Follow-up Compliance and Outcomes of Knee Ligamentous Reconstruction or Repair Patients Enrolled in an Electronic Versus a Traditional Follow-up Protocol
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Orthopedics
Feature Article
Follow-up Compliance and Outcomes of Knee Ligamentous Reconstruction or Repair Patients Enrolled in an Electronic Versus a Traditional Follow-up Protocol
Henry T. Shu, BS; Blake M. Bodendorfer, MD; Christopher A. Folgueras, BS; Evan H. Argintar, MD
Orthopedics. 2018;41(5):e718-e723
Abstract
Abstract
Patient-reported outcome measures are increasingly used in research and clinical practice, but their collection can be burdensome. The primary purpose of this study was to determine whether patients who underwent ligamentous reconstruction or repair of the knee enrolled in an automated electronic follow-up system had greater follow-up compliance than patients enrolled in a traditional follow-up protocol. This study also evaluated whether enrollment in an automated electronic follow-up system was associated with improved surgical outcomes. The authors retrospectively reviewed follow-up data from 183 patients who underwent ligamentous knee reconstruction or repair from 2012 to 2017 by a single surgeon. Follow-up compliance was documented as any contact with a patient greater than 6 weeks from surgery, and patient-reported outcome measures between 3 months and 1 year postoperatively were compared between groups. Patients enrolled in automated electronic follow-up had a trend toward greater follow-up compliance (80.00% vs 74.22%, P=.4028), with greater benefit for patients who underwent multiligamentous knee reconstruction (85.71% vs 65.52%, P=.3048). Patient-reported outcome measures were not significantly different between the traditional follow-up group and the automated follow-up group, despite a significantly greater time from operation to follow-up in the traditional follow-up group (9.3±2.30 vs 7.0±2.88 months, P=.038). Patients enrolled in the traditional follow-up protocol had a significantly increased complication rate (8% vs 0%, P=.034). The use of an automated electronic follow-up system has the potential to significantly increase follow-up compliance, especially in subgroups of patients having classically poor follow-up, with minimal limitations and lower burden on clinicians and staff. [Orthopedics. 2018; 41(5):e718–e723.]
Full Text
Abstract
Patient-reported outcome measures are increasingly used in research and clinical practice, but their collection can be burdensome. The primary purpose of this study was to determine whether patients who underwent ligamentous reconstruction or repair of the knee enrolled in an automated electronic follow-up system had greater follow-up compliance than patients enrolled in a traditional follow-up protocol. This study also evaluated whether enrollment in an automated electronic follow-up system was associated with improved surgical outcomes. The authors retrospectively reviewed follow-up data from 183 patients who underwent ligamentous knee reconstruction or repair from 2012 to 2017 by a single surgeon. Follow-up compliance was documented as any contact with a patient greater than 6 weeks from surgery, and patient-reported outcome measures between 3 months and 1 year postoperatively were compared between groups. Patients enrolled in automated electronic follow-up had a trend toward greater follow-up compliance (80.00% vs 74.22%, P=.4028), with greater benefit for patients who underwent multiligamentous knee reconstruction (85.71% vs 65.52%, P=.3048). Patient-reported outcome measures were not significantly different between the traditional follow-up group and the automated follow-up group, despite a significantly greater time from operation to follow-up in the traditional follow-up group (9.3±2.30 vs 7.0±2.88 months, P=.038). Patients enrolled in the traditional follow-up protocol had a significantly increased complication rate (8% vs 0%, P=.034). The use of an automated electronic follow-up system has the potential to significantly increase follow-up compliance, especially in subgroups of patients having classically poor follow-up, with minimal limitations and lower burden on clinicians and staff. [Orthopedics. 2018; 41(5):e718–e723.]
Patient-reported outcome measures (PROMs) are a crucial component of postoperative follow-up, as they can provide information on patient recovery and data for research. 1 To obtain and follow PROMs, it is necessary to maintain patient contact. Patient contact is traditionally maintained through follow-up methods such as telephone calls, physician emails, and in-clinic surveys. However, all of these methods have limitations that can impact both the quantity and the quality of PROMs. Automated electronic follow-up systems have been developed to provide a more convenient method of obtaining PROMs. Typically, these systems involve automated interactive telephone calls, emails, and/or surveys that are sent at predefined points. 2,3 Some benefits of automated electronic follow-up include improved patient adherence with scheduling and attending follow-up visits, improved continuity of care, improved cost-effectiveness, and unified formats for tracking patient outcomes and even surgeon performance data. 2–5 In addition to these benefits, automated electronic follow-up systems allow surgeons to prospectively collect and analyze raw data with the goal of facilitating clinical research. 5 However, limitations attributed to automated electronic follow-up have not been discussed extensively. Some have noted that data-entry fields within automated follow-up systems can be difficult to edit (eg, Internet-Based Refractive Analysis used in ophthalmology). 5 An example of an automated electronic follow-up system is Surgical Outcome Systems (SOS; Arthrex, Inc, Naples, Florida). Surgical Outcome Systems was developed as a novel cloud-based registry that collects surgical patient outcome scores from surveys that are automatically emailed to patients at specified time points.
Modern follow-up systems may have the potential to improve follow-up compliance among patients traditionally thought to have poor compliance, such as patients with multiligamentous knee injuries. 6,7 Patients with multiligamentous knee injuries are defined as having a disruption of at least 2 of the 4 major knee ligaments. Multiligamentous knee injuries are often the result of knee dislocations due to high-velocity trauma in nonobese patients, but may also be due to low-velocity trauma in obese patients. 6,8 Within this group of patients, poor compliance with follow-up is thought to be due to socioeconomic factors and residential distance from the hospital, as patients with multiligamentous knee injuries are often treated at tertiary referral centers covering a vast area, such as the authors' institution.
The primary purpose of this study was to determine whether patients enrolled in an electronic automated follow-up system have greater PROM survey follow-up compliance than patients enrolled in a traditional follow-up protocol. Given the increasing accessibility to technology, the authors hypothesized that enrollment in an automated follow-up system would result in greater follow-up compliance and greater efficiency than traditional follow-up protocols, especially among patients with multiligamentous knee injuries. The secondary purpose was to compare outcomes between patients enrolled in the automated follow-up system and those enrolled in a traditional follow-up protocol.
Materials and Methods
This study received institutional review board approval. The authors retrospectively reviewed follow-up data from a total of 195 patients who underwent ligamentous knee reconstruction or repair from 2012 to 2017 by a single surgeon (E.H.A.) at their institution. These patients were enrolled in either a follow-up protocol using traditional methods or a follow-up protocol using automated electronic methods. Traditional follow-up methods included phone calls, emails, and in-clinic surveys by clinical staff. If a call was unanswered, a voicemail message was left. The clinical staff documented the duration of calls. For the automated follow-up method, SOS was used. Surgical Outcome Systems follow-up included electronic surveys automatically sent via email at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Patients were also required to complete a pretreatment survey on SOS. Patients were excluded for being Spanish-speaking only (6 patients), deceased at the time of survey (2 patients), unable to physically answer survey questions (1 patient), incarcerated (2 patients), and status post-total knee replacement (total knee arthroplasty) after ligamentous reconstruction (1 patient). Of the remaining 183 patients, 36 were identified as having multiligamentous knee injuries and 16 were identified as being enrolled in both protocols. A total of 128 patients were enrolled in the traditional follow-up group and 55 in the SOS follow-up group. A total of 29 multiligamentous knee injury patients were enrolled only in the traditional follow-up protocol and 7 were enrolled in SOS. All 7 of those patients were also enrolled in the traditional follow-up protocol. A patient was identified as a “successful contact” if he or she completed a survey at 6 or more weeks postoperatively.
Follow-up data via the traditional method were originally collected for other studies involving ligamentous knee injuries. Postoperative survey questions via the traditional follow-up method included the Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and International Knee Documentation Committee score. Surgical Outcome Systems surveys included KOOS, visual analog pain scale score, Veterans RAND 12 Item Health Survey, and Single Assessment Numeric Evaluation knee score. Because only KOOS values were obtained in both survey methods, the authors could only compare those values. Any complications, such as patellofemoral pain syndrome, symptomatic graft or hardware, or arthrofibrosis, were noted.
Patients with a multiligamentous knee injury were analyzed separately from those who did not have a multiligamentous knee injury. For the PROM analysis, the authors only included surveys that were completed between 3 months and 1 year postoperatively. This time period was chosen because patients enrolled in automatic electronic follow-up were enrolled at a later time point and thus would have less time to recover from their injury and surgery, which would likely impact PROMs. A comparison of proportions was performed between patient follow-up compliance and complication incidence for each group. A 2-tailed unpaired Student's t test was used to compare subjective outcome scores. Statistical significance for all comparison methods was set at P<.05. Values, when available, were expressed as mean±standard deviation.
Results
Of the 183 patients, 139 (76.0%) responded to any form of follow-up. Of the 36 patients who underwent multiligamentous knee reconstruction, 25 (69.44%) responded to any form of follow-up. A total of 44 SOS patients (80.00%) responded to a survey at least 6 weeks postoperatively, and a total of 95 traditional method patients (74.22%) responded at any time point (Table 1 ). With subgroup analysis of multiligamentous knee reconstructions, 6 SOS patients (85.71%) responded and 19 traditional method patients (65.52%) responded (Table 2 ). The difference in response percentages was 5.58% (P=.4028) between the 2 overall groups and 20.19% (P=.3048) between the multiligamentous knee injury groups. Mean follow-up was 7.0±2.88 months for the SOS group and 9.3±2.30 months for the traditional follow-up group, which was a significant difference (P=.038).
Table 1:
Total Patients Enrolled in Either Follow-up Protocol
Table 2:
Multiligamentous Knee Injury Patients Enrolled in Either Follow-up Protocol
In the traditional follow-up group, 677 calls were documented; of these calls, 196 (28.95%) were answered. The total duration of the documented answered calls was 883.54 minutes, and the median call time was 12±8.24 minutes. The longest documented call time was 51 minutes, and the shortest documented call time was 5 minutes.
Of the 16 patients enrolled in both the traditional follow-up protocol and the SOS follow-up protocol, 13 (81.25%) responded to any SOS follow-up, whereas 6 (37.50%) responded to any traditional follow-up. Of the 13 patients who responded to any SOS follow-up, 4 (30.77%) had responded to the most recent survey. Eight patients responded to only SOS follow-up, which is a 133% increase from the number of contacts from a traditional follow-up protocol. Finally, of the 16 patients, 5 (31.25%) responded to both forms of follow-up.
Eight non–multiligamentous knee injury traditional follow-up and 23 non–multiligamentous knee injury SOS follow-up patients were eligible for analysis. Two multiligamentous knee injury traditional follow-up and 2 SOS follow-up patients were eligible for analysis. Sex, age, and body mass index of patients considered for analysis were similar between each group (Table 3 ).
Table 3:
Sex, Age, and Body Mass Index of Patients Eligible for Score Analysis in Both Follow-up Protocols
The KOOS composite and subscale scores were not significantly different between non–multiligamentous knee injury patients in either follow-up protocol. Traditional follow-up patients had slightly higher KOOS pain, symptoms, and activities of daily living subscores than SOS follow-up patients. However, both other subscores were higher in the SOS follow-up patients. The KOOS pain, symptoms, and activities of daily living scores were worse in SOS multiligamentous knee injury patients than traditional follow-up multiligamentous knee injury patients, but this was not statistically significant (Table 4 ).
Table 4:
Comparison of Knee Injury and Osteoarthritis Outcome Scores Between Patients Enrolled in Either Follow-up Protocol
No SOS patients had any reported complications. Non–multiligamentous knee injury traditional follow-up patients had 4 incidences of arthrofibrosis (3.12%), 2 incidences of symptomatic hardware (1.56%), and 4 incidences of patellofemoral pain syndrome (3.12%). Of the non–multiligamentous knee injury patients included in the analysis, 1 had symptomatic hardware (12.5%) and 1 had patellofemoral pain syndrome (12.5%). One multiligamentous knee injury traditional follow-up patient (50%) had patellofemoral pain syndrome. When complications were compared between both overall non–multiligamentous knee injury patients and those eligible for PROM analysis, complications were significantly greater in the traditional follow-up group (P=.034 and P=.015).
Discussion
The SOS follow-up resulted in a 20.19% increase in follow-up compliance among patients with multiligamentous knee injuries and a 5.58% increase in overall follow-up compliance. Although the authors' data did not show statistical significance, the SOS protocol did show an improvement in follow-up compliance with significantly less staff. This increase in follow-up compliance was surprising because the SOS patients had significantly shorter overall follow-up (7.0±2.88 vs 9.3±2.30 months), given its later introduction into the authors' clinical practice. In this way, SOS may be beneficial for research teams with limited access to research volunteers for data collection. There may also be some benefit in combining SOS with a traditional follow-up protocol to obtain PROMs from patients who may be difficult to contact. As seen with the current patients enrolled in both survey methods, the addition of SOS resulted in 81.25% total follow-up contact, despite 40% of those patients having multiligamentous knee injuries. The trend of improved follow-up has been reported by others. One group incorporated an automated system to improve follow-up among patients with osteoporosis-related fragility fractures, finding a patient follow-up rate of 60.19% compared with 14.29% among patients who did not enroll in the automated system. 2
The KOOS values for non–multiligamentous knee injury patients were not significantly different despite a significantly shorter time from surgery to follow-up among SOS patients. This could be due to an increase in patient compliance with postoperative instructions as a result of consistent postoperative contact via email shortly after the procedure, which may have ultimately facilitated a faster recovery from surgery. On the other hand, the traditional follow-up patients were not contacted about PROMs until a minimum of 7 months postoperatively.
Unfortunately, due to the authors' strict exclusion criteria, only 2 multiligamentous knee injury patients in each follow-up protocol were eligible for analysis. Although the multiligamentous knee injury SOS patients had worse KOOS pain, symptoms, and activities of daily living scores than those enrolled in the traditional follow-up protocol, the samples were too small to derive any statistical significance. The authors suspect that the differences in KOOS values simply reflect improvement with time from surgery, as both multiligamentous knee injury SOS patients had shorter time from surgery to follow-up than the multiligamentous knee injury traditional follow-up patients.
Interestingly, the authors found that patients enrolled in the traditional follow-up protocol had significantly more complications than those enrolled in SOS (P=.034). Of these, 40% were patellofemoral pain syndrome and another 40% were arthrofibrosis. This suggests that enrollment in an automated follow-up system may be associated with postoperative rehabilitation compliance, as post-anterior cruciate ligament reconstruction patellofemoral pain syndrome has been associated with quadriceps weakness and rehabilitation difficulties, both of which can be remedied with physical therapy. 9,10 However, complications, such as patellofemoral pain syndrome and symptomatic hardware, may present several months after surgery. Thus, patients in the SOS group may simply not have had enough time for these complications to manifest.
When considering the traditional follow-up protocol, the main reasons for noncompliance included, but were not limited to, incorrect phone numbers and patients being unable to complete surveys at the time of contact. There was a notable amount of variation in duration of the documented call times (range, 5–51 minutes). Because, unlike the traditional follow-up method, SOS does not require an intermediate party to read questions and answers to the patient, the authors assume that the survey time may be significantly reduced. Moreover, the authors' data also do not account for undocumented calls and time involved with unanswered calls, which may be far greater than the time spent in calls because less than 30% of calls made were answered. Thus, SOS may greatly reduce the time burden of collecting PROMs and increase compliance with patients who may be “too busy” to answer phone calls.
The major limitation of this study was nonrandomization, which is partially due to the novelty of SOS in the authors' clinical practice. Surgical Outcome Systems was incorporated several months after the initial recruitment of patients for other studies involving ligamentous injuries, preventing the authors from randomizing patients between follow-up methods. As a result, the time from surgery was substantially greater in the traditional follow-up group (1 to 5 years postoperatively) vs the SOS follow-up group (6 weeks to 2 years postoperatively). This variation greatly affected the authors' ability to accurately compare outcome scores. The authors attempted to minimize this discrepancy in their analysis by only including surveys between 3 months and 1 year postoperatively.
The authors' PROM analysis was primarily limited by the small sample and use of only KOOS subscores for analysis, as the SOS platform does not provide KOOS composite scores. The inability or difficulty in editing data-entry fields within automated electronic follow-up platforms is mostly platform dependent because other platforms may possess different data points or intervals as part their respective interfaces. 5
Finally, SOS was the only form of automated follow-up system used in this study. Thus, any conclusions that could be drawn from its use in the enrolled patient group may not have direct implications for other forms of automated follow-up. Additional automated systems and platforms should also be compared; however, this may be limited by their commercial availability. Future studies should also examine SOS follow-up at longer time intervals, as patient compliance may change as time from surgery increases. The predefined time points of SOS are also currently limited to a maximum of 2 years. Further studies should also include randomization, a larger sample, and the consideration of additional patient parameters (eg, age, race, sex, socioeconomic status, and prior surgical treatments).
Overall, automated electronic follow-up systems, such as SOS, have a great potential to improve the ease of obtaining PROMs. A group examining long-term anterior cruciate ligament reconstruction outcomes in China briefly mentioned that incorporating smartphone applications in their follow-up protocol had greatly increased their ease of obtaining follow-up information. 11 At 10 years postoperatively, they achieved more than 80% follow-up despite contact address changes and geographic limitations. This suggests that newer follow-up methods may especially benefit tertiary referral centers, which often treat patients who live far from the hospital.
Conclusion
Electronic follow-up platforms, such as SOS, have the potential to significantly improve patient follow-up compliance and the efficiency of PROM collection and analysis, with minimal limitations and lower burden on clinicians and staff. This improvement could be even more significant for patient populations with traditionally poor follow-up compliance, such as the multiligamentous knee injury population. Although PROMs were not significantly different between patients enrolled in either follow-up group, the authors noticed significantly fewer complications among patients enrolled in the automated electronic follow-up system. This suggests that the automated electronic follow-up may even have the potential to improve rehabilitative compliance. With the dramatic increase in accessibility to technology such as smartphones and tablets, cloud-based registries such as SOS offer patients a greater opportunity to remain in contact with providers to track their recoveries and provide data for future research.
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Table 1
Total Patients Enrolled in Either Follow-up Protocol
Follow-up Protocol
