Re-audit of Radiotherapy Waiting Times 2005

Transcription

1 Abstract Re-audit of Radiotherapy Waiting Times 2005 E. Summers, M Williams Royal College of Radiologists, 38 Portland Place, London W1B 4JQ, UK Aim: To determine current waiting times for radiotherapy in the UK. Method: Web-based audit of all patients commencing a radiotherapy treatment course in the week beginning Monday 26 th September Results: The data were compared with previous audits in 1997 and Waiting Times for radiotherapy remain unacceptable with 53% of radical patients and 57% of adjuvant patients waiting longer than 4 weeks from decision to treat. 33% of patients waited longer than two weeks for their palliative radiotherapy. Nevertheless, these results do show improvement when compared with 2003, but are still worse than the initial data obtained in % of patients fell into the first definitive treatment category; of these, were treated within the DH 31 day wait guideline, and 74% were treated within the 62 day guideline. However, data were incomplete, particularly for the 62 day target, and these results do not give an accurate picture of compliance. Conclusion: Radiotherapy waits remain unacceptable even though an improvement has been shown. The data on the DH 31/62 day waits were incomplete as they were collected at a time at which the system was being implemented. The targets for first definitive treatment only apply to 15 % of radiotherapy patients. The Royal College of Radiologists stands by the importance of the JCCO targets for all radiotherapy patients. Introduction: Standards for waiting times for cancer treatment were set by the JCCO in 1993 (1). 1. For urgent radiotherapy or chemotherapy Good practice 24 hours Maximum acceptable 48 hours 2. For palliative radiotherapy (according to severity of symptoms) Good practice 48 hours Maximum acceptable 2 weeks (for non-severe symptoms) 3. For radical radiotherapy involving complex treatment planning Good practice 2 weeks

2 Maximum acceptable 4 weeks* *Where additional specialist staging procedures are necessary These standards are important to patients, as there is good evidence that delay can allow cancers to progress (2) and become unsuitable for radical treatments (3). This results in decreased cure rates and worse outcomes for patients (4,5,6,7,8). This audit was initially undertaken in 1997 and showed that overall 28% of patients were waiting longer than the maximum one-month target for radical treatment advised by the JCCO (9). The audit was repeated in 2003 and showed that waiting times had lengthened in most centres with exceeding the target (10). The audit was repeated in 2005 to obtain current data on waiting times, the percentage of patients who are receiving their first definitive treatment (FDT) and their performance in terms of the Department of Health s (DH) 31 and 62 day target waits (11, 12). Method: For the first time the College used web-based technology to collect the data for this audit enabling Centres to input their data directly. Audit Leads were given the opportunity to view the web data collection tool and to make comments prior to its launch. All feedback was taken into consideration before finalising the data collection tool (see Appendix 1). All radiotherapy centres in the UK were invited to participate in this national audit. The survey covered all patients within 1 week who commenced treatment between Monday 26 th September and Sunday 2 nd October 2005 inclusive. The data collection tool was split into five sections: o Diagnosis o Site to be treated o Prescription details o Dates: Three dates were collected: The date of booking request was defined as the date when a clinical oncologist and a patient have agreed to a plan of treatment, including a course of radiotherapy, and the clinical oncologist completes a booking request or an electronic request is logged. The date the patient is able to start treatment was defined as If the patient is not ready to start immediately then the clinical oncologist should define a separate ready to start date and the general reason for this delay, which include 1) patient choice, 2) completing planned treatment and 3) medically not yet fit.

3 The date radiotherapy commenced is the date of the first fraction of treatment. For those patients whose treatment is the first definitive treatment (FDT), two further time points were required to be able to measure against the DH 31 and 62 day targets: o Date of urgent referral by GP: this is the date the GP signs the referral request and Trusts must respond within 24 hours. o The decision to treat date: this is the date of the consultation in which the patient and clinician agree the treatment plan for first treatment. Data on elective delays were also collected and asked for the reason why there was a delay if appropriate. o Treatment intent (Radical, palliative, adjuvant): for this section centres were advised to use their local definitions. o Treatment priority (emergency, urgent, routine): for this section centres were advised to use their local definitions. A comparison of all submitted data was then made with data collected in 1998 and Every attempt was made to ensure that the collection and analysis of the data were carried out consistently across all three data sets. Results: 55/57 (96%) centres responded to the College s request to provide data for this analysis. Data on 2,688 cases from 55 centres were entered into the data collection software. This is comparable to 2,631 in February 1998 from 98% of centres and 2,498 cases from 10 of Centres in 2003 in September; all audits looked at a one-week period. Table 1 shows an analysis by waiting-list status and treatment intent for all cases within this survey. For the rest of the report, patients who experienced an elective delay (because of patient choice, completing planned treatment or medically not fit) (n= 712) are excluded from the analysis. Table 1: Emergency Urgent Routine Don t Total know/not documented Radical skin Radical non-skin Palliative Adjuvant pre-op

4 Adjuvant post-op No treatment indicated Totals Total cases audited, 2688 Table 2 and Figures 1-3 show that there has been slight improvement in meeting JCCO targets in the 2005 audit, but that the majority of radical and adjuvant post-op patients still wait longer than the maximum acceptable delay of 4 weeks from the decision to treat. Table 2: Patient group % Within good practice % Maximum acceptable delay % Outside of standard Radical Palliative Adjuvant post-op For those cases whose treatment is FDT the following DH targets apply: o 10 of patients should have commenced definitive treatment within 31 days of the decision to treat. o 10 of patient referred urgently by their GP should have commenced definitive treatment within 62 days of their referral. This target only applies to the 15% of radiotherapy patients for whom it is their first definitive treatment. Figure 4 shows that the figure ranges from 4% of breast cancer patients to 15% of palliative patients. These data contain a significant proportion of Don t know, but nevertheless, it is clear that these targets apply only to a selected subset. Figures 5 and 6 show that the 31 day wait was met in 71% of cases overall (after excluding missing data). Figures 7 and 8 show that overall, (after excluding missing data) 74% of cases met the 62 day target. This data set was very incomplete. Most radiotherapy centres found it difficult to record the dates needed for the 62 day target, as the referral dates were not available within their departments. This survey was undertaken as the target was being implemented and Trusts have had to set up novel management systems in order to address this target for patients referred after initial investigation at outside hospitals.

5 Figures 9, 10 and 11 contain data received from individual centres over the three audits. These ranked charts show the percentage of patients treated at each centre within the acceptable delay. Patients who had an elective delay were excluded and some centres therefore did not start a patient with a particular indication within the week in question. The number of centres shown therefore varies between audits (see Appendix 2). The charts give an overview of the proportion of centres with all or none of the patients achieving the targets, which highlights the inequity across the UK. For all three datasets, the deterioration between 1997 and 2003 is clearly seen, as is the subsequent improvement. Adjuvant radiotherapy is predominantly prescribed for breast cancer (63% of cases): in the 2003 audit there was a marked increase in the number of centres with no patients achieving the target. This has now improved in the 2005 audit. Centre Directors will be issued with their code number, which will identify their centre on each chart. A summary of these keys, which will be issued by the RCR Audit Office, is shown in Appendix 2. Centres will be able to identify their performance over time and in comparison with peers. Discussion: These data show that radiotherapy waiting times remain unacceptable. There is good evidence that these delays reduce the chance of cure and worsen outcomes in some patients (2-8). At the time of the survey the DH First Definitive Treatment targets were just being implemented and our data are incomplete. It is particularly important to note that the 31 and 62 day targets only apply to a small subset of radiotherapy patients. The College takes the view that it is imperative that waits for radiotherapy are reduced for all patients to maximise their chance of cure. A planned programme of national investment in staff, recruitment and training is required to achieve this. The RCR welcomes the opportunity to work through the National Radiotherapy Advisory Group (NRAG) to develop such a plan. Acknowledgements: We thank the staff in all UK Radiotherapy Centres who undertook the data collection; and A Hinks and C Squire for data management in 1997 and We are grateful to Sally Ginn and Nan Parkinson for typing the manuscript. We thank Dr Robin Hunter and Dr Diana Tait for helpful comments. References: 1. Joint Council for Clinical Oncology. Reducing delays in cancer treatment: some targets. London: Royal College of Physicians, 1993.

6 2. Coles CE, Burgess L, Tan LT. An audit of delays before and during radical radiotherapy for cervical cancer: effect on tumour cure probability. Clin Oncol 2003;15: O Rourke N, Edwards R. Lung cancer treatment waiting times and tumour growth. Clin Oncol 2000;12: O Sullivan B, Mackillop W, Grice B. The influence of delay in the initiation of definitive radiotherapy in carcinoma of the tonsillar region. Int J Radiat Oncol Biol Phys 1998;42(suppl): Fortin A, Bairati I, Albert M, et al. Effect of treatment delay on outcome of patients with early stage head and neck carcinoma receiving radical radiotherapy. Int J Radiat Oncol Biol Phys 2002;52: Waaijer A, Terhaard CH, Dehnad H, et al. Waiting times for radiotherapy: consequences of volume increase for the TCP in oropharyngeal carcinoma. Radiother Oncol 2003;66: Huang J, Barbera L, Brouwers M et al. Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol 2003; 21: Mikeljevic J, Haward R, Johnston C et al. Trends in postoperative radiotherapy delay and the effect on survival in breast cancer patients treated with conservation surgery. Br J Cancer 2004; 90: Royal College of Radiologists. A national audit of waiting times for radiotherapy. London: Royal College of Radiologists, Ash D, Barrett A, Hinks A, Squire C. Re-audit of Radiotherapy Waiting Times London: Royal College of Radiologists, 2003; Clinical Oncol 2004; 16: The NHS Cancer Plan: Providing a Patient Centred Service; Department of Health, ; The NHS Cancer Plan: a Plan for Investment, a Plan for Reform; Department of Health; ;

7 Fig % Within 2 w eeks % Within 4 w eeks % Outside maximun acceptable delay JCCO Targets RADICAL Fig % Within 4 w eeks % Outside maximun acceptable delay JCCO Targets ADJUVANT Fig 2 % Within 2 days JCCO Targets PALLIATIVE 80 % Within 2 w eeks % Outside maximun acceptable delay

8 Fig 4: First Definitive Treatment RADICAL PALLIATIVE 22% 14% 15% Yes No Don't Know Yes No Don't Know 64% 65% BREAST PROSTATE 13% 4% 16% 9% Yes No Don't Know Yes No Don't Know 83% 75%

9 Fig 5 31 Day Wait Fig 6 31 Day Wait 10 9 % Within good practice limit % Outside maximun acceptable delay % missing data 44% 43% 9 65% 45% 46% 71% 1 13% 29% 4% 6% 6% 9% 1 29% Radical Palliative Breast Prostate % Within good practice limit % Outside maximun acceptable delay Fig 7 % Within good practice limit 62 Day Waits Fig 8 62 Day Wait 9 % Outside maximun acceptable delay % missing data 69% 67% 81% 82% 74% 29% 19% 12% 13% 15% 26% 1 4% 6% 3% 1 Radical Palliative Breast Prostate % Within good practice limit % Outside maximun acceptable delay

10 Figure 9: % Within Maximum Acceptable Delay for Palliative Cases Palliative Palliative 2003 Palliative

11 Figure 10: % Within Maximum Acceptable Delay for Radical Cases Radical Radical 2003 Radical

12 Figure 11: % Within Maximum Acceptable Delay for Adjuvant Cases Adjuvant Adjuvant 2003 Adjuvant

13 Appendix 1: RCR Re-Audit of Radiotherapy Waiting Times 2005 Data Collection Proforma Centre ID number (as allocated by the RCR): Patient ID number: Patient Diagnosis: Bladder Breast Central Nervous System Colorectal Gynaecological Head and Neck Lung Lymphoma (inc.leukaemia and myeloma) Prostate Sarcoma Skin Upper GI Unknown Diagnosis Other (inc. renal, germ cell etc) Site Treated: Abdomen Axilla Bladder Bone Brain Breast only Breast with nodes Breast boost Chest Chest wall Chest wall with nodes Head and Neck (+/- nodes) Neck nodes Limb (inc. sarcoma) Pelvis (not bone) Prostate Skin Total body irradiation Other (excluding bone mets) Prescribed dose: Date of booking request: Date patient able to start treatment: Date radiotherapy commenced: Gy # # s per week / / / / / / Was there an elective delay? No Please check prescription details, in the last audit there seemed to be some errors, probably due to the wrong field being filled in. Date the booking request form is completed If patient not ready to start treatment then the oncologist should define a separate ready to start date. The date of the first fraction of treatment. If yes why? Chemotherapy/Hormone Therapy Recovering from surgery Patient request (holidays etc) Post-chemotherapy delay Intercurrent illness Don t know Other (please specify)

14 Patient ID number: Treatment intent [Local definitions should be used] Waiting list status Radical skin Emergency (within 24hours) Radical non-skin Urgent (category 1) Palliative Routine (category 2) Adjuvant pre-operative Don t know Adjuvant postoperative Is this the patient s first definitive treatment for cancer? [the first intervention which is intended to remove or shrink the tumour] No Don t know Yes If yes: Date of urgent referral by GP / / [date the GP signs the request form] Date of decision to treat / / [date of the consultation in which the patient and clinician agree the treatment plan for first treatment]

15 Appendix 2 Centre rating per year per intent by RCR centre ID number, to be used in conjunction with Figures 9, 10 and 11. Centre ID Palliative Rating 1998 Palliative rating 2003 Palliative rating 2005 Radical rating 1998 Radical rating 2003 Radical rating 2005 Adjuvant rating 1998 Adjuvant rating 2003 Adjuvant rating No data No data No data No data No data 34 No data No data No data No data No data No data No data No data No data No data No data 24 No data No data No data No data No data Centre Palliative Palliative Palliative Radical Radical Radical Adjuvant Adjuvant Adjuvant

16 ID Rating 1998 rating 2003 rating 2005 rating 1998 rating 2003 rating 2005 rating 1998 rating 2003 rating No data No data No data 27 7 No data 34 No data No data No data No data No data No data 18 5 No data No data No data No data No data No data No data No data No data No data No data No data No data No data No data No data 18 7 No data No data