1
|
Stonko DP, Mohammed S, Skojec D, Rutkowski J, Call D, Verdi KG, Tsai LL, Black JH, Perler BA, Abularrage CJ, Lum YW, Salameh MJ, Hicks CW. Automatic 1-year follow-up appointment creation and reminders can improve long-term follow-up after carotid revascularization. Am J Surg 2024; 227:57-62. [PMID: 37827870 PMCID: PMC10797636 DOI: 10.1016/j.amjsurg.2023.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/17/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Long-term follow-up (LTFU) following carotid revascularization is important for post-surgical care, stroke risk optimization and post-market surveillance of new technologies. METHODS We instituted a quality improvement project to improve LTFU rates for carotid revascularizations (primary outcome) by scheduling perioperative and one-year follow-up appointments at time of surgery discharge. A temporal trends analysis (Q1 2019 through Q1 2022), multivariable regression, and interrupted time series (ITS) were performed to compare pre-post intervention LTFU rates. RESULTS 269 consecutive patients were included (151 pre-intervention, 118 post-intervention; mean 71 ± 12 years-old, 39% female, 77% White). The overall LTFU rate improved (64.9%-78.8%; P = 0.013) after the intervention. After controlling for patient factors, procedures performed after the intervention were associated with increased odds of being seen for 1-year follow-up (OR: 2.2 95%CI: 1.2-4.0). Quarterly ITS analysis corroborated this relationship (P = 0.01). CONCLUSIONS Time-of-surgery appointment creation and automated patient reminders can improve LTFU rates following carotid revascularizations.
Collapse
Affiliation(s)
- David P Stonko
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA; Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Shira Mohammed
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Diane Skojec
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Joanna Rutkowski
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Diana Call
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Katherine G Verdi
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Lillian L Tsai
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Bruce A Perler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Ying Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Maya J Salameh
- Johns Hopkins Center for Vascular Medicine, Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD, USA; Cardiovascular Specialist of Frederick, Frederick, MD, USA.
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
| |
Collapse
|
2
|
Hanba C, Lewis C. Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction. Otolaryngol Clin North Am 2023; 56:801-812. [PMID: 37380326 DOI: 10.1016/j.otc.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.
Collapse
Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Carol Lewis
- Department of Otolaryngology-Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| |
Collapse
|
3
|
Kiong KL, Moreno A, Vu CN, Zheng G, Rosenthal DI, Weber RS, Lewis CM. Enhanced recovery after surgery (ERAS) in head and neck oncologic surgery: Impact on return to intended oncologic therapy (RIOT) and survival. Oral Oncol 2022; 130:105906. [PMID: 35594776 DOI: 10.1016/j.oraloncology.2022.105906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/09/2022] [Accepted: 05/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways in head and neck cancer (HNC) have shown to improve perioperative outcomes and reduce complications. The longer term implications on adjuvant treatment and survival have not been studied. We hereby report the first study on the impact of an ERAS pathway on return to intended oncologic treatment (RIOT) and overall survival (OS) in HNC. METHODS 200 patients undergoing head and neck oncologic surgery on an ERAS pathway between March 1, 2016 and March 31, 2019 were matched to controls over the same interval. Demographic, tumor and adjuvant therapy-related data were collected, including time to adjuvant therapy(TAT) and treatment package time(TPT). Risk factors for TAT > 42 days and TPT ≥ 85 days were assessed. OS was compared and risk factors for inferior OS determined. RESULTS Baseline characteristics including co-morbidities and tumor stage were similar. Of 179 patients planned for adjuvant treatment, there was no difference in RIOT rate (89.0% vs 87.5%, p = 0.753), proportion of TAT > 42 days of surgery (55.6% vs 59.7%, p = 0.642), or TPT ≥ 85 days (48.1% vs 57.1, p = 0.258), for the ERAS and control groups, respectively. On multivariate analysis, alcohol use (OR 3.58; 95 %CI 1.11-11.52) and recurrent disease status (OR 2.88; 95 %CI 1.40-5.93) were independently associated with prolonged TAT. Three-year OS was similar between the ERAS and control groups (73% vs 76%, p = 0.521). CONCLUSION ERAS has not shown to improve RIOT or OS in the current study. However, its benefit for perioperative outcomes is undeniable and further studies are required on longer term quality and survival outcomes.
Collapse
Affiliation(s)
- Kimberley L Kiong
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Amy Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Catherine N Vu
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gang Zheng
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| |
Collapse
|
4
|
Wang R, Horwich P, Sandulache VC, Hernandez DJ, Hornig J, Graboyes EM, Liou NE, Skoner J, Haskins AD, Ranasinghe V, Day TA, Sturgis EM, Huang AT. Safety of microvascular free tissue transfer reconstruction of the head and neck in the setting of chronic pharmacologic immunosuppression. Head Neck 2022; 44:1520-1527. [PMID: 35437907 DOI: 10.1002/hed.27049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/11/2022] [Accepted: 03/24/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Patients on chronic pharmacologic immunosuppressive therapy are at increased risk of wound infection and complications after surgery. There is a paucity of data examining perioperative complications after microvascular free tissue transfer (MVFTT) reconstruction of the head and neck in this patient population. METHODS Retrospective cohort study performed at two tertiary referral centers between August 2016 and May 2020. RESULTS Nine hundred and seventy-nine patients underwent MVFTT during the study period; of these 47 (5%) patients were taking chronic immunosuppressive medications. The most common indications for immunosuppression were solid organ transplant and autoimmune disease. Fourteen (30%) patients had surgical complications within 30 days of surgery: 8 (17%) wound dehiscences, 6 (12%) hematomas, and 2 (4%) surgical site infections. There was one total and one partial flap failure with a 30-day reoperation rate of 4%. CONCLUSIONS MVFTT of the head and neck appears to be safe in patients on chronic pharmacologic immunosuppression.
Collapse
Affiliation(s)
- Ray Wang
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Horwich
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vlad C Sandulache
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David J Hernandez
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Hornig
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nelson E Liou
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Judith Skoner
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Angela D Haskins
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Viran Ranasinghe
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Terry A Day
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Erich M Sturgis
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew T Huang
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
5
|
Gisladottir U, Nakikj D, Jhunjhunwala R, Panton J, Brat G, Gehlenborg N. Effective Communication of Personalized Risks and Patient Preferences During Surgical Informed Consent Using Data Visualization: Qualitative Semistructured Interview Study With Patients After Surgery. JMIR Hum Factors 2022; 9:e29118. [PMID: 35486432 PMCID: PMC9107059 DOI: 10.2196/29118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/24/2021] [Accepted: 10/02/2021] [Indexed: 01/13/2023] Open
Abstract
Background There is no consensus on which risks to communicate to a prospective surgical patient during informed consent or how. Complicating the process, patient preferences may diverge from clinical assumptions and are often not considered for discussion. Such discrepancies can lead to confusion and resentment, raising the potential for legal action. To overcome these issues, we propose a visual consent tool that incorporates patient preferences and communicates personalized risks to patients using data visualization. We used this platform to identify key effective visual elements to communicate personalized surgical risks. Objective Our main focus is to understand how to best communicate personalized risks using data visualization. To contextualize patient responses to the main question, we examine how patients perceive risks before surgery (research question 1), how suitably the visual consent tool is able to present personalized surgical risks (research question 2), how well our visualizations convey those personalized surgical risks (research question 3), and how the visual consent tool could improve the informed consent process and how it can be used (research question 4). Methods We designed a visual consent tool to meet the objectives of our study. To calculate and list personalized surgical risks, we used the American College of Surgeons risk calculator. We created multiple visualization mock-ups using visual elements previously determined to be well-received for risk communication. Semistructured interviews were conducted with patients after surgery, and each of the mock-ups was presented and evaluated independently and in the context of our visual consent tool design. The interviews were transcribed, and thematic analysis was performed to identify major themes. We also applied a quantitative approach to the analysis to assess the prevalence of different perceptions of the visualizations presented in our tool. Results In total, 20 patients were interviewed, with a median age of 59 (range 29-87) years. Thematic analysis revealed factors that influenced the perception of risk (the surgical procedure, the cognitive capacity of the patient, and the timing of consent; research question 1); factors that influenced the perceived value of risk visualizations (preference for rare event communication, preference for risk visualization, and usefulness of comparison with the average; research question 3); and perceived usefulness and use cases of the visual consent tool (research questions 2 and 4). Most importantly, we found that patients preferred the visual consent tool to current text-based documents and had no unified preferences for risk visualization. Furthermore, our findings suggest that patient concerns were not often represented in existing risk calculators. Conclusions We identified key elements that influence effective visual risk communication in the perioperative setting and pointed out the limitations of the existing calculators in addressing patient concerns. Patient preference is highly variable and should influence choices regarding risk presentation and visualization.
Collapse
Affiliation(s)
- Undina Gisladottir
- Department of Biomedical Informatics, Harvard Medical School, Harvard University, Boston, MA, United States
| | - Drashko Nakikj
- Department of Biomedical Informatics, Harvard Medical School, Harvard University, Boston, MA, United States
| | - Rashi Jhunjhunwala
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jasmine Panton
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States.,Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
| | - Gabriel Brat
- Department of Biomedical Informatics, Harvard Medical School, Harvard University, Boston, MA, United States.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Nils Gehlenborg
- Department of Biomedical Informatics, Harvard Medical School, Harvard University, Boston, MA, United States
| |
Collapse
|
6
|
Stonko DP, Dun C, Walsh C, Shul M, Blebea J, Boyle EM, Makary MA, Hicks CW. Evaluation of a Physician Peer-Benchmarking Intervention for Practice Variability and Costs for Endovenous Thermal Ablation. JAMA Netw Open 2021; 4:e2137515. [PMID: 34905006 PMCID: PMC8672233 DOI: 10.1001/jamanetworkopen.2021.37515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE The frequency of use of endovenous thermal ablation (EVTA) to treat chronic venous insufficiency has increased rapidly in the US. Wide variability in EVTA use among physicians has been documented, and standard EVTA rates were defined in the 2017 Medicare database. OBJECTIVE To assess whether providing individualized physician performance reports is associated with reduced variability in EVTA use and cost savings. DESIGN, SETTING, AND PARTICIPANTS This prospective quality improvement study used data from all US Medicare patients aged 18 years or older who underwent at least 1 EVTA between January 1, 2017, and December 31, 2017, and between January 1, 2019, and December 31, 2019. All US physicians who performed at least 11 EVTAs yearly for Medicare patients in 2017 and 2019 were included in the assessment. INTERVENTION A performance report comprising individual physician EVTA use per patient with peer-benchmarking data was distributed to all physicians in November 2018. MAIN OUTCOMES AND MEASURES The mean number of EVTAs performed per patient was calculated for each physician. Physicians who performed 3.4 or more EVTA procedures per patient per year were considered outliers. The change in the number of procedures from 2017 to 2019 was analyzed overall and by inlier and outlier status. An economic analysis was also performed to estimate the cost savings associated with the intervention. RESULTS A total of 188 976 patients (102 222 in 2017 and 86 754 in 2019) who had an EVTA performed by 1558 physicians were included in the analysis. The median patient age was 72.2 years (IQR, 67.9-77.8 years); 67.3% of patients were female, and 84.9% were White. Among all physicians, the mean (SD) number of EVTAs per patient decreased from 2017 to 2019 (1.97 [0.85] vs 1.89 [0.77]; P < .001). There was a modest decrease in the mean number of EVTAs per patient among inlier physicians (1.83 [0.57] vs 1.78 [0.55]; P < .001) and a more substantial decrease among outlier physicians (4.40 [1.01] vs 3.67 [1.41] ; P < .001). Outliers in 2017 consisted of 90 physicians, of whom 71 (78.9%) reduced their EVTA use after the intervention. The number of EVTAs per patient decreased by a mean (SD) of 0.09 (0.46) procedures overall (median, 0.10 procedures [IQR, -0.10 to 0.30 procedures]; P < .001). The estimated cost savings associated with the decrease was $6.3 million in 2019. CONCLUSIONS AND RELEVANCE In this quality improvement study, substantial variability in the number of EVTAs performed per patient was observed across the US. When physicians were provided with a 1-time peer-benchmarked performance report card, the timing of the intervention was associated with a significant decrease in the number of EVTAs performed per patient, particularly among outlier physicians. This quality improvement initiative was associated with reduced variability in EVTA use in the US and a substantial savings for Medicare.
Collapse
Affiliation(s)
- David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Chen Dun
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christi Walsh
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Marlin Shul
- Center for Vein Restoration, Dothan, Alabama
| | - John Blebea
- Central Michigan University College of Medicine, Mount Pleasant
| | | | - Martin A. Makary
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
7
|
Ho MW, Puglia F, Tighe D, Chiu GA, Ridout F, Hutchison I, Mason M, McMahon JM. BAOMS QOMS (Quality and Outcomes in Oral and Maxillofacial Surgery), a specialty-wide quality improvement initiative: progress since conception. Br J Oral Maxillofac Surg 2021; 59:619-622. [PMID: 33985849 DOI: 10.1016/j.bjoms.2020.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/01/2020] [Indexed: 11/19/2022]
Affiliation(s)
- M W Ho
- Maxillofacial Surgery Department, Leeds Teaching Hospitals NHS Trust, Clarendon Way, LS2 9LU, Leeds, UK.
| | - F Puglia
- BAOMS QOMS Project Manager, NCEPOD, Ground Floor, Abbey House, 74-76 St John Street, London, EC1M 4DZ, UK.
| | - D Tighe
- Maxillofacial Unit, East Kent Hospitals University NHS Foundation Trust, Ethelbert Rd, Canterbury CT1 3NG, UK.
| | - G A Chiu
- Oral and Maxillofacial Surgery, East Lancashire Teaching Hospitals NHS Trust, Royal Blackburn Teaching Hospital, Haslingden Road, Blackburn BB2 3HH, UK.
| | - F Ridout
- Saving Faces - The Facial Surgery Research Foundation, 71 Tonbridge Street, Kings Cross, London, WC1H 9DZ, UK.
| | - I Hutchison
- Saving Faces - The Facial Surgery Research Foundation, 71 Tonbridge Street, Kings Cross, London, WC1H 9DZ, UK.
| | - M Mason
- NCEPOD, Ground Floor, Abbey House, 74-76 St John Street, London, EC1M 4DZ, UK.
| | - J M McMahon
- Regional Maxillofacial Unit, The Queen Elizabeth University Hospital, 1345 Govan Road, G51 4TF, Glasgow, UK.
| |
Collapse
|
8
|
Tam S, Dong W, Adelman DM, Weber RS, Lewis CM. Risk-adjustment models in patients undergoing head and neck surgery with reconstruction. Oral Oncol 2020; 111:104917. [PMID: 32721817 DOI: 10.1016/j.oraloncology.2020.104917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 07/18/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND With the current focus on value-based outcomes and reimbursement models, perioperative risk adjustment is essential. Specialty surgical outcomes are not well predicted by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP); the Head and Neck-Reconstructive Surgery NSQIP was created as a specialty-specific platform for patients undergoing head and neck surgery with flap reconstruction. This study aims to investigate risk prediction models in these patients. METHODS The Head and Neck-Reconstructive Surgery NSQIP collected data on patients undergoing head and neck surgery with flap reconstruction from August 1, 2012 to October 20, 2016. Multivariable logistic regression models were created for 9 outcomes (postoperative ventilator dependence, pneumonia, superficial recipient surgical site infection, presence of tracheostomy/nasoenteric (NE)/gastrostomy/gastrojejunostomy(G/GJ) tube 30 days postoperatively, conversion from NE to G/GJ tube, unplanned return to the operating room, length of stay > 7 days). External validation was completed with a more contemporary cohort. RESULTS A total of 1095 patients were included in the modelling cohort and 407 in the validation cohort. Models performed well predicting tracheostomy, NE, G/GJ tube presence at 30 days postoperatively and conversion from NE to G/GJ tube (c-indices = 0.75-0.91). Models for postoperative pneumonia, superficial recipient surgical site infection, ventilator dependence > 48 h, and length of stay > 7 days were fair (concordance [c]-indices = 0.63-0.69). The predictive model for unplanned return to the operating room was poor (c-index = 0.58). CONCLUSIONS AND RELEVANCE Reliable and discriminant risk prediction models were able to be created for postoperative outcomes using the specialty-specific Head and Neck-Reconstructive Surgery Specific NSQIP.
Collapse
Affiliation(s)
- Samantha Tam
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wenli Dong
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David M Adelman
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
9
|
Feasibility of an Enhanced Recovery After Surgery (ERAS) pathway for major head and neck oncologic surgery. Am J Otolaryngol 2020; 41:102679. [PMID: 32836043 DOI: 10.1016/j.amjoto.2020.102679] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/10/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Enhanced Recovery After Surgery (ERAS) protocols are gaining traction in the field of head and neck surgery following success in other specialties. Various institutions have reported on the feasibility of implementation and early outcomes in their centers. We report our experience of setting up an ERAS program in a high-volume tertiary cancer care center, including the challenges faced and overcome. METHODS With multidisciplinary input, an ERAS protocol was developed consisting of pre-, intra-, and post-operative interventions based on current evidence. We then assessed an initial series of 104 patients on the ERAS protocol and tracked the compliance rates for various interventions. RESULTS Compliance rates to interventions including pre-operative medication (84.6%), multimodal analgesia (84.6%95.1%), early removal of urinary catheters (76.0%) and early mobilization (56.7%) show a wide variation. However, response rates in the assessment of patient-reported outcomes are low. We discuss factors surrounding the feasibility of implementing an ERAS protocol and tracking outcomes in a diverse, high volume center. DISCUSSION While there are challenges in implementation, results indicate that a successful ERAS pathway in major head and neck oncologic surgery is feasible. Engaging shareholders and making full use of technology in the form of electronic medical systems are essential to this success. IMPLICATIONS FOR PRACTICE ERAS pathways should be encouraged in head and neck surgery, given their proven feasibility in a range of institutions. Further study is needed to confirm this program's impact on outcomes.
Collapse
|
10
|
Kiong KL, Vu CN, Yao CMKL, Kruse B, Zheng G, Yu P, Weber RS, Lewis CM. Enhanced Recovery After Surgery (ERAS) in Head and Neck Oncologic Surgery: A Case-Matched Analysis of Perioperative and Pain Outcomes. Ann Surg Oncol 2020; 28:867-876. [PMID: 32964371 DOI: 10.1245/s10434-020-09174-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/01/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways are well established in certain surgical specialties because findings have shown significant improvements in outcomes. Convincing literature in head and neck cancer (HNC) surgery is lacking. This study aimed to assess the effect of an ERAS pathway on National Surgical Quality Improvement Program (NSQIP)-based occurrences and pain-related outcomes in HNC surgery. METHODS The study matched 200 patients undergoing head and neck oncologic surgery on an ERAS pathway between 1 March 2016 and 31 March 2019 with control subjects (1:1 ratio) during the same period. Demographic and perioperative data collected from the NSQIP database were extracted. Pain scores and medication usage were electronically extracted from our electronic medical record system and compared. Risk factors for high opioid usage also were assessed. RESULTS Both groups were statistically similar in baseline characteristics. The ERAS group had fewer planned intensive care unit (ICU) admissions (4% vs. 14%; p < 0.001), a shorter mean hospital stay (7.2 ± 2.3 vs. 8.7 ± 4.2 days; p < 0.001), and fewer overall complications (18.6% vs. 27.0%; p = 0.045). Morphine milligram equivalent requirements over 72 h were significantly reduced during 72 h in the ERAS group (138.8 ± 181.5 vs. 207.9 ± 205.5; p < 0.001). In the multivariate analysis, the risk factors for high opioid analgesic usage included preoperative opioid usage, age younger than 65 years, race, patient-controlled analgesia use, and ICU admission. CONCLUSION The study findings showed that ERAS in HNC surgery can result in improved outcomes and resource use, and that these results are sustainable. The outcomes described in this report can be further used to optimize ERAS pathways.
Collapse
Affiliation(s)
- Kimberley L Kiong
- Division of Surgery, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Catherine N Vu
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher M K L Yao
- Division of Surgery, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brittany Kruse
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gang Zheng
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peirong Yu
- Department of Plastics and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Division of Surgery, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol M Lewis
- Division of Surgery, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
11
|
Boukovalas S, Goepfert RP, Smith JM, Mecham E, Liu J, Zafereo ME, Chang EI, Hessel AC, Hanasono MM, Gross ND, Yu P, Lewin JS, Lewis CM, Diaz EM, Weber RS, Myers JN, Offodile AC. Association between postoperative complications and long-term oncologic outcomes following total laryngectomy: 10-year experience at MD Anderson Cancer Center. Cancer 2020; 126:4905-4916. [PMID: 32931057 DOI: 10.1002/cncr.33185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Postoperative complications are an independent predictor of poor survival across several tumors. However, there is limited literature on the association between postoperative morbidity and long-term survival following total laryngectomy (TL) for cancer. METHODS We conducted a retrospective review of all TL patients at a single institution from 2008 to 2013. Demographic and clinical data were collected and analyzed, including postsurgical outcomes, which were classified using the Clavien-Dindo system. Multivariable Cox regression analyses were performed to identify factors associated with overall survival (OS) and disease-free survival (DFS). RESULTS A total of 362 patients were identified. The mean age was 64 years, and the majority of patients were male (81%). The median follow-up interval was 21 months. Fifty-seven percent of patients had received preoperative radiation, and 40% had received preoperative chemotherapy. Fifty-seven percent of patients underwent salvage TL, and 60% underwent advanced reconstruction (45% free flap and 15% pedicled flap). A total of 136 patients (37.6%) developed postoperative complications, 92 (25.4%) of which were major. Multivariable modeling demonstrated that postoperative complications independently predicted shorter OS (hazard ratio [HR], 1.50; 95% CI, 1.16-1.96; P = .002) and DFS (HR, 1.36; 95% CI, 1.05-1.76; P = .021). Other independent negative predictors of OS and DFS included positive lymph node status, preoperative chemotherapy, comorbidity grade, and delayed adjuvant therapy. Severity of complication and reason for TL (salvage vs primary) were not shown to be predictive of OS or DFS. CONCLUSION Postoperative complications are associated with worse long-term OS and DFS relative to uncomplicated cases. Patient optimization and timely management of postoperative complications may play a critical role in long-term survival.
Collapse
Affiliation(s)
- Stefanos Boukovalas
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Michael Smith
- Division of Plastic Surgery, The University of Texas Medical Branch, Galveston, Texas
| | | | - Jun Liu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Edward I Chang
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy C Hessel
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew M Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peirong Yu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan S Lewin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo M Diaz
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
12
|
Edwards DA, Medhavy A, Hoffman OG, Hoffman GR. Postoperative Delirium is Associated With Prolonged Head and Neck Resection and Reconstruction Surgery: An Institutional Study. J Oral Maxillofac Surg 2020; 79:249-258. [PMID: 32898481 DOI: 10.1016/j.joms.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Delirium is a recognized complication of surgery. It has a deleterious effect on a patient's postoperative recovery and well-being. The purpose of this study was to estimate the frequency and identify the risk factors for the development of postoperative delirium (POD) in a cohort of patients who underwent extensive head and neck surgery (HNS) of greater than five hours duration. MATERIALS AND METHODS The authors undertook a retrospective cohort study of patients who underwent HNS of greater than five hours duration. The primary predictor variables comprised a set of risk factors (sociodemographic, disease-specific, duration of surgery, and duration of inpatient stay) that were thought to be associated with the development of POD. The primary outcome variable was the development of POD. Descriptive, bivariate, and multivariate statistical analysis was undertaken, and significance was set at P < .05. RESULTS One hundred and seventy patients were included in the study. There were 124 males and 46 females. Forty patients (23.53%) developed POD: 30 documented and 10 inferred. The mean age of the POD cohort was 65 years (SD 13), with a median age of 69 years. The occurrence of POD was statistically related to increased age, mental health status, American Society of Anesthesiologists (ASA) score, and drug dependence (either illicit or prescription). POD and operative duration were statistically associated. POD and length of stay were not statistically associated. CONCLUSION Delirium did occur postoperatively in 23.53% of our patients who underwent extensive and prolonged HNS. POD may go unrecognized by treating teams. As POD has a deleterious effect on the cognitive function, it is important to identify and aggressively treat episodes of POD that occur during a patient's postoperative recovery.
Collapse
Affiliation(s)
- Delyth A Edwards
- Consultant (Attending) Anaesthetist, Department of Anaesthetics, John Hunter Hospital, Newcastle, Australia
| | - Aditi Medhavy
- Resident Medical Officer, Liverpool Hospital, Liverpool, Australia
| | - Olivia G Hoffman
- First year Medical Student, The University of Melbourne, Melbourne, Australia
| | - Gary R Hoffman
- Consultant (Attending) in Head and Neck Surgery, Department of Maxillofacial Surgery, John Hunter Hospital, Newcastle, Australia; Professor, Medical School, The University of Newcastle, Newcastle, Australia.
| |
Collapse
|
13
|
Kiong KL, Lin F, Yao CMKL, Guo T, Ferrarotto R, Weber RS, Lewis CM. Impact of neoadjuvant chemotherapy on perioperative morbidity after major surgery for head and neck cancer. Cancer 2020; 126:4304-4314. [DOI: 10.1002/cncr.33103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Kimberley L. Kiong
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Fang‐Yu Lin
- Department of Symptom Research The University of Texas MD Anderson Cancer Center Houston Texas
| | - Christopher M. K. L. Yao
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Theresa Guo
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Renata Ferrarotto
- Department of Thoracic Head and Neck Medical Oncology The University of Texas MD Anderson Cancer Center Houston Texas
| | - Randal S. Weber
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Carol M. Lewis
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| |
Collapse
|
14
|
Tong JY, Pasick LJ, Benito DA, Sataloff RT. Adverse Events Associated With Laser Use in the Upper Airway. Otolaryngol Head Neck Surg 2020; 164:911-917. [PMID: 32660346 DOI: 10.1177/0194599820938743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Surgical lasers are used extensively in head and neck surgery. Laser use in the upper airway offers many advantages but also presents risks to patients and operators that are not reported comprehensively. This study aims to summarize device malfunctions, patient complications, and subsequent interventions related to laser use in the upper airway. METHODS The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of surgical laser adverse events from January 2010 to March 2020. Data were extracted from reports pertaining to the upper airway. RESULTS Sixty-two reports involving upper airway laser use in an operating room were identified, from which 95 events were extracted. Of these, 40 (42.1%) were adverse events to patients, 2 (2.1%) adverse events to operators, and 53 (55.8%) device malfunctions. Dislodgement of laser fiber in the airway (23 [57.5%]), burn (8 [20%]), and scar (5 [12.5%]) were the most common adverse events to patients. Two incidents of eye exposure through unfiltered microscope lenses were the only adverse events to operators. Fiber break (26 [49.1%]) and flare (12 [22.6%]) were the most common device malfunctions. DISCUSSION Surgical lasers have demonstrated utility in head and neck surgery but are associated with risks. This study discusses adverse events and device malfunctions associated with airway laser surgery and emphasizes shortcomings in current reporting. IMPLICATIONS FOR PRACTICE Standardized reporting and multi-institutional research are needed to better understand adverse events related to surgical laser use and to allow accurate estimation of their prevalence.
Collapse
Affiliation(s)
- Jane Y Tong
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Luke J Pasick
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Daniel A Benito
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Robert T Sataloff
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.,Lankenau Institute for Medical Research, Philadelphia, Pennsylvania, USA
| |
Collapse
|
15
|
Tapia B, Garrido E, Cebrian JL, Castillo JLD, Alsina E, Gilsanz F. New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients. Minerva Anestesiol 2020; 86:861-871. [PMID: 32486605 DOI: 10.23736/s0375-9393.20.13997-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.
Collapse
Affiliation(s)
- Blanca Tapia
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain -
| | - Elena Garrido
- Department of Anesthesia an Intensive Care, Wexner Medical Center, Columbus, OH, USA
| | - Jose L Cebrian
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Jose L Del Castillo
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Estibaliz Alsina
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
| | - Fernando Gilsanz
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
| |
Collapse
|
16
|
Quimby AE, Corsten MJ, Grose E, Odell M, Johnson-Obaseki S. Quality Indicators of Central Compartment Neck Dissection in Thyroid Surgery. Otolaryngol Head Neck Surg 2020; 163:938-946. [PMID: 32453652 DOI: 10.1177/0194599820925757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Quality metrics are an increasingly important means of improving patient care. Variability in the number of lymph nodes removed during central compartment lymph node dissection (CCLND) at the time of thyroidectomy has not been studied. STUDY DESIGN A retrospective cohort study was performed using American College of Surgeons National Quality Improvement Program (ACS-NSQIP) data. SETTING Centers in North America and worldwide contributing data to ACS-NSQIP and performing thyroidectomy on adults in inpatient and outpatient settings were included. SUBJECTS AND METHODS Adult patients undergoing thyroidectomy with or without CCLND were included. Outcomes of interest were number of nodes removed during CCLND and risks of postoperative hypocalcemia. RESULTS In total, 6108 patients met inclusion criteria (1565 with CCLND). The median number of lymph nodes removed during CCLND was 2. There was no statistically significant association between postoperative hypocalcemia and CCNLD, regardless of number of nodes removed. However, we were underpowered to detect this association based on the overall low nodal yield of many CCLNDs performed. CONCLUSION In many cases where CCLND is documented as part of thyroidectomy, very few lymph nodes are removed. Our ability to draw conclusions regarding the effect of CCLND on postoperative hypocalcemia is restricted due to the limited nature of many CCLNDs performed.
Collapse
Affiliation(s)
- Alexandra E Quimby
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Martin J Corsten
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Elysia Grose
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Odell
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | |
Collapse
|
17
|
Marinone Lares SG, Clark S, Mathy JA, Chaplin J, McIvor N. Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction. ANZ J Surg 2020; 90:1386-1390. [PMID: 32436238 DOI: 10.1111/ans.15974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre. METHODS A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature. RESULTS The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively. CONCLUSION The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.
Collapse
Affiliation(s)
| | - Sita Clark
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Jon A Mathy
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand.,Auckland Regional Plastic Surgery Unit, Auckland, New Zealand
| | - John Chaplin
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Nick McIvor
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
18
|
The Next Frontier of Outcomes Research: Collaborative Quality Initiatives. Plast Reconstr Surg 2020; 145:1315-1322. [DOI: 10.1097/prs.0000000000006748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
19
|
Crosby DL, Sharma A. Evidence-Based Guidelines for Management of Head and Neck Mucosal Malignancies during the COVID-19 Pandemic. Otolaryngol Head Neck Surg 2020; 163:16-24. [PMID: 32340549 DOI: 10.1177/0194599820923623] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Due to the current coronavirus disease 2019 (COVID-19) pandemic, otolaryngologists face novel challenges when treating patients with head and neck cancer. The purpose of this review is to evaluate the current evidence surrounding the treatment of these patients during this pandemic and to provide evidence-based recommendations with attention to increased risk in this setting. DATA SOURCES A review of the literature was performed with PubMed. Because recently published articles on this topic may not yet be indexed into PubMed, otolaryngology journals were hand searched for relevant articles. Guidelines from national organizations were reviewed to identify additional relevant sources of information. REVIEW METHODS Two groups of search terms were created: one with terms related to COVID-19 and another with terms related to head and neck cancer and its management. Searches were performed of all terms in each group as well as combinations of terms between groups. Searches and subsequent exclusion of articles were performed in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Additional articles were identified after relevant journals and guidelines from national organizations were reviewed. CONCLUSIONS Patients with head and neck mucosal malignancy require continued treatment despite the current pandemic state. Care must be taken at all stages of treatment to minimize the risk to patients and health care workers while maintaining focus on minimizing use of limited resources. IMPLICATIONS FOR PRACTICE Patient care plans should be guided by best available evidence to optimize outcomes while maintaining a safe environment in the setting of this pandemic.
Collapse
Affiliation(s)
- Dana L Crosby
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Arun Sharma
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| |
Collapse
|
20
|
Mascarella MA, Richardson K, Mlynarek A, Forest VI, Hier M, Sadeghi N, Mayo N. Evaluation of a Preoperative Adverse Event Risk Index for Patients Undergoing Head and Neck Cancer Surgery. JAMA Otolaryngol Head Neck Surg 2020; 145:345-351. [PMID: 30789650 DOI: 10.1001/jamaoto.2018.4513] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Patients 65 years or older are the most frequent users of operative resources and are also the most vulnerable to postoperative adverse events (AEs). Frailty indices are increasingly being used for preoperative risk stratification within head and neck cancer surgery, but most models lack a multifactorial basis and cannot be directly applied to clinical practice. A practical risk index is needed for clinicians to gauge risk factors preoperatively. Objective To develop a preoperative risk index of short-term major postoperative AEs for patients undergoing head and neck cancer surgery. Design Cohort analysis of patients from multiple medical centers undergoing inpatient ablative or reconstructive head and neck cancer surgery and registered in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) from 2006 to 2016. Exposures Inpatient ablative or reconstructive head and neck cancer surgery. Main Outcomes and Measures Sociodemographic, frailty-related, and surgical factors in the derivation cohort were evaluated using simple and multiple logistic regression. Risk factors were subsequently integrated into a preoperative head and neck surgery risk index (HNSRI) and compared with existing models using the validation cohort. A composite variable of major postoperative AEs was used, including death within 30 days of surgery. Results A total of 43 968 operations were found using the ACS NSQIP database. Of these, 12 569 cases were excluded as non-head and neck cancer or emergency surgery. Of the included 31 399 operations reviewed, the mean (SD) patient age was 56.9 (15.4) years, and 16 994 of the patients were women (54.1%). A total of 4556 (14.5%) patients had a major postoperative AE, and 209 (0.7%) died. Older age, male sex, smoking, anticoagulation, recent weight loss, functional dependence, free-tissue transfer, tracheotomy, duration of surgery, wound classification, anemia, leukocytosis, and hypoalbuminemia were independently associated with major AEs or death on multiple regression analysis (C statistic, 0.83). The area under the curve of the HNSRI to predict major AEs including death using the validation cohort (n = 15 699) was 0.84 (95% CI, 0.83-0.85) with a sensitivity of 80.1% (95% CI, 79.4%-80.8%) and specificity, 72.3% (95% CI, 70.3%-74.2%). The HNSRI outperformed existing risk models for prediction of AEs: delta C index of the HNSRI to the modified frailty index 11, 0.23 (95% CI, 0.22-0.25); the American Society of Anesthesiologists classification, 0.14 (95% CI, 0.13-0.16); and the ACS risk calculator, 0.02 (95% CI, 0.01-0.03). Conclusions and Relevance The proposed HNSRI demonstrated a high sensitivity and specificity for major postoperative AEs and death in the studied population. This risk index can be used to counsel patients awaiting head and neck cancer surgery.
Collapse
Affiliation(s)
- Marco Antonio Mascarella
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Keith Richardson
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Alex Mlynarek
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Michael Hier
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Nader Sadeghi
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Nancy Mayo
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,School of Physical and Occupational Health, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
21
|
Tam S, Weber RS, Lewis CM. ASO Author Reflections: Unplanned Return to the Operating Room: Implementing a Specialty-Specific NSQIP in Patients Undergoing Head and Neck Surgery with Free Flap Reconstruction. Ann Surg Oncol 2019; 27:449-450. [PMID: 31664616 DOI: 10.1245/s10434-019-07978-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Samantha Tam
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
22
|
Hanasono MM. Invited Editorial: "The Head and Neck Reconstructive Surgery National Surgical Quality Improvement Program (NSQIP): Evaluating Unplanned Returns to the Operating Room" by Tam S et al. Ann Surg Oncol 2019; 27:325-326. [PMID: 31531794 DOI: 10.1245/s10434-019-07679-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Indexed: 11/18/2022]
|
23
|
Tam S, Weber RS, Liu J, Ting J, Hanson S, Lewis CM. Evaluating Unplanned Returns to the Operating Room in Head and Neck Free Flap Patients. Ann Surg Oncol 2019; 27:440-448. [PMID: 31410610 DOI: 10.1245/s10434-019-07675-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Head and neck oncologic surgery with reconstruction represents one of the most complex operations in otolaryngology. Unplanned return to the operating room represents an objective measure of postoperative complications. The purpose of this study was to identify reasons and risk factors for unplanned return to the operating room in patients undergoing head and neck surgery with reconstruction. METHODS This retrospective cohort study of 467 patients undergoing head and neck surgery with free flap reconstruction used a previously-developed Head and Neck-Reconstructive Surgery-specific National Surgical Quality Improvement Program. Disease and site-specific preoperative, intraoperative, and postoperative data were gathered. Comparisons between those with and without an unexpected return to the operating room were completed with univariate and multiple logistic regression models. RESULTS The rate of unexpected return to the operating room was 18.8% (88 patients). Most common reasons for URTOR were flap compromise (24 patients, 5.1%), postoperative infection (21 patients, 4.5%), and hematoma (20 patients, 4.3%). Two risk factors were identified by multivariate analysis: coagulopathy (ORadjusted = 2.83, 95% CI = 1.24-6.19, P = 0.010), and use of alcohol (ORadjusted = 1.9, 95% CI = 1.14-3.33, P = 0.025). CONCLUSIONS Preexisting coagulopathy and increased alcohol consumption were associated with increased risk of unexpected return to the operating room. These findings can aid physicians in preoperative patient counseling and medical optimization and can inform more precise risk stratification of patients undergoing head and neck surgery with reconstruction. Strategies to prevent and mitigate unexpected returns to the operating room will improve patient outcomes, decrease resource utilization, and facilitate successful integration into alternative payment models.
Collapse
Affiliation(s)
- Samantha Tam
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic and Reconstructive Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose Ting
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Summer Hanson
- Department of Plastic and Reconstructive Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
24
|
Tierney W, Shah J, Clancy K, Lee MY, Ciolek PJ, Fritz MA, Lamarre ED. Predictive value of the ACS NSQIP calculator for head and neck reconstruction free tissue transfer. Laryngoscope 2019; 130:679-684. [PMID: 31361334 DOI: 10.1002/lary.28195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/15/2019] [Accepted: 07/05/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Predictive models to forecast the likelihood of specific outcomes after surgical intervention allow informed shared decision-making by surgeons and patients. Previous studies have suggested that existing general surgical risk calculators poorly forecast head and neck surgical outcomes. However, no large study has addressed this question while subdividing subjects by surgery performed. OBJECTIVES To determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator in estimating length of hospital stay and risk of postoperative complications after free tissue transfer surgery. STUDY DESIGN A retrospective chart review of patients at one institution was performed using Current Procedural Terminology codes for anterolateral thigh (ALT) flap, fibula free flap (FFF), and radial forearm free flap (RFFF) reconstruction. Output data from the ACS NSQIP surgical risk calculator were compared with the observed rates in our patients. METHODS Incidences of cardiac complications, pneumonia, venous thromboembolism, return to the operating room, and discharge to skilled nursing facility (SNF) were compared to predicted incidences. Length of stay was also compared to the predicted length of stay. RESULTS Three hundred thirty-six free flap reconstructions with 197 ALT flaps, 85 RFFFs, and 54 FFFFs were included. Brier scores were calculated using ACS NSQIP forecast and actual incidences. No Brier score was <0.01 for the entire sample or any subgroup, which indicates that the NSQIP risk calculator does not accurately forecast outcomes after free tissue reconstruction. CONCLUSION The ACS NSQIP failed to accurately forecast postoperative outcomes after head and neck free flap reconstruction for the entire sample or subgroup analyses. LEVEL OF EVIDENCE 4 Laryngoscope, 130:679-684, 2020.
Collapse
Affiliation(s)
- William Tierney
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, U.S.A.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Janki Shah
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, U.S.A
| | - Kate Clancy
- Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Maxwell Y Lee
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Peter J Ciolek
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, U.S.A
| | - Michael A Fritz
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, U.S.A
| | - Eric D Lamarre
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, U.S.A.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
| |
Collapse
|
25
|
Augustine HFM, Hu J, Najarali Z, McRae M. Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research. Plast Surg (Oakv) 2019; 27:54-65. [PMID: 30854363 DOI: 10.1177/2292550318800499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research. Methods A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication. Results A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery. Conclusion This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.
Collapse
Affiliation(s)
- Haley F M Augustine
- Department of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jiayi Hu
- Department of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Zainab Najarali
- Department of Family Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Matthew McRae
- Department of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
26
|
Reducing morbidity and complications after major head and neck cancer surgery: the (future) role of enhanced recovery after surgery protocols. Curr Opin Otolaryngol Head Neck Surg 2018; 26:71-77. [PMID: 29432221 DOI: 10.1097/moo.0000000000000442] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
Collapse
|
27
|
Ma Y, Laitman BM, Patel V, Teng M, Genden E, DeMaria S, Miles BA. Assessment of the NSQIP Surgical Risk Calculator in Predicting Microvascular Head and Neck Reconstruction Outcomes. Otolaryngol Head Neck Surg 2018; 160:100-106. [DOI: 10.1177/0194599818789132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective This study evaluated the accuracy of the Surgical Risk Calculator (SRC) of the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) in predicting head and neck microvascular reconstruction outcomes. Study Design Retrospective analysis. Setting Tertiary medical center. Subjects and Methods A total of 561 free flaps were included in the analysis. The SRC-predicted 30-day rates of postoperative complications, hospital length of stay (LOS), and rehabilitation discharge were compared with the actual rates and events. The SRC’s predictive value was examined with Brier scores and receiver operating characteristic area under the curve. Results A total of 425 myocutaneous, 134 osseous (84 fibula, 47 scapula, and 3 iliac crest), and 2 omental free flaps were included in this study. All perioperative complications evaluated had area under the curve values ≤0.75, ranging from 0.480 to 0.728. All but 2 postoperative complications had Brier scores >0.01. SRC-predicted LOS was 9.4 ± 2.38 days (mean ± SD), which did not strongly correlate with the actual LOS of 11.98 ± 9.30 days ( r = 0.174, P < .0001). Conclusion The SRC is a poor predictor for surgical outcome among patients undergoing microvascular head and neck reconstruction.
Collapse
Affiliation(s)
- Yue Ma
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vir Patel
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marita Teng
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric Genden
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brett A. Miles
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
28
|
Cao A, Khayat S, Cash E, Nickel C, Gettelfinger J, Tennant P, Bumpous J. ACS NSQIP risk calculator reliability in head and neck oncology: The effect of prior chemoradiation on NSQIP risk estimates following laryngectomy. Am J Otolaryngol 2018; 39:192-196. [PMID: 29174070 DOI: 10.1016/j.amjoto.2017.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/03/2017] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To determine whether inclusion of chemoradiation history increases estimated risk for complications following total laryngectomy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator. MATERIALS AND METHODS A retrospective review of 96 patients with laryngeal cancer, approximately half of who had received prior chemoradiation, who underwent laryngectomy between January 2010 and December 2014. NSQIP estimates were calculated and compared to actual event occurrence using receiver operating characteristic (ROC) curves, Brier scores, and risk estimates. RESULTS Patients who had received prior chemoradiation were at significantly greater risk for complication postoperatively (OR=2.63, 95% CI=1.145-6.043). NSQIP Calculator discriminability and accuracy were generally poor for this sample. While NSQIP estimates significantly predicted risk for any postoperative complication, pneumonia, and discharge to nursing care for primary laryngectomy patients, predictive capability was lost among salvage laryngectomy patients. NSQIP adjustments to both Somewhat Higher and Significantly Higher Risk categories did not improve predictive capability. Of the risk factors considered by NSQIP, preoperative functional status (p=0.041), age at time of surgery (p<0.008), and inclusion of neck dissection (p=0.035) emerged as significant predictors of actual postoperative complications, though again estimates lost significance among salvage laryngectomy patients. CONCLUSIONS The NSQIP Calculator may be poorly calibrated to estimate postoperative complication risk for patients previously exposed to chemoradiation undergoing salvage laryngectomy. Caution should be used when estimating postoperative risk among patients undergoing salvage procedures, especially those of older age, poorer functional status, and those requiring neck dissection.
Collapse
|
29
|
Kakarala K, Shnayder Y, Tsue TT, Girod DA. Mandibular reconstruction. Oral Oncol 2018; 77:111-117. [DOI: 10.1016/j.oraloncology.2017.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/18/2017] [Accepted: 12/29/2017] [Indexed: 11/24/2022]
|
30
|
Abstract
Performance improvement requires establishing a platform to set benchmarks and monitor the quality of care provided through quality indicators and metrics. This has long been recognized as critical to overall quality improvement and more recently, has become federally mandated. Here, we review recent studies evaluating performance in head and neck cancer care, from those spanning all phases of head and neck cancer care to others focused on head and neck surgical performance, including both national and departmental/institutional efforts.
Collapse
Affiliation(s)
- Carol M Lewis
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1445, Houston, TX, 77030, USA.
| | - Randal S Weber
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1445, Houston, TX, 77030, USA
| |
Collapse
|
31
|
Eskander A, Kang SY, Tweel B, Sitapara J, Old M, Ozer E, Agrawal A, Carrau R, Rocco J, Teknos TN. Quality Indicators: Measurement and Predictors in Head and Neck Cancer Free Flap Patients. Otolaryngol Head Neck Surg 2018; 158:265-272. [DOI: 10.1177/0194599817742373] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective To determine the predictors of length of stay (LOS), readmission within 30 days, and unplanned return to the operating room (OR) within 30 days in head and neck free flap patients. Study Design Case series with chart review. Setting Tertiary academic cancer hospital. Subjects and Methods All head and neck free flap patients at The Ohio State University (OSU, 2006-2012) were assessed. Multivariable logistic regression to assess the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes. Results In total, 515 patients were identified, of whom 66% had oral cavity cancers, 33% had recurrent tumors, and 28% underwent primary radiotherapy. Of the patients, 31.5% had a LOS greater than 9 days, predicted by longer operative time, oral cavity and pharyngeal tumor sites, blood transfusion, diabetes mellitus, and any complication. A total of 12.6% of patients were readmitted within 30 days predicted by absent OSU preoperative assessment clinic attendance and any complication, and 14.8% of patients had an unplanned OR return predicted by advanced age. Conclusions When assessing quality metrics, adjustment for the complexity involved in managing patients with head and neck cancer with a high comorbidity index, clean contaminated wounds, and a high degree of primary radiotherapy is important. Patients seen in a preoperative assessment clinic had a lower risk of readmission postoperatively, and this should be recommended for all head and neck free flap patients. Quality improvement projects should focus on predictors and prevention of complications as this was the number one predictor of both increased length of stay and readmission.
Collapse
Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada
| | - Stephen Y. Kang
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Benjamin Tweel
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jigar Sitapara
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Matthew Old
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Enver Ozer
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Amit Agrawal
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Ricardo Carrau
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - James Rocco
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Theodoros N. Teknos
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| |
Collapse
|
32
|
Head & neck reconstruction: Predictors of readmission. Oral Oncol 2017; 74:159-162. [DOI: 10.1016/j.oraloncology.2017.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/08/2017] [Accepted: 06/20/2017] [Indexed: 11/17/2022]
|
33
|
Mallen-St. Clair J. Quality Metrics in Oral Cavity Cancer—Developing Standards for Optimal Lymph Node Yield. JAMA Otolaryngol Head Neck Surg 2017; 143:973-974. [DOI: 10.1001/jamaoto.2017.0978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Jon Mallen-St. Clair
- Department of Head and Neck Surgery, University of California-San Francisco, San Francisco
| |
Collapse
|
34
|
Validity of the American College of Surgeons' National Surgical Quality Improvement Program risk calculator in South Australian glossectomy patients. The Journal of Laryngology & Otology 2017; 132:173-179. [DOI: 10.1017/s0022215117001451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Appropriate selection of tongue cancer patients considering surgery is critical in ensuring optimal outcomes. The American College of Surgeons' National Surgical Quality Improvement Program (‘ACS-NSQIP’) risk calculator was developed to assess patients' 30-day post-operative risk, providing surgeons with information to guide decision making.Method:A retrospective review of 30-day actual mortality and morbidity of tongue cancer patients was undertaken to investigate the validity of this tool for South Australian patients treated from 2005 to 2015.Results:One hundred and twenty patients had undergone glossectomy. Predicted length of stay using the risk calculator was significantly different from actual length of stay. Predicted mortality and other complications were found to be similar to actual outcomes.Conclusion:The American College of Surgeons' National Surgical Quality Improvement Program risk calculator was found to be effective in predicting post-operative complication rates in South Australian tongue cancer patients. However, significant discrepancies in predicted and actual length of stay may limit its use in this population.
Collapse
|
35
|
Riley CA, Barton BM, Lawlor CM, Cai DZ, Riley PE, McCoul ED, Hasney CP, Moore BA. NSQIP as a Predictor of Length of Stay in Patients Undergoing Free Flap Reconstruction. OTO Open 2017; 1:2473974X16685692. [PMID: 30480171 PMCID: PMC6239043 DOI: 10.1177/2473974x16685692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 11/29/2016] [Accepted: 12/02/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The National Surgical Quality Improvement Program (NSQIP) calculator was created to improve outcomes and guide cost-effective care in surgery. Patients with head and neck cancer (HNC) undergo ablative and free flap reconstructive surgery with prolonged postoperative courses. METHODS A case series with chart review was performed on 50 consecutive patients with HNC undergoing ablative and reconstructive free flap surgery from October 2014 to March 2016 at a tertiary care center. Comorbidities and intraoperative and postoperative variables were collected. Predicted length of stay was tabulated with the NSQIP calculator. RESULTS Thirty-five patients (70%) were male. The mean (SD) age was 67.2 (13.4) years. The mean (SD) length of stay (LOS) was 13.5 (10.3) days. The mean (SD) NSQIP-predicted LOS was 10.3 (2.2) days (P = .027). DISCUSSION The NSQIP calculator may be an inadequate predictor for LOS in patients with HNC undergoing free flap surgery. Additional study is necessary to determine the accuracy of this tool in this patient population. IMPLICATIONS FOR PRACTICE Head and neck surgeons performing free flap reconstructive surgery following tumor ablation may find that the NSQIP risk calculator underestimates the LOS in this population.
Collapse
Affiliation(s)
- Charles A. Riley
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Blair M. Barton
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Claire M. Lawlor
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - David Z. Cai
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Phoebe E. Riley
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Edward D. McCoul
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
- Department of Otorhinolaryngology,
Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of
Queensland, New Orleans, Louisiana, USA
| | - Christian P. Hasney
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
- Department of Otorhinolaryngology,
Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of
Queensland, New Orleans, Louisiana, USA
| | - Brian A. Moore
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
- Department of Otorhinolaryngology,
Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of
Queensland, New Orleans, Louisiana, USA
| |
Collapse
|
36
|
Cannady SB, Hatten KM, Bur AM, Brant J, Fischer JP, Newman JG, Chalian AA. Use of free tissue transfer in head and neck cancer surgery and risk of overall and serious complication(s): An American College of Surgeons-National Surgical Quality Improvement Project analysis of free tissue transfer to the head and neck. Head Neck 2016; 39:702-707. [DOI: 10.1002/hed.24669] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/29/2016] [Accepted: 11/04/2016] [Indexed: 12/22/2022] Open
Affiliation(s)
- Steven B. Cannady
- Department of Otorhinolaryngology - Head and Neck Surgery; The University of Pennsylvania; Philadelphia Pennsylvania
| | - Kyle M. Hatten
- Department of Otorhinolaryngology - Head and Neck Surgery; The University of Pennsylvania; Philadelphia Pennsylvania
| | - Andres M. Bur
- Department of Otorhinolaryngology - Head and Neck Surgery; The University of Pennsylvania; Philadelphia Pennsylvania
| | - Jason Brant
- Department of Otorhinolaryngology - Head and Neck Surgery; The University of Pennsylvania; Philadelphia Pennsylvania
| | - John P. Fischer
- Division of Plastic and Reconstructive Surgery; The University of Pennsylvania; Philadelphia Pennsylvania
| | - Jason G. Newman
- Department of Otorhinolaryngology - Head and Neck Surgery; The University of Pennsylvania; Philadelphia Pennsylvania
| | - Ara A. Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery; The University of Pennsylvania; Philadelphia Pennsylvania
| |
Collapse
|
37
|
Helman SN, Brant JA, Moubayed SP, Newman JG, Cannady SB, Chai RL. Predictors of length of stay, reoperation, and readmission following total laryngectomy. Laryngoscope 2016; 127:1339-1344. [DOI: 10.1002/lary.26454] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/04/2016] [Accepted: 11/14/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Samuel N. Helman
- Department of Otolaryngology-Head and Neck Surgery; New York Eye and Ear Infirmary of Mount Sinai; New York New York
| | - Jason A. Brant
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Sami P. Moubayed
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Beth Israel; New York New York U.S.A
| | - Jason G. Newman
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Steven B. Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Raymond L. Chai
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Beth Israel; New York New York U.S.A
| |
Collapse
|
38
|
Johnson C, Campwala I, Gupta S. Examining the validity of the ACS-NSQIP Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Investig Med 2016; 65:722-725. [PMID: 27793973 DOI: 10.1136/jim-2016-000224] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 11/04/2022]
Abstract
American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) created the Surgical Risk Calculator, to allow physicians to offer patients a risk-adjusted 30-day surgical outcome prediction. This tool has not yet been validated in plastic surgery. A retrospective analysis of all plastic surgery-specific complications from a quality assurance database from September 2013 through July 2015 was performed. Patient preoperative risk factors were entered into the ACS Surgical Risk Calculator, and predicted outcomes were compared with actual morbidities. The difference in average predicted complication rate versus the actual rate of complication within this population was examined. Within the study population of patients with complications (n=104), the calculator accurately predicted an above average risk for 20.90% of serious complications. For surgical site infections, the average predicted risk for the study population was 3.30%; this prediction was proven only 24.39% accurate. The actual incidence of any complication within the 4924 patients treated in our plastic surgery practice from September 2013 through June 2015 was 1.89%. The most common plastic surgery complications include seroma, hematoma, dehiscence and flap-related complications. The ACS Risk Calculator does not present rates for these risks. While most frequent outcomes fall into general risk calculator categories, the difference in predicted versus actual complication rates indicates that this tool does not accurately predict outcomes in plastic surgery. The ACS Surgical Risk Calculator is not a valid tool for the field of plastic surgery without further research to develop accurate risk stratification tools.
Collapse
|