Patients Prefer Chemotherapy on the Same Day As Their Medical Oncology Outpatient Appointment

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1 Health Care Delivery Original Contribution Patients Prefer Chemotherapy on the Same Day As Their Medical Oncology Outpatient Appointment By Peter K.H. Lau, MBBS, Melanie J. Watson, MSc (Stat), and Arman Hasani, MBBS Royal Perth Hospital; Department of Health, Western Australia; and Sir Charles Gairdner Hospital, Perth, Western Australia, Australia Abstract Purpose: Numerous oncology units have separated outpatient appointments and chemotherapy delivery to another day (TOD) to improve efficiency. This survey assessed patient preferences for scheduling medical oncology outpatient appointments and chemotherapy delivery for either treatment delivered on the same day as the outpatient appointment (TSD) or TOD. Patients and Methods: Patients (N 198) from two major metropolitan tertiary centers in Perth Sir Charles Gairdner Hospital (n 110) and Royal Perth Hospital (n 88) completed surveys from April 15 to May 24, Eligibility criteria included any adult patient with cancer receiving an intravenous chemotherapy or targeted agent who had completed two cycles of treatment or attended two chemotherapy appointments on a concurrent chemoradiotherapy program. Results: The majority of patients preferred TSD (85%) versus TOD. Convenience (50%) and distance or difficulty in transportation to hospital (25%) were the most common reasons for TSD preference. Current treatment schedule (odds ratio [OR], 59.2; 95% CI, 18.7 to 265.2) was significantly associated with treatment schedule preference. Younger age (58.3 v 65.2 years; P.01) and presence of household dependents (OR, 4.2; 95% CI, 1.2 to 27.1) were also associated with TSD preference. Scheduling preference 2 was not influenced by time prepared to wait for chemotherapy ( (2) 3.86; P.14), with 44% and 39% of patients willing to wait up to 60 and 120 minutes, respectively. Almost all patients preferred chemotherapy delivery before 2 PM (99%). Conclusion: Patients preferred to receive chemotherapy on the same day as their medical oncology outpatient appointment. Morning delivery of chemotherapy was preferred. Meeting patients expectations will present significant challenges to efficient service provision as caseloads increase. Introduction Chemotherapy suites face increasing capacity constraints that limit efficient delivery of treatment. An ageing global population and increased incidence and survival, along with ever-expanding treatment options, have combined to drive chemotherapy outpatient service demand. 1-3 Consequently, there have been increasing efforts to improve chemotherapy unit efficiency, 4-8 and adoption of business methodologies with a focus on patient waiting times is becoming more widespread. 4,8 Comprehensive auditing of outpatient appointment demand and actual infusion time aids in service mapping. 4,5,8 Improved scheduling software and modeling of appointments to match demand with available staffing are also important in service improvement. 5,7,9 Allocation of low-risk patients not requiring blood tests or physical examination to off-peak timeslots, 6 parking incentives to promote afternoon treatment delivery, 10 and patient reminders 10,11 have also been described. Numerous units have also separated medical oncology outpatient appointments and moved chemotherapy delivery to other days (TOD), which has been shown to limit drug wastage and improve waiting times and overall efficiency. 12 Anecdotally, a number of sites in Australia, Canada, and the United Kingdom have moved to TOD scheduling. Royal Perth Hospital (RPH) and Sir Charles Gairdner Hospital (SCGH) are the two largest public metropolitan tertiary academic referral centers in Western Australia, serving a large statewide catchment area with a population in excess of 2.5 million. The development of a new tertiary hospital site with reorganization of outpatient chemotherapy services to exclusive TOD scheduling and the expansion of medical oncology outpatient clinics into the evening were proposed. Moving to a TOD schedule would allow additional time to verify chemotherapy orders and permit allocation of a set chair time for preparation and delivery of chemotherapy. Regularly at SCGH, an estimated 20% of preprepared chemotherapy drugs for patients scheduled on the same day (TSD) were not used because of cancellations or postponement, which represented significant drug and labor costs (Michael Caine, SCGH Senior Pharmacist Oncology, personal communication, May 1, 2013). A reduction in patient waiting time, moderation of chair demand, and increased efficiency using a constrained nursing and pharmacy workforce were also cited as advantages of TOD scheduling. These changes, together with a paucity of published data describing patient impact and preferences for chemotherapy scheduling, prompted us to launch this survey. In contrast to other reported literature focusing on institutional outcomes, our quality improvement project investigated chemotherapy scheduling preferences from a patient perspective. The objective was to survey patient preferences for TSD or TOD. Secondary aims were to profile socioeconomic, cancer, physical, geographic, and transportation factors thought to be e380 JOURNAL OF ONCOLOGY PRACTICE VOL. 10, ISSUE 6 Copyright 2014 by American Society of Clinical Oncology

2 Patients Prefer Chemotherapy on Same Day As Outpatient Appointment important in patient preference. Preferred chemotherapy delivery time was also surveyed. Patients and Methods We conducted a survey of patients currently receiving chemotherapy at RPH and SCGH. Both hospital ethics committees approved the survey as a quality improvement project (RPH, reference No ; SCGH, reference No. 4059). Eligibility criteria for the survey included any adult patient receiving an intravenous chemotherapy or targeted agent who had completed two cycles of treatment or attended two chemotherapy appointments on a concurrent chemoradiotherapy program. The sample size to detect a majority treatment scheduling preference of 60% with 80% power and 5% significance was 194. Eligible patients were approached in the chemotherapy suite immediately before or during their intravenous treatment by recruiting physicians and nurses. Patients consented verbally and completed the survey independently while receiving their treatment. The survey comprised 30 questions; demographic and socioeconomic factors were profiled in eight questions, with 12 questions about transportation to hospital and 10 questions regarding scheduling of treatment. The questionnaire received favorable feedback during a pilot (n 10) conducted before the survey period. Cancer type, treatment intent, and chemotherapy regimen were extracted from patient records. Surveys were deidentified after data collection. TSD patients were defined as those having their medical oncology outpatient appointment only on the same day as their chemotherapy treatment. Patients requiring multiple infusions per cycle were assessed as TSD if their physician appointment was on the same day as their treatment exclusively. TOD patients were those seen in the medical oncology outpatient clinic on a different day from their treatment. Patient treatment schedule was determined by hospital records and visit data. Patient treatment preference was the primary outcome, and comparisons between the two groups (TSD v TOD) were analyzed using 2, t, and Wilcoxon rank sum tests as appropriate. Statistical analyses were conducted using R software (version 3.0.1; R Foundation for Statistical Computing, Vienna, Austria), and a significance level of.05 was assumed. Results A total of 199 surveys were completed from SCGH (n 110) and RPH (n 89) between April 15 and May 24, One survey was excluded from analysis because it was received 3 weeks after the survey period concluded. A total of 198 evaluable surveys represented 45% of eligible patients. Metropolitan area patients accounted for 82% of respondents, which is representative of the overall state population distribution (Table 1). A majority of patients (79%) were not currently working, and total reported household income was Australian $25,000 in 47% of respondents (median Australian household income at time of survey was approximately $78,000). 13 Preferred Treatment Schedule The majority of patients (85%; 162 of 190) preferred TSD scheduling. Patients who preferred TSD were younger compared with those favoring TOD (58.3 v 65.2 years; P.01; Table 1). Two other variables were found to be statistically significantly associated with patient preference: existing treatment schedule and presence of a dependent (Figs 1A and 1B). Patients on an existing TSD schedule strongly preferred a TSD schedule compared with patients on an existing TOD schedule (odds ratio [OR], 59.2; 95% CI, 18.7 to 265.2). Caring for a dependent was associated with a preference for TSD scheduling (OR, 4.2; 95% CI, 1.2 to 27.1); 5% of patients with a dependent preferred TOD compared with 17% with no dependents. Cancer type was marginally statistically significantly associated with treatment preference. Patients with breast cancer had a tendency to prefer TSD compared with patients with other 2 cancer types ( (3) 7.89; P.05). Those with a household income $25,000 trended toward preferring TSD compared with those with a higher income ( 2 (1) 3.25; P.07). There was no association between scheduling preference and time prepared to wait for chemotherapy after a medical oncology outpatient appointment ( 2 (2) 3.86; P.14). The majority of patients (83%) were prepared to wait 30 minutes, with 39% of respondents willing to wait up to 120 minutes. Reasons for Chemotherapy Scheduling Preference and Preferred Delivery Time Patients were asked to identify reasons for their preferred treatment schedule. Convenience and difficulty and distance in transport to hospital were the two most common reasons for selecting TSD at 50% and 25%, respectively. Delays between chemotherapy and medical oncology appointment or feeling physically tired after the physician appointment were the most frequent reasons for preferring TOD at 32% and 21%, respectively. Almost all patients preferred their chemotherapy to be delivered in the morning, with 99% selecting chemotherapy to be delivered before 2 PM and 80% choosing times slots before 11 AM (Fig 2). No patients selected chemotherapy delivery after 5 PM. Discussion Our survey sought to assess patient preferences for chemotherapy appointment scheduling and delivery. To our knowledge, this is the largest survey on preferences for chemotherapy scheduling, also exploring associations between preferred treatment time and demographic, socioeconomic, and transportation patient factors. The majority of patients preferred to receive chemotherapy on the same day as their medical oncology appointment, which is consistent with previous literature. 4 Patients already on a TSD schedule overwhelmingly favored their existing treatment schedule, which may suggest an increase in patient dissatisfaction if rescheduled to TOD. Although it is likely patient preferences were heavily influenced by their existing treatment experience, patients who were already receiving TOD did not have a clear treatment scheduling preference; Copyright 2014 by American Society of Clinical Oncology NOVEMBER 2014 jop.ascopubs.org e381

3 Lau, Watson, and Hasani Table 1. Patient, Cancer, and Chemotherapy Delivery Characteristics by Treatment Schedule Preference Treatment Preference TOD (n 28)* TSD (n 162)* Total (N 198)* Characteristic No. % No. % No. % P Age, years.01 (t ) Mean SD Sex.25 ( (1) 1.30) Female Male Area of residence.59 ( (1) 0.29) Metropolitan Nonmetropolitan Employment status.13 ( (1) 2.29) Working Not working Household income, Australian $.07 ( (1) 3.25) 0 to 25, , Dependent(s).04 ( (1) 4.21) Yes No Median travel time, minutes (W 1,852) Mode of transport.76 ( (1) 0.09) Private car Other Treatment intent.27 ( (1) 1.24) Curative Palliative Cancer type.05 ( (3) 7.89) Breast Colorectal Lung Other Karnofsky score.49 ( (1) 0.49) Current delivery schedule.001 ( (1) 78.2) TOD TSD Time prepared to wait for chemotherapy delivery after clinic appointment, minutes Up to Up to Up to ( 2 (2) 3.86) Abbreviations: SD, standard deviation; TOD, treatment scheduled for other day than outpatient visit; TSD, treatment scheduled for same day as outpatient visit. * Categories may not sum to total because of small amounts of missing data. Travel time from place of residence on day of treatment to hospital (one way). Wilcoxon rank sum test used to compare medians. however, the proportion of participants currently on TOD was small (n 48; 24%). Convenience and transport difficulties were the primary reasons for preferring TSD. Despite the two hospital sites being close to public transport hubs, 79% of patients came to hospital via private car, with the majority (70%) requiring a second person to drive. Service planning data at SCGH indicate the median waiting time for chemotherapy delivery after a medical e382 JOURNAL OF ONCOLOGY PRACTICE VOL. 10, ISSUE 6 Copyright 2014 by American Society of Clinical Oncology

4 Patients Prefer Chemotherapy on Same Day As Outpatient Appointment A B Percentage of Patients Percentage of Patients % TSD (n = 145) 5% 95% 2% oncology appointment is 88 minutes, which is within expectations for a significant proportion of patients in our survey. 14 This time to chemotherapy after appointment is virtually identical to the travel time for our cohort to and from hospital, which indicates patients would not save time when allocated to TOD. 56% 44% TOD (n = 45) Current Treatment Schedule Dependent (n = 42) Presence of Household Dependent(s) Figure 1. (A) Current treatment schedule by schedule preference. (B) Dependents by schedule preference. OR, odds ratio; TOD, treatment scheduled for day other than outpatient visit; TSD, treatment scheduled for same day as outpatient visit. 19.7% 0.5% 6.0% 73.8% 17% 83% No dependent (n = 143) Figure 2. Preferred chemotherapy delivery time. TOD preference TSD preference OR = % CI, 18.7 to TOD preference TSD preference OR = % CI, 1.2 to to 8 AM 8 to 11 AM 11 AM to 2 PM 2 to 5 PM 5 PM to 7 PM Although patients overall preferred TSD, an exploratory analysis failed to identify variables that may predict a preference for TOD; however, the sample of patients was small in the TOD group. Factors that predicted a preference for TSD were younger age, existing treatment schedule, and caring for a dependent. Patients with breast cancer had a trend toward preferring TSD compared with other cancer types; this may be the result of a higher proportion of patients with breast cancer caring for a dependent (38% v 14% for all other cancers). In addition, there was a trend for patients with a low household income to prefer TSD, which may relate to fewer resources for transportation. Hence, several socioeconomic and demographic factors may influence chemotherapy schedule preference. Although interesting results have been obtained, there were several limitations in our survey. Because of workforce limitations, we were unable to approach all eligible patients. Patients were not randomly selected; hence, an element of bias may have been introduced. The smaller number of TOD-scheduled patients in the survey hampered meaningful regression analysis for factors that may predispose toward TOD preference. However, the proportion of TOD-scheduled respondents surveyed was representative of actual patient scheduling allocation at both hospitals. Additional surveys are in progress to address these weaknesses. Lastly, RPH and SCGH are public statewide referral centers, which may limit the applicability of our survey results to private and suburban practices, particularly with respect to transportation and other demographics. Similar to previous work, our survey has shown patients strongly prefer TSD and morning delivery of treatment in a metropolitan public hospital setting. 4 Numerous chemotherapy units have employed TOD scheduling to improve efficiency and waiting times, with little consideration of the issues that patients face. In this survey, TOD patients were disadvantaged because their total travel time to and from hospital exceeded their waiting time for chemotherapy after an outpatient appointment on a TSD schedule. Increased travel to hospital may in turn increase patient stress and carer burden, particularly given the high proportion of respondents relying on others for transport. This survey also highlights the global challenge of balancing clinical efficiency and providing patient-centered care. With rising oncology drug and labor costs, the need to limit wastage is essential in a climate of escalating health care expenditure. 1,15 Additionally, workforce shortages place further pressure on administrators to maximize clinical efficiency. Given these demands, patient expectations need to be balanced with the capacity and scheduling constraints of chemotherapy suites. These challenges are not unique to Australia; all oncology units planning to implement TOD scheduling need to determine whether the potential financial and efficiency gains outweigh the negative impact on patients and their families. Patient-centered care is paramount, but optimizing resource use is also critical. We suggest allocation of scheduling based on patient proximity to the chemotherapy unit or other transportationrelated factors. Tighter integration with medical and pharmacy staff with respect to drug ordering may also mitigate drug wast- Copyright 2014 by American Society of Clinical Oncology NOVEMBER 2014 jop.ascopubs.org e383

5 Lau, Watson, and Hasani age. Patients receiving high-cost drugs with short shelf lives could also be considered for TOD scheduling to limit wastage. As a result of this quality-improvement project, services at the new tertiary hospital are currently planned to continue on a TSD schedule. Further research is under way to explore psychosocial factors associated with preferred chemotherapy scheduling and to confirm our results. Acknowledgment Supported by Department of Health, Western Australia through Cancer Research Fellowship (P.K.H.L.). We thank the respondents to the survey for their participation. Presented orally at the Eighth State Cancer Conference of Cancer Council Western Australia, Perth, Western Australia, Australia, October 24, 2013, and as a poster abstract at the 36th Annual Scientific Meeting of the Clinical Oncological Society of Australia, Adelaide, South Australia, Australia, November 12-14, We also thank Jennifer Doyle for her assistance in recruitment; Debbie Redman, Michael Millward, MBBS, MA, and Andrew Davidson, MBBS, MBIO, for supporting this survey; and Claire Johnson, PhD, for editorial comments and assistance. Authors Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a U are those for which no compensation was received; those relationships marked with a C were compensated. For a detailed description of the disclosure categories, or for more information about ASCO s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: None Consultant or Advisory Role: Arman Hasani, Roche (C) Stock Ownership: None Honoraria: None Research Funding: Peter K.H. Lau, Department of Health, Western Australia Expert Testimony: None Patents, Royalties, and Licenses: None Other Remuneration: Peter K.H. Lau, Roche, Pfizer Author Contributions Conception and design: All authors Collection and assembly of data: Peter K.H. Lau, Arman Hasani Data analysis and interpretation: Peter K.H. Lau, Melanie J. Watson Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Peter K.H. Lau, MBBS, Royal Perth Hospital, Wellington St, Perth WA 6000, Australia; pkhlau@tpg.com.au. DOI: /JOP ; published online ahead of print at jop.ascopubs.org on September 23, References 1. American Society of Clinical Oncology: The state of cancer care in America, 2014: A report by the American Society of Clinical Oncology. J Oncol Pract 10: , De Angelis R, Sant M, Coleman MP, et al: Cancer survival in Europe by country and age: Results of EUROCARE-5 A population-based study. Lancet Oncol 15:23-34, Australian Bureau of Statistics: Australian Health Survey: First Results, Canberra, Australia, Australian Bureau of Statistics, Lingaratnam S, Murray D, Carle A, et al: Developing a performance data suite to facilitate lean improvement in a chemotherapy day unit. J Oncol Pract 9:e115- e121, Kallen MA, Terrell JA, Lewis-Patterson P, et al: Improving wait time for chemotherapy in an outpatient clinic at a comprehensive cancer center. J Oncol Pract 8:e1-e7, Hendershot E, Murphy C, Doyle S, et al: Outpatient chemotherapy administration: Decreasing wait times for patients and families. J Pediatr Oncol Nurs 22:31-37, Wallis M, Tyson S: Improving the nursing management of patients in a hematology/oncology day unit: An action research project. Cancer Nurs 26:75-83, van Lent WA, Goedbloed N, van Harten WH: Improving the efficiency of a chemotherapy day unit: Applying a business approach to oncology. Eur J Cancer 45: , Ahmed Z, Elmekkawy T, Bates S: Developing an efficient scheduling template of a chemotherapy treatment unit: A case study. Australas Med J 4: , Gruber M, Smith D, O Neal C, et al: Quality improvement project to determine outpatient chemotherapy capacity and improve utilization. J Nurs Care Qual 23: 75-83, Farrugia D, Ingledew I, Dawes E, et al: Use of electronic pagers to recall patients undergoing outpatient-based chemotherapy. Eur J Oncol Nurs 10: , Dobish R: Next-day chemotherapy scheduling: A multidisciplinary approach to solving workload issues in a tertiary oncology center. J Oncol Pharm Pract 9:37-42, Australian Bureau of Statistics: Average Weekly Earnings, Australia, Nov Canberra, Australia, Australian Bureau of Statistics, Haddow L, Ives A, Babe G, et al: Service mapping of the flow of care for chemotherapy outpatients at Sir Charles Gairdner Hospital. Presented at the 40th Annual Scientific Meeting of the Clinical Oncological Society of Australia, Adelaide, Australia, November 12-14, Karikios DJ, Schofield D, Salkeld G, et al: Rising cost of anticancer drugs in Australia. Intern Med J 44: , 2014 e384 JOURNAL OF ONCOLOGY PRACTICE VOL. 10, ISSUE 6 Copyright 2014 by American Society of Clinical Oncology