Determining Acceptable Waiting Times for the Surgical Treatment of Solid Organ Malignancies - A...

Determining Acceptable Waiting Determining Acceptable Waiting Times for the Surgical Treatment of Times for the Surgical Treatment of

Solid Organ Malignancies -Solid Organ Malignancies -

A Systematic ReviewA Systematic Review

CIHR Grant: Toward Canadian CIHR Grant: Toward Canadian Benchmarks for Health Services Wait Benchmarks for Health Services Wait

Times – Evidence, Application and Times – Evidence, Application and Research PrioritiesResearch Priorities

Nicole Choptain, Donna Turner, Steve Latosinsky, Tom Noseworthy, Mark Taylor

January, 2006

Goal of ProjectGoal of Project

To provide an in-depth summary To provide an in-depth summary of the issues and evidence for of the issues and evidence for

establishing waiting time establishing waiting time benchmarks in solid organ benchmarks in solid organ

malignancies treated by surgery.malignancies treated by surgery.

IntroductionIntroduction

Feb 2005 – CIHR RFA : Toward Canadian Feb 2005 – CIHR RFA : Toward Canadian Benchmarks for Health Services Wait Benchmarks for Health Services Wait Times – Evidence, Application and Times – Evidence, Application and Research PrioritiesResearch Priorities

Systematic reviews of existing evidence Systematic reviews of existing evidence in 5 areas, one of which was cancerin 5 areas, one of which was cancer

Provide first ministers with advice re Provide first ministers with advice re establishment of benchmark waiting timesestablishment of benchmark waiting times

Literature Review –Literature Review – Existing Benchmarks Existing Benchmarks

Description of the benchmarks being Description of the benchmarks being used, for what purposes and by whomused, for what purposes and by whom

Description of the range of settings where Description of the range of settings where such benchmarks are currently appliedsuch benchmarks are currently applied

Summary of wait-time benchmarks Summary of wait-time benchmarks currently used nationally or elsewhere, & currently used nationally or elsewhere, & research evidence that was used to research evidence that was used to support their selection.support their selection.

Evidence for BenchmarksEvidence for Benchmarks

Identify areas / procedures where there Identify areas / procedures where there is currently sufficient evidence, and is currently sufficient evidence, and general consensus exists, regarding general consensus exists, regarding wait timewait time

RelationshipsRelationships

Synthesis of the research evidence Synthesis of the research evidence regarding the relationships between regarding the relationships between patient characteristics, health service patient characteristics, health service wait-times, and outcome (mortality, wait-times, and outcome (mortality, health status or quality of life).health status or quality of life).

CIHR Benchmark RFA CIHR Benchmark RFA Funded Cancer ApplicationsFunded Cancer Applications

May, 2005May, 2005

Marcy Winget – Marcy Winget – Wait-times for colorectal and Wait-times for colorectal and lung cancer, “Three Province Study”lung cancer, “Three Province Study”

Bill MacKillop – Bill MacKillop – Time to radiotherapyTime to radiotherapy

Paul Moayyedi – Paul Moayyedi – Time to diagnosis for upper Time to diagnosis for upper and lower GI cancerand lower GI cancer

Mark Taylor – Mark Taylor – Time from decision to undergo Time from decision to undergo cancer surgery to actual surgerycancer surgery to actual surgery

1. Review available evidence on cancer waiting time 1. Review available evidence on cancer waiting time benchmarks in randomized & non-randomized benchmarks in randomized & non-randomized trials.trials. 2. Identify practical & clinically established waiting 2. Identify practical & clinically established waiting

time measures re: impact on mortality, quality time measures re: impact on mortality, quality of life, & surgical treatment of of life, & surgical treatment of cancer.cancer. 3. Assess completeness of existing reviews & audits 3. Assess completeness of existing reviews & audits

on cancer waiting time benchmarks & how on cancer waiting time benchmarks & how applicable they are to the health care system in applicable they are to the health care system in Canada.Canada. 4. To compare the appropriateness & effectiveness 4. To compare the appropriateness & effectiveness

of evidence-based cancer waiting times as a of evidence-based cancer waiting times as a part of quality patient carepart of quality patient care..

OBJECTIVES

Waiting Times for Surgical Treatment of Solid Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic ReviewOrgan Malignancies - A Systematic Review


First stage of the project involved review of main First stage of the project involved review of main medical sources, well-defined search strategy, & medical sources, well-defined search strategy, & inclusive search criteria. inclusive search criteria.

Specific search strategy developed in consultation Specific search strategy developed in consultation with medical librarian, to exclude highly irrelevant with medical librarian, to exclude highly irrelevant material & focus on surgical waiting times & material & focus on surgical waiting times & benchmarks. benchmarks.

The search for evidence-based waiting timeThe search for evidence-based waiting time benchmarks was investigated according to a list of benchmarks was investigated according to a list of relevant keywordsrelevant keywords

SEARCH METHODOLOGY


Published and unpublished sources -1985 to 2005. Published and unpublished sources -1985 to 2005.

Searches conducted nationally & internationally Searches conducted nationally & internationally

Not limited by language, provided that an English title Not limited by language, provided that an English title or keywords were available.or keywords were available.

First search conducted on MEDLINE.First search conducted on MEDLINE.

SEARCH METHODOLOGY


1. Neoplasms and surgery or surgical procedures or operative.1. Neoplasms and surgery or surgical procedures or operative.

2. Cancer or neoplasms or oncology or malignancy or tumour or carcinoma 2. Cancer or neoplasms or oncology or malignancy or tumour or carcinoma or adenocarcinoma or sarcoma or mastectomy or hysterectomy or or adenocarcinoma or sarcoma or mastectomy or hysterectomy or orchiectomy or prostatectomy and surgery or surgically. orchiectomy or prostatectomy and surgery or surgically.

3. #1 OR #2 3. #1 OR #2

4. Time factors or waiting lists or appointments & schedules or time & motion 4. Time factors or waiting lists or appointments & schedules or time & motion studies or time management or referral and consultation or patient selection.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 5. Wait or referral or time factor or fast track or surgical delay or delay in surgical or delay or interval.surgical or delay or interval.

6. #4 OR #56. #4 OR #5

7. #3 AND #67. #3 AND #6

8. Management audit or nursing audit or medical audit or utilization review or 8. Management audit or nursing audit or medical audit or utilization review or audit.audit.

9. #3 AND #89. #3 AND #8

MEDLINE SEARCH TERMS – (PubMed including Cancerlit) Brief Version


MEDLINEMEDLINE

Relevance Level:Relevance Level: Number of Records:Number of Records:Level 1 Level 1 Highly RelevantHighly Relevant 3939

Level 2Level 2 Probably RelevantProbably Relevant 3333

Level 3Level 3 Possible RelevantPossible Relevant 6161

Level 4Level 4 Probably Not RelevantProbably Not Relevant 2424

Level 5Level 5 Definitely Not RelevantDefinitely Not Relevant 1515

TotalTotal 172172

1st SEARCH RESULTS- Titles Reviewed


Relevance of all 172 articles reassessed based on Relevance of all 172 articles reassessed based on the full article or abstract for a second relevance the full article or abstract for a second relevance rating. rating.

Rating of articles done by 2 of 3 reviewers – scored Rating of articles done by 2 of 3 reviewers – scored

with standard templatewith standard template

Articles were identified as “Auxiliary” under the Articles were identified as “Auxiliary” under the following conditions:following conditions:

- only editorial or commentary information provided, review of - only editorial or commentary information provided, review of other studies or not directly referring to all 3 terms: cancer, waiting other studies or not directly referring to all 3 terms: cancer, waiting times, and surgery.times, and surgery.

ARTICLE RE-ASSESSMENT


Studies were graded according to study Studies were graded according to study design & qualitydesign & quality Grade A – Benchmark based on Level 1 Grade A – Benchmark based on Level 1

studies (RCTs)studies (RCTs) Grade B – Benchmark based on Level 2&3 Grade B – Benchmark based on Level 2&3

studies (cohort or case-control)studies (cohort or case-control) Grade C – Benchmark based on Level 4 Grade C – Benchmark based on Level 4

studies (case series)studies (case series) Grade D – Benchmark based on Level 5 Grade D – Benchmark based on Level 5

studies (expert opinion)studies (expert opinion)


Relevance Level:Relevance Level: # Records Auxiliary# Records Auxiliary ReviewedReviewed Level 1Level 1 Highly Relevant 29 Highly Relevant 29 4 4 22 22

Level 2Level 2 Probably Relevant 17 Probably Relevant 17 7 7 9 9

Level 3Level 3 Possible Relevant 28 Possible Relevant 28 16 16 10 10

Level 4Level 4 Probably Not Probably Not 75 75 --

Level 5Level 5 Definitely Not Definitely Not 23 23 --

TotalTotal 172 172 27 27 41 41 (24% of 172)(24% of 172)

MEDLINE ARTICLE RE-ASSESSMENT RESULTS :

Waiting Times for Surgical Treatment of Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Solid Organ Malignancies - A Systematic

Review, Report 1 – July 22, 2005Review, Report 1 – July 22, 2005

Few cancer surgery benchmark waiting Few cancer surgery benchmark waiting times were foundtimes were found

Those that existed were based solely on Those that existed were based solely on expert opinion, with very little evidence to expert opinion, with very little evidence to support them (Grade D)support them (Grade D)

Available studies assessed compliance Available studies assessed compliance with these benchmarkswith these benchmarks


From references listed in Medline articlesFrom references listed in Medline articles

Relevance Level:Relevance Level: Number of Records:Number of Records:

Level 1Level 1 Highly RelevantHighly Relevant 3333




Level 5Level 5 Definitely Not RelevantDefinitely Not Relevant 9 9

To Be RankedTo Be Ranked 5656

TotalTotal 175175

2nd SEARCH RESULTS


Report 2 – October 14, 2005Report 2 – October 14, 2005

100% of identified benchmarks based solely on 100% of identified benchmarks based solely on expert opinionexpert opinionMost studies assessed compliance with arbitrary Most studies assessed compliance with arbitrary benchmarksbenchmarksNo compelling evidence that waiting impacted No compelling evidence that waiting impacted on outcomeon outcome49% of studies had poor methodology, & 80% 49% of studies had poor methodology, & 80% not generalizablenot generalizableOnly 6 studies assessed health status in relation Only 6 studies assessed health status in relation to waitingto waiting10 studies looked at reducing waiting times 10 studies looked at reducing waiting times through referral or flow changesthrough referral or flow changes


1. Cancer & surgery1. Cancer & surgery2. Neoplasm or cancer or oncology or malignancy or 2. Neoplasm or cancer or oncology or malignancy or tumour or carcinoma or sarcomatumour or carcinoma or sarcoma3. #1 or #23. #1 or #24. Orchiectomy or hysterectomy or prostatectomy or 4. Orchiectomy or hysterectomy or prostatectomy or mastectomy or surgery or operation or pre-operative or re-mastectomy or surgery or operation or pre-operative or re-operativeoperative5. #3 or #45. #3 or #46. Cancer patient or surgical patient or hospital admission 6. Cancer patient or surgical patient or hospital admission or medical audit or nursing audit or management auditor medical audit or nursing audit or management audit7. #5 or #67. #5 or #68. Waiting list or surgical delay or delay in surgery or 8. Waiting list or surgical delay or delay in surgery or waiting time or surgery delay or time or times or wait 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 waiting or delay or tracking or interval or fast track or fast 9. #7 and #89. #7 and #8

3rd Search - EMBASE SEARCH TERMS - Brief Version


EMBASEEMBASERelevance Level:Relevance Level: Number of Records:Number of Records:

Level 1Level 1 Highly RelevantHighly Relevant 2 2


Level 3Level 3 Possible Relevant Possible Relevant 4343



To Be Ranked To Be Ranked 1313

TotalTotal 142142

3rd SEARCH RESULTS

Librarian used the cited reference feature based Librarian used the cited reference feature based on most relevant references identified first search on most relevant references identified first search results (PubMed etc). results (PubMed etc).

These were entered to retrieve citations that cited These were entered to retrieve citations that cited them (and also in some cases citations that they them (and also in some cases citations that they cited). cited).

In addition, librarian used judgement in identifying In addition, librarian used judgement in identifying only those that appeared somewhat relevant. only those that appeared somewhat relevant.

4th Search - Web of Science SEARCH STRATEGY



Web of ScienceWeb of Science

Relevance Level:Relevance Level: Number of Records:Number of Records:

Level 1Level 1 Highly RelevantHighly Relevant 88





To Be Ranked To Be Ranked 1313

TotalTotal 150150

4th SEARCH RESULTS


Comparisons:Comparisons:

Database Database # of Journal Articles# of Journal Articles

1. MEDLINE1. MEDLINE 1721722. References from2. References from MEDLINE ArticlesMEDLINE Articles 1751753. EMBASE3. EMBASE 1421424. Web of Science4. Web of Science 150150 (WOS)(WOS)

TOTAL:TOTAL: 639639

OVERVIEW

Waiting Times for Surgical Treatment of Solid Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review- Organ Malignancies - A Systematic Review-

Final Report due May, 2006Final Report due May, 2006Preliminary ImpressionsPreliminary Impressions

May be some evidence of impact on waiting May be some evidence of impact on waiting on outcome – breast, bladder, testicleon outcome – breast, bladder, testicle

There will never be conclusive proof that There will never be conclusive proof that delay in treatment beyond “x” weeks delay in treatment beyond “x” weeks reduces survivalreduces survival

Cancer surgery should be available with Cancer surgery should be available with minimal delay for reasons of fundamental minimal delay for reasons of fundamental fairnessfairness

Waiting Times for Surgical Treatment of Solid Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review- Organ Malignancies - A Systematic Review-

Final Report due May, 2006Final Report due May, 2006

First step is system change, improving First step is system change, improving patient flow from time of first symptom, patient flow from time of first symptom, through diagnosis, treatment, recovery, through diagnosis, treatment, recovery, and follow-upand follow-up

Establishing mandatory benchmarks may Establishing mandatory benchmarks may provide impetus leading to these changesprovide impetus leading to these changes

These benchmarks will be arbitraryThese benchmarks will be arbitrary

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