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Cancer Imaging Program

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Presentation on theme: "Cancer Imaging Program"— Presentation transcript:

1 Cancer Imaging Program
The Quality Agenda J. Dobranowski MD FRCPC MITT 2013 1

2 Cancer Imaging Program Cancer Care Ontario
No conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships)

3 Agenda About CCO About CIP Why Quality Improvement Priorities
The CIP Quality Journey Access to Care

4 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

5 CCO’s Evolution THE EVOLUTION Today
Cancer Act passed; Ontario Cancer Treatment Research Foundation (OCTRF) born Ontario Breast Cancer Screening Program launched Cancer Quality Council of Ontario created to measure system performance Ontario Renal Network created Cancer Care Ontario Specialized Cancer Services 1940 1990 2002 2009 THE EVOLUTION Today 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) Access to Care Ontario Renal Network 5

6 Our Core Competencies Driving performance and quality Mandated Service
Performance Management and Management Cycle Access to Care Building on Ontario’s Wait Time Strategy Chronic Kidney Disease Ontario Renal Network launched June 2009 Cancer As mandated by the Cancer Act; Ontario Cancer Plan III Health System Policy Expertise Driving performance and quality Standards and Guidelines Public Reporting and Transparency CCO has the Foundation and Competencies to Support our Business lines Clinical Engagement and Alignment Regional Partnerships IM/IT 6

7 Our Performance Improvement Cycle
Quality and its continuous improvement is a critical goal across the health care system. Performance Management Data/Information Knowledge Transfer 7

8 Vision and Mission 8

9 Areas of Focus Patient-Centred Care Prevention of Chronic Disease
Integrated Care Value for Money Knowledge Sharing & Support 9

10 Presented by: Michael Sherar, President & CEO April 8,2011
Ontario Cancer Plan Patient-centered, quality driven cancer care Presented by: Michael Sherar, President & CEO April 8,2011

11 Six strategic priorities in Ontario Cancer Plan III
Develop and implement a focused approach to cancer risk reduction Implement integrated cancer screening Continue to improve patient outcomes through accessible, safe, high quality care Continue to assess and improve the patient experience Develop and implement innovative models of care delivery Expand our efforts in personalized medicine 11

12 Why Imaging? 2009 IMAGING Prevention Screening Diagnosis Treatment
Recovery End-of-Life Care 2009 IMAGING 12

13 Cancer Imaging Program
PET Scans Ontario PET Steering Committee Operations Reimbursement PET Access Evidence building PEBC review Registry/Access Clinical Trials Communication Cancer Imaging Program Regional Leadership Provincial Priorities SETTING PRIORITIES

14 Patient Centred/ Responsive
Cancer Imaging Program-Opportunities Safe Effective Accessible/ Timely Patient Centred/ Responsive Equitable Integrated Efficient Prevention Screening Diagnosis Treatment Recovery End-of-Life Care 14

15 Cancer Imaging Program – Priorities
Four priority areas: Appropriateness Timely Access to Imaging Standardized/Synoptic Reporting Development and Fostering of Imaging Communities of Practice

16 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)

17 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

18 CIP Guideline Endorsement - Methods
Guideline selection and review Review Lung Cancer Diagnosis DPM 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

19 CIP Guideline Endorsement - Methods
Recommendations compiled Review Lung Cancer Diagnosis DPM Guideline selection and review Endorsed recommendations externally reviewed Recommendations relevant to the decision identified through DPM complied and reviewed by the working group as candidates for endorsement 19

20 CIP Guideline Endorsement - Methods
Endorsed recommendations externally reviewed Review Lung Cancer Diagnosis DPM Guideline selection and review Recommendations compiled 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

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23 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

24 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)) Data Collection Identify Procedures Analysis and Interpretation Participating hospitals ed 1x per month and asked to submit first and second available appointments for each procedure 24

25 IR Wait Time Collection - Methods
Analysis and Interpretation Data collection Identify Priorities Data collected between Apr 2012 to Jan 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

26 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 (%) Within 7 days 29 (81%) 24 (67%) Within 14 days 35 (97 %) 35 (97%) Within 28 days 36 (100%) 26

27 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)    1st Available Appointment 2nd Available Appointment Value n (%) Within 7 days 13 (37%) 7 (20%) Within 14 days 26 (74%) 21 (60%) Within 28 days 35 (100%) 27

28 Timely Access to MRI/CT - ATC
MRI & CT Scans Key Health Services Targeted Cancer Surgery Cataract Surgery Perioperative Efficiencies (SETP) Expansion to major Surgical Areas Hip & Knee Replacement Cardiac Procedures Ontario’s Wait Time Strategy was introduced by the Ministry of Health and Long-Term Care in November 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.

29 MRI CT Approach

30 Ontario MRI CT Targets 2005 MRI 62 per 1000 CT 114 per 1000
P targets

31 ATC- CT 96 CT scanners hospitals 4 CT in IHF’s 81 day P4 wait

32 CT Scan Rate per 1,000 population
CT 2005 How did we compare? (OECD)(CIHI) CT Scan Rate per 1,000 population 2005 2006 2007 Ontario 79.4 Canada 101.6 Australia 88.6 France 111.1 United States 194.8 Denmark 71.4

33 Provincial Wait Time Trend: CT
CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4 target.

34 CT scans ordered and completed by Fiscal Year
171 scanners (base 94)

35 CT scan rates per 1,000 population
Data Source: – Wait Time Information System, Cancer Care Ontario

36 CT Scan Rate per 1,000 population
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

37 CT what changed? Capacity- bulk buy incremental funding Demand-
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

38 CT current wait time P4 February 2013 – P4 Wait time 90 percentile = 28 days Increased capacity Improved efficiencies Stable or decreasing demand

39 ATC- MRI 52 MRI scanners in hospitals 5 MRI in IHF’s
257,042 total scans 120 day P4 wait

40 MRI Scan Rate per 1,000 population
MRI 2005 How did we compare? (OEDC) (CIHI) MRI Scan Rate per 1,000 population 2005 2006 2007 Ontario 27.4 Canada 30.7 Australia 20.2 France 38.2 United States 84.3 Denmark 27

41 Provincial Wait Time Trend: MRI
Wait time for MRI scans peaked on October 2010 at 127

42 Comparison of MRI Orders Received & Scans Completed

43 MRI scan rates per 1,000 population

44 MRI Scan Rate per 1,000 population
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

45 Removing variability

46 Provincial Wait Time Trend: MRI and CT

47 Backlog time capacity demand

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50 Looking at the MRI backlog

51 Backlog management- The Blitz

52 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

53 MRI – System improvement

54 PIP Outcome Indicators
Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals Outcome Indicators 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 MRI Report Turnaround Times Time between exam completed and report verified MRI Exams Requested Number of exams requested (i.e. demand) MRI Volumes Performed Number of exams completed Planned Operating Hours Utilization [Sum of actual scanning time for pre-booked patients/Sum of operating hours dedicated to pre-booked patients] *100 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

55 Process Indicators Requisition Completeness
[Number of complete requisitions / Number of requisitions received] * 100 Booking Turnaround Time Time between requisition received and appointment booked Booking Volumes Number of appointments booked Booked Time Utilization [Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100 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 Actual Hours Performed Relative to Time Allocated [Sum of actual scanning time/Sum of hours in scheduling template] *100 Protocolling Turnaround Time Time between requisition sent for and received from protocolling No Show Rate [Number of no shows / Number of appointments booked] * 100 No Shows Filled [Number of no shows filled / Number of no shows] * 100 On-Time Scan Starts [Number of early and on-time exams / Number of exams completed] * 100 Patient Prep Time Time between registration and scan start Room Turnaround Time Time between patient 1 exiting scan room to patient 2 entering Planned Scan Time Accuracy Planned scan time – Actual scan time By procedure

56 MRI PIP Wait Times Improve in London
Patients Getting Needed MRIs Sooner The London Free Press. Aug 2010 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). 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. 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. MRI PIP MRI PIP

57 Wait Times Improve in Ottawa
MRI PIP Wait Times Improve in Ottawa Improving Equitable Access to Imaging J American College of Radiology. Aug 2010 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: 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 MRI PIP MRI PIP

58 MRI- 2013 current wait time P4
February 2013 – P4 Wait time 90 percentile = 60 days Increased capacity Improved efficiencies

59 Future considerations
If no significant wait time… Then are we doing enough or are others doing too much? ?Over or Underutilization

60 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

61 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

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64 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 (May) Health Technology Assessment of Positron Emission Tomography (PET) – A Systematic Review. An ICES Investigative Report. 64

65 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

66 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

67 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

68 PET Scans Ontario

69 Measuring

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71 Questions/Discussion


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