Ontario s New Colorectal Cancer Screening Program. OHA May 15, 2007

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1 Ontario s New Colorectal Cancer Screening Program OHA May 15, 2007

2 Outline The Context Facts About Colorectal Cancer Research and Background Information The CRC Screening Program Average Risk Screening At Increased Risk Screening Colonoscopy Funding, Standards and Reporting 2

3 Facts about Colorectal Cancer (CRC) Colorectal cancer screening saves lives. Ontario has one of the highest rates of CRC in the world. In 2006, an estimated 7,500 Ontarians were diagnosed with CRC and 3,100 died from the disease. Risk of CRC increases with age. CRC is the second deadliest form of cancer, but one of the most preventable. CRC is 90% curable if detected early Without effective screening, it will remain the most common cause of cancer death in non-smokers. 3

4 Research Supporting CRC Screening Three landmark studies show that FOBT performed every two years reduces death from colorectal cancer by an average of 16% over 10 years of screening (Minnesota, Nottingham and Funen) 2001 Canadian Task Force on Preventive Health Care and the U.S. Preventive Services Task Force, endorse performing biennial FOBT on average-risk persons. Health Canada Committee on Colorectal Cancer Screening recommended population-based screening 4

5 Other Jurisdictions with CRC Screening Program Population-based colorectal screening programs have been implemented successfully in the U.K., France, Israel, and Australia. Manitoba and Alberta announced colorectal cancer screening programs spring British Columbia, Quebec and Nova Scotia are developing proposals. 5

6 CRC Screening using FOBT In the years 2004 and 2005, 17% of Ontarians over age 50 had an FOBT. Only 20% have been screened for colorectal cancer using any method. 6

7 Background on CRC Screening in Ontario June , 2005 & Pilot project tests different recruitment strategies for colorectal cancer screening using FOBT in Ontario (Final Report of Pilot to MOHLTC 2006) CCO recommended population based CRC screening program in Ontario Cancer Plan with strong support from advocacy groups Ongoing discussions with MOHLTC, CCO and other partners on program design issues 7

8 Ontario Announces CRC Screening Program January 2007: The Ontario Government announced a population-based provincial colorectal cancer screening program, starting in spring Target: Men and women, 50 years and older. Family physicians and primary care professionals will have a central role delivering the program. For average-risk Ontarians, the FOBT will be the primary screening tool. For those who are at increased risk because of a family history of one or more first degree relative with CRC, or positive FOBT, colonoscopies will be used. 8

9 Business Goals & Benefits Colorectal Cancer is the 2 nd most prominent killer & the 1 st most preventable Cancer Decrease the incidence and mortality of colorectal cancer Develop a provincial population-based colorectal cancer screening program that can be model for other screening programs Develop capacity for provincial planning on colonoscopy service delivery Build on CCO s role in cancer screening Increased CRC Screening Rates Improved Program Delivery develop a population based screening model for other screening programs Reduction in CRC mortality 9

10 FOBT Kits Continue to use existing FOBT kits as primary screening tool for average risk patients 2008/09, branded FOBT kits will be distributed throughout Ontario to family physicians, other primary care sites, and for people without a family physician, through pharmacies and Telehealth Ontario Patients will send FOBT kits with stamped preaddressed envelope for processing Family physicians will follow-up with patients to arrange a colonoscopy for positive FOBT results Persons with a negative FOBT will be reminded about repeat screening in two years 10

11 Colonoscopy Colonoscopy will be the primary screening mechanism for people with one or more first degree relative with CRC diagnosis or who have had a + FOBT Colonoscopy capacity will be increased in 2007/08 and beyond with additional funding provided to hospitals New standards to be developed for program based colonoscopies Wait-times will be tracked and reported 11

12 Phased Implementation Year 1 Year 2 Focus on screening individuals at increased risk for developing colorectal cancer. Expand colonoscopy capacity for increased risk and FOBT+ with additional funding to hospitals and support interim reporting tool. Distribute new clinical standards for colonoscopies. Build awareness and support for the program among key stakeholders at the provincial and regional levels. Establish provincial network to develop regional implementation plans. Create and deliver health professional education program, supported by clinical guidelines. Establish partnership with OCFP, OMA, OPA, CCS and others. Use media relations to raise public awareness and understanding of colorectal cancer screening, Ontario s program and build anticipation. Large scale public education and social marketing campaign on colorectal cancer screening program and screening of average risk individuals. Wide distribution of branded FOBT kits to the public via family physicians and through pharmacists or Telehealth Ontario for individuals without physicians. A new information management system will track and facilitate follow up with patients. Financial incentives to family physicians and pharmacists. Ongoing regional implementation initiatives. 12

13 COLONOSCOPY FUNDING 2007/08 13

14 Colonoscopy Funding 2007/08 CCO is contracting with hospitals to deliver additional colonoscopies for patients at increased risk (family history and FOBT+) Hospitals were surveyed in winter 2007 to estimate capacity CCO used survey data plus other sources to model program uptake and impacts New funding to begin April 1, 2007 March 31, 2008 New Colonoscopy Standards introduced to align with funding (April 2007) developed by CCO s Program in Evidence-based care (PEBC) 55 hospitals have been funded to perform 34,000 colonoscopies 14

15 Principles for 2007/08 Allocation Population-based LHIN-level allocation Centres must have minimum current volume & stated capacity Minimum incremental volume fewer hospitals, larger increments Geographical distribution within LHINs 15

16 Eligibility Criteria To be eligible, hospitals must Be governed by the Public Hospitals Act and have in place accreditation, standards and infection control Be current or planned implementation sites for the Wait Time Information System (WTIS) Have performed a minimum of 500 colonoscopy cases in 2005/06 Contribute at least one per cent of the total hospital-based colonoscopies in 2006/07 Indicate additional capacity to do at least 500 more procedures in Exceptions have been made in certain cases to address issues of access and geographical distribution 16

17 Hospital Allocations Formula driven approach Allocate cases to LHINs using population-based approach Allocate all eligible hospitals 500 cases Allocate remainder of LHIN volumes in proportion to remaining capacity Review allocations based on LHIN characteristics If LHIN has few eligible providers, identify additional hospitals close to meeting criteria: Meet all criteria but proposed capacity <500 (allocate to capacity) Meet all criteria but total share <1.0% (include next largest volume hospital as eligible) In North West & North East, allocate additional volume beyond LHIN allocation to bring on additional centres to increase geographic coverage Obtained RVP feedback on Geographical distribution Maturity of regional program Ability of hospitals to deliver identified capacity 17

18 18 COLONOSCOPY STANDARDS

19 Colonoscopy Physician and Institutional Standards Physician Endoscopist Standards Based on training, credentials and experience Minimum of 200 procedures/year Institutional Standards Patient Assessment pre-procedure assessment prior to preparation and follow-up care Infection Control Monitoring During and After Administration of Conscious Sedation Resuscitation Capacity 19

20 Colonoscopy Performance Standards Cecal Intubation All colonoscopies should be performed using video colonoscope Cecal intubation rate be at least 95 per cent for screening and surveillance Perforation Rates Screening perforation rates no higher than 1/2000 Overall perforation rates no higher than 1/1000 Sedation All patients should be offered sedation unless the endoscopist judges this to contraindicated Bowel Preparation Appropriate bowel prep is recommended to obtain better cecal intubation and adenoma detection Pathology Tools and infrastructure are required to support collection of data and should include synoptic reports using uniform criteria and nomenclature and integration with other CCO reporting initiatives 20

21 21 INTERIM REPORTING REQUIREMENTS

22 Interim Reporting Requirements Reporting requirements will include Facility Number, Chart Number, Health Number, Provider Number Inpatient / outpatient flag Indication for colonoscopy Quality Indicators: Rate of cecal intubation (yes/no) Adequate bowel preparation (yes/no) Bowel perforation at time of procedure (yes/no) Wait time to be measured receipt of referral to colonoscopy procedure. Reporting Tool will be implemented in May 2007 Training and education seminars will be available to hospital staff responsible for reporting in early May

23 Program Coordinates Website: Phone: Website: Phone: