PITTSBURGH—In 2000, if you were a patient at the Pittsburgh VAMC and were found to have a lung nodule, it took an average of six weeks to be evaluated for lung cancer. With the possibility of being diagnosed with a life-threatening disease hanging over your head, those six weeks could seem like an eternity.
It was a delay that oncology leaders at Pittsburgh found unacceptable, so they started a lung-nodule program in the pulmonary division of the hospital, taking nodule evaluations outside of the traditional clinic process. They expedited it by having a nurse practitioners call patients and work with them on getting appropriate testing, rather than having the veteran go from one clinic to another to get all of the care and follow-up they needed.
For the last 10 years, the lung-module program at the Pittsburgh VAMC has been meticulously tracking patients who were found to have nodules, seeing when they were followed up, documenting who had biopsies, then cataloguing all of that data. The gap between nodule discovery and lung-cancer evaluation has dropped from six weeks to 10 days.
When VA Central Office put out a call for proposals to set up cancer centers of excellence, Pittsburgh VAMC thought this would be an excellent opportunity to take what they had learned in cancer evaluation and apply it to the entire lung-cancer treatment process.
Organizing Cancer Care
“VA Central Office had this desire to improve the quality of cancer care throughout VA. They wanted to standardize care so that all of us were speaking the same language,” explained Gurkamel Chatta, MD, Pittsburgh VA’s chief of oncology. “Then we could measure our progress against each other. What do we mean by timeliness of care? What techniques do we use for surgery? What kind of radiation do we use?”
Pittsburgh was one of 10 sites selected by VA to focus on lung cancer care. The VAMC’s proposal involved the creation of a Lung Cancer Collaborative, a multidisciplinary team designed to improve timeliness and reliability of lung-cancer care from the moment a patient begins the screening process.
“When you look at lung-cancer care, there are always many disciplines involved,” Chatta said. “You need a medical oncologist, a radiation oncologist and a surgical oncologist, as well as good people working in pathology and radiology. They’re already working together, but, before the collaborative, they were not necessarily organized.”
Lack of organization led to delays in treatment. Pittsburgh VAMC’s answer was to use its Office of Systems Redesign to take a look at the process with an objective eye to help align the work of these professionals.
“We really looked at it from a consultant’s perspective,” said Robert Monte, director of the Office of Systems Redesign. “My role was to bring all of these professionals together from all of these disciplines, help them understand what the current state of their process looked like, using flow-mapping and process-mapping, and make unbiased evaluations of how things were working.”
The next step was to come to an agreement and decide on a series of changes—small course corrections in the process—to shorten the time between screening and treatment, and to improve reliability. “They already had a pretty well-defined, lean process from detection to diagnosis. That usually occurred in a pretty expedited fashion,” Monte said. “Where the process started to get lengthy was from diagnosis to treatment.”
According to Monte, Chatta devised the concept of using what was already being done with the diagnosis of lung nodules—i.e., using close coordination and communication between physicians combined with keeping meticulous track of patients’ progress—and expand it to the rest of the treatment process, including other professionals such as pathologists and surgeons.
Every two weeks, all of the players have a conference. They go through patients in the pipeline—usually 10 to 20 patients every two weeks—and develop a plan for their treatment. If a patient needs surgery, the surgeons plan their care; if they need surgery and radiation, the radiologists and surgeons work together to plan a course of treatment.
The result is an overall decrease in the time between diagnosis and treatment. Prior to the redesign, the time between lung-cancer detection and lung resection averaged 160 days.
Decrease Delay for Peace of Mind
Now, that delay is hovering around 30 days—an average the facility has sustained for several years.
In terms of chemotherapy, the average delay before initiation dropped from 21 days to 14 days. The delay between detection and diagnosis, which ranged from 14 to 45 days prior to the redesign, now is in the range of 14 to 20 days.
So far, however, there has been no perceptible impact on patient survival in terms of patient outcomes, Chatta said.
“I’m not sure anyone has the answer to that now. However, there’s patient perception and family perception. It’s basically just good care to do these things as expeditiously as possible,” he said.
Charlie Atwood, MD, the pulmonologist who originally helped cut down the delay from detection to diagnosis, added, “If you look at this strictly from a survival standpoint, it’s not likely that it makes a difference. But if you look at it in terms of patient satisfaction and dealing with what is always a very emotionally charged diagnosis, then getting things done as quickly as possible has the potential to allay anxiety and make an already bad experience less bad for patients.”
Accounting for nearly a third of all cancer diagnoses, prostate cancer is the most frequently diagnosed cancer in the VHA, where past research has suggested that the malignancy is caught earlier than in other healthcare systems.
In the past five years, 10 new system therapies have been approved for renal cell carcinoma (RCC), the most common type of kidney cancer.