Out of Committee: Patient Safety and Quality Improvement (PSQI) | Equitable Head and Neck Cancer Care
The delivery of equitable care is a pillar of quality according to the National Academy of Medicine (formerly Institute of Medicine). Equitable care delivery is also a core component in the mission statement of many healthcare organizations.
Evan M. Graboyes, MD, MPH; Carol M. Lewis, MD, MPH; John D. Cramer, MD; Chanita Hughes-Halbert, PhD
Strategies to improve the delivery of timely, equitable HNC care are therefore desperately needed to improve survival and decrease disparities in outcomes for patients with HNC.6,7 Delays initiating treatment,8,9 commencing postoperative radiation therapy,10,11 and completing the entire package of treatment (from surgery to the end of adjuvant therapy)12,13 disproportionately burden particular racial/ethnic groups and underinsured patients. These treatment delays are strongly associated with poor oncologic outcomes such as higher rates of recurrence and worse survival.14,15 The impact of these treatment delays on survival is large, comparable in magnitude to the excess mortality risk conferred by adverse pathologic features such as extranodal extension or positive margins.14,15
Prior to a diagnosis of HNC, suboptimal access to care and health literacy hinder detection and delay presentation to a healthcare provider. Regular dental visits are associated with an earlier stage at diagnosis for oral and pharyngeal cancer.16 However, certain racial/ethnic groups are less likely to have ever received oral cancer screening and are less likely to be screened by a physician.17,18 Once symptoms develop, patients with low health literacy are also more likely to hold fatalistic cancer beliefs such as “prevention is not possible” or “cancer is fatal” that may delay presentation to a healthcare provider.19
Once HNC is diagnosed, disparities in the delivery of timely HNC treatment lead to worse outcomes for certain groups. Several recent studies have begun to elucidate the underlying mechanisms for these delays. For example, a recent publication by Liao et al. identified the three most common reasons for delays initiating treatment as missed appointments, extensive pretreatment evaluation, and treatment refusal.9 A study by Divi et al. found that the key drivers of delays starting adjuvant radiation therapy were delayed dental extractions, delayed radiation oncology consults, and inadequate patient engagement.20 Others have expanded on these findings, suggesting that key determinants of delayed adjuvant radiation therapy also include inadequate education about the urgency and significance of timely adjuvant radiation therapy, postsurgical sequelae, insufficient care coordination and communication during care transitions, fragmentation of care across healthcare organizations, travel burden, and inadequate social support.21,22
Based on these studies, researchers have now begun applying quality improvement methodologies to improve the delivery of timely, equitable HNC care. A landmark paper from the head and neck team at Stanford University developed a multicomponent intervention targeting the three key drivers of delays starting adjuvant radiation therapy.20 Examples of intervention components included placing dental consults at the new patient visit, extracting indicated teeth concurrent with the surgical resection, placing a referral for adjuvant therapy at the new patient visit, and providing patient education about the timeline and steps necessary to start adjuvant radiation therapy. In this pilot study, the multicomponent intervention improved the delivery of timely guideline adherent adjuvant therapy by 11% (from 62% to 73%) relative to the time period prior to the intervention. A recent publication from the Medical University of South Carolina described the development of a navigation-based multilevel intervention targeting (1) patient education, (2) travel support, (3) a standardized process for initiating the discussion of expectations for adjuvant therapy, (4) adjuvant therapy care plans, (5) referral tracking and follow-up, and (6) organizational restructuring.23 In this pilot study, the rate of timely, guideline-adherent adjuvant therapy was 86% overall and 100% for African American patients. Collectively, these studies provide exciting preliminary data that the HNC care delivery system (1) is potentially modifiable through quality improvement and health systems interventions and (2) represents an appealing target to decrease mortality and racial disparities in survival for patients with HNC.
As we develop strategies to improve the delivery of timely, equitable care for patients with HNC, we can look to cancer care delivery models for other types of cancer with racial/ethnic disparities in access to care (e.g., breast, colon, lung) for guidance.24 For example, patient navigation is a patient-centered, healthcare delivery intervention that aims to eliminate barriers to cancer care, thereby improving outcomes and decreasing disparities in health. There is a strong evidence base showing that patient navigation improves cancer screening and treatment initiation and decreases disparities in these outcomes.25 Although there is currently no screening test for patients with HNC, the principles underlying patient navigation are potentially applicable to improving timely HNC care. There is also growing recognition in other fields that quality improvement interventions to improve the delivery of timely, equitable cancer care should be multilevel in nature (e.g., target providers, healthcare team, and the organization).26
In conclusion, treatment delays are highly prevalent across the HNC treatment continuum, disproportionately burden racial/ethnic minorities and other medically vulnerable populations, and contribute to disparities in outcomes. Ongoing work is beginning to elucidate the mechanisms underlying treatment delay and resultant targeted quality improvement interventions have significant potential to improve the timeliness, equity, and quality of HNC care delivery. Continued efforts from academy members and collaborations between the American Academy of Otolaryngology–Head and Neck Surgery, the American Head and Neck Society, and other organizations will be necessary to drive meaningful change at the clinical practice and/or health system levels to improve the timeliness, equity, and quality of HNC care.
References
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