Discussion
With the recent centralization of healthcare in Canada, many patients and their families must travel considerable distances to access specialized care. Our results confirm the immense distance travelled by some patients and their families. However, what was unknown was whether families from out of town were offered the same rates of follow-up, and if they were able to attend their appointments. Non-MUC patients were offered fewer follow-up appointments; however, the attendance rates were the same. There was no difference in complications noted, suggesting that reduced follow-up might not have diminished patient care. Severity of illness was not captured during data collection. Thus, it was unknown as to whether or not follow-up differed depending on the severity of the condition that the patient was referred for. Our study focused on patients having surgery with an anticipated shorter length of stay (<48 hours). It did not include patients with major neonatal surgical conditions and congenital malformations for whom we would routinely offer follow-up. We sought to assess if patients from nearby and far away having undergone smaller procedures had a difference in complications and in follow-up compliance. Follow-up by the surgeon for these conditions/procedures could be eliminated, thus saving the healthcare system, and patients and their families, valuable time and money.
The indication for offering patients a follow-up appointment in our cohort was not documented in the medical records. Routine criteria for the need of a follow-up visit are not currently in place (see table 3). Offering a follow-up appointment is a decision made based on surgeon preference and experience, taking into consideration the complexity of the procedure and individual patient factors. Follow-up may in fact not be required for routine operations. And surgeons are not mandating follow-up. Therefore, they are accepting decreased personal remuneration over patient inconvenience, while ensuring patient safety. Patients who were deemed to not require a follow-up at WCH were advised instead to follow-up with their referring physician or local healthcare provider as needed. However, it is currently unknown if most referring physicians are comfortable with managing postoperative follow-up of simple pediatric surgical conditions given appropriate instructions.
A study from Alberta, Canada, found that overall 58% of pediatric general surgery patients attended a postoperative follow-up appointment.15 Patients living closer to the hospital had an approximately twofold greater chance of attending follow-up, and those farther away had a 60% decreased likelihood of attending, which is not in keeping with our findings. Often, postoperative complication rates are low and may be managed by local primary healthcare providers without the need for specialist assessment, as found in our study, as well as in the Alberta study.15
Pediatric urology patients in Quebec, Canada, travel a mean of 70 km one way for their clinic appointments, but those from farther away can travel in excess of 1000 km.16 Provincial monetary reimbursement is available for travel greater than 200 km for medical care. Our patient population can also receive subsidized medical transportation for care unavailable in their community, or if their required specialist care is not available within 100 km from their home.12–14 From our records, the number of patients in our cohort that use available provincial monetary support for their medical travel is unknown but is likely to include all of our non-MUC patients from Nunavut, Northern Ontario, Northern Manitoba, and some from the Interlake-Eastern geographic region of Manitoba. However, costs still arise in excess of the amount funded and do not cover days of missed school and work. One recent Canadian study found that 75% of families had one or more parents absent from half a day or more of work to attend their child’s surgical appointment.8 Gimon et al found that postoperative follow-up visits for pediatric surgery patients after common surgeries were likely of little need and posed great financial burdens to patients, families, and the system.15
Surgeons and their patients could use other methods of follow-up to document complications and to track patient outcomes. One possible solution for reducing financial costs and school and employment absenteeism is telemedicine or e-medicine follow-up options,8 16–18 although minimal research exists with respect to telemedicine in pediatric surgery.16 In other surgical specialties using telemedicine, patient’s families and surgeons have reported satisfaction with the system along with a decreased financial burden.8 Telehealth and e-consult are both available for use by physicians in Manitoba; however, there is no mention of their use in our studied population. This is likely due to patient preference for in-person follow-up appointments, and inconveniences associated with telehealth use in Manitoba, such as requiring a special room and equipment, and to lack of remuneration for surgeons. However, in examining our data, there were no unexpected findings or anything else of intrinsic value to the patient or family that arose during our in-person follow-up appointments, thus questioning the need for these appointments following an uncomplicated and short-duration surgery.
Another solution is the creation of ‘outreach’ clinics, where the surgeon travels to remote communities to provide follow-up in person.19 There is scant Canadian literature with regard to surgical outreach clinics. Bernstein describes his experience in setting up and running a rural neurosurgery outreach clinic. He identified a need due to the large distances between surgical specialties and the communities they served.19 Bernstein highlights the following advantages for the surgeon, patients, and local physicians: providing valuable care for underserviced areas, networking in these areas, and avoiding long trips to appointments, which directly results in patient cost savings and allows local physicians to provide this group of patients with the specialist care they need.19
A British systematic review focused on outreach clinics in primary care,20 highlighting improved patient experiences and access to care in the outreach clinic setting, along with a greater patient preference for outreach clinics compared with the hospital-based equivalent. O’Brien et al ran a randomized controlled trial looking at specialist outreach clinics in the field of orthodontics and similarly found a higher patient preference towards attending an appointment at an outreach clinic.21 Lastly, Haynes et al found that offering an outreach clinic for cataract surgery provided patients with a shorter travel time and less costly journey, along with significantly greater satisfaction.22 These studies have found similar advantages and highlights of outreach clinics across various medical and surgical specialties. However, outreach clinics may result in an increase in physician workload and increased physician-associated financial costs.19
Along with telehealth and e-consult, remote follow-up was not used in our patient cohort. However, given their advantages and the desire from patients who must travel great distances to continue seeking ongoing care, there are plans to implement them as follow-up modalities for use by our pediatric surgeons. The use of telemedicine and remote follow-up would also be recommended for chronically ill children in order to increase patient satisfaction and ensure a high level of compliance. Of note, four of our patients (3.3%) received a phone call regarding their surgical pathology as it was deemed that an in-person follow-up was not required (table 3). Currently, telephone calls are not commonly used as another means of follow-up for patients living farther from our center, nor is email communication. However, a study by McVay et al at the Arkansas Children’s Hospital demonstrated that postoperative follow-up performed using a structured telephone protocol was in fact a positive substitute for in-person follow-up.23 They implemented their protocol in select pediatric surgical procedures, such as herniorrhaphy, non-perforated laparoscopic appendectomy, circumcision, dermatological excisions, laparoscopic cholecystectomy, and ingrown toenails. They noted multiple advantages of this follow-up modality, namely not having to miss school and work for travel for an appointment that was usually straightforward and did not yield anything of significance, decreased costs and use of healthcare services, and a decline in clinic no-show rates. This especially allows for more time being spent on new consults or complicated cases. Their telephone follow-up was found to be favored with 90% family satisfaction, and none of them asked for an in-person visit.23 The use of telephone follow-up in pediatric inguinal hernia repair had previously been documented as practical and efficient.24 Furthermore, Fischer et al compared rates of postoperative follow-up between in-person visits and telephone calls following select pediatric general surgery procedures and found better rates in the phone call group, along with a 93% satisfaction.25 A reduction in institutional costs, along with family and patient financial savings, was documented.25 Telephone follow-up calls are therefore an effective alternative modality that will allow for family-centered patient care and appropriate follow-up attendance.
Telemedicine and remote postoperative follow-up have become very important modalities during the recent COVID-19 pandemic. As a result, telemedicine, including videoconference calls, which allow the surgical provider the ability to perform visual wound inspections, is being used more often in our center, and will likely continue to be used.
Limitations to this study are its retrospective nature and the lack of complete documentation within the pediatric surgical charts. Multiple patients had a postoperative follow-up appointment with no documented correspondence; as such, their postoperative course and potential complications were unknown. Many patients who were not offered a postoperative follow-up appointment did not have documentation with regard to why. Thus, it is unknown if this was due to distance and travel, surgeon or patient preference, or the type of procedure the patient underwent.