Patient Loss to Follow-up After Upper Extremity Surgery: A Review of 2563 Cases

Abstract

Background: Postoperative care is essential to optimizing patient outcome. We sought to determine the incidence and associated demographic and surgical factors of postoperative patient loss to follow-up following hand and upper extremity surgery. Methods: In all, 2834 surgical cases (2467 patients) were retrospectively reviewed. All surgical cases from July 2014 to June 2015 at a single practice with five surgeons were assessed. Charts were reviewed for compliance with postoperative follow-up. Variables were described with proportions and compared using logistic regression analysis. Results: In total, 2563 cases (2388 patients) met the inclusion criteria. Overall loss to follow-up rate was 26%. Patients lost to follow-up based on insurance type were 13% for worker’s compensation, 22% for private insurance, 21% for Medicare, 38% for Medicaid, and 44% for self-pay. Patients with expected short-term follow-up were lost at a 23% rate. Expected mid- and long-term follow-up patients were lost at 34% and 20% rates, respectively. Patients below 30 years old were lost to follow-up at a 42% rate compared to patients 30 to 64 years old (26%) and greater than or equal to 65 years (13%). Males had a higher rate of loss to follow-up, 32%, compared with females (22%). Patients living greater than 50 miles from our surgery center were lost to follow-up at a rate of 31%, compared with those who lived less than 50 miles (25%). Conclusions: We have identified demographic variables associated with patients being lost to follow-up after hand and upper extremity surgery. With this knowledge, we hope to develop methods of either improving in-office follow-up rates or discover new avenues to deliver postoperative care.

Introduction

Postoperative follow-up is an essential part of caring for surgical patients. At these visits, patient subjective progress is reviewed. Objective examination is performed, identifying any possible complications, such as nerve or tendon injury, infection, or stiffness, and functional progress is monitored and advanced. Patient concerns can be addressed and patients’ questions answered. However, when patients do not attend these visits, surgical site infections could progress unmonitored, safety restrictions or protocols may not be followed, and problems that start as minor may evolve into major complications. Postoperative follow-up is not only important to help the individual patient to achieve an optimal outcome but also helps the provider understand the value of the care they have provided. Surgeons’ practices in the preoperative, intraoperative, and postoperative phases for future patients may be modified based on prior experiences. Knowing and understanding patient outcome after surgical management is critical to a surgeons’ evolving practice.

Improved patient outcome has been correlated with good compliance with postoperative follow-up. Murray et al studied the outcomes of 2268 total hip arthroplasty patients during a 16-year follow-up to assess outcomes in those who followed up and those who did not. They noted a cumulative loss to follow-up of 20% at 15 years, and those who were lost to follow-up had significantly worse outcomes than those who were not.⁹

Prior studies have also attempted to discover factors associated with a patient lost to follow-up. Murnaghan et al analyzed 236 patient records from a Canadian trauma database to determine characteristics of patients lost to follow-up. Significantly higher rates of loss to follow-up were found in younger patients, unskilled workers, those with status of “trauma patient,” and in Aboriginal Canadian (indigenous) patients.⁸ Ten Berg and Ring studied 335 patients with metacarpal fractures and identified uninsured status to be a socioeconomic risk factor for loss to follow-up.¹²

Ultimately, we seek to improve patient care by increasing postoperative follow-up rates. As a first step in this process, we sought to determine the rate of loss to follow-up after surgery for our patients in a large, university-based hand and upper extremity practice. We additionally aim to identify any potential risk factors for patient loss to follow-up by correlating follow-up rates with patient demographic variables. We hypothesized that patients with the following variables would be more likely to become lost to follow up: male patients, younger patients, patients with longer-term follow-up, patients with “self-pay insurance,” and patients who lived farther away from the hand center.

Materials and Methods

Study Population

In this study, we retrospectively reviewed medical records of patients seen through the hand and upper extremity center at a large Midwestern university hospital. Institutional Review Board approval was obtained. The electronic medical record (EMR) was first queried for all surgical patients from July 2014 through June 2015. There were 2834 surgical cases (2467 patients) during this time. The inclusion criterion for the study was that the surgery was performed in a university-owned surgical facility by one of five fellowship-trained hand and upper extremity surgeons. Exclusion criteria were patients who were prisoners, scheduled to follow up outside of our facilities, currently still being followed, underwent bedside procedures, died before follow-up was complete, or had Veterans Association Insurance or unknown insurance status at the time of billed procedure. A total of 2563 surgeries in 2388 patients met the inclusion criteria and were included for analysis.

Patient and Surgery Characteristics

The EMR of surgical cases that met criteria for inclusion in the study was accessed and reviewed in detail. Patient information, including date of birth, gender, home address, and insurance provider, was collected. Insurance provider was categorized into self-pay, Medicaid, Medicare, private insurance, and worker’s compensation. In addition to gathering patient demographic information, we also collected information regarding the surgery, including surgeon, primary diagnosis code, primary procedure code, date of surgery, date of last follow-up, and expected and typical duration of postoperative follow-up. The follow-up period was categorized into short (1-2 weeks), middle (2-12 weeks), and long (>12 weeks; see Table 1).

Table 1.

Expected Follow-up Periods for Common Hand Procedures Included in Our Study.

Expected follow-up period	Procedures
Short term (1-2 weeks)	Uncomplicated peripheral nerve release, trigger digit release, uncomplicated cyst excision
Midterm (2-12 week)	ORIF or CRPP of uncomplicated fractures of the phalanges, hand, or wrist, wrist arthroscopy, CMC arthroplasty, tendon release or debridement
Long term (>12 weeks)	Tendon transfers, replantation, wrist and elbow arthroplasty, reconstruction, or arthrodesis, complex fractures or revision ORIF, forearm, elbow, or proximal humerus fracture ORIF

Note. ORIF = open reduction and internal fixation; CRPP = closed reduction and percutaneous pinning; CMC = carpometacarpal.

Patient charts were further reviewed for compliance with postoperative follow-up in the office. A patient was considered to have completed follow-up if the chart indicated that the patient could follow up as needed or if no appointment was scheduled for the future. If a patient canceled an appointment, but rescheduled within 1 week, the patient was considered compliant. However, if a patient canceled an appointment and did not schedule a follow-up appointment, rescheduled the appointment outside an acceptable window (acceptable window determined on a case-by-case basis), or rescheduled with a new primary complaint, the patient was considered lost to follow-up.

Statistical Analysis

All statistical tests were performed with a standard software package (STATA 14.0, StataCorp, College Station, Texas). Variables were described with proportions and compared using logistic regression analysis to control for possible confounding. Adjusted odds ratios (ORs) are presented, controlling for all other variables in each case. Comparison of follow-up presence/absence among sex (male, female), follow-up term (shot, middle, long), insurance provider (self-pay, Medicaid, Medicare, private, and worker’s compensation), travel-distance from patient home to clinical office (⩽50 miles, >50 miles), and age (<30, 30-64, >64 years old) were made. An α of .05 was considered to represent statistical significance.

Results

Of the included 2563 billed procedures (2388 patients) from July 2014 through June 2015, there was an overall loss to follow-up rate of 26% (Figure 1). The rate of loss to follow-up varied for insurance types: 22% for private insurance (n = 1199), 13% for worker’s compensation (n = 113, OR = 2.18, p = .008), 21% for Medicare (n = 477, OR = 0.562, p = .001), 38% for Medicaid (n = 708, OR = 0.455, p < .0001), and 44% for self-pay (n = 66, OR = 0.389, p < .0001). All groups differed significantly from privately insured patients when adjusted to the other variables (p < .05).

Figure 1.

Bar graph depicting results and patients lost to follow-up by variable.

Note. OR = odds ratio; CI = confidence interval.

Loss to follow-up rates also varied based on expected duration of follow-up after surgery. Patients with expected short-term follow up (1-2 weeks) were lost at a rate of 23% (n = 1319), while those with mid-term follow-up (2-12 weeks) were lost at a rate of 34% (OR = 0.694, p ⩽ .0001 when compared with short-term follow-up, n = 851). Patients with long-term follow-up (>12 weeks) were lost at a rate of 20% (n = 393, OR = 1.32, p = .064 when compared with short-term follow-up).

In addition to insurance carrier and expected duration of follow-up after surgery, we also looked at patient age and gender when assessing risk factors for patient loss to follow-up. Patients below 30 years of age had a loss to follow-up rate of 42% (n = 359), compared with 26% for patients 30 to 64 years of age (n = 1868, OR = 1.99, p < .0001), and 13% for patients 65 years and older (n = 336, OR = 5.19, p < .0001).

Males were more frequently lost to follow-up (32%, n = 1,111) compared with females (22%, n = 1452, OR = 1.64, p < .0001). Thus, females, when compared with males, were 1.64 times as likely to follow-up.

Finally, we measured the travel distance from a patient’s home address to the hand surgery office and investigated its effect on loss to follow-up rates. Patients who lived less than or equal to 50 miles from the hand surgery office were lost to follow-up at a rate of 25% (n = 2085), compared with 31% for patients who lived more than 50 miles away (n = 487, OR = 0.751, p = .015).

Discussion

The purpose of this study was to determine the rate of patient loss to follow-up after hand and upper extremity surgery and to identify any patient or surgical factors that may predict likelihood of loss to follow-up. To our knowledge, the current study is the largest surgical cohort studied overall, and certainly the largest within the hand and upper extremity literature. In total, in the current study, 26% of patients did not return to follow-up after surgery. We further determined that patients of male gender, younger age, self-pay or Medicaid insurance status, those who lived further away from the hand surgery office, and those who undergo surgeries with expected midterm follow-up between 2 and 12 weeks are at greater risk of loss to follow-up after surgery.

Prior studies also identified some of the variables we found to have an association with patient loss to follow-up. Murnaghan et al analyzed 236 patient records from a Canadian trauma database to determine characteristics of patients lost to follow-up. Their overall rate of loss to follow-up was 16%. Significantly higher rates of loss to follow-up were found in younger patients, unskilled workers, and in Aboriginal Canadian (indigenous) patients.⁸ The authors suggested that it was possible the nonattenders had a less flexible schedule and simply did not have the time to attend their follow-up visits. Sielatycki et al also identified younger age as an independent risk factor for loss of follow-up among spine surgery patients.¹¹ While it is beyond the scope of this article to identify specific reasons for patients to be lost to follow-up, a potential explanation for this pattern is that younger patients have commitments either to work or school that make it more difficult for them to follow-up compared with older patients who may be retired. Another possibility is that the younger patients may heal more quickly therefore obviating any appreciated need of returning to follow-up.

Ten Berg and Ring studied 335 patients with metacarpal fractures and found an overall rate of loss to follow-up of 31% by the second visit. They identified uninsured status to be a socioeconomic risk factor for loss to follow-up.¹² Our study population mirrored those data, demonstrating that self-pay (ie uninsured) patients tended to have a higher rate of loss to follow-up. The simplest explanation for this is that follow-up visits may present an economic burden to patients. Despite the fact that during the study period, the visits in the first 90 days postoperatively were free to the patient, there may have been other costs such as transportation or the opportunity cost of lost time at work that dissuaded patients from returning for clinical follow-up after surgery.

Prior literature, to our knowledge, has not identified male gender or distance needed to travel to the clinic as risk factors for patient loss to follow-up. The latter is fairly intuitive as greater traveling distance poses a greater inconvenience, cost, and time to a patient, and thus all things being equal, those patients will be less likely to return to the office for a follow-up visit. Male gender may also seem intuitive as males have been previously suggested to be at greater risk of noncompliance in the treatment of other medical conditions including hypertension,^3,7,10 tuberculosis,² and stroke.¹ A possible explanation for this is that females tend to have increased perception of their medical problems compared with men.⁴ It must be noted, however, that more recent literature has suggested that males and females may in fact have equal risk of noncompliance,^6,13 or even than females may be at higher risk than males,⁵ in which context our results are less intuitive.

Our study also identified patients with expected final follow-up between 2 and 12 weeks as being at greater risk for loss to follow-up. Patients who underwent procedures that may require only one follow-up visit for suture removal (such as trigger finger release or carpal tunnel release) were more likely to return perhaps because it is their first follow-up visit after surgery, and therefore they may not know or remember what was done during surgery and the expected rehabilitation afterward. Conversely, patients with expected follow-up beyond 12 weeks were more likely to return as well; however, this difference did not reach clinical significance. In these cases, patients may have had more complex surgeries and therefore they may have felt uneasy managing them without physician guidance.

In the end, 26% of our patients did not return for follow-up after hand and upper extremity surgery. The consequences of this noncompliance are not completely clear, as we did not evaluate patient outcomes in this study. However, it implies that we as surgeons do not know how one-third of our surgical patients actually do at final follow-up, and therefore, at least in our practice, anecdotal surgical experience is at best limited to 74% of our patients.

Limitations of this study include its retrospective nature. There was no standardization in documentation or in addressing how to handle patients who were lost to follow-up. Also, we did not survey patients to identify the reasons they did not attend follow-up visits. Strengths of the current study include the large sample size and standardization of treatment—all patients were treated surgically.

Future research in this area may help to elucidate the specific reasons patients are lost to follow-up in hand and upper extremity surgery, and what if any effect loss to follow up has on patient outcome. Furthermore, we hope to develop methods of improving patient follow-up in the clinic after surgery. For the patients who do not have the desire or means to return to the clinic after surgery, we hope to develop and utilize alternative means of evaluating recovery, such as with the use of telephone or video phone.