Download 2016 Programmatic Review Environmental Scan

2016 Programmatic Review
on the Diagnostic Phase
Environmental Scan
June 2016
The Cancer Quality Council of Ontario
Report prepared by the Cancer Quality Council of Ontario (CQCO) as a backgrounder to inform the joint
CQCO-Cancer Care Ontario (CCO) Programmatic Review on the Diagnostic Phase.
Contents
Executive summary ....................................................................................................................................... 4
Background ................................................................................................................................................... 5
Cancer Quality Council of Ontario ............................................................................................................ 5
Figure 1: CQCO Mission, Tools and Outcomes ..................................................................................... 6
CQCO 2016 Programmatic Review: Main components ................................................................................ 7
Environmental Scan ...................................................................................................................................... 8
Objective ................................................................................................................................................... 8
Scope ......................................................................................................................................................... 8
Search methodology ................................................................................................................................. 8
Groups interviewed .................................................................................................................................. 9
Defining the diagnostic phase for cancer ..................................................................................................... 9
Figure 2: From Improving Diagnosis in Health Care, National Academies of Sciences, 2015....... Error!
Bookmark not defined.
Introduction ................................................................................................................................................ 10
Linkages and communication in the diagnostic phase ............................................................................... 10
eTools at Cancer Care Ontario ................................................................................................................ 15
The role of primary care in early cancer diagnosis ................................................................................. 11
Referral pathways for suspected cancer .................................................................................................... 11
The Danish three-legged strategy for cancer referrals ........................................................................... 12
The United Kingdom’s urgent referral pathway ..................................................................................... 12
National Institute for Health and Care Excellence (NICE) suspected cancer referral guidelines ........... 13
NICE clinical and diagnostic guidelines ................................................................................................... 14
Uniting Primary Care and Oncology Network (UPCON) ......................................................................... 14
Patient education/awareness of the diagnostic phase .............................................................................. 16
Patients First ............................................................................................................................................... 18
Impact on patient mental health in the diagnostic phase .......................................................................... 19
Efficiency and coordination of the diagnostic phase .................................................................................. 21
Laboratory Services Expert Panel ........................................................................................................... 26
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Eastern Ontario Regional Laboratory Association (EORLA) .................................................................... 27
Diagnostic Imaging Program ................................................................................................................... 27
Rapid Diagnosis and Support (RADS) Clinic............................................................................................. 26
Choosing Wisely Canada ......................................................................................................................... 19
Nova Scotia Breast Screening Program................................................................................................... 24
Thoracic Triage Panel at Eastern Health (Newfoundland and Labrador) ............................................... 25
Coordination of diagnostic services in the United States ....................................................................... 22
Cancer Council Australia: Optimal Care Pathways ................................................................................. 22
The ACE (Accelerate, Coordinate and Evaluate) Program ...................................................................... 23
Important factors in cancer care coordination ....................................................................................... 28
Barriers to effective cancer care coordination ........................................................................................... 29
Measurement of the diagnostic phase ....................................................................................................... 30
Cancer System Quality Index 2016 Measures for Diagnosis................................................................... 31
Manitoba’s In Sixty program ................................................................................................................... 24
Metrics to evaluate patient navigation during diagnosis: U.S. Study ..................................................... 30
Measuring diagnostic intervals ............................................................................................................... 30
Measurement of cancer trends in Ireland .............................................................................................. 31
Measuring performance on early diagnosis in the UK............................................................................ 31
Organization of the diagnostic phase ......................................................................................................... 32
Toronto East General Hospital’s Time to Treat Program ........................................................................ 34
Diagnostic Assessment Program (DAP) Organization ............................................................................. 35
Cancer Care Nova Scotia - Cancer Patient Navigation ............................................................................ 21
National Cancer Institute - Patient Navigation Research Program......................................................... 20
The National Health Service’s focus on processes to reduce wait times ............................................... 32
Ireland’s centralization of cancer services .............................................................................................. 33
Conclusion ................................................................................................................................................... 36
References .................................................................................................................................................. 39
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Executive summary
The Cancer Quality Council of Ontario (CQCO) is an arm’s length advisory group that was established in
2002 to guide Cancer Care Ontario (CCO) and the Ministry of Health and Long-Term Care in their efforts
to improve the quality of cancer care in Ontario. The CQCO’s mandate is to monitor and publicly report
on the quality of cancer services in Ontario and to improve the quality of the cancer system by
identifying quality gaps in the system.
The Programmatic Review typically brings CQCO members, CCO’s executive team, clinical leads, senior
staff and leading experts, patients, family members, and caregivers within the province together with
international experts to review an existing or emerging cancer system program, analyze its effectiveness
and make recommendations to CCO regarding future directions and improvements to the program. The
topic of this year’s review is the diagnostic phase, which is not a program itself but rather an area of care
with involvement from a number of programs.
The purpose of this environmental scan is to serve as background material for the June 22, 2016
Programmatic Review event on the diagnostic phase. A set of discussion questions have been developed
to guide the discussion at the Programmatic Review event and the scan has been organized according to
the themes of the questions. The scan summarizes the approaches that international and national
jurisdictions and Ontario have taken to address:
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linkages and communication in the diagnostic phase between healthcare providers,
patient education and awareness of the diagnostic phase,
efficiency and coordination of the diagnostic phase,
measurement of the diagnostic phase; and
how the diagnostic phase is organized both at the program and organization wide level.
Key findings from the environmental scan include the fact that the diagnostic phase is a complex phase
of care that requires the efficient use of resources in order to optimize the patient experience. The time
between suspicion of illness to diagnosis is extremely complex and requires efficient coordination of the
healthcare system. Additionally, the diagnostic phase may include the need for multiple tests and
consultations with various healthcare providers. This may increase wait times and may induce
considerable anxiety among patients as they navigate this complex phase of care. Many jurisdictions
struggle with how to optimize the diagnostic phase and communication between healthcare providers
and their peers as well as with patients is an important area for focus. Patient education and awareness
of the diagnostic phase would be helpful to both give patients a roadmap for what they might expect
during the diagnostic phase and to help answer questions, and reduce anxieties.
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Background
Cancer Quality Council of Ontario
The Cancer Quality Council of Ontario (CQCO) is an advisory group that was established in 2002 by the
Ministry of Health and Long-Term Care (MOHLTC) and is quasi-independent to Cancer Care Ontario
(CCO). It was set up to provide advice to CCO and the MOHLTC in their efforts to improve the quality of
cancer care in the province. The CQCO is supported by a Secretariat housed within CCO.
The CQCO is a multidisciplinary group of healthcare providers, cancer survivors, family members and
experts in the areas of oncology, health system policy, performance measurement, health services
research and health care governance.
The CQCO has a mandate to monitor and report publicly on the performance of the Ontario cancer
system and to motivate improvement by bringing national and international expertise to bear on quality
improvement initiatives in Ontario. The CQCO works with CCO’s Board of Directors to assess cancer
system performance and quality, identifying areas for improvement and advising on planning and
strategic priorities. In 2010, the CQCO expanded its mandate to include international benchmarking of
cancer system performance. More information can be found at www.cqco.ca.
The CQCO Programmatic Review is one of four key tools used to achieve our mandate. The
Programmatic Review typically brings CQCO members, CCO’s Executive Team, senior staff, Ontario
clinical leads, patients, family members, and caregivers together with international and local experts to
review an existing or emerging cancer system program, analyze its effectiveness and make
recommendations to CCO regarding strategic directions and improvements.
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Figure 1: CQCO Mission, Tools and Outcomes
The other three tools used by the CQCO are:
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The annual Cancer System Quality Index (CSQI), an interactive web-based reporting tool that
tracks Ontario’s progress towards better outcomes in cancer care and highlights where cancer
service providers can advance the quality and performance of care. A North American first, the
CSQI was launched in 2005 and now in its twelfth year, the CSQI presents overall Ontario
contextual information including mortality and survival as well as a rolling snapshot of activity
across 39 key indicators. The CSQI serves as a valuable system-wide monitor that allows us to
track the quality and consistency of all key cancer services delivered across the spectrum of
Ontario’s cancer system, from prevention through to survivorship and end-of-life care. More
details can be found at: www.csqi.on.ca
An annual Signature Event that brings practice leaders, policy makers, providers, patient and
family representatives together with international and national experts to provide practical
solutions to address a quality gap and identify areas of opportunity to improve the quality of
health services delivery within the Ontario context. More details can be found at:
www.cqco.ca/events
The Quality and Innovation Awards, sponsored by the Quality Council, CCO, and the Canadian
Cancer Society, Ontario Division, recognize significant contributions to quality and innovation in
the delivery of cancer care across the province of Ontario. More details can be found at:
www.cqco.ca/awards
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CQCO 2016 Programmatic Review: Main components
The Programmatic Review process has four main components:
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Environmental scan – literature/best practice search to identify key themes and topics. Sets the
foundation and backdrop for the other inputs.
Current statement assessment – detailed description of current operations and functions.
Critical (self) appraisal – via key informant interviews and SWOT analysis.
International input – experts to participate in the discussion and advise CCO on future
recommendations.
The 2016 CQCO Programmatic Review is on the topic of the diagnostic phase in cancer. There are
several programs involved in diagnosis including Prevention and Cancer Control, Clinical Programs and
Quality Initiatives, Planning and Regional Programs, Analytics and Informatics, and the Ontario Renal
Network. Because there are so many programs involved in this phase, this programmatic review will aim
to evaluate the overall effectiveness and sustainability of the current practices and processes of the
diagnostic phase.
Table 1. Current cancer diagnosis programs at CCO:
Clinical Programs and Quality Initiatives
Planning and Regional Programs
Cancer Imaging
Disease Pathway Management
Pathology and Laboratory Medicine
Primary Care
Surgical Oncology
Ontario Breast Screening Program, Colon
Cancer Check, Ontario Cervical Screening
Program, and Primary Care
Quality Management Partnership-colonoscopy,
mammography and pathology
Diagnostic Assessment Programs
Analytics and Informatics
Access to Care
Ontario Renal Network
Integrated Care
Prevention and Cancer Control
Programmatic Reviews culminate in an event where stakeholders are brought together to develop a set
of recommendations for how to improve the quality of a CCO program. This year’s Programmatic Review
event will be held on June 22, 2016 and will focus on:
 reviewing the current state of the diagnostic phase for cancer in Ontario including Cancer
Care Ontario’s role
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learning from other jurisdictions (both national and international) about best practices in
service delivery with regard to cancer diagnosis
providing Cancer Care Ontario with recommendations for improvement and future
activities with regard to the process to diagnose cancer and to enhance quality of care
received by patients and their families.
Environmental Scan
Objective
The objective of the environmental scan is to review literature pertaining to the diagnostic phase and to
highlight notable trends and best practices in Canada and to highlight noteworthy international
programs. Australia, Denmark, the United Kingdom and the United States were captured as part of the
international component of the environmental scan.
Scope
The scope of the environmental scan included reviewing local, national and international programs that
focus on the diagnostic phase of cancer. Specifically the scan focused on looking at how various
jurisdictions address linkages and communication in the diagnostic phase between healthcare providers,
patient education and awareness of the diagnostic phase, efficiency and coordination of the diagnostic
phase, measurement of the diagnostic phase and how the diagnostic phase is organized both at a
program and organization wide level. Where possible, innovations and best practices were identified in
order to help inform conversations at the June 22, 2016 Programmatic Review event.
Search methodology
The scan was undertaken from January to May 2016. This report is intended to be a piece of
foundational information for the 2016 Programmatic Review event to be held on June 22, 2016 where
stakeholders will come together to identify and review the critical success factors of an efficient and
patient-centred diagnostic process for cancer. The goal of the day will be to reach agreement on a core
set of recommendations for CCO on strategic directions and improvements, in order to have a more
effective diagnostic phase, with patients as a priority.
Advice was provided by the Programmatic Review Steering Committee and the Programmatic
Review Working Group which included staff from the Quality Management Partnership, Cancer
Screening, Cancer Imaging, Pathology and Laboratory Medicine, Surgical Oncology, Primary Care,
Disease Pathway Management, Diagnostic Assessment Programs, Access to Care and Integrated
Care (see Appendix 1 for a list of Programmatic Review Steering Committee and Working Group
members). The CQCO Secretariat contacted administrators, academics, clinicians, program
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managers and patients in Ontario and across Canada (Manitoba, Newfoundland and Nova Scotia
agreed to participate in interviews), Denmark, Australia, the United Kingdom and the United States.
A snowballing approach was used to identify additional experts. The CQCO Secretariat conducted
32 interviews to inform this environmental scan.
Additionally a scan of documents published by relevant stakeholders in both academic and grey
literature was completed. Relevant government websites were also consulted to confirm
information collected during interviews.
Groups interviewed
The following groups of stakeholders were interviewed for this project:
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Clinicians
Patient navigators
Program managers
Academics
Patients
External stakeholders including the College of Physicians and Surgeons of Ontario
Defining the diagnostic phase for cancer
A definition of the diagnostic phase was developed with advice from the Programmatic Review
Steering Committee for the purposes of the discussion at the Programmatic Review event on June 22,
2016. The definition was developed to provide all participants with a common understanding of the
diagnostic phase.
The diagnostic phase starts with a patient experiencing a sign or symptom, or as a result of a screening
abnormality or incidental testing. The patient will then engage with the health care system where a
number of steps will be taken. These include:
1. Referral and consultation
2. Collection of clinical history
3. Diagnostic testing
Once the information from diagnostic testing has been interpreted, the diagnosis will be
communicated to the patient. The diagnostic phase ends once staging and clinical assessment has
been completed and a final treatment plan, based on the diagnosis, has been established (if no
treatment is chosen by a patient, then the diagnostic phase ends at that decision point).
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Introduction
In Ontario, the number of new cancer cases diagnosed each year has increased annually since 1981.
Aging of the population and population growth have contributed proportionally more new cases of
cancer over the last three decades than any changes in the risk of developing cancer (also referred to as
the change in the cancer rate). In 2016, approximately 85,648 new cancer cases are projected to occur, a
189% increase over the 29,649 new cancer cases reported in 1981 (Cancer System Quality Index, 2016).
This growth demonstrates the need for high-quality cancer care that is cost-effective and resource
efficient.
With an aging population and a higher demand for cancer services every year, the need for high quality
and timely diagnostic services grows. With limited funding, there is a need for a change in the cancer
system to provide more high-quality care with fewer resources. This means considering the concepts of
value and efficiency when allocating funds. Beyond the high demand for these services, early diagnosis
can improve outcomes in patients and increase survival. It has been recognized that improving
diagnostic services relies on the efficient use of existing capacity and timelier uptake of new, costeffective technologies (Deloitte Center for Health Solutions, 2013).
Earlier diagnosis can be beneficial in reducing downstream costs of health care, lowering hospitalization
rates, cutting avoidable or inappropriate interventions, and enabling minimally invasive procedures that
decrease length of stay, and rehabilitation. From a patient perspective, earlier diagnosis can relieve a
great deal of unwanted stress and anxiety (Deloitte Center for Health Solutions, 2013).
As the care pathway becomes more complex, the potential for miscommunication, poor coordination
between providers and fragmentation of services increases. There are several gaps that need to be
addressed to enable more prompt and efficient cancer diagnosis; these include gaps in coordination and
communication between the various healthcare providers in the diagnostic phase and with patients,
patient education and awareness of the diagnostic phase, efficiency and coordination of the diagnostic
phase, measurement of the diagnostic phase to enable evidence-based decision making, and reviewing
how the diagnostic phase is organized and where accountabilities lie.
This environmental scan has been organized to address each of the above themes. This scan includes a
review of provincial, national and international jurisdictions to provide a summary of the approaches
that various jurisdictions are taking to address the various issues in the diagnostic phase for cancer.
Linkages and communication in the diagnostic phase
The diagnostic phase for cancer requires communication and functional relationships across healthcare
providers and the various settings they work in. Increasing and streamlining communication across
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healthcare providers could lead to a more streamlined diagnostic phase as communication is not always
structured in this phase of care. Communication with patients in this phase of care is also important,
because it helps patients to navigate the diagnostic phase and help alleviate anxieties they might
experience throughout the diagnostic process.
A number of jurisdictions that are working to address communication issues throughout the diagnostic
phase are highlighted below.
The role of primary care in early cancer diagnosis
Danish studies and the International Cancer Benchmarking Partnership have shown that healthcare
systems with a “gatekeeping” role (like those in the United Kingdom and Denmark) have significantly
lower one year cancer survival than systems without such gatekeeper functions. A gatekeeper is defined
as a defined point of entry each time care is needed for a health problem (Willems, 2001). The role of
primary care physicians, who tend to be the gatekeepers in early cancer diagnosis is challenging given
that there are more than 200 different types of cancer and many may have vague symptoms (Cancer
Research UK , 2015). Primary care physicians play a pivotal role in the diagnostic phase as they ensure
that a patient gets on the right pathway at the earliest opportunity.
Findings from the International Cancer Benchmarking Partnership found that primary care physicians in
the United Kingdom would be less likely to send a patient with potential cancer symptoms for tests, or
to refer them to a specialist at their first appointment, than doctors from Australia, Canada, Denmark,
Norway or Sweden (Rose, 2015). The study showed that there is a correlation between these referral
patterns and the differences between the countries’ one-year cancer survival.
Patients presenting with symptoms to a primary care physician in the United Kingdom are referred after
the first or second visit. But in approximately 25% of cases, particularly for younger patients, those from
ethnic minority groups, and those presenting with vague symptoms patients reported visiting their
primary care physician three or more times before specialist referral. It was also found that if patients
with vague symptoms have an inconclusive test they can end up going back and forth between primary
care and different diagnostic services, thereby potentially increasing patient anxiety.
Referral pathways for suspected cancer
Referral pathways for cancer may help to improve linkages and communication among healthcare
providers. Referral pathways may be particularly useful for increasing communication between primary
care and oncology and may lead to a more structured and timely diagnostic process. The Danish three
legged strategy for cancer referrals and the United Kingdom’s urgent referral pathway are highlighted
below. Cancer Care Ontario has developed diagnosis pathways for lung cancer and soft tissue sarcoma.
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Implementing diagnostic pathways for other disease site is potentially feasible in Ontario as Cancer Care
Ontario already has experience in this domain.
The Danish three-legged strategy for cancer referrals
In 2008, Denmark introduced an urgent referral pathway for suspected cancer to help improve the
diagnostic phase for patients with very serious symptoms. The purpose of the system was to ensure an
urgent referral pathway was available for patients with “alarm” cancer symptoms so that they could be
diagnosed faster. After the implementation of the urgent referral pathway, gaps were found in how to
deal with patients with symptom severities that did not fit into the “alarm” category. This led to the
development of a “three-legged” strategy to accommodate timely diagnosis of early-stage cancer
patients as well as late-stage patients. The majority of symptoms seen by general practitioners were not
“alarm” symptoms, therefore it was critical to address pathways for patients with less severe symptoms.
This strategy recognizes that there are different levels of symptom severity along a continuum. There is
“certainly not serious” on one end, “low-risk-but-not-no-risk” in the middle, and “definitely serious” on
the other end. Depending on the symptom and the severity, a different referral route is taken (Olesen &
Vedsted, 2015).
The three-legged approach refers to the three pathways that a general practitioner can refer a patient
to based on their symptoms. Patients with urgent “alarm” symptoms, they are immediately referred to a
specialist. For patients with non-specific serious symptoms, a filter function is implemented. Patients
with these symptoms will undergo a number of standard tests including blood work, urine analysis and
diagnostic imaging. The results are sent to the general practitioner within four business days and they
can decide whether to refer the patient to a diagnostic centre within eight business days should the
results not rule out the possibility of cancer. At diagnostic centres, patients have access to more
specialized tests for a more comprehensive medical investigation. The final category is patients with
vague symptoms who are low-risk-but-not-no-risk. If a patient presents these types of symptoms, the
general practitioner can refer the patient to a No-Yes-Clinic (NYC). In this route, the patient can get
direct access to diagnostic tests without having to first go through more routine testing (Olesen &
Vedsted, 2015).
This program has shown to be an efficient use of resources and diagnostic testing, and is more inclusive
of patients with a wide range of symptom severities. One study showed that after giving general
practitioners direct access to refer patients for a low-dose CT scan for suspected lung cancer, the use of
CT scan did not increase (Olesen & Vedsted, 2015).
The United Kingdom’s urgent referral pathway
In the United Kingdom (UK), primary care physicians have a gatekeeper role for access to specialist care.
The UK, like Denmark, introduced an urgent referral pathway for cancer to enable rapid access to a
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specialist opinion or diagnostic test (within two weeks in England) for patients with specified alarm
symptoms, such as abnormal bleeding, unexplained weight loss, or an unexplained lump or abdominal
mass. These pathways are supported by clinical guidelines for their use (Moeller, et al., 2015).
The current pathway in the UK was revised in June 2015. For some cancers, evidence now suggests that
use of the pathway is associated with a shorter time to diagnosis and treatment, although the size of the
effect varies by cancer site (Moeller, et al., 2015). For colorectal cancer, in one report from a Spanish
research group, an assessment of a rapid referral pathway for suspected colorectal cancer in Madrid
found that the time to diagnosis after urgent referral was 19 days less than by routine referral
(Vallverdú-Cartié H, Comajuncosas-Camp J, Orbeal-Sáenz RA,, 2011). However, there is not yet evidence
indicating that this diagnostic strategy has an effect on the overall prognosis and mortality of patients
with cancer in the population.
In the United Kingdom, the frequency with which general practices use the urgent referral pathway for
suspected cancer and the accuracy of their patient selection for urgent referral varies considerably
(Moeller, et al., 2015). However, greater use of this pathway has been shown to be linked with reduced
mortality though only 27% of cancers are diagnosed through this route. The proportion of patients
referred through the urgent pathway who are subsequently diagnosed with cancer is approximately
10%.
National Institute for Health and Care Excellence (NICE) suspected cancer referral
guidelines
In 2005, the United Kingdom implemented the National Institute for Health and Care Excellence (NICE)
guidelines for suspected cancer referral. The guidelines offer evidence-based advice on the recognition
of and referral for suspected cancer in children, young people and adults (National Institute for Health
and Care Excellence , 2015). These guidelines are a comprehensive approach to patient care in the
diagnostic phase, including guidelines around signs and symptoms, recommendations on appropriate
diagnostic testing, the timeline for consultation or diagnostic tests depending on signs and symptoms,
recommendations for the information and support to provide to people with suspected cancer and their
families, and recommendations for ‘safety-netting’ patients which involves a general practitioner
monitoring a patient and advising to return if symptoms persists or worsen, or conducting more routine
tests for further medical investigation. This is used for very low risk patients to avoid over-referral
(National Institute for Health and Care Excellence , 2015).
The guidelines are based on thresholds where if the risk of cancer is above a certain threshold then
investigation or referral is required. The thresholds were lowered in an updated version of the
guidelines in 2015. This change was to encourage earlier diagnosis and referral (National Institute for
Health and Care Excellence , 2015).
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The NICE guidelines provide a framework for general practitioners for suspected cancer, although the
guidelines also emphasize the importance of clinical judgment. The guidelines are not meant to
eliminate the need for the clinicians’ personal judgement of a case. The updated guidelines also
highlight that better engagement and communication between primary and secondary care is essential
(National Institute for Health and Care Excellence , 2015).
A study of diagnostic intervals before and after the implementation of NICE guidelines showed that the
time from a patient’s first presentation of symptoms to a general practitioner to diagnosis decreased for
patients diagnosed between 2001-2002 and patients diagnosed 2007-2008. This could indicate the
implementation of the NICE guidelines in 2005 had an effect on decreasing diagnostic intervals. The
NICE guidelines have since been updated in 2015 to include lower risk thresholds. It was also updated to
allow general practitioners to refer patients directly for diagnostic tests such as imaging rather than
through a specialist (Caret, P., Din, N.U., Hamilton, W., Neal, R.D., Rubin, G., Ukoummune. O.C. , 2014).
NICE clinical and diagnostic guidelines
NICE has developed clinical guidelines that outline the recognition or diagnosis and management of
various types of cancers and diagnostic guidelines which outline specific recommendations for disease
site specific diagnostic tests. Both sets of guidelines are evidence-based and were developed to assist
clinicians throughout the diagnostic process. The guidelines provide recommendations and explain the
evidence behind the recommendations. The clinical guidelines provide details about what diagnostic
investigations should be offered to a patient, staging recommendations, preoperative or pretreatment
management, follow-up care, and other advice that is disease site specific (National Instistute of Health
and Care Excellence, 2016). They are continuously reviewed and updated as new evidence arises to
ensure the best possible research is informing diagnostic recommendations for patients. The diagnostic
testing guidelines spans across many different types of diagnostic testing including certain types of
imaging, gene expression profiling, and colposcopy technologies, for example. The guidelines describe
evidence supporting the use of these tests, or if further research is required to provide accurate advice.
In addition, they describe what the test is, the situations in which it should be used, the outcomes
expected from the tests, and the accuracy and effectiveness of the test (National Instistute of Health
and Care Excellence, 2016).
Uniting Primary Care and Oncology Network (UPCON)
The Uniting Primary Care and Oncology Network (UPCON) was developed by CancerCare Manitoba in
2004 to enhance partnerships between family practitioners and the cancer system. In 2012, UPCON and
the Community Cancer Program Network (CCPN) partnered to become the Community Oncology
Program at CancerCare Manitoba. There are over 50 participating primary care clinics and family
practices across the province (CancerCare Manitoba, 2016).
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Some of the objectives of this program include enhancing the knowledge of family practitioners about
cancer, improving communication and strengthening relationships between primary care and oncology,
and promoting the role of primary care in the cancer system. UPCON is working to achieve these goals
through a few main initiatives one of which includes providing clinics with access to Manitoba’s unique
provincial cancer electronic medical record system (McCormack & Sisler, 2009). Once staff are trained in
this program, physicians can use it to access specific patient information. This has decreased duplication
in lab tests, while giving primary care providers a real time view of their patients’ cancer journey.
(CancerCare Manitoba, 2016) CancerCare Manitoba was the first Canadian cancer agency to make its
electronic medical record available to lead family physicians in their clinics through secure Internet
access (McCormack & Sisler, 2009).
UPCON is also engaged in implementing small group cancer education sessions for clinic lead physicians
and their colleagues as well as informational newsletters. Each clinic has an appointed lead physician
who takes on the role of attending UPCON educational sessions, learning about the electronic medical
record and sharing information they learn with their clinic staff. This program has shown to be an
effective tool to support shared care of a patient and collaboration of primary care physicians and
cancer specialists (CancerCare Manitoba, 2016).
Developing a program such as UPCON in Ontario would be useful to address the current gaps in
communication between primary care physicians and specialists and oncologists that were identified by
a number of interviewees (this includes primary care providers, oncologists, radiologists, pathologists
and patients) who informed both this environmental scan and the Programmatic Review companion
documents (SWOT Analysis and Current State Assessment). It is potentially feasible for the Clinical
Programs and Quality Initiatives portfolio at Cancer Care Ontario to address these communication gaps
through the Primary Care program.
eTools at Cancer Care Ontario
At Cancer Care Ontario, the purpose of eTools is to integrate patient, family and clinician needs, and to
ensure the work is going to help in meeting the goals of Cancer Care Ontario and the Ontario Cancer
Plan IV (OCP IV). There are a number of ways eTools can achieve the goals of the OCP IV. These include:
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enhancing communication among all providers across the cancer care continuum
improving communication, decision-making, self-management,
increasing the availability of relevant clinical information to patients and providers; and
expanding the use of technologies and tools for providers that drive adherence to evidencebased guidelines
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There are currently many systems in use that are largely not integrated or interoperable, and Cancer
Care Ontario is working to improve integration through the eTools strategy for seamless care. This is
especially important in the diagnostic phase as there can be many facilities and tests involved and
efficient sharing of information and coordination of these tools is crucial to timely diagnosis (Cancer
Care Ontario, 2016).
The top priority identified by patients in terms of technology was a single access point to consolidate
patient medical record information. In a survey, 92% of patients noted that they would like full access to
their electronic health record data. The main type of data that patients would like access to is laboratory
and blood work (Cancer Care Ontario, 2016).
In the diagnostic phase, there are tools used in both primary care and oncology to facilitate the process
for patients and health care providers. In primary care, the specifications from OntarioMD describe
what functionality an electronic medical record (EMR) needs to have in Ontario and is enforced so there
is consistency. On the oncology side, the Oncology Information System Standards have functionality
requirements and information and data standards at the diagnosis stage to improve quality of care,
patient safety and efficiencies for staff. However, these recommendations are not strictly enforced
(Cancer Care Ontario, 2016).
Some other eTools used in the diagnostic phase are the Diagnostic Assessment Program Electronic
Pathway Solution (DAP-EPS) (note this program is being sunsetted in 2016/17). This interactive and webbased solution connects physicians, patients and staff at DAP Facilities. There are two websites, one for
patients and one for health care providers. Providers external to DAP facilities are also able to utilize this
tool. The sites are used to view and share personal health information electronically (Cancer Care
Ontario, 2015).
The Ontario Laboratories Information System (OLIS), developed by eHealth Ontario, is a province-wide,
integrated repository of tests and results. This system allows practitioners to have timely access to
information to help clinical decision making. The organizations contributing data into OLIS represent
over 84% of the annual provincial laboratory test volumes. This system has benefits to both patients and
clinicians including fewer gaps in information as patients move between health care facilities, reduced
number of unnecessary laboratory tests, timely access to information for practitioners leading to overall
improved coordination and improved workflow (eHealth Ontario , 2016).
Patient education/awareness of the diagnostic phase
For many patients and their families, the diagnostic phase is wrought with anxiety and fear. The patients
who were interviewed for this environmental scan felt that navigating the diagnostic phase was difficult
as it was not always clear how many tests would need to be performed in order to reach a diagnosis.
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Patients also feel unsure about what questions to ask of their healthcare provider and what they should
expect throughout the diagnostic phase. Patients feel that they are left to navigate the diagnostic phase
on their own which leads to mounting anxiety and confusion about the diagnostic process.
Patients noted that the wait time from the time of suspicion to diagnosis was lengthy. This in addition to
navigating the diagnostic phase were noted as key challenges for patients. Patients noted that having
navigation supports in place would be helpful from a coordination perspective but also to help alleviate
some of the psychosocial challenges one may encounter. Having a point person who patients could
contact to ask questions, get support for symptom management and emotional support were noted as
opportunities for the diagnostic phase. It was also noted that having increased coordination between
specialists would be useful for patients undergoing the diagnostic phase.
Patients did agree that public education with regard to the diagnostic phase would be helpful. It was
noted that members of the public may only be interested to learn about the diagnostic phase if they are
faced with a potential diagnosis. While there are supports in place once someone has a confirmed
diagnosis such as the Canadian Cancer Society’s Peer Support Service, no organized support services
were found for patients going through the diagnostic phase.
The International Cancer Benchmarking Partnership (ICBP) is a collaboration across 6 countries
(Australia, Canada, Denmark, Norway, Sweden and the UK) and 12 jurisdictions of comparable wealth
and with universal access to healthcare, established to examine international differences in cancer
outcomes and identify possible causes. Cancer survival is highest in Australia, Canada and Sweden,
intermediate in Norway, and lowest in Denmark and the UK (Rose, 2015). Differences between the
countries in the proportion of patients diagnosed with cancer at an early stage, suggest that differences
in the period prior to diagnosis contribute to the international variation in cancer survival, along with
other potential factors, such as access to treatment and the quality of treatments (Rose, 2015).
Public awareness of signs and symptoms, and beliefs about cancer, appear to be quite similar across
jurisdictions and are therefore unlikely to account for much of the variation seen between countries.
The ICBP found that patients in the UK are significantly more worried and embarrassed than those in
other countries about seeing their doctor with a symptom that might be serious – ‘worried about
wasting the doctor’s time’ being the main endorsed statement. They also report greater difficulty in
getting an appointment with a primary care physician as a barrier to presentation. Awareness campaigns
which focus on the need to present if a set of symptoms exists may be a useful approach in encouraging
the public to see their primary care provider (Cancer Research UK , 2015).
Be Clear on Cancer is a set of social marketing campaigns, run by Public Health England in partnership
with the Department of Health and National Health Service (NHS) England and supported by Cancer
Research UK. The brand has been used to promote symptom awareness and early diagnosis of eight
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different cancer types, as well as a more generic campaign which focused on four key signs of many
types of cancer. All of these campaigns have been carefully evaluated, with the majority delivering
positive results in encouraging earlier presentation.
An evaluation of the national lung campaign in 2012 showed that an estimated 700 additional lung
cancers were diagnosed during that period compared to the same period the previous year.
Approximately 400 more people had their cancers diagnosed at an earlier stage and around 300
additional patients had surgery, a treatment that is inappropriate once lung cancers are more advanced.
These campaigns have also helped educate the public that many cancers are treatable if caught early
and have helped to change attitudes amongst some primary care providers (Cancer Research UK , 2015).
Though the diagnostic phase is not as well studied as the treatment phase when it comes to the impact
on patients, Cancer Care Ontario’s Person-Centre Care program was involved in a CQCO Signature Event
on patient activation and self-management where a set of recommendations were developed on how to
integrate self-management form the diagnostic phase onward. Ontario could build on the work of the
Person-Centered Care program to ensure that self-management principles are weaved throughout the
diagnostic phase to provide patients with tools on how to manage their anxieties throughout the
diagnostic phase.
Patients First
Patients First: An Action Plan for Health, is an Ontario initiative developed in 2015 that is working to
improve health care, with a focus on a more patient-centred approach. This plan builds on the Action
Plan for Health Care in 2012 to set a framework for the next phase of health system transformation.
Some of the basic principles of the Patients First action plan are to engage Ontarians and be more
transparent in health care to understand patient needs and allow patients to make informed choices. In
addition, the plan aims to provide coordinated and integrated care and help patients understand how
the system works to enable patients to get the right care when they need it (Ministry of Health and
Long-term Care, 2015).
There are four main objectives of the plan:




Access: Improve access – providing faster access to the right care.
Connect: Connect Services – delivering better coordinated and integrated care in the
community, closer to home
Inform: Support people and patients – providing the education, information and transparency
they need to make the right decisions about their health
Protect: Protect our universal public health care system – making decisions based on value and
quality, to sustain the system for generations to come.
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(Ministry of Health and Long-term Care, 2015)
This plan aligns with many of the areas in the diagnostic phase that have been identified as challenges
including coordinated care, making decisions based on value and quality, and sustainability. There were
several gaps in care that were identified as challenges when creating the action plan. One of the main
gaps identified that applies to the diagnostic phase is fragmentation in the way health services are
planned and delivered, which can be an inefficient use of time and resources (Ministry of Health and
Long-Term Care, 2015).
While this plan is not specific to cancer, there are certainly aspects that the diagnostic phase fits in to
and aligns with. In the first year of implementation, there were changes made to work towards each of
these objectives including strengthening and investing more in home and community care, expanding
access to fertility services, creating a public education campaign about vaccinations, and selecting
Ontario’s first-ever patient Obudsman (Ministry of Health and Long-Term Care, 2016).
Choosing Wisely Canada
Choosing Wisely Canada (CWC) is a campaign to support and inform clinicians and patients to be able to
make smart and effective choices to ensure high-quality care, while recognizing that some tests or
treatments may be unnecessary. Unnecessary tests and treatments can lead to causing a patient more
harm than good, and may cause added anxiety over a false positive test, for example. Beyond the
negative impacts that unnecessary tests can have on a patient, it places a large burden on the
healthcare system (Choosing Wisely Canada , 2016)
Choosing Wisely Canada has identified a number of tests and treatments that are commonly done that
are not supported by evidence and may cause patients unnecessary harm. Choosing Wisely Canada has
developed recommendations in domains that address efficiencies in the cancer system including some
diagnostic testing. There are specific recommendations for physicians as well as patients to consider
when going through screening, testing, diagnosing, and planning treatment (Choosing Wisely Canada ,
2016). The lists are meant to encourage conversation between patients and providers, although each
patient is unique.
Health Quality Ontario has worked with Choosing Wisely Canada to review and provide evidence-based
recommendations about a variety of important health interventions including diagnostic tests, devices,
procedures, health care programs and models of care. The Choosing Wisely Canada lists were created in
partnership with Health Quality Ontario.
Impact on patient mental health in the diagnostic phase
It is well known that many cancer patients experience emotional distress throughout the course of their
experience with cancer and emotional distress is well studied in patients after a cancer diagnosis
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(Brocken, Prins, Dekhuijzen , & van der Heijden, 2012). The emotional impact of the diagnostic phase on
patients is an area that needs more attention as it is not well studied and often over-looked (Brocken,
Prins, Dekhuijzen , & van der Heijden, 2012). The emotional impact of the diagnostic phase requires
more investigation for a number of reasons including the high prevalence of emotional distress in cancer
patients during the course of their illness. A number of studies suggest the prevalence of emotional
distress among cancer patients to be between one fifth to half of all cancer patients (BrintzenhofeSzoc &
Curbow, 2001), (Graves, Arnold, & Love, 2007), (Aass, Fossa, & Dahl, 2005). It has been found that
anxiety, depression and quality of life can be improved by psychosocial interventions in cancer patients,
and early detection may be beneficial to patients with regards to emotional distress as it would shorten
length of time in the diagnostic phase (Brocken, Prins, Dekhuijzen , & van der Heijden, 2012). Shortening
the length of time in the diagnostic phase could be achieved by implementing rapid diagnostic pathways
(one or two-stop diagnostic services) which have been shown to shorten the period of uncertainty for
patients and improve patient satisfaction.
In the case of a confirmed cancer diagnosis, anxiety tends to increase or sustains (Brocken, Prins,
Dekhuijzen , & van der Heijden, 2012). A systematic review found a beneficial effect of a rapid diagnostic
pathway on distress in the case of benign disease (Brocken, Prins, Dekhuijzen , & van der Heijden,
2012). For patients who are diagnosed with cancer, the rapid pathway shortens the period of diagnosisrelated distress and the relatively few studies included in the systematic review suggested the absence
of a detrimental effect on anxiety compared with regular pathways (Brocken, Prins, Dekhuijzen , & van
der Heijden, 2012).
National Cancer Institute - Patient Navigation Research Program
The National Cancer Institute has a program called the Patient Navigation Research Program. The goals
of this program are to develop innovative patient navigation interventions to reduce or eliminate cancer
health disparities and test their efficacy and cost effectiveness, and to decrease the time between a
cancer-related abnormal finding, definitive diagnosis, and delivery of quality standard cancer care
services. These interventions were targeted at four main cancer types: breast, cervical, prostate, and
colorectal. The program’s research has concluded that patient navigation leads to increased rates of
resolution of abnormal cancer screening findings and decreased time from suspicion to diagnostic
resolution (National Cancer Institute, 2005-2010). In a study conducted by the Patient Navigation
Research Program, it was concluded that patient navigation improves timeliness of care. Both diagnostic
evaluation and cancer treatment were initiated earlier in a group with a navigator compared to a control
group from 91 to 365 days of observation, but not in the first 90 days. This may attributed to the time it
took to connect the patient with the navigator. The greatest impact was seen in cancer centres that
previously experienced longer delays, suggesting that patient navigation is most beneficial in centres
that have long follow-up delays (Freund, et al., 2014).
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Cancer Care Nova Scotia - Cancer Patient Navigation
Cancer Care Nova Scotia introduced a program called Cancer Patient Navigation in 2001 to address
barriers in the cancer system such as fragmented care, delays in system access, and poor
communication and coordination between health care providers. The goals of this approach are to help
patients, families and health providers handle the cancer system more effectively. Patient navigators,
who are oncology nurses, are able to provide support to patients to provide them with information,
guidance, and support to assist them with managing the cancer system. (Cancer Care Nova Scotia, 2016)
The program is a community-based partnership between Cancer Care Nova Scotia and eight district
health authorities. Access to the program is available through self-referral or from any health
professional (Canada, Accreditation, 2013).
Some of the benefits of this program include identifying gaps in the system, improved coordination and
collaboration, and a source of central knowledge (Cancer Care Nova Scotia, 2016) An evaluation of the
program confirmed that cancer patients and their families experienced significant improvements in
dealing with the emotional turmoil, informational needs and logistical challenges associated with having
cancer (Cancer Care Nova Scotia, 2016). After the program was evaluated and the benefits of patient
navigation were confirmed, the Canadian Partnership Against Cancer recognized the program as a best
practice model and developed a guide to facilitate implementation of a patient navigation program
(Canada, Accreditation, 2013).
Patient navigations throughout the diagnostic phase would be helpful to address issues such as gaps in
coordination and communication and delays in the cancer system. Cancer Care Ontario’s Aboriginal
Patient Navigators provide support and advocacy for First Nations Metis and Inuit (FNIM) patients and
families by facilitating and coordinating access to cancer services for palliative and supportive care,
addressing cultural and spiritual needs, and networking with FNIM and non-Aboriginal partners to make
the cancer journey a culturally safe experience. The Diagnostic Assessment Programs (DAPs) in Ontario
provide access to a patient navigator who is the patient's main contact and coordinates all testing for
the patient throughout the diagnostic journey. Lung/thoracic, colorectal and prostate cancer DAPs have
been created across Ontario. Some regions also have disease site specific DAPs (e.gd DAP for esophageal
cancer). The Strategic Plan, Navigating the Diagnostic Phase, outlines the Cancer Care Ontario DAP
Program priorities to address the gaps in the diagnostic phase for cancer.
Efficiency and coordination of the diagnostic phase
The diagnostic phase for cancer requires coordination across a number of healthcare providers and
settings. The diagnostic phase includes pathology and imaging services as well as other laboratory
services. Diagnostic services are specialized and require human and financial resources and as such,
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issues such as duplication, and quality of testing have to be addressed in order to ensure that the
diagnostic phase is efficiently utilizing healthcare resources. A number of innovations to address
efficiency, quality and coordination both internationally and in Ontario are summarized below.
Coordination of diagnostic services in the United States
Interviews were held with three representatives from two major United States (US) hospitals to inform
this environmental scans. The interviews conducted focused on how the diagnostic phase is structured
and specifically how access to good testing technology enables quick diagnosis, as well as how quality
oversight and reduction in duplication in testing has been achieved. Interviewees noted that there does
not seem to be much agreement around best practice with regard to diagnostic testing between
hospitals and their payers (insurance companies). This is challenging given that the diagnostic phase can
sometimes require multiple tests. Additionally, it was noted that a reduction in duplication of tests has
not been achieved as some hospitals have high quality pathology and laboratory testing facilities and
highly trained pathologists to undertake diagnostic testing. As such, patients who have been tested
outside of the hospital setting often undergo a second round of testing to ensure the results received
are correct. Though the hospitals have access to an electronic hospital information system called EPIC,
this solution only works when all referring hospitals are on the same system. It was also noted that part
of the reason that the US has quick diagnostic test turnaround times is because of the higher human
resource and technology resource capacity. One interviewee noted that the US is moving from a
revenue generation to cost containment model with regard to healthcare spending however this is a
slow process and conversations around how to approach this have just begun.
Cancer Council Australia: Optimal Care Pathways
Cancer Council Australia has developed several optimal care pathways for different types of cancer.
There are currently pathways for 13 types (or groups) of cancer. Each care pathway has guidelines
across the care continuum from prevention, early detection and first presentation of signs and
symptoms to after treatment care and end-of life care. For each type of cancer, there are specific
guidelines for “Presentation, initial investigations and referral”, as well as “Diagnosis, staging, and
treatment plan” (Cancer Council Australia , 2016)
The presentation, initial investigations and referral sections provide guidelines for timeframes for
general practitioner consultation, completing investigations, and referral to specialists. There are also
guidelines for support and communication with patients and families (Cancer Council Australia , 2016).
The “diagnosis, staging and treatment plan” sections provide guidelines for these areas specific to each
type of cancer. They outline specific staging investigations that should be done, the role of the
multidisciplinary team and roles of each individual member, as well as rehabilitation guidelines for
patients about nutrition, exercise and psychological strategies to prepare for treatment, and guidelines
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for support and communication with patients during this particular stage (Cancer Council Australia ,
2016).
In research done by the International Cancer Benchmarking Partnership which includes 6 countries:
Canada, Denmark, Sweden, Australia, United Kingdom and Norway, a link was found between cancer
survival and how likely general practitioners were to refer their patients immediately. General
practitioners in Australia were consistently found to be more likely to refer patients quickly (Rose, 2015).
The Optimal Care Pathways are patient friendly and are easily accessible online. The pathways are well
laid out, succinct and provide information that is written for a lay audience. Though these pathways are
resource intensive they are potentially feasible to develop or adapt.
The ACE (Accelerate, Coordinate and Evaluate) Program
The ACE (Accelerate, Coordinate and Evaluate) Program is an initiative between NHS England, Cancer
Research UK and Macmillan Cancer Support and was established to help improve the UK’s cancer
survival rates by providing evidence on how best to design diagnostic pathways. There are 60 projects
underway as part of the program. By mid-2017, Wave 1 of the ACE projects will have been completed
and evaluated, generating lessons for commissioners and providers to improve earlier diagnosis.
There are a number of additional areas to be tested alongside the existing concepts being explored
through ACE. One current area of weakness is that there is no optimal referral pathway for patients with
nonspecific but persistent concerning symptoms. These patients often fall through gaps, resulting in
delays to diagnosis. Others may end up shuttling between primary and secondary care if the first or
second test ordered is uninformative.
One model that could address this is the multidisciplinary diagnostic centre (MDC) concept – a single
testing location where a patient can undergo several tests relevant to their symptoms on the same day.
An MDC could be based in a community or a hospital setting and would supplement diagnostic
pathways for ‘red flag’ symptoms that are more clearly indicative of a particular type of cancer. It would
address symptoms for which primary care providers find it hard to determine the appropriate referral
pathway (including ‘low-risk-but-no-risk’ groups) or with which patients tend to present late. These
could include persistent vague abdominal pain, fatigue, bloating or weight loss.
The concept of a multi-disciplinary diagnostic centre has been implemented in Silkeborg, Denmark. This
diagnostic centre is a ‘one-stop shop’ for all diagnostic activities in the Silkeborg catchment area. This
diagnostic centre has been successful in reducing wait times, increasing efficiencies (as all diagnostic
tests are performed in one centre) and enhance communication between primary care providers and
specialists. The director of the Silkeborg diagnostic centre will be presenting at the June 22
Programmatic Review to provide a critical appraisal of the diagnostic centre and to discuss the feasibility
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of implementing such a centre in other jurisdictions (note this Silkeborg model has been implemented in
Norway, Finland and the NHS will be opening 6 centres based on the Silkeborg model).
Manitoba’s In Sixty program
In November 2011, Cancer Care Manitoba implemented a program called IN SIXTY (also known as the
Cancer Patient Journey Initiative) to improve the cancer journey for patients. The goal of the program is
to reduce the time between first suspicion of cancer by a doctor to first treatment to 60 days or less, by
2016. This program captures information on referrals, testing, diagnosis, retesting and the development
of a treatment plan into the 60 day objective (CancerCare Manitoba, 2016).
It was found that there were several factors contributing to delays in timely diagnosis including lack of
coordination and integration, which led to complex care pathways, and difficult transitions for patients
between health care professionals. Some of the initiatives the IN SIXTY program leveraged to improve
the diagnostic cancer journey for patients and decrease wait times included guideline and target
development, implementing advisory groups, and improving access.
A Patient Participatory Advisor group was formed to involve survivors and patients in their work on the
cancer journey. In addition, breast cancer guidelines were revised to explain referral processes. New
wait time targets for diagnosis were developed for several types of cancers. Other initiatives included
improving the cancer helpline service for health care professionals through texting and online, investing
in advanced diagnostic equipment for breast cancer, and adding nurse navigators to Cancer Navigation
Services to help guide cancer patients and general practitioners through the system and diagnostic
services (CancerCare Manitoba, 2016).
A representative from CancerCare Manitoba will be presenting a critical appraisal of the In Sixty program
at the June 22 Programmatic Review event.
Nova Scotia Breast Screening Program
The Nova Scotia Breast Screening Program was established in 1991 and was modeled after a similar
program in British Columbia to provide screening for women aged 50-69. In addition to providing
screening, the program develops standards and guidelines to support breast screening at several sites
across Nova Scotia, and evaluates the application and outcomes of the standards and guidelines.
There are several components to this program that contribute to its success. The program offers
opportunistic screening for women, which entails proactively booking a screening test for a woman if
she meets certain criteria for medical and family history. Another aspect of this program is mobile breast
screening, which is utilized in harder to reach locations. Because this program is outcome driven, an
annual report is developed to assess performance and make improvements (Nova Scotia Breast
Screening Program, 2015).
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One of the strengths of the program are patient navigators. The patient navigator ensures that the
patients’ appointments are scheduled in a timely manner. They act as a resource to patients and
primary care physicians. Once the patient has been booked for further tests and appointments, the
primary care physician is notified. This proactive approach to scheduling appointments has worked well,
and the program itself has proven to be a good use of resources and fairly cost-effective. In addition, the
program has not found quality of testing to be an issue which is an important aspect of the diagnostic
phase. The program has a very effective clinical database that has all screening and diagnostic reporting
for patients, with the exception of two sites. These factors have contributed to a strong relationship
between primary care and oncology.
Some of the challenges with diagnosis are that two of the sites are outliers, causing an inequity among
women. The information system is also in the process of being updated to combine the Mammography
Information System and the Breast Imaging System and is not yet complete. In addition, radiologists
must peer review many cases as clinical rounds are a requirement, which is time consuming.
Thoracic Triage Panel at Eastern Health (Newfoundland and Labrador)
Eastern Health has a system in place called the Thoracic Triage Panel to help coordinate care for patients
with suspected lung cancer. This system was implemented to help patients get diagnosed quicker and at
an earlier stage. The team that coordinates this care includes a respirologist, thoracic surgeon, a
radiation and medical oncologist, radiologist, pathologist and two nurses who act as patient navigators.
When a patient is suspected of having cancer, a letter is sent to that patient’s primary care physician and
they are asked to fill out a form with some of the patient’s medical information. At weekly panel
meetings, a requisition is filled out, and a patient navigator will contact the patient and review the role
of the panel and overview of the diagnostic steps that will be taken, giving the patient reassurance and
helping to guide them. The primary care physician is kept involved throughout the process and copied
on all reports. The hand-off between the family doctor and the panel is done directly, and the primary
care physician will still receive a letter stating what has been arranged for the patient.
Before the Thoracic Triage Panel was implemented, many patients would receive their diagnosis later
than they could have, as a result of going through a prolonged diagnostic process consisting of referrals
and tests.
Overall, the diagnostic phase has improved with the establishment of the Thoracic Triage Panel. The
Panel has been successful in moving patients through the diagnostic phase quicker. Specifically,
duplication of services is reduced, resources are used more efficiently, and healthcare provider time is
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also used more efficiently. The Thoracic Triage Panel is currently not a provincial program due to limited
resources.
Rapid Diagnosis and Support (RADS) Clinic at the Ottawa Hospital
A multidisciplinary team of breast cancer specialists launched a pilot program called the Rapid Diagnosis
and Support (RADS) Clinic at the Ottawa Hospital in March 2011. This pilot program was launched to
coordinate the diagnostic workup and nursing support for patients with a high chance of breast cancer.
A total of 211 patients participated in the RADs clinic and several measures of improvement were
identified. Firstly, biopsy wait times improved from a mean of 7 days to 3 days. Pathology wait times
improved from 3.9 days to 3.3 days, surgical consultation from 16.1 days to 5.9 days, and operative wait
times from 31.5 days to 24.1 days. Overall, there was a 95.3% satisfaction rate with the RADS clinic.
Specifically, there was significant improvement in patients’ sense of understanding of the treatment
plan, timeliness of tests, and timeliness of results. The diagnostic phase of care is an anxiety-provoking
experience for many cancer patients and their families, therefore programs such as RADS has shown to
improve wait times and satisfaction scores for patients with a high probability of diagnosis of breast
cancer (Arnaout, et al., 2013).
Laboratory Services Expert Panel
Laboratory services are a fundamental part of the diagnostic phase of cancer. The Ministry of Health and
Long-Term Care established the Laboratory Services Expert Panel to make recommendations on a future
funding model for community labs with a focus on value, quality, and access. In 2015, the Laboratory
Services Expert panel conducted a review of the current state in Ontario and made recommendations
for the future, specifically with regards to funding, delivery and management of laboratory services. The
recommendations are rooted in the concept of shifting from a transaction-based model to a value-based
model. The panel believes that there is great potential to get greater value in the community and the
broader laboratory sector (Laboratory Services Expert Panel, 2015).
The panel concluded that the budget could actually be reduced and that there are areas where savings
could be made while still achieving greater value in the laboratory sector. The panel identified specific
actionable recommendations for a funding model for community laboratory services. Performance
contracts were identified as one of the key levers to improvement as well as robust performance
management. The panel would like to see the negotiation of long-term formal performance contracts
with each community laboratory service supplier. The contracts would set out specific performance and
service standards determined by the Ministry. These standards would incorporate access, quality, and
ordering physician experience (Laboratory Services Expert Panel, 2015).
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Eastern Ontario Regional Laboratory Association (EORLA)
EORLA is a non-profit organization consisting of 16 member hospital clinical laboratories under the same
corporate business model. EORLA was the first major initiative to implement a corporate regional
business model for hospital laboratories in Ontario and serves as flagship initiative for other regions.
EORLA was created in response to a number of trends in pathology and laboratory medicine, one of
included the volume of laboratory tests in Ontario growing at a rate that was on track to surpass the
number of laboratory professionals available to support the increase. Statistics showed that laboratory
costs were increasing disproportionately to available funding. There was a need to increase capacity,
sustain or improve quality and enhance cost-effectiveness moving forward.
EORLA offers a model of integrated laboratory practices with the goal of delivering patient-focused,
consistent, high-quality and cost-effective diagnostic testing. It was created to address growing
laboratory costs and the need for a more sustainable system to support greater capacity (Eastern
Ontario Regional Lab Association , 2016). Some of the advantages to this model are more integration
and standardized care, which leads to better quality of care for patients.
Key to the success and sustainability of the EORLA model was the establishment of a funding mechanism
addressing both operating and capital budgeting, with members funding EORLA laboratory operations.
The funding mechanism allows EORLA to maintain operational flexibility while lowering expenses and
retaining savings gains through operational efficiency. It is designed to meet the requirements of EORLA
member organizations as both owners and customers. From an owner perspective, members are
assured of continuing delivery of laboratory services with sufficient operating funds. As customers,
members will benefit from an integrated system of service delivery that enhances quality and generates
savings over time through improving efficiency of service and the gradual lowering of costs per test
(Eastern Ontario Regional Lab Association , 2016).
Diagnostic Imaging Program – eHealth Ontario
To address the difficulties caused by paper reporting and imaging, eHealth Ontario developed a
Diagnostic Imaging (DI) program that supports systems such as the Picture Archiving and
Communications System (PACS) and regional DI repositories (DI-r). These systems have replaced film
and paper images and are stored in a digital repository making patient DI information easily accessible.
The repositories include patient radiology reports and images such as hospital-based CT scans,
ultrasounds, MRIs, mammograms and x-rays (eHealth Ontario, 2016)
This format has benefits to both patients and physicians in terms of easier access, reduced wait times,
reducing duplicate exams and procedures, eliminating the need to physically transport images, and
enhanced remote reporting (eHealth Ontario, 2016)
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There are four regional Diagnostic Imaging Repositories. These include the Southwestern Ontario
Diagnostic Imaging Network (SWODIN) DI-r, the Hospital Diagnostic Imaging Repository Services (HDIRS)
DI-r, the Northern and Eastern Ontario Diagnostic Imaging Network (NEODIN) DI-r, and the Greater
Toronto Area (GTA) West DI-r, covering GTA and North Simcoe Muskoka LHINs (eHealth Ontario, 2016).
SWODIN encompasses 60 hospitals in the southwestern region of Ontario. It is currently one of the
largest networks of its kind in North America providing secure access to patient images from multiple
facilities and platforms. HDIRS connects 38 hospitals and has seen reductions in delays between an X-ray
being taken, clinicians receiving reports and the patients being treated has been drastically reduced, as a
result of implementing PACS. NEODIN integrates diagnostic imaging across North West and Champlain
Local Health Integration Networks which includes 67 hospitals. NEODIN has helped support physicians in
more remote communities and enhanced coordination of care by allowing seamless transfer of images
and reports. GTA West has 35 hospital sites integrated to the repository, serving a population of 5
million and seeing 1.5 million patient visit every year. This repository increases efficiency by improving
patient flow and reducing repeat scans, enabling communication and collaboration, and reducing wait
times.
Important factors in cancer care coordination
In an exploratory study that took place in New South Wales, Australia, researchers investigated what
components patients, caregivers, and clinicians feel are important to cancer care coordination. From this
qualitative data, seven key areas were identified: organization of patient care, access to and navigation
through the healthcare system, effective communication and cooperation among the multidisciplinary
team and other health service providers, allocation of a key contact person, delivery of services in a
complementary and timely manner, needs assessment and sufficient and timely information to the
patient (Walsh, et al., 2011). These key areas were grouped under three themes: organization of
services, information sharing, and relationships.
Among participants, it was a commonly held view that the cancer system can be complex and an
overwhelming experience. They felt that that effective organization and administrative support
contributed to a more seamless journey and reduced anxiety. In terms of access to navigation, support
when moving back and forth between providers and health care settings was viewed as important. This
was especially relevant for patients who had to travel for treatment and felt isolated when they
returned home and lacked support. Clinicians and patients also felt that a key contact person was
necessary throughout the whole cancer journey because patients often were unsure who they should
reach out to for advice. Participants identified some advantages to having a key contact including giving
patients more confidence knowing that they had someone to ask about concerns, and having someone
familiar with their case to talk to. Timely delivery of services including specialist appointments, surgical
wait times, and appropriate and prompt referral were also identified as important (Walsh, et al., 2011).
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One of the main findings of the study was that a needs assessment is necessary and a critical part of
cancer coordination. Assessing a person’s physical, psychological and supportive care needs was
identified by care coordinators as an important step to empower patients to manage challenges along
their journey (Walsh, et al., 2011).
Lastly, sufficient and timely information to the patient was recognized as important to patients. Patients
felt that receiving appropriate information including appointment details and other medical and logistic
information made patients feel more involved in their care and helped them to cope with their disease.
They also valued receiving information that was presented in a way they could understand (Walsh, et al.,
2011). Patients also expressed that organizational and administrative support was very important to
them and highlighted that obtaining patient records, organization of paperwork, and facilitation of
transportation, all contributed to self-efficacy (Walsh, et al., 2011).
Barriers to effective cancer care coordination
In a qualitative study done in Australia, several key areas were identified by patients and health
professionals as barriers to effective cancer care coordination. Many of these areas apply to the
diagnostic phase. One area was “recognizing health professionals” roles and responsibilities. Patients as
well as health professionals experienced confusion about accountability. The study noted that this
confusion lead to limited referrals to care coordinators from the patients' health care team. Patients
also expressed that there a number of healthcare professionals involved in their care that they could
not remember exactly what each persons’ responsibility was (Walsh, et al., 2010)
The barrier most frequently mentioned by health professionals was “inadequate communication
between specialist and primary care”. Health professionals reported inconsistent, delayed and
incomplete communication amongst the health care team. Family physicians found that there was a
delay in the delivery of diagnostic findings, treatment, complications and follow-up that prevented them
from providing appropriate advice. They found that the situation became even more challenging
because they did not know who to contact in the hospital care team to get the necessary information
(Walsh, et al., 2010).
Inequitable access to health resources and managing scarce resources were also identified as barriers. A
rural or regional disadvantage was identified as one of the reasons for inequity because there are
limited health providers in these areas leading to limited care and support (Walsh, et al., 2010). In terms
of managing scarce resources, efficiency is important to consider when addressing this barrier to make
better use of health professionals time and resources.
2016 Programmatic Review Environmental Scan
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Measurement of the diagnostic phase
Collecting data in order to measure the efficiency of the diagnostic phase is important in order to make
evidence-based decisions with regard to resource allocation for diagnostic services. Collecting measures
in the diagnostic phase is crucial in helping to understand not only wait times for diagnostic services but
also to monitor resource allocation and efficiency of diagnostic services.
Metrics to evaluate patient navigation during diagnosis: U.S. Study
Based on research that supports a link between patient navigation and better patient outcomes, a U.S.
article in Cancer proposed metrics that address patient navigation in both the diagnostic and treatment
phase. In the diagnostic phase, patient navigation programs can improve timely adherence to screening,
diagnostic follow-up, and staging work-up. The article suggests that “time-to” variables that show the
time between certain diagnostic intervals should be used to measure patient navigation in this phase.
Some of the domains of metrics include diagnostic resolution, timeliness of care, patient education, and
continuity of care. Under diagnostic resolution, some metrics include percent diagnostic resolutions at
30, 60, and 120 days, and dates of diagnostic testing. Timeliness of care metrics include interval from
symptom to provider evaluation (if not screen detected), screening test to diagnostic resolution,
diagnostic confirmation to patient notification, diagnostic confirmation to consult with oncology
specialist, and diagnosis date to first treatment date. Patient reported metrics on care processes and
satisfaction with navigation, guideline adherence, and metrics that document preventable
hospitalizations and emergency room visits are also valuable (Guadagnolo, Dohan, & Raich, 2011).
Measuring diagnostic intervals
One way to measure the diagnostic phase is through wait times. Some key time intervals along the
diagnostic phase are suspicion to referral, referral to diagnosis, and diagnosis to first treatment
(Guadagnolo, Dohan, & Raich, 2011). Suspicion to referral is a challenging phase to capture, however
there are some strategies available to measure this phase. One strategy is to divide the diagnostic phase
into more patient delay stages (appraisal, help-seeking, diagnostic) and pretreatment (Guadagnolo,
Dohan, & Raich, 2011). Another method of capturing this phase could be to use administrative data to
look back at the first relevant encounter with the health care system to the point of definitive diagnosis
(Guadagnolo, Dohan, & Raich, 2011). The time from referral to diagnosis is an important measure to
assess timeliness. Practices can vary in this stage in primary care depending on if further testing is
completed before referral, whereas other may refer more quickly. DAPs can also affect the timeliness of
this stage. From diagnosis to first treatment, there are further tests such as imaging, staging, and
multidisciplinary conferences that must happen before treatment planning can begin. This stage can be
considered part of the diagnostic phase and where measurement is valuable to work to achieve more
timely cancer care (Guadagnolo, Dohan, & Raich, 2011)
2016 Programmatic Review Environmental Scan
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Measurement of cancer trends in Ireland
The National Cancer Registry of Ireland (NCRI) provides comprehensive capture of cancer incidence,
prevalence, mortality and site-specific trends. This registry is an independent entity with its own Board
and captures data on demographics, pathology, staging and the first year of treatment. Collaboration
and comparison of international outcomes is a key element of their work. For patients diagnosed up to
2007, Ireland had similar outcomes to England, Wales and Scotland, but fell short of the better five year
age-adjusted survivals reported by mature cancer control systems, such as some of the Scandinavian
countries, Australia and Canada. The Cancer Intelligence Unit of the NCCP relies on NCRI data and HSE
hospital data from the Hospital Inpatient Enquiry (HIPE) system to evaluate workload and plan for
revenue, staff and capital developments. In addition the NCCP develops and implements key
performance indicators for cancer services, including access times and other quality clinical parameters.
These are consistently monitored by hospitals, screening services, the NCCP and the wider HSE. Planning
and guidance is conducted in partnership with hospitals and HSE divisions (National Cancer Control
Programme, 2014).
Measuring performance on early diagnosis in the UK
Cancer Research UK has proposed that the urgent referral pathway in the UK be replaced and that all
referrals for testing for possible cancer should be considered urgent (Cancer Research UK , 2015). In the
UK elements of the urgent referral pathway are measured however none measure the whole time
elapsed from a primary care physician referral to a patient receiving a definitive diagnosis. Cancer
Research UK has proposed that the diagnostic phase (from symptom presentation to definitive
diagnosis) should take 4 weeks. Focusing on this measure might encourage healthcare providers and
decision makers to consider how to best streamline and optimise the diagnostic pathways (Cancer
Research UK, 2016).
Cancer System Quality Index 2016 Measures for Diagnosis
The Cancer System Quality Index (CSQI) has several indicators for measuring the performance of the
cancer system in the diagnostic phase, including a few that specifically look at the performance of the
Diagnostic Assessment Programs (DAPs). The 2016 CSQI features six measurements for the diagnostic
phase including Reporting of Cancer Stage at Diagnosis, Patient Experience with Diagnostic Assessment,
Wait Times for Diagnostic Assessment, Turnaround Times for Pathology, Access to PET/CT, and Quality
and Efficiency of Breast Cancer Screening Tests (Cancer Care Ontario, 2016).
Reporting of Cancer Stage at Diagnosis can help physicians develop a treatment plan that is appropriate
and effective for the particular cancer stage that a patient has been diagnosed with. Patient Experience
with Diagnostic Assessment provides valuable information about patient perspectives on DAP programs,
collected through the Patient Experience Survey. Wait Times for Diagnostic Assessment are an
2016 Programmatic Review Environmental Scan
31
important measure because delays between referral and diagnosis can increase stress and anxiety in
patients, and collecting wait time data can help inform the allocation of resources for the health system.
Turnaround Times for Pathology is reporting on the percentage of synoptic resection reports signed off
by pathologists within 14 calendar days of the date of surgery. This measure reporting on timeliness,
which is an important component of quality and positive patient outcomes. Access to PET/CT refers to
PET/CT scans which are imaging techniques. The anatomical images from these scans can be used to
diagnose cancer and make decisions about treatment. Quality and Efficiency of Breast Cancer patients is
important to address appropriateness of testing and reducing unnecessary tests (Cancer Care Ontario,
2016).
The Organizational Standards of Diagnostic Assessment Programs lists several provincial indicators of
quality for cancer DAPs. These are time intervals, clinical outcomes, quality of care and patient
satisfaction (Cancer Care Ontario, 2007).
Organization of the diagnostic phase
The diagnostic phase, from the onset of symptoms until the time of diagnosis can be lengthy as a result
of delays from multiple diagnostic tests and fragmented care (Lo, et al., 2007). Wait times for
consultative, diagnostic and cancer treatment services have been reported as being undesirable in
Canada (Lo, et al., 2007). Below are summaries of international, national and local jurisdiction’s
strategies to streamline the diagnostic phase for cancer.
The National Health Service’s focus on processes to reduce wait times
A number of strategies have been developed and implemented in order to reduce wait times using both
demand-side and supply-side strategies. The National Health Service (NHS) in the UK has been successful
in positively affecting the demand and supply side of healthcare services by focusing on process issues.
The King’s Fund commissioned a study in the UK to identify successful strategies for sustaining
reductions in wait times (Appleby, et al., 2004). The report found that there are several key factors that
can positively affect wait times by looking at processes and optimizing resources. Understanding the
nature of wait lists and recognizing that they are not simply a backlog problem has been helpful to some
trusts in the UK to resolve problems with regard to the flow of the interconnected parts of the
healthcare system (Appleby, et al., 2004). Additionally, detailed, consistent and accurate time-series and
cross-sectional information on waiting lists and times, as well as on key resources, provided successful
trusts with a means to analyze and understand their waiting lists, to see them in context with other
trusts, and to allow them to monitor progress and outcomes of changes in service delivery (Appleby, et
al., 2004). This information has enabled trusts to plan future changes in services to meet targets, and to
find the resources required to provide them. Finally, the development of appropriate capacity to reduce
2016 Programmatic Review Environmental Scan
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wait times through more efficient use of resources and managing the demand on those resources has
been shown to be successful in helping to reduce wait times.
Ireland’s centralization of cancer services
Ireland developed its first national Cancer Strategy in 1996 with the aim of reducing mortality from
cancer in the under-65 age group by 15% in the ten-year period from 1994-2004. Prior to the
development of the first Cancer Strategy, there had been little dedicated investment in cancer services
in Ireland.
In 2006, the second national cancer strategy, ‘A Strategy for Cancer Control in Ireland 2006’, was
developed by the second National Cancer Forum, an advisory body to the Minister for Health and
Children. It aimed to address the rising burden of cancer in the Irish population at a time when Ireland
compared poorly with other developed countries in terms of cancer risk, cancer incidence and deaths
from cancer. The 2006 National Cancer Strategy advocated a whole population approach that is
integrated and cohesive approach to cancer that involves prevention, screening, diagnosis, treatment,
and supportive and palliative care.
The 2006 National Cancer Strategy and the 2007 Health Service Executive framework ‘Establishment of
Managed Cancer Control Networks and Designation of Eight Cancer Centres’ led to the implementation
of changes in the delivery of hospital-based specialised cancer services. Eight cancer centres were
designated, to each serve approximately 500,000 residents and four cancer networks were established,
each of which has two cancer centres. The networks are now evolving into the six new hospital groups.
The key characteristics of the designated cancer centres are sustainable high volume multidisciplinary
cancer services spanning the range of diagnostics, surgery, radiation oncology and medical oncology.
Those centres without onsite radiotherapy facilities have consultant radiation oncologists participating
in treatment planning (National Cancer Control Programme, 2014). All new patients and selected
patients with recurrent cancer are reviewed at multidisciplinary team meetings comprising all diagnostic
and therapeutic specialists. Integrated care pathways from primary care into consultant oncology
services have been developed in close collaboration with the Irish College of General Practitioners and
with hospital consultants. Electronic GP referral has been developed and implemented for breast, lung
and prostate cancer clinics and will soon include pigmented lesions.
The centralization of services from 32 hospitals to eight cancer centres has resulted in more
streamlined, coordinated and efficient cancer services in Ireland. The reorganisation of cancer services
in Ireland is expected to show significant improvement in survival over the next decade (National Cancer
Control Programme, 2014).
2016 Programmatic Review Environmental Scan
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Ontario Wait Times Strategy
The Ontario Wait Times Strategy was developed to improve access to five key health services by
reducing wait times for cancer surgery, cardiac procedures, cataract surgery, hip and knee replacement
and MRI and CT scans. The strategy has since expanded to include all surgeries and time spent in
emergency rooms (ER). The Ontario government’s goal is to improve public access to surgeries and
procedures delivered to Ontarians, implement new initiatives to improve ER processes, and create a
system of accountability through transparent reporting of wait time information.
Toronto East General Hospital’s Time to Treat Program
Multiple diagnostic tests often result in lengthy processes from the onset of lung-cancer symptoms until
diagnosis (Lo, et al., 2007). An unpublished chart audit at the Toronto East General Hospital (TEGH)
found suboptimal delays in patients’ courses from onset of symptoms until diagnosis of lung cancer. A
solution for the delays in lung cancer diagnostic workup was proposed through the development of the
Time to Treat program. This system redesign was a pilot project consisting of a streamlined referral
system and a clerical facilitator to fast-track patients though the diagnostic pathways algorithm (Lo, et
al., 2007).
The Time to Treat project developed a single-entry point of contact and a new referral form to access
the program. The referral form collected information related to patient demographics, referring
physician contact information, the date of the suspicious radiograph and asked the referring physician
for the reason of referral by way of a checklist. The referring physician was reminded to send clinical
notes, including medication and blood test results to the consultant physician. The referring physician
was also asked to remind patients to bring their radiographs and CT scans to the initial subspecialty
appointment.
All referral sheets were faxed to a central booking clerk also referred to as a navigator. The navigator’s
responsibility was to coordinate the care of patients during the diagnostic work up. In addition to
collecting referrals and booking appointments, the navigator also recorded data related to patient
appointments and investigations.
A diagnostic algorithm was developed called the “Lung Cancer Pathway.” There were three routes of
entry into the pathway: direct referral by a treating clinicians, by an in-house radiologist or through by
being redirected into the pathway by a specialist who was initially consulted.
The Time to Treat Program had two daily CT scan slots. If the time slots were not used, they were
reallocated to the hospital general pool 48 hours before the time slot. There was also pooling of
bronchoscopy slots at TEGH to ensure even shorter wait times.
2016 Programmatic Review Environmental Scan
34
Multidisciplinary tumor boards with representation from two hospitals met weekly where cases of
patients with early or locally advanced disease or treatment issues were discussed. A standardized form
was developed for patient presentation and a new synoptic sheet was developed to record patient
cases.
Target wait times were set and dates of investigation and patient visits were recorded and tracked in an
electronic database by the navigator. Median wait times were compared before and after the Time to
Treat program implementation.
Local family practice units, the radiology department and referring physicians were educated about the
Time to Treat program. Physician input into the new referral form was sought and a physician
representative from each of the large local family practice groups was asked to increase awareness of
the program.
The Time to Treat program was a successful local process improvement initiative as it helped to create
stronger linkages between healthcare services at TEGH. Streamlined referral, the navigator, diagnostic
and treatment algorithms and dedicated investigations and booking slots all helped to successfully
decrease the overall median wait time and each interval median wait time. The interval time to obtain
CT scan was especially reduced. Decreasing wait times has been shown to have a positive impact on
patient anxiety, mental well-being and satisfaction (Lo, et al., 2007).
Diagnostic Assessment Program (DAP) Organization
DAPs were created to ensure organized and coordinated care. DAPs manage the entire process of a
person's diagnostic care, from testing and referrals to a definitive diagnosis or rule out of cancer. In
Ontario, there are DAP programs in lung, colorectal, and prostate cancer. There are specific
Organizational Standards of Diagnostic Assessment Programs in place to ensure consistency. The
structure of each DAP program is influenced by the regional and geographic states of each jurisdiction,
the diagnostic tests that are required for specific types of cancer, and the anticipated volume of cases
(Cancer Care Ontario, 2007).
There are two core organizational models: One-Stop Diagnostic Assessment Units (DAUs), and Virtual
Diagnostic Assessment Units. DAUs provide complete diagnostic services in one place. Virtual Diagnostic
Assessment Units are used when patient populations and geographic dispersion does not permit a single
location. They are systems of diagnostic services that are coordinated centrally but spread out
geographically. Regardless of the model, a Central Access System (CAS), a single point of entry, is an
important element of the DAP. The CAS ensures that diagnostic plans for patients are developed and
communicated to the patients, referring physicians, other primary care providers, and local
multidisciplinary care conference coordinators. Other key elements of the structure of the DAP program
2016 Programmatic Review Environmental Scan
35
include meeting common standards for centralized access, scope of activity, team criteria, linkages and
collaborations, and measuring performance indicators (Cancer Care Ontario, 2007).
By providing coordinated, evidence-based and patient-centred care through centralized services,
multidisciplinary teams and patient education, the DAP program has seen reductions in wait times and
an overall high satisfaction from patients.
Conclusion
The increasing incidence and prevalence of cancer driven by an aging population and advancements in
technology and treatment will continuously drive increases in demands for diagnostic services for
cancer. Costs associated with innovations in cancer diagnostics and treatments will also continue to rise
and fiscal constraints will continue to be a reality. Finding efficiencies in the diagnostic process for
cancer by improving communication, coordination and collaboration will serve to streamline a
complicated process and thereby improve the experience for patients, families and healthcare
providers.
The purpose of this environmental scan is to serve as background material for the June 22, 2016
Programmatic Review event on the diagnostic phase.
The day will focus on number of themes that were highlighted through the interviews and review of
literature that informed this environmental scan, including:





improving linkages and communication
efficiency and coordination of diagnostic practices
collaboration with stakeholders
measurement of the diagnostic phase
organization of the diagnostic phase
Stakeholders at the Programmatic Review event on June 22, 2016 will come together to learn from
other jurisdictions (both national and international) about best practices in service delivery with regard
to cancer diagnosis. The goal of the day will be to reach agreement on a core set of recommendations
for Cancer Care Ontario for improvement and future activities with regard to the process to diagnose
cancer and to enhance quality of care received by patients and their families.
2016 Programmatic Review Environmental Scan
36
Appendix 1: 2016 Programmatic Review Steering Committee and Working Group
members
Steering Committee members:
Name
Darren Larsen (Chair of Steering Committee)
Virginia McLaughlin
Jenny Cockram
Judie Coutts
Michelle Karker
Garth Matheson
Robin McLeod
Linda Rabeneck
Julian Dobranowski
Claire Holloway
Aaron Pollett
Affiliation
CQCO, Vice-Chair
CQCO, Chair
CQCO, Member
CQCO, Member
CQCO, Member
VP, Planning and Regional Programs
VP, Clinical Programs and Quality Initiatives, and ex-officio
CQCO
VP, Prevention and Cancer Control
Provincial Head, Cancer Imaging Program
Provincial Clinical Lead, DAP and DPM
Provincial Head, Pathology & Laboratory Medicine Program
Working Group members:
Name
Rebecca Anas
Jennifer Stiff
Hasina Jamal
Kristina Ellis
Laurie Bourne
Gillian Bromfield
Barb Bunker
Angelika Gollnow
Marnie MacKinnon
Elaine Meertens
Jill Ross
Vicky Simanovski
Melissa Kaan
Affiliation
Director, Cancer Quality Council of Ontario secretariat and Clinical Council
Manager, Cancer Quality Council of Ontario secretariat
Policy Lead, Cancer Quality Council of Ontario secretariat
Research Assistant, Cancer Quality Council of Ontario secretariat
Director, Quality Management Partnerships
Direcor, Program Design, Cancer Screening
Director, Access to Care
Director, Palliative Care, Suvivorship and Primary Care Engagement
Director, Integrated Care
Director, Clinical Engagement Programs (Surgery, Pathology, Imaging)
Director, Cancer System Quality Improvement Initiatives
Director, Regional Program Development
Group Manager, Diagnostic Assessment Program
2016 Programmatic Review Environmental Scan
37
Name
Meaghan Cunningham
Dana Chmelnitsky
Jennifer Hart
Deanna Langer
Leigh McKnight
Jonathan Norton
Shamara Baidoobonso
Affiliation
Manager, Cancer Screening
Manager, Disease Pathway Management
Manager, Pathology
Manager, Imaging
Manager, Surgical Oncology
Manager, Access to Care
Team Lead, Evidence & Program Integration, ColonCancerCheck & GI Endoscopy
2016 Programmatic Review Environmental Scan
38
References
Ball, J., Balogh, E., Miller, Miller, B. (2016). Improving Diagnosis in Health Care. Washington : National
Academies of Sciences.
Aass, N., Fossa, S., & Dahl, A. (2005). The course of psychological disorders in the 1st year after cancer
diagnosis. Journal of Clinical Psychology, 763-768.
Appleby, J., Boyle, S., Devlin, N., Harley, M., Harrison, A., Lacock, L., & Thorby, R. (2004). Sustaining
Reductions in Waiting Times: Identifying successful strategies Final report to the Department of
Health. London: King's Fund.
Arnaout, A., Smylie, J., Seely, J., Robertson, S., Knight, K., Shin, S., . . . Watters, J. (2013). Improving
breast diagnostic services with a rapid access diagnostic and support (RADS) program. Annals of
Surical Oncology, 3335-3340.
BrintzenhofeSzoc, Z. J., & Curbow, B. (2001). The prevalence of psychological distress by cancer site.
Journal of Psycho-Oncology, 19-28.
Brocken, P., Prins, J., Dekhuijzen , R., & van der Heijden, H. F. (2012). he faster the better?—A systematic
review on distress in the diagnostic phase of suspected cancer, and the influence of rapid
diagnostic pathways. Journal of Psycho-Oncology, 1-10.
Canada, Accreditation. (2013). Nova Scotia's Cancer Patient Navigation Program. Retrieved from
Accreditaiton Canada: https://accreditation.ca/nova-scotia%E2%80%99s-cancer-patientnavigation-program
Cancer Care Nova Scotia. (2016). Cancer Patient Navigation. Retrieved from Cancer Care Nova Scotia:
http://www.cancercare.ns.ca/en/home/patientsfamilies/cancerpatientnavigation/default.aspx
Cancer Care Nova Scotia. (2016). Patient Navigation, A Success. Retrieved from Cancer Care Nova Scotia:
http://www.cancercare.ns.ca/en/home/patientsfamilies/cancerpatientnavigation/success.aspx
Cancer Care Ontario. (2007, June). Organizational Standards for Daignostic Assessment. Retrieved from
Cancer Care Ontario: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=36872
Cancer Care Ontario. (2016). Diagnosis. Retrieved from Cancer System Quality Index:
http://www.csqi.on.ca/by_patient_journey/diagnosis/
Cancer Care Ontario, Canadian Cancer Society, Canadian Health Infoway. (2016, May 11). Diagnostic
Assessment Program Electronic Pathway Solution. Retrieved from Diagnostic Assessment
Program Electronic Pathway Solution: Diagnostic Assessment Program Electronic Pathway
Solution
2016 Programmatic Review Environmental Scan
39
Cancer Council Australia . (2016, May 11). Optimal Care Pathways . Retrieved from Cancer Council
Australia : http://www.cancer.org.au/health-professionals/optimal-cancer-care-pathways.html
Cancer Research UK . (2015). Achieving World-Class Cancer Outcomes - A Strategy For England 20152020. London : Cancer Research UK.
Cancer Research UK. (2016, May 11). NICE suspected cancer referral guidelines. Retrieved from Cancer
Research UK : http://www.cancerresearchuk.org/health-professional/learning-anddevelopment-tools/nice-cancer-referral-guidelines
CancerCare Manitoba. (2016, May 11). In Sixty for Patients . Retrieved from CancerCare Manitoba:
http://www.cancercare.mb.ca/home/patients_and_family/cancer_patient_journey/in_sixty_qu
estions_answers/
CancerCare Manitoba. (2016). UPCON - Uniting Primary Care and Oncology. Retrieved from CancerCare
Manitoba:
http://www.cancercare.mb.ca/home/health_care_professionals/information_for_health_care_
professionals/upcon/
Caret, P., Din, N.U., Hamilton, W., Neal, R.D., Rubin, G., Ukoummune. O.C. . (2014). Comparison of
cancer diagnostic intervals before and after implementation of NICE guidelines. British Journal of
Cancer, 584-592.
Choosing Wisely Canada . (2016). Choosing Wisely Canada. Retrieved from Choosing Wisely Canada:
http://www.choosingwiselycanada.org/about/what-is-cwc/
Deloitte Center for Health Solutions. (2013). Working Differently to Provide Early Diagnosis: Improving
Access to Diagnostics. London : Deloitte.
Diagnostic Imaging Repository: Greater Toronto Area West. (2016, May 9). Diagnostic Imaging
Repository: Greater Toronto Area West. Retrieved from eHealth Ontario :
ftp://ftp.ihe.net/MarketingAndPresentations/Success_Stories/success%20story%20GTA.pdf
Eastern Ontario Regional Lab Association . (2016, May 11). About Us. Retrieved from Eastern Ontario
Regional Lab Association : http://www.eorla.ca/about/us/
eHealth Ontario . (2016, May 8). Ontario Laboratories Information System. Retrieved from eHealth
Ontario : http://www.ehealthontario.on.ca/en/initiatives/view/olis
eHealth Ontario. (2016, May 16). Diagnostic Imaging Program. Retrieved from Diagnostic Imaging
Program: http://www.ehealthontario.on.ca/en/initiatives/view/diagnostic-imaging-program
2016 Programmatic Review Environmental Scan
40
Emery, J. (2015). The challenges of early diagnosis of cancer in general practice. Medical Journal of
Australia, 391-393.
Freund, K. M., Battaglia, T. A., Calhoun, E., Darnell, J. S., Dudley, D. J., Friscella, K., . . . Paskett, E. D.
(2014). Impact of Patient Navigation of Timely Cancer Care: The Patient Navigation Program.
Journal of the National Cancer Institue.
Graves, K., Arnold, S., & Love, C. (2007). Distress screening in a multidisciplinary lung cancer clinic:
prevalence and predictors of clinically significant distress. Lung Cancer, 215-224.
Guadagnolo, A., Dohan, D., & Raich, P. (2011). Metrics for Evaluating Patient Navigation During Cancer
Diagnosis and Treatment. Cancer, 3565-3574.
Guadagnolo, B. A., Dohan, D., & Raich, P. (2011). Metrics for Evaluating Patient Navigation During
Cancer Diagnosis and Treatment. Cancer, 3563-3572.
Hospital Diagnostic Imaging Repository Services (HDIRS) . (2016, May 2016). Hospital Diagnostic Imaging
Repository Services (HDIRS) . Retrieved from Hospital Diagnostic Imaging Repository Services
(HDIRS) : http://www.hdirs.com/Home/tabid/36/Default.aspx
Laboratory Services Expert Panel. (2015). Laboratory Services Expert Panel Review. Toronto : Ministry of
Health and Long-Term Care.
Lo, D. S., Zeldin, R., Skrastins, R., Fraser, I., Newman, H., Monavvari, A., . . . Meharchand, J. (2007). Time
to Treat: A System Redesign Focusing on Decreasing the Time from Suspicion of Lung Cancer to
Diagnosis. Journal of Thoracic Oncology, 1001-1006.
McCormack, P., & Sisler, J. (2009). Bridging the gap between primary care and the cancer system.
Canadian Family Physician.
Ministry of Health and Long-Term Care. (2015, December 17). Patients First: A Proposal to Strengthen
Patient-Centred Health Care in Ontario. Retrieved from Ministry of Health and Long :
http://www.health.gov.on.ca/en/news/bulletin/2015/docs/discussion_paper_20151217.pdf
Ministry of Health and Long-term Care. (2015, February). Patients First: An Action Plan For Health.
Retrieved from Ministry of Health and Long-Term Care:
http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_patientsfirst.pdf
Ministry of Health and Long-Term Care. (2016, March 31). Patients First: Action Plan for Health Care.
Retrieved from Ministry of Health and Long-Term Care.
2016 Programmatic Review Environmental Scan
41
Moeller, H., Gildea, C., Meechan, D., Rubin, G., Round, T., & Vedsted, P. (2015). Use of teh English
Urgent Referral Pathway for Suspected Cancer and Mortality in Patients with Cancer: Cohort
Study. British Medical Journal , 351-355.
National Cancer Control Programme. (2014). A Report on the Implmentation of "A Strategy for Cancer
Control in Ireland 2006". Dublin: National Cancer Control Programme.
National Cancer Institute. (2005-2010). Patient Navigation Research Program. Retrieved from
http://www.cancer.gov/about-nci/organization/crchd/disparities-research/pnrp
National Instistute of Health and Care Excellence. (2016). Guidance and Advice List. Retrieved from
National Instistute of Health and Care Excellence:
https://www.nice.org.uk/guidance/published?type=cg
National Instistute of Health and Care Excellence. (2016). Guidance and Advice List. Retrieved from
National Instistute of Health and Care Excellence:
https://www.nice.org.uk/guidance/published?type=dg
National Institute for Health and Care Excellence . (2015, June ). Suspect Cancer: Recognition and
Referral . Retrieved from NICE Guidelines : https://www.nice.org.uk/guidance/ng12
Neal, R. D., Nafees, S., Pasterfield, D. H., Hendry, M., Gollins, S., Makin, M., . . . Robling, M. (2014).
Patient-reported measurement of time to diagnosis in cancer: development of the Cancer
Symptom Interval Measure (C-SIM) and randomised controlled trial of method of delivery. BMC
Health Services Research.
Northern and Eastern Ontario Diagnostic Imaging Network. (2016, May 9). Northern and Eastern Ontario
Diagnostic Imaging Network. Retrieved from eHealth Ontario :
https://www.ehealthontario.on.ca/images/uploads/regional_partners/NEODIN_Fact_Sheet_EN.
pdf
Nova Scotia Department of Health and Wellness . (2016, April 6). Who we are. Retrieved from Nova
Scotia Breast Screening Program : https://breastscreening.nshealth.ca/who-we-are
Olesen, F., & Vedsted, P. (2015). A differentiated approach to referrals from general practice to support
early cancer diagnosis - the Danish three-legged strategy. British Journal of Cancer, 65-69.
Rose, P. J. (2015). Explaining variation in cancer survival between 11 jurisdictions in the International
Cancer Benchmarking Partnership: a primary care vignette survey. British Medical Journal .
Southwestern Ontario Diagnostic Imaging Network (SWODIN). (2016, May 10). About SWODIN: History.
Retrieved from Diagnostic Imaging Network: http://www.swodin.ca/about-swodin/history
2016 Programmatic Review Environmental Scan
42
Vallverdú-Cartié H, Comajuncosas-Camp J, Orbeal-Sáenz RA,. (2011). Results of implementation of a fast
track pathway for diagnosis of colorectal cancer. Revista Española de Enfermedades Digestivas,
402-407.
Walsh, J., Harrison, J. D., Young, J. M., Butow, Phyllis N, S. M., & Masya, L. (2010). What are the current
barriers to effective cancer care coordination? A qualitative study. BMC Health Services
Research .
Walsh, J., Young, J., Harrison, J., Butow, P., Solomon, M., Masya, L., & White, K. (2011). What is
important in cancer care coordination? A qualitative investigation. European Journal of Cancer,
220-227.
Willems, D. J. (2001). Balancing rationalities: gatekeeping in health care. Journal of Medical Ethics , 2529.
2016 Programmatic Review Environmental Scan
43