15th ISRRT World CongressApril 24-28, 2008 Durban

Introduction

ISRRT Congress FeedbackISRRT Congress Feedback

Causes of waiting listsCauses of waiting lists

The New Zealand approach to waiting list The New Zealand approach to waiting list recording and wait list managementrecording and wait list management

Future Reporting ChangesFuture Reporting Changes

The Nigerians

From imaging to therapy

John BuscombeJohn Buscombe

Nuclear Medicine PhysicianNuclear Medicine Physician

Royal Free HospitalRoyal Free Hospital

Neuroendocrine tumours

Family of rare tumoursFamily of rare tumoursAssociated with the neuroectodermal ridge Associated with the neuroectodermal ridge

in the embryoin the embryo Includes the followingIncludes the following

CarcinoidCarcinoidPhaechromocytomaPhaechromocytomaSmall cell lung cancerSmall cell lung cancer

Why radionuclide treatment of NETs

Often present too late for curative surgeryOften present too late for curative surgeryLow turn-over rate makes cells less Low turn-over rate makes cells less

susceptible to chemotherapy and external susceptible to chemotherapy and external DXTDXT

Maybe given in patients who have been Maybe given in patients who have been heavily pre-treatedheavily pre-treated

Few side effectsFew side effects

123I mIBG uptake rates (Bomanji et al)

PhaeochromocytomaPhaeochromocytomaNeuroblastomaNeuroblastomaCarcinoidCarcinoidMedullary thyroid CaMedullary thyroid Ca

95 %95 %95 %95 %60 %60 %10 %10 %

Does CT change or symptom relief help predict survival

RFH, review of 38 patient – completed RFH, review of 38 patient – completed 3x5.5GBq I-131 mIBG therapy3x5.5GBq I-131 mIBG therapy

All with minimum of 12 months follow-upAll with minimum of 12 months follow-upLooked at PFS and OS compared toLooked at PFS and OS compared to

CT changesCT changesSymptom responseSymptom response

Overall survival related to symptom response

Overall survival related to change on CT

Pre Rx 6 m

9 m

131I mIBG Therapy Response

Neuroblastoma in a 4 year old

Radiotherapy Waiting List Management: The New Zealand Experience

Rob Hallinan

Clinical Resource Radiation Therapist

Waikato Hospital

Hamilton

New Zealand

Key Stats

18000 new cancer 18000 new cancer registrations per yearregistrations per year

8000 deaths/year8000 deaths/year

7200 patients treated 7200 patients treated with radiotherapy/yearwith radiotherapy/year

Waiting Lists: The New Zealand Experience

Oncological Sites where delay in Radiotherapy has resulted in increased local recurrence rates

Head and NeckHead and Neck High Grade GliomasHigh Grade Gliomas BreastBreast CervixCervix NSCLCNSCLC Soft Tissue SarcomasSoft Tissue Sarcomas OesophagusOesophagus

Waiting List Causes

DemandDemand

SupplySupply ResourceResource

HumanHuman EquipmentEquipment

ProcessProcess ClinicalClinical

0

50

100

150

200

250

300

January February March April May June July August September October November December

Month

2006 Referrals

Resource Factors

Levels of planning, actors, decisions and waiting list effects

Level of planning Actors Decisions Impact

NationalNational GovernmentGovernment Total level of Total level of healthcare healthcare expenditureexpenditure

Insufficient Insufficient funding increases funding increases wait listswait lists

RegionalRegional Healthcare Healthcare purchaserspurchasers

Volumes of Volumes of contractcontract

Incorrect volumes Incorrect volumes lead to wait listslead to wait lists

HospitalHospital Management and Management and specialtiesspecialties

Resource per Resource per specialtyspecialty

Insufficient Insufficient resources resources increase wait listsincrease wait lists

ProcessProcess DepartmentalDepartmental Efficiency of Efficiency of processprocess

Inefficiencies Inefficiencies increase wait listsincrease wait lists

Vissers, J et al. Health Care Management Science 4, 133-142, 2001

The Multidisciplinary Team

Radiation OncologistsRadiation Oncologists

Medical PhysicistsMedical Physicists

Radiation TherapistsRadiation Therapists

EngineersEngineers

Equipment

Treatment CapacityTreatment Capacity

NetworkingNetworking

Immobilisation Immobilisation

Process Factors

Electronic RecordElectronic Record

Small TeamsSmall Teams

MondaysMondays

Value Time/Real Time Ratio

Value TimeValue Time The time spent The time spent

working on a productworking on a product

Real TimeReal Time The total time of the The total time of the

product in the systemproduct in the system

Urgent Referrals

05

1015202530354045

Mon

day

Tue

sday

Wed

nesd

ay

Thu

rsda

y

Frid

ay

Sat

urda

y

Sun

day

New Starts 2008

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Clinical Factors

FractionationFractionation

BreastBreast

Bony metastasesBony metastases

Prostate HDRProstate HDR

ComplexityComplexity

Radiotherapy Booking Priorities

Source: NZROAC Report 1999

Pitfalls

Joint reporting of radical Joint reporting of radical

and palliative patientsand palliative patients

Inconsistency of Inconsistency of applicationapplication

Too simplistic?Too simplistic?

Needs revision?Needs revision?

Shifting the goalposts

Referral FSA Start of Treatment

Wait List Reporting Criteria 2002

Referral to FSAReferral to FSA

FSA to Start of RxFSA to Start of Rx

Referral to Start of RxReferral to Start of Rx

   Waikato DHB Cancer Centre Summary Waikato DHB Cancer Centre Summary 

   Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment)Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment)

Assessment Assessment

A. Numbers waiting for first specialist assessment A. Numbers waiting for first specialist assessment  Dec-07Dec-07

   Priority A Priority A Priority B Priority B Priority C Priority C Priority D Priority D TotalTotal

Assesments completed in current month Assesments completed in current month (number of people)(number of people) 99 3636 5050 55 100100

Average wait from referral to assessment Average wait from referral to assessment (days)(days) 11 88 1313 3737   

Number of people waiting for assessment at month end Number of people waiting for assessment at month end (people)(people) 00 2121 109109 6868 198198

TreatmentTreatment

B. Time between the first specialist assessment and the start of radiation B. Time between the first specialist assessment and the start of radiation treatment treatment 

Dec-07Dec-07

      Priority A Priority A Priority B Priority B Priority C Priority C Priority D Priority D TotalTotal

Treatments started in current month Treatments started in current month (number of people)(number of people) Waited < 4 weeksWaited < 4 weeks 88 1515 6767 1515 105105

Waited 4-8 weeksWaited 4-8 weeks 00 11 11 11 33

Waited 8-12 weeksWaited 8-12 weeks 00 00 00 00 00

Waited >12 weeksWaited >12 weeks 00 00 00 00 00

Average wait from assessment to treatment Average wait from assessment to treatment (weeks)(weeks) 0.020.02 1.41.4 1.61.6 2.52.5   

Number of people with completed assessments waiting for treatment at month end Number of people with completed assessments waiting for treatment at month end (people)(people) 00 1414 4646 55 6565

C. Time between receipt of referral and the start of radiation treatment C. Time between receipt of referral and the start of radiation treatment  Dec-07Dec-07

      Priority A Priority A Priority B Priority B Priority C Priority C Priority D Priority D TotalTotal

Treatments started in current month Treatments started in current month (people) (people) Waited < 4 weeksWaited < 4 weeks 77 1111 1313 22 3333

Waited 4-8 weeksWaited 4-8 weeks 00 22 3434 33 3939

Waited 8-12 weeksWaited 8-12 weeks 00 00 11 22 33

Waited >12 weeksWaited >12 weeks 00 00 11 66 77

Total Total  77 1313 4949 1111 8282

Average wait from referral to treatment Average wait from referral to treatment (weeks)(weeks)    0.340.34 2.952.95 5.135.13 1313 4.244.24

   National Summary National Summary                   

Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment)Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment)

Time between the first specialist assessment and the start of Time between the first specialist assessment and the start of 

radiation treatment radiation treatment 

Dec-07Dec-07

     

Priority A Priority A Priority B Priority B Priority Priority CC

Priority Priority DD

TotalTotal

Waited < 4 weeksWaited < 4 weeks 4242 5656 226226 33 327327

Waited 4-8 weeksWaited 4-8 weeks 00 2929 6060 1616 105105

Waited 8-12 weeksWaited 8-12 weeks 00 11 1212 44 1717

Waited >12 weeksWaited >12 weeks 00 11 99 4141 5151

TOTALTOTAL 4242 8787 307307 6464 500500

Ministry of Health Monthly Report

National wait times for patients in priority categories A, B & C

HEALTH TARGET100% of patients treated in less than 8 w eeks

0%

20%

40%

60%

80%

100%

July

2007

Aug 2

007

Sept 2007

Oct 2007

Nov 2

007

Dec 2

007

HEALTH TARGET

% Waited < 4 w eeks % Waited 4-8 w eeks

A matter of perspective

PatientPatient

FunderFunder

ClinicianClinician

Service DeliveryService Delivery

Ministry of HealthMinistry of Health

Controversy

What dates are What dates are significant?significant?

DiagnosisDiagnosis SurgerySurgery ReferralReferral FSAFSA Decision to treatDecision to treat Ready to start treatmentReady to start treatment

What factors should What factors should be discounted?be discounted?

Patient morbiditiesPatient morbidities Factors outside Factors outside

oncology department oncology department controlcontrol

Factors outside Factors outside radiation oncology radiation oncology controlcontrol

Categorisation!

Future Changes

Cancer Control Cancer Control Strategy GoalStrategy Goal

MOH ReportingMOH Reporting

CWG ReportingCWG Reporting

MOH Reporting

New Goal FSA to Start < 6 weeksNew Goal FSA to Start < 6 weeksMultivariate analysisMultivariate analysis

CategoryCategoryEthnicityEthnicityDHBDHB

Separation of palliative and radical patientsSeparation of palliative and radical patientsReasons for patients waiting > 6 weeks Reasons for patients waiting > 6 weeks Chemotherapy FSA-Start of TreatmentChemotherapy FSA-Start of Treatment

Reasons for patients waiting > 6 weeks

Post-operative/chemo complicationsPost-operative/chemo complicationsTreatment of intercurrent co-morbiditiesTreatment of intercurrent co-morbiditiesPatient requestPatient requestAwaiting radiology/pathology resultsAwaiting radiology/pathology resultsDental interventionDental interventionOther outside department controlOther outside department controlDepartment/facility constraintDepartment/facility constraint

CWG Reporting Requirements4 Waiting Times

4.1Average Days Referral to FSA days

4.2Ready to Treat (booking date) to Commencement

of Treatment

4.2.1 Urgent (A) - < 24 Hours % Within Guidelines

4.2.2 Curative (B) - within 2weeks % Within Guidelines

4.2.3 Palliative (C) - within 2 weeks % Within Guidelines

4.2.4 Radical (C) -within 4 weeks % Within Guidelines

4.2.5 Pre Scheduled (D) Days

Categorisation Changes

Initial ReferralInitial Referral 1 Urgent1 Urgent 2 Curative2 Curative 3 Radical3 Radical 4 Protocol 4 Protocol 5 Palliative5 Palliative

RT CategorisationRT Categorisation AA BB CC DD C PallC Pall

Colonel Roger Fray

Oncology Referral Database

Colonel Roger Fray

Data EntryData Entry Initial ReferralInitial ReferralDecision to TreatDecision to TreatStart of TreatmentStart of Treatment

Patient DataPatient DataName, NHI Number, DHB, EthnicityName, NHI Number, DHB, Ethnicity

Colonel Roger Fray

Referral InformationReferral Information ReferrerReferrer Referral DateReferral Date CategorisationCategorisation FSA DateFSA Date

Radiotherapy InformationRadiotherapy Information ModalityModality CategorisationCategorisation Radiation OncologistRadiation Oncologist Ready to Treat DateReady to Treat Date Simulation DateSimulation Date Planning DatePlanning Date Start DateStart Date Delay ReasonsDelay Reasons

Actual Wait Times RTT-Start

0

5

10

15

20

25

30

35

Oct-06

Dec-06

Feb-0

7

Apr-0

7

Jun-

07

Aug-0

7

Oct-07

Dec-07

Feb-0

8

Apr-0

8

Prostate

Breast

B

Total Patients on Wait List vs Daily Linac Treatments

0

20

40

60

80

100

120

140

Oct-0

6

Dec-0

6

Feb-0

7

Apr-0

7

Jun-

07

Aug-0

7

Oct-0

7

Dec-0

7

Feb-

08

Apr-0

8

Patients Waiting for RT

Linac Patients

Take Home Messages

Waiting lists are not just a function of staff Waiting lists are not just a function of staff and equipment shortagesand equipment shortages

A national categorisation system needs to A national categorisation system needs to have internal and external consistency of have internal and external consistency of applicationapplication

An independent database is a valuable An independent database is a valuable tool for analysis and reporting of practice.tool for analysis and reporting of practice.

ReferencesImproving Non-Surgical Cancer Treatment Services in New Zealand,Improving Non-Surgical Cancer Treatment Services in New Zealand,

New Zealand Ministry of Health, July 200New Zealand Ministry of Health, July 200

Towards Decision Support for Waiting Lists: An Operations Towards Decision Support for Waiting Lists: An Operations Management View,Management View,

Vissers, J. et al., Health Care Management Science 4, 133-142, Vissers, J. et al., Health Care Management Science 4, 133-142, 20012001

Management of waiting lists for Radiation Therapy, Management of waiting lists for Radiation Therapy,

The Royal Australian and New Zealand College of Radiologists, The Royal Australian and New Zealand College of Radiologists, Faculty of Radiation Oncology, April 2004Faculty of Radiation Oncology, April 2004

Waiting for Radiotherapy,Waiting for Radiotherapy,

Dodwell, D. & Crellin, A; British Medical Journal, 14 January Dodwell, D. & Crellin, A; British Medical Journal, 14 January 20062006

Killing time: The consequences of delays in radiotherapy,Killing time: The consequences of delays in radiotherapy,

Mackillop, W., Radiotherapy and Oncology 84 (2007) 1-4Mackillop, W., Radiotherapy and Oncology 84 (2007) 1-4