Timely access and quality of care in colorectal cancer: Are they related?

Division of General Surgery, QEII Health Sciences Centre, Dalhousie University, 1278 Tower Rd., Halifax, Nova Scotia, Canada.
International Journal for Quality in Health Care (Impact Factor: 1.76). 03/2010; 22(3):219-28. DOI: 10.1093/intqhc/mzq010
Source: PubMed


Colorectal cancer patients want both timely access and high-quality care. The objective of this study was to explore relationships between quality indicators and access time intervals specific to colorectal cancer patients.
Prospective consecutive cohort study.
Single health district.
Between February 2002 and February 2004, all patients undergoing non-emergent surgery for primary colorectal cancer were enrolled.
A standardized method was used to collect clinicodemographic, diagnostic and treatment event data.
Associations between accepted colorectal cancer-specific quality indicators and benchmarked access time intervals for diagnosis, surgery and adjuvant therapy were examined using multivariate logistic regression, controlling for clinicodemographic factors.
Among the 392 patients in the study cohort, 9.9% were diagnosed on screening examination, 53.1% underwent preoperative staging imaging and 74.5% underwent full preoperative colonic examination. On multivariate logistic regression, patients presenting via screening were more likely to move from presentation to diagnosis within the 4-week benchmark for this access time interval, compared with symptomatic patients (RR 8.1, P < 0.001). The absence of preoperative staging imaging was associated with achievement of the 4-week benchmark for the access time interval from diagnosis to surgery (RR 2.5, P < 0.001). Similarly, an absence of complete preoperative colonic examination was associated with achievement of the 8-week benchmark for the access time interval from surgery to adjuvant therapy (RR 6.6, P = 0.008).
Although several associations between quality indicators and benchmarked access time intervals for colorectal cancer patients were identified, the relationship between quality and access is complex and far from universal. It is therefore clear that quality care and timely access are not synonymous, and that both must be studied to improve colorectal cancer care.

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Available from: Yarrow Mcconnell, Dec 11, 2015
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    • "Only about one-third of patients in the current study were diagnosed within 4 weeks of presentation. As discussed by McConnell et al. [14], the processes involved in diagnosis are complex, involving expertise from a variety of individuals (primary care, diagnostic imaging, surgery, pathology), often translating into increased time. In a small jurisdiction such as NS, capacity issues may cause increased wait times for appointments, and delays in the processing and reporting of laboratory and radiology results. "
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    ABSTRACT: While efforts to improve cancer outcomes have typically focused on improving quality of care, recently, a growing emphasis has been placed on timely access to quality cancer care. This retrospective cohort study examines, at a population level, the relationship between quality and timeliness of colorectal cancer (CRC) care in a single Canadian province (Nova Scotia). Through the provincial cancer registry, we identified all residents diagnosed with invasive CRC between 2001 and 2005 that underwent a non-emergent resection. Using anonymized administrative databases that are individually linked at the patient level, we obtained clinicodemographic, diagnostic, and treatment event data. Selected charts were reviewed to ensure completeness of chemotherapy data.Performance on six quality indicators and the percentage of patients achieving wait time benchmarks for diagnosis, surgery, and adjuvant therapy were calculated. The relationship between quality indicators and wait time intervals was examined using logistic regression. Where an association was identified, patients who received 'higher quality care' had longer wait times. Individuals who received a complete preoperative colonoscopy were less likely to meet benchmarks for time from presentation to diagnosis and from diagnosis to surgery. Those who received an appropriate radiation oncology consultation were less likely to meet benchmarks for time from diagnosis to surgery and from surgery to adjuvant therapy. As governments and other organizations move forward with strategies to reduce wait times, they must also focus on how to define and monitor quality care, and consider the relationship between these two dimensions of health care. Similarly, when developing quality improvement initiatives, the impact on resource utilization and potential to create longer waits for care must be considered.
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    • "The rates of assessment by medical and radiation oncology within 8 weeks for patients with rectal cancer are quite low. Others have reported higher rates [10,40]. When extending the timeframe to 16 weeks, the rate of consultation with medical and radiation oncology nearly doubled. "
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    ABSTRACT: Background The Canadian province of Manitoba covers a large geographical area but only has one major urban center, Winnipeg. We sought to determine if regional differences existed in the quality of colorectal cancer care in a publicly funded health care system. Methods This was a population-based historical cohort analysis of the treatment and outcomes of Manitobans diagnosed with colorectal cancer between 2004 and 2006. Administrative databases were utilized to assess quality of care using published quality indicators. Results A total of 2,086 patients were diagnosed with stage I to IV colorectal cancer and 42.2% lived outside of Winnipeg. Patients from North Manitoba had a lower odds of undergoing major surgery after controlling for other confounders (odds ratio (OR): 0.48, 95% confidence interval (CI): 0.26 to 0.90). No geographic differences existed in the quality measures of 30-day operative mortality, consultations with oncologists, surveillance colonoscopy, and 5-year survival. However, there was a trend towards lower survival in North Manitoba. Conclusion We found minimal differences by geography. However, overall compliance with quality measures is low and there are concerning trends in North Manitoba. This study is one of the few to evaluate population-based benchmarks for colorectal cancer therapy in Canada.
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    • "Clinically significant DD was defined as delay >2 months. The literature [31] [32] suggests that 2 months is an appropriate DD threshold for a patient presenting with vague or ambiguous symptoms to be followed-up with testing (e.g., blood work) and have had a colonoscopy scheduled or performed. "
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    ABSTRACT: To examine the influence of patient and physician communication factors on diagnostic delay (DD). 242 patients diagnosed with colorectal cancer (CRC) in the past 6 months who experienced symptoms prior to diagnosis were administered a 2-h semi-structured qualitative interview to assess communication with health care provider and ease of access to care, among other factors. Patient-provided information was verified via review of medical records. The factors associated with DD>2 months included lower income (OR=0.56, p=0.03), having regular physician prior to receiving a cancer diagnosis (OR=2.52, p=0.03), having a physician who used temporizing communication strategies during the consultation (OR=2.41, p=0.02), receiving an initial alternate diagnosis (OR=3.36, p=0.02), experiencing referral delay (OR=3.61, p=<0.001), and experiencing follow-up delay of any kind (OR=3.32, p=0.01). Excellent communication skills that appropriately probe for relevant social and economic patient information, assist patients in distinguishing and elaborating on symptoms, and provide clear rationale and instructions for future steps, will speed along the diagnosis process and could be the difference between early and late stage CRC. Increased understanding of physician communication and practice styles that contribute to DD could have a positive impact on decreasing the morbidity and mortality from this disease.
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