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A Woman with Peritonsillar Swelling and BleedingA 29-year-old woman was admitted to the hospital because of sore throat and peritonsillar swelling and bleeding. Symptoms did not abate with antimicrobial therapy. A diagnosis was made.

While outpatient otolaryngology procedures have been increasingly performed at ambulatory surgery centers (ASCs), the cost differences compared to hospital outpatient departments (HOPDs) remain unclear. Utilizing newly available data collected from Turquoise Health's Rate Sense as required under the Transparency in Coverage rule, we assess, in this cross‐sectional analysis, the differences in negotiated facility fees between ASCs and HOPDs for 20 common otolaryngologic procedures. Analyzing data from 4613 ASCs and 2382 hospitals, we found significantly higher facility fees at HOPDs, with a median relative price difference of +146% (P < .0001). This may be explained by greater infrastructure costs and market power differences between facilities. Our findings suggest that further shifting outpatient otolaryngology procedures toward ASCs could yield substantial cost reductions across health care systems. Additional research is needed to ensure safe and cost‐effective patient selection for ASCs.

Objective Online resources may provide an ideal forum for expert presentation of surgical techniques. The purpose of this study was to investigate utilization patterns of a sinus surgery website, SinusVideos.com, to gain insight into the needs of viewers. Study Design Retrospective analysis. Setting Surgical teaching website. Subjects and Methods The website’s anonymized analytic database was queried from 2009 to 2014. Quantified data included user demographics, geographic location, viewing device, page visits, and time spent on the website. Results A total of 428,691 website pages were viewed during the study period. Growth in viewership was observed each successive year since the site was launched. The mean time spent viewing webpages was 96.1 seconds for desktop computer users, 98.0 for tablet users, and 103.8 for mobile users. The percentage of mobile devices used to view the site increased significantly between 2009 and 2014 (2.1% vs 25.4%, respectively; P < .0001). The website’s viewership expanded globally, with a significant increase in site views from outside North America over this same period (18.4% vs 51.7%, P < .0001). Conclusion The observed increase in global participation and mobile device usage may reflect new areas of growth for surgical education.

Objective Understanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS. Methods A retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS. Results A total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF—73.8%, anterolateral thigh flap—11.3%, and fibula free flap—14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [C] = +4.26, P < .0001), in‐hospital PNA or UTI (C = +2.52, P = .037), wound breakdown or fistula (C = +5.0, P < .0001), surgical site infection (C = +3.54, P = .017), and prior radiation therapy (C = +2.59, P = .004). Conclusion Several perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution‐level protocols for postoperative care and disposition of free flap patients. Level of Evidence 2b; retrospective cohort.

•Overall, rate of early-stage HNC presentation remained unchanged.•On the contrary, late-stage HNC increased post-ACA.•Early-stage HNC presentation increased only among patients with Medicaid.•Medicaid expansion may have impacted stage for low income patients. Early diagnosis and stage at presentation, two prognostic factors for survival among patients with head and neck cancer (HNC), are significantly impacted by a patient’s health insurance status. We aimed to assess the impact of the Patient Protection and Affordable Care Act (ACA) on stage at presentation across socioeconomic and demographic subpopulations of HNC patients in the United States. Retrospective data analysis. The National Cancer Database, a hospital-based cancer database (2011–2015), was queried for adults aged 18–64 years and diagnosed with a malignant primary HNC. The outcome of interest was change in early-stage diagnoses between 2011–2013 (pre-ACA) and 2014–2015 (post-ACA) using logistic regression models. A total of 91,137 HNC cases were identified in the pre-ACA (n = 53,726) and post-ACA (n = 37,411) years. Overall, the odds of early-stage diagnoses did not change significantly post-ACA (aOR = 0.97, 95 % CI 0.94, 1.00; p = 0.081). However, based on health insurance status, HNC patients with Medicaid were significantly more likely to present with early-stage disease post-ACA (aOR = 1.12, 95 % CI 1.03, 1.21; p = 0.007). We did not observe increased odds of early-stage presentation for other insurance types. Males were less likely to present with early-stage disease, pre- or post-ACA. We demonstrate a significant association between ACA implementation and increased early-stage presentation among Medicaid-enrolled HNC patients. This suggests that coverage expansions through the ACA may be associated with increased access to care and may yield greater benefits among low-income HNC patients.

Objectives To describe a 10‐year single center experience with parotid gland malignancies and to determine factors affecting outcomes. Study Design Retrospective review. Methods The institutional cancer registry was used to identify patients treated surgically for malignancies of the parotid gland between January 2005 and December 2014. Clinical and pathologic data were collected retrospectively from patient charts and analyzed for their association with overall survival (OS) and disease‐free survival (DFS). Results Two hundred patients were identified. Mean age at surgery was 57.8 years, and mean follow‐up time was 52 months. One hundred two patients underwent total parotidectomy, while 77 underwent superficial parotidectomy, and 21 underwent deep lobe resection. Seventy patients (35%) required facial nerve (FN) sacrifice. Acinic cell carcinoma was the most common histologic type (22%), followed by mucoepidermoid carcinoma (21.5%) and adenoid cystic carcinoma (12.5%). Twenty‐nine patients (14.5%) experienced recurrences, with mean time to recurrence of 23.6 months (range: 1‐82 months). Five‐ and 10‐year OS were 81% and 73%, respectively. Five‐ and 10‐year DFS were 80% and 73%, respectively. In univariate analyses, age > 60, histologic type, positive margins, high grade, T‐stage, node positivity, perineural invasion, and FN involvement were predictors of OS and DFS. In the multivariate analysis, histology, positive margins, node positivity, and FN involvement were independent predictors of OS and DFS. Conclusions Our single‐center experience of 200 patients suggests that histology, positive margins, node positivity, and FN involvement are independently associated with outcomes in parotid malignancies. Level of Evidence 4

Private negotiated facility fees at hospitals are on average double the ambulatory surgery center facility fees for common outpatient procedures.Private negotiated facility fees at hospitals are on average double the ambulatory surgery center facility fees for common outpatient procedures.

Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10–707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83–0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17–0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69–0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09–1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.

Objective The need for intensive care unit (ICU) admission and mechanical ventilation after head and neck microvascular free flap reconstructive surgery remains controversial. Our institution has maintained a longstanding practice of immediately taking patients off mechanical ventilation with subsequent transfer to intermediate, non‐ICU level of care with specialized otolaryngologic nursing. Our objective was to describe postoperative outcomes for a large cohort of patients undergoing this protocol and to examine the need for routine ICU transfer. Materials and Methods We performed a retrospective review of 512 consecutive free flaps treated with a standard protocol of immediate postoperative transfer to an intermediate‐level care unit with specialized otolaryngology nursing. Outcome measures included ICU transfer, ventilator requirement, flap failure, postoperative complications, and length of stay. Predictors of ICU transfer were identified by multivariable logistic regression. Results The vast majority of patients did not require intensive care. Only a small fraction (n = 18 patients, 3.5%) subsequently transferred to the ICU, most commonly for respiratory distress, cardiac events, and infection. The most common complications were delirium/agitation (n = 55; 10.7%) and pneumonia (n = 51; 10.0%). Sixty‐five cases (12.7%) returned to the OR, most commonly for hematoma/bleeding (n = 41; 8.0%) and anastomosis revision (n = 20; 3.9%). Heavy alcohol consumption and greater number of medical comorbidities were significant predictors of subsequent ICU transfer. Conclusions Among head and neck free flap patients, routine cessation of mechanical ventilation and transfer to intermediate‐level care with specialized ENT nursing was found to be safe with infrequent subsequent ICU transfer and low complication rates. Routine transfer to intermediate‐level care in this population may prevent unnecessary ICU utilization and facilitate the delivery of high‐value, disease‐centered care. Level of Evidence 3b