Diagnostic Assessment Programs Research Articles

Factors Influencing the Timeliness and Completeness of Appropriate Staging Investigations for Patients with Stage I-III Lung Cancer in Southeastern Ontario.

(1) Background: Comprehensive and timely lung cancer (LC) staging is essential for prognosis and management. The Lung Diagnostic Assessment Program (LDAP) in Southeastern (SE) Ontario aims to provide rapid, guideline-concordant care for suspected LC patients. We evaluated factors affecting the completeness and timeliness of staging for stage I-III LC patients in SE Ontario, including the impact of LDAP management. (2) Methods: This was a population-based retrospective cohort study using the LDAP database (January 2017-December 2019), linked with the Ontario Cancer Registry, to identify newly diagnosed LC patients. A Cox model approach identified variables associated with staging completeness and timeliness. (3) Results: Among 755 patients, 459 (60.8%) were managed through LDAP. Optimal staging was achieved in 596 patients (78.9%), 23 (3.0%) had alternative staging, and 136 (18.0%) had incomplete staging. In the adjusted analyses, LDAP management was associated with a higher likelihood of complete staging (OR 2.29, p < 0.0001) and faster staging completion (β = -18.53, p < 0.0001). Increased distance to PET centres was associated with a longer time to complete staging (β = 8.95 per 100 km, p = 0.0007), as was longer time to diagnosis (β = 21.63 per 30 days, p < 0.0001). (4) Conclusions: LDAP management in SE Ontario significantly improved staging completeness and shortened staging time for stage I-III LC patients.

Income differences in time to colon cancer diagnosis.

People with low income have worse outcomes throughout the cancer care continuum; however, little is known about income and the diagnostic interval. We described diagnostic pathways by neighborhood income and investigated the association between income and the diagnostic interval. This was a retrospective cohort study of colon cancer patients diagnosed 2007-2019 in Ontario using routinely collected data. The diagnostic interval was defined as the number of days from the first colon cancer encounter to diagnosis. Asymptomatic pathways were defined as first encounter with a colonoscopy or guaiac fecal occult blood test not occurring in the emergency department and were examined separately from symptomatic pathways. Quantile regression was used to determine the association between neighborhood income quintile and the conditional 50th and 90th percentile diagnostic interval controlling for age, sex, rural residence, and year of diagnosis. A total of 64,303 colon cancer patients were included. Patients residing in the lowest income neighborhoods were more likely to be diagnosed through symptomatic pathways and in the emergency department. Living in low-income neighborhoods was associated with longer 50th and 90th-percentile symptomatic diagnostic intervals compared to patients living in the highest income neighborhoods. For example, the 90th percentile diagnostic interval was 15 days (95% CI 6-23) longer in patients living in the lowest income neighborhoods compared to the highest. These findings reveal income inequities during the diagnostic phase of colon cancer. Future work should determine pathways to reducing inequalities along the diagnostic interval and evaluate screening and diagnostic assessment programs from an equity perspective.

HTA model for laboratory medicine technologies: overview of approaches adopted in some international agencies.

The Health Technology Assessment (HTA) Working Group of the Emerging Technology Division of International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) aims to develop a methodological approach for producing structured HTA information for laboratory medicine technologies. This approach seeks to support decision-making processes at the country, regional, and/or hospital levels regarding the introduction of specific technologies. The focus of this model will primarily be ondefining assessment elements within the domains of 'organizational aspects' and 'costs and economic evaluations', potentially differentiated by the type of diagnostic technology (e.g., genetic tests, molecular tests). To achieve this project's goal, a literature review and examination ofwebsites of international HTA agencies have been conducted. The research aims to identify multidisciplinary methodological approaches used to assess laboratory diagnostic technologies and to pinpoint the domains and assessment elements utilized. Wefound 7 methodological articles describing methodological approaches adopted toassess laboratory diagnostic technologies. Among the HTA organizations considered, 23 reports were found, of which 7 were produced by the European Network of HTA (EUnetHTA), 4 by the National Institute for Health and Care Excellence Diagnostic Assessment Program (NICE DAP), and 12 by other HTA agencies. The EUnetHTA reports wererapid collaborative assessments covering various domains, while the NICE DAP reports focused on diagnostic guidances, including descriptions of technologies, clinical need and practice, diagnostic tests, accuracy, effectiveness, and cost-effectiveness. Finally, a survey targeting laboratory professionals will be conducted to introduce assessment elements, differentiated by the type of diagnostic technology, primarily for organizational and economic domains.

Assessing the impact of the COVID-19 pandemic on patients referred to a lung cancer rapid assessment clinic in Ontario, Canada

RATIONALE The COVID-19 pandemic negatively impacted lung cancer (LC) outcomes. The Lung Diagnostic Assessment Program (LDAP) in Southeastern Ontario is a rapid assessment clinic for patients with suspected LC. OBJECTIVE Characterize the impact of COVID-19 on presentations and timeliness of care within LDAP. METHODS Retrospective study of LDAP-referred patients pre-COVID-19 (December 2019–March 2020) with matched cohorts post-COVID-19 Year 1 (December 2020–March 2021), and Year 2 (December 2021–March 2022). Data included: patient demographics, LC diagnosis, stage, timeliness of care and symptoms. Statistical analysis included unpaired t-tests and chi-squared tests. MEASUREMENTS AND MAIN RESULTS We reviewed 273 patients pre-COVID-19, 287 post-COVID-19 Year 1 and 218 Year 2. Post-COVID-19, more patients were suspected to have cancer at referral (pre-COVID-19, 28.6% vs. post-COVID-19 Year 2, 37.2%, p = 0.03), and more patients did not attend consultation (9.8%, 10.7% vs 1.0% pre-COVID-19, p = 0.0002) due to hospitalization or declining assessment. Average time from referral to consultation was longer during post-COVID-19 Year 1 (12.2 vs. 17.0 days, p = 0.003) but unchanged by Year 2; times from referral to diagnosis and treatment were unchanged across cohorts (42.7 vs. 44.1 vs. 40.9, p = NS) and (74.0 vs. 66.2, vs. 70.3, p = NS, respectively). Post-COVID-19 patients reported longer symptom duration (5.0 vs. 3.5 months, p = 0.04). CONCLUSIONS During the COVID-19 pandemic, patient characteristics and timeliness of care within LDAP were unchanged, but more patients experienced clinical decline and longer symptom duration prior to consultation. While care within LDAP was relatively insulated, barriers to care prior to referral may have contributed to later presentation.

Improving Access to Care, Patient Costs, and Environmental Impact Through a Community Outreach Lung Cancer Rapid Assessment Clinic.

In Southeastern Ontario, increased patient distance from the regional lung cancer diagnostic assessment program (LDAP) is associated with a lower likelihood of patient care via LDAP while receiving care via LDAP is associated with improved survival. We implemented an LDAP outreach clinic to provide specialist assessment for patients with suspected lung cancer at a regional community hospital and assessed the impact on timeliness and accessibility of care. The Kingston Health Sciences Centre LDAP team engaged with community hospital partners to develop and launch the LDAP outreach clinic. We performed a retrospective chart review of LDAP patients (N = 1,070) before (August-November 2021; n = 234) and after implementation of the outreach clinic (November 2021-October 2022; n = 836). Descriptive data are reported as No. (%). Unpaired t tests and statistical process control charts assess for significance. A cost analysis of out-of-pocket patient costs related to travel and parking is presented in 2022 Canadian dollars (CAD). Compared with a 3-month matched time period before (August-October 2021) and after outreach clinic (August-October 2022), the mean time from referral to assessment and time from referral to diagnosis decreased from 20.3 to 14.4 days (P = .0019) and 40.0 to 28.9 days (P = .0007), respectively. Over 12 months, the total patient travel was reduced by 8,856 km, which combined with parking cost-savings, resulted in patient out-of-pocket savings of CAD $5,755.60 (CAD $47.60/patient). Accounting for physician travel, the total travel saved was 5,688 km, corresponding to reduced CO2 emissions by 1.9 tCO2. Implementation of a lung cancer outreach clinic led to improved timeliness of care, patient cost-savings, and reduced carbon footprint while serving patients in their community.

Prostate-Specific Membrane Antigen (PSMA) Expression Predicts Need for Early Treatment in Prostate Cancer Patients Managed with Active Surveillance.

Metabolic dysregulation is an early event in carcinogenesis. Here, we examined the expression of enzymes involved in de novo lipogenesis (ATP-citrate lyase: ACLY), glucose uptake (Glucose Transporter 1: GLUT1), and folate-glutamate metabolism (Prostate-Specific Membrane Antigen: PSMA) as potential biomarkers of risk for early prostate cancer progression. Patients who were managed initially on active surveillance with a Gleason score of 6 or a low-volume Gleason score of 7 (3 + 4) were accrued from a prostate cancer diagnostic assessment program. Patients were asked to donate their baseline diagnostic biopsy tissues and permit access to their clinical data. PSMA, GLUT1, and ACLY expression were examined with immunohistochemistry (IHC) in baseline biopsies, quantitated by Histologic Score for expression in benign and malignant glands, and compared with patient time remaining on active surveillance (time-on-AS). All three markers showed trends for elevated expression in malignant compared to benign glands, which was statistically significant for ACLY. On univariate analysis, increased PSMA and GLUT1 expression in malignant glands was associated with shorter time-on-AS (HR: 5.06, [CI 95%: 1.83-13.94] and HR: 2.44, [CI 95%: 1.10-5.44], respectively). Malignant ACLY and benign gland PSMA and GLUT1 expression showed non-significant trends for such association. On multivariate analysis, overexpression of PSMA in malignant glands was an independent predictor of early PC progression (p = 0.006). This work suggests that the expression of metabolic enzymes determined by IHC on baseline diagnostic prostate biopsies may have value as biomarkers of risk for rapid PC progression. PSMA may be an independent predictor of risk for progression and should be investigated further in systematic studies.

Improving Access and Timeliness of Early Palliative Care Specialist Assessment for Patients With Advanced Lung Cancer in a Rapid Assessment Clinic.

Background: Integrating palliative care in the management of patients with lung cancer improves quality of life, patient satisfaction, and overall survival. However, few patients receive timely palliative care consultation. The Lung Diagnostic Assessment Program (LDAP) in Southeastern Ontario is a multidisciplinary rapid assessment clinic that expedites the diagnosis and management of patients with suspected lung cancer. Objectives: We sought to increase the percentage of LDAP patients with stage IV lung cancer receiving palliative care consultation within three months of diagnosis. Design: We integrated a palliative care specialist in LDAP to facilitate in-person, same-visit consultation for patients with a new lung cancer diagnosis. Setting/Subjects: Five hundred fifty patients in a Canadian academic center (154 initial baseline, 104 COVID baseline, 292 post-palliative care integration). Measurements: Baseline data were established using retrospective chart review (February-June 2020 and December 2020-March 2021 due to COVID-19 pandemic). Data were collected prospectively to assess improvement (March-August 2021). Statistical Process Control charts assessed for special cause variation; chi-square tests assessed for differences between groups. Results: The percentage of patients with stage IV lung cancer seen by palliative care within three months increased from 21.8% (12/55) during early-COVID baseline to 49.2% (32/65) after palliative care integration (p < 0.006). Palliative care integration in LDAP reduced mean time from referral to consultation from 24.8 to 12.3 days, including same-day consultation for 15/32 (46.8%) patients with stage IV disease. Conclusions: Integrating palliative care specialists into LDAP improved the timeliness of palliative care assessment for patients with stage IV lung cancer.

Characterizing Variability in Lung Cancer Outcomes and Influence of a Lung Diagnostic Assessment Program in Southeastern Ontario, Canada.

Regional variability in lung cancer (LC) outcomes exists across Canada, including in the province of Ontario. The Lung Diagnostic Assessment Program (LDAP) in southeastern (SE) Ontario is a rapid-assessment clinic that expedites the management of patients with suspected LC. We evaluated the association of LDAP management with LC outcomes, including survival, and characterized the variability in LC outcomes across SE Ontario. We conducted a population-based retrospective cohort study by identifying patients with newly diagnosed LC through the Ontario Cancer Registry (January 2017-December 2019) and linked to the LDAP database to identify LDAP-managed patients. Descriptive data were collected. Using a Cox model approach, we compared 2-year survival for patients managed through LDAP vs. non-LDAP. We identified 1832 patients, 1742 of whom met the inclusion criteria (47% LDAP-managed and 53% non-LDAP). LDAP management was associated with a lower probability of dying at 2 years (HR 0.76 vs. non-LDAP, p < 0.0001). Increasing distance from the LDAP was associated with a lower likelihood of LDAP management (OR 0.78 for every 20 km increase, p < 0.0001). LDAP-managed patients were more likely to receive specialist assessment and undergo treatments. In SE Ontario, initial diagnostic care provided via LDAP was independently associated with improved survival in patients with LC.

Impact of an Accelerated Diagnostic Assessment Program on the Timeliness of Cancer Diagnosis and Treatment.

The Accelerated Diagnostic Assessment Program (ADAP) manages patients with imaging abnormalities, with or without concomitant symptoms, where cancer is suspected. The ADAP is offered to primary care practitioners and emergency departments with cases triaged by a medical oncologist. We performed a retrospective patient chart review of electronic medical records from January 2019 until June 2021 to validate the program. We collected information on the referral pathways, patient demographics, wait-times, and diagnostic results. The control group consisted of outpatients who were referred for biopsy over a 1-year period outside the ADAP stream. Statistical analyses were performed using IBM SPSS software. Of the 97 patients included, 54% were female, with ages ranging from 18 to 96 years. Twenty-nine percent (n = 20) of the malignant cases were incidental findings. Most patients referred to the ADAP were diagnosed with a malignancy (71%; n = 69), comprising hematologic (45%; n = 31), GI (26%; n = 18), or other cancers (29%; n = 20). The ADAP had decreased wait-times from referral to biopsy collection (17.6 days ± 10.7 [standard deviation (SD)]; n = 43) when compared with the control group (41.2 days ± 40.0 [SD]; n = 67; P < .001). ADAP patients with malignancies saw a treating specialist 7.6 ± 7.6 days [SD] after their follow-up appointment at the ADAP. The ADAP accelerated time to biopsy in a statistically significant manner when compared with age-, referring physician-, and biopsy site-matched controls. It also outperformed national and provincial standards, suggesting that its model addresses a gap in care by providing an underserved population timely access to diagnosis and treatment.

EP04.01-024 Influence of Lung Diagnostic Assessment Program on Health Resource Utilization in Lung Cancer in Southeastern Ontario, Canada

Lung cancer (LC) is the leading cause of cancer-related mortality and is associated with high socioeconomic impact. The Lung Diagnostic Assessment Program (LDAP) in Southeastern (SE) Ontario, Canada is a rapid assessment clinic that provides efficient and guideline-recommended care for patients undergoing evaluation for suspected LC. We evaluate the influence of LDAP management on health resource utilization (HRU) in the diagnostic phase of suspected LC in SE Ontario.

EP13.01-012 Exploring Factors Affecting Variability in Lung Cancer Outcomes Across Southeastern Ontario, Canada

Lung cancer (LC) is the leading cause of cancer-related mortality. The five-year relative LC survival varies across Ontario, ranging from 22-32% (2014-2018), with the lowest survival in Southeastern (SE) Ontario. Lung Diagnostic Assessment Program (LDAP) is a rapid assessment clinic that provides specialist care for patients undergoing evaluation for suspected LC. We sought to characterize patient, disease, and system factors, including the influence of LDAP care on survival outcomes, that may contribute to regional differences in LC outcomes.

Diagnostic assessment program for prostate cancer: Lessons learned after 2 years and degree of compliance to Canadian guidelines.

In 2018, our Institute launched the Diagnostic Assessment Program (DAP) for prostate cancer. It enabled quick access to a urologist for patients presented to family physician with elevated PSA and allowed fast multidisciplinary patient care. We aim to document our data over 2 years in comparison to data before implementation of DAP and its impact on the degree of adherence to Canadian guidelines. From April 2016 to April 2020, 880 patients who were evaluated for prostate cancer at Thunder Bay Regional Health Sciences Centre (TBRHSC) were included in this study. Patients' characteristics, clinical data, waiting times and line of treatment before and after implementation of DAP were calculated and statistically analysed. The median waiting time to urology consultation was significantly reduced from 68 (IQR 27-168) days to 34 (23-44) days (p < 0.001). The time from patient's referral to prostate biopsy decreased substantially from 34 (20-66) days to 18(11- 25) days after DAP (p < 0.001). After DAP, the percentage of Gleason 6 detected prostate cancers were significantly increased (19.7% to 30%) (p = 0.02). After DAP, rate for intermediate-risk patients elected for external beam radiotherapy (from 53.5% to 57.9%, p = 0.53) and radical prostatectomy (from 34.5% to 39.4%, p = 0.47) increased. More compliance to Canadian guidelines was observed in intermediate risk patients (88% vs 97.3%, p =.008). Implementation of DAP has led to a notable reduction of waiting time to urology consult and prostate biopsy. There is significant increase in Gleason 6 detected prostate cancer. Increased compliance to Canadian guidelines was detected in intermediate risk patients.

Expediting specialist referral for patients with suspected lung cancer through standardization of radiologist reporting

RATIONALE Lung cancer (LC) diagnostic pathways are often initiated following suspicious clinical and radiologic findings. We identified delays from first thoracic imaging suspicious for LC to specialist evaluation in a rapid assessment clinic [Lung Diagnostic Assessment Program (LDAP)]. OBJECTIVES We evaluate the impact of a quality improvement initiative consisting of standardized Computed Tomography (CT) reporting on timeliness of LC diagnostic pathways. METHODS Retrospective chart review of LDAP-referred patients established baseline data (January – December 2018). Improvement initiatives included (i) implementation of standardized LDAP referral recommendations at an academic center for patients with suspected LC by thoracic imaging (January 2019), and (ii) spread of standardized reporting to 3 community hospitals (March 2019). Prospective chart review (January - September 2019) evaluated for improvement. Data include dates of CT chest, LDAP referral/assessment and specific phrasing of radiology reports. Continuous data are reported as medians, categorical data as percentages; Mann-Whitney U and chi-squared tests assess for significance. MEASUREMENTS AND MAIN RESULTS We reviewed 1,244 LDAP referrals (697 baseline; 547 post-standardization). Patients with a radiologist recommendation for LDAP referral had faster times from CT to referral (median [75th, 90th percentile]) (5[9,15] vs. 6[16,33] days) and specialist assessment (20[27,35] vs. 22[33,50] days). Following standardization, the percentage of LDAP-referred patients with a radiologist recommendation for referral increased (29.2% to 48.3%; P < .001), significant for the academic center (50.2% to 61.8%; P = .006) and community hospitals (12.1% to 35.3%; P < .001). CONCLUSIONS Standardized radiologist reporting and specialist referral recommendations for patients with imaging suspicious for LC leads to faster patient referral and assessment.

The effect of diagnostic assessment programs on the diagnosis and treatment of patients with lung cancer in Ontario, Canada.

INTRODUCTION:Diagnostic assessment programs (DAPs) were implemented in Ontario, Canada, to improve the efficiency of the lung cancer care continuum. We compared the efficiency and effectiveness of care provided to patients in DAPs relative to usual care (non-DAPs).METHODS:Lung cancer patients diagnosed between 2014 and 2016 were identified from the Ontario Cancer Registry. Using administrative databases, we identified various health-care encounters 6 months before diagnosis until the start of treatment and compared utilization patterns, timing, and overall survival between DAP and non-DAP patients.RESULTS:DAP patients were younger (P < 0.0001), had fewer comorbidities (P = 0.0006), and were more likely to have early-stage disease (36% vs. 25%) than non-DAP patients. Although DAP patients had a similar time until diagnosis as non-DAP patients, the time until treatment was 8.5 days shorter for DAP patients. DAP patients were more likely to receive diagnostic tests and specialist consultations and less likely to have duplicate chest imaging. DAP patients were more likely to receive brain imaging. Among early-stage lung cancers, brain imaging was high (74% for DAP and 67% for non-DAP), exceeding guideline recommendations. After adjustment for clinical and demographic factors, DAP patients had better overall survival than non-DAP patients (hazard ratio [HR]: 0.79 [0.76–0.82]), but this benefit was lost after adjusting for emergency presentation (HR: 0.96 [0.92–1.00]). A longer time until treatment was associated with better overall survival.CONCLUSION:DAPs provided earlier treatment and better access to care, potentially improving survival. Quality improvement opportunities include reducing unnecessary or duplicate testing and characterizing patients who are diagnosed emergently.

EXPEDITING REFERRAL TO A LUNG CANCER RAPID ASSESSMENT CLINIC THROUGH REGIONAL STANDARDIZATION OF RADIOLOGIST REPORTING

SESSION TITLE: Advances in Patient-Centered and Compassionate Care SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Lung cancer (LC) diagnostic pathways are often initiated following suspicious radiographic findings but are prone to delays in coordination of care. We previously demonstrated that a standardized Radiology report recommending referral to a rapid assessment clinic (Lung Diagnostic Assessment Program [LDAP]), led to faster specialist referral and assessment for patients with suspected LC at an academic centre. We spread this initiative to regional community hospitals and report the impact on LC diagnostic milestones. METHODS: Retrospective chart review of all LDAP-referred patients (Jan - Dec 2018), local standardization of Radiology reporting (Jan 2019), spread to 3 community hospitals (Mar 2019), prospective chart review (Jan - Sept 2019 for academic centre, Mar - Sept 2019 for community hospitals). Data include dates of: imaging suspicious for LC, CT chest, specialist referral and assessment, Radiology recommendation, including non-standardized language used for suspected LC. Continuous data are reported as means; unpaired t-tests assess for significance. Categorical data are reported as percentages; chi-squared tests assess for differences. RESULTS: We reviewed 1244 LDAP referrals (697 baseline [Jan - Dec 2018 academic centre, Jan 2018 - Feb 2019 community hospitals]; 547 post-standardization [Jan - Sep 2019 academic centre, Mar - Sept 2019 community hospitals]). Following standardization, the percentage of LDAP-referred patients that had a Radiologist recommendation for referral increased (27.4% to 45.9%, p<0.00001), significant for both the academic centre (50.2% to 61.8%, p=0.006) and community hospitals (12.1% to 35.3%, p< 0.00001). The uptake in standardized Radiology reporting varied across community hospitals (Site A, 6.5% to 42.5%, p< 0.00001; Site B, 30.5% to 22.4%, p=0.31; Site C, 2.0% to 12.9%, p=0.045), significant for Sites A and C. Of all LDAP-referred patients, 2.6% had a CT report with non-standardized language recommending specialist referral for suspected LC, most from Site B (74.2%). Following regional standardization, time to LDAP referral and specialist assessment remained faster (7.5 vs. 15.1 days, p=0.0001; 21.3 vs. 26.5 days, p=0.0004). After standardization, the overall percentage of inappropriate referrals to the LDAP decreased (18.4% to 13.9%, p=0.03), significant for the academic centre but unchanged for community hospitals. CONCLUSIONS: Regional spread of standardized Radiology reporting recommending specialist referral for patients with imaging suspicious for LC led to significant uptake in standardized reporting and a faster time to specialist referral and patient assessment. CLINICAL IMPLICATIONS: Timeliness of care and regional equity in the LC diagnostic process is improved with standardized Radiology reporting. Next steps include a Radiology directed referral process to further improve quality of care. DISCLOSURES: No relevant relationships by Gurmohan Dhillon, source=Web Response No relevant relationships by Genevieve Digby, source=Web Response No relevant relationships by Breanne Golemiec, source=Web Response No relevant relationships by Thomas Howard, source=Web Response No relevant relationships by Monica Mullin, source=Web Response

The impact of concordance with a lung cancer diagnosis pathway guideline on treatment access in patients with stage IV lung cancer.

BackgroundTimely access to treatment of lung cancer is dependent on efficient and appropriate patient assessment and early referral for diagnostic workup. This study assesses the impact of Cancer Care Ontario (CCO) Lung Cancer Diagnostic Pathway Guideline (LCDPG) concordance on access to treatment of stage IV lung cancer patients referred to the Diagnostic Assessment Program (DAP) at a Canadian tertiary cancer centre.MethodsThis retrospective cohort study includes patients diagnosed with clinical stage IV lung cancer referred to the DAP at a Canadian tertiary cancer centre between November 1, 2015 and May 31, 2017. Referral concordance was determined based on CCO LCDPG. The primary outcome; time to treatment from initial healthcare presentation; was compared between the concordant and discordant referrals.ResultsTwo hundred patients were referred for clinical stage IV lung cancer during the study period. Of these referrals, 151 (75.5%) were assessed and referred in concordance with LCDPG. Guideline concordant referrals were associated with reduced time to treatment from first healthcare presentation compared with guideline discordant referrals (55.3 vs. 108.8 days, P<0.001). Time to diagnostic procedure (32.2 vs. 86.7 days, P<0.001) and decision to treat (38.5 vs. 93.8 days, P<0.001) were also reduced with guideline concordance. The most common reason for discordant assessment and referral was delayed or inadequate investigation of symptoms in a high risk patient (32.7% of discordant referrals).ConclusionsGuideline concordant assessment and referral of stage IV lung cancer patients results in reduced time to diagnosis and treatment. Future research and education should focus on improving factors that delay DAP referral.

Development of a clinical score to distinguish malignant from benign esophageal disease in an undiagnosed patient population referred to an esophageal diagnostic assessment program

BackgroundEsophageal cancer is associated with poor prognosis. Diagnosis is often delayed, resulting in presentation with advanced disease. We developed a clinical score to predict the risk of a malignant diagnosis in symptomatic patients prior to any diagnostic tests.MethodsWe analyzed data from patients referred to a regional esophageal diagnostic assessment program between May 2013 and August 2016. Logistic regression was performed to identify predictors of malignancy based on patient characteristics and symptoms. Predicted probabilities were used to develop a score from 0 to 10 which was weighted according to beta coefficients for predictors in the model. Score accuracy was evaluated using a receiver operating characteristic (ROC) curve and internally validated using bootstrapping techniques. Patients were classified into low (0–2 points), medium (3–6 points), and high (7–10 points) risk groups based on their scores. Pathologic tissue diagnosis was used to assess the effectiveness of the developed score in predicting the risk of malignancy in each group.ResultsOf 530 patients, 363 (68%) were diagnosed with malignancy. Factors predictive of malignancy included male sex, family history of cancer and esophageal cancer, fatigue, chest/throat/back pain, melena and weight loss. These factors were allocated 1–2 points each for a total of 10 points. Low-risk patients had 70% lower chance of malignancy (RR =0.28, 95% CI: 0.21–0.38), medium-risk had 50% higher chance of malignancy (RR =1.5, 95% CI: 1.26–1.77), and high-risk patients were 8 times more likely to be diagnosed with malignancy (RR =8.2, 95% CI: 2.60–25.86). The area under the ROC curve for malignancy was 0.82 (95% CI: 0.77–0.87).ConclusionsA simple score using patient characteristics and symptoms reliably distinguished malignant from benign diagnoses in a population of patients with upper gastrointestinal symptoms. This score might be useful in expediting investigations, referrals and eventual diagnosis of malignancy.

Using Lean to Improve Wait Time Performance in Diagnostic Assessment for Lung Cancer.

Cancer Care Ontario developed a diagnostic assessment program (DAP) to improve patients' experience in the diagnostic phase of their cancer journey and improve health system efficiency and effectiveness. The Stronach Regional Cancer Centre Lung DAP (at Southlake Regional Health Centre) used learnings from a Lean improvement event to increase capacity to meet patient demand for service and to achieve/improve upon the provincial wait time target from consultation to diagnosis for lung cancer patients (65% within 28 days), improving overall patient experience of care. Monthly patient volumes have increased by 65%, and wait time has improved by 60%.

The Impact of Diagnostic Assessment Programs on the Diagnosis and Treatment of Colon and Rectal cancers in a Single Payer System

Introduction: To streamline the diagnostic and pre-treatment assessments for patients with colorectal cancer, specialised Diagnostic Assessment Programs (DAPs) were developed across the province of Ontario, Canada. We compared the performance of DAPs with usual care (non-DAPs). Methods: Patients with colorectal cancer diagnosed between 2014 and 2016 were identified from the Ontario Cancer Registry. Using administrative databases, we compared wait times, healthcare utilization, and overall survival between DAP and non-DAP patients. Results: A total 2,606/18,046 (14%) colorectal cancer patients attended a DAP for part of their diagnostic assessment. DAP patients were younger, lived closer to a DAP, had higher income, were more likely to have stage 2-3 disease (versus stage 1), had tumors in the rectum or rectosigmoid junction, and were less likely to have been an inpatient at the time of diagnosis [odds ratio 3.39 (2.68-4.29)]. DAP patients were more likely to receive diagnostic imaging before treatment, consultation with a medical oncologist or radiation oncologist, and chemotherapy or radiation compared with non-DAP patients. After adjusting for case mix, DAP patients had a time until treatment that was longer by 9.5 (7.4, 11.5) days, but better overall survival than non-DAP patients [hazard ratio 0.84 (0.75-0.94)]. A longer time from diagnosis until treatment was not associated with worse overall survival [hazard ratio 0.96 (0.93-1.00)]. Conclusion: Colorectal DAPs provide more comprehensive healthcare and are associated with better overall survival. Wait-times as efficiency metrics should be interpreted carefully, as this is affected by triaging or enhanced treatment planning that may promote improved outcomes.

S01.15 Service Requirements; Staff and Platforms Availability

Lung cancer screening encompasses a pathway that includes several integral elements. It starts with the active recruitment of individuals and their risk assessment. The pathway continues into radiology, with the actual scanning using low dose computed tomography (LDCT), as well as standardized reporting that focuses on the follow up of both lung nodules and incidental findings. At the end of the pathway is the seamless integration into a diagnostic assessment program for confirmation and timely and appropriate treatment of the detected lung cancer. High quality, and quality assurance of the radiology performance is the central piece in this pathway, to decrease the harm from radiation and false positives. Since lung cancer screening is most often a newly established program in an institution, this presents a unique opportunity to build robust quality standards for radiology. Radiology quality assurance comes with requirements regarding acquisition, interpretation and reporting of the low-dose computed tomography (LDCT) scans. The facility standards need to provide equipment that does allow low dose data acquisition. Scanning protocols need to be defined, and protocol compliance needs to be assured, radiation exposure needs to be regularly measured with phantoms, and image storage needs to be properly identified. Personnel requirements cover both the technologists and the reporting radiologists. Both have to provide the necessary training and certification. Radiologists need to document their ongoing experience in chest reporting, participate in a workshop or alternative training regarding nodule follow up, and get familiar with the respective reporting template. Radiologists training programs have received positive feedback on content, their goal is to increase confidence in reading lung cancer screening LDCTs and appropriate recommend follow up for screen-detected nodules. Complex cases are collected and their discussion fosters mutual learning. Ongoing quality assurance measures include peer review and double reads, to minimize false positive. An adjudication process can provide expert opinion and support learning where consensus cannot initially be reached. Report completeness should be confirmed with regular audits. All these requirements should be available and met by a facility planning to engage in lung cancer screening using LDCT. All above standards are available; they need to be monitored, must be met at baseline and during tailored annual assessments, ensuring compliance across screening sites. In summary, the implementation of a robust quality assurance program assures a high standard around the radiology workflow, from LDCT scanning to image interpretation and follow up recommendations. Radiologist training programs, centre minimum requirements, and standardized reporting can ensure that quality standards are consistently high