Performance Initiatives in Head and Neck Surgery: LSU Shreveport Oral & Maxillofacial Surgery Experience

Statement of the Problem:

The aim of this study is to evaluate one institution’s performance based on published performance standards.

Materials and Methods:

This retrospective chart review utilizes data of patients treated July 2011 through March 2015. Inclusion criteria include: histopathological subtype of squamous cell carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, melanoma, basal cell carcinoma, sarcoma, carcinoma ex pleomorphic adenoma, and adenocarcinoma. Lesion location includes oral cavity, lip, cutaneous lesions of the face, neck or scalp, and salivary gland.  Recorded variables include tumor histology, T stage, margin status, transfusion, hospital length of stay, and documentation of adverse events.  Microsoft Excel spreadsheets were used to collect and code data for statistical analysis.  All patient identifiers were removed at the time of collection to avoid dissemination of sensitive medical information.

Methods of Data Analysis

Descriptive statistics were calculated including: hospital length of stay, 30-day readmission, return to operating room within seven days of operation, 30 day mortality, use of blood products, surgical site infection, as well as margin status upon initial resection.

Results:

123 records met inclusion criteria for the analysis. There were 71 males and 52 females (58% male). Average age of treatment is 64.5 years. Squamous cell carcinoma represents 82% of tumor histology. There is a bimodal distribution of T stage with 33% being T1 and 35% being T4.

Table showing descriptive data as compared to published benchmarks.

 

	Hospital Length of Stay	30-day Readmission Rate	7-day Reoperation Rate	30-day mortality Rate	Use of Blood Products	Wound Infection Rate	Margin Status (close or positive)
Our Institution	68% stay <3 days for low acuity*, 63% <12 days for high acuity**.	2% after low acuity, 14% after high acuity	2% for low acuity, 22% for high acuity	0% for low acuity, 22% for high acuity	95% received NO transfusion for low acuity, 43% received NO transfusion for high acuity	11% regardless of low or high acuity	20% for T1 and T2 lesions
Published Benchmark	75% of patients: < 3 days for low acuity procedures, < 12 days for high acuity procedures	< 5% after low acuity, <13% after high acuity	<2% after low acuity, <10% after high acuity	< 0.3% after low acuity, <2% after high acuity	75% undergoing low acuity receive <1U of blood, 75% undergoing high-acuity receive <3U	98% SSI free regardless of low or high acuity	Reported to be 7-21% for T1 and T2 lesions

* Low Acuity: panendoscopy/biopsy, limited resection not requiring a flap, unilateral neck dissection, endoscopic partial laryngectomy, parotidectomy, thyroidectomy

** High Acuity: glossectomy (with recon), open partial laryngectomy, total laryngectomy, total mandibulectomy, pharyngolaryngectomy, bilateral lymphadenectomy, total maxillectomy, procedures requiring free or regional rotational flap reconstruction (local flaps such as nasolabial or forehead flaps do not constitute a high-acuity procedure; however, a pectoralis, latissimus or trapezius flap does).

Conclusion

This is an important area for the future of Maxillofacial Oncology & Reconstructive Surgery because not only will performance standards to be tied to reimbursement but performance measures should be kept prospectively for future study and for self-evaluation.  Current quality initiatives may not be statistically meaningful in head and neck cancer management and further study would be to incorporate five-year disease specific survival as a statistical endpoint for each of these benchmarked predictors.

References

1.  Shellenberger TD, Madero-Visbal R, Weber RS. Quality indicators in head and neck operations: a comparison with published benchmarks. Arch Otolaryngol Head Neck Surg. 2011 Nov;137(11):1086-93.
2. Luryi AL et al. Positive surgical margins in early stage oral cavity cancer: an analysis of 20,602 cases. Otolaryngol Head Neck Surg. 2014 Dec;151(6):984-90