Readmission after surgery for oropharyngeal cancer: An analysis of rates, causes, and risk factors

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.

Association of comorbidity score with perioperative outcomes following transoral robotic surgery: National analysis

BACKGROUND

The association of comorbidities with perioperative outcomes after transoral robotic surgery (TORS) is not well-defined in the literature.

METHODS

Using the National Cancer Database, 4004 patients with T1-T2 oropharyngeal cancer between 2010 and 2017 were stratified based on their Charlson-Deyo Comorbidity Class (CDCC). Thirty-day unplanned readmissions, 30-day mortality, and 90-day mortality were compared using chi-square test and logistic regression. Hospital length of stay (LOS) was compared using the Kruskal-Wallis test.

RESULTS

LOS was greater for patients with CDCC 2 or 3 compared to CDCC 0 or 1 (p < 0.001). Increasing age and CDCC ≥3 were associated with 30-day mortality (CDCC ≥3: odds ratio [OR] 5.55, 95% confidence interval [CI] 1.59-19.45). CDCC ≥3 (OR 2.61, 95%CI 1.09-6.27) was significantly associated with 30-day readmissions.

CONCLUSION

This national analysis demonstrates greater rates of unplanned 30-day readmissions, longer hospitalizations, and increased 30- and 90-day mortality after TORS in patients with CDCC ≥3.

Outcomes After Oral Cavity and Oropharyngeal Salvage Surgery

OBJECTIVES

Investigate outcomes following oral cavity and oropharyngeal salvage surgery.

METHODS

Adult patients who underwent salvage surgery for recurrent squamous cell carcinoma of the oral cavity and oropharynx from 1996 to 2018 were analyzed using multivariable Cox proportional hazards regression. Disease-free survival (DFS), overall survival (OS), associated factors, and basic quality measures were analyzed.

RESULTS

One hundred and eight patients (72% oral cavity, 28% oropharynx) were followed for a median of 17.9 months. Median DFS and OS were 9.9 and 21 months, respectively. Surgery with adjuvant chemoradiotherapy compared to surgery alone (hazard ratio [HR] = 0.15, 95% confidence interval [CI]: 0.03-0.78) and negative margins (HR = 0.36, 95% CI: 0.14-0.90) were associated with better DFS, while lymphovascular space invasion (LVSI) (HR = 2.66, 95% CI: 1.14-6.19) and higher stage (III vs. I-II, HR = 3.94, 95% CI: 1.22-12.71) were associated with worse DFS. Higher stage was associated with worse OS (HR = 3.79, 95% CI: 1.09-13.19). Patients were hospitalized for a median of 8 days with 24% readmitted within 30 days. A total of 72% and 38% of patients, respectively, underwent placement of a feeding tube or tracheostomy.

CONCLUSIONS

After oral cavity and oropharyngeal salvage surgery, adjuvant chemoradiotherapy, negative margins, negative LVSI, and lower stage were associated with a lower risk of recurrence. Only lower-stage disease was associated with improved survival. The majority of patients had feeding tubes, half underwent free tissue transfer, a third required tracheostomy, and a quarter was readmitted.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

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.

Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer

PURPOSE

Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored.

METHODS

Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission.

RESULTS

Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission.

CONCLUSION

Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.

Risk factors, causes, and rates associated with hospital readmission after pediatric neck mass surgery

BACKGROUND

To understand rates, risk factors, and costs associated with hospital readmission in pediatric patients who underwent neck mass excision.

METHODS

This was a retrospective review of the Nationwide Readmissions Database (NRD) between 2010 and 2014 of select neck mass procedures, defined as affecting the following: thyroid, salivary gland, cervical lymph nodes, branchial cleft, thymus, and head and neck vessels. We analyzed rates and causes of 30-day readmissions using univariate and multivariate logistic regression.

RESULTS

There were a total of 11,824 weighted cases identified with a 30-day readmission rate of 9.0% and a mean age of 9.5 years old. The sex distribution of patients undergoing neck mass procedures was 55.8% female and 44.2% male. The most common cause of readmission was associated with a comorbid condition likely unrelated to the neck mass procedure (53%). The most common procedure-related readmission causes were associated with a postoperative neck mass (14.4%), wound (13%), and infection (6.5%). In the multivariate model, number of procedures≥5 (OR: 2.11, 95% CI: 1.28-3.49), number of chronic conditions≥1 (OR: 2.33, 95% CI: 1.16-4.66), length of hospital stay of≥7 days (OR: 2.43, 95% CI: 1.48-0.3.98), and cervical lymph node procedure (OR:2.61, 95% CI: 1.47-4.63) were associated with higher readmission risk.

CONCLUSION

Readmission after surgery for pediatric neck masses is relatively common, with an average of 9.0%. Risk factors associated with readmission include length of initial hospital stay, number of chronic conditions, number of procedures performed, and undergoing a cervical lymph node procedure.

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.

30-day unplanned readmission rate in otolaryngology patients: A population-based study in Thuringia, Germany

Purpose

Analyze associations between patients’ characteristics and treatment factors with 30-day unplanned readmissions in hospitalized otolaryngology patients in the German Diagnosis Related Group (D-DRG) system.

Methods

A retrospective cohort study was performed on 15.271 otolaryngology admissions of 12.859 patients in 2015 in Thuringia, Germany. The medical records of the 1173 cases (7.6%) with readmission within 30-days were analyzed in detail.

Results

The 30-day readmission was planned in 747 cases (4.9%) and was unplanned in 422 cases (2.8%). The median interval between primary and next inpatient treatment was 11 days. The principal diagnosis was the same as during the primary index treatment in 72% of the cases. The most frequent reasons for readmission were: Need for non-surgical therapy (31.2%), need for further surgery (26.3%), post-surgical complaints (16.9%), and recurrence of primary complaints (10.7%). The multivariate analysis revealed that discharge due to patient’s request against medical advice was a strong independent factor with high risk for unplanned readmission (Odds Ratio [OR] = 9.62]; confidence interval [CI] = 2.69–34.48). Surgery at index admission (OR = 3.33; CI = 1.86–5.96) was the second important independent risk factor for unplanned readmission. Unplanned readmission had more frequently a non-surgical treatment at readmission than a surgical treatment (OR = 3.92; CI = 2.24–6.84) and needed more frequently further diagnostics (OR = 2.34; CI = 1.34–4.11). The following index International Classification of Diseases (ICD) categories had the highest risk for unplanned readmission: Injury, poisoning and certain other consequences of external causes, ICD: S00-T98 (OR = 66.67; CI = 15.87–333.33), symptoms, signs, abnormal findings, ill-defined causes, not otherwise classified, ICD: R00-R99 (OR = 62.5; CI = 11.76–333.33), blood forming organ diseases, ICD: D50-D90 (OR = 21.276; CI = 3.508–125), and eye/ ear diseases, ICD: H00-H95 (OR = 12.66; CI = 4.29–37.03).

Conclusions

The causes of unplanned 30-day readmission in German otolaryngology inpatients are multifactorial. Specific patient and treatment characteristics were identified to be targeted with health care interventions to decrease unplanned readmissions.

Understanding nationwide readmissions after parotidectomy

OBJECTIVES

To evaluate the incidence, causes, risk factors, and costs associated with 30-day readmissions in parotidectomy patients utilizing the Nationwide Readmissions Database (NRD).

STUDY DESIGN

Retrospective cohort study.

METHODS

We examined the NRD for patients who underwent parotidectomy between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.

RESULTS

Among 15,102 included patients, 594 (3.9%) were readmitted within 30 days. The average cost per readmission was $12,502. Infectious (22.7%) and wound (11.2%) complications were the two most common causes of readmission. After controlling for other covariates, significant predictors of readmission included advanced comorbidity (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.09-2.37), a malignant parotid tumor (OR, 2.37; 95% CI, 1.63-3.43), length of stay ≥2 days (OR, 1.54; 95% CI, 1.09-2.18), and nonroutine discharge destinations (home with care [OR, 1.88; 95% CI, 1.27-2.78] and nursing facility [OR, 2.69; 95% CI, 1.55-4.67]).

CONCLUSION

In this nationwide database analysis, we found that nearly 4% of all patients undergoing parotidectomy are readmitted within 30 days. Readmissions are commonly due to infections and wound complications. Quality improvement proposals targeting avoidable readmissions should focus on early recognition and prevention of infection and wound complications. Risk factors contributing to readmission include advanced comorbidity, malignant parotid tumor, prolonged index hospitalization, and nonroutine discharge destinations.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1212-1217, 2020.