Preoperative Care Clinic Improves Survival for Patients Undergoing Free-Flap Reconstruction

Abstract

Objective: This study aims to evaluate whether perioperative care improves postoperative outcomes for head and neck reconstruction patients with preexisting health conditions.

Study design: Retrospective cohort study.

Setting: Single tertiary academic center between 2013 and 2021.

Methods: This study included adult patients who underwent free-flap reconstruction for head and neck cancer. Patients who received perioperative care were compared with patients who received our institution's standard of care. Comorbid health conditions were measured using the Charlson comorbidity index (CCI) excluding solid tumors. Primary outcomes were major and minor complications, length of hospital stay (LOS), days in intensive care unit (ICU), discharge to acute/subacute facility, hospital-free days, and overall survival (OS). Interaction models were specified to evaluate the impact of preoperative care with respect to CCI.

Results: Of the 148 patients included, 83 received perioperative care and 65 received institutional standard of care (mean [SD]: age, 62.1 [10.8]; male, 100 [67.6%]; CCI $\ge$ 4, 43 [29.1%]). Patients with higher CCI who received perioperative care spent fewer days in the hospital (CCI 3: coefficient [ $\beta ]$ , -5.50; P = .012 and CCI $\ge$ 4: $\beta$ , -6.41; P = .022) and ICU (CCI 3: $\beta$ , -2.90; P = .002 and CCI $\ge$ 4: $\beta$ , -6.54; P = .001), gained more hospital-free days (CCI $\ge$ 4: $\beta$ , 17.00; P = .002), and had improved OS (CCI $\ge$ 4: adjusted hazard ratio [aHR], 0.14; P = .023). Perioperative care was not significantly associated with lower rates of major and minor complications or placement at a facility.

Conclusion: Perioperative care provides a robust benefit for patients with medical comorbidities undergoing head and neck reconstruction, but this effect incrementally decreases for healthier patients.

Keywords: free‐flap reconstruction; head and neck cancer; hospital‐free days; length of hospital stay; preoperative care; quality improvement; squamous cell carcinoma; survival.

Figure 1

Multivariable model measuring the association between perioperative care and (A) minor or (B) major complications with respect to comorbidity score. Model adjusted for extracapsular extension. 95% CI, 95% confidence interval; CCI, Charlson comorbidity index; OR, odds ratio.

Figure 2

Multivariable model measuring the association between perioperative care and length of intensive care unit stay with respect to comorbidity score. Model adjusted for smoking history and tumor grade. 95% CI, 95% confidence interval; CCI, Charlson comorbidity index; ICU, intensive care unit.

Figure 3

Multivariable model measuring the association between perioperative care and length of hospital stay with respect to comorbidity score. Model adjusted for pathological N stage, surgical margins, and primary site. 95% CI, 95% confidence interval; CCI, Charlson comorbidity index.

Figure 4

Multivariable model measuring the association between perioperative care and discharge to acute/subacute care facility with respect to comorbidity score. Model adjusted for age, pathological N stage, surgical margins, and perineural invasion. 95% CI, 95% confidence interval; CCI, Charlson comorbidity index; OR, odds ratio.

Figure 5

Multivariable model measuring the association between perioperative care and number of hospital‐free days in the first 90 days with respect to comorbidity score. Model adjusted for age and primary site. 95% CI, 95% confidence interval; CCI, Charlson comorbidity index.

Figure 6

Multivariable model measuring the association between perioperative care and overall survival with respect to comorbidity score. Model adjusted for age, previous treatment, surgical margins, perineural invasion, extracapsular extension, and primary site. 95% CI, 95% confidence interval; aHR, adjusted hazard ratio; CCI, Charlson comorbidity index.