American Medical News
By — Posted Aug. 5, 2013
New research is posing the question of whether the most productive visit after certain surgeries or procedures is one in which the patient, by design, doesn't show up at the doctor's office.
A study posted online July 10 in JAMA Surgery found that open hernia repair or laparoscopic cholecystectomy patients who followed up their surgery with a phone call instead of a doctor's visit had the same rate of complications of those who showed up at the office — none for the hernia patients and a small rate for the cholecystectomy patients.
Almost all patients who did their follow-ups by phone said they were very satisfied with the experience. Most of them, given the option, asked for phone calls over personal visits, with 71% of 115 hernia patients and 90% of 26 cholecystectomy patients electing to get a phone call.
Study author Sherry M. Wren, MD, chief of general surgery at the VA Palo Alto Health Care System and professor of surgery at the Stanford University School of Medicine in California, said the results show that, in some cases, a planned phone call in postoperative care can be beneficial to patients and physicians.
Often, she said, patients don't make it to follow-up visits because they had a conflict that kept them from the doctor's office, or they feel they're OK and don't need to see a doctor. By reducing those no-shows, doctors can fill appointment slots with other patients and could help reduce hospital readmissions and doctors' liability risk, experts said.
“I think you do capture more people who would ordinarily not show up,” Dr. Wren said. “They don't have to get a ride or take off work. This is about making it easier on the patients, and it saves health care systems funds.”
However, the strategy of phone calls over physician visits isn't foolproof. For one thing, Dr. Wren noted, the phone visits must be scheduled, rather than having the doctor make a random call, so patients and the physicians' office can conduct an effective review. Physicians said the strategy would be limited to any visit where a doctor would not be expected to have to see or touch a patient to ascertain his or her condition.
In the study, conducted at the VA Palo Alto Health Care System, patients were asked if they wanted to be called rather than go to the office following their procedures. If they wanted to be called, a phone visit would be scheduled.
Physician assistants called patients, asking them questions from a scripted template. Patients were assessed for overall health, pain, fever, swelling, activity levels, appetite and patient concerns. Responses were noted in the patients' electronic health records.
If patients experienced increased pain, despite the use of analgesics, or showed signs of infections, such as fever, drainage from incision, wound opening or increased swelling at the incision site, they were advised to return for follow-up visits in person.
Three cholecystectomy patients reported complications. One patient had a superficial skin separation. Another had a local wound infection, and he was prescribed oral antibiotics. The third patient had incisional hematoma, which required three inpatient admissions to treat his complications.
Study results found that the most effective way to follow up with patients is to schedule phone call appointments in the early evening. Although the study didn't look at how the system affected no-show patients, it's likely it would cut down on missed appointments, Dr. Wren said.
This type of follow-up appointment is catching on slowly, said Jonathan Linkous, CEO of the American Telemedicine Assn. Employed physicians, for example, may find that their hospitals are particularly interested in this form of telemedicine, because it's a cost-effective way to check up on patients, especially when Medicare is penalizing hospitals for unnecessary readmissions, he said.
“Some hospitals give patients [a checklist] … of what to do after their surgeries and what to look for,” Linkous said. “Many of them forget or never look at the paper, and it's no surprise that they are back in the hospital in a couple of days.”
Consultants said that although most insurers don't pay doctors for phone calls, new payment models that reward physicians based on quality and efficiency of care might provide a boost to the idea of phone-based follow-ups.
Physicians need to engage patients in their follow-up care. A failure to follow up can result in legal complications for doctors, according to a May survey of 723 patient care sites by The Doctors Company, a medical liability insurer.
In the study, 53% of respondents said referrals and scheduling follow-up appointments were their top risk-management problems. Failure to contact patients after missed appointments and a lack of tracking to ensure appropriate follow-up care was completed were cited as the most frequent risk-management issues.
How a follow-up phone call rather than an office visit would affect lawsuits if patients sued depends on the nature of the illness, said Rich Cahill, vice president and associate general counsel for The Doctors Company. Like most medical liability claims, cases would hinge on what similarly trained physicians would have done in comparable circumstances.
“They would look into whether the injuries would have been prevented, more likely than not, had the patient been examined in the office setting,” Cahill wrote in an email. “The more routine and benign the situation, the greater likelihood that the standard care would permit a telephone or email follow-up. … However, the more worrisome the condition being reported — and therefore the greater risk to the patient's health if something is missed — the more probable that an actual office visit with direct physician contact would be required.”
Dr. Wren said calling patients for follow-ups would work best for procedures with low-risk complications where potential complications are easily characterized.
Other conditions also could be candidates for telephone follow-ups, said Jeffrey Cain, MD, president of the American Academy of Family Physicians. He is associate professor in the Dept. of Family Medicine at the University of Colorado Health Sciences Center.
Following up by phone is appropriate for family physicians when the purpose is to understand patients' medical conditions better or to help them manage their conditions, Dr. Cain said. For chronic issues, physicians might call patients with diabetes to follow up on blood sugar and blood pressure control, as well as for guidance and counseling on weight loss, diet and exercise, he said.
Whenever care requires doctors to check patients physically or symptoms are more nuanced for some illnesses, phone calls would not be sufficient, he said.
Calling patients is inappropriate “if you need to lay a hand on the patient,” Dr. Cain said.