Reducing Delays in Breast Cancer Care Using an Innovative Digital Health Platform

ABSTRACT

Objectives: Among women with early-stage breast cancer, prolonged time from core needle biopsy to initiation of treatment is associated with a lower rate of overall survival. The primary goal of this study was to reduce historical time to treatment (TTT) by greater than 50%. A secondary goal was to reduce TTT to fewer than 30 days to minimize the adverse impact of a delay on survival.

Study Design: We conducted an institutional review board–approved quality improvement initiative among patients with Medicare Advantage at an integrated health system in Nevada utilizing novel clinical management and prior authorization digital health software (XpediteMD).

Methods: All participants were evaluated at a single imaging facility for inconclusive or suspicious breast imaging. A total of 552 patients with Breast Imaging Reporting and Data Systems category 0, 4, or 5 radiology diagnosis were enrolled on the XpediteMD digital health platform. Seventy-two were ultimately found to have invasive or in situ breast cancer. Ten were excluded from the TTT analysis due to treatment delay caused by intercurrent illness, and 12 were excluded because they initially declined treatment.

Results: For the remaining 50 patients whose cases were managed with XpediteMD, median TTT was 33 days compared with 74 days among 99 patients in the historical cohort, a significant 55% reduction in TTT (P < .0001) that exceeded the 50% TTT goal.

Conclusions: By reducing TTT to 33 days, the XpediteMD platform minimized delays in initiation of breast cancer therapy that could potentially compromise patient overall survival.

The American Journal of Accountable Care. 2024;12(2):23-29. https://doi.org/10.37765/ajac.2024.89569

A growing body of evidence associates delayed initiation and completion of cancer care with reduced cancer survival.^1-4 The survival implications of delayed initiation of breast cancer care were brought to light by recent analyses of the National Cancer Database (NCDB) Registry and the Surveillance, Epidemiology, and End Results–Medicare (SEER-Medicare) Program Database.⁵ Beginning 30 days from the date of a needle biopsy, each additional 30-day delay interval resulted in a statistically significant 9% to 10% (P < .001) relative reduction in 10- and 15-year overall survival. In this population-based study, the overall survival reduction was found to disproportionately affect patients with stage I and II breast cancer (HR, 1.09-1.16; P < .001), which is the most common newly diagnosed breast cancer. Similar results were confirmed by Prakash et al in an independent NCDB analysis of time to surgery among women undergoing primary surgery for stage I to III breast cancer.⁶ Following breast cancer surgery, delays in the completion of adjuvant chemotherapy and adjuvant radiotherapy exceeding 8 months were associated with a reduction in overall survival.⁷

The adverse effect of prolonged time to surgery was also shown in a study within the universal access US Military Health System, which demonstrated a 30% relative increased risk of all-cause mortality (P = .042) when the time interval between needle biopsy and breast cancer surgery exceeded 36 days compared with a 1- to 21-day delay, a finding made more compelling when considering the younger mean age of the military population (54 years) compared with the NCDB (mean age, 60 years) and SEER-Medicare (mean age, 75 years) populations.⁸

Multiple patient-level, provider-level, and system-level barriers may delay the timely initiation of cancer care. Patient-level delays may arise from lack of convenient transportation; scheduling conflicts with work, travel, or childcare; second opinions; intercurrent disease; patient reluctance to proceed with treatment; high-deductible insurance; and patient desire to explore alternative treatment options, among other factors. Provider-level delays include provider educational barriers (eg, ordering the wrong study or referral), backlogged electronic health records (EHRs) or email inboxes, and limited availability. System-level delays include prior authorization delays; barriers to efficient scheduling and completion of laboratory tests, referrals, imaging studies, and procedures; and limited appointment slots. However, even for motivated patients who are anxious to proceed with care, persistent provider-level and system-level delays in the initiation, scheduling, and completion of standard medical orders for ancillary services (eg, radiology), specialist referrals, and treatment continue to pose a significant barrier to efficient cancer care.

With the goal of minimizing provider-level and system-level barriers to breast health care, we initiated an institutional review board (IRB)–approved quality improvement initiative (WCG IRB, tracking ID: 20214516) at an integrated health system with the overall mission of reducing the time from a malignant core needle biopsy demonstrating breast cancer to initiation of breast cancer treatment by streamlining and automating the clinical management processes while also identifying unrecognized or underappreciated provider- and system-level barriers to efficient care. The following discussion summarizes the key outcomes of the quality improvement initiative.

METHODS

This IRB-approved quality improvement initiative was conducted at Intermountain Healthcare Nevada (IMHCN), a large integrated health care organization based in Las Vegas. At the institution’s request, the quality improvement initiative was restricted to women with Medicare Advantage insurance referred for diagnostic breast imaging (ie, mammograms, ultrasound, and/or MRI) for evaluation of inconclusive (Breast Imaging Reporting and Data Systems [BI-RADS] category 0) and suspicious (BI-RADS categories 4 or 5) breast findings at contracted radiology facilities (Table 1). Because this was a quality improvement initiative, patient informed consent was not required under IRB guidelines. Hence, the initiative was made available to all Medicare Advantage patients.

The quality improvement initiative evaluated the use of XpediteMD, a web-based, technology-enabled service (or software as a service) platform designed to help health system teams improve cancer care, improve adherence to evidence-based national and institutional guidelines, reduce cancer inequity and mortality, and enhance value-based care. The XpediteMD platform achieves these aims using clinical decision support (CDS) tools, clinical pathways, embedded national guidelines, and automation of prior authorization workflows. Order trackers with time-based prompts alert providers of orders that are delayed beyond predetermined time parameters.

The XpediteMD platform tracks patient progress through disease-specific clinical pathways, which can be customized to fit the needs of client organizations. Unique clinicopathologic data (eg, BI-RADS score, tumor size, receptor status, etc) are input to determine how individual patients’ cases are managed on clinical pathways. Embedded national and institutional guidelines elevate the quality of care by encouraging uniform adherence to pathway-compliant care.

To eliminate one of the most intractable barriers, prior authorizations, the XpediteMD platform uses CDS software, national treatment guidelines, and existing payer guidelines to provide immediate, automated, point-of-care approval of referrals, imaging studies, laboratory tests, and procedures designated by the software as “recommended” or “optional.” This ensures that submitted orders are both compliant with national guidelines and in line with payer authorization standards to enable instant adjudication of claims at the point of request. Off-pathway orders are permitted to preserve clinician autonomy, but these orders may require traditional prior authorization.

Similar to commercial trackers (eg, those used for pizza deliveries, express mail, or baggage), XpediteMD employs built-in status trackers to document the progress of the patient and individual orders to their respective destinations. Patient trackers document the key events in a patient’s journey from abnormal imaging to treatment in a specified time frame. Order trackers document the key events in an order’s journey from submission to acknowledgment of the results within a specified time frame. If patients or orders miss key milestones, team members are notified via time-based prompts and the patients are moved to priority worklists to ensure that their care gets back on track. For example, a patient with highly suspicious (eg, BI-RADS 5) imaging findings would be required to have a biopsy scheduled within a specified time frame (eg, 7 business days). If the appointment is not documented as being scheduled or completed within the required time frames, care managers would be prompted to act. With worklists that can be targeted by patients’ level of acuity and point in the care journey, end users have simple workflows that intuitively guide them to focus on the patients who are most in need of support.

In this quality improvement initiative, all Medicare Advantage patients were entered into the XpediteMD platform upon receipt of a BI-RADS 0, 4, or 5 breast radiology diagnosis and their cases were then managed on the platform until either the inconclusive radiology finding was resolved (eg, BI-RADS 0 was reassessed as BI-RADS 1, 2, or 3) or until a core needle biopsy yielded a benign or malignant result. Patients with a malignant core needle biopsy result had their cases further managed on the XpediteMD platform until either surgery or neoadjuvant systemic therapy was initiated. Time to treatment (TTT) was assessed among the subset of patients with malignant core needle biopsy diagnoses by calculating the number of days between the date of the core needle biopsy procedure and the date when surgery or neoadjuvant systemic therapy was initiated. For patients requiring multiple cancer-related operations (eg, re-excision of positive margins or delayed reconstruction), the initial resection date was utilized as the date of surgery.

The study’s overall accrual goal was to enroll Medicare Advantage patients on the XpediteMD platform until a minimum of 50 patients with a breast cancer diagnosis on core biopsy had initiated treatment in the form of surgery or neoadjuvant systemic therapy. The primary end point was to determine the magnitude of reduction of TTT achieved with the use of XpediteMD by comparing the cohort of patients enrolled on the platform with a historical cohort of Medicare Advantage patients treated for breast cancer at the same facility during the 12 months preceding the launch of the quality improvement initiative. Within this primary end point, the specific aim of the quality improvement initiative was to reduce the historical TTT by greater than or equal to 50%. A secondary aim was to reduce median TTT to fewer than 30 days to minimize impact on survival.

RESULTS

Between September 2021 and June 2022, 552 patients with BI-RADS category 0, 4, or 5 breast imaging were enrolled in the quality improvement initiative and their cases were managed on the XpediteMD platform. A total of 444 patients were entered into the XpediteMD platform with BI-RADS 0 breast imaging; later, 372 patients’ categories were reassigned as BI-RADS 1, 2, or 3 (ie, no suspicious findings; n = 251) or BI-RADS 4 (n = 116) or BI-RADS 5 (n = 5) following completion of their diagnostic workup (Table 2). Seventy-two patients had an ongoing workup at the time of study closure. Ninety-five additional patients had BI-RADS 4 breast imaging, and 13 additional patients had BI-RADS 5 imaging. A total of 229 patients with BI-RADS 4 or 5 imaging underwent diagnostic core needle biopsies. Of these, 143 were found to have benign pathology for which imaging follow-up was recommended, 14 were found to have high-risk benign pathology for which surgical referral was initiated, and 72 were found to have invasive or in situ breast cancer for which surgical and medical oncology referrals were initiated. The historical cohort consisted of 99 Medicare Advantage patients with breast cancer who were treated in the same health care system the preceding year, between September 2020 and August 2021. For this historical cohort, the median TTT was 74 days, excluding patients who refused treatment or who were unable to proceed with treatment due to intercurrent illness.

TTT calculations for patients on the XpediteMD platform were limited to those who received a diagnosis of in situ and invasive breast cancer by core needle biopsy, excluding those with benign or high-risk benign pathology. Of the initial cohort of 72 patients who received a breast cancer diagnosis, 12 were excluded from the TTT calculation because they initially refused to proceed with treatment and 10 were excluded due to treatment delay caused by intercurrent illness (eg, COVID-19–related hospitalization, cardiac disease, surgery for another condition). For the remaining 50 patients on the XpediteMD platform, the median TTT was 33 days compared with 74 days in the historical cohort. This constitutes a significant 55% reduction in TTT (P < .0001) over 9 months, exceeding the 50% TTT reduction goal that was established at the outset of the quality improvement initiative. Although the quality improvement initiative did not achieve the secondary end point of fewer than 30 days median TTT for the entire cohort, ongoing use and increasing adoption of the XpediteMD platform at IMHCN produced a steady drop in treatment times, which resulted in median TTT of only 17 days, an overall 77% reduction from baseline over 12 months.

DISCUSSION

Although delay in cancer care is a well-recognized cause of poor patient experience, an expanding body of published literature now firmly links delays in the workup and management of breast cancer to a reduction in patient survival.^1-9

The adverse effects of treatment delay have drawn national attention to the need to recognize timely care as a breast cancer quality measure. In 2022, the American Society of Breast Surgeons established “time to first treatment” of fewer than 60 days as a quality metric despite the absence of widely utilized policies, procedures, or technologies to achieve this goal.¹⁰ In 2022, the lead organization accrediting cancer programs in the US, the American College of Surgeons Commission on Cancer (CoC) National Cancer Database, established “time to therapeutic breast surgery” of fewer than 60 days as a surveillance measure for its 1500-plus CoC-accredited sites.¹¹ Effective January 2026, CMS will attempt to reduce prior authorization–related delays by mandating standardized use of electronic prior authorizations and shortened authorization time frames (ie, urgent prior authorization < 3 days and routine prior authorizations < 7 days) for Medicare Advantage plans, Medicaid, and the Children’s Health Insurance Programs.¹²

The necessity of TTT quality metrics reflects the reality that many patients face provider- and system-level barriers that impede their access to efficient care. In a real-world case study exemplary of many of those barriers, a 50-year-old premenopausal health care provider with preferred provider organization insurance experienced a 9-month treatment delay after originally presenting with a lump in her right breast on March 3, 2022 (Figure). The primary care physician (PCP) improperly ordered screening mammography (performed April 1, 2022) instead of diagnostic mammography and breast ultrasound, which were finally performed on June 2, 2022, revealing a suspected 2-cm, stage IA breast cancer. Additional authorization and scheduling delayed a core needle biopsy until July 21, 2022, which on August 5, 2022, confirmed a 2.3-cm, stage IIA, hormone receptor–positive, HER2/neu-negative invasive ductal cancer. The PCP then referred the patient to a medical oncologist (August 9, 2022), who ordered a breast MRI (performed September 8, 2022) but recognized that the patient should have first been referred to a breast or general surgeon. Due to additional authorizations and scheduling delays, the patient was finally seen in the surgeon’s office on October 6, 2022, where a breast ultrasound measured the tumor at 3.5 cm. Following consultation with a plastic surgeon, the patient finally underwent breast surgery on December 14, 2022—more than 9 months after her initial imaging study and nearly 4 months after her needle biopsy.

The provider- and system-level barriers encountered by this patient are exactly what XpediteMD sought to overcome at IMHCN in its effort to reduce TTT, meet or exceed quality metrics, improve adherence to national guidelines, and enhance patient and provider experience (Figure). Had this patient’s case been managed on the XpediteMD platform, the CDS software and clinical pathways would have assisted the PCP in selecting the correct initial diagnostic workup for this patient’s breast lump. XpediteMD’s time-based prompts would have detected that the patient had not been scheduled for or completed the designated diagnostic workup and needle biopsy within the recommended 1- to 2-week time frame, and the accountable parties in the PCP’s office and radiology would have been notified. Similarly, the platform would have captured and responded to inappropriate delays in the release of the final pathology report. Based on clinical data captured from the radiology and pathology reports, the CDS software would have guided the PCP (or the PCP’s surrogate) to order in a single step the breast MRI, other studies, and all referrals appropriate for the patient’s age, stage, and tumor biology and facilitated prior authorization for such studies. The CDS tool would have prioritized this patient’s referral to breast/general surgery (< 10 days from diagnosis), medical oncology (< 30 days), and radiation oncology (< 60 days) based on the most appropriate order of treatment for her diagnosis.

Limitations

Despite the positive outcome of the current study, several limitations were observed. First, the lack of randomization increases the impact of confounding factors that could influence TTT calculations. However, this limitation is offset by the quality improvement initiative design of the study, which eliminated selection bias by (1) enabling the management of 100% of eligible patient cases on the XpediteMD platform and (2) comparing this cohort with a historical cohort composed of Medicare Advantage patients who were diagnosed with and treated for breast cancer during a finite period. Another limitation in the study design was the exclusive enrollment of patients with Medicare Advantage at an integrated health system, a study population whose experience might not be representative of non–Medicare Advantage populations or illustrative of patients receiving treatment in nonintegrated health systems. However, the generalizability of this experience is reflected by the reality that Medicare Advantage is the fastest-growing segment of the health care market (currently 30 million beneficiaries) and constitutes a large segment of all major health insurers, each of which could see the kinds of TTT improvements that were reported herein.¹³ Furthermore, if a 55% reduction in TTT is achievable in a Medicare Advantage population, where relatively fewer provider access and prior authorization barriers exist, it is highly plausible that greater reductions in TTT could be achieved in patients with lower-tier insurance or for patients treated in fragmented health care settings, where greater treatment delays and prior authorization challenges are expected. The XpediteMD platform is currently being utilized in a Medicaid population and a nonintegrated health care setting. Results of those experiences will be reported in future publications. Finally, the study was also limited by the fact that IMHCN elected to defer capture of direct and indirect health care costs in the historical and study cohorts, which prevented measurement of potential cost savings. However, apart from direct health care cost savings attributed to prevention or reduction of stage progression and appropriate use of health care resources, we hypothesize that streamlining and automating prior authorization processes will significantly reduce provider and payer administrative overhead, aims that should be facilitated by full EHR integration of the XpediteMD platform. Findings from multiple studies have demonstrated the ability of clinical pathways to reduce health care costs.^14-16 Electronic prior authorization also significantly reduces payer and provider overhead.¹⁷ The 55% reduction in TTT accomplished in the quality improvement initiative was accomplished with just 2 full-time XpediteMD clinical coordinators and 2 part-time hospital utilization management staff members.

CONCLUSIONS

Despite these limitations, the XpediteMD platform and the quality improvement initiative successfully instituted organizational and clinical improvements in breast health care delivery that have the potential to reduce the direct and indirect cost of health care, essentially making breast health care faster, better, and potentially more cost-effective. The initiative also revealed additional opportunities to expedite cancer care and further improve patient experience. For example, inclusion of an upcoming patient engagement feature could reduce patient-level barriers to care and further improve patient experience. Furthermore, only a limited number of designated surgeons and medical oncologists participated in the quality improvement initiative. Had more surgeons or medical oncologists been involved earlier in the quality improvement initiative, the supply of appointment slots would have been greater and time to initial appointment and TTT might have been achieved by the 9th month rather than by the 12th month. Lastly, the XpediteMD platform was not integrated into the EHR system of the hospital or the radiology center or the private EHR of the surgeons and oncologists, which caused delays in the transfer of information to the XpediteMD platform. Had EHR integration been established with key partners at the outset of the study, data transfer delays could have been minimized by the direct sharing of information via application programming interfaces between the XpediteMD platform and the EHRs.

Author Affiliations: Adventist Health Glendale (DRH), Glendale, CA; XpediteMD, Inc (DRH), Torrance, CA; SilverSummit, a Centene Regional Healthplan (SDE), Las Vegas, NV; Intermountain Healthcare Nevada (WF, DW), Las Vegas, NV; Ria Biomedix, Inc (RP), Rolling Hills Estates, CA.

Source of Funding: This quality improvement initiative was funded by Intermountain Healthcare Nevada.

Author Disclosures: Dr Holmes is a cofounder and shareholder of XpediteMD and received grants from Intermountain Healthcare Nevada. Dr Evans is a member of the editorial board of The American Journal of Accountable Care^®. Dr Pulicharam is a cofounder, part owner, and board member of XpediteMD. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DRH, SDE, WF, DW, RP); acquisition of data (DRH, SDE, DW, RP); analysis and interpretation of data (DRH, SDE, WF, RP); drafting of the manuscript (DRH, SDE); critical revision of the manuscript for important intellectual content (DRH); statistical analysis (DRH); provision of study materials or patients (SDE, DW, RP); obtaining funding (DRH, SDE); administrative, technical, or logistic support (DRH, SDE, WF, RP); and supervision (SDE, WF, DW).

Send Correspondence to: Dennis R. Holmes, MD, Adventist Health Glendale, Physicians Medical Terrace, 1505 Wilson Terrace, Ste 370, Glendale, CA 91206. Email: drholmesmd50@gmail.com.

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