A Comprehensive Clinical Care Pathway for Microvascular Maxillofacial Reconstructive Surgery

The treatment of head and neck cancer is amongst the most expensive of all solid tumours¹. It involves multidisciplinary-based treatment planning and multiple discipline and specialties involvement. One way to standardize this treatment process especially in the post-operative period is through implementation of a clinical care pathway (CCP)². A CCP is a communication tool that allows for an organized and structured daily patient interventions and goals. Our objective is twofold: first, to create an evidence based perioperative CCP for patients undergoing benign or malignant maxillofacial resection and microvascular reconstruction. Second, to compare the cost-effectiveness of utilizing this CCP to a historical cohort of patients treated prior to its implementation.

Materials and Methods:This is a comparative pilot study between a prospective cohort of patients managed post-operatively using the CCP (April 2015 and February 2016) compared to a retrospective cohort of patients managed without CCP (July 2013 and January 2015). All data was gathered through patient chart review. The inclusion criteria consisted of patients’ undergoing benign or malignant maxillofacial resection and microvascular reconstruction. The exclusion criteria consisted of patients receiving neo-adjuvant radiation and/or chemotherapy. Microsoft Excel software was used to collect and compute the statistics for this research. Costs calculations were based on data provided by the financial department of McGill University Health Centre (MUHC).

Methods of data analysis:Descriptive statistics were calculated for the following population data: age, gender, primary tumour site, stage of the disease, type of flap used for reconstruction, American Society of Anesthesiologists (ASA) classification, alcohol and smoking status; and for the following outcomes data: length of stay (LOS) in the intensive care unit (ICU), total hospital LOS, and the costs for each. Also, for the following three main complications: return to the operating theater (OR), flap failure, and mortality. Inferential statistics using the student’s t-test were calculated for LOS in the ICU and total LOS.

Results: A total of 48 patients managed prior to the implementation of CCP met the inclusion criteria for the historical cohort group, and were compared to a total of 33 patients for the CCP group. The average total LOS in the control group is 16.6 days; the average total LOS for the CCP pilot group is 9.7 days. The average LOS in ICU in the control group and the CCP pilot group are 4.2 days and 1.97 days respectively. 22.3% of patients in the control group had to return to the OR compared to 9.1% in the CCP group. Flap failure accounted for 6.3% in the control group and 3.03% in the CCP group. Mortality accounted for 6.3% in the control group and none in the CCP group. The average hospital and pharmacy cost per patient in the post-operative period in the control group is $34,150.06, and in the CCP pilot group is $18,965.75; this translates to a saving of $16,234.92 (Canadian $) per patient.

Conclusion: Implementation of a CCP for patients undergoing maxillofacial resection with microvascular reconstruction decreased the total hospital stay by 6.9 days (p=0.0013), and decreased hospital associated costs by 46%. The results of this pilot study favor the implementation of a CCP and allow for further gathering of data to study factors such as pre-habilitation, morbidity and mortality. This CCP would be the first to be implemented in the Oral and Maxillofacial Surgery specialty.

1.        Lang K et al. The Economic Cost of Squamous Cell Cancer of the Head and Neck: Findings From Linked SEER-Medicare Data. Arch Otolaryngol Head Neck Surg. 2004;130(11):1269-1275.

2.        Gendron KM et al. Clinical care pathway for head and neck cancer: a valuable tool for decreasing resource utilization. Arch Otolaryngol Head Neck Surg. 2002;128(3):258-262.