The RoaDmaP pilot study  feasibility of implementing a primary care intervention …
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The RoaDmaP pilot study feasibility of implementing a primary care intervention …


Hi everyone. Please forgive me if I start
coughing furiously, I’m recovering from the flu. So this project is funded by
Sydney Catalyst and is a feasibility project, so on a very small scale
compared to what we’ve just heard about, but with the idea that we would look at
how we can improve the referral process for people with a potential lung
cancer. I have no disclosures to make. So if you
think in terms of what we know about lung cancer, it’s the number one cause of
cancer death, more than 80 percent of people are diagnosed with a late stage
disease when there’s no chance of cure and the survival rates for people for
five years is less than 15 percent. However if we could intervene earlier and pick up
those people, given that there’s no lung cancer screening program in
Australia, but we could pick them up when they first had early symptoms, how could
how well could we do in terms of improving their chances of being cured?
So this is the WHO’s overview of how they describe screening versus early
diagnosis, so we’re thinking very much here in terms of the early diagnosis of
lung cancer. Our program has been underpinned by a model in terms of how
we wanted to approach this. So the thing to focus on here – this model from Fiona
Walter and Jon Emery – is around the process of early cancer diagnosis. And
you look in the middle of the screen there, in terms of intervals, we’re
thinking about the appraisal that a patient goes through in terms of when
they have symptoms, their decision to help– to seek help and to arrange to see
a healthcare provider through to that process then of going through appraisal,
investigations, referrals and appointments for their diagnosis and
through to the scheduling and planning of treatments in pre-diagnosis. Oh, slides are jumping. But there’ll be a whole range of contributing factors that will
intervene on how those intervals– how people present for getting
assistance and they will be at the patient level, the provider level and of
course the disease level. I’m just going to skip that slide. So in terms of
publications from our team, we’ve done a lot of background work over the last
five years to identify what the evidence practice gaps are in lung cancer. We
approached three lung cancer multidisciplinary teams across Sydney
Catalyst, so a team working in Orange, a team at St. Vincent’s and a team at RPA and we did some priority-setting with them around those gaps. What did they
consider were the most important or significant gaps and where did they see
that the greatest level of change could be implemented in their clinical
practices? So just very briefly, those seven gaps were around early diagnosis
and treatment, making sure that there was no under-utilisation of effective – oh
gosh, this is on a timer that I don’t know about – the under-utilisation of
effective treatments, curative treatments, the – sorry – the under-utilisation of
palliative treatments, a lack of referral to multidisciplinary teams, a lack of
psychosocial support and lack of referral to palliative care services. So
our team worked with those three different groups and very consistently
the message came back that they saw where they could affect the greatest
period– changing their service was to address the early diagnosis of lung
cancer. We also conducted qualitative interviews then with general
practitioners to talk to them about what their issues were and with patients
about the barriers to getting patients referred into the system early when they
first presented with symptoms. And resoundingly
from those interviews with the 11 GPs that we talked to was the issue of not
knowing where to refer to for lung cancer patients.
That’s probably driven by the fact that most GPs will see less
than one case of lung cancer per year and then there aren’t guidelines or a
lot of evidence that GPs necessarily can access at the right time for them to
think about “where should I be referring this patient?” So in terms of where our
intervention sits then, when you’re thinking about those intervals that I
showed you in the model, we’re right in the centre. The roadmap feasibility study
is about improving that diagnostic referral process. There have been another
number of other small trials in lung cancer in Australia – so the two of those up
on the screen, John Emery’s work around the IRCO trial – improving rural cancer
outcomes – and the CHEST trial which has been to look at encouraging people to
recognize their signs and symptoms and to present earlier for a respiratory
consultation. And then further back, public awareness campaigns – like the ones
that you mentioned in the panel this morning – looking out for lung cancer that the Cancer Institute have run. And then as you move across the screen to the right-hand
side and you think about pre-treatment, there are a number of other interventions that you could pursue in this area, particularly around fast-track
or rapid referral clinics, looking at navigator interventions and then as you
move towards treatment, MDT interventions. So our intervention is very clearly in
the middle of that. So our aim was to develop a referral decision prompt that
would support GPs in referring their patients with a suspicious lesion on a
CT scan to a respiratory physician for a respiratory consultation. However, when we
started to look at unpacking this issue and whether any previous studies
had been done, there’s nothing in Australia and we found only one or two
studies – one in Spain and one in Ireland – where people had actually used the
radiological consultation as the point at which to deliver an intervention. And
we wanted to therefore make sure that it was feasible for us to think about the
fact that probably about 90 percent of people with lung cancer will
have a CT scan, so is this the ideal– the teachable moment at which we can pick up
patients and think about then how they’re going to get from that step of
having their CT scan through to seeing the respiratory physician as quickly as
possible? Okay, so in a nutshell, this is what the referral decision prompt looks
like. It’s got five elements. The first is the background about guidelines: what do
the optimal care pathway guidelines say about lung cancer care and is that key
time point that people should be referred to a specialist within two
weeks? The next line is to give people the information about where the local
respiratory physician is located and the contact details. The third element is a
link to the health pathways site. The fourth element is a link to the Cancer
Institute’s CanRefer multidisciplinary team website. And then finally a link to
patient information. So the idea behind this is that you give your general
practitioners a range of different options for how they can find the right
specialist for their patient to refer to. And this literally gets pasted into the
bottom of the CT scan result so the GP will see all of this information along
with the respiratory, oh sorry, the radiological report and what the
CT scan says. So it’s not a separate piece of information that’s delivered
later on, the GP will see this is all one continuous piece of information. So what
we needed to do was actually recruit some radiologists who were willing to
let us try this out. So you can see here from the phase one pilot flowchart,
that we had a component of the project where we had the radiologists reviewing
and inserting the prompt into the patient’s record. In order to be able to
do that, we had to consent patients first. So we went through a process of actually
seeking the patient’s consent, making sure we included nothing about
lung cancer in any of the documentation so as not to distress or alarm the
patient in any way but then if the patient actually did have a suspicious
lesion then that information would go back to the general practitioner, which
you can see here in the green section, and then we’ve followed up with the GP
and said tell us about your patient. What happened? Did they actually end up with a
lung cancer and can we also consent you then to give us information about the
the key dates during the referral pathway? And we had then an extra step in
the orange section of the slide, there at the bottom, to say we will go to each of
the hospitals that those patients have been referred on to see what
treatment they have then had. So very briefly, the feasibility study is
just as I’ve described in the slide. We did a process evaluation with GPs,
radiologists and the practice staff to ask them about ten items across whether
they thought this intervention was feasible and we also did a retrospective
audit of chest CT scans in two of our sites to ask people, I’m sorry, to ask the
radiologists how many scans they were actually get picking up for suspicious
lesions so that we could get some baseline data about what to expect. So as
I mentioned, we had three practices. Anyone presenting for a chest CT scan
was eligible and the radiologist included the suspicious findings
according to the American College of Radiologists guidelines. So apologies that the print is quite small, but I’ll just take you
through it. In essence, we had four hundred and forty five patients across
those three radiology practices presenting. We were able to give the
forms to four hundred people and out of those, 293 people consented to take part
which meant we could access their medical records. Out of those people,
twelve had a suspicious lesion so you can see it’s a very small proportion.
Only four percent of those people that we consented
actually had the lesion. For all of those, the referral decision prompt was
included as part of their scan and was sent to their GP. So twelve GPs – well it was
actually 11 because one GP had referred 2 patients – received the prompt. Eight of
those people ended up with a diagnosis of lung cancer, two of them had
respiratory problems that were not lung cancer, one had lymphoma and one we lost
to follow up. And then we collected patient data in the hospitals and we
asked the GPs to complete the information for us in terms of whether
it had changed their practice. So you can see that just to go through this process
of doing a feasibility study takes quite a lot of effort to get a very small
number of patients. But what we feel that the main outcomes of this– doing this
feasibility study is that firstly we’ve been able to show that the intervention
is feasible, acceptable and appropriate to GPs. Radiologists are very, very happy
to include it, as you can see from the quote there on screen, they consider– the
radiologists– a number of whom we interviewed said that this was definitely
a good idea because it’s a way of us being able to target those patients with
that lesion and making sure that there’s no reason why the GP can’t get the
patient in to see the specialist as quickly as possible, rather than having to wait a long time for that person to flow through the
system. As you can appreciate, with only eight lung cancer cases, we don’t
have enough GPs to actually test whether this is impacted on the timeliness of
their referral practice but when we looked at those eight patients,
three-quarters of them, so sorry beg your pardon, two-thirds of them– 66% actually
saw the clinician within that two week time frame that had been stipulated. So
again, small numbers but at least it gives us an indication of in comparison –
thank you – to the usual hundred to 120 days that most people are waiting from
the point where they first have suspicions through to starting
treatment. We can target in on that small diagnostic interval window and actually
try and reduce that period to something more manageable. So in terms of next
steps, well, we think we now have the evidence to show that this low-cost
intervention is feasible in terms of we can integrate it into existing radiology
reports, we’ve got the baseline data that we need for designing a larger cluster
randomized control trial and we also have a lot of feedback from the
radiologists to say if you were to use the LUNG-RADS, which is the
classification for suspicious nodules that’s been used in the lung cancer
screening trial in the US, that we could become even more precise in
picking up the right group of patients who would receive the prompt. And we have 12 different radiology companies who are interested in enrolling the project out
across New South Wales and a lot of work’s been done in the intervening time
at St. Vincent’s Hospital with looking at how to customize the RDP for their rapid
referral clinic in Liverpool. We have clinicians working on using it with a
nurse coordinator model and RPA looking at ways we can “routine-ise”
this prompt for all of the patients who are seen at
Alfred Imaging. So the next step, of course, then is funding. And just very
briefly, to acknowledge my co-investigators and particularly to say
a big thank you to our clinical investigators in the radiology clinics
who were willing to give this a go so thank you very much.

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