Qualitative Study Assessing Factors for 30-day Readmissions: A Head and Neck Oncology Cohort

Abstract

Objectives:

There is a paucity of literature on what contributes to 30-day readmission rates from the patient’s perspective in head and neck cancer patients. Post-operatively, these patients are often discharged with multiple surgical sites and home equipment requiring education and a large responsibility upon arriving home. Patients have a unique understanding of the discharge process and rationale behind presenting for care following initial discharge. Understanding the experience of the readmitted patient may be critical in finding effective methods to prevent unnecessary readmissions.

Methods:

Through key-informant interviews, we assessed factors that impact readmission rates from the patient perspective. Patients were eligible if they were discharged within the last 30 days and subsequently readmitted following an admission for a head and neck cancer surgery. Inductive coding was used to analyze interview transcripts and develop themes.

Results:

Thirteen respondents were interviewed. 46% (n = 6) did not feel ready for discharge after the index admission. Out of these 6 patients, 83% (n = 5) felt their readmission could have been avoided. Patients often encountered unexpected events after returning home from the index admission and felt their readmissions were potentially avoidable with more information regarding what to expect at home, prior to discharge. Although medically stable upon discharge, these findings indicate some patients might be discharged sooner than they should be due to factors outside of medical indications.

Conclusions:

To address the various biopsychosocial components of patient care in addition to medical aspects, an otolaryngology-specific, prior-to-discharge checklist could aid in lowering 30-day readmissions. Since the amount of education each patient requires to feel competent managing their health at home varies, more work is needed to craft post-education assessments of patient/caregiver competencies for home equipment, prior to discharge to reduce avoidable readmissions.

Keywords

healthcare quality assessments education intervention adult learning

Introduction

Thirty-day readmission rates are a metric often used as a proxy for quality of care. All-cause hospital re-admission rates for Medicare beneficiaries averaged 16.0% in 2013.¹ Many efforts have been initiated to decrease these rates.² Although effective, these interventions are typically complex and focus on hospital procedures. Current literature suggests that single intervention strategies to decrease readmission rates are not as effective as multi-component measures such as those involving both pre- and post-discharge interventions.^2
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There are many difficulties and nuances surrounding postoperative care in head and neck cancer (HNC) patients. Understanding the experience of the readmitted patient may be critical in finding effective methods to prevent unnecessary readmissions in this cohort. The patient, and/or their caregiver, have a unique perspective of the discharge process and an intimate understanding of the rationale behind presenting for care following discharge and subsequent readmissions. In one recent study, the most common reasons for readmission were not feeling ready for discharge at the time of discharge, no scheduled follow-up, and poor satisfaction with the discharging team. Within this study’s cohort, 28% of patients believed their readmission could have been prevented.⁸

Present qualitative literature has mainly focused on the clinician’s perspective^9,10 or specific patient cohorts such as heart failure patients.¹¹ To this date there are no qualitative or mixed-methods studies regarding 30-day readmissions within a HNC patient group. Past studies regarding 30-day readmissions within the otolaryngology field have identified many related risk factors for 30-day readmissions such as socioeconomic factors, comorbidities, postoperative complications, and discharge destinations.^12
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The purpose of this study was to qualitatively assess the factors that impact readmission rates from the patient and caregiver perspective via semi-structured interviews of patients who were discharged and subsequently readmitted within 30 days following a HNC surgery. Our secondary objective was to identify specific gaps in care that resulted in readmission that are amenable to intervention.

Materials and Methods

This study was reviewed by the University of Kansas Medical Center Institutional Review Board prior to the commencement of all study activities. This was a parallel-methods study design involving descriptive data and semi-structured interviews with subsequent qualitative analysis.

Recruitment of Subjects

Inclusion criteria were adult subjects who had an unplanned 30-day readmission after being discharged from the HNC service. Patients that met the inclusion criteria were approached while in the hospital for their readmission. If the patient was unable to participate, a caregiver was asked to participate in the interview alongside the patient or on their behalf. A caregiver was defined as a family member or hired worker who plays a pivotal role in the care of the patient’s health. No financial incentives were given to participants. Data gathering took place from November 2021 to March 2022. All interview moderators (S.B., J.P., M.O.) had medical and clinical research experience.

Demographic and Descriptive Data

The study included 3 surveys and 1 single item questionnaire. The validated Short Form Health Survey (SF-12) and Self-Efficacy Decision Scale were used to assess the subjects’ self-reported health and healthcare decision-making skills. The SF-12 is a health questionnaire designed to gauge a patient’s perception of their own general physical and mental health.^15,16 The validated single-item questionnaire assessed health literacy. An additional survey created by the study team (see Supplemental Appendix 1) was used to collect data on the subject’s primary hospitalization and perceived reason for readmittance.

Study survey and demographic data were collected and managed using REDCap^® 65 (Research Electronic Data Capture) electronic data capture tools. REDCap^® 66 is a secure, web67 based software platform designed to support data capture for research studies, providing an interface for validated data capture.^17,18

Semi-Structured Interview

A semi-structured 7-question interview (Supplemental Appendix 2) was conducted for each patient/caregiver. The questions were designed to explore aspects surrounding discharge and education, the patient experience after the index admission discharge, and factors that led to the patient/caregiver returning for readmission. Items from an interview guide for unexpected readmission patients following a general, acute-care discharge published by Considine et al¹⁹ were used in combination with questions made by the research team.

Data Analysis

Thematic analysis was accomplished under the framework proposed by Braun and Clarke using an inductive coding method.²⁰ Transcripts were created using Trint software²¹ and verified for accuracy by at least 2 members of the team. A preliminary codebook was developed and revised in iterative rounds until consensus was reached among all team members regarding salient themes and subthemes. Content saturation was complete after 13 interviews once it was determined no new themes were arising from the data. The decision was made to stop data collection as it was determined the content validity requirements had been met.^15,16

Results

Participant Characteristics

Fourteen participants were interviewed (8 interviews were patient-only, 3 interviews were a dyad of the patient and primary caregiver). In the 3 cases involving a caregiver, the caregivers were either a spouse or an adult child. 90.9% of participants self-identified as white. 63.6% were male (n = 7) with a mean age of 61.5 years old (Refer to Table 1).

Table 1.

Demographic Information.

	n = 11	n (%)
Gender
Female	4	36.4
Male	7	63.6
Mean age [SD]	61.5	[7.3]
Race/Ethnicity
White	10	90.9
Highest level of education completed
High school	6	53.8
College graduate	5	46.2
Consistent primary care provider
Yes	11	100
Medical insurance
Private insurance	6	54.5
Medicare	5	45.5

Index Admission and Readmission Characteristics

During the study period, 16 patients were eligible for inclusion; 11 (68.8%) were successfully recruited to participate in the study (Refer to Table 2). All recruited patients were initially admitted for planned inpatient surgery. Most HNC readmissions (n = 7, 63.6%) followed resections and free flap reconstructions. Primary reasons for readmission were infection (n = 3, 27.3%), gastric tube complications (n = 3, 27.3%), tracheostomy-related complications (n = 3, 27.3%), and bleeding/hematoma formation (n = 2, 18.2%). Tracheostomy-related complications included decannulation, development of subcutaneous emphysema development, and fistula formation. Gastric tube complications included not tolerating tube feeds due to nausea and having the tube fall out of the patient’s nose.

Table 2.

Descriptive Information.

	n = 11	n (%)
Index admission surgery
Maxillectomy with free flap reconstruction	3	27.3
Mandibulectomy with free flap reconstruction	3	27.3
Total laryngectomy with pedicle flap	2	18.2
Hemi-glossectomy with free flap reconstruction	1	9.1
Partial glossectomy with STSG	1	9.1
Parotid tumor resection with SCM graft	1	9.1
Reasons for readmission
Infection or abscess formation	3	27.3
Gastric tube complications	3	27.3
Tracheostomy complication	3	27.3
Bleeding or hematoma formation	2	18.2
Patient felt ready for discharge on final day of index admission
Yes	5	45.5
No	6	54.5
Patient believed their readmission could have been avoided
Yes	6	54.5
No	5	45.5
Preferred method to receive medical info: (allowed multiple responses)
Pictures/Graphics alone	2	18.2
Reading written info alone	3	27.3
Combo of written info and pictures/graphics	1	9.1
Conversations with physician/care team	10	90.9
Index admission length of stay
Less than 7 d	2	18.2
7 d or more	9	81.8
Readmission admitted via:
Emergency Department	7	63.6
Otolaryngology service direct admission	4	36.4
SF-12: PCS-12 score average (50 = population avg.)	35.3	N/A
SF-12: MCS-12 score average (50 = population avg.)	42.8	N/A
Self-efficacy decision scale average (0-100)	88.4	N/A

Abbreviations: SCM, sternocleidomastoid; STSG, split thickness skin graft.

Via the survey, 54.5% (n = 6) of patients reported they did not feel ready for discharge on the final day of their index admission. Out of these 6 patients, 5 (83.3%) believed their readmission could have been avoided. One patient reported feeling ready for discharge on the final day of the index admission, yet also believed readmission could have been avoided. All caregivers shared the same opinion as the patient regarding this data.

81.2% (n = 9) of patients had index admission length of stays of 7 days or more.

Both PCS-12 (physical) and MCS-12 (mental) scores of the SF-12 questionnaire (35.3, 42.8 respectively) were below the United States population average score of 50. These scores were recorded during the participant’s readmission stay.

Interviews lasted between 5 and 30 minutes. The wide variety of time was because some patients were limited in their ability to speak, and their caregivers were not present to answer on their behalf. Three main limited themes—(1) Lack of Relevant and Actionable Education During the Index Admission, (2) Concise Communication is Preferred by Patients, (3) Unexpected Events After Returning Home—emerged from the interviews.

Theme 1—Lack of Relevant & Actionable Education During the Index Admission

Patient education during the index admission was frequently the patient’s first point of critique for potential improvement. Participant 8 was a maxillectomy, free flap patient who was readmitted for bleeding reported that their education centered around, “not lifting too big of weights but [there was] nothing that said you really need to watch for bleeding or how to fix it.” (Participant 8)

Participant 1′s caregiver had a particularly frightening experience when her spouse’s tracheostomy tube was decannulated. She said her pre-discharge education consisted of a “short course on the trach and suctioning in the stoma area and pretty much that [was] it. . . We had supplies from [home health], but I really didn’t feel comfortable.”

During the interview, participant 1′s caregiver described the decannulation experience as “debilitating and helpless.” As if “there’s nothing you can do, and you just feel like you’re yelling into this abyss.” (Participant 1 Caregiver) She voiced, “I want to do it right, but I don’t feel like I can right now presently. Not that I couldn’t do it. It’s just that right now I don’t feel qualified/prepared.”

Theme 2—Concise Communication is Preferred by Patients

Patients frequently reported being overwhelmed with the quantity of information they received from the variety of health care providers involved in their care (egˍ, nurses, doctors, therapists). Participant 3 said, “sometimes [the providers] conflict each other or aren’t sure what the other team says.” She thought it would be helpful if “every team [could] meet with [her] at 1 time to discharge together.”

Another topic where patients cited overwhelming quantities of instructions was discharge packets. 23.1% (n = 3) of patients specifically said they did not look at the discharge packet because of its large size. Participant 8 reported that if the Physician’s Assistant (PA) “hadn’t sat down and went through it with me. . . I would not have looked at it. . . it’s just too big.”

One caregiver felt that amidst the ever-increasing quantity of digital tools used in the hospital, the discharge packet could be valuable “especially with older people.” However, she was hesitant because she admitted that “it’s a lot of paper.” She cited that the “most important thing [a nurse] did was highlight the most important things [in the packet].” She said that it “ended up making a difference for us.” (Participant 7 Caregiver)

Theme 3—Unexpected Events After Returning Home

30.8% (n = 4) of patients desired additional information regarding what to expect at home. They also thought that receipt of this information prior to admission would have been helpful so they could better prepare for their discharge. This was thought to be particularly important as patients felt these unexpected experiences that resulted in their return to the hospital were potentially avoidable.

For example, some reported being surprised by how overwhelming it was to take care of themselves at home. One patient who was discharged with a tracheostomy and gastric tube reported, “The tracheostomy was much more difficult to take care of at home than we had thought. . . Between the [Dobhoff] tube and the tracheostomy there was just a little more than we were comfortable with managing. . . When we got home, a lot of little details came up that we hadn’t thought about with the feedings and the tracheostomy.” (Participant 4)

One caregiver was frustrated by only receiving positive remarks regarding her father’s surgery. She felt that if she had “understood that it had been a bloody surgery, [she] probably would have checked on [the patient] multiple times at night.” (Participant 3 Caregiver) Instead, she waited until the morning when there was already “blood everywhere.” (Participant 3 Caregiver)

Another caregiver was surprised by the difference in quality between the home-health supplies and the hospital supplies. She knew the “home [suctions] are not like they are in the hospital,” but was surprised that the “home suction didn’t suck anything. It could do water. But there was so much thickness and mucus. . . It just moved it around.” (Participant 1 Caregiver)

Discussion

As greater efforts are being made to improve 30-day readmission rates within the field of head and neck oncology, it is critical to understand patient and caregiver experiences surrounding discharge and unplanned readmissions. Via semi-structured interviews in a specifically HNC cohort, the emergence of 3 main themes resulted: (1) Lack of Relevant and Actionable Education During the Index Admission, (2) Concise Communication is Preferred by Patients, and (3) Unexpected Events After Returning Home.

Promoting patient engagement and empowerment has shown a decrease in unplanned 30-day readmissions.^3,22 54.5% (n = 6) of patients cited not feeling ready for discharge upon the last day of the index admission. Out of those patients, 83.3% (n = 5) believed their readmission could have been avoided. Howard-Anderson et al⁸ identified patients’ concerns about self-care at home as a primary reason for not feeling ready for discharge. In our study, Participant 4 was medically stable and theoretically ready for discharge. However, they felt underprepared and overwhelmed with the burden of managing a Dobhoff tube and a tracheostomy after discharge. These findings indicate some patients might be discharged sooner than they should be due to factors outside of medical indications.

Within the field of HNC, there is wide variety of provider practices and a paucity of clear, evidence-directed guidelines for post-operative progression. Not only might the creation of a prior-to-discharge checklist improve provider guidelines, but it could also improve patient readiness for discharge and decrease 30-day readmissions. Currently, the only published otolaryngology-specific discharge checklist aims to improve the number of discharges by noon by refining structural hospital characteristics.²³ This checklist has many benefits but did not show an improvement in 30-day readmissions. In another study, Revell et al²⁴ generated a physiological scoring system to help determine readiness for discharge in otolaryngology patients. This system also, however, does not take other factors outside of the medical state of the patient into account. Creating HNC-specific, prior-to-discharge checklist that addresses various biopsychosocial components of patient care in addition to the medical aspects could lead to lower rates. Immediate needs indicated by patients were more education with specific equipment such as gastric tubes and tracheostomy tubes, improved consistency in quality of home health supplies, and clearer/more concise discharge instructions. Further investigation into a comprehensive, patient-centered discharge checklist may be a high-impact area to decrease 30-day readmissions in HNC patients. Possible next steps could include adapting the previously validated, Readiness for Hospital Discharge Scale (RHDS), to HNC-specific cohorts, as it has shown to lower risk of readmission in others.^25,26

Regarding more equipment education, to account for unexpected variability between a patient’s experience in a hospital setting compared to home, it is crucial to assure patient readiness with using home equipment upon discharge. Since the amount of education each patient/caregiver will need to feel competent in managing their health at home will vary, it can be difficult to assess if they are truly ready. Much work has been published on effective techniques for patient education such as the teach-back method, demonstration, and role playing.^27,28 Within a HNC cohort however, more work is needed to assess the effectiveness of patient education prior to discharge. Increased provider confidence in the ability to educate on tracheostomy care has been shown by creating a standardized quiz.²⁹ However, no such tool exists for patients/caregivers in the discharge setting. The development of such post-education tools assessing competence and confidence could be an integral component of a prior-to-discharge checklist. Post-education assessments could be created for each item requiring in-patient teaching such as Dobhoff tubes, tracheostomies, and Jackson-Pratt drains. This patient-centered approach to discharge would have unique components specific to each patient’s personal needs.

One challenge with data gathering was the sensitive nature of potential participants being unexpectedly readmitted to the hospital. Three patients or caregivers did not feel comfortable speaking with our team because they were considering pursuing legal action. Two patients declined to partake because they were unable to speak because of their tracheostomy tube. Our team offered to speak to a caregiver or allow them to write out responses, but the patients ultimately decided to decline to participate.

Conclusion

These findings provide unique insight directly from patients and caregivers surrounding the discharge and unexpected readmission experience. As prior data has suggested in other cohorts, this HNC-specific cohort also desires more education and wants to be involved in the decision-making process.³⁰ This study reinforces the idea that many aspects outside of medical stability are crucial to avoiding 30-day readmissions.¹⁴ Patients in this study felt their readmissions could have been avoided through better education during the index admission and more consistent/concise information provided during their stay. Further work needs to be done to create a patient-focused, post-education assessment tool and a comprehensive, prior-to-discharge checklist for HNC patients.

Supplemental Material

sj-docx-1-aor-10.1177_00034894221147809 – Supplemental material for Qualitative Study Assessing Factors for 30-day Readmissions: A Head and Neck Oncology Cohort

Supplemental material, sj-docx-1-aor-10.1177_00034894221147809 for Qualitative Study Assessing Factors for 30-day Readmissions: A Head and Neck Oncology Cohort by Simon Beatty, Joseph Penn, Mackenzie O’Donnell and Jennifer Villwock in Annals of Otology, Rhinology & Laryngology

Supplemental Material

sj-docx-2-aor-10.1177_00034894221147809 – Supplemental material for Qualitative Study Assessing Factors for 30-day Readmissions: A Head and Neck Oncology Cohort

Supplemental material, sj-docx-2-aor-10.1177_00034894221147809 for Qualitative Study Assessing Factors for 30-day Readmissions: A Head and Neck Oncology Cohort by Simon Beatty, Joseph Penn, Mackenzie O’Donnell and Jennifer Villwock in Annals of Otology, Rhinology & Laryngology

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Simon Beatty

Jennifer Villwock

Supplemental Material

Supplemental material for this article is available online.

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