A Health Technology Assessment in Maxillofacial Cancer Surgery by Using the Six Sigma Methodology

Squamous cell carcinoma represents the most common cancer affecting the oral cavity. At the University of Naples “Federico II”, two different antibiotic protocols were used in patients undergoing oral mucosa cancer surgery from 2006 to 2018. From 2011, there was a shift; the combination of Cefazolin plus Clindamycin as a postoperative prophylactic protocol was chosen. In this paper, a health technology assessment (HTA) is performed by using the Six Sigma and DMAIC (Define, Measure, Analyse, Improve, Control) cycle in order to compare the performance of the antibiotic protocols according to the length of hospital stay (LOS). The data (13 variables) of two groups were collected and analysed; overall, 136 patients were involved. The American Society of Anaesthesiologist score, use of lymphadenectomy or tracheotomy and the presence of infections influenced LOS significantly (p-value < 0.05) in both groups. Then, the groups were compared: the overall difference between LOS of the groups was not statistically significant, but some insights were provided by comparing the LOS of the groups according to each variable. In conclusion, in light of the insights provided by this study regarding the comparison of two antibiotic protocols, the utilization of DMAIC cycle and Six Sigma tools to perform HTA studies could be considered in future research

Application of DMAIC Cycle and Modeling as Tools for Health Technology Assessment in a University Hospital

Background. The Health Technology Assessment (HTA) is used to evaluate health services, manage healthcare processes more efficiently, and compare medical technologies. The aim of this paper is to carry out an HTA study that compares two pharmacological therapies and provides the clinicians with two models to predict the length of hospital stay (LOS) of patients undergoing oral cavity cancer surgery on the bone tissue. Methods. The six Sigma method was used as a tool of HTA; it is a technique of quality management and process improvement that combines the use of statistics with a five-step procedure: “Define, Measure, Analyze, Improve, Control” referred to in the acronym DMAIC. Subsequently, multiple linear regression has been used to create two models. Two groups of patients were analyzed: 45 were treated with ceftriaxone while 48 were treated with the combination of cefazolin and clindamycin. Results. A reduction of the overall mean LOS of patients undergoing oral cavity cancer surgery on bone was observed of 40.9% in the group treated with ceftriaxone. Its reduction was observed in all the variables of the ceftriaxone group. The best results are obtained in younger patients (−54.1%) and in patients with low oral hygiene (−52.4%) treated. The regression results showed that the best LOS predictors for cefazolin/clindamycin are ASA score and flap while for ceftriaxone, in addition to these two, oral hygiene and lymphadenectomy are the best predictors. In addition, the adjusted R squared showed that the variables considered explain most of the variance of LOS. Conclusion. SS methodology, used as an HTA tool, allowed us to understand the performance of the antibiotics and provided variables that mostly influence postoperative LOS. The obtained models can improve the outcome of patients, reducing the postoperative LOS and the relative costs, consequently increasing patient safety, and improving the quality of care provided

Reconstructive Techniques of the Parotid Region

The aim of our study was to evaluate and check (analyze and compare the results) the complications of patients with benign parotid disease reconstructed with the 3 reconstructive techniques used after the removal of benign tumors of the parotid gland treated at our institution. The reconstruction of this anatomical region may include the use of superficial musculoaponeurotic system (SMAS) flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap to prevent aesthetic and functional complications. PATIENTS AND METHODS: We carried out a retrospective review of 224 patients operated on between February 2002 and March 2009 with benign primary parotid tumors. Extracapsular dissection or superficial parotidectomy was performed and then these patients were reconstructed with the 3 techniques that we used to apply at the Department of Maxillofacial Surgery in the University Federico 2 of Naples: the SMAS flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap. The statistical difference between the extracapsular dissection versus superficial parotidectomy and the statistical difference between the 3 types of flaps as concerns evaluated recurrence rate and complications were measured with the χ test. The chosen level of statistical significance was P less than 0.05. RESULTS: Out of the 224 enrolled patients, 103 were women and 121 men, with an average age of 54 years. After histopathological examination, 136 adenomas and 88 cystadenoma lymphomas were diagnosed. Enucleoresection was the surgical technique adopted in 169 cases while superficial parotidectomy was used in the remaining 55 cases. The reconstruction was performed with SMAS flap in 122 patients, with muscle flap SMC in 66 patients and temporoparietal fascia flap in 36 patients. Table 1 shows that no significant differences as concerns hematoma and wound infection were observed after extracapsular dissection and superficial parotidectomy(1.8% vs.1.8% [P > 0.05] and 1.8% vs. 5.5% [P > 0.05]). Transient facial nerve weakness, fistula, dip skin, Frey syndrome, spinal nerve injury, and facial paralysis were significantly more frequent after superficial parotidectomy than after extracapsular dissection (4.1% vs. 27.3% [P < 0.001], 1.8% vs. 10.9% [P < 0.001], 3% vs. 12.7% [P < 0.001], 0% vs. 5.5% [P < 0.001], 0% vs. 3.6% [P < 0.001], and 0% vs. 9.1% [P < 0.001], respectively). Table 3 shows that the presence of Frey syndrome is statistically significant in the first 2 comparisons, group I against group IV and group II against group V, respectively (P < 0.05 and P < 0.01). And in the first comparison between group I and IV, there was a statistically significant presence of transient facial nerve weakness (P < 0.001), fistula (P < 0.001), dip skin (P < 0.05), and facial paralysis (P < 0.001). In the second comparison between group II and group V besides the presence of Frey syndrome, there is also a statistically significant presence of transient facial nerve weakness (P < 0.05), skin depression (P < 0.05), accessory spinal nerve injury (P < 0. 01), and facial paralysis (P < 0.01). In the comparison between the third and the sixth group, there is a statistically significant presence of transient facial nerve weakness (P < 0.05), fistula (P < 0.01), and facial paralysis(P < 0.05). CONCLUSIONS: Extracapsular dissection showed similar effectiveness and fewer side effects than superficial parotidectomy, and the 3 reconstruction techniques used in this trial drastically reduce the occurrence of post-parotidectomy Frey syndrome and greatly reduce functional and aesthetic complication

Special Issue &ldquo;New Frontiers in Facial Surgery&rdquo;

Facial surgery remains a challenge for surgeons in order to achieve the best results, both functionally and aesthetically [...