Value of Intensive Care Unit-Based Postoperative Management for Microvascular Free Flap Reconstruction in Head and Neck Surgery.

Importance: Although routine postoperative care for microvascular free flap reconstruction typically involves admission to the intensive care unit (ICU), few studies have investigated the effect of postoperative care setting on clinical outcomes and institution cost. Objectives: To determine the value of non-ICU-based postoperative management for free tissue transfer for head and neck surgery, in terms of clinical outcomes and cost-effectiveness. Design, Setting, and Participants: This is a retrospective cohort study of two groups of adults who underwent vascularized free tissue transfer from October 2013 to October 2017 at an academic tertiary care center and community-based hospital, respectively. Postoperative management differed such that the first group recovered in a protocol-driven non-ICU setting and the second group was cared for in a planned admission to the ICU. A single surgeon performed all tissue harvest and reconstruction at both centers. Main Outcomes and Measures: Descriptive statistics and cost analyses were performed to compare clinical outcomes and total surgical and downstream direct cost to the institution between the two patient groups. Categorical variables were compared using χ2 test where appropriate. Results: Among a total of 338 patients who underwent microvascular free flap reconstruction for head and neck surgical defects, there was no significant difference in patient characteristics such as demographics, comorbidities, history of surgical resection, prior free flap, and locoradiation between the postoperative ICU cohort (n = 146) and protocol-driven non-ICU cohort (n = 192). There were 16 patients in the non-ICU group who spent >3 days in the ICU postoperatively secondary to patient comorbidities and patient care priorities. Still, the average ICU length of stay was 7 days (interquartile range [IQR] 6-9 days) for the planned ICU cohort versus 1 day (IQR 0-1) for the non-ICU group (p < 0.00001). There was no difference in operative variables such as donor site, case length, or total length of stay, and postoperative management in the ICU versus non-ICU setting resulted in no significant difference in terms of flap survival, reoperation, readmission, and postoperative complications. However, average cost of care was significantly higher for patients who received ICU-based care versus non-ICU postoperative care. Specifically, room and board were 239% more costly for the planned ICU care group than the non-ICU setting (p < 0.00001). Conclusions and Relevance: This study demonstrates that postoperative management after vascularized free tissue transfer in a non-ICU setting is equivalent to standard ICU-based management, in terms of clinical outcomes, while being less costly.