Clinical Value Of The Execution Of Clinical Pathway In The Treatment Of Breast Cancer

BACKGROUND AND OBJECTIVEBreast cancer is one kind of malignant tumors threatening human's health, and is one of the most common feminine malignant neoplasms. It occupies 7%~10% of all the systemic malignant tumors in China, and has become the malignancy with the highest morbility of Chinese female.Clinical pathway (CP) is a kind of process standardizing the clinical diagnosis and treatment, and it is a strict working sequenced and exact time required diagnostic and therapeutic plan established by a group in hospital containing clinical doctors, anaesthetists, technicians, nurses and medical managers at all levels for a certain disease or operation to promote recovery, reduce cost and provide medical treatment and nursing care with the best quality to service objects. It contains the control of medical quality, holistic nursing and medical cost, and ensures the scientificity, rationality and normalization of the diagnosis and treatment based on the evidence based medical concept and continuous improves the management of quality. CP was proposed by Boston New England Medical Center in America in 1980s most early, and now it has been applied in more than 60% of American hospitals. Recently, CP has been widely actualized in England, Australia, Japan, and Taiwan and Hongkong in China. Moreover, some domestic large scale comprehensive hospitals have begun to applied CP in succession, now the objects of CP in China contain both traditional surgical diseases and operation, such as cesarean section, repair of ventricular septal defect and so on, and various kinds of chronic internal diseases, such as cardiovascular disease, all receives satisfactory outcomes.CP is a strict work sequence established by a work team in hospital for the monitoring, treatment, recovery and nursing of a certain disease in nature, it can reduce the recovery delay and resource waste in some degree because of the demand of exact time restriction, and the concrete manifestation is to shorten the hospitalization days and reduce the medical cost. During the process of application of CP, the doctors and nurses apply medical and nursing services following scientific, standard and normative diagnostic and therapeutic scheme strictly, avoid bringing to the patients unnecessary sufferings due to their own careless omission and fallacy in maximal degree, at the same time, the instruction and education of relative knowledge and the enhancement of preoperative, intraoperative and postoperative guidance make the patients understand disease condition sufficiently, relieve psychological pressure, enhance health belief, participate in the therapy and nursing care positively with a good state of mind, take behaviors which are harmful to health self-consciously, and attain to the purpose of improving and maintaining health at last, therefore, application of CP can reduce the mobility of operative complication in a certain degree. The objective of this research was to discuss the clinical value of the execution of clinical pathway in the treatment of breast cancer.METHODSThis research analyzed 61 primary breast cancer patients receiving breast cancer modified radical mastectomy or breast conserving surgery in Breast Surgical Department of the First Hospital of Jilin University during June 2008 to October 2008, postoperative pathologic diagnosis were all breast cancer, and underlying diseases such as cardiopathy, hypertension, diabetes mellitus and so on, and other conditions affecting the application of CP obviously such as bilateral breast cancer, breast cancer modified radical mastectomy + breast prosthesis implantation and so on were all excluded in this research. All the patients were female, the average age was 48.57 (21~76); the average tumor diameter was 1.66cm (0.5~4.0cm); 34 tumors located in the left and 27 tumors were in the right; the numbers of the stage 0, I, II, III in the clinical staging were 4, 24, 25 and 8; 56 patients received breast cancer modified radical mastectomy, and 5 patients received breast conserving surgery. The 61 cases were divided into research group (CP group) containing 31 cases and control group (non CP group) containing 30 cases randomly, the two groups did not have significant statistical differences in age, side, clinical staging, tumor diameter, operative type and medical group (P>0.05). Organized and established CP work group, formulated the diagnostic criteria strictly according to the"Clinical diagnosis and treatment guideline - Surgical Fascicule"(Chinese Medical Association, People's Medical Publishing House, December, 2006, the first edition):①clinical signs: masses with unclear border, adhesion of skin, and orange-peel sign;②medical imaging manifestations: breast color doppler ultrasonography and molybdenum target radiography suggested the diagnosis of breast caner;③p athology: pathological diagnosis after puncture biopsy was breast cancer. Established the inclusion criteria of CP:①the primary diagnosis must be coincident with the disease codes of breast cancer C50, D05 in ICD10;②the patients with other diseases at the same time who need not received nonspecific treatment and whose other treatments did not affect the application of CP of the primary diagnosis could also be divided into CP group. Reviewed literatures, medical records and relative materials to established the CP tables (textual edition, clinical edition and patients'edition), the main contents and requirements were:①preoperative preparation, 3~5 days, completed each examinations, such as routine biochemical examinations (blood routine test, urine routine test, coagulation routine test, surgical comprehensive test, hepatic function test, renal function test, fasting plasma glucose and so on), chest X-ray, electrocardiogram, abdominal doppler ultrasonography (digestive and urinary system), ultrasonic cardiography, pulmonary function test (the patients with old age or relative past history), breast color doppler ultrasonography and molybdenum target radiography and so on; chose the first and second generation cephalosporins or quinolones as the preventative drugs, and the administration time was 1 day;②operation days, the third to the seventh day, applied general anesthesia or epidural anesthesia, utilized operative internal fixator and skin stapler, used the routine anesthetics and postoperative analgesia pump, determined if transfusion was applied or not according the certain condition in the operation, delivered specimens for pathological diagnosis (frozen section and paraffin section + immunohistochemical method);③postoperative recovery, 10~14 days, applied the first and second generation cephalosporins or quinolones after the operation for 3 days to prevent infection. Formulated the operation related criteria:①basic requirements: professors or associate professors accomplished operation as the operator; dissociated the skin flaps with electrotome under direct vision; dissected the axillary lymph nodes to the standard of Level-II;②modified radical mastectomy related criteria: operation type of Auchincloss (conserved pectoralis major and pectoralis minor); incision type of Stewart (transverse incision); the range of the dissociation of skin flaps were interior to the sternal border, exterior to the anterior border of latissimus dorsi, up to subclavian region and down to rectus abdominis anterior sheath at the costal arch;③breast conserving surgery related criteria: extended tumor resection; two incisions scheme recommended by National Surgical Adjuvant Breast and Bowel Project (NSABP); resected continuously the breast tissues around tumor until no cancer cell was found in the incisal margin according the pathological diagnosis of intraoperative frozen sections. Established the judgment standards of operative complications:①subcutaneous hydrops;②skin flap necrosis;③postoperative hemorrhage;④lymphedema of the upper limb of affected side;⑤other nonspecific operative complications. Formulated the discharged criteria:①the incision healed well without infection, subcutaneous hydrops (or little hydrops which could be treated in clinic) and skin flap necrosis;②drainage tube had been removed;③no complication needing treated in hospital. The research group entered CP as soon as hospitalization, received standard treatment and nursing care, and the control group received traditional therapy in the whole course. Compared the average hospitalization days, average preoperative days, average cost and the incident rate of the operative complications of the two groups, and analyzed the variation of the CP group. All the data were processed by SPSS 17.0 statistical package, used t test to compare the measurement data of the two groups, and usedχ~2 test to compare the numeration data, the difference had statistical signification if P<0.05.RESULTSThe average hospitalization days of CP group were 14.87 days (10～17 days), were shorten than 21.53 days (15～29 days) in the control group, the difference between the two groups had statistical significance (t=10.1842, P<0.01); the average preoperative days of CP group were 2.03 days (1~3 days), were shorten than 2.57 days (1~4 days) in the control group, the data of the two groups had significant statistical difference (t=3.7273, P<0.01); at the aspect of average hospitalization cost, CP group spend $ 8490.73 ( $ 8088.4~ $ 8905.3), were less than $ 9003.22 ( $ 8645.1~$9209.9) in the control group, there was significant statistical difference between the two groups (t=14.7359, P<0.01), compared with the control group, CP group reduced about $500 (5.56%); there was only 1 patient in the CP group suffered subcutaneous hydrops, the incident rate of operative complication of CP group was 3.26% (1/31), and 8 patients in the control group suffered operative complication: 4 subcutaneous hydrops, 2 skin flap necrosis and 2 postoperative hemorrhage, the incident rate of operative complication was 36.36% (8/30), the difference had statistical significance (χ~2=4.9272,P<0.05). 7 cases of CP (22.58%, 7/31) group occurred variations, but no one was dropout, including 4 positive variations (12.90%, 4/31), the main reasons of which were the outcomes of tests returned in advance and leaded to arrange the operation 1 day before and the patients discharged 1~2 days ahead of the original plan because of good recovery, and 3 negative variations (9.68%, 3/31) because of that the patients required continue to observe in hospital and the hospital did not arrange the operation at weekend, festivals and holidaysCONCLUSIONS1. Application of clinical pathway in the treatment of breast cancer can shorten the hospitalization time and reduce medical cost significantly; 2. Implementation of clinical pathway of breast cancer can decrease the incident rate of operative complications obviously; 3. Clinical pathway is the concrete embodiment of patients centered service concept, and will surely enhance the medical service quality.