Lung cancer (LC) is the leading cause of cancer-related mortality [1
] and is associated with significant health system resource utilization [2
]. Timely LC care requires the integration of various specialists, given the diverse management options, frequently advanced presentation, and disparities in care [6
]. Delivering timely LC care is challenging, with delays in diagnosis and treatment being common [7
]. These delays can lead to tumour progression [8
] and patient distress [9
]. In turn, LC care is becoming increasingly expensive for patients, caregivers, and the healthcare system, with costs related to provider visits, investigations, and new treatment modalities rising over the past decade [2
Multidisciplinary cancer clinics (MDC) have increasingly been shown to have several benefits in LC care, including: improved care coordination, communication between providers, and compliance with guideline-recommended care; reduced delays in time to diagnosis and treatment; and reduced healthcare costs from improved resource utilization, fewer patient visits, and reduced out-of-pocket costs for patients [3
]. Furthermore, there is evidence that involvement of a Respirologist in the care of LC patients has been shown to improve patient quality of life measures and survival through optimization of obstructive lung disease [16
], highlighting the role of comprehensive patient evaluation and optimization prior LC treatment. That said, there have been no studies to date that assess the clinical efficiencies achieved through quality improvement (QI) in an LC MDC, and few studies evaluating the health resource utilization and secondary patient benefits achieved through LC MDC models [3
Kingston Health Sciences Centre (KHSC) is an academic tertiary care centre that serves a catchment area of greater than 500,000 residents living in a 20,000-square-kilometre, predominantly rural area. The Lung Diagnostic Assessment Program (LDAP) at KHSC is a rapid assessment clinic responsible for coordinating care for patients with suspected LC, through which approximately two-thirds of the region’s LC diagnoses are made.
To streamline patient diagnostic and treatment pathways, an LC MDC was implemented in the LDAP in 2017 and has since undergone continuous QI initiatives to improve clinical efficiencies and timeliness of care. Within a year of implementation, the LC MDC led to decreased time from LC diagnosis to oncology assessment of 10 days and decreased time to first treatment of 25 days [18
]. Qualitative evaluation of patient, caregiver, and provider perceptions of the clinic revealed positive experiences and perceived benefits by all clinic participants [14
]. Now, more than two years following MDC implementation, we seek to characterize the impact of QI on MDC clinic capacity, resource utilization, patient and clinic visit costs, and secondary patient benefits.
Implementation and continuous QI of an LC MDC clinic led to improved clinic capacity and health resource utilization, patient and clinic visit cost savings, and secondary patient benefits. MDC clinic capacity increased while maintaining efficiency, reduced individual patient oncology visits prior to first cancer treatment, facilitated non-LC patient care, and reduced administrative, patient, and caregiver costs. Previously published data from our MDC also demonstrated a 10-day decrease in time from LC diagnosis to oncology assessment and a 25-day decrease in time from LC diagnosis to first cancer treatment [18
] and also led to patient-reported benefits of satisfaction with care, convenience, and positive effect of family presence at appointments [14
]. While the evidence for MDC models is limited outside of our clinic model [11
], MDCs have been shown to improve the timeliness of care, staging and treatment guideline compliance, and reduce patient distress levels [11
]. We build on these findings by demonstrating that QI in healthcare can create sustainable change [50
], improve efficiency for patients and the healthcare system, and can lead to unanticipated benefits including improved adherence to guideline recommended mediastinal staging. While the economic evaluation is focused on the direct impact of the MDC clinic, and may not provide a comprehensive evaluation of the entirety of the costs associated with LC care, we include an assessment of potential increased costs associated with increased invasive mediastinal staging.
The number of patients seen in MDC increased over time as a result of implemented measures to maintain timeliness of care, including the inclusion of a community MO in the clinic rotation and cross coverage of Respirologists and Oncology specialists to ensure no cancelled clinics. Sustainability and spread are key markers of successful QI and maintenance of gains from an improvement project [52
]; as such, these changes were essential to ensure the ongoing success of our program. Furthermore, sustainability does not happen by chance [52
]; providers reported perceived improved communication and collegiality, clinic efficiency, and patient outcomes [14
], which created a culture of improvement and sustainability in MDC.
MDC led to a statistically significant reduction in the number of oncology visits between diagnosis and first cancer treatment (2.68 to 1.62), with subgroup analysis demonstrating significance for patients with stages 1, 3, and 4 disease. Voong et al. found there was a significant reduction of two provider visits per patient (6.8 versus 4.8) from referral to treatment [3
] in MDC; however, each individual clinician interaction was counted as one visit. In contrast, in our MDC, a visit included up to three individual clinician interactions which was counted as one individual oncology visit. This reduction in oncology visits likely contributed to improved time to LC treatment, as demonstrated previously [18
]. Although not measured here, this reduction in oncology visits may improve assessment and treatment times for non-LC patients, being assessed by MDC clinicians who treat other cancer subtypes.
There was a trend towards a reduction in the mean number of biopsies and staging imaging completed, which has previously been demonstrated by Voong et al. [3
]. This possible reduction in health resource utilization has wider impacts, including avoiding exposing patients to unnecessary morbidity (related to radiation and biopsies), reducing patient travel for tests, and reducing resource wait times for other non-LC patients. This warrants further evaluation in larger-scale studies.
Guideline-recommended mediastinal staging increased significantly in the MDC (15.0 to 60.0%). Friedman et al. found a similar significant increase in mediastinal staging for suspected stage 3 NSCLC [45
] in MDC (from 24.5 to 57.7%), although they did not include patients with stage 2 NSCLC. This increase in adherence to guideline-recommended care for stage 2/3 LC speaks to improved physician communication and a better understanding of each other’s roles in helping to develop treatment plans in MDC [14
]. The MDC likely also allowed oncologists to relay more immediately their perception of the importance of mediastinal staging in developing a treatment plan to the Respirologist(s) in MDC, and likely has had a long-term impact in Respirologist practice.
There was no difference in patients receiving curative intent therapy in the MDC. Several studies have examined the rates of curative intent therapy in MDC, with mixed results. Ray et al. found non-significant increases in chemoradiotherapy for patients with stage 3 NSCLC [15
] while Martin-Ucar et al. found increased rates of surgical resection in the MDC model [53
]. These mixed results speak to the heterogeneity of LC patients, even when analysed by stage and pathologic subtype, and likely reflect nuances in multidisciplinary decision-making processes, and variability in MDC formats.
This study also demonstrates several unanticipated benefits, including expediting the care for patients with symptomatic metastatic disease and providing concurrent expedited care for patients with a non-LC diagnosis. We facilitated care for 31 patients with symptomatic metastatic disease requiring urgent assessment and/or treatment. While it is difficult to determine whether this led to any health system cost savings, timely care and identification of patients at high risk for unplanned acute care admission has been associated with reduced hospitalizations [54
]. Furthermore, patients with non-lung cancer subtypes also benefitted from MDC, receiving concurrent oncology assessment when the MO or RO in clinic also treated that corresponding non-LC disease site. This has not previously been demonstrated in other MDC clinics and warrants further exploration as to the associated timeliness of care improvements for these patients. There were five patients in MDC who ultimately were found to have benign lesions; notably, despite early oncology consultation, none of these patients actually received therapy inappropriately. While we cannot compare this data to our baseline (as this data is not available), we previously demonstrated no significant change in the percentage of patients who were referred to and assessed by oncology [18
]. This suggests that the development of MDC did not increase the oncology referrals for benign lesions.
MDC led a total out-of-pocket cost savings to be CAD 24,167 (CAD 69/patient) related to a reduction in travel and parking costs associated with clinic visits. Not surprisingly, this benefit was observed by patients; in fact, a qualitative study evaluating patient perceptions of LC care in the MDC model revealed that patients receiving care in the MDC reported convenience of multiple same-day assessments and the positive effects on the patient experience and availability of family support [14
]. While it is challenging to measure the overall impact of increased family presence in the consolidated appointment structure, many studies have shown the value of improved caregiver involvement [12
]. While several studies descriptively outline these out-of-pocket costs [4
], Wood et al. quantified patient costs to be EUR 848 (~1290 CAD), which included child care, wages forgone, and transportation costs [32
]. We did not capture childcare costs. Lastly, caregiver attendance likely yields unmeasurable impacts, by ensuring patients understand their diagnosis, providing psychosocial support, and helping with health system navigation [55
From a societal perspective, LC care poses a significant burden, with losses estimated in the billions annually [10
]. We found that there was a total reduction of CAD 6379 in patient productivity losses and CAD 17,335 in caregiver productivity losses in MDC, assuming a caregiver employment rate of 50%. While there have not been studies in a Canadian context for comparison, Wood et al. found the annualized productivity loss attributable to NSCLC to be EUR 1,484 (~CAD 2265) for patients and EUR 2839 (~CAD 4330) for caregivers [32
] while Yabroff et al. found that informal caregiver costs over a 2-year period were USD 72,702 (~CAD 102,500) [37
]. These costs often garnish limited attention but represent a significant personal society economic burden [37
With respect to costs associated with clinic visits, the MDC resulted in cost savings of CAD 508 related to the reduced administrative burden. Several studies have measured these impacts [3
], with one study estimating that MDC reduced health system cost per patient by 23% [3
] (or CAD 5839 savings/patient); however, this analysis accounted for system costs not included in our analysis. Lastly, we did not look at health system cost categories that were common to both MDC and the traditional model of care in our analysis, such as the number of physician consults between referral and treatment, which previously demonstrated this to be unchanged between the two models; as such, physician billings would be unchanged between models and are therefore not reported [18
The increase in EBUS uptake paradoxically resulted in increased health system and patient costs, including an additional CAD 98,563 in the MDC model. However, from the threshold analysis, we found that the increased use of invasive mediastinal staging observed in our study cost CAD 25,707 per QALY, well below previously published willingness to pay thresholds (CAD 80,000) [24
]. Furthermore, improved adherence to guideline-recommend staging is likely to improve patient outcomes through reduced surgical mediastinal staging, reduced treatment burdens, and cancer down-staging [59
This is a single centre study in a public hospital system; however, the study demonstrates important benefits of continuous QI in LC care. While we previously demonstrated improved timeliness of assessment and treatment, as well as patient satisfaction in MDC, we have not yet studied patient survival, as this was not the intention of our initiative, and this data has not yet matured to perform this analysis. Furthermore, assessment of mortality can be confounded by multiple other variables, such newer treatments (immunotherapy, checkpoint inhibitors, etc.) for LC. Although there was an increase mediastinal staging in MDC, it is possible that reflects the evolution and increased uptake of EBUS at KHSC, as our local EBUS program only started in 2014. We also acknowledge the 8th Edition LC staging guidelines were released during our study (1 January 2017), however nodal staging was unchanged [60
Furthermore, retrospective cost analysis is challenging where there is continuous clinic refinement and a mix funding for care. However, we conducted sensitivity analyses demonstrating that parameter uncertainty did not substantially affect the results. There may ultimately be unaccounted for random sampling error arising from the study sample size. The lack of visit standardization at KHSC Cancer Centre (i.e., number and type of nursing assessments and triage) made assessing resource utilization difficult. That said, registration clerk resources are standard across the site. Finally, while there are limitations to extrapolating cost savings, particularly in terms of impact of sample size, presenting summative cost savings help to understand the overall potential impact of an initiative according to scale.
Lastly, while we did not measure the duration of clinic visits directly, and thus relied upon published clinic visit durations in our sensitivity analysis, a qualitative thematic analysis of the MDC clinic published by our group identified that physicians noted increased efficiency of use of clinic time, enabling assessment of a large number of patients per clinic [14
]. As such, clinic visit durations would likely be similar or shorter to that used in the current analyses.
It is difficult to account for societal cost reductions fully in our study; however, our qualitative study captured some of these themes anecdotally [14
]. We acknowledge the potential error in our economic and sensitivity analysis. Productivity loss of 50% in our base model reflects previous literature and clinical observations of caregiver age [10
]. We observed clinically that the age status of caregivers roughly reflects that of the patients they accompany (23% < 65 years old) with many having an adult child present at the visit as well, leading us to believe that 50% loss of caregiver productivity is appropriate for the cohort as a whole. The cost savings per patient likely represent an underestimate, given other unmeasured out-of-pocket costs (childcare, meals, etc.). Lastly, We acknowledge that the costs included in the invasive mediastinal staging sensitivity analysis may vary depending on the costing source, healthcare system, and types of costs included (i.e., procedural sedation vs. general anaesthesia) [24
], however we chose the costing reference that most closely resembles our model with EBUS-TBNA provided under conscious sedation, within the same single-payer healthcare system and province [38
While we recognize an imbalanced sample size of patients in the traditional model (78 patients) compared with the MDC model (350 patients), the baseline period was selected in accordance with recommendations for assessing baseline stability in a process from which variation can be assessed [61
]. The sample size of the traditional model was chosen for our initial QI study [18
], from which we continued to measure prospectively for further improvements. Despite this, the large number of patients studied in this MDC model represents a relative strength of our study, as the sample size is larger than many prior studies [11
Finally, we acknowledge the paucity of Thoracic Surgery presence in the MDC during the period of evaluation. As mentioned previously, at our institution, Respirology and Thoracic Surgery run parallel LC assessment clinics, to which patients are triaged according to suspicion of resectable and operable LC based on available clinical information and imaging at the time of triage. The quality improvement initiative upon which this study is based sought to streamline care in the larger Respirology clinic and represents the focus of the present evaluation; however, ongoing improvement efforts are underway to increased participation of Thoracic Surgery in the MDC, which is likely to further reduce patient out-of-pocket expenses through streamlined care.