Diagnostic pathways and rapid referral services
Rapid referral pathways streamline the pre-diagnosis process and improve the speed with which patients get accurate diagnoses. This can improve patient outcomes by finding cancers earlier and the reduction of repeat-scans also helps reduce the emotional turmoil patients face before a definitive diagnosis7,11–13
Primary health care teams play a critical role in the diagnosis process but may lack necessary knowledge or information to ensure patients have timely access to care14. Resource availability, lack of awareness of diagnostic tests and when to refer patients can be compounding factors in accessing the right diagnostic services at the right time.
Education and supports, including tailored strategies co-created with primary health care providers to facilitate uptake of new guidelines and educational programs, are important components in the early diagnosis phase.
While connected-care models have shown to streamline the diagnosis process, the lack of patient access to family physicians and the resulting reliance on walk-in clinics can affect continuity of care and impact timely diagnosis.
Digital navigation tools can provide practical solutions
Patient navigators are often a limited resource. Digital navigation tools can accelerate the diagnosis process and help with symptom management by providing educational material, answering frequently asked questions and connecting patients and their caregivers to additional resources in the community.
A connected-care approach
A connected-care approach can support and enhance the organization of patient care through patient access to information and navigation, effective communication and cooperation across health care providers, as well as timely delivery of services15.
Key enablers to implementing innovative models of care in the early diagnosis phase include:
- Engagement of both cancer and primary health care teams
- Leadership buy-in
- Creation of multidisciplinary teams
- Involvement of patients in planning and decision making
- A robust evaluation and sustainability plan.
The principles of equity-by-design, including goal clarity, a focus on equity-mindedness and continual learning, serve as core tenets of any major model implementation, especially those involving multiple care providers.16
Defining characteristics of a diagnostic pathway map
A – Provides a tailored snapshot of a patient’s unique care pathway.
B – Organizes information by cancer type and phase along the cancer journey
C – Designed as a tool for use by health-care providers, administrators and people new to the cancer system.
D – Evidence-based from local, national and international clinical practice guidelines.
E – Responsive to new and rapidly evolving treatment or technology evidence.
Evaluating the impact of an intervention
Outcome indicators used in evaluation of an intervention in the pre-diagnosis phase include wait time measures, patient experience measures and clinical outcome measures. Incorporating these indicators early in the model implementation process will support continuous quality improvement.
Equity-based outcome indicators are critical to measuring impact and effectiveness of initiatives that are designed to address the needs of First Nations, Inuit and Métis and/or underserved communities.
Rapid reviews, environmental scans, consultation with partners and guidance from our Models of Care Working Group helped identify a list of approaches across Canada and around the world that have the potential to be scaled and spread to other Canadian cancer programs.
Denmark’s three-legged referral strategy provides a roadmap for primary health care teams that is based on the patient’s symptoms. Recognizing that each patient may present differently along the disease trajectory, the strategy provides a clear pathway for alarm symptoms, serious but not cancer-specific symptoms and vague and non-serious symptoms.
Patients with specific alarm symptoms represent approximately half of cases and have access to an urgent referral with a 2-week wait time for a specialist based on symptom criteria listed in pathway.
Patients with serious but unspecific symptoms represent approximately 20% of cases and have access to an urgent pathway. A family physician orders a standard battery of tests then either refers the patient to the specific urgent referral pathway or decides on further diagnostic testing.
Patients with vague and non-serious symptoms represent approximately 30% of patients. No-Yes-Clinics provide family physicians access to more detailed diagnostic investigations without referring the patient to a specialist.
The three-legged referral model supports:
- Reduced wait times
- Enhanced collaboration between primary health care and cancer care
- A shift to earlier stages at diagnosis in some cancers and an increase in one-year survival rates
- Enhanced satisfaction with quality of care and wait times among patients and staff
Learn more about Denmark’s three-legged referral strategy17,18.
Diagnostic Assessment Programs (DAPs) were implemented in Ontario to serve as a centralized management and coordination approach to cancer diagnosis. By providing a single point of contact for patients, the program uses evidence-based pathways to help patients and their health-care providers navigate the diagnostic phase.
DAPs support connected care with primary health care teams to ensure safe and effective coordination of diagnostic services using a risk-stratification approach. While some DAPs are not considered sustainable within the province’s cancer system, there are opportunities to capitalize on DAP’s streamlined approach to facilitate coordinated management of patients during cancer diagnosis.
DAPs seek to:
- Improve quality and accessibility of care for patients
- Advance a person-centred approach to diagnostic care
- Drive integrated-care delivery among services and providers
- Maximize value of care delivered
Recognizing that not all patients have a family physician, DAP referrals support access from a range of settings, including emergency departments, radiology clinics and primary health care, as well as through self-referrals. Coordinating services between the cancer program and primary health care team ensures that everyone involved in patient care has access to test results.
The DAP model supports:
- Reduced wait times from suspicion to referral
- Enhanced emotional supports to address anxiety during diagnosis phase
- Identifying cancers faster and at an earlier stage
Learn more about Ontario’s Diagnostic Assessment Program.19
Dial-a-specialist provides virtual solutions for connected care
Primary health care-led diagnostic processes and post-cancer treatment surveillance/wellness programs support person-centred care in a timely way. However, studies show that primary health care providers often feel that they do not have sufficient time and expertise to provide cancer support for their patients20.
BC’s Rapid Access to Consultative Expertise (RACE) connects primary health care providers to speciality services for real-time advice over the phone. This virtual support service enhances the success of connected care models.
The Ontario eConsult program leverages a secure web-based tool allowing physicians and nurse practitioners timely access to specialist advice for all patients, often eliminating the need for a referral. Primary care physicians can link to cancer specialists and receive a response within an average of two days.
Tips for delivering culturally appropriate care
A rapid review commissioned from McMaster Health Forum to support the identification of connected care models, sought but did not identify any First Nations, Inuit or Métis-led initiatives specific to cancer pre-diagnosis. The Partnership will work with partners to identify other ways to learn about First Nations, Inuit and Métis-led models and, if warranted ways to incorporate innovative models into Indigenous-led cancer care. In the meantime, consider these tips for delivering culturally appropriate care21
- Develop care pathways and models of care in partnership with First Nations, Inuit and Métis partners and community health services
- Provide appropriate and accessible interpretation and support services
- Designate a culturally appropriate health-care provider to keep in contact with the patient to maintain engagement along the cancer pathway
- Ensure access to supportive care services to address specific social, practical and cultural needs of First Nations, Inuit and Métis patients and families, including children. The supportive Care Needs Assessment Tool for Indigenous People can help identify services.
- Ensure appropriate supports are in place for those who must travel to complete diagnostic interventions
- Lavis JN, Hammill AC. Care by sector. In Lavis JN (editor), Ontario’s health system: Key insights for engaged citizens, professionals and policymakers. Hamilton: McMaster Health Forum; 2016, p. 209-69.
- Tremblay D, Latreille J, Bilodeau K, et al. Improving the transition from oncology to primary care teams: A case for shared leadership. J Oncol Pract. 2016;12(11):1012-1019.
- Tremblay D, Prady C, Bilodeau K, et al. Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies. BMC Health Serv Res. 2017;17(1).
- Meiklejohn JA, Mimery A, Martin JH, et al. The role of the GP in follow-up cancer care: a systematic literature review. J Cancer Surviv. 2016;10(6):990-1011.
- Kang J, Park EJ, Lee J. Cancer survivorship in primary care. Korean J Fam Med. 2019;40(6):353-361.
- Watson L, Qi S, Delure A, et al. Virtual cancer care during the COVID-19 pandemic in Alberta: Evidence from a mixed methods evaluation and key learnings. JCO Oncol Pract. 2021;17(9):e1354-e1361.
- Cancer Quality Council of Ontario. Programmatic Review on the Diagnostic Phase: Environmental Scan.; 2016.
- Gorin SS, Haggstrom D, Han PKJ, Fairfield KM, Krebs P, Clauser SB. Cancer care coordination: A systematic review and meta-analysis of over 30 years of empirical studies. Ann Behav Med. 2017;51(4):532-546.
- Mittmann N, Beglaryan H, Liu N, et al. Examination of health system resources and costs associated with transitioning cancer survivors to primary care: A propensity-score–matched cohort study. J Oncol Pract. 2018;14(11):e653-e664.
- Zhao Y, Brettle A, Qiu L. The effectiveness of shared care in cancer survivors-A systematic review. Int J Integr Care. 2018;18(4):2.
- Jensen, H. Implementation of cancer patient pathways and the association with more timely diagnosis and earlier detection of cancer among incident cancer patients in primary care. PhD dissertation. Aarhus University; 2015
- Møller H, Gildea C, Meechan D, Rubin G, Round T, Vedsted P. Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study. BMJ. 2015;351:h5102
- Prades J, Espinàs JA, Font R, Argimon JM, Borràs JM. Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study. Br J Cancer. 2011;105(6):753-759.
- Canadian Partnership Against Cancer. Leading Practices to Create a Seamless Patient Experience for the Pre-Diagnosis Phase of Care: An Environmental Scan. 2018. Accessed November 22, 2021. https://canimpact.utoronto.ca/wp-content/uploads/2018/04/Leading-Practices-to-Create-a-Seamless-Patient-Experience-for-the-Pre-Diagnosis-Phase-of-Care-CPAC-2018.pdf
- Walsh J, Young JM, Harrison JD, et al. What is important in cancer care coordination? A qualitative investigation: What is important in care coordination? Eur J Cancer Care (Engl). 2011;20(2):220-227.
- Wong WF, LaVeist TA, Sharfstein JM. Achieving health equity by design. JAMA. 2015;313(14):1417-1418.
- Vedsted P, Olesen F. A differentiated approach to referrals from general practice to support early cancer diagnosis – the Danish three-legged strategy. Br J Cancer. 2015;112 Suppl 1(S1):S65-9.
- All.Can. Danish Cancer Patient Pathways: three-legged strategy for faster referral and diagnosis of cancer. Accessed November 24, 2021. https://www.all-can.org/efficiency-hub/danish-cancer-patient-pathways-three-legged-strategy-for-faster-referral-and-diagnosis-of-cancer/
- Ontario Health (Cancer Care Ontario). Navigating the Diagnostic Phase of Cancer – Ontario’s Strategic Directions 2014-2018. Accessed November 23, 2021. https://www.cancercareontario.ca/sites/ccocancercare/files/assets/CCODAPStrategyReport.pdf
- Lewis RA, Neal RD, Hendry M, et al. Patients’ and healthcare professionals’ views of cancer follow-up: systematic review. Br J Gen Pract. 2009;59(564):e248-59.
- Cancer Council Victoria. Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer Draft for National Public Consultation.; 2017. Accessed November 22, 2021. https://apo.org.au/sites/default/files/resource-files/2017-09/apo-nid108366.pdf
- Jefford M, Koczwara B, Emery J, Thornton-Benko E, Vardy JL. The important role of general practice in the care of cancer survivors. Aust J Gen Pract. 2020;49(5):288-292.
- Cancer Care Manitoba. Manitoba’s Moving Forward After Cancer program. Accessed November 24, 2021. https://www.cancercare.mb.ca/Treatments/after-treatment-is-over
- Alberta Health Services. Home to Hospital to Home Transitions. Accessed November 24, 2021. https://www.albertahealthservices.ca/info/Page17125.aspx
- Ontario Health (Cancer Care Ontario). Follow-Up Model of Care for Cancer Survivors. Accessed November 24, 2021. https://www.cancercareontario.ca/sites/ccocancercare/files/guidelines/full/FollowUpModelOfCareCancerSurvivors.pdf
- Canadian Partnership Against Cancer. 5,000+ paramedics in six provinces to provide palliative care in the home. Accessed November 24, 2021. https://www.partnershipagainstcancer.ca/news-events/news/article/5000-paramedics-six-provinces-palliative-care-home/
- Canadian Hospice Palliative Care Association. Innovative Models of Integrated Hospice Palliative Care, the Way Forward Initiative: An Integrated Palliative Approach to Care.; 2013. Accessed November 24, 2021. http://www.hpcintegration.ca/media/40546/TWF-innovative-models-report-Eng-webfinal-2.pdf