow-Up for Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Access to remote appointments (RA) by telephone or video is increasing as technology advances and becomes more available to patients. This meta-analysis of randomized controlled trials (RCTs) aims to discover whether surgical patients are satisfied with RAs when compared with conventional outpatient clinics (OPC). A literature search of RCTs of surgical patient satisfaction of RAs versus OPC appointments was performed. The PubMed, EMBASE, OVID, Cochrane Library, and Google Scholar databases were searched to include articles from January 2000 to 2020. A random-effects meta-analysis model was used to compare outcomes. All 7 RCTs showed that patients were as satisfied with RAs as OPC appointments (RR = 1.00, [0.98-1.02]; P = .73). Furthermore, both patient cohorts would prefer RAs for future follow-up (RR = 2.29, [1.96-2.97]; P < .00001). One RCT found the cost to institutions was less in the RA group ($19.05 vs $52.76) and another found the patients would save $9.96 on transportation costs. The majority of RCTs suggested cost to patients and or institutions would be less for RA. In conclusion, surgical patients are satisfied with RAs and in fact would prefer them.

Current and future use of telemedicine in surgical clinics during and beyond COVID-19: A narrative review

Introduction

Telemedicine has emerged as a powerful tool in the delivery of healthcare to surgical patients and enhances clinician-patient encounters during all phases of patient care. Our study aims were: to review the current use and applicability of telemedicine; evaluate its suitability, safety and effectiveness in a surgical outpatient setting, particularly in the era of social distancing restrictions and provide insight into future applications.

Methods

Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient" and "surgical clinic". For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting and if they had a focus during the COVID-19 pandemic.

Results

335 articles were identified and screened, so that 63 articles were included in the review. Almost all articles were from Western countries (n = 60), mostly in surgical journals (n = 35) and from a range of sub-specialities, but pre-dominantly orthopaedics (n = 12) and general surgery (n = 7). The majority were original comparative studies where 31 studies directly compared telemedicine to in-person appointments and 14 papers focused on implementation during COVID-19.

Discussion/conclusions

Telemedicine has been safely used across various phases of surgical outpatient care, with its effectiveness evaluated by clinical outcomes, economics and user/provider satisfaction. Telemedicine has multiple accepted benefits including time efficiency, patient/healthcare cost savings and community access, but with reported limitations of clinical uncertainty, technology infrastructure requirements, cybersecurity vulnerabilities and healthcare regulatory restraints. These limitations are being overcome by accelerated implementation during COVID-19 via fast-tracked practice development. Further work is required via development of research protocols to refine the application of emerging telemedicine technologies and their applicability to different surgical sub-specialties.

Patient preferences for using technology in communication about symptoms post hospital discharge

Background

Technology is increasingly transforming the way we interact with others and undertake activities in our daily lives. The healthcare setting has, however, not yet realised the potential of technology solutions to facilitate communication between patients and healthcare providers. While the procedural and policy requirements of healthcare systems will ultimately drive such solutions, understanding the preferences and attitudes of patients is essential to ensure that technology implemented in the healthcare setting facilitates communication in safe, acceptable, and appropriate ways. Therefore, the purpose of this study was to examine patient preferences for using technology to communicate with health service providers about symptoms experienced following discharge from the hospital.

Methods

Primary data were collected from patients admitted to a large metropolitan hospital in Australia during three consecutive months in 2018. Participants were asked about their daily use of technology including use of computers, email, phone, text messaging, mobile applications, social media, online discussion forums, and videoconference. They were then asked about their use of technologies in managing their health, and preferences for use when communicating about symptoms with health service providers following discharge from hospital.

Results

Five hundred and twenty-five patients with a wide range of differing clinical conditions and demographics participated. Patients indicated they used a range of technologies in their everyday lives and to manage their health. Almost 60% of patients would prefer to return to hospital if they were experiencing symptoms of concern. However, if patients experienced symptoms that were not of concern, over 60% would prefer to communicate with the hospital via telephone or using technology. Admitting condition, income, and age were significantly associated with preferences for communication about symptoms following hospital discharge.

Conclusions

Patients have varied preferences for communicating with their health service providers post-hospital discharge. Findings suggest that some, but not all patients, would prefer to use technology to traditional methods of communicating with the healthcare team. Health services should offer patients multiple options for communicating about their recovery to ensure individual needs are appropriately met.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06119-7.

Phone follow-up after inguinal hernia repair

BACKGROUND

Typically, in-person follow-up in clinic is utilized after outpatient inguinal hernia repair. Studies have shown that phone follow-up may be successfully used for the detection of postoperative hernia recurrences. However, no studies have evaluated the detection rates of other postoperative complications, such as emergency department visits and readmissions, with the utilization of phone follow-up after inguinal hernia repair. The objective of our study was to investigate the safety of a phone follow-up care pathway following elective, outpatient inguinal hernia repair.

METHODS

In this retrospective cohort study, adult patients who underwent elective, outpatient inguinal hernia repair between 2013 and 2019 at a large academic health system in the Midwest United States were identified from the electronic health record. Patients were categorized by type of postoperative follow-up: in-person or phone follow-up. Baseline demographics, operative, and postoperative data were compared between follow-up groups. Multivariable logistic regression was performed to investigate predictors of having any related emergency department (ED) visit/readmission/reoperation within 90 days.

RESULTS

We included 2009 patients who underwent elective inguinal hernia repair during the study period. 321 patients had in-person follow-up only, while 1,688 patients had phone follow-up. There was a higher rate of laparoscopic repair in the phone follow-up group (85.4% vs. 53.0% for in-person follow-up). There were no differences in rates of related 90-day ED visits, readmissions, and reoperations between the phone and in-person follow-up groups. On multivariable logistic regression, receipt of phone follow-up was not a predictor of having 90-day ED visits, readmissions, or reoperations (OR 1.30, 95% CI [0.83, 2.05]).

CONCLUSIONS

Patients who underwent phone follow-up had similarly low rates of adverse outcomes to those with in-person follow-up. Phone follow-up protocols may be implemented as an alternative for patients and provide a means to decrease healthcare utilization following inguinal hernia repair.

Telephone Follow-Up for Emergency General Surgery Procedures: Safety and Implication for Health Resource Use

BACKGROUND

It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population.

STUDY DESIGN

Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively.

RESULTS

Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication.

CONCLUSIONS

Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.