Cancer Imaging Program
The Quality Agenda
J. Dobranowski MD FRCPC
MITT 2013
Cancer Care Ontario
No conflicts of interest to disclose
( i.e. no industry funding received or other commercial relationships)
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• About CCO
• About CIP
• Why Quality Improvement
• Priorities
• The CIP Quality Journey
• Access to Care
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• Directs and oversees more than $1 billion to hospitals and other cancer care providers to deliver high quality, timely cancer, kidney and other healthcare services
• Uses information technology/management, informatics, project management and clinical expertise to execute provincial strategies
Cancer
CCO’s core mandate since
1943 as mandated by the provincial Cancer Act
Access to Care
Building on Ontario’s
Wait Times Strategy
Chronic Kidney Disease
Ontario Renal Network launched June 2009
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Cancer Act passed;
Ontario Cancer
Treatment
Research
Foundation
(OCTRF) born
1940
Ontario
Breast Cancer
Screening
Program launched
1990
Cancer Quality
Council of
Ontario created to measure system performance
2002
THE EVOLUTION
Ontario
Renal Network created
2009
1970
Ontario
Cancer Registry transferred to OCTRF
1997
CCO launches under new name to promote better integration of cancer services
2004/5
CCO implements
Wait Times
Information
System public reporting of wait times
2010
Specialized cancer services
(i.e., Bone
Marrow
Transplant)
Cancer
Care Ontario
Specialized
Cancer
Services
Today
Access to
Care
Ontario Renal
Network
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Mandated Service
Cancer
Access to Care
Chronic
Kidney
Disease
Driving performance and quality
As mandated by the
Cancer Act;
Ontario
Cancer Plan
III
Building on
Ontario’s
Wait Time
Strategy
Ontario
Renal
Network launched
June 2009
Core Competencies
Performance
Management and
Management Cycle
Health System
Policy Expertise
Standards and Guidelines
Public Reporting and Transparency
Clinical Engagement and Alignment
Regional Partnerships
IM/IT
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Quality and its continuous improvement is a critical goal across the health care system.
Data/Information
Performance
Management
Knowledge
Transfer
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Patient-Centred
Care
Prevention of
Chronic Disease
Integrated
Care
Value for
Money
Knowledge Sharing
& Support
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2011-2015
Patient-centered, quality driven cancer care
Presented by: Michael Sherar,
President & CEO
April 8,2011
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1.
Develop and implement a focused approach to cancer risk reduction
2.
Implement integrated cancer screening
3.
Continue to improve patient outcomes through accessible, safe, high quality care
4.
Continue to assess and improve the patient experience
5.
Develop and implement innovative models of care delivery
6.
Expand our efforts in personalized medicine
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Prevention
Screening
Diagnosis
Treatment
Recovery
End-of-Life Care
IMAGING
2009
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Cancer Imaging Program
Cancer Imaging Program
• Regional Leadership
• Provincial Priorities
PET Scans Ontario
• PET Steering Committee
• Operations
• Reimbursement
• PET Access
• Evidence building
• PEBC review
• Registry/Access
• Clinical Trials
• Communication
SETTING
PRIORITIES
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Prevention
Screening
Diagnosis
Treatment
Recovery
End-of-Life
Care
Safe Effective
Accessible/
Timely
Patient
Centred/
Responsive Equitable Integrated Efficient
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Four priority areas:
• Appropriateness
• Timely Access to Imaging
• Standardized/Synoptic Reporting
• Development and Fostering of Imaging
Communities of Practice
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Ensure patients are being referred for tests that would benefit them.
Optimize safety and system resources by avoiding tests that won’t.
How:
• Endorsement guidelines One-stop decision support for appropriate use of cancer imaging
• Collation of existing guidance, packaged into a useable form
• Topic-specific guideline development
• Often target areas of emerging technology (breast MRI, suggesting prostate MRI)
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Review Lung
Cancer Diagnosis
DPM
Guideline selection and
Review
Recommendations compiled
Endorsed recommendations externally reviewed
• Disease Pathway Maps (DPMs)
• comprehensive pathways of disease-specific cancer journey’s
• The CIP worked with the DPM team to create a radiology cut of the pathway
• Critical imaging nodes identified in pathway
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Review Lung
Cancer Diagnosis
DPM
Guideline selection and review
Recommendations compiled
Endorsed recommendations externally reviewed
• Lung cancer imaging guidelines identified by internet search using:
• The Program in Evidence Based Care preferred list of guideline developers
• Guideline directories of Canadian and international health organizations
• The National Guidelines Clearinghouse
• Guidelines were screened for relevance by lead author
• All relevant guidelines reviewed by other members of the working group.
• Selected relevant guidelines assessed for quality
• Using the AGREE II scores available through the SAGE database
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Review Lung
Cancer Diagnosis
DPM
Guideline selection and review
• Recommendations relevant to the decision identified through DPM complied and reviewed by the working group as candidates for endorsement
Recommendations compiled
Endorsed recommendations externally reviewed
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Review Lung
Cancer Diagnosis
DPM
Guideline selection and review
Recommendations compiled
Endorsed recommendations externally reviewed
• Endorsed recommendations were reviewed:
• Internally by CIP Clinical leads
• Externally by a group of health professionals including radiologists and other imaging professionals, medical oncologists, radiation oncologists, surgeons
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To support and ensure timely, equitable access to quality imaging across the province.
But first, we need data….
• Wait times – Interventional Radiology Initial, then ongoing survey of wait times for priority (high-volume, high impact) procedures
• Report in preparation
• Wait times – ‘Cancer Flag’ Leverage ATC CT/MRI wait time data collection – addition of cancer flag
• Improving clarity regarding use
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Identify Procedures
Data collection Analysis and Interpretation
• Priority procedures identified via consensus
• Selected based on volume and impact to patient care
• PICC (peripherally inserted central catheter) lines, portacaths and CT-guided lung biopsies (CTBx))
Identify Procedures Data Collection Analysis and Interpretation
• Participating hospitals emailed 1x per month and asked to submit first and second available appointments for each procedure
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Identify Priorities Data collection
Analysis and
Interpretation
• Data collected between Apr 2012 to Jan 2013 analyzed to determine:
• Median wait times
• 90 th percentiles; and
• Variance for each procedure
• Target timelines identified through consensus to aid interpretation of results:
• 7 Days
• 14 Days
• 28 Days
Data Limitations:
• High level data, non-patient level
• Does not capture all possible PICC line and poratcath insertions
• Assumes referral is complete and procedure occurs on given date
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*LHIN Numbers removed and data placed in random sequence for anonymity
Within 7 days
Within 14 days
Within 28 days
Number/percentage of hospitals meeting timeline
(number of participating hospitals = 36)
1st Available Appointment
Value n (%)
29 (81%)
35 (97 %)
36 (100%)
2nd Available Appointment
Value n (%)
24 (67%)
35 (97%)
36 (100%)
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*LHIN Numbers removed and data placed in random sequence for anonymity
Within 7 days
Within 14 days
Within 28 days
Number/percentage of hospitals meeting timeline
(number of participating hospitals = 35)
1st Available Appointment 2nd Available Appointment
Value n (%)
13 (37%)
26 (74%)
35 (100%)
Value n (%)
7 (20%)
21 (60%)
35 (100%)
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Key Health Services
Targeted
Ontario’s Wait Time Strategy was introduced by the Ministry of
Health and Long-Term Care in November 2004. The Wait Time
Strategy was developed to improve access to five key health services by reducing wait times, and then expanded to include wait time data for major surgeries as well as perioperative efficiencies.
MRI & CT Scans
Cancer Surgery
Cataract Surgery
Hip & Knee
Replacement
Cardiac Procedures
Expansion to major Surgical
Areas
Perioperative Efficiencies
(SETP)
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• MRI 62 per 1000
• CT 114 per 1000
• P1- 4 targets
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96 CT scanners hospitals
4 CT in IHF’s
81 day P4 wait
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(OECD)(CIHI)
CT Scan Rate per 1,000 population
Ontario
Canada
Australia
France
United States
Denmark
2005
79.4
101.6
194.8
71.4
2006
111.1
2007
88.6
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• CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4 target.
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171 scanners (base 94)
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•
• Data Source:
2008-2011 – Wait Time Information System, Cancer Care Ontario
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(OECD)(ATC)
CT Scan Rate per 1,000 population
Ontario
Canada
Australia
France
United States
Denmark
2007
---
---
88.6
120.3
227.9
73.6
2008
78.3
119.0
93.4
130
---
83.8
2009
81.5
125.4
93.9
138.7
---
---
2010
---
---
79.7
---
---
---
2011
---
---
78.5
---
---
---
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•
• Capacitybulk buy incremental funding
• Demand-
Completed Scan
Volume
YEAR
2008
2009
2010
2011
CT
1,012,868
1,065,470
1,053,540
1,050,597
Population
12,919,572
13,050,754
13,193,809
13,349,125
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• February 2013 – P4 Wait time 90 percentile
= 28 days
• Increased capacity
• Improved efficiencies
• Stable or decreasing demand
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• 52 MRI scanners in hospitals
• 5 MRI in IHF’s
• 257,042 total scans
120 day P4 wait
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(OEDC) (CIHI)
MRI Scan Rate per 1,000 population
Ontario
Canada
Australia
France
United States
Denmark
2005
27.4
30.7
84.3
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2006 2007
38.2
20.2
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• Wait time for MRI scans peaked on October 2010 at 127
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(OECD)(ATC)
MRI Scan Rate per 1,000 population
2007 2008 2009 2010
Ontario
Canada
Australia
France
United States
Denmark
---
---
20.2
44.2
91.2
36
38.7
40.6
21.4
48.4
---
37.8
---
---
41.2
43.0
23.3
55.2
43.7
---
---
---
---
---
2011
47.5
---
---
---
---
---
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45
46
time
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Participating hospitals were notified of their additional volume allocations in November 2010, December 2010, January 2011
Provincial wait times closely followed wait times for blitz hospitals
Participating hospitals reached the lowest wait time of 93 days in June 2011, 3 months after receipt of funding
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Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals
Outcome Indicators
1.
MRI Wait Times
Time between requisition received and exam completed
•
By priority
•
By body division
•
By hospital site (for multi-site facilities)
•
By contrast/non-contrast
1.
MRI Report Turnaround Times
1.
MRI Exams Requested
1.
MRI Volumes Performed
1.
Planned Operating Hours
Utilization
Time between exam completed and report verified
Number of exams requested (i.e. demand)
•
By priority
•
By body division
Number of exams completed
•
By priority
•
By body division
•
By hospital site (for multi-site facilities)
•
By contrast/non-contrast
[Sum of actual scanning time for pre-booked patients/Sum of operating hours dedicated to prebooked patients] *100
1.
Unplanned Operating Hours
Utilization
[Sum of actual scanning time for unscheduled patients (e.g. inpatients and emergency) /Sum of operating hours dedicated to unscheduled patients] *100
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Process Indicators
1.
Requisition Completeness
2.
Booking Turnaround Time
3.
Booking Volumes
4.
Booked Time Utilization
3.
Requisitions Received Relative to Time
Allocated
[Number of complete requisitions / Number of requisitions received] * 100
Time between requisition received and appointment booked
Number of appointments booked
[Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100
[Sum of hours of incoming requests/Sum of hours in scheduling template] *100
• By priority
• By body division
• By contrast/non-contrast
3.
Actual Hours Performed Relative to Time
Allocated
3.
Protocolling Turnaround Time
3.
No Show Rate
3.
No Shows Filled
3.
On-Time Scan Starts
3.
Patient Prep Time
3.
Room Turnaround Time
3.
Planned Scan Time Accuracy
[Sum of actual scanning time/Sum of hours in scheduling template] *100
• By priority
• By body division
• By contrast/non-contrast
Time between requisition sent for and received from protocolling
[Number of no shows / Number of appointments booked] * 100
[Number of no shows filled / Number of no shows] * 100
[Number of early and on-time exams / Number of exams completed] * 100
Time between registration and scan start
Time between patient 1 exiting scan room to patient 2 entering
Planned scan time – Actual scan time
• By procedure
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300
Patients Getting Needed MRIs Sooner
The London Free Press. Aug 2010
250
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The improvements mean 780 more patients can be scanned each year with MRI at St. Joseph’s, said Glen Kearns, integrated vice president, clinical support services and information technology services at St. Joe’s and London
Health Sciences Centre (LHSC).
200
150
100
156
50
As part of a project with Ontario’s Health Ministry, St. Joe’s dissected every MRI process, assessed what worked and what could be tweaked, then put the process back together more effectively for patients and staff.
0
187
St. Joe’s MRI Wait Time
172
MRI PIP
128
151
145
113
94
56 56
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The results:
• An average 50 days’ wait for semi-urgent patients (down from 104 days a year ago) and 60 days (down from 149) for non-urgent patients;
• 212 MRI exams each week, or 15 more a week than a year ago.
LHSC is in the middle of a similar process, one made more complex by the wider range and type of MRI services offered for inpatients and outpatients. So far, the waits there have dropped to an average 86 days, from 150 as recently as six months ago. That pace of improvement means 1,000 more patients can be scanned each year, he said.
LHSC MRI Wait Time
300
250
200
150
100
215
195
187
MRI PIP
135
144 146
152
162
150
120
86
75
50
0
56
400
Improving Equitable Access to Imaging
J American College of Radiology. Aug 2010
300
237
The Ottawa Hospital Rapid Improvement Event team was assembled and completed a 4-day review of the booking process and scheduling in MRI. They then delineated additional steps that could be initiated to potentially reduce wait times. This was undertaken using Lean methodology brought forth by the Ontario government to evaluate process improvement and patient throughput at all stages of navigation through the system . Some of the main goals and strategies of the Lean project include the following:
200
100
0
TOH MRI Wait Time
352 349 347 348
307 MRI PIP
263
188
117
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• Improving efficiency of each scan
• Improving patient flow and throughput
• Improving booking process
• Evaluating the patterns of unfilled spots and adjusting the schedule commensurately
• Reducing physicians’ redundant ordering of diagnostic imaging tests through education on appropriate indications
400
Montfort MRI Wait Time
MRI PIP
300
58
193
202
163 200
96
100 63
39
63
76
90
82 84
75 76
0
57
• February 2013 – P4 Wait time 90 percentile
= 60 days
• Increased capacity
• Improved efficiencies
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If no significant wait time…
Then are we doing enough or are others doing too much?
?Over or Underutilization
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Collect uniform and complete data to improve the information available to referring clinicians for diagnosis and treatment planning
How:
• Champion rectal cancer MRI template
• Developed by SOP to ensure surgeons get information needed, distributed in part by Leads and working towards implementation
• Multi-disciplinary Expert Panel
• To determine minimum standards needed in synoptic reports, identify disease sites of focus, recommend development and maintenance framework
• Roadmap
• To guide provincial deployment
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May 20, 1896
Dear Dr Stieglitz:
The X ray shows plainly that there is no stone of an appreciable size in the kidney. The hip bones are shown & the lower ribs and lumbar vertebrae, but no calculus. The region of the kidneys is uniformly penetrated by the X ray & there is no sign of an interception by any foreign body.
I only got the negative today and could not therefore report earlier. I will have a print made tomorrow. The picture is not so strong as I would like, but it is strong enough to differentiate the parts.
Yours very sincerely
W.J. Morton
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1999 OANM - Request for Provincial funding for PET
2000 ICES- Review of Evidence
2001 ICES- Report- Health Technology Assessment of PET
“despite the availability of PET scanning for almost three decades, the number of methodologically high quality studies (and the numbers of patients within these studies) is distressingly small.”
Institute for Clinical Evaluative Sciences. 2001 (May) Health Technology
Assessment of Positron Emission Tomography (PET)
– A Systematic Review. An
ICES Investigative Report.
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2004
Ministry of Health in Ontario (MOH) takes evidence-based approach to the introduction of PET imaging
2009
MOH insured nine indications, and transitioned oversight of a continuing evaluative program for new indications to
Cancer Care Ontario (CCO)
Program Objective:
Introduce and use PET according to high-quality evidence, insuring availability of PET for appropriate indications on a timely basis
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Ensure PET/CT scans are available to Ontario patients for
appropriate indications on a timely basis.
What is appropriate?
• Use of PET scanning where there is evidence that the scan has the potential to impact patient management
How?
• Access
• Evidence
• Advice
• Communication
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Evaluative Program Elements:
PET Steering Committee
Expert advisors to MOH
PET Registry
Field evaluation of promising indications
Clinical Trials
Testing diagnostic accuracy and impact to patient management
PET Access Program
Case-by-case review for patients not meeting other eligibility criteria
Evidence Review
Continuous review, ensuring recommendations are current
Communication
Ongoing promotion of equitable access across Ontario
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• www.petscansontario.ca
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