ILCOP web conference summary:

Histological confirmation rates and diagnostics in lung cancer services

5th July 2011

• Lisa Martin, ILCOP QI facilitator, chaired the session

• Dr Paul Beckett, Burton Hospitals, presented his experience in improving histological confirmation rates

• Dr Paul Walker, Aintree Hospitals, and Tamsin Bendle, Royal Cornwall Hospitals, joined the session.

Discussion summary

• How to raise the profile of HCR within your local stakeholders, use local data to generate debate, be prepared to take your discussions to network level, and wider (slides 6-9)

• Revise the use of diagnostic technology over time, which may change the point of decision making in the pathway, i.e. as your experience with technology evolves, you become more confident with taking decisions earlier in the pathway, decreasing the time to treatment and the number of steps in the pathway(slides 10 to 14)

Please press F5 now

HCR and Diagnostics

Dr Paul BeckettBurton Hospitals NHS Foundation Trust

HISTOLOGICAL CONFIRMATION

Burton Hospitals NHS Trust

NLCA Data 2005 2006 2007 2008 2009 2010

HCR 73% 79% 70% 68% 83% 80%

Surgery 9% 22% 19% 12% 16% 24%

Anti-cancer 57% 63% 63% 62% 62% 72%

Histological Confirmation Rate

• There is no agreed optimum but it is probably more than 75%…..

• Every patient deserves a diagnosis

• Histological type influences therapy

• “It won’t change management” can now only rarely be justified

How to Improve your HCR

• Ensure the team buy in to the importance of HCR– Discuss results in local/national context

– Discuss importance of histological subtype and molecular markers

• Review availability of diagnostic tests– Are we missing diagnoses we could make on neck FNA, TBNA etc?

• Review pathways for diagnostic tests– Don’t feel that you are imposing on people by asking for help

– Ensure pathways are clear, simple and efficient for both patients and staff

– Example of EBUS…..

• Review performance of diagnostic tests– Are our results comparable to the best units?

DIAGNOSTIC PATHWAY(PLEASE, SEE AS SLIDE SHOW - PRESS ALT+F5)

Redesigning the Pathway

Referral

OPA

CT Scan

MDT

PET

MDT

Biopsy

Shorter, more efficient pathway

Aim/Hypothesis

Describe your test of change Person responsible When to be done Where to be done

Ordering a PET scan earlier in the pathway without recourse to MDT discussion will improve pathway times, improve patient experience, and reduce MDT discussions.

Paul Beckett Jan 2011 – May 2011 Outpatients

Plan

List tasks needed to set up this test of change Person responsible When to be done Where to be done

Dr Beckett to select a patient in clinic with high likelihood of lung cancer and fit for radical treatment.PET scan to be ordered at first clinic appointment and MDT discussion delayed until PET result available.

Paul Beckett May 2011 Outpatients

Predict what will happen when the test is carried out Measures to determine if the prediction succeeds

It will be easily possible to predict (for some patients) that a PET scan will be needed. The patient will appreciate the certainty of knowing the next step rather than having to wait for the MDT decision.The MDT will be better able to make a decision with the PET scan result.

Analysis of the patient pathway; adherence to 31-day and 62-day targets for this patient; MDT view on appropriateness of PET scan

Do – Describe what actually happened when you ran the test

A patient was seen in clinic with a malignant-looking SPN and a PET was ordered. The result was available in 1 week and an MDT discussion took place 2 days later, recommending a surgical referral. Patient very satisfied with the process and outcome, but did not like travelling to Birmingham.

Study – Describe the measured results and how they compared to the predictions and what you learned from the cycle; what have you not learned?

31-day and 62-day targets easily achieved. RTT 32 days.MDT happy that PET was appropriate.Satisfied patient.

Act – Describe modifications for the next cycle based on what you learned. What are your next questions? What is your updated hypothesis?

Repeat the cycle with 3 patients to try to capture different scenarios

Redesigning the Pathway

Referral

CT Scan

OPA

PET

MDT

BiopsyBiopsy

How to Improve your Pathway

• Consider process mapping

• Look for the bottlenecks

• Identify an enabler

• Use PDSA cycles to demonstrate effectiveness and slowly

bring others on board

• Avoid long policy reviews and multiple meetings

• Measure to demonstrate change for the better

Let the ILCOP team know if you would like to discuss implementing similar changes within

your service.

Senai.jimenez@rcplondon.ac.uk Lisa.martin@rcplondon.ac.uk