René Leemans

Presentation
Introduction
Improving the quality of care in head and neck surgical oncology is crucial, driven by the guiding philosophy: “We have to get it right the first time” by Goodwin. The Institute for Healthcare Improvement provides a crucial framework for quality enhancement, encompassing the monitoring of structure, process, and outcome.

Structure
Sufficient structural quality begins with the training of the healthcare professional (HCP) and facility characteristics, such as patient volumes. A well-trained surgeon is required, preferably achieved through a fellowship of at least one year following basic training.

Both nationally and internationally several options exist. For example in the Netherlands, a combined head and neck fellowship for both otolaryngologists and maxillofacial surgeons has been established since 1998, requiring two years of additional training. Globally, the Global On Line Fellowship (GOLF), initiated by IFHNOS in collaboration with Memorial Sloan Kettering Cancer Center in 2014, offers a solid theoretical foundation for performing head and neck surgery. By 2022, GOLF had 339 graduates and involved participants from 45 countries in a two-year self-learning program.

Evidence demonstrates an increasing effect of volume, both at the institutional and individual surgeon levels, on survival. Higher volume centers are associated with reduced morbidity and mortality. For total laryngectomy, operating higher volumes per hospital results in lower in-hospital deaths, surgical complications, and medical complications. In the Netherlands, centralization efforts, driven by a 2010 consensus, ensure that over 95% of patients are treated in 8 designated Head and Neck Centers, each handling over 200 new cases per year. High volume surgeons (>20 cases/year) performing oral cavity surgery demonstrated differences linked to lower involved margins and a higher lymph node count compared to low volume surgeons (1-15 cases/year).

Process
Process involves the actual delivery of care, including the surgical procedure and perioperative treatment.

Multidisciplinary Tumor Board (MDT): The introduction of the MDT is the hallmark development in the management of head and neck cancer patients. MDTs have been proven to improve patient survival and increase the likelihood of receiving combination therapy (e.g., CRT or Surgery and RT). The quality of the MDT appears to be influenced by the volume of patients discussed. Our institutional data showed that MDT discussions can lead to changes in treatment recommendations (22% total changes, 17% major changes), often involving intensification (59%) or deintensification (38%).

Treatment Timing (TTI): The time to treatment initiation (TTI) is critical. A fast-track workup decreased the median time to diagnosis from 9.0 to 2.0 days and time to treatment from 25.0 to 18.0 days. Analysis of the National Cancer Data Base registries showed that a TTI of more than 61 days resulted in worse survival compared toa TTI of less than 30 days.

Surgical quality and guidelines: The introduction of pre- and post-operative surgical checklists has shown positive effects on outcomes such as surgical site infections, unplanned return to the operating room, and mortality. Improving surgical quality is tied to specific metrics, including achieving negative margins and obtaining an adequate nodal yield. Nodal yield is an independent prognostic factor for overall survival, with a meta-analysis suggesting that a cut-off of 18 nodes has a significant effect on survival. It has also been established that patients with recurrent disease referred to high-volume centers often received care that did not comply with guidelines.

Outcome
Outcome analysis assesses the results of the healthcare experience, including survival endpoints and functional recovery measures.

Outcome Guided Improvement: Careful assessment of outcomes, including complications, morbidity, and mortality is essential. Improvements can then be implemented on both a collective and individual surgeon basis.

Quality Criteria and VBHC: High-quality care criteria include achieving negative margins, neck dissection with > 18 nodes, and starting adjuvant therapy < 6 weeks. Recent developments in quality control employed within clinical trials, offer opportunities to also improve the clinical practice.

Furthermore, quality improvement is linked to Value Based Health Care (VBHC), defined as Value Outcome divided by the Cost to Achieve Outcome. Outcomes encompass Clinical Outcomes, Patient Reported Outcome Measures (PROMs), and Patient Reported Experience Measures (PREMs).

Audit Initiatives: Initiatives for departmental improvement include national audits such as the Dutch Head and Neck Audit, the ACS NSQIP database in the US, and the Otolaryngology Head and Neck Surgery pan-national audit in Australia & New Zealand.

Conclusion
To improve the quality of care in head and neck surgery, key factors highlighted are the utilization of a fellowship trained surgeon, practice within a high volume center, consistent use of a multidisciplinary tumor board, and rigorous outcome monitoring.

Bio
Professor C. René Leemans, MD, PhD is chair of the Department of Otolaryngology Head and Neck Surgery at the Amsterdam University Medical Centres, VUmc, Amsterdam. He is Director of the Advanced Fellowship Program in Head and Neck Surgery and Oncology at the VU University Medical Centre Amsterdam. His special interests include head and neck oncology, reconstructive and microvascular surgery, and basic research.
René Leemans has made a sustained and internationally recognised contribution to cancer care and research in the field of head and neck oncology over the past decades. His scientific standing has been recognised by election as President of the Netherlands Society of Otolaryngology-Head and Neck Surgery, and the Dutch and European Head and Neck Societies. He also serves on the Leadership of the American Head and Neck Society (AHNS).
He (co-)authored more than 500 papers and book chapters on head and neck oncology and is regularly invited to speak at international conferences and tutor at courses. He was a travelling faculty member of 2010 Global CME program “Current Concepts in Head and Neck Surgery and Oncology” of the IFHNOS. In 2022 he was awarded the Eugene N. Myers, MD International Lecture on Head and Neck Cancer at the American Academy of Otolaryngology-Head and Neck Surgery Meeting in Philadelphia. He leads the impactful Make Sense Awareness Campaign.