Using Economic Evaluation to Illustrate Value of Care for Improving Patient Safety and Quality: Choosing the Right Method.

ABSTRACT: To scale and sustain successful quality improvement (QI) interventions, it is recommended for health system leaders to calculate the economic and financial sustainability of the intervention. Many methods of economic evaluation exist, and the type of method depends on the audience: providers, researchers, and hospital executives. This is a primer to introduce cost-effectiveness analysis, budget impact analysis, and return on investment calculation as 3 distinct methods for each stakeholder needing a measurement of the value of QI at the health system level. Using cases for the QI of hospital-acquired condition rates (e.g., pressure injuries), this primer proceeds stepwise through each method beginning from the same starting point of constructing a model so that the repetition of steps is minimized and thereby capturing the attention of all intended audiences.

Building a business case for colorectal surgery quality improvement.

BACKGROUND: Improving surgical quality is a priority, but building a business case for the efforts could be challenging. Bridging the gap between the clinicians and hospital leaders is the first step to align quality and financial priorities within health care. OBJECTIVE: The aim of this study was to evaluate the financial impact of the surgical comprehensive unit-based safety program on colorectal surgery procedures. DESIGN: This a retrospective cohort study. SETTING: This study was conducted at a university-based tertiary care hospital. PATIENTS: All patients undergoing colectomy or proctectomy between July 2010 and June 2012 were included. INTERVENTION: A comprehensive unit-based safety program focused on colorectal surgical site infection reduction was implemented. Three surgeons participated in the program in year 1, and 5 surgeons participated in year 2. Patients were categorized as participating or nonparticipating based on the surgeon who performed the procedure. MAIN OUTCOME MEASURES: Resource utilization and cost were the main outcome measures. RESULTS: During the 2 years, there were 626 patients who met the selection criteria. Participating surgeons operated on 444 patients (70.9%), and the nonparticipating surgeons operated on 182 patients (29.1%). After adjusting for covariates, the variable direct cost was significantly lower for the participating surgeons in laboratory work by $191 (p = 0.009), operating room utilization by $149 (p = 0.05), and supplies by $615 (p = 0.003). The surgical site infection rates, need for an intensive care unit stay, and length of stay were not significantly different between the 2 groups. LIMITATIONS: The multiple biases related to surgeon self-selection for program participation and surgeon training and clinical skills were not addressed in this study owing to the limitations in sample size and data collection. CONCLUSION: A comprehensive unit-based safety program implementation, including dedicated frontline providers who focused on the standardization of protocols, was able to reduce the variation in resource utilization and costs in comparison with a control group.

Robot-assisted minimally invasive distal pancreatectomy is superior to the laparoscopic technique.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) reduces postoperative morbidity, hospital stay, and recovery as compared with open distal pancreatectomy. Technical limitations of laparoscopic surgery may limit patient eligibility and require conversion to open or hand-assisted surgery to maintain patient safety. We hypothesized that robot-assisted distal pancreatectomy (RADP) was superior to LDP as a result of improved surgical manipulation and visualization, potentially expanding the indications for minimally invasive pancreatectomy. METHODS: We performed a retrospective analysis of all minimally invasive distal pancreatectomies at University of Pittsburgh Medical Center between January 2004 and February 2011. We compared the perioperative outcomes, 90-day morbidity and mortality of our first 30 RADPs to 94 consecutive historical control LDPs. RESULTS: Patients undergoing RADP and LDP demonstrated equivalent age, sex, race, American Society of Anesthesiologists' score, and tumor size. Postoperative length of hospital stay and rates of pancreatic fistula, blood transfusion, and readmission were not statistically different. Patients in the RADP group did not require conversion to open surgery unlike the LDP group (16%, P < 0.05) and had reduced risk of excessive blood loss. There were more pancreatic ductal adenocarcinomas approached robotically (43%) than laparoscopically (15%) (P < 0.05). Oncological outcomes in these cases were superior for the robotic-assisted group with higher rates of margin negative resection and improved lymph node yield for both benign and malignant lesions (P < 0.0001). CONCLUSIONS: RADPs were equivalent to LDPs in nearly all measures of outcome and safety but significantly reduced the risk of conversion to open resection, despite a statistically greater probability of malignancy in the robotic cohort. We concluded that robotic assistance may broaden indications for minimally invasive pancreatectomy.

Association between number of stages in Mohs micrographic surgery and surgeon-, patient-, and tumor-specific features: a cross-sectional study of practice patterns of 20 early- and mid-career Mohs surgeons.

OBJECTIVE: To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early- to mid-career Mohs surgeons and to assess other factors affecting number of stages. METHODS: Statistical analysis of MMS logs of 20 representative early- to mid-career surgeons. RESULTS: There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p<.001), with the greatest number of stages for nose (2.01) and ear (2.06) lesions and the fewest for neck (1.47), back and shoulder (1.47), and lower extremity (1.33) lesions. Basal cell carcinomas required 1.92 stages (median 2.00), compared with 1.66 (median 1.00) for squamous cell carcinoma (p<.001). CONCLUSIONS: Early- and mid-career Mohs surgeons appear to remove tumors with similar numbers of stages regardless of their experience, case volume, or geographic location. Number of stages varies with anatomic location and tumor type. The authors have indicated no significant interest with commercial supporters.

Modified single-sling myocutaneous island pedicle flap: series of 61 reconstructions.

BACKGROUND: Bilevel undermining above and below the transverse nasalis muscle in the construction of a myocutaneous island pedicle flap produces a bilateral or unilateral muscular sling with exceptional vascular supply for reconstruction of defects on the distal nose. We present further modification of the single-sling myocutaneous island pedicle flap that expands its application to a wide variety of nasal defects and further defines its usefulness in nasal reconstruction. METHODS: A series of 61 consecutive myocutaneous island pedicle flap reconstructions performed after Mohs surgery between March 2005 and July 2006 are presented. Flap modifications are presented, and advantages and limitations are discussed. RESULTS: Flap modifications introduce additional reach and rotational mobility to the flap that permit extension of the flap to defects on the nasal tip and distal ala. CONCLUSION: Modifications of the bilevel approach to the single-sling nasalis myocutaneous island pedicle flap further define its practicality in nasal reconstruction and expand its application to a variety of nasal defects.

KTP-nd:YAG laser therapy for the treatment of vestibulodynia: a follow-up study.

OBJECTIVE: To evaluate the results of KTP-Nd:YAG laser therapy for the treatment of vestibulodynia. STUDY DESIGN: Retrospective review and follow-up mail survey of women with vestibulodynia who underwent laser treatment. Demographics, number of laser treatments and symptom severity prior to laser treatment (100-mm visual analog scale) were obtained from the medical record. The survey included questions regarding current sexual pain, sexual quality of life and satisfaction with treatment. RESULTS: Of41 treated women, 37 women were located and agreed to participate. The mean number of laser sessions was 2.81 (range, 1-8). The mean age was 32.9 years and mean follow-up, 2.8. Following laser treatment, most (24 of 37, 68%) subjects reported less pain with sexual intercourse. One subject reported more pain, while 29% (11 of 37) reported no change. Sixty percent (21 of 37) reported their sex lives to be more satisfying/pleasurable following laser treatment. Thirteen women (13 of 37, 35%) underwent vestibulectomy following laser therapy, and 2 subjects were treated with a laser after failed vestibulectomy. CONCLUSION: Most women with vestibulodynia treated with a KTP-Nd:YAG laser achieve a reduction in sexual pain and improved sexual satisfaction without excisional therapy.

Fusiform elliptical Burow's graft: a simple and practical esthetic approach for nasal tip reconstruction.

BACKGROUND: Reconstruction of cutaneous nasal tip and supratip defects presents a common challenge in which esthetic outcomes are dependent on appropriate flap or graft selection and execution. OBSERVATION: We describe the fusiform elliptical Burow's graft, a modified full-thickness skin graft, for repair of moderately sized nasal tip and supratip defects. It has the advantage of being a one-stage procedure with incisions and undermining similar to a primary closure. This technique allows the defect to become smaller in size and shallower in depth while taking the shape of a fusiform ellipse confined to a single cosmetic subunit. The color and texture match of the adjacent Burow's skin graft combined with its fusiform elliptical shape allow it to blend in more naturally with the nasal tip contour compared with the traditional circular-shaped Burow's graft, which is typically used on the nose. CONCLUSION: The fusiform elliptical Burow's graft is a simple, reliable, easily reproducible, and esthetically pleasing technique for repair of defects on the nasal tip and supratip.

Increased metastasis and mortality from cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia.

In patients with chronic lymphocytic leukemia, squamous cell carcinoma behaves aggressively. Our purpose was to compare squamous cell carcinoma metastasis and mortality between patients with chronic lymphocytic leukemia and control subjects. Medical records were assessed retrospectively for 28 patients with chronic lymphocytic leukemia who underwent surgical excision of cutaneous squamous cell carcinoma and for 56 matched control subjects. The rate of metastasis and mortality from cutaneous squamous cell carcinoma were determined on a per-patient basis. Three of 28 patients with chronic lymphocytic leukemia had metastasis and died of metastatic disease. No metastases or deaths occurred among the 56 control subjects. Compared with control subjects, chronic lymphocytic leukemia patients with cutaneous squamous cell carcinoma were more likely to have metastasis (P = .0031) and die of metastasis (P = .0033). No significant association was detected between metastasis and history of chemotherapy administration for chronic lymphocytic leukemia. Among patients with chronic lymphocytic leukemia, surveillance for skin cancer and a decreased threshold for biopsy of suspect lesions are warranted.

Surgical revision.

Even the best surgeons must confront scars and complications that are aesthetically unacceptable and need revision. With careful assessment of the scar, various scar revision techniques can be applied to create an aesthetically pleasing result.

Otolaryngologic manifestations of PHACE syndrome.

Two case reports of PHACE syndrome (posterior fossa malformations (P), hemangiomas (H), arterial anomalies (A), coarctation of the aorta and cardiac defects (C), and eye abnormalities (E)) are presented. Clinical characteristics consisted of cutaneous and airway hemangiomas, aortic coarctation, and left superior vena cava in one child and cutaneous and airway hemangiomas, sternal clefting, and supraumbilical raphe in the other child. Treatment modalities included systemic and intralesional steroids for cutaneous and airway hemangiomas, submucosal resection and laryngotracheal reconstruction for airway hemangiomas, repair of aortic coarctation, and laser treatment of cutaneous hemangiomas. PHACE syndrome poses a significant potential for airway compromise from hemangiomas, which may require multimodality treatment.

Sentinel lymph node biopsy.

The introduction of sentinel lymph node biopsy (SLNB) has been an important development in the management of malignant melanoma. Lymph nodes have long been known to play a key role in melanoma metastasis. The importance of nodal staging accounted for the previous surgical practice of elective lymph node dissection (ELND) even with its controversial impact on final outcomes and associated morbidity. Although this morbidity has been reduced with the ability to identify the SLN, numerous questions have subsequently surfaced with respect to this procedure's utility and therapeutic efficacy. This chapter will focus on the indications for SLNB, as well as the current controversies surrounding this procedure.

Biopsy techniques. Diagnosis of melanoma.

The biopsy of a suspicious pigmented lesion is critical to establishing a correct and complete diagnosis. It allows the dermatopathologist accurately to diagnose melanoma and to gauge maximum depth of invasion (and other histologic criterion). This, in turn, influences the extent of further necessary surgery or other adjuvant therapy. Furthermore, choosing the appropriate biopsy technique provides adequate cosmetic results, bearing in mind that the excisional technique is ideal because it removes the suspicious lesion en toto. Excisional biopsies should extend to the subcutaneous fat by means of a punch biopsy, a fusiform ellipse, or a saucerization. Incisional biopsies can be performed in certain circumstances, but should be done so with caution because sampling error may lead to missed diagnosis or inaccurate histologic criterion, such as depth.