|Year : 2023 | Volume
| Issue : 5 | Page : 407-414
Determining the clinical value of routine post operative follow up in common paediatric surgical conditions: A prospective observational study
Revathy Menon1, Manish Pathak1, Shubhalaxmi Nayak1, Manoj Kumar Gupta2, Rahul Saxena1, Avinash Jadhav1, Kirtikumar Rathod1, Arvind Sinha1
1 Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Community and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Submission||02-Mar-2023|
|Date of Decision||29-Jun-2023|
|Date of Acceptance||13-Jul-2023|
|Date of Web Publication||05-Sep-2023|
All India Institute of Medical Sciences, Basni Phase 2 Industrial Area, Jodhpur - 342 001, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The traditional postoperative visit consists of an in-person hospital visit at a predetermined date which requires the investment of time and resources. This implies a need to prioritize visits rather than mandating them, which can be assessed by the requirement of clinical intervention at the time of follow-up. The purpose of this study is to determine the clinical value of routine postoperative physical follow-up in common pediatric surgery conditions, to identify factors determining follow–up, and to estimate the cost of routine follow-up.
Materials and Methods: Surgical data of 226 patients admitted for routine pediatric surgical procedures were collected. The postoperative period was documented in detail and interventions done either physically or telephonically at the time of follow-up were used as a proxy measure of clinical value.
Results: There were 226 patients enrolled, of which 64.60% followed up physically in outpatient department and 35.40% followed up telephonically. Maximum percentage of patients with postoperative complications belonged to the group of laparotomy at 22.22%, followed by complicated appendicitis at 15.62%. 13.27% of patients required clinical intervention at the time of follow-up.
Conclusion: Patients undergoing simpler procedures such as inguinal hernia, hydrocele, and orchidopexy have lesser rate of complications which translates to requirement of fewer clinic visits, whereas those undergoing procedures such as appendectomy and laparotomy require a physical visit after discharge since they are more susceptible to develop complications requiring interventions. By selecting patients for physical visit, we can potentially eliminate unnecessary visits in patients who have low chance of developing complications.
Keywords: Clinical value, follow-up, pediatric surgery, telemedicine
|How to cite this article:|
Menon R, Pathak M, Nayak S, Gupta MK, Saxena R, Jadhav A, Rathod K, Sinha A. Determining the clinical value of routine post operative follow up in common paediatric surgical conditions: A prospective observational study. J Indian Assoc Pediatr Surg 2023;28:407-14
|How to cite this URL:|
Menon R, Pathak M, Nayak S, Gupta MK, Saxena R, Jadhav A, Rathod K, Sinha A. Determining the clinical value of routine post operative follow up in common paediatric surgical conditions: A prospective observational study. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Oct 2];28:407-14. Available from: https://www.jiaps.com/text.asp?2023/28/5/407/385147
| Introduction|| |
The traditional postoperative visit after most surgical procedures consists of an in-person hospital visit at a predetermined date. Follow-up requires the investment of a substantial amount of health professionals' time and resources and usually results in lost productivity at school and work for the family., Roadblocks to follow-up include lack of awareness leading to irregular doctor–patient contact, high-cost burden incurred, loss of work, and school days due to hospital visits. Despite these issues, the majority of parents prefer to bring the child back for a visit even if the child is asymptomatic.
Postoperative follow-up must be considered an essential part of health-care practice by considering its benefits and risks. Patients undergoing simpler procedures are rarely seen to require interventions at follow-up. This implies a need to identify which patient population can be spared from a rigid follow-up. This means prioritizing high-risk patients who might benefit from a scheduled postoperative visit rather than mandating it to every patient. This may be assessed by the requirement of clinical intervention at the time of follow-up.
Except for a handful of studies, publications are yet to uniformly acknowledge the requirement of optimizing follow-up in third-world nations. This study attempts to determine the clinical value of follow-up in our institute with the help of postoperative interventions. It also attempts to determine the need for follow-up based on the perceived clinical value of follow-up, cost burden, socioeconomic, educational background, and other factors impacting the preference for follow-up.
Aim and objectives
The primary aim is to determine the clinical value of routine postoperative physical follow-up in common pediatric surgical conditions. The secondary aim is to identify factors determining the routine postoperative physical follow-up such as wound care, suture removal, need for any additional laboratory tests or radiological investigations, plan for further surgery, and to estimate the cost of routine postoperative physical follow-up and evaluate the impact of socioeconomic status, educational background on pattern, and preference of physical follow-up.
| Materials and Methods|| |
This was a prospective study conducted between January 2020 and November 2021. Ethical clearance for the study was obtained from the Institutional Ethics Committee (certificate number AIIMS/IEC/2020/2089). Patients <18 years of age admitted to the Department of the Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, with the following conditions were included in the study:
Inguinoscrotal pathologies (inguinal hernia, hydrocele, undescended testis, testicular torsion), appendicitis (both complicated and uncomplicated), infantile hypertrophic pyloric stenosis (IHPS), laparotomy for various intra abdominal pathologies (adhesive intestinal obstruction, Meckel's diverticulum, malrotation, volvulus, intussusception, bowel perforation, biliary atresia), circumcision.
Patients older than 18 years and those requiring staged surgeries were excluded. Patients who fell under inclusion criteria but had undergone any additional procedures were also excluded from the study.
Parents were counseled at the time of admission regarding the nature of the illness, surgery planned, possible complications, expected hospital course, and the necessity for follow-up. Every parent was counseled for a physical follow-up visit after 7 days of discharge. They were also informed regarding the availability of a telemedicine service through which they could schedule an appointment for a telephonic follow-up. Discharge documents handed over to the parents instructed them regarding follow up for any postoperative concerns and explained future surgical plans.
Baseline data were collected from the patient at admission. The data were entered into a Google Form as part of a questionnaire [Appendix 1].
Baseline data recorded included:
- Demographic data of patient: Age, sex, and place of residence
- Distance from hospital
- Reason for admission
- Preference for follow-up (at admission)
- Occupation of the head of the family
- Educational background of the head of the family
- Monthly income of the family.
Modified Kuppusamy Socioeconomic Scale (2021) was used to categorize patients into different groups of socioeconomic scale based on data collected regarding occupation, education of the head of family, and income status of the family.
Clavien–Dindo grading of surgical complications was used to grade the various surgical complications faced by the patients during the hospital stay and postoperative follow-up.
After the patient underwent the scheduled procedure, further data were collected regarding the surgery and hospital course, including expenses. The data entered at the time of discharge included:
- Date and type of surgical procedure performed
- Intra-operative and postoperative complications
- Total expenses incurred during the hospital stay, which included hospital expenses, cost of stay, and food
- Cost of travel to and from the hospital
- Days of job work lost of a parent during hospital stay of the child.
Patients were seen to follow-up after 7 days either telephonically or physically. At the time of follow-up, the patient's general condition was assessed, questions were asked pertaining to the disease, and the surgical site was examined.
A separate questionnaire was filled at follow-up collecting details of the postoperative period, recovery status, bowel bladder habits, and appetite. Details were also collected regarding details of issues faced by patients during the postoperative period and clinical intervention done during follow-up if any. Interventions underwent were used as a proxy measure of clinical value. Patients underwent clinical intervention at the physical visit as well as through telemedicine.
Definition of interventions for the purpose of this study included:
- Wound care
- Suture removal
- Prescription of medication
- Follow-up imaging
- Additional laboratory tests
- Planning further surgery.
Time from discharge to follow-up was noted. At follow-up, every parent was enquired regarding the further preference of follow-up and this was compared to the initial preference of follow-up answered at admission.
Among those who followed up physically, the data on the cost of follow-up were collected.
They were enquired regarding their satisfaction with the physical visit.
In the case of those who followed up telephonically, informed consent was taken for the purpose of telemedicine consultation. Surgical site examination was done by asking the parents to share multimedia through chat service and follow-up questions were asked telephonically. The patients who followed up through telemedicine had the provision of an online chat service and a departmental telephone number through which the necessary follow-up questions were asked. After routine follow-up, they were also enquired regarding the reason for not following up physically.
The data were collected using Google Forms and tabulated in Microsoft Excel. Descriptive statistics was used for describing the population under study and follow-up pattern. The data were presented in the form of frequencies and percentages. Median and interquartile range (IQR) were calculated for the data that were not normally distributed. Z-test and Chi-square test of interdependence were used to examine the relationship between two variables. P < 0.05 was considered significant at 95% confidence interval.
All statistical analyses were performed using SPSS Version 28.0 IBM Corporation, Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY, USA: IBM Corporation.
| Results|| |
There were 226 patients enrolled, of which 157 (69.50%) were male patients and 69 (30.50%) were female patients. There were 102 (64.97%) males and 44 (63.76%) female patients who followed up in the physical outpatient department (OPD), whereas 55 (35.03%) males and 25 (36.24%) female patients who followed up telephonically with a preference for physical follow-up in both genders, but there was no significant difference between both groups (P = 0.862).
The age distribution ranged from 5 days to 17 years, with the maximum number of patients falling in the category of 1–5 years (111; 49.12%). The mean age of presentation was 4.74 years; the median age was 2 years with IQR 1–8 years. There was no significant difference in the preferred mode of follow-up on admission in any of the age groups.
Maximum patients included in the study underwent surgery for inguinal hernia (74; 32.74%), followed by uncomplicated appendicitis (47; 20.8%). Out of the 226 patients, 146 (64.60%) followed up physically in OPD after discharge from the hospital, and 80 (35.40%) followed up telephonically, with a significant difference between modes of follow-up (P < 0.001). Ninety-five (65.10%) answered that the physical follow-up was found to be beneficial. On enquiring the caregivers at admission about their preferred mode of follow-up in future, 108 (47.79%) patients answered they would follow-up telephonically, whereas 118 (52.21%) responded that they would follow up physically. At the time of follow-up, 55 out of 80 (68.75%) continued to prefer telephonic follow-up who had followed up telephonically. Out of 146 who were followed up physically, 92 (63.01%) opted to continue with a physical follow-up in the future.
The patients who did not follow-up physically were contacted telephonically and enquired regarding the reason for not following up physically in OPD. The caregivers cited different reasons for not following up in physical OPD [Table 1].
There was a significant difference between the preferred mode of follow-up at admission in patients with complicated appendicitis, hydrocele, and laparotomy. Twenty-seven patients with complicated appendicitis opted for physical follow-up, and five opted for telephonic follow-up with a P = 0.00001. There were 17 patients with hydrocele who were followed up telephonically and only six who followed up physically, with P = 0.008. Out of 18, 14 patients of laparotomy were followed up physically, whereas four patients were followed up physically with P = 0.023.
Regarding the actual mode of follow-up, there was a significant difference between the modes of follow-up in patients who underwent laparotomy and those who had laparotomy [Table 2].
Ten out of 26 patients (4.42%) developed postoperative complications. The maximum percentage of patients with postoperative complications belonged to the laparotomy group at 22.22% (4 patients out of 18), followed by complicated appendicitis at 15.62% (5 patients out of 32). All patients with postoperative complications were followed up physically in the OPD for follow-up.
Postoperative complications were graded using the Clavien–Dindo classification. Overall, there were five patients with Grade I surgical complications and five patients with Grade 2 surgical complications during the course of their hospital stay [Table 3].
Thirty (13.27%) patients required clinical intervention at the time of follow-up, of which 3 (10%) patients were followed up by telemedicine and 27 (90%) were followed up physically. All patients with requirements of clinical intervention were seen to follow-up earlier than the routine follow-up date, either by telemedicine or physical follow-up.
Patients requiring clinical intervention were 11/18 (61.11%) patients of laparotomy, 8/32 (25.00%) patients of complicated appendicitis, 8/47 (17.02%) patients of uncomplicated appendicitis, 1/23 (4.34%) patient of hydrocele, and 2/74 (2.70%) patients of inguinal hernia [Table 4].
|Table 4: Presenting complaint and clinical intervention done for the same on follow-up|
Click here to view
The median value of total expenses for physical follow-up was 500 INR, with IQR 250–800 INR. The cost expenses ranged from 120 to 8500 INR. The median days of wages missed due to physical follow-up were 2 days with IQR 1–4 days. The median distance from the hospital was 55 km, with IQR 12–109.25 km.
There was no significant difference in preference of mode of follow-up with distance from the hospital (P = 0.470) and mode of follow-up with distance from the hospital (P = 0.541). There was no significant difference in preferred mode of follow-up with expenses (P = 0.223) and mode of follow-up with expenses (P = 0.319).
There was no significant difference in preferred mode and mode of follow-up with the cost of follow-up or socioeconomic scale of the patient [Table 5].
| Discussion|| |
Follow-up after discharge is the first step in an ongoing dialogue about the patient's complaints, general well-being, review of investigations, and additional prescriptions if required. Follow-up care reinforces positive behavior and mitigates issues at the earliest. There is a growing demand for convenient health-care access, including affordable follow-up appointments. This raises the question if follow-up is necessarily a physical encounter at the health-care center and if a more cost-effective telemedicine platform can substitute it. In the pediatric surgical population, it is seen that patients require meticulous postoperative care. Yet, there are certain common surgical diseases that require straightforward interventions with a low rate of complication in comparison to a higher-risk group requiring strict follow-up. The primary purpose of the visit in this group of patients is seen to be parental reassurance. It is seen that outpatient follow-up may be enhanced with postdischarge follow-up calls/telemedicine follow-up. We may not entirely replace it but can consider it an adjunct to follow-up. These calls can potentially identify those who have undergone simpler procedures who may not necessarily require a visit. Identification of at-risk patients can assist in the allocation of energy and resources optimally. Parents' ability to judge the need for physical follow-up may be reflected in the observation that all the patients who required workup or evaluation urgently visit earlier than the scheduled follow-up date. In our study, out of 30 patients requiring clinical intervention, all were seen to follow-up earlier than the prescribed follow-up date.
We included patients with complicated and uncomplicated appendicitis, hydrocele, inguinal hernia, undescended testis, testicular torsion, circumcision, IHPS, and those who underwent laparotomy. 108 patients (47.79%) preferred a telephonic follow-up at admission, which suggests that there are sufficient number of parents who are willing to try out newer modes of telecommunication.
There were 146 out of 226 patients (64.60%) who followed up physically in OPD. This was in spite of the fact that most patients did not face any postoperative issue that would have necessitated a visit. Due to our protocol at the discharge of advising a physical visit to all patients irrespective of any factors, we observed a slightly higher preference for a physical visit when compared to other studies. Out of 146 patients, 95 patients answered that the visit was found to be beneficial. This indicates that parents who visited for follow-up have found the visit beneficial despite the cost burden. Hence, satisfaction with follow-up is also an essential component of a clinical assessment.
Koulack et al. studied follow-up practices and complication rates in routine pediatric inguinal hernia repair. The complication rate was a mere 0.7%. A questionnaire handed out showed that 80% of parents felt that the follow-up visit was helpful, but 35% would have been satisfied with a telephone follow-up. Despite a low complication rate, the positive attitude toward the follow-up suggests that the main purpose of the visit was parental reassurance. In our study, 65.10% of patients who followed up physically found the visit beneficial.
Follow-up is also utilized to trace and review pathology/other laboratory reports, which are not often available at the time of discharge. The postdischarge follow-up makes for an ideal time to review these results together. This can be streamlined by advising the specific cohort of patients with pending reports to follow-up at a recommended time as per the availability of their reports. However, with the advent of telemedicine, it is certainly possible to trace and review reports online and convey the same to the parents. If a strategically constructed discharge plan is employed with written instructions, we can potentially avoid following up patients with no or less requirement of follow-up in the OPD and ensure that follow-up is employed by those with an actual requirement of examination or intervention, therefore avoiding preventable hospital readmissions.
At the time of follow-up, both telephonic and physical, we asked the patient's family what mode of follow-up would they prefer for the future. Out of 146 who followed up physically, 92 opted to continue with a physical follow-up in the future. Of the 80 patients who followed up telephonically, 55 chose to continue a telephonic mode, and 25 opted for a future physical follow-up. To the best of our knowledge, no previous study has collected data and analyzed the pattern and preference of pediatric surgical follow-up at admission and follow-up. In this era of cost constraints within our health-care system, one might expect that the perceived value of a follow-up visit be considered in the background of a significant economic burden on the family. There are multiple barriers to a standard follow-up, including the distance to be travelled, travel expenditure, meals, and time away from school and work. This paves the way for more and more families to opt for telephonic in lieu of a physical follow-up.,
Parents may also opt for follow-up with their family physician or local health-care center. It is favored mostly by patients who hail from distant places for whom there is a significant burden for travel expenses. This follow-up detail is also incorporated in our data using our telemedicine follow-up. Our study encompasses both simple and complex diagnoses, with the purpose of analyzing the follow-up pattern and preference in both. The hospital course of a patient with a relatively simple inguinal pathology widely varies from that of a patient who has undergone laparotomy, but both are scheduled for a follow-up visit irrespective of the predicted postsurgical course. With regards to the diseases with complicated presentation, the pattern of follow up was in favour of physical visits. This could be due to diligent counselling about major risks, side effects. These parents are apprehensive even at the time of discharge after being instructed about the danger signs and possible risks, and they usually wish that the child be examined thoroughly and investigated on follow-up visits to not miss out on any future issues. Patients of inguinal hernia and hydrocele were followed up telephonically more than physically, whereas patients of laparotomy and complicated appendicitis were followed up physically more than telephonically. All patients with a postoperative complication during hospital stay were seen to follow-up physically in OPD, suggesting that parents correctly interpret the need for dedicated follow-up visits in at-risk patients. Appropriate counseling during hospital stay translates into encouraging alertness and awareness in the parents to rightly recognize the need for a follow-up visit. This again suggested that in diseases with a possibly longer course of treatment and hospital stay and increased morbidity and time to recovery, parents tended to prefer to follow-up physical in outpatient.
These visits are deemed beneficial usually if they result in any procedural intervention and identification of potential complications and their management. The rate of clinical intervention was 13.27%. The small number of patients requiring formal review and intervention on follow-up is comparable to other similar studies. All patients in our study requiring clinical intervention were seen to follow-up earlier than the routine follow-up date, either by telemedicine or physical follow-up. Three patients in our study had initiated a follow-up via telemedicine earlier than the scheduled date for the purpose of a clinical intervention which was carried out successfully. Out of 18 patients who underwent laparotomy in our setting, 11 required clinical intervention at follow-up. This suggests that patients who have undergone exploratory laparotomy are more susceptible to develop complications and would benefit from a standardized follow-up routine in comparison to patients of less complicated conditions such as hydrocele and hernia. A study by Gimon et al. studied the optimization of postoperative follow-up in pediatric surgery patients and the clinical value of follow-up, and it was considered in patients with surgical site issues or other postoperative complaints. Clinical value was hence identified in 16.4% of patients. Parental identification and subsequent early presentation of postoperative issues was also a common observation. Early presentation of a patient with the postoperative issue was also observed in our study.
Our study did not find any statistically significant difference between the mode of follow-up and distance from the hospital. We calculated total expenses incurred, which included the cost of travel to and from the hospital, hospital expenses, cost of stay, and cost of food. No significant difference was found between the total cost and mode of follow-up. Similarly, the socioeconomic scale also did not have any significant difference in the mode of follow-up. Wiebe and Shawyer also performed a retrospective review on the impact of distance on postoperative follow-up in pediatric surgical cases at a tertiary health-care center in Canada. The 723 patients were divided into two groups as per distance from the major urban center, and the study highlighted no significant difference in follow-up rates between the two groups. Gimon et al. also found that defined follow-up order is a significant factor in determining the mode of follow-up. However, in their study, parents living nearby were also an independent factor in determining the mode of follow-up. Upon detailed enquiry in our study, it was noted that parents were willing to travel longer distances and even bear the cost for the purpose of getting their child evaluated in person by the treating doctor. This indicates that parents, even in developing nations, are willing to comply with the surgeon's instructions at discharge to follow-up physically, irrespective of the distance they need to travel. The onus lies on the surgeon to identify the procedures that do not need a routine physical follow-up visit and counsel the patients/parents accordingly. Since significant costs are incurred by those cases who had no clinical issues identified at follow up, the majority of parents of children undergoing simple uncomplicate surgeries require simple reassurance without any need for intervention. If we attempt a telephonic follow-up in patients with simpler diseases not requiring any clinical intervention, we can cut down on unnecessary cost expenses.
Limitations of the study
Our study is limited by a small sample size which can be attributed to the COVID pandemic resulting in fewer routine surgeries. The pandemic resulted in disproportionate distribution of cases at follow-up, with a larger cohort of complicated cases than usually expected from a pediatric surgical center. Long-term complications of any patients have not been documented, and our study is limited to data collection till the first scheduled follow-up.
| Conclusion|| |
Although our study is not adequately powered to arrive on any definitive conclusion, we may infer that patients undergoing simpler procedures such as inguinal hernia, hydrocele, and orchidopexy might face lesser rate of complications which translates to the requirement of fewer clinic visits. Telemedicine can be considered an alternative in these patients. All parents who followed up with telemedicine were comfortable with the system, and a majority of them have opted to continue with the same mode in future. Patients undergoing procedures such as appendectomy and laparotomy require a physical visit after discharge since they are usually more susceptible to develop complications requiring interventions. Since all patients in our study requiring clinical interventions presented earlier than the scheduled follow-up date, we may consider eliminating strict follow-up protocol and instead educate parents at the time of discharge regarding basic signs and symptoms to watch for. This can eliminate potentially unnecessary and costly clinic visits especially in patients who have very little chance of developing complications. Our study is limited by a small sample size due to the COVID pandemic which resulted in fewer routine surgeries, and we expect future prospective studies with larger sample sizes to generate established results which may arrive at a similar conclusion.
- Study conception and design: Dr. Manish Pathak, Manoj Kumar Gupta
- Data acquisition: Dr. Revathy Menon
- Analysis and data interpretation: Dr. Manish Pathak, Dr. Rahul Saxena, Dr. Kirti Kumar Rathod, and Dr. Shubhalaxmi Nayak
- Drafting of manuscript: Dr. Revathy Menon, Dr. Manish Pathak, and Dr. Shubhalaxmi Nayak
- Critical revision: Dr. Rahul Saxena, Dr. Avinash Jadhav, and Dr. Arvind Sinha.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
Questionnaire at admission
- Name of patient:
- Name of parent with contact details:
- Reason for admission:
- Monthly income of family:
- Educational status of head of family:
- Occupational status of head of family:
- Distance from hospital:
- Complications during hospital stay:
- Preference for follow-up:
- Signature of parent/legal guardian
- Signature of doctor.
Questionnaire at follow-up
- Name of patient:
- Name of parent with
- Contact details:
- Reason for admission:
- Date of surgery:
- Cost of follow-up:
- Daily wages missed: Expense of travel, stay, food:
- Site of surgery: Left/right/bilateral not applicable
- Reason for follow-up:
- Follow-up date given
- Suture removal
- Dressing check/change/removal
- Date for next procedure
- Follow-up image advised
- Medication prescribed
- Follow-up laboratory investigations.
- Follow-up earlier than expected date: Yes/no
- Appetite/diet: Normal/abnormal
- Bowel/bladder habit: Normal/abnormal
- Activity: normal/reduced activity
- Is your preferred mode of follow-up, visit or telephonic? - Visit/telephonic
- Was this visit benifical to you
- Signature of parent/legal guardian
- Signature of doctor.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]