Compliance and efficiency before and after implementation of a clinical practice guideline for laryngeal carcinomas.

We evaluated whether the implementation of a nationwide clinical practice guideline for diagnosis, treatment and follow-up of laryngeal carcinomas led to changes in hospital costs, balanced against clinical changes observed following the guideline's implementation. Charts of 822 patients with larynx carcinoma (459 treated before the introduction of the guideline and 363 thereafter) in five hospitals were retrospectively investigated. In all phases, no differences in total hospital costs were observed after the guideline's implementation. Total mean costs were Euro 3,207 (95%CI 3,091-3,395) for diagnosis, Euro 3,169 (2,153-4,182), Euro 5,026 (3,996-6,057), Euro 6,458 (5,579-7,337), Euro 8,037 (7,469-8,606), Euro 12,765 (10,763-14,769), Euro 19,227 (16,848-21,605) for treatment of dysplasia, carcinoma in situ, T1, T2, T3 and T4 carcinoma, respectively, and Euro 1,856 (1,491-2,220) for 1 year disease-free follow-up. In an earlier study, we observed several positive changes after the guideline's implementation. Balanced against the equal costs before and after the guideline's implementation, we conclude that the efficiency of the care process improved.

Repetitive endoscopic sinus surgery failure: a role for radical surgery?

OBJECTIVES: Endoscopic sinus surgery (ESS) is considered to be the golden standard for surgery in patients with chronic rhinosinusitis and nasal polyposis. However, there is still a small group of patients unresponsive despite repetitive surgery. Radical surgery aimed at reduction of the inflammatory burden and optimization of drainage of the sinuses has been suggested as a last resort for these patients. STUDY DESIGN: A prospective, questionnaire-based study was conducted in a group of 23 patients who underwent Denker's procedure for refractory chronic rhinosinusitis. Symptoms were evaluated before Denker's procedure and 12 months and 2 years after surgery. RESULTS: Patients reported improvement of feelings of congestion in 74%, rhinorrhea in 70%, and nasal obstruction in 60% of the cases. The following postoperative improvements were statistically significant: rhinorrhea (P = 0.001), feelings of congestion (P = 0.02), and nasal obstruction (P = 0.03). Reduced olfactory perception and asthma did not improve. CONCLUSION: Radical surgery may be a viable treatment option in case of recurrent ESS failure. EBM RATING: C-4.

Evaluating adherence to the Dutch guideline for diagnosis, treatment and follow-up of laryngeal carcinomas.

BACKGROUND AND PURPOSE: An evidence-based clinical practice guideline for laryngeal carcinomas was introduced in the Netherlands late 1999. The objective of this guideline was to ensure uniformity in the diagnosis, treatment, and follow-up. We retrospectively evaluated whether clinical practice changed according to the recommendations of this guideline and whether it succeeded in its aim. MATERIAL AND METHODS: In five out of eight Dutch university hospitals, chart data of 459 patients treated before the guideline introduction were compared to data of 363 patients treated after the guideline introduction. RESULTS: Patient and tumour characteristics were comparable among both groups. In general, the guideline recommendations were properly complied with. The patients treated before the guideline introduction were actually also for a large part already treated according to the guideline's recommendations. After its introduction, several changes according to the guideline were observed: increased rates of reassessment of biopsy samples taken in local hospitals, psychological screening (although still only performed in 10.5% of patients), application of accelerated radiotherapy schedules, clinical trial treatments, function-preserving treatments, and decreased rates of total laryngectomy, and annual chest X-rays during follow-up. CONCLUSIONS: Although a causal relationship cannot be established in this kind of observational studies, several positive changes were observed after the introduction of the guideline, and therefore the guideline seems to have contributed to more uniformity. The largest changes were seen for the guideline recommendations based on the highest levels of evidence.

On the enhancement of efficiency in care for cancer patients in outpatient clinics: an instrument to accelerate psychosocial screening and referral.

Many cancer patients experience psychosocial problems that go unnoticed by caregivers. To improve this situation, an instrument has been developed and tested to identify such problems. This instrument, the integral checklist, was put to the test in two outpatient departments of different hospitals with an intervention and a control group (105 and 124 patients, respectively). To evaluate the efficiency of the checklist, both groups had to complete a questionnaire after consultation. Results showed that the checklist assisted specialists to be more often pro-active in discussing psychosocial problems with their patients, and more patients with psychosocial problems were referred. Most of the patients appreciated going through the checklist with their specialist. The checklist proves to fit in well with hospital routines and using it costs the specialist no extra time. It appears to be an instrument which improves efficiency of consultation. Moreover, the checklist is turned out to be useful as a management tool to divert patients' attention away from the waiting time.

Denker operation is an effective surgical approach in managing juvenile nasopharyngeal angiofibroma.

This article presents our experience with the various surgical approaches for angiofibroma and establishes the Denker procedure as an effective approach for removal of the tumor. The medical records of 29 patients treated between the years 1981 and 2001 were examined. The clinical extent of the tumor, the surgical approach, complications, and recurrences were evaluated. The surgical approaches used before 1992 consisted of the transnasal, transpalatal, and combined transnasal-transpalatal ones. Although no major recurrence or major morbidity was observed, late complications occurred, such as persistent palatal fistula in 3 patients who underwent operation via a transpalatal approach, and an unsightly scar with lacrimal duct stenosis in 2 patients who underwent operation via a combined transnasal-transpalatal approach. From 1992 onward, the above-mentioned surgical approaches were replaced with the Denker and midfacial degloving techniques, which proved to be just as effective in removing the tumor and did not produce late complications. According to our experience, the Denker approach is effective for angiofibromas confined to the nasal cavity and nasopharynx with small extensions in the infratemporal fossa. On the other hand, large tumor extension in the infratemporal fossa can be effectively approached in combination with a midfacial degloving technique.

Markers for nodal metastasis in head and neck squamous cell cancer.

OBJECTIVE: To identify markers that are relevant as predictors of lymph node metastasis in head and neck squamous cell cancer. DESIGN: Expression of p53, Rb, cyclin D1, E-cadherin, and epithelial cell adhesion molecule was examined using immunohistochemical analysis and traditional histological parameters, and the correlation of these markers with the histologically verified presence of regional metastases was determined. SUBJECTS: The study sample comprised 121 patients with head and neck squamous cell cancer from whom paraffin-embedded material of primary tumors was used. RESULTS: Lymph node metastasis was correlated with the loss of expression of Rb (P =.04) and marginally correlated with the loss of expression of E-cadherin (P =.06). If the results are broken down to subsites, loss of E-cadherin expression in oral cancer (P =.04) and absence of eosinophilic infiltration in laryngeal cancer (P =.003) correlated with nodal metastasis. None of the other markers correlated. A combination of relevant parameters did not result in a much stronger correlation. CONCLUSIONS: The expression of the investigated genetic markers and histopathological features of primary tumors can supply limited information on the metastatic behavior of tumors. Although the use of markers for regional metastasis would be a welcome additional tool, these results do not warrant the use of these parameters for clinical decision making concerning the treatment of the neck in patients with head and neck squamous cell cancer.