[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.147.238.168. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Download PDF
Table 1. 
Patient Demographics
Patient Demographics
Table 2. 
Reason for Referral and Time to Diagnosis
Reason for Referral and Time to Diagnosis
Table 3. 
Impact on Disease Presentation and Type of Prereferral Care
Impact on Disease Presentation and Type of Prereferral Care
Table 4. 
Types of Providers Involved in Prereferral Management
Types of Providers Involved in Prereferral Management
Table 5. 
Rates of National Comprehensive Cancer Network (NCCN) Noncompliance and Reasons
Rates of National Comprehensive Cancer Network (NCCN) Noncompliance and Reasons
1.
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century.  Washington, DC National Academy Press2001;
2.
Berwick  DM A user's manual for the IOM's “Quality Chasm” report. Health Aff (Millwood) 2002;21 (3) 80- 90
PubMedArticle
3.
Weber  RS Improving the quality of head and neck cancer care. Arch Otolaryngol Head Neck Surg 2007;133 (12) 1188- 1192
PubMedArticle
4.
Browman  GPBrouwers  M The role of guidelines in quality improvement for cancer surgery. J Surg Oncol 2009;99 (8) 467- 469
PubMedArticle
5.
Kapadia  MMehri-Basha  MMadhavan  RRajamani  KChaturvedi  S High rate of inappropriate carotid endarterectomy in an urban medical center. J Stroke Cerebrovasc Dis 2009;18 (4) 277- 280
PubMedArticle
6.
Bair  DPham  JSeaton  MBArya  NPryce  MSeaton  TL The quality of screening colonoscopies in an office-based endoscopy clinic. Can J Gastroenterol 2009;23 (1) 41- 47
PubMed
7.
Shah  HAPaszat  LFSaskin  RStukel  TARabeneck  L Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology 2007;132 (7) 2297- 2303
PubMedArticle
8.
Chagpar  ABScoggins  CRMartin  RC  II  et al. University of Louisville Breast Sentinel Lymph Node Study, Factors determining adequacy of axillary node dissection in breast cancer patients. Breast J 2007;13 (3) 233- 237
PubMedArticle
9.
Malin  JLSchneider  ECEpstein  AMAdams  JEmanuel  EJKahn  KL Results of the National Initiative for Cancer Care Quality: how can we improve the quality of cancer care in the United States? J Clin Oncol 2006;24 (4) 626- 634
PubMedArticle
10.
Cheung  WYPond  GRRother  M  et al.  Adherence to surveillance guidelines after curative resection for stage II/III colorectal cancer. Clin Colorectal Cancer 2008;7 (3) 191- 196
PubMedArticle
11.
Bilimoria  KYBentrem  DJLinn  JG  et al.  Utilization of total thyroidectomy for papillary thyroid cancer in the United States. Surgery 2007;142 (6) 906- 913, e1-e2
PubMedArticle
12.
Patel  MRChen  AYRoe  MT  et al.  A comparison of acute coronary syndrome care at academic and nonacademic hospitals. Am J Med 2007;120 (1) 40- 46
PubMedArticle
13.
 NCCN Guidelines for head and neck cancer care National Comprehensive Cancer Network Web site. http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf. Accessed January 15, 2010
14.
Cook  NLAyanian  JZOrav  EJHicks  LS Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care. Circulation 2009;119 (18) 2463- 2470
PubMedArticle
15.
Benasso  MLionetto  RCorvò  RPonzanelli  AVitale  VRosso  R Impact of the treating institution on the survival of patients with head and neck cancer treated with concomitant alternating chemotherapy and radiation. Eur J Cancer 2003;39 (13) 1895- 1898
PubMedArticle
16.
Kubicek  GJWang  FReddy  EShnayder  YCabrera  CEGirod  DA Importance of treatment institution in head and neck cancer radiotherapy. Otolaryngol Head Neck Surg 2009;141 (2) 172- 176
PubMedArticle
17.
van Walraven  CTaljaard  MBell  CM  et al.  Information exchange among physicians caring for the same patient in the community. CMAJ 2008;179 (10) 1013- 1018
PubMedArticle
18.
Wright  FCLookhong  NUrbach  DDavis  D McLeod  RSGagliardi  AR Multidisciplinary cancer conferences: identifying opportunities to promote implementation. Ann Surg Oncol 2009;16 (10) 2731- 2737
PubMedArticle
19.
Abraham  NSGossey  JTDavila  JAAl-Oudat  SKramer  JK Receipt of recommended therapy by patients with advanced colorectal cancer. Am J Gastroenterol 2006;101 (6) 1320- 1328
PubMedArticle
20.
Bober  SLRecklitis  CJCampbell  EG  et al.  Caring for cancer survivors: a survey of primary care physicians. Cancer 2009;115 (18) ((suppl)) 4409- 4418
PubMedArticle
21.
Hannan  ELO’Donnell  JFKilburn  H  JrBernard  HRYazici  A Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. JAMA 1989;262 (4) 503- 510
PubMedArticle
22.
Luft  HSBunker  JPEnthoven  AC Should operations be regionalized? the empirical relation between surgical volume and mortality. N Engl J Med 1979;301 (25) 1364- 1369
PubMedArticle
23.
Flood  ABScott  WREwy  W Does practice make perfect? part I: the relation between hospital volume and outcomes for selected diagnostic categories. Med Care 1984;22 (2) 98- 114
PubMedArticle
24.
Flood  ABScott  WREwy  W Does practice make perfect? part II: the relation between volume and outcomes and other hospital characteristics. Med Care 1984;22 (2) 115- 125
PubMedArticle
25.
Dudley  RAJohansen  KLBrand  RRennie  DJMilstein  A Selective referral to high-volume hospitals: estimating potentially avoidable deaths. JAMA 2000;283 (9) 1159- 1166
PubMedArticle
26.
Birkmeyer  JDSiewers  AEFinlayson  EV  et al.  Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346 (15) 1128- 1137
PubMedArticle
27.
Long  DMGordon  TBowman  H  et al.  Outcome and cost of craniotomy performed to treat tumors in regional academic referral centers. Neurosurgery 2003;52 (5) 1056- 1065
PubMedArticle
28.
Gordon  TABurleyson  GPTielsch  JMCameron  JL The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg 1995;221 (1) 43- 49
PubMedArticle
29.
Wouters  MWWijnhoven  BPKarim-Kos  HE  et al.  High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data. Ann Surg Oncol 2008;15 (1) 80- 87
PubMedArticle
30.
Rosenthal  GEQuinn  LHarper  DL Declines in hospital mortality associated with a regional initiative to measure hospital performance. Am J Med Qual 1997;12 (2) 103- 112
PubMedArticle
31.
Bach  PBCarson  SSLeff  A Outcomes and resource utilization for patients with prolonged critical illness managed by university-based or community-based subspecialists. Am J Respir Crit Care Med 1998;158 (5, pt 1) 1410- 1415
PubMedArticle
Original Article
December 20, 2010

Prereferral Head and Neck Cancer TreatmentCompliance With National Comprehensive Cancer Network Treatment Guidelines

Arch Otolaryngol Head Neck Surg. 2010;136(12):1205-1211. doi:10.1001/archoto.2010.206
Abstract

Objective  To evaluate the prereferral treatment of patients referred to our tertiary care center with recurrent or persistent head and neck cancer for compliance with National Comprehensive Cancer Network (NCCN) guidelines.

Design  A prospective recruitment and retrospective chart review.

Patients  The study included new patients identified at multidisciplinary treatment planning conference from October 1, 2008, to February 1, 2009, who had received prior treatment at an outside institution and presented to our department with recurrent or persistent disease.

Main Outcome Measures  All facets of prior care were examined, including the time from initial symptoms to diagnosis and whether their prereferral treatment was compliant with or deviated from NCCN guidelines for head and neck cancer.

Results  A total of 566 consecutive new patients were identified, of whom 107 (18.9%) had persistent or recurrent disease. The average time from first presentation with initial symptoms to diagnosis among patients who presented with persistent disease was 23.8 weeks. Nearly half of the patients who presented with persistent or recurrent disease had either endocrine (21.5%) or cutaneous (24.2%) primary cancers, with the rest of the cases being distributed among 10 other sites. Of the patients who presented with recurrent or persistent disease, 43.0% had prereferral care that was noncompliant with NCCN guidelines. Of these patients, 58.7% had inadequate surgical management, 15.2% were treated for the wrong diagnosis, 10.9% received inadequate adjuvant therapy, 4.4% received inadequate radiotherapy, and 10.9% refused indicated recommended treatment.

Conclusions  Significant deviation from NCCN guidelines for head and neck cancer treatment was observed in the cohort of study patients. The failure to administer adjuvant therapy when indicated by NCCN guidelines is particularly concerning. Economic and noneconomic costs, including lost wages, cost of “do-over” therapy, and potentially diminished survival, are substantial. Measures to ensure that patients receive therapy according to guidelines should be a national priority.

Evaluating the quality of medical care has become increasingly important, as highlighted by the Institute of Medicine's (IOM) report, “Crossing the Quality Chasm: A New Health System for the 21st Century.”1 This publication articulated the need to avoid both overuse of ineffective care and underuse of health care practices with proven benefit.2 Significantly, the IOM's report recognized the importance of optimizing the quality of cancer care.3

Most commonly, the outcomes of mortality, morbidity, and length of hospital stay are used as indirect indicators of quality of care. Another approach is to evaluate adherence to clinical practice guidelines as an indicator of the quality of care. Clinical practice guidelines are consensus- and evidence-based recommendations that establish the standard of care that is to be achieved. Also, these guidelines create priorities for quality improvement and validate the indicators by which quality is measured.4 Compliance with established clinical practice guidelines has been reported in both academic and community health care settings with regard to carotid endarterectomy,5 colonoscopy,6,7 axillary lymph node dissection,8 colorectal cancer care9 and surveillance,10 and management of papillary thyroid cancer11 and acute coronary syndrome,12 among others.

The National Cancer Comprehensive Network (NCCN) has invested extensive resources to improve the care of patients with head and neck cancer.13 To our knowledge, compliance with NCCN guidelines for head and neck cancer outside of tertiary care centers has not been assessed. To determine the quality of care received by head and neck cancer patients in the community setting, we evaluated the prereferral treatment received by patients referred to our tertiary care center with persistent or recurrent disease for compliance with NCCN guidelines.

METHODS

New patients who are referred to the Department of Head and Neck Surgery at the University of Texas MD Anderson Cancer Center, Houston, are routinely presented at a weekly multidisciplinary treatment planning conference attended by head and neck surgeons, radiation oncologists, medical oncologists, dental oncologists, speech pathologists, radiologists, and pathologists. Treatment recommendations are in compliance with NCCN or institutional guidelines whenever possible. All eligible patients are also offered treatment under clinical protocols approved by our institutional review board. New patients were prospectively recruited as they were presented at the conference between October 1, 2008, and February 1, 2009. Their prereferral medical records were subsequently retrospectively reviewed. For those patients who had previously been treated elsewhere and who were presenting with persistent or recurrent disease, this included a review of available outside records detailing previous imaging and pathology reports, treatment, and office visits. All cases that presented with persistent or recurrent disease were reviewed by the first (C.M.L.) and senior (R.S.W.) authors, and a consensus was reached. For each review, prereferral treatment was correlated with NCCN guidelines to determine compliance or deviation. Outside records are diligently collected by our business center, which contacts both the patient and the referring physician to obtain all existing records regarding prereferral care. Despite our best efforts, obtaining complete outside records, including documentation of all patient visits, was difficult. Among patients who presented with persistent or recurrent disease, complete records were available for 66.7% of those evaluated by medical or radiation oncologists, half of those evaluated by general surgeons, 7.5% of those evaluated by dermatologists, 6.1% of those evaluated by otolaryngologists, and 4.6% of those evaluated by primary care physicians. The rest of the patients' treatment histories were obtained from patient interview, pathology and imaging reports, and operative records.

In addition to demographic data, collected information included time to diagnosis, outside provider information, and details of prereferral workup and treatment. For patients who presented with persistent or recurrent disease, an assessment of compliance with NCCN guidelines was made based on available prereferral information by the first (C.M.L.) and senior (R.S.W.) authors. This evaluation included a rigorous assessment of available operative notes, summaries of adjuvant therapy, histopathology and imaging reports, and clinic notes for each patient.

Whether surgical treatment was insufficient was determined by a review of all prereferral imaging and pathology reports and operative records. For example, 1 patient underwent an indicated neck dissection, but the corresponding pathology report did not identify any lymph nodes in the surgical specimen. This patient was deemed to have received inadequate surgical treatment. Likewise, patients with lymphadenopathy on preoperative imaging that was still present on postoperative imaging fell into this category. Inadequate primary radiation therapy refers to cases in which patients did not receive adequate dosing, did not complete treatment, or had unexplained or extended treatment breaks. Assessment was based on radiation oncology summaries and clinic notes. The adequacy of adjuvant treatment was also determined by relevant office notes and summaries. Examples of patients who were treated for the wrong diagnosis include those with metastatic neck masses who were treated with antibiotics for more than 6 months before being diagnosed as having malignancy.

Commercial statistical software was used to enumerate descriptive statistics for scaled values and frequencies of study patients within the categories for each of the parameters of interest. Correlations between parameters and end points were assessed by Pearson χ2 test or, in instances in which there are fewer than 10 subjects in any cell of a 2 × 2 grid, by 2-tailed Fisher exact test. Intervals between initial presentation and diagnosis were compared with the Kruskal-Wallis analysis of variance by rank multiple comparisons test. These calculations were performed with a commercially available statistical software package (Statistica; StatSoft Inc, Tulsa, Oklahoma).

RESULTS

A total of 566 consecutive new patients (355 men [62.7%] and 211 women [37.3%]) were identified at multidisciplinary treatment planning conferences between October 1, 2008, and February 1, 2009. Demographic data are summarized in Table 1. Briefly, for the entire cohort, the mean age at presentation was 56.6 years (median age, 57.4 years; age range, 7.5-92.8 years). Four hundred forty-one patients (77.9%) were white, 57 (10.0%) were Hispanic, and 49 (8.6%) were black. Otolaryngologists accounted for 38.7% of referring physicians, and 25.0% of patients were self-referred. The rest of referrals were made by primary care physicians (11.7%), dermatologists (7.2%), endocrinologists (5.2%), dental professionals (27%), oncologists (3.8%), and general surgeons (1.4%). Table 1 also details the subsites of disease on presentation.

The majority of patients (65.3%) presented for initial workup and treatment; 13.5% presented with recurrent disease and 5.5% with persistent disease. Patients with no evidence of disease who were transferring their surveillance care accounted for 6.4% of cases, and those who were referred for completion of treatment (generally for postoperative adjuvant therapy) accounted for 6.8% (Table 2). The median time from initial presentation to diagnosis was 3.9 weeks (range, <0.1-170.4 weeks) for patients who were referred for initial treatment, 0.3 weeks (range, <0.1-53.4 weeks) for patients with no evidence of disease who were transferring surveillance care, less than 0.1 week (range, <0.1-159.0 weeks) for patients who presented with recurrent disease, and 2.4 weeks (range, <0.1-197.9 weeks) for patients who were referred with persistent disease (mean values also shown in Table 2).

Presenting with persistent or recurrent disease did not correlate significantly with sex, ethnicity, referring provider type, or subsite of disease (Table 3) when compared with presenting for initial workup and management. Also, whether prereferral management was NCCN compliant did not correlate with any of these factors or with insurance status (Table 3). Furthermore, we examined the types of physicians who were providing prereferral care to those patients who presented with persistent or recurrent disease (Table 4). While the involvement of radiation oncologists or endocrinologists appeared to affect NCCN compliance, neither had a statistically significant impact.

Of those patients who presented with recurrent or persistent disease, 43% had prereferral care that was not compliant with NCCN guidelines.Of the 43%, 59% received inadequate surgical treatment, 15% refused appropriate recommendations, and 11% were treated for the wrong diagnosis. Table 5 lists the reasons for discordant care.

COMMENT

Assessing the quality of care has become a national priority, as espoused by the IOM 2001 report “Crossing the Quality Chasm: A New Health System for the 21st Century.”1 This report emphasized the importance of improving the effectiveness, timeliness, efficiency, equity of delivery, and safety of medical care to optimize the quality of medical care.2,3 It also highlighted the need to develop quality indicators to address these issues.

Most studies evaluate the quality of care through examination of mortality, morbidity, and length of hospital stay. However, clinical practice guidelines offer specialty- and disease-specific treatment recommendations that can, in turn, be used to develop criteria for measurable quality.4,12 To examine the care received by patients with head and neck cancer prior to referral to a tertiary care medical center, we used NCCN guidelines for head and neck cancer management as a quality standard. We found that some aspect of prereferral care was noncompliant with NCCN recommendations in 43% of patients who were referred with persistent or recurrent disease.

Patients who were referred with persistent or recurrent disease accounted for 18.9% (107 of 566) of all new patients who presented to our department over a 4-month period. In attempting to address the issue of timeliness of care, as emphasized by the IOM, we had difficulty accurately assessing the weeks to diagnosis owing to limited available information on prereferral care (Table 2). Although head and neck cancer is relatively rare, cumulatively accounting for fewer than 3% of solid tumors diagnosed annually in the United States, our study data highlight the need for raised awareness among community providers who are evaluating the initial symptoms of these patients.

We did not identify any factors associated with whether prereferral care was noncompliant with NCCN guidelines, despite examining the potential effects of race, sex, insurance status, subsite of disease, or type of referring or treating physicians (Tables 3 and 4). While indicating compliance with the IOM goal of equity of care, our data also suggest that efforts to improve the quality of head and neck cancer care should be globally directed, regardless of physician subspecialty training. It would be expected that subspecialists would compose a greater percentage of referring physicians for patients with persistent or recurrent disease. The lack of a significant difference between referral patterns for patients presenting for initial treatment and those with recurrent or persistent disease indicates that perhaps referral criteria, especially for complicated cases, should be devised. Recently, Cook et al14 reported that patients with heart disease who were treated at community health centers were significantly less likely to have specialist consultations or follow-up consultations than were those who were treated at an academic medical center. While there are no concrete criteria for specialist referrals, addressing this issue would serve the interest of timeliness of diagnosis and efficiency of care. However, further studies are needed to determine the impact of delayed referral on patient outcomes.

Of the patients who presented with persistent or recurrent disease, 43% had an element of prereferral care that deviated from NCCN guidelines (Table 5). This accounted for 8.1% of all new patient evaluations. Most of these cases (58.7%) were noncompliant by reason of inadequate surgical treatment, as determined by preoperative imaging reports, operative notes, and pathology reports. Misdiagnosis leading to inappropriate treatment occurred in 15.2% of cases. This number underscores the need to raise awareness of head and neck cancer among community providers who are evaluating patients' presenting complaints. Inadequate primary radiation therapy was identified in 4.4% of cases, and insufficient adjuvant therapy was seen in 10.9%. Surprisingly, 15.2% of noncompliant care was attributable to patient refusal of indicated recommended treatment. This raises questions concerning how informed these patients were in making these decisions and how well they were educated about the ramifications of such decisions.

There are many studies evaluating adherence to established guidelines. The National Initiative for Cancer Care Quality established a set of explicit quality measures for early- and intermediate-stage breast and colorectal cancer, finding that 82% to 87% of patients with breast cancer and 78% of patients with colorectal cancer received care that was compliant with evidence-based guidelines. However, significant variation in adherence was identified, indicating opportunities for improvement.9 Patel et al12 evaluated whether care was concordant with guidelines established by the American College of Cardiology and the American Heart Association for the management of acute coronary syndrome. They found that compliance ranged from 74% to 78%. They also noted that there were slightly higher rates of adherence at academic hospitals and higher rates of variability among nonacademic settings.

While there are many reports of rates of compliance with guidelines, most do not correlate compliance with patient outcome. Kapadia et al5 determined a 57% rate of inappropriate carotid endarterectomy, based on recommendations set by the American Academy of Neurology, in an urban community hospital. Furthermore, they found that these nonindicated procedures resulted in a higher rate of complications than indicated cases. Specific to head and neck cancer, Benasso et al15 reported that patients in a clinical trial of chemoradiotherapy had a significantly better 3-year survival if they were treated by the coordinating medical center instead of by community affiliates. They attributed this to their finding that community hospitals had lower treatment compliance: they treated patients with lower doses of chemotherapy and radiation therapy than the coordinating medical center and were more likely than the coordinating medical center to delay treatment despite no reported differences in toxicity. Furthermore, the community affiliates had much lower volumes of patients (127 patients among 8 treatment centers) as compared with the coordinating medical center (166 patients in 1 treatment center). Interestingly, the authors found no difference among patients treated with radiotherapy alone. Kubicek et al16 reported no difference in survival or recurrence rates among patients with head and neck cancer who were treated with radiotherapy at academic vs nonacademic settings and found a trend for better survival in patients who received chemoradiotherapy at an academic medical center vs a community setting, although this did not reach statistical significance. Relative to our findings, further study is needed to evaluate how care that deviates from NCCN guidelines affects patient outcomes.

We recognize that there are limitations of this study. Although we evaluated 107 patients, the patient case mix was fairly heterogeneous, with no more than 20% of cases representing a single subsite of disease. While this may pose a limitation in discussing site-specific management, we did not find that disease subsite significantly correlated with whether a patient presented with recurrent or persistent disease or whether a patient was newly diagnosed. Despite our best efforts in systematically contacting both the patient and the referring physician's office to obtain complete records of prereferral treatment, accessing records was difficult. Evaluations of prereferral care were made based on all available records and information obtained from patient interview. In cases in which such information was not available and care could not be proved to deviate from NCCN guidelines, providers were given the benefit of the doubt and care was presumed to be compliant with NCCN standards. Therefore, our determination of deviation from NCCN recommendations is possibly understated.

The difficulty we faced in obtaining information about prereferral management also emphasizes the need for continuity of information among physicians. We found that complete records, documenting the initial encounter and patient visits through treatment and follow-up, were available for fewer than 5% of patients who were evaluated by a primary care physician and for only 6% of those who were previously treated by an otolaryngologist. However, even in cases in which complete records were not available, often some of the records were obtainable. A recent study evaluated the exchange of information among community providers, finding that physicians had information from previous visits with other practitioners in only 22% of patient visits. The exchange of information was found to be better when it came from consultants to primary care providers rather than vice versa.17 Continuity of care requires physician continuity, information continuity, and management continuity. A uniform system of electronic medical records would facilitate this flow of information, but until the flow is established, effort must be made by providers to ensure continuity of information to optimize the quality of care that is being delivered to their patients.

We initially attempted to evaluate the percentage of patients who were presented at multidisciplinary conferences but found mention of multidisciplinary conferences to be too sparse to be reliable. Wright et al18 recently surveyed general surgeons in academic and community practices in Ontario, Canada, and found that 100% of academic and 44% of community hospitals hold multidisciplinary conferences. Importantly, academic clinicians attended these conferences weekly, whereas community providers attended on a monthly basis, even when the conference was held more frequently. Multidisciplinary conferences improve patient care; a study of patients with rectal cancer in a Veterans Affairs hospital found that care was more likely to adhere to National Cancer Institute guidelines if the case was discussed at a multidisciplinary conference.19 Note must be made that deviation from NCCN guidelines is occasionally intentional, depending on individual patient factors. However, in such cases, the decision to deviate should be reached as a consensus, optimally in a multidisciplinary forum. Presentation of patients with head and neck cancer at multidisciplinary conferences may be a means by which community providers can improve compliance with NCCN guidelines.

Prereferral physicians, however, may not be aware of or practice by the guidelines we used as the standard of quality. Bober et al20 surveyed primary care physicians who were caring for long-term cancer survivors and found that although 82% thought that guidelines for the primary care of cancer survivors were not well defined, more than 90% were not aware of the IOM report describing the health care needs of these patients. They also identified a general lack of awareness about NCCN and American Society of Clinical Onocology survivorship guidelines. We did not survey the physicians who were providing prereferral care to determine their awareness of NCCN guidelines, although our findings suggest that disseminating and encouraging the implementation of these recommendations may improve the care of patients with head and neck cancer.

Our findings support the regionalization of head and neck cancer care. Treatment recommendations from multidisciplinary treatment planning conferences at our tertiary care medical center are in accordance with NCCN or institutional guidelines whenever possible. Also, all eligible patients are offered treatment protocols that have been approved by our institutional review board. Past reports have convincingly shown that medical centers and physicians who are treating a higher volume of patients with a particular disease have a lower mortality, even after adjustment for case mix. These reports have been both regional, encompassing multiple surgical conditions and medical diseases,2126 and procedure or disease specific.2729 Although the high-volume hospitals in many studies are academic medical centers, the added of benefit of teaching status is not clear.30,31 It should be noted that volume-outcome relationships reflect a structural characteristic, while NCCN guidelines delineate a process of care. Furthermore, most of these studies implemented short-term measures of morbidity and mortality, which are not appropriately extrapolated to cancer care. However, specific to head and neck cancer care, the previously discussed study by Benasso et al15 indicates that treatment center volume significantly affects the prognosis of patients with head and neck cancer who are undergoing chemoradiotherapy. To improve the quality of head and neck cancer care through increased compliance with national guidelines, steps need to be taken toward educating community providers through dissemination of guidelines, implementation of multidisciplinary conferences, and regionalization of the care of this patient population.

In conclusion, assessing and optimizing the quality of care has become a national priority. Compliance with clinical practice guidelines, which are built on evidence and expert consensus, can serve as a quality indicator. We found that for patients who were referred to a tertiary care center for persistent or recurrent head and neck cancer, prereferral care deviated from NCCN guidelines in 43% of cases, indicating the need for dissemination and implementation of NCCN recommendations.

Back to top
Article Information

Correspondence: Randal S. Weber, MD, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1445, Houston, TX 77030 (rsweber@mdanderson.org).

Submitted for Publication: March 31, 2010; final revision received June 17, 2010; accepted June 21, 2010.

Author Contributions: Drs Lewis and Weber had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Lewis, Hessel, Ginsberg, and Weber. Acquisition of data: Lewis and Guo. Analysis and interpretation of data: Lewis, Roberts, Holsinger, El-Naggar, and Weber. Drafting of the manuscript: Lewis, Guo, and Weber. Critical revision of the manuscript for important intellectual content: Lewis, Roberts, Holsinger, Ginsberg, El-Naggar, and Weber. Statistical analysis: Roberts. Administrative, technical, and material support: Lewis, Guo, Holsinger, and El-Naggar. Study supervision: Hessel, Holsinger, and Weber.

Previous Presentation: This study was presented at the annual meeting of the American Head and Neck Society; April 28, 2010; Las Vegas, Nevada.

Financial Disclosure: None reported.

References
1.
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century.  Washington, DC National Academy Press2001;
2.
Berwick  DM A user's manual for the IOM's “Quality Chasm” report. Health Aff (Millwood) 2002;21 (3) 80- 90
PubMedArticle
3.
Weber  RS Improving the quality of head and neck cancer care. Arch Otolaryngol Head Neck Surg 2007;133 (12) 1188- 1192
PubMedArticle
4.
Browman  GPBrouwers  M The role of guidelines in quality improvement for cancer surgery. J Surg Oncol 2009;99 (8) 467- 469
PubMedArticle
5.
Kapadia  MMehri-Basha  MMadhavan  RRajamani  KChaturvedi  S High rate of inappropriate carotid endarterectomy in an urban medical center. J Stroke Cerebrovasc Dis 2009;18 (4) 277- 280
PubMedArticle
6.
Bair  DPham  JSeaton  MBArya  NPryce  MSeaton  TL The quality of screening colonoscopies in an office-based endoscopy clinic. Can J Gastroenterol 2009;23 (1) 41- 47
PubMed
7.
Shah  HAPaszat  LFSaskin  RStukel  TARabeneck  L Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology 2007;132 (7) 2297- 2303
PubMedArticle
8.
Chagpar  ABScoggins  CRMartin  RC  II  et al. University of Louisville Breast Sentinel Lymph Node Study, Factors determining adequacy of axillary node dissection in breast cancer patients. Breast J 2007;13 (3) 233- 237
PubMedArticle
9.
Malin  JLSchneider  ECEpstein  AMAdams  JEmanuel  EJKahn  KL Results of the National Initiative for Cancer Care Quality: how can we improve the quality of cancer care in the United States? J Clin Oncol 2006;24 (4) 626- 634
PubMedArticle
10.
Cheung  WYPond  GRRother  M  et al.  Adherence to surveillance guidelines after curative resection for stage II/III colorectal cancer. Clin Colorectal Cancer 2008;7 (3) 191- 196
PubMedArticle
11.
Bilimoria  KYBentrem  DJLinn  JG  et al.  Utilization of total thyroidectomy for papillary thyroid cancer in the United States. Surgery 2007;142 (6) 906- 913, e1-e2
PubMedArticle
12.
Patel  MRChen  AYRoe  MT  et al.  A comparison of acute coronary syndrome care at academic and nonacademic hospitals. Am J Med 2007;120 (1) 40- 46
PubMedArticle
13.
 NCCN Guidelines for head and neck cancer care National Comprehensive Cancer Network Web site. http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf. Accessed January 15, 2010
14.
Cook  NLAyanian  JZOrav  EJHicks  LS Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care. Circulation 2009;119 (18) 2463- 2470
PubMedArticle
15.
Benasso  MLionetto  RCorvò  RPonzanelli  AVitale  VRosso  R Impact of the treating institution on the survival of patients with head and neck cancer treated with concomitant alternating chemotherapy and radiation. Eur J Cancer 2003;39 (13) 1895- 1898
PubMedArticle
16.
Kubicek  GJWang  FReddy  EShnayder  YCabrera  CEGirod  DA Importance of treatment institution in head and neck cancer radiotherapy. Otolaryngol Head Neck Surg 2009;141 (2) 172- 176
PubMedArticle
17.
van Walraven  CTaljaard  MBell  CM  et al.  Information exchange among physicians caring for the same patient in the community. CMAJ 2008;179 (10) 1013- 1018
PubMedArticle
18.
Wright  FCLookhong  NUrbach  DDavis  D McLeod  RSGagliardi  AR Multidisciplinary cancer conferences: identifying opportunities to promote implementation. Ann Surg Oncol 2009;16 (10) 2731- 2737
PubMedArticle
19.
Abraham  NSGossey  JTDavila  JAAl-Oudat  SKramer  JK Receipt of recommended therapy by patients with advanced colorectal cancer. Am J Gastroenterol 2006;101 (6) 1320- 1328
PubMedArticle
20.
Bober  SLRecklitis  CJCampbell  EG  et al.  Caring for cancer survivors: a survey of primary care physicians. Cancer 2009;115 (18) ((suppl)) 4409- 4418
PubMedArticle
21.
Hannan  ELO’Donnell  JFKilburn  H  JrBernard  HRYazici  A Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. JAMA 1989;262 (4) 503- 510
PubMedArticle
22.
Luft  HSBunker  JPEnthoven  AC Should operations be regionalized? the empirical relation between surgical volume and mortality. N Engl J Med 1979;301 (25) 1364- 1369
PubMedArticle
23.
Flood  ABScott  WREwy  W Does practice make perfect? part I: the relation between hospital volume and outcomes for selected diagnostic categories. Med Care 1984;22 (2) 98- 114
PubMedArticle
24.
Flood  ABScott  WREwy  W Does practice make perfect? part II: the relation between volume and outcomes and other hospital characteristics. Med Care 1984;22 (2) 115- 125
PubMedArticle
25.
Dudley  RAJohansen  KLBrand  RRennie  DJMilstein  A Selective referral to high-volume hospitals: estimating potentially avoidable deaths. JAMA 2000;283 (9) 1159- 1166
PubMedArticle
26.
Birkmeyer  JDSiewers  AEFinlayson  EV  et al.  Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346 (15) 1128- 1137
PubMedArticle
27.
Long  DMGordon  TBowman  H  et al.  Outcome and cost of craniotomy performed to treat tumors in regional academic referral centers. Neurosurgery 2003;52 (5) 1056- 1065
PubMedArticle
28.
Gordon  TABurleyson  GPTielsch  JMCameron  JL The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg 1995;221 (1) 43- 49
PubMedArticle
29.
Wouters  MWWijnhoven  BPKarim-Kos  HE  et al.  High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data. Ann Surg Oncol 2008;15 (1) 80- 87
PubMedArticle
30.
Rosenthal  GEQuinn  LHarper  DL Declines in hospital mortality associated with a regional initiative to measure hospital performance. Am J Med Qual 1997;12 (2) 103- 112
PubMedArticle
31.
Bach  PBCarson  SSLeff  A Outcomes and resource utilization for patients with prolonged critical illness managed by university-based or community-based subspecialists. Am J Respir Crit Care Med 1998;158 (5, pt 1) 1410- 1415
PubMedArticle
×