Running Head: IMPROVING QUALITY OF LIFE 1

Improving Quality of Life: Clinical Guideline Implementation for Head and Neck Cancer

Jamie A. Meyer

University of Detroit Mercy

McAuley School of Nursing

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Improving Quality of Life: Clinical Guideline Implementation for Head and Neck Cancer

Head and neck cancer is a category of multiple types of cancers that include the

oral cavity, pharynx, nasal cavity, paranasal sinuses, salivary glands, and larynx. Per the

American Society of Clinical Oncology (2015) head and neck cancer accounts for about

3% of all cancers in the United States with an estimated 61,760 (45,330 men and 16,430

women) individuals developing head and neck cancer this year. Depending on the

location of head and neck cancer the 5-year survival rate ranges from 30-90%; an

estimated 13,190 deaths (9,800 men and 3,390 women) will occur this year (American

Society of Clinical Oncology, 2015). However, as a result of the advances in technology

and clinical trials that provide evidence-based medications to treat this disease there are

head and neck cancer patients who are being successfully cured of their disease. These

improvements have come at the expense of increased acute and late effects, which may

have a more profound effect on function and quality of life than has been previously

recognized (Gilbert et al., 2015, para. 2).

An important aspect to consider when caring for these patients is quality of life.

Diagnosis of cancer can leave patients frightened and vulnerable, and often unable to

understand the full implications of the treatment required; which affects their definition

of quality of life (Webber, 2008).

Background and Significance

A multidisciplinary treatment plan for head and neck cancer is often

complex because of the anatomical position of disease and the long-term effects

associated with combined treatment. Combined multimodality treatment, including

surgery, chemotherapy, and radiation, has increased disease control for locally-advanced
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head and neck cancer (Gilbert et al., 2015, para. 2). Due to the complexity of the

treatment regimens, patients have a marked deterioration in physical functioning,

especially if they go through surgery prior to chemotherapy and/or radiation. Side effects

can be severe and require acute interventions along with ongoing assessments.

Countless hours are spent providing emotional support, education, guidance, and

reinforcement to help patients get through treatment, which includes addressing the

patients perception of his or her quality of life. Currently, in my role as head and neck

nurse navigator within Mercy Health Saint Marys Head and Neck Cancer Program,

quality of life is not consistently being included into treatment considerations or baseline

assessments. Since one of the guiding behaviors at Mercy Health Saint Marys is to treat

the patient using a holistic approach (mind, body, and spirit), assessing the patients

quality of life is needed to assure holistic care is provided. The quality of life assessment

should be focused on the subjective suffering of the patient and on his or her individual

needs and wishes; based on the context in which the patient lives (Singer, Langendijk, &

Yarom, 2013). Assessment of the head and neck quality of life and overall quality of life

in head and neck cancer patients should be a standard of care that drives education and

appropriate interventions towards improving quality of life outcomes and the response to

treatment.

By focusing on patient preferences, needs, and values health outcomes will

improve; and ultimately, there will be a reduction in emergency hospital admissions and

emergency department visits (ED). Within the last ten months at Mercy Health Saint

Marys a total of thirteen hospital admissions or ED visits by head and neck cancer

patients were identified:

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Two hydration related complications

Three decline in nutritional status
Three aspiration pneumonia
Three thrush requiring IV antifungal
Two uncontrolled pain due to mucositis or radiation dermatitis

As patients are admitted to hospital due to side effects from treatment they will endure

further financial implications. Those patients receiving all three treatments (surgery,

radiation, and chemotherapy) have the highest cost of care, ranging from $96,520 in the

Medicare population to $153,892 in the Commercial population (Jacobson, et al., 2012, p.

7). Implementation of a clinical guideline is needed within the Mercy Health Saint

Marys Head and Neck Cancer Program to assure continual assessments are completed,

and education, guidance, and reinforcement is offered to each patient; otherwise, patients

are put in jeopardy of experiencing avoidable adverse events and significant financial

burden.

Review of Literature

As more and more patients are being diagnosed with head and neck cancers,

treatment modalities will continue to advance to provide the best care to each patient.

However, treatment of head and neck cancer has a great impact on the patients life

(Dinescu et al., 2015). Due to the complexity of the treatment regimens, patients have a

marked deterioration in physical functioning; especially if they go through surgery prior

to chemotherapy and/or radiation. An important component of the patients care is to

assess their quality of life by the use of an evidence based questionnaire, which enables

the provider to identify the patients ever changing needs during the prescribed cancer

treatment period and beyond (Ehrsson, Sundberg, Laurell, & Langius-Eklof, 2015).
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Head and neck cancer patients receive extensive treatments that place them at

greater risk for morbidity and mortality because of the acute and late side effects

associated with these treatments. These patients have multiple, unique, and challenging

symptoms due to their disease and treatment side effects such as xerostomia, taste

disturbances, dietary restrictions, dysphagia and pain, fatigue, distortion of physical

appearance, permanent disfigurement and infirmity which has an impact on the patients

quality of life, thus, the concept of quality of life is extremely important for these

patients(Shavi et al., 2015, p. 23).

Evaluation of quality of life and symptoms are becoming increasingly essential

and beneficial for the treatment of patients with chronic diseases, such as cancer and

particularly head and neck cancer. Oliveria et al. (2014) provides insight that pain and

symptom control are the best predictors of overall quality of life scores because the

effects of unrelieved pain and poorly managed symptoms have been shown to interfere

with the activities of daily living, mood, mobility, and independence. When symptoms

are controlled, quality of life tends to increase.

Quality of life is a multidimensional construct because it is compromised by

clinical and sociodemographic factors (Sterba et al., 2016). As indicated by Oliveira et al.

(2014) quality of life is self-reported by the patient and all-multidimensional factors need

to be considered, including financial burden. Health care cost for patients are rising in the

U.S. and cancer diagnosis and treatment contributes significantly to these costs (Jacobson

et al., 2012). Head and neck cancer patients in particular have extensive treatment

regimens, along with short and long-term side effects as a result of their treatment.

Further, head and neck cancers are extremely expensive to treat, have high morbidity, and
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of those individuals that survive only 48% return to work (Jacobson et al., 2012, p 1).

Patients that receive all three-treatment modalities have the highest health care cost when

compared to one-modality treatment. Jacobson et al. (2012) states that multimodality

treatment has twice the cost of single modality; three treatments modality can cost from

$96,520 in the Medicare population to $153,892 in the commercial insurance population.

As the cost associated with treatment starts to accumulate, the patients quality of life will

need to be monitored to assess the impact from the financial burden of treatment as well

as the long-term side effects.

Over the past several years determining how to measure and quantify quality of

life has been a challenge for practitioners and nurses. Being able to assess quality of life

and symptoms in head and neck patients will help practitioners and nurses best manage

the debilitating problems with swallowing, speech, and hearing, as well as the

psychological effects of loss of function and change in body image (Leung et al., 2011).

Surveys or assessment tools addressing quality of life in head and neck patients need to

be multi-dimensional incorporating physical, psychological, social, financial, and

emotional functional domains (Leung et al., 2011; Shavi et al., 2015; Singer et al., 2013).

Unfortunately, quality of life is not routinely measured in clinical practice. As

health care professionals begin to use a tool to assess quality of life and symptoms, they

will be able to direct their attention to the most important symptoms and provide

counseling for appropriate interventions toward improving quality of life outcomes and

the response to the treatment (Shavi et al. 2015). Assessing quality of life needs to be

based on the patients perspective and be disease specific. According to multiple studies,

the European Organization for Research and Treatment of Cancer Quality of Life
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Questionnaire Core-30 (EORTC QLQ-C30) and head and neck module (QLQ_H&N35)

are two of the best questionnaires that need to be used together to assess quality of life in

head and neck cancer patients (Oliveira et al, 2014; Leung et al. 2011; Shavi et al. 2015;

Kovacs et al. 2015; Dinescu et al. 2015). Once a tool to assess quality of life and

treatment related symptoms in head and neck cancer patients is implemented to direct

interventions and education, quality of life of patients should begin to increase.

Purpose Statement

The purpose of this project is to implement a clinical guideline to direct care that

is respectful and responsive to individual patients preferences, needs, and values and

ensures that patient values guide all decisions within the Mercy Health St. Marys Head

and Neck Cancer Program over a 6-month period.

Aim
An opportunity exits to improve assessment, diagnosis, and management of head

and neck cancer patients by integrating a clinical guideline to assist the provider and

patient in decisions about appropriate healthcare that impacts the quality of life of

patients receiving radiation and/or chemotherapy. The process starts at diagnosis and

continues through survivorship. Success will be measured by maintaining self-reported

quality of life in 75% of head and neck cancer patients.

Organizational Assessment

Currently the Head and Neck Cancer Program does not routinely measure

quality of life and direct care based on self-reported patient perceptions. To facilitate

timely and appropriated evidenced-based management of patient reported quality of life

symptoms and treatment related symptoms patients perception of quality of life

indicators need to be considered. A SWOT analysis is used to identify this opportunity of

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change for the Head and Neck Cancer Program at Lacks Cancer Center at Mercy Health

Saint Marys.

Strength
Leadership support
Head and Nurse Navigator coordinating
best care for patients
Team members of multidisciplinary team
with a wide range of experience and
knowledge
Opportunities
Improve communication between
departments
Create a team-orientated culture
Improve patient center care
Increase patient satisfaction and
involvement/engagement in care
Decrease hospital and ED admissions
Decrease morbidity related to treatment
related symptoms
Weakness
Communication barriers between
departments
Three different physician practices
managing patients during treatment
Staff reluctant to change practice
Threats
Decrease quality of care without
improvement
Change management has to be effective
for the process to work
Overwhelm patients
Potential reimbursement cuts
Unstable financial climate

Strengths

The Head and Neck Cancer Program is ran by a nurse navigator who coordinates

all patient appointments along with being a one-point contact for the patient during the

continuum of care. The nurse navigator is crucial for this quality improvement project

since majority of patient related problems falls on the nurse navigator. As the cancer

center is looking at a redesign in care coordination and patient centered care, leadership

support for this quality improvement project would align with the new goal of the cancer

center. With support of the leaders potentially this will motivate physicians to accept this

project. Lastly the multidisciplinary team meets weekly to discuss head and neck cancer

patients on treatment by including them in this project will enhance continuity of care

along with meeting patients expectations.

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Weakness

As advances in technology and cancer screening continue to grow having three

different physician practices to coordinate care and symptom management leads to

communication break down. Patients information is not being transmitted between the

three practices effectively ultimately affecting patients care. Lastly many of the staff

members are reluctant to change due to being set in their ways.

Opportunities

This quality improvement project brings great opportunities not just for patients

but also the healthcare team. The team-orientated culture will provide patients with a

sense of peace that everyone is on the same page along with continuity of the care the

patient is to receive. Ultimately this will improve patient center care because the patient

will be at the forefront of the decision making process right from the beginning. Next as

care is being implemented based on patient self-reported quality of life assessment,

patients will feel involved and engaged in their care along with satisfied with the care

they receive. The communication between the different departments will improve

because each provider will be invested in the patients care. As the healthcare team will

be addressing patient reported quality of life issues and symptom management aspects

patient admissions to the hospital and ED will decrease in result of timely management of

symptoms. These opportunities impact the patients satisfaction of care provided by each

and every healthcare provider.

Threats
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Lastly this quality improvement project provides a few threats that need to be

addressed upfront before change is put in place. Quality of care is being compromised

due to the disjointed care patients are receiving. The change needs to be effective for this

process to work that all parties involved need to have buy-in. Lastly patients may feel

overwhelmed with two extensive tools that they will need to fill out at different intervals

during their treatment. Without making a change physician and hospital are looking at

potential financial climate and decrease reimbursement due to adverse events.

Budget

The maximum out-of-pocket funds for the project director will approximately be

$300. The associated cost for printing and copying the EORTC QLQ-C30) and

QLQ_H&N35 questionnaires that will be used at different intervals during the project

will be $50. Material for initial education to the healthcare staff will be $100. Lastly an

incentive of gift cards will be provided to the healthcare professionals at different

increments during the project implementation. The incentive cost will be $150.

Methods

Structural Framework

The American Association of Critical-Care Nurses (AACN) Synergy Model for

Patient Care will provide the structural framework for this quality improvement project.

This model is a reconceptulized model of certified practice. Providing the best quality of

care to head and neck cancer patients, by focusing on the quality of life aspect, results in

the needs and concerns of patients influencing and driving nurse competencies. Per the

AACN synergy model, synergy results when the needs and characteristics of a patient,

system are matched with nurse's competencies. When nurse competencies stem from
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patient needs and the characteristics of the nurse and patient synergize, optimal patient

outcomes can result (AACN, 2015). This model assumes that the whole patient will be

considered. A goal of this model is to restore a patient to an optimal level of wellness as

defined by the patient, which is reaching towards the patients definition of his/her quality

of life (AACN, 2015).

Head and neck cancer patients are very compromised patients that have very

severe or complex needs during their cancer treatment journey. Using this model, the

needs of the patient and family will be driving the nurses practice. As noted by AACN

(2015), this requires nurses to be proficient in the multiple dimensions of the nursing

continuums. Using the Synergy Model for Patient Care as a framework will help improve

quality of life for head and neck cancer patients by providing the appropriate

interventions focused on their concerns and needs.

All of the eight nursing competencies within the Synergy Model are essential in

providing care to the head and neck cancer population. These competencies are defined

as clinical judgment, advocacy and moral agency, caring practice, facilitation of learning,

collaboration, systems thinking, response to diversity, and clinical inquiry. Three main

nursing competencies that are very important to focus on for this project are clinical

judgment, clinical inquiry, and collaboration. Clinical judgment is used in each

interaction with the patient by synthesizing, interpreting, and making decisions on the

assessment data. Clinical inquiry means observing, questioning, smelling, sensing,

intuitively, listening, and integrating findings into oneself for the benefit of the patient"

(Hardin & Hussey, 2003, p. 75). Lastly collaboration results in the use of resources in the

community and organization to meet the needs of the patient. Using this model as a
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framework for this project will help provide the best care to the patient while facilitating

interventions and education based on the quality of life tool and site-specific symptom

tool. This model allows the nurse to recognize how vulnerable the patient is and how to

provide the right direction and education to optimize patient outcomes.

Design

This project involves implementation of a head and neck quality of life and site-

specific symptom-screening tool for patients receiving radiation and/or chemotherapy.

Then health care providers in the radiation oncology department will use a rapid-cycle

quality improvement process to improve screening and symptom management.

Ultimately patient reported quality of life and symptom screening information will be

obtained as an aggregate.

Setting and Subjects

This project will be carried out at Mercy Health Saint Marys Lacks Cancer

Center Radiation Oncology Unit in Grand Rapids, Michigan. The target population

includes all head and neck cancer patients receiving radiation therapy and/or

chemotherapy. The Head and Neck Cancer Program averages three new consults a month

with approximately five patients on treatment a week. This quality improvement project

will include a sample size of 12 patients all diagnosed with head and neck cancer as

identified by the National Comprehensive Cancer Network guidelines. Only adults age 18

years or older will be eligible for this quality improvement project. Inclusion criteria will

include being age 18 years or older, able to fluently speak, read, and understand English,

and receiving radiation treatment at Mercy Health Saint Marys. Recruitment for this

improvement project will begin in January 2017 until 12 patients are identified.
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Instruments and Data Collection

For all patients data will be abstracted from paper and electronic medical records

(EMR). Patient baseline data including demographics, smoking and/or alcohol history,

and comorbidities will be obtained from the EMR in radiation oncology. The European

Organization for Research and Treatment of Cancers Quality of Life Questionnaire,

Core-30-version 3 (EORTC QLQ-C30) and specific module Head and Neck (EORTC

QLQ_H&N35) questionnaires will be used at different intervals during the treatment

trajectory to provide more comprehensive assessment of patient reported difficulties

(Loorents, Rosell, Wiliner & Borjeson, 2016, para. 10). Both of these instruments are

robust and have widespread clinical usage with established reliability, validity and

sensitivity to change as described by Loorents et al. (2016). The type of scales used by

both of these questionnaires are answered from 1 to 4 where 1= not at all, 2= a little, 3=

quite a bit, and 4= very much. Lastly some symptoms are answered by yes or no. See

Appendix A and B for samples of both questionnaires.

Prior to the quality improvement initiation the project director (Jamie Meyer) will

provide the nurse clinicians and physicians in the radiation oncology department

education. This education will be directed on how to administer the questionnaires along

with information outlining the project, risks and consent process. Baseline measurement

of patient reported symptoms would be assessed by the use of both questionnaires at

consultation prior to radiation treatment start. Subsequently the patient will fill out both

questionnaires during different treatment trajectory timeframes: weekly on-treatment

visit, last day of radiation, one month follow up, and three month follow up appointment.

The questionnaires will be assigned study ID numbers by the project director making sure
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the tools are de-identified. Post administration of both of the questionnaires at the

specific timeframes the questionnaires will be placed in a designated place for data entry

into a database by the project director.

Lastly information gleaned from both of these questionnaires will help healthcare

providers offer patient specific education, provide appropriate interventions, and manage

site-specific side effects during the weekly on0treatment visits and follow up

appointments. Healthcare providers will be able to identify education needs such as oral

care, nutritional aspects, pain management, and radiation site effects. Next interventions

such as speech therapy, social worker consultation, physical therapy referral, and

medications will be ordered for patients depending on their specific needs. Finally site-

specific side effects reports by the patient will be managed on a timely manner by the

multidisciplinary team.

Measures and Analysis

Quality of life and symptom management scores will be analyzed and calculated

according to the EORTC QLQ-C30 scoring manual. Then all of the EORTC scale and

single item score measures will be converted to a scale ranging from 0 to 100. All data

will be entered into an Access database. Using an SPSS system will provide the statistical

analyses whereas the Mann-Whitney U test will be used to investigate differences.

Institutional Review Board

This project will be submitted for Institutional Review Board (IRB) approval as

an expedited project due to minimal risk to the subjects. The subjects in the process may

have minor discomfort during the process due to the nature of the questions asked.
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Approval from the University of Detroit Mercy and Mercy Health Saint Marys IRB will

be obtained prior to any quality improvement activities.

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Reference

American Society of Clinical Oncology (2015). Head and neck cancer. Retrieved from

http://www.cancer.net/cancer-types/head-and-neck-cancer/statistics

AACN. (2015). The AACN Synergy Model of Patient Care. Retrieved from

www.aacn.org

Dinescu, F., Tiple, C., Chirila, M., Muresan, R., Drugan, T., & Cosgarea, M. (2015).

Evaluation of health-related quality of life with EORTC QLQ-C30 and QLQ-

H&N35 in Romanian laryngeal cancer patients. European Archives of

Otorhinolarngolpgy. 10, 1-6. Doi:10.1007/s00405-015-3809-0

Ehsson, Y., Sundberg, K., Laurell, G., & Langius-Eklof, A. (2015). Head and neck

cancer patients perceptions of quality of life and how it is affected by the disease

and enteral tube feeding during treatment. Upsala Journal of Medical Sciences,

120, 280-289.

Gilbert, J., Murphy, B., Jackson, L., Brocksten, B., Ganz, P., Brizel, D., & Fried, M.

(2015). Quality of life in head and neck cancer. Retrieved from

http://www.uptodate.com/contents/quality-of-life-in-head-and-neck-cancer

Hardin, S. & Hussey, L. (2003). AACN synergy model for patient care case study of a

CHF patient. Critical Care Nurse, 23(1), 73-76.

Jacobson, J., Epstein, J., Eichmiller, F., Gibson, T., Carls, G., Vagtmann, E., Wang, S., &

Murphy, B. (2012). The cost burden of oral, oral pharyngeal, and salivary gland

cancers in three groups: Commercial insurance, Medicare, and Medicaid. Head &

Neck Oncology, 4(15), 1-17.

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Kluit, M., Ros, W., & Schrijvers, A. (2014). Nurse-led clinics for patients with chronic

diseases in hospital and transmural care organizations. Clinical Nurse Specialist,

332-342.

Kovacs, A., Stefenelli, U. & Thorn, G. (2015). Long-term quality of life after intensified

multi-modality treatment of oral cancer including intra-arterial induction

chemotherapy and adjuvant chemoradiation. Annals of Maxillofacial Surgery,

5(1), 26-31.

Leung, S., Lee, T., Chien, C., Chao, P., Tsai, W., & Fang, F. (2011). Health-related

quality of life 640 head and neck cancer survivors after radiotherapy using

EORTC QLQ- C30 and QLQ-H&N35 questionnaires. Bio Medical Central

Cancer, 11(128), 1-10. Doi: 10.1186/1471-2407-11-128

Loorents, V., Rosell, J., Willner, H., & Borjeson, S . (2016). Health-related quality of life

up to 1 year after radiotherapy in patients with head and neck cancer (HNC).

SpringerPlus 5, 669. Doi: 10.1186/s40064-016-2295-1

Oliveira, K., Zeidler, S., Podesta, J., Sena, A., Souz, E., Lenzi, J., . Gouvea, S. (2014)

Influence of pain severity on the quality of life in patients with head and neck

cancer before antineoplastic therapy. Retrieved from

http://biomedcentral.com/1471-2407/14/39

Shavi, G., Thakur, B, Bhambal, A., Jain, S., Singh, V., & Shukla, A. (2015) Oral health

related quality of life in patients of head and neck cancer attending cancer hospital

of Bhopal City, India. Journal of International Oral Health, 7(8), 21-27.

Singer, S., Langendijk, J., & Yarom, N. (2013). Assessing and improving quality of life

in patients with head and neck cancer. Retrieved from

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http://meetinglibrary.asco.org/sites/meetinglibrary.asco.org/files/Educational%20

Book/PDF%20Files/2013/EdBookAM201333e230.pdf

Sterba, K., Zapka, J., Cranos, C., Laursen, A., & Day, T. (2016). Quality of life head and

neck cancer patient-caregiver dyads. Cancer Nursing, 39(3), 238-250.

Webber, M. (2008). The role of the CNS in the care of patients with head and neck

cancer. Cancer Nursing Practice, 7(8), 35-39.

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Appendix A
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Appendix B