- Email: [email protected]
Development and evaluation of an “Interdisciplinary Postoperative Support Program” in outpatient clinics after thoracic esophagectomy
International Journal of Surgery 43 (2017) 58e66
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original Research
Development and evaluation of an “Interdisciplinary Postoperative Support Program” in outpatient clinics after thoracic esophagectomy Takeo Fujita a, *, Yoko Iida b, Chiharu Tanaka b, Kumi Nakamura b, Keiko Yamanaka b, Junya Ueno c, Yoshie Iino c, Haruka Chitose d, Hatoe Sakamoto b, Hiroyuki Daiko a a
Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan Supportive Care Center, National Cancer Center Hospital East, Kashiwa, Japan Division of Rehabilitation Medicine, National Cancer Center Hospital East, Kashiwa, Japan d Division of Nutrition, National Cancer Center Hospital East, Kashiwa, Japan b c
h i g h l i g h t s In esophagectomy, patient education and their postoperative status remain unknown. We tested the above issues with “Interdisciplinary Postoperative Support Program”. This program provided appropriate satisfactory information after esophagectomy. This program contribute to a reduced incidence of unscheduled outpatient visits.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 March 2017 Received in revised form 13 May 2017 Accepted 15 May 2017 Available online 19 May 2017
Background: To support patients discharged from the hospital after surgery, we launched an “Interdisciplinary Postoperative Support Program” in outpatient clinics for patients who were discharged within 1 month after thoracic esophagectomy and their families. We introduce our program and clarify the patient's physical and psychologic status by analyzing the questionnaire provided from this program. Materials and methods: From August 2014 to January 2015, we conducted the Interdisciplinary Postoperative Support Program every month. Thus, questionnaires regarding physical and psychologic symptoms as well as the meaningfulness of the program were obtained from 59 patients and prospectively analyzed. Results: We obtained valid responses from 48 patients (81.4%). Frequent postoperative difficulties included dysphagia (50%) and decreased physical strength (39.5%). Oral intake decreased to half (55.3%) and one-fourth (25.5%) of that before esophagectomy. Frequent requests made by patients to medical staff included explanations of the postoperative symptoms (97.9%), further information on the treatments of esophageal cancer (93.8%), and the typical postoperative course experienced by other patients (76.6%). A higher percentage of positive comments were obtained regarding the management of symptoms (87.8%) and optimal access to the consultations (78.9%). The incidences of unscheduled outpatient visits were 4.1% and 14.0%, respectively, under conditions with and without this postoperative program (P ¼ 0.03). Conclusion: We found that our program could provide appropriate information with higher levels of satisfaction after thoracic esophagectomy. Further investigations regarding longer periods of physical and psychologic symptoms, as well as the needs of patients and their families should be conducted to augment our program. © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Interdisciplinary support program Esophagectomy Esophageal cancer
1. Introduction * Corresponding author. Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, 277-8577, Japan. E-mail address: [email protected] (T. Fujita).
Esophageal cancer is one of the well-known diseases associated with a relatively high incidence of impaired quality of life after
http://dx.doi.org/10.1016/j.ijsu.2017.05.036 1743-9191/© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
treatment, particularly after thoracic esophagectomy. Multidisciplinary treatment approaches, including nutritional support, immunologic management, and other preoperative preparations, together with modern perioperative and postoperative care have substantially improved the immediate results of surgical treatment of esophageal cancer [1]. These treatment advances have led to an increase in the population of survivors of esophageal cancer. Esophagectomy and chemoradiation have brought improved surgical outcomes along with treatment-related impairment of quality of life (QOL) for patients with esophageal cancer [2]. The impairment of QOL has been observed in the short and long terms after treatment [3]. Therefore, optimal support programs are required to help in the daily life of patients and their families. Recently, daily activity and appropriate education of patients on the postoperative physiologic status have proven to be important factors determining QOL after surgical treatment of cancers [4]. Thus, the development of a more focused comprehensive program and symptom-specific education would be of great significance for healthcare providers and patients. Further, the optimal evaluation of the postoperative status is required to explore optimal treatment approaches for these patients. In the outpatient clinic, an interdisciplinary support team approach that improves the efficacy and quality of care offers a novel educational method for patients and families [5]. Contrary to the traditional visit between a single healthcare provider and patient, a provider engages a group of patients with similar healthcare needs in an extended visit that allows more time for patientcentered education and discussion [6]. Although interdisciplinary support team approaches were initially piloted in the primary care setting, this model now has been applied to more specific cases, such as diabetes [7], heart failure [8], and pregnancy [9]. It also has been used in various surgical subspecialties, including bariatric [10] and cardiac [11] surgery. Published results comparing the traditional models of care to interdisciplinary support team programs have improved clinical outcomes, such as lower hemoglobin A1c level [12], increased exercise [13], and improved blood pressure control [13]. Despite the potential benefit of interdisciplinary support approaches for patients and their families, there have been few attempts to use this model in oncology [14,15], particularly in the field of gastrointestinal surgery [16]. We developed and conducted a pilot study to determine whether an interdisciplinary support program would be feasible for patients shortly after thoracic esophagectomy at the outpatient clinic. Additionally, we described the development and implementation of an “Interdisciplinary Postoperative Support Program (IPSP)” for post-esophagectomy patient education as well as provided our initial results from this ongoing program. We evaluated the physical symptoms, weekly activities, and the incidence of unscheduled outpatient visits of patients after thoracic esophagectomy.
59
and consent process for several surgical procedures. We developed a teaching checklist and post-esophagectomy education slide presentations, which were delivered by each specialist or administrative staff. In the presentations, topics included basic principles of cancer therapy, common symptoms after thoracic esophagectomy, suggestions and solutions for managing common symptoms, and optimal rehabilitation programs for improving daily activity, including vocational and pharyngeal functions. The presentation also covered the introduction of useful social security services, important contact information for ambulatory treatment access, and helpful tips. The presentation concluded with discussions and a questioneanswer session. Printed copies of the slide presentation were provided to patients and caregivers. The materials were reviewed and approved by The Office of Supportive Care Center to ensure appropriate description and readability. Fig. 1 shows a representation of a booklet for the IPSP. 2.2. Implementation of the program 2.2.1. Patient recruitment Patients with esophageal cancer who underwent thoracic esophagectomy and were discharged from the hospital in the prior 1 month were eligible to participate. Participation was voluntary, and the patients were referred to The Office of Supportive Care Center. To raise awareness about IPSP and encourage patient enrollment, the program team provided informational posters and panels in the hospital, and further presented informational brief sessions to the nurse, practice providers, and medical assistants. We created a patient handout that explained the time schedule of visits. We monthly held the program, which resulted in an increase in participants. 2.2.2. Structure and flow of visit The IPSP is monthly held on 3rd Thursday from 2:00 to 3:30 p.m. After filling out the brief questionnaire about the present status and troublesome postoperative symptoms, patients and family members are escorted to a patients' education classroom, where the patients meet the advanced practice providers. A group session commences with an educational presentation delivered by each member of the interdisciplinary support team. The session includes actual physical, vocal, and pharyngeal functional exercises. Further, tasting and mastication trials of various solid foods are held, ranging from easy to slightly difficult to swallow. After the group session, patients and families are offered individual time with the staff surgeons and other specialists to address additional questions and/or medical concerns that were not addressed during the group setting. After the end of the entire program, patients and families are requested to voluntarily participate in the brief questionnaire that assesses their satisfaction and their opinions about the program. 2.3. Patients
2. Material and methods 2.1. Program development and educational lists We assembled an interdisciplinary team of support specialists that comprised surgeons, nurses, physical therapists, occupational therapists, speech therapists, nutrition managers, medical social workers, administrators, and a member of the Office of Cancer Supportive Care Center, to develop a comprehensive IPSP for patients after thoracic esophagectomy for esophageal cancer. This program was held for patients and their families to achieve a better life after thoracic esophagectomy. Various attempts were undertaken to standardize the education
This project was approved by the Investigational Review Board of the National Cancer Center. Preoperative diagnoses were based on preoperative imaging studies, including contrast agent swallow studies, endoscopy, and conventional cross-sectional imaging studies (computed tomography). Histologic evaluation of specimens obtained by preoperative endoscopically-guided biopsy was performed in all cases. The patients' medical records were reviewed to determine the clinical disease stage, surgical procedures performed, histopathologic diagnoses of the lesions, and outcomes. In all cases, either thoracoscopic esophagectomy or transthoracic esophagectomy with three-field lymph node dissection was performed in the usual manner by two surgeons (H.D. and T.F.).
60 T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66 Fig. 1. Representative presentation sheets of the patient education class in the IPSP. During the education session, each medical professional provided detailed information that could enhance patient understanding of the postoperative status.
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
61
The extent of lymph node dissection was the same for the open thoracotomy and minimally-invasive thoracoscopic approaches [9]. Clinical stage was classified according to the criteria of the Union for International Cancer Control (UICC) version 6. In stages II and III disease, preoperative systemic chemotherapies were, in principle, administered and followed by esophagectomy. A gastric tube was used to reconstruct the resected esophagus usually via the posterior mediastinal route. For patients who underwent gastrectomy, reconstruction was performed with pedicled right colon grafts via either the sternal or posterior mediastinal route. 2.4. Participants and data collection All 59 participating patients had undergone R0 thoracic esophagectomy as a part of their treatment for cancer. Between 1 and 2 months after esophagectomy, these 59 patients voluntarily participated in the IPSP at the outpatient clinic together with their families. After the program, we provided information about data confidentiality and assured them that inherent risks could be controlled by their volunteer membership. Our research protocol and proposal were accepted and approved by the two committee boards. All 59 participants agreed to participate in the study after attending a verbal introduction and detailed explanation of the questionnaires. Each participant was asked to complete a questionnaire package, which included the Japanese version of the International Physical Activity Questionnaire (IPAQ) and VoiceRelated QOL (V-RQOL). All participants were asked to participate in an interview conducted by the trained members of our team in an outpatient clinic, where they explained potential difficulties or problems related to the questionnaires to precisely evaluate the postoperative status of participants. 2.5. Statistical analysis Statistical differences between the two groups were analyzed using the c2 and ManneWhitney U tests. Data were analyzed using R Statistical Software (version 3.0.3). A P value of <0.05 was considered statistically significant. 3. Results 3.1. Patients characteristics In total, 136 patients who underwent esophagectomy for cancer of the thoracic esophagus from August 2014 to July 2015 were identified from the surgical unit in the Division of Esophageal Surgery at the National Cancer Center Hospital East. Of these 136 patients, 59 participated in the IPSP (Fig. 2). The questionnaire package included a datasheet that asked for patients' recent symptoms and difficulties, and the amount of oral intake compared to that before esophagectomy. Eleven of the questionnaires were not fully returned. Final patient data included information on 48 patients (all of whom underwent curative resection of cancer) who did fill out the questionnaires (48 of 59 response rate, 81.4%). Patient characteristics are shown in Table 1. 3.2. Summary of the postoperative symptoms The major postoperative troublesome physical symptoms are summarized in Fig. 3. The most frequent troublesome physical symptom after thoracic esophagectomy was dysphagia (50%). However, contrast agent swallow studies and endoscopic examinations demonstrated that organic neck anastomotic stenosis was found in <10% of these
Fig. 2. Flow chart showing the selection of patients for the present study.
Table 1 Patients' characteristics. variables
Participants(n ¼ 48) Number
Age (mean ± S.D.) (Range) Gender Male Female Marital status Married Not married Divorced Others Serum pre-Albumin (Range) Body Mass Index (Range) Thoracic surgical approach Thoracoscopic Thoracotomy Abdominal Surgical approach Laparoscopic laparotomy Clinical Stage (UICC 7th) Stage I Stage II Stage III Stage IV
(%)
68.1 ± 7.2 (52e88) 37 11
(77.1%) (22.9%)
39 5 2 2 18.2 ± 5.8 (5.8e31.7) 20.7 ± 2.6 (16.2e26.4)
(79.2%) (10.4%) (4.2%) (4.2%)
35 13
(72.9%) (27.1%)
41 7
(85.4%) (14.6%)
9 8 28 3
(18.8%) (16.6%) (58.3%) (6.3%)
symptom-positive patients (data not shown). The second most frequent troublesome physical symptom was decrease in physical strength (39.5%). 3.3. Results of the amount of oral intake after esophagectomy The results of the amount of oral intake after esophagectomy compared to the status before surgery are shown in Fig. 4. The oral amount was decreased to half of that before esophagectomy in more than 50% of the patients, one-fourth in 25%, and three-fourths in 12.5%. 3.4. Summary of the physical activity after esophagectomy The results of weekly physical activity after esophagectomy are summarized in Fig. 5.
62
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
Fig. 3. The frequency of troublesome postoperative physical symptoms after thoracic esophagectomy, which were noted on questionnaires during the IPSP. The most frequent troublesome physical symptom was dysphagia, followed by a decreased sense of physical strength. Dry cough, weight loss, and reflux also were frequently found.
esophageal cancer” (93.8%) even after curative esophagectomy. More than 70% of patients requested “further information about available public services” (70.3%). 3.6. Summary of the patients' comments The patients' comments after the program are summarized in Fig. 7. In total, 80% of the patients answered that IPSP was helpful in resolving their questions (Fig. 7a), more than 60% reported that the meeting was informative to improve daily life (Fig. 7b), and over 90% agreed that the IPSP was useful (Fig. 7c). 3.7. Incidence of readmission and unscheduled outpatient visits after esophagectomy
Fig. 4. The summary of the oral intake after thoracic esophagectomy compared to that before surgery. More than 75% of patients experienced less than half the amount of oral intake compared to the status before surgery.
Low strength physical activity was most frequently found (410 min/week), while high strength physical activity was seldom found (13.03 min/week) in patients at 1e2 months after esophagectomy. The mean duration of walking was 74.84 min/week after surgery (Fig. 5a). The frequency of weekly physical activity is summarized in Fig. 5b. Low strength physical activity was found almost every day (6.8 days/week), while high strength physical activity occurred less than 1 day in a week and was the least frequent (0.81 days/week). The mean frequency of walking activity was 5.69 days in a week. 3.5. Summary of frequent required information from patients The medical information frequently requested by patients from medical staff is summarized in Fig. 6. A high percentage of patients requested “Further understanding of postoperative body status and symptoms” (97.9%) and “further information about the treatment of
To evaluate the educational impact and clinical significance of IPSP, we investigated the incidence of readmission and unscheduled outpatient visits after esophagectomy. For this purpose, we evaluated 50 consecutive patients who underwent thoracic esophagectomy before the implementation of the IPSP (before IPSP), and analyzed the clinical factors compared to 48 patients after the implementation of the IPSP (after IPSP). There were no differences in demographics and characteristics between the two groups (data not shown). The incidences of readmission were 4.0% and 2.1% in patients before and after IPSP (P ¼ 0.17; Fig. 8a). The incidences of unscheduled outpatient visits were 14.0% and 4.1% in patients before and after IPSP (P ¼ 0.03; Fig. 8b). 4. Discussion The actual daily situation of patients after esophagectomy has not been fully unveiled because of the insufficiency of specific tools to measure daily activity and the symptomatic status of patients with esophageal cancer, particularly those who undergo thoracic esophagectomy with three-field lymph node dissection. We explored the daily activity and symptomatic problems of patients after thoracic esophagectomy through an IPSP, which was developed to resolve troublesome postoperative symptoms and enhance the daily activity in relative early periods after esophagectomy. In the present study, we introduced our attempt to conduct an IPSP to
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
63
Fig. 5. The summary of the patients' weekly physical activities after thoracic esophagectomy evaluated by International Physical Activity Questionnaire (IPAQ). (a) The total time of physical activity revealed 410 min of low strength physical activity in a week. On the contrary, less than 30 min of physical activities were performed at middle and high strength levels. The average weekly total time of walking was 74.8 min. (b) The frequency of physical activity indicated that low strength physical activity was performed 6.8 days in a week, whereas high and middle level of physical activities were performed 0.8 and 1.2 days, respectively. The average frequency of walking was 5.7 days in a week.
Fig. 6. The summary of the patients' frequently requested information from medical staff after thoracic esophagectomy. The most frequently requested information was “Explanation of postoperative body status and symptoms,” followed by “Information about the treatment of esophageal cancer.”
investigate the postoperative status and to support and educate patients and families after thoracic esophagectomy. Interdisciplinary team care can be defined as the structured working practices that dictate how different healthcare practitioners interact together to contribute to patient care. The importance of the interdisciplinary team approach has been well recognized [17]. There has been an increase in the reports of intervention trials in outpatient clinics to support patients and
families, particularly after the cases of advanced stage cancer increased [18]. However, most of these trials were focused on the specific status, such as caregiving for end-stage disease. In the previous studies of interdisciplinary support programs for postoperative patients, attempts to evaluate the efficacy of postoperative interdisciplinary team care were mostly focused on medical hospital wards to evaluate the commonly used clinical parameters such as length of hospital stay, readmission, morbidity,
64
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
Fig. 7. The summary of the patients' comments after the Interdisciplinary Postoperative Support Program (IPSP). (a) More than 80% of the patients answered that the IPSP meeting was helpful to solve their questions after esophagectomy. (b) More than 60% patients reported that the IPSP meeting was informative to improve daily life after esophagectomy. (c) More than 90% patients thought that the IPSP was useful.
Fig. 8. The incidence of readmission and unscheduled outpatient visits. (a) The incidence of readmission before and after thoracic esophagectomy and after the completion of the IPSP. Although there was no significant difference, the incidence of readmission tended to decrease after the completion of the IPSP. (b) A significant decrease in unscheduled outpatient visits was found after the completion of the IPSP.
and mortality [17]. In this setting, although there is some evidence that improvement in interdisciplinary collaboration may reduce complications of care [19], most of the previous studies demonstrated that interdisciplinary interventions do not affect these clinical outcomes. Significant contemporaneous secular reductions in the length of stay have been reported [20]. Thus, interdisciplinary interventions confined to the inpatient setting are unlikely to reduce the incidence of readmissions or increase daily activity and QOL level after discharge from the hospital. However, the actual clinical benefit of interdisciplinary intervention for outpatients is not clearly identified. Therefore, clinical significance to evaluate the daily status of outpatients should be more focused, particularly in patients undergoing highly invasive procedures, such as thoracic esophagectomy.
Our results demonstrated the frequency of troublesome postoperative symptoms other than daily activities and the actual oral intake status. There were no significant trends in troublesome postoperative symptoms regardless of the surgical approaches (data not shown). The investigation of the frequent troublesome physical symptoms indicated that dysphagia was the most frequent troublesome symptom, which was understood in the broad sense of the word, such as a feeling of dysphagia manifesting as swallowing discomfort with no actual stasis of oral diet. The incidence and frequency of other postoperative symptoms such as dry cough, weight loss, and reflux were reasonable, and further observation with long-term follow-up would be required. Regarding the incidence of readmission and unscheduled outpatient visits, our study indicated the potential importance of an
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
IPSP. Although not significantly different, a lower incidence of readmission was found and unscheduled outpatient visits in the after IPSP group significantly decreased. Frequent physical symptoms resulting in these unscheduled outpatient visits were not clinically significant, and included low grade fever and swallowing discomfort with no signs of anastomotic stricture on esophagography (data not shown). The implementation of an IPSP led patients to further understanding of predictable physical symptoms, which could be related to a lower incidence of unscheduled outpatient visits. The present study had several limitations. The study period covered a span of 2 years, during which slight modifications of the postoperative clinical management protocol occurred. Thus, the outcome of the present study may be affected by the perioperative management of patients with different patient characteristics. An important point of the present study is that operative procedures were performed with the same indication criteria for thoracic and abdominal approaches.
65
Guarantor Takeo Fujita, M.D., Ph.D., F.A.C.S. Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan, 6-5-1, Kashiwanoha, Kashiwa, Chiba 2778577, Japan. E-mail: [email protected]. Human rights statement and informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and the Helsinki Declaration of 1964 and later versions. Informed consent or substitute for it was obtained from all patients for being included in the study. Consent for publication Not applicable.
5. Conclusions Availability of data and material Our attempt at conducting an IPSP achieved acceptable value from patients and their families. This program clarified the frequent postoperative troublesome symptoms as well as the actual oral intakes and weekly activities at 1 month after thoracic esophagectomy. Further investigations would be considered because we did not examine the measurement properties of different familial backgrounds. Moreover, we must consider further follow-up evaluation to manage long-term postoperative troublesome symptoms after thoracic esophagectomy.
Please contact author for data requests. Acknowledgments We greatly appreciate the critical discussion of our manuscript provided by the members of the Division of Gastrointestinal Oncology. Appendix A. Supplementary data
Ethical Approval All patients provided written informed consent for their information to be stored in hospital database. Study approved was obtained from independent ethics committees at the National Cancer Center Hospital. Sources of funding There are no financial relationships or support that may pose a conflict of interest. Author contribution Takeo Fujita, Hatoe Sakamoto and Hiroyuki Daiko contributed the design and the concept of the article. Takeo Fujita contributed the interpretation and drafting the article. Yoko Iida, Chihau Tanaka, Kumi Nakamura, Keiko Yamanaka, Junya Ueno, Yoshie Iino, Chitose Haruka, and Hatoe Sakamoto contributed acquisition and analysis of data. All authors participated in drafting the article. All authors gave final approval of the version submitted. Conflict of interest All authors declare that they have no conflict of interest. Trial registry number Researchregistry2420.
Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.ijsu.2017.05.036. References [1] P. van Hagen, M.C. Hulshof, J.J. van Lanschot, E.W. Steyerberg, M.I. van Berge Henegouwen, B.P. Wijinhoven, et al., Preoperative chemoradiotherapy for esophageal or junctional cancer, N. Engl. J. Med. 366 (2012) 2074e2084. [2] M. Nakamura, Y. Kido, M. Yano, Y. Hosoya, Reliability and validity of a new scale to assess postoperative dysfunction after resection of upper gastrointestinal carcinoma, Surg. Today 35 (2005) 535e542. [3] H. Yamashita, K. Okuma, Y. Seto, K. Mori, S. Kobayashi, R. Wakui, et al., A retrospective comparison of clinical outcomes and quality of life measures between definitive chemoradiation alone and radical surgery for clinical stage II-III esophageal carcinoma, J. Surg. Oncol. 100 (2009) 435e441. [4] M. van Heijl, M.A. Sprangers, A.G. de Boer, S.M. Lagarde, H.B. Reitsma, O.R. Busch, et al., Preoperative and early postoperative quality of life predict survival in potentially curable patients with esophageal cancer, Ann. Surg. Oncol. 17 (2010) 23e30. [5] R.D. Stock, D. Reece, L. Cesario, Developing a comprehensive interdisciplinary senior healthcare practice, J. Am. Geriatr. Soc. 52 (2004) 2128e2133. [6] J. Berger-Fiffy, The “nuts and bolts” of implementing shared medical appointments: the Harvard Vanguard Medical Associates experience, J. Ambul. Care. Manage 35 (2012) 247e256. [7] N. Gutierrez, N.E. Gimple, F.J. Dallo, B.M. Foster, E.J. Ohagi, Shared medical appointments in a residency clinic: an exploratory study among Hispanics with diabetes, Am. J. Manag. Care 17 (2011) e212ee214. [8] A. Lin, J. Cavendish, D. Boren, T. Ofstad, D. Seidensticker, A pilot study: reports of benefits from a 6-months, multidisciplinary, shared medical appointment approach for heart failure patients, Mil. Med. 173 (2008) 1210e1213. [9] H. Daiko, T. Fujita, The Concept of lymphadenectomy along the recurrent laryngeal nerves during thoracoscopic esophagectomy in the prone position, Nihon. Geka. Gakkai. Zasshi 117 (2016) 144e147. [10] M.J. Seager, R.J. Egan, H.E. Meredith, S.E. Bates, S.A. Norton, J.D. Morgan, Shared medical appointments for bariatric surgery follow-up: a patient satisfaction questionnaire, Obes. Surg. 22 (2012) 641e645. [11] M.D. Harris, Shared medical appointments after cardiac surgery-the process of implementing a novel pilot paradigm to enhance comprehensive postdischarge care, J. Cardiovasc. Nurs. 25 (2010) 124e129. [12] A.B. Guirguis, J. Lugovich, J. Jay, K.A. Sanders, S.T. Cioffi, S.M. Jeffery, et al., Improving diabetes control using shared medical appointments, Am. J. Med.
66
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
126 (2013) 1043e1044. [13] K. Dickman, C. Pintz, K. Gold, C. Kivlahan, Behavior changes in patients with diabetes and hypertension after experiencing shared medical appointments, J. Am. Acad. Nurse. Pract. 24 (2012) 43e51. [14] S.C. Reed, A.H. Partridge, L. Nekhlyudov, Shared medical appointments in cancer survivorship care: a review of the literature, J. Oncol. Pract. 11 (2015) 6e11. [15] K.A. Calzone, S.A. Prindiville, O. Jourkiv, J. Jenkins, M. DeCarvalho, D.B. Wallerstedt, et al., Randomized comparison of group versus individual genetic education and counseling for familial breast and/or ovarian cancer, J. Clin. Oncol. 23 (2005) 3455e3464. [16] K. Trotter, A. Frazier, C.K. Hendricks, H. Scarsella, Innovation in survivor care: group visits, Clin. J. Oncol. Nurs. 15 (2011) E24eE33. [17] S. Pannick, R. Davis, H. Ashrafian, B.E. Byrne, I. Beveridge, T. Athanasiou, et al.,
Effects of interdisciplinary team care interventions on general medical wards. A systematic Review, JAMA. Int. Med. 175 (2015) 1288e1298. [18] L.S. Prescott, A.S. Dickens, S.L. Guerra, J.M. Tanha, D.G. Phillips, K.T. Patel, et al., Fighting cancer together: development and implementation of shared medical appointments to standardize and improve chemotherapy education, Gynecol. Oncol. 140 (2016) 114e119. [19] R. Fernandez, D.T. Tran, M. Johnson, S. Jones, Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery, J. Nurs. Manag. 3 (2010) 265e274. [20] S. Saint, K.E. Fowler, S.L. Krein, S.A. Flanders, T.W. Bodnar, E. Young, et al., An academic hospitalist model to improve healthcare worker communication and learner education: results from a quasi-experimental study at a veterans Affairs medical center, J. Hosp. Med. 8 (2013) 702e710.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original Research
Development and evaluation of an “Interdisciplinary Postoperative Support Program” in outpatient clinics after thoracic esophagectomy Takeo Fujita a, *, Yoko Iida b, Chiharu Tanaka b, Kumi Nakamura b, Keiko Yamanaka b, Junya Ueno c, Yoshie Iino c, Haruka Chitose d, Hatoe Sakamoto b, Hiroyuki Daiko a a
Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan Supportive Care Center, National Cancer Center Hospital East, Kashiwa, Japan Division of Rehabilitation Medicine, National Cancer Center Hospital East, Kashiwa, Japan d Division of Nutrition, National Cancer Center Hospital East, Kashiwa, Japan b c
h i g h l i g h t s In esophagectomy, patient education and their postoperative status remain unknown. We tested the above issues with “Interdisciplinary Postoperative Support Program”. This program provided appropriate satisfactory information after esophagectomy. This program contribute to a reduced incidence of unscheduled outpatient visits.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 March 2017 Received in revised form 13 May 2017 Accepted 15 May 2017 Available online 19 May 2017
Background: To support patients discharged from the hospital after surgery, we launched an “Interdisciplinary Postoperative Support Program” in outpatient clinics for patients who were discharged within 1 month after thoracic esophagectomy and their families. We introduce our program and clarify the patient's physical and psychologic status by analyzing the questionnaire provided from this program. Materials and methods: From August 2014 to January 2015, we conducted the Interdisciplinary Postoperative Support Program every month. Thus, questionnaires regarding physical and psychologic symptoms as well as the meaningfulness of the program were obtained from 59 patients and prospectively analyzed. Results: We obtained valid responses from 48 patients (81.4%). Frequent postoperative difficulties included dysphagia (50%) and decreased physical strength (39.5%). Oral intake decreased to half (55.3%) and one-fourth (25.5%) of that before esophagectomy. Frequent requests made by patients to medical staff included explanations of the postoperative symptoms (97.9%), further information on the treatments of esophageal cancer (93.8%), and the typical postoperative course experienced by other patients (76.6%). A higher percentage of positive comments were obtained regarding the management of symptoms (87.8%) and optimal access to the consultations (78.9%). The incidences of unscheduled outpatient visits were 4.1% and 14.0%, respectively, under conditions with and without this postoperative program (P ¼ 0.03). Conclusion: We found that our program could provide appropriate information with higher levels of satisfaction after thoracic esophagectomy. Further investigations regarding longer periods of physical and psychologic symptoms, as well as the needs of patients and their families should be conducted to augment our program. © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Interdisciplinary support program Esophagectomy Esophageal cancer
1. Introduction * Corresponding author. Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, 277-8577, Japan. E-mail address: [email protected] (T. Fujita).
Esophageal cancer is one of the well-known diseases associated with a relatively high incidence of impaired quality of life after
http://dx.doi.org/10.1016/j.ijsu.2017.05.036 1743-9191/© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
treatment, particularly after thoracic esophagectomy. Multidisciplinary treatment approaches, including nutritional support, immunologic management, and other preoperative preparations, together with modern perioperative and postoperative care have substantially improved the immediate results of surgical treatment of esophageal cancer [1]. These treatment advances have led to an increase in the population of survivors of esophageal cancer. Esophagectomy and chemoradiation have brought improved surgical outcomes along with treatment-related impairment of quality of life (QOL) for patients with esophageal cancer [2]. The impairment of QOL has been observed in the short and long terms after treatment [3]. Therefore, optimal support programs are required to help in the daily life of patients and their families. Recently, daily activity and appropriate education of patients on the postoperative physiologic status have proven to be important factors determining QOL after surgical treatment of cancers [4]. Thus, the development of a more focused comprehensive program and symptom-specific education would be of great significance for healthcare providers and patients. Further, the optimal evaluation of the postoperative status is required to explore optimal treatment approaches for these patients. In the outpatient clinic, an interdisciplinary support team approach that improves the efficacy and quality of care offers a novel educational method for patients and families [5]. Contrary to the traditional visit between a single healthcare provider and patient, a provider engages a group of patients with similar healthcare needs in an extended visit that allows more time for patientcentered education and discussion [6]. Although interdisciplinary support team approaches were initially piloted in the primary care setting, this model now has been applied to more specific cases, such as diabetes [7], heart failure [8], and pregnancy [9]. It also has been used in various surgical subspecialties, including bariatric [10] and cardiac [11] surgery. Published results comparing the traditional models of care to interdisciplinary support team programs have improved clinical outcomes, such as lower hemoglobin A1c level [12], increased exercise [13], and improved blood pressure control [13]. Despite the potential benefit of interdisciplinary support approaches for patients and their families, there have been few attempts to use this model in oncology [14,15], particularly in the field of gastrointestinal surgery [16]. We developed and conducted a pilot study to determine whether an interdisciplinary support program would be feasible for patients shortly after thoracic esophagectomy at the outpatient clinic. Additionally, we described the development and implementation of an “Interdisciplinary Postoperative Support Program (IPSP)” for post-esophagectomy patient education as well as provided our initial results from this ongoing program. We evaluated the physical symptoms, weekly activities, and the incidence of unscheduled outpatient visits of patients after thoracic esophagectomy.
59
and consent process for several surgical procedures. We developed a teaching checklist and post-esophagectomy education slide presentations, which were delivered by each specialist or administrative staff. In the presentations, topics included basic principles of cancer therapy, common symptoms after thoracic esophagectomy, suggestions and solutions for managing common symptoms, and optimal rehabilitation programs for improving daily activity, including vocational and pharyngeal functions. The presentation also covered the introduction of useful social security services, important contact information for ambulatory treatment access, and helpful tips. The presentation concluded with discussions and a questioneanswer session. Printed copies of the slide presentation were provided to patients and caregivers. The materials were reviewed and approved by The Office of Supportive Care Center to ensure appropriate description and readability. Fig. 1 shows a representation of a booklet for the IPSP. 2.2. Implementation of the program 2.2.1. Patient recruitment Patients with esophageal cancer who underwent thoracic esophagectomy and were discharged from the hospital in the prior 1 month were eligible to participate. Participation was voluntary, and the patients were referred to The Office of Supportive Care Center. To raise awareness about IPSP and encourage patient enrollment, the program team provided informational posters and panels in the hospital, and further presented informational brief sessions to the nurse, practice providers, and medical assistants. We created a patient handout that explained the time schedule of visits. We monthly held the program, which resulted in an increase in participants. 2.2.2. Structure and flow of visit The IPSP is monthly held on 3rd Thursday from 2:00 to 3:30 p.m. After filling out the brief questionnaire about the present status and troublesome postoperative symptoms, patients and family members are escorted to a patients' education classroom, where the patients meet the advanced practice providers. A group session commences with an educational presentation delivered by each member of the interdisciplinary support team. The session includes actual physical, vocal, and pharyngeal functional exercises. Further, tasting and mastication trials of various solid foods are held, ranging from easy to slightly difficult to swallow. After the group session, patients and families are offered individual time with the staff surgeons and other specialists to address additional questions and/or medical concerns that were not addressed during the group setting. After the end of the entire program, patients and families are requested to voluntarily participate in the brief questionnaire that assesses their satisfaction and their opinions about the program. 2.3. Patients
2. Material and methods 2.1. Program development and educational lists We assembled an interdisciplinary team of support specialists that comprised surgeons, nurses, physical therapists, occupational therapists, speech therapists, nutrition managers, medical social workers, administrators, and a member of the Office of Cancer Supportive Care Center, to develop a comprehensive IPSP for patients after thoracic esophagectomy for esophageal cancer. This program was held for patients and their families to achieve a better life after thoracic esophagectomy. Various attempts were undertaken to standardize the education
This project was approved by the Investigational Review Board of the National Cancer Center. Preoperative diagnoses were based on preoperative imaging studies, including contrast agent swallow studies, endoscopy, and conventional cross-sectional imaging studies (computed tomography). Histologic evaluation of specimens obtained by preoperative endoscopically-guided biopsy was performed in all cases. The patients' medical records were reviewed to determine the clinical disease stage, surgical procedures performed, histopathologic diagnoses of the lesions, and outcomes. In all cases, either thoracoscopic esophagectomy or transthoracic esophagectomy with three-field lymph node dissection was performed in the usual manner by two surgeons (H.D. and T.F.).
60 T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66 Fig. 1. Representative presentation sheets of the patient education class in the IPSP. During the education session, each medical professional provided detailed information that could enhance patient understanding of the postoperative status.
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
61
The extent of lymph node dissection was the same for the open thoracotomy and minimally-invasive thoracoscopic approaches [9]. Clinical stage was classified according to the criteria of the Union for International Cancer Control (UICC) version 6. In stages II and III disease, preoperative systemic chemotherapies were, in principle, administered and followed by esophagectomy. A gastric tube was used to reconstruct the resected esophagus usually via the posterior mediastinal route. For patients who underwent gastrectomy, reconstruction was performed with pedicled right colon grafts via either the sternal or posterior mediastinal route. 2.4. Participants and data collection All 59 participating patients had undergone R0 thoracic esophagectomy as a part of their treatment for cancer. Between 1 and 2 months after esophagectomy, these 59 patients voluntarily participated in the IPSP at the outpatient clinic together with their families. After the program, we provided information about data confidentiality and assured them that inherent risks could be controlled by their volunteer membership. Our research protocol and proposal were accepted and approved by the two committee boards. All 59 participants agreed to participate in the study after attending a verbal introduction and detailed explanation of the questionnaires. Each participant was asked to complete a questionnaire package, which included the Japanese version of the International Physical Activity Questionnaire (IPAQ) and VoiceRelated QOL (V-RQOL). All participants were asked to participate in an interview conducted by the trained members of our team in an outpatient clinic, where they explained potential difficulties or problems related to the questionnaires to precisely evaluate the postoperative status of participants. 2.5. Statistical analysis Statistical differences between the two groups were analyzed using the c2 and ManneWhitney U tests. Data were analyzed using R Statistical Software (version 3.0.3). A P value of <0.05 was considered statistically significant. 3. Results 3.1. Patients characteristics In total, 136 patients who underwent esophagectomy for cancer of the thoracic esophagus from August 2014 to July 2015 were identified from the surgical unit in the Division of Esophageal Surgery at the National Cancer Center Hospital East. Of these 136 patients, 59 participated in the IPSP (Fig. 2). The questionnaire package included a datasheet that asked for patients' recent symptoms and difficulties, and the amount of oral intake compared to that before esophagectomy. Eleven of the questionnaires were not fully returned. Final patient data included information on 48 patients (all of whom underwent curative resection of cancer) who did fill out the questionnaires (48 of 59 response rate, 81.4%). Patient characteristics are shown in Table 1. 3.2. Summary of the postoperative symptoms The major postoperative troublesome physical symptoms are summarized in Fig. 3. The most frequent troublesome physical symptom after thoracic esophagectomy was dysphagia (50%). However, contrast agent swallow studies and endoscopic examinations demonstrated that organic neck anastomotic stenosis was found in <10% of these
Fig. 2. Flow chart showing the selection of patients for the present study.
Table 1 Patients' characteristics. variables
Participants(n ¼ 48) Number
Age (mean ± S.D.) (Range) Gender Male Female Marital status Married Not married Divorced Others Serum pre-Albumin (Range) Body Mass Index (Range) Thoracic surgical approach Thoracoscopic Thoracotomy Abdominal Surgical approach Laparoscopic laparotomy Clinical Stage (UICC 7th) Stage I Stage II Stage III Stage IV
(%)
68.1 ± 7.2 (52e88) 37 11
(77.1%) (22.9%)
39 5 2 2 18.2 ± 5.8 (5.8e31.7) 20.7 ± 2.6 (16.2e26.4)
(79.2%) (10.4%) (4.2%) (4.2%)
35 13
(72.9%) (27.1%)
41 7
(85.4%) (14.6%)
9 8 28 3
(18.8%) (16.6%) (58.3%) (6.3%)
symptom-positive patients (data not shown). The second most frequent troublesome physical symptom was decrease in physical strength (39.5%). 3.3. Results of the amount of oral intake after esophagectomy The results of the amount of oral intake after esophagectomy compared to the status before surgery are shown in Fig. 4. The oral amount was decreased to half of that before esophagectomy in more than 50% of the patients, one-fourth in 25%, and three-fourths in 12.5%. 3.4. Summary of the physical activity after esophagectomy The results of weekly physical activity after esophagectomy are summarized in Fig. 5.
62
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
Fig. 3. The frequency of troublesome postoperative physical symptoms after thoracic esophagectomy, which were noted on questionnaires during the IPSP. The most frequent troublesome physical symptom was dysphagia, followed by a decreased sense of physical strength. Dry cough, weight loss, and reflux also were frequently found.
esophageal cancer” (93.8%) even after curative esophagectomy. More than 70% of patients requested “further information about available public services” (70.3%). 3.6. Summary of the patients' comments The patients' comments after the program are summarized in Fig. 7. In total, 80% of the patients answered that IPSP was helpful in resolving their questions (Fig. 7a), more than 60% reported that the meeting was informative to improve daily life (Fig. 7b), and over 90% agreed that the IPSP was useful (Fig. 7c). 3.7. Incidence of readmission and unscheduled outpatient visits after esophagectomy
Fig. 4. The summary of the oral intake after thoracic esophagectomy compared to that before surgery. More than 75% of patients experienced less than half the amount of oral intake compared to the status before surgery.
Low strength physical activity was most frequently found (410 min/week), while high strength physical activity was seldom found (13.03 min/week) in patients at 1e2 months after esophagectomy. The mean duration of walking was 74.84 min/week after surgery (Fig. 5a). The frequency of weekly physical activity is summarized in Fig. 5b. Low strength physical activity was found almost every day (6.8 days/week), while high strength physical activity occurred less than 1 day in a week and was the least frequent (0.81 days/week). The mean frequency of walking activity was 5.69 days in a week. 3.5. Summary of frequent required information from patients The medical information frequently requested by patients from medical staff is summarized in Fig. 6. A high percentage of patients requested “Further understanding of postoperative body status and symptoms” (97.9%) and “further information about the treatment of
To evaluate the educational impact and clinical significance of IPSP, we investigated the incidence of readmission and unscheduled outpatient visits after esophagectomy. For this purpose, we evaluated 50 consecutive patients who underwent thoracic esophagectomy before the implementation of the IPSP (before IPSP), and analyzed the clinical factors compared to 48 patients after the implementation of the IPSP (after IPSP). There were no differences in demographics and characteristics between the two groups (data not shown). The incidences of readmission were 4.0% and 2.1% in patients before and after IPSP (P ¼ 0.17; Fig. 8a). The incidences of unscheduled outpatient visits were 14.0% and 4.1% in patients before and after IPSP (P ¼ 0.03; Fig. 8b). 4. Discussion The actual daily situation of patients after esophagectomy has not been fully unveiled because of the insufficiency of specific tools to measure daily activity and the symptomatic status of patients with esophageal cancer, particularly those who undergo thoracic esophagectomy with three-field lymph node dissection. We explored the daily activity and symptomatic problems of patients after thoracic esophagectomy through an IPSP, which was developed to resolve troublesome postoperative symptoms and enhance the daily activity in relative early periods after esophagectomy. In the present study, we introduced our attempt to conduct an IPSP to
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
63
Fig. 5. The summary of the patients' weekly physical activities after thoracic esophagectomy evaluated by International Physical Activity Questionnaire (IPAQ). (a) The total time of physical activity revealed 410 min of low strength physical activity in a week. On the contrary, less than 30 min of physical activities were performed at middle and high strength levels. The average weekly total time of walking was 74.8 min. (b) The frequency of physical activity indicated that low strength physical activity was performed 6.8 days in a week, whereas high and middle level of physical activities were performed 0.8 and 1.2 days, respectively. The average frequency of walking was 5.7 days in a week.
Fig. 6. The summary of the patients' frequently requested information from medical staff after thoracic esophagectomy. The most frequently requested information was “Explanation of postoperative body status and symptoms,” followed by “Information about the treatment of esophageal cancer.”
investigate the postoperative status and to support and educate patients and families after thoracic esophagectomy. Interdisciplinary team care can be defined as the structured working practices that dictate how different healthcare practitioners interact together to contribute to patient care. The importance of the interdisciplinary team approach has been well recognized [17]. There has been an increase in the reports of intervention trials in outpatient clinics to support patients and
families, particularly after the cases of advanced stage cancer increased [18]. However, most of these trials were focused on the specific status, such as caregiving for end-stage disease. In the previous studies of interdisciplinary support programs for postoperative patients, attempts to evaluate the efficacy of postoperative interdisciplinary team care were mostly focused on medical hospital wards to evaluate the commonly used clinical parameters such as length of hospital stay, readmission, morbidity,
64
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
Fig. 7. The summary of the patients' comments after the Interdisciplinary Postoperative Support Program (IPSP). (a) More than 80% of the patients answered that the IPSP meeting was helpful to solve their questions after esophagectomy. (b) More than 60% patients reported that the IPSP meeting was informative to improve daily life after esophagectomy. (c) More than 90% patients thought that the IPSP was useful.
Fig. 8. The incidence of readmission and unscheduled outpatient visits. (a) The incidence of readmission before and after thoracic esophagectomy and after the completion of the IPSP. Although there was no significant difference, the incidence of readmission tended to decrease after the completion of the IPSP. (b) A significant decrease in unscheduled outpatient visits was found after the completion of the IPSP.
and mortality [17]. In this setting, although there is some evidence that improvement in interdisciplinary collaboration may reduce complications of care [19], most of the previous studies demonstrated that interdisciplinary interventions do not affect these clinical outcomes. Significant contemporaneous secular reductions in the length of stay have been reported [20]. Thus, interdisciplinary interventions confined to the inpatient setting are unlikely to reduce the incidence of readmissions or increase daily activity and QOL level after discharge from the hospital. However, the actual clinical benefit of interdisciplinary intervention for outpatients is not clearly identified. Therefore, clinical significance to evaluate the daily status of outpatients should be more focused, particularly in patients undergoing highly invasive procedures, such as thoracic esophagectomy.
Our results demonstrated the frequency of troublesome postoperative symptoms other than daily activities and the actual oral intake status. There were no significant trends in troublesome postoperative symptoms regardless of the surgical approaches (data not shown). The investigation of the frequent troublesome physical symptoms indicated that dysphagia was the most frequent troublesome symptom, which was understood in the broad sense of the word, such as a feeling of dysphagia manifesting as swallowing discomfort with no actual stasis of oral diet. The incidence and frequency of other postoperative symptoms such as dry cough, weight loss, and reflux were reasonable, and further observation with long-term follow-up would be required. Regarding the incidence of readmission and unscheduled outpatient visits, our study indicated the potential importance of an
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
IPSP. Although not significantly different, a lower incidence of readmission was found and unscheduled outpatient visits in the after IPSP group significantly decreased. Frequent physical symptoms resulting in these unscheduled outpatient visits were not clinically significant, and included low grade fever and swallowing discomfort with no signs of anastomotic stricture on esophagography (data not shown). The implementation of an IPSP led patients to further understanding of predictable physical symptoms, which could be related to a lower incidence of unscheduled outpatient visits. The present study had several limitations. The study period covered a span of 2 years, during which slight modifications of the postoperative clinical management protocol occurred. Thus, the outcome of the present study may be affected by the perioperative management of patients with different patient characteristics. An important point of the present study is that operative procedures were performed with the same indication criteria for thoracic and abdominal approaches.
65
Guarantor Takeo Fujita, M.D., Ph.D., F.A.C.S. Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan, 6-5-1, Kashiwanoha, Kashiwa, Chiba 2778577, Japan. E-mail: [email protected]. Human rights statement and informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and the Helsinki Declaration of 1964 and later versions. Informed consent or substitute for it was obtained from all patients for being included in the study. Consent for publication Not applicable.
5. Conclusions Availability of data and material Our attempt at conducting an IPSP achieved acceptable value from patients and their families. This program clarified the frequent postoperative troublesome symptoms as well as the actual oral intakes and weekly activities at 1 month after thoracic esophagectomy. Further investigations would be considered because we did not examine the measurement properties of different familial backgrounds. Moreover, we must consider further follow-up evaluation to manage long-term postoperative troublesome symptoms after thoracic esophagectomy.
Please contact author for data requests. Acknowledgments We greatly appreciate the critical discussion of our manuscript provided by the members of the Division of Gastrointestinal Oncology. Appendix A. Supplementary data
Ethical Approval All patients provided written informed consent for their information to be stored in hospital database. Study approved was obtained from independent ethics committees at the National Cancer Center Hospital. Sources of funding There are no financial relationships or support that may pose a conflict of interest. Author contribution Takeo Fujita, Hatoe Sakamoto and Hiroyuki Daiko contributed the design and the concept of the article. Takeo Fujita contributed the interpretation and drafting the article. Yoko Iida, Chihau Tanaka, Kumi Nakamura, Keiko Yamanaka, Junya Ueno, Yoshie Iino, Chitose Haruka, and Hatoe Sakamoto contributed acquisition and analysis of data. All authors participated in drafting the article. All authors gave final approval of the version submitted. Conflict of interest All authors declare that they have no conflict of interest. Trial registry number Researchregistry2420.
Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.ijsu.2017.05.036. References [1] P. van Hagen, M.C. Hulshof, J.J. van Lanschot, E.W. Steyerberg, M.I. van Berge Henegouwen, B.P. Wijinhoven, et al., Preoperative chemoradiotherapy for esophageal or junctional cancer, N. Engl. J. Med. 366 (2012) 2074e2084. [2] M. Nakamura, Y. Kido, M. Yano, Y. Hosoya, Reliability and validity of a new scale to assess postoperative dysfunction after resection of upper gastrointestinal carcinoma, Surg. Today 35 (2005) 535e542. [3] H. Yamashita, K. Okuma, Y. Seto, K. Mori, S. Kobayashi, R. Wakui, et al., A retrospective comparison of clinical outcomes and quality of life measures between definitive chemoradiation alone and radical surgery for clinical stage II-III esophageal carcinoma, J. Surg. Oncol. 100 (2009) 435e441. [4] M. van Heijl, M.A. Sprangers, A.G. de Boer, S.M. Lagarde, H.B. Reitsma, O.R. Busch, et al., Preoperative and early postoperative quality of life predict survival in potentially curable patients with esophageal cancer, Ann. Surg. Oncol. 17 (2010) 23e30. [5] R.D. Stock, D. Reece, L. Cesario, Developing a comprehensive interdisciplinary senior healthcare practice, J. Am. Geriatr. Soc. 52 (2004) 2128e2133. [6] J. Berger-Fiffy, The “nuts and bolts” of implementing shared medical appointments: the Harvard Vanguard Medical Associates experience, J. Ambul. Care. Manage 35 (2012) 247e256. [7] N. Gutierrez, N.E. Gimple, F.J. Dallo, B.M. Foster, E.J. Ohagi, Shared medical appointments in a residency clinic: an exploratory study among Hispanics with diabetes, Am. J. Manag. Care 17 (2011) e212ee214. [8] A. Lin, J. Cavendish, D. Boren, T. Ofstad, D. Seidensticker, A pilot study: reports of benefits from a 6-months, multidisciplinary, shared medical appointment approach for heart failure patients, Mil. Med. 173 (2008) 1210e1213. [9] H. Daiko, T. Fujita, The Concept of lymphadenectomy along the recurrent laryngeal nerves during thoracoscopic esophagectomy in the prone position, Nihon. Geka. Gakkai. Zasshi 117 (2016) 144e147. [10] M.J. Seager, R.J. Egan, H.E. Meredith, S.E. Bates, S.A. Norton, J.D. Morgan, Shared medical appointments for bariatric surgery follow-up: a patient satisfaction questionnaire, Obes. Surg. 22 (2012) 641e645. [11] M.D. Harris, Shared medical appointments after cardiac surgery-the process of implementing a novel pilot paradigm to enhance comprehensive postdischarge care, J. Cardiovasc. Nurs. 25 (2010) 124e129. [12] A.B. Guirguis, J. Lugovich, J. Jay, K.A. Sanders, S.T. Cioffi, S.M. Jeffery, et al., Improving diabetes control using shared medical appointments, Am. J. Med.
66
T. Fujita et al. / International Journal of Surgery 43 (2017) 58e66
126 (2013) 1043e1044. [13] K. Dickman, C. Pintz, K. Gold, C. Kivlahan, Behavior changes in patients with diabetes and hypertension after experiencing shared medical appointments, J. Am. Acad. Nurse. Pract. 24 (2012) 43e51. [14] S.C. Reed, A.H. Partridge, L. Nekhlyudov, Shared medical appointments in cancer survivorship care: a review of the literature, J. Oncol. Pract. 11 (2015) 6e11. [15] K.A. Calzone, S.A. Prindiville, O. Jourkiv, J. Jenkins, M. DeCarvalho, D.B. Wallerstedt, et al., Randomized comparison of group versus individual genetic education and counseling for familial breast and/or ovarian cancer, J. Clin. Oncol. 23 (2005) 3455e3464. [16] K. Trotter, A. Frazier, C.K. Hendricks, H. Scarsella, Innovation in survivor care: group visits, Clin. J. Oncol. Nurs. 15 (2011) E24eE33. [17] S. Pannick, R. Davis, H. Ashrafian, B.E. Byrne, I. Beveridge, T. Athanasiou, et al.,
Effects of interdisciplinary team care interventions on general medical wards. A systematic Review, JAMA. Int. Med. 175 (2015) 1288e1298. [18] L.S. Prescott, A.S. Dickens, S.L. Guerra, J.M. Tanha, D.G. Phillips, K.T. Patel, et al., Fighting cancer together: development and implementation of shared medical appointments to standardize and improve chemotherapy education, Gynecol. Oncol. 140 (2016) 114e119. [19] R. Fernandez, D.T. Tran, M. Johnson, S. Jones, Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery, J. Nurs. Manag. 3 (2010) 265e274. [20] S. Saint, K.E. Fowler, S.L. Krein, S.A. Flanders, T.W. Bodnar, E. Young, et al., An academic hospitalist model to improve healthcare worker communication and learner education: results from a quasi-experimental study at a veterans Affairs medical center, J. Hosp. Med. 8 (2013) 702e710.