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      Predicting length of stay in head and neck patients who undergo free flap reconstruction

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          Abstract

          Objective

          Understanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS.

          Methods

          A retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS.

          Results

          A total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF—73.8%, anterolateral thigh flap—11.3%, and fibula free flap—14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [ C] = +4.26, P < .0001), in‐hospital PNA or UTI ( C = +2.52, P = .037), wound breakdown or fistula ( C = +5.0, P < .0001), surgical site infection ( C = +3.54, P = .017), and prior radiation therapy ( C = +2.59, P = .004).

          Conclusion

          Several perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution‐level protocols for postoperative care and disposition of free flap patients.

          Level of Evidence

          2b; retrospective cohort.

          Abstract

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          Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006.

          Héctor Bueno (2010)
          Whether decreases in the length of stay during the past decade for patients with heart failure (HF) may be associated with changes in outcomes is unknown. To describe the temporal changes in length of stay, discharge disposition, and short-term outcomes among older patients hospitalized for HF. An observational study of 6,955,461 Medicare fee-for-service hospitalizations for HF between 1993 and 2006, with a 30-day follow-up. Length of hospital stay, in-patient and 30-day mortality, and 30-day readmission rates. Between 1993 and 2006, mean length of stay decreased from 8.81 days (95% confidence interval [CI], 8.79-8.83 days) to 6.33 days (95% CI, 6.32-6.34 days). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) in 1993 to 4.3% (95% CI, 4.2%-4.4%) in 2006, whereas 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Discharges to home or under home care service decreased from 74.0% to 66.9% and discharges to skilled nursing facilities increased from 13.0% to 19.9%. Thirty-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%; all P < .001). Consistent with the unadjusted analyses, the 2005-2006 risk-adjusted 30-day mortality risk ratio was 0.92 (95% CI, 0.91-0.93) compared with 1993-1994, and the 30-day readmission risk ratio was 1.11 (95% CI, 1.10-1.11). For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in 30-day readmission rates were observed.
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            Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals.

            Keven R. Johnson, Jason Hockenberry, Peter Kaboli … (2012)
            Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. Observational study from 1997 to 2010. All 129 acute care Veterans Affairs hospitals in the United States. 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.
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              Factors associated with complications in microvascular reconstruction of head and neck defects.

              Arthur Cordeiro, Thomas Pfister, A R Shaha … (1999)
              The use of microvascular free tissue transfer has allowed the reconstruction of increasingly complex defects in higher risk patients after head and neck cancer resections. However, the combination of these factors also gives rise to a higher risk for the development of complications. This study was performed to establish the pretreatment factors associated with complication development after microvascular free tissue transfer for the reconstruction of defects resulting from head and neck cancer ablations, with particular attention to the role of comorbid conditions. A retrospective cohort study was conducted including 200 consecutive microvascular free tissue transfers performed for the reconstruction of surgical defects in the head and neck region at a single tertiary care institution. Comorbidity severity was assessed using the Charlson comorbidity index, a novel approach to comorbid staging in this setting. The flap survival rate was 98 percent. Complications developed in 56 cases (28 percent), with multiple complications occurring in 21 of these cases (10.5 percent). Univariate analysis revealed that prior radiation treatment (p = 0.03), anesthesia time over 10 hours (0.05), and advanced Charlson comorbidity grade (0.002) were associated with an increased risk for the development of complications. However, only the presence of advanced Charlson grade proved significant after multivariate analysis (odds ratio 3.9; 95 percent CI = 1.5 to 10.1). In addition, increasing Charlson grade (p = 0.003) and age over 70 years (p = 0.04) correlated with increasing complication severity. Systemic complications occurred in 28 patients (14 percent), with advanced Charlson grade being the only significant factor associated with the development of complications after controlling for confounding factors (odds ratio 3.8; 95 percent CI = 1.5 to 9.7). In patients over 70 years of age, increasing operative time also impacted on the development of systemic complications (p = 0.002), especially in patients with advanced Charlson grades (0.01). Recipient site complications occurred in 30 patients (15 percent), with history of prior radiation therapy being the only factor associated with increased risk by multivariate analysis (odds ratio 2.5; 95 percent CI = 1.1 to 5.7). No factors predicted the development of donor-site complications, which occurred in 11 cases (5.5 percent). The median hospital stay for the entire population was 16 days. The development of complications increased the median hospital stay by 7.5 days (p < 0.001). The effect of the development of complication on hospital stay remained significant even after controlling for the effects of confounding variables (relative risk = 9.87; 95 percent CI = 5.9 to 19.9). Microvascular surgery is a highly successful and relatively safe method for the reconstruction of large head and neck defects. The Charlson comorbidity index grading may be useful for identifying patients at increased risk for the development of complications after microvascular reconstruction, allowing for improved perioperative planning. In addition, patients with prior radiation exposure have a significantly higher risk for developing complications at the recipient site. Although advanced age is not associated with an increased risk for complications, older patients may be more sensitive to the effects of prolonged anesthesia and are likely to develop more severe complications.
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                Author and article information

                Contributors
                Daniel G. Deschler: daniel_deschler@meei.harvard.edu
                Journal
                Journal ID (nlm-ta): Laryngoscope Investig Otolaryngol
                Journal ID (iso-abbrev): Laryngoscope Investig Otolaryngol
                Journal ID (doi): 10.1002/(ISSN)2378-8038
                Journal ID (publisher-id): LIO2
                Title: Laryngoscope Investigative Otolaryngology
                Publisher: John Wiley & Sons, Inc. (Hoboken, USA )
                ISSN (Electronic): 2378-8038
                Publication date (Electronic): 28 May 2020
                Publication date Collection: June 2020
                Volume: 5
                Issue: 3 ( doiID: 10.1002/lio2.v5.3 )
                Pages: 461-467
                Affiliations
                [ 1 ] Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts USA
                [ 2 ] Department of Otolaryngology Harvard Medical School Boston Massachusetts USA
                [ 3 ] Department of Otolaryngology University of Michigan Ann Arbor Michigan USA
                [ 4 ] Department of Otolaryngology Washington University School of Medicine in Saint Louis Saint Louis Missouri USA
                [ 5 ] Department of Medicine Massachusetts General Hospital Boston Massachusetts USA
                Author notes
                [*] [* ] Correspondence

                Daniel G. Deschler, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114.

                Email: daniel_deschler@ 123456meei.harvard.edu

                Author information
                https://orcid.org/0000-0001-5860-6097
                https://orcid.org/0000-0003-0968-1028
                https://orcid.org/0000-0002-6570-5672
                Article
                Publisher ID: LIO2410
                DOI: 10.1002/lio2.410
                PMC ID: 7314462
                SO-VID: 9b8358cc-7e21-4ed7-82f7-0652cdff3213
                Copyright © © 2020 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals, Inc. on behalf of The Triological Society.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Date received : 17 April 2020
                Date revision received : 09 May 2020
                Date accepted : 15 May 2020
                Page count
                Figures: 1, Tables: 3, Pages: 7, Words: 4593
                Categories
                Subject: Original Research
                Subject: Head and Neck, and Tumor Biology
                Subject: Original Research
                Custom metadata
                source-schema-version-number 2.0
                cover-date June 2020
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.4 mode:remove_FC converted:24.06.2020

                Keywords: anterolateral thigh flap,fibula free flap,free flap,head and neck cancer,head and neck reconstruction,length of stay,radial forearm free flap
                Data availability:
                Keywords: anterolateral thigh flap, fibula free flap, free flap, head and neck cancer, head and neck reconstruction, length of stay, radial forearm free flap

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