1. Determining Acceptable Waiting Times for the Surgical Treatment of Solid Organ Malignancies - A Systematic Review CIHR Grant: Toward Canadian Benchmarks for Health Services Wait Times – Evidence, Application and Research Priorities Nicole Choptain, Donna Turner, Steve Latosinsky, Tom Noseworthy, Mark Taylor January, 2006

2. Goal of Project To provide an in-depth summary of the issues and evidence for establishing waiting time benchmarks in solid organ malignancies treated by surgery.

3. Introduction Feb 2005 – CIHR RFA : Toward Canadian Benchmarks for Health Services Wait Times – Evidence, Application and Research Priorities Systematic reviews of existing evidence in 5 areas, one of which was cancer Provide first ministers with advice re establishment of benchmark waiting times

4. Literature Review – Existing Benchmarks Description of the benchmarks being used, for what purposes and by whom Description of the range of settings where such benchmarks are currently applied Summary of wait-time benchmarks currently used nationally or elsewhere, & research evidence that was used to support their selection.

5. Evidence for Benchmarks Identify areas / procedures where there is currently sufficient evidence, and general consensus exists, regarding wait time

6. Relationships Synthesis of the research evidence regarding the relationships between patient characteristics, health service wait-times, and outcome (mortality, health status or quality of life).

7. CIHR Benchmark RFA Funded Cancer Applications May, 2005 Marcy Winget – Wait-times for colorectal and lung cancer, “Three Province Study” Bill MacKillop – Time to radiotherapy Paul Moayyedi – Time to diagnosis for upper and lower GI cancer Mark Taylor – Time from decision to undergo cancer surgery to actual surgery

8. 1. Review available evidence on cancer waiting time benchmarks in randomized & non-randomized trials. 1. Review available evidence on cancer waiting time benchmarks in randomized & non-randomized trials. 2. Identify practical & clinically established waiting time measures re: impact on mortality, quality of life, & surgical treatment of cancer. 2. Identify practical & clinically established waiting time measures re: impact on mortality, quality of life, & surgical treatment of cancer. 3. Assess completeness of existing reviews & audits on cancer waiting time benchmarks & how applicable they are to the health care system in Canada. 3. Assess completeness of existing reviews & audits on cancer waiting time benchmarks & how applicable they are to the health care system in Canada. 4. To compare the appropriateness & effectiveness of evidence-based cancer waiting times as a part of quality patient care. 4. To compare the appropriateness & effectiveness of evidence-based cancer waiting times as a part of quality patient care. OBJECTIVES Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review

9. First stage of the project involved review of main medical sources, well-defined search strategy, & inclusive search criteria. Specific search strategy developed in consultation with medical librarian, to exclude highly irrelevant material & focus on surgical waiting times & benchmarks. The search for evidence-based waiting time benchmarks was investigated according to a list of relevant keywords SEARCH METHODOLOGY

10. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review Published and unpublished sources -1985 to 2005. Searches conducted nationally & internationally Not limited by language, provided that an English title or keywords were available. First search conducted on MEDLINE. SEARCH METHODOLOGY

11. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review 1. Neoplasms and surgery or surgical procedures or operative. 2. Cancer or neoplasms or oncology or malignancy or tumour or carcinoma or adenocarcinoma or sarcoma or mastectomy or hysterectomy or orchiectomy or prostatectomy and surgery or surgically. 3. #1 OR #2 4. Time factors or waiting lists or appointments & schedules or time & motion studies or time management or referral and consultation or patient selection. 5. Wait or referral or time factor or fast track or surgical delay or delay in surgical or delay or interval. 6. #4 OR #5 7. #3 AND #6 8. Management audit or nursing audit or medical audit or utilization review or audit. 9. #3 AND #8 MEDLINE SEARCH TERMS – (PubMed including Cancerlit) Brief Version

12. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review MEDLINE MEDLINE Relevance Level:Number of Records: Level 1 Highly Relevant39 Level 2Probably Relevant33 Level 3Possible Relevant61 Level 4Probably Not Relevant24 Level 5Definitely Not Relevant15 Total172 Total172 1 st SEARCH RESULTS- Titles Reviewed

13. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review Relevance of all 172 articles reassessed based on the full article or abstract for a second relevance rating. Relevance of all 172 articles reassessed based on the full article or abstract for a second relevance rating. Rating of articles done by 2 of 3 reviewers – scored with standard template Rating of articles done by 2 of 3 reviewers – scored with standard template Articles were identified as “Auxiliary” under the following conditions: Articles were identified as “Auxiliary” under the following conditions: - only editorial or commentary information provided, review of other studies or not directly referring to all 3 terms: cancer, waiting times, and surgery. ARTICLE RE-ASSESSMENT

14. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review Studies were graded according to study design & quality Grade A – Benchmark based on Level 1 studies (RCTs) Grade A – Benchmark based on Level 1 studies (RCTs) Grade B – Benchmark based on Level 2&3 studies (cohort or case-control) Grade B – Benchmark based on Level 2&3 studies (cohort or case-control) Grade C – Benchmark based on Level 4 studies (case series) Grade C – Benchmark based on Level 4 studies (case series) Grade D – Benchmark based on Level 5 studies (expert opinion) Grade D – Benchmark based on Level 5 studies (expert opinion)

15. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review Relevance Level:# Records AuxiliaryReviewed Level 1 Highly Relevant 29 4 22 Level 2 Probably Relevant 17 7 9 Level 3 Possible Relevant 28 16 10 Level 4 Probably Not 75- Level 5 Definitely Not 23- Total 172 27 41 (24% of 172) MEDLINE ARTICLE RE-ASSESSMENT RESULTS :

16. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review, Report 1 – July 22, 2005 Few cancer surgery benchmark waiting times were found Those that existed were based solely on expert opinion, with very little evidence to support them (Grade D) Available studies assessed compliance with these benchmarks

17. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review From references listed in Medline articles From references listed in Medline articles Relevance Level:Number of Records: Level 1Highly Relevant33 Level 2Probably Relevant23 Level 3Possible Relevant35 Level 4Probably Not Relevant19 Level 5Definitely Not Relevant 9 To Be Ranked56 Total175 2 nd SEARCH RESULTS

18. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review Report 2 – October 14, 2005 100% of identified benchmarks based solely on expert opinion Most studies assessed compliance with arbitrary benchmarks No compelling evidence that waiting impacted on outcome 49% of studies had poor methodology, & 80% not generalizable Only 6 studies assessed health status in relation to waiting 10 studies looked at reducing waiting times through referral or flow changes

19. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review 1. Cancer & surgery 2. Neoplasm or cancer or oncology or malignancy or tumour or carcinoma or sarcoma 3. #1 or #2 4. Orchiectomy or hysterectomy or prostatectomy or mastectomy or surgery or operation or pre-operative or re- operative 5. #3 or #4 6. Cancer patient or surgical patient or hospital admission or medical audit or nursing audit or management audit 7. #5 or #6 8. Waiting list or surgical delay or delay in surgery or waiting time or surgery delay or time or times or wait or waiting or delay or tracking or interval or fast track or fast 9. #7 and #8 3rd Search - EMBASE SEARCH TERMS - Brief Version

20. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review EMBASE EMBASE Relevance Level:Number of Records: Level 1Highly Relevant 2 Level 2Probably Relevant 10 Level 3Possible Relevant 43 Level 4Probably Not Relevant 30 Level 5Definitely Not Relevant 44 To Be Ranked 13 To Be Ranked 13 Total 142 3 rd SEARCH RESULTS

21. Librarian used the cited reference feature based on most relevant references identified first search results (PubMed etc). These were entered to retrieve citations that cited them (and also in some cases citations that they cited). These were entered to retrieve citations that cited them (and also in some cases citations that they cited). In addition, librarian used judgement in identifying only those that appeared somewhat relevant. 4 th Search - Web of Science SEARCH STRATEGY Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review

22. Web of Science Web of Science Relevance Level:Number of Records: Level 1Highly Relevant8 Level 2Probably Relevant20 Level 3Possible Relevant50 Level 4Probably Not Relevant41 Level 5Definitely Not Relevant18 To Be Ranked 13 To Be Ranked 13 Total150 4 th SEARCH RESULTS

23. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review Comparisons: Database # of Journal Articles 1. MEDLINE172 1. MEDLINE172 2. References from MEDLINE Articles175 MEDLINE Articles175 3. EMBASE142 4. Web of Science150 (WOS) (WOS) TOTAL:639 TOTAL:639 OVERVIEW

24. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review- Final Report due May, 2006 Preliminary Impressions May be some evidence of impact on waiting on outcome – breast, bladder, testicle There will never be conclusive proof that delay in treatment beyond “x” weeks reduces survival Cancer surgery should be available with minimal delay for reasons of fundamental fairness

25. Waiting Times for Surgical Treatment of Solid Organ Malignancies - A Systematic Review- Final Report due May, 2006 First step is system change, improving patient flow from time of first symptom, through diagnosis, treatment, recovery, and follow-up Establishing mandatory benchmarks may provide impetus leading to these changes These benchmarks will be arbitrary