Ellen Schultz

Timeliness of care in patients with lung cancer: a systematic review

Background: Timeliness is an important dimension of health care quality. It is unclear whether timeliness improves clinical outcomes in patients with lung cancer. Methods: This study systematically reviewed studies that described timeliness of care, examined associations between timeliness and clinical outcomes or tested an intervention to improve timeliness of care in patients with lung cancer. English language studies published between 1 January 1995 and 1 June 2007 were included. Two reviewers independently abstracted data on study methods, population, sample size, relevant time intervals and outcomes. Results: 49 studies were identified that reported at least one time interval in lung cancer care, 18 studies that examined the association between timeliness and clinical outcomes and 8 studies that described interventions aimed at improving timeliness. Most studies were performed in European Union member countries, including 24 studies performed in Great Britain and Ireland. Median times to diagnosis (range 8–60 days) and times to treatment (range 30–84 days) often exceeded published recommendations. Three studies found that timely care was associated with better survival, eight found no association and four reported better survival in patients who received less timely care. Interventions that improved timeliness included nurse-led care coordination, multidisciplinary meetings via teleconference and a standardised expedited “two-stop” diagnostic process. Conclusions: Times to diagnosis and treatment of lung cancer are often longer than recommended. Factors associated with timeliness have been incompletely examined, and it remains unclear whether more timely care improves outcomes.

Validation of two models to estimate the probability of malignancy in patients with solitary pulmonary nodules

Background: Effective strategies for managing patients with solitary pulmonary nodules (SPN) depend critically on the pre-test probability of malignancy. Objective: To validate two previously developed models that estimate the probability that an indeterminate SPN is malignant, based on clinical characteristics and radiographic findings. Methods: Data on age, smoking and cancer history, nodule size, location and spiculation were collected retrospectively from the medical records of 151 veterans (145 men, 6 women; age range 39–87 years) with an SPN measuring 7–30 mm (inclusive) and a final diagnosis established by histopathology or 2-year follow-up. Each patient’s final diagnosis was compared with the probability of malignancy predicted by two models: one developed by investigators at the Mayo Clinic and the other developed from patients enrolled in a VA Cooperative Study. The accuracy of each model was assessed by calculating areas under the receiver operating characteristic (ROC) curve and the models were calibrated by comparing predicted and observed rates of malignancy. Results: The area under the ROC curve for the Mayo Clinic model (0.80; 95% CI 0.72 to 0.88) was higher than that of the VA model (0.73; 95% CI 0.64 to 0.82), but this difference was not statistically significant (Δ = 0.07; 95% CI −0.03 to 0.16). Calibration curves showed that the probability of malignancy was underestimated by the Mayo Clinic model and overestimated by the VA model. Conclusions: Two existing prediction models are sufficiently accurate to guide decisions about the selection and interpretation of subsequent diagnostic tests in patients with SPNs, although clinicians should also consider the prevalence of malignancy in their practice setting when choosing a model.

A systematic review of the care coordination measurement landscape

BackgroundCare coordination has increasingly been recognized as an important aspect of high-quality health care delivery. Robust measures of coordination processes will be essential tools to evaluate, guide and support efforts to understand and improve coordination, yet little agreement exists among stakeholders about how to best measure care coordination. We aimed to review and characterize existing measures of care coordination processes and identify areas of high and low density to guide future measure development.MethodsWe conducted a systematic review of measures published in MEDLINE through April 2012 and identified from additional key sources and informants. We characterized included measures with respect to the aspects of coordination measured (domain), measurement perspective (patient/family, health care professional, system representative), applicable settings and patient populations (by age and condition), and data used (survey, chart review, administrative claims).ResultsAmong the 96 included measure instruments, most relied on survey methods (88%) and measured aspects of communication (93%), in particular the transfer of information (81%). Few measured changing coordination needs (11%). Nearly half (49%) of instruments mapped to the patient/family perspective; 29% to the system representative and 27% to the health care professionals perspective. Few instruments were applicable to settings other than primary care (58%), inpatient facilities (25%), and outpatient specialty care (22%).ConclusionsNew measures are needed that evaluate changing coordination needs, coordination as perceived by health care professionals, coordination in the home health setting, and for patients at the end of life.

Timeliness of Care in Veterans With Non-small Cell Lung Cancer

BACKGROUND Timeliness is an important dimension of quality of care for patients with lung cancer. METHODS We reviewed the records of consecutive patients in whom non-small cell lung cancer (NSCLC) had been diagnosed between January 1, 2002, and December 31, 2003, at the Veterans Affairs Palo Alto Health Care System. We used multivariable statistical methods to identify independent predictors of timely care and examined the effect of timeliness on survival. RESULTS We identified 129 veterans with NSCLC (mean age, 67 years; 98% men; 83% white), most of whom had adenocarcinoma (51%) or squamous cell carcinoma (30%). A minority of patients (18%) presented with a solitary pulmonary nodule (SPN). The median time from the initial suspicion of cancer to treatment was 84 days (interquartile range, 38 to 153 days). Independent predictors of treatment within 84 days included hospitalization within 7 days (odds ratio [OR], 8.2; 95% confidence interval [CI], 2.9 to 23), tumor size of > 3.0 cm (OR, 4.8; 95% CI, 1.8 to 12.4), the presence of additional chest radiographic abnormalities (OR, 3.0; 95% CI, 1.1 to 8.5), and the presence of one or more symptoms suggesting metastasis (OR, 2.6; 95% CI, 1.1 to 6.2). More timely care was not associated with better survival time (adjusted hazard ratio, 1.6; 95% CI, 1.3 to 1.9). However, in patients with SPNs, there was a trend toward better survival time when the time to treatment was < 84 days. CONCLUSIONS The time to treatment for patients with NSCLC was often longer than recommended. Patients with larger tumors, symptoms, and other chest radiographic abnormalities receive more timely care. In patients with malignant SPNs, survival may be better when treatment is initiated promptly.

What is care coordination

Introduction Care coordination is a high-priority area for improvement across healthcare systems, but no consensus definition of care coordination exists. Methods This article reviews published definitions of the term “care coordination,” identifies common themes among them, and presents a broad working definition of care coordination. Results The review identified 57 unique definitions of care coordination, ranging widely in the scope of participants, settings, and care processes included. Five major themes emerged from the definitions: care coordination involves numerous participants, is necessitated by interdependence among participants and activities, requires knowledge of others’ roles and resources, relies on information exchange, and aims to facilitate appropriate healthcare delivery. Only one definition identified included all five themes, and no one theme was found in a clear majority of definitions. The synthesized themes were incorporated into a broad working definition of care coordination, which has resulted in numerous uses (e.g. guide for systematic review of interventions, development of a measures repository, reference for this journal’s recast focus on the subject). Discussion Some ambiguity remains about the definition of care coordination, but the breadth of definitions in use underscores its widespread recognition as important for high-quality care. Even as understanding of care coordination continues to evolve, broad and flexible definitions can help guide the iterative process of developing conceptual models, testing them empirically, refining models, generating evidence about what works best, and ultimately improving the quality of care.

Hospital Characteristics Associated with Timeliness of Care in Veterans with Lung Cancer

RATIONALE Timeliness is one of six important dimensions of health care quality recognized by the Institute of Medicine. OBJECTIVES To evaluate timeliness of lung cancer care and identify institutional characteristics associated with timely care within the Veterans Affairs (VA) health care system. METHODS We used data from a VA nation-wide retrospective chart review and an independent audit of VA cancer programs to examine the association between time to first treatment and potentially explanatory institutional characteristics (e.g., volume of lung cancer patients) for 2,372 veterans diagnosed with lung cancer between 1 January 2002 and 1 September 2005 at 127 VA medical centers. We developed linear mixed effects models to control for clustering of patients within hospitals and we stratified analyses by stage. MEASUREMENTS AND MAIN RESULTS Median time to treatment varied widely between (23 to 182 d) and within facilities. Median time to treatment was 90 days in patients with stage I or II cancer and 52 days in those with more advanced disease (P < 0.0001). Factors associated with shorter times to treatment included a nonacademic setting and the existence of a specialized diagnostic clinic (in patients with limited-stage disease), performing a patient flow analysis (in patients with advanced disease), and leadership beliefs about providing timely care (in both groups). However, institutional characteristics explained less than 1% of the observed variation in treatment times. CONCLUSIONS Time to lung cancer treatment in U.S. veterans is highly variable. The numerous institutional characteristics we examined explained relatively little of this variability, suggesting that patient, clinician, and/or unmeasured institutional characteristics may be more important determinants of timely care.

Timeliness Across the Continuum of Care in Veterans with Lung Cancer

Introduction: By providing timely care at all steps along the continuum of lung cancer care, providers may be able to limit disease progression before treatment and possibly improve clinical outcomes. This study examines the timeliness of key events in the process of care between initial radiograph and first treatment. Methods: Dates of key events were extracted from the medical records of 2463 veterans receiving lung cancer care at 133 Department of Veterans Affairs (VA) facilities. After reviewing their site’s abstraction results, facility leaders completed a survey on their perceptions of their local processes of lung cancer care. Results: Median time from first radiography to first treatment was 71 days. The longest intermediate time interval examined was between first treatment referral and first treatment (median = 12 days). Time from first to last diagnostic test was most variable (interquartile range = 0–27 days). We found a significant trend indicating that the time interval from first radiograph to treatment was shorter for patients with more advanced disease. This effect was also significant within six of the seven intermediate time intervals we examined. Survey responses indicated that the chart review process stimulated improvement activity. Conclusions: Although patients with earlier stage disease benefit more from treatment, they do not proceed as quickly through the continuum of care as patients with more advanced disease. By measuring variability in timeliness of care at multiple steps in the lung cancer care process, facilities may identify opportunities for improvement.

Assessment of a Novel Hybrid Delphi and Nominal Groups Technique to Evaluate Quality Indicators

OBJECTIVE To test the implementation of a novel structured panel process in the evaluation of quality indicators. DATA SOURCE National panel of 64 clinicians rating usefulness of indicator applications in 2008-2009. STUDY DESIGN Hybrid panel combined Delphi Group and Nominal Group (NG) techniques to evaluate 81 indicator applications. PRINCIPAL FINDINGS The Delphi Group and NG rated 56 percent of indicator applications similarly. Group assignment (Delphi versus Nominal) was not significantly associated with mean ratings, but specialty and research interests of panelists, and indicator factors such as denominator level and proposed use were. Rating distributions narrowed significantly in 20.8 percent of applications between review rounds. CONCLUSIONS The hybrid panel process facilitated information exchange and tightened rating distributions. Future assessments of this method might include a control panel.

Variation in Experts’ Beliefs about Lung Cancer Growth, Progression, and Prognosis

Introduction: Little is known about the natural history of malignant solitary pulmonary nodules (SPN). Experts’ beliefs may help fill these knowledge gaps and explain variation in clinical practices. Methods: Using a modified Delphi process, we surveyed a group of lung cancer experts about tumor growth, disease progression, and prognosis in patients with malignant SPN. After completing the first survey, experts were given the opportunity during a second survey to revise their responses in light of their peers’ beliefs. Results: The response rate was 100% (14 of 14) for both surveys. There was consensus that disease progression depends on the tumor growth rate, that survival for patients with untreated lung cancer is approximated by a declining exponential function, and that treatment is delayed by approximately 1 tumor volume doubling time (TVDT) in patients who undergo a period of “watchful waiting.” Just over half of experts (8 of 14) agreed that lung cancer progresses in three steps (from local to regional to distant disease), whereas 43% (6 of 14) preferred a 2-step model (from local to systemic disease). Likewise, 64% of experts (9 of 14) believed that malignant nodules grow exponentially, whereas 36% (5 of 14) believed that growth is slower than exponential. Experts’ estimates of the risk of disease progression during a period of observation lasting 1 TVDT varied from 1 to 50%. Estimates of 5-year survival for patients in whom diagnosis and treatment were delayed by 1 TVDT varied between 40% and 80%. Conclusions: There is substantial variability in experts’ beliefs about the natural history of untreated, malignant SPN. Different beliefs may be partly responsible for variation in management practices.

Disparities in lung cancer staging with positron emission tomography in the cancer care outcomes research and surveillance (cancors) study

Introduction:Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes. Methods:Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities. Results:Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77–0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76–0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57–0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use. Conclusions:Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage.