Principles of Patient Care
Rohan R. Walvekar
Marcie C. Tauzin
Neelima Tammareddi
Principles of care for the head and neck patient can be defined by understanding of the concepts of quality health care and the methods and processes necessary to secure it. An appropriate definition of quality care must be agreed upon in order to implement it. There are several mechanisms that have been introduced in current medicine as ways to measure, implement, and audit quality health care and ensure an equitable and ethical practice of medicine. Clinical guidelines and critical pathways are used to direct medical decision making. The appropriate evaluation of clinical outcomes through evidence-based research provides a reasonable justification for everyday clinical decision making. Multidisciplinary team (MDT) approaches ensure complete and efficient care for the patient. In addition, safety, standardization of care, and associated costs can be examined to allocate health care resources in an equitable fashion.
PURPOSE
The aim of this chapter is to highlight the importance of quality care, particularly with regard to the head and neck cancer patient. We define the different components of quality care and describe the various tools used to improve it. Reviews of current literature are used to support the importance of this topic and offer examples of implementation. The goal is to emphasize the need for high-quality medical care and to provide a resource that explains how it can be incorporated into the care of a head and neck cancer patient.
QUALITY OF CARE
Historical Background
Beginning in the 1990s and rising over the last two decades, there has been an increasing focus on the quality of medical care in the United States. It has prompted the development of several organizations to assess and improve health care, including the Agency for Healthcare Research and Quality (AHRQ), which oversees the National Guideline Clearinghouse (NGC), the Patient-Centered Outcomes Research Institute, and the National Quality Forum (NQF). In addition, there was rapid growth of existing programs such as the Institute of Medicine (IOM), which is the health arm under the National Academy of Sciences, dating back to the 1860s. Some of these initiatives are government-based, some are nonprofit, and others are professionally associated. The Clinical Guidelines Task Force established by the American Academy of Otolaryngology (AAO) and the Quality of Care Committee created by the American Head and Neck Society (AHNS) are organizations specific to otolaryngology. The emphasis on quality improvement also coincided with a new shift toward the use of evidence-based medicine (EBM). It has become increasingly important in all aspects of health care, especially those that affect the quality of health care delivery.
Defining Quality Care
In 2001, the IOM published a report entitled “Crossing the Quality Chasm: A New Health System for the 21st Century,” which highlighted the disparity between optimal care based on the best evidence and the quality of care that is delivered. In this report the IOM proposed six critical goals to redefine health care: improved safety, effectiveness, timeliness, efficiency, individualization, and equality of delivery of health care. It defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired heath outcomes and are consistent with current professional knowledge” (1). The AHRQ simplified this definition as “doing the right thing, at the right time, in the right way, for the right person—and having the best possible results” (2, 3).
The three general aspects studied in assessing quality of care are structure, process, and outcomes. Structure refers
to health system characteristics. Process refers to the role of the health care provider. Outcome refers to what happens to the patient (3, 4). These three concepts are intertwined and must all be addressed for effective quality improvement. This involves analysis of how organizations and systems fail and the practice of devising, testing, and evaluating tools and techniques to address those deficiencies.
to health system characteristics. Process refers to the role of the health care provider. Outcome refers to what happens to the patient (3, 4). These three concepts are intertwined and must all be addressed for effective quality improvement. This involves analysis of how organizations and systems fail and the practice of devising, testing, and evaluating tools and techniques to address those deficiencies.
Organizations For Improved Quality
The national initiatives dedicated to the improvement of quality health care all work together but also focus on different aspects of the same goal. The AHRQ focuses on research that promotes improvement of health care quality, safety, efficiency, and effectiveness. The IOM identifies key health care areas that need to be addressed more urgently. The Patient-Centered Outcomes Research Institute commissions research focused on evidence-based information as well as specific values and interests of patients. The NQF was formed in 1999 to identify and enforce performance measures and disseminate quality measures. Currently, there are 55 of these performance quality measures pertaining to oncology; however, none that explicitly pertain to head and neck cancer.
The Clinical Guidelines Task Force of the AAO was formed for the development of rigorous evidence-based guidelines in head and neck surgery. There are several published treatment guidelines available such as those for hoarseness (5), otitis externa (6), and acute sinusitis (7). These focus on improving quality of care and standardizing clinical protocols and algorithms for patients with specific otolaryngologic diagnoses based on best current evidence. They describe accurate diagnosis, treatment options, and prevention measures.
The Quality of Care Committee, formed in 2007 by the AHNS, works to establish consensus quality measures in head and neck cancer care and to promote compliance with these standards as a framework for measuring quality of care in head and neck surgery. Currently, there are quality measures for the two most common head and neck cancers: oral cavity and laryngeal cancer, approved by the AHNS in 2007 and 2009, respectively. Pretreatment measures include histopathologic confirmation of diagnosis, appropriate Tumor Node Metastasis (TNM) staging (8), and tobacco cessation counseling. Treatment-related measures involve referrals to radiation oncology, medical oncology, and speech pathology when necessary. Appropriate followup for symptom management and cancer surveillance encompasses the posttreatment measures (4).
Outcomes of Care
Another important aspect of quality health care is assessing the outcomes of care received. The IOM defines three general categories of outcomes: clinical status, functional status, and patient satisfaction. Clinical status is defined as the biologic outcome of disease, for example, 30-day mortality rates. Functional status is the patient’s physical, emotional, and cognitive activity levels as the disease affects them, for example, Karnofsky score (4). Quality of life has become an important goal for head and neck oncology outcomes, in addition to cancer control and overall survival. Attempts to measure health-related quality of life have led to an increase in production of formal assessments to evaluate physical, mental, and social function for a variety of clinical topics. A frequently used example of such a tool is the University of Washington Quality of Life Revised Version 4 (9). Finally, patient satisfaction is a measure of patients’ opinions about the care they receive, for example, Likert scale (10). It should be noted that patient satisfaction and high-quality care have not been shown to be correlative, and thus, it may not be the best means of measuring quality of care (4). Quality of care can be improved by considering these three aspects of clinical outcomes.
CLINICAL GUIDELINES
Clinical practice guidelines present systematically and precisely developed evidence-based recommendations for diagnostic procedures and medical treatment options that are used for standard patients (11). They use EBM to help set national standards and aid in decisions regarding appropriate health care for specific clinical circumstances. While there is increasing integration of evidence-based practice into clinical decision making, most clinical practice is still not based on the best available evidence. Guidelines are tools used to ensure that this evidence is put into current practice. They serve not only as references for clinical decision making and best practices but also as criteria for performance evaluation (12).
The general goals of developing clinical guidelines are to improve the quality of clinical care by helping physicians and patients in decision making and to support the delivery of cost-effective care by reducing unwarranted variations in clinical practice (13). In addition to promoting improved decision making, they can be used to initiate improvement strategies, prioritize research goals, and support reimbursement for particular services.
However, physicians must be careful in the use of guidelines. A flawed guideline can impair the whole health care system through the same pathways that an effective one makes improvements. There is a potential threat to individualized patient care if guidelines are used without proper evaluation. Every clinician must remember that in medicine every patient and every situation is slightly different. Guidelines must be developed in a very strict fashion to prevent inappropriate use (12, 14).
Many review articles, consensus statements, practice parameters, and policy recommendations are labeled as “guidelines,” without possessing the diligent methodology to merit such a designation (12). A variety of tools such
as the Conference on Guideline Standardization (COGS) checklist, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (11), and the Appraisal of Guidelines Research and Evaluation (AGREE) instrument exist to measure the quality of guidelines. The AGREE instrument is a widely used generic measure of guideline quality characterized by the attributes outlined in Table 109.1 (15).
as the Conference on Guideline Standardization (COGS) checklist, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (11), and the Appraisal of Guidelines Research and Evaluation (AGREE) instrument exist to measure the quality of guidelines. The AGREE instrument is a widely used generic measure of guideline quality characterized by the attributes outlined in Table 109.1 (15).
Clinical guidelines for a variety of otolaryngologic issues can be found through several different databases. The NGC database, an initiative of the AHRQ, is a repository that includes national guidelines that meet specific criteria. As of the publication date, the NGC database contains a total of 151 published guidelines with the search term “head and neck” and 71 with the search term “otolaryngology.” A few resources for finding guidelines are listed in Table 109.2.
TABLE 109.1 AGREE INSTRUMENT PRINCIPLES | ||
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TABLE 109.2 RESOURCES FOR CLINICAL PRACTICE GUIDELINES | |
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CLINICAL PATHWAYS
Clinical pathways are manifestations of guidelines, typically set up by a single institution, to specify care through protocols and to provide action plans with the appropriate support systems in place. Also known as critical pathways, they are developed by MDTs and establish the optimum timing of essential care in the management of patients who have specific conditions or undergo specific procedures. The development of these pathways through critical analysis has become a way to further streamline the clinical workup, treatment, and follow-up of head and neck cancer patients (16). By utilizing evidence-based interventions and reducing variations in care, the development of pathways can benefit patients by reducing complications, providing better quality of life, improving survival, and allowing more cost-effectiveness (17).
Several institutions have described experiences with critical pathways in head and neck oncology, reporting on associations between the implementation of a pathway and lengths of stay (LOS) in the hospital. Some studies compare observational cohorts of critical pathway patients to prepathway historical cohorts for the same or similar procedure. Others controlled for changes in medical care over time by comparing pathway cohorts with nonpathway counterparts during the same time frame. Pathway implementation does appear to decrease LOS, but the effect is confounded by temporal trends such as increased utilization review, more cost-conscious care, and better-educated medical providers regarding the importance of minimizing hospitals stays (17).
Chen et al. examined the implementation of a clinical pathway for unilateral neck dissection. Pathway patients were compared with historical controls and with a nonpathway contemporaneous cohort. Significantly decreased LOS and median costs were seen in pathway patients. Interestingly, LOS and median cost of care for the nonpathway contemporaneous control group was in between that of the pathway patients and historical controls. This suggests that care was made more efficient and cost-effective through both changes over time as well as through the clinical pathway (18).
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