Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction

Abstract

Objective: Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction.Study Design: Retrospective review of prospectively collected databases. Methods: Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n = 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death).Results: The mean age of patients discharged home was lower (60 SD AE 13, n = 1450) compared to those discharged to an SNF (68 SD AE 14, n = 168) or a rehabilitation facility (71 SD AE 14, n = 200; p < 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p < 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p < 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p = 0.006), thromboembolism (59% vs. 80%; p = 0.001), a pulmonary complication (46% vs. 81%; p < 0.0001), a cardiac complication (46% vs. 80%; p < 0.0001), or a cerebral vascular event (25% vs. 80%; p < 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination.Conclusion: There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination.

Discharge Disposition After Head and Neck Reconstruction: Effect on Adjuvant Therapy and Outcomes

“…In a recent multi‐institutional study, Sweeny et al reported risk factors associated with higher likelihood of SNF disposition, including older age, a higher comorbid burden specifically relating to cardiopulmonary or vascular disease, and a higher incidence of postoperative complications leading to SNF disposition. Interestingly, their findings revealed no differences between post‐discharge surgical complications or 30‐day readmission rates between different discharge destinations 15 . Previous studies have also shown that patient education, postoperative sequelae, coordination of care, fragmentation across care organizations, a lack of family support, and socioeconomic status are all factors that have been shown to impact a patient's ability to receive the treatment they need on time 5,6,14,16,17 .…”

“…Interestingly, their findings revealed no differences between post-discharge surgical complications or 30-day readmission rates between different discharge destinations. 15 Previous studies have also shown that patient education, postoperative sequelae, coordination of care, fragmentation across care organizations, a lack of family support, and socioeconomic status are all factors that have been shown to impact a patient's ability to receive the treatment they need on time. 5,6,14,16,17 Our patients discharged to SNF initiated adjuvant therapy later than those discharged home (70.1 vs. 59 days, respectively).…”

Malnutrition and Adverse Outcomes After Surgery for Head and Neck Cancer

“…These authors note similar disparities in the rates of discharge to home vs SNF among patients and postulate a number of potential contributing factors that include clinicians’ desire to protect—by promoting institutional postacute care—the patients they perceive to be most vulnerable to adverse discharge outcomes . Within the head and neck surgery literature, Sweeny et al recently reported that older age, undergoing longer surgical procedures (>10 hours), and having postoperative complications were all associated with discharge to SNF as opposed to discharge to home. They found no correlation with anatomic site, free-flap donor selection, or free-flap survival.…”

Factors Predicting Discharge Disposition Following Head and Neck Free Flap Reconstruction

“…Although we did find a similar result regarding older aged patients, the focus of our study aligned more with physical therapy metrics and discharge to IPR, a concept not yet studied in the field of otolaryngology to our knowledge. Other studies have found only slight correlations between CCI and discharge to IPR or an SNF 8 . One study found that longer operative duration correlates with a higher percentage of patients being discharged to IPR or an SNF 8 .…”

“…8 One study found that longer operative duration correlates with a higher percentage of patients being discharged to IPR or an SNF. 8 This could be a valuable tool, specifically for PTOT metrics, when evaluating a patient perioperatively. Parhar et al found that patients discharged to post-acute care have significantly higher rates of multiple comorbidities, were of black ethnicity, and were male gender.…”