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Vlad Sandulache, Anita Sabichi, George Chen, and Scott Charnitsky

Background: The Veterans Health Administration (VHA) is the only nationally integrated healthcare delivery system in the United States. The vertical and horizontal integration of the VHA make it an ideal environment for development of tools designed to streamline cancer diagnosis and treatment. Head and neck cancer (HNC) remains a difficult disease to diagnose and treat. Delivery of multimodality treatment for advanced HNC is challenging at both academic centers and in the community setting. This problem is magnified by the increased incidence of HNC, powered by an epidemic increase in the incidence of human papilloma virus (HPV)–associated oropharyngeal cancer (OPC). Objective: To develop a non–resource-intensive approach to improving: (1) time to treatment initiation and (2) compliance with optimal treatment package time for HNC patients. Methods: Retrospective analysis of 300 patients with a diagnosis of HNC from the Michael E. DeBakey VA Medical Center (MEDVAMC) was used to generate baseline data (2000–2010) for: (1) time to treatment (surgery, 24 days; radiation, 48 days) and (2) treatment package time <100 days compliance (68%). We developed a tool available to providers and clinic staff to prospectively track patients from initial referral, through diagnosis and treatment, along with completion of ancillary studies (modified barium swallow) and completion of the survivorship care plan. Between June 2016 and October 2018, 350 patients were tracked using this tool; 275 patients were new HNC diagnoses. Results: Implementation of the tracking tool reduced diagnosis to treatment start (mean, 44 days; median, 26 days). Compliance with treatment package time <100 days was increased to 95%; compliance with initiation of adjuvant radiation within 6 weeks of surgery was increased to 75%. Utilization of the tool allowed for streamlined surgical care, particularly through integration of dental extractions into the oncologic resection, and facilitated timely initiation of adjuvant radiation for advanced HNC. Conclusions: It is possible to improve: (1) time to diagnosis, (2) time to treatment initiation, and (3) treatment completion rates for complex HNC requiring multimodality treatment without additional resource utilization. However, appropriate implementation requires a robust multidisciplinary treatment team, with appropriate “buy in” from all participants and is facilitated by the presence of a fully integrated health care delivery system.