As surgical procedures continue to shift from inpatient to ambulatory settings, the prevailing belief is that patients are now triaged to inpatient facilities mainly because comorbidities put them at higher risk of postoperative complications.
However, a new study of otolaryngologic procedures shows socioeconomic factors—including race/ethnicity and type of insurance—are associated with surgical settings independent of comorbidity status.
Regan W. Bergmark, MD, a sinus and endoscopic skull base surgeon in the Department of Otolaryngology–Head and Neck Surgery at Brigham and Women’s Hospital, Shekhar K. Gadkaree, MD, a resident in the Department of Otolaryngology–Head and Neck Surgery at Mass Eye and Ear, and colleagues report the details in Otolaryngology–Head and Neck Surgery.
The U.S. Agency for Healthcare Research and Quality maintains state-specific databases on hospitalizations, ambulatory surgery and emergency department visits. Florida, Maryland and New York were selected for this study because they are the largest and most diverse states whose databases allow tracking of readmissions.
The researchers identified 55,311 adults who underwent otolaryngologic surgery in 2016 and could be followed for 30 days. Procedures examined were those that could feasibly be performed in the ambulatory setting; prominent examples were neck dissection, parotidectomy, endoscopic sinus surgery, septoplasty and rhinoplasty.
Distribution of Procedures
The setting of the procedures was examined for three subspecialties (not mutually exclusive):
- Head and neck surgery—3,120 patients (51%) had ambulatory surgery and 3,044 (49%) had inpatient surgery
- Rhinology—28,144 (97%) and 989 (3%)
- Facial plastic and reconstructive surgery (FPRS)—36,250 (98%) and 717 (2%)
Odds of Ambulatory Care
On multivariable analysis, factors associated with decreased odds of having ambulatory surgery were (P<0.001 for all):
Head and neck surgery
- Charlson Comorbidity Index (CCI) ≥2 (adjusted OR [aOR]=0.08)
- Medicaid (aOR=0.57)
- Medicare (aOR=0.67)
- CCI ≥2 (aOR=0.12)
- Age >65 (aOR=0.39)
- Black race (aOR=0.59)
- CCI ≥2 (aOR=0.10)
- Black race (aOR=0.59)
- Other nonwhite race/ethnicity (aOR=0.63)
Odds of 30-day Revisit
For patients who had ambulatory surgery, the odds of an emergency department visit or hospital readmission within 30 days were:
- Overall—2.23 greater than for patients who had inpatient surgery (P<0.001)
- Head and neck surgery—2.23 times greater (P<0.001)
- Rhinology—1.39 times greater (P=0.02)
- FPRS—Odds not significantly increased
As expected, ambulatory surgery costs substantially less than inpatient procedures (median, $14,899 vs. $59,112; P<0.001). Across subspecialties, Black or other nonwhite race/ethnicity, receiving care in a rural setting, CCI ≥2, and readmission were all associated with higher costs.
Guidance for Clinicians and Administrators
The findings of 30-day revisits emphasize the importance of appropriate patient selection for ambulatory care and adequate pre- and postoperative counseling to avoid unnecessary emergency department visits.
Healthcare decision-makers should recognize the potential for socioeconomic disparities in access to ambulatory otolaryngologic surgery and strive to implement equitable policies.