Flow redesign to improve prostate cancer access and care at the public healthcare system in Sao Jose dos Campos, Brazil.

Abstract

e13595 Background: Prostate cancer is the second most common cancer diagnosis in São José dos Campos (SJC) and the sixth cause of cancer mortality. Access to early diagnosis and treatment is one big challenge in the local public healthcare system (Sistema Único de Saude) due limited resources. Between 2018 and 2020 the healthcare public system of SJC redesigned the access flow for diagnosis and prostate cancer care in SJC is a mid-sized city (720,000 hab.) in Sao Paulo state, Brazil. Methods: The local SUS was designed to provide access to all patients with elevated PSA (>4.00µg) to a urologist for further evaluation and subsequent reevaluation if needed. This process created long queues and median time to access the few overburdened specialists available to over a year (410 days median), risking significant disease progression and stage upgrade. The flow redesign was done using lean and queue theory techniques and involved basically a new Fast Track to patients with PSA > 10.0µg with age between 50 and 79, considering the probability of 67% chance of prostate cancer (Catalona, et al. NEJM 1991; 324: 1156-61). Patients were referred from the primary care doctor straight forward to a biopsy and then to a medical oncologist, that would recommend further treatment, including a urologist evaluation. Patients with PSA between 4 and 10 would keep regular access to urology. The aim was to guarantee access to specialist up to 60 days from the first PSA > 4.0µg. Results: From April 2019 to September 2020, 277 patients (PSA > 10.0µg) were submitted to a biopsy through the Fast Track; 150 were positive (54,2%) for prostate cancer; and 72% with Gleason score 7 or higher. The diagnosis of prostate cancer from 2017 to 2020 increased over 300% (from 93 to 283), and access to treatment in less than 60 days increased from 15 to 140 patients in 2020. Patient with PSA > 4.0µg access to urology in less than 60 days also increased dramatically by eliminating several medical appointments and unneeded process steps (Table). Conclusions: The process redesign for patients with elevated PSA was able to provide access to care < 60 days for more than 80% of patients with elevated PSA or positive for prostate cancer by splitting high risk and low risk patients and using alternative flows to reduce urology overloaded agenda. Access to Urology for patients with PSA >4.00 < 10.00µg (not in Fast Track).[Table: see text]