Propelled by a patient-centric philosophy, clinicians at Cleveland Clinic Cancer Center launched a multidisciplinary effort in 2014 aimed at reducing the amount of time it takes for a patient with cancer to receive their first disease-driven therapy after being diagnosed, commonly referred to as time-to-treatment initiation (TTI).
A total of 13 teams comprised of surgeons, nurses, radiologists, program managers, patient navigators, and other clinicians and administrative staff who are organized by cancer type were created for the program. Over the next 4 years, the multidisciplinary teams would implement a data-driven approach that reduced TTI for all cancers by 33 percent to 25 days for internally diagnosed patients and 31 days for externally diagnosed patients.
In a recent article, titled "Reducing Time-to-Treatment For Newly-Diagnosed Cancer Patients: The Cleveland Clinic Experience," published online at NEJM Catalyst, Brian Bolwell, MD, Chairman of Cleveland Clinic Taussig Cancer Institute, along with Alok Khorana, MD, Gastrointestinal Oncologist at Cleveland Clinic and first author of the research, and colleagues detailed their strategy.
Bolwell has shared a first-hand account with Oncology Times of how the initiative was developed and implemented.
What was the inspiration for the time-to-treatment initiative?
"We're a very patient-centric cancer center, so we certainly appreciate that cancer patients, especially those who are newly diagnosed, are scared and full of anxiety. Getting a patient treated as quickly as possible is a good thing to do from many perspectives.
"About 6 years ago, we had access to a national database that looks at a lot of metrics, including time to treat. I hadn't really seen that before in published form. It was troubling how time to treat for the largest academic medical centers was 45 days. Then, as we dove deeper into that data, we noticed that it seemed to be getting more prolonged. It was shorter in the 1990s, got a little worse in the 2000s, and then just seemed to be getting worse every year.
"We then looked at our own data and had to figure out a meaningful way to measure it. Of course, we naively thought our time to treat would be dramatically better than the national data-but it wasn't. It was 39 days, which was a few days better than the national time to treat, but it certainly wasn't where we wanted it to be.
"We decided that, if we wanted to be true to our mission to be as patient-centric as possible, then this was an opportunity to prove it and drive change."
Did you have any inkling about what was causing the time-to-treatment delays to get worse over the past few decades?
"Actually, we didn't have a good handle on that at all-until we started to look.
"The first thing we did was organize each disease group into a multidisciplinary team. In the breast cancer program, for example, that meant getting surgeons, medical oncologists, radiation therapists, nurses, social workers, and others together and really act as one unit or one entity.
"The cancer center needed to help do that. We set goals that were shared across all of the disease-based programs, such as reducing time to treat and also forming our own treatment algorithms and improving our tumor board participation, among others. And then we added resources; each program has a program manager as well as a patient navigator. During this time, we designed and opened a new cancer building, which is organized by cancer type. This allows patients to have all of their appointments in one area. The design improved our multidisciplinary approach and supported our time-to-treat goals.
"Then, we needed to analyze what was causing our time-to-treat challenges. The first thing we noticed was that each program was different because a patient's access into the program was different. For breast cancer, for example, much of the access occurs in imaging because people have abnormal mammograms and then get a biopsy and then are diagnosed. But with colorectal cancer, the access might be in endoscopy suites. And then with lung cancer, frequently patients are accessed in the pulmonary department when they get a bronchoscopy following an abnormal chest X-ray. There were many different entry points into the system that we had to get our arms around.
"Frequently, people need to get staging X-rays and staging studies ahead of surgery, and that can be a time-to-treat challenge. Sometimes, if a patient needs to get an operation, they need to have cardiac clearance first, and we needed to see if that was causing the delays. And sometimes insurance pre-authorizations were causing delays.
"Importantly, we had an executive meeting every other week where we shared best practices. We tried to figure out what we could learn from each other to make time-to-treat better. We made tracking data continuously a priority. Physicians tend to respond to data, so the more we could generate about what our overall results were by program the better."
Were there any surprises along the way?
"A lot of things surprised us. Number one, this is really hard work. But if you can get people to work together collaboratively and buy into what the goal is, then you can drive change.
"In the breast cancer program, for example, we have a huddle that occurs several times a week, in which every single patient awaiting surgery is discussed and tracked. We know how long they have been waiting, and we also know which surgeons are available. Importantly, we try to assign them the appropriate surgeon not by when a surgeon has time in clinic, but rather when they have operating room time available.
"One of the key things we have done is drive down the outliers, which we defined as a patient waiting 45 days or longer to get their first disease-directed therapy. This was something that really bothered me, because sometimes these patients in particular might feel lost and overwhelmed by the medical system-which is pretty complicated. I think it is important for providers to try to walk in the shoes of the patient and the patient's family. We've really tried to reduce that number dramatically. And we have, reducing the number of outliers in every cancer program."
What were some causes of time-to-treatment delays for patients who were internal outliers?
"Some of the cause was communication, which is why having a patient navigator who tracks every newly diagnosed cancer patient from the first phone call is valuable. Sometimes, because of gaps in communication, even the patient or the care team wasn't aware of the diagnosis for a period of time. Sometimes the cause was coordinating services.
"Using breast cancer again as an example, occasionally reducing the delay is just a matter of coordinating general surgery and plastic surgery so they are able to operate at the same time. Cardiac clearance issues for lung cancer can be important. The patient usually requires thoracic surgery, which is significant, and sometimes there were barriers to getting cardiac clearance as rapidly as needed. We pretty easily addressed it by making surgery scheduling adjustments to get patients in sooner.
"The main thing is to do the work and track everything that happens patient by patient-and to stay committed. I think that if you do that and if you are honest about the challenges and willing to tackle them, then you can drive change. Another thing that was important was to educate the entire organizational leadership about what we're doing and why it's important, which was actually one of my roles. We got buy-in, not just from the other clinical institutes, but also from the CEO, because providers from across the organization had to participate in helping drive down time to treat."
You mention commercializing software developed for the time-to-treat initiative in your article. Can you explain that?
"The software was primarily a tool developed for the patient navigators to make it easier to track patients. It helped caregivers answer questions about what needed to happen next for a newly diagnosed patient, including whether they have had the appropriate X-rays, have seen someone in a consultation, and are on the operating room schedule. We incorporated all of these steps for each cancer program and diagnosis into the software program, automating the process. It has been successful. We are in discussions with outside groups about commercializing this tool."
What is the first step you would recommend others take if they are interested in reducing time to treat at their facility?
"I think the first step is to commit to it-you have to make reducing time to treat part of your culture. You have to get everybody's buy-in and then form multidisciplinary teams of people willing to work collaboratively. When you also have commitment to a patient-centric mission, you can make change happen. We proved it's possible.
"We've discovered that directing change, stemming from collaboration and a team-based environment, has elevated our culture. I think everybody is pretty proud of what we have been able to accomplish."
Chuck Holt is a contributing writer.
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