Introduction

As in all surgical disciplines, an accurate, comprehensive and contemporary patient past medical history is crucial in formulating a safe and appropriate surgical management plan, and to avoid unnecessary and preventable complications. In Oral and Maxillofacial surgery private practices in Australia, the majority of referrals are from Dental Health Professionals, so a patient’s medical history is usually limited and incomplete. There are multiple sources a medical history can be obtained [1-5], including but not limited to, a Medical General Practitioner (GP) health care summary and a patient-completed health questionnaire. As the general population continues to age, more elderly patients are presenting for surgical management in Oral and Maxillofacial Surgery practices6 . With age these patients present with more co- morbidities [6], that need management and optimisation prior to committing to a surgical plan, especially treatment under a general anaesthetic. However, in the elderly population with multiple co-morbidities, the validity of the patient-completed health questionnaire is questionable as it is documented cognitive decline is associated with age and multiple co-morbidities [7].

Unfortunately, there are no studies documenting the accuracy of elderly patients’ patient health questionnaires, particularly when compared to another source of patient medical history such as the GP health care summary. Since the majority of specialist medical and dental correspondence regarding a patient’s chronic disease management is forwarded to a patient’s medical GP, it is expected a patient’s GP health summary to be comprehensive. The aim of this study was to identify which source of a patient’s medical history was more accurate and comprehensive in patients aged over 50-years; GP health care summary versus the patient health questionnaire. We hypothesised the GP health summary to be more accurate and comprehensive than the patient questionnaire in documenting a new patient’s medical history over the age of 50-years.

Materials and Methods

A hundred self-administered patient health questionnaires (Figure 1) and corresponding GP health care summaries were collected of new patients attending Dr Richard Conway’s private Oral and Maxillofacial Surgery practice (34 Castlereagh Street, Penrith, NSW, 2750). Inclusion criteria included all patients 50-years and over in age, and both documents completed within 6-months. De-identified data underwent binomial comparison analysis. Paired t-test statistical analysis was performed to determine statistical significance of any difference between the two data groups for medical conditions, medications and allergies. Sincere thanks to Dr Karen Byth (Senior Biostatistician, Westmead Hospital, Westmead, NSW, Australia) for her support with statistical analysis. Ethics was approved by the Nepean Blue Mountains Local Health District Research Ethics Committee (NBMLHD HREC approval number 2020/ETH03176).

Results and Discussion

Data for 100 patients (n=100) was collected. The mean age of patients was 71 years with a range of 50-91 years. 39 patients were male, 61 were female. All the GP health-summaries were signed and dated by the GPs. Only 91% of the patient health questionnaires were signed and 87% dated. This is important with medico-legal implications suggesting the GP health summaries are more credible to base surgical management plans compared to the un-signed patient-completed questionnaires (Table 1).

Table 1 above shows that the GP health summary consistently reported significantly more total medical co-morbidities (2 times more, p<0.001), medications (2.5 times more, p<0.001) and allergies (over 1.5 times more, p=0.002) than did the patient-completed health questionnaires. These differences are alarming in highlighting those patients over 50-years of age routinely under-report their medical health issues when attending private Oral and Maxillofacial Surgery practices, and that full medical history is only uncovered with GP health-care summaries. This has significant implications in appropriately managing these patients surgically, in both a general anaesthetic setting as well as in the clinics when operating under local anaesthetic settings.

With regards to various medical co-morbidities, Table 1 also highlights that patient questionnaires significantly under-reported in all conditions including Gastroenterological (GIT) conditions, surgery, rheumatological conditions, cardiological conditions, endocrine, ENT and ophthalmological issues, neurology, renal, oncological issues, psychiatry, respiratory and haematological issues. With regards to the treatment of oncological diseases, radiotherapy was significantly under-reported by patients (p=0.025), however not so with regards to chemotherapy (p=0.083). In both oncological treatment modalities, the patients did not report chemotherapy or radiotherapy, however the GP health summaries identified it in three and five patients respectively. The statistical in-significance in the chemotherapy group is attributed to the low number of patients who received it in this study group, but still would have had significant surgical implications if not screened for blood dyscrasias. The systematic patient underreporting of medical conditions documented in Table 1 is reflected in the percentage showing complete agreement between GP health summary and patient questionnaire highlighted in Table 2 below. Of the medical co-morbidities, GIT (43%), cardiological (47%), surgery (49%) and MSK/rheumatological (50%) conditions have the worst percentage agreement between GP health summary and patient questionnaire.

Table 3 breaks-down every medical co-morbidity reported by GPs and patients. The most common reported condition by patients was hypertension. Otherwise, cardiac conditions were under-reported by patients, picked up only with the GP-health summary, such as ischemic heart disease, atrial fibrillation, valvular disease and pacemaker presence. All of which have significant implications in managing patients

surgically. Also of note is the amount of under-reporting of obstructive sleep apnoea and COPD. Neurological conditions were generally well reported by patients, however GORD and hepatic conditions seem to be under-reported, which have general anaesthetic and coagulopathy implications in surgical management. Interestingly osteoporosis was significantly under-reported by patients, having implications in assessing for anti-resorptive therapy during consultations and discussing/consenting for issues involving Medication Related Osteonecrosis Of The Jaws (MRONJ). Benign Prostate Hypertrophy (BPH) was also under-reported by patients, having implications in managing urine retention in patients undergoing elective surgery. Further, despite significant difference in reported surgeries by GPs and patients, these seem to be mainly related to orthopaedic and gynaecological procedures. Surgeries related to thyroidectomies, nephrectomies and head and neck cancer were equally reported by GPs and their patients. Psychiatric conditions were also significantly under-reported by patients which can have implications in deciding on managing surgery under a general or local anaesthetic. Again, all these results present significant implications in surgically managing the over-50-year-old patient and avoiding unnecessary and avoidable complications.

Table 1 also shows the significant under-reporting of medications by patients compared to the GP health-summary. This is also reflected in the poor complete agreement shown in Table 2, of 23% between the GP health summary versus the patient questionnaire for all medications. Specific to surgical management, patients significantly under-reported anti-platelet (by 2 times, p=0.001) but not anti-coagulant (mean difference 0.02 per patient, p=0.158) therapies. Interestingly, as shown in Table 3, all three types of anti-platelets were under-reported by patients (aspirin, clopidogrel and Asasantin). Anti-resorptive therapy was also significantly under-reported by patients, only identified by GP health summary (Table 1, p<0.001). As Table 4 highlights, the anti-resorptive therapies patients under-reported include denosumab (by more than 3 times), risodronic acid, zolendronic acid and alendronic acid. This has significant implications with managing Oral and Maxillofacial surgery, particularly with patient consent and mitigating risk of medications related osteonecrosis of the jaws (MRONJ) [8]. With regards to immunosuppressants, there was no statistical difference in the reporting between the two groups (Table 1) however it can be seen from Table 4 that prednisone therapy was significantly under-reported by patients, which would have significant implications in preventing adrenal and Addisonian crises when managing patients surgically. Nonetheless, it is important to be cautious with these medication results as electronic GP health-summaries are known to document ceased/modified medications [9].

Allergies were also under reported by patients (Table 1). As seen in Table 2, there was only a 69% agreement in all allergies between the GP health summary and patient questionnaire. Table 4 explores the breakdown of various allergies reported by GPs and patients. Interestingly patients and GPs reported penicillin allergies equally. Again, missing patient allergies prior to committing to a surgical treatment plan can have dire consequences for patient outcome. Hence the need for GP health summaries in identifying all patient allergies.

Tables 5 and 6 highlight the number of reported smokers, alcohol and illicit drug use. It can be seen that the GP only reported smoking status of patients in 27% of cases whereas patients self-reported smoking status in 96% of cases. Alcohol consumption was report in 25% of GP health summaries, while patients self-reported in 96%. Illicit drug use (or not) was reported in only one GP summary, as opposed to 96% of cases with patient questionnaires. This shows that patient questionnaires were still important in gathering data on a patient’s social history, to help improve patient surgical management. Such as the use of nicotine replacement therapies, alcohol withdrawal scales and testing for liver disease and blood dyscrasia/coagulopathies, optimising any disease processes and prior to embarking on elective surgical treatment.

This study clearly shows the need for GP health care summary in addition to the patient health questionnaire, for all patients aged over 50-years during the initial surgical consultation to better manage any surgical needs. However, it is important to realise that there are limitations to committing to a single source of patient health information. For example, if a patient does not have a GP with which to review regularly regarding their chronic diseases, the health care summary would be expected to be deficient. Also, as explored above, GP health care summaries can have out-dated redundant information [9]. Therefore, as highlighted in other studies, patient health history accuracy improves with multiple modalities such as interviewing patients [3,4], as well as hospital in- and out-patient documents [2] and health care specialist correspondence [3], in addition to the patient health questionnaire and GP health summary.

The current study also raises more questions for further research in improving patient health information accuracy and comprehensiveness prior to committing to surgical management. It would be interesting to assess the above data to information gathered during interview with the surgeons. It would also be helpful to compare the above data with regards to patient medications, to pharmacy dispensing history. Further, it would be interesting to assess if similar discrepancies in GP health summary and patient questionnaire exist in publicly treated patients.

Conclusion

GP health summaries reported significantly more medical co-morbidities, medications and allergies as compared to the patient health questionnaire. However, the GP summaries routinely under-reported smoking/alcohol/illicit drug use status of patients as compared to the patient health questionnaires. This study hence helps change daily practice to recommend routine acquisition of GP health care summary, in addition to the patient health questionnaire, in private patients over 50-years, prior to committing to a surgical management plan.

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Tables

References

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