Instituting Time to Treatment Initiation as a Quality Measure in Cancer Care

Vikas Mehta, MD, MPH, Albert Einstein College of Medicine, proposes instituting time to treatment initiation as an oncology, site-specific quality measure, looking at time from diagnosis to first treatment, and establishing metrics around that time point as a means to improve oncologic outcomes, especially for disparate populations.

Transcript

Hi, my name is Vikas Mehta. I'm the vice chair and associate professor of otolaryngology, head and neck surgery here at Montefiore Medical Center and Albert Einstein College of Medicine, which is located in the Bronx in New York. I'm here to talk to you today about an opinion paper that we wrote about time for timeliness, which is essentially around proposing the institution of a quality measure for oncology, looking at time from diagnosis to first treatment, and establishing metrics around that time point. So how we came about this essentially was, we had done some work in the past and being a head and neck surgical oncologist, we had done some work looking at time from diagnosis to first treatment and its impact on our patients here in the Bronx. We serve a population that is very racially and socioeconomically disadvantaged historically.

And the Bronx is one of the poorest counties in the entire United States. And so with that, we did some work looking at our patients and the timelines of care around when they first were diagnosed with cancer to when they started. And what we found was that in our retrospective series of a thousand patients, patients whose care was delayed beyond a month and a half or two months, those patients had a significant reduction in survival and a significant risk of recurrence of their disease. So just having their care delayed beyond that time, doubled their chance of dying from their cancer and doubled their chance of recurrence. And that was independent of all other variables. And so what that showed us was that this is really an opportunity for us to improve the care for our patients, just by improving the timing of when we diagnose, when we deliver. Within that study, we also looked into why those patients were delayed.

And for the most part, it was because they missed appointments or couldn't get the right transportation. And again, a lot of the factors that were associated with increased risk of delay are your classic. Things that you see in a lot of studies looking at disparities in health care. So patients who were African American or had Medicaid insurance also had a much higher risk of having delayed care and thus suffering these poor outcomes. And so based on this study, we expanded and looked at the literature across the United States, and there's been multiple studies showing similar things where mostly in the slightly more aggressive malignancies like lung, pancreas, things like colorectal, breast and upper GI malignancies, in addition to head and neck, the national data all supports that delays in these populations, delays in these cancer types, results in significantly decreased survival. And there's a dose dependent curve that you see where the longer the delay is, the worse that the survival is.

And again, those are outcomes that are independent and this has been replicated. And like I said, in national cancer database data, as well as systematic reviews and meta-analysis with millions of patients. And so with that, we decided that we were tired of publishing about it and looking into it and wanted to try to do something about it. So one of the things that we've done here at Montefiore is we've created a dashboard that tracks this measure in real time. And we're publishing data again on risk factors for delay in these particular cancer types, across thousands of patients that we've treated here. In addition to that, we've instituted more oncology navigation, as well as this electronic tracking system. And we've improved on our timelines and showed that having that navigator there can help impact and improve the patient's timelines, thus independently improving their outcomes, hopefully down the road.

And so by proposing this as a measure, we hope that if this gets instituted, it is something that gets standardized across other oncology sites. And these measures in the past with other things like cardiac surgery, for example, where they've looked at 30 day mortality and said only this percent of patients should have mortality after a cabbage that showed significant improvement in that metric over time, even though people weren't happy about being measured on this. It does show us that establishing these metrics can happen. And so our hope is that if we do the due diligence and establish smart metrics centered around tumors, where these timelines matter, that cancer centers and academic centers and hospitals, and all these areas will respond and improve their timelines as well, and meet that and help improve outcomes. And especially for the disparate populations who are more often subject to these delays. Thank you.