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

Presentation: AHNS060
Topic: Quality of Care and Clinical Pathways
Type: Oral
Date: Thursday, April 19, 2018
Session: 3:30 PM - 4:30 PM Quality Engineering and Pathways
Authors: Pratyusha Yalamanchi1, William W Thomas, MD2, Alan Workman1, Karthik Rajasekaran, MD1, Rabie M Shanti, DMD, MD2, Ara C Chalian, MD2, Jason G Newman, MD, FACS2, Steven B Cannady2
Institution(s): 1Perelman School of Medicine at the University of Pennsylvania, 2Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania

Importance: While 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: 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 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 Chi-square analyses 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 prior radiation 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 (IQR 6-9 days) for the planned ICU cohort versus 1 day (IQR 0-1) for the non-ICU group (p<.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 post-operative care (p=.000054). Specifically, average room and board was 239% more costly for the planned ICU care group ($27,352.40) compared to the non-ICU setting ($11,449.47, p<.00001).

Conclusions and relevance: This study demonstrates that postoperative management following microvascular free tissue transfer in a non-ICU setting is equivalent to standard ICU-based management in terms of clinical outcomes, while being less costly.