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Comparing Microvascular Outcomes at a Large Integrated Health Maintenance Organization with Flagship Centers in the United States

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Comparing Microvascular Outcomes at a Large Integrated Health Maintenance Organization with Flagship Centers in the United States ORIGINAL ARTICLE Comparing Microvascular Outcomes at a Large Integrated Health Maintenance Organization With Flagship Centers in the United States Edgar A. Lueg, MD, FRCSC Objective: To determine if patients undergoing micro- Results: All 5 flagship centers are major academic health vascular reconstructive head and neck surgery (MRHNS) centers ranked in the top 18 “best head and neck hospi- at a large integrated health maintenance organization can tals” in the United States. Flap loss (1.7% vs 4.4% for flag- expect outcomes similar to some of the best or flagship ship centers; range, 0.9%-8.8%) and mortality (2.6% vs 2.8% centers in the United States. for flagship centers; range, 0.5%-6.3%) rates were not sig- nificantly different. Although lengths of stay in flagship cen- Design: Outcomes (flap loss, mortality, length of stay), ters were similar to each other and the literature (mean, 21.4 days; range, 20.1-22.5 days), our length of stay was eligibility (recent consecutive US center experience), high- Ͻ experience (100 cases), high-volume (26 cases per year), significantly shorter (8.8 days, P .001). and flagship criteria were prospectively defined. A sys- Conclusion: For high-experience and high-volume cen- tematic MEDLINE search identified 17 eligible reports. ters, patients undergoing MRHNS at a large integrated Independent, blinded medical reviewers identified 5 cen- health maintenance organization can expect morbidity ters (29%) as flagship centers. and mortality outcomes similar to flagship centers in the United States, with shorter hospitalizations. Patients: The first 116 consecutive patients (average, 39 cases per year) who underwent MRHNS on this service. Arch Otolaryngol Head Neck Surg. 2004;130:779-785 HE QUALITY OF THE TER- METHODS tiary surgery provided by major academic health cen- INTEGRATED HMO SERIES ters (MAHCs)1 in the United States is recog- Roughly 1 in every 4 insured Southern Cali- Tnized worldwide. On the other hand, Kai- fornians are members of Kaiser-Permanente, ser-Permanente, the nation’s largest inte- a large, nonprofit, group-model (patients grated (physicians and hospitals share choose their physicians from our group), in- financial risk2) health maintenance orga- tegrated HMO, which provides comprehen- nization (HMO), now provides most ter- sive health care.2 The Southern California tiary surgery for its own members. In 1998, Permanente Medical Group is composed of a dedicated microvascular reconstructive more than 4000 multispecialty (partner and af- filiated) physicians who are exclusively con- head and neck surgery (MRHNS) service tracted to provide their health care at roughly was established to provide this for our 200 outpatient facilities and 12 major medi- members living in the Los Angeles (Calif) cal centers across Southern California. I per- referral basin (south of Fresno and north formed all 117 free flaps (Table 2), most on of San Diego) who underwent oncologic our dedicated Flap Tuesday, with the other resection at our Regional Head, Neck, and head and neck surgical oncologist (HNSO) (Mi- Skullbase Surgical Oncology Center. This chael P. McNicoll, MD) assisting. All patients From the Microvascular service was the first high-volume (see flag- were evaluated prospectively at our multidis- Reconstructive Head and Neck ship criteria) MRHNS service to be estab- ciplinary (HNSOs and radiation oncologists) Surgery Service, Regional Head, lished outside an MAHC in the United tumor board and received extensive preopera- Neck, and Skullbase Surgical tive medical and psychological preparation. As Table 1 3-7 Oncology Center, Southern States ( ). The objective of this team leader, the patient’s admitting HNSO man- California Permanente Medical study was to determine if patients under- aged the surgical issues. Medical issues were Group, Los Angeles. The author going MRHNS at a large integrated HMO managed by an intensivist in the dedicated in- has no relevant financial can expect outcomes similar to some of the tensive care unit and a hospitalist on the dedi- interest in this article. best or flagship centers in the United States. cated ward. Discharge planners coordinated (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 130, JUNE 2004 WWW.ARCHOTO.COM 779 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Table 1. Center Comparison Variable Description Integrated HMO Flagship Mean Flagship 1 Flagship 2 Flagship 3 Flagship 4 Flagship 5 Series median patient (year)* 1999 1992 1991 1993 1990 1997 1989 Series duration, y 3.0 6.7 3.8 13.0 5.0 2.8 9.0 Total patients, No. 116 314 288 698 184 115 286 Total flaps, No. 117 332 308 728 200 119 305 Center volume, patients per year, No. 39 48 76 54 37 41 32 Surgeon volume, No. of MRHNS procedures performed 39 25 19 18 37 41 11 Early (first 100) flaps, % 85† 43† 32 14 50 84 33 Abbreviations: HMO, health maintenance organization; MRHNS, microvascular reconstructive head and neck surgery. *Calendar year during which half of the series’ patients had already undergone surgery. †Significant by Newcombe-Wilson hybrid score 95% confidence interval of difference. Table 2. Surgery Comparison Integrated HMO, Flagship Mean Significant Flagship 1, Flagship 2, Flagship 3, Flagship 4, Flagship 5, Description No. (%) (95% CI)* Difference No. (%) No. (%) No. (%) No. (%) No. (%) Sample size (flaps) 117 (100) 332 NA 308 (100) 728 (100) 200 (100) 119 (100) 305 (100) Basic techniques Secondary cases 4 (3) 11 (−0.16 to 0.00) No 43 (14) 14 (2) 29 (14) 5 (4) 68 (22) Nonworkhorse donor sites 4 (3) 11 (−0.16 to 0.00) No 67 (22) 56 (8) 18 (9) 6 (5) 39 (13) Vein grafted cases 0 (0) 4 (−0.10 to 0.00) No 17 (6) 7 (1) 16 (8) 0 20 (7) Simultaneous donor sites 1 (1) 4 (−0.09 to 0.02) No NR 7 (1) 11 (6) 1 (1) 18 (6) Composite (bone) cases 30 (26) 33 (−0.19 to 0.06) No 91 (30) 221 (30) 120 (60) 29 (24) 70 (23) Donor site selection Radial forearm 64 (55) 31 (0.10 to 0.36) Yes 79 (26) 218 (30) 47 (24) 69 (58) 57 (19) Fibular 27 (23) 15 (−0.03 to 0.19) No 53 (17) 200 (27) 7 (4) 27 (23) 15 (5) Anterolateral thigh 22 (19) 0 (0.12 to 0.28) Yes 00000 Extremity total† 113 (97) 48 (0.38 to 0.59) Yes 138 (45) 427 (59) 57 (28) 96 (81) 80 (26) Rectus abdominis 1 (1) 16 (−0.23 to −0.08) Yes 44 (14) 173 (24) 20 (10) 17 (14) 48 (16) Latissimus dorsi 0 (0) 5 (−0.07 to −0.02) Yes 23 (7) 19 (3) 2 (1) 3 (3) 40 (13) Scapular/parascapular 3 (3) 6 (−0.10 to 0.03) No 19 (6) 21 (3) 19 (10) 1 (1) 32 (10) Jejunum 0 (0) 13 (−0.21 to −0.07) Yes 65 (21) 81 (11) 5 (2) 0 89 (29) Iliac crest 0 (0) 15 (−0.23 to −0.08) Yes 19 (6) NR 96 (48) 2 (2) 11 (4) Torso total† 4 (3) 52 (−0.59 to −0.38) Yes 170 (55) 301 (41) 143 (72) 23 (19) 225 (74) Abbreviations: CI, confidence interval; HMO, health maintenance organization; NA, not applicable; NR, not reported. *Difference between integrated HMO and flagship mean calculated by Newcombe-Wilson hybrid method. †Totals include miscellaneous sites not listed separately in this table. outpatient resources, including routine daily home nursing vis- FLAGSHIP CENTER SELECTION its. After the first 57 patients, all the following patients were placed on a target 6-day inpatient clinical care pathway (CCP) Similar (single US center, complete, consecutive, MRHNS expe- (Figure 1).8 The study period began with the first service case rience reports of cases not restricted to a particular defect or do- on October 27, 1998, and was closed on the anniversary after nor site) and recent (published within 10 years of the close of this having met the anticipated high-experience criteria. There- study) reports met the eligibility criteria. Flagship centers were fore, the first 116 consecutive patients (average, 39 cases per defined as those centers that have published an eligible report that year) who underwent MRHNS on this service between Octo- also satisfies both the high-experience (at least 100 consecutive ber 27, 1998, and October 27, 2001 were the subjects of this cases) and high-volume (averages at least 1 case every few weeks comparison (Table 3). or 26 cases per year) criteria. High-experience centers were se- lected, since most microvascular surgeons believe that greater ex- MAIN OUTCOME SELECTION perience is associated with improved outcomes.3-7,9,11-15 High- volume centers were selected, since a “broad body of evidence Flap loss (patients with complete flap loss) was selected because from large, population-based studies” has consistently demon- it is the most commonly used specific measure of reconstructive strated better outcomes for both major oncologic resections and morbidity following MRHNS3-7 and most microvascular sur- high-risk vascular procedures.10 Once the outcomes, eligibility, geons believe it is an indicator (albeit relatively crude) of qual- high-experience, high-volume, and flagship criteria were specifi- ity.9 Perioperative mortality (any cause within 30 days) was se- cally defined, a systematic MEDLINE search was undertaken. A lected because it is the most commonly used measure of mortality review of the 722 citations containing the words free flap following MRHNS3-7 and most health care experts believe it is an and head within their text identified 17 eligible reports. indicator of quality.10 Length of stay (LOS) (complete contigu- Two independent (no interest in the findings of this study) and ous days) was selected because it is the most commonly used mea- blinded (no knowledge of the study’s objective) medical review- sure of hospitalization following MRHNS5,11-15 and most health ers evaluated the abstracts (text only with center identifiers re- care experts believe it is an indicator of resource cost.16 moved) for the flagship criteria.
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