The effect of pneumonia on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA.
The Laryngoscope (Impact Factor: 2.14). 09/2012; 122(9):1994-2004. DOI: 10.1002/lary.23446
Source: PubMed


The Centers for Medicare and Medicaid Services has threatened to discontinue reimbursements for ventilator-associated pneumonia (VAP) as a preventable "never event." We sought to determine the relationship between pneumonia and in-hospital mortality, complications, length of hospitalization and costs in head and neck cancer (HNCA) surgery.
Retrospective cross-sectional study.
Discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2003 to 2008 were analyzed using cross-tabulations and multivariate regression modeling.
VAP was rarely coded. Infectious pneumonia was significantly associated with chronic pulmonary disease (odds ratio [OR], 1.5; P < .001), while aspiration pneumonia was associated with dysphagia (OR, 2.0; P < .001). Pneumonia from any cause was associated with weight loss (OR, 3.3; P < .001), age >80 years (OR, 2.0; P = .007), comorbidity (OR, 2.3; P < .001), and major procedures (OR, 1.6; P < .001), with increased in-hospital mortality for infectious (OR, 2.9; P < .001) and aspiration pneumonia (OR, 5.3; P < .001). Both infectious and aspiration pneumonia were associated with postoperative medical and surgical complications, increased length of hospitalization, and hospital-related costs.
Postoperative pneumonia is associated with increased mortality, complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Variables associated with an increased risk of pneumonia are inherent comorbidities in HNCA and known risk factors for VAP, making this a high-risk group for this never event. Caution must be used in the institution of reforms that threaten to inadequately reimburse the provision of care to this vulnerable population. Aggressive preoperative identification and treatment of underlying pulmonary disease, weight loss, and dysphagia may reduce morbidity and mortality.

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Available from: Yevgeniy R Semenov
    • "Background Dysphagia is the most common long term side effect of chemoradiotherapy (CRT) treatment for head and neck cancer (HNC) [1]. Swallowing ability is a priority issue for patients [1] and is associated with higher risk of pneumonia, poorer oral intake, prolonged tube feeding, weight loss as well as fundamental changes to eating patterns, social activities and consequently poorer quality of life [2] [3]. In light of this, much work is now focused towards finding predictors of post-treatment dysphagia, developing regimes with reduced toxicity and preventative swallowing interventions [4] [5]. "
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    ABSTRACT: Objectives: Dysphagia is a common and debilitating side effect of chemoradiotherapy. Assessment is difficult; swallowing is multifactorial and studies choose from a range of dysphagia assessments. This study intended to investigate the relationship between swallowing assessments of dysphagia in a cohort of patients and to evaluate whether clinical swallowing measures can predict patient reported swallowing outcomes. Materials and methods: One hundred and seventy-three head and neck cancer patients from two teaching hospitals were recruited prospectively over 25months. At three months follow-up patients were assessed using Rosenbeck's Penetration-Aspiration Scale (PAS), The 100ml Water Swallow Test (WST), The Performance Status Scale: Normalcy of Diet and the MD Anderson Dysphagia Inventory (MDADI). Results: The highest correlation was observed between the MDADI and Normalcy of Diet (rho 0.68) and the lowest between the MDADI and the PAS (rho 0.34). Using multiple regression the PAS and WST accounted for 44% of the variance in the MDADI scores (R(2)=0.44, F=37.8, p<0.001). On stepwise regression, the model only retained the Normalcy of Diet scores (R(2)=0.42, F=107.9, p<0.001). Separating the PAS into subgroups, those with no penetration or aspiration on the PAS scored significantly higher on the MDADI (p=<0.001). Conclusion: Patient reported swallowing outcomes were strongly aligned with diet restrictions but poorly aligned with clinical assessment. The WST, however, was more correlated than the PAS score, representing a more functional assessment. Clinical dysphagia, associated with significant morbidity, and patient reported dysphagia related to quality of life are not interchangeable and must be measured separately.
    No preview · Article · Nov 2015
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    • "Post-treatment pneumonia was associated with increased medical costs in studies conducted in France, Taiwan, and the USA [16, 49, 59]. In the French prospective cohort study, post-operative pneumonia added €19,000 of direct medical costs to treatment. "
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    ABSTRACT: Background: Head and neck cancer (HNC) and its treatment can affect communication, nutrition, and physical appearance, and the global impact of this disease on patients' quality of life may be substantial. Objective: The aim of this systematic literature review was to describe the impact of HNC and its treatment on the physical, emotional, and social well-being of patients over time, by examining longitudinal studies of patient-reported outcomes (PRO) evaluating these domains. Methods: Databases (MEDLINE and Embase) were searched to identify studies published in English between January 2004 and January 2014 analyzing the humanistic aspects of HNC in adult patients. Additional relevant publications were identified through manual searches of abstracts from recent conference proceedings. Results: Of 1,566 studies initially identified, 130 met the inclusion criteria and were evaluated in the assessment. Investigations using a variety of PRO instruments in heterogeneous patient populations consistently reported that PRO scores decrease significantly from diagnosis through the treatment period, but generally recover to baseline in the first year post-treatment. This trend was observed for many functional domains, although some side effects, such as xerostomia, persisted well beyond 1 year. In addition, considerable evidence exists that baseline PRO scores can predict clinical endpoints such as overall and progression-free survival. Conclusions: Many aspects of HNC, both disease and treatment specific, profoundly affect patients' quality of life. Improved knowledge of these effects on PRO may allow for more informed treatment decisions and can help physicians to better prepare patients for changes they may experience during therapy. Furthermore, the predictive value of baseline PRO data may enable healthcare providers to identify at-risk patients in need of more intensive intervention.
    Full-text · Article · May 2014 · PharmacoEconomics
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    • "For example, patients undergoing major cardiac surgery are likely to be intubated during the initial recovery; however, in general, these patients are expected to be extubated within a number of hours and should be at relatively low risk for hospital-acquired pneumonia. In fact, early extubation is a major goal for teams caring for postoperative cardiac surgery patients [28] "
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    ABSTRACT: Patients with traumatic brain injury (TBI) frequently require mechanical ventilation (MV). The objective of this study was to examine the association between time spent on MV and the development of pneumonia among patients with TBI. Patients older than 18 y with head abbreviated injury scale (AIS) scores coded 1-6 requiring MV in the National Trauma Data Bank 2007-2010 data set were included. The study was limited to hospitals reporting pneumonia cases. AIS scores were calculated using ICDMAP-90 software. Patients with injuries in any other region with AIS score >3, significant burns, or a hospital length of stay >30 d were excluded. A generalized linear model was used to determine the approximate relative risk of developing all-cause pneumonia (aspiration pneumonia, ventilator-associated pneumonia [VAP], and infectious pneumonia identified by the International Classification of Disease, Ninth Revision, diagnosis code) for each day of MV, controlling for age, gender, Glasgow coma scale motor score, comorbidity (Charlson comorbidity index) score, insurance status, and injury type and severity. Among the 24,525 patients with TBI who required MV included in this study, 1593 (6.5%) developed all-cause pneumonia. After controlling for demographic and injury factors, each additional day on the ventilator was associated with a 7% increase in the risk of pneumonia (risk ratio 1.07, 95% confidence interval 1.07-1.08). Patients who have sustained TBIs and require MV are at higher risk for VAP than individuals extubated earlier; therefore, shortening MV exposure will likely reduce the risk of VAP. As patients with TBI frequently require MV because of neurologic impairment, it is key to develop aggressive strategies to expedite ventilator independence.
    Full-text · Article · Jun 2013 · Journal of Surgical Research
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