Download A multidisciplinary approach to creating a sustainable cancer system

A multidisciplinary approach
to creating a sustainable
cancer system
A Cancer Agency / Policy perspective
Dr. S. Eshwar Kumar MBBS, FRCR
Co-CEO, New Brunswick Cancer Network
May 9, 2016
Cancer Agencies across Canada
Eastern Health
BC Cancer Agency
Katherine Chubbs (Vice-Chair)
Dr. Malcolm Moore
PEI Cancer
Treatment Centre
Dr. Philip Champion
Alberta Health Services
Cancer Care Nova Scotia
Nancy Guebert
Dr. Drew Bethune
Saskatchewan Cancer
Agency
CancerCare Manitoba
Scott Livingstone
Dr. Sri Navratnam
New Brunswick Cancer Network
Dr. Eshwar Kumar
Cancer Care Ontario
Direction québécoise de
cancérologie
Michael Sherar (Chair)
Dr. Jean Latreille
Canadian Partnership
Against Cancer
Shelly Jamieson
The Issue
The Issue
Agency Perspective
System capacity and Capability
1. Costs
2. Human resources and workload
Agency Perspective - Costs
 Drug costs
 Rapidly evolving technology
 Imaging : 3T-MRI, PET-CT, etc.
 Genetic sequencing and Testing Biomarkers
 Radiation Therapy: IMRT, IGRT, SRS, SBRT, etc.
Agency Perspective
 Human Resources-multiple disciplines
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Primary Care
Pathology/ Lab technology
Surgical Oncology
Medical Oncology/ Haematology Oncology
Radiation Oncology
Medical physics
Dosimetry
Radiation Therapy
Oncology Nursing
Psychology
Social work
Agency Perspective
 Workload
 Lack of Pan-Canadian consensus/standards
Agency Perspective
 Service Delivery
 Models of Care
 Survivorship
Policy Perspective
Health – Population Health and Chronic Diseases
 Obesity
 Diabetes
 Hypertension
Policy Perspective
Political
THANK YOU
Questions or Comments
Plenary Panel: Patient SelfManagement Perspective
DR. DORIS HOWELL RN, PHD.
RBC CHAIR, ONCOLOGY NURSING
RESEARCH & ASSOCIATE PROFESSOR,
LSBFN, UNIVERSITY OF TORONTO. SENIOR
SCIENTIST, PRINCESS MARGARET CANCER
CENTRE, TORONTO, ON.
Number of cancer
survivors will double
in the next decade
to 2 million by 2020
Oncologists can
expect >50% of
cancer patients
>65 years will have
another chronic
condition
(ASCO, 2011)
Some Alarming Facts

83% of patients don’t follow treatment plans
as prescribed

>64.8% of adjuvant breast cancer patients
adherent to Tamoxifen at 3 years (Hoheneker,
JOP, 2011)

Medication non-adherence >50% =$290
billion in avoidable spending.

40% of patients on adjuvant chemotherapy
end up in the ED.

Average physician visit=8 minutes.

24/hours/7 days/week/life = the amount of
time patients must manage cancer and
treatment consequences.
Osterberg L Adherence to medication. NEJM 2005; 353(5):487-97; Sokol Impact of medication adherence on hospitalization
risk and healthcare cost. Med Care 2005; 43(6): 521-30; CSQI-CCO, 2015; Hoheneker JOP, 2011
Patients Perspective
Better drugs help
many of us to live
long and well despite
our cancer, diabetes,
heart disease for
example, but using
them correctly
requires us to
restructure our lives.
Scientific advances
means more
specialists, more
diagnostic tests and
sources of care to
coordinate.
Who coordinates all
these players/services?
We do.
Better surgical techniques mean we come home from
the hospital quicker and sicker and have to provide our
own care. We manage the symptoms, operate the
devices, do the rehabilitation and calibrate the
medications.

Medicine and public health advocating for
considering patients as human resources that
should be actively involved in healthcare
organization and process of care delivery.

Making patients better informed and more
directly responsible for their health and care
management is pivotal to make health care
organizations sustainable at the:


economic,

organizational,

psychological level.
Key to better health outcomes!
Barello, S., Graffigna, G., Vegni, E., and Bosio, A. C. (2014b). The challenges of conceptualizing
patient engagement in healthcare: a lexicographic literature review. J. Particip. Med. 6:e9.
“Patient engagement in
health care: the 4th
Revolution in Personalized
Cancer Medicine.”
“The Blockbuster Drug
of the Century: An
Engaged Patient”

The active engagement of
patients is a common thread
across numerous reports aimed
towards achieving
sustainable high quality
health and cancer care.
Schlisky, ASCO President, 2014; Leonard Kish, 2012.
Patients and their
families are “arguably
the single-most
underutilized, untapped
resource for achieving
sustainable health care”.
Catherine Craig and Eva Powell,
Institute for Healthcare Improvement Triple Aim
faculty
Empowerment
“A process through
which people gain
control over decisions
and actions affecting
their health” (WHO,
1998).
Lost in Terms
Empowerment
Engagement
Engagement
“Actions individuals
must take to obtain
the greatest benefit
from the health care
services available to
them” (AHRQ, 2010).
Activation
SelfManagement
Patient
Activation
“Individual’s
knowledge, skill,
and confidence
for managing
their health and
health care”
(Hibbard, 2004).
SelfManagement
“Tasks individuals
must undertake
to live well with
illness & the
confidence to
deal with
medical, role &
emotional
management of
illness” (IOM,
2003).
Patient Activation = Self-Management Support
Self-management support
= Systematic provision
of education and
supportive interventions by
health care staff;
Goal: To increase patients’
skills and confidence in
managing their health
problems, including regular
assessment or progress and
problems, goal setting, and
problem-solving support.
(Adams 2004. Centers for
Advancement of Health,
p. 57)
Howell et al. The Patient Education Program Committee. Self-management Education for Cancer Patients:
Evidence Summary. Toronto (ON): CCO, Program in Evidence-based Care Evidence Summary No.: 20-3
Quality of Self-Management Support
Patient Group
PACIC (1-5 Scale)
None to Always
Subscale
Overall
(n = 428)
Breast
(n = 156)
Colorectal
(n = 105)
Prostate
(n = 157)
M
M
M
M
Patient Activation/
Involvement
3.06
3.16
2.90
3.06
Delivery System Design/
System Support
3.08
3.18
2.96
3.05
Goal Setting/ Tailoring
2.47
2.64
2.37
2.35
Problem Solving/
Contextual Factors
2.86
2.93
2.80
2.82
Follow-up/ Coordination
2.15
2.41
2.05
1.92
Summary Score
2.65
2.79
2.55
2.54
Howell, 2014. Tailoring a Chronic Disease Self-Management Approach to Cancer Populations, CIHR. Adams K
et al. (2004). Report of a summit. National Academies Press; Center for Advancement of Health
Cancer as a Chronic Disease

Medical Management

Multi-modal treatment

Permanent pathological
alterations

Lifelong treatment
regimes and multimorbidity

Pattern of chronicity
varies by cancer and
treatment modality.

Multiple specialists and
care sectors

Weigh complex
evidence and trade-off


Role Management

Work Issues

Multiple transition points
Emotional Management

Uncertainty and Existential
distress
What patients see
through the glass is not a
world outside cancer, but
a world taken over by it—
cancer reflected
endlessly around them
like a hall of mirrors.”
“
Mukherjee S. The Emperor of All Maladies: A Biography of
Cancer. New York: Scribner; 2011: 398.
Better Survival
Better Quality of Life
Howell D *Harth et al. for The Patient Education Program Committee. Self-management
Education for Cancer Patients: Evidence Summary. Toronto (ON): CCO, Program in
Evidence-based Care Evidence Summary No.: 20-3
Potential for Cost Savings: CDSMP

POTENTIAL COST SAVINGS

Potential savings of 3.3. billion in healthcare costs by
reaching 5% of adults with one or more chronic
conditions.

Healthcare savings of $38,803 for a small country; and
$732,290 for metropolitan city.
COST OF PARTICIPATION

Cost of participation in CDSMP is $350/10
participants/class=$50,000 to $75,000 per QUALY.

If CDSMP reaches a minimum of 1% of patients with a
chronic condition
health care savings of 0.7 billion to 65.7 billion by
averting from ER visits and hospitalizations.
Frontiers in Public Health, Volume 3, Article 27. Cost-effectiveness of the
CDSMP, 2015; Preventing Chronic Disease, A Meta-analysis…CDSMP, 2013.
“To adopt a selfmanagement philosophy
and embed selfmanagement within
current and future health
care, it is necessary to
make shifts in cultures,
attitudes, infrastructure,
tools and practices”.
Queensland Australia Framework for
Self Management (2008-2015)
1.
2.
3.
4.
5.
Delivery System
a.
Redesign systems to promote efficient, high quality care, and
self-management.
b.
Stepped care models
Clinical Information Systems
a.
Use PRO to track scores on outcomes “real time”, any sector
b.
Customize care to patient activation level
c.
Written shared treatment plans-articulate patient plan
Decision Support
a.
Promote self-management consistent with evidence and
patient preferences
b.
Telephone engagement/action plans/scale commitment
and confidence
Community Services
a.
Information and linkages with community services-CDSMP
b.
Integration-disrupt silo based care
Self-Management Support
a.
Evidence-based guideline-target patient
b.
Train clinicians-knowledge, attitude, skills
New Mindset
Self-management is one of the
most powerful resources we
have in health care. It is
fundamental to assisting people
to better manage their health
New Results
and live fuller, healthier lives
and yet it is one of the least
utilized approaches to chronic
disease.
Plenary Panel: The Primary Care Perspective
ARCC Conference 2016
Jon Emery
Herman Professor of Primary Care Cancer Research
Director of PC4
The issues for sustainability
Colorectal 78.7%
Lung 46.4%
Prostate 96.8%
Breast 55.4%
Canadian Cancer Statistics 2015
A common problem: the Australian view
By 2025-2029 the annual
incidence of cancer in
Victoria will reach over
41,000, an increase of
39% from 2010-2014.
Victorian Cancer Registry
Issues for sustainability: workforce
517 medical oncologists in Canada
in 2015
Canadian Medical Association 2015
Issues for sustainability: workforce
114 per
100,000
111 per
100,000
59 per
100,000
40,517 family physicians in Canada
in 2015
Canadian Medical Association 2015
‘To capitalise on the unique
strengths of primary care,
there needs to be better
integration of health-care
systems between primary,
secondary and tertiary care.’
Lancet Oncology Commission Oct 2015
Primary care along the cancer continuum
Emery, Shaw, Williams, Mazza, FallonFergusson, Varlow, Trevena.
Nature Reviews Clin. Oncol.
doi:10.1038/nrclinonc.2013.212
Impact of increased incidence of cancer in
primary care
• Increase in number of new cases to
diagnose
• Increased demand for diagnostic tests
Change in waiting times
for gastroenterology in
Canada 2005-2012
D Leddin et al Can J
Gastroenterol 2013
Not just about oncology workforce:
diagnostic workforce
Reducing demand for unnecessary tests
Managing demand for cancer diagnostic
tests: the role of fast track pathways
‘The hazard of death was 4%
lower for the 16% of patients
from practices with high use and
7% higher for the 37% of
patients from practices with low
use, compared with the 47% of
all patients from practices with
intermediate use.’
Moller et al BMJ 2015
Applying risk thresholds for urgent cancer
diagnostic tests
Explicit 3% risk of
undiagnosed cancer as
threshold for urgent
referral
Diagnostic pathways and risk assessment
tools
Emery et al BMJ Open 2014; Chiang, Emery BJC 2015
Cancer survivorship
Full time GP in 2015
70 cancer survivors
Full time GP in 2040
140 cancer survivors
Primary care and cancer survivorship
‘Two systematic reviews
have shown that a range
of outcomes – including
quality of life, satisfaction
and clinical outcomes,
such as recurrencedetection or survival, were
not dependent on followup being provided in the
primary care or specialist
setting.’
Emery et al Nat Rev Clin Onc 2013
Primary care and cancer survivorship
‘The evidence supports the fact that most of
breast cancer patients requiring well follow-up
care can be safely provided by primary care
physicians. Therefore, Cancer Care Ontario
endorses the recommendations from Canada’s
Steering Committee on Clinical Practice
Guidelines for the Care and Treatment of
Breast Cancer.’
The multilevel context of cancer care.
Stephen H. Taplin et al. Cancer Epidemiol Biomarkers Prev
2012;21:1709-1715
©2012 by American Association for Cancer Research
Caution: cancer is not the only problem
K Emslie Public Health Agency of Canada 2015