The effect of diagnostic assessment programs on the diagnosis and treatment of patients with lung cancer in Ontario, Canada

Abstract

INTRODUCTION: Diagnostic assessment programs (DAPs) were implemented in Ontario, Canada, to improve the efficiency of the lung cancer care continuum. We compared the efficiency and effectiveness of care provided to patients in DAPs relative to usual care (non-DAPs). METHODS: Lung cancer patients diagnosed between 2014 and 2016 were identified from the Ontario Cancer Registry. Using administrative databases, we identified various health-care encounters 6 months before diagnosis until the start of treatment and compared utilization patterns, timing, and overall survival between DAP and non-DAP patients. RESULTS: DAP patients were younger ( P < 0.0001), had fewer comorbidities ( P = 0.0006), and were more likely to have early-stage disease (36% vs. 25%) than non-DAP patients. Although DAP patients had a similar time until diagnosis as non-DAP patients, the time until treatment was 8.5 days shorter for DAP patients. DAP patients were more likely to receive diagnostic tests and specialist consultations and less likely to have duplicate chest imaging. DAP patients were more likely to receive brain imaging. Among early-stage lung cancers, brain imaging was high (74% for DAP and 67% for non-DAP), exceeding guideline recommendations. After adjustment for clinical and demographic factors, DAP patients had better overall survival than non-DAP patients (hazard ratio [HR]: 0.79 [0.76–0.82]), but this benefit was lost after adjusting for emergency presentation (HR: 0.96 [0.92–1.00]). A longer time until treatment was associated with better overall survival. CONCLUSION: DAPs provided earlier treatment and better access to care, potentially improving survival. Quality improvement opportunities include reducing unnecessary or duplicate testing and characterizing patients who are diagnosed emergently.

Variation in Diagnosis, Treatment, and Outcome of Esophageal Cancer in a Regionalized Care System in Ontario, Canada

“…Patients with esophageal cancer waited 1 week longer than patients with lung cancer in Ontario to receive a PET/CT scan and have a consultation with a radiation or medical oncologist, which may have translated into a longer time until treatment (median of 46 vs 40 days). 14 The reasons for these differences are unknown, despite treatment at the same designated thoracic surgery centers. However, there is limited evidence that longer wait times are associated with worse survival.…”

“… 15 , 16 , 17 , 18 , 19 The association of having a longer time until treatment with better overall survival has been demonstrated previously in patients with cancer and is likely due to a triaging effect. 14 , 20 Patients with more overt symptoms are more likely to have advanced disease and be diagnosed or treated urgently, which may only be partially accounted for by stage and is likely to confound any associations between wait times and survival.…”

“…[15][16][17][18][19] The association of having a longer time until treatment with better overall survival has been demonstrated previously in patients with cancer and is likely due to a triaging effect. 14,20 Patients with more overt symptoms are more likely to have advanced disease and be diagnosed or treated…”

“…14). Esophagectomy was performed at a designated thoracic center in 94% of patients (n = 2864) who traveled a median of 29 minutes (IQR, 14-61 minutes; 90th percentile, 105 minutes), whereas patients who received an esophagectomy elsewhere traveled a median of 16 minutes (IQR, 9-29 minutes; 90th percentile, 46 minutes).…”

Implementing and Sustaining Early Cancer Diagnosis Initiatives in Canada: An Exploratory Qualitative Study

“…The few studies describing barriers to early cancer diagnosis services focused on barriers to accessing existing programs. For instance, a recent systematic review described barriers to accessing lung cancer diagnosis programs [ 23 ]. The studies in this review showed that poor relationships between primary care providers and patients, lack of accessibility of services for patients due to geography, and patient and provider lack of awareness of cancer symptoms and treatments were barriers to access.…”