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CMAJ • February 5, 2002; 166 (3)
© 2002 Canadian Medical Association or its licensors

Letters
Correspondance

Addressing the challenges of queues

Ivo A. Olivotto, Christina Bancej and Lisa Kan

Clinical Professor Radiation Oncology BC Cancer Agency — Vancouver Island Centre Victoria, BC; Head Breast Screening Unit Screening and Early Detection Section Cancer Division Population and Public Health Branch Health Canada Ottawa, Ont.; Screening Program Evaluator Population and Preventive Oncology BC Cancer Agency Vancouver, BC

Dalis Rotstein and David Alter have highlighted one problem brought about by a health care planning decision made in Canada in the late 1980s when provincial screening programs were being established in parallel with existing imaging facilities. The organizers of screening programs developed processes to effect recruitment, quality control and evaluation, but for medicopolitical reasons they decided to leave investigation of abnormal screens within the diagnostic sector. The result is that family physicians must continue to work out triage, referral and diagnostic sequences for each woman with a breast screening abnormality. This results in considerable intra- and inter-provincial variation in the time to diagnosis, as we demonstrated.1 This contrasts with a service model in which the screening centre undertakes the diagnostic workup.2,3

We disagree that an analysis of this problem needs to start with a description of the sequence of investigations. First, one needs to see if there is a problem (a delay) then one should examine the components of the process, identify opportunities for improvement, implement redesign and finally evaluate whether or not the problem (the delay) has been resolved. The Screening Mammography Program of British Columbia (SMPBC) has taken these steps4 and demonstrated that process change can reduce delay.5

In an SMPBC-sponsored project, 5 BC communities implemented different strategies to improve the diagnostic process after an abnormal breast screen. A simple change had the biggest effect: a screening centre that directly communicated abnormal findings to the diagnostic centre rather than advising the family physician to do the same slashed the median time to diagnosis from 23 to 7 days (p = 0.001) for the 81% of women not requiring a biopsy.5 Four of the 5 strategies reduced the interval to diagnosis for women requiring biopsy.5 Facilitated referral from screening to diagnosis has also recently been successfully implemented in other Canadian jurisdictions.

Process change can improve care. Having the will to implement change is a larger challenge.

References

  1. Shapiro S, Coleman EA, Broeders M, Codd M, de Koning H, Fracheboud J, et al. Breast cancer screening programmes in 22 countries: current policies, administration and guidelines. International Breast Cancer Screening Network (IBSN) and the European Network of Pilot Projects for Breast Cancer Screening. Int J Epidemiol 1998; 27 (5) :735-42.[Abstract/Free Full Text]
  2. Organizing assessment. Sheffield (UK): National Health Service Breast Screening Programme Publications; 1989.
  3. Olivotto IA, Bancej C, Goel V, Snider J, McAuley RG, Irvine B, et al. Waiting times from abnormal breast screen to diagnosis in 7 Canadian provinces. CMAJ 2001;165(3):277-83.[Abstract/Free Full Text]
  4. Olivotto IA, Kan L, King S. Waiting for a diagnosis after an abnormal screening mammogram. Can J Public Health 2000;91:113-7.[Medline]
  5. Olivotto IA, Borugian MJ, Kan L, Harris SR, Rousseau EJ, Thorne SJ, et al. Improving the time to diagnosis after an abnormal screening mammogram. Can J Public Health 2001;92:366-71.[Medline]




This Article
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