Total Laryngectomy Surgery in the United States and Spain : A Tale of Two Healthcare Systems

For individuals entering the field of health professions, an understanding of variation among global health systems can foster more informed viewpoints when working with multicultural populations. To investigate this relationship between the Spanish and U.S. systems, I analyzed the macro-structure of the healthcare systems in the United States and Spain to better understand plans of treatment, economic burden to patients and quality of life of patients undergoing total laryngectomy surgery in each country. A critical review of scholarly journals and studies relating to the healthcare systems of each country and total laryngectomy surgeries showed a unique picture of each system. When compared to the Spanish healthcare system, the United States’ health system is associated with increased financial burden to the patient and more difficulties in coordinating appointments and procedures needed for successful treatment. This is attributed to the Spanish system’s universal healthcare without copay and supportive care. Other factors such as low socioeconomic status and difficulty regarding access contribute to poorer outcomes in both healthcare systems. Engaging with the differences between systems illustrates that care can be achieved in different ways; this is a crucial lesson in increasing the knowledge base and intercultural competence of the upcoming workforce in United States healthcare. TOTAL LARYNGECTOMY ACROSS HEALTH SYSTEMS 3 Total Laryngectomy Surgery in the United States and Spain: A Tale of Two Healthcare Systems The nature of a country’s health system can be seen as a reflection of not only the needs of its people, but also common cultural opinions regarding competent and holistic care. The evolution of both Spain’s and the United State’s healthcare systems over the course of recent history reveals the impact of a multitude of factors such as cultural values, legislation, and socioeconomic diversity. The juxtaposition of the predominately privatized system of the United States and the public healthcare system of Spain also serves to differentiate these care systems. The analysis of these healthcare systems through the lens of a standardized surgery such as total laryngectomy exposes the nature of each health system from point of entry to long-term care. To gain a deeper understanding of each health system, this paper analyzes the cultural, economic and legislative elements of the US and Spanish healthcare systems through the narrow scope of treatment for individuals undergoing total laryngectomy (TL) surgery. This project reviews the current practices of each system and provides insight into the evolution of care throughout recent history. The first portion of this project details the hypothetical course of the patient population in both the United States and Spanish healthcare systems following a complete laryngectomy. This includes aspects such as procedure, costs and related therapy considering important population factors such as age, socioeconomic status and patient history. The second objective of this project is to explore and define the keystone traits of both the Spanish and US healthcare systems. This includes investigation into basic principles, balance of private and public financing, access to care, legislation, and the role of socioeconomic status in each system. Hallmarks of each system provide the opportunity for understanding the diverse pathways by which quality is achieved. Given the growing diversity of the United States, efforts to increase TOTAL LARYNGECTOMY ACROSS HEALTH SYSTEMS 4 awareness of global health systems serve to positively impact future health professionals and their efforts to better serve their patients through interculturally appropriate care. Total Laryngectomy Treatment Patterns In order to accurately analyze the characteristics of TL in both respective populations, it is first necessary to clearly define the term total laryngectomy along with basic associated characteristics. According to Remacle and Eckle (2010), the term total laryngectomy refers to, “removal of all laryngeal and associated strap muscles, from hyoid bone and epiglottis superiorly to the tracheal rings inferiorly” (Remacle & Eckle, 2010, p. 229). This procedure is commonly used as treatment for cancer of larynx or surrounding areas. TL is just one of many different surgical routes in head and neck cancers with both advantages and disadvantages. When weighing procedure options, the main drawback in choosing a total laryngectomy is the mandate of permanent tracheostomy (Remacle & Eckle, 2010). The encyclopedia of health explains that during a total laryngectomy procedure, a tracheostomy is performed in which the trachea is brought up through the skin of the front of the neck to create a hole or passageway for breathing (“Larynx”, 2018). This characteristic of total laryngectomy brings both psychological and physiological changes that impact the patient and requires significant adjustments to daily functions. Even with the mandate of tracheostomy and subsequent loss of natural voice, TL is the gold standard in treatment for advanced laryngeal cancers. The researchers Remacle and Eckle (2010) found that due to the comprehensive nature of tissue removal, TL maintains the highest rate of patient survival in spite of emerging technologies. Given the superior outcome of this procedure, the benefits many times outweigh the costs when considering successful treatment options for those diagnosed with cancer of the larynx. TOTAL LARYNGECTOMY ACROSS HEALTH SYSTEMS 5 The clinical decision to pursue total laryngectomy is based on many patient-specific criteria. Primarily, in a study of patients opting for TL, Fagan (2014) typifies candidates as those with cancers of the larynx that are severe, widespread and aggressive in nature. Therefore, TL is the main course of treatment in tumors of aggressive natures. Also worthy of brief mention is the small portion of individuals who undergo TL without indications of cancer. Although the majority of TL surgeries are necessitated for cancer treatment, a minority of procedures are performed due to Chondronecrosis, a condition resulting in erosion of laryngeal structures as denoted by Remacle and Eckle (2010). Chondronecrosis is most often controlled by less drastic measures with TL surgery only seen as a last resort. With most patients worldwide undergoing TL as a course of cancer treatment, it falls in line that the overall focus of this analysis considers this majority population. With advancements in clinical research and techniques, it is important to understand that total laryngectomy is not the sole modality used in the treatment of laryngeal cancers. Emerging therapies are aimed at preserving the structures of the larynx while simultaneously maintaining successful survival rates. Currently, technologies are utilizing chemotherapy-based approaches in tandem with more minor surgical intervention as a means of successful treatment (Remacle & Eckle, 2010). Less invasive manners such as these are mostly being utilized as a primary course of treatment in low and middle grade cancer diagnoses. Attempts have been made to ascribe such treatment to more advanced head and neck cancers, but with little success. When comparing nonsurgical organ preservation modalities with total laryngectomy, Xiaoyuan, Qi Zhou, Fu, Zhou, and Zhang (2016) found that TL surgery was still the most beneficial course of treatment for individuals with severe or aggressive tumors. This study effectively highlights that although new treatment options are emerging, the effectiveness of such modalities is still considerably TOTAL LARYNGECTOMY ACROSS HEALTH SYSTEMS 6 limited. A second option for some patients with cancer of the head and neck is varying degrees of partial laryngectomy. Partial laryngectomy is often preferred if feasible as there is potential for restored function of the larynx and natural voice. Candidacy for such procedures vary and is based in large part on tumor size and location (Xiaoyyuan et al., 2016). Although these courses of treatment are increasing, total laryngectomy remains the most comprehensive manner of treatment for laryngeal cancers. Total Laryngectomy Patient Characteristics In contrast to many idiopathic cancers, there is a clear consensus regarding general demographics of patients who undergo a total laryngectomy. Recent studies have made use of surgical data along with other patient records to gain a comprehensive picture of the patient population at hand. One study implemented by Gupta, Johnson and Kumar (2016) looked at data from North American and European health systems and found that, although there is variation among countries, the international incidence of laryngeal cancer remains steady (M = 2.1 per 100,00). Additionally, aggregate data in this analysis found that hazardous occupational exposure and behavior patterns such as smoking have the greatest impact on patient population (Gupta, Johnson & Kumar 2016). In a similar study, Simard, Torre and Jamal (2014) more deeply analyzed behavioral risk factors on a global scale and found tobacco exposure and consumption stood as the greatest risk factor in cancers of the head and neck. Use and abuse of alcohol was also noted as a contributing factor with the combination of tobacco and alcohol showing the greatest impact. In perhaps one of the most striking findings of their study, the researchers report that smoking is the predominant contributor (75%) to the global prevalence of head and neck cancers (Simard, Torre & Jamal, 2014). Both the US and Spain each have a long history of tobacco use and smoking, with this history playing an important role in the modern day TOTAL LARYNGECTOMY ACROSS HEALTH SYSTEMS 7 population. In particular, Simard, Torre and Jamal (2014) report a surge in popularity in the use of recreational tobacco in the United States in the early 1960s, while the European nations studied lacked these