Alberta Breast Cancer Diagnostic Assessment Pathway

THEMES:

• Timely Diagnosis Expedited Referrals to Surgery

• Patient Reported Experiences (PREs)

• Improved Health Outcomes

• Improved Patient Care

• Coordinated Care • Better Access to Information

• Nurse Navigation

SUMMARY

The Breast Health Initiative was initiated in 2016 to improve patient experiences, address care gaps, reduce variation and improve health system efficiencies. One of the key deliverables was to reduce the average wait-time from diagnostic imaging to referral for highly suspicious breast lesions. The Cancer Strategic Clinical Network (CSCN) and Cancer Care Alberta partnered with patients, clinicians, operators and community providers to establish and implement a standardized Diagnostic Assessment Pathway and a robust measurement framework to ensure ongoing quality improvement and sustainment (Law et al, 2019).

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APPROACH

Using data and best practices, a breast cancer Diagnostic Assessment Pathway was designed and implemented in Edmonton and Calgary with input from patients, primary care, community breast imaging providers, and breast surgical programs. It resulted in expedited diagnostic work-up and surgical consults for patients with highly suspicious breast lesions on imaging. It initiated changes that prompt immediate referral to a breast surgical program or community surgeon; notification back to primary care; and an online dashboard report to provide feedback on timelines for breast cancer diagnostic work-up to the primary care provider, radiologist, surgeons and clinical programs.

CHALLENGES

An important problem for Alberta women was related to the quality of care across the pathway: from detection of a suspicious breast lesion to referral to a diagnostic imaging facility for evaluation, definitive diagnosis and consultation with the appropriate provider for a treatment plan.

This process required multiple visits with the family physician, including arrangements for imaging, biopsy, and appointments to discuss results, and subsequent referral to a surgeon and/or oncologist for definitive management. Each step in diagnostic assessment required formal requisitions and was associated with various lengths of waiting time. Potential delays, patient anxiety, confusion, and inappropriate care, over multiple provider transitions had been challenging for women.

"Breast cancer is so smooth, like you get on the train and they tell you when to get off. There’s a very prescribed procedure and its similar for all women... you have a lump, a, b, c, d is going to happen."

- Female, 59, breast cancer and melanoma survivor

SOLUTIONS

The pathway reduced the number of visits and diagnostic wait times, including the interval from BI-RADS 5 imaging to surgical consultation.
In order to mitigate delays and ensure that all patients completed follow-up, standardized and dual notification of primary care providers and breast surgical programs were identified as solutions. This improved communication.
Nurse navigators arranged surgical consults five days after biopsy, confirmed the surgical consult date with primary care providers, provided patient pre-consultation education, monitored key diagnostic intervals and maintained patient registries.
There was ongoing measurement of diagnostic work-up wait times and patient experience.

ACCOMPLISHMENTS

The Breast Cancer Diagnostic Assessment Pathway, introduced by CSCN in 2017, successfully reduced the median wait time for breast program referrals by over 50%, dropping from 15 days to just 6 and improved patient satisfaction (Bond et al, 2019).

Specifically, it reduced average wait times for:

Suspicious imaging to biopsy from 8.5 days (N = 185) to 7.5 days (N = 285)
Suspicious imaging to referral from 18.6 days (N = 181) to 6.2 days (N = 239)
Biopsy to consult from 19.5 days (N = 185) to 15.5 days (N = 241)

Over 60% of patients were satisfied with diagnosis wait times (N = 294). It improved relationships between providers and improved resource planning for breast health programs. Finally, it created an early navigation touchpoint that is being leveraged for future work.

LESSONS LEARNED

During Provincial Breast Health Initiative 2018-2019 Phase I

An end-to-end pathway is a foundational component for planning and implementing improvements for specific parts of the patient trajectory.
Engaging local primary care leaders early, at the problem identification stage, enabled engagement, prioritization, and presentation of solutions by primary care to primary care.
Local clinical teams can design a provincial care pathway using common principles of care and defined provincial measures and targets.KEY THEMES Bringing together multiple partners (e.g., primary care and radiology) resulted in ongoing relationships that spanned beyond the project to future work.
Resourcing prospective data collection with clerical resources was essential when there was a lack of electronic data sources.
Patient experience measurement needed to be incorporated into continuous improvement by local clinical teams to address unmet patient needs.
Spread and scale across the province need to address local gaps in access to biopsy for appropriate diagnostic investigations.
The sustainability of process changes by operational partners can be supported by ongoing measurement and reporting.

Sources:

1 Alberta’s end-to-end breast health clinical pathway https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-cancer-breast-health-infographic.pdf

2 Laws, A., Crocker, A., Dort, J. et al. Improving Wait Times and Patient Experience Through Implementation of a Provincial Expedited Diagnostic Pathway for BI-RADS 5 Breast Lesions. Ann Surg Oncol 26, 3361–3367 (2019). https://doi.org/10.1245/s10434-019-07558-7

3 Cancer Strategic Clinical Network Provincial Breast Health Initiative 2018-2019

(Phase I). Cancer SCN Breast Health 2018-19 Summary Report

(albertahealthservices.ca)

4 Cancer Strategic Clinical Network Provincial Breast Health Initiative 2019-2020

(Phase II). https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-cancer-breast-health-2019-20.pdf

5 Bond TR, Estey A, Elwi A; Cancer Strategic Clinical Network. Cancer Strategic Clinical Network: Improving cancer care in Alberta. CMAJ. 2019 Dec 4;191(Suppl):S13-S14. doi: 10.1503/cmaj.190576.

6 "Cancer: Strategic Clinical NetworkTM." Alberta Health Services.

www.ahs.ca/cancerscn. Alberta breast cancer patients experiencing improved care https://www.albertahealthservices.ca/news/Page14760.aspx