Long-term patient follow-up after surgery for orthopedic trauma is a known challenge.
Researchers at Brigham and Women’s Hospital recently demonstrated that the post-surgical global period is a critical timepoint influencing follow-up rates, and follow-up at six months was lowest for patients on Medicaid. Michael J. Weaver, MD, chief of the Orthopaedic Trauma Service at Brigham and Women’s Hospital, Abhiram R. Bhashyam, MD, PhD, a hand and upper extremity surgeon in the Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues report the details in BMC Musculoskeletal Disorders.
The team retrospectively studied 328 adults treated at three Harvard-affiliated level 1 trauma centers over four months in 2018. Eligibility criteria were an isolated extremity fracture and inpatient treatment following admission from the emergency department.
The patients were expected to have at least six months of follow-up. The post-surgical global period for the types of surgeries involved was 90 days.
Likelihood of Follow-up
Follow-up rates decreased significantly between the following:
- Six-week and six-month postoperative visits (68% vs. 48%; P<0.0001)
- Six-week and three-month visits (68% vs. 59%; P=0.004)
- Three-month and six-month visits (59% vs. 48%; P<0.001)
- Six-month and one-year visits (48% vs. 31%; P<0.0001)
Predictors of Follow‑up
Injury/fracture type was not related to the length of follow-up. Instead:
- Age was the only significant predictor of follow-up within the global period at two weeks, six weeks, or three months (OR, 0.96 per year; P=0.004)
- After the global period, Medicaid insurance predicted a decreased likelihood of follow-up at six months (compared with Medicare; OR, 0.27; P=0.02)
The insurance factor most strongly correlated with six-month follow-up was the out-of-pocket maximum, although the effect size was smaller than for demographic- and treatment-related factors.
What Clinicians Can Do
It’s a particular concern that the follow-up rate was significantly lower after the 90-day global period for patients who were expected to follow-up for six months. After periarticular injuries, weight-bearing often doesn’t begin until six to 12 weeks postoperatively, and radiographic union of fractures takes three to six months. It’s important for insurers to cover postoperative care for a longer period.
Although structural change is needed, individual clinicians may be able to help increase healthcare equity after orthopedic trauma. Patients need to be educated about the expected progression of recovery, the signs of complications, and the benefits of follow-up visits. Increasing the availability of virtual visits for routine care may also encourage follow-up, especially among older patients.