Amy C. Hessel

Quality and Performance Indicators in an Academic Department of Head and Neck Surgery

OBJECTIVE to create a method for assessing physician performance and care outcomes that are adjusted for procedure acuity and patient comorbidity. DESIGN between 2004 and 2008 surgical procedures performed by 10 surgeons were stratified into high-acuity procedures (HAPs) and low-acuity procedures (LAPs). Risk adjustment was made for comorbid conditions examined singly or in groups of 2 or more. SETTING a tertiary care medical center. PATIENTS a total of 2618 surgical patients. MAIN OUTCOME MEASURES performance measures included length of stay; return to operating room within 7 days of surgery; and the occurrence of mortality, hospital readmission, transfusion, and wound infection within 30 days of surgery. RESULTS the transfusion rate was 2.7% and 40.6% for LAPs and HAPs, respectively. Wound infection rates were 1.4% for LAPs vs 14.1% for HAPs, while 30-day mortality rate was 0.3% and 1.6% for LAPs and HAPs, respectively. The mean (SD) hospital stay for LAPs was 2.1 (3.6) vs 10.5 (7.0) days for HAPs. Negative performance factors were significantly higher for patients who underwent HAPs and had comorbid conditions. Differences among surgeons significantly affect the incidence of negative performance indicators. Factors affecting performance measures were procedure acuity, the surgeon, and comorbidity, in order of decreasing significance. Surgeons were ranked low, middle, and high based on negative performance indicators. CONCLUSIONS performance measures following oncologic procedures were significantly affected by comorbid conditions and by procedure acuity. Although the latter most strongly affects quality and performance indicators, both should weigh heavily in physician comparisons. The incidence of negative performance indicators was also influenced by the individual surgeon. These data may serve as a tool to evaluate and improve physician performance and outcomes and to develop risk-adjusted benchmarks. Ultimately, reimbursement may be tied to quantifiable measures of physician and institutional performance.

Compliance With Quality Assurance Measures in Patients Treated for Early Oral Tongue Cancer

The objective of this study was to identify measurable parameters that provide quality data for assessing how well cancer care adheres to accepted treatment guidelines and is delivered to any given patient with oral tongue cancer.

Secondary Tracheoesophageal Puncture With In-Office Transnasal Esophagoscopy

OBJECTIVE To evaluate the outcomes of voice restoration using office-based transnasal esophagoscopy (TNE) to guide placement of the secondary tracheoesophageal puncture (TEP). DESIGN Retrospective chart review. SETTING Two tertiary care medical centers. PATIENTS The study included 39 patients who underwent the TNE-TEP procedure from January 2004 to December 2008. MAIN OUTCOME MEASURES Clinical, demographic, and TE speech-related data were recorded to examine the ease, efficiency, complications, and speech-related outcomes. RESULTS Among 39 patients identified, the average age was 65 years (age range, 47-83 years), with 32 male (82%) and 7 female (16%) patients. Twenty-five patients (64%) underwent total laryngectomy; 8 (21%) underwent total laryngectomy with partial pharyngectomy; and 14 (36%) underwent microvascular flap reconstruction. The overall success rate of secondary TNE-assisted TEP placement was 97% (n = 38), with 1 unsuccessful attempt. There was no statistically significant correlation found between patients having undergone radiation therapy (either before or after oncologic resection) or a cricopharyngeal myotomy and successful TEP placement, type of reconstruction used to close the pharyngeal defect when compared with the difficulty in the placement of the TEP, development of complications associated with TEP placement, use of the TEP prosthesis, or speech intelligibility at the last follow-up visit. Thirty-one patients (79%) were still using their TEP prosthesis for speech at the last follow-up visit. Of the patients reviewed, 28 (72%) had understandable TE speech. CONCLUSIONS In-office TNE-assisted TEP placement can safely be performed, with excellent speech outcomes. Reconstruction with musculocutaneous or microvascular free-tissue transfer did not limit our ability to place secondary TEPs with TNE.

Sinonasal Teratocarcinosarcoma of the Head and Neck : A Report of 10 Patients Treated at a Single Institution and Comparison With Reported Series

OBJECTIVES To present the clinicopathologic features of 10 sinonasal teratocarcinosarcomas managed at a single center. Teratocarcinosarcoma is a rare morphologically heterogeneous and highly malignant neoplasm. Previous reports of these tumors have focused on their differential diagnosis and histogenesis and consisted of individual case reports and consultation based series. DESIGN Review of patient medical records and microscopic slides of all tumor tissues. The histopathologic features for each tumor and the demographic, clinical, treatment, and follow-up information were recorded for each patient. Also, a comparison with previously reported series was performed. SETTING The University of Texas M. D. Anderson Cancer Center. PATIENTS Ten men ranging in age from 35 to 69 years (mean age, 53 years) were included in the study. They all experienced a short course of symptoms, with an average duration of 3.5 months, and 9 presented with nasal obstruction and epistaxis. Nine patients were treated with both surgery and irradiation. RESULTS Histologically, the tumors showed primitive neuroepithelial elements and various malignant epithelial and mesenchymal components. Six patients had no evidence of disease by the end of follow-up, which ranged from 72 to 372 months. Three patients died of disease, and 1 patient was lost to follow-up. CONCLUSION Sinonasal teratocarcinosarcoma of the head and neck is a histologically and biologically heterogeneous malignant neoplasm that is best managed with surgery and postoperative radiotherapy.

Development and Feasibility of a Specialty-Specific National Surgical Quality Improvement Program (NSQIP): The Head and Neck–Reconstructive Surgery NSQIP

IMPORTANCE The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) serves the need for continual quality assessment in general surgery. Previously, no parallel mechanism specific to head and neck oncologic surgery existed. OBJECTIVE To address the need for continual quality assessment in subspecialty surgery by adapting the ACS NSQIP platform for complex head and neck oncologic surgical procedures. DESIGN, SETTING, AND PARTICIPANTS With an institutional ACS NSQIP teams guidance, surgeons from the departments of head and neck surgery and plastic and reconstructive surgery developed disease- and procedure-specific preoperative, intraoperative, and postoperative variables specific to head and neck surgery requiring reconstruction. Collection occurred with 100% sampling and standard ACS NSQIP 30-day follow-up. After a pilot period, long-term functional outcomes were added to this platform. A total of 312 patients underwent head and neck surgery requiring reconstruction at an academic medical center between August 1, 2012, and June 30, 2013. EXPOSURES Development of a specialty-specific head and neck surgery ACS NSQIP platform. MAIN OUTCOMES AND MEASURES The feasibility of adapting the ACS NSQIP platform to capture complex head and neck surgery metrics in all patients. RESULTS Head and neck surgery-specific preoperative, intraoperative, and postoperative variables were added to the ACS NSQIP platform and evaluated in 312 patients (201 [64.4%] male). Only 42 patients (13.5%) had no preoperative risk factors, and 136 (43.6%) had 3 or more risk factors. The mean (SD) duration of operation was 9.4 (3.0) hours (range, 1.7-19.3 hours). The mean (SD) postoperative length of stay was 7.9 (4.7) days (range, 1-40 days), 58 patients (18.6%) had an unplanned return to the operating room, 23 patients (7.4%) were readmitted within 30 days, and 3 patients (1.0%) died within 30 days. More than half of the patients (160 [51.3%]) did not experience a postoperative occurrence. CONCLUSIONS AND RELEVANCE To our knowledge, this is the first comprehensive complex oncologic surgery outcomes platform derived from ACS NSQIP methods. The initial pilot demonstrates the ability to systematically capture head and neck surgery-specific variables with complete sampling. With multi-institutional expansion, increased accrual, and long-term patient-reported outcomes, we hope to set risk-adjusted benchmarks that may underpin quality improvement efforts in complex head and neck surgery.

Complications, hospital length of stay, and readmission after total laryngectomy

The purpose of this study was to describe the 30‐day incidence of complications after total laryngectomy (TL) in a high‐volume institution and their impact on the hospital length of stay (LOS) and readmission rates.

Management of the lymph node-positive neck in the patient with human papillomavirus-associated oropharyngeal cancer

The goal of the current study was to assess the rates of recurrence in the neck for patients with lymph node‐positive human papillomavirus‐associated cancer of the oropharynx who were treated with definitive radiotherapy (with or without chemotherapy).

Sleep-related breathing disorders in patients with tumors in the head and neck region.

BACKGROUND Sleep disturbance is a prominent complaint of cancer patients. Most studies have focused on insomnia and cancer-related fatigue. Obstructive sleep apnea (OSA) has been reported in small studies and case reports. METHODS In a retrospective review of patients who underwent formal sleep evaluation and polysomnography (PSG) from 2006 to 2011, 56 patients with tumors in the head and neck region were identified. Clinical characteristics, sleep-related history, and PSG data were reviewed. RESULTS Most patients had active cancer (80%), and the majority had squamous pathology (68%). Prominent symptoms included daytime fatigue (93%), daytime sleepiness (89%), and snoring (82%). Comorbid conditions primarily included hypertension (46%) and hypothyroidism (34%). Significant sleep-related breathing disorder was noted in 93% of patients, and 84% met clinical criteria for OSA. A male predominance (77%) was noted, and patients were not obese (body mass index <30 kg/m(2) in 52%). The majority of patients (79%) underwent radiation prior to sleep study, of which 88% had OSA, and in the group without prior radiation, 67% had OSA. Adherence to positive airway pressure (PAP) therapy was slightly better when compared with the general population. A subset of patients with persistent hypoxia despite advanced forms of PAP required tracheostomy. Multivariate analysis revealed that patients with active disease and radiation prior to PSG were more likely to have OSA. CONCLUSION Sleep-related breathing disorder was common in patients with tumors in the head and neck region referred for evaluation of sleep disruption, and most met clinical criteria for OSA. Daytime fatigue and sleepiness were the most common complaints. OSA was prevalent in male patients, and most with OSA were not obese. Architectural distortion from the malignancy and/or treatment may predispose these patients to OSA by altering anatomic and neural factors. A heightened clinical suspicion for sleep-related breathing disorder and referral to a sleep specialist would be beneficial for patients with these complaints.

An audit and feedback system for effective quality improvement in head and neck surgery: Can we become better surgeons?

An evaluation system was established for measuring physician performance. This study was designed to determine whether an initial evaluation with surgeon feedback improved subsequent performance.

Desmoplastic melanoma of the lip

This retrospective study looks at the prognosis of desmoplastic melanoma of the lip, correlating it with the clinical course, treatment, and patterns of failure.