Risk-based lung cancer screening performance in a universal healthcare setting.

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Delivery of Cancer Care in Ontario, Canada, During the First Year of the COVID-19 Pandemic.

Importance: The COVID-19 pandemic has impacted cancer systems worldwide. Quantifying the changes is critical to informing the delivery of care while the pandemic continues, as well as for system recovery and future pandemic planning. Objective: To quantify change in the delivery of cancer services across the continuum of care during the COVID-19 pandemic. Design, Setting, and Participants: This population-based cohort study assessed cancer screening, imaging, diagnostic, treatment, and psychosocial oncological care services delivered in pediatric and adult populations in Ontario, Canada (population 14.7 million), from April 1, 2019, to March 1, 2021. Data were analyzed from May 1 to July 31, 2021. Exposures: COVID-19 pandemic. Main Outcomes and Measures: Cancer service volumes from the first year of the COVID-19 pandemic, defined as April 1, 2020, to March 31, 2021, were compared with volumes during a prepandemic period of April 1, 2019, to March 31, 2020. Results: During the first year of the pandemic, there were a total of 4 476 693 cancer care services, compared with 5 644 105 services in the year prior, a difference of 20.7% fewer services of cancer care, representing a potential backlog of 1 167 412 cancer services. While there were less pronounced changes in systemic treatments, emergency and urgent imaging examinations (eg, 1.9% more parenteral systemic treatments) and surgical procedures (eg, 65% more urgent surgical procedures), major reductions were observed for most services beginning in March 2020. Compared with the year prior, during the first pandemic year, cancer screenings were reduced by 42.4% (-1 016 181 screening tests), cancer treatment surgical procedures by 14.1% (-8020 procedures), and radiation treatment visits by 21.0% (-141 629 visits). Biopsies to confirm cancer decreased by up to 41.2% and surgical cancer resections by up to 27.8% during the first pandemic wave. New consultation volumes also decreased, such as for systemic treatment (-8.2%) and radiation treatment (-9.3%). The use of virtual cancer care increased for systemic treatment and radiation treatment and psychosocial oncological care visits, increasing from 0% to 20% of total new or follow-up visits prior to the pandemic up to 78% of total visits in the first pandemic year. Conclusions and Relevance: In this population-based cohort study in Ontario, Canada, large reductions in cancer service volumes were observed. While most services recovered to prepandemic levels at the end of the first pandemic year, a substantial care deficit likely accrued. The anticipated downstream morbidity and mortality associated with this deficit underscore the urgent need to address the backlog and recover cancer care and warrant further study.

Novel coronavirus disease 2019: predicting prognosis with a computed tomography-based disease severity score and clinical laboratory data.

INTRODUCTION: Currently, there are known contributing factors but no comprehensive methods for predicting the mortality risk or intensive care unit (ICU) admission in patients with novel coronavirus disease 2019 (COVID­19). OBJECTIVES: The aim of this study was to explore risk factors for mortality and ICU admission in patients with COVID­19, using computed tomography (CT) combined with clinical laboratory data. PATIENTS AND METHODS: Patients with polymerase chain reaction-confirmed COVID­19 (n = 63) from university hospitals in Tehran, Iran, were included. All patients underwent CT examination. Subsequently, a total CT score and the number of involved lung lobes were calculated and compared against collected laboratory and clinical characteristics. Univariable and multivariable proportional hazard analyses were used to determine the association among CT, laboratory and clinical data, ICU admission, and in­hospital death. RESULTS: By univariable analysis, in­hospital mortality was higher in patients with lower oxygen saturation on admission (below 88%), higher CT scores, and a higher number of lung lobes (more than 4) involved with a diffuse parenchymal pattern. By multivariable analysis, in­hospital mortality was higher in those with oxygen saturation below 88% on admission and a higher number of lung lobes involved with a diffuse parenchymal pattern. The risk of ICU admission was higher in patients with comorbidities (hypertension and ischemic heart disease), arterial oxygen saturation below 88%, and pericardial effusion. CONCLUSIONS: We can identify factors affecting in­hospital death and ICU admission in COVID-19. This can help clinicians to determine which patients are likely to require ICU admission and to inform strategic healthcare planning in critical conditions such as the COVID­19 pandemic.

Systematic Review of the Application of Lean and Six Sigma Quality Improvement Methodologies in Radiology.

PURPOSE: Preventable yet clinically significant rates of medical error remain systemic, while health care spending is at a historic high. Industry-based quality improvement (QI) methodologies show potential for utility in health care and radiology because they use an empirical approach to reduce variability and improve workflow. The aim of this review was to systematically assess the literature with regard to the use and efficacy of Lean and Six Sigma (the most popular of the industrial QI methodologies) within radiology. METHODS: MEDLINE, the Allied & Complementary Medicine Database, Embase Classic + Embase, Health and Psychosocial Instruments, and the Ovid HealthStar database, alongside the Cochrane Library databases, were searched on June 2015. Empirical studies in peer-reviewed journals were included if they assessed the use of Lean, Six Sigma, or Lean Six Sigma with regard to their ability to improve a variety of quality metrics in a radiology-centered clinical setting. RESULTS: Of the 278 articles returned, 23 studies were suitable for inclusion. Of these, 10 assessed Six Sigma, 7 assessed Lean, and 6 assessed Lean Six Sigma. The diverse range of measured outcomes can be organized into 7 common aims: cost savings, reducing appointment wait time, reducing in-department wait time, increasing patient volume, reducing cycle time, reducing defects, and increasing staff and patient safety and satisfaction. All of the included studies demonstrated improvements across a variety of outcomes. However, there were high rates of systematic bias and imprecision as per the Grading of Recommendations Assessment, Development and Evaluation guidelines. CONCLUSIONS: Lean and Six Sigma QI methodologies have the potential to reduce error and costs and improve quality within radiology. However, there is a pressing need to conduct high-quality studies in order to realize the true potential of these QI methodologies in health care and radiology. Recommendations on how to improve the quality of the literature are proposed.

Creation of a diagnostic wait times measurement framework based on evidence and consensus.

PURPOSE: Public reporting of wait times worldwide has to date focused largely on treatment wait times and is limited in its ability to capture earlier parts of the patient journey. The interval between suspicion and diagnosis or ruling out of cancer is a complex phase of the cancer journey. Diagnostic delays and inefficient use of diagnostic imaging procedures can result in poor patient outcomes, both physical and psychosocial. This study was designed to develop a framework that could be adopted for multiple disease sites across different jurisdictions to enable the measurement of diagnostic wait times and diagnostic delay. METHODS: Diagnostic benchmarks and targets in cancer systems were explored through a targeted literature review and jurisdictional scan. Cancer system leaders and clinicians were interviewed to validate the information found in the jurisdictional scan. An expert panel was assembled to review and, through a modified Delphi consensus process, provide feedback on a diagnostic wait times framework. RESULTS: The consensus process resulted in agreement on a measurement framework that identified suspicion, referral, diagnosis, and treatment as the main time points for measuring this critical phase of the patient journey. CONCLUSIONS: This work will help guide initiatives designed to improve patient access to health services by developing an evidence-based approach to standardization of the various waypoints during the diagnostic pathway. The diagnostic wait times measurement framework provides a yardstick to measure the performance of programs that are designed to manage and expedite care processes between referral and diagnosis or ruling out of cancer.

Circulating fibrocytes are an indicator of poor prognosis in idiopathic pulmonary fibrosis.

RATIONALE: The clinical management of idiopathic pulmonary fibrosis (IPF) remains a major challenge due to lack of effective drug therapy or accurate indicators for disease progression. Fibrocytes are circulating mesenchymal cell progenitors that are involved in tissue repair and fibrosis. OBJECTIVES: To test the hypothesis that assay of these cells may provide a biomarker for activity and progression of IPF. METHODS: Fibrocytes were defined as cells positive for CD45 and collagen-1 by flow cytometry and quantified in patients with stable IPF and during acute exacerbation of the disease. We investigated the clinical and prognostic value of fibrocyte counts by comparison with standard clinical parameters and survival. We used healthy age-matched volunteers and patients with acute respiratory distress syndrome as control subjects. MEASUREMENTS AND MAIN RESULTS: Fibrocytes were significantly elevated in patients with stable IPF (n = 51), with a further increase during acute disease exacerbation (n = 7; P < 0.001 vs. control subjects). Patients with acute respiratory distress syndrome (n = 10) were not different from healthy control subjects or stable patients with IPF. Fibrocyte numbers were not correlated with lung function or radiologic severity scores, but they were an independent predictor of early mortality. The mean survival of patients with fibrocytes higher than 5% of total blood leukocytes was 7.5 months compared with 27 months for patients with less than 5% (P < 0.0001). CONCLUSIONS: Fibrocytes are an indicator for disease activity of IPF and might be useful as a clinical marker for disease progression. This study suggests that quantification of circulating fibrocytes may allow prediction of early mortality in patients with IPF.

Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging.

BACKGROUND: Cricoid pressure (CP) is often used during general anesthesia induction to prevent passive regurgitation of gastric contents. The authors used magnetic resonance imaging to determine the anatomic relationship between the esophagus and the cricoid cartilage ("cricoid") with and without CP. METHODS: Magnetic resonance images of the necks of 22 healthy volunteers were reviewed with and without CP. Esophageal and airway dimensions, distance between the midline of the vertebral body and the midline of the esophagus, and distance between the lateral border of the cricoid or vertebral body and the lateral border of the esophagus were measured. RESULTS: The esophagus was displaced laterally relative to the cricoid in 52.6% of necks without CP and 90.5% with CP. CP shifted the esophagus relative to its initial position to the left in 68.4% of subjects and to the right in 21.1% of subjects. Unopposed esophagus was seen in 47.4% of necks without CP and 71.4% with CP. Lateral laryngeal displacement and airway compression were demonstrated in 66.7% and 81.0% of necks, respectively, as a result of CP. CONCLUSION: In the absence of CP, the esophagus was lateral to the cricoid in more than 50% of the sample. CP further displaced both the esophagus and the larynx laterally.

The cricoid cartilage and the esophagus are not aligned in close to half of adult patients.

PURPOSE: To determine the frequency and degree of lateral displacement of the esophagus relative to the cricoid cartilage ("cricoid") using computed tomography (CT) images of normal necks. METHODS: Fifty-one cervical CT scans of clinically normal patients were reviewed retrospectively. Esophageal diameter, distance between the midline of the cricoid and the midline of the esophagus, and distance between the lateral border of the cricoid and the lateral border of the esophagus were measured. RESULTS: Lateral esophageal displacement was observed in 49% (25/51) of CT images. When present, the mean length of displaced esophagus relative to the midline of the cricoid was 3.3 mm +/- SD 1.3 mm. Of those with lateral displacement, 64% had esophageal displacement beyond the lateral border of the cricoid (mean 3.2 mm +/- SD 1.2 mm). There is a relatively normal distribution of the grouped measures of percentage of esophageal diameter that is displaced. Of those with displacement, 48% had over 15% of the total width of the esophagus displaced laterally and 20% had over 20% of the esophageal width displaced laterally. CONCLUSION: There is a 49% frequency of some degree of lateral displacement of the esophagus relative to the cricoid.