0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

Patient-Reported Problems After Office Procedures FREE

Eleni Linos, MD, DrPH1; Mackenzie R. Wehner, MPhil1; Dominick L. Frosch, PhD2; Louise Walter, MD3; Mary Margaret Chren, MD1
[+] Author Affiliations
1Department of Dermatology, University of California, San Francisco
2Patient Care Program, Gordon and Betty Moore Foundation
3Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco
JAMA Intern Med. 2013;173(13):1249-1250. doi:10.1001/jamainternmed.2013.1040.
Text Size: A A A
Published online

Even though 83 million procedures are performed in medical offices in the United States each year,1 patients are only rarely asked about problems they experience after these procedures. This oversight may highlight a key opportunity to improve health care because patient self-reporting is known to offer both clinical and scientific value.2,3 To inform decision making for office-based procedures, we studied patients treated for nonmelanoma skin cancer (NMSC), the most common malignant neoplasm,4 which is most often treated with an office procedure.

We conducted a prospective cohort study of 886 consecutive patients with basal or squamous cell skin cancer who completed an in-person questionnaire before treatment. Office treatments for NMSC included Mohs surgery, excision, and destruction with cryotherapy or electrodessication and curettage. At 3, 12, and 18 months and annually up to 5 years after treatment, patients were asked “In your opinion, have there been any complications of your treatment during or after the treatment itself?” Those who reported a complication were asked to describe it and to rate its severity using a Likert-like scale ranging from minimally to extremely serious. Descriptions were classified by 2 independent clinicians into the following 2 categories: (1) medical complications (bleeding, infection, pain, swelling, poor wound healing, numbness or itching, problem with motor function, and/or allergic reaction to bandages or antibiotics) and (2) nonmedical problems (problems with scar or appearance, need for additional treatment, administrative problems, or other). Overall, 83% of patients responded to at least 1 questionnaire. We calculated complication rates as the number of patients of our baseline cohort who reported a complication at any time point, making the conservative assumption that all nonresponders, including patients lost to follow-up, did not experience complications. Two clinicians reviewed all medical charts for complications up to 5 years after treatment.

Cohort patients were typical of patients with skin cancer nationwide (Table). More than a quarter of patients (236 of 866 [27%]) reported a problem after treatment, and 14% overall described medical complications (Figure). For example, 7% experienced pain, numbness, or itching; 5% had problems with wound healing; 5% had infection or swelling; 2% had bleeding; and 2% had problems with motor nerve function. Overall, 10% of all patients described problems that were “moderate, very, or extremely serious.” Complications were noted by the clinician in 3% of patients’ medical charts.

Table Graphic Jump LocationTable.  Characteristics of 866 Patients With NMSC Who Responded to Baseline Questionnaire and Were Followed up for 5 Years After Treatment
Place holder to copy figure label and caption
Figure.
Types of Complications Described by Patients Treated for Nonmelanoma Skin Cancer (NMSC)

The “Administrative” category includes problems with insurance, travel or telephone contact with clinic. The “Other” category includes patient responses reported by less than 1% sample, for example, allergic reactions, anxiety, problems relating to postoperative period (eg, “not able to wear glasses because ear flap attached to scalp,” “have to wear a dressing over my mouth, need to drink with a straw,” “can’t swim anymore and I was a competitive swimmer”).

Graphic Jump Location

Our findings show that more than a quarter of patients perceived complications after a common office procedure, treatment for skin cancer, and that 10% of patients regarded their problems as at least moderately serious. We also found a notable discrepancy between patients’ perceptions and clinicians’ reports of complications after office procedures. In fact, patients’ problems were only rarely documented in the medical record. The reasons for our findings are unclear. Clinicians may be unaware of patients’ experiences, or they may decide that these problems do not warrant documentation as complications in the medical chart. Patients may overstate problems (eg, scars) that are, to clinicians, largely unavoidable. Overall, this discrepancy suggests that patients may have a broader view of what it means to have complications after procedures, including nonmedical problems (eg, problems with insurance or follow-up appointments) and expected consequences of a procedure (eg, scars or need for additional treatment).

Medical care is probably improved if clinicians understand patients’ experiences.2,5 Such understanding may identify adverse outcomes that can be prevented or may highlight situations in which educating and preparing patients may more closely align their expectations with likely outcomes. Knowledge about patients’ experiences after procedures can also improve decision making by future patients by providing clear data about prognosis. Because office procedures are among the most common medical interventions, efforts to improve their outcomes are important. We propose that these efforts can be strengthened by asking patients directly about their experiences.

Corresponding Author: Eleni Linos, MD, Department of Dermatology, University of California San Francisco, 2340 Sutter St, N421, Box 0808, San Francisco, CA 94143-0808 (linose@derm.ucsf.edu).

Published Online: May 20, 2013. doi: 10.1001/jamainternmed.2013.1040

Author Contributions: Drs Linos and Chren had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Linos, Wehner, and Chren.

Acquisition of data: Chren.

Analysis and interpretation of data: Linos, Wehner, Frosch, Walter, and Chren.

Drafting of the manuscript: Linos.

Critical revision of the manuscript for important intellectual content: Linos, Wehner, Frosch, Walter, and Chren.

Statistical analysis: Linos.

Obtained funding: Linos and Chren.

Administrative, technical, and material support: Linos and Wehner.

Study supervision: Linos and Chren.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Amy J. Markowitz, JD, provided editorial assistance; Sarah Stuart, BA, assisted with data management; and John Boscardin, PhD, and Rupa Parvataneni, BA, assisted with statistical analysis.

Hsiao  CJ, Cherry  DK, Beatty  PC, Rechtsteiner  EA.  National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. November 3, 2010;(27):1-32.
PubMed
Basch  E.  The missing voice of patients in drug-safety reporting. N Engl J Med. 2010;362(10):865-869.
PubMed   |  Link to Article
Basch  E, Jia  X, Heller  G,  et al.  Adverse symptom event reporting by patients vs clinicians: relationships with clinical outcomes. J Natl Cancer Inst. 2009;101(23):1624-1632.
PubMed   |  Link to Article
Centers for Disease Control and Prevention. Skin Cancer Statistics. December 12, 2012; http://www.cdc.gov/cancer/skin/statistics/. Accessed January 10, 2013.
Patient-Centered Outcomes Research Institute (PCORI) website. http://www.pcori.org/about/mission-and-vision/. Accessed January 2013.

Figures

Place holder to copy figure label and caption
Figure.
Types of Complications Described by Patients Treated for Nonmelanoma Skin Cancer (NMSC)

The “Administrative” category includes problems with insurance, travel or telephone contact with clinic. The “Other” category includes patient responses reported by less than 1% sample, for example, allergic reactions, anxiety, problems relating to postoperative period (eg, “not able to wear glasses because ear flap attached to scalp,” “have to wear a dressing over my mouth, need to drink with a straw,” “can’t swim anymore and I was a competitive swimmer”).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Characteristics of 866 Patients With NMSC Who Responded to Baseline Questionnaire and Were Followed up for 5 Years After Treatment

References

Hsiao  CJ, Cherry  DK, Beatty  PC, Rechtsteiner  EA.  National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. November 3, 2010;(27):1-32.
PubMed
Basch  E.  The missing voice of patients in drug-safety reporting. N Engl J Med. 2010;362(10):865-869.
PubMed   |  Link to Article
Basch  E, Jia  X, Heller  G,  et al.  Adverse symptom event reporting by patients vs clinicians: relationships with clinical outcomes. J Natl Cancer Inst. 2009;101(23):1624-1632.
PubMed   |  Link to Article
Centers for Disease Control and Prevention. Skin Cancer Statistics. December 12, 2012; http://www.cdc.gov/cancer/skin/statistics/. Accessed January 10, 2013.
Patient-Centered Outcomes Research Institute (PCORI) website. http://www.pcori.org/about/mission-and-vision/. Accessed January 2013.

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles