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Improving Access to Cancer Care in
Ontario: A Four-Point Strategy
Dr. Thomas McGowan
Head, Clinical Programs and
Director, Analytic Unit
Wait List Colloquium
Aylmer, Quebec
March 31, 2004
Based on a Pending CQCO Position Paper
Gaining Access to Appropriate Cancer Services:
The CQCO Four-Point Remedy to Reduce Lengthy
Waiting Times in Ontario
Prepared by:
Farrah Schwartz, Health Policy Researcher, CQCO Secretariat
Dr. Bill Evans, Provincial Vice President and Chief Medical Officer, CCO
Dr. Terry Sullivan, Chief Operating Officer, CCO
Helen Angus, Director, CQCO Secretariat
With Critical Commentary from:
Dr. Robert Bell, Vice-President, Chief Operating Officer, PMH
Donna Kline, Provincial Vice-President, Communications, CCO
Dr. William Mackillop, Radiation Oncology Research Unit, KRCC
Dr. Thomas McGowan, Head, Clinical Programs and Director, Analytic Unit, CCO
Table of Contents
• Background on waiting for cancer services in
Ontario
• CCO approach to access issues based on
Cancer Quality Council of Ontario Four-Point
Remedy to Reduce Lengthy Waiting Times
Waiting for Cancer Services: Data Sources
Prevention/Screening
Ontario Breast Screening Program tracks time to
diagnosis for abnormal screens
Diagnosis
Limited
(Imaging/Pathology)
Radiation
100% capture from referral to cancer centre to
treatment, all disease sites
Surgery
Current GTA data. Year-old data available from
admin databases.
Systemic
Approx. 50% capture (all Regional Cancer
Centres)
Palliative
Limited
Challenges
• Who manages the wait list?
• Clear leadership difficult due to complexity
of process
• Little clear evidence linking waiting times to
outcomes
• Data capture
• Data quality
• Timely information dissemination
Patient Journey: Many Points of Waiting for Care
Goes to
Family doctor/
health centre
Routine
Screening
Local hospital or cancer centre to
undergo tests
Cancer not
diagnosed
Diagnosis of cancer
Treatments
End of treatment
Long-term monitoring
and follow up
Cure
Key points in the cancer journey
Palliative Care
Continuing treatment
Relapse
Terminal care
Long-term survival
Source: Fitch, MI, 2003.
Waiting for a Breast Cancer Diagnosis
Time To Diagnosis from an Abnormal Breast Screening Result in the
Ontario Breast Screening Program -- 2001 and 2002
% diagnosed within the reference time frame
100
89
90
80
80
76
82
79
81
79
90
89 88
77
76 75
72
69
64
70
53
50
44
42
40
76
6161
60
60
90
38
33
36
30
43
35
37
33
24
37
36
25
2424
18
20
10
0
Northw est Northeast
East
Southeast
Central
East
Central
West
Southw est
South
No Open Biopsy - % Diagnosed Within 5 Weeks, 2001
No Open Biopsy - % Diagnosed Within 5 Weeks, 2002
With Open Biopsy - % Diagnosed Within 7 Weeks, 2001
With Open Biopsy - % Diagnosed Within 7 Weeks, 2002
Ontario
National
Standard
Timeline targets to
diagnosis for Canadian
breast screening programs
were established by
a Working Group on the
integration of screening
and diagnosis for the
Canadian breast cancer
screening initiative. The
proportion of OBSP
abnormal breast screens
diagnosed within the
recommended time
intervals was 69.2% for
screens without
an open biopsy and
53.0% with an open
biopsy.
Waiting for Cancer Surgery
Waiting times for cancer surgery have gone up significantly over the
past decade. The median surgical waiting time in the year 2000 among
patients that underwent breast, colorectal, lung and prostate cancer
surgery had increased 36%, 46%, 36% and 4%, respectively, from
1993.
Median wait (days) for Cancer Surgery
1993
1994
1995
1996
1997
1998
1999
2000
Breast
14
15
14
15
16
16
18
19
Colorectal
13
14
14
14
15
16
19
19
Lung
25
26
28
27
29
32
33
34
Prostate
80
83
96
107
99
99
92
83
Source: Simunovic et al., 2003.
Waiting for Radiation Therapy
Proportion of Cases
Estimated lifetime rate* of radiotherapy use in Ontario
(Based on cases treated between July 1st, 1997 and June 30th, 1998)
Provincial Target
50%
40%
30%
20%
Counties where Cancer Centres with short waiting times are located
Counties where Cancer Centres with long waiting times are located
Counties where no Cancer Centre is located
10%
0%
0
10
20
30
Counties in Order of XRT Rate
* Calculated actuarially using the life expectancy method.
** Error bars show standard errors.
40
50
Waiting for Systemic Therapy
50th and 90th Percentile By Centre – CORE January 2003 to December 2003
ALL DISEASE SITES
Weeks Wait
20
14.1
15
12.4
10.7
10.4
10
8.9
8.3
5.1
5
5.7
4.0
4.4
8.4
8.3
4.0
5.3
6.1
4.3
0
HAM
KNG
LND
- 50th
Percentile
NEO
NWO
- 90th
Percentile
OTT
TSB
WND
Source:Cancer Care Ontario,
Wait Time Reports (2003)
CQCO Four-Point Approach to Waiting Times
I.
II.
III.
IV.
Enhance capacity of cancer resources in
Ontario
Reduce demand for services by reducing risk
factors for cancer and promoting early
detection
Coordinate access to cancer services at the
point of entry into the cancer system
Increase efficiency of use of existing cancer
resources
Strategy I: Increase Supply of Cancer Resources
in Ontario
Tactics
•
Target expansion of cancer system
according to need
•
Work to streamline the processes for
bringing new facilities on-line
•
Expand roles and develop skill mix for
health care professionals to increase
system capacity
Strategy II: Reduce Demand for Services
Tactics
• Invest in tobacco reduction strategies
• Fund targeted cancer prevention programs
• Optimize screening for the early detection of
breast, cervical and colorectal cancers
Strategy III: Coordinate Access to Cancer
Services at Point of Entry into the Cancer System
Tactics
• Coordinate patient journey from entry into
system
• Establish diagnostic assessment units
(DAUs) and rapid access models for rapid
access to appropriate diagnostic services
Strategy IV: Increase Efficiency of Use of
Existing Cancer Resources
Tactics
• Implement process improvement changes throughout
the system
• Optimize use of hospital beds through use of care
paths and integration with community-based service
• Increase resources for integration of supportive care
services with acute care services; develop a greater
menu of options for the palliative care of cancer
patients
• Ensure patients are treated according to evidence for
best practices
CCO Strategy and the Patient Journey
I. Increase supply of cancer resources in Ontario
II. Reduce demand for services
Prevention
III Coordinate
access to services
Screening
Diagnosis
IV. Increase efficiency of use of existing cancer
resources
Acute Care
Palliative Care
I. Increase supply of cancer resources in Ontario
• Targeted expansion of cancer system according to need
•Work to streamline the processes for bringing new facilities on-line
• Expand roles and develop skill mix for health care professionals to increase system capacity
II. Reduce demand for services
ƒ
Invest in tobacco reduction strategies
ƒ
Fund targeted cancer prevention
programs
ƒ
III. Coordinate
access to
services
IV. Increase efficiency of use of
existing cancer resources
• Implement process improvement changes
Optimize screening for the early
detection of breast, cervical and
colorectal cancers
• Coordinate patient
journey from entry into
system
• Establish DAUs
and rapid access
models for optimized
access to
appropriate
diagnostic services
•Optimize use of hospital beds
•Increase resources for integration of
supportive care services
•Ensure patients are treated according to
evidence for best practices
Strategy II Example: Potential Benefits from
Investing in Prevention
Cancer Care Ontario has
completed an impact
analysis of implementing
an aggressive strategy to
decrease smoking rates,
increase fruit and
vegetable consumption
and increase physical
activity amongst
Ontarians. This figure
shows over 15,000
cancer cases avoided by
2020 by implementing
comprehensive
strategies.
Strategy IV Example: The CROS Experience
• Model demonstrates that improvements in
efficiency are possible
• 60% improvement in efficiency on radiation
treatment floor compared to operations
elsewhere in Ontario
• System redesign can add capacity through
more efficiency