Thirty-Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa

Reassessing the Utility of Surgical Intervention for Skull Base Osteomyelitis: A 16-Year Experience

OBJECTIVE

The role of surgery in lateral skull base osteomyelitis (SBO) is controversial. Surgical intervention is often requested by consulting services in the interest of additional culture data to inform medical management. However, whether surgery alters subsequent antibiotic treatment or modifies disease outcome remains unknown. The aim of this study was to investigate the role of surgical intervention in the treatment of SBO by (1) comparing nonsurgical and surgical culture data and (2) assessing clinical outcomes and treatment course following surgical intervention.

STUDY DESIGN

Retrospective.

SETTING

Tertiary care center.

METHODS

The electronic record was queried for all patients with SBO who presented to a single institution over a 16-year period (2007-2023). Information recorded included history and exam, bedside and intraoperative culture data, antibiotic course, and disease outcomes. Primary outcome measures included change in medical management based on intraoperative cultures, recurrence rates, and mortality rates.

RESULTS

Forty patients (41 ears, average age 73 ± 13 years) met inclusion criteria. Out of 13 (32%) patients who underwent surgical intervention, one intraoperative culture changed the antibiotic course due to identification of resistance to the original antibiotic used. Surgery did not demonstrate a benefit in overall mortality (23% vs 18%, P = 0.36) or facial nerve function (33% vs 50%, P = 0.56) compared to medical management, and was associated with increased recurrence rates (54% vs 11%, P = 0.05).

CONCLUSION

Surgical cultures rarely changed antibiotic selection. Surgical debridement in treatment-refractory SBO was also not associated with improvement in recurrence or mortality rates, though this may reflect underlying differences in disease severity.

Neighborhood-level socioeconomic status, extended length of stay, and discharge disposition following elective lumbar spine surgery

Background

In the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery.

Methods

We employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively.

Results

779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge.

Conclusions

Patient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.

Emerging themes in necrotising otitis externa: a scoping review of the literature from 2011 to 2020 and recommendations for future research

OBJECTIVE

Necrotising otitis externa is an invasive, infective condition, with minimal evidence underpinning its diagnosis and management. This work aimed to analyse literature from the past decade, to identify emerging themes and important topics for future research.

METHODS

A robust literature search and review were conducted by two researchers. Sixty studies were filtered into the final review. A grounded theory approach was used to identify core themes. Data within these themes formed the basis of the review.

RESULTS

There is no consensus regarding a clinical definition or outcome measures of necrotising otitis externa, and there exists no level 1, 2 or 3 evidence to diagnose, investigate, monitor or treat necrotising otitis externa. Emerging themes in the literature direct researchers to important topics for future clinical trials, including risk factors, microbiological culture, management strategies and radiology.

CONCLUSION

In order to optimise understanding and management of necrotising otitis externa, future research requires robust clinical trials and consistently reported outcome measures.

Neighborhood-level Socioeconomic Status Predicts Extended Length of Stay Following Elective Anterior Cervical Spine Surgery

BACKGROUND

A significant portion of healthcare spending is driven by a small percentage of the overall population. Understanding risk factors predisposing patients to disproportionate utilization of healthcare resources is critical. Our objective was to identify risk factors leading to a prolonged length of stay (LOS) following cervical spine surgery.

METHODS

A single center cohort analysis was performed on patients who underwent elective anterior spine surgery from 2015-2021. Multivariate logistic regression evaluated the effects of sociodemographic factors including Area of Deprivation Index (quantifies income, education, employment, and housing quality), procedural, and discharge characteristics on postoperative LOS. Extended LOS was defined as greater than the 90^th percentile in midnights for the study population (greater than or equal to three midnights).

RESULTS

There were 686 patients included in the study, with a mean age of 57 years (range 26-92), median of 1 level (1-4) fused, and median LOS of 1 midnight (IQR 1,2). After adjusting for confounders, patients had increased odds of extended LOS if they were highly disadvantaged on the Area of Deprivation Index (ADI, OR=2.24, 95% CI=1.04 - 4.82; p=.039); had surgery on Thursday or Friday (OR=1.94; 1.01 - 3.72; p=.046); had a corpectomy performed (OR=2.81; 1.26 - 6.28; p=.012); or discharged not to home (OR=8.24; 2.88 - 23.56; p<.001). Patients with extended LOS were more likely to present to the emergency department or be re-admitted within 30 days after discharge (p=.024).

CONCLUSION

After adjusting for potential cofounders, patients most disadvantaged on ADI were more likely to have an extended LOS.

Necrotising Otitis Externa - is poor outcome predictable? The application of a diagnosis-based scoring system in patients with skull base osteomyelitis

Background

The increased incidence of necrotising otitis externa over the last decade has had a significant burden on healthcare providers. Several factors may affect outcome, and stratifying risk may allow personalised treatment.

Method

Retrospectively identified patients were prospectively surveyed over 12 months. The Cox proportional hazards model was used to identify predictors of poor prognosis.

Results

Twenty-six patients with necrotising otitis externa (average age of 80 years) were admitted from 2018 to 2019. At one year, 19 per cent mortality was observed. A high Charlson Comorbidity Index was associated with increased mortality (p = 0.03), prolonged in-patient stay (p = 0.047) and increased odds of adverse outcomes (odds ratio = 1.48, 95 per cent confidence interval = 0.26–2.67, p = 0.019). The Charlson Comorbidity Index in our prognostic model was validated using the receiver operating characteristic curve (area under the curve = 0.76). Charlson Comorbidity Index score of 5 or more independently predicted one-year morbidity and mortality (hazard ratio = 1.30, 95 per cent confidence interval = 0.94–1.79, p = 0.03).

Conclusion

Risk-stratifying patients may enable clinicians to holistically counsel patients and tailor their treatment to improve their prognosis and subsequently alleviate the burden of necrotising otitis externa.

Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery

Objective:

To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events.

Methods:

The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy.

Results:

A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations ( P = 0.020), higher length of hospitalization ( P < 0.001), and higher mortality ( P = 0.027) and readmission rates ( P = 0.023).

Conclusion:

Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.