Presentation: S041
Topic: Value and Quality in H&N Surgery (Value-Based Care)
Type: Oral
Date: Thursday, April 27, 2017
Session: 1:00 PM - 2:00 PM Value-Based H&N Cancer Care
Authors: Fangfang Wang, BM1, Robert Lindau, MD2, Oleg Militsakh, MD2, Andrew Coughlin, MD2, Russell Smith, MD2, Harlan Sayles, MS3, Daniel Lydiatt, MD2, William Lydiatt, MD2, Aru Panwar, MD, FACS4
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Institution(s): 1College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, 2Head and Neck Surgery, Nebraska Methodist Hospital, Omaha, Nebraska, 3College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, 4Division of head and neck surgery, University of Nebraska Medical Center & Nebraska Methodist Hospital, Omaha, Nebraska
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Background: Discharge planning for laryngectomy patients is often initiated late during the patients’ inpatient surgical stay and it contributes significantly to unnecessary extension of hospitalization, increased acute care costs, and diminished patient satisfaction. Identification of risk factors that predict discharge to intermediate care facilities can help physicians initiate discharge planning at an earlier time point during the course of surgical management. This may further streamline discharge planning for laryngectomy patients and optimize resource utilization.

Objective: To identify factors predictive of discharge destination following total laryngectomy.

Methods: Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP) database to identify discharge patterns for total laryngectomy patients (n=492) between 2011 and 2014. Univariate analyses were performed to identify differences between groups stratified by discharge destination. Multivariate analyses were used to create nomograms predicting discharge to intermediate care facility.

Results: Four hundred and one patients (81.5%) were discharged to home and 86 others (17.5%) were discharged to intermediate care facilities. On univariate analysis, patients discharged to intermediate care facilities had a higher incidence of partially or totally dependent functional status (20%) compared to patients that were discharged home (4%) (p<0.001). Additionally, those patients that were discharged to intermediate care facilities had higher incidence of preceding diagnosis of congestive heart failure (CHF) (6% versus 2%, p=0.043), chronic steroid use (12% versus 4%, p=0.011), and presence of severe COPD (31% versus 19%, p=0.020). Additional differences were observed across the groups with regards to American Society of Anesthesiologist (ASA) classification (p=0.002) and age (p=0.001).

Patients discharged to intermediate care facilities were more likely to have experienced longer hospitalization (mean 14 days versus 10 days, p=0.002), higher likelihood of post-operative pneumonia (6% versus 1%, p=0.019), sepsis (5% versus 1%, p=0.021), and unplanned intubation (5% versus 1%, p=0.021).

On multivariable analyses, advanced age (>70 years versus younger), poor functional status (partially/ totally dependent versus independent), pre-operative CHF, and chronic steroid use, persisted as independent predictors of discharge to a non-home destination. Length of hospitalization, post-operative pneumonia, and post-operative sepsis were other variables that were independently associated with discharge to an intermediate care facility.

Conclusion and clinical significance:

  • Preoperatively, patients who are older (>70 years), or those who present with functional dependence, preceding heart failure, or chronic steroid use, are more likely to require discharge to an intermediate care facility following total laryngectomy.
  • When these risk factors are present, physicians should consider initiating early discharge planning and counsel patients about anticipated discharge to a non-home based facility.
  • Association between discharge destination and post-operative adverse events (such as pneumonia and sepsis) emphasizes the impact of such events on discharge disposition, and further supports the rationale and importance of optimal peri-operative care. 
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