A MULTIDISCIPLINARY QUALITY INITIATIVE TO ADDRESS DELAYS IN INITIATING POST-OPERATIVE RADIOTHERAPY IN HEAD AND NECK CANCER PATIENTS

Abstract

Purpose:

The American College of Surgeons Commission on Cancer’s (ACS/CoC) head and neck (HN) quality metric requires post-operative radiotherapy (PORT) initiation within 42 days from surgery. A 2021/2022 quality improvement (QI) audit revealed only 43% of our patients met this metric. Root cause analysis suggested radiation oncologist (RO) assessment ≤21 days post-op supports timely PORT. This QI initiative aimed to increase adherence from 43% to 70% by the end of 2024.

Materials and Methods:

This multidisciplinary QI initiative (registered with our institution, REB not required) implemented a new standard operating procedure. Included were patients with mucosal and skin squamous cell carcinomas (SCC), melanomas, salivary gland and other high-risk skin carcinomas undergoing surgery & PORT (January - December 2024), excluding those with prior HN radiotherapy. The intervention involved: 1) HN clinical specialist radiation therapist (CSRT) identifying relevant patients and informing RO of PORT goal dates, and 2) an order for a 3-week post-op RO follow-up (FU) booked via the computerized provider order entry system. Measures included: percentage of patients initiating PORT ≤ 42 days (outcome), seeing RO ≤21 days post-op (process), and initiating PORT ≤42 days with rushed planning process (<14 days) from simulation to treatment (balancing). Quarterly updates maintained project momentum through team feedback and addressing concerns.

Results:

Of the 135 patients included, 62 (46%) began PORT ≤42. Among those with SCC, timely PORT was seen in 50/92 (54%) compared to 12/43 (28%) with non-SCC histology. Timely PORT in 2024 was variable with an improvement of 12/26 (46%) in Q1 to 21/39 (54%) in Q4, but 13/33 (39%) in Q2 and 16/37 (43%) in Q3. RO assessment ≤ 21 days post-op occurred in 54/135 (40%) patients. This improved from 10/26 (38%) in Q1 to 17/39 (44%) in Q4 but varied with 14/33 (47%) in Q2 and 13/37 (35%) in Q3. Among patients with timely RO assessment, 38/54 (70%) achieved timely PORT, increasing from 7/10 (70%) in Q1 to 14/17 (82%) in Q4, but varied with 10/14 (71%) in Q2 and 7/13 (54%) in Q3. Rushed planning increased from 4/12 (33%) in Q1 to 5/13 (38%) in Q2 and 10/16 (63%) in Q3 but decreased to 8/21 (38%) in Q4. For the 73 patients with delayed PORT, main causes were: care coordination issues (56%), post-op complications (32%), and other (12%). Analysis revealed 70% of delays were unavoidable, including post-op complications, wound healing issues, delayed referrals from non-cancer centre surgeons, and patient-requested delays.

Conclusions:

The QI intervention improved adherence to the ACS/ CoC metric from 43% to 46%. This fell short of the 70% goal which can be attributed to 70% of delays deemed as unavoidable. Future sustainable interventions include dedicated patient navigation, automated FU booking, and enhanced care pathway visualization.