Conversely, when clinical pathways are not followed, there is a trend towards poorer clinical outcomes. Dr. Roman pointed to a representative study by Carol M. Lewis, MD, MPH, and colleagues at MD Anderson, which looked at factors that might explain why patients who were referred to a tertiary care center for recurrence or disease persistence after definitive head and neck cancer treatment had not adequately responded to prior therapy. The researchers found that more than 40% of those patients had not been given National Comprehensive Cancer Network (NCCN) guideline-compliant care prior to their referral (Arch Otolaryngol Head Neck Surg. 2010;136:1205-1211).
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November 2015“It should be noted that our results do not reflect the rate that community-based head and neck care deviates from NCCN guidelines,” stressed Dr. Lewis, an assistant professor in MD Anderson’s department of head and neck surgery. “Those data are as yet unknown. However, it does indicate that when head and neck cancer does not comply with NCCN guidelines, that may [result in] disease recurrence or persistence.”
Dr. Lewis said better adherence to guidelines is only one strategy for adding value to head and neck cancer. She also advocated more widespread use of ancillary services, such as those focused on speech pathology. Specifically, she urged clinicians to monitor patients’ ability to swallow post-surgery and provide exercises and assistance before and throughout treatment, “as opposed to when problems are recognized.” The goal, she explained, is “to limit the overall cost of treatment by limiting long-term morbidity and maximizing patient function throughout and after treatment.”
Dr. Roman agreed that having head and neck surgeons work with speech pathologists and other ancillary support service providers can boost value. That type of multidisciplinary care “is crucial—especially in cases of complex head and neck surgery requiring a big ablation and microvascular free-flap reconstruction, where post-operative functional sequelae are a key outcome,” he said.
He added that the literature supports such an approach. Studies have shown, he said, that integrated care improves a wide variety of patient-focused outcomes, including shorter wait times, better nutrition assessments and smoking cessation counseling, and, perhaps most importantly, better adherence to guideline-based care such as chemoradiation for advanced disease (Am J Otolaryngol. 2013;34:57-60).
Peri-operative complications are another quality variable that head and neck surgeons can have more control over—provided the focus is on the resulting long-term outcomes. Dr. Roman said the specialty is beginning to examine such outcomes, thanks in part to the ongoing work of the American Head and Neck Society (AHNS) Quality of Care Committee, which is in the midst of an effort to establish a head and neck surgery-specific quality reporting database.
Another Vote for Value
Dr. Roman’s emphasis on functional patient outcomes echoes the approach taken by Jonas A. de Souza, MD, an assistant professor of medicine at the University of Chicago Medicine and Biological Sciences. Dr. De Souza, a surgeon medical oncologist, advocates a value framework that balances survival, toxicities, cost, and other variables from the patient’s perspective.