Cancer Imaging Program The Quality Agenda J Dobranowski

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

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

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

Who is Cancer Care Ontario? • Directs and oversees more than $1 billion to 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

CCO’s Evolution Cancer Act passed; Ontario Cancer Treatment Research Foundation (OCTRF) born Ontario Breast CCO’s Evolution Cancer Act passed; Ontario Cancer Treatment Research Foundation (OCTRF) born Ontario Breast Cancer Screening Program launched 1940 1990 Cancer Quality Council of Ontario created to measure system performance Ontario Renal Network created Cancer Care Ontario 2002 2009 Specialized Cancer Services THE EVOLUTION Today 1970 1997 2004/5 2010 Ontario Cancer Registry transferred to OCTRF CCO launches under new name to promote better integration of cancer services CCO implements Wait Times Information System public reporting of wait times Specialized cancer services (i. e. , Bone Marrow Transplant) Access to Care Ontario Renal Network 5

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

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

Vision and Mission 8 Vision and Mission 8

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

Ontario Cancer Plan 2011 -2015 Patient-centered, quality driven cancer care Presented by: Michael Sherar, Ontario Cancer Plan 2011 -2015 Patient-centered, quality driven cancer care Presented by: Michael Sherar, President & CEO April 8, 2011 10

Six strategic priorities in Ontario Cancer Plan III 1. Develop and implement a focused Six strategic priorities in Ontario Cancer Plan III 1. Develop and implement a focused approach to cancer risk reduction 2. Implement integrated cancer screening 3. Continue to improve patient outcomes through accessible, safe, high quality care 4. Continue to assess and improve the patient experience 5. Develop and implement innovative models of care delivery 6. Expand our efforts in personalized medicine 11

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

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

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

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

Appropriateness Ensure patients are being referred for tests that would benefit them. Optimize safety 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) 16

CIP Guideline Endorsement - Methods Review Lung Cancer Diagnosis DPM • Disease Pathway Maps CIP Guideline Endorsement - Methods Review Lung Cancer Diagnosis DPM • 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

CIP Guideline Endorsement - Methods Guideline selection and review • Lung cancer imaging guidelines CIP Guideline Endorsement - Methods Guideline selection and review • 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

CIP Guideline Endorsement - Methods Recommendations compiled • Recommendations relevant to the decision identified CIP Guideline Endorsement - Methods Recommendations compiled • Recommendations relevant to the decision identified through DPM complied and reviewed by the working group as candidates for endorsement 19

CIP Guideline Endorsement - Methods Endorsed recommendations externally reviewed • Endorsed recommendations were reviewed: CIP Guideline Endorsement - Methods Endorsed recommendations externally reviewed • 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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Timely Access to Cancer Imaging To support and ensure timely, equitable access to quality 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 23

IR Wait Time Collection - Methods • Priority procedures identified via consensus • Selected IR Wait Time Collection - Methods • 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 • Participating hospitals emailed 1 x per month and asked to submit first and second available appointments for each procedure 24

IR Wait Time Collection - Methods • Data collected between Apr 2012 to Jan IR Wait Time Collection - Methods • Data collected between Apr 2012 to Jan 2013 analyzed to determine: • Median wait times • 90 th 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

IR Wait Time Collection – PICC Line Results *LHIN Numbers removed and data placed 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) 1 st Available Appointment 2 nd Available Appointment Value n (%) Within 7 days 29 (81%) 24 (67%) Within 14 days 35 (97 %) 35 (97%) Within 28 days 36 (100%) 26

IR Wait Time Collection – CTBx Results *LHIN Numbers removed and data placed in 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) 1 st Available Appointment 2 nd Available Appointment Value n (%) Within 7 days 13 (37%) 26 (74%) 35 (100%) 7 (20%) 21 (60%) 35 (100%) Within 14 days Within 28 days 27

Timely Access to MRI/CT - ATC MRI & CT Scans Cancer Surgery Key Health Timely Access to MRI/CT - ATC MRI & CT Scans Cancer Surgery Key Health Services Targeted Cataract Surgery Hip & Knee Replacement Cardiac Procedures Expansion to major Surgical Areas Ontario’s Wait Time Strategy was introduced by the Ministry of Health and Long-Term Care in November 2004. 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. Perioperative Efficiencies (SETP) 28

MRI CT Approach 29 MRI CT Approach 29

Ontario MRI CT Targets 2005 • MRI 62 per 1000 • CT 114 per Ontario MRI CT Targets 2005 • MRI 62 per 1000 • CT 114 per 1000 • P 1 - 4 targets 30

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

CT 2005 How did we compare? (OECD)(CIHI) CT Scan Rate per 1, 000 population CT 2005 How did we compare? (OECD)(CIHI) CT Scan Rate per 1, 000 population 2005 Ontario 79. 4 Canada 101. 6 2006 Australia 2007 88. 6 France 111. 1 United States 194. 8 Denmark 71. 4 32

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

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

CT scan rates per 1, 000 population • • Data Source: 2008 -2011 – CT scan rates per 1, 000 population • • Data Source: 2008 -2011 – Wait Time Information System, Cancer Care Ontario 35

CT Scan Rate per 1, 000 population – comparison (OECD)(ATC) CT Scan Rate per 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 --- --- 36

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

CT- 2013 current wait time P 4 • February 2013 – P 4 Wait CT- 2013 current wait time P 4 • February 2013 – P 4 Wait time 90 percentile = 28 days • Increased capacity • Improved efficiencies • Stable or decreasing demand 38

ATC- MRI • 52 MRI scanners in hospitals • 5 MRI in IHF’s • ATC- MRI • 52 MRI scanners in hospitals • 5 MRI in IHF’s • 257, 042 total scans 120 day P 4 wait 39

MRI 2005 How did we compare? (OEDC) (CIHI) MRI Scan Rate per 1, 000 MRI 2005 How did we compare? (OEDC) (CIHI) MRI Scan Rate per 1, 000 population 2005 Ontario 27. 4 Canada 30. 7 2006 Australia 2007 20. 2 France 38. 2 United States 84. 3 Denmark 27 40

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

Comparison of MRI Orders Received & Scans Completed 42 Comparison of MRI Orders Received & Scans Completed 42

MRI scan rates per 1, 000 population 43 MRI scan rates per 1, 000 population 43

MRI Scan Rate per 1, 000 population –comparison (OECD)(ATC) MRI Scan Rate per 1, 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 --- 44

Removing variability 45 Removing variability 45

Provincial Wait Time Trend: MRI and CT 46 Provincial Wait Time Trend: MRI and CT 46

Backlog time demand capacity 47 Backlog time demand capacity 47

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Looking at the MRI backlog 50 Looking at the MRI backlog 50

Backlog management- The Blitz 51 Backlog management- The Blitz 51

MRI Blitz: Impact on Overall Provincial Wait Times § Participating hospitals were notified of 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 52

MRI – System improvement 53 MRI – System improvement 53

PIP Outcome Indicators Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals Outcome Indicators PIP Outcome Indicators Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals Outcome Indicators 1. 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 1. MRI Report Turnaround Times Time between exam completed and report verified 1. MRI Exams Requested Number of exams requested (i. e. demand) • By priority • By body division 1. MRI Volumes Performed Number of exams completed • By priority • By body division • By hospital site (for multi-site facilities) • By contrast/non-contrast 1. Planned Operating Hours Utilization 1. Unplanned Operating Hours Utilization [Sum of actual scanning time for pre-booked patients/Sum of operating hours dedicated to prebooked patients] *100 [Sum of actual scanning time for unscheduled patients (e. g. inpatients and emergency) /Sum of operating hours dedicated to unscheduled patients] *100 54

Process Indicators 1. Requisition Completeness [Number of complete requisitions / Number of requisitions received] Process Indicators 1. Requisition Completeness [Number of complete requisitions / Number of requisitions received] * 100 2. Booking Turnaround Time between requisition received and appointment booked 3. Booking Volumes Number of appointments booked 4. Booked Time Utilization [Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100 3. Requisitions Received Relative to Time Allocated 3. Actual Hours Performed 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 [Sum of actual scanning time/Sum of hours in scheduling template] *100 • By priority • By body division • By contrast/non-contrast 3. Protocolling Turnaround Time between requisition sent for and received from protocolling 3. No Show Rate [Number of no shows / Number of appointments booked] * 100 3. No Shows Filled [Number of no shows filled / Number of no shows] * 100 3. On-Time Scan Starts [Number of early and on-time exams / Number of exams completed] * 100 3. Patient Prep Time between registration and scan start 3. Room Turnaround Time between patient 1 exiting scan room to patient 2 entering 3. Planned Scan Time Accuracy Planned scan time – Actual scan time • By procedure 55

MRI PIP Wait Times Improve in London St. Joe’s MRI Wait Time 200 177 MRI PIP Wait Times Improve in London St. Joe’s MRI Wait Time 200 177 MRI PIP 187 172 156 151 128 150 145 113 94 100 56 56 63 Jul-Aug-Sep 10 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). 250 Apr-May-Jun 10 The London Free Press. Aug 2010 Jan-Feb-Mar 10 Patients Getting Needed MRIs Sooner Number of Days 300 250 215 Oct-Nov-Dec 09 Jul-Aug-Sep 09 Apr-May-Jun 09 Jan-Feb-Mar 09 Oct-Nov-Dec 08 Jul-Aug-Sep 08 Apr-May-Jun 08 Jan-Feb-Mar 08 195 200 MRI PIP 187 135 150 144 146 152 162 150 120 86 100 75 ul-Aug-Sep 10 r-May-Jun 10 n-Feb-Mar 10 ct-Nov-Dec 09 ul-Aug-Sep 09 r-May-Jun 09 n-Feb-Mar 09 ct-Nov-Dec 08 ul-Aug-Sep 08 r-May-Jun 08 0 n-Feb-Mar 08 50 ct-Nov-Dec 07 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. LHSC MRI Wait Time 300 Number of Days 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 nonurgent patients; • 212 MRI exams each week, or 15 more a week than a year ago. 0 Oct-Nov-Dec 07 50 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. 56

MRI PIP Wait Times Improve in Ottawa TOH MRI Wait Time 400 349 347 MRI PIP Wait Times Improve in Ottawa TOH MRI Wait Time 400 349 347 348 307 300 MRI PIP 263 237 188 200 117 Apr-May-Jun '10 Jul-Aug-Sep '10 75 76 Jan-Feb-Mar '10 Apr-May-Jun '10 Jan-Feb-Mar '10 84 Oct-Nov-Dec '09 82 Jul-Aug-Sep '09 90 Oct-Nov-Dec '09 58 Jul-Aug-Sep '09 Apr-May-Jun '09 Jan-Feb-Mar '09 Oct-Nov-Dec '08 Jul-Aug-Sep '08 Apr-May-Jun '08 Jan-Feb-Mar '08 0 96 65 100 Oct-Nov-Dec '07 Montfort MRI Wait Time 400 MRI PIP 300 193 202 76 Apr-May-Jun '09 63 Jan-Feb-Mar '09 39 Oct-Nov-Dec '08 Apr-May-Jun '08 0 Jul-Aug-Sep '08 63 100 Jul-Aug-Sep '10 163 200 Jan-Feb-Mar '08 • 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 352 Oct-Nov-Dec '07 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: Number of Days J American College of Radiology. Aug 2010 Number of Days Improving Equitable Access to Imaging 57

MRI- 2013 current wait time P 4 • February 2013 – P 4 Wait MRI- 2013 current wait time P 4 • February 2013 – P 4 Wait time 90 percentile = 60 days • Increased capacity • Improved efficiencies 58

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

Standardized/Synoptic Reporting Collect uniform and complete data to improve the information available to referring 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 60

Synoptic reporting May 20, 1896 Dear Dr Stieglitz: The X ray shows plainly that 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 61

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PET/CT 1999 OANM - Request for Provincial funding for PET 2000 ICES- Review of 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. 2001 (May) Health Technology Assessment of Positron Emission Tomography (PET) – A Systematic Review. An ICES Investigative Report. 64

2004 Ministry of Health in Ontario (MOH) takes evidence-based approach to the introduction of 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 65

PET (Positron Emission Tomography) Ensure PET/CT scans are available to Ontario patients for appropriate 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 66

Evaluative Program Elements: PET Steering Committee Expert advisors to MOH PET Registry Field evaluation 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 67

PET Scans Ontario • www. petscansontario. ca 68 PET Scans Ontario • www. petscansontario. ca 68

Measuring 69 Measuring 69

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Questions/Discussion 71 Questions/Discussion 71




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