Overview of the Engagement Process to Develop the Future of Cancer Impact (FOCI) Report in Alberta: The Power of Collective Action

This commentary provides a detailed overview of the extensive stakeholder engagement efforts critical to the development of the Future of Cancer Impact (FOCI) in Alberta report. The overarching aim of the FOCI report was to support informed and strategic discussions and actions that will help key stakeholders in the province prepare for a future with increasing cancer incidence and survival. Employing a comprehensive approach and a diverse range of engagement activities, insights from a wide spectrum of stakeholders were gathered and subsequently used to shape the content of the report. This inclusive process ensured broad representation of perspectives, contributing to a deeper understanding of the complexities in cancer care. The outcome is a robust, consensus-driven report with recommendations set to drive significant transformations within the healthcare system. These efforts highlight the critical role of extensive, inclusive, and collaborative engagement in shaping healthcare initiatives and advancing discussions crucial for the future of cancer care in Alberta.

Exploring the Future of Cancer Impact in Alberta: Projections and Trends 2020-2040

The impact of cancer in Alberta is expected to grow considerably, largely driven by population growth and aging. The Future of Cancer Impact (FOCI) initiative offers an overview of the present state of cancer care in Alberta and highlights potential opportunities for research and innovation across the continuum. In this paper, we present a series of detailed projections and analyses regarding cancer epidemiological estimates in Alberta, Canada. Data on cancer incidence and mortality in Alberta (1998-2018) and limited-duration cancer prevalence in Alberta (2000-2019) were collected from the Alberta Cancer Registry. We used the Canproj package in the R software to project these epidemiological estimates up to the year 2040. To estimate the direct management costs, we ran a series of microsimulations using the OncoSim All Cancers Model. Our findings indicate that from 2020, the total number of annual new cancer cases and cancer-related deaths are projected to increase by 56% and 49% by 2040, respectively. From 2019, the five-year prevalence of all cancers in Alberta is projected to increase by 86% by 2040. In line with these trends, the overall direct cost of cancer management is estimated to increase by 53% in 2040. These estimates and projections are integral to future strategic planning and investment.

Improving Wait Times and Patient Experience Through Implementation of a Provincial Expedited Diagnostic Pathway for BI-RADS 5 Breast Lesions

BACKGROUND

Long diagnostic intervals following abnormal breast imaging (DI) cause patient anxiety and possibly poorer prognosis. This study evaluates the effect of a provincial diagnostic pathway for BI-RADS 5 lesions on wait times and the patient-reported experience (PRE).

METHODS

With multidisciplinary input, we developed a pathway for BI-RADS 5 lesions featuring expedited biopsy, early surgical referral, and nurse (RN) navigator support. Key diagnostic intervals were captured prospectively and compared with a prepathway control cohort. PRE data were obtained from a voluntary survey.

RESULTS

1205 patients were managed on the BI-RADS 5 pathway with 797 primary care physicians, 57 imaging centers, and 2 regional breast programs participating. Median duration from DI to biopsy was 6 days, from biopsy to pathology report was 5 days, DI to surgical referral was 6 days, and DI to surgical consult was 21 days. Compared with 128 prepathway controls, median intervals from DI to surgical referral and consult were significantly improved (15 vs. 6 days, 26 vs. 21 days, p < 0.001). Amongst 294 women who completed the survey, 92% experienced ≥ 1 anxiety complaint during assessment; prompt surgical consultation and multiple features of RN support reduced anxiety, and wait time satisfaction was high (70%). Patient preferences varied for receiving biopsy results from a surgeon (57%) vs. another provider (43%).

CONCLUSIONS

A diagnostic pathway for BI-RADS 5 lesions reduced wait times and improved the patient experience through prompt surgical referral and RN navigator support. Differing preferences for receiving biopsy results emerged, and future iterations should incorporate individualized patient wishes.

Same-Day Surgery for Mastectomy Patients in Alberta: A Perioperative Care Pathway and Quality Improvement Initiative

BACKGROUND

Same-day surgery (SDS) following mastectomy is safe and well accepted. Overnight admission in patients fit for discharge is an inefficient use of health resources. In response to a national review highlighting SDS following mastectomy at 1.4% in Alberta, a perioperative pathway was conceived.

METHODS

The pathway was implemented across Alberta at 13 hospitals beginning in 2016. A steering committee was assembled, and clinical and administrative leads at each site were identified. Opportunities along the patient care experience whereby action could be taken to promote uptake of SDS were identified. Provincially branded support materials including presentations, order sets, and standard operating procedures were developed. Nurse educators provided in-service teaching such as standardized drain care and discharge teaching. Educational booklets, group classes, and online resources were developed for patients and families. An audit of SDS rates, unscheduled return to the emergency department (ED), and readmission rates was reported to teams quarterly, allowing for iterative modifications. Patient-reported experience measures (PREMs) were collected.

RESULTS

SDS following mastectomy increased from 1.7 to 47.8%, releasing an estimated 831 bed days per year. No differences in unexpected return to the ED or readmission to hospital existed between SDS patients and those admitted overnight. A total of 102 patients completed the PREM survey, of whom 90% felt "excellent or good" with the plan to go home, how to care for themselves once home, and who to contact should issues arise.

CONCLUSIONS

Implementation of a provincial perioperative pathway improved uptake of SDS following mastectomy and demonstrated favorable PREMs.

Breast cancer care in Alberta: a Patients perspective

IntroductionEach year in Alberta, over 2,300 women are affected by breast cancer. In Alberta, a multi-year Breast Health Initiative is underway to improve breast cancer care; reduce wait times, coordinate care, and enhance patient experience. Patient reported experience measurements are important to inform and advance patient and family-centred care. Objectives and ApproachThe aim is to assess breast cancer patients’ experiences at two survey points; after surgeon consult and after breast surgery. Patients meeting inclusion criteria; highly suspicious of cancer on imaging result (i.e. BI-RADS 5), referral to Calgary or Edmonton breast program, English speaking, and having an email address are recruited by RN coordinators or nurse navigators. Automated survey invitations from REDCap are used. Seven days after the surgeon consult the first survey is sent and seven days after breast surgery the second survey is sent. ResultsPatient recruitment began November 27, 2017 and January 2, 2018 for Edmonton and Calgary, respectively. As of February, 2018, 45 patients had been recruited. Of these, the first survey was sent to 34 (i.e. seven days post surgeon consult) and 19 (56%) had completed the survey. All those eligible (18) agreed to participate in the upcoming second survey. Of those, six had provided their surgery date and the second survey which both were completed. Recruitment is ongoing until the conference, at that time there will be sufficient numbers to report findings. Conclusion/ImplicationsPatient and family-centred care is an element of high-quality healthcare which AHS has identified as a priority. These results will report on the breast cancer patients’ perspectives and generate important information for clinicians and administrators to use for decision making and quality improvement of health services.

Understanding the causes of overcrowding in emergency departments in the Capital Health Region in Alberta: a focus group study

OBJECTIVES

To determine the perceptions of health care professionals and service providers with regard to emergency department (ED) overcrowding, including definitions of overcrowding, characteristics of an overcrowded ED, and causes of overcrowding, and secondarily to solicit potential solutions to the problem.

METHODS

Focus groups were conducted with front-line staff, physicians and managers from 7 EDs within an integrated health region. Participants received questions before the sessions, and an experienced moderator conducted the sessions and prepared transcripts from audio tapes. Analyses included identification of key themes and the interrelationships between those themes.

RESULTS

Focus group participants defined service pressures that result in overcrowding as "anything that impedes the flow of patients through the ED, affects the quality of care delivered or results in patient frustration and stress to staff." Overcrowding, which can occur at any time of the day, was perceived to have many causes, including some seasonal factors. Two key problems were identified as causing many spin-off pressures: inefficient access to ED beds (stretchers) because of slow throughput of patients and staff shortages. Other perceived causes included the changing role and use of EDs and limited access to services such as home care, diagnostic imaging, laboratory services, social services and specialist care. Participants generally believed that the characteristics and causes of overcrowding could not be viewed independently; rather, in the search for remedies, they should be considered as interrelated variables.

CONCLUSION

Qualitative studies of this complex issue can identify and describe complex interactions in real-world settings. The findings of such studies can lead to quantitative studies involving objective measurement.

Determinants of patient and surgeon perspectives on maximum acceptable waiting times for hip and knee arthroplasty

OBJECTIVES

Lengthy waiting times for hip and knee arthroplasty have raised concerns about equitable and timely access to care. The Western Canada Waiting List project has developed priority criteria scores linked to maximum acceptable waiting times (MAWT) for different levels of priority. Our study purpose was to assess the determinants of patient- and surgeon-rated MAWT, and to test whether the anticipated waiting time has an independent influence after adjusting for age, sex and patient urgency. A second aim was to compare MAWT, waiting time and anticipated waiting time for different levels of urgency assessed using the priority criteria score.

METHODS

Orthopaedic surgeons assessed 233 consecutive patients waiting for arthroplasty in terms of their urgency (assessed using the priority criteria score and a visual analogue scale), MAWT and anticipated waiting time. Patient data included urgency (assessed by a visual analogue scale), MAWT and the Western Ontario McMaster Osteoarthritis index. We used hierarchical linear regression to test the models.

RESULTS

After adjusting for age and sex, urgency (assessed by priority criteria score and visual analogue scale) and anticipated waiting time accounted for 40% of the variance in surgeon MAWT. The patient model accounted for 30% of the variance in patient MAWT. Older patients preferred signficantly shorter MAWTs (P <0.05). Anticipated waiting time added significantly to both the surgeon and patient MAWT models (R(2) change 0.11 and 0.07, respectively). Actual waiting time was weakly correlated with urgency assessed using the priority criteria score (r = -0.25, P <0.0001).

CONCLUSIONS

Patients' and surgeons' views are critical to a fair process of establishing MAWT for elective procedures. Anticipated waiting time may influence the perspectives on MAWT and must be considered in their interpretation.

Prioritization of patients on waiting lists for hip and knee replacement: validation of a priority criteria tool

OBJECTIVES

This study tested the reliability and validity of the Western Canada Waiting List Project priority criteria score (PCS) for prioritizing patients waiting for hip and knee arthroplasty.

METHODS

Sixteen orthopedic surgeons assessed 233 consecutive patients at consultation for hip or knee arthroplasty. Measures included the PCS, a visual analogue scale of urgency (VAS urgency), and maximum acceptable waiting time (MAWT). Patients completed a VAS urgency, an MAWT, the Western Ontario McMaster Osteoarthritis Index (WOMAC), and the EQ-5D. Using correlational analysis, convergent and discriminant validity was assessed between similar constructs in the priority criteria and WOMAC. Median MAWTs were determined for five levels of urgency based on PCS percentiles. Internal consistency reliability was assessed with Cronbach's alpha.

RESULTS

The sample of 233 patients (62 percent female) ranged in age from 18 to 89 years (mean, 66.3 years). A total of 45 percent were booked for hip and 55 percent for knee arthroplasty. Correlations were strong between the PCS and surgeon VAS urgency (r = .79) and weaker between patient and surgeon measures of VAS urgency (r = .24) and MAWT (r = .44). Correlation coefficients between similar constructs in the priority criteria and WOMAC ranged from 0.24 to 0.32 and were higher than those measuring dissimilar constructs. For decreasing levels of urgency, the median MAWT ranged from 10 to 12 weeks for surgeons and 4 to 12 weeks for patients. Cronbach's alpha was 0.79.

CONCLUSIONS

Results support the validity of the PCS as a measure of surgeon-rated urgency. Patients might be ranked differently with different prioritization measures.

Variations in the use of emergency departments in Alberta's Capital Health region 1998-2000

The objectives of this study were to describe the utilization of emergency departments in the Capital Health region, Alberta, between 1998 and 2000, and temporal variations in emergency department utilization by month, day of week, and time of day in 2000. Between 1998 and 2000, the annual number of visits to emergency departments in the region increased by six percent. The mean length of stay, median length of stay and the number of patients who left without being seen increased by six minutes, eight minutes, and 4,442 patients respectively. Variations in the number of visits, mean and median lengths of stay, and numbers of patients who left without being seen by month, day of week, and time of day were modest except for patients who left without being seen. Service pressures in Capital Health emergency departments continue to exist. Temporal variations in service pressures were small. Causes of emergency department pressures are multiple and interrelated. Therefore, system-wide changes should be considered in addressing emergency department pressures.

The early post-operative concerns of men after radical prostatectomy

The aim of this study was to explore the concerns of men with urinary incontinence in the early weeks of recovery after radical prostatectomy for early stage prostate cancer. As part of a larger study evaluating effectiveness of intensive physiotherapy for post prostatectomy incontinence, semistructured interviews were conducted at study entry. Sixty-three men approximately 8 weeks post-surgery participated. The descriptive data were analysed for themes. Pre-operative concerns focused on dealing with the diagnosis of prostate cancer, information gathering and decision-making. Post-operatively, a frequently repeated concern was lack of knowledge about the post-surgery recovery period. Specifically, men stated they did not process much of the detailed pre-operative teaching provided by the urologists and the nurses because of the overwhelming nature of the diagnosis. As a result, at discharge, they revealed many knowledge gaps about catheter care, post-operative pain, incontinence and erectile dysfunction. Participants also perceived a lack of health care professional support. These information deficits severely affected quality of life and healthy post-operative rehabilitation. The results of the informal interviews provide a deeper understanding of the post-operative recovery experience and suggest some strategies for improving the early weeks of recovery after radical prostatectomy including telephone follow-up, additional written information and on-going support.

Patient's understanding of health information: a multihospital comparison

Patient education is an integral component of the care most hospital patients receive. The use of printed health material is widespread due to its perceived benefit and convenience. Unfortunately, there is a discrepancy between reading level of many materials selected for patients and the reading ability of the intended reader group. Although research suggests the need for simplified text, ease of reading is only one component of readability; the other is comprehension. This article presents results from a study completed in 1990 and replicated in two hospitals the following year. Using a Cloze technique, researchers tested patient's ability to understand health information prepared at grade levels five and nine. Scores revealed that 77% of subjects were able to comprehend material prepared at the grade five level independently, 8% required some assistance, and 14% were not able to comprehend the material. When comprehension of the material prepared at the grade nine level was tested only 30% of subjects were able to comprehend it, 31% required some help, and 39% were unable to comprehend it. These results suggest the importance of simplifying health material to no higher than a grade five level so it is comprehensive to the majority of hospital patients.

Evaluation of a patient information booklet

Preoperative teaching is an integral component of the care surgical patients receive. The need for consistent preoperative information has resulted in growing use of printed health information. There are many printed materials for nurses to choose from; however, these materials serve no useful teaching purpose if patients are unable to understand them. This study evaluates how well surgical patients understand the content presented in an educational booklet used for preoperative teaching. A Cloze test was designed to assess comprehension of a booklet prepared at a grade five reading level. Scores revealed that 84% of subjects scored above 56% and were able to comprehend the material independently; 10% scored between 44% and 56%, indicating they would require some help; and 6% scored less than 44% and were not able to comprehend the information.

Developing printed materials for patients with visual deficiencies

In preparing educational materials for patients with vision deficiencies, nurses must take into consideration type size, typeface, and color. Patients surveyed preferred 14-point, sans serif type. Black type on white paper was also preferred. Collaboration between the nurse and the graphic designer will help ensure that the printed material will be understandable to the target group.