Abstract
BackgroundIn radiotherapy, minimizing the time between referral and start of treatment (waiting time) is important to possibly mitigate tumor growth and avoid psychological distress in cancer patients. Radiotherapy pre-treatment workflow is driven by the scheduling of the first irradiation session, which is usually set right after consultation (pull strategy) or can alternatively be set after the pre-treatment workflow has been completed (push strategy). The objective of this study is to assess the impact of using pull and push strategies and explore alternative interventions for improving timeliness in radiotherapy.MethodsDiscrete-event simulation is used to model the patient flow of a large radiotherapy department of a Dutch hospital. A staff survey, interviews with managers, and historical data from 2017 are used to generate model inputs, in which fluctuations in patient inflow and resource availability are considered.ResultsA hybrid (40% pull / 60% push) strategy representing the current practice (baseline case) leads to 12% lower average waiting times and 48% fewer first appointment rebooks when compared to a full pull strategy, which in turn leads to 41% fewer patients breaching the waiting time targets.An additional scenario analysis performed on the baseline case showed that spreading consultation slots evenly throughout the week can provide a 21% reduction in waiting times.ConclusionsA 100% pull strategy allows for more patients starting treatment within the waiting time targets than a hybrid strategy, in spite of slightly longer waiting times and more first appointment rebooks. Our algorithm can be used by radiotherapy policy makers to identify the optimal balance between push and pull strategies to ensure timely treatments while providing patient-centered care adapted to their specific conditions.
Highlights
In radiotherapy, minimizing the time between referral and start of treatment is important to possibly mitigate tumor growth and avoid psychological distress in cancer patients
We verify that the total average waiting time (WT) output by the discrete-event simulation (DES) model (7.8 days) is very close to the one measured in the actual system, i.e. in the Netherlands Cancer Institute (NKI) practice (7.9), with the actual system value falling within the 95% confidence interval of the DES model
A 100% pull strategy, in which patients are scheduled a start of treatment right after consultation, provides increased predictability on the fulfillment of waiting time targets in detriment of a small increase in the average waiting times when compared to a push strategy
Summary
In radiotherapy, minimizing the time between referral and start of treatment (waiting time) is important to possibly mitigate tumor growth and avoid psychological distress in cancer patients. The pre-treatment workflow includes imaging (CT, MRI, PET-CT), contouring of the tumor and organs-at-risk, and treatment planning, and is commonly driven by the scheduling of the first irradiation session, which is usually set immediately after consultation This demands pre-treatment workflow to be programmed a priori before the scheduled starting date for treatment. Setting a treatment start date right after consultation (pull strategy) may lead to increased patient and staff (doctors) satisfaction, when time slots for doctors’ activities (e.g. contouring of the tumor) are pre-allocated in coordination with treatment scheduling decisions. It may increase control over the work in progress, leading to a reduced number of patients breaching the waiting time targets. Appropriate workflow management systems (e.g. scheduling routines) and the design of efficient resource planning schemes are crucial to meet the intended waiting time targets [11] while ensuring patient centeredness and quality of labor
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