Research Award Details

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Remote Follow-up in the Post-operative care of Surgically Treated Supracondylar Humerus Fractures - A Quality Initiative

Grant Recipient: Christopher Makarewich, MD

Co-Investigators:
Institution:
Univ of Utah, Dept. of Orthopaedics
Presentations & Publications:
Further Funding:
Additional Information:
Study Aims:  Supracondylar humerus fractures are an extremely common injury in school aged children, making them an ideal model for quality improvement projects.  In our practice alone, we treat approximately 350 of these fractures per year surgically with closed reduction and percutaneous pinning.  Although there is some variability, after surgical fixation most surgeons will see these patients back in clinic for removal of pins at 3-4 weeks post operatively followed by one additional visit at about 8 weeks post op for a range of motion check.  Our project aimed to limit the number of in-office visits by conducting this last motion check remotely.  Our protocol was such that at the postoperative visit during which the pins are removed, the family will be provided with instructional materials for demonstrating a range of motion check to be delivered to our office by means of pictures or video through a secure email system and/or mail. After review by the treating physician, the patients was then transitioned to as needed follow-up, referral for physical therapy, or called back in to the office for an in person visit as appropriate.  Inclusion criteria were patients with supracondylar humerus fractures treated with closed reduction and percutaneous pinning. Exclusion criteria were be patients with neurovascular injury, additional ipsilateral injury, and open reduction at initial surgery.  The primary outcome was be the percentage of patients enrolled who are able to perform this last motion check visit remotely.  We hope that this project will limit the number of in office visits, reducing costs to the healthcare system as well as limiting cost and travel inconvenience for families.  This is of particular importance in the rural communities of our catchment area who travel long distances for follow-up. 

This project aligns well with POSNA’s mission of improving care for children, particularly the Quality, Safety and Value Initiative.  Reducing costs in healthcare while maintaining or even improving patient outcomes and satisfaction is a primary focus of our practice, and we believe this project will be an important addition.  This initiative will continue to not only decrease costs to the hospital but will be a service to the families we treat to decrease their travel burden and cost while still providing excellent care.  We hope that this can serve as a model for implementation in other healthcare systems as well.   
Research findings:  The primary outcome was the percentage of patients enrolled who are able to successfully perform this last motion check visit remotely. 

Enrollment and Early Data 
Over the grant period, we enrolled 25 patients.  Of these, 22 have met their final follow up time point, and 3 have not yet met their final follow up time point.  Of the 22 who have met their final follow up, 18 have successfully completed their telehealth visit, while 4 have been lost to follow up / did not return or present for their motion check.  This 18% loss to follow up is lower than our internal history follow up for a motion check after supracondylar humerus fracture pin pull of about 39%. 

None of the 18 patients required referral to physical therapy or a subsequent in person visit with our office. 

Regarding satisfaction, all patients reported excellent or good satisfaction scores for both the in person and telehealth visits, with over 90% reporting excellent satisfaction.  70% of respondents would be willing to participate in a telehealth consultation again.  100% of respondents would recommend a telehealth visit for a friend / family member.   

Future directions 
We are planning on statistical analysis to evaluate the following. 

Validation of using telehealth / pictures to measure elbow range of motion 
Using the follow up pictures, we plan to perform a validation assessment of the measurement of pediatric elbow motion remotely / by telehealth.  We have collected measurements from the uninjured arm in clinic and will compare this to the 3-month motion check follow up with pictures of the uninjured arm. 

Within cohort evaluation of satisfaction scores 
We are planning to perform an intra cohort analysis to compare outcome and satisfaction scores between the in person and telehealth visits. 

Comparison to a retrospective cohort 
We are planning to compare this prospective cohort to a retrospective cohort to formally compare rates of loss to follow up and referral to physical therapy.