Quality indicators in head and neck oncology

This thesis shows the complexity and multidimensional concept of quality of care in head and neck cancer. The selected topics represent examples of quality assessment using structure [centralization (Chapter 2) and variation of care (Chapter 3)], process [waiting time (Chapter 4) and pathologic specimen handling (Chapter 5, 6)] and outcome indicators [influence of volume and variation of care on outcome (Chapter 3) and specific outcome of rare head and neck tumors arising in the salivary gland (Chapter 7, 8)]. Head and neck cancer care in the Netherlands is centralized in specific head and neck cancer centers, but nonetheless the care given varied per head and neck center. We showed that volume may play a role in this variation, but several other quality related aspects of head and neck cancer care are of influence as well. For instance: waiting time differences, as we showed that waiting time has significant influence on outcome. What we also showed is that pathology specimen handling is another key factor, and that non-standardized workflow leads to differences and non-uniformity. For the more rare types of head and neck cancer, like salivary gland tumors, the low volume in the Netherlands makes quality assurance almost impossible. For proper quality assessment and thereby quality assurance, based upon this thesis, redistribution of rare head and neck cancers appears inevitable. The variation in numbers and treatment we found could have been biased by case-mix factors we did not include. The relatively small sample size of our study population limited us regarding some statistics.