Development and validation of a novel nomogram model for identifying risk of prolonged length of stay among patients receiving free vascularized flap reconstruction of head and neck cancer

Background

The aim of the present study was to build and internally validate a nomogram model for predicting prolonged length of stay (PLOS) among patients receiving free vascularized flap reconstruction of head and neck cancer (HNC).

Methods

A retrospective clinical study was performed at a single center, examining patients receiving free vascularized flap reconstruction of HNC from January 2011 to January 2019. The variables were obtained from the electronic information system. The primary outcome measure was PLOS. Univariate and multivariate analyses were used to find risk factors for predicting PLOS. A model was then built according to multivariate results. Internal validation was implemented via 1000 bootstrap samples.

Results

The study included 1047 patients, and the median length of stay (LOS) was 13.00 (11.00, 16.00) days. Multivariate analysis showed that flap types ((radial forearm free flap (odds ratio [OR] = 2.238; 95% CI, 1.403-3.569; P = 0.001), free fibula flap (OR = 3.319; 95% CI, 2.019-4.882; P < 0.001)), duration of surgery (OR = 1.002; 95% CI, 1.001-1.003; P = 0.004), postoperative complications (OR = 0.205; 95% CI, 0.129-0.325; P = P < 0.001) and unplanned reoperation (OR = 0.303; 95% CI, 0.140-0.653; P = 0.002) were associated with PLOS. In addition to these variables, blood transfusion was comprised in the model. The AUC of the model was 0.78 (95% CI, 0.711-0.849) and 0.725 (95% CI, 0.605-0.845) in the primary and internal validation cohorts, respectively. The DCA revealed the clinical utility of the current model when making intervention decisions within the PLOS possibility threshold range of 0.2-0.8.

Conclusions

Our study developed a nomogram that exhibits a commendable level of accuracy, thereby aiding clinicians in assessing the risk of PLOS among patients receiving free vascularized flap reconstruction for HNC.

Oncological and functional outcome after laryngectomy for laryngeal and hypopharyngeal cancer: a population-based analysis in Germany from 2001 to 2020

Prognostic factors for overall survival (OS), percutaneous endoscopic gastrostomy (PEG) dependency, and long-term speech rehabilitation via voice prosthesis (VP) after laryngectomy for laryngeal or hypopharyngeal cancer were investigated in a retrospective population-based study in Thuringia, Germany. A total of 617 patients (68.7% larynx; hypopharynx; 31.3%; 93.7% men; median age 62 years; 66.0% stage IV) from 2001 to 2020 were included. Kaplan-Meier and Cox multivariable regression analyses were performed. 23.7% of patients received a PEG. 74.7% received a VP. Median OS was 131 months. Independent factors for lower OS were stage IV (compared to stage II; hazard ratio [HR] = 3.455; confidence interval [CI] 1.395-8.556) and laryngectomy for a recurrent disease (HR = 1.550; CI 1.078-2.228). Median time to PEG removal was 7 months. Prior partial surgery before laryngectomy showed a tendency for independent association for later PEG removal (HR = 1.959; CI 0.921-4.167). Postoperative aspiration needing treatment was an independent risk factor (HR = 2.679; CI 1.001-7.167) for later definitive VP removal. Laryngectomy continuously plays an important role in a curative daily routine treatment setting of advanced laryngeal or hypopharyngeal cancer in Germany. Long-term dependency on nutrition via PEG is an important issue, whereas use of VP is a stable long-term measure for voice rehabilitation.

Total laryngectomy and readmission: causes, rates and predictors

BACKGROUND

Total laryngectomy (TL) is a complex procedure, and patients undergoing TL are at high risk for readmission, which exposes them to hospital-acquired complications. Readmission rate is a metric for quality of care. We aimed to identify the rate, causes, and predictors of hospital readmission within 60 days after discharge following TL.

METHODS

This is a 12-year retrospective study where we included all patients undergoing TL in a single tertiary care center between 2008 and 2022. Patient charts were reviewed for demographics, comorbidities, and causes for readmission.

RESULTS

Of 83 patients who underwent TL, 12 (14.50%) were readmitted within 60 days. Common causes were surgical site infection (33.33%) and mucocutaneous fistula (25%). Significant predictors for readmission were tobacco use (P = 0.003), African ethnicity (P = 0.004), being unmarried (P < 0.001), lower preoperative serum albumin (P < 0.001), higher preoperative TSH (P = 0.03), higher preoperative neutrophil count (P = 0.035), higher American Society of Anesthesiology (ASA) score (P = 0.028), and higher Cumulative Illness Rating Scale (CIRS) score (P = 0.029).

CONCLUSION

One in every seven patients were readmitted following TL. Frequent causes include wound infection and fistulas. Predictors include preoperative hypoalbuminemia, hypothyroidism, African ethnicity, being unmarried, tobacco use, and a higher baseline burden of comorbidities. Such factors can be targeted to reduce hospital readmission rates.

A nationwide analysis of salvage surgery for laryngeal cancer in the elderly

BACKGROUND

We aim to describe outcomes of elderly patients undergoing salvage surgery for laryngeal cancer and to characterize the interplay of age with various other factors in this growing population.

METHODS

Using the National Cancer Database, we identified cases of salvage laryngectomy in patients who failed chemoradiation. An age cutoff of 70 years was used to separate subjects into two groups. Various factors were compared.

RESULTS

Of the 825 patients included, 166 (20.1%) were elderly. Elderly patients had worse overall survival (p = 0.001), higher 30-day and 90-day mortality (p = 0.006, p < 0.001), and a longer length of stay (LOS) (p = 0.015). LOS over 1 week was associated with worse survival (p = 0.032).

CONCLUSION

Elderly patients had worse overall perioperative survival than their younger counterparts. LOS and 30-day readmissions were associated with higher risk of mortality in this group. We provide a contemporary set of relevant information for head and neck cancer providers to consider in this growing population.

The Enhanced Recovery After Surgery (ERAS) protocol in head and neck cancer: a matched-pair analysis

Objective

In this study, we aimed to describe the prospective implementation of the Enhanced Recovery after Surgery (ERAS) protocol in an Italian tertiary academic centre.

Methods

Adult patients receiving surgery for primary or recurrent clinical stage III/IV squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were enrolled. The primary objective was to evaluate the impact of the ERAS protocol on length of hospital stay (LOS). The secondary objective was to assess its impact on complications. To evaluate the results of the ERAS protocol, a matched-pair analysis was conducted, comparing ERAS patients with comparable cases treated before 2018.

Results

Forty ERAS and 40 non-ERAS patients were analysed. There were no significant differences between the cohorts regarding age, gender, stage of disease, comorbidity, ASA score, and duration of surgery. A significantly shorter LOS for the ERAS group (median, 14 days; range, 10-19) than for non-ERAS patients (median, 17.5 days; range, 13-21) was observed (p = 0.0128). The incidence of complications was not significantly different (p = 0.140).

Conclusions

Our study demonstrates that the introduction of an ERAS protocol in the daily practice is feasible, and can result in significant reduction in LOS.

Frailty Index as a Predictor of Readmission in Patients With Head and Neck Cancer

OBJECTIVE

To evaluate the predictive utility of the Hospital Frailty Risk Score (HFRS), a stratification tool based on the ICD-10 (International Classification of Disease, Tenth Revision), and other risk factors for 30-day readmissions and mortality in a nationally representative cohort.

STUDY DESIGN

Retrospective database review.

SETTING

Nationwide Readmissions Database (2017).

METHODS

Patients with head and neck cancer who underwent major surgical procedures were identified from the 2017 Nationwide Readmissions Database, representing 116 medical centers nationwide. Bivariate and multivariable logistic regression methods were used to identify factors associated with unplanned 30-day readmission, 30-day readmission mortality, and increased length of hospital stay.

RESULTS

A total of 14,420 patients underwent major head and neck cancer surgery. Unplanned readmission occurred in 11% of patients. The most common reasons for unplanned readmission were procedural complications (26.5%), sepsis (7.3%), and respiratory failure (3.9%). Elevated frailty index (HFRS ≥5) was identified in 22% of patients. Frailty was associated with higher 30-day readmission rates (18.0% vs 9.5%, P < .01), which held on multivariate modeling (odds ratio [OR], 1.59 [95% CI, 1.37-1.85]). Frail patients spent more days in the hospital (8.2 vs 6.8, P = .02) and incurred more charges across hospital stays ($275,000 vs $188,000, P < .01). Patients >75 years old (OR, 1.26 [1.03-1.55]) and patients with electrolyte abnormalities (OR, 1.25 [1.07-1.46] were significantly more likely to be readmitted.

CONCLUSION

In this head and neck cancer surgical population, HFRS significantly predicted unplanned readmission. HFRS is a potential risk stratification tool and should be compared with other methods and explored in other cancer populations. Beyond the challenge of identifying at-risk patients, future work should explore potential interventions aimed at mitigating readmission.

Head and neck cancer readmission reduction (HANCARRE) project: Reducing 30-day readmissions

Objective

Unplanned 30-day readmissions result in increased costs and decreased patient satisfaction. The objective of this study was to compare readmission rates before and after a multidisciplinary quality improvement initiative that focuses on patient and staff education, use of targeted skilled nursing facilities, and appropriate use of patient observation status.

Methods

This was a quality improvement study of all unplanned admissions to the Head and Neck Oncology service at a tertiary care facility during a 3-year period between October 2015 and September 2018. In October 2016, when the Head and Neck Oncology service revised its discharge practices for patients undergoing extirpative and/or reconstructive surgery. These changes included enhancing patient education, increasing the use of a skilled nursing facility with directed staff education and patient handoffs by advanced practice nurses, and appropriate utilization of 23-h observation status for returning patients. The readmission rate from the pre-intervention era (October 2015 through September 2016) was compared to the readmission rate from the post-intervention era (October 2016 through September 2018). Secondary outcomes were the rates of 23-h observation within 30 days of the discharge as well as emergency room visits within 30 days of discharge.

Results

In this sample of 449 patients, 161 (35.9%) were observed before the change-in-practice (before October 2016), and 288 (64.1%) were observed following the change-in-practice (after September 2016). On univariable analysis, the risk of readmission declined by approximately 41.4% from the pre-intervention era, though this conclusion was not statistically significant (P = 0.06). On multivariable analysis, patients at moderate or high risk of death were 2.31 times more likely than those at minor risk of death to readmit within 30 days (P = 0.03). Similarly, those with recurrent or persistent cancer were 3.33 times more likely than those undergoing initial curative surgical management of cancer to readmit within 30 days (P = 0.001). No patient characteristics were associated with a 23-h observation following discharge (all P > 0.05). Conclusions were similar for emergency room visits following discharge.

Conclusions

A three-part quality improvement strategy resulted in a clinically important decrease in 30-day readmissions, though the decline was not statistically significant. There were no significant changes in 23-h observation within 30 days of discharge or emergency room visits within 30 days of discharge.

Surgical wound classification in otolaryngology: A state-of-the-art review

Objective

To describe the issues related to the assignment of surgical wound classification as it pertains to Otolaryngology-Head & Neck surgery, and to present a simple framework by which providers can assign wound classification.

Data Sources

Literature review.

Conclusion

Surgical wound classification in its current state is limited in its utility. It has recently been disregarded by major risk assessment models, likely due to inaccurate and inconsistent reporting by providers and operative staff. However, if data accuracy is improved, this metric may be useful to inform the risk of surgical site infection. In an era of quality-driven care and reimbursement, surgical wound classification may become an equally important indicator of quality.

Outcomes for head and neck cancer patients admitted to intensive care in Australia and New Zealand between 2000 and 2016

OBJECTIVE

To report intensive care unit admission outcomes for head and neck cancer patients.

METHODS

A retrospective, observational cohort analysis of all Australian and New Zealander head and neck cancer patient intensive care unit admissions from January 2000 to June 2016, including data from 192 intensive care units.

RESULTS

There were 10 721 head and neck cancer patients, with a median age of 64 years (71.6 per cent male). Of admissions, 76.4 per cent were in public hospitals, 96.9 per cent were post-operative and 43.6 per cent required mechanical ventilation. Annual head and neck cancer admissions increased from 2000 to 2015 (from 348 to 1132 patients), but the overall proportion of intensive care unit admissions remained constant. In-hospital mortality was 2.7 per cent, and intensive care unit mortality was 0.7 per cent. The in-hospital mortality risk decreased three-fold (p < 0.001).

CONCLUSION

Head and neck cancer patients had low mortality in the intensive care unit and in hospital. Risk of dying decreased despite more intensive care unit admissions. This is the first large-scale cohort study quantifying intensive care unit utilisation by head and neck cancer patients. It informs future work investigating alternatives to the intensive care unit for these patients.

Stapler closure versus manual closure in total laryngectomy for laryngeal cancer: A systematic review and meta-analysis

OBJECTIVE

Total laryngectomy (TL) is a life-saving procedure for individuals with advanced laryngeal cancer and those suffering from recurrence after initial treatment. The present study aimed to evaluate the differences between stapler closure (SC) and manual closure (MC) of the pharynx during TL for patients with laryngeal cancer.

DESIGN/SETTING

A systematic literature search was performed using the PubMed, EMBASE and Cochrane Library databases. The data were analysed using Comprehensive Meta-Analysis software (Version 3; Biostat). Dichotomous data were calculated as odds ratios (ORs), and continuous data were calculated as mean differences (MD) with 95% confidence intervals (CI).

MAIN OUTCOME/RESULTS

A total of seven studies (535 patients) were included in this meta-analysis. Pooled analysis showed that the operative time of TL was significantly reduced in the SC group (MD, -63.2; 95% CI, -106.0 to -20.4). Moreover, the SC group had a lower incidence of pharyngocutaneous fistula (OR = 0.38; 95% CI, 0.18 to 0.83; P = .016) and hospital stay (MD, -2.9; 95% CI, -5.6 to -0.1). The incidence of postoperative surgical site infection (OR = 0.41; 95% CI, 0.02 to 8.73; P = .565) was comparable between the two groups.

CONCLUSION

Based on these results, SC may be a useful option for patients who need TL.

The Cost of Postoperative Complications and Economic Validation of the Comprehensive Complication Index: Prospective Study

OBJECTIVE

To validate the Comprehensive Complication Index (CCI) via an assessment of its relation to postoperative costs.

BACKGROUND

The CCI summarizes all the postoperative complications graded by the Clavien-Dindo classification (CDC) on a numerical scale. Its relation to hospital costs has not been validated to date.

METHODS

Prospective observational cohort study, including all patients undergoing surgery at a general surgery service during the 1-year study period. All complications graded with the CDC and CCI and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. The surgeries were classified according to their Operative Severity Score (OSS) and in 4 groups of homogeneous surgeries. All postoperative costs were recorded.

RESULTS

In all, 1850 patients were included, of whom 513 presented complications (27.7%). The CDC and the CCI were moderately to strongly correlated with overall postoperative costs (OPCs) in all OSS groups (rs = 0.444-0.810 vs 0.445-0.820; P < 0.001), homogeneous surgeries (rs = 0.364-0.802 vs 0.364-0.813; P < 0.001), prolongation of postoperative stay (rs = 0.802 vs 0.830; P < 0.001), and initial operating room costs (rs = 0.448 vs 0.451; P < 0.001). This correlation was higher in emergency surgery. With higher CDC grades, the OPC tended to increase an upward trend. In the multivariate analysis, CDC, CCI, age, and duration of surgery were all associated with OPC (P < 0.001).

CONCLUSIONS

In our environment, the CCI presented associations with OPC. This demonstration of its economic validity enhances its clinical validity.

Prolonged inpatient stay after upfront total laryngectomy is associated with overall survival

OBJECTIVES

To investigate factors and complications associated with prolonged inpatient length of stay (LOS) in patients who receive total laryngectomy (TL), and to analyze its effect on short-term and long-term overall survival (OS).

METHODS

The National Cancer Database (NCDB) was queried from 2004 to 2016 for patients with laryngeal cancer, who received TL within 60 days of diagnosis, and who had an inpatient LOS ≥1 night. Multivariable binary logistic regression and survival analyses on propensity score matched cohorts with Kaplan-Meier analysis and extended Cox regression were utilized.

RESULTS

Eight thousand two hundred and ninety-eight patients from the NCDB were included. Median inpatient LOS was 8 days after TL (IQR: 7, 12). Prolonged LOS was defined as above the 75th percentile or 13 days or greater. On multivariable analysis, increasing patient age (OR 1.14 per 10 years, P = .003), female sex (OR 1.35, P < .001), and Charlson-Deyo comorbidity score of ≥2 compared to a score of 0 (OR 1.43, P < .001) were associated with prolonged LOS. Patients treated at high surgical case volume centers had a decreased likelihood for prolonged LOS (OR 0.67, P < .001). Ninety-day mortality increased over time in patients who stayed ≥13 days. Prolonged LOS was independently associated with worse OS on multivariable analysis (HR 1.40, 95% CI: 1.22, 1.61) in a matched cohort.

CONCLUSIONS

Prolonged LOS after TL serves as a strong indicator for postoperative long-term mortality and may help identify patients who warrant closer surveillance.

LEVEL OF EVIDENCE

3.

Surgical Site Infection Affects Length of Stay After Complex Head and Neck Procedures

OBJECTIVES/HYPOTHESIS

Quality improvement (QI) initiatives emphasize a need for reduction in hospital length of stay (LOS). We sought to determine the impact of surgical site infections (SSIs) on LOS after complex head and neck surgery (HNS).

STUDY DESIGN

Retrospective cohort analysis.

METHODS

An analysis of the American College of Surgeons National Surgical Quality Improvement Program was undertaken. All adult patients undergoing complex HNS from 2005 to 2016 were included in the analysis. Our main outcomes were SSI incidence and increase in hospital LOS attributable to SSI.

RESULTS

Of 4,014 patients identified, 16.5% developed SSI. History of smoking, diabetes, preoperative wound infection, contaminated or dirty wound classes, and prolonged operative time were found to significantly predict postoperative SSI. Adjusting for significant pre- and postoperative factors, SSI was associated with significantly increased LOS (hazard ratio = 0.486, 95% confidence interval: 0.419-0.522).

CONCLUSIONS

SSI following complex HNS is associated with significantly increased hospital LOS. This result supports the need for institutional QI strategies that target SSIs after head and neck procedures in an effort to provide the highest quality care at the lowest possible cost. Our analysis identifies risk factors that can allow identification of patients at high risk of SSI and prolonged hospitalization.

LEVEL OF EVIDENCE

2b Laryngoscope, 2020.

Short-Term Morbidity and Predictors of Adverse Events Following Esthesioneuroblastoma Surgery

INTRODUCTION

The short-term adverse events and predictors of morbidity in surgical resection of esthesioneuroblastoma (ENB) are largely unknown, and investigating these variables can help direct planning for at-risk patients.

METHODS

The 2005-2017 National Surgical Quality Improvement Program database was queried to identify patients with a diagnosis of ENB undergoing skull base surgery for tumor resection. Information regarding demographics, patient morbidity score, pre-operative and intra-operative data, and post-operative outcomes were extracted. Cox proportional hazard analysis was utilized to assess complication and readmission/reoperation rates.

RESULTS

A total of 95 patients undergoing skull base surgery for resection of ENB were included. Mean age, BMI, operation time, and post-operative length of stay (LOS) of the cohort were 53.6 ± 16.2 years, 29.1 ± 6.5, 392.0 ± 204.6 minutes, and 5.8 ± 4.6 days, respectively. In total, 31 patients (32.6%) experienced at least one 30-day adverse event, which included blood transfusion intra-operatively or within 72 hours from the operation (22.1%), readmission (10.7%), intubation >48 hours (7.4%), reintubation (4.2%), organ or space infection (4.2%), reoperation (4.0%), superficial or deep surgical site infection (2.1%), sepsis (2.1%), pulmonary embolism (1.1%), and myocardial infarction (1.1%). Patients who experienced at least one adverse event had significantly higher operation time (486.8 ± 230.4 vs. 347.5 ± 176.2 minutes, p = 0.002), LOS (9.2 ± 5.6 days vs. 4.2 ± 3.0, p < 0.001), and lower hematocrit (37.3 ± 5.9 vs. 41.2 ± 3.8, p < 0.001) and albumin levels (3.8 ± 0.6 vs. 4.2 ± 0.3, p = 0.009). Patients with a higher American Society of Anesthesiologists (ASA) score (HR = 2.39; p = 0.047) or longer operation time (HR = 1.004; p = 0.001) had a significantly higher risk for experiencing adverse events. Obesity was not associated with different intra- or post-operative outcomes, but older patients had shorter operations (p = 0.002) and LOS (p = 0.0014).

CONCLUSION

Longer operation time and lower pre-operative hematocrit and albumin levels may all increase complication rates in ENB resection. Patients with high ASA score or more advanced age may have different short-term outcomes.

Predictors of surgical readmission, unplanned hospitalization and emergency department use in head and neck oncology: A systematic review

OBJECTIVE

To identify predictors of unplanned hospitalization and emergency department (ED) use among head and neck oncology patients.

METHODS

Peer reviewed publications were identified through a systematic search of MEDLINE, Embase and Cochrane CENTRAL. Studies describing a cohort of HNC patients that detailed predictors of unplanned hospitalization or ED use in risk-adjusted models were eligible for inclusion. The methodologic quality of included studies was assessed using the Quality In Prognostic Studies (QUIPS) tool and an adapted version of the GRADE framework.

RESULTS

Of the 932 articles identified, 39 studies met our inclusion criteria with 31/39 describing predictors of surgical readmission and 10/39 describing predictors of ED use or unplanned hospitalization during radiation/chemoradiation treatment. Risk factors were classified into either 'patient-related', 'cancer severity' or 'process' factors. In the subset of studies looking at readmission following surgery wound complications (10/14 studies), presence of comorbidity (16/28 studies), low socioeconomic status (8/17 studies), cancer stage (9/14 studies), and prolonged hospital stay (7/18 studies) were the variables most frequently associated with readmission on multivariable analysis. Presence of comorbidity (6/10) and chemotherapy use (4/10) were more frequently associated with ED use and unplanned hospitalization.

CONCLUSIONS

Several consistent predictors have been identified across a variety of studies. This work is a critical first step towards the development of readmission and ED prediction models. It also enables meaningful comparison of hospital readmission rates with risk adjustment in HNC patients.

Predictive factors of a prolonged length of stay in a community Nursing-Led unit: A retrospective cohort study

AIMS AND OBJECTIVES

To describe the care provided to patients admitted into a community Nursing-Led inpatient unit and to identify factors predicting a length of stay exceeding an established threshold.

BACKGROUND

Few studies have been conducted to describe the care provided in a Nursing-Led unit. No studies have investigated factors affecting length of stay in these services.

DESIGN

Retrospective cohort study.

METHODS

Consecutive patients admitted to a community Nursing-Led unit between 2009-2015 were enrolled. Sociodemographic, medical and nursing care (diagnoses and activities) variables were collected from electronic health records. Descriptive analysis and a backward stepwise logistic regression model were applied. The study followed the STROBE guidelines.

RESULTS

The study enrolled 904 patients (mean age: 77.7 years). The most frequent nursing diagnoses were bathing self-care deficit and impaired physical mobility. The nursing activities most provided were enteral medication administration and vital signs measurement. Approximately 37% of the patients had a length of stay longer than the established threshold. Nine covariates, including being discharged to home, having an impaired memory nursing diagnosis or being treated for advanced wound care, were found to be independent predictors of prolonged length of stay. Variables related to medical conditions did not affect the length-of-stay threshold.

CONCLUSIONS

The length of stay in the community Nursing-Led unit was mainly predicted by conditions related to sociodemographic factors, nursing complexity and functional status. This result confirms that the medical and nursing needs of a community Nursing-Led unit population substantively differ from those of hospitalised acute patients.

RELEVANCE TO CLINICAL PRACTICE

The nursing complexity and related nursing care to be provided may be adopted as a criterion to establish the appropriate length of stay in the community Nursing-Led unit for each individual patient.

Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study

BACKGROUND

Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort.

METHODS

Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models.

RESULTS

Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival.

CONCLUSIONS

Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.

Predicting length of stay in head and neck patients who undergo free flap reconstruction

OBJECTIVE

Understanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS.

METHODS

A retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS.

RESULTS

A total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF-73.8%, anterolateral thigh flap-11.3%, and fibula free flap-14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [C] = +4.26, P < .0001), in-hospital PNA or UTI (C = +2.52, P = .037), wound breakdown or fistula (C = +5.0, P < .0001), surgical site infection (C = +3.54, P = .017), and prior radiation therapy (C = +2.59, P = .004).

CONCLUSION

Several perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution-level protocols for postoperative care and disposition of free flap patients.

LEVEL OF EVIDENCE

2b; retrospective cohort.

National Surgical Quality Improvement Program risk calculator validity in South Australian laryngectomy patients

BACKGROUND

Assessing an individual patient's post-operative risk profile prior to laryngectomy for cancer is difficult. The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator was developed to better inform preoperative decision-making. The calculator uses patient-specific characteristics to estimate the risk of experiencing post-operative complications within 30 days of surgery. We investigated the ACS-NSQIP risk calculator's performance for Australian laryngectomy patients.

METHODS

The ACS-NSQIP risk calculator was used to retrospectively calculate the 30-day post-operative predicted outcomes in patients who underwent laryngectomy for laryngeal, hypopharyngeal and thyroid cancers (with laryngeal involvement) in two institutions in South Australia. These data were compared against the actual mortality, morbidity, complications and length of stay (LOS) collected from a retrospective chart review.

RESULTS

A total of 144 patients underwent surgical intervention for malignancies with laryngeal involvement. The median LOS was 25 days (range 13-197) compared to the predicted LOS of 6.5 days (range 3.5-12.5). Overall mortality was 2.78% with post-operative complications occurring in 63% of patients. The most common complication was wound infection, occurring in 33% of patients. Hosmer-Lemeshow plots demonstrated good agreement between predicted and observed rates for complications.

CONCLUSION

The ACS-NSQIP risk calculator effectively predicted post-operative complication rates in South Australian laryngeal cancer patients undergoing laryngectomy. However, differences in predicted and actual LOS may limit the usefulness of the calculator's LOS predictions for Australian patients.

Understanding Risk Factors Associated With Unplanned Reoperation in Major Head and Neck Surgery

Importance

Understanding the preoperative, intraoperative, and postoperative risk factors of reoperation is the optimal way to approach decreasing its incidence.

Objective

To identify risk factors of unplanned reoperation following major operations of the head and neck.

Design, Setting, and Participants

This retrospective cohort study queried the American College of Surgeons National Surgical Quality Improvement Program database and identified 2475 cases of major operations of the head and neck performed between 2005 and 2014. Specific operations analyzed were glossectomy, mandibulectomy, laryngectomy, and pharyngectomy. Univariate and multivariate analyses were performed to compare demographic and clinical characteristics of patients with or without unplanned reoperation. Data were analyzed between September and November 2017.

Main Outcomes and Measures

The primary outcome was incidence of unplanned reoperation in patients with major operations in the head and neck region. An additional aim was to assess the risk factors associated with an increased likelihood of reoperation.

Results

In total, 1941 patients were included in this study (1298 [66.9%] males), with most patients (961 [49.5%]) between 61 and 80 years of age. The overall unplanned reoperation rate within 30 days after the principal operative procedure was 14.2% (275 patients). The operative procedure with the highest reoperation rate was pharyngectomy (8 of 46 [17.4%]), followed by glossectomy (95 of 632 [15.0%]), laryngectomy (53 of 399 [13.3%]), and mandibulectomy (25 of 240 [10.4%]). Among the unplanned reoperation patients, 516 patients (76.8%) underwent reoperation during their initial hospital admission and 156 patients (23.2%) after readmission. The mean (SD) number of days from the principal operative procedure to unplanned reoperation was 8.5 (3.6) days for initial-admission reoperations and 16.0 (4.8) days for readmission reoperations. The most common unplanned reoperation procedures overall included repair, surgical exploration, and revision procedures on arteries and veins (47 of 2475 [1.9%]), incision procedures on the soft tissue of the neck and thorax (37 of 1941 [1.9%]), and incision and drainage procedures on the skin, subcutaneous, and accessory structures (21 of 1941 [1.1%]). Multivariate analysis results indicated that the independent risk factors for unplanned reoperation following a major cancer operation of the head or neck included black race (odds ratio [OR], 1.72; 95% CI, 1.09-2.74), disseminated cancer (OR, 1.85; 95% CI, 1.14-3.00), greater total operation time (OR, 2.05; 95% CI, 1.49-2.82), superficial (OR, 2.56; 95% CI, 1.55-4.24) or deep (OR, 4.83; 95% CI, 2.60-8.95) surgical site infection, wound dehiscence (OR, 8.36; 95% CI, 5.10-13.69), and ventilator dependence up to 48 hours after surgery (OR, 2.95; 95% CI, 1.79-4.87).

Conclusions and Relevance

The identification of a significant association of black race, disseminated cancer, total operation time, surgical site infection in either the superficial or deep spaces, wound dehiscence, or ventilator dependence for more than 48 hours after surgery with increased risk of reoperation in major head and neck surgery may guide the modification and adaptation of these risk factors to decrease the burden that unplanned reoperation places on patients, surgeons, and the health care system.

Clinical Factors Associated With Reoperation and Prolonged Length of Stay in Free Tissue Transfer to Oncologic Head and Neck Defects

Importance

Prolonged hospitalization and reoperation after free tissue transfer may be associated with certain clinical factors.

Objective

To determine patient and surgical factors associated with length of stay (LOS) and reoperation following surgical procedures for malignant neoplasm of the head and neck involving microvascular free tissue transfer reconstruction.

Design, Setting, and Participants

This was a retrospective review of American College of Surgeons National Surgical Quality Improvement Program data from 2012 to 2014 using International Classification of Diseases, Ninth Revision (ICD-9), codes for malignant neoplasms of the head and neck. Multivariable logistic regression modeling was used to examine correlation of patient and surgical variables with reoperation and LOS. The national retrospective database included outcomes from community and academic participant hospitals (517 member institutions in 2014). A total of 1115 cases of head and neck malignant neoplasm ablation with microvascular free tissue transfer flap were reviewed retrospectively.

Main Outcomes and Measures

Incidence of reoperation within 30 days of index operation and hospitalization equal to or longer than 13.0 days, which is equal to being in the top quartile for duration of stay.

Results

Of the 1115 patients, 370 (33.2) were female, and the mean (SD) age was 66.8 (3.9) years. Predictors of prolonged length of stay included return to the operating room (odds ratio [OR], 4.8; 95% CI, 3.3-6.9), smoking (OR, 2.1; 95% CI, 1.5-3.1), clean-contaminated wound (OR, 2.2; 95% CI, 1.3-4.0), bony flap (OR, 1.8; 95% CI, 1.2-2.8), age (OR, 1.5; 95% CI, 1.2-1.7), and operative time (OR, 1.2; 95% CI, 1.1-1.3). Reoperation occurred 298 times for 225 patients (20.2%). Mean (SD) time to reoperation was 8.0 (7.7) days, with 180 (80%) occurring before discharge from the primary operation. The most common indications for reoperation were neck exploration (37 [12.4%]) or incision and drainage of neck (35 [11.7%]).

Conclusions and Relevance

American College of Surgeons National Surgical Quality Improvement Program data allow for large database analysis of free flap transfer to the head and neck. The data herein provide information to help guide surgeons on which patients will require longer stay in hospital and the most common reasons for return to the operating room. Wound class of index operation, subsequent wound-related complications, and long duration of the index operation were the primary drivers of increased risk for reoperation and, therefore, prolonged hospitalization. These same factors were also associated with prolonged hospitalization without reoperation.

Level of Evidence

NA.

Clinical Validation of the Comprehensive Complication Index as a Measure of Postoperative Morbidity at a Surgical Department: A Prospective Study

OBJECTIVE

Using clinical outcomes, to validate the comprehensive complication index (CCI) as a measure of postoperative morbidity in all patients undergoing surgery at a general surgery department.

BACKGROUND

The Clavien-Dindo classification (CDC) is the most widely used system to assess postoperative morbidity. The CCI is a numerical scale based on the CDC. Once validated, it could be used universally to establish and compare the real postoperative complications of each surgical procedure.

METHODS

Observational prospective cohort study. All patients who underwent surgery during the 1-year study period were included. All the complications graded with the CDC and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. Surgical procedures were classified according to the operative severity score (OSS) as minor, moderate, major, or major+. The clinical validation of the CCI was performed by assessing its correlation with 4 different clinical outcomes.

RESULTS

A total of 1850 patients were included: 513 (27.7%) presented complications and 101 (5.46%) were readmitted. In the multivariate analysis, the CCI and CDC were associated with postoperative stay, prolongation of postoperative stay, readmission, and disability in all OSS groups (P < 0.001). The CCI was superior to the CDC in all models except for prolongation of stay for OSS moderate and major+.

CONCLUSIONS

The CCI can be applied in all the procedures carried out at general surgery departments. It is able to determine the morbidity and allows the comparison of the outcomes at different services.

Effect of medical comorbidities on treatment regimen and survival in T3/T4 laryngeal cancer

OBJECTIVE

Investigate the impact of medical comorbidities on treatment regimen and overall survival (OS) in patients with locally advanced laryngeal cancer.

STUDY DESIGN

Retrospective Review of the National Cancer Database (NCDB).

METHODS

The NCDB was queried for patients with T3 and T4 laryngeal cancer. Comorbidity scores were calculated from the Charlson-Deyo comorbidity index (CDCI). Univariate and multivariate analyses explored the association of CDCI scores on treatment regimen and OS.

RESULTS

14,053 patients were analyzed. 65% of patients had a CDCI score of 0, whereas 25%, 7%, and 3% had CDCI score of 1, 2, and ≥3, respectively. As patients' CDCI increased, they became more likely to receive treatment options other than a laryngectomy or chemoradiation therapy (CRT) (P < 0.0001). Patients with CDCI ≥1 were more likely have a laryngectomy than those with CDCI 0 (P < 0.0001). In patients with T3 tumors, OS did not differ between those receiving CRT versus laryngectomy with any CDCI score. In patients with T4 tumors, laryngectomy was associated with improved OS compared to CRT across all CDCI scores except CDCI ≥3.

CONCLUSION

Our results support the current national guidelines with a recommendation for CRT or TL for T3 tumors and a preference for TL for T4 tumors. These outcomes are generally consistent in patients as their CDCI scores increases.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1459-1464, 2020.

Clinical Factors Associated with Longer Hospital Stay Following Ovarian Cancer Surgery

Background: Ovarian cancer (OC) is the leading cause of death from gynecologic malignancy and is treated with a combination of cytoreductive surgery and platinum-based chemotherapy. Extended length of stay (LOS) after surgery can affect patient morbidity, overall costs, and hospital resource utilization. The primary objective of this study was to identify factors contributing to prolonged LOS for women undergoing surgery for ovarian cancer. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify women from 2012-2016 who underwent hysterectomy for ovarian, fallopian tube and peritoneal cancer. The primary outcome was LOS >50th percentile. Preoperative and intraoperative variables were examined to determine which were associated with prolonged LOS. Results: From 2012-2016, 1771 women underwent elective abdominal surgery for OC and were entered in the ACS-NSQIP database. The mean and median LOS was 4.6 and 4.0 days (IQR 0-38), respectively. On multivariate analysis, factors associated with prolonged LOS included: American Society of Anesthesiologists (ASA) Classification III (aOR 1.71, 95% CI 1.38-2.13) or IV (aOR 1.88, 95% CI 1.44-2.46), presence of ascites (aOR 1.88, 95% CI 1.44-2.46), older age (aOR 1.23, 95% CI 1.13-1.35), platelet count >400,000/mm3 (aOR 1.74, 95% CI 1.29-2.35), preoperative blood transfusion (aOR 11.00, 95% CI 1.28-94.77), disseminated cancer (aOR 1.28, 95% CI 1.03-1.60), increased length of operation (121-180 min, aOR 1.47, 95% CI 1.13-1.91; >180 min, aOR 2.78, 95% CI 2.13-3.64), and postoperative blood transfusion within 72 h of incision (aOR 2.04, 95% CI 1.59-2.62) (p < 0.05 for all). Conclusions: Longer length of hospital stay following surgery for OC is associated with many patient, disease, and treatment-related factors. The extent of surgery, as evidenced by perioperative blood transfusion and length of surgical procedure, is a factor that can potentially be modified to shorten LOS, improve patient outcomes, and reduce hospital costs.

Predicting postoperative delirium severity in older adults: The role of surgical risk and executive function

OBJECTIVES

Delirium is an important postoperative complication, yet predictive risk factors for postoperative delirium severity remain elusive. We hypothesized that the NSQIP risk calculation for serious complications (NSQIP-SC) or risk of death (NSQIP-D), and cognitive tests of executive function (Trail Making Tests A and B [TMTA and TMTB]), would be predictive of postoperative delirium severity. Further, we demonstrate how advanced statistical techniques can be used to identify candidate predictors.

METHODS/DESIGN

Data from an ongoing perioperative prospective cohort study of 100 adults (65 y old or older) undergoing noncardiac surgery were analyzed. In addition to NSQIP-SC, NSQIP-D, TMTA, and TMTB, participant age, sex, American Society of Anesthesiologists (ASA) score, tobacco use, surgery type, depression, Framingham risk score, and preoperative blood pressure were collected. The Delirium Rating Scale-R-98 (DRS) measured delirium severity; the Confusion Assessment Method (CAM) identified delirium. LASSO and best subsets linear regression were employed to identify predictive risk factors.

RESULTS

Ninety-seven participants with a mean age of 71.68 ± 4.55, 55% male (31/97 CAM+, 32%), and a mean peak DRS of 21.5 ± 6.40 were analyzed. LASSO and best subsets regression identified NSQIP-SC and TMTB to predict postoperative delirium severity (P < 00.001, adjusted R² : 0.30). NSQIP-SC and TMTB were also selected as predictors for postoperative delirium incidence (AUROC 0.81, 95% CI, 0.72-0.90).

CONCLUSIONS

In this cohort, we identified NSQIP risk score for serious complications and a measure of executive function, TMT-B, to predict postoperative delirium severity using advanced modeling techniques. Future studies should investigate the utility of these variables in a formal delirium severity prediction model.

Associations between pre-, post-, and peri-operative variables and health resource use following surgery for head and neck cancer

OBJECTIVE

We examined associations between pre-, post-, and peri-operative variables and health resource use in head and neck cancer patients.

METHODS

Patients (N = 183) who were seen for a pre-surgical consult between January 2012 and December 2014 completed surveys that assessed medical history, a patient-reported outcome measure (PROM) of dysphagia, and quality of life (QOL). After surgery, peri-operative (e.g., tracheostomy, feeding tube) and post-operative (e.g., complications) variables were abstracted from patients' medical records.

RESULTS

Multivariate regression models using backward elimination showed that pre-surgical University of Washington Quality of Life (UW-QOL) Inventory and M.D. Anderson Dysphagia Inventory (MDADI) composite scores, documented surgical complications, and having a tracheostomy, were all significant predictors of hospital length of stay, explaining 57% of the total variance (F(5, 160) = 18.71, p < .001). Male gender, psychiatric history, and lower pre-surgical MDADI scores significantly predicted thirty-day unplanned readmissions (30dUR). Pre-surgical MDADI composite scores also significantly predicted emergencey department (ED) visits within 30 days of initial hospital discharge (p = .02).

CONCLUSIONS

Assessment of PROMs and QOL in the pre-surgical setting may assist providers in identifying patients at risk for prolonged LOS and increased health resource use after hospital discharge.

Free Flap Versus Pedicled Flap Reconstruction of Laryngopharyngeal Defects: A 10-Year National Surgical Quality Improvement Program Analysis

OBJECTIVES/HYPOTHESIS

Large defects after total laryngectomy (TL) and total laryngopharyngectomy (TLP) often benefit from free flap (FF) or pedicled flap (PF) reconstruction to maintain continuity of the aerodigestive tract, protect great vessels, or reinforce pharyngeal closure. Although both techniques are commonly used, no consensus exists as to which results in fewer complications. The goal of this study was to determine if 30-day morbidity/mortality outcomes differ between PF and FF reconstruction in patients undergoing TL/TLP.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients were analyzed who underwent TL/TLP with reconstruction using records from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015).

RESULTS

A total of 347 patients were included; 204 received FF reconstruction, whereas 143 received PF reconstruction. FF reconstruction was more commonly used with TLP defects (P = .001). The total operative time in the FF (590 ± 140 minutes) was longer than the PF (441 ± 125 minutes) group (P < .0001). There was a higher rate of postoperative transfusions in those undergoing FF reconstruction (P = .022). There was no significant difference in complication rates among TLP patients. Among TL patients only, FF reconstruction had a higher association with wound infections than PFs (P = .040). On multivariate analysis, low hematocrit was associated with complications (P = .031). Age (P = .031) and congestive heart failure exacerbation (P < .001) were associated with increased hospital stay. Overall, there were no differences in readmissions, reoperations, or deaths between the groups.

CONCLUSIONS

Reported complication rates after TL/TLP remain high, despite widespread usage of vascularized flaps in reconstruction. This comparison reveals no significant difference in postoperative complications between patients who received PF and FF laryngopharyngeal reconstruction.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:105-112, 2019.

Intracranial Meningioma Surgery: Value-Based Care Determinants in New York State, 1995-2015

OBJECTIVE

Intracranial meningiomas are the most commonly diagnosed brain tumor in the United States. With increasing incidence, efficient allocation of limited health care resources is a critical component of emerging value-based models of care. The purpose of this study was to evaluate the effect of patient and hospital variables on metrics of value-based care.

METHODS

The Statewide Planning and Research Cooperative System database was queried for records of patients undergoing intracranial meningioma surgery in New York State from 1995 to 2015. Multivariate logistic regression was used to investigate the effect of hospital volume and patient demographics on 30-day readmissions, 30-day mortality, prolonged length of stay (pLOS), and excess hospital charges.

RESULTS

Among the 14,239 patients included, 10,252 (72%) cases were performed at high-volume centers (HVC) (>75th percentile). HVC were associated with lower rates of readmissions, mortality, and pLOS, but higher hospital charges. In the multivariate analysis, HVC had reduced odds of pLOS (odds ratio, 0.56; P < 0.0001) and 30-day mortality (odds ratio, 0.39; P < 0.0001). Patient variables associated with adverse outcomes in the multivariate model included advanced age, male gender, higher Charlson Comorbidity Index, lower socioeconomic status (low income, Medicaid, and Medicare insurance), black race, and Hispanic ethnicity. These populations were more likely to undergo treatment at lower-volume centers.

CONCLUSIONS

This statewide population analysis of readmissions, mortality, length of stay, and hospital charges after intracranial meningioma surgery identified patient predictors of adverse outcomes. These determinants may be used by hospitals to develop improved systems of care in at-risk populations.

Head and Neck Cancer Patients: Rates, Reasons, and Risk Factors for 30-Day Unplanned Readmission

Objective

To analyze rates, risk factors, and complications for 30-day readmission among head and neck cancer (HNC) patients.

Methods

Retrospective review of administrative records from Vizient (Irving, Texas) Clinical Data Base/Resource Manager on HNC patients who underwent a head and neck surgical procedure from January 2013 through September 2015 at 176 academic and community medical centers.

Results

Of the 18,121 patients included in the study, 2502 patients were readmitted within 30 days (13.8%). Mean time to readmission was 11 ± 8.2 days. Cancer of the hypopharynx, oropharynx, pharynx, and larynx all had higher odds of readmission compared to oral cavity (odds ratio [OR], 1.8, 1.7, 1.6, and 1.5; 95% confidence interval [CI], 1.4-2.2, 1.4-1.9, 1.2-2.3, and 1.3-1.7, respectively). Consistent with this, flap procedures and laryngectomy had the highest odds of readmission (OR, 1.4 and 1.3; 95% CI, 1.3-1.6 and 1.0-1.5 vs glossectomy, respectively). The most common surgical causes for readmission were postoperative infection (17.6%) and surgical wound dehiscence (16.8%), which most commonly presented on postdischarge days 4 to 5. Acute cardiac events occurred in up to 15.4% of patients depending on complexity of surgery. Dysphagia and electrolyte disturbances were common (15.8% and 15.4%, respectively); patients with these complications typically presented earlier, between days 3 and 4.

Discussion

Patients with HNC are at high risk of readmission. The cancer subsite and procedure significantly influenced the risk, rate, and reason for readmission.

Implications for Practice

Findings from this study can help quality improvement and patient safety administrators develop interventions that uniquely target HNC populations.

Sequelae of Index Complications following Inpatient Head and Neck Surgery: Characterizing Secondary Complications

Objective To characterize patterns of secondary complications after inpatient head and neck surgery. Study Design Retrospective cohort study. Setting National Surgical Quality Improvement Program (2005-2015). Subjects and Methods We identified 18,584 patients who underwent inpatient otolaryngologic surgery. Four index complications were studied: pneumonia, bleeding or transfusion event (BTE), deep/organ space surgical site infection (SSI), and myocardial infarction (MI). Each patient with an index complication was matched to a control patient based on propensity for the index event and event-free days. Rates of 30-day secondary complications and mortality were compared. Results Index pneumonia (n = 254) was associated with several complications, including reintubation (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.2-26.4), sepsis (OR, 8.8; 95% CI, 4.5-17.2), and death (OR, 5.3; 95% CI, 1.9-14.9). Index MI (n = 50) was associated with increased odds of reintubation (OR, 17.2; 95% CI, 3.5-84.1), ventilatory failure (OR, 5.8; 95% CI, 1.8-19.1), and death (OR, 24.8; 95% CI, 2.9-211.4). Index deep/organ space SSI (n = 271) was associated with dehiscence (OR, 7.2; 95% CI, 3.6-14.2) and sepsis (OR, 38.3; 95% CI, 11.6-126.4). Index BTE (n = 1009) increased the odds of cardiac arrest (OR, 3.9; 95% CI, 1.8-8.5) and death (OR, 2.9; 95% CI, 1.6-5.1). Conclusions Our study is the first to quantify the effect of index complications on the risk of specific secondary complications following inpatient head and neck surgery. These associations may be used to identify patients most at risk postoperatively and target specific interventions aimed to prevent or interrupt further complications.

Quality Indicators: Measurement and Predictors in Head and Neck Cancer Free Flap Patients

Objective

To determine the predictors of length of stay (LOS), readmission within 30 days, and unplanned return to the operating room (OR) within 30 days in head and neck free flap patients.

Study Design

Case series with chart review.

Setting

Tertiary academic cancer hospital.

Subjects and Methods

All head and neck free flap patients at The Ohio State University (OSU, 2006-2012) were assessed. Multivariable logistic regression to assess the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes.

Results

In total, 515 patients were identified, of whom 66% had oral cavity cancers, 33% had recurrent tumors, and 28% underwent primary radiotherapy. Of the patients, 31.5% had a LOS greater than 9 days, predicted by longer operative time, oral cavity and pharyngeal tumor sites, blood transfusion, diabetes mellitus, and any complication. A total of 12.6% of patients were readmitted within 30 days predicted by absent OSU preoperative assessment clinic attendance and any complication, and 14.8% of patients had an unplanned OR return predicted by advanced age.

Conclusions

When assessing quality metrics, adjustment for the complexity involved in managing patients with head and neck cancer with a high comorbidity index, clean contaminated wounds, and a high degree of primary radiotherapy is important. Patients seen in a preoperative assessment clinic had a lower risk of readmission postoperatively, and this should be recommended for all head and neck free flap patients. Quality improvement projects should focus on predictors and prevention of complications as this was the number one predictor of both increased length of stay and readmission.

The national landscape of unplanned 30-day readmissions after total laryngectomy

OBJECTIVES/HYPOTHESIS

Examine rates of readmission after total laryngectomy and determine primary etiologies, timing, and risk factors for unplanned readmission.

STUDY DESIGN

Retrospective cohort study.

METHODS

The Nationwide Readmissions Database was queried for patients who underwent total laryngectomy between January 2013 and November 2013. Patient-, procedure-, admission-, and institution-level characteristics were compared for patients with and without unplanned 30-day readmission. Outcomes of interest included rates, etiology, and timing of readmission. Multivariate logistic regression was used to identify predictors of 30-day readmission.

RESULTS

There were 2,931 total laryngectomies performed in 2013 with an unplanned readmission rate of 17.5%. Postoperative fistula accounted for 13.7% of readmissions. The odds of readmission were elevated for patients undergoing concurrent procedures, including primary tracheoesophageal fistulization (adjusted odds ratio [aOR]: 2.44, 95% confidence interval [CI]: 1.15-5.18, P = .02) and/or pedicle graft or flap procedures (aOR: 1.73, 95% CI: 1.13-2.66, P = .01). Additionally, patients with comorbid coagulopathy (aOR: 3.04, 95% CI: 1.13-8.22, P = .03), liver disease (aOR: 2.48, 95% CI: 1.08-5.71, P = .03), and valvular heart disease (aOR: 3.18, 95% CI: 1.20-8.41, P = .02) had increased risk for unplanned 30-day readmission. Private insurance and longer lengths of stay were associated with decreased odds of readmission.

CONCLUSIONS

Nearly one-fifth of total laryngectomy patients are readmitted to the hospital within 30 days of discharge. Risk factors identified in this nationally representative cohort should be carefully considered during the postoperative period to reduce preventable readmissions after total laryngectomy.

LEVEL OF EVIDENCE

2c Laryngoscope, 1842-1850, 2018.