Evan M. Graboyes

Risk Factors for Unplanned Hospital Readmission in Otolaryngology Patients

Objective Identify the risk factors that predict 30-day unplanned readmission in hospitalized otolaryngology patients. Study Design Retrospective cohort study. Setting Single academic hospital. Subjects and Methods All otolaryngology admissions for the 1-year period between January 1, 2011, and December 31, 2011, at an academic hospital were reviewed. Univariate logistic regression and multivariate logistic regression, employing a backward elimination stepwise approach, were performed to identify risk factors for unplanned readmission to the hospital within 30 days of discharge from the otolaryngology service. Results There were 1058 patients that accounted for 1271 hospital admissions. The 30-day unplanned readmission rate for patients discharged from the otolaryngology service was 7.3% (93/1271). Significant predictors identified on univariate analysis were used to build a multivariable logistic regression model of risk factors for unplanned readmission. These risk factors included presence of a complication (odds ratio [OR] = 11.60, 95% confidence interval [CI], 7.11-18.93), new total laryngectomy (OR = 4.72, 95% CI, 1.58-14.10), discharge destination of skilled nursing facility (OR = 2.70, 95% CI, 1.21-6.02), severe coronary artery disease or chronic lung disease (OR = 2.33, 95% CI, 1.38-3.93), and current illicit drug use (OR = 2.60, 95% CI, 1.27-5.34). The discriminative ability of the multivariate regression model to predict unplanned readmissions, as measured by the c-statistic, was 0.85. Conclusion Otolaryngology patients have unique risk factors that predict unplanned readmission within 30 days of discharge. These data identify specific patient characteristics and care processes that can be targeted with quality improvement interventions to decrease unplanned readmissions.

Patients Undergoing Total Laryngectomy: An At-Risk Population for 30-Day Unplanned Readmission

IMPORTANCE Patients undergoing total laryngectomy are at high risk for hospital readmission. Hospital readmissions are increasingly scrutinized because they are used as a metric of quality care and are subject to financial penalties. OBJECTIVE To determine the rate of, reasons for, and risk factors that predict 30-day unplanned readmission for patients undergoing total laryngectomy. DESIGN, SETTING, AND PATIENTS Retrospective cohort study at a single academic tertiary referral medical center. The study population comprised 155 patients who underwent total laryngectomy with or without flap closure between January 2007 and December 2012 as either a primary treatment or salvage treatment for prior nonsurgical management. INTERVENTIONS Total laryngectomy. MAIN OUTCOMES AND MEASURES Rate of 30-day unplanned readmission, readmission diagnoses, and risk factors for unplanned readmission. Univariable and multivariable logistic regression were performed to identify risk factors for unplanned readmission within 30 days of discharge. RESULTS The 30-day unplanned readmission rate for patients following discharge after total laryngectomy was 26.5% (41 of 155). The most common readmission diagnoses were pharyngocutaneous fistula (27% of readmissions; n = 11) and stomal cellulitis (16% of readmissions; n = 7). The median time to unplanned readmission was 7 days. Thirty-four percent of readmissions (14 of 41) occurred within 3 days of discharge. Significant predictors of 30-day unplanned readmission on multivariable analysis were postoperative complication after discharge (odds ratio [OR], 11.50; 95% CI, 4.10-32.28), visit to the emergency department within 30 days after discharge (OR, 5.25; 95% CI, 1.84-14.99), salvage total laryngectomy (OR, 3.52; 95% CI, 1.56-13.12), and chyle fistula during the index hospitalization (OR, 5.25; 95% CI, 0.86-29.92). The discriminative ability of the model to predict unplanned readmission, as measured by the C statistic, was 0.88. CONCLUSIONS AND RELEVANCE Patients undergoing total laryngectomy are an at-risk patient population with a high rate of unplanned readmission within 30 days of discharge. By identifying the risk factors that predict 30-day unplanned readmission, these data can be used to design and implement quality-improvement interventions to decrease readmissions.

Management of human papillomavirus–related unknown primaries of the head and neck with a transoral surgical approach

Amidst a rising incidence of p16‐positive (p16+) oropharyngeal cancer, a significant number of cases present as regionally metastatic disease with an “unknown” primary. Preliminary data support transoral surgery as an effective method of primary detection/treatment.

Efficacy and Safety of Acute Injection Laryngoplasty for Vocal Cord Paralysis Following Thoracic Surgery

The primary objective of this study was to evaluate the effectiveness and safety of injection laryngoplasty using a temporary injectable agent in the acute setting for patients with unilateral vocal cord paralysis following thoracic surgical procedures.

Practical Guide to Understanding the Need for Clinical Practice Guidelines

With recent changes in the landscape of health care, clinical practice guidelines (CPGs) have proliferated. Attitudes about guidelines differ considerably, forming 2 competing viewpoints with considerable tension between them. Some feel CPGs are unneeded or are efforts to create automated “cookie cutter” medical practice; at best, they are perceived as suggestions that may be altered by experience. Others feel they are mandates that must be followed to the letter. This article attempts to explain how and why we have arrived at this point and to explain the origins of the differing viewpoints. We begin by describing the 2 viewpoints and proceed to define the origin of medicine as a profession and to chronicle the evolution of health insurance, medical education, and scientific methods for evaluating evidence.

30-day hospital readmission following otolaryngology surgery: Analysis of a state inpatient database

Determine patient and hospital‐level risk factors associated with 30‐day readmission for patients undergoing inpatient otolaryngologic surgery.

Postoperative care fragmentation and thirty‐day unplanned readmissions after head and neck cancer surgery

Postdischarge care fragmentation, readmission to a hospital other than the one performing the surgery, has not been described in head and neck cancer patients. We sought to determine the frequency, risk factors, and outcomes for head and neck cancer patients experiencing postdischarge care fragmentation.

Evaluation of Quality Metrics for Surgically Treated Laryngeal Squamous Cell Carcinoma

Importance Quality metrics for patients with laryngeal squamous cell carcinoma (SCC) exist, but whether compliance with these metrics correlates with improved survival is unknown. Objective To examine whether compliance with proposed quality metrics is associated with improved survival in patients with laryngeal SCC treated with surgery with or without adjuvant therapy. Design, Setting, and Participants This retrospective cohort study included patients from a tertiary care academic medical center who had previously untreated laryngeal SCC and underwent surgery with or without adjuvant therapy from January 1, 2003, through December 31, 2012. Data analysis was performed from August 4, 2015, through December 13, 2015. Interventions Surgery with or without adjuvant therapy. Main Outcomes and Measures Compliance with quality metrics from the American Head and Neck Society (AHNS), National Comprehensive Cancer Network (NCCN) guidelines, and institutional metrics with face validity covering pretreatment evaluation, treatment, and posttreatment surveillance was evaluated. The association between compliance with the group of metrics and overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) was explored using Cox proportional hazards analysis. The association between compliance with individual metrics and survival was similarly determined. Results A total of 243 patients (184 men and 59 women) were included in the study (median age, 62 years; age range, 23-87 years). No association was found between increasing levels of compliance with the AHNS or NCCN metrics and survival. The only AHNS or NCCN metric for which greater compliance correlated with improved survival on multivariable Cox proportional hazards analysis controlling for pT stage, pN stage, extracapsular spread, margin status, and comorbidity was pretreatment multidisciplinary evaluation for patients with stage cT3-4 or cN1-3 disease (OS adjusted hazard ratio [aHR], 0.47; 95% CI, 0.24-0.94; DFS aHR, 0.45; 95% CI, 0.23-0.85). For the institutional metrics, multidisciplinary evaluation for all patients (OS aHR, 0.51; 95% CI, 0.29-0.88; DFS aHR, 0.50, 95% CI, 0.32-0.80) and elective neck dissection yield of 18 lymph nodes or more (DFS aHR, 0.36; 95% CI, 0.14-0.99) were associated with improved survival on multivariable Cox proportional hazards analysis. Conclusions and Relevance In this cohort of patients with surgically treated laryngeal SCC, multidisciplinary evaluation and elective neck dissection yield of 18 lymph nodes or more are associated with improved survival. Development of better quality metrics is necessary because increased compliance with metrics described by the AHNS and NCCN is not associated with improved survival. Previously described metrics for surgically treated oral cavity cancer are not prognostic for surgically treated laryngeal SCC. Future multi-institutional collaboration will be required to validate these findings, develop better quality metrics, and evaluate whether quality metrics for head and neck cancer are site specific.

Definitive Surgical Therapy after Open Neck Biopsy for HPV-Related Oropharyngeal Cancer

Objective To determine the impact of prior open neck biopsy on the prognosis of patients with human papillomavirus (HPV)–related oropharyngeal squamous cell carcinoma (OPSCC) who are subsequently treated with a definitive surgical paradigm, including adjuvant therapy when indicated. Study Design Retrospective cohort. Setting Tertiary care university hospital. Subjects and Methods Patients with open neck biopsies who were treated with definitive surgery, with or without adjuvant therapy, for HPV-related OPSCC between 1998 and 2012 were compared with a matched control group who did not undergo open neck biopsy. Outcomes were disease-free survival, overall survival, disease-specific survival, incidence of tumor deposit in dermal scar, patterns of recurrence, and neck dissection complications. Results Forty-five patients who underwent open neck biopsy were compared with 90 matched controls. Tumor deposits in dermal scars from the prior open neck biopsy were found in 3 patients (7%) during completion neck dissection. Overall complications of the neck dissection were not significantly increased in the open biopsy group over matched controls (20% vs 12%, respectively; P > .05). Five-year Kaplan-Meier estimates for disease-free survival, overall survival, and disease-specific survival were not significantly different between the open biopsy and control groups (93% vs 91%, 98% vs 97%, 98% vs 99%, respectively; all P > .05). Recurrence rates were also not significantly different between groups. Conclusions Patients with HPV-related OPSCC who have undergone a prior open neck biopsy can be successfully treated with a definitive surgical paradigm. Although needle biopsy is preferable to establish a diagnosis, previous open neck biopsy does not affect prognosis in these patients.

Risk Factors Associated With Unplanned Readmission in Patients Undergoing Parotid Cancer Surgery: A Study of the National Cancer Database

IMPORTANCE Thirty-day unplanned readmissions are increasingly used as a measure of quality care. OBJECTIVE To describe the incidence of and risk factors for 30-day unplanned readmissions for patients undergoing treatment for cancer of the parotid gland. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using the National Cancer Database. Records on patients in the database undergoing surgery for previously untreated primary parotid cancer between 2003 and 2012 were reviewed. The data were analyzed in October 2015. INTERVENTIONS Parotidectomy with or without neck dissection. MAIN OUTCOMES AND MEASURES The main outcome measure was patient-, area-, and hospital-level risk factors for readmission. Secondary outcome measures were the rate of 30-day unplanned readmission and the rate of 30-day mortality. RESULTS We identified 11 394 cases of previously untreated parotid cancer undergoing definitive surgery. The 30-day unplanned readmission rate following parotidectomy was 2.1% (235 of 11 394 surgical procedures). Reported as odds ratios (95% CIs), factors associated with the 30-day unplanned readmission rate on multivariable analysis included advanced pathologic T category (1.59 [1.14-2.20]), uninsured status (2.27 [1.07-4.80]), and increased morbidity as measured by the Charlson/Deyo Score (CDS) (CDS 1, 1.57 [1.05-2.35]; CDS >1, 2.08 [1.06-4.08]). Thirty-day unplanned readmission was associated with an 8.4-fold (8.36 [2.04-34.30]) increased risk of 30-day mortality (1.9% vs 0.2%). CONCLUSIONS AND RELEVANCE Thirty-day unplanned readmission following surgery for parotid cancer is not common. Risk factors associated with 30-day unplanned readmission include pathologic T category, comorbidity, and uninsured status. Having an unplanned 30-day readmission is associated with greater risk of 30-day mortality.