Identifying Institutional Causes of Delay to Radical Cystectomy among Patients with High Risk Bladder Cancer Treated at a Tertiary Referral Center Using Process Map Analysis

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

Downstream Studies Following the Use of Bone Scan in the Staging of Muscle-invasive Bladder Cancer

OBJECTIVE

To quantify the use of downstream studies following staging bone scans in patients with muscle-invasive bladder cancer. Bone scans may be obtained in high-risk bladder cancer patients prior to radical cystectomy to exclude bone metastases. However, false-positive bone scans can occur, resulting in the need for additional studies.

PATIENTS AND METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified 4404 patients diagnosed with muscle-invasive bladder cancer from 2004 to 2011. We further identified those who underwent a bone scan prior to treatment within 6 months of diagnosis and prior to any treatment with cystectomy, radiotherapy, or chemotherapy. We determined the proportion of patients who underwent a subsequent study (bone X-ray, bone CT, bone MRI, and/or bone biopsy) within 3 months of the bone scan and prior to treatment.

RESULTS

Among patients diagnosed with muscle-invasive bladder cancer, 1373 (31%) had a staging bone scan of whom 26% received a downstream study (n = 213). Overall, 61 patients (7%) received downstream bone-specific X-rays, more than 141 patients (>17%) received bone-specific CTs, and 28 patients (3%) received bone-specific MRIs. The use of bone biopsy was rare (n < 11; <1%). The total cost of all downstream studies was $103,468. Furthermore, there was a one-month delay in treatment for those who received a downstream study compared to those who did not (P < 0.001).

CONCLUSION

Use of bone scan in the staging of muscle-invasive bladder cancer often results in the need for additional downstream studies. The delay in treatment and cost burden of downstream studies highlights a potential disadvantage of the routine use of this staging modality.