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    © 2019 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
    Keywords: Outcomes; Length of stay HNSCC; Audit
    As survival after cancer improves, the focus on cure as the all-important marker of effective treatment seems to be inade-quate, particularly when complex multimodal treatments can result in so many complications that affect a patient’s quality of life. In the UK surgical APTSTAT3-9R and in our specialty in particular, the focus is now turning towards outcomes. Datasets of the surgical outcomes of consultants routinely report unplanned returns to theatre and deaths within 30 days, usually with specialty-specific complications. All specialties, except that of head and neck oncology, adjust for case mix when reporting early complications. The complexity of the
    ∗ Corresponding author. E-mail addresses: [email protected] (D. Tighe), [email protected] (I. Sassoon), [email protected] (A. Hills), [email protected] (R. Quadros). 
    intervention and adjustments for case mix currently do not feature in reports of length of stay.
    Patients who have operations with curative intent for SCC of the head and neck form a particularly heterogeneous group and many are frail with multiple coexisting conditions. The risk factors for developing the disease are also implicated in cardiac, respiratory, and liver disorders. Notwithstanding the anatomical disruption of the operation, the effort to return patients to form and function with immediate reconstruction, can leave them with considerable adjustments to make in swallowing and speaking. These can make it necessary to consider a transfer to a residential or nursing home, which can often take time after a patient has been deemed fit enough to be discharged from hospital.
    Our primary outcome was to model the length of hospital stay in this group of patients to enable effective audit of the quality of care. To test length of stay as a proxy marker for the quality of care, we did not include postoperative com-
    0266-4356/© 2019 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
    2 D. Tighe et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx
    plications in the analysis, though we expect that this would add to the accuracy of the model. A secondary outcome was to define “outlier status” (patients whose stay in hospital is extremely long). Finally, we wanted to find out if markers of socioeconomic deprivation contributed to a longer stay.
    To build models for the adjustment of case mix, we ana-lysed a combined dataset of four case-note audits from four cancer networks arrector pili treated patients for SCC of the head and neck (n = 638 care episodes) between 2009 and 2015. A total of 112 care episodes from a fifth cancer network were tested as an (external) validation set. The data from each centre comprised a combination of retrospective (12 months) and APTSTAT3-9R prospective (6-12 months) data. All patients had histopathologically-confirmed SCC of the head and neck, and operations were done under general anaesthesia using conventional surgical techniques (excluding laser cases) by maxillofacial or ear, nose, and throat (ENT) surgeons, or both. All the datasets were registered with the clinical audit departments at the respective hospital Trusts, and data were collected by the lead author with permission from the treat-ing consultants. Ethics approval was sought for the validation phase of the audit, as application of the mathematical mod-els could be generalised. Data on socioeconomic status was sought only in the validation group, and were not included in the model’s development.
    For consistency throughout the audit period, the BUPA severity of surgery index (minor = less than 1 hour; intermedi-ate = less than 6 hours; and major or major complex = 6 hours or requirement for free tissue transfer) was used to grade the complexity of the operation. Patients’ demographics; comorbidity using the Adult Comorbidity Evaluation-27 index (ACE-27); World Health Organization (WHO) perfor-mance status; American Joint Commission on Cancer (AJCC version 7) tumour size and nodal classification; and oper-ative and anaesthetic treatment, were included. Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (OPC4) codes were used for a derived variable, the “high-risk” field, which included any operation requiring mucosal closure in association with a neck dissection that could lead to an escape of saliva (such as mandibulectomy, glossectomy, excisions of the floor of the mouth, and pharyngectomy with or without laryngectomy). Any case for which pertinent data points were missing (as selected by each predictive model) was excluded.