Cancer Imaging Program

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

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

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

4. 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

5. CCO’s Evolution Cancer Act passed; Ontario Cancer Treatment Research Foundation (OCTRF) born Ontario Breast Cancer Screening Program launched Cancer Quality Council of Ontario created to measure system performance Ontario Renal Network created Cancer Care Ontario Specialized Cancer Services 1990 2002 1940 2009 THE EVOLUTION Today 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 1997 2004/5 1970 2010 Ontario Renal Network

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

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

8. Vision and Mission

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

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

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

12. Why Imaging? 2009 IMAGING

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

14. Cancer Imaging Program-Opportunities

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

16. 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)

17. CIP Guideline Endorsement - Methods Endorsed recommendations externally reviewed Review Lung Cancer Diagnosis DPM Guideline selection and Review Recommendations compiled • 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

18. CIP Guideline Endorsement - Methods Endorsed recommendations externally reviewed Guideline selection and review Review Lung Cancer Diagnosis DPM Recommendations compiled • 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

19. CIP Guideline Endorsement - Methods Endorsed recommendations externally reviewed Recommendations compiled Guideline selection and review Review Lung Cancer Diagnosis DPM • Recommendations relevant to the decision identified through DPM complied and reviewed by the working group as candidates for endorsement

20. CIP Guideline Endorsement - Methods Recommendations compiled Endorsed recommendations externally reviewed Review Lung Cancer Diagnosis DPM Guideline selection and review • 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

23. 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

24. IR Wait Time Collection - Methods Identify Procedures Analysis and Interpretation Analysis and Interpretation Data Collection Data collection Identify Procedures • 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)) • Participating hospitals emailed 1x per month and asked to submit first and second available appointments for each procedure

25. IR Wait Time Collection - Methods Analysis and Interpretation Data collection Identify Priorities • Data collected between Apr 2012 to Jan 2013 analyzed to determine: • Median wait times • 90th 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

26. IR Wait Time Collection – PICC Line Results *LHIN Numbers removed and data placed in random sequence for anonymity

27. IR Wait Time Collection – CTBx Results *LHIN Numbers removed and data placed in random sequence for anonymity

28. Timely Access to MRI/CT - ATC MRI & CT Scans Key Health Services Targeted Cancer Surgery Cataract Surgery Hip & Knee Replacement 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. Cardiac Procedures Expansion to major Surgical Areas Perioperative Efficiencies (SETP)

29. MRI CT Approach

30. Ontario MRI CT Targets 2005 • MRI 62 per 1000 • CT 114 per 1000 • P1- 4 targets

31. ATC- CT 96 CT scanners hospitals 4 CT in IHF’s 81 day P4 wait

32. CT 2005 How did we compare?(OECD)(CIHI)

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

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

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

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

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

38. CT- 2013 current wait time P4 • February 2013 – P4 Wait time 90 percentile = 28 days • Increased capacity • Improved efficiencies • Stable or decreasing demand

39. ATC- MRI • 52 MRI scanners in hospitals • 5 MRI in IHF’s • 257,042 total scans 120 day P4 wait

40. MRI 2005 How did we compare?(OEDC) (CIHI)

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

42. Comparison of MRI Orders Received & Scans Completed

43. MRI scan rates per 1,000 population

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

45. Removing variability

46. Provincial Wait Time Trend: MRI and CT

47. Backlog time capacity demand

50. Looking at the MRI backlog