RESEARCH ARTICLE
Patient Satisfaction with Postoperative Follow-up by a Hand Therapist Sherif Elnikety* PgDip, Moataz El-Husseiny PgDip, Tamer Kamal MSc, Gautam D. Talawadekar MS, Hayley Richards BSc & Andrew M. Smith MSc East Kent Hospitals NHS Foundation Trust, Queen Elizabeth The Queen Mother Hospital, Margate, Kent, UK
Abstract Purpose. There has been a move to reduce and, indeed, stop postoperative appointments for uncomplicated surgical procedures within the National Health Service. The purpose of this study was to measure patient satisfaction with postoperative follow-up conducted by a hand therapist, with no routine postoperative follow-up by the surgeon. Methods. A total of 124 patients were recruited over two years. Fifty patients post-simple trapeziectomy and 74 patients post-single-digit Dupuytren’s fasciectomy were prospectively surveyed for their opinion on their postoperative care and whether or not they would have liked to be reviewed by the surgeon in a routine postoperative follow-up appointment. All patients included in this study had their operations performed by one surgeon in one hospital. All patients were reviewed by a hand therapist within two weeks of surgery. Results. A total of 116 patients completed the study, of whom 106 patients (91%) were satisfied with their postoperative management and 99 patients (85%) did not want to be reviewed by the surgeon in a postoperative outpatient follow-up appointment. Discussion. This study reflects the successful application of postoperative follow-up by a hand therapist. Copyright © 2011 John Wiley & Sons, Ltd. Keywords follow up; survey; Dupuytren’s; trapeziectomy; hand therapy; patient satisfaction *Correspondence Sherif Elnikety, 9 Weston Drive, Stanmore,Middlesex, HA7 2EX, UK. E-mail:
[email protected]
Published online 20 December 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.225
Introduction Changes in the National Health System (NHS) have involved the redesign of service provision and application of new policies. These changes are driven by the financial need to improve cost efficiency and redirect the budget to areas in need. In the NHS, there are over 80 million outpatient appointments scheduled each year (NHS Information Centre, 2010). Nearly 40 million of these are follow-up appointments (NHS Health and Social Care Information Centre, 2010). The ‘did not attend’ (DNA) rate varies
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between 6% and 10%, with an estimated cost of about £600 million a year (Doctor Foster, 2010). Seventy-five per cent of DNA appointments are follow-up appointments (Modernisation Agency, 2004). As part of the NHS redesign strategy, the ‘High Impact Changes’ document was created [Modernisation agency, 2004]. It emphasized the need to avoid unnecessary follow-up appointments and encouraged a one-stop streamlining approach for outpatient clinics. Similar recommendations were advocated in a report issued by the University of Manchester (Roland and Sibbald, 2006).
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This report stated that routine follow-up appointments could be replaced by no follow-up, patient controlled follow-up or primary care follow-up. The aim of the present study was to measure patient satisfaction with the new follow-up policy. Two requently conducted operations, trapeziectomy and single-digit Dupuytren’s fasciectomy, were chosen for this study, as they have low postoperative complication rates.
Methods In this prospective study, all patients who underwent trapeziectomy or single-digit Dupuytren’s fasciectomy between April 2008 and April 2010 by one hand surgeon in one hospital were selected. Patients with multiple-digit Dupuytren’s disease or who had undergone tendon reconstruction or any additional procedure, or had digital nerve injury as a complication of Dupuytren’s fasciectomy, were excluded from the study. All patients were reviewed by the surgeon in the preadmission clinic two to four weeks prior to their operation. None of the patients were reviewed routinely by the surgeon postoperatively. An occupational hand therapist reviewed all patients within two weeks of their surgery and rehabilitation protocols were followed in all cases. Patients who expressed a desire to be reviewed by the surgeon were seen by him within two weeks. Postoperative pain levels, using the visual analogue score, were recorded for post-trapeziectomy patients. For post-Dupuytren’s fasciectomy patients, pre- and postoperative fixed flexion deformity involving the metacarpophalangeal joint (MCPJ), proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) were recorded. All patients completing the study were asked to fill in a questionnaire survey in the waiting area just before their discharge by the hand therapist. After completion, this survey was handed in to the clinic receptionist and was collected later by the physiotherapist. For simplification, the questionnaire was in a tick-box ‘Yes’ or ‘No’ format, questioning patients’ satisfaction with postoperative management and whether they would have liked to see the surgeon postoperatively.
Results A total of 124 patients were recruited. Three patients who had postoperative digital nerve injury were excluded from the study and were reviewed by the surgeon. 40
Five patients did not complete the questionnaire and were excluded from the study (all five were post-Dupuytren’s fasciectomy). A total of 116 patients completed the study – 50 patients post-trapeziectomy and 66 postDupuytren’s fasciectomy. In the trapeziectomy group, the average preoperative visual analogue pain score was 8 (range 6–10), while the average postoperative pain score was 2 (range 0–7). In this group, eight patients wanted to be reviewed by the surgeon in a postoperative outpatient follow-up appointment and four patients were not satisfied with their management. The pre-/postoperative pain levels of these four patients were 10/1, 7/2, 8/5 and 8/0.3 patients were in both groups, requested to see the surgeon and were not satisfied with their post operative management. In the Dupuytren’s group, the average preoperative deformity was 61 (range 0 – 80 ), while the average postoperative deformity was 13 (range 10 –60 ); the average improvement in the deformity was 48 (range 0 –140 ). In this group, nine patients wanted to be reviewed by the surgeon in a postoperative outpatient follow-up appointment and of whom six patients were not satisfied with their postoperative management. All the six patients who expressed dissatisfaction with their postoperative management showed a significant improvement in deformity. Out of the 116 patients who completed the study, 106 patients (91%) across both groups were satisfied with their postoperative management and 99 patients (85%) did not want to be reviewed by the surgeon. Of the 17 patients who wanted to be reviewed by the surgeon postoperatively, all had one appointment with the surgeon in the outpatient clinic within two weeks of being discharged by the hand therapist. None of these patients needed a further intervention, no prescriptions were given and there was no clinical need for further follow-up appointments.
Discussion In 2004, the government recommended ‘a no routine follow-up policy’ to improve NHS efficiency (NHS modernisation agency, 2004).This policy also aimed to reduce the inconvenience to patients of multiple trips to the hospital. In addition it minimized the waste of resources in the form of unnecessary follow-up appointments. A total of 215 unnecessary appointments were saved during the present study (232 routine appointments, of which 17 were requests for surgical review), with an average saving of £16,340 (Doctor Foster, 2010). Musculoskelet. Care 10 (2012) 39–42 © 2011 John Wiley & Sons, Ltd.
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In 2007, the national clinical director for primary care advocated that six-week postoperative appointments should be carried out by general practitioners (GPs) rather than hospital surgeons (Colin-Thomé, 2007). This proposal was questioned, as it was felt that it would have a negative effect on doctor–patient relationships and the training of junior staff, and would complicate the auditing of surgeon and unit results; there were also questions around the competence of GPs in diagnosing complications in the early postoperative stages (Bamji, 2007; Kmietowicz, 2007). The policy of having no routine follow-up appointments with the surgeon has been used in trauma and orthopaedics for uncomplicated postoperative patients for many years – mainly in post-trauma operations such as dynamic hip screw and hip hemiarthroplasty operations. However, this practice is not yet widely used in elective procedures. A questionnaire study (Sethuraman et al., 2000), examining the opinion of post-total hip or knee replacement patients about their routine follow-up visit, found that 45% of the patients preferred not to attend the clinic in person, and to have their follow-up done by postal questionnaire. Hacking et al. (2010) questioned the need for routine postoperative follow-up after total hip arthroplasty. Harle et al. (2009) conducted a questionnaire study among postoperative orthopaedic patients attending outpatient clinics, local GPs and orthopaedic trainees. They concluded that most of the participants had serious doubts about providing postoperative follow-up appointments in the community by trained nurses and GPs. These findings contradict those of a study examining patient satisfaction with general orthopaedic outpatient clinics (Nielsen et al., 2005), which found no difference in satisfaction rates between patients seen by a consultant and those seen by either a GP with a special interest or a specialist physiotherapist. Several papers have discussed the role of physiotherapists in outpatient clinics (Daker-White et al., 1999; Jette et al., 2006; McClellan et al., 2006; Oldmeadow et al., 2007; Pearse et al., 2006). These papers agree on the usefulness and ability of physiotherapists to manage patients independently, with high satisfaction rates. Prior to the present study, our patients were seen by the surgeon postoperatively at two weeks, to ensure that there were no problems with the wound site. Patients were also seen at six to eight weeks postoperatively, to ensure satisfactory clinical progress, and occasionally also at 12 to 16 weeks if clinically indicated. Musculoskelet. Care 10 (2012) 39–42 © 2011 John Wiley & Sons, Ltd.
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Our results reflect the importance of communication within multidisciplinary teams and the role of physiotherapists and occupational therapists in the management of musculoskeletal conditions. The internal email system was used for effective interdisciplinary communication. The role of the hand therapy team was paramount for the successful application of this policy. Clear postoperative treatment protocols, experience in rehabilitating hand surgery patients and a clear mechanism for highlighting concerns ensured its success. To minimize the effect of this policy on their training, trainee doctors can attend hand therapy clinics as observers. This policy had no effect on the waiting time or the availability of the hand therapist. Before the application of this policy, two parallel follow-up appointments had run; one with the surgeon and the other with the hand therapist. The new policy eliminated this duplication and streamlined the follow-up process. The policy described here provides a safe and efficient healthcare service; it is recommended that it is applied selectively on uncomplicated surgical procedures.
REFERENCES Bamji AN (2007). Proposal strikes at the heart of medicine. British Medical Journal 334: 109–10. Colin-Thomé D (2007). Department of Health. Keeping it personal. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065094 [Accessed 28 November 2011]. Daker-White G, Carr AJ, Harvey I, Woolhead G, Bannister G, Nelson I, Kammerling M (1999). A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and Community Health 53: 643–50. Doctor Foster research website (2010). Outpatient appointment no-shows cost hospitals £600 m a year. Available at http://www.drfosterhealth.co.uk/features/ outpatient-appointment-no-shows.aspx [Accessed 28 November 2011]. Hacking C, Weinrauch P,Whitehouse SL, Crawford RW, Donnelly WJ (2010). Is there a need for routine follow-up after primary total hip arthroplasty? ANZ Journal of Surgery 80: 737–40. Harle D, Ilyas S, Darrah C, Tucker K, Donell S (2009). Community-based orthopaedic follow-up. Is it what doctors and patients want? Annals of the Royal College of Surgeons of England 91: 66–70. 41
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Jette DU, Ardleigh K, Chandler K, McSheaL (2006). Decisionmaking ability of physical therapists: Physical therapy intervention or medical referral. Physical Therapy 86: 1619–29. Kmietowicz Z (2007). GPs to follow up patients after surgery. British Medical Journal 334: 9. McClellan CM, Greenwood R, Benger RJ (2006). Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department. Emergency Medicine Journal 23: 384–7. NHS Health and Social Care Information Centre (2010). Hospital episode statistics, outpatients data. Available at http://www.hesonline.nhs.uk/Ease/servlet/ContentServer? siteID=1937&categoryID=890[Accessed 28 November 2011]. NHS Information Centre (2010). Hospital outpatients activities 2009–2010. In Statistics and data collection, Hospital care, outpatients. Available at http://www.ic.nhs. uk/statistics-and-data-collections/hospital–care/outpatients/hospital-outpatient-activity-2009-10 [Accessed 28 November 2011]. NHS Modernisation Agency (2004). High impact changes: Change number 5. Available at http:// www.qualitymk.nhs.uk/default.asp?ContentID=3351 [Accessed 28 November 2011]
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Nielsen DM, Gill K, Ricketts DM (2005). Satisfaction levels in orthopaedic outpatients. Annals of the Royal College of Surgeons of England 87: 106–8. Oldmeadow LB, Bedi SH, Burch HT, Smith JS, Leahy ES, Goldwasser M (2007). Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care. Medical Journal of Australia 186: 625–8. Pearse EO, Maclean A, Ricketts DM (2006). The extended scope physiotherapist in orthopaedic out-patients – An audit. Annals of the Royal College of Surgeons of England 88: 653–5. Roland M, Sibbald B (2006). Outpatient services and primary care. National Primary Care Research and Development Centre and Centre for Public Policy and Management of the University of Manchester. Available at http://www. medicine.manchester.ac.uk/primarycare/npcrdc-archive/ Publications/Studyinghealthcare_Roland_finalreport.pdf [Accessed 28 November 2011] Sethuraman V, McGuigan J, Hozack WJ, Sharkey PF, Rothman RH (2000). Routine follow-up office visits after total joint replacement: Do asymptomatic patients wish to comply? Journal of Arthroplasty 15: 183–6.
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