Zachary Feuer, MD, on building a rapid access program for prostate cancer diagnostic evaluation

Men referred for an elevated prostate-specific antigen (PSA) level often wait months between an initial referral and a definitive biopsy, a gap capable of heightening anxiety and, in some workflows, delaying diagnosis and treatment decisions. At the University of North Carolina (UNC), Chapel Hill, clinicians traced much of the delay to scheduling bottlenecks rather than clinical necessity and built a telehealth-based rapid access program (RAP) to close it.

The results, published in Urology Practice, come from 120 men evaluated before the program and 700 evaluated after it launched.¹ Median time from referral to biopsy fell from 161 days to 71 days, a 55.9% reduction. Patients also avoided a median round trip of 58 miles and 66 minutes of travel per visit.

Zachary Feuer, MD, an assistant professor of urology at UNC, spoke with Urology Times® about the program's origins and how its advanced practice provider (APP)-led triage and biopsy-decision algorithms were built. He also discussed what the access data revealed, the barriers to scaling the program without added resources, and what other health systems need in place to build something similar.

Urology Times: Please provide an overview of this study and its notable findings.

Feuer: We'd learned at our institution that there was a significant delay in the process from initial consultation to diagnosis of prostate cancer. The goal of the project was to evaluate the impact of a telehealth-based rapid access program we developed for men referred with an elevated PSA on diagnostic timeliness and on patient access. It was an advanced practice provider-led, telehealth-based program, and we sought to reduce time from referral to diagnosis for men undergoing evaluation and secondarily assess the impact of the program on patient access. Overall, we reduced referral to biopsy from 161 days, [which is] nearly 6 months, down to 71 days, just over 2 months, representing over a 50% reduction in the overall timeliness of the diagnostic interval. Patients also saved a considerable amount of time traveling through the program and reduced some of their costs.

Urology Times: What was the catalyst for creating the RAP, based on what patients were experiencing beforehand?

Feuer: We were getting feedback from patients that was defining the problem for us. Our patients were bothered that it was taking 6 months from when their primary care doctor referred them to urology until they actually had a diagnosis in hand. Through some process metrics, we realized that a lot of that time was even being spent waiting for the initial consultation to get in the door and talk about this. That can be a pretty anxiety-inducing experience.

Urology Times: How did you develop the triage algorithms that let APPs drive this workflow?

Feuer: A lot of that came down to breaking down the intake process. We wanted to understand what were sequential steps vs things that could be done in parallel. For example, in the pre-intervention state, patients would not be scheduled for an initial consultation until their MRI data or other external data was received by the institution. When we looked at the data, that outside data was often received in a shorter period of time than the actual wait time for the next visit. So, if we just scheduled patients and worked on getting that data in the interim, we could reduce half of the time we were waiting to get the patient scheduled.

For the biopsy decision algorithms, we provided a structural framework for the process using the best available evidence, understanding that certain PI-RADS scores, PSA densities, and so on were impactful in making biopsy decisions. We provided a framework without it purely being a decision algorithm that had to be followed directly.

Urology Times: How did you build physician confidence in APP-directed biopsy decisions?

Feuer: I think there were a couple of components. First, the rapid access consultation visits were carried out by a very experienced APP in our department who's been in practice for over 15 years, and that gave it a lot of confidence off the bat. In addition, we've been monitoring our outcomes for rapid access patients throughout the entire implementation process to ensure we're maintaining both our timeliness and our diagnostic outcome standards.

Urology Times: The access findings showed median round-trip distances of 58 miles avoided and 66 minutes of travel time saved. What does that access burden look like in practical terms for a statewide referral center?

Feuer: Those medians probably under[estimate] the actual extent of the problem. If you look at our data, a significant number of patients are traveling more than 100 miles round-trip to see us. One of the striking statistics we published is that approximately a third of our patients would have traveled more than 3 hours round-trip for this consultation. Reducing that need to travel significantly impacted their experience and access.

Urology Times: How did geography and rurality correlate with who benefited most from telehealth?

Feuer: Pre-intervention, we presented data at one of the AUA national meetings demonstrating that patients in our system who live more than 50 miles from the medical center experienced additional diagnostic delays compared [with] patients who lived closer by. We're currently studying the impact of this intervention on timeliness for those patients specifically by geographic distance. Given that our program is equal access and available to everyone, we anticipate that those living further away should have experienced a similar benefit, and that the gap in access should be reduced by the program.

Urology Times: What were the most significant implementation barriers you encountered scaling this program?

Feuer: At UNC, we're fortunate to provide care at an institution whose mission is to improve the health of all North Carolinians, not just a select group. This program was born from the passionate efforts of multiple stakeholders across the institution and across various disciplines who adhere to that mission. Given the public mission of the institution, one significant barrier was creating this program without additional resources. That required an extra layer of creativity among our collaborators and a thoughtful approach to workflow redesign rather than additional resource allocation to solve what is a complex problem.

Urology Times: What are the non-negotiable design elements for urologists building a similar program?

Feuer: Generalizability can be a challenge in instituting similar programs, but I think the broader approach to quality improvement is very generalizable. It breaks down to 4 critical components: understanding your process, identifying and engaging your stakeholders, determining your measurable outcomes, and anticipating what are referred to as balancing measures.

First, when it comes to understanding your process and identifying bottlenecks, in our case it was not the broad steps, the consultation, the MRI, the biopsy, but really understanding the back-end processes that underlie each of those components. How many referrals are coming in each week for a given problem? What happens to that referral when it comes in? What are the schedulers doing on the back end, and what are their bottlenecks? What happens when you order an MRI, and how does that patient get scheduled? When you break those processes down, you understand where patients get delayed, and you can imagine that over a fairly complex problem, 1- and 2-day delays at each step amount to 30-, 40-, and 50-day delays when you [add them up].

Second is identifying and engaging your stakeholders. That's important for ensuring a clear understanding of the current state—you can't really know what's happening in radiology unless you speak with the radiology schedulers and the radiologists themselves. It’s also important in identifying the people who can help improve your process. For example, we had control over prioritizing referrals and the biopsy capacity we could offer, but we couldn't shorten wait times for MRI without engaging our radiology colleagues. It's important to engage those people early.

Third is figuring out what your desired outcome is, and equally important, how to measure it. It's hard to determine whether your interventions are working if you don't know how to measure those outcomes appropriately and reliably.

And lastly, anticipating that balancing-measure component means anticipating what is going to suffer at the expense of increased resource allocation toward the problem [you're addressing]. In a resource-confined setting, freeing up a provider for more elevated-PSA visits may come at the expense of increased wait times for other services, so you want to make sure you measure those things.

For health system leaders or other urologists, it's not necessarily this specific replicable concept that's the important part. It's making sure you go through these important steps, which I think leads to a change in your institution that's sustainable, measurable, reliable, and doesn't come at the expense of other things.

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