Need for post-operative outpatient appointments after discharge following cervical spinal surgery - a narrative review

The initial search was performed in Pubmed using the concept terms from Table 1 combined with AND operator. Additionally, the search was also performed with the concept terms from Table 1 in CENTRAL and EMBASE databases. All duplicates that were encountered from the three databases were subsequently removed. Only study designs that compare a post-operative outpatient clinic appointment study group with one or more intervention(s) were included. All studies irrespective of the type of intervention(s) were included in the search strategy. Additionally, the papers included patient reported outcome measurements, complication rates, patient satisfaction or quality of care as outcome measurement.

In the search strategy four concept terms were used, respectively spinal surgery, post-operative appointment, outpatient and Quality of Care (Table 1), to identify all studies. Search terms of these categories were combined with the AND operator. The search strategy was verified by the medical librarian from the Radboud university medical center. Only studies published in 2017 or the preceding 10 years were included in order to get results that are not outdated.

First, a title and abstract selection was performed by three independent observers (3 observers: KdB, EvL and FA) on all studies that were identified with the search strategy. The selected papers were included according to the in-and exclusion criteria (Table 2). Papers were selected for further review in case at least one of the observers selected the abstract. In case one observer selected the abstract and the others did not, the abstract was as yet included in the second step.

In the second step full text papers of the selected studies from the abstract selection were screened by the same three observers (KdB, EvL and FA). The same in- and exclusion criteria were used with additional main outcome measurements (Table 3). Studies were included for further review if all three observers selected the full text paper. If only one of the observers selected the paper final consensus between the observers had to be reached about including the study or not. Finally, the reference lists of the selected papers were screened for additional papers for selection by KdB.

In our experience the post-operative follow-ups can be more effective, by creating a more targeted care for patients. Unfortunately, any evidence suggesting any benefit or disadvantage for patients is currently not available. Moreover, no subpopulations could be identified to distinguish in which patients the follow-up can be replaced by an alternative, or be omitted, and who benefits from these visits. Usually, patients contact our department when in doubt about the normal post-operative course. Additionally, if adequate information about the post-operative course is pre-operative provided there is not much information left to discuss at the outpatient clinic appointment. Moreover, against the backdrop of value-based healthcare the post-operative follow-up might be considered low value care since it does not contribute to the quality of care, while the post-operative visits require significant healthcare resources. Neurosurgery consultants cannot see new patients if these spots are taken by post-operative patients consuming expensive resources. Additionally these consultations may result in unnecessary diagnostics and may consequently be harmful for the healthcare system which can spend resources only once. It might even be considered as systematic overuse, considering the overlap with published characteristics of overuse procedures [12]. In all, there should be good quality evidence for the need of the post-operative outpatient follow-up after spinal surgery to continue this practice, considering the potential harmful effects on the patients and healthcare system.

Currently it is common using digital applications as a substitute for medical interventions in post-operative follow-ups. The study of Debono B. et al., replaced the standard outpatient post-operative appointment for a mobile application and a telephone call the first post-operative day [11]. They found an increase in patient satisfaction without an increase in complications or decrease in quality of care. Although interventional studies with mobile applications show promising results, the development of applications and studies with multiple study groups are often very expensive and do not necessary increase value of healthcare nor reduce over usage [6]. Less expensive and more elementary alternatives have not been studied for post-operative outpatient follow-ups after spinal surgery. Omitting the post-operative outpatient clinic appointment or replacing it with a telephone consultation by a paramedic might be equal to a mobile application in efficiency and patient satisfaction without extra expenses. These alternatives should be investigated before implementation of the more expensive methods.

In other surgical specialties, the discussion about effective logistics in the outpatient clinic follow-up is also subject of debate. Outpatient clinic resources are increasingly demanding and require more effective usage. Bromage et al. studied the urology outpatient follow-up visits and concluded appropriateness and timing of outpatient follow-ups is necessary for more efficient usage of outpatient follow-up recourses [13]. Alternatives for post-operative follow-ups for benign pathology results are being explored to create more time for outpatient clinic visits for new patients. About 50% of the attendances could be avoided for recurrent patients with normal test results, with the potential to optimize outpatient clinic resources [14]. Both Bromage et al. and Gurjar et al. use the earlier mentioned elementary alternatives to create a more efficient outpatient clinic visits. In this saved time, consultants have more time for patients who require more attention, research, education and training their surgical skills for example. The implementation of more effective outpatient follow-ups is an elegant strategy to reduce healthcare resources, thereby creating high value healthcare.

More efficient utilities at the outpatient clinic can not only be beneficial for the quality of care, patient satisfaction and hospital or healthcare costs, but also for patients and possible decreasing the economic burden on society. By implementing (digital) alternatives or skipping the outpatient post-operative appointment after surgery, the patient does not have to travel to the clinic, cancel work or arrange a day-care provider. These non-medical considerations must also be taken in account as a possible positive side effect in an alternative for the post-operative outpatient appointment after spinal surgery. It is also important to consider what makes it worthwhile to attend the outpatient clinic for a patient. Smith and Sanderson concluded that the consultations lasting more than 10 min, receiving advice and having been reassured are important aspects for patients in outpatient consultation [15]. Reassurance, as mentioned by Smith and Sanderson, about the normal post-operative course or doubts about the presence of complications and questions could be an important necessity of the post-operative outpatient consultation for patient satisfaction. However, this study was performed in 1992 when the current communication possibilities were not available. The modern techniques facilitate management of expectations, consultation for minor problems and reassurance. Although skipping the regular outpatient clinic appointment after spinal surgery and its replacement by alternative methods using modern communication technology can be efficient, it is currently unclear if this is in the best interest for the patient satisfaction and value of healthcare.

Although the fore mentioned arguments favor omitting the outpatient appointment, the disadvantages and potential harmful effects should also be explored. Determinants of patients who might benefit from an outpatient appointment after ACD, ACDA or ACDF should be identified. High risk patients for post-operative complications should be identified and may need a post-operative follow-up. Adequate discharge education of patients about the normal post-operative course and complications enhances the participation in their healthcare management [16]. Additionally, mismatch in expectancy of patient and doctor in different healthcare domains could lead to overrating low value healthcare [6]. Therefore, adequate preoperative information and post-operative discharge education of patients is essential. High risk patients and patients susceptible for misinterpretation of information at discharge might benefit from a post-operative outpatient appointment. Alternatively, the impact on performance of the surgeon by omitting outpatient post-operative appointments should also be explored. There is a difference in the need for post-operative outpatient appointments for trainees and non-spine specialized neurosurgeons compared to experienced spinal surgery consultants for whom this is a routine procedure. The effect of missing feedback or reassurance from patients in the residual symptoms from degenerative disease, the technique used or indication might be essential for non-spine specialized surgeons, especially in training. Besides the patient and surgeon related aspects, there are also differences in society, cultural and level of healthcare to consider. The quality of care in a highly centralized and specialized healthcare system, were omitting might be opportune, can differ greatly between countries or even regions. Lastly, possible problems that could be detected and managed at the standard post-operative consultation, such as wound problems or postoperative pain, could be missed when omitting these visits. The question remains if the visits are necessary for detecting such problems or that alternatives that are suitable can be found. Considerations about omitting or implementing alternatives for postoperative outpatient appointments the aforementioned aspects need to be taken into account.