Every specialty of medicine, including otolaryngology, faces challenges to providing a safer environment for patients. Responding to these challenges will not only improve patient safety, but overall quality of care, as well. – -Kenneth I. Shine, MD
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October 2007How will 21st-century otolaryngologists meet these challenges? Like all other physicians-by doing the right thing, at the right time, in the right way, for the right person and having the best possible results, according to the Agency for Healthcare Research and Quality (AHRQ).
We, as head and neck surgeons, have to get it right the first time and every time, said Randal S. Weber, MD, Professor and Chairman of the Department of Head and Neck Surgery at University of Texas M.D. Anderson Cancer Center, during his Presidential Address at the 2007 Combined Otolaryngology Spring Meeting. If we fail to control the patient’s head and neck cancer by providing the highest quality of evidenced-based care available, subsequent survival and outcome are negatively impacted.
It is no longer acceptable to be a ‘dabbler,’ described by John M. Lore, MD,i as one who manages a few patients, does not have the necessary support personnel, lacks appropriate rehabilitation facilities, and fails to keep abreast of the continuing education in head and neck surgical oncology, said Dr. Weber.
Fortunately, there are strategies that we can use to overcome many of the factors, such as rarity of the disease, lack of high-quality evidence-based data from randomized controlled trials, variations in practitioner experience, skill, bias, and philosophy, and differences in treatment center capabilities that affect the quality of head and neck cancer care, continued Dr. Weber. Some of these strategies are currently in use by head and neck surgeons and others are gaining in momentum.
Strategies to Improve Quality
Multiple strategies and opportunities exist for improving the quality of head and neck cancer care.
Head and neck surgeons should be familiar with and follow the National Comprehensive Cancer Network (NCCN) and/or specialty society evidence-based treatment guidelines during their decision-making process, to avoid omitting any aspects of appropriate care. These guidelines (www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf ) are updated continually and are based on evaluation of scientific data integrated with expert judgment by multidisciplinary panels of physicians from NCCN member institutions. They clearly indicate the importance of having patients participate in and surgeons support clinical trials, as currently, fewer than 2% of head and neck cancer patients are entered into clinical trials.
The best care is provided by an experienced and collaborative multidisciplinary team made up of head and neck surgeons, radiation oncologists, and medical oncologists who are supported by allied health care providers who focus on all aspects of the patient’s care and rehabilitation. The electronic medical record (EMR) provides comprehensive data for a particular patient and the patient’s disease that are readily available to all members of the multidisciplinary treatment team. Transfer of important data is vitally important in medical decision making. The use of pathology templates to convey important pathologic information to the treating physicians allows appropriate decision making based on complete pathologic data. These pull-down menus populate fields that are critical to the management of an individual head and neck cancer patient. Complete pathologic data prevents errors of omission.
Effective perioperative pathways that streamline care and track outcome data for continuous quality improvement of head and neck cancer care have been developed through a collaborative and multidisciplinary approach, and are generally followed. The goals of these pathways include diminishing variation and omission of care, minimizing length of stay, decreasing resource utilization, prospectively managing comorbidity, reducing complications, and providing patient- and family-centered education.
The American Head and Neck Society (AHNS) Quality Committee and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) are working collaboratively to develop global quality measures that will improve the care of patients with neoplastic and non-neoplastic diseases of the head and neck. Because head and neck cancer care today is multidisciplinary, the AHNS will also work with the American Society for Therapeutic Radiology and Oncology (ASTRO) and the American Society of Clinical Oncology (ASCO) to develop quality oncology performance indicators (QOPI™) (www.asco.org ).
The goal of QOPI is to promote excellence in cancer care by helping practices create a culture of self-examination and improvement. The process employed for improving cancer care includes measurement, feedback, and improvement tools for medical oncology practices. Certain benchmarks, which are global but also disease- and discipline-specific, must be met. For the head a neck surgical oncologist, quality outcome measures include length of stay, transfusion, perioperative mortality, readmissions within 30 days, return to the operating room, and surgical margins.
Additionally, Dr. Weber recommended the creation of a peer review process to evaluate the performance of the multidisciplinary team and the institutions that care for patients with head and neck cancer. Global quality indicators are local regional disease control, overall survival, treatment package time, treatment-related mortality, unplanned hospitalizations, and patient satisfaction. Performance for these quality parameters can be assessed through site visits and focused case reviews. Results of these evaluations and disease outcomes (with acuity adjustment) should be transparent-that is, available and accessible in the public domain. EMRs will be necessary to track all of these clinical data, which are becoming fundamental for assessing, rating, and reporting provider and institutional performance.
The importance of tracking data is to look for outliers and best practices, said Dr. Weber. At M.D. Anderson, we constantly review our data and make changes where and when necessary. We can then compare our data with our colleagues’ to see if we are meeting or exceeding certain benchmarks.
Shape of Things to Come
As Dr. Shine indicated in his presentation, pay-for-performance [P4P] is here to stay and physicians need to be proactive about identifying the things they wish to be paid for and get on board.
Although there are many constituents already in place that are driving P4P, Dr. Weber highlighted two programs in particular. The Premier Hospital Quality Incentive Program is overseen by Premier, Inc., a nationwide consortium of 270 nonprofit hospitals and health systems offering financial bonuses to reward its members for performance in select clinical areas. The rewards are based on quality measures extensively validated by AHRQ, the Joint Commission on Accreditation of Health care Organizations (JCAHO), and the National Quality Forum (NQF); funding is provided by the Centers for Medicare and Medicaid Services (CMS) (www.premierinc.com .
Similarly, the Leapfrog Hospital Rewards Program™ measures hospital performance on five conditions for effectiveness and affordability; hospitals that demonstrate excellence or that show improvement along both dimensions will be rewarded. The Leapfrog Group strongly supports evidence-based hospital referrals (EHR) based on volume and mortality criteria-that is, directing patients with high-risk conditions to hospitals with characteristics shown to be associated with better outcomes. The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality, and customer value will be recognized and rewarded (www.leapfroggroup.com ).
Dr. Weber recommended the creation of a three-tier model of head and neck cancer care so that patients can be directed to institutions with subspecialty expertise and the support infrastructure to provide optimum care. This model would be driven by purchasers, CMS, managed care organizations, and informed patients, who would incentivize providers and institutions to move these patients through the system from a community hospital to a regional and/or tertiary cancer center where they can be placed with a trained head and neck oncology specialist who is part of a multidisciplinary care team. These head and neck cancer specialists must have completed not only basic surgical training, but also general otolaryngology, head and neck surgery, and advanced head and neck surgical oncology training.
Referring back to Dr. Lore’s prophetic plea for added qualifications from a decade ago, Dr. Weber recommended that physicians, medical organizations, and associations must work to solve these problems concerning quality and safety in head and neck cancer care. Failure to take the lead in assuring outstanding training for head and neck cancer specialists and developing treatment centers with a well-defined multidisciplinary treatment team, while at the same time avoiding the proliferation of inadequate patient management efforts, will lead to the external imposition of standards that may not be in the patient’s best interests.
We have an obligation to develop these quality standards and to ensure that our patients with head and neck cancer receive the best care available that will provide the optimum change for survival and functional restoration.
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Reference
- Lore, JM Jr. Dabbling in head and neck oncology (a plea for added qualifications). Arch Otolaryngol Head Neck Surg 1987;113(11):1165-8.
©2007 The Triological Society
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