Measuring quality of care in head and neck cancer (HNC) is important for optimizing patient outcomes, identifying targets for quality improvement initiatives, and transitioning towards value-based care. The Quality and Value of Care (QVOC) Service of the American Head and Neck Society was charged to “inform the process for quality reporting…and help define high-value care for head and neck cancer patients.” To that end, the service developed a database with important quality indicators with broad input across North America to form the basis of the AHNS Quality Reporting Initiative.
The QVOC committee convened 7 content experts to perform a review of the literature and identify quality metrics for management of patients with HNC. A Redcap database was constructed to capture 27 metrics identified by the committee. The metrics fell into four categories: pre-treatment (11), treatment (9), post-treatment (4), and value (3). Seven pilot institutions contributed 20 consecutive patients treated for mucosal UADT squamous cell carcinoma with at least one year of follow up to test feasibility and provide feedback, which was used to improve the database for ease of use. The larger AHNS community was then invited to submit patients to the modified database. Participating institutions were asked to submit 20 patients to the database and provide feedback.
Quality metrics for 491 patients from 26 institutions were collected. The majority of patients had oral cavity (40.1%) and p16+ oropharynx (27.9%) cancer. 46.8% of patients were cT3/cT4, and 51.6% were cN+. Surgery was the initial treatment in 66.6% of patients. Of the 27 metrics, 8 metrics had >90% compliance (e.g. AJCC staging prior to treatment, pathological confirmation of malignancy). Pre-treatment: Pre-surgical dental evaluation was performed in 63.6% of patients. Tobacco cessation counseling was performed in 70.3% of patients. Only 52.0% of patients were evaluated by speech language pathology prior to treatment. The median time from new patient visit to treatment was 26 days (IQR 17-40 days). Treatment: Of patients with oral cavity cancer with >4mm depth of invasion, 87% had the regional nodes addressed. 79.4% of neck dissections had a >=18 lymph node yield. Post-operative radiation therapy was started within 6 weeks of surgery in 64.9% of patients. Post-Treatment: TSH levels were checked in 70.4% of patients within 12 months of completing radiotherapy. Value: Surveillance imaging was performed >24 months after the completion of treatment in 37.5% of asymptomatic patients with negative physical exams. 29.8% of asymptomatic patients had their initial PET scan performed <12 weeks after treatment completion. Median time for entering a single patient into the database was 10 minutes.
The QVOC demonstrated the ability to construct a database containing quality metrics for HNC patients. The results from this initial experience demonstrated significant gaps in care and variability in practice patterns for known quality metrics. These gaps could be addressed by focused quality improvement efforts at the local or national level. After formal endorsement by the AHNS, this database will serve as the foundation for an open quality reporting initiative for AHNS members.