Impact of fast-track intervention systems on time intervals

First author, year [ref.]Study design, intervention and settingSample size without intervention/control group (group C) nSample size with intervention (group I) nGP–LCS interval daysTreatment interval daysOther intervals from figure 1 daysNew intervals described daysAuthor conclusionsStatistical significance
Brocken, 2011 [34]Retrospective study comparing delays in a RODP (including PET-CT) for suspected lung cancer patients with delays described in literature and guideline recommendations (the Netherlands, 1999–2009)280Median (IQR) 7 (5–9) days
Median (IQR) for group I 19 (6.5–27) days
Median (IQR) primary care interval 18 (6–46) days; median (IQR) secondary care interval 36 (26–46) daysMedian (IQR) interval from LCS to diagnosis (“diagnostic delay”) 2 (1–17.5) daysThe RODP including PET-CT resulted in timely care, with strongest effect on diagnostic and secondary care intervalsN/T
Prades, 2011 [35]Mixed–methods study including prospective data analysing a cancer fast-track programme's impact on reducing the time that elapsed between clinical suspicion of breast, colorectal and lung cancer and treatment start (Spain, 2006–2009)3481 (for year 2009)Mean total interval 36.7 daysApproximately half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track programme, although the cancer detection rate declined across the periodN/T
Murphy, 2015 [36]Prospective cluster randomised trial assessing use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays (USA, 2015)Unknown (total sample 19)Unknown (total sample 19)Median interval from scan to diagnosis 65 days in group I versus 93 days in group C (p=0.59)No statistical difference was observed in the time to diagnostic evaluation between the intervention and control groupsNonsignificant
Leiro-Fernandez, 2014 [37]Prospective analysis of effectiveness of an email alert system to a pulmonologist attached to a lung cancer rapid diagnostic unit (Spain, 2008–2010)47Median (IQR) interval from scan to diagnosis 13 (7.3–30) daysThis strategy for radiological suspicion of lung cancer improves diagnostic efficacy and the communication between GPs, radiologists and pulmonologistsN/T
Iachina, 2017 [38]Retrospective cohort study evaluating effect of hospital transfers on the delay in diagnosis and treatment using 2009 national fast track cancer care pathways initiative (Denmark, 2008–2012) and data from the Danish Lung Cancer Registry11 273Mean±sd for group I 16.9±10.64 daysMean±sd secondary care interval 38.4±15.42 daysTransfer between hospitals during the care pathway might cause delay from diagnosis to treatment as well as in the total time from referral to treatment in patients with NSCLCN/T
Alsamarai, 2013 [39]Retrospective cohort study analysing effect of the CCCP at a Veterans Affairs hospital (USA, 2005–2010)163189Median (range) 28 (0–265) days; mean 40 days for total sample

Mean for n=163 versus n=189:
46 days versus 43 days (p=0.6)
Mean system interval in group C versus group I 126 days versus 101 days (p=0.015)Mean interval from scan to diagnosis in group C 76 days versus group I 53 days (p=0.016)A centralised, hospital-based CCCP can significantly reduce times to diagnosis of cancers that are early stage/incidentally found and reduce system interval by 25 daysSignificant reduction for system and scan to diagnosis intervals; not for treatment interval
Cattaneo, 2015 [40]Report on effect of RACLAP in one medical centre
RACLAP includes rapid thoracic nurse consultation, navigation and triage referral system (USA, 2010)
121Median interval from scan to diagnosis 16 daysRACLAP provided rapid and evidence-based evaluation and management of patients resulting in a short time to diagnosisN/T
Murray, 2003 [41]Multisite prospective randomised pilot study to test feasibility of two-step rapid diagnostic system (Royal Marsden Hospital) compared to conventional diagnostic workup in three local district hospital chest clinics (UK, 1998–2001)4543Median total interval in group C versus group I 49 days versus 21 days (p=0.0025)There are several advantages to investigations and diagnosis in the intervention arm, particularly in time to treatment initiation, patient satisfaction and rate of radical treatmentsSignificant reduction in total interval
Lo, 2007 [42]Retrospective cohort study of waiting times pre- and post-implementation of TTT programme: streamlined referral system from GPs to LCS (Canada, 2004–2005)52430Median for group C 17 days versus group I 4 daysMedian times from scan to diagnosis in group C versus group I 39 versus 6; “suspicion” to LCS referral in group C versus group I 20 versus 6; LCS visit to CT in group C versus group I 52 versus 3; “suspicion” to diagnosis in group C versus group I 128 versus 20TTT programme was effective in shortening the time from suspicion of lung cancer to diagnosis and reduced time intervals at each step in the processN/T
Dransfield, 2006 [43]Retrospective cohort study of timeliness for patients referred to specialised lung mass clinic (USA, 1999–2003)31 (resected), 125 (nonresected)Median time from LCS to diagnosis in resected patients versus nonresected patients 70 days versus 8 days (p<0.001)
Median time from LCS to resection in resected patients 104 days
Since the inception of the lung mass clinic, the resection rate at Birmingham VA Medical Center has improvedSignificant reduction only for LCS to diagnosis
Laroche, 1995 [44]Prospective review of a new quick access “two-stop” multidisciplinary investigation service at Papworth Hospital (UK, 1995)209Median (range) time from LCS to surgical resection 35 (7–81) daysThe two-stop investigation service led to higher rates of histological confirmation, routine CT scanning and review of every patient with confirmed lung cancer by a thoracic surgeon. This resulted in a substantial increase in the successful surgical resection rateN/T
Spurgeon, 2000 [45]Retrospective tracking cohort study assessing impact of TWW system (UK, 1997–1998)Unknown (total sample 767)Unknown (total sample 767)Median (IQR) before and after 12 (7–22) days versus 7 (3–13) days, respectivelyMedian (IQR) secondary care interval in group C versus group I 47 (28–77) days versus 39 (21–61) days, respectivelyWaiting times for urgent appointments were significantly less than the waiting times for nonurgent appointments for all 10 types of cancerN/T
Jiwa, 2004 [46]Retrospective review of impact of urgent (TWW or marked “urgent”) system (UK, 1990)Unknown (total sample 6)Unknown (total sample 6)Mean primary care interval 40 days; mean diagnostic interval 95 daysMean time from GP referral to diagnosis 55 daysPatients referred as “urgent” were diagnosed soonestNonsignificant
Neal, 2014 [47]Retrospective cohort study of diagnostic intervals between two cancer cohorts, defined before and after the implementation of the 2005 NICE referral guidelines for suspected cancer and by NICE-qualifying presenting symptoms (UK, 2001–2008)18162851Median (IQR) diagnostic interval in group C versus group I 114 (48–238) days versus 112 (45–251) days (p=0.47)Fast-track referrals may prioritise those with advanced disease in lung cancer, who are more likely to have “red flag” symptomsNonsignificant
Neal, 2007 [48]Retrospective cohort study comparing outcomes of cancer patients referred through the urgent TWW referral guidance with those who were not (UK, 2000–2001)31396Median (IQR) for group C 10 (4–17) days versus group I 10 (6–13) days, respectivelyMedian LCS to diagnosis in group C versus group I 15 (4–28) days versus 18 (8–36) days, respectivelyUrgent guideline referrals had later-stage diagnosis compared with patients diagnosed through other routes. There was some evidence for differences in outcomes for lung cancer between urgent guideline referrals (and all referrals marked as urgent) and those diagnosed through other routesNonsignificant
Forrest, 2015 [49]Retrospective data linkage study investigating factors impacting timely care in the setting of NHS Cancer Plan diagnostic pathways, including the TWW systemUnknown (total sample 28 733)Unknown (total sample 28 733)Median (IQR) 10 (6–17) days
(n=14 507)
Median (IQR) 35 (21–55) days
(n=14 692)
Median (IQR) secondary care interval 56 (39–79) daysMedian (IQR) time from GP referral to diagnosis 13 (7–24) days and from LCS to diagnosis 0 (0–0) daysNo detail of proportion of urgent referrals, but 70% of patients referred by GP saw a LCS within target interval of 14 days and 61% within secondary care target interval of 62 daysN/T
Devbhandari, 2008 [50]Prospective tracking cohort study of how bronchoscopy results affected waiting times to lung cancer treatment in patients referred by standard (via urgent GP TWW referral) and nonstandard referral pathways (UK, 2003–2005)149193Median for group C 1 dayRange of medians in group C 8–12 daysRange of median secondary care intervals 45–75 daysRange of median times from LCS to diagnosis 33–57 daysDelays persist despite TWW fast-track system due to hospital barriers
Treatment, secondary care and LCS diagnosis intervals significantly longer for bronchoscopy-negative groups
Bowen, 2002 [51]Prospective pilot study evaluating time between occurrence of symptoms and presentation to GP for patients presenting with lung cancer to two NHS trusts with “rapid access clinics” (UK, 2002)37Median (range) interval from first GP visit to first LCS visit 56 (0–175+) daysThere were delays in assessment and referral in primary careN/T
Hunnibell, 2012[52]Prospective tracking cohort study to investigate timeliness of lung cancer care before and after creation of a CT-VAHCS nurse navigator position (USA, 2007–2010)5766Median system interval in group C versus group I 40 and 45 daysMedian scan to LCS group C versus group I 13 and 10 days, respectivelyCT-VAHCS created and modified several processes to improve timeliness and quality of cancer care as soon as a patient's imaging suggested a new diagnosis of malignancy. The cancer care coordinator effected a measurable improvement in timelinessN/T
Lal, 2011 [53]Retrospective comparative cohort study of patients referred by GPs to lung cancer clinics for investigation of suspicious imaging before and after introduction of fast-track CT pathway
(UK, 2006–2007)
12486Median secondary care interval in group C versus group I 55 and 49 days, respectively (p=0.095)Median referral to decision to treat l in group C versus group I 42 and 35 days, respectively (p<0.05)Fast-tracking outpatients with suspicious chest radiographs straight to CT results in more effective use of clinic appointments, reduced diagnostic delay and more rapid treatment decision timesSignificant reduction only for interval from referral to diagnosis
Aasebo, 2012 [54]Retrospective cohort study of workup times for patients with lung cancer using the “Lean” quality improvement process (using mechanisms to identify and sustain high-value encounters and eliminate obstacles) to improve patient flow (Norway, 2006–2009)4033Median time to surgery/chemo/XRT=26.5/6/5.5 days, respectively
Median/mean time to surgery for intervention group 15/17 days (n=14)
Median scan to diagnosis in group C versus group I 64 versus 16 days, respectively
Median time from chest radiography to CT in group C versus group I 10 versus 5.5 days, respectively
It is feasible to improve patient flow for patients with lung cancer by employing the Lean method as a pathway instrumentN/T
Lewis, 2005 [55]Retrospective comparative cohort study examining the impact of TWW referral pathway for lung cancer over three different time periods, presented here as three separate samples: 1) 1999–2000; 2) 2000–2001; and 3) 2001–2002 (UK, 1999–2002)Sample (1) n=286Sample (2) n=352
Sample (3) n=404
Median (range):
1) 7 (0–124) days
2) 8 (0–101) days
3) 9 (0–98) days
(p=0.0009 for (1) versus (3))
Median (range) secondary care interval:
1) 37 (2–228) days;
2) 41 (2–307) days;
3) 42 (0–239) days
(p<0.04 for (1) versus (2) versus (3))
Median (range) GP referral to diagnosis:
1) 26 (0–228) days;
2) 33 (2–307) days;
3) 27 (0–300) days
(p<0.00001 for (1) versus (2); p=0.0003 for (2) versus (3))
Median (range) LCS to diagnosis:
1) 15 (0–219) days;
2) 21 (0–294) days;
3) 15 (0–300) days
(p<0.00001 for (1) versus (2) versus (3))
The TWW system failed to reduce waiting times for lung cancer in this study due to urgent referral routes used outside the TWW scheme and a large increase (42%) in referrals. Patients referred outside the TWW appear to be disadvantagedSignificant increase in all waiting times
Larsen, 2013 [56]Retrospective population-based study of changes in secondary care intervals in two hospital groups (Vejle versus other) after 2008 introduction of urgent referral scheme for cancer (Denmark, 2007–2009)Vejle n=387; other n=3131Vejle n=388; other n=2612Median (IQR) secondary care interval in group C versus group I for Vejle 31 (20–41) days versus 29 (23–65) days
Median (IQR) secondary care interval in group C versus group I for other 37 (21–64) days versus 33 (16–53) days
Urgent referral systems had a positive effect on secondary care intervals, although location-specific factors played a roleSignificant reduction in secondary care interval
Riedel, 2006 [57]Retrospective sequential single-institution (Veterans Affairs) cohort study evaluating the impact of a MTOC (USA 1999–2003) pre- and post-implementation101244Median before (n=89) versus after (n=205) 23 versus 21 days, respectively
Median diagnostic interval in group C versus group I 47 (n=89) versus 45 days (n=201), respectively
Median GP visit to LCS visit interval in group C versus group I 22 (n=90) versus 25 days (n=162), respectively
Median LCS to diagnosis interval in group C versus group I 14 (n= 90) versus 12 days (n=166), respectively
Median LCS to surgery interval in group C versus group I 40 (n=30) versus 50 days (n=56), respectively
Retrospective comparison with attendant confounders failed to reveal benefit of a MTOC as an intervention for timely lung cancer careSignificant reduction only for interval from first GP to first LCS visit

Group C: control group: group I: intervention group; GP: general practitioner; LCS: lung cancer specialist; RODP: rapid outpatient diagnostic programme; PET-CT: positron emission tomography-computed tomography; IQR: interquartile range; N/T: not tested; NSCLC: nonsmall cell lung cancer; CCCP: cancer care coordination programme; RACLAP: rapid access chest and lung assessment programme; TTT: time to treat; TWW: 2-week wait; NICE: National Institute for Health and Clinical Excellence; NHS: National Health Service; CT-VAHCS: Connecticut Veterans Affairs Healthcare System; XRT: radiation therapy; MTOC: multidisciplinary thoracic oncology clinic.