Unplanned Office Visits Following Outpatient Hand Surgery

Background Returning to the office for an unplanned visit postoperatively can be burdensome to both the patient and provider. The purpose of this study was to quantify the rate of unplanned office visits after common soft tissue hand surgeries and assess the reasons for these unplanned visits. Methods Patients who underwent common soft tissue hand surgeries over a 6-month time period were queried from an electronic medical record database. Manual chart review was performed to record patient demographics, unplanned visits within 3 months postoperatively, and specific reasons for unplanned visits. A total of 1648 postoperative follow-up visits in 1224 patients were included in analysis. Results Within 3 months of surgery, 6.3% (103/1648) of postoperative visits were found to be unplanned. There was no difference in the rate of unplanned visits among the included surgeries ( P = .46). The most common reasons for an unplanned office visit overall were wound problems (34%), pain (23.3%), and stiffness (17.5%). The trigger finger release group had significantly more patients return to the office for stiffness ( P = .01), the De Quervain release group had significantly more patients return for pain ( P = .02), and the carpal tunnel release group had significantly more patients return for persistent symptoms ( P < .05). Conclusions Unplanned office visits represented about 1 of 16 postoperative visits. Orthopedic surgeons should be aware of the most common reasons for these visits and be prepared to address these problems promptly. Preoperative patient education on these potential problems may help decrease the frequency of unplanned follow-up visits.

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Combined Cubital and Carpal Tunnel Release Results in Symptom Resolution Outside of the Median or Ulnar Nerve Distributions

The Open Orthopaedics Journal ◽

10.2174/1874325001610010111 ◽

2016 ◽

Vol 10 (1) ◽

pp. 111-119 ◽

Cited By ~ 1

Author(s):

Peter C. Chimenti ◽

Allison W. McIntyre ◽

Sean M. Childs ◽

Warren C. Hammert ◽

John C. Elfar

Keyword(s):

Median Nerve ◽

Ulnar Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Symptomatic Improvement ◽

Patient Counseling ◽

Symptom Resolution ◽

Persistent Symptoms ◽

Validated Questionnaires

Background: Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after combined release of the ulnar nerve at the elbow with simultaneous release of the median nerve at the carpal tunnel. Methods: 20 patients with combined cubital and carpal tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected pre-operatively and at six-week follow-up. Results: Probability of resolution was greater in the median nerve distribution than the ulnar nerve for numbness (71% vs. 43%), tingling (86% vs. 75%). Seventy percent of the cohort reported at least one extra-anatomic symptom pre-operatively, and greater than 80% of these resolved at early follow-up. There was a decrease in pain as measured by validated questionnaires. Conclusion: This study documents resolution of symptoms in both extra-ulnar and extra-median distributions after combined cubital and carpal tunnel release. Pre-operative patient counseling may therefore include the likelihood of symptomatic improvement in a non-expected nerve distribution after this procedure, assuming no other concomitant pathology which may cause persistent symptoms. Future studies could be directed at correlating pre-operative disease severity with probability of symptom resolution using a larger population.

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Bridging to survivorship in breast cancer: How BMI weighs in.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.31_suppl.32 ◽

2013 ◽

Vol 31 (31_suppl) ◽

pp. 32-32

Author(s):

Janet L. Espirito ◽

Brian Turnwald ◽

Robyn K. Harrell ◽

Debajyoti Bhowmik ◽

Neelima Denduluri ◽

...

Keyword(s):

Breast Cancer ◽

Early Stage ◽

Office Visit ◽

Large Network ◽

Office Visits ◽

Complete Treatment ◽

Impact On Survival ◽

Planning Methods ◽

Survivorship Care Planning

32 Background: Obesity and depression complicate survivorship in early stage breast cancer (BC) by having a direct impact on survival and morbidity among patients (pts) who complete treatment (tx). The prevalence of obesity after BC tx in the community and concordance with BC tx type is poorly described, but important as we characterize risks of tx and optimize goals for survivorship care planning. Methods: We queried the electronic health record (EHR), iKnowMed, from a large network of community oncology practices for pts diagnosed with stage I-III BC from 2007-2010 with at least 5 office visits and follow up through 11-2012 for our retrospective study. We excluded pts who developed metastatic disease or died. We stratified pts by chemotherapy (CT) utilization (yes/no), hormone receptor (HR) status, age, and documented body mass index (BMI) at first office visit and annually. We evaluated changes in BMI characteristics by tx cohort. Results: We identified 8,506 pts with a documented BMI at first office visit and 1, 2, and 3 years (yrs) thereafter. 4,369 (51% of the total) pts received adjuvant CT and 4,137 (49%) did not. 6,897 pts (81%) were HR positive. Baseline BMI between tx cohorts were similar, though the prevalence of overweight (31%) and overweight or obese (68%) is high. Percent change of BMI at 3 yrs varied significantly between T cohorts (p<0.01) with greater rise among the cohorts who received CT in comparison to those who did not. Pts receiving CT were 46% more likely to have a 5 point or more increase in BMI at 3 yrs compared to pts that did not receive CT (OR 1.46, CI[1.08-1.96]). A stronger association for BMI increase of at least 0.5 points at 3 yrs (OR 1.53, CI [1.4-1.7]) was also observed amongst pts who received CT compared to those that did not. HR positive pts were less likely than HR negative or unknown pts to increase their BMI by at least 0.5 points (OR 0.84, p<0.01), but there was no difference at detecting a difference of 5 points in BMI (OR 0.88, p=0.49). Conclusions: With 3 yrs of follow up, overweight and obese status is remarkably common among BC survivors in the community and appears to be more prevalent after CT tx. Determinants of obesity require further study and point to necessary intervention to improve the health of early stage BC pts.

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Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release

Hand ◽

10.1177/1558944718793984 ◽

2018 ◽

Vol 15 (3) ◽

pp. 311-314 ◽

Cited By ~ 1

Author(s):

Steven R. Niedermeier ◽

Robert J. Pettit ◽

Travis L. Frantz ◽

Kara Colvell ◽

Hisham M. Awan

Keyword(s):

Sleep Quality ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Hand Surgery ◽

Outpatient Setting ◽

Compressive Neuropathy ◽

Carpal Tunnel Surgery ◽

Tunnel Syndrome ◽

And Function

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship–trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant ( P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, “How soon after your carpal tunnel surgery did you notice an improvement in your sleep?” Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.

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Electronic health record note review in an outpatient specialty clinic: who is looking?

JAMIA Open ◽

10.1093/jamiaopen/ooab044 ◽

2021 ◽

Vol 4 (3) ◽

Author(s):

Jimmy S Chen ◽

Michelle R Hribar ◽

Isaac H Goldstein ◽

Adam Rule ◽

Wei-Chun Lin ◽

...

Keyword(s):

Electronic Health Records ◽

Electronic Health Record ◽

Clinical Care ◽

Office Visit ◽

Health Record ◽

Office Visits ◽

Health Records ◽

Ancillary Staff ◽

Electronic Health

Abstract Note entry and review in electronic health records (EHRs) are time-consuming. While some clinics have adopted team-based models of note entry, how these models have impacted note review is unknown in outpatient specialty clinics such as ophthalmology. We hypothesized that ophthalmologists and ancillary staff review very few notes. Using audit log data from 9775 follow-up office visits in an academic ophthalmology clinic, we found ophthalmologists reviewed a median of 1 note per visit (2.6 ± 5.3% of available notes), while ancillary staff reviewed a median of 2 notes per visit (4.1 ± 6.2% of available notes). While prior ophthalmic office visit notes were the most frequently reviewed note type, ophthalmologists and staff reviewed no such notes in 51% and 31% of visits, respectively. These results highlight the collaborative nature of note review and raise concerns about how cumbersome EHR designs affect efficient note review and the utility of prior notes in ophthalmic clinical care.

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Fever in Pediatric Primary Care: Occurrence, Management, and Outcomes

PEDIATRICS ◽

10.1542/peds.105.s2.260 ◽

2000 ◽

Vol 105 (Supplement_2) ◽

pp. 260-266

Author(s):

Jonathan A. Finkelstein ◽

Cindy L. Christiansen ◽

Richard Platt

Keyword(s):

Primary Care ◽

Laboratory Testing ◽

Office Visit ◽

Pediatric Primary Care ◽

Care Practice ◽

Meningococcal Sepsis ◽

Office Visits ◽

Health Maintenance ◽

Entire Cohort

Objective. To describe the epidemiology, management, and outcomes of children with fever in pediatric primary care practice. Patients. A cohort of 20 585 children 3 to 36 months of age cared for in 11 pediatric offices of a health maintenance organization between 1991 and 1994. Methods. Using automated medical records we identified all office visits with temperatures ≥38°C for a random sample of 5000 children, and analyzed diagnoses conferred, laboratory tests performed, and antibiotics prescribed. We also determined the frequency of in-person and telephone follow-up after initial visits for fever. Finally, we reviewed hospital claims data for the entire cohort of 20 585 to identify cases of meningitis, meningococcal sepsis, and death from infection. Results. Among 3819 initial visits of an illness episode, 41% of children had no diagnosed bacterial or specific viral source. Of these, 13% with a temperature of 38°C to 39°C and 36% with a temperature of ≥39°C received laboratory testing. Almost half (43%) received some documented follow-up care in the subsequent 7 days. Among the 26 970 child-years of observation in the entire cohort, 15 children (56 per 100 000 child-years) were treated for bacterial meningitis or meningococcal sepsis. Five had an office visit for fever in the week before hospitalization, but only 1 had documented fever ≥39°C and received neither laboratory testing for occult bacteremia nor treatment with an antibiotic. Conclusion. The majority of febrile children in ambulatory settings were diagnosed with a bacterial infection and treated with an antibiotic. Of highly febrile children without a source, 36% received laboratory testing consistent with published expert recommendations, and short-term follow-up was common. Meningitis or death after an office visit for fever without a source was predictably rare. These data suggest that increased testing and/or treatment of febrile children beyond the rates observed here are unlikely to affect population rates of meningitis substantially.

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Postoperative follow-up time and justification in prospective hand surgery research: a systematic review

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193420931478 ◽

2020 ◽

Vol 45 (9) ◽

pp. 899-903

Author(s):

Rachel C. Hooper ◽

Jacob S. Nasser ◽

Helen E. Huetteman ◽

Shale J. Mack ◽

Kevin C. Chung

Keyword(s):

Carpal Tunnel Release ◽

Demographic Data ◽

Tendon Repair ◽

Hand Surgery ◽

Level Of Evidence ◽

Thumb Carpometacarpal Joint ◽

Expected Time ◽

Surgery Research ◽

Thumb Carpometacarpal

We systematically reviewed prospective studies for five hand procedures to analyse postoperative follow-up time, clinical or radiographic plateau, and whether the authors provide justification for times used. Demographic data, outcomes and mean follow-up were analysed. A total of 188 articles met our inclusion criteria. The mean postoperative follow-up time among these studies were carpal tunnel release, 21 months (range 1.5–111); cubital tunnel release, 27 months (2.5–46); open reduction and internal fixation for the distal radius fracture, 24 months (3–120); thumb carpometacarpal joint arthroplasty, 64 months (8.5–228); and flexor tendon repair, 25 months (3–59). Authors provided justification for follow-up intervals in 10% of these reports. We conclude that most prospective clinical studies in hand surgery do not properly justify follow-up length. Clinically unnecessary follow-up is costly without much benefit. In prospective research, we believe justified postoperative follow-up is essential, based on expected time to detect clinical plateau, capture complications and determine the need for secondary surgery. Level of evidence: III

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Comparing telehealth to traditional office visits for patient management in the COVID-19 pandemic: A cross-sectional study in a respiratory assessment clinic

Journal of Telemedicine and Telecare ◽

10.1177/1357633x21990197 ◽

2021 ◽

pp. 1357633X2199019

Author(s):

J Cole Phillips ◽

Richard W Lord ◽

Stephen W Davis ◽

Amanda A Burton ◽

Julienne K Kirk

Keyword(s):

Emergency Department ◽

Hospital Admission ◽

Primary Outcome ◽

Office Visit ◽

Cross Sectional Study ◽

Office Visits ◽

Sectional Study ◽

Cross Sectional ◽

Significant Difference

Introduction The aim of this study was to examine whether telehealth is as safe and effective as traditional office visits in assessing and treating patients with symptoms consistent with COVID-19. Methods In this retrospective cross-sectional study, the primary outcome was any 14-day related healthcare follow-up event(s). Secondary outcomes were the type of 14-day related follow-up event including hospital admission, emergency department visit, office visit, telehealth visit and/or multiple follow-up visits. Individual visit types were identified due to the significant difference between a hospital admission and an office visit. Logistic regressions were done using the predictors of visit type, age, gender and comorbidities and the primary outcome variable of a related follow-up visit and then by follow-up type: hospital admission, emergency department visit or office visit. Results Of 1305 visits, median age was 42.3 years and 65.8% were female. Traditional office visits accounted for 741 (56.8%) of initial visits, while 564 (43.2%) visits occurred via telehealth. One hundred and forty-six (25.9%) of the telehealth visits resulted in a 14-day related healthcare follow-up visit versus 161 (21.7%) of the office visits (adjusted odds ratio (OR) 1.22, 95% CI 0.94–1.58). Discussion There was no significant difference in related follow-ups of initial telehealth visits compared to initial office visits including no significant difference in hospital admission or emergency department visits. These findings suggest that based on follow up healthcare utilization, telehealth may be a safe and effective option in assessing and treating patients with respiratory symptoms as the COVID-19 pandemic continues.

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48Remote monitoring of Heart Failure patients with a Multisensor ICD Algorithm: value of an alert-based follow-up strategy

EP Europace ◽

10.1093/europace/euaa162.194 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

D Pecora ◽

V Tavoletta ◽

A Dello Russo ◽

E De Ruvo ◽

F Ammirati ◽

...

Keyword(s):

Heart Failure ◽

Office Visit ◽

Signs And Symptoms ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Office Visits ◽

Ventricular Ejection Fraction ◽

Increased Risk ◽

Remote Data

Abstract Background The HeartLogic algorithm measures and combines multiple parameters, i.e. heart sounds, intrathoracic impedance, respiration pattern, night heart rate, and patient activity, in a single index. The associated alert has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation, and the HeartLogic alert condition was shown to identify patients during periods of significantly increased risk of HF events. Purpose To report the results of a multicenter experience of remote HF management with HeartLogic algorithm and appraise the value of an alert-based follow-up strategy. Methods The HeartLogic feature was activated in 104 patients (76 male, 71 ± 10 years, left ventricular ejection fraction 29 ± 7%). All patients were followed according to a standardized protocol that included remote data reviews and patient phone contacts every month and at the time of HeartLogic alerts. In-office visits were performed every 6 months or when deemed necessary. Results During a median follow-up of 13[11-18] months, centers performed remote follow-up at the time of 1284 scheduled monthly transmissions (10.5 per pt-year) and 100 HeartLogic alerts (0.82 alerts/pt-year). The mean delay from alert to the next monthly remote data review was 14 ± 8 days. Overall, the patient time in the alert state (i.e. HeartLogic index above the threshold) was 14% of the total observation period. HF events requiring active clinical actions were detected at the time of 11 (0.9%) monthly remote data reviews and at 43 (43%, p < 0.001) HeartLogic alerts. Moderate to severe symptoms of HF were reported during 2% of remote visits when the patient was out of HeartLogic alert condition and during 15% of remote visits performed in alert condition (p < 0.001). Out of 100 alerts, 17 required an in-office visit and 5 a hospitalization to manage the clinical condition. Overall, 282 scheduled and 56 unscheduled in-office visits were performed during follow-up. Any HF sign (i.e. S3 gallop, rales, jugular venous distension, edema) was detected during 18% of in-office visits when the patient was out of HeartLogic alert condition and during 34% of visits performed in alert condition (p = 0.002). Conclusions HeartLogic alerts are frequently associated with relevant actionable HF events. Events are detected earlier and the volume of alert-driven remote follow-ups is limited when compared with a monthly remote follow-up scheme. The probability of detecting common signs and symptoms of HF at regular remote or in-office assessment is extremely low when the patient is out of HeartLogic alert state. These results support the adoption of an alert-based follow-up strategy.

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Bridging to survivorship in breast cancer: How BMI weighs in.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.9605 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 9605-9605

Author(s):

Janet L. Espirito ◽

Brian Turnwald ◽

Robyn K. Harrell ◽

Debajyoti Bhowmik ◽

Neelima Denduluri ◽

...

Keyword(s):

Breast Cancer ◽

Early Stage ◽

Office Visit ◽

Large Network ◽

Office Visits ◽

Complete Treatment ◽

Impact On Survival ◽

Planning Methods ◽

Survivorship Care Planning

9605 Background: Obesity and depression complicate survivorship in early stage breast cancer (BC) by having a direct impact on survival and morbidity among patients (pts) who complete treatment (tx). The prevalence of obesity after BC tx in the community and concordance with BC tx type is poorly described, but important as we characterize risks of tx and optimize goals for survivorship care planning. Methods: We queried the electronic health record (EHR), iKnowMed, from a large network of community oncology practices for pts diagnosed with stage I-III BC from 2007-2010 with at least 5 office visits and follow up through 11-2012 for our retrospective study. We excluded pts who developed metastatic disease or died. We stratified pts by chemotherapy (CT) utilization (yes/no), hormone receptor (HR) status, age, and documented body mass index (BMI) at first office visit and annually. We evaluated changes in BMI characteristics by tx cohort. Results: We identified 8,506 pts with a documented BMI at first office visit and 1, 2, and 3 years (yrs) thereafter. 4369 (51% of the total) pts received adjuvant CT and 4137 (49%) did not. 6897 pts (81%) were HR positive. Baseline BMI between tx cohorts were similar, though the prevalence of overweight (31%) and overweight or obese (68%) is high. Percent change of BMI at 3 yrs varied significantly between T cohorts (p<0.01) with greater rise among the cohorts who received CT in comparison to those who did not. Pts receiving CT were 46% more likely to have a 5 point or more increase in BMI at 3 yrs compared to pts that did not receive CT (OR 1.46, CI[1.08-1.96]). A stronger association for BMI increase of at least 0.5 points at 3 yrs (OR 1.53, CI [1.4-1.7]) was also observed amongst pts who received CT compared to those that did not. HR positive pts were less likely than HR negative or unknown pts to increase their BMI by at least 0.5 points (OR 0.84, p<0.01), but there was no difference at detecting a difference of 5 points in BMI (OR 0.88, p=0.49). Conclusions: With 3 yrs of follow up, overweight and obese status is remarkably common among BC survivors in the community and appears to be more prevalent after CT tx. Determinants of obesity require further study and point to necessary intervention to improve the health of early stage BC pts.

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Successes and Failures of a Freedom™ Constrained Cup Used in a Major Salvage Procedure

Reconstructive Review ◽

10.15438/rr.7.3.191 ◽

2017 ◽

Vol 7 (3) ◽

Author(s):

Thomas Donaldson ◽

Ian Clarke

Keyword(s):

Office Visit ◽

Salvage Procedure ◽

Office Visits ◽

Wear Performance ◽

Hip Impingement ◽

Hip Motion ◽

Backside Wear ◽

Total Knee ◽

Eccentric Ring

Background: This is a case report of a 36mm constrained cup (Freedom™, Biomet IN) that performed successfully for 7-years in a salvage case involving a total-femur implanted in a leg already short by 3-4 inches. The goal was to enhance hip motion and stability using a 36mm head instead of the usual 32mm size. Templating indications were for a 50mm cup (Freedom™; Arcom™ liner). The proximal femur inserted in 2008 incorporated the 36mm constrained THA and was anchored distally to bone using the Compress™ fixator. By 2012 the fixator loosened and was replaced by hinged total-knee arthroplasty (TKA). The THA was retained at revision and patient’s clinical follow-up was satisfactory for 4 years. As indicated by Martel radiographic method, the Arcom™ liner showed minimal wear over this period. Radiographs in Feb-2016 showed the cup’s constraint ring had rotated slightly but the patient had no symptoms. By Dec-2016, the patient had experienced three falls and also had heard a popping sound in her hip. At Dec-2016 office visit, radiographs indicated additional rotation of the constraint ring and CT scans showed an eccentric head position contacting the metal shell. At revision, 50% of the Arcom rim was ablated and the remainder present as a loose fragment. Following insertion of new Freedom liner and 36mm head, her follow-up appears satisfactory 10-months later. Her leg shortening remains but she walks to office visits using a cane and doesn’t need the cane at home.Methods: Retrieved Arcom liner and detached rim fragment were reconstructed, photographed, and then bi-valved for comparison to similarly prepared exemplar liners, one identical to our revision and one with a thicker wall. Details of liner sections were taken from photographs and reconstructed by computer graphics (Canvas Draw-3™). Wear performance over the first 7 years was assessed using the Martel x-ray method.Results: Inspection of retrieved liner showed a large oval depression in the ablated rim. The contra-rim featured the large Arcom fragment and the underlying liner wall was less than 1mm thick. Comparison to exemplar liners showed that the large fragment had separated along the lower edge of the constraint groove. Exemplars demonstrated a substantial rim buttress spanning 13mm, which had been ablated in our retrieval.Discussion and Conclusion: Although this was not a high-demand patient, the considerable hip-impingement forces in a flail limb likely levered the head repeatedly against the liner’s constrained rim. Neck impingement was clearly evident in the damaged liner. A subluxing femoral head would also thin the contra-wall, as would backside wear. We do not know if the eccentric ring image in Feb-2016 radiographs depicted failure. The liner may have escaped from the shell’s locking-ring and with activity, ablated the Arcom contours and led to rim fracture. It is also possible that the liner constraint was damaged when the patient fell, thereby allowing the liner to mobilize.

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