CCO Strategy for DI Appropriateness in Cancer Imaging

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Cancer Imaging Program
The Quality Agenda
J. Dobranowski MD FRCPC
MITT 2013
Cancer Imaging Program
Cancer Care Ontario
No conflicts of interest to disclose
( i.e. no industry funding received or other commercial relationships)
2
Agenda
•
•
•
•
•
•
About CCO
About CIP
Why Quality Improvement
Priorities
The CIP Quality Journey
Access to Care
3
Who is Cancer Care Ontario?
•
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
4
CCO’s Evolution
Cancer Act
passed;
Ontario Cancer
Treatment
Research
Foundation
(OCTRF) born
Ontario
Breast Cancer
Screening
Program
launched
1940
1990
Cancer Quality
Council of
Ontario created
to measure
system
performance
Ontario
Renal Network
created
Cancer
Care Ontario
2002
2009
Specialized
Cancer
Services
THE EVOLUTION
Today
1970
1997
2004/5
2010
Ontario
Cancer Registry
transferred
to OCTRF
CCO launches
under new name
to promote better
integration of
cancer services
CCO implements
Wait Times
Information
System public
reporting of wait
times
Specialized
cancer services
(i.e., Bone
Marrow
Transplant)
Access to
Care
Ontario Renal
Network
5
Our Core Competencies
Mandated Service
Cancer
Access
to Care
Core Competencies
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
Performance
Management and
Management Cycle
Health System
Policy Expertise
Standards
and Guidelines
Public Reporting
and Transparency
Clinical Engagement
and Alignment
Regional Partnerships
IM/IT
6
Our Performance Improvement Cycle
Quality and its
continuous
improvement is a
critical goal across the
health care system.
Data/Information
Performance
Management
Knowledge
Transfer
7
Vision and Mission
8
Areas of Focus
Patient-Centred
Care
Prevention of
Chronic Disease
Integrated
Care
Value for
Money
Knowledge Sharing
& Support
9
Ontario
Cancer Plan
2011-2015
Patient-centered, quality driven cancer care
Presented by: Michael Sherar,
President & CEO
April 8,2011
10
Six strategic priorities in
Ontario Cancer Plan III
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
11
Why Imaging?
Prevention
Screening
Diagnosis
2009
Treatment
Recovery
End-of-Life Care
IMAGING
12
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
13
Cancer Imaging Program-Opportunities
Safe
Effective
Accessible/
Timely
Patient
Centred/
Responsive
Equitable
Integrated
Efficient
Prevention
Screening
Diagnosis
Treatment
Recovery
End-of-Life
Care
14
Cancer Imaging Program – Priorities
Four priority areas:
•
•
•
•
Appropriateness
Timely Access to Imaging
Standardized/Synoptic Reporting
Development and Fostering of Imaging
Communities of Practice
15
Appropriateness
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)
16
CIP Guideline Endorsement - Methods
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
17
CIP Guideline Endorsement - Methods
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
18
CIP Guideline Endorsement - Methods
Review Lung
Cancer Diagnosis
DPM
Guideline
selection and
review
Recommendations
compiled
Endorsed
recommendations
externally reviewed
• Recommendations relevant
to the decision identified
through DPM complied and
reviewed by the working
group as candidates for
endorsement
19
CIP Guideline Endorsement - Methods
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
20
21
22
Timely Access to Cancer Imaging
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
23
IR Wait Time Collection - Methods
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
24
IR Wait Time Collection - Methods
Identify Priorities
Data collection
Analysis and
Interpretation
• Data collected between Apr 2012 to Jan 2013 analyzed to determine:
• Median wait times
• 90th 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
25
IR Wait Time Collection – PICC Line Results
*LHIN Numbers removed and data placed in random sequence for anonymity
Number/percentage of hospitals meeting timeline
(number of participating hospitals = 36)
1st Available Appointment
2nd Available Appointment
Value n (%)
Value n (%)
Within 7 days
29 (81%)
24 (67%)
Within 14 days
35 (97 %)
35 (97%)
Within 28 days
36 (100%)
36 (100%)
26
IR Wait Time Collection – CTBx Results
*LHIN Numbers removed and data placed in random sequence for anonymity
Number/percentage of hospitals meeting timeline
(number of participating hospitals = 35)
Within 7 days
Within 14 days
Within 28 days
1st Available Appointment
2nd Available Appointment
Value n (%)
Value n (%)
13 (37%)
26 (74%)
35 (100%)
7 (20%)
21 (60%)
35 (100%)
27
Timely Access to MRI/CT - ATC
MRI & CT Scans
Cancer Surgery
Key Health Services
Targeted
Cataract Surgery
Hip & Knee
Replacement
Cardiac Procedures
Expansion to major Surgical
Areas
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.
Perioperative Efficiencies
(SETP)
28
MRI CT Approach
29
Ontario MRI CT Targets 2005
• MRI 62 per 1000
• CT 114 per 1000
• P1- 4 targets
30
ATC- CT
96 CT scanners hospitals
4 CT in IHF’s
81 day P4 wait
31
CT 2005 How did we compare? (OECD)(CIHI)
CT Scan Rate per 1,000 population
2005
Ontario
79.4
Canada
101.6
2006
2007
88.6
Australia
111.1
France
United States
194.8
Denmark
71.4
32
Provincial Wait Time Trend: CT
•
CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4
target.
33
CT scans ordered and completed by
Fiscal Year
171 scanners (base 94)
34
CT scan rates per 1,000 population
•
•
Data Source:
2008-2011 – Wait Time Information System, Cancer Care Ontario
35
CT Scan Rate per 1,000 population –
comparison (OECD)(ATC)
CT Scan Rate per 1,000
population
2007
2008
2009
2010
2011
Ontario
---
78.3
81.5
79.7
78.5
Canada
---
119.0
125.4
---
---
Australia
88.6
93.4
93.9
---
---
France
120.3
130
138.7
---
---
United States
227.9
---
---
---
---
Denmark
73.6
83.8
---
---
---
36
CT what changed?
• Capacity•
• Demand-
bulk buy
incremental funding
Completed Scan
Volume
YEAR
CT
Population
2008
1,012,868
12,919,572
2009
1,065,470
13,050,754
2010
1,053,540
13,193,809
2011
1,050,597
13,349,125
37
CT- 2013 current wait time P4
• February 2013 – P4 Wait time 90 percentile
= 28 days
• Increased capacity
• Improved efficiencies
• Stable or decreasing demand
38
ATC- MRI
• 52 MRI scanners in
hospitals
• 5 MRI in IHF’s
• 257,042 total scans
120 day P4 wait
39
MRI 2005 How did we compare? (OEDC) (CIHI)
MRI Scan Rate per 1,000 population
2005
Ontario
27.4
Canada
30.7
2006
2007
20.2
Australia
38.2
France
United States
84.3
Denmark
27
40
Provincial Wait Time Trend: MRI
•
Wait time for MRI scans peaked on October 2010 at 127
41
Comparison of MRI Orders Received &
Scans Completed
42
MRI scan rates per 1,000 population
43
MRI Scan Rate per 1,000 population –
comparison (OECD)(ATC)
MRI Scan Rate per 1,000
population
2007
2008
2009
2010
2011
Ontario
---
38.7
41.2
43.7
47.5
Canada
---
40.6
43.0
---
---
Australia
20.2
21.4
23.3
---
---
France
44.2
48.4
55.2
---
---
United States
91.2
---
---
---
---
Denmark
36
37.8
---
---
---
44
Removing variability
45
Provincial Wait Time Trend: MRI and CT
46
Backlog
time
demand
capacity
47
48
49
Looking at the MRI backlog
50
Backlog management- The Blitz
51
MRI Blitz: Impact on Overall Provincial
Wait Times

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
52
MRI – System improvement
53
PIP Outcome Indicators
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
Time between exam completed and report verified
1.MRI Exams Requested
Number of exams requested (i.e. demand)
•By priority
•By body division
1.MRI Volumes Performed
Number of exams completed
•By priority
•By body division
•By hospital site (for multi-site facilities)
•By contrast/non-contrast
1.Planned Operating Hours
Utilization
[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
54
Process Indicators
1.Requisition Completeness
[Number of complete requisitions / Number of requisitions received] * 100
2.Booking Turnaround Time
Time between requisition received and appointment booked
3.Booking Volumes
Number of appointments booked
4.Booked Time Utilization
[Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100
3.Requisitions Received Relative to Time
Allocated
[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
[Sum of actual scanning time/Sum of hours in scheduling template] *100
•By priority
•By body division
•By contrast/non-contrast
3.Protocolling Turnaround Time
Time between requisition sent for and received from protocolling
3.No Show Rate
[Number of no shows / Number of appointments booked] * 100
3.No Shows Filled
[Number of no shows filled / Number of no shows] * 100
3.On-Time Scan Starts
[Number of early and on-time exams / Number of exams completed] * 100
3.Patient Prep Time
Time between registration and scan start
3.Room Turnaround Time
Time between patient 1 exiting scan room to patient 2 entering
3.Planned Scan Time Accuracy
Planned scan time – Actual scan time
•By procedure
55
MRI PIP
Wait Times Improve in London
St. Joe’s MRI Wait Time
300
187
172
156
151
145
128
150
113
56
56
63
Jan-Feb-Mar
10
Apr-May-Jun
10
Jul-Aug-Sep
10
94
100
Oct-Nov-Dec
09
Jul-Aug-Sep
09
Apr-May-Jun
09
Jan-Feb-Mar
09
Jul-Aug-Sep
08
Oct-Nov-Dec
08
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.
Apr-May-Jun
08
0
Jan-Feb-Mar
08
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.
LHSC MRI Wait Time
300
250
215
195
200
MRI PIP
187
135
150
144
146
152
162
150
120
86
100
75
Jul-Aug-Sep
10
Apr-May-Jun
10
Jan-Feb-Mar
10
Oct-Nov-Dec
09
Jul-Aug-Sep
09
Apr-May-Jun
09
Jan-Feb-Mar
09
Oct-Nov-Dec
08
Jul-Aug-Sep
08
0
Apr-May-Jun
08
50
Jan-Feb-Mar
08
Number of Days
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.
200
MRI PIP
177
Oct-Nov-Dec
07
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).
250
Oct-Nov-Dec
07
The London Free Press. Aug 2010
Number of Days
Patients Getting Needed MRIs Sooner
56
MRI PIP
Wait Times Improve in Ottawa
400
352
347
348
MRI PIP
307
263
237
188
200
117
Apr-May-Jun
'10
Jul-Aug-Sep
'10
84
75
76
Apr-May-Jun
'10
Jan-Feb-Mar
'10
82
Oct-Nov-Dec
'09
90
Jan-Feb-Mar
'10
58
Oct-Nov-Dec
'09
Jul-Aug-Sep
'09
96
65
Jul-Aug-Sep
'09
Apr-May-Jun
'09
Jan-Feb-Mar
'09
Oct-Nov-Dec
'08
Jul-Aug-Sep
'08
Apr-May-Jun
'08
Jan-Feb-Mar
'08
Oct-Nov-Dec
'07
100
Montfort MRI Wait Time
400
MRI PIP
300
193
202
200
163
100
63
63
76
Jul-Aug-Sep
'10
Apr-May-Jun
'09
Jan-Feb-Mar
'09
Oct-Nov-Dec
'08
Jul-Aug-Sep
'08
Apr-May-Jun
'08
0
Jan-Feb-Mar
'08
39
Oct-Nov-Dec
'07
•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
349
300
0
Number of Days
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:
Number of Days
Improving Equitable Access to Imaging
J American College of Radiology. Aug 2010
TOH MRI Wait Time
57
MRI- 2013 current wait time P4
• February 2013 – P4 Wait time 90 percentile
= 60 days
• Increased capacity
• Improved efficiencies
58
Future considerations
If no significant wait time…
Then are we doing enough or are others doing
too much?
?Over or Underutilization
59
Standardized/Synoptic Reporting
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
60
Synoptic reporting
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
61
62
63
PET/CT
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.
64
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
65
PET (Positron Emission Tomography)
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
66
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
67
PET Scans Ontario
• www.petscansontario.ca
68
Measuring
69
70
Questions/Discussion
71
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