BACKGROUND: Up to 50% of complications following hypospadias repair occur >1 year postoperatively, necessitating long-term follow-up for prompt management of complications. Standardized postoperative follow-up protocols have been proposed for outcome tracking but adherence to these schedules varies. In June 2018, a post-operative follow-up protocol was implemented at our institution (Figure 1) for patients undergoing hypospadias surgery. We aimed to evaluate adherence to the protocol and determine barriers leading to deviations from the protocol.
METHODS: A retrospective review of patients who underwent hypospadias surgery at our institution from the time of protocol implementation (June 2018) to June 2022 was planned. Patients who underwent distal and proximal hypospadias repairs were included (n=507). Meatoplasties, first-stage proximal repairs, and patients with inadequate documentation were excluded. Preliminary review of a random sampling of 10 patients from each year (total N=50) was performed to assess data collection feasibility and revealed poorer than expected short-term follow-up. This prompted a shift in study focus to assess long-term adherence to the follow-up protocol, revising our inclusion criteria to patients ≥5 years old at the time of the study. We reviewed a second random sampling of 50 patients meeting revised inclusion criteria prior to review of the total cohort. Number of follow-up visits was tabulated and reasons for deviation from the follow-up protocol were assessed.
RESULTS: Review of the random sampling of 100 patients (50 with initial inclusion criteria, 50 with the revised criteria) revealed that only 9 adhered to the follow-up protocol. 85 did not adhere and 6 were excluded due to complications resulting in additional surgery. Of patients who did not follow the protocol, most (60/85) had appropriate protocol driven follow-up recommended by their physician. 12/85 (14%) had no follow-up aside from stent/dressing removal, 32/85 (38%) attended a 1-month postop visit, and 23/85 (27%) attended 1 additional visit on protocol. Only 18/85 (21%) patients had ≥2 follow-up visits prior to deviation from the protocol. Lack of follow-up was deemed to be physician-driven in 18% of cases, related to patient or system factors in 70% of cases, and a combination in 12% (Figure 2). Given the poor follow-up for our initial sample, complete data collection on the full cohort (n=507) was not completed, though limited data collection demonstrated 60% had <3 follow-up visits.
CONCLUSIONS: A standardized follow-up protocol after hypospadias surgery was implemented at our institution to track post-operative outcomes. We found that physicians consistently recommended follow-up according to protocol, but patient follow-up remained extremely poor. Further evaluation of patient and system level barriers to appointment scheduling and follow-up adherence is required. This review emphasizes the need to audit quality improvement efforts after implementation to ensure the desired goal is being met.
