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Final Report
National Stocktake of Innovative Services
for People with Suspected Lung Cancer
Secondary Care Responses
Wendy Stevens, Melissa Murray, Jeff Garrett,
Chris Lewis, Denise Aitken, Rob McNeil,
Expert Advisory Group & Inequalities Team
December 2010
Acknowledgements
The National Stocktake of Innovative Services for People with Suspected Lung
cancer was funded by a Health Research Council and District Health Boards New
Zealand (HRC_DHBNZ) Grant, as part of the project Identification of barriers to the
early diagnosis of people with lung cancer and description of best practice solutions.
The stocktake was developed by the Expert Advisory Group (EAG) and the
Inequalities Team (IT) of the project.
Members of the EAG:
Dr Wendy Stevens (Chair)
Mr Gary Thompson
A/Prof Jeffrey Garrett
Ms Lynelle Black
Dr Christopher Lewis
Mr Ajit Arumlambalam
Dr Denise Aitken
Dr Matire Harwood
Dr John Cameron
Ms Kate Moodabe
Dr Richard Hulme
Mr John Fraser
Mr Karel Lorier
Northern Cancer Network & University of Auckland
Northern Cancer Network
Counties Manukau DHB
Counties Manukau DHB
Auckland DHB
Auckland DHB
Lakes DHB
Tamaki PHO
ProCare Health Ltd
ProCare Health Ltd
Total Healthcare Otara
New Zealand Guidelines Group
Consumer Representative
Members of the IT:
Mr Gary Thomspon (Chair)
Dr Matire Harwood
Ms Phyllis Tangitu
Mr Eru George
Ms Sandra Mullineaux
Dr Heidi Charlick
Māori Representative, Northern Cancer Network
Māori Representative, Tamaki PHO
Māori Representative, Lakes DHB
Māori Representative, Lakes DHB
Māori Representative, ProCare Health Ltd
Pacific Representative
Refinement of the survey into paper and electronic versions was performed by Dr Rob
McNeil of the Survey Research Unit of the University of Auckland. Ms Melissa
Murray (research coordinator) assisted Dr Wendy Stevens in the conduct of the
stocktake.
The research team would like to thank all those within the District Health Boards,
Cancer Networks and Lung Cancer Tumour Streams who responded to or facilitated
the secondary care stocktake. The research team is grateful to all those who have
contributed their time, information and expertise to this component of the project.
Contents
Page
Executive summary …………………………………………………….
i
1.
Introduction …………………………………………………….
1
2.
Methods
…………………………………………………….
1
3.
Results
…………………………………………………….
2
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
4.
Referral processes
Appointment reminders and ‘do not attend’ processes
Expedited chest CT scans
Expedited FSA and investigations
Care coordination
Lung cancer multidisciplinary meetings
Information resources
Initiatives to improve cultural acceptability of services
National and Regional Initiatives to Improve Lung Cancer Care
9
Appendices
Appendix A
District Health Boards
…………………………..
11
Appendix B
Northern Cancer Network’s ……………….………….
Algorithm for Rapid Diagnostic Workup
12
Appendix C
Otago DHB Respiratory Fast Tract Clinic Leaflet .........
13
Appendix D
Otago DHB Respiratory Fast Track Clinic Pathway ......
14
Appendix E
MDM Forms Used at the DHBs ……………………….
19
Appendix F
Regional Cancer Network Targets. …………………….
32
Appendix G
Data Collected from MDM Forms
………………….
33
.........................................
35
Abbreviations
Executive Summary
As part of the HRC_DHBNZ funded project Identification of barriers to the early
diagnosis of people with lung cancer and description of best practice solutions, a
national stocktake was performed to identify services that could be of benefit to
people with suspected lung cancer. The secondary care stocktake was sent to all
District Health Boards (DHBs) in New Zealand, and all responded. The results of the
stocktake are summarised briefly below.
Referral processes for the first specialist appointment (FSA) for people with suspected
lung cancer were similar across DHBs. People with suspected lung cancer were
prioritised to be seen within two weeks of referral. The majority of DHBs sent
appointment reminders to the patient, however fewer DHBs notified the general
practitioner (GP) of the appointment date.
A fairly recent initiative at many DHBs aimed to expedite diagnosis by performing a
chest CT scan prior to the FSA. This involved dedicated CT slots for suspected lung
cancer patients, and/or direct GP/radiology referral for a CT scan in the presence of a
suspicious CXR. Some DHBs reported that improved access to CT scanning had been
successful in streamlining the pathway to diagnosis. However some DHBs
commented on inadequate radiology facilities and significant delays to CT scanning.
At a small number of DHBs, bronchoscopy was still the first investigation to be
performed routinely.
Four DHBs had instigated, or were in the process of instigating, a dedicated lung
cancer clinic with expedited investigation. At three of these, the FSA, lung function
tests, blood tests, CT scan and bronchoscopy were generally performed on the same
day, whereas at the other DHB these investigations were undertaken within a week of
the FSA. An evaluation of the first ‘fast track’ lung cancer clinic indicated that it had
been successful, and had reduced diagnostic delay whilst remaining cost-neutral.
Considerable variation existed between DHBs in how care was coordinated for lung
cancer patients. Nine DHBs reported having a care coordinator. At most of these
DHBs the position of lung cancer care co-ordination was 1 FTE. Different titles
were used for the role, which was not always limited to lung cancer. The role of the
care coordinator typically involved coordinating investigations, tracking results,
collating information for the multidisciplinary meeting (MDM), and informing
patients of services and providing support. The care coordinator was involved at
different stages of the pathway at different DHBs; and at some DHBs the role was
specifically targeted to Māori and Pacific patients. The source of funding for the
position also varied. Oncology nurses were available at many of the DHBs, although
their role did not usually commence until after diagnosis, commonly at the
commencement of treatment. DHBs with a care coordinator reported favourable
results from patient and staff feedback, and considered the position a success. An
audit of transit times at one DHB indicated that the median time from the first
respiratory appointment until referral to another specialty was reduced when a lung
cancer clinical nurse specialist was involved in the coordination of care.
i
Fifteen of the DHBs reported participation in a lung cancer MDM. Only one DHB
reported using a videolink to the MDM. Almost all of the DHBs used a standard
MDM referral and management plan form, and most collected data from the MDM.
Information resources for patients were largely limited to information on
investigations (such as bronchoscopy), to Cancer Society pamphlets or Australian
Lung Foundation resources. Two DHBs reported using Health Point. None of the
information resources were specifically targeted to Māori. Only three DHBs reported
providing GP education sessions by respiratory specialists.
Whilst most DHBs had Tikanga training courses for staff, only some DHBs reported
specific initiatives to improve the cultural acceptability of their services. Such
initiatives mostly comprised Māori Health Units with Māori and Pacific support
persons, a Māori Liaison Officer, or Māori nurses and social workers. One DHB
reported Kaupapa Māori clinics and wards, one reported a marae-based navigator
service, and another reported providing emergency accommodation for the whanau of
in-patients.
In summary, considerable differences existed between DHBs in the services available
for people with suspected lung cancer and their whanau. Notable variations occurred
in access to chest CT scans, dedicated lung cancer clinics with expedited
investigation, lung cancer care co-ordinators, MDMs, and Kaupapa Māori services.
There also seemed to be a general deficiency in pre-diagnostic information resources,
and none of the available information was targeted to Māori. This stocktake together
with other components of the research will form the basis for recommendations to
improve lung cancer services.
In recent years, there has been a considerable focus on improving lung cancer care in
NZ, with particular emphasis on collecting data, streamlining the pathway with
expedited referral and investigation, and increasing multidisciplinary discussion.
Regional Lung Cancer Tumour Streams have formed; a National Lung Cancer
Working Group is currently developing national standards for lung cancer care; and
the regional Cancer Networks have agreed to collect and monitor three key
performance indicators (KPIs) related to lung cancer. Substantial achievements with
respect to lung cancer care have been made in some DHBs. Yet little change has
occurred in other DHBs, resulting in important regional differences in the services
available for people with suspected lung cancer. Whilst local services should be
tailored to the needs of the local population, national consistency and cultural
appropriateness in lung cancer care are essential, if equitable lung cancer outcomes
are to be achieved.

ii
National Stocktake of Innovative Services for People with Suspected
Lung Cancer: Secondary Care Responses
1.
Introduction
As part of the HRC-DHBNZ funded project Identification of barriers to the early
diagnosis of people with lung cancer and description of best practice solutions,i
conducted by the Northern Cancer Network in conjunction with the University of
Auckland and other stakeholders, a national stocktake was performed to identify
services within the healthcare system that could be of benefit to people with suspected
lung cancer.
The aim of the stocktake was to identify what, if any, services had been initiated
which could potentially improve the clinical journey for people with suspected lung
cancer from initial presentation to health care services until diagnosis. Services did
not have to be specifically for people with lung cancer provided they could be
relevant to such patients. The stocktake was separated into one for primary care and
another for secondary care. The findings from the stocktake will be used with those
from other components of the research to inform recommendations for best practice
lung cancer care.
The results of the secondary care stocktake are presented below. The results of the
primary care stocktake are reported separately.
2.
Methods
The stocktake was developed by the project’s Expert Advisory Group and Inequalities
Team, and then refined by the Survey Research Unit, University of Auckland. The
stocktake was sent to several key people within each DHB, including the respiratory
services manager, the chief operating officer, and the general manager of funding and
planning. In addition, the stocktake was sent to lead respiratory physicians at each
DHB (as identified by the Thoracic Society of Australia and New Zealand (TSANZ)
and by the respiratory physicians on the Expert Advisory Group), and to all the
members of the National Lung Cancer Working Group. The stocktake was also sent to
the managers of the four regional Cancer Networks.
The stocktake could be completed either on paper, electronically, or responses could
be made by email, phone or by sending a brochure on the service. Details were
requested of any successful or innovative service or pilot program that could be
relevant to people with suspected lung cancer within the pathway from presentation to
health care services until diagnosis. The survey asked for a description of the service,
when it commenced, how it was funded, whether it had been evaluated and whether it
was considered successful and the reasons for this, whether the service was targeted to
Māori, Pacific or rural groups, measures to improve the cultural acceptability of
services, and what information and support services were available to people with
i
Information about this research project is available on the Northern Cancer Network’s website at:
http://www.northerncancernetwork.org.nz/Research/LungCancerResearchProject/tabid/117/language/e
n-NZ/Default.aspx
1
suspected cancer. The secondary care stocktake specifically asked about any
initiatives to streamline the referral process and investigation for people with
suspected lung cancer; the availability of a lung cancer care coordinator or navigator,
and access to multidisciplinary meetings.
To ensure accurate documentation of the responses, a draft summary was sent to those
who responded to the stocktake, so that the information could be checked, corrected
and supplemented. The final responses are summarised below.ii
3.
Results
All 21 DHBs (Appendix A) responded to the stocktake. Two of these DHBs (Otago
and Southland) subsequently merged (forming the Southern DHB); however a
separate response was obtained from each. Several (2-4) responses were received
from many DHBs, whereas other DHBs provided a single coordinated response. In
addition, the Southern, Midland, and Northern Cancer Networks provided regional
responses.
3.1
Referral processes
Referral processes for a first specialist appointment (FSA) for people with suspected
lung cancer were similar across all the DHBs. Referrals were triaged on a daily to
twice weekly basis by a respiratory physician. Patients with suspected lung cancer
were prioritised to be seen within two weeks (1 week at Canterbury DHB). Two
DHBs commented on difficulties with this process. Southland DHB had only one
respiratory physician although some support was available from Otago; at Bay of
Plenty DHB there was no triage roster and each physician triaged independently.
At most DHBs, referrals were tracked by clerical staff of the Central Referral Office.
At Northland DHB, referrals were tracked by the lung cancer nurse specialist. Some
DHBs used a patient management system. At South Canterbury DHB, individual
consultants tracked their own referrals, as there was no formal tracking process. At
Wairarapa DHB, referrals were not tracked.
The South Island’s ‘Canterbury Initiative’ included improvement of the referral
process for people with suspected lung cancer in Canterbury. Health pathways had
been developed for chronic cough and haemoptysis with ‘red flags’ for urgent referral
to the Canterbury DHB respiratory department. Linked to these pathways was an
electronic referral pilot of 30 GP practices (due to finish at the end of July 2010). The
West Coast DHB was developing a version of Health Pathways linked to the
Canterbury Initiative. In Auckland (ie Auckland, Counties Manukau and Waitemata
DHBs), the first phase of an electronic referrals project had been initiated with
electronic referrals for elective services to the central referral office of each DHB. The
second phase will enable electronic triage of referrals by clinicians and the third phase
will provide on-line decision support.
3.2
Appointment reminders and do not attend (DNA) processes
Most DHBs sent appointment reminders to patients by mail, phone or both. Auckland
and Hawkes Bay DHBs also used text messaging. Waikato and Taranaki DHBs did
ii
When multiple responses from the same DHB differed, the positive response was reported. For
example if one response stated that GPs were not routinely notified but another response stated that
GPs were routinely notified, the reported response was that GPs were notified.
2
not send reminders. Bay of Plenty DHB had a call centre and patients were required to
phone the centre to confirm attendance at appointments or investigations.
Fewer DHBs (Waitemata, Waikato, Taranaki, MidCentral, Hawkes Bay and
Wairarapa DHBs) reported notifying the referring GP of the appointment date.
MidCentral and Hawkes Bay sent the GP notification electronically.
Nelson/Marlborough DHB did not notify the GP, unless the patient had not attended
on three previous occasions.
In general, DHBs followed-up did not attends (DNAs) by contacting the patient by
phone or mail. Usually, clerical staff contacted the patient to re-schedule the
appointment. At Hawkes Bay the respiratory nurse followed up DNAs. At Wairarapa
and the Southern DHBs in addition to contact by the clerical staff, the Māori Health
Team followed up all Māori DNAs.
Several DHBs (Auckland, Northland, Lakes, Waikato, Bay of Plenty, Tairawhiti,
Taranaki, MidCentral) also routinely informed the GP of DNAs. At Tairawhiti, after
two DNAs a letter was sent to the GP discharging the patient back to GP care. At
Hawkes Bay and Southland DHBs, the GP was only notified if there were problems
contacting the patient or if the patient declined a further appointment.
3.3
Expedited chest CT scans
DHBs commonly reported delays in obtaining CT scans. Performing a chest CT scan
prior to the FSA to expedite lung cancer diagnosis was a fairly recent initiative which
had commenced over the past 12-18 months in many DHBs. This process was
generally considered a success. A chest CT scan (with or without other investigations
such as lung function tests) could be requested prior to the FSA at most DHBs
(Auckland, Counties Manukau, Waitemata, Northland, Lakes, Taranaki, Tairawhiti,
MidCentral, Hawkes Bay, Wairarapa, Nelson/Marlborough, Canterbury, South
Canterbury, West Coast, Whanganui and Southland DHBs). At Waitemata DHB,
staging CTs were ordered on-line and the scheduling clerk arranged the FSA after the
CT. Southland DHB commented that although a chest CT scan was generally
requested on receipt of the referral, many scans had not been performed by the time of
the FSA. A chest CT scan was not ordered pre-FSA at Waikato DHB, although
patients were able to attend the CT suite for imaging directly from respiratory clinic
(ie walk-in appointments were available for patients referred by respiratory
physicians).
The first investigation performed by two of the three physicians at Bay of Plenty DHB
was a bronchoscopy, which was scheduled as the first specialist appointment (this had
been done since 1985). Bay of Plenty DHB commented on the need for faster access
to chest CT and CT fine needle aspirate (CTFNA) and also reported intra-regional
inequity of access to CT scans with waiting times considerably longer in Tauranga
than in Whakatane. Currently, following the bronchoscopy, patient could wait up to
four weeks for a chest CT scan or a CTFNA. If both were required the process could
take up to two months. GPs in the Bay of Plenty could order a CT scan if the CXR
was suggestive of cancer (the request being triaged by radiology), however this was
not commonly done. At Whanganui DHB, a bronchoscopy was performed urgently
for suspected lung cancer and this was considered to have facilitated reduced times to
treatment.
Specific initiatives to reduce delays to chest CT scans:
Waitemata DHB reported rapid access to CT scanning and bronchoscopy.
3
Counties Manukau DHB reported that a chest CT scan was routinely
performed prior to the FSA. This had improved the time from referral to
treatment by two weeks on average and facilitated decision-making at the FSA
regarding investigations and treatment (eg whether to perform a CTFNA,
bronchoscopy or the likely need for PET).
Northland DHB had attempted to prioritise chest CTs since the end of 2009
but reported inadequate facilities such that scans could not always performed
in a timely manner.
Lakes DHB initiated expedited chest CT scans in early 2010. If a CXR was
suggestive of lung cancer, a chest CT was booked immediately in conjunction
with the GP / radiologist and the hospital specialist. No additional funding was
available for this initiative. So far it had been successful with earlier diagnosis
and earlier discussion of treatment options.
Waikato DHB reported walk-in CT appointments were available for patients
referred by respiratory physicians.
Wairarapa DHB - ‘Getting Results Quicker’ In order to improve access for
patients to diagnostic services, GPs, following verbal consultation with
specialist, were able to order a chest CT scan prior to the FSA. The service
began 18 months ago with community referred funding. The service had been
successful and had streamlined the pathway.
West Coast DHB - GPs could order a chest CT scan (following an abnormal
CXR) with the verbal authority of the physician; if the CT scan was suggestive
of lung cancer; the physician then sent a referral to the respiratory department
at Canterbury DHB.
Canterbury DHB had designated CT slots for suspected lung cancer patients.
A CT slot was made available each morning for one (sometimes two) patients
prior to the afternoon bronchoscopy list. This had commenced within the past
year and had been successful largely due to a good relationship with the
radiology department and support from designated thoracic radiologists.
South Canterbury DHB: Following their recent Lung Cancer Audit which
assessed gaps and bottlenecks in the lung cancer pathway in 2008, a
streamlined referral process from the GP to the Medical Outpatient
Department to Specialist Respiratory Services at Christchurch Hospital had
been developed. It was planned that in the future, GPs would have direct
access to chest CT scanning under strict criteria within an agreed referral
pathway.
3.4
Expedited FSA and investigations
Auckland DHB was in the process of setting up a dedicated clinic for
suspected lung cancer patients (on a Monday) with the aim of completing
investigations the same week. The Northern Cancer Network via the Lung
Cancer Tumour Stream had developed an investigation algorithm for rapid
diagnostic workup (Appendix B) which was used by all of the four Northern
DHBs.
Hawkes Bay DHB had a respiratory clinic booker / coordinator to streamline
the FSA and also two dedicated lung cancer clinics:
- Urgent lung cancer clinic (on a Friday) was booked during the week and any
non-utilised slots were filled with non-urgent patients. The clinic began in
2000 and had improved access with all lung cancer referrals being seen in less
than two weeks.
4
- Same day clinic – a weekly clinic predominantly for ‘out-of-town’ patients
with suspected lung cancer, with the FSA, lung function tests, CT scan and
bronchoscopy performed on the same day if possible. Although there were no
dedicated CT slots, radiology maintained free time for urgent cases.
Accommodation was available for rural patients. Patient and staff satisfaction
was high, patient throughput had increased, efficiency had been enhanced and
numerous appointments had been avoided.
Hutt Valley DHB: One stop lung cancer clinic was due to commence in July
2010. Patients deemed physically and emotionally fit enough to undergo
investigation during an estimated eight hour period would have on the same
day, a medical assessment, lung function tests, blood tests, CT scan,
bronchoscopy and biopsy, cancer nurse assessment and support. No additional
funding had been provided.
Otago DHB: The Respiratory Fast Track Clinic (RFTC) commenced in July
2009 and occurred weekly, with funding from established funding for services.
The most important aspect was negotiating protected CT scanning times for
the RFTC. Following GP referral, patients with suspected lung cancer (eg an
abnormal CXR and suspicious history) were booked into the RFTC within two
weeks. The GP liaison representative notified GPs of the RFTC and ensured
that any referred patients had been warned about the possibility of lung cancer.
A patient information leaflet to outline the day and inform both patient and
whanau was provided (Appendix C). There was a day stay admission for up to
three cases. There were three designated CT scan slots which linked in with an
established afternoon bronchoscopy list. On the same day, patients underwent
clinical assessment, blood tests, spirometry, CT scan and, if indicated
bronchoscopy. A RFTC day-case pathway was developed to ensure
coordination and availability of tests (Appendix D). Preliminary results were
discussed with the patient later that day and a follow-up appointment was
arranged. All cases of malignancy were discussed within ten days at the lung
cancer multidisciplinary team meeting and referral for treatment was made
according to the recommendations.
Assessment of the RFTC after 12 months showed:
- 83 patients had been assessed – 55% had a malignancy; 42% had lung
cancer, 11% had another malignancy and 45% had non-malignant
diagnoses.
- shorter time to FSA (94% were seen within the 2 week FSA target),
diagnosis and commencement of treatment (71% commenced the first
anti-cancer treatment within 62 days)
- reduced number of hospital appointments
- good integration with the MDM with 91% of lung cancer patients
being discussed at the MDM (some of the remaining cases died prior to
the MDM)
- excellent teaching opportunity
- good communication with patients and family was essential to
minimise anxiety; and effective communication with GPs who act as
the liaison (eg via timely discharge information and access to results on
i-soft) was also important.
- a part-time care coordinator position (specialist nurse) was considered
necessary to assist the lung cancer journey.
5
Conclusion of the assessment was that the fast track cancer clinic was a
success as it had reduced diagnostic delay and was cost-neutral.
Whanganui DHB: patients with suspected lung cancer were referred to
oncology prior to histology results being available to reduce waiting times to
the oncology FSA.
3.5
Care coordination
There was considerable variation in whether DHBs had a care coordinator (or
similar), the funding of this position, the title, the role and at what stage in the
pathway the coordinator became involved.
Nine DHBs (Auckland, Counties Manukau, Northland, Lakes, Waikato, Bay of
Plenty, Hutt Valley, Canterbury, and West Coast) reported having a care coordinator.
Different titles were used for the role. For example: lung cancer care coordinator, lung
cancer specialist nurse, lung cancer clinical nurse specialist, lung cancer nurse
coordinator, nurse navigator or cancer support nurse. The role was not always tumour
specific, extending across all cancers at some DHBs. Funding was provided from
general service funding or by the Cancer Network. These positions were fairly
recently instituted, the earliest being appointed in 2004 and the most recent being
appointed in 2010. At most DHBs, the position was 1 FTE.
Southern DHB (Otago and Southland) had complex care coordinators who
coordinated care of complex cases on treatment and these coordinators were
supported by oncology social workers, oncology counsellors and oncology district
nurses. In addition to the lung cancer clinical nurse specialist at Canterbury DHB,
there was also a cardiothoracic clinical nurse specialist who co-ordinated surgical
referrals and worked in close liaison with the lung cancer clinical nurse specialist. At
West Coast DHB, there was also an oncology nurse specialist who liaised with the
lung cancer clinical nurse specialist at Canterbury DHB and coordinated
investigations. Bay of Plenty DHB had oncology nurses based in Tauranga and
Whakaktane, specifically for medical oncology patients receiving chemotherapy.
The role of the care coordinator typically involved coordinating investigations,
tracking results, collating information for the MDM, and informing the patients of
services and providing support. At some DHBs, the role was specifically targeted to
Māori and Pacific patients.
At Northland DHB, the role involved coordination throughout the entire clinical
pathway. In Auckland, the role commenced at referral and finished at FSA for
treatment. At Lakes DHB, the role started at identification of an abnormal CXR report
and extended until discharge from oncology and transition to palliative care. At
Waikato, the role commenced at FSA with a respiratory physician through diagnosis
and cardiothoracic surgery to transition to non-surgical oncology treatment providers.
At Bay of Plenty, the role commenced at diagnosis and finished on discharge from
oncology or transition to palliative care. At West Coast DHB, the navigator became
involved following referral and assisted especially with coordination of transport,
accommodation and investigation at Canterbury DHB. At Canterbury, involvement
usually commenced at diagnosis although it could occur earlier.
Waitemata, Taranaki, Tairawhiti, MidCentral, Wairarapa, Hawkes Bay,
Nelson/Marlborough, and South Canterbury did not have a care coordinator. However
Taranaki DHB had case managers. Tairawhiti had an oncology nurse who became
involved once treatment commenced. Hawkes Bay DHB had an oncology nurse who
6
became involved at diagnosis and performed some of the role of a care coordinator,
and the respiratory clinic booker facilitated prioritisation, appointment bookings and
follow-up. At Nelson/Marlborough DHBs an oncology service with three oncology
nurses was initiated in 2000 to provide support in the community, arrange
appointments and administer chemotherapy. An evaluation showed that the initiative
was highly successful. Similarly, South Canterbury had 2-3 oncology nurses who
supported cancer patients on treatment and provided chemotherapy. Also Whanganui
DHB had an oncology nurse specialist who supported patients once they had been
referred to the oncology service. Waitemata DHB commented that all co-ordination
and follow-up of investigations was done by the respiratory physicians and registrars
without any secretarial support. Otago DHB had an MDM coordinator however this
was an administrative role without any outreach role.
DHBs with a care coordinator reported favourable results from patient and staff
feedback and judged the position as a success. Patients and their whanau/family were
better informed about the clinical pathway, felt better supported and were more able
to participate in decision-making. An audit of transit times at Waikato DHB showed
that patients appeared to benefit from the involvement of the lung cancer clinical
nurse specialist, and that the median time from respiratory FSA to referral to another
specialty was shortened. Findings from patient interviews and satisfaction surveys
indicated that lung cancer clinical nurse specialist delivered a high level of service
that promoted patient satisfaction and met patients’ needs.
3.6
Lung cancer multidisciplinary meetings (MDMs)
The majority (15) of DHBs (Auckland, Counties Manukau, Waitemata, Northland,
Lakes, Waikato, Bay of Plenty, Tairawhiti, Mid-Central, Hawkes Bay, Wairarapa,
Capital and Coast, Canterbury, Otago and Southland) participated in a MDM,
generally with 60% of all lung cancer cases discussed at the MDM. Northland
participated in the Counties Manukau MDM; Lakes, Bay of Plenty and Tairawhiti,
participated in the Waikato MDM; Wairarapa participated in either the MidCentral or
Capital and Coast MDM depending on the case; and currently an Otago physician
presented cases on behalf of the Southland clinician at the Otago MDM.
All but Hawkes Bay DHB used a standard MDM referral and management plan form
(Appendix E). In the Northern Region, all 4 DHBs used the same MDM form and this
was used as the referral form following the MDM to reduce delays to oncology or
surgical assessment and treatment. At Otago DHB, the agreed and approved treatment
plan was uploaded onto an electronic proforma and was available to the patient’s GP
within 24hrs of the MDM. The Waikato Chest Conference report was distributed to
referring clinicians and others within 1-2 days of the meeting and was accessible
electronically in the patient record; information was also entered into a database.
Data collection occurred via the MDM at: ADHB / CMDHB / Waitemata / NDHB;
Lakes / Bay of Plenty / Tairawhiti / Waikato; MidCentral; Capital & Coast;
Canterbury; and Otago / Southland; but not at Hawkes Bay DHB.
Only Northland DHB reported access to a MDM via a videolink. However an IT
project was underway in the Southern DHB to connect Southland and Dunedin
Hospitals and allow radiology and pathology to be viewed in both centres, and enable
clinicians in Southland to fully participate in the Lung MDM at Dunedin Hospital.
Whanganui and West Coast DHBs stated they did not participate in a lung cancer
MDM. Neither did Nelson/Marlborough DHB although a videolink was available.
7
3.7
Information resources
3.7.1 Information resources for patients
DHBs commonly reported using Cancer Society leaflets. Australian Lung Foundation
resources were also used. Patient information leaflets on investigations, such as
bronchoscopy and CTFNAs, were used by Hutt Valley DHB, Waikato DHB and
Counties Manukau DHB. Counties Manukau and Capital and Coast DHBs also used
Health Point as an information resource for patients. Otago DHB had a pamphlet on
the Respiratory Fast Track Clinic. Waikato had recently developed a graphic of the
lung cancer work-up pathway for patients. None of the DHBs reported providing
practical information on the hospital, parking, transport, accommodation, financial
assistance or support services. None of the information resources reported were
specifically targeted to Māori.
Lung cancer support groups facilitated by the Cancer Society were reported as a
source of information as well as other support.
3.7.2 GP Education
Lakes DHB held meetings with GPs to provide information on the early
diagnosis of lung cancer and on prioritising early CXR for conditions such as
‘unusual cough’. The initiative was targeted to Māori and rural patients. It was
driven by respiratory physicians and supported by specialist nurses. Specialist
time was provided by the DHB. It provided an opportunity to meet all the GPs
in the DHB and to highlight high risk groups that needed further support. It
commenced in early 2010 and had been deemed a success. GPs appeared to
appreciate the initiative.
Waikato Hospital Respiratory Service held a lung cancer mini-conference
every second year.
As part of the Canterbury Initiative, a respiratory physician in Canterbury
provided GP education and in-practice consultation.
3.8
Initiatives to improve cultural acceptability of services
Tikanga training courses were reported by most DHBs. Such training was reported to
have led to improved cultural understanding and responsiveness by staff.
Specific initiatives reported by DHBs to improve the cultural acceptability of their
services were:
Counties Manukau DHB had a Māori and Pacific liaison service and a
community Māori cancer care co-ordinator.
Waitemata DHB had Māori and Pacific support persons who visited all Māori
and Pacific cancer patients admitted to the hospital
Lakes DHB had a Māori specialist cancer nurse. Aroha Mai and the Te Kahui
Hauora Trust supported both Māori in-patients and community-based patients,
and coordinated access. Attendance at appointments had improved and patient
feedback had been very positive.
Tairawhiti DHB had a Māori Health Advisory Service and Kaiatawhai Service
to ensure that information and support was provided to patients and their
whanau in a culturally appropriate manner. The Kaiatawhai Service was
predominantly for in-patients although it could be accessed by community
patients.
Waikato hospital had a Māori Health Support Service which focused on inpatients and carried out whanau ora assessments.
8
Bay of Plenty DHB: Te Puna Hauora provided kaupapa Māori health services
consisting of Kaupapa Māori nurses and social workers that assisted Māori
patients with complex respiratory and other problems in medical wards.
Emergency accommodation for whanau of in-patients was available. Tauranga
Hospital had a kaupapa Māori ward and some kaupapa Māori clinics. There
was a Tauranga based Kaitiaki Nursing Service comprising a team of
specialised registered nurses who provided supportive care services for Māori
and their whanau affected by cancer. Whakatane hospital had Māori specialist
support staff for inpatients and outpatients
Taranaki DHB: Kaimahi Hauora from the Māori Health Team assisted
patients, their whanau and staff, acted as advocates for patients and whanau,
and facilitated positive contact with the hospital service. Also in the
Kaiawhina pilot, staff worked in low socioeconomic areas to assist with
access, disseminate health information and provide links to services. This had
successfully assisted attendance at appointments. Within the community
Māori providers had held demystifying cancer workshops and professionals
had come into the community to talk with people.
Hawkes Bay DHB had a Māori health liaison officer which had led to
increased patient satisfaction with services.
Whanganui DHB had a Kaiwhakahaere (co-ordinator of Māori Health) to
provide support to Māori patients.
Wairarapa DHB had a Māori Health Unit which provided support,
coordination and follow-up. This had reduced DNAs and improved support in
the community.
South Canterbury DHB had a marae-based navigator service which was
funded by the DHB to support Māori patients and their whanau.
Southland DHB had a Māori Health Unit which assisted patients and their
whanau and facilitated positive contact with the hospital service.
The other DHBs did not comment on specific initiatives to improve the cultural
acceptability of their cancer services.
In summary, considerable differences existed between DHBs in the services
available for people with lung cancer. Notable variations occurred in access to chest
CT scans, dedicated lung cancer clinics with expedited investigation, lung cancer care
co-ordinators, MDMs, and Kaupapa Māori services. There also seemed to be a
general deficiency in pre-diagnosis information resources other than information on
investigations, and none of the available information was targeted to Māori.
This stocktake together with other components of the current research will form the
basis for recommendations to improve lung cancer services.
4.
National and Regional Initiatives to Improve Lung Cancer Care
An audit of lung cancer management in 2004 in the Northern Cancer Network and
other subsequent lung cancer pathway mapping projects in other Cancer Networks
suggested low treatment rates in NZ compared with international rates, and variability
in lung cancer care across and within regions. Partially in response to such findings,
Lung Cancer Tumour Streams were established in each Cancer Network and a
National Lung Cancer Work Group was formed to set standards and promote national
9
consistency in care. Management targets and key performance indicators (KPIs) were
developed by the regional tumour streams (Appendix F) and data to monitor these
targets were collected via the MDM form at some DHBs (see above and. Appendix
G). All of the regional cancer networks agreed to collect and report three KPIs for
lung cancer:
- time from initial referral to FSA for newly diagnosed lung cancer patients
- time from referral to first anticancer treatment for lung cancer patients
- percentage of lung cancer patients reviewed at an MDM.
National and regional standards have the potential to promote both consistency in care
and optimal health outcomes. However to be effective, efforts must be made by all
DHBs to achieve these standards. Monitoring of DHB performance against standards
is essential to ensure that improvements in lung cancer care are taking place, in order
to achieve equitable and optimal lung cancer outcomes.

10
Appendix A:
District Health Boards (DHBs)
Northern Cancer Network
Auckland DHB (regional cancer centre)
Counties Manukau DHB
Waitemata DHB
Northland DHB
Midland Cancer Network
Bay of Plenty DHB
Lakes DHB
Waikato DHB (regional cancer centre)
Central Cancer Network
Tairawhiti
Taranaki
Whanganui
MidCentral
Hawkes Bay
Wairarapa
Hutt Valley
Capital & Coast
(Two cancer centres: Palmerston North Hospital and Wellington Hospital)
Southern Cancer Network
Nelson/Marlborough
Canterbury
West Coast
South Canterbury
Otago and Southland (these two DHBs have joined to form the Southern DHB)
(Two cancer centres: Christchurch Hospital and Dunedin Hospital)

11
Appendix B: Algorithm for Rapid Diagnostic Workup
This diagnostic algorithm has been developed because non-diagnostic bronchoscopies often result in a 3 weeks
delay for the patient. A non-diagnostic bronchoscopy is a bronchoscopy that fails to collect enough cells to decide
whether the patient has lung cancer or not. Non-diagnostic bronchoscopies happen fairly often (30%-40%).
In the past bronchoscopies were planned and the results from pathology were awaited. If the pathologist had no
diagnosis, some other investigation was planned. For example: EBUS, EUS or mediastinoscopy. Most of these
investigations had a wait time of several weeks. The idea of this algorithm is to skip a bronchoscopy if a nondiagnostic outcome is likely. Or to book the next step (EBUS, EUS, mediastinoscopy) as soon as possible. If the
bronchoscopy turns out non-diagnostic, the next investigation can soon take place. If the bronchoscopy turns out
diagnostic, the next investigation is cancelled.
STAGING CT BEFORE FSA (CT chest + upper abdomen)
Stage 4 on CT
Aim: biopsy most accessible site
Intra
thoracic
Extra
thoracic
Bronch/ chest
mass FNA/
pleural
cytology
Liver/ bone/
lymph node/
skin/ adrenals/
brain
All other patients
Aim: biopsy and stage the cancer, assess
fitness for radical treatment. Plan all tests at
once.
Mediastinal/
hilar LN
>1cm and
accessible
No enlarged
or accessible
LN
→ EUS/ EBUS/
TBNA most
accessible site
Central tumour
Mid way tumour
Peripheral tumour
Standard bronch
Bronch and book CTFNA at bronch, if no
diagnosis expected
Book CT-FNA at FSA,
only bronch if it doesn’t
delay CT-FNA



12












Appendix C
Respiratory Fast Tract Clinic Leaflet
13
Appendix D
Respiratory Fast Track Clinic Pathway
Date of admission:
Date of discharge:
Pathway Track
Nurse to complete. When all critical criteria are ticked, asterisk the graph at the corresponding stage and time of stay.
Check follow-up
arrangements.
*
Bronch. checklist completed.
Observations stable.
Test swallow completed.
Tolerating light diet.
*
Stage 1
Recovery
Observations stable.
Bronchoscopy
Check procedure still needed.
CT scan
Appointment time confirmed.
Admission
Patient is clerked by Medical
Officer and procedures
explained.
*
Consent form signed.
Premed given.
Note: The pre-drawn graph shows expected clinical outcomes.
Some patients will fall to the right of this ‘expected track’,
indicating that their recovery is taking longer than expected.
3–4 hrs
Actual Hours
*
2–3 hrs
Stage
*
Proced.
Patient transported to
radiology for CT scan.
Blood tests, ECG,
spirometry (CXR)
undertaken.
*
X-ray
Stage 2 _
Pre-discharge
Discharge criteria met.
Admit
Discharge
Time
Specimen initials
Initials Name (print)
Designation
Initials Name (print)
Designation
Discharge Planning
Contact person details:
Living arrangements on admission:
Planned living arrangements for discharge:
Transport arrangement on discharge:
Adult Bronchoscopy — Guidelines
Stage 1 Nursing
Respiratory: No evidence of cyanosis, respiratory stridor,
haemoptysis, shortness of breath. SaO2 > 94% on air.
Observations: 1/2 hrly BP, HR, SaO2 Respirations for 4 hrs.
Diet: Nil by mouth for 4 hrs.
Stage 2 Nursing
Observations: Observations stable & complete after 4 hrs.
Diet: Test swallow achieved 3 hrs post-procedure with 20 mL
Education/discharge: Bronchoscopy sheet checklist complete. water.
Progress Notes
Either initial, or write in * (variation), / (N/A), or C (comment)
14
Stages of Care
N3
Admission Initial Date
Assessment & discharge information
completed
Pathway reviewed & education
reinforced
Baseline obs completed
N4
Nil per mouth for 4 hrs
N5
In hospital gown
N6
Pre-medication given
N1
Stage 1 Recovery
Observations as per guidelines
N2
Nil by mouth as per guidelines
N1
Stage 2 Pre-discharge
Observations stable
Code
N1
N2
N2
N4
Cannula removed
Test swallow complete, tolerating
light diet
Bronchoscopy checklist complete
D1
Discharge Checklist (Nursing staff)
Transport arrangements complete
D2
OPD appt and prescriptions given
D3
Patient confident regarding discharge
D4
Discharge summary given to patient
N3
Variations
Code
Time :
Observation
Chart
200
39
190
38
180
37
170
36
160
35
150
Blood
pressure
(mmHg)
140
 Heart rate
(BPM)
110
18
90
16
80
14
70
12
60
10
50
8
40
6
30
4
20
2
10
 Resp rate /min
 Temp ºC
40
130
120
100
SaO2 :
15
Variation and plan
Initial Date
Respiratory Fast Track Clinic Admission
Physical examination:
Cardiovascular JVP:
Pulse:
BP:
Apex:
Heart sounds:
Respiratory Clubbing:
Respiratory rate:
Lymphadenopathy:
Trachea:
Expansion:
Percussion:
Auscultation:
Abdomen -
Admission Checklist:
 1. CT scan booked
 2. CXR: PA + lateral — unless recent (< 4/52) ones available
 3. ECG (if patient > 50 years)
 4. Spirometry – unless recent (< 6/12) recordings available
 5. Full blood count, U&E, liver function tests, Ca2+
 6. Coagulation profile
 7. Fasted for 4 hours minimum
 8. Consent form signed
 9. IV line left forearm
Prof Taylor / Dr Wong Pethidine 50 mg IM – 30 min pre-bronchoscopy (unless PaCO2 elevated)
 10. Pre-med charted:
Atropine 0.6 mg IM – 30 min pre-bronchoscopy (unless in AF)

Lignocaine 1% 4 mL NEB – 10 min pre-bronchoscopy


Dr Brockway
Salbutamol 2.5 mg NEB / 6 puffs MDI – if obstruction prior to bronch.

Lignocaine 2% 5 mL NEB – 15-30 min prior

No Atropine or Pethidine

Name:
Designation:
Signature:
Date:
16
Bronchoscopy Report
Consultant:
Name:
Date of procedure:
Operator:
Name:
Signature:
Sedation:
17
Post-Bronchoscopy
Fast for three (3) hours or until gag reflex is normal.
Oxygen therapy:
Sputum collection for cytology (circle):
yes / no
CXR to exclude pneumothorax (circle):
yes / no
To be discharged home if stable (circle):
yes / no
Observations Prior to Discharge
You should be concerned if:
1.
Pulse rate 100/min or more at rest
2.
Blood pressure 20 mmHg or more lower than pre-bronchoscopy recording
3.
Respiratory rate 25/min or more
4.
The patient is audibly wheezy
5.
SaO2 < 92%
6.
Gag reflex remains absent
7.
There is ongoing haemoptysis
If in doubt, do not discharge.
Follow-up Arrangements Required
Other outpatient investigations required?
Chest Clinic appointment with:
at
18
weeks
Appendix E: MDM Forms Used by Various DHBs
Lung Cancer MDM Form_1
REFERRAL INFORMATION
Fill in after TMDM
Please paste or copy from TMDM form
Name:
NHI:
Age:
Sex:
Ethnicity:
DOB:
Referral to:
(delete as
applicable)
Referral
priority:
Intent of
treatment
Date of MDM:
Date of Referral (resp):
Type of referral: IP,OP,Pvt
Presenter:
Primary Consultant:
Thoracic Radiation oncology Medical
surgery
oncology
A
A
B
B
C
C
Palliative care
Curative / Palliative / Not determined / No Decision-To-Treat yet
DHB of
domicile
Notes
Refer all palliative patients (symptomatic and asymptomatic) to the palliative care
specialist of your DHB (Northland: Dr Warrick Jones, Waitemata: Prof Rod Macleod,
Auckland: Dr Bruce Foggo, Counties Manukau: Dr Willem Landman).
For referral to hospice please use the generic Hospice Referral Form.
Priorities medical oncology:
A = small cell lung cancer
B = curable non-small cell lung cancer (adjuvant and chemo-RT)
C = all others
Priorities radiation oncology:
A = spinal cord compression, SVCO, major airway narrowing, major haemoptysis
B = radical lung (chemo-RT or radical radiotherapy alone), very urgent palliative patients
(e.g. pain not responding to analgesic)
C = all other palliative patients
Fax referral to
Central Referrals
19
Lung Cancer MDM Form_2
Name:
NHI:
Age:
Sex:
Ethnicity:
DOB:
Date of MDM:
Date of Referral (resp):
Type of referral: IP,OP,Pvt
Presenter:
Primary Consultant:
Oncological Diagnosis (including histology and stage)
Proposed management / reason for presentation:
Clinical details:
Co-morbidities:
Medications:
ECOG Score:
Smoking:
Pack-years:
Occupational Exposures:
Functional State:
Diagnosis and staging investigations: (delete as applicable)
Radiology:
Date:
Finding:
CT chest upper abdo contrast +/ Histopathology:
Bronchial cytology/biopsy
Pleural cytology / biopsy
Others
EBUS
Lung function and blood tests:
FEV1:
FVC:
%pred:
%pred:
Hb:
Calcium:
Other Relevant:
DLCO
%pred:
Liver:
Peak V02:
eGFR/Cr
AFTER MDM
Patient was discussed: in normal MDM / in core group / only by TMDM chair
Summary of MDM:
Patient informed: yes/ no
SMOs present at TMDM:
20
Lung Cancer MDM Form_3
2.
MDM Forms
DEPARTMENT OF RESPIRATORY MEDICINE
CHEST CONFERENCE
Name:
NHI:
old)
Conf Date:
dob:
Previous Conf date:
Referring Consultant:
CC:
Diagnosis (including stage):
PHx:
Clinical Details: (including smoking history)
9th June 2010
(
yr
C
H
E
S
T
Question for Conference:
Functional status (eg ECOG):
Bloods (eg Ca, LFT):
CBC
Hb
Renal
Liver
CEA
Lung Function Test:
, Platelets
, WBC
Na
,K
, Cr
Alb
, Alk Phos
, ALT
Coag profile:
FEV1
FVC
TLCO
KCO
(
% predicted)
(
% predicted)
% predicted
% predicted
Radiology (eg CXR, CT):
Bronchoscopy:
Mode of diagnosis (eg FNA, biopsy):
Discussion:
Validation/Reason for this decision:
Action:
Patient been spoken to: Yes/No
DICTATED BY:
RESPIRATORY PHYSICIAN
Present:
TYPED:
3.
, Ca
Mid Central DHB MDM Forms
21
, cCa
C
O
N
F
E
R
E
N
C
Lung Cancer MDM Form_4
22
23
Lung Cancer MDM Form_5
Multidisciplinary Meeting Lung
Save
Attendance List
Meeting Details
Clinical
Record
####
Med Onc
Meeting Date
####
Med Onc
Date referral received
####
Palliative Care
Date of FSA
####
Palliative Care
Presenter
####
Rad Onc
Lead Consultant
####
Rad Onc
Previously Discussed
####
Radiology
####
####
Respiratory
####
Respiratory
Last Name
####
Surgeon
First Name
####
Surgeon
DOB
####
Surgeon
Address
?
?
View CR
Letter
Patient Details
NHI
24
Refresh
Patient
Details
Email to
attendees
Surgeon
Address 2
####
Medicine
Gender
####
Respiratory
Ethnicity
####
Radiology
Domicile
####
Respiratory
GP
Clean Up Results
####
GP Practice
Background Information
Presentation
Medications
25
Send to
Admin/DB
Send
Referrals
View
Procedures and Testing
Date
38
Test/Procedure
CT Scan
Result
Comment
View
Bone Scan
View
Chest X-Ray
View
Bronchoscopy
View
PET Scan
View
Histology
View
Cytology
?
Lung Questions
Pack year History
Smoker (CCDHB System overwrite if incorrect)
26
Lung Function Tests
Date
Actual
Predicted
FEV1
VC
Imaging/Other Information
Diagnosis
74
Malignant Neoplasm of Bronchus or Lung, unspecified
Concurrent Medical Illness and factors influencing planning
ECOG
Score
Add Staging Info
Date
Score
Disease Staging
Date
Method
Days from referral to now
27
69
Type
Score
Plan
MDT Discussion
Is this good enough for rad onc/med onc or do they need more definitive pathology?
Treatment Intent
Referral
Internal
?
Probable
Complete
External Referral/Notify
Probable
Complete
Surgery
FALSE
TRUE
FALSE
TRUE
Rad Onc
FALSE
TRUE
FALSE
FALSE
Med Onc
FALSE
FALSE
FALSE
FALSE
Genetics
FALSE
FALSE
FALSE
FALSE
Palliative Care
FALSE
FALSE
FALSE
FALSE
FALSE
FALSE
FALSE
FALSE
Other (internal email address):
FALSE
FALSE
Responsiblity for informing patient of MDM outcome
MDM Document Confirmed by:
28
Lung Cancer MDM Form_6
Name:
NHI:
Age:
DOB:
Ethnicity:
Address:
Clinical Details
GP:
Consultant:
Date of Referral:
Source of Referral:
Date of Respiratory FSA:
Sex: M/F
Clinical Presentation/History:
Co-morbidities:
FEV1 :
FVC :
Ratio:
L ( %)
L ( %)
%
Smoking: current / ex / non
Pack/Years:________
ECOG Score:
Weight loss:
Radiology:
CXR
CT chest
PET/CT
Other
Date:
Finding:.
Procedures:
Bronchoscopy
Pleural aspiration
Image guided lung FNA/Bx
FNA other sites
Thoracoscopy
Mediastinoscopy
Surgical resection
Other
Diagnosis
Non small cell lung cancer
Adenocarcinoma
Squamous cell carcinoma
Small cell lung cancer
Staging
Mesothelioma
Non malignant
No tissue / biopsy
Other: __________________
T:
N:
Primary Site:
Staging Basis:
M:
Clinical
Radiologic
Pathology
Further Investigation Recommended:
Management Plan/Care Plan
Surgical Resection
Best Supportive Care
Radical Radiotherapy
Other
Combined Chemo-radiotherapy
Chemotherapy
Intent of treatment
Curative
Adjuvant
Palliative Radiotherapy
Palliative
Palliative Chemotherapy
Clinical Comment
Post Surgical
For Surgical discussion
Clinical Decision Making
Not for Discussion
29
Lung Cancer MDM Form_7
30
31
Appendix F: Regional Cancer Network Targets
Northern Cancer Network Lung Cancer Targets

Time from GP referral to outpatient FSA

Time from referral to first multidisciplinary meeting

Time from MDM to thoracic surgery (as first treatment)
2 weeks

Time from MDM to FSA in medical oncology
2 weeks

Time from MDM to FSA in radiation oncology
2 weeks.
2 weeks
75% within 4 weeks
In addition the Northern Lung Cancer Tumour Stream agreed that for 2010/11 they
would set targets to be recorded in each DHBs District Annual Plan (DAP) to
demonstrate commitment to improving processes to meet access standards.
The lung cancer targets agreed by the Lung Cancer Tumour Steering Group for
inclusion in the DAP were:

Increase from 43% to 50% the patients discussed in MDM within 28 days of
referral

Increase from 30 % to 50% the patients that have thoracic surgery within 14
days of the MDM

Increase from 36% to 50% the patients that have a FSA in radiation oncology
within 14 days of the MDM

Increase from 7% to 50% the patient that has FSA in medical oncology within
14 days of the TMDM.
Southern Cancer Network Lung Cancer Targets

Time from GP referral to FSA
2 weeks

Time from Respiratory FSA to MDM
2 weeks

Time from MDM to treatment FSA
2 weeks

Time from receipt of GP referral to first definitive treatment
62 days

Percentage of patients discussed at the MDM
>75%

Percentage of stage I/II patients receiving curative resection
>70%

Percentage of patients receiving anticancer treatment
>70%

Percentage of patients referred to palliative care services
>20%

32
Appendix G: Data collected from MDM Forms
The Northern Cancer Network reports quarterly on the following to the Lung Cancer
Tumour Stream to monitor performance against standards. The data is sourced from
the database created from the thoracic MDM forms, the NZ Cancer Registry and DHB
decision support teams. The table below is being refined and results will be reported
in graph format with explanatory notes.
Table D1:
Data and key performance indicators calculated from the received
MDM forms
NDHB
WDHB
No. of lung cancer patients in 2009
Expected no. of lung cancer patients
No. of lung cancer patients discussed
Percentage of lung cancer patients discussed,
based on the expected number of lung cancer
patients from data from 2008
No. of patients with recorded stage
Percentage of patients with recorded stage
No. of patients with stage 1-2 NSCLC
Percentage of patients with stage 1-2
No. of stage 1-2 pts planned for thoracic
surgery
Percentage of stage 1-2 pts planned for
thoracic surgery
No. of pts planned for thoracic surgery
Percentage of patients planned for thoracic
surgery
No. of SCLC patients
No. of missing (not filled in) items
Average no. of missing items/ patient
No. of outpatients
No. of inpatients
No. of private patients
No. of patients of unknown origin
No. of outpatients with FSA <15 days
Denominator
Percentage of outpatients with timely FSA
No. of outpatients with TMDM <29 days
Denominator
Percentage of outpatients with timely TMDM
Treatment intent = curative
Treatment intent = palliative
Treatment intent = not filled in
No. of outpatients with TMDM <43 days
Denominator
Percentage of outpatients with TMDM<6w
33
ADHB
CMDHB
Northern
Region
Regional
Standard
Table D2:
Data collected for Māori patients only
No. of Māori patients presented in TMDM
Percentage of Māori patients of total no. presented
No. of Māori patients with stage 1-2
No. of stage 1-2 Māori patients with thoracic surgery
No. of Māori outpatients
No. of Māori inpatients
No. of Māori private patients
No. of Māori patients of unknown origin
No. of Māori outpatients with FSA <15 days
Denominator
Percentage of Māori outpatients with timely FSA
No. of Māori outpatients with TMDM <29 days
Denominator
Percentage of Māori outpatients with timely TMDM
Table D3:
Data collected for Pacific patients only
No. of Pacific patients presented in TMDM
Percentage of Pacific patients of total no. presented
No. of Pacific patients with stage 1-2
No. of stage 1-2 Pacific patients with thoracic surgery
No. of Pacific outpatients
No. of Pacific inpatients
No. of Pacific private patients
No. of Pacific patients of unknown origin
No. of Pacific outpatients with FSA <15 days
Denominator
Percentage of Pacific outpatients with timely FSA
No. of Pacific outpatients with TMDM <29 days
Denominator
Percentage of Pacific outpatients with timely TMDM
Table D4:
Type of patients
Patients with
thoracic surgery first
Patients with
radiotherapy first
Patients with
chemotherapy first
Patients with any
anticancer treatment
Access to anticancer treatment
Number
% Cohort
Wait Time
% within Regional
Standard (<15 days)
(Average time from MDM to
thoracic surgery) =
(Average time from MDM to FSA
radiation oncology) =
(Average time from MDM to FSA
medical oncology) =
(Average time from MDM to FSA in
first oncological service) =

34
Abbreviations
CT
CTFNA
CXR
DNA
DHB
FSA
FTE
GP
`
HRC-DHBNZ
KPI
MDM
RFTC
TSANZ
Computer Axial Tomography
CT Fine Needle Aspirate
Chest X-ray
Do Not Attend
District Health Board
First Specialist Appointment
Full Time Equivalent
General Practitioner
Health Research Council & District Health Boards New Zealand
Key Performance Indicator
Multidisciplinary Meeting
Respiratory Fast Track Clinic
Thoracic Society of Australia and New Zealand

35