Impact of Surgical Airways on Location of Death, Healthcare Utilization, and Costs Among Patients With Head and Neck Cancer: A Population‐Based Study

BACKGROUND: Patients with surgical airways experience barriers to high quality end-of-life (EOL) care. Recognizing differences in healthcare utilization and location of death among patients with surgical airways may inform improvements in EOL care delivery. This study aimed to compare location of death and selected aspects of healthcare in the last 90 days of life between head and neck cancer (HNC) patients with and without a surgical airway. METHODS: Retrospective decedent cohort study of health administrative data from the Institute of Clinical Evaluative Sciences in Ontario, Canada of individuals with HNC who died between January 1, 2008, and December 31, 2018. The exposure group included those with a total laryngectomy any time prior to death or emergency tracheostomy within 90 days prior to death. Primary outcomes included location of death and length of stay in hospital, palliative care encounters, and burdensome transitions of care in the last 90 days of life. Secondary outcomes included healthcare costs during the last 90 days of life. RESULTS: Patients with surgical airways (n = 1280, 7.8%) were more likely to die in a subacute care center (OR = 1.51 [95% CI: 1.26-1.81], p < 0.001) than those without surgical airways. There were no significant differences between the groups for deaths occurring in acute care (OR = 1.11 [95% CI: 0.97-1.27], p = 0.14) or long-term care settings (OR = 0.85 [95% CI: 0.62-1.16], p = 0.30). In the last 90 days of life, they spent more time in acute care hospitals (6.37 days [95% CI: 5.40-7.39], p < 0.001), had higher odds of experiencing burdensome transitions (OR = 1.46 [95% CI: 1.29-1.67], p < 0.001) and had greater costs associated with their care (mean cost ratio = 1.43 [95% CI: 1.36-1.51], p < 0.001). However, after adjusting for covariates, there was no statistically significant difference in palliative care involvement between patients with and without surgical airways (OR = 1.14 [95% CI: 0.98-1.31], p = 0.09). CONCLUSIONS: Patients with surgical airways were more likely to die in subacute care centers and experienced increased healthcare utilization, including longer hospital stays, higher rates of burdensome transitions, and greater costs in the last 90 days of life. There was no statistically significant difference in palliative care involvement between groups after adjustment. These findings should be interpreted with caution, as adjustment for disease stage and tumor site was not possible due to missing data. Further research is needed to better understand the underlying drivers of these differences and their implications for EOL care.