Free Flap Friday: Interdisciplinary clinic implementation and outcomes for patients undergoing head and neck cancer surgery

DOI: https://doi.org/10.21203/rs.3.rs-1809004/v1

Abstract

Purpose:

Patients with complex head and neck cancer benefit from preoperative education and multidisciplinary support. However, such care may not adequately address the need for advance care planning (ACP) in the preoperative setting. We evaluated the feasibility and impact of “Free Flap Fridays” (FFF), a comprehensive preoperative education program that offers recommendations to patients undergoing head and neck surgery with free flap reconstruction. The program is led by an interdisciplinary team comprised of social work, surgical nursing, speech and language pathology, nutrition, and specialty palliative care.

Methods:

This study was a quantitative, retrospective chart review analysis at an academic cancer center. We compared demographics pre- and post-surgical engagement with the interdisciplinary team, and ACP outcomes, among 48 patients who participated in FFF and 44 patients who received usual care prior to the launch of the FFF clinic. 

Results:

Preoperative involvement of each of the five disciplines included in the interdisciplinary team increased among the intervention group. Engagement with FFF increased rates of advance care planning discussions (66.7% vs. 4.5%, p<0.0001). Documentation of a durable power of attorney also increased between the groups (72.9% vs. 31.8%, p<0.0001), although there was no difference in completed advance care documents, including advance directives or Physician Orders for Life Sustaining Treatment (POLST) documents.

Conclusions:

Implementation of an interdisciplinary, preoperative clinic for patients undergoing free flap reconstruction for head and neck cancer is feasible and leads to increased patient engagement and preoperative ACP discussions.

Background

Head and neck cancer and its treatments impact basic functions including speaking, swallowing, eating, drinking and breathing, with long-term implications for appearance and quality of life. As such, multidisciplinary care is accepted as best practice for patients with head and neck cancer and has been shown to improve adherence to clinical quality indicators (1, 2). Incorporating early and concurrent palliative care into the multidisciplinary approach helps guide decision making and support quality of life before, during and after treatment (3).

All patients undergoing major head and neck cancer surgery with free flap reconstruction should receive preoperative education (4). The content and timing of such education has not been well defined, and there are no high-quality studies specifically evaluating the impact of preoperative education on clinical outcomes in this population (4). Notably, head and neck cancer patients have reported feeling unprepared for postoperative long-term lifestyle changes (5). Advance care planning (ACP) is an essential part of preoperative preparation, yet among older adults with multiple chronic conditions undergoing high-risk surgery, only 25.7% had preoperative ACP documentation (6).

The University of California San Francisco (UCSF) medical center serves as a tertiary referral site for patients with head and neck cancer who require surgical resection with free flap reconstruction. Beginning in December 2017, we piloted an interdisciplinary clinic, including the Head and Neck surgery team, social work, speech-language pathology, nutrition, and specialty palliative care. This preoperative half-day clinic, termed “Free Flap Friday” [FFF], offers comprehensive education, expectation setting, and identification of appropriate supportive resources to all patients scheduled for free flap surgeries. We sought to evaluate the feasibility and impacts on preoperative ACP of the FFF clinic.

Methods

Study design and setting

This study was a quantitative, retrospective chart review analysis that was conducted through the UCSF Helen Diller Family Comprehensive Cancer Center. The study was performed in partnership with Oncology Social Work, the Symptom Management Service (SMS) (the cancer center’s outpatient palliative care service), Nutrition, and Otolaryngology–Head and Neck Surgery (OHNS). The study was approved by the UCSF Institutional Review Board.

Participants and recruitment

Study participants were selected based on a diagnosis of head and neck cancer requiring surgical resection with free flap reconstruction. The intervention group was selected from the calendar year 2018, which was after the initiation of the Free Flap Friday Interdisciplinary Clinic. The usual care group was selected from the calendar year 2017, prior to the implementation of the FFF Clinic. The retrospective chart analysis selected patients based on the primary surgeon’s name, the assigned procedure code, and date of surgery. Pediatric and non-cancer patients were excluded from the analysis.

Study groups

Usual care participants received their preoperative evaluation before the implementation of the FFF Clinic. Usual care included a preoperative visit with the ablative and reconstructive surgeons. Patients in the usual care group were not routinely offered appointments with other disciplines, but may have met with an a registered nurse (RN) or physician assistant (PA), licensed clinical social worker (LCSW), speech and language pathologist (SLP), registered dietician (RD), and, very rarely, a palliative care physician (PC) at some point prior to treatment if referred by their surgeon. The intervention group was identified by the surgeons and the practice coordination team, who routinely scheduled patients to meet with the interdisciplinary team for preoperative education with the FFF Clinic, once the operative date was confirmed. The preoperative education and support was provided by a RN or PA, LCSW, PC, SLP, and RD. Practice coordinators attempted to schedule all eligible patients with the FFF Clinic, though due to scheduling limitations, patient declination of visit, or need for urgent surgical admission, preoperative evaluation was not accomplished for all patients. The preoperative intervention included three parts: a 60-minute in-person or video visit with an RN to review the procedure; a 60-minute visit with an RD and SLP to evaluate current speech and swallow function, current needs for tube feedings and nutrition. and to discuss expectations for post-operative changes; and a 60-minute joint visit with an LCSW and palliative care physician to discuss physical symptoms, advance care planning (ACP), psychosocial needs, and emotional support. The interdisciplinary team members discussed patients at weekly tumor board and prior to FFF visits. The team coordinated jointly on any follow-up needs that required addressing prior to the patients’ admissions: including after care needs, barriers to utilizing care, and psychosocial interventions.

Procedure

A retrospective chart analysis was completed by two independent investigators (TS and SS) from the spring of 2020 through the summer of 2021. Charts were selected through the creation of an Electronic Health Record (EHR) report that included procedure code, date of surgery, and the primary surgeon’s name. The initial chart review excluded non-cancer patients, patients without the appropriate surgery, and pediatric patients. The investigators evaluated either the usual care or intervention group for initial analysis. The investigators completed the secondary analysis by swapping data sets to correct any errors in analysis. The few discrepancies in the analysis were reviewed by both investigators and consensus was easily established. The investigators delineated the demographics of the patient cohorts and determined how each group engaged in ACP preoperatively: including documentation of an ACP conversation, documentation of a designated power of attorney (DPOA), and inclusion of an advance directive (AD) and Physician Orders for Life-Sustaining Treatment (POLST).

Statistical analysis

Frequencies were calculated for categorical variables. We used chi-squared tests (\({\chi }\)2) to examine bivariate associations between categorical variables and analysis of variance (ANOVA) to examine associations between categorical and continuous variables. We used a two-sided alpha of 0.05 to determine statistical significance. All analyses were undertaken using SPSS, version 28 for MAC (SPSS Inc, Chicago, IL).

Results

Patient characteristics

A total of 44 patients were assigned the usual care group and 48 patients the intervention group. No statistically significant differences were found between the usual care and intervention groups’ characteristics. Overall, we found that were there were no statistical differences between the two study groups in terms of age (63.5 vs. 61.2 years, p = 0.46), or sex (male: 63.6% vs. 70.8; p = 0.46). The study population was predominantly White/Caucasian (70.7%, 65/92) and English speaking (90.2%, 83/92), with no difference between the two study groups (p = 0.2, p = 0.77 respectively) (Table 1). Only 28.3% (26/92), reported having an underlying mental health condition (p = 0.11). All participants were housed, and the mean distance they travelled for surgery was 69.8 miles. Among all participants, 92.8% had an emergency contact listed and 80.4% had a primary care physician. The average admission length was 8.8 days. Most surgeries, 56.5%, were for recurrent cancer, and 80.4% of the study group was still alive at the time of analysis. The readmission rate was the same across both groups, with a mean of 20.7%. At discharge, 42.4% of patients were referred to home health, and 32.6% were discharged to a skilled nursing facility (SNF). The majority of patients, 69.6%, received adjuvant radiation treatment, and 43.5% received adjuvant systemic therapy, chemotherapy or immunotherapy.

Interdisciplinary clinic utilization

There was no statistical difference in rates of preoperative evaluation by SLP between patients in the intervention group, 72.9%, and in the usual care group, 54.5% (p = 0.07) (Table 2). However, patients in the intervention group did have higher rates of preoperative evaluation by the LCSW, RD, PC, and RN/PA. Preoperative LCSW evaluation occurred in 66.7% of the intervention group and 36.4% of the usual care group (p = 0.004). Of patients in the intervention group, 41.7% were seen by a RD preoperatively as compared with only 2.3% in the usual care group (p < 0.0001). Preoperative PC assessment was performed in 4.5% of patients receiving usual care and 56.3% of patients in the invention group (p = < 0.0001). Nearly all patients in the intervention group were seen by a RN/PA for pre-operative education, 91.7%, as compared with less than half, 45.5%, of the patients who received usual care (p < 0.0001).

Rates of postoperative evaluation by LCSW, SLP, RD, and PC were not statistically different for patients in the intervention and usual care groups. However, more patients in the intervention group, 95.8%, received postoperative support from the surgical nurse or physician assistant compared with the patients in the usual care group, 72.7% (p = 0.002).

Advance Care Planning

Rates of advance care planning discussions were significantly different between the usual care and intervention groups, with 66.7% of patients in the intervention group having documented ACP discussions preoperatively compared with just 4.5% among patients who received usual care (p < 0.001) (Table 3). More patients in the intervention group, 72.9%, had a documented durable power of attorney (DPOA) preoperatively than patients in the usual care group, 31.8% (p < 0.001). There was not a statistical difference between completed Advance Directives and POLST documents preoperatively between the two groups. 29.5% of patients in the usual care group and 43.8% of patients in the intervention group had a completed AD document in the medical record prior to surgery. POLST completion was universally low with 4.5% of the usual care group and 2.1% of the intervention group (p = 0.51) having a POLST document scanned into the medical record before surgery.

Discussion

Implementation of our preoperative interdisciplinary clinic (FFF) successfully increased patient access to a surgical nurse or physician assistant, social work, nutrition, and palliative care assessment and support prior to their scheduled surgery. Notably, preoperative SLP evaluation was not different between the two groups. This is likely due to an existing embedded relationship between SLP and the Head and Neck Surgical team which pre-dated FFF. We did not see increased postoperative engagement with any of the disciplines except for the surgical RN/PA.

Although the findings appear to be valid, our study does have limitations. The content of the preoperative assessments and education provided to each patient/caregiver was not explicitly defined, nor standardized, and thus may have been subject to provider-specific variability. Furthermore, patient and caregiver satisfaction with the preoperative clinic was not assessed in this study, however does appear to be positive. We do not have information about the relative contributions of each discipline to the outcomes achieved.

While our intervention group did have more ACP discussions and increased frequency of DPOA documentation pre-operatively, there was no change in completed Advance Directive documents or POLSTs. This highlights that the advance care planning process is rarely completed in a single visit or conversation. It may also suggest the potential need for additional resources such as on-site notary services to aid in document completion, especially when the timeline from surgical consultation to surgery date is short.

Some challenges with this interdisciplinary care model include schedule coordination between clinicians and management of visit burden for patients and their caregivers. We did find that joint discipline visits and the option of telemedicine helped with reducing the burdens of preoperative visits, especially for those patients who lived farther from the medical center. Even so, there were some instances where timing or coordination of scheduling was a barrier to patients receiving preoperative support from all disciplines.

Future investigation is needed to better characterize the content of the preoperative education provided, the relative contributions of each discipline, and the impact of FFF on postoperative experience, including expectation management, quality of life measures, and overall patient/caregiver satisfaction. With the potential to impact medical decision-making and health care utilization, the finding of increased ACP is notable but clinical outcomes and overall costs of care must be included in subsequent evaluations. Future efforts include implementation of routine postoperative visits by all disciplines to ensure continuity and sustained interdisciplinary support, especially for those patients who require adjuvant systemic therapies.

In conclusion, we demonstrate here that implementation of an interdisciplinary pre-operative clinic for patients undergoing free flap reconstruction for head and neck cancer is feasible and leads to increased patient engagement and ACP discussions preoperatively.

Declarations

Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Conflicts of interest/Competing interests: The authors have no relevant financial or non-financial interests to disclose.

Availability of data and material: The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

Authors' contributions: Teddy Scheel and Sarah Sedki contributed to the study conception and design. Material preparation, data collection and analysis were performed by Teddy Scheel, Sarah Sedki, and David O’Riordan. The first draft of the manuscript was written by Teddy Scheel, Sarah Sedki, and David O’Riordan; and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics approval: Approval was granted by the UCSF Institutional Review Board (02/09/2021, 19-27402).

Consent to participate: N/A

Consent for publication:  N/A

Acknowledgments

We acknowledge and appreciate the support of UCSF Helen Diller Family Comprehensive Cancer Center, specifically the Otolaryngology—Head and Neck Surgery Department and the Symptom Management Service. 

References

  1. Starmer H, Sanguineti G, Marur S, Gourin C. Multidisciplinary head and neck cancer clinic and adherence with speech pathology. Laryngoscope. 2011;121(10):2131–2135. doi:10.1002/lary.21746
  2. Kelly S, Jackson J, Hickey B, Szallasi F, Bond C. Multidisciplinary clinic care improves adherence to best practice in head and neck cancer. Am J Otolaryngol. 2013;34(1):57–60. doi:10.1016/j.amjoto.2012.08.010
  3. McCammon SD. Concurrent palliative care in the surgical management of head and neck cancer. Journal of Surgical Oncology. 2019;120(1):78–84. https://doi.org/10.1002/jso.25452
  4. Dort JC, Farwell DG, Findlay M, Huber GF, Kerr P, Shea-Budgell MA, Simon C, Uppington J, Zygun D, Ljungqvist O, Harris J. Optimal perioperative care in major head and neck cancer surgery with free flap reconstruction: a consensus review and recommendations from the enhanced recovery after surgery society. JAMA Otolaryngol Head Neck Surg. 2017;143(3):292–303. doi:10.1001/jamaoto.2016.2981
  5. Newell R, Ziegler L, Stafford N, Lewin RJ. The information needs of head and neck cancer patients prior to surgery. Annals of the Royal College of Surgeons of England. 2004;86(6):407. doi: 10.1308/147870804722
  6. Tang VL, Dillon EC, Yang Y, Tai-Seale M, Boscardin J, Kata A, Sudore RL. Advance care planning in older adults with multiple chronic conditions undergoing high-risk surgery. JAMA Surg. 2019;154(3):261–264. doi:10.1001/jamasurg.2018.4647

Tables

Table I: Patient characteristics and outcomes

Patient Characteristics

Total

Study Group

P


 

Usual Care

Intervention

 

 

Mean (95%CI)

Mean (95%CI)

Mean (95%CI)

 

Age at surgery

62.3 (59.2, 65.4)

63.5 (58.5, 68.4)

61.2 (57.3, 65.1)

0.46

 

 

 

 

 

 

%(n)

%(n)

%(n)

 

 

N= 92

N= 44

N= 48

 

Sex (Male)

67.4 (62)

63.6 (28)

70.8 (34)

0.46

 

 

 

 

 

Race

N= 92

N= 44

N= 48

 

White/Caucasian

70.7 (65)

63.8 (28)

77.1 (37)

0.2

Asian

15.2 (14)

20.5 (9)

104 (5)

 

Hispanic/Latinx

7.6 (7)

11.4 (5)

4.2 (2)

 

Black/African American

3.3 (3)

4.5 (2)

2.1 (1)

 

Other

3.3 (3)

0 (0)

6.3 (3)

 

Language

N= 92

N= 44

N= 48

 

English

90.2 (83)

88.6 (39)

91.7 (44)

0.77

Cantonese

3.3 (3)

4.5 (2)

2.1 (1)

 

Arabic

1.1 (1)

0 (0)

1 (2.1)

 

Mandarin

2.2 (2)

2.3 (1)

2.1 (1)

 

Spanish

3.3 (3)

4.5 (2)

2.1 (1)

 

 

 

 

 

 

 

N= 92

N= 44

N= 48

 

Mental Health Diagnosis (Yes)

28.3 (26)

20.5 (9)

35.4 (17)

0.11

 

 

 

 

 

 

N= 92

N= 44

N= 48

 

Disposition (Alive)

80.4 (74)

79.5 (35)

81.3 (39)

0.84

 

 

 

 

 

 

N= 92

N= 44

N= 48

 

Housed (Yes)

100 (92)

100 (44)

100 (48)

  •  

 

 

 

 

 

Length of Admission (Days)

8.8 (7.9, 9.8)

8.3 (7.1, 9.5)

9.3 (7.9, 10.8)

0.27

 

 

 

 

 

Distance from Hospital (Miles)

69.8 (54.5, 85.1)

75.7 (48.6, 102.9)

64.2 (48.1, 80.3)

0.46

 

 

 

 

 

Emergency Contact (Yes)

97.8 (90)

95.5 (42)

100 (48)

0.14

 

 

 

 

 

Primary Care Physician (Yes)

80.4 (74)

79.5 (35)

81.3 (39)

0.84

 

 

 

 

 

Cancer Recurrence (Yes)

56.5 (52)

54.5 (24)

58.3 (28)

0.56

 

 

 

 

 

Adjuvant Radiation Treatment (Yes)

69.6 (64)

63.6 (28)

75.0 (36)

0.24

 

 

 

 

 

Adjuvant Systemic Treatment (Yes)

43.5 (40)

34.1 (15)

52.1 (25)

0.08

 

 

 

 

 

Readmission (Yes)

20.7 (19)

20.5 (9)

20.8 (10)

0.96

 

 

 

 

 

Post-operative Home Health (Yes)

42.4 (39)

40.9 (18)

43.8 (21)

0.78

 

 

 

 

 

Post-operative Skilled Nursing Facility (Yes)

32.6 (30)

38.6 (17)

27.1 (13)

0.24


Table II: Perioperative discipline-specific utilization


Total

Study Group

P


 

Usual Care

Intervention

 

 

%(n)

%(n)

%(n)

 

Social Worker

 

 

 

 

Pre

52.2 (48)

36.4 (16)

66.7 (32)

0.004

Post

44.6 (41)

45.5 (20)

43.8 (21)

0.86

 

 

 

 

 

Speech-Language Pathologist

 

 

 

 

Pre

64.1 (59)

54.5 (24)

72.9 (35)

0.07

Post

73.9 (68)

68.2 (30)

79.2 (38)

0.23

 

 

 

 

 

 

 

 

 

 

Registered Dietician 

 

 

 

 

Pre

22.8 (21)

2.3 (1)

41.7 (20)

<0.0001

Post

34.8 (32)

34.1 (15)

35.4 (17)

0.89

 

 

 

 

 

 

 

 

 

 

Palliative Care Physician 

 

 

 

 

Pre

31.5 (29)

4.5 (2)

56.3 (27)

<0.0001

Post

19.6 (18)

13.6 (6)

25.0 (12)

0.17

 

 

 

 

 

Surgical Nurse

 

 

 

 

Pre

69.6 (64)

45.5 (20)

91.7 (44)

<0.0001

Post

84.8 (78)

72.7 (32)

95.8 (46)

0.002


Table III: Advance care planning outcomes


Total

Study Group

P


 

Usual Care

Intervention

 

 

%(n)

%(n)

%(n)

 

Advance Directive Discussion (Yes)

37.0 (34)

4.5 (2)

66.7 (32)

<0.0001

 

 

 

 

 

Durable Power of Attorney (Yes)

53.3 (49)

31.8 (14)

72.9 (35)

<0.0001

 

 

 

 

 

Advance Directive Pre-op (Yes)

37.0 (34)

29.5 (13)

43.8 (21)

0.16

 

 

 

 

 

POLST Pre-op (Yes)

3.3 (3)

4.5 (2)

2.1 (1)

0.51