Quality Improvement Intervention to Improve Head and Neck Cancer Care in Safety Net Hospital Settings: Outcomes From...

Safety net hospitals (SNHs)-institutions committed to providing care regardless of a patient's ability to pay-are the primary access point for nearly one-third of the US population. Patients at SNHs consistently present with more advanced-stage head and neck cancer (HNC) and experience significant challenges related to social determinants of health (SDOH), often resulting in delays in diagnosis and treatment initiation. This delay can be associated with decreased overall survival, locoregional control, and an increased risk of recurrence. Thus, we propose utilizing a single-visit multidisciplinary clinic (MDC) to consolidate appointments and create comprehensive treatment plans to help combat systemic issues, reduce time to treatment initiation (TTI), and improve pretreatment speech language pathology (SLP), nutrition, and dental oncology consult completion.

This retrospective cohort and quality improvement study was conducted at an urban, publicly funded tertiary care center that functions as the city's sole SNH. Patients with newly diagnosed squamous cell carcinoma of the head and neck were identified between May 2019 and May 2022. Baseline demographics, ancillary service consultations, and treatment information from our single-institution database were collected. Patients were divided into the pre-MDC cohort and the post-MDC cohort. Primary outcome was TTI while the secondary objective was to improve completion of pretreatment evaluation by SLPs, nutrition oncology, and dental oncology. The MDC was developed using the Plan Do Study Act (PDSA) method for quality improvement and established in June 2021. HNC surgeons, radiation oncologists, medical oncologists, and ancillary services designed a clinic to host a single-day visit to include a needs assessment for treatment optimization, a comprehensive discussion of therapeutic options, and consideration of the SDOH that may present barriers to care.

Sixty-nine patients met the inclusion criteria. Mean age was 59.1 years (range: 34-83), and over 71% of patients were uninsured or Medicaid-insured. The post-MDC cohort was associated with a significant decrease in TTI compared to the pre-MDC cohort (44.1 ± 16.1 vs. 57.4 ± 30.5 days, p = 0.038) and trended toward improvement in those patients undergoing primary chemoradiation therapy (44.9 ± 11.1 vs. 54.9 ± 19.9 days, p = 0.097) and for patients undergoing primary surgical resection (40.0 ± 35.2 vs. 61.0 ± 41.8 days, p = 0.287). In a multivariable analysis, participation in the MDC was the only independent variable associated with a statistically significant shorter TTI in the overall patient population (p = 0.05). We also observed an improvement in pretreatment consult completion including SLP (96.0% vs. 54.5%, p ≤ 0.001), nutrition (96.0% vs. 59.1%, p ≤ 0.001), and pre-radiation therapy dental oncology evaluation (96.0% vs. 59.1%, p ≤ 0.001).

Implementation of a single-visit HNC MDC is associated with an improvement in TTI and pretreatment consult referral and completion for patients with HNC in a SNH setting. Our findings underscore the potential of structural care redesign to help facilitate timely care at SNHs. As SNHs continue to absorb a growing share of the HNC care burden, targeted investments in care coordination and infrastructure are critical to help deliver timely, high-quality cancer care.