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The formulation of an enhanced recovery programme for patients undergoing laryngectomy. The Journal of Laryngology & Otology 2022; 136:848-860. [DOI: 10.1017/s0022215122000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveEnhanced recovery programmes have been widely adopted in other surgical disciplines but are not commonplace in head and neck surgery. The authors of this study created a pathway for post-operative laryngectomy patients.MethodA multidisciplinary working group reviewed the literature and agreed standards of care. A retrospective audit was conducted to measure current practice against our new pathway; after programme implementation our performance was reaudited in two prospective cycles, with an education programme and review after the first prospective cycle.ResultsStatistically significant improvement in performance was realised in catheter and surgical drain removal, opiate analgesia use, mobilisation, and timeliness of swallow assessment. The rate of hospital acquired pneumonia reduced from 23.1 to 9.5 per cent and length of stay reduced by a median of 5.2 days to 14.8 days (non-significant).ConclusionThe programme improved consistency of patient care across most areas that were measured. Improving patient stoma training needs to be prioritised.
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Outcomes for head and neck cancer patients admitted to intensive care in Australia and New Zealand between 2000 and 2016. The Journal of Laryngology & Otology 2021; 135:702-709. [PMID: 34154686 DOI: 10.1017/s0022215121001602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To report intensive care unit admission outcomes for head and neck cancer patients. METHODS A retrospective, observational cohort analysis of all Australian and New Zealander head and neck cancer patient intensive care unit admissions from January 2000 to June 2016, including data from 192 intensive care units. RESULTS There were 10 721 head and neck cancer patients, with a median age of 64 years (71.6 per cent male). Of admissions, 76.4 per cent were in public hospitals, 96.9 per cent were post-operative and 43.6 per cent required mechanical ventilation. Annual head and neck cancer admissions increased from 2000 to 2015 (from 348 to 1132 patients), but the overall proportion of intensive care unit admissions remained constant. In-hospital mortality was 2.7 per cent, and intensive care unit mortality was 0.7 per cent. The in-hospital mortality risk decreased three-fold (p < 0.001). CONCLUSION Head and neck cancer patients had low mortality in the intensive care unit and in hospital. Risk of dying decreased despite more intensive care unit admissions. This is the first large-scale cohort study quantifying intensive care unit utilisation by head and neck cancer patients. It informs future work investigating alternatives to the intensive care unit for these patients.
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Lee XJ, Blythe R, Choudhury AAK, Simmons T, Graves N, Kularatna S. Review of methods and study designs of evaluations related to clinical pathways. AUST HEALTH REV 2020; 43:448-456. [PMID: 30089529 DOI: 10.1071/ah17276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/19/2018] [Indexed: 11/23/2022]
Abstract
Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users' experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation. Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases. Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings. Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost-consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed. What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited. What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis. What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.
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Affiliation(s)
- Xing Ju Lee
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Robin Blythe
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Adnan Ali Khan Choudhury
- Northern Queensland Primary Health Network, James Cook University, Building 500, 1 James Cook Drive, Douglas, Qld 4811, Australia. Email
| | - Toni Simmons
- Mackay Hospital and Health Service, Mackay, 475 Bridge Road, Mackay, Qld 4740, Australia. Email
| | - Nicholas Graves
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Sanjeewa Kularatna
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
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Mhawej R, Harmych BM, Houlton JJ, Tabangin ME, Meinzen-Derr J, Patil YJ. The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes. J Laryngol Otol 2020; 134:1-9. [PMID: 31971118 DOI: 10.1017/s0022215120000080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- R Mhawej
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
| | - B M Harmych
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
| | - J J Houlton
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
| | - M E Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - J Meinzen-Derr
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Y J Patil
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati Medical Center, Ohio, USA
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Abo Sharkh H, Madathil S, Al-Ghamdi O, Agnihotram RV, Sinha A, El-Hakim M, Nicolau B, Makhoul N. A Comprehensive Clinical Care Pathway for Microvascular Maxillofacial Reconstructive Surgery. J Oral Maxillofac Surg 2019; 77:2347-2354. [PMID: 31153941 DOI: 10.1016/j.joms.2019.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Haider Abo Sharkh
- Fellow in Maxillofacial Oncology and Microvascular Reconstruction, Department of Oral and Maxillofacial Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Sreenath Madathil
- Research Director, Department of Oral and Maxillofacial Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Osama Al-Ghamdi
- Previous Fellow in Maxillofacial Oncology and Microvascular Reconstruction, Department of Oral and Maxillofacial Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Ramanakumar V Agnihotram
- Adjunct Professor, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Avinash Sinha
- Assistant Professor, Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Michel El-Hakim
- Assistant Professor, Department of Oral and Maxillofacial Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Belinda Nicolau
- Associate Professor, Division of Oral Health and Society, Faculty of Dentistry, McGill University, Montreal, Quebec, Canada
| | - Nicholas Makhoul
- Director and Associate Professor, Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, McGill University, and Chief, Department of Dentistry and Oral and Maxillofacial Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
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Moreno MA, Bonilla‐Velez J. Clinical pathway for abbreviated postoperative hospital stay in free tissue transfer to the head and neck: Impact in resource utilization and surgical outcomes. Head Neck 2019; 41:982-992. [DOI: 10.1002/hed.25525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 11/05/2022] Open
Affiliation(s)
- Mauricio A. Moreno
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Juliana Bonilla‐Velez
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
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Gordon SA, Reiter ER. Effectiveness of critical care pathways for head and neck cancer surgery: A systematic review. Head Neck 2016; 38:1421-7. [DOI: 10.1002/hed.24265] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Steven A. Gordon
- Department of Otolaryngology - Head and Neck Surgery; Virginia Commonwealth University School of Medicine; Richmond Virginia
| | - Evan R. Reiter
- Department of Otolaryngology - Head and Neck Surgery; Virginia Commonwealth University School of Medicine; Richmond Virginia
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El Baz N, Middel B, van Dijk JP, Oosterhof A, Boonstra PW, Reijneveld SA. Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research. J Eval Clin Pract 2007; 13:920-9. [PMID: 18070263 DOI: 10.1111/j.1365-2753.2006.00774.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Noha El Baz
- Department of Health Sciences, Subdivision Care Sciences, University Medical Center Groningen, University of Groningen, The Netherlands
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van Agthoven M, Heule-Dieleman HAG, Knegt PP, Kaanders JHAM, Baatenburg de Jong RJ, Kremer B, Leemans CR, Marres HAM, Manni JJ, Langendijk JA, Levendag PC, Tjho-Heslinga RE, de Jong JMA, de Boer MF, Uyl-de Groot CA. Compliance and efficiency before and after implementation of a clinical practice guideline for laryngeal carcinomas. Eur Arch Otorhinolaryngol 2006; 263:729-37. [PMID: 16699832 DOI: 10.1007/s00405-006-0062-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2005] [Accepted: 09/13/2005] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Michel van Agthoven
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus MC, University Medical Centre Rotterdam, PO Box 1738, 3000 DR, Rotterdam, The Netherlands.
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van Agthoven M, Heule-Dieleman HAG, de Boer MF, Kaanders JHAM, Baatenburg de Jong RJ, Kremer B, Leemans CR, Marres HAM, Manni JJ, Langendijk JA, Levendag PC, Tjho-Heslinga RE, de Jong JMA, Uyl-de Groot CA, Knegt PP. Evaluating adherence to the Dutch guideline for diagnosis, treatment and follow-up of laryngeal carcinomas. Radiother Oncol 2005; 74:337-44. [PMID: 15763316 DOI: 10.1016/j.radonc.2005.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2004] [Revised: 12/14/2004] [Accepted: 01/19/2005] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Michel van Agthoven
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus MC, University Medical Centre, PO Box 1738, 3000 DR Rotterdam, The Netherlands
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Abstract
Surgical treatment for head and neck cancer includes a variety of complex operative procedures. Patients scheduled for these operations often are presented with overwhelming amounts of information. Even after participating in the multidisciplinary, preoperative teaching process, they may be unable to fully comprehend the treatment plan. Pathways for head and neck surgery were designed to facilitate the patient- and family-education process and assist the patient in navigating through the surgical experience. This article discusses head and neck surgery pathway development, implementation, and outcome evaluation.
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