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Meers AJ, Warren JD, Dmowska J, Kane AC, Tassone P. Unplanned Return to Hospital After Same Day Oral Cavity Resection: A Dual Institution Study. Ann Otol Rhinol Laryngol 2024; 133:449-453. [PMID: 38321926 DOI: 10.1177/00034894241230355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVES Primary objective: describe rates of 30-days unplanned readmission following outpatient resection of oral cavity cancer. Secondary objective: evaluate for patient and treatment factors associated with readmission. METHODS Retrospective, dual-institution cohort study of 2 tertiary care referral centers involving adult patients undergoing resection of oral cavity cancer with plans for same-day discharge. Consecutive sample of 77 patients included. Primary outcome was unplanned readmission to emergency room or inpatient stay in the 30 days following surgery. Comparison testing was used between return and non-return groups. RESULTS Among 77 patients treated with outpatient surgery for oral cavity cancer, 19 (25%) returned to the hospital within 30 days. Among the reasons for return, 16 (80%) were directly related to surgery, and 4 (20%) were related to perioperative medical complications not directly related to a surgical site. Among the 25 patients also undergoing sentinel lymph node biopsy with their oral cavity resection, none returned to the hospital for neck-related complications. While most patients could be safely observed and discharged after return to the hospital, 8 patients (10%) required inpatient readmission. No significant differences between return and non-return groups were identified, although there was a trend toward shorter driving distance from hospital for the return group (47.6 miles vs. 69.5 miles, P = 0.097). CONCLUSION Unplanned return to the hospital following outpatient oral cavity resection is prevalent and primarily driven by postoperative primary resection site concerns. Among patients selected for same day discharge, no definite population at highest risk of unplanned return was identified.
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Affiliation(s)
- Aaron J Meers
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - James D Warren
- Department of Otolaryngology - Head and Neck Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Julia Dmowska
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Anne C Kane
- Department of Otolaryngology - Head and Neck Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Patrick Tassone
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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Nyirjesy SC, McCrary HC, Zhao S, Judd RT, Farlow JL, Seim NB, Ozer E, Agrawal A, Old MO, Rocco JW, Kang SY, Haring CT. National Trends in 30-Day Readmission Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg 2024; 150:133-141. [PMID: 38153724 PMCID: PMC10853828 DOI: 10.1001/jamaoto.2023.4025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/27/2023] [Indexed: 12/29/2023]
Abstract
Importance As the incidence of oropharyngeal squamous cell carcinoma (OPSCC) continues to rise in the US, an increasing number of patients are being treated with transoral robotic surgery (TORS). Readmission following surgery can potentially delay initiation of adjuvant treatment and affect survival outcomes. Objective To identify risk factors for 30-day postoperative readmission in patients undergoing TORS for OPSCC. Design, Setting, and Participants This retrospective, population-based cohort study used data from the Nationwide Readmissions Database from 2010 to 2017. All patients undergoing TORS for OPSCC were identified using International Classification of Diseases codes and included. Exclusion criteria were age younger than 18 years or incomplete information regarding index admission or readmission. The analysis was performed from April to October 2023. Exposure TORS for OPSCC. Main Outcomes and Measures Univariate and multivariate analyses were performed to determine factors associated with 30-day readmission. Covariates included demographics and medical comorbidities, socioeconomic factors, hospital characteristics, and surgical details. Trends in readmission over time, reasons for readmission, and characteristics of the readmission were also examined. Results A weighted total of 5544 patients (mean [SD] age, 60.7 [0.25] years; 4475 [80.7%] male) underwent TORS for OPSCC. The overall readmission rate was 17.5% (n = 971), and these rates decreased over the study period (50 of 211 patients [23.7%] in 2010 vs 58 of 633 patients [9.1%] in 2017). Risk factors associated with readmission included male sex (adjusted odds ratio [AOR], 1.54; 95% CI, 1.07-2.20) and a diagnosis of congestive heart failure (AOR, 2.42; 95% CI, 1.28-4.58). Factors associated with decreased rate of readmission included undergoing concurrent selective neck dissection (AOR, 0.30; 95% CI, 0.22-0.41). Among the 971 readmissions, the most common readmission diagnoses were bleeding (151 [15.6%]), electrolyte and digestive problems (44 [4.5%]), pneumonia (44 [4.5%]), and sepsis (26 [2.7%]). Conclusions and Relevance In this cohort study, readmission rates following TORS for oropharynx cancer decreased over time; however, a subset of patients required readmission most commonly related to bleeding, infection, and electrolyte imbalance. Concurrent neck dissection may be protective against readmission. Elucidation of risk factors for readmission after TORS for OPSCC offers opportunities for evidence-based shared decision-making, quality improvement initiatives, and improved patient counseling.
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Affiliation(s)
- Sarah C. Nyirjesy
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Hilary C. McCrary
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Songzhu Zhao
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University College of Medicine, Columbus
| | - Ryan T. Judd
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Janice L. Farlow
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Nolan B. Seim
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Enver Ozer
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Amit Agrawal
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Matthew O. Old
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - James W. Rocco
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Stephen Y. Kang
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
| | - Catherine T. Haring
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
- The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
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Leung CK, Walton NC, Kheder E, Zalpour A, Wang J, Zavgorodnyaya D, Kondody S, Zhao C, Lin H, Bruera E, Manzano JGM. Understanding Potentially Preventable 7-day Readmission Rates in Hospital Medicine Patients at a Comprehensive Cancer Center. Am J Med Qual 2024; 39:14-20. [PMID: 38127668 PMCID: PMC10841441 DOI: 10.1097/jmq.0000000000000157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
This study aimed to describe the potentially preventable 7-day unplanned readmission (PPR) rate in medical oncology patients. A retrospective analysis of all unplanned 7-day readmissions within Hospital Medicine at MD Anderson Cancer Center from September 1, 2020 to February 28, 2021, was performed. Readmissions were independently analyzed by 2 randomly selected individuals to determine preventability. Discordant reviews were resolved by a third reviewer to reach a consensus. Statistical analysis included 138 unplanned readmissions. The estimated PPR rate was 15.94%. The median age was 62.50 years; 52.90% were female. The most common type of cancer was noncolon GI malignancy (34.06%). Most patients had stage 4 cancer (69.57%) and were discharged home (64.93%). Premature discharge followed by missed opportunities for goals of care discussions were the most cited reasons for potential preventability. These findings highlight areas where care delivery can be improved to mitigate the risk of readmission within the medical oncology population.
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Affiliation(s)
- Cerena K. Leung
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Natalie C. Walton
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Ed Kheder
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Ali Zalpour
- Department of Pharmacy Clinical Programs, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Justine Wang
- Department of Pharmacy Clinical Programs, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sonia Kondody
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Christina Zhao
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joanna-Grace M. Manzano
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Leung C, Andersen CR, Wilson K, Nortje N, George M, Flowers C, Bruera E, Hui D. The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center. Support Care Cancer 2023; 32:66. [PMID: 38150077 DOI: 10.1007/s00520-023-08265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/17/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE This study examined the 30-day unplanned readmission rate in the medical oncology population before and after the implementation of an institution-wide multicomponent interdisciplinary goals of care (myGOC) program. METHODS This retrospective study compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period (May 1, 2019, to December 31, 2019) and the post-implementation period (May 1, 2020, to December 31, 2020). Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders, and palliative care consults. We randomly selected a hospitalization encounter for each unique patient during each study period for statistical analysis. A multivariate analysis model was used to examine the association between 30-day unplanned readmission rates and implementation of the myGOC program. RESULTS There were 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The overall 30-day unplanned readmission rate decreased from 24.0 to 21.3% after implementation of the myGOC program. After adjusting for covariates, the myGOC program implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p = 0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were an inpatient DNR order, advanced care planning documentation, and an emergent admission type. We also observed a significant decrease in 7-day unplanned readmission rates (OR [95% CI] 0.75 [0.64, 0.89]) after implementation of the myGOC program. CONCLUSION The 30-day and 7-day unplanned readmission rates decreased in our hospital after implementation of a system-wide multicomponent GOC intervention.
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Affiliation(s)
- Cerena Leung
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaycee Wilson
- Department of Inpatient Analytics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nico Nortje
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina George
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Flowers
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Nyirjesy SC, Zhao S, Judd R, McCrary H, Kuhar HN, Farlow JL, Seim NB, Rocco JW, Kang SY, Haring CT. Hypothyroidism as an Independent Predictor of 30-day Readmission in Head and Neck Cancer Patients. Laryngoscope 2023; 133:2988-2998. [PMID: 36974971 DOI: 10.1002/lary.30675] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/21/2023] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
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.
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Affiliation(s)
- Sarah C Nyirjesy
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Songzhu Zhao
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, 320 Lincoln Tower, 1800 Cannon Drive, Columbus, Ohio, 43210, USA
| | - Ryan Judd
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Hilary McCrary
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Hannah N Kuhar
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Janice L Farlow
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Nolan B Seim
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - James W Rocco
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Stephen Y Kang
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Catherine T Haring
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
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Interrelationships between Dietary Outcomes, Readmission Rates and Length of Stay in Hospitalised Oncology Patients: A Scoping Review. Nutrients 2023; 15:nu15020400. [PMID: 36678271 PMCID: PMC9865609 DOI: 10.3390/nu15020400] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Poor food intake is an independent risk factor for malnutrition in oncology patients, and achieving adequate nutrition is essential for optimal clinical and health outcomes. This review investigated the interrelationships between dietary intakes, hospital readmissions and length of stay in hospitalised adult oncology patients. METHODOLOGY Three databases, MEDLINE, Web of Science and PubMed were searched for relevant publications from January 2000 to the end of August 2022. RESULTS Eleven studies investigating the effects of dietary intakes on length of stay (LOS) and hospital readmissions in cohorts of hospitalised patients that included oncology patients were identified. Heterogenous study design, nutritional interventions and study populations limited comparisons; however, a meta-analysis of two randomised controlled trials comparing dietary interventions in mixed patient cohorts including oncology patients showed no effect on LOS: mean difference -0.08 (95% confidence interval -0.64-0.49) days (p = 0.79). CONCLUSIONS Despite research showing the benefits of nutritional intake during hospitalisation, evidence is emerging that the relationship between intakes, LOS and hospital readmissions may be confounded by nutritional status and cancer diagnosis.
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7
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Wang EY, Chen MK, Hsieh MY, Kor CT, Liu YT. Relationship between Preoperative Nutritional Status and Clinical Outcomes in Patients with Head and Neck Cancer. Nutrients 2022; 14:nu14245331. [PMID: 36558490 PMCID: PMC9782741 DOI: 10.3390/nu14245331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
The nutritional status in cancer patients is related to cancer survival and surgical outcome. The objective of this study was to examine the relationship between preoperative prognostic nutritional index (PNI) and post-operative clinical outcomes in head and neck cancer (HNC) patients. A total of 1282 head and neck cancer patients receiving surgical resection in Changhua Christian Hospital between 1 January 2010 and 30 August 2021 were recruited in the final analysis after undergoing propensity score matching analysis. The logistic regression model was used to assess the association of the PNI group with overall and various complications. The patients in the high PNI group had a significant lower incidence of overall complications, medical complications, and pulmonary complications; but not significant surgical complications. The high PNI group had lower mortality risk. The results in this study revealed that PNI score was a significant independent predictor of postoperative complications in HNC patients undergoing surgical resection. We recommend preoperative testing and evaluation of HNC patients to identify low PNI and high-risk groups for postoperative surveillance.
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Affiliation(s)
- En-Ying Wang
- Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Mu-Kuan Chen
- Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Ming-Yu Hsieh
- Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua 500, Taiwan
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua 500, Taiwan
| | - Yen-Tze Liu
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Department of Family Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Oral Cancer Research Center, Changhua Christian Hospital, Changhua 500, Taiwan
- Correspondence: ; Tel.: +886-4-7238595 (ext. 3267)
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Tucker J, Hollenbeak CS, Goyal N. Discharge destination and readmissions among patients with head and neck cancer. Laryngoscope Investig Otolaryngol 2022; 7:1407-1429. [PMID: 36262465 PMCID: PMC9575139 DOI: 10.1002/lio2.890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Lowering hospital readmission rates is a national goal, and presents an opportunity to lower health care costs, improve quality, and increase patient satisfaction. We aim to assess whether discharge disposition is associated with readmission. Methods A retrospective cohort study using logistic regression to quantify risk factors of hospital readmission in patients with confirmed head and neck cancer (HNC) who underwent surgery from 2010 to 2018 contained in the Pennsylvania Health Care Cost Containment Council database, which includes patients treated in Pennsylvania hospitals. Results The readmission rate in this study was 18.1%. Cancers of the hypopharynx had the highest rates of readmission (29.2%). Male sex (odds ratio [OR]: 0.87, 95% CI: 0.75–1.00), emergent admission (vs. elective admission: OR = 1.33, 95% CI: 1.02–1.74), discharge to home health (vs. home: OR = 1.85, 95% CI: 1.59–2.16), discharge to skilled nursing facility (SNF) (vs. home: OR = 2.21, 95% CI: 1.80–2.72), and having 4+ comorbidities (vs. 0–1: OR = 1.39, 95% CI: 1.09–1.76) were significant risk factors for hospital readmission. Conclusion It is necessary to consider the readmission risk associated with HNC patients. Reasons for readmission are multifactorial and can be related to demographics, hospital course, comorbidities, or discharge disposition–this requires further assessment. There is importance in increasing HNC awareness and staff education about the unique needs of this population. Level of Evidence 4.
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Affiliation(s)
- Jacqueline Tucker
- College of Medicine The Pennsylvania State University Hershey Pennsylvania USA
| | - Christopher S. Hollenbeak
- Department of Health Policy and Administration, College of Health and Human Development The Pennsylvania State University University Park Pennsylvania USA
| | - Neerav Goyal
- College of Medicine The Pennsylvania State University Hershey Pennsylvania USA
- Department of Otolaryngology–Head and Neck Surgery Penn State College of Medicine Hershey Pennsylvania USA
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9
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Voora RS, Qian AS, Kotha NV, Qiao EM, Meineke M, Murphy JD, Orosco RK. Frailty Index as a Predictor of Readmission in Patients With Head and Neck Cancer. Otolaryngol Head Neck Surg 2022; 167:89-96. [PMID: 34520305 DOI: 10.1177/01945998211043489] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the predictive utility of the Hospital Frailty Risk Score (HFRS), a stratification tool based on the ICD-10 (International Classification of Disease, Tenth Revision), and other risk factors for 30-day readmissions and mortality in a nationally representative cohort. STUDY DESIGN Retrospective database review. SETTING Nationwide Readmissions Database (2017). METHODS Patients with head and neck cancer who underwent major surgical procedures were identified from the 2017 Nationwide Readmissions Database, representing 116 medical centers nationwide. Bivariate and multivariable logistic regression methods were used to identify factors associated with unplanned 30-day readmission, 30-day readmission mortality, and increased length of hospital stay. RESULTS A total of 14,420 patients underwent major head and neck cancer surgery. Unplanned readmission occurred in 11% of patients. The most common reasons for unplanned readmission were procedural complications (26.5%), sepsis (7.3%), and respiratory failure (3.9%). Elevated frailty index (HFRS ≥5) was identified in 22% of patients. Frailty was associated with higher 30-day readmission rates (18.0% vs 9.5%, P < .01), which held on multivariate modeling (odds ratio [OR], 1.59 [95% CI, 1.37-1.85]). Frail patients spent more days in the hospital (8.2 vs 6.8, P = .02) and incurred more charges across hospital stays ($275,000 vs $188,000, P < .01). Patients >75 years old (OR, 1.26 [1.03-1.55]) and patients with electrolyte abnormalities (OR, 1.25 [1.07-1.46] were significantly more likely to be readmitted. CONCLUSION In this head and neck cancer surgical population, HFRS significantly predicted unplanned readmission. HFRS is a potential risk stratification tool and should be compared with other methods and explored in other cancer populations. Beyond the challenge of identifying at-risk patients, future work should explore potential interventions aimed at mitigating readmission.
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Affiliation(s)
- Rohith S Voora
- School of Medicine, University of California-San Diego, San Diego, California, USA.,Division of Otolaryngology-Head and Neck Surgery, University of California-San Diego, San Diego, California, USA
| | - Alexander S Qian
- School of Medicine, University of California-San Diego, San Diego, California, USA.,Department of Radiation Medicine and Applied Sciences, School of Medicine, University of California-San Diego, La Jolla, California, USA
| | - Nikhil V Kotha
- School of Medicine, University of California-San Diego, San Diego, California, USA.,Department of Radiation Medicine and Applied Sciences, School of Medicine, University of California-San Diego, La Jolla, California, USA
| | - Edmund M Qiao
- School of Medicine, University of California-San Diego, San Diego, California, USA.,Department of Radiation Medicine and Applied Sciences, School of Medicine, University of California-San Diego, La Jolla, California, USA
| | - Minhthy Meineke
- Department of Anesthesiology, School of Medicine, University of California-San Diego, La Jolla, California, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, School of Medicine, University of California-San Diego, La Jolla, California, USA.,Moores Cancer Center, La Jolla, California, USA
| | - Ryan K Orosco
- Division of Otolaryngology-Head and Neck Surgery, University of California-San Diego, San Diego, California, USA.,Moores Cancer Center, La Jolla, California, USA
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10
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Sharma BK, Contrera KJ, Jia X, Fleming C, Lorenz RR, Koyfman SA, Mahomva C, Arianpour K, Burkey BB, Fritz M, Ku JA, Lamarre ED, Scharpf J, Prendes BL. Outcomes After Oral Cavity and Oropharyngeal Salvage Surgery. Laryngoscope 2022; 132:1984-1992. [PMID: 35191537 DOI: 10.1002/lary.30070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/06/2021] [Accepted: 02/02/2022] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Bhavya K Sharma
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, U.S.A
| | - Kevin J Contrera
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Xuefei Jia
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Christopher Fleming
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Robert R Lorenz
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | | | | | - Brian B Burkey
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Michael Fritz
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Jamie A Ku
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Eric D Lamarre
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Joseph Scharpf
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
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11
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Association of Surrogate Objective Measures With Work Relative Value Units. Ochsner J 2022; 21:371-380. [PMID: 34984052 PMCID: PMC8675618 DOI: 10.31486/toj.20.0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The determination of accurate measures of evaluating surgeon work for reimbursement is poorly characterized. This study defines the correlation of surgical work relative value units (work RVUs) with several surrogate objective measures for otolaryngologic work. The defined surrogate objective measures evaluated in this study are length of hospital stay (LOS), operative time, 30-day mortality, 30-day unplanned readmission, 30-day reoperation, and 30-day morbidity. Methods: We collected data on otolaryngologic cases from 2016 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program. Pearson correlation coefficient was used to associate work RVUs with objective measures of surgeon work. Linear regressions were used to identify predictors of work RVUs from the surrogate objective measures. Studentized residuals were used to identify outlying procedures. Results: Work RVUs correlated strongly with operative time (R=0.6775), 30-day readmission (R=0.6100), and LOS (R=0.6083); moderately with 30-day reoperation (R=0.5257) and 30-day morbidity (R=0.4842); and very weakly with 30-day mortality (R=0.1383). The best predictors for work RVUs based on multivariable linear regression analysis were morbidity, reoperation, and operative time. Analysis revealed that the projected work RVU is 12.23 units higher than the current value for excision of bone, mandible (Current Procedural Terminology [CPT] code 21025) and 19.48 units lower than the current value for resection/excision of lesion infratemporal fossa space apex extradural (CPT code 61605). Conclusion: Using objective surrogate measures for time and intensity of physician work in head and neck cases may improve work RVU assignment accuracy compared to the current system of physician survey. Future investigation with additional objective parameters may be beneficial to make work RVU assignments less subjective.
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12
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Mady LJ, Poonia SK, Baddour K, Snyder V, Kurukulasuriya C, Frost AS, Cannady SB, Chinn SB, Fancy T, Futran N, Hanasono MM, Lewis CM, Miles BA, Patel U, Richmon JD, Wax MK, Yu P, Solari MG, Sridharan S. Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction. Head Neck 2021; 43:3032-3041. [PMID: 34145676 DOI: 10.1002/hed.26789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/10/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aim to define a set of terms for common free flap complications with evidence-based descriptions. METHODS Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. RESULTS Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." CONCLUSION Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.
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Affiliation(s)
- Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Seerat K Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vusala Snyder
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Ariel S Frost
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Tanya Fancy
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Neal Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brett A Miles
- Department of Otolaryngology, Northwell Health, New York, New York, USA
| | - Urjeet Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mario G Solari
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Sindhar S, Kallogjeri D, Wildes TS, Avidan MS, Piccirillo JF. Association of Preoperative Functional Performance With Outcomes After Surgical Treatment of Head and Neck Cancer: A Clinical Severity Staging System. JAMA Otolaryngol Head Neck Surg 2021; 145:1128-1136. [PMID: 31045219 DOI: 10.1001/jamaoto.2019.1035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patients with head and neck cancers have comorbidities and other constitutional symptoms known to be associated with adverse postoperative outcomes, but the role of functional performance is not well studied. Objective To explore the addition of functional performance to other clinical factors for association with 3 patient outcomes: 30-day unplanned readmission (UR), 90-day medical complications, and overall survival (OS). Design, Setting, and Participants This retrospective cohort study was conducted in a single tertiary care center with patients surgically treated for squamous cell cancer of the lip, oral cavity, pharynx, or larynx from January 2012 to December 2016. All analysis took place between January 2018 and November 2018. Data from 2 registries were analyzed, supplemented with medical record review. Logistic regression analysis was used to explore association of preoperative functional performance with outcomes. Conjunctive consolidation was used to create a useful clinical severity staging system, which included functional performance (estimated from metabolic equivalent [MET] score: <4, light-intensity activities; ≥4 at least moderate-intensity activities); overall comorbidity severity; preoperative weight loss; and TNM tumor staging. Logistic regression was used to assess the prognostic accuracy of the clinical severity staging system for 30-day UR and 90-day complications, and Cox proportional hazard regression for OS. Exposures All patients underwent surgical treatment for head and neck cancer. Main Outcomes and Measures The primary outcomes were 30-day UR and 90-day complications; the secondary outcome was OS. Results For the 657 patients included, the mean (SD) age was 62.0 (11.3) years; 73% were men (n = 477), and 88% were white (n = 580). A total of 75 (11%) had a 30-day UR; 204 (31%) developed a 90-day complication; and 127 (19%) patients died during the observation period. Individually, poor functional performance (<4 METs), high comorbidity burden, preoperative weight loss, and advanced TNM stage were associated with all 3 outcomes; the increased risk for each outcome ranged from 1.5 to 3.0 times the reference range. Using these 4 variables in combination, the 4-category clinical severity staging system demonstrated a strong association between severity stage and all 3 adverse outcomes: 30-day UR (C statistic, 0.63), 90-day complications (C statistic, 0.63), and OS (C statistic, 0.68). Conclusions and Relevance Poor preoperative functional performance, high comorbidity burden, preoperative weight loss, and advanced tumor stage were all associated with worse patient outcomes after head and neck cancer surgery. The model incorporating all 4 of these factors developed in this study may facilitate patient-centered risk assessment and patient-physician shared preoperative decision making.
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Affiliation(s)
- Sampat Sindhar
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri.,Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri.,Editor, JAMA Otolaryngology-Head & Neck Surgery
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14
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Jacobs D, Kafle S, Earles J, Rahmati R, Mehra S, Judson BL. Prolonged inpatient stay after upfront total laryngectomy is associated with overall survival. Laryngoscope Investig Otolaryngol 2021; 6:94-102. [PMID: 33614936 PMCID: PMC7883619 DOI: 10.1002/lio2.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/12/2020] [Accepted: 07/25/2020] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel Jacobs
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Samipya Kafle
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Joseph Earles
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Rahmatullah Rahmati
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Saral Mehra
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Benjamin L. Judson
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
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15
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Harris BN, Patel R, Kejner A, Russell B, Ramadan J, Bewley A. Thrombocytosis Predicts Surgical Site Infection in Head and Neck Microvascular Surgery- A Pilot Study. Laryngoscope 2021; 131:1542-1547. [PMID: 33443771 DOI: 10.1002/lary.29386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/07/2020] [Accepted: 01/03/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE/HYPOTHESIS Early and objective prediction of complications in head and neck reconstructive surgery could decrease morbidity and prolonged hospital stays but unfortunately most complications are not identified until their effect is fully realized. There are limited data regarding the association of platelet levels and post-operative complications. Post-operative thrombocytosis (POTCT) is proposed as a possible indicator for complications following free-flap reconstruction. STUDY DESIGN Retrospective review. METHODS A multisite retrospective chart review of patients undergoing free tissue transfer between 2013 and 2018 was undertaken. POTCT was recorded and data normalized between institutions. Data were compared between groups using t-tests and logistic regression (P < .05). A lag-1 difference was used to compare the rate of change in platelet values. RESULTS A total of 398 patients were included. POTCT and a rate of change of 30 K between POD5 and POD6 was significantly associated with the presence of post-operative complication (P = .007). Additionally, lag-1 difference demonstrated a significant association of change in daily platelet counts and complication rates. CONCLUSIONS Isolated POTCT may be an early predictor of complications in HNC patients undergoing free-flap reconstruction. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1542-1547, 2021.
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Affiliation(s)
- Brianna N Harris
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Rusha Patel
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Alexandra Kejner
- Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Benjamin Russell
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Jad Ramadan
- Department of Statistics, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Arnaud Bewley
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
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16
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Khoury H, Bellamkonda N, Benharash P, Lee JT, Wang MB, Suh JD. National Analysis of 30-Day Readmission Following Inpatient Sinus Surgery for Chronic Rhinosinusitis. Laryngoscope 2020; 131:E1422-E1428. [PMID: 33098341 DOI: 10.1002/lary.29117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/01/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To characterize the incidence, causes, risk factors, and costs of 30-day readmission after inpatient functional endoscopic sinus surgery (FESS) for patients with chronic rhinosinusitis. STUDY DESIGN Retrospective cohort study. METHODS The Nationwide Readmissions Database was used to characterize readmission after inpatient sinus surgery for chronic rhinosinusitis from 2015 to 2017. International Classification of Disease codes were used to identify the patient population, which included 5,644 patients. Incidence, causes, costs, and predictors of readmission were analyzed and determined. RESULTS Among 6,386 patients who underwent inpatient FESS, 742 (11.6%) were readmitted within 30 days of discharge. On univariate analysis, patients who were readmitted were more commonly older than 70 years (23.3% vs. 16.2%); had a higher burden of comorbidities including chronic kidney disease (15.0% vs. 7.8%), diabetes (25.6% vs. 20.4%), and hypertension (13.5% vs. 8.5%); had a greater rate of postoperative complications (20.7% vs. 12.2%); and had a longer length of stay (12.4 vs. 6.9 days) compared to patients who were not readmitted. Readmissions cost an additional $27,141 per patient. On multivariable analysis, age greater than 70 years, Medicaid insurance, several comorbidities, prolonged length of stay, postoperative neurologic complications, and lower hospital volume were independent predictors of 30-day readmission. The most common cause for readmission was infection (36.3%). CONCLUSION Readmission following inpatient FESS is not uncommon. Identification and management of preoperative comorbidities, optimized patient selection for inpatient surgery, and thorough postoperative discharge care may improve patient outcomes and decrease healthcare expenditures. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E1422-E1428, 2021.
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Affiliation(s)
- Habib Khoury
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, U.S.A
| | - Nikhil Bellamkonda
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, U.S.A
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratory (CORELAB), University of California Los Angeles, Los Angeles, California, U.S.A
| | - Jivianne T Lee
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, U.S.A
| | - Marilene B Wang
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, U.S.A
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, U.S.A
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17
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Noel CW, Forner D, Wu V, Enepekides D, Irish JC, Husain Z, Chan KKW, Hallet J, Coburn N, Eskander A. Predictors of surgical readmission, unplanned hospitalization and emergency department use in head and neck oncology: A systematic review. Oral Oncol 2020; 111:105039. [PMID: 33141060 DOI: 10.1016/j.oraloncology.2020.105039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/18/2020] [Accepted: 10/04/2020] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vincent Wu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Danny Enepekides
- Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Natalie Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
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18
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Thiagarajan S, Sawhney S, Jain S, Chakraborthy A, Menon N, Gupta A, Chaukar D. Factors Predisposing to the Unplanned Hospital Readmission (UHR) in Patients Undergoing Surgery for Oral Cavity Squamous Cell Carcinoma (OSCC): Experience from a Tertiary Cancer Centre. Indian J Surg Oncol 2020; 11:475-481. [PMID: 33013131 DOI: 10.1007/s13193-020-01135-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/08/2020] [Indexed: 01/22/2023] Open
Abstract
Unplanned hospital readmissions (UHR) are known to add to patient morbidity, increase the cost of the treatment, and negatively impact the postoperative quality of life. The objective of the study was to identify the UHR rates of oral cavity squamous cell carcinoma (OSCC) patients following surgery and identify the predisposing factors for UHR. We conducted this retrospective analysis of all patients who underwent surgery for OSCC in our (single) surgical unit from January 2016 to December 2018. A total of 804 patients satisfied the eligibility criteria. Majority of the patients were males (n = 650, 80.8%). The median age of the patients was 50 years (Range: 16-89 years). The most common oral cavity subsite was buccal mucosa gingivobuccal (BM-GBS) OSCC. Forty patients (5%) required an UHR after discharge. The most common reason for readmissions was flap-related issues (11/40) and orocutaneous fistula (10/40). Other causes included wound infection (7/40), chest infection (2/40), hematoma/bleeding (3/40), and other lesser prevalent causes (7/40). Factors that significantly predisposed patients for UHR were re-exploration following the initial surgery [p < 0.001, OR 7.9 (4.09-15.59)] and BM-GBS subsite [< 0.001, OR: 2.89(1.24-6.73)]. The UHR rate in our study was 5%. Patients requiring re-exploration following the initial surgery and those with BM-GBS cancer were most likely to have the UHR.
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Affiliation(s)
- Shivakumar Thiagarajan
- Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
| | - Shikhar Sawhney
- Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
| | - Siddhanth Jain
- Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
| | - Adhara Chakraborthy
- Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
| | - Nandini Menon
- Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
| | - Alaknanda Gupta
- Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
| | - Devendra Chaukar
- Department of Head & Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
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19
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30-day unplanned readmission rate in otolaryngology patients: A population-based study in Thuringia, Germany. PLoS One 2019; 14:e0224146. [PMID: 31622434 PMCID: PMC6797198 DOI: 10.1371/journal.pone.0224146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/06/2019] [Indexed: 11/30/2022] Open
Abstract
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.
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20
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Redmann AJ, Yuen SN, VonAllmen D, Rothstein A, Tang A, Breen J, Collar R. Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology–Head and Neck Surgery? Otolaryngol Head Neck Surg 2019; 161:629-634. [DOI: 10.1177/0194599819861524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives (1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission. Study Design Retrospective case series. Setting Tertiary academic hospital. Subjects and Methods The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology–head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate. Results In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6. Conclusion For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.
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Affiliation(s)
- Andrew J. Redmann
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sonia N. Yuen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Douglas VonAllmen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Rothstein
- UC Health, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alice Tang
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joseph Breen
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ryan Collar
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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Ettyreddy AR, Kao WTK, Roland LT, Rich JT, Chi JJ. Utility of the LACE Scoring System in Predicting Readmission Following Tracheotomy and Laryngectomy. EAR, NOSE & THROAT JOURNAL 2019; 98:220-222. [PMID: 31056944 DOI: 10.1177/0145561319827908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
In the current value-based health-care environment, 30-day unplanned hospital readmissions have been identified as a quality measure and an opportunity to help reduce health-care costs. The LACE Index Scoring Tool for Risk Assessment of Death and Readmission utilizes length of stay, acuity of admission, comorbidities, and emergency department visits to stratify patients into high and low risk of readmission. A retrospective chart review of 161 patients who underwent a tracheotomy or laryngectomy for head and neck indications at a tertiary care academic center demonstrated that the readmitted patient cohort was not statistically or clinically different from the nonreadmitted cohort when comparing LACE scores ( P = .789), length of hospital stay ( P = .237), discharge disposition ( P = .569), or insurance status ( P = .85). Addressing the problem of unplanned 30-day readmissions will likely require enhanced patient education, improved coordination of care, and further research.
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Affiliation(s)
- Abhinav R Ettyreddy
- 1 Department of Otolaryngology-Head & Neck Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Wee Tin Katherine Kao
- 1 Department of Otolaryngology-Head & Neck Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Lauren T Roland
- 1 Department of Otolaryngology-Head & Neck Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Jason T Rich
- 1 Department of Otolaryngology-Head & Neck Surgery, Washington University in St Louis, St Louis, MO, USA
| | - John J Chi
- 1 Department of Otolaryngology-Head & Neck Surgery, Washington University in St Louis, St Louis, MO, USA
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Bright HR, Chandy SJ, Chacko RT, Backianathan S. Intercycle Unplanned Hospital Admissions Due to Cisplatin-based Chemotherapy Regimen-induced Adverse Reactions: A Retrospective Analysis. Curr Drug Saf 2019; 14:182-191. [PMID: 31250766 PMCID: PMC6865053 DOI: 10.2174/1574886314666190619123047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/16/2019] [Accepted: 05/27/2019] [Indexed: 12/04/2022]
Abstract
BACKGROUND Cisplatin is a commonly used chemotherapy agent known to induce serious adverse reactions that may require hospital readmission. We aimed to analyze the extent and factors associated with unplanned hospital admissions due to cisplatin-based chemotherapy regimen-induced adverse reactions. METHODS Retrospective review of medical records of those patients who received at least one cycle of chemotherapy with cisplatin-based regimen during a six-month period from March to August 2017. RESULTS Of the 458 patients who received cisplatin during the study period, 142 patients did not meet inclusion criteria. The remaining 316 patients had a total of 770 episodes of primary admissions for chemotherapy administration. Overall, 187 episodes (24%) of intercycle unplanned hospital admission were recorded of which a major proportion (n=178; 23%) was due to chemotherapy-induced adverse reactions. Underweight patients had higher odds of unplanned admission (OR 1.77, 95% confidence interval [CI] 1.11 to 1.77). Significantly, more number of patients with cancers of head and neck and cancers of musculoskeletal were readmitted (p<0.001). Compared to high-dose cisplatin, low- and intermediate-dose cisplatin had lesser odds of unplanned admission (OR 0.52 and 0.77; 95% CI, 0.31 to 0.88 and 0.41 to 1.45, respectively). Patients without concomitant radiotherapy, drug-drug interaction and initial chemotherapy cycles had lesser odds of unplanned admission (OR 0.38, 0.50 and 0.52; 95% CI, 0.26 to 0.55, 0.25 to 0.99 and 0.32 to 0.84 respectively). Unplanned admissions were mainly due to blood-related (31%) and gastrointestinal (19%) adverse reactions. Among chemotherapy regimens, cisplatin monotherapy (34%) and cisplatin with doxorubicin (20%) regimens resulted in a major proportion of unplanned admissions. CONCLUSION These findings highlight risk factors that help identify high-risk patients and suggest that therapy modifications may reduce hospital readmissions due to cisplatin-based chemotherapy-induced adverse reactions.
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Affiliation(s)
- Heber Rew Bright
- Address correspondence to this author at the Pharmacy Services, Christian Medical College & Hospital, Vellore 632 004, Tamil Nadu, India; Tel: 91-416-228 2690; E-mail:
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