Transcript Waiting Times for Surgical Treatment of Solid Organ Malignancies

Determining Acceptable Waiting
Times for the Surgical Treatment of
Solid Organ Malignancies A Systematic Review
CIHR Grant: Toward Canadian
Benchmarks for Health Services Wait
Times – Evidence, Application and
Research Priorities
Nicole Choptain, Donna Turner, Steve Latosinsky,
Tom Noseworthy, Mark Taylor
January, 2006
Goal of Project
To provide an in-depth summary
of the issues and evidence for
establishing waiting time
benchmarks in solid organ
malignancies treated by surgery.
Introduction
Feb 2005 – CIHR RFA : Toward Canadian
Benchmarks for Health Services Wait
Times – Evidence, Application and
Research Priorities
Systematic reviews of existing evidence
in 5 areas, one of which was cancer
Provide first ministers with advice re
establishment of benchmark waiting times
Literature Review –
Existing Benchmarks
Description of the benchmarks being
used, for what purposes and by whom
Description of the range of settings where
such benchmarks are currently applied
Summary of wait-time benchmarks
currently used nationally or elsewhere, &
research evidence that was used to
support their selection.
Evidence for Benchmarks
Identify areas / procedures where there
is currently sufficient evidence, and
general consensus exists, regarding
wait time
Relationships
Synthesis of the research evidence
regarding the relationships between
patient characteristics, health service
wait-times, and outcome (mortality,
health status or quality of life).
CIHR Benchmark RFA
Funded Cancer Applications
May, 2005
Marcy Winget – Wait-times for colorectal and
lung cancer, “Three Province Study”
Bill MacKillop – Time to radiotherapy
Paul Moayyedi – Time to diagnosis for upper
and lower GI cancer
Mark Taylor – Time from decision to undergo
cancer surgery to actual surgery
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
OBJECTIVES
1. Review available evidence on cancer waiting time
benchmarks in randomized & non-randomized
trials.
2. Identify practical & clinically established waiting
time measures re: impact on mortality, quality
of life, & surgical treatment of cancer.
3. Assess completeness of existing reviews & audits
on cancer waiting time benchmarks & how
applicable they are to the health care system in
Canada.
4. To compare the appropriateness & effectiveness
of evidence-based cancer waiting times as a
part of quality patient care.
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
SEARCH METHODOLOGY
First stage of the project involved review of main
medical sources, well-defined search strategy, &
inclusive search criteria.
Specific search strategy developed in consultation
with medical librarian, to exclude highly irrelevant
material & focus on surgical waiting times &
benchmarks.
The search for evidence-based waiting time
benchmarks was investigated according to a list of
relevant keywords
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
SEARCH METHODOLOGY
Published and unpublished sources -1985 to 2005.
Searches conducted nationally & internationally
Not limited by language, provided that an English title
or keywords were available.
First search conducted on MEDLINE.
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
MEDLINE SEARCH TERMS –
(PubMed including Cancerlit) Brief Version
1. Neoplasms and surgery or surgical procedures or operative.
2. Cancer or neoplasms or oncology or malignancy or tumour or carcinoma
or adenocarcinoma or sarcoma or mastectomy or hysterectomy or
orchiectomy or prostatectomy and surgery or surgically.
3. #1 OR #2
4. Time factors or waiting lists or appointments & schedules or time & motion
studies or time management or referral and consultation or patient selection.
5. Wait or referral or time factor or fast track or surgical delay or delay in
surgical or delay or interval.
6. #4 OR #5
7. #3 AND #6
8. Management audit or nursing audit or medical audit or utilization review or
audit.
9. #3 AND #8
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
1st SEARCH RESULTS- Titles Reviewed
MEDLINE
Relevance Level:
Level 1
Highly Relevant
Number of Records:
39
Level 2
Probably Relevant
33
Level 3
Possible Relevant
61
Level 4
Probably Not Relevant
24
Level 5
Definitely Not Relevant
15
Total
172
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
ARTICLE RE-ASSESSMENT
Relevance of all 172 articles reassessed based on
the full article or abstract for a second relevance
rating.
Rating of articles done by 2 of 3 reviewers – scored
with standard template
Articles were identified as “Auxiliary” under the
following conditions:
- only editorial or commentary information provided, review of
other studies or not directly referring to all 3 terms: cancer, waiting
times, and surgery.
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
Studies were graded according to study
design & quality




Grade A – Benchmark based on Level 1
studies (RCTs)
Grade B – Benchmark based on Level 2&3
studies (cohort or case-control)
Grade C – Benchmark based on Level 4
studies (case series)
Grade D – Benchmark based on Level 5
studies (expert opinion)
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
MEDLINE ARTICLE RE-ASSESSMENT RESULTS :
Relevance Level:
# Records
Auxiliary
Reviewed
Level 1 Highly Relevant
29
4
22
Level 2 Probably Relevant
17
7
9
Level 3 Possible Relevant
28
16
10
Level 4 Probably Not
75 -
Level 5 Definitely Not
23 -
Total
172
27
41
(24% of 172)
Waiting Times for Surgical Treatment of
Solid Organ Malignancies - A Systematic
Review, Report 1 – July 22, 2005
Few cancer surgery benchmark waiting
times were found
Those that existed were based solely on
expert opinion, with very little evidence to
support them (Grade D)
Available studies assessed compliance
with these benchmarks
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
2nd SEARCH RESULTS
From references listed in Medline articles
Relevance Level:
Number of Records:
Level 1
Highly Relevant
33
Level 2
Probably Relevant
23
Level 3
Possible Relevant
35
Level 4
Probably Not Relevant
19
Level 5
Definitely Not Relevant
9
To Be Ranked
56
Total
175
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
Report 2 – October 14, 2005
100% of identified benchmarks based solely on
expert opinion
Most studies assessed compliance with arbitrary
benchmarks
No compelling evidence that waiting impacted
on outcome
49% of studies had poor methodology, & 80%
not generalizable
Only 6 studies assessed health status in relation
to waiting
10 studies looked at reducing waiting times
through referral or flow changes
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
3rd Search - EMBASE SEARCH TERMS - Brief Version
1. Cancer & surgery
2. Neoplasm or cancer or oncology or malignancy or
tumour or carcinoma or sarcoma
3. #1 or #2
4. Orchiectomy or hysterectomy or prostatectomy or
mastectomy or surgery or operation or pre-operative or reoperative
5. #3 or #4
6. Cancer patient or surgical patient or hospital admission
or medical audit or nursing audit or management audit
7. #5 or #6
8. Waiting list or surgical delay or delay in surgery or
waiting time or surgery delay or time or times or wait or
waiting or delay or tracking or interval or fast track or fast
9. #7 and #8
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
3rd SEARCH RESULTS
EMBASE
Relevance Level:
Number of Records:
Level 1
Highly Relevant
2
Level 2
Probably Relevant
10
Level 3
Possible Relevant
43
Level 4
Probably Not Relevant
30
Level 5
Definitely Not Relevant
44
To Be Ranked
13
Total
142
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
4th Search - Web of Science SEARCH STRATEGY
Librarian used the cited reference feature based
on most relevant references identified first search
results (PubMed etc).
These were entered to retrieve citations that cited
them (and also in some cases citations that they
cited).
In addition, librarian used judgement in identifying
only those that appeared somewhat relevant.
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
4th SEARCH RESULTS
Web of Science
Relevance Level:
Number of Records:
Level 1
Highly Relevant
8
Level 2
Probably Relevant
20
Level 3
Possible Relevant
50
Level 4
Probably Not Relevant
41
Level 5
Definitely Not Relevant
18
To Be Ranked
13
Total
150
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic Review
OVERVIEW
Comparisons:
Database
1. MEDLINE
2. References from
MEDLINE Articles
3. EMBASE
4. Web of Science
(WOS)
TOTAL:
# of Journal Articles
172
175
142
150
639
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic ReviewFinal Report due May, 2006
Preliminary Impressions
May be some evidence of impact on waiting
on outcome – breast, bladder, testicle
There will never be conclusive proof that
delay in treatment beyond “x” weeks
reduces survival
Cancer surgery should be available with
minimal delay for reasons of fundamental
fairness
Waiting Times for Surgical Treatment of Solid
Organ Malignancies - A Systematic ReviewFinal Report due May, 2006
First step is system change, improving
patient flow from time of first symptom,
through diagnosis, treatment, recovery,
and follow-up
Establishing mandatory benchmarks may
provide impetus leading to these changes
These benchmarks will be arbitrary