Mar 25, 2019
Dr. Pennell talks with Dr. Genevieve Digby about the importance of timely care for cancer patients, and more specifically, lung cancer patients.
Hello, and welcome to the ASCO Journal of Oncology Practice
Podcast. This is Dr. Nate Pennell, medical oncologist at the
Cleveland Clinic and consultant editor for the JOP. On this month's
podcast, we're going to be talking about a new study from the JOP
Quality and Action series, titled Improving
Timeliness of Oncology Assessment and Cancer Treatment Through
Implementation of a Multidisciplinary Lung Cancer Clinic,
published online in the JOP, January, 2019.
Joining me today on this podcast is the author, Dr. Genevieve
Digby, assistant professor in the division of respirology at
Queen's University School of Medicine, where she's also the
clinical lead for the lung diagnostic assessment program. She has
an active interest in quality improvement projects, which is what
led to this paper that we're going to be discussing today. Dr.
Digby, thank you for joining me.
Thank you so much for the invitation.
Obviously, everyone likes to be seen as quickly as possible when
they're trying to get into the doctor, but can you give us just a
little bit of background into what led you to do this particular
quality project? Why is the timeliness of care more important for
cancer patients or, specifically, lung cancer patients?
So great questions, Nate. Timely care is very important for
patients, as you pointed out. In fact, the Institute of Medicine
has timeliness as one of the six dimensions of quality. And for
lung cancer patients this is particularly important, as we know
that there's evidence to show that patients who have delays in
their diagnosis or delays in treatment, that this is associated
with progression of disease, and there's evidence to show that more
advanced disease is associated with worse outcomes. And as we know
from the lung cancer screening trials, earlier detection of disease
is associated with better outcomes.
Not only is timeliness of care important for patients from the
point of view of getting their treatment underway, but it also is
important in terms of the anxiety and distress that patients have.
So we know that the longer delays are associated with more
distress, and lung cancer patients to begin with are some of the
patients who have the highest levels of anxiety and distress
amongst oncology patients. So for us, the study arose because of an
identification locally that there were delays in our care processes
in regards to transitioning patients from the diagnostic phase of
the lung cancer pathway to the treatment phase and a desire to
improve those care processes.
I think that that really resonates with me. I know at my
institution we've been paying attention to the time to initiate
treatment for a while, and it's not like going to see the
dermatologist. When you're diagnosed with cancer, you really have a
lot of anxiety, and you want to get in to get treatment as quickly
as possible. And of course, as you've mentioned, especially for
early stage lung cancer, there's pretty good data suggesting that
the longer someone waits to make a diagnosis, the more likely they
are to have their potentially earlier stage cancer turn into a
later stage cancer with worse outcomes. So I applaud you for
addressing this.
And in your particular project, you focused on the establishment of
a multidisciplinary clinic. And this is something where I think a
lot of the literature out there on looking at processes and time to
treatment has focused on that. So is there data suggesting that
multidisciplinary clinics specifically are a good intervention for
improving timeliness of care?
So that's a good question. And the literature varies in terms of
its robustness based on the type of cancer that we look at. So my
group published a systematic review looking at multidisciplinary
clinic models in lung cancer specifically. And we were surprised,
actually, by the relative paucity of data in terms of what the
optimal catalytic characteristics are, even just in terms of the
number of studies that's actually evaluated a multidisciplinary
clinic, per se.
In other cancer types, there is evidence that multidisciplinary
clinics lead to better collaboration between specialists. There is
some evidence, even in lung cancer, that perhaps there's better
compliance with staging guidelines and guideline-based care when
care is delivered in a multidisciplinary clinic. And there's also
some evidence, though limited again, especially for lung cancer,
surrounding the patient experience and patient satisfaction with
their care when it's delivered in a multidisciplinary clinic
model.
Yeah. Honestly, I don't think I've ever heard anyone argue that
there's a downside to a multidisciplinary clinic. But I do
appreciate studying measurable metrics that may demonstrate
benefits because, of course, you have to get support for these
sorts of things. So why don't you take me through your project's
design, and what were the goals that you tried to achieve?
So this is a quality improvement study. We started by identifying
what our overall goals and outcome measures were and how we would
go about achieving those goals. For us, the focus was to improve
our transitions from the point of care of receiving a diagnosis of
lung cancer through to starting treatment with an oncologist. So
this particular setup was due to the fact that in our center we
have a separate thoracic surgery program where patients with
suspected early stage disease directly go to a thoracic surgery
program and those with more advanced disease or suspected
non-operable disease are initially managed by a respirologist, and
then are seen through with the appropriate thoracic oncology
specialist subsequently.
So for us, we looked at our data, and we actually identified that
that time from transition, where a patient receives a diagnosis of
lung cancer, to when they're first assessed by an oncologist was
upwards of about two weeks. The time then to go on and start their
first treatment for cancer was in the range of 40 to 45 days. And
we identified that there was room to improve and set a target of
reducing both of these individual time frames by about 10 days.
We hypothesized that if it could improve timeliness to seeing an
oncologist from about 14 days to closer to 4 days-- 3 to 4 days--
that we would similarly lead to maybe about a 10-day improvement in
time to treatment on the other end. So our improvement plan was to
launch this multidisciplinary clinic. And we used a quality
improvement called plan, do, study, act cycles, or PDSA cycles, to
help facilitate that and fine-tune our multidisciplinary clinic
along the way to make it even more efficient.
That sounds great. It sounds like a very worthy project. So what
did you find?
We found that by implementing a multidisciplinary clinic, even
within a very short time of implementing it, that we were able to
significantly reduce the time from a patient's lung cancer
diagnosis to when they were first assessed by an oncologist. In
fact, just with the implementation of the clinic, we led to about a
10-day improvement. We fine-tuned our processes to help create
sustainability of the teams. Initially, there was still some
variability. And we were able to maintain about a 10-day
improvement overall over time.
What we found though, and what was really interesting, was that as
we went about our change processes, we had ongoing improvement in
time to treatment, so that time from lung cancer diagnosis to time
to first treatment. With our initial clinic implementation, we had
about a 10-day improvement in time to treatment as well. But as we
noticed, as we fine-tuned our processes, that improvement actually
increased such that we overall reduced time to treatment from about
40 days at baseline to 15 to 20 days by the end of our quality
improvement initiative.
And that is incredible. I think, to me, was the most impressive
thing is not so much that you, by moving up your evaluation by 10
days, you improved time to treat by 10 days, which makes perfect
sense, but that somehow implementing this entire project, you
greatly exceeded your expected improvement in time to treat. And
so, did you look at what specific interventions might have led to
that even better improvement than you expected?
So that's a great question. And as you said, what surprised us was
the extent to which timeliness, in terms of receiving first
treatment improved, even beyond just time to seeing an oncologist.
And when we considered the data, some of the things that came out
were likely the increase in collaboration that we were seeing
amongst specialists, particularly medical and radiation oncologists
in terms of being able to decide on a treatment plan a bit sooner
and get that plan up and running.
In fact, when we looked at the data, the patients that had the
greatest improvement in time to treatment were those with stage 2
and 3 lung cancer, and also including patients with stage 4 lung
cancer. And those are often-- especially stage 2 and 3-- where
patients are most likely to need a concurrent chemoradiation, where
the treatment plans are often decided together amongst the
radiation oncologist and the medical oncologist. And so having that
ability to discuss the treatment plans and come up with a clear
plan sooner is what we hypothesized is leading to be faster kind of
treatment.
To evaluate this further, we actually also have recently completed
a qualitative study, where we interviewed physicians, and including
patients and caregivers, about the impact of a multidisciplinary
clinic. And while I don't want to give away all the results yet
before it's published, one of the themes that comes up certainly
for the physicians and particularly oncologists is just the overall
ability to collaborate and have real-time discussions with each
other and with the patients about what their treatment plans would
be, leading to a faster implementation of that plan.
Well there you go, listeners. You're getting a sneak peek of a
future study going to be coming out of this group. But I think that
makes perfect sense. So again, as a group that has, at least
internally, been focusing on improving our time to getting patients
to treatment, I think just having an emphasis on studying how long
it takes to treat and that everyone understanding that it's a
priority to try to make that as short as possible seems to just
lead to improvements because everyone's aware that it's an
important aspect of treatment. And things tend to show improvements
without any real specific interventions taking place.
And then, of course, the multidisciplinary clinic. It makes perfect
sense that multidisciplinary care would be better coordinated. So I
think that that's a really nice validation of what you were trying
to do. So how would other centers that maybe are starting to look
at this, how would they take what you've done and apply it to their
own programs?
So that's a great question. I think there's a few things to
consider. Firstly, quality improvement processes can be instituted
in any organization. And part of quality improvement is identifying
what the main barriers are to achieving the timeliness of care
goals that an individual center has and just implementing the PDSA
cycles at their own institution to help achieve those targets
because the barriers can be different between different
organizations. So where possible, I think eliminating the silos
that exist in our care models of the traditional model of seeing
one person at a time and really trying to get people to work
together, that can be challenging administratively. But once those
barriers are overcome, it's actually more convenient for people to
really work collaboratively to improve patient care as a whole.
That's great. And this really fits in nicely with both the US
National Cancer Institute and ASCO, in particular, have really paid
a lot of attention in recent years to teamwork and building team
science to help improve outcomes. And I think that your study is a
wonderful example of how that can lead to direct and measurable
improvements in care.
Well, thank you. We certainly think that we've led to some
improvement locally and hope that other centers can learn from what
we've learned to help drive change.
Dr. Digby, thank you so much for talking with me today about your
study. And I really want to thank you for sharing the results of
your project because I think high quality quality improvement
projects that are going on all over the world, really, but
oftentimes don't get shared outside of the individual team or
institution where they're doing them. And this is going to allow,
hopefully, a lot of people to see how investments in teamwork and
trying to improve on these metrics can lead to really important
results for our patients.
I completely agree. It's important to share the knowledge that's
learned, particularly with quality improvement. We're all working
towards common goals for delivering better patient care, and it's
great to be able to share those learned experiences with
others.
And I also want to thank our listeners out there who joined us for
this podcast. The full text of the paper was published online at
ascopubs.org/journal/jop on January 7, 2019. This is Dr. Nate
Pennell for the Journal of Oncology Practice signing off.