Financial impact of the COVID-19 pandemic on an academic otolaryngology department.

Objective: To quantify the financial impact of the coronavirus disease (COVID-19) pandemic on an academic otolaryngology department. Methods: A year-over-year comparison was used to compare department revenue from April 2020 and April 2021 as a percentage of baseline April 2019 activity. Results: At the onset of the COVID-19 pandemic in April 2020, total department charges decreased by 83.4%, of which outpatient clinic charges were affected to the greatest extent. One year into pandemic recovery, department charges remained down 6.7% from baseline, and outpatient clinic charges remained down 9.9%. The reduction in outpatient clinic charges was mostly driven by a decrease in in-office procedure charges. Conclusion: Given that precautions to mitigate the risk of viral transmission in the health care setting are likely to be long-lived, it is important to consider the vulnerabilities of our specialty to mitigate financial losses going forward.

Impact of Race and Insurance Status on Primary Treatment for HPV-Associated Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVE: To assess the impact of sociodemographic factors on primary treatment choice (surgery vs radiotherapy) in patients with human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). STUDY DESIGN: Retrospective analysis of the National Cancer Database. SETTING: Data from >1500 Commission on Cancer institutions (academic and community) via the National Cancer Database. METHODS: Our sample consists of patients diagnosed with HPV+ OPSCC from 2010 to 2015. The primary outcome of interest was initial treatment modality: surgery vs radiation. We performed multivariable logistic models to assess the relationship between treatment choice and sociodemographic factors, including sex, race, treatment facility, and insurance status. RESULTS: Of the 16,043 patients identified, 5894 (36.7%) underwent primary surgery while 10,149 (63.3%) received primary radiotherapy. Black patients were less likely than White patients to receive primary surgery (odds ratio [OR], 0.80; 95% CI, 0.66-0.96). When compared with privately insured patients, those who were uninsured or on Medicaid or Medicare were also less likely to receive primary surgery (OR, 0.70 [95% CI, 0.56-0.86]; OR, 0.77 [95% CI, 0.65-0.91]; OR, 0.85 [95% CI, 0.75-0.96], respectively). Patients receiving treatment at an academic/research cancer program were more likely to undergo primary surgery than those treated at comprehensive community cancer programs (OR, 1.33; 95% CI, 1.14-1.56). CONCLUSION: In this large sample of patients with HPV+ OPSCC, race and insurance status affect primary treatment choice. Specifically, Black and nonprivately insured patients are less likely to receive primary surgery as compared with White or privately insured patients. Our findings illuminate potential disparities in HPV+ OPSCC treatment.

Resident Safety Huddles: Our Department's Experience in Improving Safety Culture.

OBJECTIVE/HYPOTHESIS: Our department sought to develop a quality improvement initiative in the interest of promoting resident involvement within the departmental safety culture. Specifically, we aimed to identify any barriers to incident reporting among residents and to create an approach to rectify this problem. STUDY DESIGN: Patient Safety/Quality Improvement. METHODS: This is a descriptive, qualitative study taking place at a large teaching hospital. A brief survey was administered to all Otorhinolaryngology residents and based on feedback a two-pronged approach to creating a patient safety and quality improvement curriculum was undertaken. This entailed implementation of 1) a formalized online curriculum and 2) a resident-driven forum for discussion of safety concerns termed a "Resident Safety Huddle." RESULTS: The survey identified three main barriers to incident reporting among residents, including increased workload, the punitive nature of the system, and fear of retribution. During the study period, the residents completed the curriculum required to obtain the Institute for Healthcare Improvement Basic Certificate of Quality and Safety and participated in 10 Resident Safety Huddles. Each huddle was dedicated to discussion of a unique safety concern and frequently led to sustainable solutions. After implementation of this curriculum, an increase in the number of safety events reported by residents was recognized. CONCLUSIONS: In building an educational foundation for incident reporting and further bolstering it with a resident-driven forum for discussion of safety concerns, we were able to achieve a recognizable and meaningful impact on our residents and the greater departmental safety culture. LEVEL OF EVIDENCE: 4 (single descriptive or qualitative study) Laryngoscope, 131:E1811-E1815, 2021.

Value of Intensive Care Unit-Based Postoperative Management for Microvascular Free Flap Reconstruction in Head and Neck Surgery.

Importance: Although routine postoperative care for microvascular free flap reconstruction typically involves admission to the intensive care unit (ICU), few studies have investigated the effect of postoperative care setting on clinical outcomes and institution cost. Objectives: To determine the value of non-ICU-based postoperative management for free tissue transfer for head and neck surgery, in terms of clinical outcomes and cost-effectiveness. Design, Setting, and Participants: This is a retrospective cohort study of two groups of adults who underwent vascularized free tissue transfer from October 2013 to October 2017 at an academic tertiary care center and community-based hospital, respectively. Postoperative management differed such that the first group recovered in a protocol-driven non-ICU setting and the second group was cared for in a planned admission to the ICU. A single surgeon performed all tissue harvest and reconstruction at both centers. Main Outcomes and Measures: Descriptive statistics and cost analyses were performed to compare clinical outcomes and total surgical and downstream direct cost to the institution between the two patient groups. Categorical variables were compared using χ2 test where appropriate. Results: Among a total of 338 patients who underwent microvascular free flap reconstruction for head and neck surgical defects, there was no significant difference in patient characteristics such as demographics, comorbidities, history of surgical resection, prior free flap, and locoradiation between the postoperative ICU cohort (n = 146) and protocol-driven non-ICU cohort (n = 192). There were 16 patients in the non-ICU group who spent >3 days in the ICU postoperatively secondary to patient comorbidities and patient care priorities. Still, the average ICU length of stay was 7 days (interquartile range [IQR] 6-9 days) for the planned ICU cohort versus 1 day (IQR 0-1) for the non-ICU group (p < 0.00001). There was no difference in operative variables such as donor site, case length, or total length of stay, and postoperative management in the ICU versus non-ICU setting resulted in no significant difference in terms of flap survival, reoperation, readmission, and postoperative complications. However, average cost of care was significantly higher for patients who received ICU-based care versus non-ICU postoperative care. Specifically, room and board were 239% more costly for the planned ICU care group than the non-ICU setting (p < 0.00001). Conclusions and Relevance: This study demonstrates that postoperative management after vascularized free tissue transfer in a non-ICU setting is equivalent to standard ICU-based management, in terms of clinical outcomes, while being less costly.

Association of Type of Treatment Facility With Overall Survival After a Diagnosis of Head and Neck Cancer.

Importance: Patients with head and neck cancer receive care at academic comprehensive cancer programs (ACCPs), integrated network cancer programs (INCPs), comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). The type of treatment facility may be associated with overall survival. Objective: To examine whether type of treatment facility is associated with overall survival after a diagnosis of head and neck cancer. Design, Setting, and Participants: This population-based retrospective cohort study included patients from the National Cancer Database, a prospectively maintained, hospital-based cancer registry of patients treated at more than 1500 US hospitals. Participants were diagnosed with malignant tumors of the head and neck from January 1, 2004, through December 31, 2016. Data were analyzed from May 1 through November 30, 2019. Exposures: Treatment at facilities classified as ACCPs, INCPs, CCCPs, or CCPs. Main Outcomes and Measures: Overall survival after diagnosis and treatment of head and neck cancer was the primary outcome. The secondary outcome was the odds of receiving treatment at ACCPs and INCPs vs CCCPs and CCPs. Multivariable Cox proportional hazards regression and univariable and multivariable logistic regression models were used for analysis. Results: A total of 525 740 patients (368 821 men [70.2%]; mean [SD] age, 63.3 [14.0] years) were diagnosed with malignant tumors of the head and neck during the study period. Among them, 36 595 patients (7.0%) were treated at CCPs; 174 658 (33.2%), at CCCPs; 232 867 (44.3%), at ACCPs; and 57 857 (11.0%), at INCPs. The median survival for patients with aerodigestive cancers was 69.2 (95% CI, 68.6-69.8) months; salivary gland cancers, 107.2 (95% CI, 103.9-110.2) months; and skin cancers, 113.2 (95% CI, 111.4-114.6) months. Improved overall survival was associated with treatment at ACCPs (hazard ratio [HR], 0.89; 95% CI, 0.88-0.91), INCPs (HR, 0.94; 95% CI, 0.92-0.96), and CCCPs (HR, 0.94; 95% CI, 0.92-0.95) compared with CCPs. Compared with patients with private insurance, those with government insurance (odds ratio [OR], 1.35; 95% CI, 1.29-1.41), no insurance (OR, 1.12; 95% CI, 1.09-1.16), or Medicaid (OR, 1.17; 95% CI, 1.14-1.20) were more likely to receive treatment at ACCPs and INCPs, whereas patients with Medicare were less likely to receive treatment at ACCPs and INCPs (OR, 0.95; 95% CI, 0.94-0.97). Compared with white patients, black (OR, 1.55; 95% CI, 1.52-1.59) and Asian (OR, 1.56; 95% CI, 1.49-1.63) patients were more likely to receive care at ACCPs and INCPs. Compared with patients from lower-income areas, patients from high-income areas were more likely to receive treatment at ACCPs and INCPs (OR, 1.25; 95% CI, 1.22-1.28). Conclusions and Relevance: These findings suggest that treatment at ACCPs and INCPs was associated with a better overall survival rate in patients with head and neck cancer. Key social determinants of health such as race/ethnicity, socioeconomic status, and type of insurance were associated with receiving treatment at ACCPs and INCPs.

American College of Surgeons National Surgical Quality Improvement Program assessment of risk factors for 30-day unplanned readmission in patients undergoing head and neck surgery requiring free tissue reconstruction.

BACKGROUND: Unplanned readmissions have become a metric for measuring quality of care. We analyzed the factors associated with 30-day unplanned readmission (30dUR) following head and neck cancer resections that included free tissue reconstruction (FTR). METHODS: The 2012-2014 ACS-National Surgical Quality Improvement Program (NSQIP) data set was queried. Univariate and multivariate logistic regression analyses were performed. RESULTS: Out of 1114 cases, 121 had a 30dUR. The most common reasons were wound complications, including incisional infections, hematoma, and hemorrhage. A significant independent risk factor for 30dUR included a clean/contaminated wound class (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.20-4.76). Patients receiving an osseous FTR had lower readmission rates (OR, 0.51; CI, 0.27-0.91). Discharge destination had no statistical significance. CONCLUSIONS: Based on the NSQIP data set, 10.9% of patients receiving an FTR for head and neck malignancy had a 30dUR. Although large, population-based data sets have limitations, these results elucidate that these patients are at an increased risk for unplanned readmissions, which can guide patient expectations and discharge planning.

Impact of payer status on survival in parotid malignancy.

OBJECTIVE: In the setting of current national healthcare reform, it becomes especially relevant to understand the current state of healthcare disparities with regards to insurance status. To determine the impact of payer status on survival in parotid malignancy, we utilized the National Cancer Database (NCDB). STUDY DESIGN: Retrospective database review. SETTING: National Cancer Database (2004-2012). SUBJECTS AND METHODS: The NCDB was queried for cases of primary malignancy of the parotid gland between 2004 and 2012. The impact of payer status on overall survival was evaluated, as well as the relationship of insurance status with patient and tumor variables. RESULTS: 15,815 cases met inclusion criteria. A majority had private insurance (47.8%), followed by Medicare (40.9%), Medicaid (5.0%), uninsured (3.2%) and other government sources (1.3%). Medicare patients had the lowest 5 and 10-year survival rates (50.7% (95% CI [49.3-52.1]) and 27.8% (95% CI [25.0-30.9]), respectively). On multivariable analysis, uninsured, Medicare, and Medicaid patients had worse overall survival than the privately insured (HR 1.42, 95% CI [1.17-1.74]; HR 1.29, 95% CI [1.17-1.42]; HR 1.36, 95% CI [1.13-1.62], respectively). Uninsured and Medicaid patients were more likely than the privately insured to present with advanced stage disease, nodal metastasis and longer times to treatment following diagnosis. CONCLUSION: In parotid malignancy, uninsured, Medicaid, and Medicare patients have worse survival outcomes compared to those with private insurance. Uninsured and Medicaid patients also present with more advanced stage disease and have increased wait times before definitive treatment is initiated.