Health Services Research and Regionalization of Care—From Policy to Practice: the Ontario Experience in Head and Neck Cancer

A preliminary assessment of guideline adherence and clinical variation in oral cancer treatment: a MarketScan database study

BACKGROUND

To assess variations in adherence to guideline-recommended processes of care for oral cavity cancer patients.

METHODS

Retrospective study using a U.S. healthcare research database (MarketScan). Index diagnoses were considered from 2010 to 2012 with follow-up from 2013 to 2014. Diagnostic and procedure codes were utilized to identify oral cavity patients with a defined treatment modality. Compliance with guideline-recommended processes of care, which included pre-treatment imaging, thyroid-function testing (TFTs), multidisciplinary consultation and gastrostomy-tube insertion rates, were assessed.

RESULTS

A total of 2752 patients were identified. Surgery alone was the most common treatment (60.8%), followed by surgery with adjuvant chemoradiotherapy (20.4%) and surgery with adjuvant radiotherapy (18.8%). Head/neck and chest imaging were obtained in 60% and 62.5% of patients respectively. Significant geographical differences in head and neck imaging were observed between North-central (64%), South (58.4%) and West (56.1%) regions (p = 0.026). Differences in chest imaging were also present between North-east (65%) and West (56.8%; p = 0.007). TFTs were obtained in 54.4% of the patients after radiation treatment, and 18.6% of patients had multidisciplinary consultation during the 6 months before and 3 months after initiation of treatment. During the year after treatment initiation, 21.2% of patients underwent G-tube placement, with significantly higher rates in patients receiving triple modality treatment (58%) when compared to surgery plus radiation (27%) and surgery alone (15%; p < 0.01).

CONCLUSION

Adherence to evidence-based practices was low based on the database coding. These data suggest a potential to improve adherence and increase the routine use of practices delineated in national clinical practice guidelines.

CLINICAL RELEVANCE

This study reflects a suboptimal adherence to guidelines based on the database employed. This study should be considered by healthcare providers and efforts should be maximized to follow the processes of care which have proven to impact on patient's outcomes.

Carbon footprint reduction associated with a surgical outreach clinic

BACKGROUND

Healthcare systems generate substantial carbon footprints that may be targeted to decrease greenhouse gas emissions. Outreach clinics may represent tools to assist in this reduction by optimizing patient related travel. Therefore, we sought to estimate the carbon footprint savings associated with a head and neck surgery outreach clinic.

METHODS

This study was a cross-sectional survey of patient travel patterns to a surgical outreach clinic compared to a regional cancer treatment centre from December 2019 to February 2020. Participants completed a self-administered survey of 12 items eliciting travel distance, vehicle details, and ability to combine medical appointments. Canadian datasets of manufacturer provided vehicular efficiency were used to estimate carbon emissions for each participant. Geographic information systems were used for analyses.

RESULTS

One hundred thirteen patients were included for analysis. The majority of patients (85.8%) used their own personal vehicle to travel to the outreach clinic. The median distance to the clinic and regional centre were 29.0 km (IQR 6.0-51.9) and 327.0 km (IQR 309.0-337.0) respectively. The mean carbon emission reduction per person was therefore 117,495.4 g (SD: 29,040.0) to 143,570.9 g (SD: 40,236.0). This represents up to 2.5% of an average individual's yearly carbon footprint. Fewer than 10% of patients indicated they were able to carpool or group their appointments.

CONCLUSION

Surgical outreach clinics decrease carbon footprints associated with patient travel compared to continued care at a regional centre. Further research is needed to determine possible interventions to further reduce carbon emissions associated with the surgical care of patients.

Dietary Phytochemicals as a Potential Source for Targeting Cancer Stem Cells

The tumor microenvironment is composed of various types of cells that lead to tumor heterogeneity. In the middle of these populations, cancer stem cells play a vital role in the initiation and progression of cancer cells and are capable of self-renewal and differentiation processes. These cancer stem cells are resistant to conventional therapy such as chemotherapy and radiotherapy. To eradicate the cancer stem cells in the tumor environment, various natural product has been found in recent years. In this review, we have selected some of the natural products based on anticancer potential including targeting cancer cells and cancer stem cells. Further, this review explains the molecular mechanism of action of these natural products in various cancer stem cells. Therefore, targeting a multi-drug resistant cancer stem cell by natural products is a novel method to reduce drug resistance and adverse effect during conventional therapy.

Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer: A Longitudinal Population-Based Study

PURPOSE

To determine the association between patient-reported symptom burden and subsequent emergency department use and unplanned hospitalization (ED/Hosp) in a head and neck cancer (HNC) patient population.

METHODS

This was a population-based study of patients diagnosed with HNC who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario, Canada. Logistic regression models were used to determine the relationship between outpatient ESAS scores and subsequent 14-day ED/Hosp use. A generalized estimating equation approach with an exchangeable correlation structure was incorporated to account for patient-level clustering.

RESULTS

There were 11,761 patients identified, completing a total of 73,282 ESAS assessments and experiencing 5,203 ED/Hosp events. Six of the nine ESAS symptom scores were positively associated with ED/Hosp use, with pain, appetite, shortness of breath, and tiredness demonstrating the strongest associations. A global ESAS score was calculated by selecting the highest individual symptom score (h-ESAS). Among patients reporting a maximum h-ESAS score of 10, 15.1% had an ED/Hosp event within 14 days compared with 1.5% for those with the lowest possible score of zero. In adjusted analysis, the odds of ED/Hosp use increased with h-ESAS (1.23 per one-unit increase [95% CI, 1.22 to 1.25]). When treated as a categorical variable, patients with the maximum h-ESAS score of 10 had 9.23 (95% CI, 7.22 to 11.33) higher odds of ED/Hosp use, relative to the minimum score of zero.

CONCLUSION

ESAS scores are strongly associated with subsequent ED/Hosp events in patients with HNC. Clinician education around how ESAS data might inform patient care may enhance symptom detection and management.

Novel Strategies to Effectively De-escalate Curative-Intent Therapy for Patients With HPV-Associated Oropharyngeal Cancer: Current and Future Directions

The treatment of patients with HPV-associated oropharyngeal cancer (HPV-OPC) is rapidly evolving and challenging the standard of care of definitive radiotherapy with concurrent cisplatin. There are numerous promising de-escalation strategies under investigation, including deintensified definitive chemoradiotherapy, transoral surgery followed by de-escalated adjuvant therapy, and induction chemotherapy followed by de-escalated locoregional therapy. Definitive radiotherapy alone or with cetuximab is not recommended for curative-intent treatment of patients with locally advanced HPV-OPC. The results of ongoing phase III studies are awaited to help answer key questions and address ongoing controversies to transform the treatment of patients with HPV-OPC. Strategies for de-escalation under investigation include the incorporation of immunotherapy and the use of novel biomarkers for patient selection for de-escalation.

Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID-19) pandemic: Wuhan and Toronto experience

The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID-19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.

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.

Symptom burden among head and neck cancer patients in the first year after diagnosis: Association with primary treatment modality

PURPOSE

Head and neck cancer (HNC) and its treatment affects quality of life, with significant symptom burden. The main objectives of this study were to examine symptom trajectories of HNC patients by treatment and to identify factors associated with high ESAS scores.

METHODS AND MATERIALS

We conducted a retrospective cohort study in patients diagnosed with HNC in Ontario, Canada from 2007 to 2015 using linked health administrative databases. The primary outcome was a monthly patient self-reported moderate-to-severe (≥4) symptom score in the year following diagnosis. Multivariable Modified Poisson regression analyses with robust variance were used to investigate factors associated with moderate-to-severe scores.

RESULTS

Of 13,827 HNC patients identified, 4793 had ≥1 ESAS assessment within 12 months of cancer diagnosis. Overall, 60% (n = 2708) and 65% (n = 2903) of patients reported moderate-to-severe pain and poor appetite, respectively. The proportion of patients reporting a score ≥4 increased significantly during treatment and was most pronounced for those who received chemoradiation (CRT). On multivariable analysis, patients who were female (Relative Risk (RR) 1.15, 95% CI 1.08-1.23, received CRT, had a higher comorbidity burden (RR 1.31, 1.23-1.39), and had a diagnosis of oropharyngeal (1.10, 1.02-1.19), or oral cavity cancer (1.31, 1.19-1.45), were at an increased risk of reporting severe pain scores (p < 0.01 for all).

CONCLUSION

The majority of HNC patients report high pain scores, with symptom burden highest during the treatment phase, and especially for patients who received radiation or chemoradiation. This large study highlights the need for proactive symptom management during the HNC patients' cancer journey.

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.

AHNS series: Do you know your guidelines? Guideline recommendations for recurrent and persistent head and neck cancer after primary treatment

Locoregional recurrent/persistent head and neck cancer following primary treatment is a significant challenge as it is usually difficult to treat and has worse outcomes compared to the primary setting. Surgical resection of a local or regional recurrence offers the best chance of cure when feasible. Local recurrence outcomes vary by subsite with laryngeal recurrences having the best prognoses and hypopharynx having the worst. Instances of persistent neck masses following primary nonsurgical treatment can be evaluated with positron emission tomography (PET) with CT (PET-CT) when there is no definitive diagnosis of a recurrence/persistence. Reirradiation with or without chemotherapy can be considered for primary treatment when surgery is not an option, for adjuvant treatment following salvage surgery, or for palliation. Immunotherapy represents a newer class of chemotherapeutic agents. Current guidelines recommend enrollment in clinical trials especially when surgery is not an option as outcomes remain universally poor in the recurrent/persistent setting.

Evaluation of early oral cavity cancer treatment quality at a single institution

OBJECTIVE

To evaluate the adherence to oral cavity quality guidelines endorsed by the American Head and Neck Society (AHNS) at a large tertiary care hospital.

METHODS

This retrospective study identified patients treated for early-stage oral tongue squamous cell carcinoma at a tertiary care hospital from 1992 to 2013. Patient charts were reviewed for 26 process quality measures and four key indicator process quality measures as endorsed by the AHNS. Patients were then grouped by diagnosis date either before (historical group, 1992-2007) or after (current treatment group, 2008-2013) the published process quality measures from the AHNS. Descriptive statistics were used to evaluate the rates of adherence for each process quality measure within the 2 groups.

RESULTS

Of the 57 patients identified, 29 were female (51%). The mean age was 62.3 years. A majority of the oral cavity cancers were stage I (59.6%), followed by stage II (35.1%) and stage III (5.3%). Compliance with the process quality measures was in the acceptable range in both cohorts. However, several areas demonstrated lower adherence in both cohorts. Statistically significant improvements were noted between the two cohorts, which showed a measurable improvement in adherence to process quality measures in several key areas over time.

CONCLUSION

Using the process quality measures proposed by the AHNS, adherence to the process quality measures for early-stage oral cavity cancer care at a tertiary care center was successfully evaluated. In general, good compliance with the proposed process quality measures was found and several areas for improvement were identified.

LEVEL OF EVIDENCE

2c Laryngoscope, 129:1816-1821, 2019.

Consultation diagnoses and procedures billed among recent graduates practicing general otolaryngology - head & neck surgery in Ontario, Canada

Background

An analysis of the scope of practice of recent Otolaryngology – Head and Neck Surgery (OHNS) graduates working as general otolaryngologists has not been previously performed. As Canadian OHNS residency programs implement competency-based training strategies, this data may be used to align residency curricula with the clinical and surgical practice of recent graduates.

Methods

Ontario billing data were used to identify the most common diagnostic and procedure codes used by general otolaryngologists issued a billing number between 2006 and 2012. The codes were categorized by OHNS subspecialty. Practitioners with a narrow range of procedure codes or a high rate of complex procedure codes, were deemed subspecialists and therefore excluded.

Results

There were 108 recent graduates in a general practice identified. The most common diagnostic codes assigned to consultation billings were categorized as ‘otology’ (42%), ‘general otolaryngology’ (35%), ‘rhinology’ (17%) and ‘head and neck’ (4%). The most common procedure codes were categorized as ‘general otolaryngology’ (45%), ‘otology’ (23%), ‘head and neck’ (13%) and ‘rhinology’ (9%). The top 5 procedures were nasolaryngoscopy, ear microdebridement, myringotomy with insertion of ventilation tube, tonsillectomy, and turbinate reduction. Although otology encompassed a large proportion of procedures billed, tympanoplasty and mastoidectomy were surprisingly uncommon.

Conclusion

This is the first study to analyze the nature of the clinical and surgical cases managed by recent OHNS graduates. The findings demonstrated a prominent representation of ‘otology’, ‘general’ and ‘rhinology’ based consultation diagnoses and procedures. The data derived from the study needs to be considered as residency curricula are modified to satisfy competency-based requirements.

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: Measurement and Predictors in Head and Neck Cancer Free Flap Patients

Objective

To determine the predictors of length of stay (LOS), readmission within 30 days, and unplanned return to the operating room (OR) within 30 days in head and neck free flap patients.

Study Design

Case series with chart review.

Setting

Tertiary academic cancer hospital.

Subjects and Methods

All head and neck free flap patients at The Ohio State University (OSU, 2006-2012) were assessed. Multivariable logistic regression to assess the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes.

Results

In total, 515 patients were identified, of whom 66% had oral cavity cancers, 33% had recurrent tumors, and 28% underwent primary radiotherapy. Of the patients, 31.5% had a LOS greater than 9 days, predicted by longer operative time, oral cavity and pharyngeal tumor sites, blood transfusion, diabetes mellitus, and any complication. A total of 12.6% of patients were readmitted within 30 days predicted by absent OSU preoperative assessment clinic attendance and any complication, and 14.8% of patients had an unplanned OR return predicted by advanced age.

Conclusions

When assessing quality metrics, adjustment for the complexity involved in managing patients with head and neck cancer with a high comorbidity index, clean contaminated wounds, and a high degree of primary radiotherapy is important. Patients seen in a preoperative assessment clinic had a lower risk of readmission postoperatively, and this should be recommended for all head and neck free flap patients. Quality improvement projects should focus on predictors and prevention of complications as this was the number one predictor of both increased length of stay and readmission.

Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey

BACKGROUND

The Surgeons OverSeas Assessment of Surgical Need tool (SOSAS) was created to evaluate the burden of surgically treatable conditions in low- and middle-income countries. The goal of our study is to describe the face, head, and neck (FHN) conditions that need surgical care in Uganda, along with barriers to that care and disability from these conditions.

METHODS

A 2-stage cluster randomized SOSAS survey was administered in a cross-sectional manner between August and September 2014. Participants included randomly selected persons in 105 enumeration areas in 74 districts throughout Uganda with 24 households in each cluster. The SOSAS survey collected demographic and clinical data on all respondents. Univariate and multivariate logistic models evaluated associations of demographic characteristics and clinical characteristics of the FHN conditions and outcomes of whether health care was sought or surgical care was received.

RESULTS

Of the 4428 respondents, 331 (7.8%) reported having FHN conditions. The most common types of conditions were injury-related wounds. Of those who reported an FHN condition, 36% reported receiving no surgical care whereas 82.5% reported seeking health care. In the multivariate model, literacy and type of condition were significant predictors of seeking health care whereas village type, literacy, and type of condition remained significant predictors of receiving surgical care.

CONCLUSIONS

Many individuals in Uganda are not receiving surgical care and barriers include costs, rural residency, and literacy. Our study highlights the need for targeted interventions in various parts of Uganda to increase human resources for surgery and expand surgical capacity.