Patient Concerns in the Immediate Postoperative Period After Mohs Micrographic Surgery

Abstract

BACKGROUND

Postoperative concerns after Mohs micrographic surgery (MMS) are not well characterized.

OBJECTIVE

To better define patient concerns and contributing characteristics in the immediate postoperative period after MMS.

MATERIALS AND METHODS

A standardized telephone encounter template was implemented to better assess patient concerns in the 24-hour postoperative period. A review was then performed of patients undergoing MMS from October 2016 to July 2017 to assess for the most common patient concerns and association with clinical characteristics.

RESULTS

We included 307 patients. Overall, 60.6% of patients reported a concern. Fifty-four percent of patients reported pain. Most pain was characterized as “a little” (67.7%). On univariate analysis, flap repairs, location on the upper extremities, and swelling were associated with higher mean postoperative pain. Tumor type was not associated with increased pain. On multivariate analyses, patients with larger defects and associated edema were statistically significantly associated with higher degrees of pain.

CONCLUSION

Over half of patients experience postoperative concerns after MMS, most commonly pain. The immediate postoperative period may be an optimal time to identify patient concerns allowing for reassurance or early intervention when necessary.

The postoperative patient experience often serves as a major contributor to overall patient satisfaction with surgical procedures.¹ Anticipation of possible postsurgery complications is a source of patient preoperative anxiety.² Fortunately, Mohs micrographic surgery (MMS) is remarkably safe, and postoperative complications are uncommon, occurring in only 0.72% of cases.³ Despite the low complication rate, patient concerns are frequent. A complication is typically defined as an objective, physician-assessed event, such as an infection or hematoma, whereas a concern is subjective and patient-derived. One of the most widely studied postoperative patient concerns is pain.^4,5 A better understanding of patient concerns can allow physicians to better inform and ease patient preoperative anxiety while anticipating postoperative needs.

Postoperative telephone calls are frequently used in surgery to rapidly identify potential surgical-site infections and enhance time to intervention.^6,7 For patients undergoing MMS, the postoperative telephone call may provide an opportunity to systematically assess patient concerns and provide reassurance. In our practice, we implemented a telephone encounter template to standardize postoperative care. The objective of this study was to identify patient-reported concerns in the immediate postoperative period after MMS using this standardized template and to identify clinical predictors of postoperative patient concerns.

Methods

This study was conducted in a dermatologic surgery clinic at a single tertiary care cancer center under an institutional review board approval. All patients received discharge instructions and postoperative care, which included taking acetaminophen as needed for pain relief. Selected patients were provided a prescription for pain medication based on the physician’s anticipation for need (e.g., complicated repair, large size, or identified intraoperative sensitivity).

Implementation of a Standardized Telephone Encounter Template

All patients undergoing MMS receive a phone call from the nurse the morning after surgery (postoperative day [POD] 1) to assess for patient concerns. An initial assessment of nonstandardized postoperative telephone calls from July 2016 to September 2016 was performed. The most frequent patient concerns were pain, bleeding, and swelling. Charts and questions were inconsistent in their content, structure, and format. A telephone encounter template was developed based on this preliminary analysis (See Supplemental Digital Content 1, Table S1, http://links.lww.com/DSS/A175). Patients were asked, “Do you have any pain/swelling/bleeding?” and their responses were categorized on a grading system from 0 to 3, corresponding to “none,” “a little,” “moderate,” and “extreme.”

Review of Patient-Reported Concerns

A retrospective review of telephone encounters using the new template was performed from October 2016 to July 2017 to assess the frequency of reported symptoms. Only patients who underwent MMS and repair by dermatologic surgery were included. Patient medical records were reviewed for age, sex, tumor type, anatomical location, postoperative defect size, repair size, repair type, history of anxiety or depression, use of pain medication, and use of blood thinner at the time of surgery.

Statistical Analyses

The outcome variable for these analyses was postoperative pain, treated as a semicontinuous variable scaled from 0 “no pain” to 3 “extreme pain.” Cross-classification and chi-square tests were performed to assess the distribution of postoperative pain categories by repair type. Linear regression models were used to assess trends in pain scores for preoperative lesion size and surgical defect size. Stepwise regression was used to explore the association between postoperative pain and other study variables. A predetermined p-value cutoff of .20 was used for selection of variables. Thirty-six patients contributed more than 1 surgical site to the data, and where applicable, variance estimates were adjusted for the clustering of observations by the participant. Most analyses were based on the individual patient because postoperative pain was assessed as a general metric and not a specific, per-surgical-site measure. Marginal mean responses based on the stepwise regression model were estimated, reported as the average responses for patient-reported pain, controlling for the other variables. All analyses were performed with Stata V.14.2, Stata Corporation, College Station, TX.

Results

Patient Characteristics

A total of 307 patients contributing 346 surgical sites were included in the analysis. Two hundred seventy-one patients (88.3%) had a single surgical site, and 36 patients (11.7%) had more than 1 surgical site. Two hundred twenty-five (65.0%) lesions were located on the head and neck, 66 (19.1%) on the trunk, 20 on the upper extremities (5.8%), and 35 (10.1%) on the lower extremities. The mean age of participants was 70.4 years (range 26–100 years), and most participants were men (n = 182, 59.3%). Of the total number of respondents, 60.6% (186 of 307) of patients reported a concern during the phone call. Postoperative pain was the predominant concern with 167 patients (54.4%) reporting some degree of pain, 45 (14.7%) reporting swelling, and 11 (3.6%) reporting bleeding in the 24-hour postoperative period (Table 1).

TABLE 1.

Frequency of Patient-Reported Concerns Recorded During the 24-Hour Postoperative Telephone Encounter in 307 Patients (n = 346 Total Sites)

	n (%)
Pain
None	160 (46.2)
Little	128 (37.0)
Moderate	42 (12.1)
Extreme	16 (4.6)
Swelling
None	294 (85.0)
Little	44 (12.7)
Moderate	7 (2.0)
Extreme	1 (0.3)
Bleeding
No	334 (96.5)
Yes	12 (3.5)

Prescription pain medications were used by 16.3% of patients (n = 50), with 76% of these (38 of 50) being prescribed on the day of surgery (POD0). No association was observed between prescription pain medication and the number of surgical sites treated. For patients with multiple surgical sites (n = 36), heterogeneity of closure was not associated with pain medications.

Clinical Characteristics Associated With Postoperative Pain

Average preoperative lesion size was 1.1 cm (SD = 0.8; range 0.4–7.5 cm) in the longest dimension. We observed a positive trend for preoperative lesion size and postoperative pain, with patients who reported “no pain” with smaller lesions (mean = 1.0 cm, SD = 0.7) compared with those who reported “extreme pain” (mean = 1.6 cm, SD = 0.9) (p_trend = .006). Figure 1 presents the distribution of postoperative pain in relation to size of the surgical defect. The average defect size in the longest dimension was 2.0 cm (SD = 1.2). An increasing trend in reported pain with defect size was observed. The average defect sizes for those patients who reported “no pain” to “extreme pain” were as follows: “no pain” 1.8 (SD = 1.1), “a little” 2.1 (SD = 1.1), “moderate” 2.2 (SD = 1.3), and “extreme pain” 2.9 (SD = 1.5), respectively, p_trend < .001.

Figure 1.

Postoperative pain as related to surgical defect size. An increasing trend in reported pain with increasing defect size was observed, p_trend < .001.

Most lesions healed by primary closure (57.8%, n = 203), followed by secondary intent (17.6%, n = 61), flap (5.5%, n = 19), and graft (9.0% [31]). Thirty-two (9.3%) patients had more than 1 closure type due to multiple-site surgery. Over 70% of patients who underwent second intention healing reported no pain, compared with less than 50% for primary closures and xenografts and less than 40% for flaps and full-thickness skin grafts (FTSGs). Among the 16 patients (4.6%) who reported “extreme” pain, most had primary closures (n = 10); however, this accounted for only 5% of the primary repairs. Patients with multisite surgery did not report moderate or extreme pain. Flaps were associated with a higher mean pain score on univariate analysis (Supplemental Digital Content 2, Table S2, http://links.lww.com/DSS/A325).

Patient-reported postoperative swelling was associated with a higher mean pain score (1.21, 95% CI: 0.97–1.43) compared with patients without swelling (0.67, 95% CI: 0.58–0.76, p < .001). Procedures on the upper extremities had higher mean postoperative pain scores than the head and neck location on univariate analysis. A history of anxiety/depression was associated with a higher mean pain score but did not achieve statistical significance (p = .2). Mean pain scores were not statistically different whether 1 or more than 1 lesion was excised concurrently.

Multivariate Analysis of Postoperative Pain

The relationship between postoperative pain and all variables is shown in Supplemental Digital Content 3, Table S3, http://links.lww.com/DSS/A326. Age, sex, and tumor type were dropped from the model for being nonsignificant. Defect size and postoperative swelling were the only independent predictors of pain. When comparing the marginal effect on mean pain scores (that compares the average pain with having zero pain), nonhead and neck sites had higher adjusted average pain scores, but this did not achieve significance. Larger surgical defects were associated with increased pain levels, with each additional centimeter associated with a 0.23 (95% CI: −0.09 to 0.37, p = .002) higher reported pain score. Patients who reported swelling also experienced pain levels, on average, 0.62 points higher (95% CI: −0.38 to 0.86, p < .001) than those who did not report swelling.

Postoperative Bleeding

One hundred twenty-five of the 307 patients (40.7%) were on daily antiplatelet and/or anticoagulants at the time of surgery. Twelve (3.5%) patients reported bleeding, of which 4 were on daily antiplatelet/anticoagulants drugs. All patients reported the bleeding as “a little” and ceased with pressure. Repair types and anatomical sites were varied.

Discussion

The overall rate of patients reporting concerns during the phone call was 60.6% (186 of 307). Postoperative pain was the most commonly reported concern, with 54.4% of patients reporting some degree of pain. However, for most, the pain was mild and only 16.3% of patients required prescription pain medications. This relatively high frequency but low magnitude is consistent with previous studies assessing pain in MMS. In one study, postoperative pain was confirmed in 82% of MMS cases on postoperative Day 0 and 64% of cases on postoperative Day 1.⁴ Firoz and colleagues demonstrated mean pain scores of 2.34 (SD 2.31) (ranging from 1 to 10) on postoperative Day 0 after MMS and 1.56 (SD 1.98) on postoperative Day 1.⁵

Previous studies demonstrated that the most painful anatomical sites are the lip, nose, ear, forehead,⁸ scalp,⁴ and periorbital region.⁹ We did not find a statistically significant relationship between pain and anatomical location in the multivariate analysis. However, pain was more prominent in locations such as the trunk and extremities, which may be related to larger defect sizes and complex tumor repairs. Flaps were more painful compared with primary closures in the univariate analysis, similar to previous studies,^5,9 which may be the sequelae of a larger defect size, rather than the repair type itself. Pain of varying severity was reported by over half of patients with primary repair, flap repair, and FTSGs. However, for most, pain was reported as mild. Second-intention healing had the lowest associated pain. Larger lesion and postoperative defect sizes were significantly associated with higher postoperative pain scores. This contrasts with previous studies, which found that defect size does not contribute significantly to pain.^4,5 Patient-reported swelling and bleeding were uncommon; however, concomitant surgical-site swelling was significantly associated with higher levels of postoperative pain in univariate and multivariate analysis. Although it did not reach statistical significance, patients with a history of anxiety or depression had a higher average pain score. Identifying patients at higher risk of postoperative pain or swelling and targeting interventions early may in turn reduce concerns after surgery.

Although patient satisfaction of the standardized phone call was not assessed in this study, attempts at addressing symptoms or demonstrating concern for patients’ pain have been suggested to increase overall satisfaction.^1,10 A retrospective review of patients who underwent MMS found that 89% of patients considered postoperative follow-up to be important. In a previous study, patient satisfaction was higher for those receiving a postoperative telephone follow-up call on the evening of surgery.¹¹ As patients tend to underreport their minor discomforts during the intraoperative period,⁹ standardized postoperative telephone calls may allow physicians to assess concerns efficiently and systematically. Further research is needed on the effectiveness of a standardized telephone encounter on patient outcomes and satisfaction in a randomized study.

Limitations

Data was collected from a single tertiary cancer center and limited to the immediate postoperative period. Extension of data collection to greater than 24 hours may reveal additional concerns, such as drainage, itching, or rash, suggestive of later-occurring complications including infection, contact dermatitis, or dehiscence. In addition, in our practice, the nurse conducts the postoperative phone call, resulting in possible variability in patient’s reporting that was not assessed. However, an advantage of standardizing telephone calls is that it can be implemented by physicians as well as advanced practice providers. Finally, patients were not randomized to the type of surgical repair or administration of postoperative analgesics, resulting in an uneven distribution of subgroups and limitations that result from the observational nature of the study.

Conclusions

Utilization of a standardized telephone encounter template in the immediate postoperative period assists in identifying patient concerns in a timely manner. Identification of clinical characteristics associated with patient concerns may aid clinicians in conducting appropriate preoperative counseling. Patient–physician discussion and management of expectations, both preoperatively and postoperatively, may ameliorate patient anxiety and improve overall care.