An Analysis of Processes of Care Measures Related to Delayed Postoperative Radiation Therapy in Patients with Surgically-Treated Head and Neck Cancer

Presentation: AHNS061
Topic: Quality of Care and Clinical Pathways
Type: Oral
Date: Thursday, April 19, 2018
Session: 3:30 PM - 4:30 PM Quality Engineering and Pathways
Authors: Tyler A Janz, BS, Anand K Sharma, MBBS, Terry A Day, MD, Evan M Graboyes, MD
Institution(s): Medical University of South Carolina

Importance: Adherence to evidence-based treatment guidelines and timely care are measures of quality cancer care. Prior research has demonstrated that delays in timely postoperative radiation (PORT) following surgery for head and neck squamous cell carcinoma (HNSCC) surgery are common and associated with decreased survival. Details regarding the processes of care that may contribute to delays in PORT remain unknown.

Objectives: Determine the frequency of PORT that is non-adherent to National Comprehensive Cancer Network guidelines regarding initiation within 6 weeks of surgery, and examine processes of care associated with delays in the initiation of PORT.

Methods: A single institution retrospective cohort study at an academic medical center was performed for patients with HNC undergoing surgery and PORT. Inclusion criteria consisted of patients > 18 years of age undergoing surgery at the Medical University of South Carolina (MUSC) followed by PORT (at MUSC or elsewhere) with/without chemotherapy between 2014-2016. Patients with indications for PORT who did not ever start PORT and those with incomplete treatment records were excluded from the study. Univariable and multivariable logistic regression analysis was performed to identify process of care measures associated with delayed initiation of PORT.

Outcome Measures: The main outcome measure was the rate of delayed, non-guideline adherent initiation of PORT (i.e. initiating PORT more than 6 weeks postoperatively). Secondary outcome measures included processes of care related to delayed PORT. Other characteristics of quality PORT (e.g. dose, RT fields) were not evaluated.

Results: 198 patients were included in the study. 79.8% of the patients were white, 68.7% were male, and the median age was 59. The most common subsite was the oral cavity (60.8%), 54.5% of patients had American Joint Committee on Cancer (AJCC) pathologic T4a classification tumors, and 59.30% underwent free flap reconstruction.  Overall, 44.7% of patients (89/199) experienced delayed initiation of PORT (i.e. more than 6 weeks after surgery). No oncologic or treatment factors were associated with delayed PORT. On multivariable analysis, the following process of care factors remained significantly associated with delayed PORT: pathology report issued more than 7 days following surgery (Odds Ratio [OR] 2.66; 95% Confidence Interval [CI] 1.31-5.42), adjuvant radiation outside of MUSC (OR 5.74; 95% CI 2.75-11.99), unplanned reoperation after hospital discharge (OR 7.12; 95% CI 1.31-38.65), more than 21 days from surgery to 1st postoperative radiation oncology appointment (OR 3.73; 95% CI 1.37-10.17), and failure to undergo dental extractions prior to hospital discharge (OR 6.15; 95% CI 1.68-22.50).

Conclusions: Delays in timely, guideline-adherent PORT affected 44.7% of patients in this study and appear primarily due to process of care factors instead of oncologic or treatment characteristics. These processes of care can be used to design and implement quality improvement interventions to improve timely HNC care.