Reducing the Time from Surgery to Adjuvant Radiation Therapy: An Institutional Quality Improvement Project

Abstract

Objective The National Comprehensive Cancer Network guidelines recommend an interval between surgery and adjuvant radiation therapy of less than 6 weeks, but only 44% of patients meet this metric nationally. We sought to identify key components of an improvement process focused on starting adjuvant radiation therapy within 6 weeks of surgery. Methods This project used an A3 model to improve a defined process measure. We studied a consecutive sample of 56 patients with oral cavity carcinoma who were treated at our institution with upfront surgical resection followed by adjuvant radiation therapy. Twelve proposed interventions tested during the study period focused on 3 key drivers of delays: delayed dental evaluation and teeth extraction, delayed radiation oncology consults, and inadequate patient engagement. The primary outcome measure was the number of days from surgery to the start of radiation therapy. Results Prior to the intervention, 62% of patients received adjuvant radiation within 6 weeks of surgery. Following the intervention, 73% of patients achieved this metric. The percentage of patients with avoidable delays decreased from 24% to 9%. The percentage of patients with unavoidable delays was relatively constant before and after the intervention (15% and 18%, respectively). Discussion Defining disease-specific metrics is critical to improving care in our head and neck cancer patient population. We demonstrate several key components to develop and improve self-defined metrics. Implications for Practice As we transition to a system of value-based care, structured quality improvement projects can have a measurable impact on cancer patient process measures.

Association of Treatment Delays With Survival for Patients With Head and Neck Cancer

“…14,15,19,20 For these reasons, S-PORT has been proposed as a quality measure for HNC, 15 and benchmark targets for timely S-PORT have been proposed. 48 …”

“…However, 1 promising single institution study provided preliminary data that using quality improvement methods to target key process-of-care drivers for delayed PORT (timely dental consultation, timely radiation oncology consultations, and patient engagement) can decrease delays starting PORT. 48 Future research is required to identify whether this strategy can be generalized and implemented at other institutions to achieve similar improvements in timely PORT. In addition, whether interventions aimed at improving S-PORT can be applied to other time intervals along the HNC care continuum in which delays are noted is important and should be addressed in future research.…”

“…Causes of prolonged TPT therefore include all of those present for S-PORT plus additional challenges for timely completion of adjuvant therapy. The barriers to timely S-PORT, which reflect issues related to postoperative complications, care coordination, timely radiation oncology consultation, and patient engagement, 48 are qualitatively different than the barriers that cause treatment breaks during adjuvant therapy. Barriers to timely completion of (chemo) radiotherapy, whether in the definitive or adjuvant setting, primarily include issues related to acute toxic effects of treatment and high symptom burden secondary to mucositis, dehydration, malnutrition, and pain, as well as hemato logic complications.…”

Surgical Management of Multiple Myeloma With Symptomatic Involvement of the Spine

“…The National Comprehensive Cancer Network guidelines suggest that the time gap should not exceed 6 weeks between surgery and the commencement of adjuvant RT. 62…”

Quality improvement in hospitals' surgery-related processes: A systematic review

“…Of course, communication can be very difficult sometimes, and there are numerous examples of the lack of understanding changes. When implementing changes, continues leadership and regular monitoring and evaluating are essential (56).…”