•Consistent risk factors for unplanned hospitalization and emergency department use and were identified.•Risk factors can be categorized as: ‘patient-related’, ‘cancer severity’ or ‘process’ ...factors.•This work is a critical step towards the development of patient-level risk prediction tools.
To identify predictors of unplanned hospitalization and emergency department (ED) use among head and neck oncology patients.
Peer reviewed publications were identified through a systematic search of MEDLINE, Embase and Cochrane CENTRAL. Studies describing a cohort of HNC patients that detailed predictors of unplanned hospitalization or ED use in risk-adjusted models were eligible for inclusion. The methodologic quality of included studies was assessed using the Quality In Prognostic Studies (QUIPS) tool and an adapted version of the GRADE framework.
Of the 932 articles identified, 39 studies met our inclusion criteria with 31/39 describing predictors of surgical readmission and 10/39 describing predictors of ED use or unplanned hospitalization during radiation/chemoradiation treatment. Risk factors were classified into either ‘patient-related’, ‘cancer severity’ or ‘process’ factors. In the subset of studies looking at readmission following surgery wound complications (10/14 studies), presence of comorbidity (16/28 studies), low socioeconomic status (8/17 studies), cancer stage (9/14 studies), and prolonged hospital stay (7/18 studies) were the variables most frequently associated with readmission on multivariable analysis. Presence of comorbidity (6/10) and chemotherapy use (4/10) were more frequently associated with ED use and unplanned hospitalization.
Several consistent predictors have been identified across a variety of studies. This work is a critical first step towards the development of readmission and ED prediction models. It also enables meaningful comparison of hospital readmission rates with risk adjustment in HNC patients.
Objectives
Physician and patient/parent communication is of utmost importance in consultations to improve the shared decision‐making (SDM) processes. This study investigated SDM‐related outcomes ...through turn analysis and an assessment of patient‐centred dialogue.
Design
Multi‐centre prospective cohort study analysing audio‐ and video‐recorded patient/parent‐physician interactions.
Setting
Two tertiary paediatric hospitals in Halifax, Nova Scotia and Salt Lake City, Utah.
Participants
Paediatric otolaryngologists, patients and parents during consultation for adenotonsillectomy.
Main outcome measures
Medical dialogue measures (turn analysis, patient‐centredness scores via the Roter Interaction Analysis System) and SDM questionnaires (SDM‐Q‐9).
Results
Turn density was significantly higher for physicians than patients/parents (P < .001), as were total statements (P < .001), and total time talking (P < .001). The opening statement was completed by the physician in 91.5% of interactions and was significantly longer than family opening statements (P = .003). The mean number of informed consent elements addressed per interaction was 4.5 out of 6. The mean patient‐centredness score was 0.2 (range 0‐0.56). Significant negative correlations between patient‐centredness score and physician turn density (r = −.390, P = .002), physician mean turn time (r = −.406, P = .001), total physician statements (r = −.426, P = .001) and total physician speaking time (r = −.313, P = .016) were noted. There were no correlations in SDM questionnaire scores with turn analysis variables, informed consent elements or patient‐centredness scores.
Conclusions
Surgeons dominated the consultation in terms of talking, mostly in a unidirectional manner. Neither patient‐centredness nor turn analysis correlated with perceptions of SDM from the parents' perspective.
Objectives/Hypothesis
Sonographic risk criteria may assist in further prognostication of indeterminate thyroid nodules (ITNs). Our aim was to determine whether sonographic criteria could further ...delineate the post‐test probability of malignancy in ITNs.
Study Design
Meta‐analysis of diagnostic test accuracy.
Methods
A systematic review of Web of Science, MEDLINE, EMBASE, and CINAHL was performed from inception to April 15, 2021. Eligible studies included those which reported ultrasonographic evaluations with the American Thyroid Association (ATA) or the Thyroid Imaging Reporting and Data System (TIRADS) in adult patients with ITNs. ATA or TIRADS were scored as low (negative) or high (positive) malignancy risk using a previously validated binary classification. Primary outcomes included pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratio for all sonographic criteria. Studies were appraised using Quality Assessment of Diagnostic Accuracy Studies and the data were pooled using bivariate random‐effects models.
Results
Seventeen studies were included in the analysis. For Bethesda III, ATA had a specificity (0.90, 95% confidence interval (CI): 0.74–0.94), but a sensitivity of 0.52 (95% CI: 0.25–0.77). Conversely, K‐TIRADS had the highest sensitivity (0.78, 95% CI: 0.62–0.89) with a specificity of 0.53 (95% CI: 0.31–0.74). Furthermore, American College of Radiology and EU TIRADS had specificities of 0.60 (95% CI: 0.36–0.80) and 0.81 (95% CI: 0.73–0.87) with sensitivities of 0.70 (95% CI: 0.37–0.90) and 0.38 (95% CI: 0.20–0.60), respectively. There were few studies with Bethesda IV nodules.
Conclusions
Though dependent on malignancy rates, Bethesda III nodules with low‐suspicion TIRADS features may benefit from clinical observation, whereas nodules with high‐suspicion ATA features may require molecular testing and/or surgery.
Level of Evidence
NA Laryngoscope, 132:242–251, 2022
To understand practice patterns and identify care gaps within a large-scale depression screening program for patients with head and neck cancer (HNC).
Retrospective cohort study.
This was a ...population-based study of adults diagnosed with a HNC between January 2007 and October 2020. Each patient was observed from time of first symptom assessment until end of study date, or death. The exposure of interest was a positive depressive symptom screen on the Edmonton Symptom Assessment System (ESAS). Outcomes of interest included psychiatry/psychology assessment, social work referral, or palliative care assessment. Cause specific hazard models with a time-varying exposure were used to investigate the exposure-outcome relationships.
Of 14,054 patients with HNC, 9016 (64.2%) reported depressive symptoms on at least one ESAS assessment. Within 60 days of first reporting depressive symptoms, 223 (2.7%) received a psychiatry assessment, 646 (7.9%) a social work referral, and 1131 (13.9%) a palliative care assessment. Rates of psychiatry/psychology assessment (HR 3.15 95% CI 2.67-3.72), social work referral (HR 1.83 95% CI 1.64-2.02), and palliative care assessment (HR 2.34 95% CI 2.19-2.50) were higher for those screening positive for depression. Certain patient populations were less likely to receive an assessment including the elderly, rural residents, and those without a prior psychiatric history.
A high proportion of head and neck patients report depressive symptoms, though this triggers a referral in a small number of cases. These data highlight areas for improvement in depression screening care pathways.
3 Laryngoscope, 2023.
•This work disentangles the relative effects of ethnicity and immigration on head and neck cancer (HNC) outcomes.•In Ontario Canada, HNC patients experience a ‘healthy immigrant effect’.•HNC patients ...of Chinese ethnicity experience improved survival relative to the general population.
While it is known that certain ethnic and immigrant groups are at increased risk of developing head and neck cancer, the individual effects of immigration status and ethnicity on head and neck cancer outcomes is less clear. We sought examine the independent effects of immigration and Chinese and South Asian ethnicity on overall survival in a head and neck cancer patient population.
This was a population-based retrospective matched cohort study using linked Ontario administrative databases between 1994 and 2017. Incident cancer cases were captured in long-standing residents of Chinese and South Asian ethnicity, Chinese and South Asian immigrants, as well as a reference population. Subjects were followed until death. A hard-matching approach was used to adjust for key differences and ensure both groups were balanced with respect to age, sex and cancer site. Cox proportional hazard models were used to estimate the impact of Chinese and South Asian ethnicity on overall survival while further adjusting for baseline covariates.
Among 1639 immigrants with head and neck cancer, matched to 3278 controls, the overall 5-year survival rate was 66% and 59%, respectively. After adjusting for between group-differences, all-cause mortality was lower for immigrants (HR 0.7695%CI 0.69–0.83) and individuals of Chinese ethnicity (HR 0.7895%CI 0.68–0.90), relative to the general population.
In Ontario, immigrants experience lower mortality rates following a head and neck cancer diagnosis. Individuals of Chinese ethnicity with head and neck cancer experience a survival advantage, relative to South Asian individuals and the general population.
Objectives/Hypothesis
Despite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt ...and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital‐level characteristics that impact these outcomes.
Study Design
Retrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database.
Methods
Adult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in‐hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level.
Results
In a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals 0.564, 0.788), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals 0.880, 0.954).
Conclusions
Blunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury.
Level of Evidence: Level 3 Laryngoscope, 131:E1109–E1116, 2021
Objectives/Hypothesis
Performance of thyroidectomy on an outpatient basis has gained popularity although many jurisdictions have not shifted their practice despite a strong safety profile. We sought ...to assess the uptake and safety of outpatient thyroidectomy in Ontario.
Study Design
Retrospective cohort study.
Methods
This was a population‐based retrospecive cohort of adult patients undergoing hemithyroidectomy or total thyroidectomy between 1993 and 2017 in Ontario, Canada. Outpatient surgery was defined as discharge home on the same day of surgery. Outcomes of interest include 30‐day all cause death, hematoma, emergency department use, and readmission. To adjust for confounding, propensity scores were calculated. Logistic regression models with inverse probability of treatment weighting (IPTW) were then used to estimate the exposure‐outcome relationship.
Results
The final cohort consisted of 81,199 patients: 8,442 underwent same day surgery and 72,757 were admitted. The proportion of patients undergoing outpatient thyroidectomy increased overtime (2.3% in 1993–1994 to 17.8% in 2016–2017). Factors associated with higher odds of outpatient thyroidectomy included: younger age, less material deprivation, less comorbidities, and higher surgeon volume. The absolute number of deaths (≤5) and hematomas (64, 0.8%) in the outpatient cohort was low. After IPTW adjustment, patients with outpatient management had lower odds of neck hematoma (OR 0.7395CI% 0.58–0.93), but higher odds of emergency department use (OR 1.6795%CI 1.56–1.79).
Conclusions
Outpatient thyroidectomy is not associated with an increased mortality risk. Less than one in five patients undergo outpatient thyroidectomy in Ontario, despite a well‐established safety profile.
Level of Evidence
3 Laryngoscope, 131:2625–2633, 2021
The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID‐19) pandemic. Guidelines are ...emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.
While several studies have documented a link between socioeconomic status and survival in head and neck cancer, nearly all have used ecologic, community-based measures. Studies using more granular ...patient-level data are lacking.
To determine the association of baseline annual household income with financial toxicity, health utility, and survival.
This was a prospective cohort of adult patients with head and neck cancer treated at a tertiary cancer center in Toronto, Ontario, between September 17, 2015, and December 19, 2019. Data analysis was performed from April to December 2021.
Annual household income at time of diagnosis.
The primary outcome of interest was disease-free survival. Secondary outcomes included subjective financial toxicity, measured using the Financial Index of Toxicity (FIT) tool, and health utility, measured using the Health Utilities Index Mark 3. Cox proportional hazards models were used to estimate the association between household income and survival. Income was regressed onto log-transformed FIT scores using linear models. The association between income and health utility was explored using generalized linear models. Generalized estimating equations were used to account for patient-level clustering.
There were 555 patients (mean SD age, 62.7 10.7 years; 109 20% women and 446 80% men) included in this cohort. Two-year disease-free survival was worse for patients in the bottom income quartile (<$30 000: 67%; 95% CI, 58%-78%) compared with the top quartile (≥$90 000: 88%; 95% CI, 83%-93%). In risk-adjusted models, patients in the bottom income quartile had inferior disease-free survival (adjusted hazard ratio, 2.13; 95% CI, 1.22-3.71) and overall survival (adjusted hazard ratio, 2.01; 95% CI, 0.94-4.29), when compared with patients in the highest quartile. The average FIT score was 22.6 in the lowest income quartile vs 11.7 in the highest quartile. In adjusted analysis, low-income patients had 12-month FIT scores that were, on average, 134% higher (worse) (95% CI, 16%-253%) than high-income patients. Similarly, health utility scores were, on average, 0.104 points lower (95% CI, 0.026-0.182) for low-income patients in adjusted analysis.
In this cohort study, patients with head and neck cancer with a household income less than CAD$30 000 experienced worse financial toxicity, health status, and disease-free survival. Significant disparities exist for Ontario's patients with head and neck cancer.
Peritonsillar abscesses (PTAs) are common emergency consultations for otolaryngologists. Medical management alone may offer satisfactory treatment without the risk associated with surgical drainage. ...Therefore, we performed a systematic review of medical treatment alone compared to surgical drainage for the treatment of PTA.
MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov.
Studies comparing the outcomes of medically treated to surgically treated patients were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. All screening and data extraction were completed by 2 independent reviewers. Meta-analysis was performed using a random-effects model. Subgroup and sensitivity analyses were performed.
Ten cohort studies and 2 randomized studies were included (n
= 33,468). Study quality was low, with only 1 study providing multivariable analysis. The combined rate of treatment failure in patients initially treated with medical management alone was 5.7% compared to 5.5% in the surgical group. There was no statistically significant difference in the odds of treatment failure between interventions through random-effects meta-analysis (odds ratio OR, 1.10; 95% CI, 0.53-2.26;
= 41%;
= .13). Subgroup analysis excluding pediatric-specific studies revealed similar odds of treatment failure when initially managed with medical intervention (OR, 0.92; 95% CI, 0.56-1.50;
= .39;
= 0%).
Meta-analysis of available studies demonstrated no difference in odds of treatment failure for patients with PTA managed through medical intervention alone compared to surgical intervention. These findings should be interpreted with caution due to high probability of bias and overall low quality of studies.
PDF