Patient preferences for timing and access to radiation therapy

Original Article

Radiation Oncology

Patient preferences for timing and access to radiation therapy


I.A. Olivotto, MD,*,, J. Soo, MEd*, R.A. Olson, MD MSc*, L. Rowe, MA*, J. French, MSc*, B. Jensen, BSc*, A. Pastuch, BSc*, R. Halperin, MD*, P.T. Truong, MD CM*
*BC Cancer Agency, Radiation Therapy Program, Vancouver, Prince George, Surrey, Victoria, Abbotsford, and Kelowna, BC;, University of British Columbia, Division of Radiation Oncology and Developmental Radiotherapeutics, Vancouver, Prince George, Kelowna, and Victoria, BC;, University of Calgary, Calgary, AB..



doi: http://dx.doi.org/10.3747/co.22.2532


ABSTRACT

Purpose

Patient preferences for radiation therapy (rt) access were investigated.

Methods

Patients completing a course of rt at 6 centres received a 17-item survey that rated preferences for time of day; day of week; actual, ideal, and reasonable travel times for rt; and actual, ideal, and reasonable times between referral and first oncologic consultation. Patients receiving single-fraction rt or brachytherapy alone were excluded.

Results

Of the respondents who returned surveys (n = 1053), 54% were women, and 74% had received more than 15 rt fractions. With respect to appointment times, 88% agreed or strongly agreed that rt between 08h00 and 16h30 was preferred; 14%–15% preferred 07h30–08h00 or 16h30–17h00; 10% preferred 17h00–18h00; and 6% or fewer preferred times before 07h30 or after 18h00. A preference not to receive rt before 07h30 or after 18h00 was expressed by 30% or more of the respondents. When days of the week were considered, 18% and 11% would have preferred to receive rt on a Saturday or Sunday respectively; 52% and 55% would have preferred not to receive rt on those days. A travel time of 1 hour or less for rt was reported by 82%, but 61% felt that a travel time of 1 hour or more was reasonable. A first consultation within 2 weeks of referral was felt to be ideal or reasonable by 88% and 73% of patients respectively.

Conclusions

An rt service designed to meet patient preferences would make most capacity available between 08h00 and 16h30 on weekdays and provide 10%–20% of rt capacity on weekends and during 07h30–08h00 and 16h30–18h00 on weekdays. Approximately 80%, but not all, of the responding patients preferred a 2-week or shorter interval between referral and first oncologic consultation.

KEYWORDS: Radiation therapy, health service capacity, patient-centred care, preferences

INTRODUCTION

Radiation therapy (rt) is used with curative or palliative intent by approximately 50% of patients with cancer during the course of their disease. In Canada, rt services have traditionally been provided 5 days per week during “normal” business hours, except for emergencies. The increasing incidence and prevalence of cancer are predicted to cause a 2%–3% annual growth in the need for rt services1,2.

Most rt courses are delivered using linear accelerators. Linear accelerator capacity can be increased by building new cancer centres, adding rt vaults to existing facilities, or extending hours of operation. All of those strategies have been used in Canada since the late 1990s36. Compared with building a new cancer centre to increase capacity (which takes 5–8 years between the decision to build and treatment being available to patients), extending operating hours is a more immediate and flexible strategy. However, extending treatment hours can increase the cost per treatment because of the need for overlapping shifts of the personnel required for patient treatments7.

The choice between increasing the number of rt vaults and extending operating hours to increase rt capacity depends on multiple factors, including the availability of capital compared with operating resources, the priority placed on improving geographic access, perceptions of appropriate care on the part of service providers, and potentially, patient preferences. Policymakers may want to take patient preferences into consideration, but no surveys of patient time preferences for rt have been published to date. The present report describes a survey of more than 1000 patients conducted in a geographically-distributed population to determine patient preferences for extending the duration of the treatment day or week, and patient perceptions about reasonable notice, travel, and consultation times.

METHODS

Setting

During the survey interval, the BC Cancer Agency operated 6 regional centres providing 100% of the rt delivered in British Columbia4. Paper copies of a survey instrument were distributed to patients completing a course of rt at each centre. During the survey interval, all treatment units operated from 08h00 to 16h30, Monday to Friday, except when emergency rt was required in the evenings or on weekends.

Before the survey proceeded, the project plan and survey instrument were submitted to the institutional research ethics board. The committee chair deemed the survey to be a quality assurance or improvement project and completion of the survey by a patient to be sufficient informed consent. A letter to patients that accompanied the survey instrument included a statement that the findings might be published.

Survey Instrument

An initial draft of the survey, designed in English with input from rt physicians, radiation therapists, and administrators was field-tested with 6 patients receiving more than 10 rt fractions in Vancouver. The patients were subsequently interviewed by one individual (JS) to identify items that were unclear. The instrument was revised and tested on an additional 6 patients who identified only minor changes that were incorporated into the instrument that was finally used.

The survey consisted of 17 items. Questions addressed patient demographics; treatment centre; number of treatments; and preferences for the timeliness of the first oncologic consultation, for notification for the first radiation treatment, for time of day and day of the week to receive rt, and for actual, ideal, and reasonable one-way travel times to receive rt.

Preferences of the time of day for rt were examined in various 30- to 60-minute intervals from 06h00 to 08h00 and from 16h30 to 20h00 and later. Because rt was routinely available from 08h00 to 16h30, and because the primary purpose of the survey was to assess patient interest in extended hours of operation, the “normal working day” was not subdivided further. Potential responses to the time interval preference statements were “strongly agree,” “agree,” “neither agree nor disagree,” “disagree,” and “strongly disagree.” A patient could choose more than one option (positive or negative) for the time preferences. For instance, a patient could agree with rt between 08h00 and 16h30, strongly disagree with rt before 07h00, and also disagree (or agree) with rt after 19h00. The survey included a statement that weekend treatment would not shorten the overall duration of a multifraction course of rt.

Survey Subjects

Patients undergoing multifraction external-beam rt during the period 18 February–17 May 2013 were invited by a radiation therapist on their rt unit to complete the survey. Participation was voluntary. Patients who received only 1 rt fraction or brachytherapy alone were excluded, because it was felt that patients having a single intervention at the cancer centre might be influenced by different concerns (such as promptness), and the primary interest was to assess preferences for repetitive treatments. Patients perceived by the radiation therapists to be too ill or distraught to complete the survey were also excluded. Patients could use an interpreter if unable to read English. Completed surveys were returned anonymously to boxes available in each rt department.

An a priori goal was to obtain at least 1000 completed surveys. To address potential regional differences, quotas were established for each centre proportional to the number of rt courses provided in the preceding year.

Statistical Analyses

An institutional rt database provided the numbers of patients receiving a course of external-beam rt during the survey period6. To calculate the survey response rate, the numbers of patients receiving single-fraction rt or brachytherapy alone, or dying within 1 month of rt (as a surrogate for a perception by the radiation therapists of lack of fitness to complete the survey), were excluded from the denominator.

Descriptive statistics were used to characterize survey responders. The proportions of the various preferences were evaluated by dividing the number of positive preferences (“agreed” plus “strongly agreed”) or negative preferences (“disagreed” plus “strongly disagreed”) by the number of patients with at least 1 time preference expressed. The chi-square statistic was used to assess differences in proportions. Chi-square tests were also used to assess differences in characteristics between patients with positive and negative preferences for extended hours of operation and weekend treatment. Statistical significance was established at p < 0.05. Statistical analyses were performed using the OpenEpi software application (version 3.03: Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health. http://www.OpenEpi.com).

RESULTS

Of 2486 patients receiving multifraction external-beam rt in British Columbia during the survey interval, 1053 (42.4%) returned a completed survey (Table i). Compared with all patients treated during the survey interval, survey respondents were somewhat younger and less likely to be receiving short-course rt. The geographic distribution of respondents approximated the distribution of rt courses delivered in the province, except for a modest overrepresentation from the Surrey centre and a somewhat under-representation from the Victoria centre. Of the respondents, 74% reported receiving more than 15 rt fractions.

TABLE I Demographic and treatment characteristics of 1053 survey respondents and of all patients receiving multifraction external-beam radiation therapy at a BC Cancer Agency facility during 18 February–17 May 2013

 

Timeliness of the First Oncologic Consultation

Of 1038 patients who responded to questions about the ideal or reasonable time to wait for a first oncology consultation, 88% and 73% respectively reported that 2 weeks or less would be the “ideal” or “reasonable” interval to first consultation (Table ii). Only 1% of patients reported that an interval of 4 weeks or longer would be “ideal” or “reasonable.”

TABLE II Responses concerning consultation timeliness, notice before radiation therapy, and travel time by patients receiving multifraction external-beam radiation therapy

 

Timeliness of Notification for the First Radiation Treatment

Of 1038 patients who responded to a question about duration of notice before the first radiation treatment, 44% required 2 days or less. Only 6% required more than 1 week’s notice (Table ii).

Preferences of Time of Day for RT

The time-of-day section contained at least one response in 1014 of the surveys. When preference was defined as “agreed” plus “strongly agreed” to a time interval, 892 of respondents (88%) preferred to receive rt from 08h00 to 16h30 (Figure 1). A preference to receive rt from 07h30 to 08h00 or from 16h30 to 18h00 was expressed by 10% or more of respondents. Smaller proportions of respondents would have preferred either earlier or later times. The preference not to receive rt outside “normal” working hours was inversely proportional to, but more extreme than, the preference to receive rt during those hours (Figure 2, Table iii). Approximately one third of patients disagreed or strongly disagreed with rt during any one time interval before 07h30 or after 19h00.

 


 

FIGURE 1 Most patients who expressed a preference wanted radiation therapy (RT) between 8h00 and 16h30, but 10% or more preferred intervals around the “shoulders” of the normal working day. Of responders, 1014 provided at least 1 response to the statement “I would have preferred to receive RT during [specific time interval].” Responders were able to select more than 1 time interval.

 


 

FIGURE 2 Patient preference to not receive radiation therapy during a specific interval was inversely correlated with treatment preference. Of responders, 1014 provided at least 1 response to the statement “I would have preferred to receive RT during [specific time interval].” Responders were able to select more than 1 time interval.

Table III Characteristics of patients with positive (“agreed” and “strongly agreed”) and with negative (“disagreed” and “strongly disagreed”) preferences for radiation therapy at “shoulder” times

 

If preference was defined as only “strongly agreed” or “strongly disagreed” with rt during a specific time interval, the pattern was similar but less extreme (data not shown).

In an exploratory analysis, women were more likely not to prefer rt before 08h00 and to prefer rt after 16h30. Compared with older respondents, respondents 50 years of age and younger were more likely to prefer rt before 08h00 and after 16h30 (Table iii). Preference for rt before 08h00 was also associated with travel time and treatment centre.

Preference to Receive RT on a Saturday or Sunday

A response about weekend rt preference was provided in 963 surveys. Of those 963 respondents, 174 (18%) and 102 (11%) agreed or strongly agreed that they would have preferred to receive rt on a Saturday or Sunday respectively. In contrast, more than 50% of patients disagreed or strongly disagreed with receiving rt on Saturday (n = 500, 52%) or Sunday (n = 527, 55%). In an exploratory analysis (Table iv), no associations of sex, age, or treatment centre with weekend rt preferences were observed, but respondents receiving 15 or fewer fractions or having shorter travel times were more likely to prefer weekend rt.

TABLE IV Characteristics of patients with positive (“agreed” and “strongly agreed”) and with negative (“disagreed” and “strongly disagreed”) preferences for radiation therapy on weekend days

 

Actual, Ideal, and Reasonable Travel Time to Receive RT

Table ii shows the distribution of the 1038 responses about actual, reasonable, and ideal travel times to receive rt. Overall, 82% of patients travelled 1 hour or less to receive rt, but 61% felt that travel of 1 hour or more was reasonable. Responses about travel time showed substantial between-centre differences that correlated with the catchment areas of the centres (data not shown). Patients attending centres where actual travel times were longer were more likely to respond that longer travel times were reasonable (p < 0.001). For instance, at the Surrey centre in British Columbia’s urban Lower Mainland, 90% of patients travelled less than 1 hour for rt, and 48% felt that 1 hour or more was reasonable. At the Kelowna centre, which served the more distributed population of British Columbia’s Southern Interior, only 37% travelled less than 1 hour to receive rt, and 90% felt that travel of 1 hour or more was reasonable.

DISCUSSION

To our knowledge, this population-based survey of patient preferences for time interval and day of week to receive rt is the first of its kind. More than 1000 patients responded to the survey in a 3-month interval. The respondents were representative of the patients receiving rt in the geographically-defined population of British Columbia, except that survey respondents were somewhat younger and were less likely to be receiving palliative rt because the survey excluded patients receiving single-fraction rt (a common treatment for bone metastases in British Columbia8) or who were deemed not sufficiently fit to be asked.

Most survey respondents preferred to receive rt during “normal business hours” from 08h00 to 16h30. Preferences for rt before 08h00 or after 16h30 were more negative than positive, but 10% or more of respondents would have preferred to receive rt from 07h30 to 08h00 or from 16h30 to 18h00. One third of respondents disagreed or strongly disagreed with rt before 07h30 or after 19h00. A preference for Saturday or Sunday treatments was indicated by 18% and 11% respectively, but more than 50% did not want weekend rt. Those data suggest that a patient-centred rt service would operate at least some treatment capacity from 07h30 to 18h00. A cancer centre operating 5 or more treatment units might reasonably consider providing the capacity of at least 1, but not all, treatment units on a Saturday. Many cancer centres provide rt services for more than 8 hours daily, but few routinely offer rt on weekends. Whether operation of an rt service for more than 8 hours daily or on weekends is necessary, affordable, or logistically feasible are issues beyond the scope of the current report.

Similar observations were reported from a survey conducted over two days in 9 U.K. radiotherapy centres9,10. Most patients preferred “normal working hours,” which for them was 09h00–17h00. Of the respondents to that survey, 39% “would attend” rt outside of normal hours, but most of that group (23%) preferred 08h00–09h00. Somewhat higher proportions would have been willing to attend on a Saturday (39%) or a Sunday (31%), but the question posed in our survey was whether patients “agreed” or “strongly agreed” that such a treatment time was preferred. That variation in survey language could have influenced responses.

Younger patients (≤50 years age) were more likely to report positive preferences for rt before 08h00 and after 16h30 on weekdays. Respondents receiving 15 or fewer fractions were more likely to prefer weekend rt. Women were more likely to report negative preferences for rt before 08h00 and positive preferences for rt after 16h30. Patients with shorter travel times were more likely to prefer rt before 08h00. Some variation in between-centre preferences was observed.

Most survey respondents reported that travel times of 1 hour and longer were reasonable for a tertiary service such as rt. Between January 1995 and January 2015, the number of cancer centres providing rt in Canada more than doubled, improving geographic access to rt. Building additional rt centres was motivated in part by long wait times for rt, and evidence that rt utilization declined with distance to the cancer centre and improved when access was more convenient3,6,7,1115. Improving geographic access by building cancer centres is one way to be patient-centred, because more convenient locations respond to a patient preference to access care closer to home. Because of Canada’s aging and growing population, the number of new cancers diagnosed is expected to increase 2%–3% annually, with a commensurate increase in the number of courses of rt to be delivered1,2. The present survey suggests that patients would find it acceptable, at least in the short term, if a substantial proportion of the growing demand could be addressed by extending hours of operation, including the use of weekend treatments. However, there is a limit to the capacity that can be realized by extending hours of operation. Large proportions of patients stated a preference not to receive rt before 07h30, after 19h00, or on weekends. That observation is corroborated by experience from the United Kingdom10 and anecdotally in Canada, where treatment units were operated until 22h00 during times of severe mismatch between rt demand and rt capacity. In such circumstances, it was difficult to fill appointments at the extremes of the treatment day.

Factors other than patient preference that also affect the duration of the treatment day include the number of linear accelerators available relative to demand, staff preferences, union contracts, and operating costs. Because of the need for overlapping shifts to operate a treatment unit continuously, it is more costly per treatment (less efficient) to operate a smaller number of treatment units for a longer duration than a larger number of units for shorter hours16,17. Extending hours increases the number of patients that can be treated per day, but does not increase the number that can be treated in an hour. In addition to radiation therapists, other staff that must be available while patients are receiving rt include medical physicists, electronics technicians, nurses, clerks, and physicians. Those providers all have to be funded at extended hours.

Accounting for all costs from the health system or patient perspective would require a sophisticated analysis. However, if the goal were to minimize operating costs during the delivery of rt, the maximum number of treatment units available should be used for the shortest interval that meets patient demand. As rt demand within a 1- to 2-hour commute of a cancer centre increases, patients would likely find it acceptable for the hours of operation to be gradually extended to 10 or 12 per day and on weekends. Extending treatment times beyond 12 hours per day would not be advisable, given that large proportions of patients would not prefer late evening or very early morning appointments on a regular basis and that extended operating hours could compromise the preventive maintenance required for safe and consistent operation.

The timeliness of consultation with an oncologist is another factor that affects the patient experience. Most, but not all, survey respondents felt that a first cancer centre consultation within 2 weeks of referral would be “reasonable” or “ideal”; only 1% felt that an interval of 4 weeks or longer was “reasonable” or “ideal.” The timeliness of consultation depends on physician availability, which is related to the total number of physicians available, the care model in the centre, and the case load per physician. A discussion of appropriate physician workload and care models is beyond the scope of the present work.

The results of the present survey should be interpreted in the context of its strengths and limitations. Given that this was a large population-based survey with respondents representative of the patients being treated, the results could be considered relatively free from selection bias. However, as described, not all patients were approached, including those with a poor performance status or undergoing a shorter treatment course. The results are therefore likely to be more generalizable to patients receiving curative-intent treatment or multifraction palliative rt. The survey did not enquire about the role or the effect on preference of the need to attend interventions such as diagnostic procedures or concurrent chemotherapy, and because of the structure of services in British Columbia at the time of the survey, no data were obtained about the preferences of patients regularly receiving rt outside of “normal” working hours. Another potential limitation is that patients could choose more than one category of time preference. Interpretation of preferences is more difficult when multiple options are offered and the number of responses on each survey varies. However, by allowing multiple selections, insights could be obtained not only about a single preferred time, but also about other times that would be considered more—or less—acceptable to patients.

CONCLUSIONS

Among 1053 survey respondents, most preferred rt between 08h00 and 16h30 on weekdays, but 10%–20% would have preferred access to rt starting at 07h30 and extending until 18h00 and on weekends. Most respondents reported that travel of 1 hour or more was reasonable to access rt. Those observations can contribute to the design of patient-centred rt services, the demand for which is increasing at 2%–3% annually because of population growth and aging.

ACKNOWLEDGMENTS

Parts of this work were presented at the Applied Research in Cancer Control annual meeting, Toronto, ON, 13 May 2014; and at the Canadian Association of Radiation Oncology annual scientific meeting, St. John’s, NL, 27 August 2014.

CONFLICT OF INTEREST DISCLOSURES

We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none. This work was conducted while IAO was professor and head of Radiation Oncology at the BC Cancer Agency and the University of British Columbia.

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Correspondence to: Ivo A. Olivotto, Tom Baker Cancer Centre, 1331 29th Street NW, Calgary, Alberta T2N 4N2. E-mail: Ivo.Olivotto@albertahealthservices.ca

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Current Oncology, VOLUME 22, NUMBER 4, August 2015








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