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Clinical Care Pathway for Head and Neck Cancer
A Valuable Tool for Decreasing Resource Utilization
Kristin M. Gendron, MD;
Stephen Y. Lai, MD, PhD;
Gregory S. Weinstein, MD;
Ara A. Chalian, MD;
Julian M. Husbands, MD;
Patricia F. Wolf, BS;
Liesje DiDonato, BS;
Randal S. Weber, MD
Arch Otolaryngol Head Neck Surg. 2002;128:258-262.
ABSTRACT
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Objective To evaluate the durability over time of the reduction of resource utilization
after implementing a clinical care pathway (CCP) for head and neck cancer
surgery.
Design Cohort study.
Setting A tertiary care academic medical center.
Patients We studied control subjects from 1995 (pre-CCP) (n = 87), a cohort from
July 1, 1996, through July 31, 1997 (the first year after CCP implementation)
(n = 43), and a cohort from 1999 (n = 82) after major resection and tracheostomy
for upper aerodigestive tract cancer.
Interventions Starting July 1, 1996, all patients undergoing major resection for head
and neck cancer were treated using a CCP, which delineates daily interventions
and goals.
Main Outcome Measures Length of stay (LOS), readmission and complication rates, and hospital
charges.
Results Median total LOS and LOS exclusive of the intensive care unit decreased
in the first year and remained stable at 3 years (from 13.0 to 8.0 days and
from 10.5 to 6.4 days, respectively). The intensive care unit LOS decreased
across 3 years from 2.2 to 1.1 days (P= .001). Median total charges
declined from $105 410 pre-CCP to $65 919 at 3 years. Incidence
of postoperative pneumonia decreased from 12% to 1% (P= .02),
and readmission rate decreased from 18% to 11% (P= .37) across
3 years.
Conclusions The CCP for head and neck cancer maintained the improvement in LOS and
charges seen in the first year of implementation and continues to decrease
resource utilization while enhancing quality of care.
INTRODUCTION
IN THE present medical climate, health care expenses are rising rapidly
because of advancing technology and an aging population. In an effort to decelerate
this process, physicians are under great pressure to decrease costs. During
the 1980s, amid growing health care expenditures and decreasing reimbursement,
clinical care pathways (CCPs) emerged as a tool for decreasing costs.1 The CCPs are structured patient health care plans
that organize daily interventions and goals for a specific diagnosis or procedure
along a time line. By explicitly outlining a daily care plan and providing
a structure for documentation of the patients' progress, CCPs standardize
patient care and define the steps necessary to limit length of stay (LOS)
in the hospital.2 The greatest potential for
CCPs to significantly decrease health care expenditures and optimize patient
care is in the context of high-volume procedures, eg, total joint replacement
and carotid endarterectomy, and those requiring complex care. Major resections
for head and neck cancer are well suited for a CCP, because subsequent postoperative
care requires the coordination of multiple services, including physical, occupational,
respiratory, and speech therapy; nutrition; and social work.3-4
At the Hospital of the University of Pennsylvania, Philadelphia, a CCP
for patients undergoing major resection for upper aerodigestive tract cancer
was implemented in July 1996. This pathway outlines daily interventions and
goals, with the ultimate objective of discharging patients undergoing laryngectomy
on postoperative day 5 or 6 and patients undergoing microvascular free- or
pectoralis-flap reconstruction on postoperative day 8. Through a process of
reviewing deviations, or variances, from the pathway and input from members
of the health care team, the CCP is continuously evaluated and has been formally
revised several times.
In 1999, Husbands et al5 published a
study showing that, in the first year of implementation of the head and neck
cancer CCP, total LOS and charges decreased. The purpose of the present study
is to evaluate the durability of the progress seen in the first year after
CCP implementation and to assess how 3 years of development has continued
to affect outcome measures.
PATIENTS AND METHODS
The CCP was developed and continues to be modified by a multidisciplinary
team that includes surgeons, nurses, and allied health care representatives.
Eligibility is determined by procedure, including total or partial laryngectomy,
major intraoral resection, and composite resection with or without reconstruction.
Patients are also included if they may require a tracheostomy and/or a feeding
tube. Because we used the diagnosis related group code for tracheostomy to
search for the control cohort, all patients included in the current study
underwent a tracheostomy. The format for the CCP is a 1-page table containing
a list of goals and interventions for each postoperative day, followed by
a page for each day on which accomplishments are recorded. When goals are
not met, the variances are recorded in detail on the flow sheet.
The 1999 study by Husbands et al5 compared
outcomes experienced by 2 cohorts of patients undergoing major resections
for upper aerodigestive tract cancer. Group 1 was treated from January 1 to
December 31, 1995, the year before the CCP was implemented, and group 2 was
treated in the year after implementation, from July 1, 1996, through July
1, 1997. Group 1 was identified by searching all surgical patients from 1995
using the diagnosis related group code for tracheostomy. The resulting list
was then limited to those patients meeting criteria for the head and neck
cancer CCP, ultimately creating a control group of 87 patients. Group 2 included
43 patients from the first year after CCP implementation. The present study
introduces group 3, which included 82 patients in the CCP treated from January
1 through December 31, 1999, 3 years after implementation. One additional
patient was excluded because the medical chart was inaccessible. All patients
in the study underwent tracheostomy and 1 or more of the following procedures:
head and neck free-flap reconstruction, total or partial laryngectomy, major
intraoral resection, composite resection, or neck dissection. All eligible
patients were enrolled in the CCP.
The inpatient medical chart and the complete charge summary for each
patient were reviewed. Data were organized according to demographics (age,
sex, alcohol and tobacco use, and comorbidities), primary tumor site, TNM
stage, and procedure. We evaluated total LOS, intensive care unit (ICU) LOS,
complication and readmission rates, and median charge per patient as the primary
outcomes. The charge summary was divided into the following 6 categories:
total, hospital room, pharmacy, operating room, laboratory, and other charges.
Professional fees were not included. An increase in charge rates of approximately
25% occurred from 1997 to 1999. No adjustments were made to the data to adjust
for this rate change.
We compared variables for 2 groups using the Mann-Whitney test, and
for 3 groups at once using the Kruskal Wallis 1-way analysis of variance.
We analyzed the categoric variables using the Pearson  2 test
with Yates correction where applicable.
RESULTS
As demonstrated in Table 1,
the recorded demographic variables were similar across the 3 groups, with
the exception of alcohol consumption and the proportion of patients with hypertension.
Although most patients in all 3 groups smoked tobacco and consumed alcohol
on a regular basis, group 3 had a higher percentage of those who did not drink
alcohol (for patients with a complete social history in each group, 32 [46%]
of 70 patients vs 20 [25%] of 81 patients). The comorbidities varied somewhat
from group to group, with a higher incidence of diabetes and hypertension
and a lower incidence of coronary artery disease in group 3 compared with
the 2 previous groups. However, only the increase in hypertension, from 20
patients (23%) in group 1 to 36 (44%) in group 3, is statistically significant
(P = .007). The most recent data indicated that the
variation in LOS relative to comorbid conditions decreased, with a median
LOS of 8.0 days for all comorbidity categories except renal disease (median,
10.0 days) (Table 2). The median
LOS for patients undergoing reconstruction decreased from 15.0 days in group
1 to 8.0 days in group 3.
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Table 1. Demographic Data*
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Table 2. Length of Stay Relative to Comorbid Conditions*
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The site and stage of the primary cancer varied minimally among groups
(Table 3). In all 3 groups, oral
cavity and laryngeal cancer were the 2 most common types, with oral cavity
cancer leading in groups 1 and 2 and laryngeal cancer leading in group 3.
The greatest proportion of patients undergoing major resection for upper aerodigestive
tract cancer had T4 cancers, and roughly half of these were stage N0. The
percentage of patients undergoing reconstruction decreased from 48 patients
(55%) and 26 (60%) in groups 1 and 2, respectively, to 38 (46%) in group 3.
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Table 3. Site and Stage of Primary Neoplasm*
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Overall, the median total LOS, ICU LOS, and total costs all decreased
since implementation of the CCP (Table 4 and Figure 1). The median
total LOS (decrease, 13.0 to 8.0 days; P<.001)
and non-ICU LOS (decrease, 10.5 to 6.4 days; P<.001)
in group 3 equaled the improvements seen in group 2. Moreover, the decrease
in ICU LOS became significant, down from 2.2 days in group 1 to 1.1 days in
group 3 (P = .001). The median total charges also
steadily declined from $105 410 in group 1 to $78 930 in group 2
and to $65 919 in group 3 (Figure 1).
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Table 4. Measured Outcomes*
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Figure 1. Charge data acquired from hospital
charge summaries. Professional fees are not included. Columns for groups 1
and 3 are labeled with correlating charge amounts. Groups are described in
the "Patients and Methods" section.
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To evaluate quality of care, complication and readmission rates were
observed. As shown in Figure 2,
complication rates remained stable after implementation of the CCP, and the
incidence of pneumonia decreased significantly, dropping from 10 patients
(11%) in group 1 to 1 (1%) in group 3 (P = .02).
The 30-day readmission rate declined from 16 patients (18%) in group 1 to
9 (11%) in group 3, but was not statistically significant (Table 4).
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Figure 2. Incidence of specific complications
derived from chart review. Columns for groups 1 and 3 are labeled with correlating
percentages. Groups are described in the "Patients and Methods" section.
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An increasing number of patients received visiting nursing care at home—increasing
to 70 patients (85%) in group 3 from 29 (33%) in group 1—and more had
tracheostomy tubes (increase, 40 patients [46%] to 66 [80%]) at the time of
discharge (Table 5).
COMMENT
In the current era of diminishing reimbursements for costly health care,
CCPs serve as a tool to decrease resource utilization. Pathways are particularly
useful for high-volume diagnoses and those requiring a complex treatment plan.
Resections for head and neck cancer are an ideal target for CCPs, because
they require well-coordinated, multidisciplinary postoperative care, including
specialists in nutrition, speech therapy, social work, physical therapy, respiratory
services, and other areas. Successful, expedient discharges depend on good
communication among these services and the family, patient education, and
timely rehabilitation therapy. A CCP helps the process by placing the necessary
interventions and daily goals on a time line. Pathways also help to prevent
costly and unnecessary variations in medications and laboratory tests by delineating
a standardized care plan.
The head and neck cancer CCP in this study was designed to provide steps
toward reaching specific discharge criteria by postoperative day 8. Discharge
criteria include evidence of wound healing; independence in tube feedings,
tracheostomy care, and flap care; a functional communication system; an understanding
of a home exercise regimen; a stable airway; and the arrangement of adequate
home health care and follow-up. To reach these goals, they are expressed to
the patient and the patient's family early during and throughout the hospitalization,
and daily objectives are clearly defined. Keeping all of the non-ICU patients
on a single ward increases the nursing staff's familiarity with the CCP and
with aspects of patient care specific to resections for head and neck cancer.
This effect is similar to the otolaryngology care units designated at some
hospitals.6 Patients are admitted on the same
day as their procedure, and medical staff for nutrition support, physical
therapy, speech therapy, and respiratory therapy are all consulted on the
operative day. Most patients are out of bed on the first postoperative day,
and patient education and discharge planning are initiated in the first 2
postoperative days. Patient education and rehabilitation are pursued aggressively
to optimize functional status, and visiting nurses are frequently involved
to help with tube feeding and tracheostomy and wound care in the period immediately
after discharge. As the LOS has decreased, the number of patients discharged
with a tracheostomy tube has risen. Although a tracheostomy tube is viewed
by some as a barrier to discharge, the readmission rate in this series decreased
despite an increased frequency of discharge with tracheostomy tubes in place.
Intensive patient education on tracheostomy care and increasing use of visiting
nursing care after discharge helped to ensure that these patients received
adequate care.
The CCPs are dynamic, and modifications at regular intervals continue
to shape the CCPs and improve their effectiveness. Several changes have been
made to the head and neck cancer CCP over time, especially in the interest
of decreasing time in the ICU. The fluid nature of the CCP is reflected in
continuously changing and improving outcomes. For example, the median LOS,
which decreased from group 1 to group 2, has been stable over time as demonstrated
by group 3. However, median ICU LOS, median total charges, and the rate of
postoperative pneumonia continued to decrease.
Several arguments have been made against the use of CCPs. A primary
concern is that CCPs encourage "cookbook medicine" because the physician is
not required to consider the details of each patient's care. At our institution,
regularly scheduled treatment plan meetings between the chief resident of
the head and neck surgery service and representatives from the nursing staff
ensure individualized care. In addition, recording variances and responding
to them with alterations in the treatment plan further customize patient care.
Another critique of CCPs was published by Falconer et al,7
who conducted a randomized clinical trial of a critical path method (CPM)
used for stroke rehabilitation and found that it did not improve outcome or
decrease LOS or charges. In that case, a CPM was introduced into a situation
in which the treatment plan for a diagnosis was already relatively standardized.
The stroke CPM also faced the challenge of being split between the conflicting
goals of maximizing the functional benefit of rehabilitation while minimizing
LOS. These issues are most problematic in the setting of rehabilitation, but
they remind us that the most important step in creating a useful CCP is that
of choosing a procedure and setting that can most benefit from the regimen.
The concern expressed by Falconer et al7
that external regulation has dramatically influenced practice, and that the
effects are indistinguishable from those due to the CPM, is most relevant
to the head and neck cancer CCP. As the use of utilization review committees
by insurance companies rises in popularity, and as more hospital days are
denied, physicians are changing their practice with or without CCPs.8 To expect a CCP to decrease resource utilization when
it has already been maximally controlled may also be unreasonable. Although
these problems undoubtedly confound the study of a CCP's effectiveness, they
do not necessarily diminish the importance of a CCP as a means to accomplish
a necessary goal. Physicians across the country are discharging their patients
after shorter hospital stays, but CCPs offer a method for standardizing treatment
plans, minimizing unnecessary variations in patient care, and decreasing LOS
and charges while optimizing therapeutic outcomes.
The present study suggests that a CCP is an effective tool for decreasing
LOS, ICU LOS, and hospital charges without compromising quality of care. Overall,
complication rates did not rise, and the incidence of postoperative pneumonia
decreased. Limiting the occurrence of postoperative pneumonia is particularly
important because it is the most common complication seen after head and neck
surgical procedures (3.26%) and is associated with a mortality rate of 10.94%.9 Readmission rates also dropped from 16 patients (18%)
to 9 (11%), although this was not statistically significant.
Although these results are encouraging, this review has some limitations.
Follow-up data, eg, readmission to outside hospitals, the number of home visits
nurses made for each patient, and the expenses related to both of these services,
are not recorded in the inpatient chart. The organization of charge summaries
changed somewhat since 1997 and may have affected the categorization of charges.
Having a dynamic CCP can continuously improve patient care, but it does
not substitute for well-controlled studies on various aspects of care. A consensus
on an appropriate plan for postoperative care reached by a multidisciplinary
team does not mean that the care plan is scientifically supported. New data
should be generated to optimize patient treatment and to incorporate new findings
into the CCP.
CONCLUSIONS
In the 3 years after implementation of a CCP for patients undergoing
major resection for head and neck cancer, a decrease in resource utilization
has been paralleled by improvements in quality of care. In particular, the
incidence of pneumonia, the most common major complication seen after head
and neck surgery, has decreased significantly. These changes have been made
by tightly coordinating the multiple services providing patient care, diminishing
unnecessary variability in clinical practice, and aggressively pursuing patient
education and independence throughout the hospital stay. The dynamic nature
of a CCP allows for continuing improvement based on a review of variants.
Modifications to the CCP have expedited transfer out of ICUs and continue
to lower ICU LOS and total charges. Overall, the pathway has been a beneficial
tool for patients and health care professionals alike.
AUTHOR INFORMATION
Accepted for publication September 12, 2001.
This study was presented at the annual meeting of the American Head
and Neck Society, Palm Desert, Calif, May 15, 2001.
We thank Barbara Pryor for her work on identifying patients for the
study and clarifying the details of the CCP.
Corresponding author and reprints: Randal S. Weber, MD, Department
of Otorhinolaryngology–Head and Neck Surgery, 3400 Spruce St, 5 Ravdin,
Philadelphia, PA 19104 (e-mail: weberRa{at}uphs.upenn.edu).
From the Departments of Otorhinolaryngology–Head and Neck Surgery
(Drs Gendron, Lai, Weinstein, Chalian, and Weber and Mss Wolf and DiDonato)
and Surgery (Dr Husbands), University of Pennsylvania Health System, Philadelphia.
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