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The True Benefit Of Process Analysis And Efficiency Research: An Immediate And Sustained Decrease In Morbidity And Operative Time
Nicholas T. Haddock, MD1, John T. Tycher, BS1, Edward Wen, BA1, Sami U. Khan, MD2, Sumeet S. Teotia, MD1.
1University of Texas Southwestern Medical Center, Dallas, TX, USA, 2Stony Brook Medicine, Stony Brook, NY, USA.

PURPOSE: Deep inferior epigastric perforator (DIEP) flaps are nuanced, multi-step procedures and it can be difficult for surgeons to focus on where to direct their research. Recent studies have hinted that operational flow can be a sensitive barometer for safety, efficiency and aesthetic outcomes. Here we critically assess the utility of Process Mapping and Analysis as a research tool in the context of morbidity and operative time.
METHODS: Co-surgeons at a university hospital implemented two, prospective, process analysis studies to carefully define and evaluate critical steps in DIEP flap reconstruction. During the 9-month period (June 2018 to February 2019), they assessed eight steps of flap harvest and microsurgery. During the 8-month period (January 2020 to August 2020), they expanded their analysis to encompass the entire operation including breast inset and donor-site closure. To produce a fair comparison, we took advantage of a historical control and divided 375 bilateral DIEP flaps into eight, consecutive 9-month intervals completed before, during and after the two studies (April 2015 to May 2021). Using risk-adjusted multivariate regressions with a Helmert contrast, we compared morbidity and operative time between intervals. Morbidity in this analysis included any flap, donor-site and medical complications. Additionally, we chose 5 hours as a reference for procedure time due to an internal analysis showing a decreased risk of morbidity in operations completed in less than 5 hours.
RESULTS: The number of flaps and patient demographics were distributed normally across all eight-time intervals. While there were no statistically significant differences in complication risk in time intervals 1-4, we see an immediate 63.4% (P=.006) decrease in risk during the 2018 process analysis study. This trend of a significant decrease in morbidity is sustained for every consecutive time interval throughout the end of data collection. In the 8th time interval, patients were 53.7% less at risk for any complication when compared to patients in the previous 63 months (P<.01). During the 2020 Process Analysis study, operations were 18 times more likely to be completed in less than 5 hours (P<.001). Similar to morbidity risk, this trend of decreasing procedure times is sustained through the end of data collection. Similar to morbidity risk, this trend of decreasing procedure times is sustained through the end of data collection. Procedures in the last interval were 12.8 times more likely to be under 5 hours when compared to bilateral DIEP flaps completed in the previous 63 months (P<.001). CONCLUSION: Process Analysis is a powerful research tool capable of generating immediate and sustained decreases in morbidity and operative time.


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