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Passchier E, Beck AJCC, Stuiver MM, Retèl VP, Navran A, van Harten WH, van den Brekel MWM, van der Molen L. Organization of head and neck cancer rehabilitation care: a national survey among healthcare professionals in Dutch head and neck cancer centers. Eur Arch Otorhinolaryngol 2024; 281:2575-2585. [PMID: 38324056 PMCID: PMC11023954 DOI: 10.1007/s00405-024-08488-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE Head and neck cancer (HNC) treatment often leads to physical and psychosocial impairments. Rehabilitation can overcome these limitations and improve quality of life. The aim of this study is to obtain an overview of rehabilitation care for HNC, and to investigate factors influencing rehabilitation provision, in Dutch HNC centers, and to some extent compare it to other countries. METHODS An online survey, covering five themes: organizational structure; rehabilitation interventions; financing; barriers and facilitators; satisfaction and future improvements, among HNC healthcare- and financial professionals of Dutch HNC centers. RESULTS Most centers (86%) applied some type of rehabilitation care, with variations in organizational structure. A speech language therapist, physiotherapist and dietitian were available in all centers, but other rehabilitation healthcare professionals in less than 60%. Facilitators for providing rehabilitation services included availability of a contact person, and positive attitude, motivation, and expertise of healthcare professionals. Barriers were lack of reimbursement, and patient related barriers including comorbidity, travel (time), low health literacy, limited financial capacity, and poor motivation. CONCLUSION Although all HNC centers included offer rehabilitation services, there is substantial practice variation, both nationally and internationally. Factors influencing rehabilitation are related to the motivation and expertise of the treatment team, but also to reimbursement aspects and patient related factors. More research is needed to investigate the extent to which practice variation impacts individual patient outcomes and how to integrate HNC rehabilitation into routine clinical pathways.
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Affiliation(s)
- Ellen Passchier
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Centre for Quality of Life, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ann-Jean C C Beck
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Martijn M Stuiver
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Centre for Quality of Life, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Arash Navran
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Michiel W M van den Brekel
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Institute of Phonetic Sciences ACLC, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Lisette van der Molen
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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Beck AJCC, Retèl VP, Bunting G, Sethi RKV, Deschler DG, van den Brekel MWM, van Harten WH. Cost-effectiveness analysis of using the heat and moisture exchangers compared with alternative stoma covers in laryngectomy rehabilitation: US perspective. Head Neck 2020; 42:3720-3734. [PMID: 32885527 DOI: 10.1002/hed.26442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 07/14/2020] [Accepted: 08/14/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND This study aims to evaluate the cost-effectiveness of using heat and moisture exchangers (HMEs) vs alternative stoma covers (ASCs) following laryngectomy in the United States. METHODS A cost-effectiveness and budget impact analysis were conducted including uncertainty analyses using real-world survey data with pulmonary events and productivity loss. RESULTS HME use was more effective and less costly compared with ASCs. Quality-adjusted life years were slightly higher for HME-users. Total costs per patient (lifetime) were $59 362 (HME) and $102 416 (ASC). Pulmonary events and productivity loss occurred more frequently in the ASC-users. Annual budget savings were up to $40 183 593. Costs per pulmonary event averted were $3770. CONCLUSIONS HME utilization in laryngectomy patients was cost-effective. Reimbursement of HME devices is thus recommended. Utilities may be underestimated due to the generic utility instrument used and sample size. Therefore, we recommend development of a disease-specific utility tool to incorporate in future analyses.
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Affiliation(s)
- Ann-Jean C C Beck
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Glenn Bunting
- Department of Otolaryngology-Head and Neck Oncology and Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Rosh K V Sethi
- Department of Otolaryngology-Head and Neck Oncology and Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Oncology and Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Michiel W M van den Brekel
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Institute of Phonetic Sciences, University of Amsterdam, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Center (Amsterdam UMC), Amsterdam, The Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
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Beck AJCC, van Harten WH, van den Brekel MWM, Navran A, Retèl VP. Cost-Effectiveness of Surgery Versus Organ Preservation in Advanced Laryngeal Cancer. Laryngoscope 2020; 131:E509-E517. [PMID: 32776557 DOI: 10.1002/lary.28954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/09/2020] [Accepted: 06/28/2020] [Indexed: 12/09/2022]
Abstract
OBJECTIVE Treatment decision-making for patients with laryngeal cancer consists of a complex trade-off between survival and quality of life. For decision makers on coverage and guidelines, costs come in addition to this equation. Our aim was to perform a cost-effectiveness analysis of surgery (laryngectomy with or without radiotherapy) versus organ preservation (OP: radiotherapy, chemo- and/or bioradiation) in advanced laryngeal cancer patients from a healthcare perspective. METHODS A cost-effectiveness analysis was conducted using a Markov model. For each modality, data on survival and quality-adjusted life years (QALYs) were sourced from relevant articles in agreement with experts, and national benchmark cost prices were included regarding treatment, follow-up, adverse events, and rehabilitation. RESULTS Total QALYs of the surgical approach (6.59) were substantially higher compared to the OP approach (5.44). Total lifetime costs were higher for the surgical approach compared to the OP approach, namely €95,881 versus €47,233. The surgical approach was therefore more effective and more costly compared to OP, resulting in an incremental cost-effectiveness ratio of €42,383/QALY. CONCLUSION Based on current literature, surgical treatment was cost-effective compared to OP in advanced laryngeal cancer within most willingness-to-pay thresholds. The study provides information on the survival adjusted for quality of life in combination with costs of two different approaches for advanced laryngeal cancer, relevant for patients, physicians, and policy makers. As financial toxicity is a relevant aspect in this population, collection of real-world data on country-specific costs and utilities is strongly recommended to enable further generalization. LEVEL OF EVIDENCE N/A. Laryngoscope, 131:E509-E517, 2021.
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Affiliation(s)
- Ann-Jean C C Beck
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands.,Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Michiel W M van den Brekel
- Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands.,Institute of Phonetic Sciences, University of Amsterdam, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Center (AUMC), Amsterdam, The Netherlands
| | - Arash Navran
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
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Beck AJCC, Kieffer JM, Retèl VP, van Overveld LFJ, Takes RP, van den Brekel MWM, van Harten WH, Stuiver MM. Mapping the EORTC QLQ-C30 and QLQ-H&N35 to the EQ-5D for head and neck cancer: Can disease-specific utilities be obtained? PLoS One 2019; 14:e0226077. [PMID: 31834892 PMCID: PMC6910681 DOI: 10.1371/journal.pone.0226077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/18/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Innovations in head and neck cancer (HNC) treatment are often subject to economic evaluation prior to their reimbursement and subsequent access for patients. Mapping functions facilitate economic evaluation of new treatments when the required utility data is absent, but quality of life data is available. The objective of this study is to develop a mapping function translating the EORTC QLQ-C30 to EQ-5D-derived utilities for HNC through regression modeling, and to explore the added value of disease-specific EORTC QLQ-H&N35 scales to the model. Methods Data was obtained on patients with primary HNC treated with curative intent derived from two hospitals. Model development was conducted in two phases: 1. Predictor selection based on theory- and data-driven methods, resulting in three sets of potential predictors from the quality of life questionnaires; 2. Selection of the best out of four methods: ordinary-least squares, mixed-effects linear, Cox and beta regression, using the first set of predictors from EORTC QLQ-C30 scales with most correspondence to EQ-5D dimensions. Using a stepwise approach, we assessed added values of predictors in the other two sets. Model fit was assessed using Akaike and Bayesian Information Criterion (AIC and BIC) and model performance was evaluated by MAE, RMSE and limits of agreement (LOA). Results The beta regression model showed best model fit, with global health status, physical-, role- and emotional functioning and pain scales as predictors. Adding HNC-specific scales did not improve the model. Model performance was reasonable; R2 = 0.39, MAE = 0.0949, RMSE = 0.1209, 95% LOA of -0.243 to 0.231 (bias -0.01), with an error correlation of 0.32. The estimated shrinkage factor was 0.90. Conclusions Selected scales from the EORTC QLQ-C30 can be used to estimate utilities for HNC using beta regression. Including EORTC QLQ-H&N35 scales does not improve the mapping function. The mapping model may serve as a tool to enable cost-effectiveness analyses of innovative HNC treatments, for example for reimbursement issues. Further research should assess the robustness and generalizability of the function by validating the model in an external cohort of HNC patients.
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Affiliation(s)
- Ann-Jean C. C. Beck
- Department of Head and Neck Oncology and Surgery, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- * E-mail:
| | - Jacobien M. Kieffer
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Valesca P. Retèl
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Lydia F. J. van Overveld
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, the Netherlands
| | - Robert P. Takes
- Department of Otolaryngology and Head and Neck surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Michiel W. M. van den Brekel
- Department of Head and Neck Oncology and Surgery, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Institute of Phonetic Sciences, University of Amsterdam, Amsterdam, the Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Wim H. van Harten
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Martijn M. Stuiver
- Department of Head and Neck Oncology and Surgery, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Clinical Epidemiology Biostatistics and Bioinformatics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Abstract
AbstractThe European Academy of Facial Plastic Surgery celebrates its 40th anniversary. We aimed to describe innovations in the diagnostics and treatment in head and neck skin cancer over the past 40 years as well as future perspectives. Landmark events, developments, and highlights over the past decades for basal cell carcinoma, cutaneous squamous cell carcinoma, and melanoma are discussed.
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Affiliation(s)
- W. Martin C. Klop
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Yannick S. Elshot
- Department of Dermatology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ann-Jean C. C. Beck
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Renate E. Brandsen
- Department of Dermatology, Mohs Klinieken Amsterdam, Amsterdam, The Netherlands
| | - Peter J. F. M. Lohuis
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Beck AJCC, Passchier E, Retèl VP, Stuiver MM, van der Molen L, Klop WMC, Navran A, van Harten WH, van den Brekel MWM. Study protocol of a prospective multicenter study comparing (cost-)effectiveness of a tailored interdisciplinary head and neck rehabilitation program to usual supportive care for patients treated with concomitant chemo- or bioradiotherapy. BMC Cancer 2019; 19:655. [PMID: 31269918 PMCID: PMC6610831 DOI: 10.1186/s12885-019-5874-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/24/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Since 2011, a tailored, interdisciplinary head and neck rehabilitation (IHNR) program, covered by the basic healthcare insurance, is offered to advanced head and neck cancer (HNC) patients in the Netherlands Cancer Institute (NKI). This program is developed to preserve or restore patients' functioning, and to optimize health-related quality of life (HRQoL). It applies an integrated approach to define patients' individual goals and provide rehabilitation care throughout the cancer care continuum. The aim of the current study is to assess the (cost-) effectiveness of the IHNR approach compared to usual supportive care (USC) consisting of monodisciplinary and multidisciplinary care in advanced HNC patients. METHODS This multicenter prospective observational study is designed to compare (cost-)effectiveness of the IHNR to USC for advanced HNC patients treated with chemoradiotherapy (CRT) or bioradiotherapy (BRT). The primary outcome is HRQoL represented in the EORTC QLQ-C30 summary score. Functional HRQoL, societal participation, utility values, return to work (RTW), unmet needs (UN), patient satisfaction and clinical outcomes are secondary outcomes, assessed using the EORTC QLQ-H&N35, USER-P, EQ-5D-5 L, and study-specific questionnaires, respectively. Both patient groups (required sample size: 64 per arm) are requested to complete the questionnaires at: diagnosis (baseline; T0), 3 months (T1), 6 months (T2), 9 months (T3) and 12 months (T4) after start of medical treatment. Differences in outcomes between the intervention and control group will be analyzed using mixed effects models, Chi-square test and descriptive statistics. In addition, a cost-effectiveness analysis (CEA) will be performed by means of a Markov decision model. The CEA will be performed using a societal perspective of the Netherlands. DISCUSSION This prospective multicenter study will provide evidence on the effectiveness and cost-effectiveness of IHNR compared to USC. RTW and societal participation, included as secondary outcomes, have not been studied sufficiently yet in cancer rehabilitation. Interdisciplinary rehabilitation has not yet been implemented as usual care in all centers, which offers the opportunity to perform a controlled clinical study. If demonstrated to be (cost-)effective, national provision of the program can probably be advised. TRIAL REGISTRATION The study has been retrospectively registered in the Netherlands Trial Registry on April 24th 2018 ( NTR7140 ).
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Affiliation(s)
- Ann-Jean C. C. Beck
- Department of Head and Neck Surgery and Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ellen Passchier
- Department of Head and Neck Surgery and Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
- Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Valesca P. Retèl
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, the Netherlands
| | - Martijn M. Stuiver
- Department of Head and Neck Surgery and Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
- Center for Quality of Life, Netherlands Cancer Institute, Amsterdam, the Netherlands
- ACHIEVE Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
| | - Lisette van der Molen
- Department of Head and Neck Surgery and Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Willem M. C. Klop
- Department of Head and Neck Surgery and Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Arash Navran
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Wim H. van Harten
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, the Netherlands
- Rijnstate Hospital, Arnhem, the Netherlands
| | - Michiel W. M. van den Brekel
- Department of Head and Neck Surgery and Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
- Institute of Phonetic Sciences, University of Amsterdam, Amsterdam, the Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Center (Amsterdam UMC), Amsterdam, the Netherlands
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Beck AJCC, Lohuis PJFM, Al-Mamgani A, Smit LA, Klop WMC. Salivary duct carcinoma: evaluation of treatment and outcome in a tertiary referral institute. Eur Arch Otorhinolaryngol 2018; 275:1885-1892. [PMID: 29785551 DOI: 10.1007/s00405-018-5000-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/14/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE The aggressive behavior of salivary duct carcinoma (SDC) necessitates an aggressive treatment strategy, including surgery and radiotherapy (RT). We evaluated practice patterns and treatment outcomes in patients with SDC treated in our Institute. METHODS Patients with SDC of the parotid or submandibular gland treated with curative intention in our Institute from 1998 until 2016 were reviewed. Our diagnostic workup and treatment strategy were evaluated together with treatment outcomes. RESULTS Fifteen patients with SDC were included. Staging included MRI and ultrasound-guided fine needle aspiration cytology. Only in a minority (20%) of patients, the preoperative diagnosis of SDC was raised due to positive immunohistochemical staining for the androgen receptor (AR) on cytology. All patients were treated with (sub)total resection of the salivary gland and 53% underwent a therapeutic neck dissection. All patients except one received postoperative RT. Immunohistochemical staining was found positive for AR (100%) and human epidermal growth factor receptor 2 (HER2/neu) (13%). No local recurrences occurred. Regional and distant failure rates were 20% and 40%, respectively. CONCLUSIONS Excellent local control rates can be achieved with extensive (local) surgical treatment and postoperative RT. In case of lymph node metastases, a neck dissection with adjuvant postoperative RT is warranted. In patients with node-negative disease, a less aggressive approach for the neck seems feasible to reduce treatment-related morbidity.
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Affiliation(s)
- Ann-Jean C C Beck
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek (NKI-AVL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Peter J F M Lohuis
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek (NKI-AVL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | | | - Laura A Smit
- Department of Pathology, NKI-AVL, Amsterdam, The Netherlands
| | - Willem M C Klop
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek (NKI-AVL), Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Beck AJCC, Hagemeijer A, Tortolani B, Byrd BA, Parekh A, Datillo P, Birkhahn R. Comparing an Unstructured Risk Stratification to Published Guidelines in Acute Coronary Syndromes. West J Emerg Med 2015; 16:683-9. [PMID: 26587091 PMCID: PMC4644035 DOI: 10.5811/westjem.2015.6.16315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction Guidelines are designed to encompass the needs of the majority of patients with a particular condition. The American Heart Association (AHA) in conjunction with the American College of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk stratification guidelines to aid physicians with accurate and efficient diagnosis and management of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the unique environment of an emergency department (ED), the feasibility of incorporating guidelines into clinical workflow remains in question. We aim to compare emergency physicians’ (EP) clinical risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in predicting ACS. Methods We conducted a prospective observational cohort study in an urban teaching hospital ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk stratification scores assigned: one by the treating physician based on clinical evaluation and the other by the AHA/ACC/ACEP guideline aforementioned. The patient’s ACS risk stratification classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30 days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits, and objective cardiac testing performed. Results We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a difference between the physician’s clinical assessment used in the ED, and the AHA/ACC/ACEP task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS. AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients diagnosed with no ACS. Conclusion In the ED, physicians are more efficient at correctly placing patients with underlying ACS into a high-risk category. A small percentage of patients were considered low risk when applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to make an efficient assessment of cardiac risk and established criteria may be overly conservative when applied to an acute care population.
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Affiliation(s)
- Ann-Jean C C Beck
- New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York
| | - Anouk Hagemeijer
- New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York
| | - Bess Tortolani
- New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York
| | - Bethany A Byrd
- New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York
| | - Amisha Parekh
- New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York
| | - Paris Datillo
- New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York
| | - Robert Birkhahn
- New York Methodist Hospital, Department of Emergency Medicine, Brooklyn, New York
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