Delivering high quality care has recently become the overarching objective in many healthcare systems. Accordingly, there has been growing recognition of the value in measuring QoC using processes of care, alongside the more traditional outcomes metrics (mortality and morbidity) [13, 14]. Although robust head and neck oncology guidelines exist [3,4,5], there are a limited number of large scale population-based reports analyzing healthcare providers adherence to these guidelines [3, 4]. Employing a large database of oral cavity cancer patients treated surgically, we evaluated adherence to the guideline-recommended processes of care. We found that concordance with the selected best practices were limited and had significant geographic variation.
Preoperative imaging had the highest adherence rates, with 60% for head and neck and 62.5% for chest from a cohort of 2,752 patients. The slightly higher adherence in chest imaging (CT, MRI or chest x-ray) could potentially be attributed to the anesthesiology preoperative workup, where chest x-rays are frequently ordered. This hypothesis is supported by the fact that 40% of the chest images corresponded to radiographies. Previous reports have shown disparities in preoperative imaging; Hessel et al. [13], examined 116 early tongue cancer patients managed at MD Anderson Cancer Center (MDACC), and noted that only 67.2% had preoperative head and neck CT scans or MRI. Using the Ontario Cancer Registry and capturing 5,720 patients with squamous cell carcinomas of the head and neck, Eskander et al. [15] found that preoperative head and neck and chest imaging was performed in 71.8% and 82.5% of patients, respectively. A more recent experience which included patients with laryngeal carcinomas using the MarketScan database, Britt et al. [16] observed that 52% of 8,392 patients (excluding early glottic cancers) had pre-treatment imaging. Our findings are in keeping with all of these studies, and using a large database of oral cavity cancers, we confirm that adherence rates are less than perfect, regardless of jurisdiction or cancer subsite.
Geographically differences with higher adherence rates reported in Canadian reports, specifically in Ontario, likely reflect an increased regionalization of care where most patients are referred to high-volume oncologic centers [17]. In the present study, we also found geographical U.S. differences in preoperative imaging. North Central and South regions, and North Central and the West, differed in head and neck imaging while North East and West and North Central and West, had differences in chest imaging. This warrants further assessment, but may be related to differing referral patterns, regional insurance providers and access to care. In the U.S., referral patterns vary significantly due to differing insurance providers’ networks and geographic availability of head and neck cancer care specialists. Nonetheless, both in Canada and the U.S., there is a push towards standardization of care processes, which is albeit still somewhat heterogeneous among centers. PET imaging demonstrated large variations in care that are, in part, related to differing evidence on the role of the technology as well as varying insurance coverage rates for this imaging modality.
The deleterious impact of radiotherapy for head and neck cancer on thyroid function is well known, with radiation-induced hypothyroidism occurring in up to 53% of patients [18]. Despite this, only 54.3% of 1,078 patients receiving adjuvant radiation had posttreatment TFTs. Rates were even lower in a laryngeal cohort16, in which only 31.9% had their thyroid function assessed after treatment. Our analysis showed that rates of thyroid testing declined even more during patients' follow-up, as 30.5% of individuals had a TFTs for each post-radiation treatment year. In cases where follow-up relies on more than one sub-specialty, the shared responsibility of ordering studies may lead to uncertainty around who should order the test, and monitoring if the TFTs have been completed.
Decision making through multidisciplinary consultation (MDT) not only improves patients' survival [19, 20] but also increases the adherence to other processes of care [21,22,23, 15
We are aware that G-tube insertion is not a QoC indicator. It is however an important and impactful process of care that was reliably coded in the data. As such we chose to describe its use in this population which typically requires a relatively low rate of G-tube insertion. Our data does add value to the literature in that there is less reporting of G-tube use in oral cavity cancer patients compared to oropharynx cancer [24, 24,25,26, 12].
Previous reports about QoC in oral cavity cancer patients addressed the adherence of healthcare providers to evidence-based guidelines [13, 27, 7, 16, 15, 14, 28
Our findings confirm the need to implement strategies to promote adherence to guidelines. Facilitating feedback between non-academic and academic healthcare facilities through multidisciplinary treatment conferences could potentially improve treatment quality [20, 29]. Similar to cancer "roadmaps" for head and neck cancer survivors as part of a comprehensive survivorship program [30, 31], checklists containing evidence-based recommendations can be developed for patients with head and neck cancer and distributed in non-academic centers in the active follow-up phase prior to transitioning into survivorship programs. Such recommendations could also be included in the electronic medical record as ‘force functions’ to ensure adherence. Treatment care plans can also be given to patients to empower them to participate in their care.
Fortunately, perfect adherence to these guidelines would minimally increase costs based on our cost analysis, with the appropriate imaging and bloodwork costing less than $2000–3000 per patient in the first 5 years of follow up. The cost variation depends on the imaging modality chosen, with PET scans significantly increasing costs. Regionalization of head and neck cancer care, with proven improvements in outcomes[17, 32], can also represent an intervention to promote adherence to guidelines and improve QoC, though both geography and the insurance landscape may limit its implementation in the US. Furthermore, regionalization significantly increases patient and caregiver travel burden. Head and neck cancer research should therefore continue to study, report and improve quality of care processes given the large variations and imperfect adherence to guidelines recommendations.
