Surgeon Volume and Laryngectomy Outcomes

OBJECTIVE

To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy.

DATA SOURCES

The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables.

METHODS

Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression.

RESULTS

Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity.

CONCLUSION

There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.

Quality Indicators for the Diagnosis and Management of Menière's Disease

OBJECTIVE

Menière's disease (MD) is a clinical disorder that often provides challenges in diagnosis and management. High-quality evidence to guide care providers is sparse, which can result in significant practice variations. Quality indicators (QIs) are one method that can be used to standardize and measure accepted care practices to improve healthcare quality and patient outcomes. Here, we developed practical, high-yield QIs that serve to measure and inform the quality of care provided to patients with MD.

STUDY DESIGN

Modified RAND Corporation University of California, Los Angeles appropriateness methodology for QI development.

SETTING

Multicenter nine-member expert panel.

PATIENTS

NA.

INTERVENTIONS

NA.

MAIN OUTCOME MEASURE

Final QIs deemed appropriate measures of quality care with agreement by the expert panel.

RESULTS

Twenty-seven candidate indicators were identified after literature review. After the first round of evaluations, the panel agreed on three candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss disagreements. Two agreed-upon QIs were revised during this discussion before final evaluations. The expert panel ultimately agreed upon five QIs as appropriate measures of high-quality care after completing final evaluations and reviewing updated literature. The five quality indicators measure audiometric documentation, minimization of electrocochleography, use of intratympanic dexamethasone, use of intratympanic gentamycin, and rate of labyrinthectomy/vestibular neurectomy in refractory MD patient.

CONCLUSIONS

This study proposes five QIs that cover key aspects of care for MD, such as accurate diagnosis and management options including initial destructive therapies. These QIs can serve multiple purposes, the most important of which is to galvanize quality improvement initiatives.

Quality Indicators for the Diagnosis and Management of Sudden Sensorineural Hearing Loss

OBJECTIVE

Sudden sensorineural hearing loss (SSNHL) is an ideal entity for quality indicator (QI) development, providing treatment challenges resulting in variable or substandard care. The American Academy of Otolaryngology-Head and Neck Surgery recently updated their SSNHL guidelines. With SSNHL demonstrating a large burden of illness, this study sought to leverage the updated guidelines and develop QIs that support quality improvement initiatives at an individual, institutional, and systems level.

METHODS

Candidate indicators (CIs) were extracted from high-quality SSNHL guidelines that were evaluated using the Appraisal of Guidelines for Research and Evaluation II tool. Each CI and its supporting evidence were summarized and reviewed by a nine-member expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND Corporation-University of California, Los Angeles appropriateness methodology.

RESULTS

Fifteen CIs were identified after literature review. After the first round of evaluations, the panel agreed on 11 candidate indicators as appropriate QIs with 2 additional CIs suggested for consideration. An expert panel meeting provided a platform to discuss areas of disagreement before final evaluations. The expert panel subsequently agreed upon 11 final QIs as appropriate measures of high-quality care for SSNHL.

CONCLUSION

The 11 proposed QIs from this study are supported by evidence and expert consensus, facilitating measurement across a wide breadth of quality domains. With the recently updated SSNHL guidelines, and a greater focus on quality improvement opportunities, these QIs may be used by healthcare providers for targeted quality improvement initiatives.

Making the Best of Limited Resources: Improving Outcomes in Head and Neck Cancer

The overwhelming majority of head and neck cancers and related deaths occur in low- and middle-income countries, which have challenges related to burden of disease versus access to care. Yet the additional health care burden of the COVID-19 pandemic has also impacted access to care for patients with head and neck cancer in the United States. This article focuses on challenges and innovation in prioritizing head and neck cancer care in Sub-Saharan Africa, the Indian experience of value-added head and neck cancer care in busy and densely populated regions, and strategies to optimize the management of head and neck cancer in the United States during the COVID-19 pandemic.

Association between postoperative complications and long-term oncologic outcomes following total laryngectomy: 10-year experience at MD Anderson Cancer Center

BACKGROUND

Postoperative complications are an independent predictor of poor survival across several tumors. However, there is limited literature on the association between postoperative morbidity and long-term survival following total laryngectomy (TL) for cancer.

METHODS

We conducted a retrospective review of all TL patients at a single institution from 2008 to 2013. Demographic and clinical data were collected and analyzed, including postsurgical outcomes, which were classified using the Clavien-Dindo system. Multivariable Cox regression analyses were performed to identify factors associated with overall survival (OS) and disease-free survival (DFS).

RESULTS

A total of 362 patients were identified. The mean age was 64 years, and the majority of patients were male (81%). The median follow-up interval was 21 months. Fifty-seven percent of patients had received preoperative radiation, and 40% had received preoperative chemotherapy. Fifty-seven percent of patients underwent salvage TL, and 60% underwent advanced reconstruction (45% free flap and 15% pedicled flap). A total of 136 patients (37.6%) developed postoperative complications, 92 (25.4%) of which were major. Multivariable modeling demonstrated that postoperative complications independently predicted shorter OS (hazard ratio [HR], 1.50; 95% CI, 1.16-1.96; P = .002) and DFS (HR, 1.36; 95% CI, 1.05-1.76; P = .021). Other independent negative predictors of OS and DFS included positive lymph node status, preoperative chemotherapy, comorbidity grade, and delayed adjuvant therapy. Severity of complication and reason for TL (salvage vs primary) were not shown to be predictive of OS or DFS.

CONCLUSION

Postoperative complications are associated with worse long-term OS and DFS relative to uncomplicated cases. Patient optimization and timely management of postoperative complications may play a critical role in long-term survival.

Association of Hospital Volume With Laryngectomy Outcomes in Patients With Larynx Cancer

Importance

A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures.

Objectives

To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes.

Design, Setting, and Participants

In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable.

Main Outcomes and Measures

Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis.

Results

Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900).

Conclusions and Relevance

Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.

Association Between Hospital Market Concentration and Costs of Laryngectomy

IMPORTANCE

High-volume hospital care for laryngectomy has been shown to be associated with reduced morbidity, mortality, and costs; however, most hospitals in the United States do not perform high volumes of laryngectomies. The influence of market competition on charges and costs for such patients has not been defined.

OBJECTIVE

To examine the association between regional hospital market concentration, hospital charges, and costs for laryngectomy.

DESIGN, SETTING, AND PARTICIPANTS

The Nationwide Inpatient Sample was used to identify 34 193 patients who underwent laryngectomy for a malignant laryngeal or hypopharyngeal neoplasm from January 1, 2003, to December 31, 2011. Hospital laryngectomy volume was modeled as a categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2003, 2006, and 2009 Hospital Market Structure Files. Statistical analysis was performed from May 19 to August 15, 2018.

MAIN OUTCOMES AND MEASURES

Multivariable generalized linear regression was used to evaluate associations between market concentration and total charges and costs for laryngectomy.

RESULTS

Among the 34 193 patients (19.3% female and 80.7% male; mean age, 62.7 years [range, 20.0-96.0 years]), 69.2% of procedures were performed at hospitals in highly concentrated (noncompetitive) markets and 26.2% were performed at hospitals in unconcentrated (highly competitive) markets. Most high-volume hospitals (68.0%) were located in highly concentrated markets, followed by unconcentrated markets (32.0%). Market share and volume were not associated with significant differences in total charges. Unconcentrated markets were associated with 28% higher costs (95% CI, 8%-53%) relative to moderately concentrated and highly concentrated markets. High-volume hospitals were associated with 22% lower costs (95% CI, -36% to -5%).

CONCLUSIONS AND RELEVANCE

Competition among hospitals is associated with increased costs of care for laryngectomy. High-volume hospital care is associated with lower costs of care. These data suggest that hospital market consolidation of laryngectomy at centers able to meet minimum volume thresholds may improve health care value.

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

OBJECTIVE

To identify prognostic case volume thresholds of facilities that manage HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer-accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

EXPOSURES

Treatment of HNSCC at facilities with varying case volumes.

MAIN OUTCOMES AND MEASURES

Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

RESULTS

Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

CONCLUSIONS AND RELEVANCE

Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for laryngeal cancer

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.

Performance Improvement in Head and Neck Cancer

Performance improvement requires establishing a platform to set benchmarks and monitor the quality of care provided through quality indicators and metrics. This has long been recognized as critical to overall quality improvement and more recently, has become federally mandated. Here, we review recent studies evaluating performance in head and neck cancer care, from those spanning all phases of head and neck cancer care to others focused on head and neck surgical performance, including both national and departmental/institutional efforts.

Quality indicators of oropharyngeal cancer care in the elderly

OBJECTIVE

To examine associations between quality of care, survival, and costs in elderly patients treated for oropharyngeal squamous cell cancer (OPSCC).

STUDY DESIGN

Retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data.

METHODS

We evaluated 666 patients diagnosed with OPSCC from 2004 to 2007 using multivariate regression and survival analysis. Using quality indicators derived from guidelines for recommended care, summary measures of quality were calculated for diagnosis, initial treatment, surveillance, treatment for recurrence, end-of-life care, performance, and an overall summary measure of quality.

RESULTS

Higher-quality care was associated with significant differences in survival for initial treatment (hazard ratio [HR] = 0.55 [0.41 to 0.73]), surveillance (HR = 0.32 [0.22 to 0.48]), treatment of recurrence (HR = 2.37 [1.56 to 3.60]), performance measures (HR = 0.50 [0.36 to 0.69]), and the overall summary measure of quality (HR = 0.53 [0.39 to 0.71]). Higher-quality salvage surgery was associated with improved survival (HR = 0.16 [0.04 to 0.54]), whereas higher-quality chemotherapy given for recurrence was associated with worse survival (HR = 5.70 [1.92 to 16.94]). Overall, higher-quality care was not associated with differences in costs. Higher-quality care was associated with significantly lower mean incremental costs for treatment of recurrence and end-of-life care, and higher costs for diagnosis and surveillance.

CONCLUSION

Higher-quality OPSCC care in elderly patients was associated with improved survival; however, higher-quality care was not associated with reduced costs, and higher-quality care for treatment of recurrence was associated with poorer survival, primarily due to poorer survival in patients treated with palliative chemotherapy. These data demonstrate a complex relationship between quality and costs in elderly OPSCC patients, which can be used to frame discussions of value and guide disease-specific quality-measure development.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:2312-2319, 2018.

Contemporary management of advanced laryngeal cancer

The treatment of advanced laryngeal cancer has undergone a paradigm shift in recent years, with an increase in chemoradiation for organ preservation and a decrease in primary surgery. This review will summarize the contemporary management of advanced laryngeal cancer and discuss treatment‐related toxicity and strategies to improve outcomes.

Level of Evidence

NA.

Quality indicators of laryngeal cancer care in commercially insured patients

OBJECTIVE

To examine associations between quality, complications, and costs in commercially insured patients treated for laryngeal cancer.

STUDY DESIGN

Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data (Truven Health Analytics, Ann Arbor, Michigan, U.S.A.).

METHODS

We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression. Using quality indicators derived from guidelines for recommended care, summary measures of quality were calculated for diagnosis, initial treatment, surveillance, treatment for recurrence, performance, and an overall summary measure of quality.

RESULTS

Higher-quality care in the initial treatment period was associated with lower odds of 30-day mortality (odds ratio [OR] = 0.21, 95% confidence interval [CI] [0.04-0.98]), surgical complications (OR = 0.39 [0.17-0.88]), and medical complications (OR = 0.68 [0.49-0.96]). Mean incremental 1-year costs were higher for higher-quality diagnosis ($20,126 [$14,785-$25,466]), initial treatment ($17,918 [$10,481-$25,355]), and surveillance ($25,424 [$20,014-$30,834]) quality indicators, whereas costs were lower for higher-quality performance measures (-$45,723 [-$56,246--$35,199]) after controlling for all other variables. Higher-quality care was associated with significant differences in mean incremental costs for initial treatment in surgical patients ($-37,303 [-$68,832--$5,775]), and for the overall summary measure of quality in patients treated nonoperatively ($10,473 [$1,121-$19,825]). After controlling for the overall summary measure of quality, costs were significantly lower for patients receiving high-volume surgical care (mean -$18,953 [-$28,381--$9,426]).

CONCLUSION

Higher-quality larynx cancer care in commercially insured patients was associated with lower 30-day mortality and morbidity. High-volume surgical care was associated with lower 1-year costs, even after controlling for quality. These data have implications for discussions of value and quality in an era of healthcare reform.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:2805-2812, 2017.

Association of Compliance With Process-Related Quality Metrics and Improved Survival in Oral Cavity Squamous Cell Carcinoma

IMPORTANCE

Quality metrics for patients with head and neck cancer are available, but it is unknown whether compliance with these metrics is associated with improved patient survival.

OBJECTIVE

To identify whether compliance with various process-related quality metrics is associated with improved survival in patients with oral cavity squamous cell carcinoma who receive definitive surgery with or without adjuvant therapy.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted at a tertiary academic medical center among 192 patients with previously untreated oral cavity squamous cell carcinoma who underwent definitive surgery with or without adjuvant therapy between January 1, 2003, and December 31, 2010. Data analysis was performed from January 26 to August 7, 2015.

INTERVENTIONS

Surgery with or without adjuvant therapy.

MAIN OUTCOMES AND MEASURES

Compliance with a collection of process-related quality metrics possessing face validity that covered pretreatment evaluation, treatment, and posttreatment surveillance was evaluated. Association between compliance with these quality metrics and overall survival, disease-specific survival, and disease-free survival was calculated using univariable and multivariable Cox proportional hazards analysis.

RESULTS

Among 192 patients, compliance with the individual quality metrics ranged from 19.7% to 93.6% (median, 82.8%). No pretreatment or surveillance metrics were associated with improved survival. Compliance with the following treatment-related quality metrics was associated with improved survival: elective neck dissection with lymph node yield of 18 or more, no unplanned surgery within 14 days of the index surgery, no unplanned 30-day readmissions, and referral for adjuvant radiotherapy for pathologic stage III or IV disease. Increased compliance with a "clinical care signature" composed of these 4 metrics was associated with improved overall survival, disease-specific survival, and disease-free survival on univariable analysis (log-rank test; P < .05 for each). On multivariable analysis controlling for pT stage, pN stage, extracapsular spread, margin status, and comorbidity, increased compliance with these 4 metrics was associated with improved overall survival (100% vs ≤50% compliance: adjusted hazard ratio [aHR], 4.2; 95% CI, 2.1-8.5; 100% vs 51%-99% compliance: aHR, 1.7; 95% CI, 1.0-3.1), improved disease-specific survival (100% vs ≤50% compliance: aHR, 3.9; 95% CI, 1.7-9.0; 100% vs 51%-99%: aHR, 1.3; 95% CI, 0.6-2.9), and improved disease-free survival (100% vs ≤50% compliance: aHR, 3.0; 95% CI, 1.5-5.8; 100% vs 51%-99% compliance: aHR, 1.6; 95% CI, 0.9-2.7).

CONCLUSIONS AND RELEVANCE

Compliance with a core set of process-related quality metrics was associated with improved survival for patients with surgically managed oral cavity squamous cell carcinoma. Multi-institutional validation of these metrics is warranted.

Evaluation of Quality Metrics for Surgically Treated Laryngeal Squamous Cell Carcinoma

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.

Overview of surgery for laryngeal and hypopharyngeal cancer in Ontario, 2003-2010

BACKGROUND

The primary purpose of this study was to describe variations in incidence rates, resections rates, and types of surgical resection for patients diagnosed with laryngeal and hypopharyngeal cancers in Ontario.

METHODS

All laryngeal and hypopharyngeal cancer cases in Ontario (2003-2010) were identified from the Ontario Cancer Registry (n = 3034). Variations in incidence rates, resection rates, and type of surgical resection were compared by sex, age group, neighborhood income, community population, health region, and physician specialty.

RESULTS

Incidence rates per 100 000 vary significantly by sex, age, neighborhood income, and community size. Women, the elderly (75+ years), those in the higher income quintiles, and those living in larger communities were significantly less likely to receive a laryngectomy procedure.

CONCLUSIONS

Laryngeal and hypopharyngeal cancer incidence rates vary by sex, age, neighborhood income, community size, and health region. Resection rates vary by age, sex, and health region. These disparities warrant further evaluation to improve the quality of delivered care in Ontario.

Understanding Quality Measures in Otolaryngology-Head and Neck Surgery

As health care reimbursements based on pay-for-performance models become more common, there is an unprecedented demand for ways to measure health care quality and demonstrate value. Performance measures, a type of quality measure, are unique tools in a health care delivery system that allow objective monitoring of adherence to specific goals and tracking of outcomes. We sought to provide information on the development of quality measures in otolaryngology-head and neck surgery, as well as the goals of performance measurement at a national level and for our specialty. The historical development, various types, and approach to creating effective performance measures are discussed. The primary methods of developing performance measures (using clinical practice guidelines, clinical registries, and alternative methods) are also discussed. Performance measures are an important tool that can aid otolaryngologists in achieving effective, efficient, equitable, timely, safe, and patient-centered care as outlined by the Institute of Medicine.

Improving patient outcomes through multidisciplinary treatment planning conference

BACKGROUND

The purpose of this study was for us to determine National Comprehensive Cancer Network (NCCN) guideline-compliance of multidisciplinary conference (MDC) recommendations and actual treatment received, and to determine this impact on patient outcomes.

METHODS

We conducted a retrospective review of patients presented at MDC between January 1, 2006, and December 31, 2006, with previously untreated incident cancers.

RESULTS

We identified 232 patients, for whom MDC recommendations were NCCN guideline-compliant in 201 (86.6%). Actual treatment was NCCN guideline-compliant in 170 of 197 patients (86.3%). Adherence of MDC recommendations to NCCN guidelines was associated with superior overall survival (hazard ratio [HR] = 0.69; 95% confidence interval [CI] = 0.33-1.39; p = .3), as was guideline-compliance of actual treatment (HR = 0.6; 95% CI = 0.64-1.07; p = .07); congruence between MDC recommendations and actual treatment conferred a statistically significant overall survival benefit (HR = 0.49; 95% CI = 0.27-0.89; p = .02).

CONCLUSION

Our findings argue for patient-centered application of NCCN guidelines. Prospective evaluation will enable more timely identification of systematic NCCN guideline deviations that quality improvement interventions may address. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1820-E1825, 2016.

Does Quality of Care Matter? A Study of Adherence to National Comprehensive Cancer Network Guidelines for Patients with Locally Advanced Esophageal Cancer

INTRODUCTION

The aim of this study was to assess whether adherence to National Comprehensive Cancer Network (NCCN) guidelines leads to differences in survival in patients diagnosed with locally advanced esophageal cancer.

METHODS

This is a retrospective cohort study of patients with stage II and III esophageal cancer included in the Cancer Registry at the Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins Hospital from 2008 to 2013. Seven quality indicators were identified using the 2014 NCCN guidelines, and individual and overall quality measure scores were calculated and used to define low and high quality of care groups.

RESULTS

One hundred forty-one patients met inclusion criteria, and 88 patients (62.4 %) were identified as receiving high-quality care. Adherence to guidelines ranged from 63.1 to 100.0 %, with an overall compliance of 81.3 %. Risk factors for receiving low quality of care included advanced age, non-white race, lower education level, and unspecified primary site of tumor. A significantly better overall survival was observed in patients who received high-quality care (HR, 0.58; 95 %, 0.37-0.90, p = 0.015).

CONCLUSIONS

Delivery of high-quality care is associated with improved survival in these patients. Efforts should be directed at minimizing disparities in treatment in regards to race and educational levels.

Hospital volume and failure to rescue after head and neck cancer surgery

OBJECTIVE

To investigate the relationship between hospital volume and mortality, complications, and failure-to-rescue rates among patients undergoing head and neck cancer (HNCA) surgery.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Nationwide Inpatient Sample.

SUBJECTS AND METHODS

Discharge data for 159,301 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2001 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. Failure to rescue was defined as death after a major complication, including acute myocardial infarction, acute renal failure, venous thromboembolism, pneumonia, gastrointestinal bleed, pulmonary failure, hemorrhage, or surgical site infection. We compared the incidence of mortality, major complications, and failure-to-rescue rates across hospital volume tertiles.

RESULTS

The majority of hospitals performing HNCA surgery were low-volume hospitals, which performed a mean of 6 HNCA cases per year (n = 7635). Intermediate-volume hospitals performed a mean of 37 cases per year (n = 729), and high-volume hospitals performed a mean of 131 cases (n = 207). High-volume hospital care was associated with significantly decreased odds of death (odds ratio, 0.56; 95% confidence interval, 0.46-0.86) and failure to rescue (odds ratio, 0.56; 95% confidence interval, 0.33-0.97) compared to low-volume hospital care. However, there was no significant difference in major complication rates between patients undergoing HNCA surgery at high-volume hospitals and those at low-volume hospitals.

CONCLUSION

Patients with HNCA who receive care at high-volume hospitals compared with low-volume hospitals have a 44% lower odds of mortality, which appears to be associated with differences in the response to and management of complications rather than differences in complication rates.

Short- and long-term outcomes of laryngeal cancer care in the elderly

OBJECTIVES/HYPOTHESIS

To examine associations between pretreatment variables, short-term and long-term swallowing and airway impairment, and survival in elderly patients treated for laryngeal squamous cell cancer (SCCA).

STUDY DESIGN

Retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data.

METHODS

Longitudinal data from 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 were evaluated using cross-tabulations, multivariate logistic regression, and survival analysis.

RESULTS

Dysphagia (odds ratio [OR] = 1.5 [1.2-1.7]), weight loss (OR = 1.3 [1.1-1.6]), esophageal stricture (OR = 3.8 [2.5-5.9]), airway obstruction (OR = 1.9, [1.6-2.3]), tracheostomy (OR = 1.5 [1.2-1.9]), and pneumonia (OR = 1.8 [1.4-2.2]) increased 1 year after treatment. The odds of airway obstruction, esophageal stricture, and pneumonia increased over subsequent years, with significantly increased risk at 5 years for airway obstruction (OR = 3.3 [1.8-5.8]) and pneumonia (OR = 5.2 [2.5-10.7]). Pretreatment dysphagia, chemoradiation, and salvage surgery were significant predictors of long-term dysphagia, weight loss, tracheostomy, and gastrostomy, with pretreatment dysphagia and salvage surgery also associated with pneumonia. Surgery and postoperative radiation was associated with long-term dysphagia (OR = 1.4 [1.0-1.9]) but reduced odds of long-term pneumonia (OR = 0.7 [0.5-0.9]). Long-term dysphagia, gastrostomy or tracheostomy dependence, weight loss, airway obstruction, and pneumonia were associated with poorer survival, with pneumonia associated with the greatest risk of death at 5 years (hazard ratio = 2.6 [2.4-2.9]).

CONCLUSIONS

Airway and swallowing impairment is common after laryngeal SCCA treatment in elderly patients, increases over time, and is associated with poorer survival-with pneumonia associated with the highest risk of long-term mortality. Patients with pretreatment dysphagia, initial treatment with chemoradiation, and salvage surgery represent a high-risk group with an increased risk of disability and death.