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Access to Care: MRI/CT Ontario Update

Meeting: Taming of the Queue

Date: March 29, 2012

Julian Dobranowski, MD, FRCPC Provincial Lead ATC MRI/CT

Provincial Lead Cancer Imaging Program CCO

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Source : Wait Time Alliance report 2011

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Overview in 3 parts

Add images

CT PET/CT MRI

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Wait Time Strategy Key Elements

Empowering patients and demonstrating

accountability to the public

Increasing health system capacity

Using a single provincial wait time

information system

Obtaining feedback and recommendations from

clinical stakeholders

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Cancer Surgery

Expansion to major Surgical

Areas

Cataract Surgery

Hip & Knee Replacement

MRI & CT Scans

Cardiac Procedures

Perioperative Efficiencies (SETP)

Ontario’s Wait Time Strategy

Key Health Services

Targeted

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.

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MRI CT Wait Times-Approach

Expert panel

2005

2006

2010

2012- ATC DI subcommittee

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MRI CT Approach- Quality dimensions

VALUE FOR

MONEY

Safe

Efficient Effective

Equitable Accessible

Integrated Responsive

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MRI CT Approach – Change Management

Data/Information

Knowledge Transfer

Performance

Management

Knowledge

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MRI CT Approach

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Ontario MRI CT Targets 2005

MRI 62 per 1000

CT 114 per 1000

P4 90th percentile

80 days

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PART 1

CT 2004 2005 Starting out

96 CT scanners hospitals

4 CT in IHF’s

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

CT Scan Rate per 1,000

population 2005 2006 2007

Ontario 79.4

Canada 101.6

Australia 88.6

France 111.1

United States 194.8

Denmark 71.4

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Provincial Wait Time Trend: CT

• CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4

target.

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CT scans ordered and completed by Fiscal Year

171 scanners (base 94)

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CT scan rates per 1,000 population

Data Source:

2008-2011 – Wait Time Information System, Cancer Care Ontario

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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 --- --- ---

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CT what changed?

Capacity- bulk buy

incremental funding

Demand-

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

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CT- 2012 current wait time P4

February 2012 – P4 Wait time 90 percentile = 29 days

Increased capacity

Improved efficiencies

Stable or decreasing demand

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PART 2

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.

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PET/CT

Approach to PET key elements:

-Access to PET through high quality clinical trials

-Access to PET through registry studies

-Access to PET through the PET Access Program

-Quality assurance standards for PET

-Ontario’s PET infrastructure

-Coordination of the PET program

-Communications

Evidence based approach to PET/CT

Evidence to support all demand

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PET/CT

2009- OHIP funded indications – 9

2010 CCO Oversight of non-funded PET/CT scan

PET Access program

PET Registry

Clinical trials

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Recommendations by PSC for Change

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Insured Uninsured

Insured Indications Additions OCOG Trials Registry Indications PET Access

• Solitary pulmonary Nodule • PET REC • Pancreatic cancer

• Case-by-case

• Thyroid cancer • Melanoma

• Germ cell tumours • Testicular Cancer

• Colorectal cancer • PET LACE

• Lymphoma

• Non-small cell lung cancer

• Stage III non-small cell lung ca

• Limited disease small cell lung ca

• Myocardial viability

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PART 3

MRI 2004 2005 Starting out

52 MRI scanners in hospitals

5 MRI in IHF’s

257,042 total scans

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

MRI Scan Rate per 1,000

population 2005 2006 2007

Ontario 27.4

Canada 30.7

Australia 20.2

France 38.2

United States 84.3

Denmark 27

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Provincial Wait Time Trend: MRI

• Wait time for MRI scans peaked on October 2010 at 127 days but has since decreased to 87

days by January 2012.

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Comparison of MRI Orders Received & Scans Completed

91 scanners (base 52)

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MRI scan rates per 1,000 population

Data Source:

* ** MRI 2005/2006 to 2006/2007 data: You, J., Venkatesh, V. and Laupacis, A. (2009). Better access to outpatient magnetic resonance imaging in Ontario – But for whom?. Open

Medicine, Vol 3, No 1. Outpatient MRI Utilization only.

2008-2011 – Wait Time Information System, Cancer Care Ontario

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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 --- --- ---

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Removing variability

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Provincial Wait Time Trend: MRI and CT

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Backlog

demand capacity

time

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Looking at the MRI backlog

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Backlog management- The Blitz

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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 funding

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MRI – System improvement

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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

[Sum of actual scanning time for pre-booked patients/Sum of operating hours

dedicated to pre-booked patients] *100

1. Unplanned Operating

Hours Utilization

[Sum of actual scanning time for unscheduled patients (e.g. inpatients and

emergency) /Sum of operating hours dedicated to unscheduled patients] *100

PIP Outcome Indicators

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Process Indicators

1. Requisition Completeness [Number of complete requisitions / Number of requisitions received] * 100

2. Booking Turnaround Time 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

[Sum of hours of incoming requests/Sum of hours in scheduling template] *100

•By priority

•By body division

•By contrast/non-contrast

3. Actual Hours Performed

Relative to Time Allocated

[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 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 Time between registration and scan start

3. Room Turnaround Time Time between patient 1 exiting scan room to patient 2 entering

3. Planned Scan Time Accuracy Planned scan time – Actual scan time

•By procedure

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MRI PIP Wait Times Improve in London

156 177

187 172

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151 145

113 94

56 56 63

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St. Joe’s MRI Wait Time Patients Getting Needed MRIs Sooner

The London Free Press. Aug 2010

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).

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.

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

non-urgent patients;

•212 MRI exams each week, or 15 more a week than a year

ago.

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.

MRI PIP

MRI PIP

215 195 187

135 144 146 152

162 150

120

86 75

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LHSC MRI Wait Time

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MRI PIP Wait Times Improve in Ottawa

193 202

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63 76

90 82 84 75 76

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Montfort MRI Wait Time

Improving Equitable Access to Imaging J American College of Radiology. Aug 2010

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:

•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 MRI PIP

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352 349 347 348

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TOH MRI Wait Time

MRI PIP

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Impact of all interventions on Provincial Wait Times (data as of February 2012)

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Summary of the Ontario Approach

1. Capacity building through additional MRI/CT scans

2. Capacity building through system and process redesign to

improve efficiencies “Value for Money”

3. Managing demand by decreasing the backlog

4. Managing demand through appropriate referrals

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Next steps:

Maintain equilibrium

-Appropriateness

-Point of care decision support

-Capacity

Sustainable backlog management

-focus on LHINs with greatest backlog

-continue collecting data on demand

-determine best practices related to backlog management

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Next steps:

Process improvement -

-Optimising the ordering process- dated examinations and booking

optimization

-CT

Disease specific wait times

Revisiting the benchmarks

-National benchmarks

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Questions?

Thank You

Access to Care

ATC@cancercare.on.ca