Predictors of Readmission in Patients Requiring Free Tissue Reconstruction for Head and Neck Cancer

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Certain factors increase the risk of unplanned readmission in the month after head and neck cancer resection requiring free tissue reconstruction, finds an analysis of data from the National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons.1 Nearly 1 in 10 patients studied had an unplanned readmission within 30 days, investigators reported at the 9th International Conference on Head and Neck Cancer.

The risk was more than doubled for patients who had a surgical wound class of II (clean-contaminated), whereas it was reduced by nearly half for those who had a bone-containing flap. Site also played a role, with higher risk seen for patients having cancer of the cervical esophagus or larynx, for example.

We have about an 11% readmission rate, which gives us a lot of room for improvement from a quality-of-care standpoint. In the current state of health care, it’s important to identify risk factors that lead to readmission.
— Orly Coblens, MD

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“We have about an 11% readmission rate, which gives us a lot of room for improvement from a quality-of-care standpoint,” maintained first author Orly Coblens, MD, an Otorhinolaryngology Resident at the University of Pennsylvania, Philadelphia, at the time of the study and now a Microvascular Head and Neck Fellow at the University of California, Davis.

“This gives us a nice framework for which patients to look at more closely. We’ve been looking at our own data,” she added.

Study Details

Introducing the study, Dr. Coblens noted that unplanned readmissions are costly and stressful for patients. “It’s also seen as a failure in quality of care, whether it be failure of initial hospital care, complications of care, or suboptimal discharge planning. Hospitals are scrutinizing admitting services because reimbursement at Centers for Medicare & Medicaid Services for hospitalizations is being reduced for institutions whose quality outcomes are below the accepted standards,” she noted. “Therefore, in the current state of health care, it’s important to identify risk factors that lead to readmission.”

The investigators queried the 2012 to 2014 NSQIP data set to identify patients with diagnosis codes consistent with head and neck malignancies (excluding thyroid cancer) and procedure codes for free flap reconstruction. Among the 1,114 patients studied, the large majority had a flap containing soft tissue only (82%) and a surgical wound classification falling into class II (clean-contaminated); this means that the respiratory, gastrointestinal, or genitourinary tract was entered under controlled conditions and without unusual contamination (81%). They were discharged a mean of 11 days after their ­operation.

Overall, 10.9% of the cohort had an unplanned readmission within 30 days, Dr. Coblens reported. These readmissions occurred an average of about 9 days from the date of the ­discharge.

Compared with counterparts who were not readmitted, the patients who were had an average length of stay during their initial hospitalization that was 1.2 days shorter (10.1 vs 11.3 days, P < .05). “However, this is almost certainly an artifact of how NSQIP collects the 30-day readmission data,” she ­cautioned.

Risk Factors for Readmission

In multivariate analysis, the risk of 30-day unplanned readmission was higher for patients having a class II (clean-contaminated) surgical wound (odds ratio, 2.44) as compared to entirely clean cases. “This unfortunately is not something we can change, given that most of the head and neck cases involve mucosal surfaces,” Dr. Coblens commented. “The frequency of contaminated and dirty cases is very low relative to the clean-contaminated cases. Therefore, statistical significance was not obtainable.”

It is unknown whether patients were discharged with antibiotics, as the NSQIP database does not provide that information, she noted.

Risk of Readmission After Reconstructive Head and Neck Surgery

  • A retrospective cohort study of 1,114 patients undergoing head and neck cancer resection requiring free tissue reconstruction found that 10.9% of patients had a 30-day unplanned readmission.
  • The risk was higher for those who had a wound class of II (clean-contaminated) (odds ratio, 2.44) and who had tumors of the cervical esophagus (40.85), larynx (5.56), middle ear or sinus (5.44), and “other mouth” (3.50).
  • The risk was lower for those who had a bone-containing flap (odds ratio, 0.52).

Risk for readmission also varied by primary tumor site, with the higher risk seen for patients who had cancer of the cervical esophagus (odds ratio, 40.85), larynx (odds ratio, 5.56), middle ear or sinus (odds ratio, 5.44), and “other mouth” as defined in the database (odds ratio, 3.50).

Looking more closely at the role of flap type, the length of the initial hospital stay was shorter for patients who received a soft tissue–only flap than for counterparts who received a flap containing bone (10.9 vs 12.5 days, P < .05). However, free tissue reconstruction using bone remained protective in analyses that controlled for length of hospital stay.

Discharge destination was not significantly associated with flap type, with about 80% of patients in both groups being discharged to home. Additionally, discharge destination did not significantly correlate with the readmission rate.

Strategy Proposed to Reduce Readmissions

A session attendee noted that surgeons often face pressure to discharge patients promptly and asked whether Dr. Coblens and colleagues are considering keeping patients longer as a possible strategy to reduce readmissions.

“We have thought about keeping them an extra day, but if they are ready to go, as long as they look good, I don’t think it would make us keep them an extra day,” she replied. “Their average length of stay [in this cohort] is a lot longer than ours is already. We were looking at the NSQIP data from 3 years ago, which is still a good way to progress and look at things. But I don’t think we’re going to change the length of stay for our patients based on this.” ■

Disclosure: Dr. Coblens reported no potential conflicts of interest.


1. Coblens OM, et al: American College of Surgeons–National Surgical Quality Improvement Program (NSQIP) assessment of risk factors for 30 day unplanned readmission in patients undergoing head and neck surgery requiring free tissue reconstruction. 2016 International Conference on Head and Neck Cancer. Abstract S298. Presented July 19, 2016.

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