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. 2019 Feb;34(1):89-104.
doi: 10.1007/s00455-018-9917-4. Epub 2018 Jun 19.

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes

Barbara Pisano Messing  1   2   3 , Elizabeth C Ward  4   5 , Cathy Lazarus  6 , Keri Ryniak  7 , Melissa Kim  7 , Jessica Silinonte  7 , Dorothy Gold  7 , Carol B Thompson  8 , Karen T Pitman  7   9 , Ray Blanco  7 , Ryan Sobel  7 , Karen Harrer  7 , Karen Ulmer  7 , Geoffrey Neuner  7 , Kruti Patel  7 , Mei Tang  7 , Gregory Lee  7
Affiliations

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes

Barbara Pisano Messing et al. Dysphagia. 2019 Feb.

Abstract

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.

Keywords: Clinical pathway; Deglutition; Deglutition disorders; Dysphagia; Head and neck cancer; Implementation; Nutrition; Oral intake.

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Conflict of interest statement

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Figures

Fig. 1
Fig. 1
Dance Head and Neck Clinical Pathway (D-HNCP) implementation timeline
Fig. 2
Fig. 2
Overview of Dance Head and Neck Clinical Pathway (D-HNCP) key time points from baseline to post-treatment for multidisciplinary team (MDT). [REDCap (Research Electronic Data Capture), NCCN National Comprehensive Cancer Network® (NCCN®)]
Fig. 3
Fig. 3
Multidisciplinary team patient care plan. GBMC Greater Baltimore Medical Center
Fig. 4
Fig. 4
Audit of the Dance Head and Neck Clinical Pathway (D-HNCP): adherence 2013–2014 during and post-treatment
Fig. 5
Fig. 5
Audit of the Dance Head and Neck Clinical Pathway (D-HNCP) cohort: completion of 2013–2014 PROs/CROs during and post-treatment
See this image and copyright information in PMC

References

    1. Tsai WC, et al. Beneficial impact of multidisciplinary team management on the survival in different stages of oral cavity cancer patients: results of a nationwide cohort study in Taiwan. Oral Oncol. 2015;51(2):105–111. doi: 10.1016/j.oraloncology.2014.11.006. - DOI - PubMed
    1. Wang YH, et al. Effects of multidisciplinary care on the survival of patients with oral cavity cancer in Taiwan. Oral Oncol. 2012;48(9):803–810. doi: 10.1016/j.oraloncology.2012.03.023. - DOI - PubMed
    1. Friedland PL, et al. Impact of multidisciplinary team management in head and neck cancer patients. Br J Cancer. 2011;104(8):1246–1248. doi: 10.1038/bjc.2011.92. - DOI - PMC - PubMed
    1. Dautremont JF, et al. Understanding the impact of a clinical care pathway for major head and neck cancer resection on postdischarge healthcare utilization. Head Neck. 2016;38(Suppl 1):E1216–E1220. doi: 10.1002/hed.24196. - DOI - PubMed
    1. Chen AY, et al. The impact of clinical pathways on the practice of head and neck oncologic surgery: the University of Texas M. D. Anderson Cancer Center Experience. Arch Otolaryngol Head Neck Surg. 2000;126(3):322–326. doi: 10.1001/archotol.126.3.322. - DOI - PubMed

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