Utility of the LACE index in predicting 30-day readmission rate in head and neck free flap microvascular reconstruction patients

Presentation: AHNS059
Topic: Quality of Care and Clinical Pathways
Type: Oral
Date: Thursday, April 19, 2018
Session: 3:30 PM - 4:30 PM Quality Engineering and Pathways
Authors: Ashley M Bauer, MD1, Kelly M Malloy, MD1, Emily Bellile, MS2, Steven B Chinn1, Matthew E Spector, MD1, Chaz L Stucken, MD1, Mark E Prince, MD1, Jeff S Moyer, MD1, Andrew G Shuman, MD1, Scott A McLean, MD, PHD1, Carol R Bradford, MD, FACS2, Keith A Casper, MD1
Institution(s): 1University of Michigan Department of Otolaryngology-Head and Neck Surgery, 2University of Michigan

Background: Readmissions to the hospital are a costly use of resources and using tools to identify patients who are at risk for readmission is an area of increased interest. The LACE index is an easy-to-use scoring system used to quantify the risk of readmission after discharge. Though this measure has been validated in the general medicine patient population, it has not been found to be as predictive in specific patient subgroups, such as heart failure patients. Moreover, it has not been extensively studied in post-surgical patients. We sought to evaluate the predictive value of the LACE index in head and neck microvascular reconstruction patients following their index operation.

Study Design: All patients from January 2016 to April 2017 who had underwent head and neck microvascular free flap reconstruction were evaluated via retrospective chart review. The data collected included age at index admission, length of stay, free flap indication, primary site of malignancy, T stage and N stage, type of free flap, comorbidities, medical/surgical complications during hospital stay, and readmission within 30 days of index discharge. Proportion of readmission episodes at each LACE score were calculated and associations between clinical and patient characteristics and readmission versus non-readmission episodes were tested using logistic regression.

Results: Data from 198 patients was analyzed in this cohort and showed an overall readmission rate of 27% (54/198). There was a significant association between LACE score and 30-day readmission rate. A LACE score of 10 or greater was a strong predictor for readmission with an odds ratio of 6.31 (3.09, 12.87). Dividing up LACE scores into risk categories of low (scores 4 to 6), immediate (scores 7 to 9) and high (score 10 or greater), we found that 1 out of 18 (5.6%) patients were readmitted in the low risk group, 12 out of 91 (13%) in the intermediate group, and 41 out of 89 (46%) patients in the high risk group. Length of stay was statistically significant for readmission. Patients who were not readmitted had a mean length of stay of 9.2 days while readmitted patients had a mean of 13.0 days. While we did not see a difference in readmissions when evaluating for presence of malignancy, tumor subsite or T stage, we did, however, see a trend for higher readmission rates among N+ patients compared to N0 patients (p=0.09) as well as presence of fistula (p=0.13); neither of these factos reached statistical significance. 

Conclusions: The LACE score calculated at discharge on head and neck microvascular reconstruction patients may identify patints at risk of 30 day readmission. While there is a continuum of risk, a score of ≥10 identifies those patients at a significantly higher risk. Interestingly, this cutoff was the score which was found to be a significant indicator in the initial studies validating the LACE index. This pilot study supports the use of the LACE index prospetively to identify patients at higher risk for readmission, and open the door to design and study early interventions for these patients to mitigate their risk of readmission.