Reduction in the diagnostic interval after the introduction of cancer patient pathways for colorectal cancer in northern Sweden

OBJECTIVE

To compare the diagnostic interval for patients with colorectal cancer before and after the introduction of cancer patient pathways in northern Sweden.

DESIGN

A retrospective study comparing two cohorts (2012 and 2018) of patients diagnosed with colorectal cancer before and after the introduction of cancer patient pathways in 2016.

SETTING

Three counties in northern Sweden with large sparsely populated areas and some cities (637143 residents ∼5.1 residents/km2).

SUBJECTS

Patients were included from the Swedish Cancer Register. Electronic health records reviews were performed and linked to socioeconomic data from Statistics Sweden.

MAIN OUTCOME MEASURES

Differences in the diagnostic intervals, the patient intervals and the characteristics associated with the longest diagnostic intervals and investigations starting at the emergency department.

RESULTS

The two cohorts included 411 patients in 2012 and 445 patients in 2018. The median diagnostic interval was reduced from 47 days (IQI 18-99) to 29 days (IQI 9-74) (p < 0.001) after the introduction of cancer patient pathways in general. Though for the cases of cancer in the right-side (ascended) colon, the reduction of the diagnostic interval was not observed and it remained associated with investigations starting at the emergency department.

CONCLUSION

Our results indicate that cancer patient pathways contributed to an improvement in the diagnostic interval for patients with colorectal cancer in general, yet not for patients with cancer in the right-side colon.

IMPLICATION

In general, cancer patient pathways seem to reduce the diagnostic interval for colorectal cancer but it is not a sufficient solution for all colorectal cancer localisations.

Colon cancer diagnosed in patients with non-specific symptoms - comparisons between diagnostic paradigms

Background In Denmark, the Cancer Patient Pathway for Non-Specific Signs and Symptoms (NSSC-CPP) has been implemented with variations: in some areas, general practitioners (GPs) do the initial diagnostic work-up (GP paradigm); in other areas, patients are referred directly to the hospital (hospital paradigm). There is no evidence to suggest the most beneficial organisation. Therefore, this study aims to compare the occurrence of colon cancer and the risk of non-localised cancer stage between the GP and hospital paradigms.Material and Methods In this registry-based case-control study, we applied multivariable binary logistic regression models to estimate the odds ratios (OR) of colon cancer and non-localised stage associated with the GP paradigm and hospital paradigm. All cases and controls were assigned to a paradigm based on their diagnostic activity (CT scan or CPP) six months before the index date. As not all CT scans in the control group were part of the cancer work-up as a sensitivity analysis, we investigated the impact of varying the fraction of these, which were randomly removed using a bootstrap approach for inference.Results The GP paradigm was more likely to result in a cancer diagnosis than the hospital paradigm; ORs ranged from 1.91-3.15 considering different fractions of CT scans as part of cancer work-up. No difference was found in the cancer stage between the two paradigms; ORs ranged from 1.08-1.10 and were not statistically significant.Conclusion Patients in the GP paradigm were diagnosed with colon cancer more often, but we cannot conclude that the distribution of respectively localised or non-localised extent of disease is different from that of patients in the hospital paradigm.

Cutaneous Melanoma Systematic Diagnostic Workflows and Integrated Reflectance Confocal Microscopy Assessed with a Retrospective, Comparative Longitudinal (2009-2018) Study

Simple Summary

A retrospective study (2009–2018), where the integration of education, a diagnostic-therapeutical workflow (with centralized and immediate assessment of suspicious lesions) and high-performance technology in a single province, seems to improve melanoma detection accuracy, as measured by the number needed to excise. From 40,832 lesions excised there was 279% increase number of melanoma excised. A systemic diagnostic-therapeutical workflow including reflectance confocal micrscopy (RCM) was described. The impact was assessed with the number of lesions needed to excise (NNE) according to excision location: reference hospital (DP) or other (NDP), NNE decreased almost 3-fold at DP and by half at NDP. Aggressive melanoma detection remained unchanged over the study period. Hypothetical cost analyses estimated health service savings.

Abstract

Background: The increasing global burden of melanoma demands efficient health services. Accurate early melanoma diagnosis improves prognosis. Objectives: To assess melanoma prevention strategies and a systematic diagnostic-therapeutical workflow (improved patient access and high-performance technology integration) and estimate cost savings. Methods: Retrospective analysis of epidemiological data of an entire province over a 10-year period of all excised lesions suspicious for melanoma (melanoma or benign), registered according to excision location: reference hospital (DP) or other (NDP). A systematic diagnostic-therapeutical workflow, including direct patient access, primary care physician education and high-performance technology (reflectance confocal microscopy (RCM)) integration, was implemented. Impact was assessed with the number of lesions needed to excise (NNE). Results: From 40,832 suspicious lesions excised, 7.5% (n = 3054) were melanoma. There was a 279% increase in the number of melanomas excised (n = 203 (2009) to n = 567 (2018)). Identification precision improved more than 100% (5.1% in 2009 to 12.0% in 2018). After RCM implementation, NNE decreased almost 3-fold at DP and by half at NDP. Overall NNE for DP was significantly lower (NNE = 8) than for NDP (NNE = 20), p < 0.001. Cost savings amounted to EUR 1,476,392.00. Conclusions: Melanoma prevention strategies combined with systematic diagnostic-therapeutical workflow reduced the ratio of nevi excised to identify each melanoma. Total costs may be reduced by as much as 37%.

Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways

Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical–professional and the administrative–institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.

GPs' perspectives of the patient encounter - in the context of standardized cancer patient pathways

Objective: We aim to explore how GPs assign meanings and act upon patients' symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs).Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n = 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism.Main outcome measures: GPs' perspectives about assigning meanings to patients' presented symptoms and perception about CPPs.Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients' symptoms - and the other with CPPs. The core category Disentangling patients' care trajectory consists of three categories, interpreted as GPs' strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs' daily work.Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics.Key points Current awareness: • GPs deliberation about patients' trajectories is a complex process, often dealing with vague symptoms. How CPPs influence this process within the encounter has not been studied. Main statements:  • GPs in our study were involved in two simultaneous interactions, one with patients' symptoms in the encounter - and the other with CPPs within the healthcare organization. • Symbolic interactionism helped capture how GPs deliberated about conflicting and paradoxical aspects of the encounter, in terms of balancing two contradictory ways of action that GPs face when providing patient/person-centered care and linking to CPPs. • Based on our results, primary care needs support from healthcare organizations to build capacity about CPPs and how to use them.

Coordinating objects of care: Exploring the role of case managers as brokers in cancer patient pathways

OBJECTIVE

Healthcare systems increasingly make use of case managers to handle organisational complexity. In Danish cancer patient pathways, case managers handle the complexities of cancer diagnostics and treatment while adhering to pathway guidelines. This article explores how case managers handle their various responsibilities and focuses on the micro-politics of case management.

METHODS

An ethnographic study was carried out in three Danish cancer patient pathways. Interactions between patients and healthcare professionals were observed, including professionals with case management tasks. We interviewed 13 cancer diagnostic patients in their homes and 26 healthcare professionals during work hours, among other things about case management.

RESULTS

We found that the work of case managers differs between cancer patient pathways and settings but overall emphasises coordination of patient trajectories and being contact person. We argue that case managers, embodying the figure of the broker, handle their responsibilities by coordinating the following co-existing objects of care, each with different goals: the diseased body, the person, the organisation and the cancer patient pathway.

CONCLUSION

We conclude that case managers, in addition to being a response to the complexity of healthcare services, impact the implementation of cancer patient pathways and influence cancer diagnostic activities.

Cancer patients' experiences with urgent referrals to cancer patient pathways

OBJECTIVE

We aimed to explore whether cancer patients urgently referred to a cancer patient pathway (CPP) (CPP referred) by a general practitioner report experiences of pre-diagnosis cancer care differently than patients not referred to a CPP (non-CPP referred).

METHODS

Data were collected from cross-sectional questionnaire surveys among cancer patients and their GPs and linked to National registries. Poisson regression was used to generate adjusted prevalence ratios (PR) to compare reported experiences.

RESULTS

The study included 2,256 individuals. CPP referred patients reported more positive overall experiences of the pre-diagnosis phase (p < 0.001). Overall, CPP referred patients were 21% more likely than non-CPP referred patients to report a positive experience after adjustment for case-mix, comorbidity, disposable household income and educational level (PR = 1.21 [95% CI: 1.11-1.30]). The difference decreased to 14% when adjusted for Quality Deviations (PR = 1.14 [95% CI: 1.06-1.23]) and to 11% when adjusted for diagnostic interval (PR = 1.11 [95% CI: 1.02-1.20]).

CONCLUSION

Our findings suggest that CPP referred cancer patients have better experiences of pre-diagnosis cancer care compared to non-CPP referred patients. A substantial part of the difference could be attributed to shorter diagnostic intervals and/or the absence of quality deviations among CPP patients, which reveals the potential for generally improving cancer patients' experiences by seamless and optimised diagnostic pathways.

Characteristics of 64 sarcoma patients referred to a sarcoma center after unplanned excision

BACKGROUND AND METHODS

Unplanned excision of sarcoma before referral to specialist centers can affect prognosis and surgical outcome. The diagnostic pathway of these patients is uncertain and needs to be reviewed. We aimed to describe patient and tumor characteristics, initial symptoms, initial and final diagnosis, and explore reasons for unplanned excision in this patient group. From a previous study on 258 sarcoma patients, we identified 64 patients referred after surgery. Medical records were reviewed.

RESULTS

The majority were soft tissue sarcomas, most often with thoracic location. Leiomyosarcoma was the most frequent final diagnosis, lipoma, and fibroma/dermatofibroma the most frequent initial diagnoses. Fifty percent were superficial small tumors, and 60.9% had not received diagnostic imaging before surgery. Fifty percent were referred from public surgical departments, and 1/3 from private specialists. Twenty-three patients had initial presence of alarm symptoms registered before surgery, the remaining 2/3 fell outside referral criteria or alarm symptoms were not discovered.

CONCLUSIONS

Patients referred after unplanned excision often have small superficial tumors and the majority fall outside of defined referral criteria. Referral criteria are not a guarantee for detection of all sarcomas and surgeons should always be aware of the possibility of malignancy when removing a tumor.