Introduction: Head and neck oncologic patients often undergo surgical resection, requiring free flap reconstruction. These surgeries are expensive, and costs are frequently compounded by patients being managed in the Intensive Care Unit (ICU). However, a growing body of evidence suggests that floor management with a trained floor staff is equally reliable and significantly less costly. We intend to determine the difference in complication rates, length of stay and cost for head and neck free flap patients managed in the floor and in the ICU.
Methodology: A retrospective analysis of 502 patients who underwent free flap reconstructive head and neck cancer surgery at a large tertiary referral center between 1/1/2003 and 12/31/2016 was performed. Comprehensive comparative analyses of short and long-term complication rates were performed. Logistic regression was performed on the following events: short-term free-flap complications (defined as those between days 0 and 14 postoperatively), take-back surgery, and major in-hospital complications. Long-term free-flap complications (between days 15 and 105) were assessed using Cox proportional hazards analyses. Length of stay, short term, and long term costs, were analyzed using a generalized linear model. Our cost data was obtained from the Rochester Cost Data Warehouse, through which standardized costs were created by applying Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges. We controlled for comorbidities such as diabetes, peripheral vascular disease, hypercholesterolemia, and hypertension in our models, as advanced cardiopulmonary compromise is in indication ICU management.
Results: Of the 502 patients in our sample, 420 were managed on the general floor and 82 were managed in the ICU. After adjusting all models, the odds ratio was higher in the ICU for short term complications, (OR 1.42 (95% CI 0.75, 2.66) (P=0.28), take back surgery (OR 1.64 (0.78, 3.45) (P=0.19), and major postoperative complications (OR 1.65 (0.76, 3.60) (P=0.21). Length of stay was also 3.29 (1.90, 4.68) (P<0.01) days longer for the ICU cohort. For the ICU sample the hazard ratio for long-term period complications was 1.01 (0.53, 1.91) (P=0.98). Additionally, short term cost was an estimated $8,772 (53,640-11,903) (P<0.01) higher in the ICU cohort, while the long-term cost was $6,541 (-2,010, 15091) (P=0.13) higher.
Conclusions and Relevance: To the best of our knowledge, this is the first study that addresses the cost of free flap management beyond the hospitalization period and the one with the largest sample. General floor management of head and neck oncologic free flap patients, when controlled for preoperative comorbidities, leads to statistically similar results regarding complications and long term costs, while displaying a statistically significant reduction in short term cost of care and length of stay. ICU based care is not necessary for most head and neck microvascular patients, and a post-operative pathway that utilizes floor management can lead to diminished financial burden for this population.