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

Trends and predictors of unplanned hospitalization among oral and oropharyngeal cancer patients; an 8-year population-based study

PURPOSE

The incidence of oral cancers, particularly HPV-related oropharyngeal cancer, is steadily increasing worldwide, presenting a significant healthcare challenge. This study investigates trends and predictors of unplanned hospitalizations for oral cavity cancer (OCC) and oropharyngeal cancer (OPC) patients in the province of Alberta, Canada.

METHODS

This retrospective, population-based, cohort study used administrative data collected from all hospitals in the province. Using the Alberta Cancer Registry (ACR), a cohort of adult patients diagnosed with a single primary OCC or OPC between January 2010 and December 2017 was identified. Linking this cohort with the Discharge Abstract Database (DAD), trends in hospitalizations, primary diagnoses, and predictors of unplanned hospitalization (UH) and 30-day unplanned readmission were analyzed.

RESULTS

Of 1,721 patients included, 1,244 experienced 2,228 hospitalizations, with 48 % being categorized as UH. The UHs were significantly associated with a higher mortality rate, 18.5 % as compared to 4.6 % for planned, and influenced by sex, age groups, comorbidities, cancer types, stages, and treatment modalities. The rate of UH per patient decreased from 0.69 to 0.54 visits during the study period (P = 0.02). Common diagnoses for UH were palliative care and post-surgical convalescence, while surgery-related complications such as infection and hemorrhage were frequent in 30-day unplanned readmissions. Predictors of UH included cancer stage, material deprivation, and treatment, while cancer type and comorbidity predicted readmissions.

CONCLUSION

The rate of UHs showed a noteworthy decline in this study, which could be a result of enhanced care coordination. Furthermore, identified primary diagnosis and predictors associated with UHs and readmissions, provide valuable insights for enhancing the quality of care for cancer patients.

Hypothyroidism as an Independent Predictor of 30-day Readmission in Head and Neck Cancer Patients

OBJECTIVES

To define the role of hypothyroidism and other risk factors for unplanned readmissions after surgery for head and neck cancer.

STUDY DESIGN

Retrospective cohort study.

METHODS

The Nationwide Readmission Database (NRD) was used to identify patients who underwent surgery for mucosal head and neck cancer (oral cavity, oropharynx, larynx, and hypopharynx) between 2010 and 2017. Univariate and multivariate logistic regression were performed to determine patient, tumor, and hospital related risk factors for 30-day readmission. Readmitted patients were stratified by preoperative diagnosis of hypothyroidism to compare readmission characteristics.

RESULTS

For the 131,013 patients who met inclusion criteria, the readmission rate was 15.9%. Overall, 11.91% of patients had a preoperative diagnosis of hypothyroidism. After controlling for other variables, patients with a preoperative diagnosis of hypothyroidism had 12.2% higher odds of readmission compared to those without hypothyroidism (OR: 1.12, 1.03-1.22, p = 0.008). Patients with hypothyroidism had different reasons for readmission, including higher rates of wound dehiscence, fistula, infection, and electrolyte imbalance. Among readmitted patients, the length of stay for index admission (mean 10.5 days vs. 9.2 days, p < 0.001), readmission (mean 7.0 vs. 6.6 days, p = 0.05), and total hospital charge were higher for hypothyroid patients ($137,742 vs. $119,831, p < 0.001).

CONCLUSION

Hypothyroidism is an independent risk factor for 30-day readmission following head and neck cancer resection. Furthermore, hypothyroid patients are more likely to be readmitted for wound complications, infection, and electrolyte imbalance. Targeted interventions should be considered for hypothyroid patients to decrease readmission rates and associated patient morbidity, potentially leading to earlier initiation of adjuvant treatment.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2988-2998, 2023.

FraMaDySc: dysphagia screening for patients after surgery for head and neck cancer

PURPOSE

Oropharyngeal dysphagia is one of the most common postoperative consequences in head and neck cancer patients. Above all, these patients often suffer from aspiration and limitations of oral intake. However, no reliable dysphagia screening is available for this target group. This study aimed to develop and validate a screening, FraMaDySc, based on a water swallow test (WST) for the identification of postsurgical patients with a risk of aspiration, limitations of oral intake, and, as their derivate, a relevant oropharyngeal dysphagia in general (OD) that constituted the main reference standard.

METHODS

A total of 184 postsurgical head and neck cancer patients were tested with a WST. The patients were, on average, 62 years old and predominantly male (71%). After WST, they underwent Fiberoptic Endoscopic Evaluation of Swallowing (FEES^®). FEES^® results were dichotomized by Penetration aspiration scale and Functional oral intake scale. Patients with a "fail" result on one of these two scales were classified as having OD. Quality criteria of WST were quantified by means of cross-tabulation with FEES^® results.

RESULTS

OD was found in 65% of patients, aspiration in 44%, limitations of oral intake in 56%. WST delivered a "fail" result in 65% of patients. WST showed sensitivity 91% and specificity 88% for OD. Quality criteria for aspiration (sensitivity 64%, specificity 93%) and limitations of oral intake (sensitivity 80%, specificity 87%) were lower.

CONCLUSION

FraMaDySc is a standardized, quick, and valid WST and therefore an excellent screening tool for the identification of OD in postoperative head and neck cancer patients.

[Post-operative prevalence of dysphagia in head-and-neck cancer patients in the acute care units]

OBJECTIVE

 Dysphagia constitutes a frequent post-operative functional impairment in head-and-neck cancer patients. This impairment can result in aspiration/penetration and limitations of oral intake. Therefore, often it requires a therapeutic intervention. In this study, prevalence of post-operative dysphagia and its associations with the tumour stage, localisation, patients' age, and biological sex were analysed for the inpatient treatment setting.

MATERIAL AND METHODS

 A total of 201 adult head-and-neck cancer patients (mean age 63 years) were analysed prospectively by FEES in two university hospitals in regard to their penetration/aspiration, limitations of oral intake, and need for therapeutic interventions directly after the operative tumour treatment. Additionally, the influence of the same patients' characteristics on these three parameters were analysed by means of univariate and multivariate statistical methods.

RESULTS

 Out of 201 patients, 66.7 % needed a therapeutic intervention because of their dysphagia, 57.2 % needed a nasogastral or PEG tube due to limitations of oral intake, 45.3 % had an aspiration. In the latter subgroup, 38.5 % had a silent aspiration. Higher tumour stage, patients' higher age and male sex were shown to be significant influence factors for dysphagia, tumour localisation showed only a marginally significant result.

CONCLUSIONS

 The study demonstrated a clinical importance and relevance of the consequent and systematic treatment of post-operative dysphagia in head-and-neck cancer patients in the acute care units as a constituent of a modern oncological therapy.

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.

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.