br Discussion br To our knowledge
To our knowledge, this is the first study to demonstrate that pre-surgical dysphagia and QOL is associated with post-surgical health service use including LOS, 30dURs, and ED visits in HNC patients. Notably, dysphagia was predictive of increased health service use across study outcomes. Overall, findings suggest that preoperative QOL and PROM assessment can provide significant information that could be used along with other oncological parameters to refine evaluation of prospective patients’ tolerance of surgery and post-surgical recovery. A major strength of this study was its inclusion of variables, in-cluding QOL measures and PROMs, from the entire hospital course to predict multiple hospital outcome variables. Previous studies have ex-amined predictors of LOS, readmission, or ED visits separately, or pre-or post-surgical factors separately, and have generally used QOL mea-sures and PROMs as outcomes rather than predictors. The current study identified variables before, during, and after surgery that may predict health service use, such as pre-surgical QOL and dysphagia scores, complications, or tracheostomy placement. The fact that the MDADI was associated with health service use outcomes across a variety of HNC tumor types is not surprising given that all the diﬀerent HN tumor locations are complicit in swallowing issues, albeit in diﬀerent ways [47–49]. However, even though the presence of dysphagia has been associated with malnutrition, dehydration, and poor healthcare out-comes, including high healthcare expenditure in HNC [50–53], self-report measures like the MDADI are rarely administered in clinical care as part of routine pre-surgical assessment. While it MK2206 is true that the MDADI assesses subjective reports of swallowing diﬃculty and there-fore cannot discriminate between the dysphagia of patients with spe-cific types of HNC (e.g., laryngeal cancer vs. oral cancer) , many patients may have baseline dysphagia that might not be severe enough
to be recognized by a clinician or considered immediately relevant when formulating the plan of care. Although this study was exploratory in nature, our findings suggest that implementation of validated dys-phagia screening tools like the MDADI in the pre-surgical setting is feasible and may allow for the early identification of dysphagia and development of clear procedures to optimize healthcare resources and improve clinical pathways.
Although some variables that we identified as significant predictors of health service use (e.g., surgical complications, having a PEG tube) were consistent with findings from other published studies [12,15,54], there were some diﬀerences. For example, studies have identified marital status as a significant predictor of health service use [11,54]. It is possible that our sample may have been too small to detect significant diﬀerences. Diﬀerences in the way certain variables were measured may have also led to diﬀerences in findings. For example, Dziegielewski
 measured whether patients had a tracheostomy at discharge, whereas we examined whether or not a tracheostomy was used to manage airway during surgery. Patients who have a tracheostomy at discharge may have had more advanced cancers, which may in turn increase their odds of readmission. In our study, relatively healthy patients could have had a brief tracheostomy placed and were perhaps decannulated prior to discharge.
This study had various limitations. First, the study has the limita-tions inherent to all retrospective medical record reviews . Second, there were a small number of events (n = 18 readmissions and 11 ED visits). This could have contributed to the wide confidence intervals for the reported risk factors. Larger scale studies with more events are needed to fully test the explanatory power of the multivariable models. Third, patients may have sought care for postoperative problems else-where, resulting in an underestimation of the rate of unplanned read-missions and ED visits. Supporting placental mammals idea, using data collected from a nationally representative sample, Chen et al found that one-fifth of all readmissions following HNC in the US did not occur at the index hos-pital . This is especially relevant in the New York metro area, where transportation issues and a large number of medical centers may result in patients seeking care at a variety of facilities. Fourth, although our otolaryngology surgical oncology practice is diverse, our findings are based on a single academic medical center and might not reflect all otolaryngology practices. Fifth, owing to the nature of the study, we cannot completely rule out the possibility that lower QOL and dys-phagia scores may reflect other hidden predictors of poor prognosis. Nevertheless, we found no relationship between disease stage and ei-ther UW-QOL or MDADI scores. Although the small sample size could