Hospital volume and failure to rescue after head and neck cancer surgery

Vascular events in patients with head and neck cancer: A systematic review and meta-analysis

OBJECTIVE

To assess the incidence of vascular events in patients with head and neck cancer.

REVIEW METHODS

Primary studies identified through April 2023. Meta-analysis was performed.

RESULTS

There were 146 studies included in the systematic review. Rates of events were collected in the overall group, those with chemoprophylaxis, and those that underwent surgery, radiation, or chemotherapy. Of 1 184 160 patients, 4.3% had a vascular event. Radiation therapy had highest risk of overall events and stroke when compared to surgery and chemotherapy. Chemotherapy had a higher risk of stroke and overall events when compared to surgery.

CONCLUSIONS

Vascular events occur in 4%-5% of patients with head and neck cancer. Our data does not support the use of routine anticoagulation. Patients undergoing radiation therapy had the highest frequency of events.

Surgeon Volume and Laryngectomy Outcomes

OBJECTIVE

To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy.

DATA SOURCES

The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables.

METHODS

Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression.

RESULTS

Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity.

CONCLUSION

There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.

Are there differences in revision stapes surgery outcomes between university and county clinics? A study from the quality register for otosclerosis surgery in Sweden

Purpose

The aim of the study was to investigate hearing outcomes in stapes revision surgery with regard to the type of clinic (university clinic or county clinic). Furthermore, the aim was to investigate the risk of complications with a focus on tinnitus, hearing deterioration, and taste disturbance 1 year after surgery.

Methods

The study is based on data from the Swedish Quality Register for Otosclerosis Surgery (SQOS). Two study protocols were completed by the surgeon, and a questionnaire was distributed to the patients 1 year after surgery. A total of 156 revisions were available for analysis with both preoperative and postoperative audiometry data.

Results

Seventy-five percent of the patients reported better to much better hearing 1 year after revision surgery. An air bone gap ≤ 20 dB postoperatively was seen in 77% of the patients. Four percent had hearing deterioration ≥ 20 dB PTA4 AC. Eleven percent had worsened or newly developed tinnitus, 5% had taste disturbance, and 3% had dizziness 1 year after surgery. Preoperative and postoperative hearing did not differ between patients operated on in university vs. county clinics.

Conclusions

Revision surgery in otosclerosis is a challenge for otologists, but no differences in hearing outcomes between university and county clinics were found in this nationwide study. The risk of hearing deterioration and deafness is higher than in primary stapes surgery, and revision surgery should be recommended primarily in cases with a large air–bone gap and moderate to severe preoperative hearing loss.

Association Between Insurance Type and Outcomes of Reconstructive Head and Neck Cancer Surgery

OBJECTIVES/HYPOTHESIS

Although the benefits of expanding health insurance coverage are clear, there are limited studies comparing the different types of insurance. This study aims to determine the association between insurance type and outcomes in patients with head and neck cancer undergoing reconstructive surgery in the United States.

METHODS

Population-based cross-sectional study of the 2012-2014 National Inpatient Sample. We identified 1,314 patients with head and neck cancers undergoing tumor ablative surgery followed by pedicled or free flap reconstruction of oncologic defects. Insurance type was classified as private, Medicare, Medicaid, self-pay, or other. The primary outcome was extended length of stay (LOS), defined as greater than 14 days, which represented the 75th percentile of the study sample. Secondary outcomes included acute medical complications, surgical complications, morbidities, and costs. Analyses were adjusted for gender, geographic location, and various medical comorbidities.

RESULTS

In univariate analysis, insurance type was associated with extended LOS (P = .001), medical complications (P = <.001), and mortalities (P = .020). After controlling for other covariates in the multivariate analysis, compared to private insurance, Medicare and Medicaid were both associated with significantly higher odds of extended LOS (adjusted odds ratio [OR] [95% confidence interval (CI)] = 1.73 [1.09-2.76] and 2.22 [1.38-3.58], respectively). Medicare was associated with significantly higher odds of medical complications, but Medicaid was not (adjusted OR [95% CI] = 1.53 [1.02-2.31] and 1.64 [0.97-2.78], respectively).

CONCLUSIONS

Medicaid and Medicare were independently associated with extended LOS after reconstructive head and neck cancer surgery. Medicare was associated with higher rates of medical complications. Efforts to address LOS should target care planning and coordination.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Impact of Hospital Volume on Outcomes Following Head and Neck Cancer Surgery and Flap Reconstruction

OBJECTIVE/HYPOTHESIS

Utilization of flaps for reconstruction of large head and neck cancer (HNCA) defects has become more prevalent. The present study aimed to assess the impact of center experience as measured by annual hospital caseload on mortality, major complications, resource utilization, and 90-day readmissions following HNCA resection with flap reconstruction.

STUDY DESIGN

Non-Randomized Controlled Cohort Study.

METHODS

All adult patients undergoing elective HNCA resection with flap reconstruction were identified utilizing the 2010 to 2018 Nationwide Readmissions Database. Hospitals were subsequently classified as low-, medium-, or high-volume based on annual institutional surgical caseload tertiles. Multivariable regression models were implemented to assess the independent association of hospital volume with the outcomes of interest.

RESULTS

Over the nine-year study period, the proportion of HNCA resection with flap reconstruction gradually increased (12.8% in 2010 vs. 17.3% in 2018, P < .001). Although increasing hospital volume did not alter the odds of mortality, patients treated at high-volume centers were less likely to experience both surgical (adjusted odds ratio [AOR] 0.81, 95% confidence interval [CI] 0.67-0.97, P = .025) and medical complications (AOR 0.70, 95% CI 0.57-0.85, P < .001). Furthermore, these patients had shorter hospitalizations (-2.1 days, 95% CI -2.7 to -1.4 days, P < .001) and decreased costs (-$8,100, 95% CI -11,400 to -4,700, P < .001) compared to counterparts at low-volume centers. However, hospital volume did not impact 90-day readmissions.

CONCLUSION

Patients undergoing HNCA resection with flap reconstruction at high-volume centers were less likely to experience surgical and medical complications while incurring shorter hospitalizations and lower costs. Implementation of volume standards may be appropriate to improve outcomes in this surgical population.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis

INTRODUCTION

Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined.

OBJECTIVE

To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction.

METHODS

We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes.

RESULTS

18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]).

CONCLUSION

There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.

Association of number and type of serious complications with failure to rescue in children undergoing surgery: A NSQIP-Pediatric analysis

BACKGROUND

Failure to rescue (FTR) represents death after a serious complication. This study aims to determine the FTR rate in a pediatric surgical population, and if number (1 or 2+) and type of serious complications are associated with FTR.

METHODS

A secondary analysis was performed using the National Surgical Quality Improvement Program Pediatric database from 2012 to 2016. Primary and secondary exposures of interest were number (1 or 2+) and type of serious complications, respectively. Propensity score analysis adjusted for baseline covariates. Primary outcome was FTR.

RESULTS

Of 36,167 children with ≥1 serious complication, there were 851 deaths resulting in a FTR rate of 2.4%. Having 2+ serious complications was associated with higher adjusted odds of FTR (OR 1.77, 95% CI 1.52-2.08, p < 0.0001). Among those who had one complication, the type of serious complication was significantly associated with FTR. When type of initial serious complication was adjusted, number of serious complications continued to be strongly associated with FTR (OR 2.00, 95% CI 1.67-2.38, p < 0.0001).

CONCLUSIONS

FTR rate within a large, diverse, multi-specialty pediatric surgical population was 2.4%. Both number and type of postoperative complications were associated with FTR. These findings may facilitate early recognition of high-risk patients and identify quality targets for pediatric surgical centers.

LEVEL OF EVIDENCE

Retrospective study (secondary analysis), Level II.

Impact of payer status and hospital volume on outcomes after head and neck oncologic reconstruction

BACKGROUND

High-volume centers improve outcomes in head and neck cancer (HNCA) reconstruction, yet it is unknown whether patients of all payer status benefit equally.

METHODS

We identified patients undergoing HNCA surgery between 2002 and 2015 using the National Inpatient Sample. Outcomes included receipt of care at high-volume centers, receipt of reconstruction, and post-operative complications. Multivariate regression analysis was stratified by payer status.

RESULTS

37,442 patients received reconstruction out of 101,204 patients who underwent HNCA surgery (37.0%). Privately-insured and Medicaid patients had similar odds of receiving high-volume care (OR = 0.99, 95% CI = 0.87-1.11) and undergoing reconstruction (OR = 0.96, 95% CI = 0.86-1.05). Medicaid beneficiaries had higher odds of complication (OR = 1.36, 95% CI = 1.22-1.51). The discrepancy in complication odds was significant at low-volume (OR = 1.44, 95% CI = 1.12-1.84) and high-volume centers (OR = 1.30, 95% CI = 1.15-1.47).

CONCLUSIONS

Medicaid beneficiaries are as likely to receive care at high-volume centers and undergo reconstruction as privately-insured individuals. However, they have poorer outcomes than privately-insured individuals at both low- and high-volume centers.

The Impact of Socially Stigmatized Preexisting Conditions on Outcomes After Injury

BACKGROUND

Socially stigmatized preexisting conditions (SSPECs), including alcohol use disorder (AUD), drug use disorder (DUD), and major psychiatric illness, may lead to provider minimization of patient symptoms and have been associated with negative outcomes. However, the impact of SSPECs on failure to rescue (FTR) has not been evaluated. We hypothesized that SSPEC patients would have increased probability of complications, mortality, and FTR.

MATERIALS AND METHODS

We performed a retrospective analysis of the 2015 National Trauma Data Bank, including patients aged ≥18 y and excluding burn victims, patients with Injury Severity Score <9, and non-SSPEC patients with drug or alcohol withdrawal. We defined SSPECs using the National Trauma Data Bank's comorbidity recording codes for AUD, DUD, and major psychiatric illnesses. We built multivariable logistic regression models to determine the relationships between SSPECs and complications, mortality, and FTR.

RESULTS

We included 365,801 patients (62% male, 76% White, median age 56 y [interquartile range 35-74], median Injury Severity Score 10 [interquartile range 9-17]). After adjusting for patient and injury characteristics, SSPEC patients were more likely to have complications (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.70-1.79), less likely to die (OR 0.43, CI 0.38-0.48), and less likely to have FTR (OR 0.34, CI 0.26-0.43). SSPEC patients had a significantly higher complication rate (12.4% versus 7.2%; P < 0.001). After excluding drug or alcohol withdrawal, the complication rate remained significantly higher for SSPEC patients (9.3% versus 7.2%; P < 0.001).

CONCLUSIONS

Although SSPEC patients have lower odds of mortality and FTR, they are at higher probability of complications after injury. Further investigation into the causality behind the higher complications despite lower mortality and FTR is warranted.

Association of Hospital Volume With Laryngectomy Outcomes in Patients With Larynx Cancer

Importance

A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures.

Objectives

To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes.

Design, Setting, and Participants

In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable.

Main Outcomes and Measures

Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis.

Results

Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900).

Conclusions and Relevance

Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.

Association Between Hospital Market Concentration and Costs of Laryngectomy

IMPORTANCE

High-volume hospital care for laryngectomy has been shown to be associated with reduced morbidity, mortality, and costs; however, most hospitals in the United States do not perform high volumes of laryngectomies. The influence of market competition on charges and costs for such patients has not been defined.

OBJECTIVE

To examine the association between regional hospital market concentration, hospital charges, and costs for laryngectomy.

DESIGN, SETTING, AND PARTICIPANTS

The Nationwide Inpatient Sample was used to identify 34 193 patients who underwent laryngectomy for a malignant laryngeal or hypopharyngeal neoplasm from January 1, 2003, to December 31, 2011. Hospital laryngectomy volume was modeled as a categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2003, 2006, and 2009 Hospital Market Structure Files. Statistical analysis was performed from May 19 to August 15, 2018.

MAIN OUTCOMES AND MEASURES

Multivariable generalized linear regression was used to evaluate associations between market concentration and total charges and costs for laryngectomy.

RESULTS

Among the 34 193 patients (19.3% female and 80.7% male; mean age, 62.7 years [range, 20.0-96.0 years]), 69.2% of procedures were performed at hospitals in highly concentrated (noncompetitive) markets and 26.2% were performed at hospitals in unconcentrated (highly competitive) markets. Most high-volume hospitals (68.0%) were located in highly concentrated markets, followed by unconcentrated markets (32.0%). Market share and volume were not associated with significant differences in total charges. Unconcentrated markets were associated with 28% higher costs (95% CI, 8%-53%) relative to moderately concentrated and highly concentrated markets. High-volume hospitals were associated with 22% lower costs (95% CI, -36% to -5%).

CONCLUSIONS AND RELEVANCE

Competition among hospitals is associated with increased costs of care for laryngectomy. High-volume hospital care is associated with lower costs of care. These data suggest that hospital market consolidation of laryngectomy at centers able to meet minimum volume thresholds may improve health care value.

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

OBJECTIVE

To identify prognostic case volume thresholds of facilities that manage HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer-accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

EXPOSURES

Treatment of HNSCC at facilities with varying case volumes.

MAIN OUTCOMES AND MEASURES

Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

RESULTS

Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

CONCLUSIONS AND RELEVANCE

Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.

Hospital volume and failure to rescue after vestibular schwannoma resection

BACKGROUND

Complication rates in many complex surgical procedures are associated with the volume of procedures performed.

OBJECTIVES

To investigate the relationship between hospital volume and complications, mortality, and failure to rescue (FTR) rates in patients undergoing vestibular schwannoma (VS) surgery.

DESIGN, SETTING, AND PARTICIPANTS

The Nationwide Inpatient Sample was used to identify 44,336 patients who underwent VS surgery in 1995-2011. Annual case volumes were stratified by quintiles and defined as very low (≤5 cases/year), low (6-12 cases/year) medium (13-22 cases/year), high (23-37 cases/year), and very high-volume (≥38 cases/year).

MAIN OUTCOMES AND MEASURES

Relationships between hospital volume and in-hospital mortality, postoperative complications, as well as FTR rates, defined as death after a major complication, were examined using multivariate regression analysis.

RESULTS

Postoperative medical and surgical complications occurred in 5.4% and 14.6% of cases, respectively, and did not differ significantly across volume quintiles. In-hospital mortality decreased with increasing hospital volume, with an incidence of 1.4% for hospitals in the lowest volume quintile compared to 0.1% for hospitals in the top volume quintile. After controlling for all other variables, the odds of in-hospital mortality were lower for medium (OR = 0.19 [0.04-0.93]) and very high-volume hospitals (OR = 0.07 [0.01-0.53]), but not high-volume hospitals (OR = 0.43 [0.05-3.77]). There was no association between hospital volume and the odds of postoperative surgical complications. FTR was associated with hospital volume, with decreasing odds for medium-volume (OR = 0.15 [0.02-0.93]), high-volume (OR = 0.17 [0.04-0.74]), and very high-volume (OR = 0.07 [0.04-0.74]) hospitals.

CONCLUSIONS

Hospital volume does not appear to be associated with complication rates but is associated with decreased likelihood of FTR after VS surgery.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1287-1293, 2020.

Head and Neck Cancer Complications in the Geriatric Population Based on Hospital Case Volume

OBJECTIVE

To determine whether surgical case volume is a predictive factor of surgical outcomes when managing geriatric patients with head andneck cancer.

METHODS

A cross-sectional study design was used. Data were obtainedfrom the Vizient Database, which included a total of 93 academicinstitutions. Men and women aged between 65 and 100 years undergoing head and neck cancer surgery during 2009 and 2012,excluding cases of thyroid cancer and skin cancer of the head and neck(n = 4544) were included in the study. Hospital case volume was definedas low (≤21 cases/year), moderate (22-49 cases/year), or high (≥50 cases/year). The frequency of comorbidities and complications wasmeasured by hospital case volume using a χ² test. Significancewas determined with an α level of .05.

RESULTS

The largest number of head and neck cancer cases involving comorbidities (90.54%) and the highest rate of overall complications(27.50%) occurred in moderate case volume institutions compared to athe complication rate of 22.89% in low volume hospitals and 21.50% in highvolume hospitals (P < .0001). The most common comorbidities across all3 hospital case volumes included hypertension, metastatic cancer,and chronic pulmonary disease and the most common complicationsincluded hemorrhage/hematoma and postoperative pulmonarycompromise.

CONCLUSION

With more geriatric patients requiring surgery for head andneck cancer, it would be beneficial to manage the more complex cases at high volume centers and to develop multidisciplinary teams to optimizecase management and minimize complications.

Failure to rescue as a center-level metric in pediatric trauma

BACKGROUND

Failure to rescue is defined as death after a complication and has been used to evaluate quality of care in adult trauma patients, but there are no published studies on failure to rescue in pediatric trauma. The aim of this study was to define the relationship among rates of mortality, complications, and failure to rescue at centers caring for pediatric (<18 years of age) trauma patients in a nationally representative database.

METHODS

We performed a retrospective cohort study of the 2015 and 2016 National Trauma Data Bank. We included patients <18 years of age with an Injury Severity Score of ≥9. We excluded centers with <50 pediatric patients or that reported no complications. We calculated the complication, failure to rescue, mortality, and precedence rates by center and divided centers into tertiles of mortality. We compared complication and failure-to-rescue rates between high and low tertiles of mortality using the Kruskal-Wallis test.

RESULTS

Of 62,190 patients from 284 centers, 2,204 patients had at least 1 complication for an overall complication rate of 4% (center level 0%-15%), and 120 patients died after a complication for an overall failure-to-rescue rate of 5% (center level 0%-67%). High-mortality centers had both higher failure-to-rescue rates (10% vs 0.6%, P < .001) and higher complication rates (5% vs 4%, P = .001) than lower-mortality hospitals. The overall precedence rate was 15% with a median rate of 0% (interquartile range 0%-25%).

CONCLUSION

Both complication and failure-to-rescue rates are low in the pediatric injury population, but both complication and failure-to-rescue rates are higher at higher-mortality centers. The low overall complication rates and precedence rates likely limit the utility of failure to rescue as a valid center-level metric in this population, but further investigation into individual failure-to-rescue cases may reveal important opportunities for improvement.

Impact of treatment expertise on the outcome of patients with head and neck cancer treated within 6 randomized trials

BACKGROUND

We evaluated the impact of center expertise, in terms of number of patients treated, on the overall survival (OS) and progression-free survival (PFS) of patients with head and neck squamous cell carcinoma (SCC).

METHODS

We performed a pooled analysis including data from 6 randomized trials in head and neck SCC conducted in Italy. We evaluated the association between OS or PFS and the number of patients recruited by the center.

RESULTS

The outcome of 903 patients who had received radiotherapy (RT) was analyzed (median follow-up 76 months). The hazard ratio (HR) comparing the third and the first quartiles of the distribution of number of patients per center showed an advantage in PFS (HR 0.59, range 0.53-0.65, P < .0001) and in OS (HR 0.70, 0.60-0.81, P < .0001) for centers with a higher number of patients recruited. A similar benefit was observed in PFS (HR 0.63, 0.60-0.66) and OS (HR 0.74, 0.69-0.79) considering the mean number of patients per year.

CONCLUSIONS

The PFS and OS were longer for patients treated in high-case-volume centers.

Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue

Failure to rescue-mortality following a major surgical complication-is a key driver of variation in postoperative mortality. However, little is known about the impact of interpersonal and organizational dynamics, or microsystem factors, on failure to rescue. In a qualitative study of providers from hospitals with high and low rescue rates, we identified five key factors that providers believe influence the successful rescue of surgical patients: teamwork, action taking, psychological safety, recognition of complications, and communication. Near-uniform agreement existed on two targets for improvement: delayed recognition of developing complications and poor interprofessional communication and inability to express clinical concerns. To improve perioperative outcomes, hospitals and payers should shift their attention to improving early detection and effective communication of major complications.

Factors pertaining to long-term mortality following emergency visits for head and neck cancer

Background/purpose

Avoiding mortality has been the ultimate goal in the management of head and neck cancer (HNC) patients with emergency department (ED) visits, however, risk factors and causes of mortality are not well studied. The objective of the present study is to verify the factors associated with long-term mortality of patients with HNC who visited ED.

Materials and methods

We retrospectively collected data of 1660 HNC patients who made ED visits from the Longitudinal Health Insurance Database 2000 during 2000–2012 in Taiwan. The multivariate Cox proportional hazard model was used to measure the mortality-associated risk factors in HNC patients who made ED visits.

Results

The prognostic factors associated with mortality risk were age (≥65 vs. < 65 y; HR = 1.58, p < 0.0001), geographic region (central vs. northern; HR = 1.20, p = 0.0384; southern vs. northern; HR = 1.38, p = 0.0001), surgery (yes vs. no; HR = 0.61, p < 0.0001), radiotherapy (yes vs. no; HR = 1.80, p < 0.0001), chemotherapy (yes vs. no; HR = 1.68, p < 0.0001), acute myocardial infarction (yes vs. no; HR = 2.01, p = 0.0303), diabetes mellitus (yes vs. no; HR = 1.60, p < 0.0001), chronic obstructive pulmonary (yes vs. no; HR = 1.51, p = 0.0002), number of ED visits (≥4 vs. 1; HR = 0.69, p = 0.0003), and number of admissions (1 vs. 0; HR = 1.54, p < 0.0001; ≥2 vs. 0; HR = 1.48, p = 0.0002).

Conclusion

Higher mortality was associated with older age, living in southern Taiwan, not having undergone surgery, having received radiotherapy and chemotherapy, comorbidities, and more hospital admissions. A coordinated and extended multidisciplinary approach including ED care is required to improve the long-term survival and further decrease the economic burden of HNC treatment.

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.

Measuring Institutional Quality in Head and Neck Surgery Using Hospital-Level Data: Negative Margin Rates and Neck Dissection Yield

Importance

Negative margins and lymph node yields (LNY) of 18 or more from neck dissections in patients with head and neck squamous cell carcinomas (HNSCC) have been associated with improved patient survival. It is unclear whether these metrics can be used to identify hospitals with improved outcomes.

Objective

To determine whether 2 patient-level metrics would predict outcomes at the hospital level.

Design, Setting, and Participants

A retrospective review of records from the National Cancer Database (NCDB) was used to identify patients who underwent primary surgery and concurrent neck dissection for HNSCC between 2004 and 2013. The percentage of patients at each hospital with negative margins on primary resection and an LNY 18 or more from a neck dissection was quantified. Cox proportional hazard models were used to define the association between hospital performance on these metrics and overall survival.

Main Outcomes and Measures

Margin status and lymph node yield at hospital level. Overall survival (OS).

Results

We identified 1008 hospitals in the NCDB where 64 738 patients met inclusion criteria. Of the 64 738 participants, 45 170 (69.8%) were men and 19 568 (30.2%) were women. The mean SD age of included patients was 60.5 (12.0) years. Patients treated at hospitals attaining the combined metric of a 90% or higher negative margin rate and 80% or more of cases with LNYs of 18 or more experienced a significant reduction in mortality (hazard ratio [HR] 0.93; 95% CI, 0.89-0.98). This benefit in survival was independent of the patient-level improvement associated with negative margins (HR, 0.73; 95% CI, 0.71-0.76) and LNY of 18 or more (HR, 0.85; 95% CI, 0.83-0.88). Including these metrics in the model neutralized the association of traditional measures of hospital quality (volume and teaching status).

Conclusions and Relevance

Treatment at hospitals that attain a high rate of negative margins and LNY of 18 or more is associated with improved survival in patients undergoing surgery for HNSCC. These surgical outcome measures predicted outcomes independent of traditional, but generally nonmodifiable characteristics. Tracking of these metrics may help identify high-quality centers and provide guidance for institution-level quality improvement.

Frailty, hospital volume, and failure to rescue after head and neck cancer surgery

OBJECTIVES/HYPOTHESIS

We previously reported that high-volume hospital head and neck cancer (HNCA) surgical care is associated with decreased mortality, largely explained by reduced rates of failure to rescue. Frailty is an independent predictor of mortality, but is significantly less likely in patients receiving high-volume care. We investigate whether differences in frailty rates explain the relationship between volume and outcomes in HNCA patients and whether frailty confounds the relationship between failure to rescue and mortality.

STUDY DESIGN

Cross-sectional analysis.

METHODS

Discharge data from the Nationwide Inpatient Sample for 159,301 patients who underwent ablative surgery for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2001 to 2010 were analyzed using cross-tabulations and multivariate regression. Failure to rescue was defined as death after a major complication. Frailty was defined using frailty-defining diagnosis clusters from the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator.

RESULTS

High-volume hospital care was associated with a lower odds of frailty (odds ratio [OR]: 0.7 [95% confidence interval [CI]: 0.5-1.0]). Frail patients had higher odds of postoperative complications (OR: 4.1 [95% CI: 3.4-4.9]) and mortality (OR: 2.0 [95% CI: 1.3-3.2]), but no difference in failure to rescue rates (OR: 1.0 [95% CI: 0.6-1.6]). High-volume care was not associated with differences in odds of complications (OR: 1.0 [95% CI: 0.8-1.2]), but was associated with significantly decreased odds of mortality (OR: 0.6 [95% CI: 0.5-0.9]) and failure to rescue (OR: 0. 6 [95% CI: 0.3-1.0]), which was not attenuated by adjusting for frailty.

CONCLUSIONS

High-volume HNCA surgical care is associated with a significantly lower odds of mortality, which appears to be associated with differences in the response to and management of complications rather than differences in frailty or complication rates.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:1365-1370, 2018.

Patient safety issues in office-based surgery and anaesthesia in Switzerland: a qualitative study

OBJECTIVES

To identify the spectrum of patient safety issues in office-based surgery and anaesthesia in Switzerland.

METHODS

Purposive sample of 23 experts in surgery and anaesthesia and quality and regulation in Switzerland. Data were collected via individual qualitative interviews using a researcher-developed semi-structured interview guide between March 2016 and September 2016. Interviews were transcribed and analysed using conventional content analysis. Issues were categorised under the headings "structure", "process", and "outcome".

RESULTS

Experts identified two key overarching patient safety and regulatory issues in relation to office-based surgery and anaesthesia in Switzerland. First, experts repeatedly raised the current lack of data and transparency of the setting. It is unknown how many surgeons are operating in offices, how many and what types of operations are being done, and what the outcomes are. Secondly, experts also noted the limited oversight and regulation of the setting. While some standards exists, most experts felt that more minimal safety standards are needed regarding the requirements that must be met to do office-based surgery and what can and cannot be done in the office-based setting are needed, but they advocated a self-regulatory approach.

CONCLUSION

There is a lack of empirical data regarding the quantity and quality office-based surgery and anaesthesia in Switzerland. Further research is needed to address these research gaps and inform health policy in relation to patient safety in office-based surgery and anaesthesia in Switzerland.

Early death among head and neck cancer patients

PURPOSE OF REVIEW

Management of advanced head and neck cancer (HNC) is characterized by high mortality. Furthermore, the treatment involves significant burden to patients and high costs to healthcare systems. Recognizing the risks of early death in patients with a high probability of noncurable disease is important for each individual treatment decision-making. It is thus critical to consider the benefits and side-effects of the planned treatment in relation to the expected survival and to discuss these factors with the patient. However, only few studies have documented early death in HNC patients, that is, during the first posttreatment 6 months. We performed a systematic literature review to find the incidence of this phenomenon and to outline the probable cause.

RECENT FINDINGS

Early mortality in patients with HNC can be explained either by direct effect of malignant disease, may be related to comorbidities, or secondary to the treatment. These factors act together resulting in expected or unexpected early death.

SUMMARY

The present review provides information on the mechanisms leading to early phase mortality (<6 months) after management of HNC. It also reports the incidence of this phenomenon among Finnish and Swedish patient populations.

Factors Influencing the Incidence of Severe Complications in Head and Neck Free Flap Reconstructions

Background:

Complications after head and neck free-flap reconstructions are detrimental and prolong hospital stay. In an effort to identify related variables in a tertiary regional head and neck unit, the microvascular reconstruction activity over the last 5 years was captured in a database along with patient-, provider-, and volume-outcome–related parameters.

Methods:

Retrospective cohort study (level of evidence 3), a modified Clavien-Dindo classification, was used to assess severe complications.

Results:

A database of 217 patients was created with consecutively reconstructed patients from 2009 to 2014. In the univariate analysis of severe complications, we found significant associations (P < 0.05) between type of flap used, American Society of Anesthesiologists classification, T-stage, microscope use, surgeon, flap frequency, and surgeon volume. Within a binomial logistic regression model, less frequently versus frequently performed flap (odds ratio [OR] = 3.2; confidence interval [CI] = 2.9–3.5; P = 0.000), high-volume versus low-volume surgeon (OR = 0.52; CI = −0.22 to 0.82; P = 0.007), and ASA classification (OR = 2.9; CI = 2.4–3.4; P = 0.033) were retained as independent predictors of severe complications. In a Cox-regression model, surgeon (P = 0.011), site of reconstruction (P = 0.000), T-stage (P = 0.001), and presence of severe complications (P = 0.015) correlated with a prolonged hospitalization.

Conclusions:

In this study, we identified a correlation of patient-related factors with severe complications (ASA score) and prolonged hospital stay (T-stage, site). More importantly, we identified several provider- (surgeon) and volume-related (frequency with which a flap was performed and high-volume surgeon) factors as predictors of severe complications. Our data indicate that provider- and volume-related parameters play an important role in the outcome of microvascular free-flap procedures in the head and neck region.

Failure-to-rescue after injury is associated with preventability: The results of mortality panel review of failure-to-rescue cases in trauma

BACKGROUND

Failure-to-rescue is defined as the conditional probability of death after a complication, and the failure-to-rescue rate reflects a center's ability to successfully "rescue" patients after complications. The validity of the failure-to-rescue rate as a quality measure is dependent on the preventability of death and the appropriateness of this measure for use in the trauma population is untested. We sought to evaluate the relationship between preventability and failure-to-rescue in trauma.

METHODS

All adjudications from a mortality review panel at an academic level I trauma center from 2005-2015 were merged with registry data for the same time period. The preventability of each death was determined by panel consensus as part of peer review. Failure-to-rescue deaths were defined as those occurring after any registry-defined complication. Univariate and multivariate logistic regression models between failure-to-rescue status and preventability were constructed and time to death was examined using survival time analyses.

RESULTS

Of 26,557 patients, 2,735 (10.5%) had a complication, of whom 359 died for a failure-to-rescue rate of 13.2%. Of failure-to-rescue deaths, 272 (75.6%) were judged to be non-preventable, 65 (18.1%) were judged potentially preventable, and 22 (6.1%) were judged to be preventable by peer review. After adjusting for other patient factors, there remained a strong association between failure-to-rescue status and potentially preventable (odds ratio 2.32, 95% confidence interval, 1.47-3.66) and preventable (odds ratio 14.84, 95% confidence interval, 3.30-66.71) judgment.

CONCLUSION

Despite a strong association between failure-to-rescue status and preventability adjudication, only a minority of deaths meeting the definition of failure to rescue were judged to be preventable or potentially preventable. Revision of the failure-to-rescue metric before use in trauma care benchmarking is warranted.

Facial fracture repair and diabetes mellitus: An examination of postoperative complications

OBJECTIVES/HYPOTHESIS

Our objectives included using a nationally representative resource to evaluate charges, demographics, and complication rates among diabetics undergoing surgical repair of facial fractures.

METHODS

We evaluated the Nationwide Inpatient Sample, a database encompassing nearly 8 million hospitalizations, for patients with a diagnosis of a facial fracture who underwent surgical intervention during their hospitalization. Patients were organized by whether they had a diagnosis of diabetes mellitus (DM).

RESULTS

Of 45,509 inpatients included, diabetics had greater costs, longer length of stays, and were significantly more likely to have a host of baseline comorbidities. On multivariate logistic regression corrected for age, race, gender, and preexisting cardiac disease, DM patients had significantly greater odds for cardiac complications (3.3; P < 0.001) and hepatic failure (15.0; P = 0.007). There were no significant differences associated with DM in the rates of enophthalmos, epiphora, and diplopia among patients with orbital fractures. Diabetics did have a significantly greater risk of postoperative infection after mandible repair.

CONCLUSION

In addition to a significant association with greater length of stay and increased hospital charges, DM patients undergoing surgical repair of facial fractures had a significantly greater risk of postoperative complications, including cardiac complications. Diabetics undergoing mandible repair had a greater risk of postoperative infection, even upon controlling for demographic factors, suggesting the need for further study evaluating the role of postoperative antibiotic prophylaxis in this patient population. These findings reveal the potential value of developing and using standardized postoperative care algorithms aimed at minimizing complications in this susceptible population.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:809-814, 2017.

Individualized Risk Estimation for Postoperative Complications After Surgery for Oral Cavity Cancer

IMPORTANCE

Postoperative complications after head and neck surgery carry the potential for significant morbidity. Estimating the risk of complications in an individual patient is challenging.

OBJECTIVE

To develop a statistical tool capable of predicting an individual patient's risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective case series derived from an institutional clinical oncologic database, augmented by medical record abstraction, at an academic tertiary care cancer center. Participants were 506 previously untreated adult patients with biopsy-proven oral cavity squamous cell carcinoma who underwent surgery between January 1, 2007, and December 31, 2012.

MAIN OUTCOMES AND MEASURES

The primary end point was a major postoperative complication requiring invasive intervention (Clavien-Dindo classification grades III-V). Patients treated between January 1, 2007, and December 31, 2008 (354 of 506 [70.0%]) comprised the modeling cohort and were used to develop a nomogram to predict the risk of developing the primary end point. Univariable analysis and correlation analysis were used to prescreen 36 potential predictors for incorporation in the subsequent multivariable logistic regression analysis. The variables with the highest predictive value were identified with the step-down model reduction method and included in the nomogram. Patients treated between January 1, 2007, and December 31, 2008 (152 of 506 [30.0%]) were used to validate the nomogram.

RESULTS

Clinical characteristics were similar between the 2 cohorts for most comparisons. Thirty-six patients in the modeling cohort (10.2%) and 16 patients in the validation cohort (10.5%) developed a major postoperative complication. The 6 preoperative variables with the highest individual predictive value were incorporated within the nomogram, including body mass index, comorbidity status, preoperative white blood cell count, preoperative hematocrit, planned neck dissection, and planned tracheotomy. The nomogram predicted a major complication with a validated concordance index of 0.79. Inclusion of surgical operative variables in the nomogram maintained predictive accuracy (concordance index, 0.77).

CONCLUSIONS AND RELEVANCE

A statistical tool was developed that accurately estimates an individual patient's risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.