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Multidisciplinary program reduces time from cancer diagnosis to treatment initiation
A program at Cleveland Clinic Taussig Cancer Institute led to sustained reductions in the time between cancer diagnosis and initiation of treatment, according to results of a case study.
The multidisciplinary program — led by Brian J. Bolwell, MD, chairman of Taussig Cancer Institute — reduced median time from diagnosis to treatment for all cancer types by 33% during a 4-year period, from a baseline of 39 days to 26 days.
In addition, the proportion of patients who experienced time-to-treatment delays of more than 45 days decreased from 30% to 14%.
“Delays in time to treatment initiation are a result of multiple, seemingly small process issues that add up to several days’ worth of lost time,” the researchers wrote. “Continuous improvement processes and value-stream mapping can help identify inefficiencies. The goal should be to map across the patient’s entry into the health care system and not simply focus on one or two steps.”
HemOnc Today spoke with Bolwell about how he and other institute officials assessed the problem, what their internal analysis showed, and the strategies they employed to reduce time to treatment initiation.
Question: How did this effort come about?
Answer: We are acutely aware that patients with cancer are scared when they are diagnosed, and receiving treatment quickly is good for many reasons. About 6 years ago, we had access to data on time to treatment — defined as time from diagnosis to the first definitive treatment, such as surgery or infusional therapy. We noticed this was more than 40 days across major academic cancer centers, which is a very long time. We then found that the metrics were getting worse over time — it was better in the 1990s and early 2000s than it is today. Our own data showed the time was not significantly better than what was reported in this national database. We wanted to make this better.
Q: How did you and colleagues assess the problem?
A: The first thing we did was organize into disease-based teams. Using breast cancer as an example, we wanted to have the breast cancer group act as an entity and include surgeons, medical oncologists and radiologists, etc, and they became a fully functional program. We then decided on appropriate goals, including reducing time to treatment, developing care paths and tumor board participation. We formed a scorecard so we could track performance and we had to figure out how to track time to treatment internally because the data are not easy to obtain. We also had to help the teams do their work. Each program has a program manager and a patient navigator. One thing that was really important to us was to track outliers — patients waiting more than 45 days for treatment. We wanted to dramatically decrease this number.
Q: What did the internal analysis show?
A: Not surprisingly, there are a lot of elements of time to treatment. First is access and identifying how people enter the health care system. There are many different access points depending on the cancer type. Second, we looked at everything that goes into the journey from the first diagnosis to treatment. Some patients need staging, so we needed to figure out how to streamline pre-authorizations required for tests or radiation therapy, for example. Surgery is another area where pre-authorization is needed, and we needed to make access as rapid as possible. We found that when we gathered people collectively as teams, a lot of progress could be made. But, a lot of work goes into this. For about 5 years, every other week, we held an after-hours executive committee meeting to discuss best practices so all programs learned from each other.
Q: Were you surprised by any of your findings?
A: An unexpected finding was that some patients chose to delay treatment for various reasons, including preference for a specific physician, work-related issues or family commitments. In setting realistic goals for reductions in time to treatment, these preferences need to be anticipated.
Q: What strategies did you adopt to reduce time to treatment initiation, and what effect did those strategies had?
A: Paying attention to access and doing everything we can to get patients into treatment quickly is now a part of our culture. Patients appear relieved and grateful for the fact that we will get them in to treatment faster. Access to treatment is not just something we talk about, but something we live every day, which has strengthened programmatic development. Our programs are now functioning much better as teams from when we first started this initiative.
Q: What should other institutions do to achieve the same improvement?
A: First, commit. This has to have buy-in at the highest levels of leadership. I socialized this issue of time to treatment with every leader at Cleveland Clinic. Each program needs to create an environment in which physicians are willing to work together as a team. Finally, institutions need to be willing to resource the initiative and data need to be generated. Generating data, socializing it and celebrating wins are all important. Any organization can do this if they have a true commitment to it. – by Jennifer Southall
Reference:
Khorana AA and Bolwell BJ. Reducing time-to-treatment for newly diagnosed cancer patients. Available at: catalyst.nejm.org/time-to-treatment-cancer-patients. Accessed on April 12, 2019.
For more information:
Brian J. Bolwell, MD, can be reached at Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave., Cleveland, OH 44106.
Disclosure: Bolwell reports no relevant financial disclosures.