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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 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