Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: Dysphagia is common following treatment for head and neck cancer and can lead to complications such as aspiration pneumonia, dehydration, and malnutrition (Manikantan et al., 2009). Surgical patients are at particularly high risk in the postoperative period, and readmission rates in this population leads to increased costs, delays in radiation, and overall worse outcomes. The primary goal for this project is to understand causes of a 30-day hospital readmission related to dehydration, malnutrition, and aspiration pneumonia following surgery for patients diagnosed with oral, pharyngeal, or laryngeal cancer (currently 8% in our historical data), and to determine if telemedicine visits or telephone calls in the early postoperative period is effective in lowering the readmission rate.
Methods: We enrolled prospective patients on and IRB approved quality improvement project over a 6 month period who underwent surgical extirpation with or without reconstruction at a tertiary care NCI designated cancer center. There were 78 patient identified who had primary cancers of the oral cavity, oropharyngeal, or laryngeal cancer. All patients were seen by speech language pathology (SLP) in the hospital and early post discharge telemedicine visits arranged (1-3 days after discharge). Ten of the 78 patients received a total laryngectomy. The remaining 68 patients received either a mandibulectomy (13), maxillectomy (8), TORS (11), partial or hemi-glossectomy (14), a direct laryngoscopy with a biopsy (10), wide local excision (1), neck dissection (1), a supraglottic laryngectomy (1), thyroid lobectomy (1), an emergent tracheotomy (6), or other (2). Of the 78 patients, 43 received a free flap reconstruction. Fifty-six patients were recommended a diet by SLP or ENT. Twenty-two patients were discharged on a modified diet and had supplemental enteral tube feeds. Eleven patients had percutaneous endoscopic gastrostomy (PEG) tubes and 11 had nasogastric or duotube feeding tubes.
Results: The goal of the post discharge telemedicine visit was to identify if the patient required further clarification of the recommended discharge diet and/or to provide recommendations pertaining to safe swallowing. Of the 78 patients identified, 65% (51) of patients agreed to participate in the intervention, 15/78 (19%) received an attempted telehealth visit (defined as the speech language pathologist receiving a voicemail or a busy signal). In the study period, there was one patient re-admitted for malnutrition (1.3%). There were 6 (11%) patients who were identified as high risk for aspiration or malnutrition on the telehealth visit and the primary team was immediately alerted, and subsequently managed at home. Almost 1/3 of patients (15/51) required further clarification about discharge diet recommendations and strategies, and felt their instructions were discordant to what they were able to do at home.
Conclusion: Up to 1/3 of patients who participated in the intervention required the additional support and appeared to be a welcomed patient care initiative. Our overall readmission rate prior to this study was 8%, and this preliminary data, while promising, suggests a further prospective study to validate this intervention.
Manikantan K, Khode S, Sayed SI, et al. Dysphagia in head and neck cancer. Cancer Treat Rev. 2009;35(8):724-732. doi:10.1016/j.ctrv.2009.08.008