Performance Measurement and Target-Setting in California's Safety Net Health Systems.

Health policies encourage implementing quality measurement with performance targets. The 2010-2015 California Medicaid waiver mandated quality measurement and reporting. In 2013, California safety net hospitals participating in the waiver set a voluntary performance target (the 90th percentile for Medicare preferred provider organization plans) for mammography screening and cholesterol control in diabetes. They did not reach the target, and the difference-in-differences analysis suggested that there was no difference for mammography ( P = .39) and low-density lipoprotein control ( P = .11) performance compared to measures for which no statewide quality improvement initiative existed. California's Medicaid waiver was associated with improved performance on a number of metrics, but this performance was not attributable to target setting on specific health conditions. Performance may have improved because of secular trends or systems improvements related to waiver funding. Relying on condition-specific targets to measure performance may underestimate improvements and disadvantage certain health systems. Achieving ambitious targets likely requires sustained fiscal, management, and workforce investments.

Neck Dissection Technique Commonality and Variance: A Survey on Neck Dissection Technique Preferences among Head and Neck Oncologic Surgeons in the American Head and Neck Society

Abstract Introduction Neck dissection (ND) technique preferences are not well reported. Objective The objective of this study is to educate practitioners and trainees about surgical technique commonality and variance used by head and neck oncologic surgeons when performing a ND. Methods Online survey of surgeon members of the American Head and Neck Society (AHNS). Survey investigated respondents' demographic information, degree of surgical experience, ND technique preferences. Results In our study, 283 out of 1,010 (28%) AHNS surgeon members with a mean age of 50.3 years (range 32-77 years) completed surveys from 41 states and 24 countries. We found that 205 (72.4%) had completed a fellowship in head and neck surgical oncology. Also, 225 (79.5%) respondents reported completing more than 25 NDs per year. ND technique commonalities (>66% respondents) included: preserving level 5 (unless with suspicious lymph nodes (LN)), only excising the portion of sternocleidomastoid muscle involved with tumor, resecting lymphatic tissue en bloc, preservation of cervical sensory rootlets, not performing submandibular gland (SMG) transfer, placing one drain for unilateral selective NDs, and performing a ND after parotidectomy and thyroidectomy and before transcervical approaches to upper aerodigestive tract primary site. Variability existed in the sequence of LN levels excised, instrument preferences, criteria for drain removal, the timing of a ND with transoral upper aerodigestive tract primary site resections, and submandibular gland preservation. Results showed that 122 (43.1%) surgeons reported that they preserve the submandibular gland during the level 1b portion of a ND. Conclusions The commonalities and variances reported for the ND technique may help put individual preferences into context.

Neck Dissection Technique Commonality and Variance: A Survey on Neck Dissection Technique Preferences among Head and Neck Oncologic Surgeons in the American Head and Neck Society.

Introduction Neck dissection (ND) technique preferences are not well reported. Objective The objective of this study is to educate practitioners and trainees about surgical technique commonality and variance used by head and neck oncologic surgeons when performing a ND. Methods Online survey of surgeon members of the American Head and Neck Society (AHNS). Survey investigated respondents' demographic information, degree of surgical experience, ND technique preferences. Results In our study, 283 out of 1,010 (28%) AHNS surgeon members with a mean age of 50.3 years (range 32-77 years) completed surveys from 41 states and 24 countries. We found that 205 (72.4%) had completed a fellowship in head and neck surgical oncology. Also, 225 (79.5%) respondents reported completing more than 25 NDs per year. ND technique commonalities (>66% respondents) included: preserving level 5 (unless with suspicious lymph nodes (LN)), only excising the portion of sternocleidomastoid muscle involved with tumor, resecting lymphatic tissue en bloc, preservation of cervical sensory rootlets, not performing submandibular gland (SMG) transfer, placing one drain for unilateral selective NDs, and performing a ND after parotidectomy and thyroidectomy and before transcervical approaches to upper aerodigestive tract primary site. Variability existed in the sequence of LN levels excised, instrument preferences, criteria for drain removal, the timing of a ND with transoral upper aerodigestive tract primary site resections, and submandibular gland preservation. Results showed that 122 (43.1%) surgeons reported that they preserve the submandibular gland during the level 1b portion of a ND. Conclusions The commonalities and variances reported for the ND technique may help put individual preferences into context.

Does a Standalone Cancer Center Improve Head and Neck Microsurgical Outcomes?

Objectives To evaluate the role of hospital setting (standalone cancer center vs. large multidisciplinary hospital) on free tissue transfer (FTT) outcomes for head and neck reconstruction. Methods Medical records were reviewed of 180 consecutive patients undergoing FTT for head and neck reconstruction. Operations occurred at either a standalone academic cancer center (n = 101) or a large multidisciplinary academic medical center (n = 79) by the same surgeons. Patient outcomes, operative comparisons, and hospital costs were compared between the hospital settings. Results The cancer center group had higher mean age (65.2 vs. 60 years; p = 0.009) and a shorter mean operative time (12.3 vs. 13.2 hours; p = 0.034). Postoperatively, the cancer center group had a significantly shorter average ICU stay (3.45 vs. 4.41 days; p < 0.001). There were no significant differences in medical or surgical complications between the groups. Having surgery at the cancer center was the only significant independent predictor of a reduced ICU stay on multivariate analysis (Coef 0.73; p < 0.020). Subgroup analysis, including only patients with cancer of the aerodigestive tract, demonstrated further reduction in ICU stay for the cancer center group (3.85 vs. 5.1 days; p < 0.001). A cost analysis demonstrated that the reduction in ICU saved $223,816 for the cancer center group. Conclusion Standalone subspecialty cancer centers are safe and appropriate settings for FTT. We found both reduced operative time and ICU length of stay, both of which contributed to lower overall costs. These findings challenge the concept that FTT requires a large multidisciplinary hospital. Level of Evidence 4.

How, when, and from whom neck dissection operative technique is learned: An international survey on neck dissection education among head and neck oncologic surgeons.

BACKGROUND: There is a paucity of evidence on how neck dissection (ND) technique is best learned. METHODS: Online survey of the American Head and Neck Society (AHNS). RESULTS: 283 of the 1010 (28%) AHNS surgeon members completed the survey. Most respondents had 3-4 mentors [n=157 (55.5%)] that they felt were most influential their ND technique. 134 (47.3% of surgeons who completed a fellowship) felt that fellowship training had the most impact on their ND technique. Most respondents ranked the most effective methods of learning ND operative technique in the following order: 1) physically performing the operation yourself (70.1%), 2) observing the attending perform maneuvers independent of verbal teaching (37.7%) and 3) verbal teaching by an attending in the operating room independent of actual maneuvers (36.3%). CONCLUSION: When learning an ND, the most benefit comes from empirical learning in the context a small group of surgeon mentors.

Benefits of Immediate Extubation Following Free Tissue Transfer for Head and Neck Reconstruction.

Background Immediate postprocedure extubation (cessation of mechanical ventilation) after free tissue transfer for head and neck reconstruction may improve outcomes, reduce intensive care unit and hospital length of stay, and reduce overall cost compared with delayed extubation in the intensive care unit. Methods Medical records of 180 consecutive patients undergoing free tissue transfer for head and neck reconstruction were reviewed. Patients immediately extubated in the operating room (immediate group, N = 63) were compared with patients who were extubated in the intensive care unit (delayed group, N = 117) by univariate and multivariate analysis. Results Medical complication rates and intensive care unit length of stay were significantly higher in the delayed extubation group (55.5 vs. 12.7%, p < 0.001, and 4.4 vs. 2.9 days, p < 0.001, respectively). Although the rate of preoperative alcohol use was similar between the two groups, significantly fewer patients underwent treatment for alcohol withdrawal or agitation in the immediate extubation group (3.2 vs. 27.4%, p = 0.001). There were no significant differences in surgical complication rates. Conclusion Immediate postprocedure extubation is associated with shorter intensive care unit length of stay, reduced medical complications, and reduced incidence of treatment for agitation/alcohol withdrawal for patients undergoing free tissue transfer for head and neck reconstruction.

The Limitations of Routine Magnetic Resonance Imaging for Long-Term Post-Treatment Locoregional Surveillance of Salivary Carcinoma.

BACKGROUND/AIMS: To determine the utility of head and neck magnetic resonance imaging (HN-MRI) for the routine surveillance of patients without concurrent symptoms or signs of recurrence more than 6 months after treatment for salivary gland carcinoma (SGC). METHODS: This is a retrospective single-institution review of SGC patients from 2000 to 2011 who underwent one or more HN-MRI scans without concurrent suspicious symptoms or signs of recurrence more than 6 months after the completion of treatment, with at least 6 months of follow-up after each scan. RESULTS: Out of an original 283 SGC patients treated surgically, 41 patients, who were disease free 6 months after treatment, had undergone 96 routine HN-MRIs without concurrent suspicious symptoms or signs. Ten out of the 41 patients (24%) experienced a false-positive finding with routine HN-MRI. None of the 96 HN-MRIs demonstrated a true-positive or false-negative finding. CONCLUSION: More than 6 months after treatment, routine HN-MRI for the detection of locoregional recurrence of SGC has a low utility in patients without concurrent suspicious symptoms or signs. While these data support the judicious use of routine HN-MRIs, the managing physician should ultimately decide on the best course of surveillance for an individual patient based on the unique risk factors and circumstances present.

An introduction to stem cell biology.

The field of stem cell biology has undergone tremendous expansion over the past two decades. Scientific investigation has continued to expand our understanding of these complex cells at a rapidly increasing rate. This understanding has produced a vast array of potential clinical applications. This article will serve as an overview of the current state of stem cell research as it applies to scientific and medical applications. Included in the discussion is a review of the many different types of stem cells, including but not limited to adult, embryonic, and perinatal stem cells. Also, this article describes somatic cell nuclear transfer, an exciting technology that allows the production of totipotent stem cells from fully differentiated cells, thereby eliminating the use of embryonic sources. This discussion should serve as a review of the field of stem cell biology and provide a foundation for the reader to better understand the interface of stem cell technology and facial plastic and reconstructive surgery.