Is follow up by specialists routinely needed after elective surgery? A controlled trial

Early Discharge and Patient-Initiated Follow-Up in Hand Surgery: A New Norm Following Simple Hand Surgery?

AIMS

The demand for elective hand surgery has increased substantially over the last 10 years. With COVID-19 providing an added challenge of restrictions on face-to-face consultations, already overflowing follow-up clinics will be stressed further. Our aim is to assess the viability, effectiveness, and safety of an early discharge directly from the operating theatre following common hand surgery procedures with the safety net of open-access follow-up.

METHODS

All eligible patients undergoing open-hand surgery under local anaesthesia between February 2019 and December 2020 were offered early discharge. Informed consent was obtained in the clinic, and they were counselled on rehabilitation immediately prior to surgery. Patients were given a custom-made "open-access business card" with clear post-operative instructions and hand exercises, along with information on how to get in touch to request clinic follow-up. A review was completed at a minimum of two months following surgery. Administrative support staff were briefed beforehand to minimise any delays in follow-up requests and either book patients who requested follow-up into a routine elective clinic or utilise ring-fenced emergency elective clinic slots depending on the patient's individual requirements.

RESULTS

A total of 105 patients were included in this study, with an average age of 60 years. The average interval between surgery and review was 20 weeks. Eighty-nine patients had a successful early discharge, with 16 patients requesting clinic follow-up. The average time to follow up in the clinic was 35 weeks (range: four to 84 weeks). There were no complications that we were made aware of, and the most common reason for returning to the clinic was a new complaint, unrelated to the surgery.

CONCLUSIONS

Although virtual follow-up is now well established in both the fracture and elective clinic settings, early discharge is largely uncharted water. Our pilot demonstrates that early discharge and patient-initiated follow-up for common elective hand surgical procedures under local anaesthesia are efficient, safe, and viable.

Digital Follow-Up After Elective Laparoscopic Cholecystectomy: A Feasibility Study

BACKGROUND

Although recommendations exist for patients to be offered a post-operative helpline or telephone follow-up appointment at discharge after cholecystectomy, implementation of these is resource-intensive. Whilst the benefits of telephone follow-up are well documented, the use of digital modalities is less so. We aimed to identify if digital follow-up (DFU) was equivalent to routine care with telephone follow-up (TFU), for patients undergoing elective laparoscopic cholecystectomy.

METHODS

All patients listed for elective laparoscopic cholecystectomy between August 2016 and March 2018 were offered routine post-operative care (TFU or no follow-up) or DFU at a tertiary referral centre in Nottingham.

RESULTS

Of 597 patients undergoing laparoscopic cholecystectomy, 199 (33.3%) opted for TFU, and 98 (16.4%) for DFU. DFU was completed for 85 (86.7%) participants and TFU for 125 (62.8%), p < 0.0001. Over 5 times as many patients who chose TFU missed their appointment compared to DFU (5.6% vs. 30.9%, p < 0.001). At 30-days post-operatively, patients undergoing TFU had significantly more post-operative wound infections identified then those undergoing DFU (17.6% vs 5.9%, p = 0.01). However, this did not impact the incidence of 30-day readmissions between groups (7.2% TFU vs. 7.1% DFU). No complications were missed by either the DFU or TFU modalities. DFU was completed significantly earlier than TFU (median 6 days vs. 13.5 days, p = 0.001) with high patient acceptability, identifying complications and alerting clinicians to those patients requiring an early review.

CONCLUSION

This feasibility study has demonstrated that digital follow-up is an acceptable alternative to telephone follow-up after elective laparoscopic cholecystectomy.

Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico

BACKGROUND

Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources.

METHODS

A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question.

RESULTS

From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made.

CONCLUSIONS

This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial

PURPOSE

To determine whether a mobile app can reduce the need for in-person visits and examine the resulting societal cost differences between mobile and conventional follow-up for postoperative anterior cruciate ligament (ACL) reconstruction patients.

METHODS

Study design was a single-center, 2-arm parallel group randomized controlled trial. All patients undergoing ACL reconstruction aged 16 to 70 years were screened for inclusion in the study. Competent use of a mobile device and ability to communicate in English was required. Patients were randomly assigned to receive follow-up via a mobile app or conventional appointments. Analysis was intention-to-treat. The primary outcome was the number of in-person visits to any health care professional during the first 6 postoperative weeks. Secondary outcomes included analysis of costs incurred by the health care system and personal patient costs related to both methods of follow-up. Patient-reported satisfaction and convenience scores, rates of complications, and clinical outcomes were also analyzed.

RESULTS

Sixty patients were analyzed. Participants in the app group attended a mean of 0.36 in-person visits versus 2.44 in-person visits in the conventional group (95% confidence interval 0.08-0.28; P < .0001). On average, patients in the app group spent $211 (Canadian dollars) less than the conventional group over 6 weeks (P < .0001) on personal costs related to follow-up. Health care system costs were also significantly less in the app group ($157.5 vs CAD $202.2; P < .0001). There was no difference between groups in patient satisfaction, convenience, complication rates, or clinical outcome measures.

CONCLUSIONS

Mobile follow-up can eliminate a significant number of in-person visits during the first 6 postoperative weeks in patients undergoing ACL reconstruction with cost savings to both the patient and health care system. This method should be considered for dissemination among similar orthopaedic procedures during early postoperative care.

LEVEL OF EVIDENCE

I: Prospective randomized controlled trial.

Measuring Surgical Site Infection From Linked Administrative Data Following Hip and Knee Replacement

BACKGROUND

Surgical site infections (SSIs) in hip and knee arthroplasty are increasing internationally. Current trends in SSI monitoring use single source administrative databases with data collection points commonly at 30 or 90 days. We hypothesize that SSI rates are being under-reported due to methodological biases.

METHODS

Data from multiple administrative data sets were contrasted and compared to look at the 90-day SSI rates for hip and knee arthroplasty in a single province from 2001 to 2015. SSI rates were calculated over time by year, and the differences in infection rates between single and multiple administrative data sets were calculated as an estimate of under reporting rates of SSIs. Days until diagnosis was measured for those diagnosed with an infection within 1 year.

RESULTS

Combining administrative data sets indicates that hospital-based data underestimate SSI rates by 0.44 (P < .0001) of a percentage point over all years, a clinically significant result given the overall infection rate of 2.2% over the period. Less than 50% of hip and knee arthroplasty was recorded as infected by 30 days and approximately 75% of cases were recorded as infected by 90 days.

CONCLUSION

Single source administrative data sets and short follow-up periods underestimate SSI rates. Administrative data sets should be combined and a minimum follow-up period of 90 days should be used to more accurately track SSI rates in hip and knee arthroplasty.

Optimizing postoperative follow-up in pediatric surgery (OFIPS)

BACKGROUND/PURPOSE

The purpose of the study was to determine variables associated with attending postoperative clinic follow-up (POFU) in pediatric surgical patients, predictors of clinical value, and visit cost estimates.

METHODS

POFU patterns of children undergoing eight common pediatric surgical procedures over one year at a tertiary pediatric hospital were examined retrospectively. Variables associated with attending POFU and associated with predetermined measures of clinical value and cost were determined. Driving distance to hospital was chosen as a proxy measure of cost to the family.

RESULTS

Six-hundred-thirty-three patients were included, and 58% attended POFU. Variables independently associated with attending follow-up included: procedure type (orchidopexy, complicated appendicitis), living close to the hospital, having a defined follow-up order, individual surgeon attending. Clinical value was identified in 16.4% of patient visits and associated with orchidopexies, having required an earlier urgent postoperative visit and longer cases considered "complex". Significant costs to the health care system (~$125,000) and families (~$15,000) could be estimated from follow-up cases that had no clinical issues identified nor required an intervention.

CONCLUSION

POFU of common pediatric surgical procedures may have limited clinical value while coming at significant costs to families and the health care system. Further study is needed to define optimal needs and means of follow-up of these common pediatric surgical procedures.

LEVEL OF EVIDENCE

Level III.

Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: a randomised controlled trial

BACKGROUND

It is standard practice to review all patients following discharge at a follow-up clinic but demands on all health services outweigh resources and unnecessary review appointments may delay or deny access to patients with greater needs.

AIMS

This randomised trial aimed to establish whether a virtual outpatient clinic (VOPC) was an acceptable alternative to an actual outpatient clinic (OPC) attendance for a broad range of general surgical patients following a hospital admission.

PATIENTS AND METHODS

All patients admitted under one general surgical service over the study period were assessed. If eligible for inclusion the rationale, randomisation and follow-up methods were explained, consent was sought and patients randomised to receive either a VOPC or an OPC appointment.

RESULTS

Two-hundred and nine patients consented to study inclusion, of which 98/107 (91.6%) in the VOPC group and 83/102 (81.4%) in the OPC group were successfully contacted. Only 6 patients in the OPC group and 10 in the VOPC group reported ongoing issues. A further follow-up indicated 78 of 82 (95%) VOPC patients were very happy with their overall experience compared with 34/61 (56%) in the actual OPC group (p<0.001). A significant proportion of both cohorts-68/82 (83%) in VOPC group and 41/61 (67%) in OPC group (p = 0.029)-preferred a VOPC appointment as their future follow-up of choice.

CONCLUSIONS

The majority of patients discharged from a surgical service could be better followed up by a virtual clinic with a significant proportion of patients reporting a preference for and a greater satisfaction with such a service.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Cost-effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: economic evaluation alongside a stepped-wedge cluster-randomised trial

OBJECTIVES

To evaluate the cost-effectiveness and cost-utility of an internet-based perioperative care programme compared with usual care for gynaecological patients.

DESIGN

Economic evaluation from a societal perspective alongside a stepped-wedge cluster-randomised controlled trial with 12 months of follow-up.

SETTING

Secondary care, nine hospitals in the Netherlands, 2011-2014.

PARTICIPANTS

433 employed women aged 18-65 years scheduled for a hysterectomy and/or laparoscopic adnexal surgery.

INTERVENTION

The intervention comprised an internet-based care programme aimed at improving convalescence and preventing delayed return to work (RTW) following gynaecological surgery and was sequentially rolled out. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or to the intervention (n=227).

MAIN OUTCOME MEASURES

The primary outcome was duration until full sustainable RTW. Secondary outcomes were quality-adjusted life years (QALYs), health-related quality of life and recovery.

RESULTS

At 12 months, there were no statistically significant differences in total societal costs (€-647; 95% CI €-2116 to €753) and duration until RTW (-4.1; 95% CI -10.8 to 2.6) between groups. The incremental cost-effectiveness ratio (ICER) for RTW was 56; each day earlier RTW in the intervention group was associated with cost savings of €56 compared with usual care. The probability of the intervention being cost-effective was 0.79 at a willingness-to-pay (WTP) of €0 per day earlier RTW, which increased to 0.97 at a WTP of €76 per day earlier RTW. The difference in QALYs gained over 12 months between the groups was clinically irrelevant resulting in a low probability of cost-effectiveness for QALYs.

CONCLUSIONS

Considering that on average the costs of a day of sickness absence are €230, the care programme is considered cost-effective in comparison with usual care for duration until sustainable RTW after gynaecological surgery for benign disease. Future research should indicate whether widespread implementation of this care programme has the potential to reduce societal costs associated with gynaecological surgery.

TRIAL REGISTRATION NUMBER

NTR2933; Results.

The effect of mobile app home monitoring on number of in-person visits following ambulatory surgery: protocol for a randomized controlled trial

Background

Women’s College Hospital, Toronto, Canada, offers specialized ambulatory surgical procedures. Patients often travel great distances to undergo surgery. Most patients receiving ambulatory surgery have a low rate of postoperative events necessitating clinic visits. However, regular follow-up is still considered important in the early postoperative phase. Increasingly, telemedicine is used to overcome the distance patients must travel to receive specialized care. Telemedicine data suggest that mobile monitoring and follow-up care is valued by patients and can reduce costs to society. Women’s College Hospital has used a mobile app (QoC Health Inc) to complement in-person postoperative follow-up care for breast reconstruction patients. Preliminary studies suggest that mobile app follow-up care is feasible, can avert in-person follow-up care, and is cost-effective from a societal and health care system perspective.

Objective

We hope to expand the use of mobile app follow-up care through its formal assessment in a randomized controlled trial. In postoperative ambulatory surgery patients at Women’s College Hospital (WCH), can we avert in-person follow-up care through the use of mobile app follow-up care compared to conventional, in-person follow-up care in the first 30 days after surgery.

Methods

This will be a pragmatic, single-center, open, controlled, 2-arm parallel-group superiority randomized trial comparing mobile app and in-person follow-up care over the first month following surgery. The patient population will comprise all postoperative ambulatory surgery patients at WCH undergoing breast reconstruction. The intervention consists of a postoperative mobile app follow-up care using the quality of recovery-9 (QoR9) and a pain visual analog scale (VAS), surgery-specific questions, and surgical site photos submitted daily for the first 2 weeks and weekly for the following 2 weeks. The primary outcome is the total number of physician visits related to the surgery over the first 30-days postoperative. The secondary outcomes include (1) the total number of phone calls and emails to a health care professional related to surgery, (2) complication rate, (3) societal and health care system costs, and (4) patient satisfaction over the first 30 days postoperative. Permutated-block randomization will be conducted by blocks of 4-6 using the program ralloc in Stata. This is an open study due to the nature of the intervention.

Results

A sample of 72 (36 patients per group) will provide an E-test for count data with a power of 95% (P=.05) to detect a difference of 1 visit between groups, assuming a 10% drop out rate. Count variables will be analyzed using Poisson regression. Categorical variables will be tested using a chi-square test. Cost-effectiveness will be analyzed using net benefit regression. Outcomes will be assessed over the first 30 days following surgery.

Conclusions

We hope to show that the use of a mobile app in follow-up care minimizes the need for in-person visits for postoperative patients.

Trial Registration

Clinicaltrials.gov NCT02318953; https://clinicaltrials.gov/ct2/show/NCT02318953 (Archived by WebCite at http://www.webcitation.org/6Yifzdjph).

Replacing ambulatory surgical follow-up visits with mobile app home monitoring: modeling cost-effective scenarios

Background

Women’s College Hospital (WCH) offers specialized surgical procedures, including ambulatory breast reconstruction in post-mastectomy breast cancer patients. Most patients receiving ambulatory surgery have low rates of postoperative events necessitating clinic visits. Increasingly, mobile monitoring and follow-up care is used to overcome the distance patients must travel to receive specialized care at a reduced cost to society. WCH has completed a feasibility study using a mobile app (QoC Health Inc, Toronto) that suggests high patient satisfaction and adequate detection of postoperative complications.

Objective

The proposed cost-effectiveness study models the replacement of conventional, in-person postoperative follow-up care with mobile app follow-up care following ambulatory breast reconstruction in post-mastectomy breast cancer patients.

Methods

This is a societal perspective cost-effectiveness analysis, wherein all costs are assessed irrespective of the payer. The patient/caregiver, health care system, and externally borne costs are calculated within the first postoperative month based on cost information provided by WCH and QoC Health Inc. The effectiveness of telemedicine and conventional follow-up care is measured as successful surgical outcomes at 30-days postoperative, and is modeled based on previous clinical trials containing similar patient populations and surgical risks.

Results

This costing assumes that 1000 patients are enrolled in bring-your-own-device (BYOD) mobile app follow-up per year and that 1.64 in-person follow-ups are attended in the conventional arm within the first month postoperatively. The total cost difference between mobile app and in-person follow-up care is $245 CAD ($223 USD based on the current exchange rate), with in-person follow-up being more expensive ($381 CAD) than mobile app follow-up care ($136 CAD). This takes into account the total of health care system, patient, and external borne costs. If we examine health care system costs alone, in-person follow-up is $38 CAD ($35 USD) more expensive than mobile app follow-up care over the first postoperative month. The baseline difference in effect is modeled to be zero based on clinical trials examining the effectiveness of telephone follow-up care in similar patient populations. An incremental cost-effectiveness ratio (ICER) is not reportable in this scenario. An incremental net benefit (INB) is reportable, and reflects merely the cost difference between the two interventions for any willingness-to-pay value (INB=$245 CAD). The cost-effectiveness of mobile app follow-up even holds in scenarios where all mobile patients attend one in-person follow-up.

Conclusions

Mobile app follow-up care is suitably targeted to low-risk postoperative ambulatory patients. It can be cost-effective from a societal and health care system perspective.

Utility of routine postoperative visit after appendectomy and cholecystectomy with evaluation of mobile technology access in an urban safety net population

BACKGROUND

The value of routine postoperative visits after general surgery remains unclear. The objective of this study was to evaluate the utility of routine postoperative visits after appendectomy and cholecystectomy and to determine access to mobile technology as an alternative platform for follow-up.

METHODS

Retrospective review of 219 appendectomies and 200 cholecystectomies performed at a safety net hospital. One patient underwent both surgeries. Patient demographics, duration of clinic visit, and need for additional imaging, tests or readmissions were recorded. Access to mobile technology was surveyed by a validated questionnaire.

RESULTS

Of 418 patients, 84% percent completed a postoperative visit. At follow-up, 58 patients (14%) required 70 interventions, including staple removal (16, 23%), suture removal (4, 6%), drain removal (8, 11%), additional follow-up (20, 28%), medication action (16, 21%), additional imaging (3, 4%), and readmission (1, 1%). Occupational paperwork (62) and nonsurgical clinic referrals (28) were also performed. Average check-in to check-out time was 100 ± 54 min per patient. One intervention was performed for every 7.8 h of time in the clinic. Additionally, 88% of the surveyed population reported access to cell phone technology, and 69% of patients <40 y had smartphone access.

CONCLUSIONS

Routine in-person follow-up after surgery consumes significant time and resources for patients and healthcare systems but has little impact on patient care. Most of the work done in the clinic is administrative and could be completed using mobile technology, which is pervasive in our population.

Is there a need for postoperative follow-up after routine urogynaecological procedures? Patients will self-present if they have problems

INTRODUCTION AND HYPOTHESIS

The value of outpatient appointments for postoperative review has been questioned for many years, and the surgeon practice around this issue is varied. The aim of this study, as part of a larger study assessing postoperative follow-up, was to assess how many patients self-present to their general practitioner (GP) or the emergency department after surgery for urogynaecology procedures.

METHODS

A retrospective observational study of postoperative urogynaecology patients between 2007 and 2012 was performed using the British Society of Urogynaecology (BSUG) database to identify patients. These records were correlated with hospital and GP records to assess whether any patient was seen postoperatively for a procedure-related problem.

RESULTS

There were 244 patients with complete data on the BSUG database, of whom 25 (10 %) presented to hospital/secondary care in the year following their surgery; only three of these were admitted for problems related to their surgery. There was a response rate of 70 % from GPs for access to their records. This represented 171 patients, 90 of whom (52.3 %) presented to their GP within a year of surgery mostly for a minor procedure-related event: 11 of these were re-referred to secondary care, and the remainder were treated in the community.

CONCLUSIONS

The most important aspect of patient care is safety, and this should not be compromised if, for example, postoperative review were to be moved to primary care. As expected, this study shows that patients will self-present if they have problems postoperatively.

Elective versus routine postoperative clinic appointments after circumcisions performed under local anesthesia

OBJECTIVE

To evaluate a model of elective postoperative clinic appointments after a minor urological procedure and to compare it to the traditional practice of routine appointments.

METHODS

A total of 104 consecutive patients undergoing adult circumcision under local anesthesia were divided into 2 groups; group A (n = 45) received routine postoperative clinic appointments and group B (n = 59) were given the option to make an appointment on an as-needed basis. Both groups received detailed postoperative instructions on the early signs of symptoms of potential adverse events. The 2 groups were compared regarding demographics, clinical profile, postoperative recovery, and outcome.

RESULTS

Group A patients ("routine appointments") were younger (51 vs 60 years, P <.0001) and included fewer African Americans (57.8% vs 78.0%, P <.03) compared to group B patients ("elective appointments"). Postoperative clinic appointments were categorized as unnecessary in 84.4% (38/45) and 71.1% (42/59) of the patients in groups A and B, respectively. Of the remaining 17 patients in group B who elected to make an appointment, only 1 patient (1.7%) had a true procedure-related issue that justified the visit and required management. Overall, there was no statistical difference between the 2 groups with regard to the number of patients with perceived postoperative issues (P = .36).

CONCLUSION

The traditional practice of routine clinic appointments after uncomplicated adult circumcision is medically unnecessary and provides little value in the majority of cases. The practice of open access elective postoperative evaluation based on clearly defined clinical criteria is efficacious, safe, convenient, and enhances resource utilization.

Is postal postoperative follow-up in urogynaecology feasible?

Postoperative follow-up after urogynaecological surgery has been little investigated. Traditionally, it is done in hospital but there is wide variation in the assessments and timing. We aimed to determine the viability of postal follow-up in women undergoing urogynaecological surgery. This is a retrospective review of prospectively collected data. All women who underwent prolapse and/or urinary incontinence surgery between January and June 2010 were included. Validated ICIQ questionnaires for prolapse and/or incontinence, as appropriate, were used, before surgery and at 6 months postoperatively. The primary outcome was the response rate to postal follow-up. A total of 70 women had urogynaecology surgery during the study period; 65 (93%) women returned the questionnaires (95% CI 84-97%, p < 0.0001). The postoperative questionnaires scores showed a statistically significant improvement compared with the preoperative scores. This results in only a small proportion of women needing hospital attendance for follow-up (10%). We conclude that postal follow-up is feasible.

Reducing the pain: a systematic review of postdischarge analgesia following elective orthopedic surgery

OBJECTIVE

This study aimed to determine which analgesic modalities used following discharge have the greatest efficacy in reducing postoperative pain after elective non-axial orthopedic surgery.

DESIGN AND SETTING

A systematic review was conducted using the databases CENTRAL, MEDLINE, and EMBASE, as well as clinical practice guidelines databases and trial registries. Titles and abstracts were perused by two reviewers for randomized clinical trials in English fulfilling inclusion and exclusion criteria. Quality assessments, including the Oxford Quality Score, selective reporting, and sources of funding, were also performed.

OUTCOME MEASURES

Pain intensity/relief, global patient evaluation, and use of rescue analgesia, as well as adverse events and withdrawals.

RESULTS

2,167 articles were retrieved and 23 articles were eligible for inclusion. They investigated analgesic modalities including alternative therapies (5); cyclooxygenase-2 inhibitors (3); nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) (12); opioids (2); and other pharmaceutical classes (1). Cycooxygenase-2 inhibitors and opioids demonstrated significant efficacy with minimal side effects. Most nonselective NSAIDs were effective analgesics but had a poorer side-effect profile. Alternative therapies demonstrated no significant efficacy.

CONCLUSIONS

Opioids and cyclooxygenase-2 inhibitors are effective in providing analgesia in the extended postoperative period following orthopedic surgery with a minimal side-effect profile, while nonselective NSAIDs need to be treated with caution. Homeopathy is not an effective analgesic, while acupuncture has varied evidence and effectiveness. Treatment of postoperative fatigue may also improve analgesia control. This study provides orthopedic surgeons with a basis for evidence-based prescribing of postdischarge analgesia. However, further studies to validate these results against modern reporting standards are needed.

Ambulatory care provided by office-based specialists in the United States

PURPOSE

Increasing use of specialist services in the United States is leading to a perception of a specialist shortage. Little is known, however, about the nature of care provided by this secondary level of services. The aim of this study was to examine the content of care provided by specialists in community settings, including visits for which the patient had been referred by another physician.

METHODS

Nationally representative visit data were obtained from the National Ambulatory Medical Care Survey (NAMCS) for the years 2002 through 2004. To describe the nature of care, we developed a taxonomy of office-based visit types and constructed logistic regression models allowing for adjusted comparisons of specialty types.

RESULTS

Overall, 46.3% of visits were for routine follow-up and preventive care of patients already known to the specialist. Referrals accounted for only 30.4% of all visits. Specialists were more likely to report sharing care with other physicians for referred, compared with not referred, patients (odds ratio [OR] = 2.99; 95% confidence interval [CI], 2.52-3.55). Overall, 73.6% of all visits resulted in a return appointment with the same physician, in more than one-half of all cases as a result of a routine or preventive care visit.

CONCLUSIONS

Ambulatory office-based activity of specialists includes a large share of routine and preventive care for patients already known, not referred, to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.

Evidence-Based Follow-up after Varicose Vein Surgery

Objective:

To determine the optimum timing and need for outpatient follow-up of patients after varicose vein operations.

Methods:

Ninety-six consecutive patients undergoing varicose vein operations were enrolled. Patients completed linear analogue scales to record pain, bruising and swelling on postoperative days 1 to 10, 12, 14, 21 and 28. Return to daily activities, visits to the general practitioner (GP) and outpatient review at 6 weeks were recorded.

Results:

Maximum scores were on day 2 for swelling, day 4 for bruising, and days 1 and 6 for pain. Median time to return to work was 14 days (range 1-42 days). During the postoperative period 29 patients visited their GP, 24 (83%) within 2 weeks of operation. Median length of outpatient consultation at 6 weeks was 5 min. Although 57 patients found the appointment reassuring, none required further treatment.

Conclusions:

Outpatient follow-up after varicose vein operations cannot be justified on clinical grounds. The majority of patients who have postoperative problems develop them within the first 2 weeks, coinciding with the peaks of pain, swelling and bruising, and these problems can be dealt with in the community.