Improving Access to Care, Patient Costs, and Environmental Impact Through a Community Outreach Lung Cancer Rapid Assessment Clinic

Abstract

PURPOSE

In Southeastern Ontario, increased patient distance from the regional lung cancer diagnostic assessment program (LDAP) is associated with a lower likelihood of patient care via LDAP while receiving care via LDAP is associated with improved survival. We implemented an LDAP outreach clinic to provide specialist assessment for patients with suspected lung cancer at a regional community hospital and assessed the impact on timeliness and accessibility of care.

MATERIALS AND METHODS

The Kingston Health Sciences Centre LDAP team engaged with community hospital partners to develop and launch the LDAP outreach clinic. We performed a retrospective chart review of LDAP patients (N = 1,070) before (August-November 2021; n = 234) and after implementation of the outreach clinic (November 2021-October 2022; n = 836). Descriptive data are reported as No. (%). Unpaired t tests and statistical process control charts assess for significance. A cost analysis of out-of-pocket patient costs related to travel and parking is presented in 2022 Canadian dollars (CAD).

RESULTS

Compared with a 3-month matched time period before (August-October 2021) and after outreach clinic (August-October 2022), the mean time from referral to assessment and time from referral to diagnosis decreased from 20.3 to 14.4 days (P = .0019) and 40.0 to 28.9 days (P = .0007), respectively. Over 12 months, the total patient travel was reduced by 8,856 km, which combined with parking cost-savings, resulted in patient out-of-pocket savings of CAD $5,755.60 (CAD $47.60/patient). Accounting for physician travel, the total travel saved was 5,688 km, corresponding to reduced CO₂ emissions by 1.9 tCO₂.

CONCLUSION

Implementation of a lung cancer outreach clinic led to improved timeliness of care, patient cost-savings, and reduced carbon footprint while serving patients in their community.

LDAP outreach clinic led to faster lung cancer diagnosis, reduced patient costs, and lessened environmental impact.

INTRODUCTION

Lung cancer is the leading cause of cancer-related mortality in Canada and is associated with significant economic burden to the health care system and to patients and caregivers.^1,2 An estimated 30% of cancer-related costs are borne by patients and their families, including out-of-pocket expenses.² Significant differences in lung cancer survival outcomes exist across the province of Ontario.^3,4 Canadian data show that people with lower income and in rural communities are more likely to be diagnosed with lung cancer while lower income is also associated with worse survival.⁵ These disparities are of particular concern in Southeastern Ontario, which serves a predominantly rural patient population with marked variation in the percentage of low-income households (up to 40%). Not surprisingly, Southeastern Ontario has one of the lowest 5-year lung cancer survival in the province.⁶

CONTEXT

• Key Objective

• To report the impact of a lung cancer diagnostic assessment program (LDAP) outreach clinic with regards to access and timeliness of care, patient travel and cost-savings, and environmental footprint.

• Knowledge Generated

• Implementation of an LDAP outreach clinic led to faster patient assessment and diagnosis for patients with suspected lung cancer. By providing care closer to home, we reduced geographic and economic barriers to care by decreasing the travel distance and out-of-pocket expenses for patients seen in the outreach clinic. The environmental footprint of LDAP care was also reduced by offsetting carbon emissions through reduced travel.

• Relevance

• This model of care can be used to alleviate geographic and socioeconomic barriers to specialized care while serving patients in their local communities.

In 2009, the province of Ontario established Lung Diagnostic Assessment Programs (LDAPs) with the goal of providing streamlined diagnostic pathways for patients with suspected lung cancer, supported by patient navigation. However, LDAPs operate independently with no standardization of care pathways between programs, and as of 2019, there is no dedicated provincial funding or oversight for LDAPs.

The LDAP at Kingston Health Sciences Centre (KHSC) in Kingston, ON, serves Southeastern Ontario, a predominantly rural catchment area of more than 500,000 people. The region sees approximately 600 new patients with lung cancer annually. Approximately 50% of new lung cancer diagnoses are managed through the regional LDAP.⁷ In this LDAP, nurse navigators establish initial patient contact by telephone and are accessible to the patient by phone to help navigate the diagnostic process. Physician consultations occur almost exclusively in-person, coordinated with concurrent testing (eg, pulmonary function testing and bloodwork). Locally, 85% of patients referred to the LDAP are seen by a respirologist at first visit; the remaining 15% with suspected operable disease are triaged to a parallel thoracic surgery clinic.

The Southeastern Ontario LDAP has implemented several initiatives to improve timely access to specialized lung cancer care, which have led to faster diagnosis, staging, oncology assessment, and treatments while reducing patient and system costs.^8-11 A multidisciplinary lung cancer clinic (supported by respirologists, thoracic surgeons, medical oncologists, and radiation oncologists) improved timeliness of lung cancer diagnosis and treatment.¹⁰ The subsequent addition of a palliative care specialist to the clinic also improved timeliness of palliative care specialist assessment for patients with stage IV disease.¹² Additionally, the LDAP launched standardized triage pathways for patient referrals, which included (1) routine interdisciplinary triage, (2) preordered staging tests at the time of triage, and (3) a new small nodule clinic to which lower-risk patients requiring surveillance imaging were redirected; unlike the LDAP, this clinic does not have support by a nurse navigator and is staffed exclusively by respirologists (Fig 1).⁹ Furthermore, the LDAP launched a regional standardized radiology reporting initiative whereby standardized radiographic criteria prompt a radiologist to recommend LDAP referral, which led to improved timeliness of LDAP referral.⁸

FIG 1.

Referral algorithm for standardized triage pathways and the LACGH outreach clinic (adapted from Mullin et al⁹). CT, computed tomography; KHSC, Kingston Health Sciences Centre; LACGH, Lennox and Addington County General Hospital; LC, lung cancer; LDAP, Lung Diagnostic Assessment Program; MRI, magnetic resonance imaging; PET, positron emission tomography; PFT, pulmonary function tests. ^aSmall nodule clinic for patients with low suspicion of malignancy, including any of low-risk patient with isolated noncalcified nodule <1 cm without evidence of serial growth, ground glass opacity with solid component <5 mm, multiple subcentimeter nodules in a low-risk patient.

The annual number of patients assessed by the LDAP has increased from approximately 200 in 2016 to almost 700 in 2021. Additionally, patients with small lung nodules requiring surveillance imaging have remained a significant component of LDAP referrals, with 8.1% of referrals triaged to the small nodule clinic between 2018 and 2019.⁹ As such, there was a growing need to expand LDAP capacity to manage referral volumes. Meanwhile, our local data demonstrate that patient care via LDAP is independently associated with improved lung cancer survival, but increased patient distance from the regional LDAP is associated with a reduced likelihood of receiving care via LDAP.⁷ Up to 40% of LDAP referrals are for patients who live in the town of Napanee or further west from the LDAP. As geographical distance is a potential modifiable barrier to care, we identified an opportunity for improvement through the development of a community LDAP outreach clinic in a regional community hospital (Lennox and Addington County General Hospital [LACGH]), in Napanee, ON.

MATERIALS AND METHODS

Context

The LACGH in Napanee serves a large geographic region west of Kingston in a predominantly rural area. LACGH provides access to clinic space, community-based respirologists, pulmonary function testing, bloodwork, and on-site imaging making it an ideal environment to support an LDAP outreach clinic.

Interventions

The KHSC LDAP team engaged with partners at LACGH to develop and launch the LDAP outreach clinic. This included several stakeholder meetings with leadership at LACGH to secure clinic space, onboard existing administrative assistants, coordinate pulmonary function testing and bloodwork concurrent with clinic appointments, and recruit community respirologists to provide patient assessments. As the outreach clinic leveraged existing clinical resources and space at the LACGH site, while administrative support and patient navigation continued to be provided by KHSC, no additional funding was required for the LDAP outreach clinic.

The LDAP outreach clinic launched in November 2021 under the supervision of a KHSC LDAP physician to establish and sustain standard processes in keeping with the tertiary care center model. Although the clinic was initially held every other week, in response to growing patient demand and ongoing high referral volumes, the clinic frequency was increased to weekly in April 2022, with the support of community-based respirologists to participate in a rotating schedule. This outreach clinic mirrors the tertiary care center model, including access to navigators and standardized care pathways; the first visit includes respirologist consultation, imaging review, and pulmonary function testing and bloodwork where necessary.

When planning the LDAP outreach clinic launch, we prioritized booking clinically stable patients with less urgent care needs to the outreach clinic while patients with more urgent needs and advanced disease were preferentially booked to the KHSC tertiary care center to ensure necessary resources were in place while building capacity in the outreach clinic (Fig 1). Patients who were initially assessed in the outreach clinic but confirmed to have lung cancer after investigations were subsequently seen in follow-up at the KHSC tertiary care center multidisciplinary clinic for expedited oncology assessments,^10,12 whereas those with confirmed nonmalignant diagnoses or those requiring ongoing surveillance imaging returned to the outreach clinic for follow-up.

Measures

The primary goal of the LDAP outreach clinic was to improve timeliness of LDAP assessment through increased clinic capacity and by alleviating barriers to care. Secondary outcomes included assessing the impact on patient travel, cost, and environmental footprint. All patients seen in-person at either the KHSC or LACGH clinic were included in the analyses; we excluded patients that received only virtual visits as these were not specific to either site.

Access and Timeliness of Care

To evaluate the impact of the LACGH outreach clinic on access to care, we monitored the number of new LDAP patient referrals triaged to the respirology pathway monthly, including the number of new patients assessed at the KHSC and LACGH sites per month (ie, total LDAP clinic capacity). Patients assessed at both the KHSC and LACGH sites were included in analysis to assess the impact of increasing capacity on timeliness of care across the region. We collected data on patient-preferred site of specialist assessment and rationale by survey question at the time of appointment booking for patients living in Napanee or further west.

To measure the impact on timeliness of care, we tracked the average number of days from LDAP referral to assessment and referral to diagnosis for all LDAP patients.

Patient Travel and Out-of-Pocket Expenses

To evaluate the impact on patient travel and costs, the estimated patient distance traveled was calculated using the first three postal code digits relative to the site of assessment (LACGH or KHSC) and Google Maps.¹³ The shortest driving distance between the center of each postal code was calculated. Each distance was summed to determine the total estimated distance for all patients in the LACGH outreach clinic, including both LDAP-referred patients and small nodule clinic patients. Parking costs were calculated using average parking costs at each site (KHSC: Canadian dollars [CAD] $3/h; free parking at LACGH.)^14,15

Total out-of-pocket savings for patients were calculated using the total estimated patient distance traveled and an average travel allowance rate of CAD $0.59/km for 2021 and CAD $0.61/km for 2022 plus estimated saved parking costs for a patient attending an appointment at LACGH.¹⁶ Finally, the return-trip costs incurred by the KHSC physician attending the LACGH clinic (88 km) was calculated using Google Maps and the average travel allowance rate.

Impact on Environmental Footprint

The MyClimate CO₂ emissions calculator was used to determine the total and average tons of CO₂ saved.¹⁷ As the LDAP outreach clinic leveraged existing and available clinic space, staff, and testing available at LACGH and administrative and nurse navigator support were provided remotely, the primary variable influencing the environmental footprint was physician and patient travel. For the purpose of this calculation, the total kilometers saved by patients was calculated by determining the total number of kilometers that patients would have driven if traveling to KHSC and subtracting their actual travel distance to LACGH. Fuel type for the calculation was gasoline and the average fuel consumption of a mid-sized car was used (8.4 L/100 km).

Analysis

Descriptive data are reported as No. (%). Unpaired t tests assessed for significance; QI Macros 2022¹⁸ for Microsoft Excel was used to create statistical process control XbarS charts to assess for special cause variation. We used SQUIRE 2.0 guidelines to report our initiative.¹⁹

Ethics

The study was approved by the Health Sciences and Affiliated Hospitals Research Ethics Board of Queen's University (November 12, 2021, 6034732).

RESULTS

We reviewed 1,070 LDAP patient referrals (234 baseline [August 2021-November 2021]; 836 post-outreach clinic implementation [November 2021-October 2022]). Of the 1,070 referrals, 107 (10.0%) were triaged to the parallel thoracic surgery LDAP pathway, 742 (69.3%) were triaged to the respirology LDAP pathway, and 221 referrals (20.7%) were either inappropriate for the LDAP, canceled, or were duplicate referrals.

The patient characteristics and triage category for the 742 respirology pathway patients are summarized in Table 1. Of these patients, 635 (85.6%) were seen at KHSC, 94 (12.7%) were seen at the LACGH outreach clinic, and 15 (2.0%) were assessed through virtual visits. Of the 635 patients assessed at KHSC, 602 (94.8%) were seen in LDAP and 33 (5.2%) in small nodule clinic. The total number of patient visits at the LACGH site from November 2021 to October 2022 was 121 (96 new patients, 25 return patients). Of the 96 new patients assessed at LACGH, 82 (85.4%) were triaged to LDAP and 14 (14.6%) to small nodule clinic. The total number of LDAP patients diagnosed with lung cancer was 347 of 602 (57.6%) in the KHSC LDAP and 41 of 82 (50.0%) in the LACGH outreach clinic (Table 2).

TABLE 1.

Patient Characteristics and Triage Category for LDAP Patients in Respirology Pathway

Patients Assessed in Respirology LDAP	Baseline (August-November 2021; N = 168)	Post-Outreach Clinic (November 2021-October 2022; N = 574)
Age, mean	71.3	71.3
Female, No. (%)	85 (50.6)	284 (49.5)
Triage category, No. (%)
2: Small nodule	10 (6)	34 (5.9)
3: Localized early stage I or II lung cancer	34 (20.2)	148 (25.8)
4s3: Advanced suspected stage III lung cancer	42 (25)	107 (18.6)
4s4: Advanced suspected stage IV lung cancer	25 (14.9)	86 (15)
5: Needs to be seen in consult for suspected cancer	57 (33.9)	199 (34.7)
Diagnosis, No. (%)
Lung cancer	87 (51.8)	301 (52.4)
Other malignancy	9 (5.4)	36 (6.3)
Nonmalignant diagnosis	72 (42.9)	237 (41.3)

NOTE. For details around the criteria for the respective triage categories, please refer to the Data Supplement in Mullin et al.⁹

Abbreviation: LDAP, Lung Diagnostic Assessment Program.

TABLE 2.

Diagnosis by Site of Respirology LDAP Assessment: Baseline v Post-Outreach Clinic Launch

Site of First Patient Visit	Baseline (August 2021-November 2021; N = 150 patients)		Post-Outreach Clinic Launch (November 2021-October 2022; N = 534 patients)
	Lung Cancer	Non–Lung Cancer Diagnosis	Lung Cancer	Non–Lung Cancer Diagnosis
Tertiary care center LDAP (KHSC; n = 602)	87/150 (58.0%)	63/150 (42.0%)	260/452 (57.5%)	192/452 (42.5%)
Outreach clinic LDAP (LACGH; n = 82)	NA	NA	41/82 (50%)	41/82 (50%)
Total	87	63	301	233

Abbreviations: KHSC, Kingston Health Sciences Centre; LACGH, Lennox and Addington County General Hospital; LDAP, Lung Diagnostic Assessment Program; NA, not available.

Access and Timeliness of Care

Monthly, an average of 41.9 and 7.4 new patients were assessed in the KHSC and LACGH LDAP outreach clinics, respectively.

Between November 2021 and July 2022, 82 patients were offered an LACGH outreach clinic appointment; 64 (78%) accepted, most commonly because of proximity (n = 61; 95.3%). Of the 18 of 82 (22%) patients that selected KHSC site as their preferred consultation location, the main reason was due to sooner appointment (17/18; 94.4%). In response to this, the frequency of LACGH outreach clinics increased from biweekly to weekly in April 2022.

After LACGH outreach clinic implementation, average time from LDAP referral to specialist assessment decreased from 21.8 to 18.0 days, demonstrating special cause variation (Fig 2A). In March 2022, increased referral volumes and departure of an LDAP physician led to an increase in average time from LDAP referral to assessment to 27 days. With increased clinic frequency and additional physician coverage, this improved to 13.8 days by July 2022 (Fig 2A).

FIG 2.

(A) Average number of days from referral to LDAP assessment. (B) Average number of days from referral to diagnosis. Red diamonds and lines represent special-cause variation, that is, it indicate instability in data and represent statistically significant differences; dark blue squares and lines represent in-control points and trends (common-cause variation). The baseline mean is represented by a light blue line, which was fixed and used to identify special-cause variation in the process moving forward. Process change with recalculation of CL occurred with (1) implementation of the outreach clinic and (2) transition to weekly clinics. CL, control limit; LCL, lower control limit; LDAP, Lung Diagnostic Assessment Program; SPC, statistical process control; UCL, upper control limit.

After LACGH outreach clinic implementation, average days from LDAP referral to diagnosis decreased from 41.9 to 28.6 days for all LDAP-referred patients (Fig 2B) and from 39.8 to 21.2 days for patients diagnosed with lung cancer (Fig 3). Compared with a 3-month matched time period before (August-October 2021) and after LACGH outreach clinic launch (August-October 2022), the average time from referral to assessment decreased from 20.3 to 14.4 days (P = .0019) and time from referral to diagnosis decreased from 40.0 to 28.9 days (P = .0007).

FIG 3.

Average number of days from referral to lung cancer diagnosis. Red diamonds and lines represent special-cause variation, that is, it indicate instability in data and represent statistically significant differences; dark blue squares and lines represent in-control points and trends (common-cause variation). The baseline mean is represented by a light blue line, which was fixed and used to identify special-cause variation in the process moving forward. Process change with recalculation of CL occurred with (1) implementation of the outreach clinic and (2) transition to weekly clinics. CL, control limit; LC, lung cancer; LCL, lower control limit; LDAP, Lung Diagnostic Assessment Program; UCL, upper control limit.

Patient Travel and Out-of-Pocket Expenses

Implementation of the LACGH outreach clinic reduced patient travel by 8,856 km (73.2 km/patient visit). On the basis of the Canada Revenue Agency Automobile travel allowance of CAD $0.59/km for 2021 and CAD $0.61/km for 2022, the estimated total patient cost savings were CAD $5,392.6 (CAD $44.6/patient visit; Table 3).¹⁶ Total parking costs were also reduced by CAD $343 (Table 3). Overall, the total out-of-pocket patient costs saved, including distance traveled and parking costs, was CAD $5,755.60 (CAD $47.60/patient; Table 3).

TABLE 3.

Patient Travel and Out-of-Pocket Expenses Saved

Year	No. of Patients Seen at LACGH LDAP	Average Travel Saved per Patient (estimated travel to KHSC minus estimated travel to LACGH)	Travel Allowance Rate	Total CAD Saved, $
Patient travel expenses
2021	6	79.7 km/patient	CAD $0.59/km	282.00
2022	115	72.9 km/patient	CAD $0.61/km	5,110.60
Total return travel expense saved				5,392.60
Out-of-pocket expenses
Total parking cost saved (3$/h; n = 121)				363.00
Total patient out-of-pocket cost savings (n = 121)				5,755.60
Out-of-pocket cost savings per patient visit				47.60

Abbreviations: CAD, Canadian dollars; KHSC, Kingston Health Sciences Centre; LACGH, Lennox and Addington County General Hospital; LDAP, Lung Diagnostic Assessment Program.

Using the average travel allowance rate of CAD $0.59/km for 2021 and CAD $0.61/km for 2022 each physician return trip costs an average of CAD $12.24.¹⁶ Given the 36 clinic dates completed during the study period, the total cost of physician travel was CAD $440.64, offset by the $5,755.60 total out-of-pocket cost savings by patients.

Impact on Environmental Footprint

The carbon equivalence (tCO₂) was calculated from the travel distance of one doctor making a return trip distance from KHSC subtracted from the total travel distance reduced for patients assessed at LACGH. For the 8,856 km driving distance saved for 121 patients traveling to LACGH, a total of 3.0 tCO₂ was saved. For the 36 trips (ie, 3,168 km) a physician traveled to each LACGH outreach clinic, a total of 1.1 tCO₂ was emitted. Thus, a total of 1.9 tCO₂ was saved during the study period.

DISCUSSION

Implementation of an LDAP outreach clinic in Southeastern Ontario led to faster patient assessment and diagnosis for patients with suspected lung cancer. By providing care closer to home, we reduced geographic and economic barriers to care by decreasing the travel distance and out-of-pocket patient expenses for patients seen in the LACGH outreach clinic. We also reduced the environmental footprint of LDAP care by offsetting carbon emissions through reduced travel. This model of care can overcome geographical barriers to specialized lung cancer care by serving patients in their local community, while improving timeliness of care for all patients in the region and reducing health care–related climate impacts that ultimately benefit the whole population.

Timeliness in lung cancer management is critical as delays in care are associated with disease progression and patient distress.^20-22 Improving timeliness of care has the potential to improve clinical outcomes, including mortality. The LDAP has implemented several initiatives to improve timely access to specialized lung cancer care, which have led to reduced time to diagnosis, staging, oncology assessment, and treatment.^8-11 Habbous et al²³ have also studied the effects of LDAPs on lung cancer diagnosis and treatment in Ontario and found that LDAPs are associated with improved time to diagnosis, specialist assessment, and treatment, with a trend toward improved survival. As the Southeastern Ontario LDAP referral volume increased three-fold in 5 years, expansion of the clinic was necessary to increase capacity and maintain timeliness of care. With the implementation of the LACGH outreach clinic, regional access to lung cancer care was improved, and we demonstrated improved timeliness of assessment and diagnosis for LDAP patients across the region.

Rural populations have higher rates of late-stage lung cancer and mortality compared with urban populations, likely due to higher rates of smoking and barriers to accessing specialized lung cancer care.^24,25 The financial, emotional, and mental costs associated with travel to access essential health care create further barriers for patients.^26,27 These disparities are of particular concern in Southeastern Ontario, composed of a predominantly rural patient population with up to 40% low-income households. In Southeastern Ontario, patient care via LDAP is independently associated with improved lung cancer survival outcomes while increased patient distance is a barrier to receiving care via LDAP and could therefore affect survival.⁷ Implementation of the LDAP outreach clinic can overcome geographical barriers to specialized lung cancer care by serving patients in their local community; our results further support that patients prefer access to specialized care closer to home.

Lung cancer care is resource and cost intensive for patients, caregivers, and the health care system.^2,28,29 We previously reported that the addition of a weekly LDAP multidisciplinary clinic to streamline patient diagnostic and treatment pathways resulted in CAD $24,167 in direct patient out-of-pocket expenses over 22 months.¹¹ Here, we demonstrate a further CAD $5,755.60 out-of-pocket cost savings for patients.

The health care system is a significant contributor to greenhouse gas emissions.³⁰ Promoting environmental sustainability in health care can improve health outcomes, reduce costs, and create more resilient health systems.³¹ Our study demonstrates that an outreach clinic can reduce carbon emissions by reducing patient travel to appointments. A similar model reduced the carbon footprint through a surgical outreach clinic for diagnosis and monitoring of head and neck cancers in Atlantic Canada.³² While virtual care can also reduce climate footprint,³³ it is suboptimal for lung cancer care which requires a physical examination, concurrent pulmonary function testing for decision making around lung cancer management options, and complex patient discussions related to diagnostic and staging procedures.

One of the limitations to implementing an outreach clinic is the ability to staff the clinic with specialized physicians and allied health support. However, in the post-COVID era, this is a ubiquitous concern and continues to be a major obstacle when it comes to implementation of health care reforms.³⁴ Furthermore, in Ontario, referral to a specialty clinic such as the LDAP must be initiated by another physician, often a primary care physician. As of 2022, 2.2 million Ontarians were without a regular primary care practitioner, and rural Ontario is particularly underserved.³⁵ Despite our initiative to bring specialist care closer to patients, there are unfortunately likely to be delays in diagnosis of lung cancer because of lack of primary care access.

In conclusion, implementation of an LDAP outreach clinic led to improved timeliness of assessment and diagnosis for patients with suspected lung cancer in our region. The LACGH outreach clinic resulted in reduced out-of-pocket expenses for patients and reduced environmental footprint. This model of care can be used to alleviate geographic and socioeconomic barriers to specialized care while preferentially serving patients in their local communities.

AUTHOR CONTRIBUTIONS

Conception and design: Breanne Golemiec, Christopher M. Parker, Geneviève C. Digby

Collection and assembly of data: Breanne Golemiec, Madison Robertson, Vincent Poon, Mary Foley, Christopher M. Parker, Craig McGann, Geneviève C. Digby

Data analysis and interpretation: Breanne Golemiec, Madison Robertson, Christopher M. Parker, Geneviève C. Digby

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Improving Access to Care, Patient Costs, and Environmental Impact Through a Community Outreach Lung Cancer Rapid Assessment Clinic

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