Timelines in Lung Cancer Diagnostic Workup

Lange ventetider for å starte kreftutredning eller -behandling fører til bekymring og oppfattes som en medisinsk risiko som kan påvirke mulighetene til å få effektiv behandling. Derfor er det innført krav til ventetider i mange land. Det er imidlertid ikke sikkert at raskere kreftutredning bedrer kvaliteten av kreftbehandlingen. Lungekreft er en av de vanligste kreftformene, har dårlig prognose, og er den kreftformen som tar flest liv. Derfor mener vi at lungekreft er godt egnet som modellsykdom for å studere organiseringen av kreftutredningen. De norske retningslinjene anbefaler at tid fra sykehuset mottar en henvisning for mistenkt lungekreft til behandlingen starter skal være ≤35 dager for cellegift og ≤42 dager ved kirurgi eller strålebehandling. St. Olavs hospital- Trondheim universitetssykehus, i Trondheim, valgte standardiserte pasientforløp som forbedringsmetode. Vi har gjennomført en retrospektiv gjennomgang av pasientjournaler til alle pasienter som ble diagnostisert med lungekreft ved lungeavdelingen på St. Olavs hospital i 2011-2013. Målsetningen var å undersøke om det er grunn til å tro at det er mulig å redusere utredningstiden slik at den anbefalte forløpstiden overholdes, og om det å overholde forløpstiden kan føre til bedre overlevelse. Vi gjennomførte tre delstudier: 1. De eksisterende utredningstidene var ikke undersøkt, og klinisk erfaring tilsier at mange pasienter ikke kan starte behandling innenfor tidsrammene av medisinske årsaker. Totalt startet 49% behandling innen anbefalt tid. Til og med blant de minst kompliserte pasientene, definert som pasienter som gjennomgikk 0-1 vevsdiagnostiske undersøkelser og som ikke hadde utsettelser >3 dager som følge av komplikasjoner ved diagnostikken eller behandling for komorbide tilstander eller akutt sykdom, ble kravet møtt hos kun 66%. 2. Vi undersøkte årsakene til forsinkelser blant pasienter der de første CT-bildene indikerte stadium I-II og som fikk kurativ behandling. Vi fant at det ble gjort flere undersøkelser enn strengt tatt nødvendig, og at man ved bedre planlegging ville redusert antall diagnostiske prosedyrer samtidig som man ville spart tid, penger og ressurser. Dersom alle var blitt optimalt utredet ville andelen som kunne startet behandling innenfor anbefalt tid økt fra 40% til 80%. 3. Totalt sett hadde pasienter som startet behandling innenfor anbefalt forløpstid kortere median overlevelse enn de som ventet lenger. Imidlertid var det ikke en slik sammenheng i alle behandlingsgruppene, hvilket tilsier at utredningstid alene ikke er en uavhengig prognostisk faktor eller en valid indikator for kvaliteten på helsetjenesten. Konklusjonen er at bedre organisering av lungekreftutredningen kan forbedre utredningstiden signifikant. Vi mener derfor at man bør implementere et mer optimalt pasientforløp i tråd med det vi foreslår. Framtidig forskning kan vise om implementeringen lykkes, og avklare om det er en assosiasjon mellom utredningstid og overlevelse

Delt lederskap i Oslo kommune

Med innføringen av parlamentarisk styreform i 1986, fikk Oslo kommune delt politisk topplederskap. Det tradisjonsrike ordførervervet ble beholdt, samtidig som byrådslederen inntok en viktig rolle som operativ politisk leder. Selv om reformen i 1986 åpenbart var inspirert av nasjonal parlamentarisme, gjorde de betydelige forskjellene mellom den kommunale og den nasjonale konteksten at rollefordelingen mellom de to ledervervene måtte utformes lokalt. Dermed er den politiske toppledelsen i Oslo kommune et interessant case for å utvikle forståelsen av delt offentlig lederskap mer generelt, et tema det er stigende interesse for innen ledelsesforskningen. Artikkelen presenterer en analysemodell basert på generell ledelsesteori samt teori om liberal konstitusjonalisme og demokratisk ansvarliggjøring, som viser tre mulige begrunnelser for å innføre delt lederskap. Innføringen av delt lederskap fremstilles videre som en «innovasjon» i en sterkt institusjonalisert kontekst. Analysemodellens relevans undersøkes empirisk ved hjelp av data fra en kvalitativ undersøkelse, som inkluderer intervjuer med alle nålevende ordførere og byrådsledere i Oslo kommune siden reformen i 1986. Artikkelens viktigste bidrag er å vise hvordan trekk ved den politiske og demokratiske konteksten utgjør spesielle premisser for delt lederskap i offentlig sektor, sammenlignet med andre kontekster

To tårn, to ledere

Prosjektet har undersøkt ordførerens representasjonsrolle innenfor den modellen for kommunal parlamentarisme som er vokst fram i Oslo kommune, særlig fordelingen av representasjonsoppgaver mellom ordføreren og byrådslederen

Delt lederskap i Oslo kommune

Med innføringen av parlamentarisk styreform i 1986, fikk Oslo kommune delt politisk topplederskap. Det tradisjonsrike ordførervervet ble beholdt, samtidig som byrådslederen inntok en viktig rolle som operativ politisk leder. Selv om reformen i 1986 åpenbart var inspirert av nasjonal parlamentarisme, gjorde de betydelige forskjellene mellom den kommunale og den nasjonale konteksten at rollefordelingen mellom de to ledervervene måtte utformes lokalt. Dermed er den politiske toppledelsen i Oslo kommune et interessant case for å utvikle forståelsen av delt offentlig lederskap mer generelt, et tema det er stigende interesse for innen ledelsesforskningen. Artikkelen presenterer en analysemodell basert på generell ledelsesteori samt teori om liberal konstitusjonalisme og demokratisk ansvarliggjøring, som viser tre mulige begrunnelser for å innføre delt lederskap. Innføringen av delt lederskap fremstilles videre som en «innovasjon» i en sterkt institusjonalisert kontekst. Analysemodellens relevans undersøkes empirisk ved hjelp av data fra en kvalitativ undersøkelse, som inkluderer intervjuer med alle nålevende ordførere og byrådsledere i Oslo kommune siden reformen i 1986. Artikkelens viktigste bidrag er å vise hvordan trekk ved den politiske og demokratiske konteksten utgjør spesielle premisser for delt lederskap i offentlig sektor, sammenlignet med andre kontekster

Gynecological cancer patients' attitudes toward follow-up care after cancer treatment: Do preferences reflect patients' experience? A cross-sectional questionnaire study

Introduction Due to an increasing number of cancer patients, new follow‐up models are being debated, among them follow‐up by general practitioners. Before changing surveillance, it is important to explore patients’ views. The purpose of this study was to compare attitudes toward follow‐up care among patients treated for gynecological cancer who had not yet started a follow‐up regimen, with those who had been attending a hospital‐based follow‐up regimen for more than one year. Material and methods We conducted a cross‐sectional survey among gynecological cancer patients recruited from three Norwegian hospitals in 2013‐2015: Sørlandet Hospital Kristiansand, Sørlandet Hospital Arendal and St. Olavs Hospital, Trondheim. Results In all, 239 patients agreed to participate, 100 who had not yet started follow‐up and 139 who had been attending more than one year of follow‐up. Patients reported that they preferred to be followed up by a gynecologist rather than by their GP, whom they viewed as less competent for this purpose. However, patients who had not yet started follow‐up were more willing to be followed up by a GP. Overall, patients rated detection of recurrence as the most important aspect of follow‐up visits. Conclusions The gynecological cancer patients in our study preferred a hospital‐based follow‐up model. However, patients who had not yet started follow‐up were more willing to be followed up by a GP. If follow‐up is to be provided by GPs for selected patients, it is important that these patients are informed early of the value and limitations of follow‐up visits, to ensure that they feel safe

Associations Between Time to Treatment Start and Survival in Patients With Lung Cancer

Background: Time-to-treatment is defined as a quality indicator for cancer care but is not well documented. We investigated whether meeting Norwegian timeframes of 35/42 days from referral until start of chemotherapy or surgery/radiotherapy for lung cancer was associated with survival. Patients and Methods: The medical records of 439 lung cancer patients at a regional cancer center were reviewed and categorized according to treatment: (i) surgery; ii) radical radiotherapy; iii) stereotactic radiotherapy; iv) palliative treatment, no cancer symptoms; v) palliative treatment with severe cancer symptoms). Results: Proportions receiving timely treatment varied significantly at 39%, 48%, 10%, 44% and 89%, respectively (p<0.001). Overall, those starting treatment on time had the shortest median overall survival (10.6 vs. 22.6 months; p<0.001). This was also the case for palliative (5.3 vs. 11.4 months) (p<0.001) but not for curative treatment (not reached vs. 38.3 months) (p=0.038). Conclusion: Timely treatment is not necessarily associated with improved survival

Medical complexity and time to lung cancer treatment - A three-year retrospective chart review

Background The time from a referral for suspected lung cancer is received at a hospital until treatment start has been defined as a quality indicator. Current Norwegian recommendation is that ≥70% should start surgery or radiotherapy within 42 calendar days and systemic therapy within 35 days. However, delays can occur due to medical complexity. The aim of this study was to quantify the proportion of patients who started treatment within the recommended timeframes; and to assess the proportion of non-complex patients for which there were no good reasons for delays. Methods We performed a retrospective chart review of all patients diagnosed with lung cancer at a university hospital during 2011–2013. We defined “non-complex” patients as those who underwent ≤1 tissue diagnostic procedure and had no delays due to comorbidity, intercurrent disease or complications to diagnostic procedures (“Medical delays”) of more than three days. Results Four hundred forty-nine cases were analyzed; 142 (32%) had >1 tissue diagnostic procedures; 67 (15%) had medical delays >3 days; 262 (58%) were non-complex and 363 (81%) received treatment for lung cancer. Median number of days until surgery or radiotherapy was 48 (overall) and 41 (non-complex patients). The proportions who started surgery or radiotherapy within 42 days were 41% (overall) and 56% (non-complex). Corresponding numbers for systemic therapy were 29 days (overall) and 25 days (non-complex), and 64% (overall) and 80% (non-complex). Conclusion Fewer lung cancer patients than desired started treatment within the recommended timeframes. Even among the least complex patients, too few patients received timely treatment. The reasons need to be identified and understood, and changes in the organization appear to be necessary in order to offer timely treatment to more patients

Reasons for prolonged time for diagnostic workup for stage I-II lung cancer and estimated effect of applying an optimized pathway for diagnostic procedures

Background:Minimizing the time until start of cancer treatment is a political goal. In Norway, the target time forlung cancer is 42 days. The aim of this study was to identify reasons for delays and estimate the effect on thetimelines when applying an optimal diagnostic pathway.Methods:Retrospective review of medical records of lung cancer patients, with stage I-II at baseline CT, receivingcurative treatment (n= 100) at a regional cancer center in Norway.Results:Only 40% started treatment within 42 days. The most important delays were late referral to PET CT (n= 27)and exercise test (n= 16); repeated diagnostic procedures because bronchoscopy failed (n= 15); and need for furtherinvestigations after PET CT (n= 11). The time from referral to PET CT until the final report was 20.5 days in median.Applying current waiting time for PET CT (≤7 days), 48% would have started treatment within 42 days (p=0.254).“Optimal pathway”was defined as 1) referral to PET CT and exercise test immediately after the CT scan and hospitalvisit, 2) tumor board discussion to decide diagnostic strategy and treatment, 3) referral to surgery or curativeradiotherapy, 4) tissue sampling while waiting to start treatment. Applying the optimal pathway, current waiting timefor PET CT and observed waiting times for the other procedures, 80% of patients could have started treatment within42 days (p< 0.001), and the number of tissue sampling procedures could have been reduced from 112 to 92 (−16%).Conclusion:Changing the sequence of investigations would significantly reduce the time until start of treatment incurative lung cancer patients at our hospital and reduce the resources needed

Additional file 2: of Medical complexity and time to lung cancer treatment – a three-year retrospective chart review

Medical complexity and time to lung cancer treatment. (DO 25 kb

A national, prospective observational study of first recurrence after primary treatment for gynecological cancer in Norway

INTRODUCTION: Gynecological cancer patients are routinely followed up for five years after primary treatment. However, the value of such follow up has been debated, as retrospective studies indicate that first recurrence is often symptomatic and occurs within two to three years of primary treatment. We prospectively investigated time to first recurrence, symptoms at recurrence, diagnostic procedures, and recurrence treatment in gynecological cancer patients after primary curative treatment. MATERIAL AND METHODS: Clinicians from 21 hospitals in Norway interviewed 680 patients with first recurrence of gynecological cancer (409 ovarian, 213 uterine, and 58 cervical cancer patients) between 2012 and 2016. A standardized questionnaire was used to collect information on self-reported and clinical variables. RESULTS: Within two years of primary treatment, 72% of ovarian, 64% of uterine, and 66% of cervical cancer patients were diagnosed with first recurrence, and 54, 67, and 72%, respectively, had symptomatic recurrence. Of symptomatic patients, 25-50% failed to make an appointment before their next scheduled follow-up visit. Computer tomography was the most common diagnostic procedure (89% of ovarian, 76% of uterine, and 62% of cervical cancer patients), and recurrence treatment in terms of chemotherapy was most frequently planned (86% of ovarian, 46% of uterine, and 62% of cervical cancer patients). CONCLUSIONS: A majority of patients experienced symptomatic recurrence, but many patients failed to make an appointment earlier than scheduled. Most first recurrences occurred within two years of primary treatment; the mean annual incidence rate for years 3-5 after primary treatment was <7%. New models for follow up of gynecological cancer patients could be considered