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Quality-Based Procedures Clinical Handbook for Cancer Surgery Ministry of Health and Long-Term Care January 2016 Version: January 12, 2015 Table of Contents 1.0 Purpose .......................................................................................................................... 3 2.0 Introduction ..................................................................................................................... 3 3.0 Cancer Surgery QBP .....................................................................................................10 4.0 Prostate Cancer Surgery ...............................................................................................15 5.0 Colorectal Cancer Surgery .............................................................................................22 6.0 Thyroid Cancer Surgery………………………………………………………………………..30 7.0 Breast Cancer Surgery ................................................................................ ………… 38 8.0 Implementation of best practices ...................................................................................... 57 9.0 What does it mean for multi-disciplinary teams? .............................................................. 58 10.0 Service capacity planning.................................................................................................. 59 11.0 Performance evaluation and feedback ............................................................................. 60 12.0 Cancer Surgery Quality Indicators .................................................................................... 64 13.0 Support for Change ........................................................................................................... 66 14.0 Frequently Asked Questions ............................................................................................. 67 15.0 Membership ....................................................................................................................... 68 Appendices ................................................................................................................................... 72 2 Quality-Based Procedures Clinical Handbook: Cancer Surgery 1.0 Purpose This clinical handbook has been created to serve as a compendium of the evidencebased rationale and clinical consensus driving the development of the policy framework and implementation approach for Cancer Surgery. This document has been prepared for informational purposes only. This document does not mandate health care providers to provide services in accordance with the recommendations included herein. The recommendations included in this document are not intended to take the place of the professional skill and judgment of health care providers. 2.0 Introduction Historically, a large portion of health service providers’ funding has been grounded on a base annualized funding (global allocation), which is used to maintain day-to-day operations, such as: staff wages & benefits; overheard costs and service/maintenance contracts and new incremental funding, based on a funding formula, which takes into account demographics and acuity: growth funding targeted at fastest growing communities, hospital type (i.e. small/rural to cover service gaps, academic hospital sites to cover higher cost and acuity). There needs to be a move to better integrate and align funding mechanisms across sectors to respond to volume and mix of services that meet population need through the pathway of care for patients. By focusing on an enhanced alignment between high quality patient care and funding, reductions in variation in practice across the province can be achieved. The results of such reduction in practice variation facilitate the adoption of best clinical evidence-informed practices, ensuring our patients receive the right care, at the right place and at the right time. In response to these fiscal challenges, as of April 1, 2012, the Ministry of Health and Long-Term Care (ministry) has implemented Health System Funding Reform (HSFR). 3 Over the fiscal years 2012/13 to 2014/15, HSFR will shift much of Ontario’s health care system funding for hospitals and Community Care Access Centres (CCACs) away from the current global funding allocation towards paying for activity and patient outcomes, to further support quality, efficiency and effectiveness in the health care system. HSFR is predicated on the tenets of Ontario’s Action Plan for Health Care and is aligned with the four core principles of the Excellent Care for All Act (ECFAA): • • • • Care is organized around the person to support their health; Quality and its continuous improvement is a critical goal across the health system; Quality of care is supported by the best evidence and standards of care; and Payment, policy and planning support quality and efficient use of resources. HSFR is comprised of three key components: 1. Organizational-Level funding, which will be allocated as base funding using the Health Based Allocation Model (HBAM); 2. Quality-Based Procedure (QBP) funding, which will be allocated for targeted clinical areas based on a “price x volume” approach premised on evidence-based practices and clinical and administrative data; and 3. Global funding approach. 2.1 What are we moving towards? Prior to the introduction of HSFR, a significant proportion of hospital funding was allocated through a global funding approach, with specific funding for select provincial programs, wait times services and other targeted activities. A global funding approach may not account for complexity of patients, service levels and costs and may reduce incentives to adopt best practices that result in improved patient outcomes in a costeffective manner. Under HSFR, provider funding is based on: the types and quantities of patients providers treat, the services they deliver, the quality of care delivered and patient experience/ outcomes. Specifically, QBPs provide incentives to health care providers to become more efficient and effective in their patient management by accepting and adopting best practices that ensure Ontarians get the right care, at the right time and in the right place. The variations in patient care evident in the global funding approach warrant the move towards a system where ‘money follows the patient” (Figure 1). 4 Internationally, similar models have been implemented since 1983. While Ontario is one of the last leading jurisdictions to move down this path, this puts the province in a unique position to learn from international best practices and pitfalls and create a funding model that is best suited for the province. Figure 1: The Ontario government is committed to moving towards patient-centred, evidenceinformed funding that reflects local population needs and incents delivery of high quality care Current Based on a lump sum, historical funding Fragmented system planning Funding not linked to outcomes Does not recognize efficiency, standardization and adoption of best practi ces Maintains sector specific silos Transition Phase Future Transpare nt, evidence-based to better reflect population needs Strong Clinical Engagement Current Agency Infrastructure System Capacity Building for Change and Improvement Knowledge to Action Toolkits Supports system service capacity planning Supports quality improvement Encourages provider adoption of best practice through linking funding to activity and patient outcomes Ontarians will get the right care, at the right place and at the right time Meaningful Performance Evaluation Feedback 2.2 How will we get there? The ministry has adopted a multi-year implementation strategy to phase in the HSFR strategy and will make modest funding shifts beginning April 2012. A three-year outlook has been provided to the field to support planning for upcoming funding policy changes. The ministry has released a set of tools and guiding documents to further support the field in adopting the funding model changes. For example, a Quality-Based Procedure (QBP) interim list has been published for stakeholder consultation and to promote transparency and sector readiness. The list is intended to encourage providers across the continuum to analyze their service provision and infrastructure in order to improve clinical processes and where necessary, build local capacity. However, as implementation evolves, the interim List will continue to undergo further refinements pending stakeholder feedback and advice from the QBP Clinical Expert Advisory Groups. The successful transition from the current, ‘provider-centred’ funding model towards a ‘patient-centred model’ will be catalyzed by a number of key enablers and field supports. These enablers translate to actual principles that guide the development of 5 the funding reform implementation strategy related to QBPs. These principles further translate into operational goals and tactical implementation, as presented in Figure 2. Figure 2: Principles guiding the implementation of funding reform related to Quality-Based Procedures Principles for developing QBP implementation strategy Cross-Sectoral Pathways Evidence-Based Balanced Evaluation Operationalization of principles to tactical implementation (examples) Development of best practice patient clinical pathways through clinical expert advisors and evidence-based analyses Integrated Quality Based Procedures Scorecard Alignment with Quality Improvement Plans Transparency Publish practice standards and evidence underlying prices for QBPs Routine communication and consultation with the field Sector Engagement Clinical Expert Advisory Groups Overall HSFR Governance structure in place that includes key stakeholders Technical and clinical engagement sessions Knowledge Transfer Applied Learning Strategy/ IDEAS Tools and guidance documents HSFR Helpline; HSIMI website (repository of HSFR resources) 2.3 What are Quality-Based Procedures? QBPs are clusters of patients with clinically related diagnoses or treatments that have been identified using an evidence-based framework as providing opportunity for process improvements, clinical re-design, improved patient outcomes, and enhanced patient experience and potential cost savings. The evidence-based framework uses data from the Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS) adapted by the ministry for its HBAM repository. The HBAM Inpatient Grouper (HIG) groups inpatients based on the diagnosis or treatment responsible for the majority of their patient stay. Additional data was used from the Ontario Case Costing Initiative (OCCI), and Ontario Cost Distribution Methodology (OCDM). Evidence such as publications from Canada and other jurisdictions and World Health Organization reports were also used to assist with the patient clusters and the assessment of potential opportunities. 6 The evidence-based framework assessed patients using five perspectives, as presented in Figure 3. This evidence-based framework has identified QBPs that have the potential to improve quality of care, standardize care delivery across the province and show increased cost efficiency. Figure 3: Evidence-Based Framework 1. Practice Variation The DAD has every Canadian patient discharge (except Quebec), coded and abstracted for over 50 years. This information is used to identify patient transition through the acute care sector, including discharge locations, expected lengths of stay and readmissions for each and every patient, based on their diagnosis and treatment, age, gender, co-morbidities and complexities and other condition specific data. A demonstrated large practice or outcome variance may represent a significant opportunity to improve patient outcomes by reducing this practice variation and focusing on evidence-informed practice. A large number of ‘Beyond Expected Length of Stay’ and a large standard deviation for length of stay and costs were flags to such variation. Ontario has detailed case costing data from many hospitals, as far back as 1991 for all patients discharged from some case costing hospitals, as well as daily utilization and cost data by department, by day and by admission. 7 2. Availability of Evidence A significant amount of research has been completed both in Canada and across the world to develop and guide clinical practice. Working with the clinical experts, best practice guidelines and clinical pathways can be developed for these QBPs and appropriate evidence-informed indicators can be established to measure the quality of QBP care and help identify areas for improvement at the provider level and to monitor and evaluate the impact of QBP implementation. 3. Feasibility/ Infrastructure for Change Clinical leaders play an integral role in this process. Their knowledge of the patients and the care provided or required represents an invaluable component of assessing where improvements can and should be made. Many groups of clinicians have already formed and provided evidence and the rationale for care pathways and evidence-informed practice. 4. Cost Impact The selected QBP should have as a guide no less than 1,000 cases per year in Ontario and represent at least one per cent of the provincial direct cost budget. While cases that fall below these thresholds may in fact represent improvement opportunity, the resource requirements to implement a QBP may inhibit the effectiveness for such a small patient cluster, even if there are some cost efficiencies to be found. Clinicians may still work on implementing best practices for these patient sub-groups, especially if it aligns with the change in similar groups. However, at this time, there will be no funding implications. The introduction of evidence into agreed-upon practice for a set of patient clusters that demonstrate opportunity as identified by the framework can directly link quality with funding. 5. Impact of Transformation The selected QBPs must align with the government’s transformational priorities including alignment with the tenets of Ontario’s Action Plan for Health Care. In addition, a natural progression and trajectory to assess a QBP’s impact on transformation would be to begin to look at other patient cohorts (e.g. paediatric patient populations), impact on the transition of care from acute-inpatient to community care setting, significant changes from historical funding models/ approaches, integrated care models etc. QBPs with a lesser cost impact but a large impact on the transformation agenda may still be a high priority for creation and implementation. 8 2.4 How will QBPs encourage innovation in health care delivery? QBP strategy is driven by clinical evidence and best practice recommendations from the Clinical Expert Advisory Groups. The Clinical Expert Advisory Groups are comprised of cross-sectoral, multi-geographic and multi-disciplinary membership with representation from patients as well. The panel members leverage their clinical experience and knowledge to define the patient populations and recommend best practices. Once recommended best practices are defined, these practices are used to understand required resource utilization for the QBPs and further assist in the development of evidence-informed prices. The development of evidence-informed pricing for the QBPs is intended to incent health care providers to adopt best practices in their care delivery models, maximize their efficiency and effectiveness, and engage in process improvements and / or clinical redesign to improve patient outcomes. Best practice development for the QBPs is intended to promote standardization of care by reducing unexplained variation and ensure the patient gets the right care, at the right place and at the right time. Best practices standards will encourage health service providers to ensure the appropriate resources are focused on the most clinically and cost effective approaches. QBPs create opportunities for health system change where evidence-informed prices can be used as a financial lever to incent providers to: • Adopt best practice standards; • Re-engineer their clinical processes to improve patient outcomes; • Improve coding and costing practices; and • Develop innovative care delivery models to enhance the experience of patients. An integral part of the enhanced focus on quality patient care will be in the development of indicators to allow for the evaluation and monitoring of actual practice and support on-going quality improvement. 9 3.0 Cancer Surgery QBP Cancer surgery and surgeons play a key role in many aspects of the patient’s journey: Diagnosis: Biopsy of a tumour and other investigations including radiological investigations to determine whether the growth is cancerous (malignant) or noncancerous (benign). Staging: Endoscopic evaluations such as panendoscopy, mediastinoscopy, needle biopsies, colonoscopies, etc. that allow evaluation of the extent and size of the tumour. Curative: Removal of the entire cancerous tumour or growth from the body. Palliative: Surgery used to treat cancer when incurable with the intent being to relieve discomfort, manage symptoms or increase effectiveness of other cancer treatments. Reconstruction and Rehabilitation: Following curative surgery a patient’s appearance or body function may be altered. Restorative surgery restores appearance or function some examples include, head and neck microvascular surgery, breast, bladder or rectal reconstruction surgery. Cancer Surgery procedures are carried out by a wide variety of surgeons, those who may specialize in cancer patients exclusively but more commonly cancer surgery is performed by surgeons who do not exclusively treat cancer patient. In Ontario, over 80 hospitals provide some type of cancer surgery services. 3.1 Overview of Cancer Surgery Agreements (CSA) Cancer Care Ontario (CCO) has been advising the Ministry of Health and Long Term Care (MOHLTC) on the allocation of cancer surgery funding through the CSA program since 2004. The intent of the CSA is to increase the volume of high quality cancer surgeries performed in Ontario to reduce wait times while continually improving the quality of cancer surgery across Ontario. The CSA program funds approximately 20% of all cancer surgeries in Ontario across 35 hospitals. As a condition of receiving funding, hospitals are required to sign the Cancer Surgery Agreements (CSA). This agreement links incremental funding with quality improvement initiatives, clear accountabilities for performance, and the development of regional cancer programs. On an annual basis, CCO distributes funding to participating hospitals and monitors the conditions set out in each agreement in association with funding and meeting the annual targets. The Regional Vice-Presidents (RVP) of Cancer Services actively works with hospitals in their regions to identify difficulties completing cases and develop solutions to meet the agreed-upon targets. Each participating hospital has four main requirements to achieve in order to attain the targets set out in the CSA. These include: 10 Volume requirements to ensure the hospital performs the allocated number of surgeries and work with hospitals within the region to ensure volumes are completed and patients have appropriate access; Quality requirements which involves developing and implementing quality guidelines and standards and implementing best practices; Reporting requirements which involves reporting performance data on all cancer surgery volumes, cancer surgery waiting times for each surgical specialty, and other key quality indicators, and Working with the RVP to develop a Regional cancer Program as described in the Ontario Cancer Plan. With the implementation of QBP for cancer surgery the goal is to: a) Use lessons learned from the CSA process and apply them to QBP b) Eventually merge the portions of the CSA program into QBP funding c) Allow the funding to follow the patient providing equitable access and distribution of funds Also with the transition, QBP will run in conjunction with Cancer Surgery Agreements (CSA), as disease sites are implemented into QBP they will be removed from CSA incremental funding. For example, in FY15/16 all funding for prostate and colorectal cancer surgery will be accounted for through QBP and prostate and colorectal cancer will not be a part of the CSA. Slowly disease sites will transition from CSA to QBP. 3.2 Overview of Cancer Surgery QBP Implementation Strategy There are over 50,000 curative cancer surgeries every year which are compiled of several hundred types of procedures across 100 hospitals in Ontario. A phased approach will be taken in order to accomplish the significant task of implementing QBP based funding for all of cancer surgery. The phased approach will be based on the patient journey and disease site. Patient Journey Scope: The patient journey scope refers to the patients experience before, during and after treatment. These are described as: • Consult / Pre-Treatment Assessment: Before a treatment plan is decided upon the surgeon will conduct an assessment to understand the extent of the disease and if the patient is a surgical candidate. This assessment may include 11 diagnostic imaging and biopsy including pathology assessment, a multidisciplinary consult or multidisciplinary cancer conference. These activities may occur within a hospital or physician office. • Treatment: This phase refers to the surgical procedure performed within an operating room. By definition, it occurs within the hospital setting. It begins at the pre-admission visit (approximately 1 week before the surgical procedure) and ends when the patient is discharged from the hospital. • Follow up: Once the surgical procedure is completed, a patient will require follow up to monitor recurrence of the disease. The frequency of visits and tests required are dependent upon the disease. This activity may occur in or out of the hospital setting. NOTE: The initial phase for Cancer Surgery QBP implementation will focus on the Treatment phase. Figure 4: Patient Journey Scope 3.3 Disease Site Selection The Cancer Surgery QBP portfolio will consists of numerous disease sites. The disease sites include: Gastrointestinal: Colon, Rectal, Stomach, Hepatobiliary: liver, biliary, pancreas Thoracic: Lung, esophagus Breast Thyroid Genitourinary: kidney, bladder, testis, adrenal gland Prostate 12 Gynecology: Endometrium, Cervical, Ovarian, Vulvar Ophthalmic Head & Neck Sarcoma: Bone, Soft Tissue Neurology: brain, spinal Skin (including melanoma) Cancer surgery has been identified as a QBP using the evidence based selection framework. These criteria are described in Figure 5. Figure 5: Evidence and Quality-Based Framework- Cancer Surgery Feasibility & Infrastructure for Change Availability of Evidence Cancer Surgery Significant number of guidelines and pathways that describe appropriate treatment paths for various disease sites Regional leadership in place for a number of disease sites Indicators in place for various disease sites that are currently measured and planned to be measured in the future Cost Estimate Demonstrated successes with identifying quality issues the improvement of specific indicators It is estimated that cancer surgery accounts for approximately $450M in funding, over 50,000 surgeries annually taking place at over 80 hospitals Impacts patient care and journey though the cancer care trajectory Positive Margins for pT2 • Ontario: 22% • LHIN Range: 16%-36% Cost Estimate GU/Prostate MCC Concordance to minimum standards • Q1 FY13/14: 66% • Q1 FY14/15: 76% 2788 x $5015 = $1.4M Potentially with transfer from hospital to community care Through Organizational Guidelines some disease sites have been centralized to designated centres. Prostate Cancer Surgery Significant number of guidelines and pathways that describe appropriate treatment paths Prostate Clinical Pathway (DPM) Margins and lymph nodes guidelines (Surgery and Pathology) Active Surveillance for the management of localized prostate cancer Leadership Prostate Champions (Surgery and Pathology) Data/Reporting Positive Margins; radiation oncology consults before surgery that are currently in place Transformation Impact Practice Variation # prostate cases x CSA case cost (merged rate) = Hospitals ~ 51 hospitals 13 Colon and Rectal Cancer Surgery Significant number of guidelines and pathways that describe appropriate treatment paths CRC Clinical Pathway (DPM) Margins and lymph nodes guidelines (Surgery and Pathology) Appropriate assessment of rectal cancer Laparoscopic surgery for colon cancer Radiology and Pathology tools/templates Leadership CRC Champions (Surgery and Pathology) Data/Reporting Positive Margins; lymph node examination, Development of indicator for appropriate assessment (eg. MRI) before surgery GI MCC Concordance to minimum standards • Q1 FY13/14: 76% • Q1 FY14/15: 86% Cost Estimate The provincial positive circumferential margin rate is less than 10% with some regional variation. Hospitals Potentially with transfer from hospital to community care # CRC cases x CSA case cost (merged rate) = 7000 x $10615 = $74M ~ 90 hospitals The lymph node retrieval rate after colon resection has been above 90% consistently. Preliminary Ontario data indicates variation in pre-op MRI assessment of rectal cancer Cancer Surgery QBP implementation will take a phased implementation approach by disease site: o FY15/16: Implementation of prostate (radical prostatectomy) and colon/rectal cancer surgery o FY16/17: Implementation of breast and thyroid cancer surgery 14 4.0 Prostate Cancer Surgery Prostate cancer is the most commonly diagnosed malignancy among Canadian men and is the second largest cause of male cancer deaths in Canada. Nearly 23 600 cases of prostate cancer are diagnosed in Canada and close to 4000 Canadian men die from prostate cancer every year (Prostate Cancer Canada, 2013). Prostate cancer occurs when cells of the prostate reproduce at a faster rate than in a normal prostate, causing a tumour. There are numerous treatment options available for men with prostate cancer based on the risk and grade of the cancer and patient preference. Active surveillance, which consists of regular monitoring for signs of disease progression, is a common treatment for prostate cancers that are slow growing and may not require a surgical procedure. Additional treatments include radiation therapy as well as hormone therapy, which stops testosterone from being released to the prostate gland to aid in the fight against cancer. Surgery for the removal of the prostate gland and surrounding tissue, known as a radical prostatectomy, is another available treatment for patients with prostate cancer. Prostate cancer surgery is performed by urologists. Urologists performing prostate cancer surgery can either be general urologists, treating a number of diseases, or urologic oncologists, focusing specifically on the treatment of urologic cancers A radical prostatectomy is the surgical removal of the prostate gland and surrounding tissue. The prostate is surrounded by important nerves that in most cases are avoided though some patients may experience urinary incontinence (stress and total) and erectile dysfunction (ED) as some of the side effects. There are four surgical approaches used for a Radical Prostatectomy. An open perineal approach is an approach for a radical prostatectomy whereby the surgeon makes a primary incision through the perineum and carries out the operation through the incision. The procedure includes the removal of the entire prostate along with the seminal vesicles. An open retropubic approach is an approach for radical prostatectomy whereby the surgeon makes a primary incision through the pubic area and carries out the operation through the incision. This process includes the removal of the entire prostate as well as the seminal vesicles. A laparoscopic approach for a radical prostatectomy is a “minimal access approach” by which small incisions are made in the abdomen and a video camera is inserted to the view the prostate while the surgeon operates surgical instruments to remove the prostate gland and seminal vesicles. A robotic-assisted radical prostatectomy is similar to the laparoscopic approach. Similar to the laparoscopic approach small incisions are made in the abdomen to allow for insertion of the robotic arms and video camera. The 15 surgeon manipulates surgical tools robotically allowing removal of the prostate gland. 4.1 Prostate Cancer Surgery Scope (Radical Prostatectomy) Factor Diagnosis & Procedure Codes Data Source Visit Type/ Activity Additional Patient Factors Included A radical prostatectomy will be identified as a case that has: Main diagnosis code: C61 (malignant neoplasm of the prostate) AND Primary intervention field: one of the following CCI procedure codes 1QT91PB - Radical excision prostate (open perineal) 1QT91PK - Radical excision prostate (open retropubic) 1QT91DA – Radical excision prostate (laparoscopic) Note: Robotic procedures are captured with the CCI procedure code 1QT91DA AND the subcode 7.SF.14.ZX Robotic assisted telemanipulation of tools, service, using system NEC, mandatory (robotic) DAD In-patient • Elective cases • Urgent cases • Emergent cases • • Government insured patients only (i.e. OHIP) Patients 18 years of age and over Excluded Records where main intervention is missing NACRS • Day Surgery • Interventions flagged as ‘Out of Hospital’ • Interventions flagged as ‘Abandoned’ • Interventions flagged as ‘Cancelled • Out-of-province records (i.e., Province not equal “ON”) • Records where responsibility for Payment is not equal to ‘01’ • Records where calculated age is less than 18 years. Age is calculated as the difference between admit date and birth date 16 4.2 Best practices guiding the implementation of Prostate Cancer Surgery Radical Prostatectomy Length of Stay Analysis Length of stay analysis was conducted for the in-scope patient cohort over the most recent timeframe available. FY12/13 Diagnosis Code CCI Procedure Code 1QT91DA (Laparoscopic) Malignant neoplasm of Prostate (C61) 1QT91DA (Robotic) 1QT91PB (Open Perineal) 1QT91PK (Open Retropubic) Description Ontario Mean Ontario Mean Volume Ontario Mean 1.95 90 1.87 1.76 1.92 1.71 376 1.73 1.57 98 2.8 2.42 43 2.58 1.61 2057 2.97 2.63 893 3.03 2.64 Volume Ontario Mean 505 2.27 209 Excision radical, prostate using open perineal approach Excision radical, prostate using open retropubic approach Excision radical, prostate, using endoscopic (laproscopic) approach Excision radical, prostate, using endoscopic (laproscopic) approach WITH LINK TO Robotics FY13/14 (Q1 +Q2) (excl. > 90th percentile) Recommendation: The following recommendations are based on analysis and expert consensus: Radical Prostatectomy Procedure Type Best Practice Length of Stay Open Perineal 3 days Open Retropubic 3 days Robotic 2 days Laparoscopic 2 days 17 (excl. > 90th percentile) Radical Prostatectomy Best Practice Definition Relevant Cancer Care Ontario Guidelines: • Guideline for Optimization of Surgical and Pathological Quality Performance in Radical Prostatectomy in Prostate Cancer Management. 173 EBS: September 2008 • Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006 Pathway Development Process To develop the best practice pathway of care for radical prostatectomy, the following process was followed: • A literature scan was completed • Existing care paths were collected from the hospitals of QBP members • Common practices and collaborative guidelines were then consolidated to create the best practice care path recommended for the patient population • Expert consensus was obtained The best practice focused on identifying and implementing evidence-informed practice driven by clinical consensus. The pathway reflects current available evidence, however it is recognized that changes to the evidence may occur between review cycles. Best practice has been categorized into the following stages: 1. Pre-Surgical Assessment (prior to surgery) 2. Day before Surgery (1 day prior) 3. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU) 4. Day of Surgery (Day 0): Operating Room 5. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU) 6. Post-operative Surgery: Day 1 onward (day after OR) 18 Final Recommendations 1. Pre-Surgical Assessment (prior to surgery) Tests: CBC to determine risk of transfusion - ~ 6% of patients require blood transfusions Na, K, CL, Creatinine, Glucose, Electrolytes If applicable: ECG if patient has heart disease, diabetes or other risk factors for cardiac condition PT/PTT/INR if patient has liver disease Urine and culture if patient at risk of or showing symptoms of urinary tract infection Assessments: Pre-admission assessment (Vital signs, HT, WT etc.) MRSA/CPE screening Assessment by transfusion nurse/nurse Consults: Anesthesiology/pain management consult- as required Internal Medicine (Cardiology)- as required Medications: Review all current medications by Pharmacist or Nurse Note allergies and intolerances Provide information about discontinuation of NSAIDS/antiplatelet/anticoagulants if necessary Patient/Family Teaching: Educate patient on the surgical procedure Review pre-operation and post- operative events and expectations Review plan for pain management Inform patient about blood transfusion should it become necessary Review self-care measures to prevent post-op complications Review patient education booklets, pamphlets, etc. Educate patient on breathing and recovery exercises Obtain consent for possible transfusion- completed by surgeon Discharge Planning: Review discharge plan with the patient including, expected length of stay, discharge time, and issues or complications that could delay discharge Involve Social worker or CCAC if necessary 2. Day Before Surgery Assessments: +/- Bowel preparation- if required Nutrition: DAT Clear liquids up to 2-3 hours prior to surgery No solids after midnight the day prior to surgery 19 3. Day of Surgery- POCU Tests: Cross match blood for patients at high risk for bleeding- if necessary Assessments: Pre-operative assessment by nurse, surgeon and anesthesiologist Blood work as required (e.g. glucose) -Type 2 diabetes impacts 15% of patients +/- Enema- if required Medications: IV antibiotics:1st/2nd gen. Cephalosporin, Aminoglycoside + Metronidazole or Clindamycin Alternative: Ampicillin/Sulbactam, Fluoroquinolone- if patient allergic Colloid fluid Tranexamic Acid, as required VTE prophylaxis (e.g. heparin, SCD as per institutional protocol) administered in the POCU or Operating Room Nutrition: NPO – no solid food after midnight the day prior to surgery Sips of water with meds Encourage 8oz. of clear carbohydrate drink (e.g.: apple juice, cranberry juice, Gatorade) 3 hours prior to the surgery- optional 4. Day of Surgery- Operating Room Assessments: Complete surgical checklist Treatments: Radical prostatectomy and pelvic lymph node dissection (if necessary) performed Ensure all equipment is available - Special equipment: arterial line, cardiac output monitors, etc.) Ensure all resources are present (OR nurse, surgeon, anesthesiologist) CCO pathology requisition completed by surgeon Ensure specimen is appropriately labelled and sent to pathology for processing/assessment Medications: Local anesthetic block- as needed 5. Day of Surgery- PACU (Day 0) Tests: CBC Electrolytes, creatinine, etc. Diabetic patient (glucose ordering and monitoring) - Type 2 diabetes impacts 15% of patient population (Tests may be performed once or as needed based on patient condition) Assessment: Post-operative assessment by nurse, surgeon and anesthesiologist (system & pain) Consults: Acute Pain Services Treatment: Monitor patient recovery (e.g. urine output, catheter drainage, wound dressing, JP drain, IV, etc.) Medication: 20 Patient specific medication Oral pain medication VTE prophylaxis Medication for bladder spasms - 100% patients get preventative medication PCA (for a duration of 24 hours), as required Activity: Breathing and recovery exercises Nutrition Clear liquids 6. Day after Surgery- Post Operative Day 1+ onwards Tests: CBC Electrolytes, creatinine, etc. Diabetic patient (glucose ordering and monitoring) - Type 2 diabetes impacts 15% of patient population (Tests may be performed once or as needed based on patient condition) Assessment: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Consults: Physiotherapy (pelvic floor rehabilitation) Treatment: Removal of IV Remove JP drain once drainage is less than 50 ml for 24 hours - Less than 2% of patients are discharged with a JP drain in place Wound dressing Medication: Patient specific medication Oral pain medication VTE prophylaxis Activity: Walking independently Nutrition Regular Diet Patient/Family Teaching: Review home management of catheter Review home management of wound Review signs and symptoms of wound infection, urine infection and bladder distention Discharge Planning: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments CCAC consult 21 5.0 Colorectal Cancer Surgery Colorectal cancer, cancer of the colon or rectum, is a disease in which malignant (cancer) cells form in the tissues of the colon. The colon is part of the body’s digestive system which helps pass waste material out of the body. The first part of the large intestine is called the colon. The last part is the rectum and the anal canal. The anal canal ends at the anus. Depending on the size, location and spread of the cancer, different modalities of therapy may be employed to treat the disease. The main treatment for colorectal cancer is surgery, but often multiple treatments are given including systemic therapy, therapies in interventional radiology, and radiation therapy. Some patients may access one or more of these therapies in the management of their disease. Surgical resection is often the main treatment for earlier stage colon and rectal cancer. Colorectal cancer surgery is performed by general surgeons, treating a number of diseases, or colorectal surgical oncologists, focusing specifically on the treatment of colorectal cancers The goals of colorectal cancer surgery are to a) remove cancer completely, b) remove adjacent lymph nodes and c) re-join the bowel to provide normal or near normal function. Achieving these goals is dependent on a number of factors such as location of tumour, tumour size, timing of surgery, stage and patient status and preferences. There are different types of surgical procedures including the following: 1. Bowel resection with anastomosis: A part of the bowel with the cancer is removed and then the bowel is joined back together (anastomosis) either with staples or sutures. 2. Bowel resection with an anastomosis and a (temporary) stoma: Whenever the bowel is joined together, there is always a chance it might not heal. Where this risk is high, sometimes a temporary stoma (ileostomy or colostomy) is constructed so digestive waste collects in the bag to allow the bowel to heal. In the future the temporary stoma can be closed once the surgeon is certain that the join (anastomosis) is healed. Hartmann’s resection: Part of the bowel is removed which includes the diseased area but instead of joining the bowel back together, a stoma is performed. The remaining colon or rectum is usually closed off with staples or sutures and left inside the abdomen. This is often done in emergency situations and the bowel can often be joined together at a later date. 3. Bowel resection with abdominoperineal resection (APR): Complete removal of the rectum, and anus resulting in a permanent colostomy. APRs are primarily used for the treatment of a rectal carcinoma situated in the distal (lower) part of the rectum. 22 5.1 Colorectal Cancer Surgery Scope Factor Included Excluded Diagnosis & Procedure Codes A colorectal cancer surgery will be identified as a case that has: • Main diagnosis code: all malignant neoplasm codes specifically C00 to C97 within ICD-10- CA or organrelated benign neoplasm, as outlined in Table 1 of Appendix A, AND Records where main intervention is missing • Primary Intervention (CCI procedure code): as listed in Table 2 of Appendix A Data Source DAD Visit Type/ Activity Inpatient • Elective cases • Urgent cases • Emergent cases NACRS • • • • Additional Patient Factors • • Government insured patients only (i.e. OHIP) Patients 18 years of age and over • • • Day Surgery Interventions flagged as ‘Out of Hospital’ Interventions flagged as ‘Abandoned’ Interventions flagged as ‘Cancelled Out-of-province records (i.e., Province not equal “ON”) Records where responsibility for Payment is not equal to ‘01’ Records where calculated age is less than 18 years. Age is calculated as the difference between admit date and birth date 23 5.2 Best practices guiding the implementation of Colorectal Cancer Surgery Colorectal Cancer Surgery Length of Stay Analysis Length of stay analysis was conducted for the in-scope patient cohort over the most recent timeframe available. Elective Colon Emergency Laparoscopic 1909 6.1 5.0 2057 5.9 4.0 -2% -20% Open 1743 9.4 7.0 1565 8.7 6.0 -8% -14% Laparoscopic 179 14.7 10.0 241 12.6 9.0 -14% -10% Open 792 17.8 13.0 739 16.6 12.0 -7% -8% 4623 9.7 6.0 4602 8.9 6.0 ·8% 0% 525 1474 27 111 6.7 9.7 15.4 19.8 5.0 7.0 8.0 13.0 507 1320 30 112 6.1 9.3 12.3 16.3 4.0 7.0 6.0 11 .0 -10% -4% -20% -18% -20% 0% -25% -15% 2137 9.6 7.0 1969 8.9 7.0 -7% 0% Total Colon Elective Rectum Emergency Laparoscopic Open Laparoscopic Open Total Rectum Recommendation: The following recommendations are based on analysis of empirical data and expert consensus: Procedure Group Admission Category Procedure Type Best Practice 24 Length of Stay Elective Colon Emergency Elective Rectum Emergency Laparoscopic 4 days Open 6 days Laparoscopic 9 days Open 12 days Laparoscopic 4 days Open 7 days Laparoscopic 6 days Open 11 days Colorectal Cancer Surgery Best Practice Definition Relevant Cancer Care Ontario Guidelines: • Optimization of Preoperative Assessment in Patients Diagnosed with Rectal Cancer 17-8 EBS: January 20, 2014 • Optimization of Surgical and Pathological Quality Performance in Radical Surgery for Colon and Rectal Cancer: Margins and Lymph Nodes 17-4 EBS: April 2008 • Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006 Pathway Development Process To develop the best practice pathway of care for colorectal cancer surgery, the following process was followed: • A literature scan was completed • Existing care paths were collected from the hospitals of QBP members. It was apparent that the majority of hospitals are implementing the Enhanced Recovery after Surgery pathway for colon and rectal surgery developed by Best Practice in General Surgery1. With working group consensus this pathway was used as the basis for the QBP best practice. • Common practices and collaborative guidelines were then consolidated to create the best practice care path recommended for the patient population • Expert consensus was obtained with the working group Aarts MA, Okrainec A, McCluskey S, Siddiqui N, Wood T, Pearsall E, & McLeod RS on behalf of the Best Practice in General Surgery. Enhanced Recovery after Surgery Guideline. www.bpigs.ca. 1 25 The best practice focused on identifying and implementing evidence-informed practice driven by clinical consensus. The pathway reflects current available evidence, however it is recognized that changes to the evidence may occur between review cycles. Best practice for colon and rectal resections has been categorized into the following stages: 1. Pre-Surgical Assessment (prior to surgery) 2. Day before Surgery (1 day prior) 3. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU) 4. Day of Surgery (Day 0): Operating Room 5. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU) 6. Post-operative Surgery: Day 1 onward (day after OR) Final Recommendations 1. Pre-Surgical Assessment (prior to surgery) Tests: CBC to determine risk of transfusion Na, K, Cl, creatinine, glucose, electrolytes CEA for all patients if one has not been ordered previously Group and screen for all patients having a colon operation If applicable: ECG if patient has heart disease, diabetes or other risk factors for cardiac condition PT/PTT/INR if patient has liver disease Assessments: Pre-admission assessment (vital signs, HT, WT etc.) Assessment by transfusion nurse/nurse Consults: Anesthesiology/pain management consult- as required Enterostomal Therapy Nurse (ET Nurse) for patients planning to have a stoma Medications: Review all current medications by pharmacist or nurse Note allergies and intolerances Penicillin allergies should be reviewed Provide information about discontinuation of NSAIDS/antiplatelet agents/anticoagulants if applicable Prescribe iron to patient or arrange iron transfusion pre-operatively to decrease transfusion rates Patient/Family Teaching: Educate patient on the surgical procedure Review pre-operation and post- operative events and expectations Review length of stay expectations with patient Review plan for pain management and anesthetics Inform patient about blood transfusion should it become necessary Review self-care measures to prevent post-op complications Review patient education booklets, pamphlets, etc. Educate patient on breathing and recovery exercises Provide patient with instructions for bowel prep- as required Educate the patient on the type of stoma, postoperative goals of care and life with an ostomy 26 Educate patient on Enhanced recovery after surgery Discharge Planning: Review discharge plan with the patient including, expected length of stay, discharge time, and issues or complications that could delay discharge Involve Social worker or CCAC if necessary - All patients having a stoma require CCAC on discharge 2. Day Before Surgery Assessments: Recommended bowel preparation for patients with anastomosis below the peritoneal reflection Nutrition: Encourage 8oz. of clear carbohydrate drink (e.g.: apple juice, cranberry juice, Gatorade®) the night before surgery and 2 hours prior to the surgery NPO – no solid food after midnight the day prior to surgery 3. Day of Surgery- POCU Tests: Cross match blood for patients at high risk for bleeding- if necessary Assessments: Pre-operative assessment by nurse, surgeon and anesthesiologist Blood work as required (e.g. glucose) Medications: Unfractionated or low molecular weight heparin injection (Administered in the POCU or Operating Room unless patient is scheduled for an epidural) NSAIDS for patients not having anastomosis Gabapentin- to decrease pain post-operatively Acetaminophen 4. Day of Surgery- Operating Room Assessments: Complete surgical checklist. Treatments: Colon/rectal resection performed, with appropriate lymph node removal Ensure all equipment is available - This includes laparoscopic equipment if the procedure is being performed Ensure all human resources are present (OR nurse, surgeon, anesthesiologist) CCO pathology requisition completed by surgeon Ensure specimen is appropriately labelled and sent to pathology for processing/assessment Perioperative normothermia - Warming blanket - Fluid warming Skin prep with chlorhexidine alcohol solution Intraoperative fluid management Avoidance of prophylactic drains and tubes Medications: SSI prophylaxis (SSI guideline) VTE prophylaxis (VTE guideline) Thoracic epidural or intravenous Lidocaine for pain management (intra-operatively) 27 5. Day of Surgery- PACU (Day 0) Assessments: Post-operative assessment by nurse, surgeon and anesthesiologist (system & pain) Patient recovery (e.g. bleeding, etc.) Consults: Acute Pain Services Medication: Patient specific medication NSAIDS for patients not having anastomosis PCA narcotics Acetaminophen Lidocaine for pain management Activity: Breathing and recovery exercises Sit up with assistance and dangle legs for at least 10-15 minutes at side of bed every 2-4 hours Nutrition Clear fluids 6. Day after Surgery- Post Operative Day 1+ onwards Assessment: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Care of Patient: Surgeon, nurse, pain service care and physiotherapy, dietician and pharmacist care and consults as necessary Special care for ostomy patients. E.g.: - Pouch emptying - Pouch changes - Ordering of supplies Treatment: Removal of foley catheter within 24 hours for colon surgery so that the patient can urinate on their own Removal of foley catheter within 72 hours for rectal surgery so that the patient can urinate on their own Medication: Patient specific medication Oral pain medication Multimodal pain management (PCA or epidural, acetaminophen, NSAIDs for patients not having anastomosis) and oral pain medication for discharge Activity: Deep breathing and coughing exercises 10 times every hour while awake Sit in chair for all meals Get up and walk every 4-6 hours (with assistance if necessary) Use the bathroom to urinate- patient will not use bedpan or urinal Nutrition Begin eating solids and continue drinking fluids Chew gum for 5 minutes 3 times a day to get the digestive system working Discharge Planning: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged (bowel movement, regular diet, no nausea, etc.) Review discharge plan with patient and family 28 Inform patients of follow-up appointments Provide patient with pain medication prescription- if necessary CCAC Consult Patient education including wound care 29 6.0 Thyroid Cancer Surgery Thyroid Cancer is characterized by abnormal growth of thyroid gland cells that have become cancerous. The thyroid gland is an endocrine organ located in the front of the neck, just below the larynx. The thyroid gland is composed of two halves, called lobes, which sit on either side of the trachea and are connected by a thin bridge of tissue called the isthmus. The main function of the thyroid gland is to regulate metabolism. Key thyroid hormones T3 and T4 regulate key bodily functions such as heart rate, blood pressure, body temperature and weight. There are four major types of thyroid cancer: • • • • Papillary thyroid cancer is the most common type of thyroid cancer. It is a differentiated form of thyroid cancer that typically grows slowly. Papillary thyroid cancer may spread to the surrounding lymph nodes in the neck, however spread to distant organs is uncommon. Follicular thyroid cancer is the second most common type of thyroid cancer and is also a differentiated thyroid cancer. Unlike papillary cancers, follicular cancers do not typically spread to lymph nodes but follicular cancers can spread to other parts of the body, such as the bones or lungs. Medullary thyroid cancer differs from the differentiated thyroid cancers (papillary and follicular) because it develops from the C cells of the thyroid gland as opposed to the follicular cells. The C cells produce calcitonin, a hormone which helps regulate the amount of calcium within blood. Anaplastic carcinoma is a rare form of thyroid cancer that is characterized by rapid growth into the neck and other parts of the body. Thyroid cancer is a common cancer and with appropriate treatment, the long-term survival rates are generally excellent. Surgery is the main treatment for thyroid cancer, except for certain anaplastic thyroid cancers. In some circumstances, additional treatments including radioactive iodine ablation, thyroid hormone replacement, external beam radiation, chemotherapy and targeted therapy may be recommended. Thyroid surgery is performed by surgeons who possess special training. The primary goal of thyroid cancer surgery is to remove the tumour and if required, some surrounding healthy tissue. The main types of thyroid cancer surgery are: 1. Partial Thyroidectomy: Partial thyroidectomy procedures can include removal of a single lobe of the thyroid gland called a ‘hemithyroidectomy’ or ‘lobectomy’. Other partial thyroidectomy procedures can include a ‘subtotal thyroidectomy’ which includes a lobe and thyroid isthmus and the medial portion of the contralateral lobe. Partial thyroidectomy procedures are sometimes necessary as diagnostic procedures where a needle biopsy is not diagnostic or equivocal. 2. Total Thyroidectomy: The removal of the entire thyroid gland. 30 In conjunction with the thyroidectomy procedure, removal of adjacent lymph nodes, a lymphadenectomy (neck dissection) may be performed if there is the possibility that cancer has spread to the lymph nodes in the neck. There are two types of neck dissections to remove the lymph nodes: • • Central Compartment Neck Dissection: The removal of lymph nodes located around the thyroid gland. This procedure is usually performed if the lymph nodes are known to contain cancer, or there is a high suspicion that they contain cancer. Lateral Neck Dissection: The removal of lymph nodes located in the lateral neck. This procedure is performed if the lymph nodes are known to contain cancer. 6.1 Thyroid Cancer Surgery Scope Factor Included Excluded Diagnosis & Procedure Codes A thyroid cancer surgery will be identified as a case that has: Main diagnosis code: • C73 – Malignant neoplasm of thyroid gland • D093 – Carcinoma in situ of thyroid and other endocrine glands • D34 – Benign neoplasm of thyroid gland • D440 – Neoplasm of uncertain or unknown behavior of thyroid gland • E041 – Nontoxic single thyroid nodule AND Records where main intervention is missing Primary Intervention (CCI procedure code): • one of 14 thyroidectomy CCI procedure codes as listed in Table 3 Appendix A Data Source Note: Due to the behavior of the disease and final pathological diagnosis may not be known at time of resection more than malignant neoplasm diagnosis codes were included. DAD NACRS Visit Type/ Activity Inpatient • Elective cases • Urgent cases • Emergent cases Day surgery • • • Interventions flagged as ‘Out of Hospital’ Interventions flagged as ‘Abandoned’ Interventions flagged as ‘Cancelled 31 Additional Patient Factors • • Government insured patients only (i.e. OHIP) Patients 18 years of age and over • • • Out-of-province records (i.e., Province not equal “ON”) Records where responsibility for Payment is not equal to ‘01’ Records where calculated age is less than 18 years. Age is calculated as the difference between admit date and birth date 6.2 Best practices guiding the implementation of Thyroid Cancer Surgery Thyroid Cancer Surgery Length of Stay Analysis Length of stay analysis was conducted for the in-scope patient cohort over the most recent timeframe available. Length of Stay (In-patient) 1213 1314 1415 Thyroid Group Interventions(s) Volume Mean Median Volume Mean Median Volume Mean Median Thyroidectomy 1246 1.2 1 1207 1.2 1 1196 1.2 1 Partial Thyroidectomy Partial Thyroidectomy with HNK* 46 1.9 1 69 1.7 1 68 1.5 1 All Partial 1292 1.2 1 1276 1.4 1 1264 1.2 1 Thyroidectomy 2080 1.8 1 2072 1.7 1 2021 1.6 1 Total Thyroidectomy Thyroidectomy 338 2.6 2 394 3.1 2 443 2.5 2 with HNK* All Total 2418 1.9 2 2466 2 1 2464 2.0 1 3710 1.7 1 3742 1.7 1 3728 1.7 1 Total Inpatient 32 *HNK procedure refers to any procedure classified as a HNK procedure in CSA (HNK-R or HNK-NR) that appears in the secondary intervention field. In the majority of these cases the HNK procedure is a neck dissection. Recommendation: The following recommendations are based on analysis of empirical data and expert consensus: Thyroid Surgery In-patient Procedure Type Best Practice Length of Stay Partial Thyroidectomy 1 days Total Thyroidectomy 2 days Total Thyroidectomy + HNK procedure* 3 days *HNK procedure refers to any procedure classified as a HNK procedure in CSA (HNK-R or HNK-NR) that appears in the secondary intervention field. In the majority of these cases the HNK procedure is a neck dissection. Please note: Analysis shows that the average LOS in hours for day surgery patients fits within the CIHI day surgery definition. The proportion of thyroid surgery patients treated as day surgery versus in-patient will be monitored to assess for practice change as a result of QBP implementation. Thyroid Cancer Surgery Best Practice Definition Relevant Documents Cancer Care Ontario Guidelines: • Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006 Additional Guidelines: • • • • • Guidelines to the Practice of Anesthesia, Revised Edition 2015 Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update 2014 Prevention of VTE in Non-orthopedic Surgical Patients, 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer American Head and Neck Society Consensus Statement on Laryngeal Examination in Thyroid and Parathyroid Surgery (publication pending) 33 Pathway Development Process To develop the best practice pathway of care for thyroid cancer surgery, the following process was followed: • A literature search and environmental scan was completed • Existing care paths were collected from the hospitals of QBP members. • Common practices and collaborative guidelines were then consolidated to create the best practice care path recommended for the patient population • Expert consensus was obtained with the working group The best practice focused on identifying and implementing evidence-informed practice driven by clinical consensus. The pathway reflects current available evidence, however it is recognized that changes to the evidence may occur between review cycles. Best practice for partial and total thyroidectomies has been categorized into the following stages: 1. Pre-Surgical Assessment (~ 4 weeks prior to 1 day prior to surgery) 2. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU) 3. Day of Surgery (Day 0): Operating Room 4. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU) 5. Post-operative Surgery: Day 1+ onward (day after OR) Final Recommendations This pathway is intended to represent care for patients receiving either a partial or total thyroidectomy for either day surgery or in-patient surgery. • • Day Surgery includes the Pre-Surgical Assessment phase to the Day of Surgery – PACU phase In-Patient includes the entire pathway from the Pre-Surgical Assessment phase to the Post-operative Day 1+ Onwards phase. 1. Pre-Surgical Assessment (~4 weeks prior to 1 day prior to surgery) Tests: All thyroid cancer patients: Serum ionized or non-ionized corrected for albumin calcium, as required Ultrasound of thyroid and neck nodes FNA of thyroid mass and any suspicious lymph nodes Pre-operative laryngeal exam should be performed on all patients undergoing thyroid surgery who are at high risk for nerve injury (e.g. pre-operative voice abnormalities, history of cervical or upper 34 chest surgery, thyroid cancer with known posterior extension or extensive cervical node metastases) Recommended if clinically indicated: ECG if patient has heart disease, diabetes or other risk factors for cardiac condition Chest X-ray CT with contrast for patients with suspicion of advanced disease (local and/or regional) Na, K, Cl, creatinine, glucose, electrolytes Urinalysis if signs of urinary tract infection Pregnancy test if pregnancy possible PT/PTT/INR for patient on Warfarin Medullary thyroid cancer patients: Blood and urinary tests (calcitonin, CEA, corrected calcium, 24-hour urine collections for fractionated metanephrines) CT neck, chest abdomen and pelvis with dual phase contract liver scan +/- bone scan, in patients with symptoms of advanced disease (local and/or regional) and patients with elevated serum calcitonin above 500 pg/mL Arrange genetic testing (RET gene) pre- or post-op Assessments: Pre-admission assessment (vital signs, HT, WT, O2 saturation, etc.) Pre-operative questionnaire (patient history and physical examination) Vitamin D level testing can be considered for patients at risk of deficiency Consults: Nursing CCAC - as required Anesthesiology/Pain management consult -as required Internal Medicine (Cardiology, Endocrinology, etc.)- as required Medications: Review all current medication (by Pharmacist) Note allergies and intolerances Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary Prophylactic calcium and vitamin D supplementation can be considered Complete medication reconciliation form Patient/Family Teaching: Educate patient on the surgical procedure Review pre-operation events and expectations Review post-operative events and expectations Review plan for pain management Review self-care measures to prevent post-op complications Review patient education booklets, pamphlets, etc. Discuss risk of nerve and parathyroid injury Clarify any patient questions Discharge Planning: Review discharge plan with the patient including, expected length of stay, discharge time, and issues or complications that could delay discharge Involve Social worker or CCAC if necessary 2. Day of Surgery- POCU Tests: Ensure tests completed as ordered Glucose, as required (if patient is diabetic and blood sugars are not within normal limits) Assessments: Pre-operative assessment by nurse and/or surgeon Ensure medications have been taken as directed Vital signs, O2 saturation Verify NPO status 35 Mark correct side for surgery in partial thyroidectomy patients Medications: Surgical site infection (SSI) prophylaxis (cefazolin) should be considered, when appropriate - Alternative: Vancomycin – if patient allergic VTE prophylaxis administered in the POCU or operating room should be considered for at risk patients (i.e. high Caprini score or other risk factors) - Particular consideration should be given to patients receiving a neck dissection or patients with comorbidities Nutrition: No solids after midnight the day prior to surgery Clear liquids until 2-3 hours prior to surgery NPO 2-3 hours prior to surgery 3. Day of Surgery- Operating Room Assessments: Complete surgical checklist Treatments: Thyroidectomy (partial or total) and neck dissection (if necessary) performed Assess for parathyroid damage and recurrent laryngeal injury Ensure all equipment is available Ensure all human resources are present (OR nurse, surgeon, anesthesiologist) CCO pathology requisition completed by surgeon Use CCO requirements for sending specimen to pathology Ensure specimen is appropriately labeled and sent to pathology Medications: Patient specific medication Antiemetic prophylaxis Pain medication- recommendations from anesthesiologist Superficial cervical plexus block - as needed 4. Day of Surgery- PACU (Day 0) NOTE: End point for day surgery Tests: For total thyroidectomy patients: Post-op calcium profile either via calcium monitoring or PTH (with results available in a timely manner) Assessment: Assess vital signs upon admittance Assess for haematoma, respiratory distress, bleeding, stridor Ensure trach tray and suture/staple remover kit is readily available For Day surgery patients: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Consults: For Total thyroidectomy patients: Endocrinology – as required Treatment: Monitor patient recovery (e.g. intake and output, pain, nausea) Monitor wound dressings Empty drain, if drain present Medication: Patient specific medication Pain medication IV therapy 36 Antiemetic Levothyroxine For total thyroidectomy patients, as clinically indicated: Calcium supplementation Vitamin D3 supplementation Thyroid replacement Activity: Ambulation as tolerated No active neck exercises Nutrition Diet as tolerated Patient/Family Teaching For Day Surgery Patients: Ensure patient has pamphlets Review home management of wound Review prescription and medication protocol Review signs and symptoms of wound infection Discharge Planning For Day Surgery patients: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments 5. Day after Surgery- Post Operative Day 1+ onwards NOTE: Only applicable to in-patient Tests: For total thyroidectomy patients: Post-op calcium profile either via calcium monitoring or PTH (with results available in a timely manner) Assessment: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Consults: CCAC consult, if necessary Treatment: Monitor patient recovery (e.g. intake and output, pain, nausea) Removal of drain, if drain present Wound dressing Medication: Patient specific medication Pain medication IV therapy Antiemetic Levothyroxine For total thyroidectomy patients: Calcium supplementation Vitamin D3 supplementation Thyroid replacement Activity: Activity as tolerated No active neck exercises Nutrition Diet as tolerated Patient/Family Teaching: Ensure patient has pamphlets Review home management of wound 37 Review prescription and medication protocol Review signs and symptoms of wound infection Discharge Planning: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments 38 7.0 Breast Cancer Surgery Breast cancer is the most commonly diagnosed cancer among women in Ontario, accounting for approximately 26%1 of all women’s cancers. Breast cancer has one of the highest survival rates, when compared to other cancers, with a five-year relative survival rate of approximately 88%2. Breast cancer treatments include surgery, radiotherapy, chemotherapy, hormone therapy, and targeted (biological) therapy. The type of treatment that an individual receives depends on factors that include the type and stage of the cancer, as well as the size and location of the tumour. Most women diagnosed with non-metastatic breast cancer are candidates for local treatment options, such as surgery. Breast cancer surgery Breast cancer surgery is performed by general surgeons while plastic surgeons complete breast reconstruction procedures. There are several surgical treatment options for the removal of breast cancer are, including: • A lumpectomy (also known as breast-conserving surgery) is the removal of the cancer and a margin of breast tissue surrounding the affected area. The additional tissue removal acts as a safety perimeter to try to remove all of the cancer. This procedure is less invasive than a mastectomy and is usually combined with radiation therapy. • A mastectomy (complete removal of breast) is used for more advanced types of breast cancer, when a woman has small breasts, or extensive ductal carcinoma in situ. A mastectomy procedure removes the entire breast and nipple. In addition, patients may require the surgical biopsy and/or removal of the breastassociated lymph nodes. Options for biopsy/removal of these lymph nodes include: • An axillary lymph node dissection (ALND) is the removal of fatty tissue and a number of lymph nodes from the underarm area. This procedure can occur at the same time as a lumpectomy or mastectomy, or at a separate encounter. This procedure is usually performed if the lymph nodes are known to contain cancer, or there is a high suspicion that they contain cancer. The tissue is reviewed by a pathologist to determine the number of lymph nodes that are positive for cancer cells – this helps to establish the stage of breast cancer. • A sentinel lymph node biopsy (SLNB) is the removal of the sentinel lymph node to help determine if breast cancer has spread to lymph node(s) in the axilla. The sentinel lymph nodes are the first lymph nodes that the cancer spreads to. If the 2 Canadian Cancer Society 39 biopsy of the sentinel node is cancer free it indicates the remaining axillary lymph nodes are unlikely to contain cancer. Breast Cancer Reconstruction Surgery: Breast reconstruction surgery rebuilds the breast for women who have had a breast removed (mastectomy) due to breast cancer. Women who have had breast conserving surgery (such as a lumpectomy) may not need reconstruction. Breast reconstruction is done by a plastic surgeon and may be performed at the time of mastectomy or at a later date. Reconstruction performed at the same time as the mastectomy is referred to as Immediate (or primary) Reconstruction while reconstruction performed after the initial mastectomy is referred to as Delayed (or secondary) Reconstruction. There is some variability in the indications and best practices for immediate and delayed breast reconstruction in Ontario. To address this variation in care, Cancer Care Ontario in partnership with the Program in Evidence Based Care have published the Breast cancer reconstruction surgery (immediate and delayed) across Ontario: Patient indications and appropriate surgical options guideline which address recommendations for the optimal delivery of breast cancer reconstruction services. There are many factors that may contribute to performing immediate versus delayed reconstruction which include (but are not limited to): • Patient choice – patients may choose to wait to have their surgery performed for a variety of reasons (e.g. indecision about treatment options, personal factors such as ability to be off from work, child care arrangements, etc.). Also, some patients may choose not to have breast reconstruction performed. • Patient medical condition - immediate breast reconstruction after a therapeutic mastectomy may be postponed due to radiation and chemotherapy treatments (which can affect the body's wound-healing ability), lymph node status, condition of tissue post-surgery, patient’s overall medical status (ability to endure another procedure), and urgency of the patient’s condition • Resource availability – hospitals around the province have variation in surgical wait times depending on the number of surgeons, support staff availability, operating room funding, population density of the region, degree of specialty of the procedure, etc. Types of Reconstruction: There are basically 3 types of breast cancer reconstruction surgery. The appropriate surgical operation for an individual patient depends on several factors including breast size, the adequacy of skin flaps and whether radiotherapy is planned or has been previously used, and reconstruction of the nipple/areola. Breast reconstruction surgery has been categorized into the following areas: a) Implant only 40 b) Microvascular tissue with or without implants c) Non-Microvascular tissue with or without implants Patient education and awareness about their options for reconstruction is an important consideration to be able to make informed decisions. All women undergoing breast cancer surgery should have access to a patient education program and be aware of their choices regarding breast cancer surgical treatment and reconstruction. Prophylactic Breast Surgery The advent of identification of inherited genes in cancer has improved the ability to identify patients that may be at increased risk of developing breast cancer during their lifetime. This has enabled prophylactic surgery to be performed on individuals who may be at very high risk of developing breast cancer in their lifetime. In most cases, this is elective surgery as the patient must weigh their risk against the side effects of the proposed treatment. Removal of the organ usually does not detect any cancer as the organ is removed before the cancer develops. The World Journal of Surgery has identified the following criteria as important in prophylactic cancer surgery: 1. The genetic mutation causing the hereditary malignancy must have a very high penetrance and be expressed regardless of environmental factors; 2. There must be a highly reliable test to identify patients who have inherited the mutated gene; 3. The organ must be removed with minimal morbidity and virtually no mortality; 4. There must be a suitable replacement for the function of the removed organ; and 5. There must be a reliable method of determining over time that the patient has been cured by "prophylactic surgery." Women who decide to have prophylactic mastectomy may choose to have breast reconstruction surgery at the same time as prophylactic mastectomy. Patients at high risk, according to the recommendations of the Cancer Care Ontario Breast Cancer Disease Pathway Management Group, may be appropriate candidates for prophylactic mastectomy. Confirmation of high risk breast cancer status must be established prior to surgery in order to ensure eligibility for QBP based funding. A preapproval process must be completed to ensure in-scope status. 41 7.1 Breast Cancer Surgery Scope Factor Included Excluded Diagnosis Lumpectomy, Mastectomy & Procedure Codes A lumpectomy or mastectomy surgery will be identified as a case that has: • Main diagnosis code: all malignant neoplasm codes specifically C00 to C97 within ICD-10- CA or organ-related benign neoplasm, as outlined in Table 4 of Appendix A Records where main intervention is missing AND Primary Intervention (CCI procedure code): o Lumpectomy as listed in Table 5 Appendix A o Mastectomy as listed in Table 6 Appendix An ALND will be identified as a case that has: • Main diagnosis code: breast-specific malignant and benign neoplasm diagnosis codes, as outlined in Table 7 of Appendix A • ALND AND Primary Intervention (CCI procedure code): as listed in Table 8 of Appendix A A SLNB will be identified as a case that has: • Main diagnosis code: breast-specific malignant and benign neoplasm diagnosis codes or observation, follow-up and screening Z codes, as outlined in Table 9 of Appendix A • SLNB AND Primary Intervention (CCI procedure code): o 2MD71LA - Biopsy, axillary lymph nodes using open approach A mastectomy + immediate reconstruction surgery will be identified as a case that has: • Main diagnosis code: all malignant neoplasm codes specifically C00 to C97 within ICD-10- CA or organ-related benign neoplasm, as outlined in Table 4 of Appendix A • Mastectomy + immediate reconstruction AND Primary Intervention (CCI procedure code): as listed in Table 10 Appendix A A delayed breast reconstruction surgery will be identified as a case that has: • Main diagnosis code: breast-specific malignant and benign neoplasm diagnosis codes or personal history of breast neoplasm diagnosis codes, as outlined in • Delayed breast reconstruction 42 Table 11 of Appendix A AND Primary Intervention (CCI procedure code): as listed in Table 12 Appendix A A prophylactic mastectomy will be identified as a case that has: Main diagnosis code: Z4000 (prophylactic removal of breast) • Prophylactic Mastectomy AND • Data Source Primary Intervention (CCI procedure code): as listed in Tables 6 & 10 of Appendix A Note: A patient must be pre-approved as highrisk for developing breast cancer to be in-scope for this QBP DAD NACRS Visit Type/ Activity Inpatient • Elective cases • Urgent cases • Emergent cases Day surgery Additional Patient Factors • • • Government insured patients only (i.e. OHIP) Patients 18 years of age and over For prophylactic surgery: Only patients identified as high-risk within the Ontario Breast Screening Program (OBSP). • • • • • • Interventions flagged as ‘Out of Hospital’ Interventions flagged as ‘Abandoned’ Interventions flagged as ‘Cancelled Out-of-province records (i.e., Province not equal “ON”) Records where responsibility for Payment is not equal to ‘01’ Records where calculated age is less than 18 years. Age is calculated as the difference between admit date and birth date 43 7.2 Best practices guiding the implementation of Breast Cancer Surgery Breast Cancer Surgery Length of Stay Analysis Length of stay analysis was conducted for the in-scope patient cohort over the most recent timeframe available. Length of Stay (In-patient) Category Breast Surgery (without immediate reconstruction) Breast Surgery (with immediate recon) Delayed Reconstruction Prophylactic Interventions(s) Lumpectomy Mastectomy ALND SLNB Implants only Microvascular Tissue (+/-implants) Non-microsurgical Tissue (+/-implants) Implants Only Microvascular Tissue (+/-implants) Non-microsurgical Tissue (+/-implants) Prophylactic Mastectomy Mastectomy with immediate reconstruction 1213 1314 1415 LOS LOS LOS LOS LOS LOS Volume Mean Median Volume Mean Median Volume Mean Median 613 1852 159 12 224 1.6 1.6 1.2 4.0 1.3 1 1 1 1 1 575 1875 116 5 228 1.6 1.5 1.2 1.5 1.3 1 1 1 1.5 1 560 1783 116 7 232 1.4 1.6 1.2 1.1 1.4 1 1 1 1 1 101 4.4 4 117 4.5 4 125 4.6 4 41 42 2.7 1.3 2 1 49 65 3.3 1.3 3 1 47 77 3.0 1.4 3 1 139 4.2 4 137 4.3 4 146 4.2 4 132 3.0 2.5 121 2.4 2 133 2.6 2 63 1.4 1 85 1.2 1 93 1.3 1 110 2.3 2 132 2.3 1 164 2.3 1 44 Recommendation: The following recommendations are based on analysis of empirical data and expert consensus: In-patient Procedure Type Breast Cancer Surgery Prophylactic Mastectomy Best Practice Length of Stay Breast surgery without reconstruction (mastectomy, lumpectomy, ALND, SLNB) 1 day Reconstruction (immediate and delayed) – Implants only 1 day Reconstruction (immediate and delayed) – Non-microsurgical tissue (+/- implants) 3 days Reconstruction (immediate and delayed) –Microsurgical tissue (+/- implants) 4 days Mastectomy without reconstruction 1 day Mastectomy with immediate reconstruction – Implants only 1 day Mastectomy with immediate reconstruction - Non-microsurgical tissue (+/- implants) 3 days Mastectomy with immediate reconstruction – Microsurgical tissue (+/- implants) 4 days Please note: Analysis shows that the average LOS in hours for day surgery patients fits within the CIHI day surgery definition. The proportion of breast surgery patients treated as day surgery versus in-patient will be monitored to assess for practice change as a result of QBP implementation. Breast Cancer Surgery Best Practice Definition Relevant Documents Cancer Care Ontario Guidelines: • Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer July 2009 • Special Report: Multidisciplinary Cancer Conferences (MCC) June 2006 • Breast cancer reconstruction surgery (immediate and delayed) across Ontario: Patient indications and appropriate surgical options (publication pending) • Breast Cancer Pathway Map (2015) Additional Guidelines: • • • Guidelines to the Practice of Anesthesia, Revised Edition 2015 Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update 2014 Prevention of VTE in Non-orthopedic Surgical Patients, 9th Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines 45 • Best Practice in General Surgery Guideline #1: Strategies to Prevent Surgical Site Infections, Updated June 2012 Pathway Development Process To develop the best practice pathways of care for breast cancer surgery procedures the following process was followed: • A literature search and environmental scan was completed • Existing care paths were collected from the hospitals of QBP members. • Common practices and collaborative guidelines were then consolidated to create the best practice care path recommended for the patient population • Expert consensus was obtained with the working group The best practice focused on identifying and implementing evidence-informed practice driven by clinical consensus. The pathway reflects current available evidence and it is recognized that changes to the evidence may occur between review cycles. Best practice for the various types of breast cancer surgery has been categorized into the following stages: 1. Pre-Surgical Assessment (~ 4 weeks prior to check-in) 2. Day of Surgery (Day 0): Pre-Operative Care Unit (POCU) 3. Day of Surgery (Day 0): Operating Room 4. Day of Surgery (Day 0): Post-Anesthetic Care Unit (PACU) 5. Post-operative Surgery: Day 1+ onward (day after OR) Final Recommendations These pathways are intended to represent care for patients receiving a breast cancer surgery procedure for either day surgery or in-patient surgery. • • Day Surgery includes the Pre-Surgical Assessment phase to the Day of Surgery – PACU phase In-Patient includes the entire pathway from the Pre-Surgical Assessment phase to the Post-operative Day 1+ Onwards phase. 46 As a number of breast procedures are included in the QBP, a summary of the best practice for each clinical pathways is provided. Surgical Treatment 1. Breast surgery without reconstruction (mastectomy, lumpectomy, ALND, SLNB) 2. Mastectomy + Immediate Reconstruction 3. Delayed Breast Reconstruction Day Surgery Pre-Surgical Assessment phase to the Day of Surgery – PACU phase In-Patient Entire pathway from the Pre-Surgical Assessment phase to the Postoperative Day 1+ Onwards phase 4. Prophylactic Surgery 47 Breast Surgery Best Practice Clinical Pathway Recommendations: a) Breast surgery without reconstruction (mastectomy, lumpectomy, ALND, SLNB) 1. Pre-Surgical Assessment (~4 weeks prior to check-in) Tests: Appropriate breast imaging Recommended if clinically indicated: CBC ECG if patient has heart disease, diabetes or other risk factors for cardiac condition Na, K, Cl, creatinine, glucose, electrolytes Urinalysis if signs of urinary tract infection Pregnancy test if pregnancy possible PT/PTT/INR for patient on anticoagulant therapy or has liver disease Assessments: Physical assessment (vital signs, HT, WT, O2 saturation) Pre-operative questionnaire (patient history and physical form) Treatments: Sentinel lymph node injection – on day prior to surgery only if this service is unavailable on day of surgery Localization – as required - on day prior to surgery only if this service is unavailable on day of surgery Consults: Nursing CCAC - as required Anesthesiology/Pain management consult - as required Internal Medicine (Cardiology, etc.) - as required Plastic surgery - as required Medical Oncology - as required Radiation Oncology - as required Physiotherapy – as required Psychosocial referral – as required Medications: Review all current medication (by Pharmacist) Note allergies and intolerances Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary Complete medication reconciliation form Patient/Family Teaching: Educate patient on the surgical procedure Review pre-operation events and expectations Review post-operative events and expectations Inform patient about blood transfusion should it become necessary – as required Review plan for pain management Review self-care measures and wound management to prevent post-op complications Teach arm exercises Particularly important for patients receiving ALND Review patient education booklets, pamphlets, etc. Provide prosthesis information – as required Clarify any patient questions Discharge Planning: Review discharge plan with the patient including, expected length of stay, discharge time, and issues or complications that could delay discharge Discuss available supports on discharge 48 Involve Social worker or CCAC if necessary 2. Day of Surgery- POCU Assessments: Pre-operative assessment by nurse, surgeon and anesthesiologist Ensure medications have been taken as directed Vital signs, O2 saturation Pre-operative marking to verify laterality Blood work - as required (e.g. glucose) Treatments: Sentinel lymph node injection – as required Localization – as required Medications: VTE prophylaxis administered in the POCU or operating room should be considered for at risk patients (i.e. high Caprini score or other risk factors) Multimodal analgesic regimen should be considered Nutrition: No solid food after midnight the day prior to surgery Clear liquids until 2-3 hours prior to surgery NPO 2-3 hours prior to surgery 3. Day of Surgery- Operating Room Assessments: Complete surgical checklist Imaging of localization – as required Intraoperative frozen section – as required Essential intra-operative imaging available – as required When lesion localization techniques are used, specimen imaging to confirm complete excision Treatments: Lumpectomy, Mastectomy (+/- SLND or ALND) , ALND or SLNB performed Ensure all equipment is available Ensure all human resources are present (OR nurse, surgeon, anesthesiologist, radiology as needed) Pathology requisition completed by surgeon Use CCO requirements for sending specimen to pathology Ensure specimen is appropriately labelled and oriented to send to pathology for processing/assessment Ensure the specimen is sent to pathology in the recommended timeframe for molecular and receptor analysis Time to specimen fixation should be within 1 hour Medications: Patient specific medication Pain medication Local anesthetic block – as required 4. Day of Surgery- PACU (Day 0) NOTE: End point for day surgery Assessment: Post-operative assessment by nurse and/or surgeon (system & pain) Patient recovery (assess for haematoma or frank bleeding at all sites) 49 Consults: Acute Pain Services - as required CCAC consult – as required o CCAC consult is required if drain is present Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Medication: Patient specific medication Pain medication Antiemetic Activity: Breathing and recovery exercises; other activity as tolerated Early ambulation is recommended, as tolerated Nutrition: Clear fluids and progress to DAT Patient/Family Teaching Deep breathing and coughing For Day Surgery Patients: Ensure patient has education materials Review prescription and medication protocol Review signs and symptoms of wound infection Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) Discharge Planning For Day Surgery patients: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments 5. Day after Surgery- Post Operative Day 1+ onwards NOTE: Only applicable to in-patient Assessment: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Consults: CCAC consult – as required • CCAC consult is required if drain is present Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Medication: Patient specific medication Pain medication Antiemetic Activity: Activity as tolerated Nutrition Diet as tolerated Patient/Family Teaching: Ensure patient has education materials 50 Review prescription and medication protocol Review signs and symptoms of wound infection Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) Discharge Planning: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments b) Mastectomy + Immediate Reconstruction 1. Pre-Surgical Assessment (~4 weeks prior to check-in) Tests: Appropriate breast imaging Recommended if clinically indicated: • CBC • ECG if patient has heart disease, diabetes or other risk factors for cardiac condition • Na, K, Cl, creatinine, glucose, electrolytes • Urinalysis if signs of urinary tract infection • Pregnancy test if pregnancy possible • PT/PTT/INR for patient on anticoagulant therapy or has liver disease Assessments: Physical assessment (vital signs, HT, WT, O2 saturation) Pre-operative questionnaire (patient history and physical form) Review of the Surgical Consent and confirm all planned procedures Treatments: Sentinel lymph node injection – on day prior to surgery only if this service is unavailable on day of surgery Localization – on day prior to surgery only if this service is unavailable on day of surgery Consults: Nursing CCAC - as required Anesthesiology/Pain management consult - as required Internal Medicine (Cardiology, etc.) - as required Plastic surgery - as required Medical Oncology - as required Radiation Oncology - as required Physiotherapy – as required Psychosocial referral – as required Medications: Review all current medication (by Pharmacist) Note allergies and intolerances Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary Complete medication reconciliation form Provide information about discontinuation of endocrine and/or hormonal therapy for patients receiving a microsurgical reconstruction Patient/Family Teaching: Educate patient on the surgical procedure Review pre-operation events and expectations 51 Review post-operative events and expectations Inform patient about blood transfusion should it become necessary – as required Review plan for pain management Review self-care measures and wound management to prevent post-op complications Teach arm exercises Particularly important for patients receiving ALND and/or immediate breast reconstruction Review patient education booklets, pamphlets, etc. Provide prosthesis information – as required Clarify any patient questions Discharge Planning: Review discharge plan with the patient including, expected length of stay, discharge time, and issues or complications that could delay discharge Discuss available supports on discharge Involve Social worker or CCAC if necessary 2. Day of Surgery- POCU Assessments: Pre-operative assessment by nurse, surgeon and anesthesiologist Ensure medications have been taken as directed Vital signs, O2 saturation Pre-operative marking to verify laterality and flap donor site (if using flap reconstruction) Blood work - as required (e.g. glucose) Treatments: Sentinel lymph node injection – as required Localization – as required Medications: VTE prophylaxis administered in the POCU or operating room should be considered for at risk patients (i.e. high Caprini score or other risk factors) - VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and non-microsurgical) and should be administered as per institution protocol Multimodal analgesic regimen should be considered Nutrition: No solid food after midnight the day prior to surgery Clear liquids until 2-3 hours prior to surgery NPO 2-3 hours prior to surgery 3. Day of Surgery- Operating Room Assessments: Complete surgical checklist Imaging of localization – as required Intraoperative frozen section – as required Essential intra-operative imaging available – as required Treatments: Mastectomy (+/- SLND or ALND if necessary) performed, plus immediate breast reconstruction Implants only Non-microsurgical (+/- implants) Microsurgical (+/- implants) Ensure all equipment is available Ensure implants or tissue expanders are available in the OR, as required Ensure microscope is available for microsurgical procedure Ensure all human resources are present (OR nurse, general surgeon + plastic surgeon, anesthesiologist) 52 Pathology requisition completed by surgeon Use CCO requirements for sending specimen to pathology Ensure specimen is appropriately labelled and oriented to send to pathology for processing/assessment Ensure the specimen is sent to pathology in the recommended timeframe for molecular and receptor analysis Time to completed specimen fixation should be within 1 hour Medications: Patient specific medication Pain medication Consider use of PCA and multimodal pain medications if patient is receiving immediate reconstruction with any type of flap Local anesthetic block – as required 4. Day of Surgery- PACU (Day 0) NOTE: End point for day surgery Tests: For patients that received a flap reconstruction: • CBC Assessment: Post-operative assessment by nurse and/or surgeon (system & pain) Patient recovery (assess for haematoma or frank bleeding at all sites) Consults: Acute Pain Services - as required CCAC consult – as required CCAC consult is required if drain is present Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Monitor flap viability, if flap reconstruction performed For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours For microsurgical flap reconstructions, assess flap every hour for the first 24 hours Medication: Patient specific medication Pain medication Consider use of PCA and multimodal pain medications if patient received immediate reconstruction with any type of flap Antiemetic Antibiotic prophylaxis should be considered for patients that received an implant to prevent infection VTE prophylaxis is recommended for all patients receiving a flap (micro and non-microsurgical) reconstruction and should be administered as per institution protocol. Activity: Breathing and recovery exercises; other activity as tolerated Early ambulation is recommended, as tolerated No heavy lifting greater than 10 lbs with arms for the first 3 weeks Nutrition: Clear fluids and progress to DAT For patients that received a microsurgical flap reconstruction: NPO for the first 24 hours and thereafter progression clear fluids and DAT Patient/Family Teaching Deep breathing and coughing For Day Surgery Patients: Ensure patient has education materials Review prescription and medication protocol 53 Review signs and symptoms of wound infection Review signs and symptoms of implant infection, as required Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) Discharge Planning For Day Surgery patients: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up regimen 5. Day after Surgery- Post Operative Day 1+ onwards NOTE: Only applicable to in-patient Assessment: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Consults: CCAC consult – as required • CCAC consult is required if drain is present Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Monitor flap viability, if flap reconstruction performed • Assess flap viability q 4-8 hours • For microsurgical flap reconstructions, assess flap every hour for the first 24 hours Medication: Patient specific medication Pain medication Antiemetic Antibiotic prophylaxis should be considered for patients that received an implant to prevent infection VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and nonmicrosurgical) and should be administered as per institution protocol. Activity: Activity as tolerated Early ambulation is recommended, as tolerated No heavy lifting greater than 10 lbs with arms for the first 3 weeks Nutrition Diet as tolerated For patients that received a microsurgical flap reconstruction: NPO for the first 24 hours and thereafter progression to clear fluids and DAT Patient/Family Teaching: Ensure patient has education materials Review prescription and medication protocol Review signs and symptoms of wound infection Review signs and symptoms of implant infection, as required Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) 54 Discharge Planning: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up regimen c) Delayed Breast Reconstruction 1. Pre-Surgical Assessment (~4 weeks prior to check-in) Tests: Recommended if clinically indicated: CBC ECG if patient has heart disease, diabetes or other risk factors for cardiac condition Na, K, Cl, creatinine, glucose, electrolytes Urinalysis if signs of urinary tract infection Pregnancy test if pregnancy possible PT/PTT/INR for patient on anticoagulant therapy or has liver disease Assessments: Physical assessment (vital signs, HT, WT, O2 saturation) Pre-operative questionnaire (patient history and physical form) Review of the Surgical Consent and confirm all planned procedure(s) Consults: Plastic surgery Nursing General surgery – as required, based on planned procedure(s) Anesthesiology/Pain management consult - as required Internal Medicine (Cardiology, etc.) - as required Physiotherapy – as required Psychosocial referral – as required Medications: Review all current medication (by Pharmacist) Note allergies and intolerances Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary Provide information about discontinuation of endocrine and/or hormonal therapy for patients receiving a microsurgical reconstruction Complete medication reconciliation form Patient/Family Teaching: Educate patient on the surgical procedure Review pre-operation events and expectations Review post-operative events and expectations Inform patient about blood transfusion should it become necessary – as required Review plan for pain management Review self-care measures and wound management to prevent post-op complications Teach arm exercises Review patient education booklets, pamphlets, etc. Clarify any patient questions Discharge Planning: Review discharge plan with the patient including, expected length of stay, discharge time, and issues or complications that could delay discharge Discuss available supports on discharge 55 Involve Social worker or CCAC if necessary 2. Day of Surgery- POCU Assessments: Pre-operative assessment by nurse, surgeon(s) and anesthesiologist Ensure medications have been taken as directed Vital signs, O2 saturation Pre-operative marking of breast to verify laterality and flap donor site (if using flap reconstruction) Blood work - as required (e.g. glucose) Medications: VTE prophylaxis administered in the POCU or operating room should be considered for at risk patients (i.e. high Caprini score or other risk factors) - VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and non-microsurgical) and should be administered as per institution protocol Multimodal analgesic regimen should be considered Nutrition: No solid food after midnight the day prior to surgery Clear liquids until 2-3 hours prior to surgery NPO 2-3 hours prior to surgery 3. Day of Surgery- Operating Room Assessments: Complete surgical checklist Treatments: Breast reconstruction (unilateral or bilateral) Implants only Non-microsurgical (+/- implants) Microsurgical (+/- implants) Ensure all equipment is available Ensure implants or tissue expanders are available in the OR, as required Ensure microscope is available for microsurgical procedures Ensure all human resources are present (OR nurse, plastic surgeon +/- general surgeon, anesthesiologist) Medications: Patient specific medication Pain medication Consider use of PCA and multimodal pain medications if patient is receiving reconstruction with any type of flap Local anesthetic block – as required 4. Day of Surgery- PACU (Day 0) NOTE: End point for day surgery Tests: For patients that received a flap reconstruction: CBC Assessment: Post-operative assessment by nurse and/or surgeon (system & pain) Patient recovery (assess for haematoma or frank bleeding at all sites) Consults: Acute Pain Services - as required 56 CCAC consult – as required o CCAC consult is required if drain is present Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Monitor flap viability, if flap reconstruction performed o For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours o For microsurgical flap reconstructions, assess flap every hour for the first 24 hours Medication: Patient specific medication Pain medication o Consider use of PCA and multimodal pain medications if patient received reconstruction with any type of flap Antiemetic Antibiotic prophylaxis should be considered for patients that received an implant to prevent infection VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and nonmicrosurgical) and should be administered as per institution protocol. Activity: Breathing and recovery exercises; other activity as tolerated Early ambulation is recommended, as tolerated No heavy lifting greater than 10 lbs with arms for the first 3 weeks Nutrition: Clear fluids and progress to DAT For patients that received a microsurgical flap reconstruction: NPO for the first 24 hours and thereafter progression clear fluids and DAT Patient/Family Teaching Deep breathing and coughing For Day Surgery Patients: Ensure patient has education materials Review prescription and medication protocol Review signs and symptoms of wound infection Review signs and symptoms of implant infection, as required Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) Discharge Planning For Day Surgery patients: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up regimen 5. Day after Surgery- Post Operative Day 1+ onwards NOTE: Only applicable to in-patient Assessment: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Consults: CCAC consult – as required • CCAC consult is required if drain is present 57 Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Monitor flap viability, if flap reconstruction performed • For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours until discharge • For microsurgical flap reconstructions, assess flap viability q 4-8 hours until discharge Medication: Patient specific medication Pain medication Antiemetic Antibiotic prophylaxis should be considered for patients that received an implant to prevent infection VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and nonmicrosurgical) and should be administered as per institution protocol. Activity: Activity as tolerated Early ambulation is recommended, as tolerated No heavy lifting greater than 10 lbs with arms for the first 3 weeks Nutrition Diet as tolerated For patients that received a microsurgical flap reconstruction: NPO for the first 24 hours and thereafter progression to clear fluids and DAT Patient/Family Teaching: Ensure patient has education materials Review prescription and medication protocol Review signs and symptoms of wound infection Review signs and symptoms of implant infection, as required Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) Discharge Planning: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments Discuss the surveillance plan for recurrence, in alignment with the regular breast cancer follow-up regimen d) Prophylactic Mastectomy (+/- immediate reconstruction) 1. Pre-Surgical Assessment (~4 weeks prior to check-in) Tests: • Confirmation that patient is at high-risk for developing breast cancer Recommended if clinically indicated: CBC ECG if patient has heart disease, diabetes or other risk factors for cardiac condition Na, K, Cl, creatinine, glucose, electrolytes Urinalysis if signs of urinary tract infection Pregnancy test if pregnancy possible PT/PTT/INR for patient on anticoagulant therapy or has liver disease 58 Assessments: Physical assessment (vital signs, HT, WT, O2 saturation) Pre-operative questionnaire (patient history and physical form) Consults: Nursing CCAC – as required Anesthesiology/Pain management consult - as required Internal Medicine (Cardiology, etc.) - as required Plastic surgery – as required Physiotherapy – as required Psychosocial referral – as required Medications: Review all current medication (by Pharmacist) Note allergies and intolerances Provide information about discontinuation of NSAIDS/ antiplatelet/ anticoagulants if necessary Complete medication reconciliation form Patient/Family Teaching: Educate patient on the surgical procedure Review pre-operation events and expectations Review post-operative events and expectations Inform patient about blood transfusion should it become necessary – as required Review plan for pain management Review self-care measures and wound management to prevent post-op complications Teach arm exercises Particularly important for patients receiving ALND and/or immediate breast reconstruction Review patient education booklets, pamphlets, etc. Provide prosthesis information – as required Clarify any patient questions Discharge Planning: Review discharge plan with the patient including, expected length of stay, discharge time, and issues or complications that could delay discharge Discuss available supports on discharge Involve Social worker or CCAC if necessary 2. Day of Surgery- POCU Assessments: Pre-operative assessment by nurse, surgeon(s) and anesthesiologist Ensure medications have been taken as directed Vital signs, O2 saturation Pre-operative marking of breast to verify laterality and flap donor site (if using flap reconstruction) Blood work - as required (e.g. glucose) Medications: VTE prophylaxis administered in the POCU or operating room should be considered for at risk patients (i.e. high Caprini score or other risk factors) - VTE prophylaxis is recommended for all patients receiving a flap reconstruction (micro and non-microsurgical) and should be administered as per institution protocol Multimodal analgesic regimen should be considered Nutrition: No solid food after midnight the day prior to surgery Clear liquids until 2-3 hours prior to surgery NPO 2-3 hours prior to surgery 59 3. Day of Surgery- Operating Room Assessments: Complete surgical checklist Treatments: Mastectomy performed, plus immediate breast reconstruction Ensure all equipment is available Ensure implants or tissue expanders are available in the OR, as required Ensure microscope is available for microsurgical procedures Ensure all human resources are present (OR nurse, general surgeon + plastic surgeon, anesthesiologist) Pathology requisition completed by surgeon Use CCO requirements for sending specimen to pathology Ensure specimen is appropriately labelled and oriented to send to pathology for processing/assessment Ensure the specimen is sent to pathology in the recommended timeframe for molecular and receptor analysis Time to completed specimen fixation should be within 1 hour Medications: Patient specific medication Pain medication Consider use of PCA and multimodal pain medications if patient is receiving reconstruction with any type of flap Local anesthetic block – as required 4. Day of Surgery- PACU (Day 0) NOTE: End point for day surgery Tests: For patients that received a flap reconstruction: CBC Assessment: Post-operative assessment by nurse and/or surgeon (system & pain) Patient recovery (assess for haematoma or frank bleeding at all sites) Consults: Acute Pain Services - as required CCAC consult – as required o CCAC consult is required if drain is present Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Monitor flap viability, if flap reconstruction performed o For non-microsurgical flap reconstructions, assess flap viability q 4-8 hours o For microsurgical flap reconstructions, assess flap every hour for the first 24 hours Medication: Patient specific medication Pain medication o Consider use of PCA and multimodal pain medications if patient received reconstruction with any type of flap Antiemetic Antibiotic prophylaxis should be considered for patients that received an implant to prevent infection For patients that received a flap reconstruction (micro and non-microsurgical): VTE prophylaxis is recommended for all patients receiving a flap reconstruction and should be administered as per institution protocol. 60 Activity: Breathing and recovery exercises; other activity as tolerated No heavy lifting greater than 10 lbs with arms for the first 3 weeks Nutrition: Clear fluids and progress to DAT For patients that received a microsurgical flap reconstruction: NPO for the first 24 hours and thereafter progression clear fluids and DAT Patient/Family Teaching Deep breathing and coughing For Day Surgery Patients: Ensure patient has education materials Review prescription and medication protocol Review signs and symptoms of wound infection Review signs and symptoms of implant infection, as required Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) Discharge Planning For Day Surgery patients: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments 5. Day after Surgery- Post Operative Day 1+ onwards NOTE: Only applicable to in-patient Assessment: Discharge assessment by nurse and/or surgeon (system, pain, recovery) Consults: CCAC consult – as required • CCAC consult is required if drain is present Treatment: Monitor patient recovery (e.g. intake and output, wound dressing, pain, nausea) Monitor closed drainage system, if drain present Monitor flap viability, if flap reconstruction performed • Assess flap viability q 4-8 hours Medication: Patient specific medication Pain medication Antiemetic Antibiotic prophylaxis should be considered for patients that received an implant to prevent infection For patients that received a flap reconstruction (micro and non-microsurgical): VTE prophylaxis is recommended for all patients receiving a flap reconstruction and should be administered as per institution protocol. Activity: Activity as tolerated No heavy lifting greater than 10 lbs with arms for the first 3 weeks Nutrition Diet as tolerated For patients that received a microsurgical flap reconstruction: NPO for the first 24 hours and thereafter progression to clear fluids and DAT 61 Patient/Family Teaching: Ensure patient has education materials Review prescription and medication protocol Review signs and symptoms of wound infection Sponge bath until drain and/or initial dressing removed Exercise program Review pre-operative teachings (home management of wound, pain management, arm exercises, etc.) Discharge Planning: Discuss discharge preparation Ensure patient meets clinical indicators to be discharged Review discharge plan with patient and family Inform patients of follow-up appointments 62 8.0 Implementation of best practices The Cancer Surgery QBP funding model is based on the following principles, ensuring the implementation of best practices: • Align funding framework development with Ontario’s Excellent Care for All Act & Patient-Based Payment policy • Address in-hospital care phase initially with expansion to the pre-treatment and follow up care phases • Transition on a disease site basis. • Use lessons learned from the Cancer Surgery Agreement (CSA) process (allocation, re-allocation and reconciliation) and apply them to QBP • Ensure clinical best practices remain current with existing evidence • Continue to maintain linking the implementation of clinical guidelines and organization guidelines similar to the Schedule B requirements within the Cancer Surgery Agreement. • Ensure model development process is transparent, multi-disciplinary and collaborative • Promote high quality care close to home as appropriate • Promote timely access to care • Support decreased practice variation • Promote value for money and improve efficiency (i.e., track and evaluate money spent by outcomes achieved) • Improve outcome measurement and accountability for reported outcomes • Balance implementation of funding framework with financial risk to organizations • Ensure that ongoing governance structure (including clinical oversight) is supported by transparent dispute resolution processes for Cancer Surgery QBP • Establish ongoing monitoring, reporting and evaluation of processes/quality indicators/outcomes • Establish recognized and transparent performance management cycle and funding agreements • Respond to and incorporate new evidence and support new models of care 63 8.1 Knowledge Transfer and Exchange of Best Practice Care Communicating the defined best practice for cancer surgery procedures (in-hospital care) is critical to the implementation of Cancer Surgery QBP. CCO will work closely not only the working groups but also hospital administrators and clinicians for successful implementation within each disease site. 9.0 What does it mean for multi-disciplinary teams? Successful implementation of the new funding model for cancer surgery requires the collaboration on the part of all those involved in the patients care delivery. Surgeons, pathologists, radiation oncologists, radiologist, medical oncologists, anaethesiologists, nursing and physiotherapists should be aware of and contribute to the best practice. Clerical staff ensure accurate data entry and coding for reimbursement and quality indicator measurement. Administrative staff need to be aware of best practice in regards of performance management and quality indicator reporting. As the initial implementation of the prostate surgery QBP only addresses the surgical procedure, the impact on some of the members of the multi-disciplinary team will be minimal. In future with further expansion of the cancer surgery QBP to include the Consult/Pre-Treatment Assessment or Follow-up phases will have a greater impact on the multidisciplinary team. 9.1 How does Cancer Surgery as a QBP align with clinical practice? The implementation of previous QBPs, and evidence informed practices have resulted in improved patient experiences, better outcomes and a streamlined length of stay for patients. QBPs align with clinical practice by encouraging the adoption of best practices in order to maximize system capacity and use of available resources. This process will result in improvements in patient satisfaction and improved quality of care. 9.2 What are the implications for clinicians? 64 The changes associated with the QBPs focus on identifying and implementing evidenceinformed practice driven by clinical consensus. Clinicians will be tasked with identifying within their own expertise best practice protocols and identifying where there are variances from such practice. Collaboration with hospital administration will assist the clinicians in identifying the challenges within the service, as well as opportunities and the feasibility for changes to the best practice. Clinicians will continue to play an essential role in guiding hospitals to meet the needs of their patient population and ensuring that the highest quality care is provided for all their patients. At this time, physician payment models and OHIP fee schedules, as they relate to QBPs will remain unchanged. Physicians currently working under fee-for-service will continue to submit claims to OHIP for consultations, treatment and follow-up 9.3 Will this change current practice? The cancer surgery procedure-based funding framework may create change in current practice for some clinicians and hospitals in Ontario. 10.0 Service capacity planning The service capacity planning for Cancer Surgery QBP will build on existing processes that are in place with the Cancer Surgery Agreements (CSA). Hospitals will be required to maintain their volumes; therefore, resulting in minimal impact or change in service capacity. 65 11.0 Performance evaluation and feedback In introducing the QBPs the ministry has a strong interest in: • Supporting monitoring and evaluation of the impact (intended and unintended) of the introduction of QBPs • Providing benchmark information for clinicians and administrators that will enable mutual learning and promote on-going quality improvement • Providing performance-based information back to Expert Panels to evaluate the impact of their work and update as required in real time There was recognition that reporting on a few system-level indicators alone would not be sufficient to meet the ministry’s aim of informing and enabling quality improvement initiatives at the provider-level. Therefore measures meaningful to hospitals and clinicians that are interpretable and have demonstrable value in improving the quality of care provided to patients are also of utmost importance. To guide the selection and development of relevant indicators for each QBP, the ministry, in consultation with experts in evaluation and performance measurement, developed an approach based on the policy objectives of the QBPs and a set of guiding principles. This resulted in the creation of an integrated scorecard with the following six quality domains: • Effectiveness (including safety) • Appropriateness • Integration • Efficiency • Access • Patient-centeredness The scorecard is based on the following guiding principles: • Relevance – the scorecard should accurately measure the response of the system to introducing QBPs • Importance – to facilitate improvement, the indicators should be meaningful for all potential stakeholders (patients, clinicians, administrators, LHINs and the ministry) • Alignment – the scorecard should align with other indicator-related initiatives where appropriate • Evidence – the indicators in the integrated scorecard need to be scientifically sound or at least measure what is intended and accepted by the respective community (clinicians, administrators and/or policy-decision makers) 66 A set of evaluation questions was identified for each of the QBP policy objectives outlining what the ministry would need to know in order to understand the intended and unintended impact of the introduction of QBPs. These questions were translated into key provincial indicators resulting in a QBP scorecard (see table below). Quality Domain What is being measured? Effectiveness What are the results of care received by patients and do the results vary across providers that cannot be explained by population characteristics as well as is care provided without harm? Is patient care being provided according to scientific knowledge and in a way that avoids overuse, underuse or misuse? Appropriateness Key provincial indicators 1. Proportion of QBPs that improved outcomes 2. Proportion of QBPs that reduced variation in outcome 3. Proportion of (relevant) QBPs that reduced rates of adverse events and infections 4. Proportion of QBPs that reduced variation in utilization 5. Proportion of (relevant) QBPs that saw a substitution from inpatient to outpatient/day surgery 6. Proportion of (relevant) QBPs that saw a substitution to less invasive procedures 7. Increased rate of patients being involved in treatment decision 8. Proportion of (relevant) QBPs that saw an increase in discharge dispositions into the community Integration Are all parts of the health system organized, connected and work with another to provide high quality care? 9. Reduction in 30-day readmissions rate (if relevant) 10. Improved access to appropriate primary and community care including for example psychosocial support (e.g. personal, family, financial, employment and/or social needs) 11. Coordination of care (TBD) 12. Involvement of family (TBD) Efficiency Access Does the system make best use of available resources to yield maximum benefit ensuring that the system is sustainable for the long term? Are those in need of care able to access services when needed? 13. Actual costs vs. QBP price 14. Increase in wait times for QBPs / for specific populations for QBP 15. Increase in wait times for other procedures 16. Increase in distance patients have to travel to receive the appropriate care related to the QBP 17. Proportion of providers with a significant change in resource intensity weights (RIW) 67 Quality Domain What is being measured? PatientCenteredness (to be further developed) Is the patient/user at the center of the care delivery and is there respect for and involvement of patients’ values, preferences and expressed needs in the care they receive? (TBC) Key provincial indicators 18. Increased rate of patients being involved in treatment decision 19. Coordination of care (TBD) 20. Involvement of family (TBD) It should be noted that although not explicitly mentioned as a separate domain, the equity component of quality of care is reflected across the six domains of the scorecard and will be assessed by stratifying indicator results by key demographic variables and assessing comparability of findings across sub-groups. Where appropriate, the indicators will be riskadjusted for important markers of patient complexity so that they will provide an accurate representation of the quality of care being provided to patients. The ministry and experts recognized that to be meaningful for clinicians and administrators, it is important to tie indicators to clinical guidelines and care standards. Hence, advisory groups that developed the best practices were asked to translate the provincial-level indicators into QBP-specific indicators. In consulting the advisory groups for this purpose, the ministry was interested in identifying indicators both for which provincial data is readily available to calculate and those for which new information would be required. Measures in the latter category are intended to guide future discussion with ministry partners regarding how identified data gaps might be addressed. In developing the integrated scorecard approach, the ministry recognized the different users of the indicators and envisioned each distinct set of measures as an inter-related cascade of information. That is, the sets of indicators each contain a number of system or provincial level measures that are impacted by other indicators or driving factors that are most relevant at the Local Health Integration Networks (LHINs), hospital or individual clinician level. The indicators will enable the province and its partners to monitor and evaluate the quality of care and allow for benchmarking across organizations and clinicians. This will in turn support quality improvement and enable target setting for each QBP to ensure that the focus is on providing high quality care, as opposed to solely reducing costs. It is important to note that process-related indicators selected by the expert panels will be most relevant at the provider level. The full list of these measures is intended to function as a ‘menu’ of information that can assist administrators and clinicians in identifying areas for quality improvement. For example, individual providers can review patient-level results in conjunction with supplementary demographic, financial and other statistical information to help target care processes that might be re-engineered to help ensure that high-quality care is provided to patients. 68 Baseline reports and regular updates on QBP specific indicators will be included as appendices to each QBP Clinical Handbook. Reports will be supplemented with technical information outlining how results were calculated along with LHIN and provincial-level results that contextualize relative performance. Baseline reports will also be accompanied by facility-level information that will facilitate sharing of best practices and target setting at the provider-level. The ministry recognizes that the evaluation process will be on-going and will require extensive collaboration with researchers, clinicians, administrators and other relevant stakeholders to develop, measure, report, evaluate and, if required, revise and/or include additional indicators to ensure that the information needs of its users are met. 69 12.0 Cancer Surgery Quality Indicators Measuring the quality of care provided to Ontarians is a significant aspect of the QBP funding initiative. Many indicators on the provincial scorecard apply to cancer surgery and have been highlighted. In addition, more indicators for cancer surgeries have been selected that either relate to: a) all cancer surgeries or b) are disease site specific. Quality Domain Description Effectiveness What are the results of care received by patients and do the results vary across providers that cannot be explained by population characteristics as well as is care provided without harm? Is patient care being provided according to scientific knowledge and in a way that avoids overuse, underuse or misuse? Appropriateness Prostate Cancer 1. 2. 3. 4. 5. 6. Thyroid Cancer* Colorectal Cancer Breast Cancer** Proportion of patients reoperated on within 30 days after radical prostatectomy Proportion of patients that died within 30 days after radical prostatectomy Proportion of patients that experience a complication (e.g. rectal injury, transfusion rate, SSI) 1. Proportion of patients reoperated on within 30 days after a colorectal resection 2. Proportion of patients that died within 30 days after a colorectal resection 3. Proportion of patients that experience a complication (e.g. anastomotic leak, SSI) 1. Proportion of patients re1. Proportion of patients reoperated on within 30 days operated on (for a nonafter thyroidectomy breast ablative procedure) 2. Proportion of patients that within 30 days after breast died within 30 days after a surgery 2. Proportion of patients that thyroidectomy died within 30 days after a 3. Proportion of patients that breast surgery experience a complication (e.g. recurrent laryngeal nerve injury, hypoparathyroidism) Discipline participation in a high-quality Multidisciplinary Cancer Conference (MCC) Proportion of patients that receive a radiation oncologist consult or discussion at a MCC prior to surgery Proportion of patients with positive pT2 margins after radical prostatectomy 3. Discipline participation in a high-quality Multidisciplinary Cancer Conference (MCC) 4. Proportion of patients with positive circumferential margins after rectal resection 5. Proportion of colon resection patients with 12 or more lymph node retrieved 6. Proportion of patients that receive a MRI and CT before rectal cancer surgery 3. Discipline participation in a 4. Discipline participation in a high-quality high-quality Multidisciplinary Cancer Conference (MCC) Multidisciplinary Cancer 5. Proportion of patients that Conference (MCC) received a partial 4. Proportion of patients that receive appropriate prethyroidectomy for low risk operative imaging of the disease breast (mammogram 6. Proportion of patients found to and/or ultrasound and/or have benign disease following MRI) thyroidectomy 5. Proportion of patients 7. Proportion of patients with staged with fine needle adequate lymph node retrieval following central neck aspiration or core biopsy dissection prior to resection 6. Proportion of patients with positive margins after 70 Quality Domain Description Prostate Cancer Thyroid Cancer* Colorectal Cancer Breast Cancer** breast cancer surgery (lumpectomy and mastectomy) Integration Efficiency Access Are all parts of the health system organized, connected and work with another to provide high quality care? Does the system make best use of available resources to yield maximum benefit ensuring that the system is sustainable for the long term? Are those in need of care able to access services when needed? 7. 8. 9. Proportion of patient readmissions within 30 days of discharge Proportion of patients with positive margins that had a radiation oncology consult post-surgery 8. Proportion of patient 8. Proportion of patient readmissions within 30 days readmissions within 30 days of discharge of discharge 7. Proportion of patient readmissions within 30 days of discharge Average length of stay for a radical prostatectomy patient 9. Average length of stay for a colorectal resection patient 8. Average length of stay for breast surgery patients 10. Proportion of prostate cancer surgery patients that received surgery (Wait 2) within the priority target 11. Proportion of patients with a discharge disposition into the community 9. Average length of stay for thyroidectomy patients 10. Proportion of thyroid cancer 10. Proportion of colorectal surgery patients that cancer surgery patients received surgery (Wait 2) that received surgery within the priority target (Wait 2) within the priority target 71 9. Proportion of breast cancer surgery (+/- immediate reconstruction) patients that received surgery (Wait 2) within the priority target 10. Proportion of mastectomy patients that receive reconstruction within 2 years post mastectomy Quality Domain Description PatientCenteredness (to be further developed) Is the patient/user at the center of the care delivery and is there respect for and involvement of patients’ values, preferences and expressed needs in the care they receive? (TBC) Prostate Cancer Thyroid Cancer* Colorectal Cancer NOTES: Breast Cancer** *Although medullary thyroid cancer patients are included in the Thyroid Cancer Surgery QBP, the Working Group felt that measurement of an indicator specific to medullary cancer would be of limited value due to the small number of patients **An indicator specific to prophylactic mastectomy may be determined at a later date 72 13.0 Support for Change Cancer Care Ontario (CCO) will continue to work with various stakeholders across the province to educate all multidisciplinary teams impacted by the new Cancer Surgery Funding Model. Currently, CCO works with numerous clinical specialists that will provide the necessary support for clinical knowledge transfer and exchange (KTE). The ministry, in collaboration with its partners, will deploy a number of field supports to support adoption of the funding policy. These supports include: • Committed clinical engagement with representation from cross-sectoral health sector leadership and clinicians to champion change through the development of standards of care and the development of evidence-informed patient clinical pathways for the QBPs. • Dedicated multidisciplinary clinical expert group that seek clearly defined purposes, structures, processes and tools which are fundamental for helping to navigate the course of change. • Strengthened relationships with ministry partners and supporting agencies to seek input on the development and implementation of QBP policy, disseminate quality improvement tools, and support service capacity planning. • Alignment with quality levers such as the Quality Improvement Plans (QIPs). QIPs strengthen the linkage between quality and funding and facilitate communication between the hospital board, administration, providers and public on the hospitals’ plans for quality improvement and enhancement of patient-centered care. • Deployment of a Provincial Scale Applied Learning Strategy known as IDEAS (Improving the Delivery of Excellence across Sectors). IDEAS is Ontario’s investment in field-driven capacity building for improvement. Its mission is to help build a high-performing health system by training a cadre of health system change agents that can support an approach to improvement of quality and value in Ontario. We hope that these supports, including this Clinical Handbook, will help facilitate a sustainable dialogue between hospital administration, clinicians, and staff on the underlying evidence guiding QBP implementation. The field supports are intended to complement the quality improvement processes currently underway in your organization. 73 14.0 Frequently Asked Questions There have been no frequently asked questions identified to date. 74 15.0 Membership The following table outlines the members of the Cancer Surgery QBP Advisory Committee: * Cancer Care Ontario representative CANCER SURGERY QBP ADVISORY COMMITTEE (2015) NAME TITLE & ORGANIZATION NAME Dr Jonathan Irish* Provincial Health, Surgical Oncology Program Faith Forbes Dr Alice Wei* Surgical Lead, Quality Improvement & Knowledge Transfer Dr. Stan Feinburg Garth Matheson* Vice- President, Planning & Regional Program Leslie Motz Irene Blais* Director, Funding Unit, Dr. John Dickie Elaine Meertens* Director, Regional Programs Brenda Carter Saul Melamed* Director, Clinical Programs & Quality Initiative, Nathalie Cadieux Amber Hunter* Manager, Surgical Oncology Program, Leigh McKnight* Sukaina Sheraly* Project Lead, Surgical Oncology Program Project Lead, Surgical Oncology Program Dr. Sudir Sundaresan Dr. Mike Anderson Tiz Silveri Julia Monakova* Manager, Funding Unit Dr. Jeff Kolbasnik Dr. Aaron Pollet* Provincial Head, Pathology & Laboratory Medicine Anubhu Prashad Jeff Booth Director, Windsor Regional Cancer Centre Thomas Smith Silvie Crawford Vice-President, Patient Centred Care, London Health Sciences Marnie Escaf Dr. Stephen Pautler Judy Burns Dr. Ved Tandan Regional Surgical Lead, St. Joseph’s Hospital- London Regional Vice-President, Grand River Regional Cancer Center Regional Surgical Lead, St. Joseph’s Hospital- Hamilton Dr. Andy Smith Filomena Travossos Kim Alvardo TITLE & ORGANIZATION Finance & Manager of Redevelopment, HBAM & QBP, Humber River Hospital Medical Director of Cancer Care & Ambulatory Care, North York General Hospital Senior Director, Surgery, Pharmacy, Ambulatory Clinics, OTN, Lakeridge Health Head, Section of Thoracic Surgery & Chief, Department of Surgery, Lakeridge Health Regional Vice President, South East LHIN, Kingston General Hospital Corporate Financial Controller, The Ottawa Hospital Chief, Division of Thoracic Surgery, The Ottawa Hospital Regional Surgical Lead, Simcoe Muskoka Regional Cancer Centre Vice President of Clinical Services, North Bay Regional Health Centre Chief, Department of Surgery, Halton Healthcare Services and Chair, General Surgery Section, Ontario Medical Association Senior Policy Consultant, MOHLTC Program Manager, Negotiations & Accountability Management Division, Provincial Programs Branch, MOHLTC Senior Vice- President & Executive Lead, PM Cancer Program, University Health Network Executive Vice President & Chief Medical Officer, Odette Cancer Centre Manager, Decision Support, Trillium Health Partners Director, Surgical Oncology, Orthopedics & Critical Care, Juravinski Cancer Centre 75 The following table outlines the members of the Prostate Cancer Surgery Working Group PROSTATE CANCER SURGERY WORKING GROUP NAME TITLE & ORGANIZATION Dr. Rag Goel Urologist, Windsor Regional Cancer Centre Dr. Paul Martin Urologist, Bluewater Health Dr. Joe Chin Urologist, London Health Sciences Centre Dr. Demo Divaris Regional Pathology Lead, Grand River Hospital & St. Mary’s General Hospital Dr. Bobby Shayegan Urologist, St. Joseph’s Healthcare- Hamilton Dr. Chris Morash Urologist, The Ottawa Hospital Dr. Munir Jamal Head, Division of Urology, Trillium Health Partners Dr. Thomas McGowan Physician Director, Radiation Oncology, Trillium Health Partners Dr. Rajiv Singal Urologist, Toronto East General Hospital Dr. Tony Finelli Urologist, University Health Network Dr. Neil Fleshner Urologist, University Health Network Dr. Stephen Pautler Regional Surgical Lead, St. Joseph’s Hospital- London The following table outlines the members of the Colorectal Cancer Surgery Working Group COLORECTAL CANCER SURGERY WORKING GROUP NAME TITLE & ORGANIZATION Dr. Patrick Colquoin Registered Nurse & Clinical Manager, Diagnostic Assessment Programs & Integrated Screening, Grand River Cancer Centre General Surgeon, London Health Sciences Centre Dr. Chala Eskicioglu General Surgeon, St. Joseph’s Healthcare Dr. Jeff Kolbasnik General Surgeon, Halton Healthcare Services Dr. William Chu Radiation Oncologist, Sunnybrook Health Sciences Centre Dr. Erin Kennedy General Surgeon, Mount Sinai Hospital Dr. Stan Feinburg General Surgeon, North York General Hospital Pamela Richards Nurse, Mackenzie Health Dr. Lynn Mikula General Surgeon, Peterborough Regional Health Centre Dr. Janet Van Vlymen Anesthesiologist, Kingston General Hospital Dr. Mike Anderson Regional Surgical Lead, North Simcoe Muskoka Maureen McGrath Nurse, The Ottawa Hospital Dr. Blair MacDonald Radiologist, The Ottawa Hospital Dr. Kevin Gagne Anesthesiologist, North Bay Regional Health Centre Dr. Bill Harris General Surgeon, Thunder Bay Regional Health Sciences Centre Barbara-Anne Maier 76 The following table outlines the members of the Thyroid Cancer Surgery Working Group THYROID CANCER SURGERY WORKING GROUP NAME TITLE & ORGANIZATION Dr. Linda Tietze Otolaryngology, Windsor Regional Hospital Dr. Deric Morrison Endocrinology, London Health Sciences Centre Dr. John Yoo Otolaryngology – Head & Neck Surgery, London Health Sciences Centre Dr. Patrick Whelan General Surgery, Markham Stouffville Hospital Dr. Julia Jones General Surgery, Lakeridge Health Dr. Ozgur Mete Pathology, Lakeridge Health Laurie Thomas Nursing, Kingston General Hospital Dr. Stephanie Thomas ENT, The Ottawa Hospital Dr. Rob Hekkenberg General Surgery, Royal Victoria Hospital Dr. Pankaj Bhatia General Surgery, Health Sciences North Dr. Tom Carr Nuclear Medicine, Health Sciences North Dr. Marc Freeman Nuclear Medicine, Trillium Health Partners Dr. Kevin Higgins Otolaryngology – Head & Neck Surgery, Sunnybrook Health Sciences Centre Dr. Jim Brierley Radiation Oncology, University Health Network Dr. Ralph Gilbert Otolaryngology – Head & Neck Surgery, University Health Network Dr. Richard Brull Anesthesiology, University Health Network Salin Kim Nursing, University Health Network Dr. Eric Monteiro Otolaryngology – Head & Neck Surgery, Mount Sinai Hospital The following table outlines the members of the Breast Cancer Surgery Working Group BREAST CANCER SURGERY WORKING GROUP NAME TITLE & ORGANIZATION Dr. David Shum Pathology, Windsor Regional Hospital Dr. Swati Kulkarni Medical Oncology, Windsor Regional Hospital Dr. Muriel Brackstone General Surgery, London Health Sciences Centre Dr. Mike Maurice General Surgery, Grand River Hospital/St. Mary’s General Hospital Dr. Peter Lovrics General Surgery, St. Joseph’s Healthcare Dr. Anna Kobylecky General Surgery, Niagara Health System Dr. Jeff Kolbasnik General Surgery, Halton Healthcare Services Dr. Anita Bane Pathology, Hamilton Health Sciences Centre Dr. Nancy Down General Surgery, North York General Hospital Dr. Elizabeth Hartley Anesthesiology, Rouge Valley Hospital Dr. Dragana Pilavdzic Pathology, Lakeridge Health 77 Kristina Cruess Nursing, Quinte Health Care Dr. Kaes Al-Ali General Surgery, Northumberland Hills Hospital Dr. Laurie Wherrett General Surgery, Lakeridge Health Dr. Angel Arnaout General Surgery, The Ottawa Hospital Dr. Jennifer Macmillan General Surgery, Muskoka Algonquin Healthcare Dr. Rachelle Paradis General Surgery, Health Sciences North Dr. Ted McAlister General Surgery, Brampton Civic Hospital Dr. Laura Snell Plastic Surgery, Sunnybrook Health Sciences Centre Fatima San Pedro Nursing, Sunnybrook Health Sciences Centre Dr. Andrea Eisen Medical Oncology, Sunnybrook Health Sciences Centre Dr. Ralph George General Surgery, St. Michael’s Hospital Dr. David McCready General Surgery, University Health Network Dr. Derek Muradali Radiology, University Health Network Janet Papadakos Nursing, University Health Network Dr. Toni Zhong Plastic Surgery, University Health Network 78 Appendix A – In-scope Diagnosis & Procedure Codes Table 1: Colon and Rectal resection diagnosis codes for Cancer Surgery QBP ICD10-CA (Diagnosis) Description From C00 to C97 All malignant neoplasm diagnosis codes ICD10-CA (Diagnosis) Description D010 Carcinoma in situ of colon D011 Carcinoma in situ of rectosigmoid junction D012 Carcinoma in situ of rectum D014 Carcinoma in situ of other and unspecified parts of intestine D017 Carcinoma in situ of other specified digestive organs D019 Carcinoma in situ of digestive organ, unspecified D097 Carcinoma in situ of other specified sites D099 Carcinoma in situ, unspecified D120 Benign neoplasm of caecum D121 Benign neoplasm of appendix D122 Benign neoplasm of ascending colon D123 Benign neoplasm of transverse colon D124 Benign neoplasm of descending colon D125 Benign neoplasm of sigmoid colon D126 Benign neoplasm of colon, unspecified D127 Benign neoplasm of rectosigmoid junction D128 Benign neoplasm of rectum D139 Benign neoplasm of ill-defined sites within the digestive system D175 Benign lipomatous neoplasm of intra-abdominal organs D1803 Haemangioma of digestive system D1809 Haemangioma, unspecified site D367 Benign neoplasm of other specified sites D369 Benign neoplasm of unspecified site D373 Neoplasm of uncertain or unknown behaviour of appendix D374 Neoplasm of uncertain or unknown behaviour of the colon D375 Neoplasm of uncertain or unknown behaviour of the rectum D377 Neoplasm of uncertain or unknown behaviour of other digestive organs D379 Neoplasm of uncertain or unknown behaviour of digestive organ, unspecified D489 Neoplasm of uncertain or unknown behaviour, unspecified 79 Table 2: Colon and Rectal resection procedure codes for Cancer Surgery QBP CCI CODE (Procedure) CCI LONG DESCRIPTION 1NQ89SFXXG Excision total, rectum abdominal [anterior] approach pouch formation 1NQ90LAXXG Excision total with reconstruction, rectum using open approach with ileum [for construction of pouch] 1NQ89KZXXG Excision total, rectum abdominoperineal approach pouch formation 1NK87DN Excision partial, small intestine endoscopic [laparoscopic] approach Enterocolostomy anastomosis technique 1NK87RE Excision partial, small intestine open approach Enterocolostomy anastomosis technique 1NM87DA Excision partial, large intestine endoscopic [laparoscopic] approach Simple excisional technique 1NM87DE Excision partial, large intestine endoscopic [laparoscopic] approach Colorectal anastomosis technique 1NM87DF Excision partial, large intestine endoscopic [laparoscopic] approach Colocolostomy anastomosis technique 1NM87DN Excision partial, large intestine endoscopic [laparoscopic] approach Enterocolostomy anastomosis technique 1NM87LA Excision partial, large intestine open approach Simple excisional technique 1NM87PN Excision partial, large intestine endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach robotic assisted telemanipulation of tools [telesurgery] 1NM87RD Excision partial, large intestine open approach Colorectal anastomosis technique 1NM87RE Excision partial, large intestine open approach Enterocolostomy anastomosis technique 1NM87RN Excision partial, large intestine open approach Colocolostomy anastomosis technique 1NM89DF Excision total, large intestine endoscopic [laparoscopic] approach Ileorectal [endorectal, ileoproctostomy] anastomosis technique 1NM89RN Excision total, large intestine open approach using Ileorectal [endorectal, ileoproctostomy] anastomosis technique 1NM91DF Excision radical, large intestine endoscopic [laparoscopic] approach Colocolostomy anastomosis technique 1NM91DN Excision radical, large intestine endoscopic [laparoscopic] approach Enterocolostomy anastomosis technique 1NM91RD Excision radical, large intestine open approach Colorectal anastomosis technique 1NM91RE Excision radical, large intestine open approach Enterocolostomy anastomosis technique 1NM91RN Excision radical, large intestine open approach Colocolostomy anastomosis technique 1NQ87CA Excision partial, rectum perineal [e.g. pull through, transanal, sacral or sphincteric] approach closure by apposition technique [e.g. 1NQ87DA Excision partial, rectum endoscopic [laparoscopic] approach closure by apposition technique [e.g. suturing, stapling] or no closure re 1NQ87DE Excision partial, rectum endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach colorectal anastomosis technique 1NQ87DF Excision partial, rectum endoscopic [laparoscopic] approach colorectal anastomosis technique 1NQ87LA Excision partial, rectum open abdominal [e.g. anterior] approach closure by apposition technique [e.g. suturing, stapling] or no closu 1NQ87PB Excision partial, rectum perineal (e.g. pull through, transanal, sacral or sphincteric) approach colorectal anastomosis technique 1NQ87PF Excision partial, rectum posterior [e.g. entering through incision between coccyx and anal verge with proctotomy] approach closure by 1NQ87RD Excision partial, rectum open abdominal [e.g. anterior] approach colorectal anastomosis technique 1NQ89GV Excision total, rectum combined endoscopic [abdominal] with perineal approach Coloanal [or ileoanal] anastomosis technique 80 1NQ89KZ Excision total, rectum abdominoperineal approach Coloanal [or ileoanal] anastomosis technique 1NQ89SF Excision total, rectum abdominal [anterior] approach Coloanal [or ileoanal] anastomosis technique 1NQ89AB Excision total, rectum, stoma formation with distal closure, combined endoscopic [laparoscopic] abdominoperinea 1NQ89LH Excision total, rectum abdominoperineal approach Stoma formation with distal closure 1NQ89LHXXG Excision total, rectum abdominoperineal approach Continent ileostomy formation 1NQ89RSXXG Excision total, rectum abdominal [anterior] approach Continent ileostomy formation 1NM91DE Excision radical, large intestine endoscopic [laparoscopic] approach Colorectal anastomosis technique 1NM87DX Excision partial, large intestine endoscopic [laparoscopic] approach Stoma formation and distal closure 1NM87TF Excision partial, large intestine open approach Stoma formation with distal closure 1NM89DX Excision total, large intestine endoscopic [laparoscopic] approach Stoma formation with distal closure 1NM91DX Excision radical, large intestine endoscopic [laparoscopic] approach Stoma formation with distal closure 1NM91TF Excision radical, large intestine open approach Stoma formation with distal closure 1NM87DY Excision partial, large intestine endoscopic [laparoscopic] approach Stoma formation with creation of mucous fistula 1NM89TF Excision total, large intestine open approach Stoma formation with distal closure 1NM91TG Excision radical, large intestine open approach Stoma formation with creation of mucous fistula 1NM87TG Excision partial, large intestine open approach Stoma formation with creation of mucous fistula 1NQ87TF Excision partial, rectum open abdominal approach [e.g. anterior] stoma formation with distal closure 1NQ89RS Excision total, rectum abdominal [anterior] approach Stoma formation with distal closure 1NM91DY Excision radical, large intestine endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach stoma formation with creation of mucous fistula 1NQ87DX Excision partial, rectum endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach stoma formation with distal closure 1NQ87PN Excision partial, rectum endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach robotic assisted telemanipulation of tools [telesurgery] 1NM87GB Excision partial, large intestine endoscopic [laparoscopic, laparoscopic-assisted, hand-assisted] approach special excisional technique (without anastomosis) 1NM87WJ Excision partial, large intestine open approach special excisional technique (without anastomosis) Table 3: Thyroidectomy procedure codes for Cancer Surgery QBP CCI CODE (Procedure) CCI LONG DESCRIPTION 1FU87DA Excision partial, thyroid gland endoscopic (video assisted) approach using device NEC 1FU87DAAG Excision partial, thyroid gland endoscopic (video assisted) approach using laser 1FU87NZ Excision partial, thyroid gland open approach [e.g. neck incision] using device NEC 1FU87NZAG Excision partial, thyroid gland open approach [e.g. neck incision] using laser 1FU87PZ Excision partial, thyroid gland open substernal approach using device NEC 1FU87PZAG Excision partial, thyroid gland open substernal approach using laser 1FU87QT Excision partial, thyroid gland open trans-oral approach [e.g. lingual, submental] using device NEC 1FU89DA Excision total, thyroid gland endoscopic (video assisted) approach using device NEC 81 1FU89DAAG Excision total, thyroid gland endoscopic (video assisted) approach using laser 1FU89NZ Excision total, thyroid gland open approach [e.g. neck incision] using device NEC 1FU89NZAG Excision total, thyroid gland open approach [e.g. neck incision] using laser 1FU89PZ Excision total, thyroid gland open substernal approach using device NEC 1FU89PZAG Excision total, thyroid gland open substernal approach using laser 1FU91NZ Excision radical, thyroid gland using open approach [e.g. neck incision] Table 4: Lumpectomy, Mastectomy (+/- immediate reconstruction) diagnosis codes for Cancer Surgery QBP ICD10-CA (Diagnosis) Description From C00 to C97 All malignant neoplasm diagnosis codes ICD10-CA (Diagnosis) Description D24 Benign neoplasm of breast D051 Intraductal carcinoma in situ D059 Carcinoma in situ of breast, unspecified D486 Neoplasm of uncertain or unknown behaviour of breast D050 Lobular carcinoma in situ D057 Other carcinoma in situ of breast D0500 Lobular carcinoma in situ of right breast D0501 Lobular carcinoma in situ of left breast D0509 Lobular carcinoma in situ of breast, unspecified side D0510 Intraductal carcinoma in situ of right breast D0511 Intraductal carcinoma in situ of left breast D0519 Intraductal carcinoma in situ of breast, unspecified side D0570 Other carcinoma in situ of right breast D0571 Other carcinoma in situ of left breast D0579 Other carcinoma in situ of breast, unspecified side D0590 Carcinoma in situ of right breast, unspecified D0591 Carcinoma in situ of left breast, unspecified D0599 Carcinoma in situ of breast, unspecified, unspecified side 82 Table 5: Lumpectomy procedure codes for Cancer Surgery QBP CCI CODE (Procedure) CCI LONG DESCRIPTION 1YM87DA Excision partial, breast using endoscopic approach with simple apposition 1YM87GB Excision partial, breast using endoscopic guide wire (or needle hook) excision technique with simple apposition of tissue 1YM87LA Excision partial, breast using open approach with simple apposition of tissue (e.g. suturing) 1YM87LAXXA Excision partial, breast using open approach and full thickness autograft to close defect 1YM87LAXXE Excision partial, breast using open approach and local flap (to close defect) 1YM87UT Excision partial, breast using open guide wire (or needle hook) excision technique and simple apposition of tissue 1YM87UTXXA Excision partial, breast using open guide wire (or needle hook) excision technique with autograft (to close defect) 1YM87UTXXE Excision partial, breast using open guide wire (or needle hook) excision technique with local flap (to close defect) Table 6: Mastectomy procedure codes for Cancer Surgery QBP CCI CODE (Procedure) CCI LONG DESCRIPTION 1YM91LAXXQ Excision radical, breast using combined sources of tissue [e.g. local flap and tissue expander] modified or NOS 1YM89LA Excision total, breast without tissue repair 1YM89LAXXA Excision total, breast with full thickness autograft 1YM89LAXXE Excision total, breast using open approach and local flap 1YM91LA Excision (modified) radical, breast without tissue 1YM91LAPM Excision radical, breast with implantation of breast prosthesis modified or NOS 1YM91LATP Excision (modified) radical, breast with implantation of tissue expander 1YM91LAXXA Excision radical (modified), breast using full thickness autograft 1YM91LAXXE Excision (modified) radical, breast using local flap 1YM91TR Excision extended radical, breast without tissue 1YM91TRXXA Excision extended radical, breast using full thickness autograft 1YM91TRXXE Excision extended radical, breast using local flap 1YM91WP Excision super radical, breast without tissue 1YM91WPXXA Excision radical, breast using autograft super [Wangensteen} 1YM91WPXXE Excision super radical, breast using local flap Table 7: Axillary Lymph Node Dissection diagnosis codes for Cancer Surgery QBP 83 ICD10-CA (Diagnosis) Description C5000 Malignant neoplasm of right nipple and areola C5001 Malignant neoplasm of left nipple and areola C5009 Malignant neoplasm of nipple and areola, unspecified side C5010 Malignant neoplasm of central portion of right breast C5011 Malignant neoplasm of central portion of left breast C5019 Malignant neoplasm of central portion of breast, unspecified side C5020 Malignant neoplasm of upper-inner quadrant of right breast C5021 Malignant neoplasm of upper-inner quadrant of left breast C5029 Malignant neoplasm of upper-inner quadrant of breast, unspecified side C5030 Malignant neoplasm of lower-inner quadrant of right breast C5031 Malignant neoplasm of lower-inner quadrant of left breast C5039 Malignant neoplasm of lower-inner quadrant of breast, unspecified side C5040 Malignant neoplasm of upper-outer quadrant of right breast C5041 Malignant neoplasm of upper-outer quadrant of left breast C5049 Malignant neoplasm of upper-outer quadrant of breast, unspecified side C5050 Malignant neoplasm of lower-outer quadrant of right breast C5051 Malignant neoplasm of lower-outer quadrant of left breast C5059 Malignant neoplasm of lower-outer quadrant of breast, unspecified side C5060 Malignant neoplasm of axillary tail of right breast C5061 Malignant neoplasm of axillary tail of left breast C5069 Malignant neoplasm of axillary tail of breast, unspecified side C5080 Overlapping malignant lesion of right breast C5081 Overlapping malignant lesion of left breast C5089 Overlapping malignant lesion of breast, unspecified side C5090 Malignant neoplasm of right breast, part unspecified C5091 Malignant neoplasm of left breast, part unspecified C5099 Malignant neoplasm of breast, part unspecified, unspecified side C773 Secondary malignant neoplasm of axillary and upper limb lymph nodes C7980 Secondary malignant neoplasm of breast D24 Benign neoplasm of breast D051 Intraductal carcinoma in situ D059 Carcinoma in situ of breast, unspecified D486 Neoplasm of uncertain or unknown behaviour of breast D050 Lobular carcinoma in situ D057 Other carcinoma in situ of breast D0500 Lobular carcinoma in situ of right breast D0501 Lobular carcinoma in situ of left breast D0509 Lobular carcinoma in situ of breast, unspecified side 84 D0510 Intraductal carcinoma in situ of right breast D0511 Intraductal carcinoma in situ of left breast D0519 Intraductal carcinoma in situ of breast, unspecified side D0570 Other carcinoma in situ of right breast D0571 Other carcinoma in situ of left breast D0579 Other carcinoma in situ of breast, unspecified side D0590 Carcinoma in situ of right breast, unspecified D0591 Carcinoma in situ of left breast, unspecified D0599 Carcinoma in situ of breast, unspecified, unspecified side Table 8: Axillary Lymph Node Dissection procedure codes for Cancer Surgery QBP CCI CODE (Procedure) CCI LONG DESCRIPTION 1MD87LA Excision partial, lymph node(s), axillary using open approach 1MD89LA Excision total, lymph node(s), axillary using open approach 1MD89LAXXA Excision total, lymph node(s), axillary using open approach with full thickness graft 1MD89LAXXE Excision total, lymph node(s), axillary using open approach with local flap 1MD89LAXXF Excision total, lymph node(s), axillary using open approach with free distant flap 1MD89LAXXG Excision total, lymph node(s), axillary using open approach with pedicled distant flap 1MD89LAXXN Excision total, lymph node(s), axillary using open approach with synthetic tissue Table 9: Sentinel Lymph Node Biopsy diagnosis codes for Cancer Surgery QBP ICD10-CA (Diagnosis) Description C5000 Malignant neoplasm of right nipple and areola C5001 Malignant neoplasm of left nipple and areola C5009 Malignant neoplasm of nipple and areola, unspecified side C5010 Malignant neoplasm of central portion of right breast C5011 Malignant neoplasm of central portion of left breast C5019 Malignant neoplasm of central portion of breast, unspecified side C5020 Malignant neoplasm of upper-inner quadrant of right breast C5021 Malignant neoplasm of upper-inner quadrant of left breast C5029 Malignant neoplasm of upper-inner quadrant of breast, unspecified side C5030 Malignant neoplasm of lower-inner quadrant of right breast C5031 Malignant neoplasm of lower-inner quadrant of left breast C5039 Malignant neoplasm of lower-inner quadrant of breast, unspecified side C5040 Malignant neoplasm of upper-outer quadrant of right breast 85 C5041 Malignant neoplasm of upper-outer quadrant of left breast C5049 Malignant neoplasm of upper-outer quadrant of breast, unspecified side C5050 Malignant neoplasm of lower-outer quadrant of right breast C5051 Malignant neoplasm of lower-outer quadrant of left breast C5059 Malignant neoplasm of lower-outer quadrant of breast, unspecified side C5060 Malignant neoplasm of axillary tail of right breast C5061 Malignant neoplasm of axillary tail of left breast C5069 Malignant neoplasm of axillary tail of breast, unspecified side C5080 Overlapping malignant lesion of right breast C5081 Overlapping malignant lesion of left breast C5089 Overlapping malignant lesion of breast, unspecified side C5090 Malignant neoplasm of right breast, part unspecified C5091 Malignant neoplasm of left breast, part unspecified C5099 Malignant neoplasm of breast, part unspecified, unspecified side C773 Secondary malignant neoplasm of axillary and upper limb lymph nodes C7980 Secondary malignant neoplasm of breast D24 Benign neoplasm of breast D051 Intraductal carcinoma in situ D059 Carcinoma in situ of breast, unspecified D486 Neoplasm of uncertain or unknown behaviour of breast D050 Lobular carcinoma in situ D057 Other carcinoma in situ of breast D0500 Lobular carcinoma in situ of right breast D0501 Lobular carcinoma in situ of left breast D0509 Lobular carcinoma in situ of breast, unspecified side D0510 Intraductal carcinoma in situ of right breast D0511 Intraductal carcinoma in situ of left breast D0519 Intraductal carcinoma in situ of breast, unspecified side D0570 Other carcinoma in situ of right breast D0571 Other carcinoma in situ of left breast D0579 Other carcinoma in situ of breast, unspecified side D0590 Carcinoma in situ of right breast, unspecified D0591 Carcinoma in situ of left breast, unspecified D0599 Carcinoma in situ of breast, unspecified, unspecified side Z031 Observation for suspected malignant neoplasm Z080 Follow-up examination after surgery for malignant neoplasm Z123 Special screening examination for neoplasm of breast 86 Table 10: Mastectomy + Immediate Reconstruction procedure codes for Cancer Surgery QBP CCI CODE (Procedure) CCI LONG DESCRIPTION 1YM88LAPM Excision partial with reconstruction, breast without tissue with implantation of prosthesis 1YM88LAPME Excision partial with reconstruction, breast with local flap with implantation of prosthesis 1YM88LAPMF Excision partial with reconstruction, breast using free flap with implantation of prosthesis 1YM88LAPMG Excision partial with reconstruction, breast using distant pedicled flap with implantation of prosthesis 1YM88LAPMK Excision partial with reconstruction, breast using homograft with implantation of prosthesis 1YM88LAQF Excision partial with reconstruction, breast without tissue with implantation of prosthesis and expander 1YM88LAQFE Excision partial with reconstruction, breast with local flap with implantation of prosthesis and expander 1YM88LAQFF Excision partial with reconstruction, breast using free flap with implantation of prosthesis and expander 1YM88LAQFG Excision partial with reconstruction, breast using distant pedicled flap with implantation of prosthesis and ex 1YM88LATP Excision partial with reconstruction, breast without tissue with implantation of tissue expander 1YM88LATPE Excision partial with reconstruction, breast with local flap with tissue expander 1YM88LATPF Excision partial with reconstruction, breast using free flap with implantation of tissue expander 1YM88LATPG Exc prt breast w tiss expand ped flp reconstr 1YM88LATPK Excision partial with reconstruction, breast using homograft with implantation of tissue expander 1YM88LAXXE Excision partial with reconstruction, breast using local flap with no implanted device 1YM88LAXXF Excision partial with reconstruction, breast using free flap with no implanted device 1YM88LAXXG Excision partial with reconstruction, breast using distant pedicled flap with no implanted device 1YM90LAPM Excision total with reconstruction, breast simple mastectomy with no node dissection without tissue with implantation of breast prosth 1YM90LAPME Excision total with reconstruction, breast simple mastectomy with no node dissection using local flap with implantation of breast pros 1YM90LAPMF Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with implantation of breast p 1YM90LAPMG Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with implantation 1YM90LAPMK Excision total with reconstruction, breast using homograft with implantation of breast prosthesis 1YM90LAQF Excision total with reconstruction, breast simple mastectomy with no node dissection without tissue with implantation of prosthesis an 1YM90LAQFE Excision total with reconstruction, breast simple mastectomy with no node dissection using local flap with implantation of prosthesis 1YM90LAQFF Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with implantation of prosthes 1YM90LAQFG Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with implantation 1YM90LATP Excision total with reconstruction, breast simple mastectomy with no node dissection without tissue with implantation of tissue expand 87 1YM90LATPE Excision total with reconstruction, breast using local flap with implantation of tissue expander 1YM90LATPF Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with implantation of tissue e 1YM90LATPG Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with implantation 1YM90LATPK Excision total with reconstruction, breast using homograft with implantation of tissue expander 1YM90LAXXE Excision total with reconstruction, breast simple mastectomy with no node dissection using local flap with no implanted device 1YM90LAXXF Excision total with reconstruction, breast simple mastectomy with no node dissection using free flap (2) with no implanted device 1YM90LAXXG Excision total with reconstruction, breast simple mastectomy with no node dissection using distant pedicled flap(1) with no implanted 1YM90LAXXQ Excision total with reconstruction, breast with no implanted device using combined sources of tissue (e.g. free 1YM92LAPME Excision (modified) radical with reconstruction, breast using local flap with implantation of breast prosthesis 1YM92LAPMF Excision (modified) radical with reconstruction, breast using free flap with implantation of breast prosthesis 1YM92LAPMG Excision (modified) radical with reconstruction, breast using distant pedicled flap with implantation of breast prosthesis 1YM92LAPMK Excision radical with reconstruction, breast modified or NOS using homograft with implantation of breast prosthesis 1YM92LAQFE Excision (modified) radical with reconstruction, breast using local flap with implantation of prosthesis and expander 1YM92LAQFG Excision (modified) radical with reconstruction, breast using distant pedicled flap with implantation of prosthesis and expander 1YM92LATPE Excision (modified) radical with reconstruction, breast using local flap with implantation of tissue expander 1YM92LATPF Excision (modified) radical with reconstruction, breast using free flap with implantation of tissue expander 1YM92LATPG Excision (modified) radical with reconstruction, breast using distant pedicled flap with implantation of tissue expander 1YM92LATPK Excision radical with reconstruction, breast modified or NOS using homograft with implantation of tissue expander 1YM92LAXXE Excision (modified) radical with reconstruction, breast using local flap with no implanted device 1YM92LAXXF Excision (modified) radical with reconstruction, breast using free flap with no implanted device 1YM92LAXXG Excision (modified) radical with reconstruction, breast using distant pedicled flap with no implanted device 1YM92LAXXQ Excision radical with reconstruction, breast modified or NOS with no implanted device using combined sources of 1YM92TRPME Excision radical with reconstruction, breast extended [Urban] using local flap with implantation of breast prosthesis 1YM92TRPMF Excision radical with reconstruction, breast extended [Urban] using free flap with implantation of breast prosthesis 1YM92TRPMG Excision radical with reconstruction, breast extended [Urban] using distant pedicled flap with implantation of breast prosthesis 1YM92TRPMK Excision radical with reconstruction, breast extended [Urban] using homograft with implantation of breast prosthesis 1YM92TRTPE Excision radical with reconstruction, breast extended [Urban] using local flap with implantation of tissue expander 1YM92TRTPF Excision radical with reconstruction, breast extended [Urban] using free flap with implantation of tissue expander 1YM92TRTPG Excision radical with reconstruction, breast extended [Urban] using distant pedicled flap with implantation of tissue expander 1YM92TRTPK Excision radical with reconstruction, breast extended [Urban] using homograft with implantation of tissue expander 1YM92TRXXE Excision extended radical with reconstruction, breast using local flap with no implanted device 1YM92TRXXF Excision extended radical with reconstruction, breast using free flap with no implanted device 1YM92TRXXG Excision radical with reconstruction, breast extended [Urban] using distant pedicled flap with no implanted device 88 1YM92TRXXQ Exc rad w reconstr breast OA w ext rad excisn combo tis 1YM92WPPME Excision radical with reconstruction, breast super [Wangensteen] using local flap with implantation of breast prosthesis 1YM92WPPMF Excision radical with reconstruction, breast super [Wangensteen] using free flap with implantation of breast prosthesis 1YM92WPPMG Excision radical with reconstruction, breast super [Wangensteen] using distant pedicled flap with implantation of breast prosthesis 1YM92WPPMK Excision radical with reconstruction, breast super [Wangensteen] using homograft with implantation of breast prosthesis 1YM92WPTPE Excision radical with reconstruction, breast super [Wangensteen] using local flap with implantation of tissue expander 1YM92WPTPF Excision radical with reconstruction, breast super [Wangensteen] using free flap with implantation of tissue expander 1YM92WPTPG Excision radical with reconstruction, breast super [Wangensteen] using distant pedicled flap with implantation of tissue expander 1YM92WPTPK Excision radical with reconstruction, breast super [Wangensteen] using homograft with implantation of tissue expander Table 11: Delayed Breast Reconstruction diagnosis codes for Cancer Surgery QBP ICD10-CA (Diagnosis) Description C5000 Malignant neoplasm of right nipple and areola C5001 Malignant neoplasm of left nipple and areola C5009 Malignant neoplasm of nipple and areola, unspecified side C5010 Malignant neoplasm of central portion of right breast C5011 Malignant neoplasm of central portion of left breast C5019 Malignant neoplasm of central portion of breast, unspecified side C5020 Malignant neoplasm of upper-inner quadrant of right breast C5021 Malignant neoplasm of upper-inner quadrant of left breast C5029 Malignant neoplasm of upper-inner quadrant of breast, unspecified side C5030 Malignant neoplasm of lower-inner quadrant of right breast C5031 Malignant neoplasm of lower-inner quadrant of left breast C5039 Malignant neoplasm of lower-inner quadrant of breast, unspecified side C5040 Malignant neoplasm of upper-outer quadrant of right breast C5041 Malignant neoplasm of upper-outer quadrant of left breast C5049 Malignant neoplasm of upper-outer quadrant of breast, unspecified side C5050 Malignant neoplasm of lower-outer quadrant of right breast C5051 Malignant neoplasm of lower-outer quadrant of left breast C5059 Malignant neoplasm of lower-outer quadrant of breast, unspecified side C5060 Malignant neoplasm of axillary tail of right breast C5061 Malignant neoplasm of axillary tail of left breast C5069 Malignant neoplasm of axillary tail of breast, unspecified side 89 C5080 Overlapping malignant lesion of right breast C5081 Overlapping malignant lesion of left breast C5089 Overlapping malignant lesion of breast, unspecified side C5090 Malignant neoplasm of right breast, part unspecified C5091 Malignant neoplasm of left breast, part unspecified C5099 Malignant neoplasm of breast, part unspecified, unspecified side Z421 Follow-up care involving plastic surgery of breast Z853 Personal history of malignant neoplasm of breast Z8530 Personal history of malignant neoplasm of right breast Z8531 Personal history of malignant neoplasm of left breast Z8539 Personal history of malignant neoplasm of breast, unspecified side D24 Benign neoplasm of breast D051 Intraductal carcinoma in situ D059 Carcinoma in situ of breast, unspecified D486 Neoplasm of uncertain or unknown behaviour of breast D050 Lobular carcinoma in situ D057 Other carcinoma in situ of breast D0500 Lobular carcinoma in situ of right breast D0501 Lobular carcinoma in situ of left breast D0509 Lobular carcinoma in situ of breast, unspecified side D0510 Intraductal carcinoma in situ of right breast D0511 Intraductal carcinoma in situ of left breast D0519 Intraductal carcinoma in situ of breast, unspecified side D0570 Other carcinoma in situ of right breast D0571 Other carcinoma in situ of left breast D0579 Other carcinoma in situ of breast, unspecified side D0590 Carcinoma in situ of right breast, unspecified D0591 Carcinoma in situ of left breast, unspecified D0599 Carcinoma in situ of breast, unspecified, unspecified side Table 12: Delayed Breast Reconstruction procedure codes for Cancer Surgery QBP Grouping Microvascular Tissue Nonmicrosurgical Tissue Type of Recon Microsurgical Flap Pedicled Flap Mixed flap and Procedure Code Description 1YM80LAPMF Repair, breast using free flap (2) with implantation of breast prosthesis 1YM80LAQFF Repair, breast using free flap (2) with implantation of prosthesis and expander 1YM80LATPF Repair, breast using free flap (2) with implantation of tissue expander 1YM80LAXXF Repair, breast using free flap with no implantation of device 1YM80LAXXG Repair, breast using distant pedicled flap with no implantation of device 1YM80LAPMG Repair, breast using distant pedicled flap (1) with implantation of breast prosthesis 90 implant Implants Only Tissue Expander or Prosthesis 1YM80LAQFG 1YM80LATPG Repair, breast using distant pedicled flap (1) with implantation of prosthesis and expander Repair, breast using distant pedicled flap (1) with implantation of tissue expander 1YM80LAPM Repair, breast without tissue with implantation of breast prosthesis 1YM80LAPMA Repair, breast using autograft with implantation of breast prosthesis 1YM80LAPME Repair, breast using local flap with implantation of breast prosthesis 1YM80LAQF Repair, breast without tissue with implantation of prosthesis and expander 1YM80LATP Repair, breast without tissue with implantation of tissue expander 1YM80LATPA Repair, breast using autograft with implantation of tissue expander 1YM80LATPE Repair, breast using local flap with implantation of tissue expander 1YM80LAQFA Repair, breast using autograft with implantation of prosthesis and expander 1YM80LAQFE Repair, breast using local flap with implantation of prosthesis and expander 1YM80LAPMK Repair, breast open approach using homograft with implantation of breast prosthesis Repair, breast open approach using homograft with implantation of tissue expander 1YM80LATPK This page has been intentionally left blank