Eur Arch Otorhinolaryngol DOI 10.1007/s00405-013-2584-z
HEAD AND NECK
A ‘‘package solution’’ fast track program can reduce the diagnostic waiting time in head and neck cancer Jesper Roed Sorensen • Jørgen Johansen • Lars Gano • Jens Ahm Sørensen Stine Rosenkilde Larsen • Peter Bøgeskov Andersen • Anders Thomassen • Christian Godballe
•
Received: 6 January 2013 / Accepted: 31 May 2013 Springer-Verlag Berlin Heidelberg 2013
Abstract In 2007, a fast track program for patients with suspicion of head and neck cancer (HNC) was introduced in Denmark to reduce unnecessary waiting time. The program was based on so called ‘‘package solutions’’ including pre-booked slots for outpatient evaluation, imaging, and diagnostic surgical procedures. The purpose of this study is to present a model for fast track handling of patients suspicious of cancer in the head and neck region and to evaluate the effect of implementation on the diagnostic work up time. Patients with suspicion of HNC referred to the same university department of ENT Head and Neck Surgery during three comparable time intervals 2006–2007, 2007–2008, and 2011–2012 (groups 1–3) were investigated. We recorded the time from patient referral, to J. R. Sorensen (&) L. Gano C. Godballe Department of ENT Head and Neck Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark e-mail:
[email protected] J. Johansen Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, Odense C, Denmark
first consultation and final diagnosis. The first interval was before initiation of the ‘‘package solution’’, the second just after the introduction, and the third interval represents the current situation. The median time from referral to first consultation was reduced from eight calendar days in group 1 to only one day in groups 2 and 3 (p \ 0.001). The combined median time from referral to the final cancer diagnosis decreased from 24 calendar days in group 1 to 7 and 10 days in groups 2 and 3, respectively (p \ 0.005). The hit rate of finding malignancy was 41 % in group 1, 49 % in group 2, and 43 % in group 3 with no difference among the groups (p = 0.13). The frequency of newly diagnosed HNC was 19 % in group 1, 21 % in group 2, and 17 % in group 3 (p = 0.52). A ‘‘package solution’’ including pre-booked slots for diagnostic procedures is feasible and can significantly reduce the waiting time for patients with suspicion of HNC. Keywords Head and neck cancer Fast track program Waiting time Pre-booked Package solution
Introduction J. A. Sørensen Department of Plastic Surgery, Odense University Hospital, Sdr. Boulevard 29, Odense C, Denmark S. R. Larsen Department of Clinical Pathology, Odense University Hospital, Sdr. Boulevard 29, Odense C, Denmark P. B. Andersen Department of Radiology, Odense University Hospital, Sdr. Boulevard 29, Odense C, Denmark A. Thomassen Department of Nuclear Medicine, Odense University Hospital, Sdr. Boulevard 29, Odense C, Denmark
Package solutions for head and neck cancer (HNC) were introduced in Denmark in 2007 in order to reduce the waiting time for diagnosis and treatment. It was observed that the 5-year survival rate in the Nordic countries increased from the beginning of the 1990s and onward. Denmark, however, did not experience this development. In the year 2000, the 5-year survival rate was significantly lower in Denmark for both HNC and cancer in general compared to the other Nordic countries [1–3]. Increasing waiting times related to clinical work-up and treatment were considered one of the main reasons and the National
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Eur Arch Otorhinolaryngol Table 1 Signs of malignancy for the general practitioner in their evaluation of patients with symptoms from the head and neck area
Suspicious site
Signs of malignancy
Sinonasal tract
New one-sided nasal obstruction without explanation, bloody secretion from the nose, recurrent bleeding from the nose without explanation, wound without healing, or visible tumor in the nose
Larynx and hypopharynx
Patients older than 40 years with hoarseness for more than 2 weeks without explanation or signs of improvement, dysphagia and/or globulus sensation combined with pain to the ears, or newly discovered recurrent laryngeal nerve paralysis
Oral cavity and oropharynx
Wound without healing, or visible or palpable tumor in oral cavity or pharynx
Rhinopharynx
Unexplainable one-sided otitis media with effusion in adults, affection of cranial nerves, or patients with specific ethnic origins need special attention (Inuit, Asians, etc.)
Salivary glands
New tumor in salivary gland, growth in known salivary gland tumor, or tumor in salivary gland with impairment of the facial nerve
Thyroid cancer
Tumor in the thyroid gland combined with hoarseness, fast growth of thyroid nodule, or firm and immobile tumor in thyroid gland
Cervical lymph nodes
Enlarged lymph nodes in the neck without infectious or other benign explanation, or cysts on the lateral part of the neck in patients older than 40 years
Cancer Plan II-Denmark from 2005 focused specifically on this subject [3–7]. In early 2007, waiting time for cancer diagnostics and treatment were intensively discussed in Denmark and during the summer of 2007, the Danish Government declared that patients with cancer should have the rights for ‘‘clear instructions and immediate action’’ regarding diagnosis and treatment from the health authorities. All phases from suspicion of cancer to start of treatment were in question. In collaboration with the Danish Regions, which administrates the public hospitals, it was planned that lung cancer, HNC, breast cancer, and intestinal cancer should be forerunners in the implementation of a fast track process. The other cancer groups should follow later on. The main goal was to avoid unnecessary waiting time and only allow waiting time, which could be explained from strictly medical reasons. The tools were pre-booked slots for clinical examination, imaging, surgery, and radiotherapy combined in so called ‘‘package solutions’’ designed for each cancer type. The National Board of Health and the national multidisciplinary cancer groups were assigned to produce these ‘‘package solution’’ guidelines, also called ‘‘national integrated cancer pathways’’. Today ‘‘package solutions’’ for HNC have been implemented all over Denmark and some experience is emerging. The purpose of this study is to present a model for a ‘‘package solution’’ to patients with suspicion of HNC and to evaluate the effect on waiting time for clinical pretreatment work up.
‘‘Package solution’’ set up During the implementation of the ‘‘package solutions’’, all general practitioners (GP) received a set of referral
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guidelines including diagnostic signs of malignancy (Table 1). If a patient presented with one or more of these signs or if suspicion of HNC arises by other causes, the GP had to contact an ear, nose, and throat (ENT) specialist in private practice by telephone to arrange a consultation (Denmark has approximately 250 ENT specialists working in privately owned outpatient clinics). The ENT specialist had to offer the patient a consultation the same day or the next working day or alternatively if this was not possible, refer the patient directly to the department of ENT Head and Neck Surgery (HNS) at the local hospital. If the ENT specialist confirmed that the suspicion of HNC was substantial, he needed immediately to contact the local department of ENT HNS for referral. However, if no substantial suspicion was found, the patient could be examined according to usual procedures and time scales in the private outpatient setting. In hospital, the patient was referred to a ‘‘package solution’’. At our Department of ENT HNS, patients were included into ‘‘package solutions’’ on Mondays, Wednesdays, and Fridays. The ‘‘Monday track’’ is shown in Table 2. In this way, it was possible to fulfill the initial governmental demand, which required that patients should be seen at the ENT HNS department within two working days (48 h) from receiving a telephone or electronic referral. In the latest version of the national integrated cancer pathways from February 2012, the National Board of Health has extended this time limit to three full working days [8]. At day 1, the patient history was recorded and a basic clinical ENT examination was performed by an ENT specialist, including fiberoptic naso-pharyngo-laryngoscopy and ultrasound examination of the neck. Based on these
Eur Arch Otorhinolaryngol Table 2 ‘‘Monday track’’ for patients suspicious of head and neck cancer used at the Department of ENT Head and Neck Surgery, Odense University Hospital, Denmark Monday
Tuesday
Wednesday
Thursday
When histology readyb
Patient history, ENT examination, RPL endoscopya, US of neck and salivary glands, FNA (optional) and Conclusion/ plan
Booking/ Registration
Dental check, nutrition check, anesthesiology check, MR/CT/PETCT, chest X-ray, blood tests, and ECG
Evaluation of imaging, endoscopy with biopsy, tumor staging and dental workc
Patient called to hospital by phone, tumor conference, conclusion, patient information, final plan, and booking for treatment
Similar tracks are started at Wednesdays and Fridays. This enables initiation of the diagnostic process within three working days (72 h), which is the actual governmental demand a
Rhino-pharyngo-laryngoscopy (RPL) with flexible scope in local anesthesia
b
If immunohistochemical examination is not necessary for histological diagnosis the pathology report is usually ready within three working days. If immunohistochemical procedures are performed, the answer has to be ready within 4–6 working days
c
If radiotherapy involving mandible or maxilla is expected
elements, it was concluded if there still was a substantial suspicion of HNC or if the patient most likely suffered from a benign condition. In the latter case, the patient would be examined according to ordinary procedures and time scales. Fine needle aspiration (FNA), as part of the initial clinical evaluation was optional. Delay caused by waiting for a cytology result is not accepted. If the examination at day 1 confirmed the suspicion of cancer, the patient would continue in the ‘‘package solution’’ program and at day 3 imaging, dental examination (if radiotherapy of the tooth bearing areas was in question), blood tests, examination by anesthesiologist, and nutritional screening were performed. Day number 2 is reserved for planning of the course. At the fourth working day, the imaging results were presented at the morning conference and afterward, the head and neck surgeon performed the planned endoscopies, biopsies, and/or other diagnostic surgical procedures in the operating room. At the same time tumor assessments and TNM staging were performed, and a working paper diagram of the tumor was done. To achieve sufficient fixation time, the biopsies were to be delivered to the department of pathology before 1 o’clock PM. As soon as histopathological examinations were ready, the patient would be contacted by phone and a consultation for the decisive information would be arranged as soon as possible. In the beginning, all information consultations were set on Mondays, Wednesdays, and Fridays. However, since the start of the multidisciplinary tumor conferences, which were placed on Tuesdays and Thursdays, most patients with a malignant histology were informed these days. On the seventh or ninth working day, approximately, the patient received the result of the histological examination and a treatment plan was made.
Materials and methods All patients with the ICD-10 diagnose Z03.1 and a substantial suspicion of HNC referred to our Department of ENT HNS were eligible for the study. To evaluate differences in waiting time for diagnostic work-up three time intervals were defined: •
•
•
1st of November 2006 to 30th of June 2007—just before the introduction of the fast track ‘‘package solution’’, ‘‘group 1’’. 1st of November 2007 to 30th of June 2008—the first time interval after the start of fast track ‘‘package solution’’, ‘‘group 2’’. 1st of November 2011 to 30th of June 2012—the most recent time interval, representing the present situation, ‘‘group 3’’.
Time intervals of 8 months were used because the necessary patient data from the period before the start of the fast track ‘‘package solution’’ were only eligible for this interval. The first consultation was in the outpatient clinic and all patients were seen by one of five consultants with special interest in HNC assisted by a resident. Patients suspicious of cancer of the oral cavity were excluded as they are treated at the Department of Plastic Surgery. Statistics Analysis of time intervals were based on calendar days and the day of referral was not included in the calculations. By comparisons to the governmental time limits working days were used. The waiting time for the three groups was compared with an ANOVA-test with Bonferroni correction and the differences in proportions were compared with a v2
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test. The results were considered significant when the p value was below 0.05. The statistical analyses were performed with Stata IC/12.1 software, StataCorp LP, College Station, USA.
Results After initiation of the ‘‘package solution’’ for HNC, an increased patient flow of 77 % in group 2 and 169 % in group 3 were observed compared with group 1 (Table 3). The average age of group 1 and 2 was 60, and 61 years for group 3 (p = 0.73). Women constituted between 39 and 47 % of the patients (p = 0.17) (Table 3). The hit rate of finding malignancy was 41 % in group 1, 49 % in group 2, and 43 % in group 3 with no difference among the groups (p = 0.13). Among these, the frequency of newly diagnosed HNC was 19 % in group 1, 21 % in group 2, and 17 % in group 3 (p = 0.52) as shown in Table 3. The different types of newly found HNC are shown in Table 4. There were significant more thyroid neoplasm in group 3 compared to groups 1 and 2 (p \ 0.01). No difference Table 3 Basic information, waiting time from referral to final diagnosis, and the underlying waiting time for pathology are presented for three groups of patients in a ‘‘package solution’’ fast track program
existed between the other cancer types. The percentage of early stage HNCs (Union of cancer control 6 (UICC-6) stages I–II) were 25 % in group 1 and 35 and 34 % in groups 2 and 3 (Union of cancer control 6 (UICC-6) stages I–II), respectively, with no difference between groups 1, 2, and 3 (p = 0.58) (Table 4). The median number of days from referral to the first consultation at the ENT department was 8 days in group 1. This decreased significantly to 1 day after initiation of the ‘‘package solution’’ for both groups 2 and 3 (p \ 0.001). According to the Danish National Board of Health (February 2012), the maximum referral time should be no more than three working days. In group 1, 41 % of the patients experienced referral times within this limit, but this was significantly increased to 98 % in both groups 2 and 3 (p \ 0.001) (Table 3). The median time from first consultation to final diagnosis was 16 days in group 1, 6 days in group 2 (p \ 0.001), and 9 days in group 3 (p \ 0.02). 62 % of the patients in group 1, 91 % of the patients in group 2, and 91 % of the patients in group 3 received their cancer diagnosis within the time limit of 11 working days (p \ 0.001) (Table 3). 2006–2007
2007–2008
2011–2012
Significance (p)
Number of patients
186
329
501
Age (mean)
60
60
61
0.73
Percentage of female patients Percentage of patients with malignancy
39 % 41 %
45 % 49 %
47 % 43 %
0.17 0.13
Percentage of patients having newly diagnosed head and neck cancer out of all cancer
19 %
21 %
17 %
0.52
Median number of calendara days from referral to first consultation
8
1
1
Percentage of patients seen within three workinga days from referral to first consultation
39 %
98 %
98 %
Median number of calendar days from first consultation to diagnosis
16
6
9
Percentage of patients using within 11 working days to secure the diagnosis
62 %
91 %
91 %
Median number of calendar days from referral to final diagnosis
24
7
10
Median number of calendar days until cytology results were available
5
2
2
Percentage of patients with cytology results ready within one working day
19 %
75 %
79 %
Median number of calendar days until biopsy results were available
6.5
5
5
Percentage of patients with biopsy results ready within four working days
70 %
80 %
79 %
\0.001
87 %
53 %
47 %
\0.001
Waiting time
\0.001
\0.001
Pathology
a
Calendar days were used as the standard unit in study calculations except in comparisons to the maximal time limits set by the government
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\0.001
Imaging Percentage of patient not receiving supplementary imaging
Eur Arch Otorhinolaryngol Table 4 Different newly diagnosed head and neck cancer and tumor stage found through groups 1–3 using the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) and Union of cancer control 6 ICD-10 diagnosis
2006–2007
2007–2008
2011–2012
Total
Significance (p)
Tumor stage
I–II
III–IV
I–II
III–IV
I–II
III–IV
I–II
III–IV
Cancer of the oropharynx, nasopharynx and hypoharynx (C01, C05, C09–14)
0
12
6
21
4
24
10
57
0.77
Cancer of the salivary glands (C07–08)
1
3
2
3
2
9
5
15
0.52
Cancer of the nasal cavity and paranasal sinus (C30–31)
2
3
6
4
1
2
9
9
0.05
Cancer of the larynx (C32)
6
4
8
9
7
6
21
19
0.15
Cancer of the thyroid gland (C73)
0
5
2
7
16
16
18
28
\0.001
Total
9
27 (75 %)
24 (35 %)
44 (65 %)
30 (34 %)
57 (66 %)
63 (33 %)
127 (67 %)
(25 %)
The combined median time from referral to final cancer diagnosis decreased from 24 days in group 1 to 7 and 10 days in groups 2 and 3, respectively (p \ 0.005). Throughout the three time periods, the median response time for cytology decreased from 5 days in group 1 to 2 days in both groups 2 (p = 0.01) and 3 (p \ 0.001) with no difference between groups 2 and 3. In 19 % of the patients, the cytology diagnosis was obtained within one full working day in group 1, compared to 75 % of patients in group 2, and 79 % of patients in group 3 (p \ 0.001) (Table 3). The median time for histology response obtained from biopsies decreased significantly from 6.5 days in group 1 to 5 days in groups 2 and 3 (p \ 0.001) with no difference between groups 2 and 3. In 70 % of the patients in group 1, histology results were delivered within four full working days for biopsies, while this was the case for 80 % in group 2 and 79 % in group 3 (p \ 0.001) (Table 3). The percentage of patient who did not receive any supplementary imaging (CT, MR, or PET-CT) changed significantly through the time periods. 87 % of the patients in group 1 did not receive supplementary imaging whereas this fell to 53 % in group 2 and 47 % in group 3 (p \ 0.001) (Table 3). The diagnosis of patients not having newly diagnosed HNC are presented in Table 5. Patient records were examined thoroughly, however, in 15 patients it was not possible to obtain the ICD-10 code, explaining that the number of patients in Tables 4 and 5 do not sum up the patients in Table 3.
Discussion By implementation of the ‘‘package solution’’, it was possible to reduce time from referral to final diagnosis among group 1 and groups 2 and 3, thereby counter acting
0.58
the increased time for clinical work up addressed in the National Danish Cancer Plan II [7]. We therefore hope to see an increase in the survival rate of our HNC patients as a metaanalysis showed a decreased survival rate RRdeath/month = 1.16 (95 % CI 1.02–1.29) with prolonged waiting time for treatment and several studies in general have shown decreased survival rate with prolonged waiting for treatment [4, 5]. However, due to a limited number of patients in our institutional study, analysis of changes in survival was not done. The aim of this study was only to present a possible model for diagnostic acceleration and to evaluate the effect on diagnostic waiting time. The principle of the ‘‘package solution’’ with prebooked slots for diagnostic procedures was introduced all over Denmark. However, the logistic set up varies among departments. Denmark (5.5 mill. inhabitants) has 12 departments of ENT HNS, which are participating in the diagnostics of HNC—the surgical treatment is centralized at four university departments. The Danish structure with approximately 250 ENT specialists in the private sector is not representative for the organization in other countries and therefore substantial parts of our diagnostic program cannot be directly projected to other nations. A private ENT specialist is expected to be superior to a general practitioner in identifying patients with suspicion of HNC, but the accuracy of referral to the departments of ENT HNS could still be improved. We found malignant disease in 43–49 % of the patients but only 17–21 % of the patients have newly diagnosed HNC. One might argue that these hit-rates are low and that we don’t get ‘‘value for money’’. However, what is the optimal hit-rate? If it is too high, we might miss cancer patients and if it is too low, the patient is presumable being over-examined especially with imaging procedures. It is difficult to define the correct hitrate. The intervention accelerate the diagnostic process and therefore we found it justified to present our experience.
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Eur Arch Otorhinolaryngol Table 5 Different diagnoses found in groups 1–3 for patients not having newly diagnosed head and neck cancer using the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
Extensive examinations of patient records have been done but for 15 patients it was not possible to obtain the ICD-10 code , explaining that the number of patients in Tables 4 and 5 do not sum up the patients in Table 3
ICD-10 diagnosis
2007–2008
2011–2012
C01–C14 malignant neoplasms, lip, oral cavity, and pharynx
5
15
C15–C26 malignant neoplasms, digestive organs
2
3
1
C30–39 malignant neoplasms, respiratory system, and intrathoracic organs
9
10
18
C40–C58 and C69–C72 other types of malignant neoplasm: bone, articular cartilage, skin, connective- and soft tissue, breast and female genitals, eye brain, and central nervous system
2
4
5
C73–75 malignant neoplasms, endocrine glands, and related structures
0
1
4
39
C76–80 malignant neoplasms, secondary, and ill-defined
11
28
25
C81–96 malignant neoplasms, stated or presumed to be primary, of lymphoid, haematopoietic, and related tissue
12
32
38
D00-48 in situ neosplasms, and benign neoplasms of uncertain or unknown kind
22
34
52
E00-90 endocrine, nutritional, and metabolic disease
5
16
52
D50-89 diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism, G00-99 diseases of the nervous system and diseases of the eye and adnexa, H00-95 diseases of the ear and mastoid process, and I00-99 diseases of the circulatory system
4
6
15
J00-99 diseases of the respiratory system
19
22
51
K00-93 diseases of the digestive system
4
3
10
L00-99 diseases of the skin and subcutaneous tissue
5
8
12
M00-99 diseases of the musculoskeletal system and connective tissue, and Q00-99 congenital malformations, deformations and chromosomal abnormalities
5
6
7
R00-99 symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
24
35
47
S00-T98 injury, poisoning and certain other consequences of external cause
5
4
5
15
30
29
144
257
410
Z00-99 factors influencing health status and contact with health services Total
Prior to the implementation of the ‘‘package solution’’ patients were diagnosed with HNC at multiple departments at our university hospital. Through clear guidelines to the private ENT specialist and GPs, these patients were incorporated in the ‘‘package solution’’, which explains the great increase in patient number between groups 1 and 3. Increased focus on fast referral could theoretically have an impact on the tumor stage at the time of first visit to hospital. However, our study is not able to detect such a change. There is though an insignificant movement from 25 % of the newly diagnosed HNC being early stage tumors before implementation of the ‘‘package solution’’ to 33 % being early stage tumor in the present situation. Some of this movement is though caused by an increasing amount of early stage thyroid cancers, which concur with national and international observations [9, 10]. It has to be underscored that the introduced ‘‘package solution model’’ was not thought as a screening program but as a method for acceleration of the process from suspicion to final
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2006–2007
diagnosis and treatment. A decrease in patient delay by more information of cancer signs might perhaps have a beneficial effect on prognosis. In our figures, it has to be taken into consideration, that a substantial part of patients in the ‘‘package solution’’ were finished with a benign diagnosis just after the first consultation at our center on the basis of patient story, ENT examination, flexible rhinopharyngo-laryngoscopy, and ultrasound of the neck. Based on our current experience and the literature, it seems that predefined ‘‘package solutions’’ do increase the use of diagnostic procedures especially imaging [11]. A very important tool in the ‘‘package solution’’ is the use of flexible working time for the cancer team in the outpatient clinic. All patients referred that day or the day before will be seen and have their clinical examination even though evening hours are used. By this strategy, no waiting time for the clinical evaluation can occur. As compensation for this a so called ‘‘clean table’’ payment was introduced. However, it is not only the financial
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compensation, which is the driving force for the project, but also the understanding of the importance in reducing waiting time and the feeling that you really might contribute to a better prognosis for the patients do presumably have a positive impact. We do not have any obvious explanations for the increment in waiting time between groups 2 and 3, but a slight decrease in the enthusiasm might be a part of the explanation. So, it is important constantly to keep the team spirit high in fast track systems like ours, since 1 or 2 days delay does have a significant impact on the time intervals. However, the increased number of patients to the ‘‘package solution’’ might also be an important part of the explanation. Since every unnecessary waiting time leads to a decreased survival rate, work is going on to bring the waiting time back to former standards of 7 days observed in 2007–2008 [12–14]. Our results are consistent with results obtained at Aarhus University Hospital, Denmark where a reduction from referral to final diagnosis from 34 to 17 days (50 %) were obtained after introduction of a fast track program [15]. The next step for further investigations is to examine the effect of the ‘‘package solutions’’ on the 5-year survival rate and compare it to the other Nordic countries. An improvement in the overall 1-year age standardized relative survival of 3 % increase to 72 % for men and 75 % for women for cancer in general after the introduction of ‘‘package solutions’’ were seen, but significant results for HNC are still not present [16]. One might fear that the introduced ‘‘package solutions’’ will generate unnecessary fear to the patients included. The GP has to explain why presumed trivial symptoms as hoarseness or a lump in the neck suddenly has to be examined from day to day—and this will undoubtedly worry the patients. However, the GPs are instructed to tell that the fast ‘‘package solution’’ is started because malignancy might be one of several explanations for the symptom. This information will of course put some pressure on the GPs who has to balance between creation of unnecessary fear and a credible explanation for the chosen strategy. The same considerations go for the ENT-specialists in private praxis. Our general impression by talking to the patients during and after the ‘‘package solution’’ is that they of course have the fear for cancer, but that the very short waiting time and the fact that they always know the exact time and place for the next step in the process, make them feel secure. For patients not having cancer waiting times might have increased, but this has not been a scope for this study. The fast track program has though made many processes work more effectively making the department overall capable to see more patients than prior to the fast track program. The reduction in waiting times might also have been achieved by well-known methods like LEAN or bench
marking. These tools are more or less an indirect part of the process we have been through. We think that ‘‘package solutions’’ might not be the only way to reduce waiting time. However, ‘‘package solutions’’ are applicable in many areas of the health system and we hope that this study will bring focus on the potential possibilities.
Conclusion A ‘‘package solution’’ including pre-booked slots for diagnostic procedures is feasible and can significantly reduce the waiting time for patients with suspicion of HNC. Conflict of interest None of the authors have any conflicts of interest in this study.
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