Risk Factors for Unplanned Hospital Readmission in Otolaryngology Patients

Gross

et al. 2016

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IMPORTANCE Quality metrics for patients with head and neck cancer are available, but it is unknown whether compliance with these metrics is associated with improved patient survival. OBJECTIVE To identify whether compliance with various process-related quality metrics is associated with improved survival in patients with oral cavity squamous cell carcinoma who receive definitive surgery with or without adjuvant therapy. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted at a tertiary academic medical center among 192 patients with previously untreated oral cavity squamous cell carcinoma who underwent definitive surgery with or without adjuvant therapy between January 1, 2003, and December 31, 2010. Data analysis was performed from January 26 to August 7, 2015. INTERVENTIONS Surgery with or without adjuvant therapy. MAIN OUTCOMES AND MEASURES Compliance with a collection of process-related quality metrics possessing face validity that covered pretreatment evaluation, treatment, and posttreatment surveillance was evaluated. Association between compliance with these quality metrics and overall survival, disease-specific survival, and disease-free survival was calculated using univariable and multivariable Cox proportional hazards analysis. RESULTS Among 192 patients, compliance with the individual quality metrics ranged from 19.7% to 93.6% (median, 82.8%). No pretreatment or surveillance metrics were associated with improved survival. Compliance with the following treatment-related quality metrics was associated with improved survival: elective neck dissection with lymph node yield of 18 or more, no unplanned surgery within 14 days of the index surgery, no unplanned 30-day readmissions, and referral for adjuvant radiotherapy for pathologic stage III or IV disease. Increased compliance with a “clinical care signature” composed of these 4 metrics was associated with improved overall survival, disease-specific survival, and disease-free survival on univariable analysis (log-rank test; P < .05 for each). On multivariable analysis controlling for pT stage, pN stage, extracapsular spread, margin status, and comorbidity, increased compliance with these 4 metrics was associated with improved overall survival (100% vs ≤50% compliance: adjusted hazard ratio [aHR], 4.2; 95% CI, 2.1-8.5; 100% vs 51%-99% compliance: aHR, 1.7; 95% CI, 1.0-3.1), improved disease-specific survival (100% vs ≤50% compliance: aHR, 3.9; 95% CI, 1.7-9.0; 100% vs 51%-99%: aHR, 1.3; 95% CI, 0.6-2.9), and improved disease-free survival (100% vs ≤50% compliance: aHR, 3.0; 95% CI, 1.5-5.8; 100% vs 51%-99% compliance: aHR, 1.6; 95% CI, 0.9-2.7). CONCLUSIONS AND RELEVANCE Compliance with a core set of process-related quality metrics was associated with improved survival for patients with surgically managed oral cavity squamous cell carcinoma. Multi-institutional validation of these metrics is warranted.

Section: Discussionmentioning

confidence: 70%

Section: Methodsmentioning

confidence: 99%

Association of Compliance With Process-Related Quality Metrics and Improved Survival in Oral Cavity Squamous Cell Carcinoma

Gross

et al. 2016

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“…We defined a 30-day unplanned readmission as an admission to any service in the hospital within 30 days of discharge that was unexpected. 18 For thyroid function testing, if a patient was dead less than 12 months after completing radiotherapy, the metric was not evaluable. For surveillance imaging, if imaging was prompted by clinical suspicion of recurrence or the patient was dead less than 6 months after the completion of therapy, the metric was not evaluable.…”

Section: Methodsmentioning

confidence: 99%

Evaluation of Quality Metrics for Surgically Treated Laryngeal Squamous Cell Carcinoma

Townsend

et al. 2016

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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 ...

“…2–5 Previous work examining risk factors for readmission of otolaryngology patients demonstrated that patients undergoing total laryngectomy (TL) are a high-risk population. 6 For the 1 year of otolaryngology discharges analyzed, the rate of 30-day unplanned readmission independent of complications following TL was 40%, more than a 5-fold increased risk of the 7.3% overall otolaryngology readmission rate. The details of the readmissions after TL were not elucidated in this prior study.…”

mentioning

confidence: 93%

Patients Undergoing Total Laryngectomy

Yang

et al. 2014

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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.