Another key part of the initiative was identifying reasons for care delay. This involved mapping — sometimes with as many as 100 steps — the processes that took place in between a patient’s initial referral to the cancer institute and treatment initiation. There was enormous disparity in cancer types, with the most complex being pancreatic and some varieties of breast cancer. “We made huge white boards looking at every step to see if we could make specific changes to reduce time-to-treatment,” the authors wrote.

Once the researchers identified reasons for delay, they were in a better position to reduce many of them, including addressing slowness to make appointments or receive approval for treatments. Some reasons for delay were, however, difficult to address, including the “unexpected” finding that patients often chose to delay treatments for personal reasons, such as a desire to consult with a particular oncologist.

A key innovation of this initiative was, however, the data infrastructure and huddle software developed to improve communication and reduce wait times. The researchers noted, as a result of their data analyses, that full-time staff members were necessary to improve cross-disciplinary communication and coordination; once hired, these staff members helped to reduce the administrative burden on physicians and improve the effectiveness of the “Teams of Teams.”

Using these relatively low-cost tactics, the researchers effectively reduced the median time to treatment by about 13 days over a sustained period. The number of patients who had delays to treatment initiation (defined as at least 45 days from diagnosis or referral) was also reduced by more than half — from 30% to 14%. Furthermore, the researchers noted an “increased recognition of patient preferences in treatment initiation.”

This initiative, while a clear signal that time to treatment initiation is an addressable issue in oncology, nonetheless would likely face significant barriers to implementation in the health care system as a whole. 

“I think barriers in the United States are fairly common and include access to physicians for diagnosis and workup and logistics of starting treatment,” said Dr Khorana. “These include molecular testing of tumors, which is becoming increasingly utilized, as well as prior authorization processes by third-party payers for both completing diagnosis (imaging) and starting treatment (approval of therapy).”

Dr Khorana noted, however, that some of these issues are specific to the United States, and may not be barriers in other countries, including the United Kingdom.

The researchers found that there is no single, simple solution to the issue of time between diagnosis and treatment, and while barriers to implementation of their process-based approach may be significant, the other methods used can, nonetheless, significantly reduce time to treatment initiation, which in turn may reduce anxiety, improve quality of life, and potentially even improve survival among patients.

“Although we have made substantial progress, we believe there are still additional gains that are possible,” said Dr Khorana. “We are working closely with third-party payers to see if we can reduce cumbersome and unnecessary prior authorization processes. We are also focused on patients diagnosed outside of our system to improve access to initial appointments to reduce their time to treatment as well.”

References

  1. Khorana AA, Tullio K, Elson P, et al. Increase in time to initiating cancer therapy and association with worsened survival in curative settings: A U.S. analysis of common solid tumors. 2017;35:15 (suppl). Abstract 6557. 
  2. Robinson KM, Christensen KB, Ottesen B, Krasnik A. Diagnostic delay, quality of life and patient satisfaction among women diagnosed with endometrial or ovarian cancer: a nationwide Danish study. Qual Life Res. 2012;21(9):1519-1525. doi: 10.1007/s11136-011-0077-3
  3. Simunovic M, Rempel E, Thériault ME, et al. Influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival. Can J Surg. 2009;52(4):E79-E86.
  4. Yun YH, Kim YA, Min YH, et al. The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery. Ann Oncol. 2012;23(10):2731-2737.
  5. Campbell D. Waiting times for NHS cancer treatment are at worst ever level. The Guardian. https://www.theguardian.com/society/2019/jan/10/nhs-england-misses-multiple-targets-for-cancer-treatment. Published January 10, 2019. Accessed April 4, 2019.
  6. Bilimoria KY, Ko CY, Tomlinson JS, et al. Wait times for cancer surgery in the United States: trends and predictors of delays. Ann Surg. 2011;253(4):779-785.
  7. Bolwell BJ, Khorana AA. Enhancing value for patients with cancer: time to treatment as a surrogate for integrated cancer care. J Natl Compr Canc Netw. 2016;14(1):115-156.
  8. Bolwell BJ, Khorana AA. Reducing time-to-treatment for newly diagnosed cancer patients. NEJM Catalyst. https://catalyst.nejm.org/time-to-treatment-cancer-patients/. Published February 14, 2019. Accessed April 4, 2019.