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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 Invest in tobacco reduction strategies Fund targeted cancer prevention programs 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