Wait Times for Diagnostic Assessment Program

Key findings

Approximately half of Ontario patients receiving a diagnosis of lung cancer in 2016 were diagnosed following assessment at one of Ontario’s 19 lung/thoracic Diagnostic Assessment Programs (DAPs). Sixty-one percent (61%) of individuals suspected of having lung/thoracic cancer who had been assessed through one of Ontario’s lung/thoracic DAPs were diagnosed within the 28-day target time following a referral from their primary care provider or other healthcare professional. From 2012 to 2016, the percentage of patients diagnosed within the 28-day target time has been increasing and is approaching Cancer Care Ontario’s target of 65%.

While this is a report only on lung/thoracic patients seen in a DAP, Cancer Care Ontario continues to work with the DAPs to improve wait times for diagnosis while developing approaches to understand the experience of patients who are not served by a DAP.

Measure	Desired Direction	As of this Report
Percentage of lung/thoracic patients who entered a DAP diagnosed within target (28 days) from referral to diagnosis
See Methodology and Approach to find out how the ratings are calculated.

What are DAPs?

• To help improve the experience in the diagnostic phase of the cancer journey for both patients and healthcare providers—and to improve the efficiency and effectiveness of the overall healthcare system—Cancer Care Ontario has developed and supported the implementation of DAPs across the province for individuals suspected of having colorectal, lung/thoracic or prostate cancer. More programs for streamlined diagnostic assessment also have been introduced for other cancer types, based on regional needs.
• There are currently 44 DAPs in Ontario, including 19 lung DAPs that specialize in the diagnosis and staging of lung/thoracic cancer in each Regional Cancer Program, 15 DAPs for colorectal cancer, 8 DAPs for prostate cancer and 2 DAPs for rectal cancer (Figure 1).
• The percentage of patients diagnosed with cancer who received their diagnosis through a DAP varies by region and type of cancer; however is not reported through CSQI. In 2015, 44% of lung cancer patients, 15% of colorectal cancer patients and 13% of prostate cancer patients in Ontario received their diagnosis through a DAP.
• DAPs may be physical or virtual programs, and they are characterized by facilitated access to coordinated diagnostic services, multidisciplinary consultation, patient information resources, symptom management and psychosocial supports¹.
• Patient navigators play a key role in DAPs, working as patient liaisons to help navigate appointments and providing psychosocial support and symptom management. Patient navigators are specially trained in healthcare navigation including navigating through the cancer care continuum, and they work with all members of the healthcare team to identify and implement quality improvement initiatives that enhance the care and services provided to patients².

Diagnosing lung cancer

• In Canada, lung cancer is the most commonly diagnosed cancer, and it is the leading cause of death from cancer for both men and women.
• Diagnosing lung cancer is a complex process that can be long and frustrating for people experiencing the relevant signs and symptoms. It requires several diagnostic tests and procedures to help the physician to rule out other health problems and make a cancer diagnosis.
• Overall, the existing literature does not suggest a clear link between diagnostic wait time and patient survival outcomes^3,4.

What do the results show?

The percentage of patients seen in a lung DAP suspected of having lung/thoracic cancer diagnosed within 28 days of referral continues to improve. (Figure 2)

• Overall, the percentage of patients suspected of having lung/thoracic cancer who are diagnosed within 28 days of referral has increased from 49% in 2012 to 61% in 2016, while the number of patients who were assessed in a DAP has risen from 5,751 in 2012 to 8,966 in 2016.
• There is regional variation in the percentage of patients suspected of having lung/thoracic cancer who are being diagnosed within a 28-day period from referral.
• Three regions surpassed the target of 65% in 2016: Toronto Central North (71%), Champlain (86%) and North East (68%).
• Improvement in the percentage of patients diagnosed within a 28-day period from referral from 2015 to 2016 was observed in Erie St. Clair, Central, South East, Champlain, North East and North West.
• Regional variability can be explained in part by differences in entry criteria when regional DAPs assess the eligibility of patients for enrolment in their program. For example, some regions enroll patients if they have an abnormal chest x-ray, while others may require a chest CT scan with the referral, which is likely to shorten the DAP wait times.
• Challenges meeting wait time targets in lung/thoracic DAPs still persist, and in some cases are worsening for a number of reasons. These include timely access to CT-guided biopsy, increased patient volumes in excess of capacity, and accommodation of patient scheduling preferences. Cancer Care Ontario is continuing to perform analyses to better understand the extent of the issue and the contributing factors.
• As the awareness of DAPs continues to increase among primary care providers, further increases in patient volumes can be expected.
• To address these challenges and improve wait times, Cancer Care Ontario is facilitating the sharing of best practices and successful strategies from regions meeting target and those making steady improvements. Individual regions are continuously developing and executing action plans to improve wait times.
• To promote equal access to lung DAP across the province, Cancer Care Ontario has developed new recommended entry and transfer of care criteria for lung/thoracic DAPs.

Why is this important to Ontarians?

• Organized diagnostic assessment occurring within DAPs streamlines appropriate testing and ensures that patients are informed of the steps in the diagnostic process.
• The delay between patient referral and diagnosis can lead to increased stress and anxiety for patients and caregivers. Psychological distress intensifies as the waiting time for diagnosis gets longer⁵.
• Emotional support is crucial to the overall patient experience and the quality of life for those undergoing testing for cancer. The uncertainty and fear associated with cancer suspicion often results in patient distress and anxiety, but navigational support can help patients cope with the emotional issues associated with testing for cancer².
• By monitoring wait times data, the province can more effectively and accurately distribute existing resources and plan for future services.

Find out more?

• Learn more about Cancer Care Ontario’s DAPs.
• Cancer Care Ontario’s Disease Pathway Management (DPM) has published several maps that outline the screening, diagnosis and treatment pathways for specific diseases (including lung cancer). Individuals with signs and/or symptoms of lung cancer are typically referred directly to a lung DAP by a family physician or other healthcare provider. Find out more about Cancer Care Ontario’s DPM program.

View Notes

1. Brouwers M, Oliver TK, Crawford J, Ellison P, Evans WK, Gagliardi A, et al. Cancer diagnostic assessment programs: standard for the organization of care in Ontario. Curr Oncol. 2009; 16(6):29–41.
2. Cancer Care Ontario. Current state of diagnostic assessment programs: ESRS phase II report. Toronto: Cancer Care Ontario; 2013.
3. Tørring ML, Frydenberg M, Hamilton W, et al. Diagnostic interval and mortality in colorectal cancer: U-shaped association demonstrated for three different datasets. J Clin Epidemiol. 2012; 65(6):669–678.
4. National Cancer Intelligence Network. Routes to diagnosis: technical supplement. London (UK): National Cancer Research Institute; 2010.
5. Risberg T, Sorbye SW, Norum J, Wist EA. Diagnostic delay causes more psychological distress in female than in male cancer patients. Anticancer Res. 1996; 16(2):995–99.