Addressing Wait Times for Endometrial Cancer Surgery in Ontario

Barriers to Surgical Intervention and Factors Influencing Motor Outcomes in Patients with Severe Peripheral Nerve Injury: A Province Wide Cohort Study

INTRODUCTION

Despite the importance of timing of nerve surgery after peripheral nerve injury, optimal timing of intervention has not been clearly delineated. The goal of this study is to explore factors that may have a significant impact on clinical outcomes of severe peripheral nerve injury that requires reconstruction with nerve transfer or graft.

MATERIALS AND METHODS

Adult patients who underwent peripheral nerve transfer or grafting in Alberta were reviewed. Clustered multivariable logistic regression analysis was used to examine the association of time to surgery, type of nerve repair, and patient characteristics on strength outcomes. Cox proportional hazard regression analysis model was used to examine factors correlated with increased time to surgery.

RESULTS

Of the 163 patients identified, the median time to surgery was 212 days. For every week of delay, the adjusted odds of achieving Medical Research Council strength grade ≥ 3 decreases by 3%. An increase in preinjury comorbidities was associated with longer overall time to surgery (aHR 0.84, 95% CI 0.74-0.95). Referrals made by surgeons were associated with a shorter time to surgery compared to general practitioners (aHR 1.87, 95% CI 1.14-3.06). In patients treated with nerve transfer, the adjusted odds of achieving antigravity strength was 388% compared to nerve grafting; while the adjusted odds decreased by 65% if the injury sustained had a pre-ganglionic injury component.

CONCLUSION

Mitigating delays in surgical intervention is crucial to optimizing outcomes. The nature of initial nerve injury and surgical reconstructive techniques are additional important factors that impact postoperative outcomes.

Time to treatment of esophageal cancer in Ontario: A population-level cross-sectional study

Objective

Timely cancer treatment improves survival and anxiety for some sites. Patients with esophageal cancer require specific workup before treatment, which can prolong the time from diagnosis to treatment (treatment interval [TI]). The geographical variation of this interval remains uninvestigated in patients with esophageal cancer.

Methods

This retrospective population-level study conducted in Ontario used linked administrative health care databases. Patients treated for esophageal cancer between 2013 and 2018 were included. The TI was time from diagnosis to treatment. Patients were assigned a geographical Local Health Integration Network on the basis of postal code. Covariates included patient, disease, and diagnosing physician characteristics. Quantile regression modeled TI length at the 50th and 90th percentile and identified associated factors.

Results

Of 7509 patients, 78% were male and most were aged between 60 and 69 years. The 50th and 90th percentile TI was 36 (interquartile range, 22-55) and 77 days, respectively. The difference between the Local Health Integration Network with the longest and shortest TI at the 50th and 90th percentile was 18 and 25 days, respectively. Older age (P < .0001), greater comorbidity (P = .0005), greater material deprivation (P = .001), rurality (P = .03), histology (P = .02), and treatment group (P < .0001) were associated with a longer median TI. Older age (P = .03), greater comorbidity (P = .003), greater material deprivation (P = .005), rurality (P = .04), and treatment group (P < .0001) were associated with a longer 90th percentile TI.

Conclusions

Geographic variability of time to treatment exists across Ontario. Investigation of facility-level differences is warranted. Patient and disease factors are associated with longer wait times. These results might inform future health care policy and resource allocation.

Ontario wait times for delayed surgical treatment of traumatic peripheral nerve injury

Background:

To better understand the occurrence and operative treatment of peripheral nerve injury (PNI) and the potential need for additional resources, it is essential to define the frequency and distribution of peripheral nerve procedures being performed. The objective of this study was to evaluate Ontario’s wait times for delayed surgical treatment of traumatic PNI.

Methods:

We retrieved data on wait times for peripheral nerve surgery from the Ontario Ministry of Health and Long-Term Care Wait Time Information System. We reviewed the wait times for delayed surgical treatment of traumatic PNI among adult patients (age ≥ 18 yr) from April 2009 to March 2018. Data collected included total cases, mean and median wait times, and demographic characteristics.

Results:

Over the study period, 7313 delayed traumatic PNI operations were reported, with variability in the case volume distribution across Local Health Integration Networks (LHINs). The highest volume of procedures (2788) was performed in the Toronto Central LHIN, and the lowest volume (< 6) in the Waterloo Wellington and North Simcoe Muskoka LHINs. The population incidence of traumatic PNI requiring surgery was 5.1/10 000. The mean and median wait times from surgical decision to surgical repair were 45 and 27 days, respectively. Both the longest and shortest wait times occurred in LHINs with low case volumes. The provincial target wait time was met in 93% of cases, but women waited significantly longer than men (p < 0.001).

Conclusion:

The provincial distribution of traumatic PNI surgery was variable, and the highest volumes were in the LHINs with large populations. The provincial wait time strategy for traumatic PNI surgery is effective, but women waited longer than men. Precise reporting from all hospitals is necessary to accurately capture and understand the delivery of care after traumatic PNI.

Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer

BACKGROUND

Diagnosis of endometrial (womb) cancer is normally made at an early stage, as most women with the disease experience abnormal vaginal bleeding, which prompts them to seek medical advice. However, delays in presentation and referral can result in delay in diagnosis and management, which can lead to unfavourable treatment outcomes. This is particularly a problem for pre- and peri-menopausal women. Providing educational information to women and healthcare providers regarding symptoms relating to endometrial cancer may raise awareness of the disease and reduce delayed treatment.

OBJECTIVES

To assess the effectiveness of health education interventions targeting healthcare providers, or individuals, or both, to promote early presentation and referral for women with endometrial cancer symptoms.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs), both individually randomised and cluster-RCTs. In the absence of RCTs we planned to include well-designed non-randomised studies (NRS) with a parallel comparison assessing the benefits of any type of health education interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated whether potentially relevant studies met the inclusion criteria for the review, but none were found.

MAIN RESULTS

A comprehensive search of the literature yielded the following results: CENTRAL (1022 references), MEDLINE (2874 references), and Embase (2820 references). After de-duplication, we screened titles and abstracts of 4880 references and excluded 4864 that did not meet the review inclusion criteria. Of the 16 references that potentially met the review inclusion, we excluded all 16 reports after reviewing the full texts. We did not identify any ongoing trials.

AUTHORS' CONCLUSIONS

There is currently an absence of evidence to indicate the effectiveness of health education interventions involving healthcare providers or individuals or both to promote early presentation and referral for women with endometrial cancer symptoms. High-quality RCTs are needed to assess whether health education interventions enhance early presentation and referral. If health education interventions can be shown to reduce treatment delays in endometrial cancer, further studies would be required to determine which interventions are most effective.

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

Waiting to see the specialist: patient and provider characteristics of wait times from primary to specialty care

Background

Wait times are an important measure of access to various health care sectors and from a patient’s perspective include several stages in their care. While mechanisms to improve wait times from specialty care have been developed across Canada, little is known about wait times from primary to specialty care. Our objectives were to calculate the wait times from when a referral is made by a family physician (FP) to when a patient sees a specialist physician and examine patient and provider factors related to these wait times.

Methods

Our study used the Electronic Medical Record Administrative data Linked Database (EMRALD) which is a linkage of FP electronic medical record (EMR) data to the Ontario, Canada administrative data. The EMR referral date was linked to the administrative physician claims date to calculate the wait times. Patient age, sex, socioeconomic status, comorbidity and FP continuity of care and physician age, sex, practice location, practice size and participation in a primary care delivery model were examined with respect to wait times.

Results

The median waits from medical specialists ranged from 39 to 76 days and for surgical specialists from 33 days to 66 days. With a few exceptions, patient factors were not associated with wait times from primary care to specialty care. Similarly physician factors were not consistently associated with wait times, except for FP practice location and size.

Conclusions

Actual wait times for a referral from a FP to seeing a specialist physician are longer than those reported by physician surveys. Wait times from primary to specialty care need to be included in the calculation of surgical and diagnostic wait time benchmarks in Canada.

Impact of Wait Times on Survival for Women With Uterine Cancer

Purpose

To determine whether wait time from histologic diagnosis of uterine cancer to time of definitive surgery by hysterectomy had an impact on all-cause survival.

Patients and Methods

Women in Ontario with a confirmed histopathologic diagnosis of uterine cancer between April 1, 2000, and March 31, 2009, followed by surgery were identified in the Ontario Cancer Registry. Survival was calculated by using the Kaplan-Meier method. Factors were evaluated for their prognostic effect on survival by using Cox proportional hazards regression. Wait time was evaluated in a multivariable model after adjusting for other significant factors.

Results

The final study population included 9,417 women; 51.9% had surgery by a gynecologist, and 69.9% had endometrioid adenocarcinoma. Five-year survival for women with wait times of 0.1 to 2, 2.1 to 6, 6.1 to 12, or more than 12 weeks was 71.1%, 81.8%, 79.5%, and 71.9%, respectively. Wait times of ≤ 2 weeks were adversely prognostic for survival after adjusting for other significant factors in the multivariable model, and patients with wait times of more than 12 weeks had worse survival than those who had wait times between 2.1 and 12.0 weeks.

Conclusion

To the best of our knowledge, this is the first report in a large population-based cohort demonstrating that longer wait times from diagnosis of uterine cancer to definitive surgery have a negative impact on overall survival.

The wait time creep: changes in the surgical wait time for women with uterine cancer in Ontario, Canada, during 2000-2009

OBJECTIVE

Uterine cancer is a major cancer of women, with outcomes potentially worsening with delayed diagnosis or hysterectomy, the main treatment. Yet cancer surgery wait times are not reported by cancer site. This study sought to examine changes in wait times for uterine cancer surgery between 2000 and 2009 and to identify predictors of longer surgery wait times.

METHODS

Population-based retrospective analysis of a cohort of uterine cancer patients diagnosed between April 2000 and March 2009. Using linked administrative data, all cases in which a patient had hysterectomy following diagnosis were identified. Wait time was defined as days from diagnosis of uterine cancer (day 0) to hysterectomy. Regression analysis was used to examine the relationship between covariates and wait time.

RESULTS

Wait times increased steadily between 2000 and 2006 from a median of 34 to 54 days, followed by a plateau until 2009-during which patients waited a median of between 53 and 55 days for surgery after diagnosis. Overall, 55% of patients had a wait time longer than 6 weeks after diagnosis. Predictors of a wait time greater than 6 weeks included older age, region, lower income, later year of diagnosis, surgery by a gynaecologic oncologist, non-sarcoma histology group and having surgery in a teaching hospital.

CONCLUSION

Over half of uterine cancer patients waited longer than the recommended 6 weeks for surgery. Future reporting of cancer wait times by each disease site regularly would help to identify progress to reduce wait times and opportunities for improvement.

Wait times for women with abnormal uterine bleeding in South-Western Ontario

OBJECTIVE

Women referred to an obstetrician-gynaecologist because of abnormal uterine bleeding (AUB) should be seen within 12 weeks, according to the benchmarks recommended for medically acceptable wait times established by the Society of Obstetricians and Gynaecologists of Canada. Our study aimed to determine the proportion of patients having wait times that meet this recommendation, and to understand patient-level sources of variation in these waits.

METHODS

We performed a secondary analysis of data from the Delivering Primary Healthcare Information (DELPHI) project database. Electronic medical record data from 10 family practices across south-western Ontario were used to study AUB wait times.

RESULTS

Over a 30-month period, 223 referrals were made to obstetrician-gynaecologists because of AUB. The mean wait time for initial assessment was 70.4 days (median = 51 days); the range among referring practices varied from 36 to 111 days. Seventy-one percent of women were seen by the obstetrician-gynaecologist within the recommended time of 12 weeks or less. Multi-level regression analysis indicated that older patients were more likely to have shorter waits. The intraclass correlation was 0.256, indicating that nearly a quarter of the variation in wait time was explained at the practice level.

CONCLUSION

Nearly 30% of women referred to specialists because of AUB wait longer than the period of time recommended by the SOGC, with younger women more likely to wait longer. This difference may be due to the perception of an increased risk of malignancy in older women. Future research on correlates of AUB wait times should take factors such as severity and prior family physician work up into account.

Evaluation of two management strategies for preoperative grade 1 endometrial cancer

OBJECTIVE

To compare the practices, adjuvant treatment, and outcomes of patients with preoperatively assessed grade 1 endometrioid endometrial cancer between two academic gynecologic oncology centers that use different treatment strategies.

METHODS

A retrospective analysis was performed at Duke University Medical Center (Duke) and the Toronto Sunnybrook Regional Cancer Center (Sunnybrook) between 1991 and 2007. Patients at Duke generally underwent surgical staging unless intraoperative assessment identified a negligible risk of nodal disease. Patients at Sunnybrook generally did not undergo surgical staging.

RESULTS

A total of 494 patients (272 from Duke and 222 from Sunnybrook were identified with preoperative, central-review-confirming, grade 1, endometrioid, endometrial cancer. Groups were similar in grade, final histology, type of hysterectomy, and length of hospital stay. Patients from Sunnybrook were older (aged 62 years compared with 59 years, P=.001) and were more likely to have capillary lymphatic space involvement (18.2% compared with 8.3%, P=.003) and cervical involvement (12.2% compared with 3.7%, P<.001). Approximately 2% of cases were upgraded to high grade on final specimen. Lymphadenectomy was performed on 49.4% of patients at Duke compared with 11.7% of patients at Sunnybrook. Overall 3-year survival was 96% at Duke and 96% at Sunnybrook (P=.217). Three-year recurrence-free survival was 96% at Duke and 95% at Sunnybrook (P=.327).

CONCLUSION

Despite differences in practice and slight differences in patient populations, the recurrence-free and overall survival of women with preoperative centrally reviewed grade 1 endometrial cancer is excellent and without statistically significant difference between the two centers.

LEVEL OF EVIDENCE

III

Should Preoperative Pathology Be Used to Select Patients for Surgical Staging in Endometrial Cancer?

Introduction:

The decision to offer surgical staging in endometrial cancer is often based on preoperative histology and grade from endometrial biopsy or dilatation and curettage. The primary objective of this study was to evaluate the concordance between preoperative and final pathology from a population-based study of endometrial cancer to address whether preoperative biopsy is a reliable determinant in selecting patients for surgical staging.

Methods:

Retrospective cohort study in Ontario, Canada, from 1996 to 2000. The study included all women with a preoperative diagnosis of endometrioid adenocarcinoma on endometrial biopsy or dilatation and curettage, followed by definitive surgery. All other histological types were excluded. Surgical staging rates were compared according to preoperative pathology. Primary outcome measure was the concordance between preoperative and final pathology, expressed as a Spearman correlation coefficient (ρ). A multivariable logistic regression estimated the effects of demographic variables and grade on our outcome measure.

Results:

There were 1804 evaluable cases in this study. For preoperative grades 1, 2, and 3 endometrioid adenocarcinoma, surgical staging rates were 9.1%, 13.7%, and 25.6%, respectively. Concordance rates with final pathology were 73%, 52%, and 53%, respectively. There was only moderate concordance between preoperative and final pathology (ρ = 0.52). There was no significant difference in concordance rates according to age, year, or hospital volume, but lower concordance rates among teaching hospitals.

Conclusion:

Preoperative biopsy has only a moderate ability to predict final pathology in endometrial cancer, and therefore, additional factors should be considered in selecting patients for a surgical staging procedure.