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”).
Linos E, Wehner MR, Frosch DL, Walter L, Chren MM. Patient-Reported Problems After Office Procedures. JAMA Intern Med. 2013;173(13):1249-1250. doi:10.1001/jamainternmed.2013.1040
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.
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 (firstname.lastname@example.org).
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.