Clinical care pathways: decreasing resource utilization in head and neck surgical patients

A 5-year experience with midline catheters in the management of major head and neck surgery patients

BACKGROUND

In the perioperative management of major head and neck surgery (HNS) patients, the performance of midline catheters (MCs) has been never tested. We present here our 5-year experience by reporting MC-related complications and by identifying the preoperative risk factors associated with their development.

METHODS

Clinical variables were extracted and the dwell time, the number, and the type of postprocedural complications of MCs were retrieved. Complications were classified into major (needing MCs removal and including catheter-related bloodstream infection or deep vein thrombosis or catheter occlusion) and into minor (accidental dislodgement, leaking, etc.). Descriptive statistics and logistic regression models were used in order to identify the predictors of complications.

RESULTS

A total of 265 patients were included, with a mean age of 67.4 years. Intraprocedural complications occurred in 1.1% of cases, while postprocedural complications occurred in 13.9% of cases (12.05/1000 days), but they were minor in more than 7.0% (5.4/1000 catheter-days). There were 19 minor complications (7.1% or 5.4/1000 catheter-days) while 18 (7%, 5.1/1000 catheter-days) patients experienced at least one major complication. Female sex (OR = 1.963, 95% CI 1.017-3.792), insertion in the right arm (OR = 2.473, 95% CI 1.150-5.318), and an ACE-27 score >1 (OR = 2.573, 95% CI 1.295-5.110) were independent predictors of major complications.

CONCLUSIONS

MCs appear to represent an effective option in the setting of major HNS. The identification of patients most at risk for MC-related complications should prompt a postoperative watchful evaluation.

Enhanced Recovery After Surgery Protocols for Head and Neck Cancer: Systematic Review and Meta-analysis

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications, decrease length of stay, and more. We aim to perform a systematic review and meta-analysis of ERAS protocols for head and neck cancer surgery with or without microvascular reconstruction.

DATA SOURCES

PubMed, Embase, and Web of Science databases were queried, and abstracts were screened independently by 2 investigators.

REVIEW METHODS

This review was conducted in accordance with the PRISMA guidelines. We included comparative observational studies but excluded animal studies, case reports, and case series.

RESULTS

Of 557 articles initially reviewed by title and/or abstract, we identified 30 for full-text screening, and 9 met the criteria for qualitative synthesis. Meta-analysis of length of stay revealed a mean decrease of 1.37 days (95% CI, 0.77-1.96; I2 = 0%; P < .00001) with the ERAS group as compared with non-ERAS controls. The standardized mean difference of the morphine milligram equivalent was 0.72 lower (95% CI, 0.26-1.18; I2 = 82%; P = .002) in the ERAS group vs controls. The quality of studies was moderate with a median MINORS score of 18.5 (range, 13.5-21.5).

CONCLUSION

Implementation of ERAS protocols can lead to decreases in length of stay and opioid drug utilization. However, further high-quality prospective studies of ERAS protocols are needed, especially with stratified analysis of outcomes based on the type of head and neck cancer surgery.

[Centralization, Specialization, and Outpatient Care for Head and Neck Tumor Patients]

Demographically, the German population is aging and becoming more morbid. At the same time, urbanization trends, medical overcapacities, and increasing care costs are being observed in association with a tight healthcare budget. Centralization, specialization, and outpatient care are intended to provide a remedy and can be controlled by modifications to remuneration. This upheaval poses new challenges for patients and physicians, which were analyzed exemplarily at the Head and Neck Tumor (HNC) Center of the University Hospital Ulm. This is a retrospective, monocentric cohort study on the development of patient volume, catchment area, treatment modality, and demographics including 2070 HNC patients at the ENT clinic between the years 2011 and 2020. It was observed that the number (new diagnoses 2011: 134 vs. 2020: 204) and the average age (2011: 61.5 years vs. 2020: 65.8 years; p < 0.0001) of HNC patients increased over time. In addition, patients tended to travel longer distances (2011: 54.4 km vs. 2020: 64.4 km; p = 0.05). At the same time, the mean number of consultations and treatments per patient per 5-year follow-up interval grew (at initial diagnosis in 2011: 7.8 vs. 2016: 10.4; p = 0.0003), with the proportion of outpatient contacts increasing from 58.9 % to 62.4 % (p = 0.09) from 2011 to 2020. Accordingly, clinical centers are expected to become more important in the care of HNC patients as the healthcare system becomes more specialized, and centralized with a growing outpatient setting. The following consequences for patient care should be considered in restructuring strategies.

Designing an evidence‐based free‐flap pathway in head and neck reconstruction

Background

The use of autologous free‐tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free‐flap care.

Data Sources

This article examines English literature from PubMed and offers expert opinion on perioperative free‐flap care for head and neck oncology.

Conclusion

Free‐flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence‐based practice is rewarded with improved outcomes.

Decreased Complications After Total Laryngectomy Using a Clinical Care Pathway

Background: Complications following total laryngectomy can lead to increased hospital length of stay (LOS) and increased health care costs. Our objective was to determine the efficacy of a clinical care pathway for improving outcomes for patients following total laryngectomy.

Methods: This quality improvement study included all adult patients undergoing total laryngectomy—either primary or salvage—at a tertiary referral center between January 2013 and December 2018. The primary outcome was hospital LOS measured in postoperative days. The total and specific postoperative complication frequencies were evaluated, as well as 30-day readmission rates and intensive care unit (ICU) LOS.

Results: Sixty-three patients were included in the study: 29 (46.0%) patients before the pathway implementation and 34 (54.0%) patients after pathway implementation. Demographic characteristics between the groups were similar. The prepathway cohort had a higher rate of total complications compared to the postpathway group (relative risk=0.5; 95% CI 0.3-1.0), although the differences in individual complications were similar. The median LOS of 10 days was the same for the 2 cohorts. The median ICU LOS was 1 day greater in the postpathway cohort, but no difference was seen in rates of ICU readmission in the 2 groups. The 30-day readmission rate also was not significant between the 2 groups.

Conclusion: Implementation of a postoperative order set pathway for patients undergoing laryngectomy is associated with decreased overall complication rates. Use of a clinical care pathway may improve outcomes in patients undergoing total laryngectomy.

Designing and integrating a quality management program for patients undergoing head and neck resection with free-flap reconstruction

Background

Care pathways (CPs) offer a proven method of systematically improving patient care. CPs are particularly helpful in complex clinical conditions where variation in care is a problem such as patients undergoing major head and neck resection with free flap reconstruction. Although CPs have been used to manage this patient group, most CPs are implemented as part of relatively short-term quality improvement projects. This paper outlines a detailed methodology for designing and delivering a quality management program sustained for 9 years.

Methods

We describe a change management approach informed by Kotter’s “8 Step Process” that provided a useful framework to guide program development and implementation. We then provide a detailed, step by step description of how such a program can be implemented as well as a detailed summary of time and costs for design, implementation and sustainability phases. An approach to design and delivery of a measurement, audit and feedback system is also provided.

Results

We present a summary of resources needed to design and implement a head and neck surgery quality management program. The primary result of this study is a design for a sustainable quality management program that can be used to guide and improve care for patients undergoing major head and neck resection with free flap reconstruction.

Conclusions

A change management approach to design and delivery of a head and neck quality management program is practical and feasible.

The impact of a quality management program for patients undergoing head and neck resection with free-flap reconstruction: longitudinal study examining sustainability

BACKGROUND

Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction.

METHODS

The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made.

RESULTS

Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing.

CONCLUSIONS

Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.

The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes

OBJECTIVE

To study the impact of a clinical care pathway and computerised order set on short-term post-operative outcomes for patients undergoing head and neck free tissue transfer.

METHODS

In this retrospective cohort study, patients who underwent head and neck free tissue transfer by a single reconstructive surgeon between January 2007 and July 2009 were assigned to one of two cohorts based on the timing of their surgery: pre- or post-clinical care pathway implementation. Measured outcomes included peri-operative complications and mortality, length of hospital stay and costs, unplanned reoperations, and readmissions within 30 days of discharge.

RESULTS

The pre-clinical care pathway cohort included 81 patients and the post-clinical care pathway cohort comprised 46. Implementation of the clinical care pathway was associated with decreased variability in length of hospital stay (median (interquartile range) = 8 (6, 11) vs 7 (6, 9) days). The post-clinical care pathway cohort also had a significantly lower unplanned reoperation rate (15.2 vs 35.8 per cent, p = 0.01).

CONCLUSION

A clinical care pathway is a successful means of standardising and improving complex patient care. In this study, care pathway implementation in head and neck free tissue transfer patients improved efficiency and the quality of patient care.

A Comprehensive Clinical Care Pathway for Microvascular Maxillofacial Reconstructive Surgery

PURPOSE

Clinical care pathways (CCPs) for major surgical procedures are less developed. We describe the development of a comprehensive microvascular maxillofacial reconstruction CCP and evaluate the impact.

MATERIALS AND METHODS

Our team developed a comprehensive CCP for patients undergoing microvascular free flap reconstruction for benign or malignant tumors. Patient data before (n = 48) and after (n = 47) implementation of the CCP were used to evaluate the impact. Bayesian negative binomial and logistic regression analyses were used to estimate the associations between the CCP and clinical outcomes (length of stay [LOS], readmission to the operating room, and readmission within 3 months of discharge).

RESULTS

The average total hospital LOS was high in the pre-CCP group (16.9 days) compared with the post-CCP group (9.8 days). Being in the post-CCP group reduced the LOS in the intensive care unit and surgical ward and reduced the risk of readmission to the operating room.

CONCLUSION

Our results underscore the importance of standardized evidence-based patient care through CCPs for complex patient populations.

Clinical Indices to Drive Quality Improvement in Otolaryngology

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.

Reducing morbidity and complications after major head and neck cancer surgery: the (future) role of enhanced recovery after surgery protocols

PURPOSE OF REVIEW

To review the development and the benefits of enhanced recovery after surgery (ERAS) protocols in non-head and neck disciplines and to describe early implementation efforts in major head and neck surgeries.

RECENT FINDINGS

Several groups have adopted ERAS protocols for major head and neck surgery and demonstrated its feasibility and effectiveness.

SUMMARY

There is growing evidence that clinical and financial outcomes for patients undergoing major head and neck surgery rehabilitation can be significantly improved by standardizing preoperative, intraoperative, and postoperative treatment protocols. Current experience is limited to single centers. A future goal is to broaden the adoption of ERAS in head and neck surgical oncology to include national and international collaboration, data sharing, and learning.

Effects of a Comprehensive Performance Improvement Strategy on Postoperative Adverse Events in Head and Neck Surgery

Objectives

We aimed to demonstrate the efficacy of a multifaceted performance improvement regimen to reduce the incidence of adverse events following a spectrum of head and neck surgical procedures.

Methods

We conducted a chart review of patients who underwent a head and neck procedure between January 1, 2013, and October 30, 2015, at our institution, including 392 patients (450 procedures) before the quality improvement regimen was implemented (October 1, 2013) and 942 patients (1136 procedures) after implementation. Multivariate statistical models were used to investigate the association of clinical parameters and the intervention with postoperative adverse event rate.

Results

The incidence of adverse events decreased from 12.9% to 7.2% (95% CI, 2.46%-9.38%) after the intervention. Male sex (adjusted odds ratio [ORadj] = 1.57; 95% CI, 1.06-2.31) and the intervention (ORadj = 0.51; 95% CI, 0.35-0.74) were predictive of overall adverse event incidence by univariate and multivariate analyses. Although patient comorbid status, quantified with the Charlson Comorbidity Index, was not found to affect overall adverse event risk, each 1-point increase in index score was associated with a 17% relative increase (ORadj = 1.17; 95% CI, 1.03-1.33) in the odds of a high-grade adverse event.

Discussion

Comprehensive performance improvement programs can improve perioperative adverse event risk in head and neck surgery. Patient comorbid status and sex are considerations during assessment of the likelihood of high-grade and overall adverse event risk, respectively.

Implications for Practice

Given the cost of surgical complications, a comprehensive approach to perioperative risk mitigation is warranted.

Prediction of Discharge Destination following Laryngectomy

Objective

To identify factors that may predict discharge to intermediate-care facilities following total laryngectomy and may promote earlier discharge planning and optimize resource utilization.

Study Design

Retrospective review of large national data set.

Setting

Academic and nonacademic health care facilities in United States, contributing deidentified, risk-adjusted clinical data to the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP).

Subjects and Methods

Retrospective evaluation of the NSQIP database (2011-2014) identified 487 patients who underwent total laryngectomy without free tissue transfer. Risk of discharge to intermediate-care facilities was evaluated. Role of preoperative and postoperative factors and their association with discharge disposition were assessed using multivariable regression analysis.

Results

Compared to reference groups, advanced age (61-70 years: odds ratio [OR], 3.16; 95% confidence interval [CI], 1.12-8.89; >70 years: OR, 3.77; 95% CI, 1.33-10.65), baseline functional dependence (OR, 5.61; 95% CI, 2.62-12.02), cardiac failure (OR, 3.80; 95% CI, 1.08-13.42), and steroid dependence (OR, 3.30; 95% CI, 1.36-8.0) independently predicted discharge to intermediate-care facilities.

Conclusion

Patients with advanced age, functional dependence, cardiac failure, and steroid dependence may benefit from preemptive counseling and discharge planning in anticipation of postlaryngectomy discharge to intermediate-care facilities.

A Clinical Care Pathway to Reduce ICU Usage in Head and Neck Microvascular Reconstruction

Objective

To design and implement a postoperative clinical care pathway designed to reduce intensive care usage on length of stay, readmission rates, and surgical complications in head and neck free flap patients.

Methods

A postoperative clinical care pathway detailing timelines for patient care was developed by a multispecialty team. In total, 108 matched patients receiving free tissue transfer for reconstruction of head and neck defects in the year before (prepathway), year after (early pathway), and second year after (late pathway) pathway implementation were compared based on postoperative length of stay, 30-day readmission rate, intensive care unit (ICU) admission, and rates of medical/surgical complications.

Results

Median length of stay decreased from 10 to 7.5 and 7 days in the pre-, early, and late-pathway groups, respectively ( P = .012). Readmission rate decreased from 16% in the prepathway group to 0% and 3% in the early and late-pathway groups. The number of patients admitted to the ICU postoperatively decreased from 100% to 36% and 6% in the pre-, early, and late-pathway groups, respectively ( P = .025). The rates of surgical and medical complications were equivalent.

Discussion

This pathway effectively reduced ICU admission, length of stay, and readmission rates, without increasing postoperative complications. These outcomes were sustainable over 2 years.

Implications for Practice

Free flap patients may not require routine ICU admission and may be taken off ventilatory support in the operating room. This effectively reduces costly resource use in this patient population. Similar pathways could be introduced at other institutions.

Critical Care Admissions following Total Laryngectomy: Is It Time to Change Our Practice?

Critical Care Unit (CCU) beds are a limited resource and in increasing demand. Studies have shown that complex head and neck patients can be safely managed on a ward setting given the appropriate staffing and support. This retrospective case series aims to quantify the CCU care received by patients following total laryngectomy (TL) at a District General Hospital (DGH) and compare patient outcomes in an attempt to inform current practice. Data relating to TL were collected over a 5-year period from 1st January 2010 to 31st December 2015. A total of 22 patients were included. All patients were admitted to CCU postoperatively for an average length of stay of 25.5 hours. 95% of these patients were admitted to CCU for the purpose of close monitoring only, not requiring any active treatment prior to discharge to the ward. 73% of total complications were encountered after the first 24 hours postoperatively at which point patients had been stepped down to ward care. Avoiding the use of CCU beds and instead providing the appropriate level of care on the ward would result in a potential cost saving of approximately £8,000 with no influence on patient morbidity and mortality.

Discharge Destination after Head and Neck Surgery: Predictors of Discharge to Postacute Care

OBJECTIVE

In recent decades, there has been a reduction in the length of postoperative hospital stay, with a corresponding increase in discharge to postacute care. Discharge to postacute care facilities represents a meaningful patient-centered outcome; however, little has been published about this outcome after head and neck surgery.

STUDY DESIGN

Retrospective review of national database.

SETTING

American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2013.

SUBJECTS AND METHODS

We compared the rate of discharge to home versus postacute care facilities in patients admitted after head and neck surgery and used multivariable logistic regression to identify predictors of discharge to postacute care.

RESULTS

The overall rate of discharge to postacute care facilities after head and neck surgery (n = 15,890) was 15.7% after major surgery (including laryngectomy, composite resection, and free tissue transfer), 4.4% after moderate surgery (including regional tissue transfer, oropharyngeal or oral cavity resection, and neck dissection), and 1.1% after minor head and neck surgery (including endocrine or salivary gland surgery). On multivariable analysis, significant preoperative predictors of discharge to postacute care were advanced age, functional status, major or moderate surgical procedures, tracheostomy, advanced American Society of Anesthesiologists class, low body mass index, and dyspnea.

CONCLUSION

Our study indicates that patients undergoing major or moderate head and neck surgery, patients with reduced functional status, and patients with advanced comorbidities are at substantial risk of discharge to postacute care. The possibility of discharge to postacute care should be discussed with high-risk patients.

Algorithm based patient care protocol to optimize patient care and inpatient stay in head and neck free flap patients

Objective

To determine if rigid adherence (where medically appropriate) to an algorithm/checklist-based patient care pathway can reduce the duration of hospitalization and complication rates in patients undergoing head and neck reconstruction with free tissue transfer.

Methods

Study design was a retrospective case-control study of patients undergoing major head and neck cancer resections and reconstruction at a tertiary referral centre. The intervention was rigid adherence to a pre-existing care pathway including flow algorithms and multidisciplinary checklists incorporated into patient charting and care orders. 157 patients were enrolled prospectively and were compared to 99 patients in a historical cohort. Patient charts were reviewed and information related to the patient, procedure, and post-operative course was extracted. The two groups were compared for number of major and minor complications (using the Clavien-Dindo system) and length of stay in hospital.

Results

Comparing pre- and post-intervention groups, no significant difference was identified in duration of hospital stay (21.5 days vs. 20.5 days, p = 0.750), the rate of major complications was significantly higher in the pre-intervention cohort (25.3 % vs. 14.0 %, p = 0.031), the rate of minor complications was not significantly higher (34.3 % vs 30.8 %, p = 0.610).

Conclusion

Rigid adherence to our patient care pathway, and improved charting techniques including flow algorithms and multidisciplinary checklists has improved patient care by showing a significant reduction in the rate of major complications.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-015-0090-6) contains supplementary material, which is available to authorized users.

Reduction of Pharyngocutaneous Fistulae in Laryngectomy Patients by a Comprehensive Performance Improvement Intervention

Objective

Pharyngocutaneous fistula is a common complication in laryngectomy patients, particularly in previously irradiated cases. We initiated a comprehensive performance improvement intervention in all head and neck surgery patients intended to reduce postoperative infection and fistulae rates. We report our review of outcomes within laryngectomy patients.

Study Design

Case series with chart review.

Setting

Academic tertiary referral center.

Subjects

Nineteen laryngectomy patients at risk of postoperative fistula formation.

Methods

We reviewed the medical records of all patients who had undergone laryngectomy procedures between January 2013 and April 2014. Clinicodemographic data were obtained, including history of diabetes, prior radiation therapy, type of reconstruction performed for closure of the pharyngeal defect, and the presence or absence of postoperative fistula.

Results

The study population comprised 19 laryngectomy patients. Prior to implementation of our performance improvement intervention, 8 of 11 (73%) patients undergoing laryngectomy developed postoperative fistulae. After intervention, 0 of 8 patients developed fistulae ( P = .002). Prior radiation, diabetes mellitus, and overall stage were not associated with a reduction in fistula rate ( P > .05).

Conclusion

Comprehensive uniform application of a standard antibiotic prophylaxis, surgical technique, perioperative care, and treatment of comorbid conditions can significantly reduce and potentially eliminate fistulae in laryngectomy patients who are especially at risk.

Defining value-driven care in head and neck oncology

In the USA, increasing attention is being paid to adopting a value-based framework for measuring and ultimately improving health care delivery. Value is defined as the benefit achieved relative to costs. The numerator of the value equation includes quality of care and outcomes achieved. The denominator includes costs, both financial costs and harms of treatment. Herein, we describe these elements of value as they pertain to head and neck cancer. A particular focus is to identify areas of the value equation where physicians have some control. We examine quality in each of three dimensions: structure, process, and outcomes. We also adopt Porter's three-tiered hierarchy of outcomes model, with specific outcomes relevant to patients with head and neck and thyroid cancer. Finally, we review issues related to costs and harms. We believe these findings can serve as a framework for further efforts to drive value-based delivery of head and neck cancer care.

Enhanced recovery programmes in head and neck surgery: systematic review

Objective:

To review the literature on enhanced recovery programmes in head and neck surgery.

Method:

A systematic review was performed in May 2013.

Results:

Thirteen articles discussing enhanced recovery after laryngectomy, neck dissection, major ablative surgery and microvascular reconstruction were identified. Articles on general pre-operative preparation and post-operative care were also reviewed.

Conclusion:

Considerable evidence is available supporting enhanced recovery in head and neck surgery that could be of benefit to patients and which surgeons should be aware of.

Improving Health Outcomes and Value with Care Pathways

With a growing interest in value-based health care, there is an emphasis on establishing best practice, measuring outcomes, and improving clinical efficiencies. Best practice is a challenging concept with our growing knowledge base, and clinical practice guidelines (CPGs) help establish an approach to prioritize care and reduce practice variation. New challenges are emerging with a larger population of insured patients and a mandate to coordinate care with a shared electronic health record, and these are coupled with a massive growth in computing power. Care pathways (also called critical or clinical pathways) structure the implementation of CPGs, stratify high-risk patients, and provide the opportunity to achieve improved value. These are dynamic processes that are supervised by interdisciplinary teams and have the potential to evolve with new information gathered from each of the steps. As we emerge from single to group medical practices and hospitals to health systems, care pathways will be critically needed for optimal population management in health care.

Cost-effectiveness analysis of a postoperative clinical care pathway in head and neck surgery with microvascular reconstruction

BACKGROUND

The objective of this study is to evaluate the cost-effectiveness of a postoperative clinical care pathway for patients undergoing major head and neck oncologic surgery with microvascular reconstruction.

METHODS

This is a comparative trial of a prospective treatment group managed on a postoperative clinical care pathway and a historical group managed prior to pathway implementation. Effectiveness outcomes evaluated were total hospital days, return to OR, readmission to ICU and rate of pulmonary complications. Costing perspective was from the government payer.

RESULTS

118 patients were included in the study. All outcomes demonstrated that the postoperative pathway group was both more effective and less costly, and is therefore a dominant clinical intervention. The overall mean pre- and post-pathway costs are $22,733 and $16,564 per patient, respectively. The incremental cost reduction associated with the postoperative pathway was $6,169 per patient.

CONCLUSION

Implementing the postoperative clinical care pathway in patients undergoing head and neck oncologic surgery with reconstruction resulted in improved clinical outcomes and reduced costs.

Quality and performance indicators in an academic department of head and neck surgery

OBJECTIVE

to create a method for assessing physician performance and care outcomes that are adjusted for procedure acuity and patient comorbidity.

DESIGN

between 2004 and 2008 surgical procedures performed by 10 surgeons were stratified into high-acuity procedures (HAPs) and low-acuity procedures (LAPs). Risk adjustment was made for comorbid conditions examined singly or in groups of 2 or more.

SETTING

a tertiary care medical center.

PATIENTS

a total of 2618 surgical patients.

MAIN OUTCOME MEASURES

performance measures included length of stay; return to operating room within 7 days of surgery; and the occurrence of mortality, hospital readmission, transfusion, and wound infection within 30 days of surgery.

RESULTS

the transfusion rate was 2.7% and 40.6% for LAPs and HAPs, respectively. Wound infection rates were 1.4% for LAPs vs 14.1% for HAPs, while 30-day mortality rate was 0.3% and 1.6% for LAPs and HAPs, respectively. The mean (SD) hospital stay for LAPs was 2.1 (3.6) vs 10.5 (7.0) days for HAPs. Negative performance factors were significantly higher for patients who underwent HAPs and had comorbid conditions. Differences among surgeons significantly affect the incidence of negative performance indicators. Factors affecting performance measures were procedure acuity, the surgeon, and comorbidity, in order of decreasing significance. Surgeons were ranked low, middle, and high based on negative performance indicators.

CONCLUSIONS

performance measures following oncologic procedures were significantly affected by comorbid conditions and by procedure acuity. Although the latter most strongly affects quality and performance indicators, both should weigh heavily in physician comparisons. The incidence of negative performance indicators was also influenced by the individual surgeon. These data may serve as a tool to evaluate and improve physician performance and outcomes and to develop risk-adjusted benchmarks. Ultimately, reimbursement may be tied to quantifiable measures of physician and institutional performance.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.

Should all head and neck cancer patients be nursed in intensive therapy units following major surgery?

PURPOSE OF REVIEW

Surgery remains a mainstay of treatment for head and neck cancer. Patients have significant comorbidities, and protracted surgery is associated with complications and may require a high-dependency nursing environment such as an intensive care or high-dependency unit postoperatively. The literature is reviewed to document the current evidence for early postoperative nursing care.

RECENT FINDINGS

The mortality associated with major head and neck oncologic surgery is low, less than 3%, most frequently being myocardial infarction and pneumonia. The majority of patients can be nursed in a step-down (high-dependency unit) environment, which has one-to-one nursing, with experience and expertise, supported by medical staff. The decision where care is provided needs to be made locally, however, depending on staffing skill and levels, resources, and volume of workload.

SUMMARY

The majority do not require the routine use of the intensive therapy unit in the immediate postoperative period. The use of a 'specialist care', high-dependency unit or ward is cost effective, without reducing quality of care. Appropriate and adequate nursing staff with experience and expertise, and sustained resourcing, is paramount to the implementation of such a care facility.

Compliance and efficiency before and after implementation of a clinical practice guideline for laryngeal carcinomas

We evaluated whether the implementation of a nationwide clinical practice guideline for diagnosis, treatment and follow-up of laryngeal carcinomas led to changes in hospital costs, balanced against clinical changes observed following the guideline's implementation. Charts of 822 patients with larynx carcinoma (459 treated before the introduction of the guideline and 363 thereafter) in five hospitals were retrospectively investigated. In all phases, no differences in total hospital costs were observed after the guideline's implementation. Total mean costs were Euro 3,207 (95%CI 3,091-3,395) for diagnosis, Euro 3,169 (2,153-4,182), Euro 5,026 (3,996-6,057), Euro 6,458 (5,579-7,337), Euro 8,037 (7,469-8,606), Euro 12,765 (10,763-14,769), Euro 19,227 (16,848-21,605) for treatment of dysplasia, carcinoma in situ, T1, T2, T3 and T4 carcinoma, respectively, and Euro 1,856 (1,491-2,220) for 1 year disease-free follow-up. In an earlier study, we observed several positive changes after the guideline's implementation. Balanced against the equal costs before and after the guideline's implementation, we conclude that the efficiency of the care process improved.

Evaluating adherence to the Dutch guideline for diagnosis, treatment and follow-up of laryngeal carcinomas

BACKGROUND AND PURPOSE

An evidence-based clinical practice guideline for laryngeal carcinomas was introduced in the Netherlands late 1999. The objective of this guideline was to ensure uniformity in the diagnosis, treatment, and follow-up. We retrospectively evaluated whether clinical practice changed according to the recommendations of this guideline and whether it succeeded in its aim.

MATERIAL AND METHODS

In five out of eight Dutch university hospitals, chart data of 459 patients treated before the guideline introduction were compared to data of 363 patients treated after the guideline introduction.

RESULTS

Patient and tumour characteristics were comparable among both groups. In general, the guideline recommendations were properly complied with. The patients treated before the guideline introduction were actually also for a large part already treated according to the guideline's recommendations. After its introduction, several changes according to the guideline were observed: increased rates of reassessment of biopsy samples taken in local hospitals, psychological screening (although still only performed in 10.5% of patients), application of accelerated radiotherapy schedules, clinical trial treatments, function-preserving treatments, and decreased rates of total laryngectomy, and annual chest X-rays during follow-up.

CONCLUSIONS

Although a causal relationship cannot be established in this kind of observational studies, several positive changes were observed after the introduction of the guideline, and therefore the guideline seems to have contributed to more uniformity. The largest changes were seen for the guideline recommendations based on the highest levels of evidence.

Critical care of the head and neck patient

The patient with head and neck disease has several peculiarities that need to be recognized for the treating team to offer optimal care. These arise from the primary disorders (eg, head and neck cancer or injuries) and the morbidity they might cause, the associated comorbidities, and the possible complications of treatment. A team approach involving the surgeon, the intensivist, and other caretaking personnel is essential to achieve high-quality care and ensure the best results possible.

Impact of age on clinical care pathway length of stay after complex head and neck resection

OBJECTIVE

This article investigates the effect of patient age on postoperative pathway length of stay (LOS) for head and neck surgery. Aggregate clinical results for 43 patients, enrolled in the CCP from June 1996-July 1997, are described. Patient age, comorbid status, and postoperative complications are analyzed with respect to impact on LOS.

SETTING

Tertiary level academic medical center with an operative otorhinolaryngology volume of approximately 1200 cases per year.

PATIENTS

Forty-three patients undergoing head and neck resection with primary closure, local flap, or free flap closure were enrolled on CCP from June 1996-July 1997. Length of stay, frequency of selected aggregated comorbidities, and frequencies of complications are analyzed with nonparametric statistics. A pre-pathway group of 87 consecutive patients is used for comparison.

MAIN OUTCOME MEASURES

Length of stay and age.

RESULTS

Median actual LOS post-pathway for the patients enrolled in the first year of the pathway was 8 days. This met the CCP target and improved on pre-pathway LOS by 5 days (p <.001). The average LOS increased 25% from 8 days to 10 days for patients older than 65 years of age (p =.036, Mann-Whitney U test). Presence of a comorbidity and a complication concomitantly was statistically associated with increased LOS though not with advancing age (p =.003).

CONCLUSIONS

The CCP-reported performance improvement achieved by this pathway suggests improved resource use, and improved patient outcomes are achieved for postoperative care of head and neck surgery patients. Our experience suggests that advancing age creates a clinically significant increase in resource use represented by our finding of increasing LOS. This finding warrants further investigation.

Critical pathways. A systematic review

Critical pathways are care plans that detail the essential steps in patient care with a view to describing the expected progress of the patient. The authors' review of the literature suggest the use of critical pathways reduces the cost of care and the length of patient stay in hospital. They also have a positive impact on outcomes, such as increased quality of care and patient satisfaction, improved continuity of information, and patient education.