Risk Factors for Post–acute care Following Free Flap Reconstruction of the Oral Cavity

Abstract

Objective Identify previously unreported factors that predict the need for post–acute care after free flap reconstruction of the oral cavity. Study Design Retrospective cohort study. Setting Single academic medical center. Methods A total of 134 patients with head and neck disease involving the oral cavity underwent free tissue transfer for reconstruction between August 2012 and October 2015. All patients had a tracheostomy placed at the time of surgery. Data were collected, including demographics, perioperative risk factors, and social variables. Univariate and multivariate logistic regression were used to identify risk factors for needing post–acute care. Results Of 134 patients, 37 (28%) required post–acute care upon discharge, and 97 of 134 (72%) were discharged home with assistance. Multivariate logistic regression revealed that lack of family support (adjusted odds ratio [AOR], 32.12; 95% CI, 13.75-274.90; P = .002), tracheostomy tube at discharge (AOR, 13.70; 95% CI, 3.20-58.44; P < .001), government insurance (AOR, 3.85; 95% CI, 1.13-13.11; P = .031), hospital stay >10 days (AOR, 3.52; 95% CI, 1.25-9.90; P = .017), and increasing age (AOR, 1.11; 95% CI, 1.04-1.18; P = .003) were significantly associated with post–acute care need. Conclusion: Lack of family support, tracheostomy tube at discharge, government insurance, hospital stay >10 days, and increasing age are independently associated with the need for post–acute care following free flap reconstruction of the oral cavity. Physicians, social workers, and nurse case managers are positioned to identify patients at high risk for needing post–acute care and to reduce the duration of hospitalizations.

Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction

“…This is consistent with prior head and neck literature demonstrating older patients were more likely to be discharged to a facility 15–17,20,23 . In addition to increasing age, Lepse et al found tracheostomy tube, length of hospitalization of greater than 10 days, absence of family support and government insurance to be independent risk factors for post‐acute care admissions following oral cavity free flap reconstruction 24 …”

“…[15][16][17]20,23 In addition to increasing age, Lepse et al found tracheostomy tube, length of hospitalization of greater than 10 days, absence of family support and government insurance to be independent risk factors for post-acute care admissions following oral cavity free flap reconstruction. 24 In our study, in addition to advanced age, we found postoperative medical complications correlated with an increased likelihood of requiring admission to a skilled nursing or rehabilitation facility. This is to be expected, as we have previously shown the occurrence of postoperative medical complications following reconstruction with a free flap correlated with patient age.…”

“…18 Like Lepse et al, we also found a greater length of hospitalization to correlate with higher rates of discharge to a rehabilitation or SNF. 24 While it is difficult to ascertain in a retrospective review of a complex patient population the reason(s) length of hospitalization is longer in the cohort ultimately requiring rehabilitation or SNF admission, the authors postulate it could be either (1) in attempt to facilitate discharge to home patients were admitted longer to address underlying deficiencies (clinical, wound care, occupational and physical therapy) and ultimately failed to achieve independence or (2) this subset of patients required a longer duration of hospitalization to identify a facility, obtain insurance approval, et cetera which ultimately delayed hospital discharge.…”

“…15 While no clear association between gender and discharge destination is known, prior literature has shown that patients with poor social support were more likely to be discharged to a facility. 24 Similarly, patients of advanced age undergoing elective surgery were more likely to require discharge to a facility if they had inadequate social support. 14 Further studies are needed to determine if female patients are at an increased risk of poor social support following surgery, contributing to greater rates of facility admissions following postoperative discharge.…”

“…Likewise, a study by Freeman et al, which reviewed patients undergoing head and neck ablation and free flap reconstruction, demonstrated female patients were more likely to require discharge to a facility 15 . While no clear association between gender and discharge destination is known, prior literature has shown that patients with poor social support were more likely to be discharged to a facility 24 . Similarly, patients of advanced age undergoing elective surgery were more likely to require discharge to a facility if they had inadequate social support 14 .…”