Improving the Quality of Lung Cancer Care in Ontario The Lung Cancer Disease Pathway Initiative

Background: Before 2008, Cancer Care Ontario (CCO) undertook provincial cancer control quality-improvement initiatives on a programmatic basis. CCO has now added Disease Pathway Management (DPM) to its quality improvement strategy, with the intent of achieving high-quality care, processes, and patient experience across the patient pathway for specific cancers. Objectives: The three goals of DPM are: to describe and share evidence-based best practice along the cancer continuum for specific cancers; identify quality-improvement priorities for specific cancers and catalyze action; monitor performance against best practice for specific cancers. The objective of this article is to describe the process by which the CCO lung cancer (LC) DPM was initiated and some of its early successes. Methods: In 2009, LC DPM began with a draft LC disease pathway map and the establishment of five multidisciplinary working groups, each focused on a phase of the LC patient journey: prevention, screening, and early detection; diagnosis; treatment; palliative care, end-of-life care, and survivorship; and patient experience. The working groups held 25 meetings of 2-hour duration and developed concepts for 17 quality-improvement projects across the patient journey. Eight were selected for detailed discussion at a provincial consensus conference, which provided input on priorities for action. A report on the priorities for action was prepared and widely circulated, and regional roadshows were held in all 14 regions of the province of Ontario. Region-specific data on incidence, stage, treatment compliance, and wait times among other issues relevant to LC, were shared with the regional care providers at these roadshows. Funding was provided by CCO to address opportunities for regional improvement based on the data and the priorities identified. Results: The LC disease pathways were refined through substantial multidisciplinary discussion, and the diagnostic pathway was posted on CCO's Web site in February 2012. The treatment pathways for small-cell LC and non-small-cell LC were posted in November 2012. LC Diagnostic Assessment Units/Programs have been initiated in 14 regions, and educational materials on dyspnea management, including a patient video, are available on CCO's Web site. An audit has been undertaken to better understand the barriers to the uniform uptake of specific evidence-based practices across the province, and the results will be reported shortly. The proportion of LC patients, whose symptoms are assessed at least once a month, using a standardized symptom assessment instrument (Edmonton Symptom Assessment System), has improved through the DPM. Conclusion: Through CCO's LC DPM initiative, Regional Cancer Programs have become aware of their performance on a range of LC-specific performance and quality metrics and have been motivated to undertake quality-improvement initiatives. Standardized diagnostic and treatment pathways have been developed. Ongoing measurement of a broad range of metrics, including stage-specific survival, guideline concordance, and measures of the patient experience will help determine the benefit of this major initiative.