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Program Number: B090
Session Name: Poster Session

Reducing Delays in Head and Neck Cancer Treatment for Veterans: A Quality Improvement Initiative

Luke Galloway, MD; Alexander Abdollahzadeh, BS; Merry Sebelik, MD; Normal Lester, MD; Carrie Flanagan, MD; Maxwell Kligerman, MD, MPH; Emory University

Background: Delays in treatment of head and neck cancer (HNC) are directly associated with worse survival and functional outcomes. Patients with HNC at our 466-bed tertiary care Veteran’s Affairs Medical Center (VAMC) anecdotally face long wait times from diagnosis to treatment initiation; however, there is limited data to contextualize this claim. This quality improvement (QI) initiative aimed to 1) quantify the time from diagnosis to treatment for patients with HNC at our VAMC, 2) identify root causes of delays in time to treatment, and 3) propose cost-free interventions that would target these root causes of delay.

Methods: We performed a mixed-methods problem analysis in accordance with standard QI principles. A retrospective review of the electronic medical record was performed to quantify the number of days from diagnosis to initiation of treatment. Inclusion criteria were veterans diagnosed at a single tertiary care VAMC with mucosal or advanced cutaneous HNC between 2014 and 2023. Quantitative data was analyzed with descriptive statistics and control charts. Patients with time to treatment > 90 days were reviewed in detail with a Pareto analysis to identify specific factors contributing to the delay. Qualitative analysis was performed via semi-structured interviews with key stakeholders. Interview summaries were coded and then inductive thematic analysis was performed. Lastly, cause-and-effect brainstorming was performed with key stake holders using the above results to propose targeted, no-cost interventions.

Results: There were 214 patients that met inclusion criteria. Median time to treatment was 55 days. Figure 1 demonstrates time to treatment per quarter. Of all patients, 16% (n=34) had time to treatment >90 days. The most frequently identified contributing factors in the Pareto analysis were community care referrals (79%, n=27), social determinants of health (26%, n=9), and the veteran’s own decision to temporarily pause treatment (26%, n=9). Inductive thematic analysis highlighted six distinct themes contributing to delays including: 1) varying perceptions of timely treatment amongst members of the treatment team; 2) lack of transparency regarding the status of individual patients during the treatment pathway; 3) fragmentation of patient care due to community care referrals; 4) patient difficulty independently coordinating multidisciplinary care; 5) untimely pre-treatment appointments; 6) staffing shortages. Key stake holders selected four initial interventions targeting these root causes of delay: a) selecting an evidenced-based and shared goal for time to treatment across all service lines and tracking success in meeting this goal; b) performing social work screening and psycho-oncology screening for all newly diagnosed HNC patients; c) providing a community care training update across services lines; d) utilizing a patient treatment tracker to provide updates at weekly tumor board for all HNC patients with pending treatment.

Conclusion: This QI initiative confirmed that 50% of HNC patients at our VAMC face time-to-treatment greater than 55 days; however, it also highlighted specific strategies to reduce delays. After implementing these QI interventions we will use control charts to monitor for statistically significant reductions in delays. This QI initiative may serve as a blueprint for other VAMCs to reduce time-to-treatment with cost free interventions.

Figure 1:

 

 

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