Indicators to evaluate quality of care in head and neck cancer in Spain

Abstract

Purpose: This study aimed to develop a set of criteria and indicators to evaluate the quality of care of patients with head and neck cancer (HNC).

Methods: A systematic literature review was conducted to identify valuable criteria/indicators for the assessment of the quality of care in HNC. With the aid of a technical group, a scientific committee of oncologists specialised in HNC used selected criteria to propose indicators that were evaluated with a two-round Delphi method. Indicators on which consensus was achieved were then prioritised by the scientific committee to develop a final set of indicators.

Results: We proposed a list of 50 indicators used in the literature or developed by us to be evaluated with a Delphi method. There was consensus on the appropriateness of 47 indicators in the first round; the remaining 3 achieved consensus in the second round. The 50 indicators were scored to prioritise them, leading to a final selection of 29 indicators related to structure (3), process (22), or outcome (4) and covering diagnosis, treatment, follow-up, and health outcomes in patients with HNC. Easy-to-use index cards were developed for each indicator, with their criterion, definition, formula for use in real-world clinical practice, rationale, and acceptable level of attainment.

Conclusions: We have developed a set of 29 evidence-based and expert-supported indicators for evaluating the quality of care in HNC, covering diagnosis, treatment, follow-up, and health outcomes.

Keywords: Criteria; Delphi; Head and neck cancer; Indicators; Quality of care; Spain.

Fig. 1

Study design

Fig. 2

PRISMA flow diagram

Fig. 3

Delphi method scores of proposed criteria. Mean scores of proposed (P) indicators. Red, indicators with the lowest scores; blue, indicators with average scores; green, indicators with the highest scores. P1 imaging study prior to initiating treatment, P2 whole-body PET/CT up to 6 weeks prior to initiating treatment in patients with stage III–IV disease, P3 whole-body PET/CT in tumours of unknown primary up to 6 weeks prior to initiating treatment, P4 access to an anatomic pathology service for immunohistochemistry, P5 access to a biomarker evaluation service, P6 Narrow Band Imaging endoscopy, P7 histological evaluation prior to initiating treatment, P8 obtain anatomopathological report that includes TNM staging and biomarker information, P9 routine evaluation of Epstein–Barr virus (EBV) and human papillomavirus (HPV) in lymphadenopathy of patients with metastatic head and neck squamous cell carcinoma of unknown primary, P10 HPV evaluation and complete TNM staging prior to initiating treatment in patients with oropharyngeal cancer, P11 EBV evaluation and complete TNM staging prior to initiating treatment in patients with cavum carcinoma, P12 existence of a multidisciplinary Tumour Board, P13 Tumour Board evaluation of histological diagnosis and TNM staging to determine the complete treatment plan using one document available to the team, P14 assessment of patients’ nutritional status prior to initiating the first treatment, P15 adequate oral cavity and dental assessment by an expert prior to initiating radiotherapy, P16 availability of speech therapists, P17 evaluation of all patients using validated comorbidity scales (e.g. Charlson Comorbidity Index) and/or performance status prior to initiating treatment, P18 encourage smoker patients with head and neck cancer to start a cessation programme with a specialised clinician, P19 encourage alcoholic patients with head and neck cancer to start a cessation programme with a specialised clinician, P20 Tumour Board establishment of an optimal timeframe between selecting a therapy with curative intent and treatment initiation, P21 complete tumour resection in patients who undergo surgery with curative intent, P22 access to transoral surgical techniques (manual or robotic), P23 maintain adequate surgical margins (≥ 3 mm and ≤ 5 mm) in patients with head and neck squamous cell carcinoma of the oral cavity larynx or pharynx who undergo open surgical resection with curative intent, P24 re-hospitalisation within 30 days of surgery for surgery-related issues, P25 repeat surgery within 7 days of the first surgery, P26 long hospitalisation (≥ 30 days) after surgery, P27 initiate adjuvant radiotherapy within 6 weeks of surgery, P28 use of intensity-modulated radiotherapy in radical radiotherapy, P29 chemoradiotherapy with cisplatin (tri-weekly or weekly) in patients with stage III or IV head and neck squamous cell carcinoma of the oral cavity larynx or pharynx with extracapsular spread and/or involved margins (< 1 mm), P30 monotherapy (surgery or radiotherapy) for patients with early-stage head and neck squamous cell carcinoma, P31 total laryngectomy in patients with head and neck squamous cell carcinoma of the larynx in stage T4a or with non-metastatic invasion of thyroid cartilage, P32 radiotherapy concomitant with cisplatin or cetuximab for patients with locally advanced head and neck squamous cell carcinoma who are not eligible for surgery, P33 evaluation of response to chemoradiotherapy using imaging (computed tomography or fluorodeoxyglucose–positron emission tomography) and physical examination (inspection of the oral cavity or nasofibroscopy) of patients with locally advanced head and neck cancer, P34 evaluation of response to chemoradiotherapy in patients with locally advanced disease 8–12 weeks after treatment completion, P35 access to immunotherapy by eligible patients with recurrent and/or metastatic disease, P36 Tumour Board re-assessment of patients with local or systemic recurrence, P37 multidisciplinary assessment of patients with recurrent oligometastasis to provide local therapy with radical intent (salvage therapy), P38 second- or third-line therapy for eligible patients with advanced head and neck cancer who have not responded to previous lines of therapy or have recurrent disease, P39 assessment of quality of life (using validated questionnaires) before and after treatment in patients with recurrent/metastatic disease who receive second- or third-line therapy, P40 determination of PD-L1 expression using Combined Positive Score in patients with advanced disease, P41 propose participation in clinical trials that fit the patient’s clinical characteristics and therapeutic needs, P42 adequate follow-up after treatment completion, P43 evaluate thyroid function every 6–12 months after neck irradiation, P44 assessment of oral cavity and teeth in patients who have received radiotherapy in the oral cavity, P45 patient follow-up by a multidisciplinary team to assess physical sequelae, P46 patient follow-up by a multidisciplinary team to assess psychosocial sequelae, P47 evaluate survival 30 and 90 days after surgery, P48 evaluate survival 30 and 90 days after non-surgical therapy with radical intent, P49 overall survival 1, 3 and 5 years from diagnosis, P50 overall survival by stage 1, 3 and 5 years from diagnosis