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Canadian Journal of Surgery -

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients

Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients

Can J Surg 2017;60(1):37-44 | PDF

Linden Head, MD; Carolyn Nessim, MD, MSc; Kirsty Usher Boyd, MD


Background: Bilateral prophylactic mastectomy (BPM) has shown breast cancer risk reduction in high-risk/BRCA+ patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency.

Methods: We retrospectively reviewed the cases of all high-risk/BRCA+ patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1–2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/BRCA+ status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared.

Results: There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model (p = 0.003, p < 0.001 and p = 0.015, respectively).

Conclusion: A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization.


Contexte : La mastectomie prophylactique bilatérale (MPB) donne lieu à une réduction du risque de cancer du sein chez les patientes à risque élevé/BRCA+. Toutefois, la priorité accordée aux cancers évolutifs alliée à une utilisation inefficace des ressources dans les blocs opératoires pose des défis lorsqu’il est question d’offrir la MPB sans retard. Pour relever ces défis, un programme d’accès rapide à la mastectomie prophylactique et à la reconstruction immédiate (RAPMIR) a été mis de l’avant. Le but de cette étude est d’évaluer le programme du point de vue de l’accès aux soins et de l’efficience.

Méthodes : Nous avons passé en revue de manière rétrospective tous les cas de patientes à risque élevé/BRCA+ ayant subi une MPB entre septembre 2012 et août 2014. Les patientes ont été scindées en 2 groupes : 1 groupe a été soumis au modèle thérapeutique standard et l’autre, au modèle RAPMIR. Le modèle RAPMIR met à contribution 2 blocs opératoires fonctionnant concomitamment où l’oncologie chirurgicale et la chirurgie plastique alternent entre les salles pour réaliser 3 MPB concurremment avec des reconstructions immédiates, en plus d’un ou 2 autres cas distincts à chaque journée opératoire. Les critères d’admissibilité à RAPMIR incluaient : risque élevé/BRCA+, MPB avec reconstruction immédiate à l’aide d’implants et admissibilité à la chirurgie d’un jour. On a mesuré et comparé les temps d’attente, les volumes de cas et le nombre de patientes.

Résultats : L’étude a regroupé 16 patientes soumises au modèle standard et 13 au modèle RAPMIR. Le temps d’attente moyen (nombre de jours entre la consultation et la chirurgie) pour RAPMIR a été significativement plus bref que pour le modèle standard (165,4 c. 309, 2 jours, p = 0,027). Le nombre de patientes/jour (4,3 c. 2,8), le volume des cas de chirurgie plastique (3,7 c. 1,6) et le volume des cas d’oncologie chirurgicale (3,0 c. 2,2) ont été significativement plus élevés avec le modèle RAPMIR qu’avec le modèle classique (p = 0,003, p < 0,001 et p = 0,015, respectivement).

Conclusion : Un modèle multidisciplinaire reposant sur une synchronisation optimisée a le potentiel d’améliorer l’accès aux soins et l’utilisation des ressources.

The findings of this study were presented at the Annual Meeting of the Canadian Society of Plastic Surgeons (CSPS) in June 2015 (Victoria, BC), and an accompanying abstract was published in Plastic Surgery 2015;23:137.

Accepted Sept. 1, 2016; Early-released Dec.1, 2016

Acknowledgements: The authors thank the other surgical oncologists providing treatment for these patients: Angel Arnaout, James Watters, and John Lorimer. The authors would also like to thank Laura Stewart and Lyne Landry-Dobson for their patience and assistance in assembling the data for this work.

Affiliations: From the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Head); the Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ont. (Nessim); and the Division of Plastic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ont. (Boyd).

Competing interests: K. Usher Boyd is a paid consultant for LifeCell. In this role, she has received honoraria for speaking about the use of acellular dermal matrix and she has had expenses for travel covered to attend meetings regarding the same. This does not pose a conflict for the present study, as the products are not mentioned in the article, nor do they influence the topic. No other competing interests declared.

Contributors: All authors designed the study and acquired the data, which L. Head and C. Nessim analyzed. L. Head wrote the article, which all authors reviewed and approved for publication.

DOI: 10.1503/cjs.001116

Correspondence to: K. Usher Boyd, The Ottawa Hospital, 1053 Carling Ave., Ottawa ON K1Y 4E9; kuboyd@gmail.com