AAOS Now

Published 4/1/2018
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Terry Stanton

Study Found Low Follow-up Rates in Patients Who Underwent Surgery for Traumatic Pelvic Injuries

A study that followed patients in Kentucky who were treated surgically for unstable pelvic ring injuries found that 12 percent of them did not appear for a single follow-up appointment, and 41 percent did not complete the 90-day global period. Patients who were older and who had diabetes were less likely to follow up, as were those who lived farther away from the trauma center.

The study, detailed in Poster 970, “The Invisible Patient: Defining the Orthopaedic Trauma Patient Who Does Not Follow Up,” which was on display at the Annual Meeting last month, identified 363 patients who underwent operative fixation of unstable pelvic ring injuries. Of these, 43 (12 percent) did not attend a single follow-up appointment. An additional 104 patients (28.9 percent) did not complete the global follow-up period of 90 days.

In total, 143 patients (40.5 percent) did not complete the global follow-up period of 90 days, including those who never followed up and those who followed up some but didn’t complete the global. Patients who failed to attend a single follow-up were significantly older (51 years vs. 44 years, P = 0.02), were more likely to be diabetic (8/43 [18.6 percent], vs. 23/319 [7.2 percent], P = 0.04), and lived a significantly greater distance from the treating trauma center (P = 0.02). Living more than100 miles away from the treating institution was associated with never attending a follow-up appointment (P <0.001, sensitivity="0.67," specificity="0.67).">

When the patients were sorted by the Economic Innovation Group’s Distressed Community Index scores, although no difference was seen between those who did and did not follow up (P >0.99), a significantly greater proportion of patients with unstable pelvic ring injuries lived in economically distressed areas when compared to the study-site state (Kentucky) as a whole (65.7 percent vs. 27 percent, P < 0.001). Similarly, while no differences were noted in smoking status between patients who did and did not follow up (P = 0.91), the prevalence of smoking was significantly greater in this series of trauma patients (42.5 percent) when compared to either the national (15.1 percent, P < 0.001) or statewide proportions (26 percent, P < 0.001).

Study author Kevin Cronin, MD, an orthopaedic resident at the University of Kentucky, explained why he and his colleagues decided to undertake the investigation, which would uncover an “alarmingly high rate” of patients who did not show up for their first follow-up appointment.

“Our institution treats a large number of trauma patients, and because of our catchment area, a significant portion of these patients live quite far away,” he said. “They are brought to us by ambulance or helicopter, sometimes from hundreds of miles away, to be treated for their injuries. In our cohort, the average distance to our trauma center was 142 miles. As residents, we are constantly switching on and off different services so we do not always get to see patients from the beginning to the end of their care. On occasion, I would look up previous patients in our medical record to see how they were doing. Often their follow-up would be incomplete or sometimes there would be no follow-up at all! We wanted to quantify this and attempt to define any factors that place patients at risk to becoming ‘invisible.’”

Addressing how the study examined the effect of economic status on follow-up compliance, he explained that the study used the Distressed Communities Index based on each patient’s zip code to identify those living in economically distressed areas. “Interestingly, we found no correlation between not following up and living in economically distressed areas,” he said. “We hypothesized that economically distressed patients would face significant barriers to care that would hinder them from keeping their follow-up appointments. We did not find this to be true.”

Dr. Cronin said that limitations of the study were that it was retrospective and “had the same inherent limitations with any retrospective design.” He added, “We were also unable to control for any patients seeking care outside of our university’s system. These patients may have elected to have their postoperative care overseen by a local community orthopaedist.”

The findings should serve as a reminder that surgeons and other participants in these trauma cases should remain attentive to the patient’s course after surgery, Dr. Cronin said. “Pelvic surgery is a large operation. The fact that greater than 12 percent of patients never attended a single postoperative clinic appointment is astounding. Our job as surgeons doesn’t end when we leave the operating room. While personal responsibility on the part of the patient does play a role in postoperative follow-up, we must be easily available to ensure a good outcome.”

In this regard, he noted that “a significant portion of our cohort of patients were smokers and diabetic and are at an even greater risk of postoperative complications,” pointing to the value of counseling patients about adopting healthful behaviors.

The study’s findings also pointed to a need to identify at discharge patients at risk for not following up “to improve our ability to follow these patients after surgery,” Dr. Cronin said. “Future studies hope to look at the role of telemedicine or novel patient engagement programs in improving postoperative follow-up.”

Dr. Cronin’s coauthors are Christopher B. Hayes MD; David Zuelzer MD; Lindsay Hockensmith BS; Cale Jacobs PhD; and Eric S. Moghadamian MD.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.