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Open Access 01-07-2020 | Pituitary Adenoma | Original Article

Feasibility, safety, and outcomes of a stratified fast-track care trajectory in pituitary surgery

Authors: Daniel J. Lobatto, Thea P. M. Vliet Vlieland, Wilbert B. van den Hout, Friso de Vries, Anne F. de Vries, Pieter J. Schutte, Marco J. T. Verstegen, Alberto M. Pereira, Wilco C. Peul, Nienke R. Biermasz, Wouter R. van Furth

Published in: Endocrine | Issue 1/2020

Abstract

Objective

Discharge policies concerning hospitalization after endoscopic pituitary tumor surgery are highly variable. A few studies support fast-track discharge; however, this is not commonplace. Our goal was to report the transition to and evaluate the feasibility, safety, clinical- and patient-reported outcomes and costs of fast-track care in pituitary surgery.

Methods

This observational study included 155 patients undergoing pituitary surgery between December 2016 and December 2018. Fast-track care consisted of planned discharge 2–3 days after surgery, followed by daily surveillance by a case manager. All outcomes were compared with patients not eligible for fast-track discharge. The total group (fast-track and non-fast-track) was compared with historic controls (N = 307).

Results

A total of 79/155 patients (51%) were considered eligible for fast-track discharge, of whom 69 (87%) were discharged within 3 days. The total group was discharged more often within 3 days compared with historic controls (49 vs. 20%, p < 0.001), the total length of stay did not differ (5.3 vs. 5.7 days, p = 0.363). Although the total group had more readmissions compared with historic controls (17 vs. 10%, p = 0.002), no life-threatening complications occurred after discharge. On average, clinical- and patient-reported outcomes improved over time, both in the fast-track and non-fast-track groups. The mean overall costs within 30 days after surgery did not differ between the total group € 9992 (SD € 4562) and historic controls € 9818 (SD € 3488) (p = 0.649).

Conclusion

A stratified fast-track care trajectory with enhanced postoperative outpatient surveillance after pituitary tumor surgery is safe and feasible. As expected, costs of the fast-track were lower than the non-fast-track group, however we could not prove overall cost-effectiveness compared with the historic controls.

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L.K. Nieman, B.M.K. Biller, J.W. Findling, M.H. Murad, J. Newell-Price, M.O. Savage, A. Tabarin, Endocrine society: treatment of Cushing’s syndrome: an endocrine society clinical practice guideline. J. Clin. Endocrinol. Metab. 100, 2807–2831 (2015). https://doi.org/10.1210/jc.2015-1818 CrossRefPubMedPubMedCentral

L. Katznelson, E.R. Laws, S. Melmed, M.E. Molitch, M.H. Murad, A. Utz, J.A.H. Wass, Acromegaly: an endocrine society clinical practice guideline. J. Clin. Endocrinol. Metab. 90048, 3933–3951 (2014). https://doi.org/10.1210/jc.2014-2700 CrossRef

P.U. Freda, A.M. Beckers, L. Katznelson, M.E. Molitch, V.M. Montori, K.D. Post, M.L. Vance, Endocrine society: pituitary incidentaloma: an endocrine society clinical practice guideline. J. Clin. Endocrinol. Metab. 96, 894–904 (2011). https://doi.org/10.1210/jc.2010-1048 CrossRefPubMedPubMedCentral

S. Melmed, F.F. Casanueva, A.R. Hoffman, D.L. Kleinberg, V.M. Montori, J.A. Schlechte, J.A.H. Wass, Endocrine society: diagnosis and treatment of hyperprolactinemia: an endocrine society clinical practice guideline. J. Clin. Endocrinol. Metab. 96, 273–288 (2011). https://doi.org/10.1210/jc.2010-1692 CrossRefPubMed

E.R. Laws, G. Barkhoudarian, The transition from microscopic to endoscopic transsphenoidal surgery: the experience at Brigham and women’s hospital. World Neurosurg. 82, S152–S154 (2014). https://doi.org/10.1016/j.wneu.2014.07.035 CrossRefPubMed

R.V.S. Bastos, C.M.D.M. Silva, J.V. Tagliarini, M.A. Zanini, F.R. Romero, C.L. Boguszewski, V.D.S. Nunes, Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary tumors: systematic review and meta-analysis of randomized and non-randomized controlled trials. Arch. Endocrinol. Metab. 1–9 (2016). https://doi.org/10.1590/2359-3997000000204

J.K. Goudakos, K.D. Markou, C. Georgalas, Endoscopic versus microscopic trans-sphenoidal pituitary surgery: a systematic review and meta-analysis. Clin. Otolaryngol. 36, 212–220 (2011)CrossRef

A. Li, W. Liu, P. Cao, Y. Zheng, Z. Bu, T. Zhou, Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: a systematic review and meta-analysis. World Neurosurg. 101, 236–246 (2017). https://doi.org/10.1016/j.wneu.2017.01.022 CrossRefPubMed

B.L. Hendricks, T.A. Shikary, L.A. Zimmer, Causes for 30-Day readmission following transsphenoidal surgery. Otolaryngol. Head. Neck. Surg. 154, 359–365 (2016). https://doi.org/10.1177/0194599815617130 CrossRefPubMed

10.

D.J. Cote, A. Alzarea, M.A. Acosta, M.M. Hulou, K.T. Huang, H. Almutairi, A. Alharbi, H.A. Zaidi, M. Algrani, A. Alatawi, R.A. Mekary, T.R. Smith, Predictors and rates of delayed symptomatic hyponatremia after transsphenoidal surgery: a systemastic review. World Neurosurg. 88, 1–6 (2016). https://doi.org/10.1016/j.wneu.2016.01.022 CrossRefPubMed

11.

R.A. Kristof, M. Rother, G. Neuloh, D. Klingmüller, Incidence, clinical manifestations, and course of water and electrolyte metabolism disturbances following transsphenoidal pituitary adenoma surgery: a prospective observational study. J. Neurosurg. 111, 555–562 (2009). https://doi.org/10.3171/2008.9.JNS08191 CrossRefPubMed

12.

C.A. Sarkiss, J. Lee, J.A. Papin, E.B. Geer, R. Banik, J.C. Rucker, B. Oudheusden, S. Govindaraj, R.K. Shrivastava, Pilot study on early postoperative discharge in pituitary adenoma patients: effect of socioeconomic factors and benefit of specialized pituitary centers. J. Neurol. Surg. B. Skull Base. 76, 323–330 (2015). https://doi.org/10.1055/s-0035-1549004

13.

J.G. Thomas, N. Gadgil, S.L. Samson, M. Takashima, D. Yoshor, Prospective trial of a short hospital stay protocol after endoscopic endonasal pituitary adenoma surgery. World Neurosurg. 81, 576–583 (2014). https://doi.org/10.1016/j.wneu.2013.11.014 CrossRefPubMed

14.

J.A. Forbes, J. Wilkerson, L. Chambless, S.D. Shay, C.M. Elswick, P.W. Abblitt, O. Adogwa, P. Russell, K.D. Weaver, G.S. Allen, A.L. Utz, Safety and cost effectiveness of early discharge following microscopic trans-sphenoidal resection of pituitary lesions. Surg. Neurol. Int. 2, 66 (2011). https://doi.org/10.4103/2152-7806.81723 CrossRefPubMedPubMedCentral

15.

J.A. Hyder, R.E. Hirschberg, L.L. Nguyen, Home discharge as a performance metric for surgery. JAMA Surg. 150, 96 (2015). https://doi.org/10.1001/jamasurg.2014.1725 CrossRefPubMed

16.

M. Bell, L.I. Eriksson, T. Svensson, L. Hallqvist, F. Granath, J. Reilly, P.S. Myles, Days at home after surgery: an integrated and efficient outcome measure for clinical trials and quality assurance. EClinicalMedicine 11, 18–26 (2019). https://doi.org/10.1016/j.eclinm.2019.04.011 CrossRefPubMedPubMedCentral

17.

D.J. Lobatto, F. de Vries, A.H. Zamanipoor Najafabadi, A.M. Pereira, W.C. Peul, T.P.M. Vliet Vlieland, N.R. Biermasz, W.R. van Furth, Preoperative risk factors for postoperative complications in endoscopic pituitary surgery: a systematic review. Pituitary. (2017). https://doi.org/10.1007/s11102-017-0839-1

18.

O.M. Dekkers, N.R. Biermasz, A.M. Pereira, F. Roelfsema, M.O. van Aken, J.H.C. Voormolen, J.A. Romijn, Mortality in patients treated for Cushing’s disease is increased, compared with patients treated for nonfunctioning pituitary macroadenoma. J. Clin. Endocrinol. Metab. 92, 976–981 (2007). https://doi.org/10.1210/jc.2006-2112 CrossRefPubMed

19.

O.M. Dekkers, S. Hammer, R.J.W. de Keizer, F. Roelfsema, P.J. Schutte, J.W.A. Smit, J.A. Romijn, A.M. Pereira, The natural course of non-functioning pituitary macroadenomas. Eur. J. Endocrinol. 156, 217–224 (2007). https://doi.org/10.1530/eje.1.02334 CrossRefPubMed

20.

N.R. Biermasz, O.M. Dekkers, J. Voormolen, R.J.W. de Keizer, K.J. Neelis, F.T. Wiggers-de Bruine, J.W. Smit, A.M. Pereira, J.A. Romijn, Transsphenoidal resection of pituitary adenomas: long-term results from the Leiden University Medical Center. Ned. Tijdschr. Geneeskd. 152, 2565–2570 (2008)PubMed

21.

A. Weigold, I.K. Weigold, E.J. Russell, Examination of the equivalence of self-report survey-based paper-and-pencil and internet data collection methods. Psychol. Methods 18, 53–70 (2013). https://doi.org/10.1037/a0031607 CrossRefPubMed

22.

D. Dindo, N. Demartines, P.A. Clavien, Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 240, 205–213 (2004). https://doi.org/10.1097/01.sla.0000133083.54934.ae

23.

C.D. Andela, M. Scharloo, S. Ramondt, J. Tiemensma, O. Husson, S. Llahana, A.M. Pereira, A.A. Kaptein, N.G.A. Kamminga, N.R. Biermasz, The development and validation of the Leiden Bother and Needs Questionnaire for patients with pituitary disease: the LBNQ-Pituitary. Pituitary 19, 293–302 (2016). https://doi.org/10.1007/s11102-016-0707-4 CrossRefPubMedPubMedCentral

24.

J.E. Ware, C.D. Sherbourne The MOS 36-ltem Short-Form Health Survey (SF-36). Med. Care. 30, 473–483 (1992). https://doi.org/10.1097/00005650-199206000-00002 CrossRefPubMed

25.

Group EuroQoL, EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16, 199–208 (1990). https://doi.org/10.1016/0168-8510(90)90421-9 CrossRef

26.

M.M. Versteegh, K.M. Vermeulen, S.M.A.A. Evers, G. Ardine de Wit, R. Prenger, E.A. Stolk, Dutch tariff for the five-level version of EQ-5D. Value Heal. 19, 343–352 (2016). https://doi.org/10.1016/j.jval.2016.01.003 CrossRef

27.

C.M. Mangione, P.P. Lee, P.R. Gutierrez, K. Spritzer, S. Berry, R.D. Hays, Development of the 25-list-item National Eye Institute Visual Function Questionnaire. Arch. Ophthalmol. 119, 1050–1058 (2001). https://doi.org/10.1097/00132578-200201000-00028 CrossRefPubMed

28.

Open DIS data (Dutch Healthcare Authority, Nederlandse Zorgautoriteit), https://www.opendisdata.nl/msz/zorgproduct/972802102. Accessed 19 Mar 2019

29.

Open DIS data (Dutch Healthcare Authority, Nederlandse Zorgautoriteit), https://www.opendisdata.nl/msz/zorgproduct/972802100. Accessed 19 Mar 2019

30.

L. Hakkaart-van Roijen, N. Van der Linden, C. Bouwmans, T. Kanters, S. Tan, Richtlijn voor het uitvoeren van economische evaluaties in de gezondheidszorg. https://www.zorginstituutnederland.nl/publicaties/publicatie/2016/02/29/richtlijn-voor-het-uitvoeren-van-economische-evaluaties-in-de-gezondheidszorg. Accessed 19 Mar 2019

31.

S.B. Cantor, M.W. Kattan, Determining the area under the ROC curve for a binary diagnostic test. Med. Decis. Mak. 20, 468–470 (2000). https://doi.org/10.1177/0272989X0002000410 CrossRef

32.

I. Eekhout, H.C. de Vet, M.R. de Boer, J.W. Twisk, M.W. Heymans, Passive imputation and parcel summaries are both valid to handle missing items in studies with many multi-item scales. Stat. Methods Med. Res. 27, 1128–1140 (2018). https://doi.org/10.1177/0962280216654511 CrossRefPubMed

33.

M.A. Bohl, S. Ahmad, H. Jahnke, D. Shepherd, L. Knecht, W.L. White, A.S. Little, Delayed hyponatremia is the most common cause of 30-day unplanned readmission after transsphenoidal surgery for pituitary tumors. Neurosurgery 78, 84–90 (2016). https://doi.org/10.1227/NEU.0000000000001003 CrossRefPubMed

34.

J. Hensen, A. Henig, R. Fahlbusch, M. Meyer, M. Boehnert, M. Buchfelder, Prevalence, predictors and patterns of postoperative polyuria and hyponatraemia in the immediate course after transsphenoidal surgery for pituitary adenomas. Clin. Endocrinol. 50, 431–439 (1999)CrossRef

35.

P.J. Marang-van de Mheen, N. van Duijn-Bakker, J. Kievit, Surgical adverse outcomes and patients’ evaluation of quality of care: inherent risk or reduced quality of care? Postgrad. Med. J. 84, 93–98 (2008). https://doi.org/10.1136/qshc.2006.021071 CrossRefPubMed

36.

K. Takeuchi, T. Nagatani, E. Okumura, T. Wakabayashi, A novel method for managing water and electrolyte balance after transsphenoidal surgery: preliminary study of moderate water intake restriction. Nagoya J. Med. Sci. 76, 73–82 (2014)PubMedPubMedCentral

37.

J. Matsuyama, H. Ikeda, S. Sato, K. Yamamoto, G. Ohashi, K. Watanabe, Early water intake restriction to prevent inappropriate antidiuretic hormone secretion following transsphenoidal surgery: low BMI predicts postoperative SIADH. Eur. J. Endocrinol. 171, 711–716 (2014). https://doi.org/10.1530/EJE-14-0530 CrossRefPubMed

38.

W.T. Burke, D.J. Cote, S.I. Iuliano, H.A. Zaidi, E.R. Laws, A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery. Pituitary 21, 25–31 (2018). https://doi.org/10.1007/s11102-017-0843-5 CrossRefPubMed

39.

K.E. Deaver, C.P. Catel, K.O. Lillehei, M.E. Wierman, J.M. Kerr, Strategies to reduce readmissions for hyponatremia after transsphenoidal surgery for pituitary adenomas. Endocrine 62, 333–339 (2018). https://doi.org/10.1007/s12020-018-1656-7 CrossRefPubMed

40.

J.L. Hutton, Are distinctive ethical principles required for cluster randomized controlled trials? Stat. Med. 20, 473–488 (2001)CrossRef

41.

R.S. Kaplan, M.E. Porter,, How to solve the cost crisis in health care. Harv. Bus. Rev. 89, 46–52 (2011)PubMed

Title: Feasibility, safety, and outcomes of a stratified fast-track care trajectory in pituitary surgery
Authors: Daniel J. Lobatto
Thea P. M. Vliet Vlieland
Wilbert B. van den Hout
Friso de Vries
Anne F. de Vries
Pieter J. Schutte
Marco J. T. Verstegen
Alberto M. Pereira
Wilco C. Peul
Nienke R. Biermasz
Wouter R. van Furth
Publication date: 01-07-2020
Publisher: Springer US
Keywords: Pituitary Adenoma
Care
Hyponatremia
Published in: Endocrine / Issue 1/2020
Print ISSN: 1355-008X
Electronic ISSN: 1559-0100
DOI: https://doi.org/10.1007/s12020-020-02308-2

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