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Swegal WC, Herbert RJ, Eisele DW, Chang J, Bristow RE, Gourin CG. Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for laryngeal cancer. Laryngoscope 2019; 130:672-678. [PMID: 31169916 DOI: 10.1002/lary.28104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/25/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer. STUDY DESIGN Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. METHODS Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume. RESULTS Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E <1 (N = 32) treated 284 patients (16.5%), with a mean O/E of 0.77 ± 0.18. Hospitals treating more than six cases with an O/E ≥1 (N = 68) treated 672 patients (39.1%), with a mean O/E of 1.17 ± 0.11. Treatment at hospitals with an O/E ≥1 was associated with improved survival (hazard ratio [HR] = 0.83 [95% confidence interval [CI]: 0.70 to 0.98]) and lower mean incremental treatment-related costs (-$3,009 [-$5,226 to -$791]) compared with hospitals with an O/E <1 (HR = 1.00 [0.80 to 1.24]) and the reference group of low-volume hospitals. CONCLUSIONS A hospital-specific O/E for NCCN treatment guideline adherence, combined with a minimum case volume criterion, is associated with survival and treatment-related costs in elderly patients with larynx cancer, and may be a feasible measure of larynx cancer quality of care. LEVEL OF EVIDENCE NA Laryngoscope, 130:672-678, 2020.
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Affiliation(s)
- Warren C Swegal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert J Herbert
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Jenny Chang
- Department of Epidemiology, University of California Irvine, Irvine, California
| | - Robert E Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange, California, U.S.A
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
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Appachi S, Shah J, Reddy C, Bowen A, Koyfman S, Lamarre E. Analysis of Process-Related Quality Metrics and Survival of Patients with Oral Cavity Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2019; 161:450-457. [DOI: 10.1177/0194599819845864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To analyze the association of prior reported key quality metrics—neck dissection ≥18 nodes, radiation oncology referral for stage III/IV disease, unplanned surgery ≤14 days, and unplanned readmission ≤30 days—with disease-free survival (DFS) and overall survival (OS) in oral cavity cancer (OCC). Study Design A retrospective chart review. Setting A tertiary care center from 1995 to 2016. Subjects and Methods Data from patients with OCC who underwent primary surgery were studied. The association of quality metrics and pathology with DFS/OS was determined by Cox proportional hazards regression analysis. Results A total of 514 patients were included, and 398 (77.4%) underwent elective neck dissection. Key metrics were not associated with DFS on analysis, but higher pathologic stage and extracapsular extension (ECE) were. When stratified by stage, unplanned readmission within 30 days was associated with decreased survival on multivariate analysis (HR = 0.40; 95% CI, 0.20-0.85; P = .02) for patients with clinical stage III or IV disease. ECE was associated with decreased survival among these patients as well. Neck dissection with ≤18 nodes (HR = 0.62; 95% CI, 0.44-0.86; P = .004) and unplanned surgery within 14 days (HR = 0.56; 95% CI, 0.32-0.96; P = .03) were associated with decreased survival on univariate analysis but not on multivariate analysis. ECE and higher-stage disease were associated with decreased OS on multivariate analysis. Conclusion In this study, aggressive pathology, rather than adherence to key quality metrics, was associated with lower DFS and OS among patients with OCC. More studies are needed to elucidate the association of quality metrics with survival.
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Affiliation(s)
- Swathi Appachi
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Janki Shah
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Chandana Reddy
- Taussig Cancer Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrew Bowen
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Shlomo Koyfman
- Taussig Cancer Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric Lamarre
- Head and Neck Institute, The Cleveland Clinic, Cleveland, Ohio, USA
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Morse E, Fujiwara RJT, Judson B, Mehra S. Treatment Times in Salivary Gland Cancer: National Patterns and Association with Survival. Otolaryngol Head Neck Surg 2018; 159:283-292. [PMID: 29460669 DOI: 10.1177/0194599818758020] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective To characterize treatment times in salivary cancer; associate treatment times with patient, tumor, and treatment characteristics; and examine the association of treatment times and overall survival. Study Design Retrospective cohort. Setting Commission-on-Cancer Accredited Hospitals 2004-2013. Subjects and Methods In total, 5953 patients with salivary cancer included in the National Cancer Database were identified. For each treatment interval, patients in the fourth quartile ("prolonged") were compared to patients in the first and second quartiles ("not prolonged"). Patient, tumor, and treatment characteristics were associated with prolonged times via multivariable binary logistic regression. Prolongation of each interval was associated with overall survival via multivariable Cox proportional hazards regression, controlling for clinically relevant factors. Results Median durations for diagnosis-to-treatment initiation, surgery-to-radiation treatment (RT), RT duration, total treatment package, and diagnosis-to-treatment end were 31, 44, 47, 92, and 110 days, respectively. Race, insurance status, comorbidities, age, T and N stage, facility volume and location, and a facility care transition from diagnosis to initial treatment were associated with prolonged treatment time. Prolonged RT duration was associated with decreased overall survival (OS) (62% vs 75% 5-year OS, HR = 1.26 [95% confidence interval (CI), 1.09-1.47]; P = .002), but prolonged diagnosis-to-treatment initiation, surgery-to-RT, total treatment package, and diagnosis-to-treatment end intervals were not (70% vs 67% 5-year OS, HR = 1.11 [95% CI, 0.92-1.34], P = .284; 72% vs 68%, HR = 0.93 [95% CI, 0.79-1.09], P = .370; 70% vs 70%, HR = 1.00 [95% CI, 0.84-1.20], P = .974; 66% vs 71%, HR = 0.99 [95% CI, 0.84-1.18], P = .920, respectively). Conclusion The median durations identified here can serve as reference points. Radiation therapy duration is associated with overall survival in salivary cancer and could be considered a quality indicator.
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Affiliation(s)
- Elliot Morse
- 1 Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rance J T Fujiwara
- 1 Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin Judson
- 1 Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saral Mehra
- 1 Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
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Graboyes EM, Townsend ME, Kallogjeri D, Piccirillo JF, Nussenbaum B. Evaluation of Quality Metrics for Surgically Treated Laryngeal Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg 2017; 142:1154-1163. [PMID: 27435696 DOI: 10.1001/jamaoto.2016.0657] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Quality metrics for patients with laryngeal squamous cell carcinoma (SCC) exist, but whether compliance with these metrics correlates with improved survival is unknown. Objective To examine whether compliance with proposed quality metrics is associated with improved survival in patients with laryngeal SCC treated with surgery with or without adjuvant therapy. Design, Setting, and Participants This retrospective cohort study included patients from a tertiary care academic medical center who had previously untreated laryngeal SCC and underwent surgery with or without adjuvant therapy from January 1, 2003, through December 31, 2012. Data analysis was performed from August 4, 2015, through December 13, 2015. Interventions Surgery with or without adjuvant therapy. Main Outcomes and Measures Compliance with quality metrics from the American Head and Neck Society (AHNS), National Comprehensive Cancer Network (NCCN) guidelines, and institutional metrics with face validity covering pretreatment evaluation, treatment, and posttreatment surveillance was evaluated. The association between compliance with the group of metrics and overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) was explored using Cox proportional hazards analysis. The association between compliance with individual metrics and survival was similarly determined. Results A total of 243 patients (184 men and 59 women) were included in the study (median age, 62 years; age range, 23-87 years). No association was found between increasing levels of compliance with the AHNS or NCCN metrics and survival. The only AHNS or NCCN metric for which greater compliance correlated with improved survival on multivariable Cox proportional hazards analysis controlling for pT stage, pN stage, extracapsular spread, margin status, and comorbidity was pretreatment multidisciplinary evaluation for patients with stage cT3-4 or cN1-3 disease (OS adjusted hazard ratio [aHR], 0.47; 95% CI, 0.24-0.94; DFS aHR, 0.45; 95% CI, 0.23-0.85). For the institutional metrics, multidisciplinary evaluation for all patients (OS aHR, 0.51; 95% CI, 0.29-0.88; DFS aHR, 0.50, 95% CI, 0.32-0.80) and elective neck dissection yield of 18 lymph nodes or more (DFS aHR, 0.36; 95% CI, 0.14-0.99) were associated with improved survival on multivariable Cox proportional hazards analysis. Conclusions and Relevance In this cohort of patients with surgically treated laryngeal SCC, multidisciplinary evaluation and elective neck dissection yield of 18 lymph nodes or more are associated with improved survival. Development of better quality metrics is necessary because increased compliance with metrics described by the AHNS and NCCN is not associated with improved survival. Previously described metrics for surgically treated oral cavity cancer are not prognostic for surgically treated laryngeal SCC. Future multi-institutional collaboration will be required to validate these findings, develop better quality metrics, and evaluate whether quality metrics for head and neck cancer are site specific.
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Affiliation(s)
- Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Melanie E Townsend
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri2Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Brian Nussenbaum
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
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Thaker NG, Pugh TJ, Mahmood U, Choi S, Spinks TE, Martin NE, Sio TT, Kudchadker RJ, Kaplan RS, Kuban DA, Swanson DA, Orio PF, Zelefsky MJ, Cox BW, Potters L, Buchholz TA, Feeley TW, Frank SJ. Defining the value framework for prostate brachytherapy using patient-centered outcome metrics and time-driven activity-based costing. Brachytherapy 2016; 15:274-282. [PMID: 26916105 PMCID: PMC5502102 DOI: 10.1016/j.brachy.2016.01.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Value, defined as outcomes over costs, has been proposed as a measure to evaluate prostate cancer (PCa) treatments. We analyzed standardized outcomes and time-driven activity-based costing (TDABC) for prostate brachytherapy (PBT) to define a value framework. METHODS AND MATERIALS Patients with low-risk PCa treated with low-dose-rate PBT between 1998 and 2009 were included. Outcomes were recorded according to the International Consortium for Health Outcomes Measurement standard set, which includes acute toxicity, patient-reported outcomes, and recurrence and survival outcomes. Patient-level costs to 1 year after PBT were collected using TDABC. Process mapping and radar chart analyses were conducted to visualize this value framework. RESULTS A total of 238 men were eligible for analysis. Median age was 64 (range, 46-81). Median followup was 5 years (0.5-12.1). There were no acute Grade 3-5 complications. Expanded Prostate Cancer Index Composite 50 scores were favorable, with no clinically significant changes from baseline to last followup at 48 months for urinary incontinence/bother, bowel bother, sexual function, and vitality. Ten-year outcomes were favorable, including biochemical failure-free survival of 84.1%, metastasis-free survival 99.6%, PCa-specific survival 100%, and overall survival 88.6%. TDABC analysis demonstrated low resource utilization for PBT, with 41% and 10% of costs occurring in the operating room and with the MRI scan, respectively. The radar chart allowed direct visualization of outcomes and costs. CONCLUSIONS We successfully created a visual framework to define the value of PBT using the International Consortium for Health Outcomes Measurement standard set and TDABC costs. PBT is associated with excellent outcomes and low costs. Widespread adoption of this methodology will enable value comparisons across providers, institutions, and treatment modalities.
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Affiliation(s)
- Nikhil G Thaker
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas J Pugh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Usama Mahmood
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Seungtaek Choi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tracy E Spinks
- Office of the SVP/Hospitals & Clinics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Neil E Martin
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ
| | - Rajat J Kudchadker
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Deborah A Kuban
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David A Swanson
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peter F Orio
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Centers, Boston, MA
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Brett W Cox
- Department of Radiation Oncology, North Shore-LIJ Health System, New York, NY
| | - Louis Potters
- Department of Radiation Oncology, North Shore-LIJ Health System, New York, NY
| | - Thomas A Buchholz
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas W Feeley
- The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Carberry K, Landman Z, Xie M, Feeley T, Henderson J, Fraser C. Incorporating longitudinal pediatric patient-centered outcome measurement into the clinical workflow using a commercial electronic health record: a step toward increasing value for the patient. J Am Med Inform Assoc 2015; 23:88-93. [PMID: 26377989 DOI: 10.1093/jamia/ocv125] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 07/11/2015] [Indexed: 11/13/2022] Open
Abstract
Patient-centered outcomes measurement provides healthcare organizations with crucial information for increasing value for patients; however, organizations have struggled to obtain outcomes data from electronic health record (EHR) systems. This study describes how Texas Children's Hospital customized a commercial EHR system and assembled a cross-functional team to capture outcomes data using existing functionality. Prior to its installation and customization, no surgical subspecialties besides the congenital heart and transplant surgery groups conducted prospective, patient outcomes measurement, but by 2015, the outcomes of over 1300 unique patients with supracondylar fractures, cleft lip and/or palate, or voiding dysfunction had been tracked. Key factors for integrating outcomes measurement into the clinical workflow include ongoing communication between cross-functional teams composed of clinicians and technical professionals, an iterative design process, organizational commitment, and prioritizing measurement as early as possible during EHR optimization.
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Affiliation(s)
- Kathleen Carberry
- Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA
| | - Zachary Landman
- Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA
| | - Michelle Xie
- Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA
| | - Thomas Feeley
- Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA
| | - John Henderson
- Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA
| | - Charles Fraser
- Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA Texas Children's Hospital, Outcomes & Impact Service, Houston, TX, USA
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Awad MI, Shuman AG, Montero PH, Palmer FL, Shah JP, Patel SG. Accuracy of administrative and clinical registry data in reporting postoperative complications after surgery for oral cavity squamous cell carcinoma. Head Neck 2014; 37:851-61. [PMID: 24623622 DOI: 10.1002/hed.23682] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/19/2013] [Accepted: 03/07/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The purpose of this study was to describe and compare how postoperative complications after oral cavity squamous cell carcinoma (SCC) surgery are reported in medical records, institutional billing claims, and national clinical registries. METHODS The medical records of 355 previously untreated patients who underwent surgery for oral cavity SCC at our institution were retrospectively reviewed for postoperative complications. Information was compared with claims and National Surgical Quality Improvement Program (NSQIP) data. RESULTS We identified 219 patients (62%) experiencing 544 complications (10% major). Billing claims identified 29% of these patients, 36% of overall complications, and 98% of major complications. Of overlapping patients, NSQIP identified 27% of patients, 33% of overall complications, and 100% of major complications noted on chart abstraction. CONCLUSION The incidence of minor postoperative complications after oral cavity SCC surgery is relatively high. Both claims data and NSQIP accurately recorded major complications, but were suboptimal compared to chart abstraction in capturing minor complications.
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Affiliation(s)
- Mahmoud I Awad
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andrew G Shuman
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Pablo H Montero
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Frank L Palmer
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jatin P Shah
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
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