Abstract
Introduction
Timely diagnosis of lung cancer is critical for improving health outcomes. During the COVID-19 pandemic, the use of virtual healthcare increased to facilitate distancing, accessibility and convenience. Despite these perceived benefits, the impact of virtual care on timeliness and quality within the lung cancer diagnostic pathway remains unclear.
Objective
To evaluate differences in time to lung cancer diagnosis and health outcomes between virtual and in-person care models.
Methods
We conducted a retrospective cohort study of all patients referred to a Lung Diagnostic Assessment Program (LDAP) at a large academic hospital in Ontario, Canada in 2022. Patients were grouped based on whether their intake visit was conducted virtually or in-person. The primary outcome was time from referral to tissue diagnosis. Secondary outcomes include time from referral to initial consultation and biopsy, time to complete all investigations, hospitalizations, cancelled procedures and death during the diagnostic interval. Outcomes were compared between groups.
Results
Across 265 clinical encounters (120 virtual, 145 in-person) the median time from referral to tissue diagnosis was 28.5 days [IQR = 18–45] for virtual and 28 days [IQR = 20–51] for in-person care (p = .55). Times to consultation, diagnostic biopsy and completion of diagnostic testing were similar between groups. Hospitalizations, procedure cancellation, and mortality did not differ between care delivery models.
Discussion
Virtual care demonstrated timeliness and health outcomes comparable to in-person care, supporting its role as a feasible alternative in the lung cancer diagnostic pathway.
Introduction
Timely assessment of patients with suspected lung malignancy is crucial, as delays in diagnosis and initiation of treatment are associated with disease progression, diminished quality of life, and increased mortality.1,2 To mitigate these risks, many jurisdictions have established guidelines to expedite the evaluation and treatment of lung cancer. In Ontario, Canada, thoracic oncology care is delivered through a universal, single-payer healthcare system that implements standardized benchmarks to guide time to diagnosis, staging and initiation of appropriate therapies for lung cancer. 3
Some Ontario centers have adopted a lung cancer diagnostic model, where centralized local Lung Diagnostic Assessment Programs (LDAPs) provide multidisciplinary care. These programs bring together Pulmonologists, Interventional Pulmonologists, Thoracic Surgeons, Radiologists, Nurse Navigators, and other specialists to deliver timely, patient-centered care. 4 The COVID-19 pandemic catalyzed a disruptive innovation in healthcare delivery, where telecommunication became a necessity for patient‒physician and multidisciplinary meetings. 5 In provinces like Nova Scotia, Canada, virtual oncologic care increased by 46% between 2019 and 2020. 6 Similarly, LDAPs adapted quickly to incorporate virtual assessments as a substitute to in-person care.
Virtual care, defined as using telecommunication technologies to provide remote healthcare services, offers several theoretical advantages in the diagnostic evaluation of lung cancer. 7 These include improved access for patients in remote or underserved areas, reduced travel burden (and thereby carbon emissions), increased scheduling flexibility, and the potential to enhance communication between multidisciplinary team members.7–10 Virtual care enables healthcare delivery despite travel and service restrictions, and reduces the spread of infection through distancing. In theory, these benefits would translate into improved diagnostic processes, reduced wait times, and faster initiation of treatment.
Despite these perceived advantages, the impact of virtual care on the quality and timeliness of lung cancer diagnosis remains unclear. To date, there are few to no studies systematically evaluating the role of virtual care on key clinical outcomes within LDAPs, including time to initial assessment and time to diagnosis. The aim of this study is to evaluate the role of virtual care in the lung cancer diagnostic pathway on time to diagnosis and other important health outcomes. Understanding the efficacy and limitations of virtual care will provide crucial insight into whether virtual care can be a sustainable and effective component of lung cancer care in the future.
Methods
We performed a single center, retrospective cohort study with the intent of quality improvement, of all patients evaluated at the LDAP at a large academic health center in Toronto, Ontario who had their initial LDAP consultation between January 1, 2022, and December 31, 2022 (Figure 1). The study period was chosen because a transition occurred in July 2022 where predominantly virtual care transitioned to in-person care due to a change in hospital “virtual care first” policy towards the end of the COVID-19 pandemic. Patients seen in the clinic January to July 2022 primarily received virtual care (with exceptions allowed at the discretion of the triaging physician), and those after July 2022 were seen predominantly in-person according to this policy. Patients were identified using a pre-existing database of referrals received by the LDAP clinic. Data were collected by chart review. Patients were excluded if relevant diagnostic testing or subsequent LDAP visits occurred at another institution during the diagnostic interval. Patients who had an initial visit with the LDAP program were further divided into three groups: investigation (patients undergoing immediate investigation for suspected intrathoracic malignancy), surveillance (patients requiring ongoing CT imaging follow-up) and referred out/discharged (patients referred to another center for ongoing care or discharged from LDAP after the initial visit).
Study design. Patients in the LDAP between January 1 to December 31, 2022, were included in this study (N = 265). These patients were categorized based on their diagnostic pathway, with those who required investigation (n = 157) being further analyzed. LDAP: Lung Diagnostic Assessment Program.
Patients were categorized by virtual or in-person consultation, based on the initial intake visit at the LDAP clinic. A virtual visit was defined as an initial encounter between the patient and physician by telephone or videoconferencing platform (Zoom Healthcare, or Ontario Telemedicine Network [OTN]). An in-person visit was defined as an initial encounter occurring face-to-face between the patient and physician. Three interventional pulmonologists work in the LDAP clinic and were conducting both the virtual and in-person encounters. The primary outcome was time from referral to tissue diagnosis. Secondary outcomes were times from referral to initial visit, referral to biopsy establishing diagnosis, and referral to completion of all diagnostic testing (e.g., invasive and non-invasive staging tests, pulmonary function testing). Hospital admissions, cancelled biopsy procedures, and death during the diagnostic interval were examined as secondary outcomes.
Statistical analysis
Shapiro‒Wilk statistical tests confirmed that the variables in the study did not follow a normal distribution. The Mann‒Whitney U test was used for comparison of continuous variables. Medians were reported with the interquartile range (IQR). The chi-square or Fisher’s exact test was used for comparison of dichotomous outcomes, as appropriate. Statistical Analysis System 9.4 (SAS Institute, Cary, NC, USA) was used for the above analysis.
Research ethics review was not required because the project met criteria for exemption from such a review based on our institutional process for confirming that the project was deemed improvement in quality and not human subject research.
Results
Study participants
Two hundred and sixty-five patients had their initial consultation in the LDAP clinic between January 1, 2022, and December 31, 2022 (Figure 1). From January to June 2022, there were 102 (79.0%) virtual consultations and 27 (21.0%) in-person consultations. From July to December 2022, there were 18 (13.2%) virtual consultations and 118 (86.8%) in-person consultation, with significantly less virtual visits in the latter 6 months of the study period (p < .001) (Figure 2). There were 157 patients in the investigation group, 80 patients in the surveillance group and 28 patients referred out/discharged after the initial visit. The investigation group was further divided into the virtual (n = 72) versus in-person (n = 85) groups.
Number of virtual and in-person patient consultations by month. There was a statistically significant reduction in virtual visits in the latter 6 months of the study period, p < .001.
Patient characteristics
The median age of study participants was 71 [IQR = 64–79] years old with 48% (n = 127) female (Table 1). Of the patients in the diagnostic pathway (n = 157), a tissue diagnosis was achieved in 94% (n = 148) of patients. Of these patients (n = 148), there was a high prevalence (82%, n = 121) of cancer, with 67% (n = 98) being a lung malignancy. Lung adenocarcinoma was the most common diagnosis identified in 55% (n = 82) of diagnosed patients. Of the patients with a lung cancer diagnosis (n = 98), 62% (n = 61) had advanced (stage III or IV) disease (Table 2). 80% (n = 118) of patients needed only one invasive diagnostic test to establish the diagnosis. There was no difference in the number of patients requiring greater than one invasive diagnostic test between the virtual and in-person groups (p = .126). Fifty-eight percent (n = 91) of diagnoses in the diagnostic pathway (n = 157) were made with endobronchial ultrasound (EBUS) and was similar between the virtual and in-person groups (Table 2). The next most frequent invasive investigation resulting in diagnosis was CT-guided transthoracic biopsy at 22% (n = 35).
Baseline characteristics at initial visit of patients seen in LDAP between January 1, 2022 and December 31, 2022
Characteristics of patients in the investigation group.
EBUS: endobronchial ultrasound; US: ultrasound.
Exposure and outcomes
The median time from referral to tissue diagnosis in all participants for the in-person (28 [IQR = 20–51] days) and virtual (28.5 [IQR = 18–45] days) groups were similar (p = .55) (Table 3A). The time from referral to initial consultation (p = .54), referral to biopsy establishing diagnosis (p = .59), and referral to completion of all diagnostic testing (p = .68) showed no statistically significant difference in all participants (Table 3A). In the subgroup of patients with a final diagnosis of lung cancer (n = 98), our primary outcome between the in-person (28 [IQR: 20–53] days) and virtual (29 [IQR: 20–44] days) groups were similar, p = .41 (Table 3B). The time from referral to initial consultation (p = .10), referral to biopsy establishing diagnosis (p = .23), and referral to completion of all diagnostic testing (p = .52) showed no statistically significant difference in patients with lung cancer (Table 3B). The number of cancelled biopsy procedures (1), hospitalizations (16) and deaths (1) that occurred during the diagnostic process were few, with no differences identified between virtual and in-person care (Table 4A and B).
Median time to waypoints in all patients.
Median time to waypoints in patients who were diagnosed with lung cancer.
Frequency of cancelled procedures, hospitalization and death for all patients. N = 101 for cancelled procedures.
Frequency of cancelled procedures, hospitalization and death in patients who were diagnosed with lung cancer.
Discussion
In this single-center, retrospective cohort study, we found no difference in time to tissue diagnosis between virtual and in-person initial consultation for patients with suspected intrathoracic malignancy. There was no significant difference in secondary outcomes, including the time from referral to the first consultation, to the biopsy establishing diagnosis, or to the completion of all diagnostic testing. These findings suggest that when appropriately integrated into a coordinated diagnostic pathway, initial virtual consultation poses no delays in the key steps of evaluating and diagnosing suspected thoracic malignancies.
Our analysis shows most patients require only one invasive diagnostic procedure to establish a diagnosis, with EBUS-guided biopsy being the most common modality. This is true for both virtual and in-person consultations, with no statistically significant difference between the groups. Furthermore, the stage and distribution of cancer type were similar between the groups. Together, this suggests that virtual care does not alter the diagnostic strategy nor require additional testing to establish a diagnosis. Hospitalizations, cancelled procedures, and deaths during the diagnostic interval, were infrequent and did not differ significantly between the two groups (Table 4A and B). Further studies with larger cohorts are needed to confirm these safety signals.
The COVID-19 pandemic was the impetus for rapid integration of telecommunication within oncological care. Studies have shown that during COVID-19, when virtual lung cancer screening was integrated within a multidisciplinary network, patients were equally likely to complete investigations such as low-dose computed tomography when ordered in a virtual encounter as in an in-person encounter. 11 In patients with advanced lung cancer, early palliative virtual care has been seen to offer equivalent effects on quality of life compared to in-person palliative care. 12 However, the efficacy and safety of this form of healthcare delivery was unclear within the diagnostic pathways for thoracic malignancies. Our study offers real-world evidence that virtual care is effective when implemented in a lung cancer diagnostic program. If used appropriately, virtual care may improve accessibility to specialized programs, reduce the number of in-person visits, and allow for physical distancing when required.13,14 Virtual consultations may also reduce the carbon footprint of patients and healthcare providers, offering a more sustainable, cost-effective approach to healthcare delivery.8–10 This study provides evidence that virtual visits are a feasible way to offer expedited care for those with suspected intrathoracic malignancy, while maintaining quality, and can provide more flexibility and convenience to existing programs. Additionally, having virtual care integrated into LDAPs may reduce disruption of care in the event of future barriers to safe in-person consultation.
The significant shift from virtual to in-person care midway through our study period reflected a change in hospital policy, with a local shift back to in-person care following the peak of the pandemic (Figure 2). This allowed for a natural experiment to compare virtual and in-person care. Additionally, a small number of patients in our program had initial consultations in-person throughout the pandemic, most of whom required diagnostic procedures that could be performed in conjunction with the initial visit (e.g., thoracentesis, US-guided biopsy). In our study, we did not see a difference in the number of biopsy procedure cancellations between patients seen virtually or in-person, suggesting that physicians were able to adequately assess a patient's suitability for invasive procedures via virtual means. This efficacy of virtual pre-procedure assessments is seen in other settings including virtual preoperative assessments for pelvic reconstruction and other surgical patients.15,16
Our study was conducted at a single urban academic health center and may not be applicable to other centers with differing patient populations or hospital resources. Due to the retrospective nature of the study, there may be confounding variables that have not been accounted for and data points that were not available for inclusion. We do not believe that the selection of virtual vs. in-person care was subject to significant bias, as care delivery was provided in accordance with COVID-19 pandemic hospital policies. Future research is needed to understand patient satisfaction and provider experience of virtual lung cancer diagnostics. Access to and end-user comfort with technology, as well as patient preferences for face-to-face encounters, may be barriers to the adoption of virtual care. Lastly, the majority of patients in the virtual arm ultimately required some in-person care during diagnostic evaluation (i.e., imaging, biopsy), as it is not possible to diagnose lung cancer without in-person contact with the healthcare system. Despite this, we believe that integrating virtual care can reduced the number of in-person appointments without compromising outcomes.
Virtual consultation in a structured lung cancer diagnostic program was not associated with delays in diagnosis in patients with suspected thoracic malignancies. These findings support the continued integration of virtual care into diagnostic pathways for lung cancer, particularly when provided through a multidisciplinary framework. This study contributes to the growing body of evidence that highlights virtual-first models as a viable approach for maintaining quality while providing remote care.
Footnotes
Ethical considerations
Research ethics review was not required because the project met criteria for exemption from such a review based on our institutional process for confirming that the project was deemed improvement in quality and not human subject research. This was based on the Sunnybrook Research Institute Ethics Review Self-Assessment Tool, and the project is registered with the Institution as a quality improvement project per hospital standard operating procedures (registration number 288).
Consent to participate
Not applicable.
Consent for publication
Not applicable.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on request.