Dr. Bukhari is chief resident of internal medicine at Wright Patterson Air Force Base in Ohio. Dr. Kumar is the section chief of hematology and oncology at the Dayton VAMC; Dr. Rajsheker is a hematologist and medical oncologist; Dr. Markert is a professor of medicine and orthopedic surgery and vice chair for research; and Dr. Bukhari is chief resident; all at Wright State University-Boonshoft School of Medicine in Dayton, Ohio.
In the present study, the primary aim was to assess system delay. The authors analyzed delay during 3 different periods: time to diagnosis (interval from date an abnormality was found on chest radiograph or computed tomography scan to date of tissue diagnosis); time to treatment initiation (interval from date of histopathologic diagnosis to date of treatment initiation); and time from date of initial abnormal imaging to date of treatment initiation. With RAND criteria applied, time to diagnosis longer than 60 days was considered diagnostic delay, time to treatment longer than 42 days was considered treatment delay, and the sum of these periods (102 days) was considered total delay. 5 Patients with diagnosis and treatment intervals that fell within these criteria were considered in adherence with the RAND criteria.
Means and standard deviations were reported for continuous variables and counts and percentages for categoric variables. Calculations were performed with IBM SPSS 21.0 (Armonk, NY).
Results
Of the 121 patients, 118 (97.5%) were men, and 3 (2.5%) were women. Mean (SD) age was 68.5 (8.9) years (range, 50-89 years). Of the 121 patients, 88 (73%) opted to be treated at Dayton VAMC, and the other 33 opted to receive palliative care only (20) or to be treated at an outside facility (13). The group of 33 patients was included in the analyses of diagnostic delay but not treatment delay (Table 1).
Mean (SD) time to diagnosis was 35.5 (31.6) days (n = 111), mean (SD) time to treatment was 55.9 (46.3) days (n = 87), and mean (SD) total time was 92.7 (62.1) days (n = 82). Table 2 lists data regarding adherence to RAND guidelines for diagnostic delay (diagnostic timeliness), treatment delay (treatment timeliness), and total delay (total timeliness) for 3 groups of patients: all patients, and those who did and did not participate in cardiopulmonary rehabilitation. Of all patients, 82.9% met the RAND diagnostic time standard, 51.7% met the treatment time standard, and 61.0% met the total time standard. As expected, the proportions of patients meeting the RAND standards were higher for the group that participated in cardiopulmonary rehabilitation: 89.2%, 58.6%, and 72.3% for diagnostic, treatment, and total time, respectively.
Table 3 lists data regarding adherence to RAND guidelines by treatment modality, excluding the patients who participated in cardiopulmonary rehabilitation. With the exception of surgery only, all other primary treatment modalities were marked by 90% or higher adherence in meeting diagnostic timeliness. However, treatment initiation adherence was lower: 40% to 76.2% in the nonsurgical groups and 25% in the surgery group.
The cardiopulmonary rehabilitation group was analyzed separately (Table 4).
Overall, 50% of the patients in this group met the RAND diagnostic time standards and 23.5% met the treatment time standards. There was no clear improvement pattern for these patients when stratified by treatment modality.
For diagnostic time, patients with advancedstage (IIIB/IV) disease and patients with small cell lung cancer (SCLC) had adherence of at least 87.5%, and patients with stage II/IIIA disease had adherence of at least 80% (Table 5). However, only 62.5% of patients with stage I disease were adherent to the diagnostic guideline. Patients with stage IIIA/IV disease and patients with SCLC had the best performance for the treatment guideline, with no group < 60% adherent.
