Medical Imaging Strategic Plan

Transcription

1 Medical Imaging Strategic Plan Prepared by: June 3rd, 2014

2 Strategic Planning Framework Medical Imaging Strategic Plan 2014 MANDATE To provide a strategic plan for Medical Imaging to 2025, to aid in equipment planning, service provision planning, and to prepare Northern Health for the challenges of tomorrow. GUIDING PRINCIPLES Medical Imaging Services in Northern Health: Will be innovative in meeting the challenges of service delivery in the North. Will be inclusive in the planning stage to inform and support decision making. Will be aligned with the over-all services offered by the facility and with HSDA planning of services. Will be accessible and provided appropriately based on facility service levels. Will demonstrate value to the public health system through strategies to reduce capital and operational costs on medical imaging equipment. Will make decisions on equipment placement and operation that demonstrate acceptable return on investment. Will seek to maximize equipment utilization through adopting benchmarked throughput targets. Will uphold and practice quality in daily activities, and regards quality as foundational to service provision planning. Will provide services that are accredited by the Diagnostic Accreditation Program of BC. DISCLAIMER This report was prepared by INSITE Consultancy Inc. for Northern Health Authority. All reasonable care has been taken by Northern Health and INSITE Consultancy Inc. to achieve accuracy of this document, but accuracy cannot be guaranteed. By proceeding to the information beyond this notice, each reader waives and releases Northern Health and INSITE Consultancy Inc. to the full extent permitted by law from any and all claims related to the usage of material or information made available. In no event shall Northern Health or INSITE Consultancy Inc. be liable for any incidental or consequential damages resulting from the use of this material. Copyright Northern Health All rights reserved A Avenue. Surrey. V4A 8A4 (604) Prepared by INSITE Consultancy Inc Page 1

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4 Executive Summary Medical Imaging Strategic Plan 2014 The Medical Imaging Strategic Plan is a critical review of current and future state for Medical Imaging (MI) services across Northern Health (NH) over the next 10 years. It is the result of a comprehensive consultation process and detailed analytical study of the current and future demand for services. The most important challenges and priorities for the future are summarized in the Key Findings and Strategic Priorities, with additional information provided in the following sections and throughout the Strategic Plan. KEY FINDINGS WORKLOAD: NH provided over 293,000 exams across more than two dozen facilities in 2012/13. Population is expected to grow 15% by 2020 (driven by LNG projects), but workload projections estimate a 25% to 28% increase in exam volume for the same period, as growth compounds with an aging population. ACCESS: Rural communities with sparse populations have difficult access to MI services, yet insufficient demand to support the permanent implementation of local services. Alternative service delivery models should be explored, especially for: MRI, CT, Bone Densitometry, Digital Mammography and Ultrasound. EQUIPMENT: MI services has $47m of equipment assets deployed, yet the replacement process is not centrally coordinated and not consistently evaluated through a business case process. This leads to an automated process of assumed equipment requirements and investment, which in some cases results in expensive assets being significantly underutilized (Bone Densitometry and CT scanners). INFORMATION TECHNOLOGY: A provincial initiative now underway presents opportunities for NH to participate in provincial sharing of medical images and reports. With a surprising number of cases that are either imports or exports from NH, patients will benefit from continuity of care. SERVICE PRESSURE POINTS: MRI: This is clearly the most pressing need in the Northeast and Northwest regions. The detailed analysis performed through this work confirmed the findings of the MRI business case (May 2013) and further recommends that specific MRI service locations be constantly reviewed as demand rises. Ultrasound: This is consistently reported by stakeholders as the second most significant gap in service for the most rural communities. Trained staff shortages are the greatest constraint to address this gap. Breast Health: Digital Mammography and the Provincial Breast Health strategy present a financial challenge to NH. It is expensive and the proposed deployment model by SMPBC will lead to 3 static units and 1 mobile unit, which are projected to be underutilized. However, breast screening participation rates are known to be related to access, and low participation is linked to late detection of breast cancer. The development of breast health centers of excellent is an opportunity for NH and is supported by strong evidence to be highly effective. Improvements in service are mainly due to process re-design and lead to a very large reduction in the time to diagnosis of suspicious breast cases. STRATEGIC PRIORITIES Implement cross-education of staff on multiple modalities to address human resource shortage and critical mass issues, particularly in smaller and more remote communities. Expand and create new rotating and mobile services to improve access in small communities with insufficient demand to safely support a full service locally. Develop a patient centric model to allow users more control and flexibility on the choice of location to receive service, based on available capacity and wait times. Achieve high equipment utilization through improved capital planning and operating models. Prepared by INSITE Consultancy Inc Page i

5 CONTEXT Northern Health (NH) provides health services to more than 300,000 people over an area of 600,000 square kilometers. Services include acute care, mental health and addictions, public health, and home and community care. Within these services, Medical Imaging (MI) is an important support service to other core clinical specialties. MI comprises eight different modalities: Radiology and Fluoroscopy, Interventional Radiology, Ultrasound, Bone Density, Nuclear Medicine, Mammography, Computerized Tomography and Magnetic Resonance Imaging. Similar to the rest of BC, and Canada in general, the population of NH is growing and aging. The compounded effect of these two factors is additional demand for services. In addition, the recently announced Liquefied Natural Gas (LNG) Strategy is expected to attract a large workforce to areas of NH, further increasing demand into the future. Given the extent and complexity of MI service delivery, and considering the anticipated growth and aging of NH s population, it became imperative to look into the future, estimate future demand, and develop service models that efficiently meet the needs of the population. The MI Strategic Plan looks at the next 10 years and makes projections for the future demand and recommendations for capacity replacement. The evolving nature of the population and service delivery means that multiple factors will continue to change and therefore this strategic planning exercise should be revised on a periodic basis to evaluate current progress and incorporate new planning considerations. METHODOLOGY This plan involved a comprehensive consultation process and analytical study. The engagement and planning process comprised several face-to-face meetings with NH staff, consultation with experts in the field, and a planning workshop with over 30 participants from different regions and areas of work in NH. The analytical study was based on record-level data from the Cerner Hospital Information System and official population projections from BC Stats (adjusted for LNG workforce increase). Utilization rates for each service were calculated at the population level for each Local Health Areas (LHA) in NH, using age and gender groups to better capture the aging effect in the population. Referral patterns depicting the sites where residents of each LHA go to receive services were determined. Access to services was also estimated using driving distance to the closest service location from each LHA. Detailed demand projections were estimated using current utilization rates over the future population, and referral patterns used to distribute demand over the different sites. Two projection scenarios were developed: 1) Baseline, consisting only of current utilization rates and future population, and 2) Adjusted, involving additional service-specific assumptions developed during the consultation process. To assist the planning process, two decision support tools were developed: the Access Tool, and the Capital Equipment Planning Tool. These are Excel-based applications with automated calculation routines, reports and charts. They allow the user to alter the present state parameters as equipment or services are developed or removed, and create scenarios to support decision-making. PRESENT STATE AND WORKLOAD PROJECTIONS Utilization of MI services across NH varies significantly. The Northern Interior region generally shows high utilization rates across all services, while the Northeast has the lowest. This is in part due to the more limited access to services in the Northeast, resulting in some people accessing services outside NH. Of special attention is MRI services. NH has the lowest utilization rate in the Province (33% lower), and only one MRI scanner, located in Prince George. MRI utilization rates outside the Northern Interior are extremely low, likely due to very limited access. Based on the size of the population and distance to the existing service location, Peace River North and Terrace are logical future locations for MRI services. Page ii Prepared by INSITE Consultancy Inc. 2014

6 In contrast, there are 7 CT scanners in 6 different locations and no significant wait times. Equipment utilization is very low (25% or less) at many sites. Despite the available capacity, utilization rates are still lower than the Provincial and National averages, especially for the Northeast region. To reduce inefficiencies, staffed operating capacities should be reduced in all under-utilized CT scanners to achieve a 75% target utilization. Projected MI exam volumes anticipate significant growth across all services and sites. Exam volumes are estimated to increase by 25% to 28% in Looking further into the future, population by 2025 is expected to decrease from 2020 due to the conclusion of LNG construction projects. However, even with that reduction in the population, exam volumes will only decrease slightly, mostly due to the aging effect. Scenario/ Period MR CT NM US BD IR XR MA Total Growth from /13 5,273 27,917 6,156 55,830 2, ,503 8, ,766 Baseline ,107 35,595 7,961 70,134 3,096 1, ,352 11, ,859 25% ,950 35,942 8,282 66,832 3,304 1, ,405 10, ,736 22% Adjusted ,676 33,815 7,961 70,134 3,406 1, ,999 12, ,988 28% ,822 34,145 8,282 66,832 3,634 1, ,933 12, ,971 25% Actual and Projected Exam Volume by Service and Period MRI services are expected to increase significantly as Provincial utilization rates are adopted throughout the region. Exam volumes would double by 2020 under these assumptions. Although there are no finalized plans to implement the recommendations of the 2013 business case, additional service locations will likely be required in the future. Projected increase in volumes for other services could reasonably be accommodated within the existing sites, although additional equipment and staff may be required to properly handle the additional demand. A direct consequence of the LNG construction projects, communities like Fort Nelson, Kitimat and Prince Rupert will experience the largest relative growth in demand, creating pressure on local facilities. Fort Nelson General Hospital, Kitimat Hospital and Health Centre and Prince Rupert Regional Hospital will likely experience increased demand for services they provide, like General Radiography and Ultrasound, but will also see an increased need to refer patients to other sites for services like CT and MRI. SERVICE DELIVERY MODELS Perhaps the biggest challenge for the provision of health care services in NH is the geographic distribution of its population, with many small communities distant from each other. In many cases, this means low local demand per service at many locations, insufficient to sustain fixed-site service delivery safely from a clinical point of view and efficiently from an administrative perspective. The response to this situation is demand consolidation at select sites, at the expense of larger distances to access the services. But even with this approach, many times there is not enough demand to warrant the full provision of service, limiting hours of operation. To improve service efficiency, staff needs to be cross-educated in multiple modalities so they are shared across services. This makes staff more specialized and harder to recruit, especially in more rural locations where they are needed more and often harder to attract. A Human Resources strategy needs to be implemented to address these issues effectively. Additionally, the implementation of rotating and mobile services aids in the provision of services to smaller communities. This opens further possibilities but requires equipment to be installed in specially conditioned vehicles and suitable parking pads (to be shared by different services, such as MRI, CT digital mammography) to be constructed at each location. Prepared by INSITE Consultancy Inc Page iii

7 Recommendations on equipment replacement criteria, prioritization and life expectancy from the CAMRT/CAR Lifecycle Guidance of Medical Imaging Equipment in Canada (2013) should be critically reviewed by the Medical Imaging program with an intention of adopting its recommendations. EQUIPMENT AND CAPITAL PLANNING MI equipment in NH is in different stages of their estimated life cycles. Based on the present equipment condition and CAMRT/CAR recommendations for equipment replacement criteria, prioritization and life expectancy, a preliminary equipment replacement schedule has been developed. The estimated cost of equipment from 2014 to 2025 is $47,621,000, as shown in the following table. Purchases of new MI equipment beyond replacement of existing inventory is not included in this estimate. Replacement Northwest Northern Northeast Total Year Interior 2014 $2,208,000 $4,818,000 $170,000 $7,196, $4,888,000 $2,050,000 $70,000 $7,008, $2,065,000 $885,000 $1,340,000 $4,290, $983,000 $2,425,000 $968,000 $4,376, $750,000 $3,976,000 $950,000 $5,676, $1,565,000 $2,120,000 $1,588,000 $5,273, $750,000 $1,170,000 $2,200,000 $4,120, $1,200,000 $2,332,000 $1,940,000 $5,472, $1,270,000 $770,000 $2,170,000 $4,210,000 Total $15,679,000 $20,546,000 $11,396,000 $47,621,000 Preliminary equipment replacement cost by HSDA, 2014 to Using the Capital Planning Tool and applying more aggressive replacement policies, life expectancy can be extended a few years for equipment with low utilization. Such a scenario could decrease the estimated replacement costs between 2014 and 2025 to $44,421,000 resulting in a capital cost saving of $3.2m. SUMMARY OF MODALITY SPECIFIC RECOMMENDATIONS Radiology and Fluoroscopy 1. Eliminate all film printers as part of a filmless strategy, while developing downtime and service continuity plans that are independent of hard copy images. 2. Require all Digital Radiography (DR) purchasing decisions to be subject to a business case that considers a threshold volume that justifies DR over Computerized Radiography (CR). 3. Consider multi-purpose rooms in place of dedicated fluoroscopy equipment replacement. 4. Review the number of CR readers available in all CR sites; 1 CR reader can support 2 rooms provided there is one additional reader available for redundancy (regional spare). Interventional Radiology 1. Continue monitoring volumes to assess utilization and capacity needs. Ultrasound: 1. Improve access to ultrasound and echocardiography services in underserved communities: a. Initiate a program to cross-educate medical imaging technologists. b. Engage BCIT or a similar institution as a partner to resolve staff shortage in ultrasound and echo in the North. 2. Apply to the Diagnostic Accreditation Program (DAP) for remote status in ultrasound. 3. Develop a business case for remote ultrasound and echocardiography in under-served communities. Page iv Prepared by INSITE Consultancy Inc. 2014

8 Bone Densitometry Medical Imaging Strategic Plan Review utilization rates per site and alter service delivery models from fixed units to a mobile service. 2. Use the equipment planning and the access to service tools provided to determine the optimal solution and rotation frequency to maintain current utilization rates in each HSDA. Nuclear Medicine 1. Closely monitor volumes and referral patterns using data from the Cerner system. Influences such as a shift of referral to alternate modalities like CT and MRI need to be reviewed at least annually. Mammography In Europe the breast health organization, EUSOMA 1 has developed a first-class operational model for suspected breast cancer. Instead of waiting weeks or months for a definitive diagnosis 80% of patients can receive the all-clear the same day and all remaining cases will have a definitive diagnosis in less than 15 working days. Northern Health has an opportunity to excel by developing breast clinic Hubs based on the EUSOMA model. The EUSOMA model is consistent with the provincial breast health strategy that is summarized in Figure 11. The Hubs adopt an operational process by arranging clinical specialties (pathology, radiology, surgery and oncology) arranged in a one-stop clinic model. The service providers are arranged around the patient instead of the traditional model which revolves around the constraints of the service (Figure 12). Recommendations for Mammography are: 1. Align the digital mammography strategy for the North with the Provincial strategy for the roll out of the digital mobile screening unit operated by SMPBC. 2. Adopt the Provincial Breast Health Strategy and actively work towards the development of one EUSOMA-based breast health hub with future expansion to one hub per HSDA. 3. Transition to digital mammography, screening and diagnostic (shared unit) using a mobile mammography service. a. Develop a business case to define the service and justify the capital and operating costs. 4. Consolidate mammography reading on fewer radiologists to achieve the BCCA minimum mammography reads per radiologist per year. Computerized Tomography Access to CT is critical to the treatment decisions of suspected stroke victims. If a cerebral hemorrhage can be ruled out in less than four and a half hours (4.5) of onset 2, thrombolytic therapy can be given and long term brain damage can be avoided. 1. In sites with under-utilized CT scanners, increase utilization through a combination of reduced operating hours and reallocation of workload to patient choice based on location and first available appointment. 2. Require all CT scanner replacement (particularly Quesnel in 2015 and Terrace in 2016) to undergo a business case process that considers access to service, mobile options and radiation risk. 3. Using the Capital Planning Tool provided, adjust the equipment replacement plan for CT to avoid replacing or investing in additional CT scanners unless there is sufficient justification within the HSDA NICE technology appraisal guidance 264.Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122) Issued: September 2012 Prepared by INSITE Consultancy Inc Page v

9 Magnetic Resonance Imaging 1. Implement a new mobile MRI unit serving the Northeast and Northwest, and replace the existing (old) MRI unit at UHNBC. 2. Continue to monitor the MRI service in the context of growth in MRI demand. 3. One year after implementation of the mobile service re-evaluate the demand for MRI and plan for future investment in fixed MRI using the planning tools provided as an adjunct to this report. Information Technology 1. Engage with the Provincial Diagnostic Imaging project to enable the NH Picture Archiving and Communication System (PACS) to store data in the Diagnostic Imaging Repository (DI-r). 2. Consider the option to adopt the DI-r as the primary PACS archive for NH once implemented in Consider extending the PACS and Radiology Information System (RIS) to the local Community Imaging Clinic (CIC) in Prince George as a means of achieving access to CIC-sourced imaging results. 4. Systems need to shift to become patient centric, allowing from self-booking and changing appointments to viewing reports and images. Other technology opportunities for patient access to results and services need to be evaluated as well. Page vi Prepared by INSITE Consultancy Inc. 2014

10 Table of Contents Medical Imaging Strategic Plan 2014 INTRODUCTION... 1 METHODOLOGY... 3 Engagement and Planning Process... 3 Medical Imaging Services... 3 Service Locations... 3 Population Analysis... 4 Demand Analysis... 5 Referral Patterns and Catchment Areas... 6 Demand Projections... 7 Access Analysis... 8 Planning Tools PRESENT STATE ANALYSIS Population Estimates and Expected Growth and Aging Medical Imaging Exam Volumes and Utilization Geographic Access FUTURE NEED Demand Projections Operating Capacity SERVICE SPECIFIC REVIEW Radiology and Fluoroscopy Interventional Radiology Ultrasound Bone Densitometry Nuclear Medicine Mammography Computerized Tomography Magnetic Resonance Imaging Information Technology CONCLUSIONS AND RECOMMENDATIONS Strategic Planning Exercise Present State Volume and Workload Projections Service Delivery Models Summary of Modality Specific Recommendations Equipment and Capital Planning APPENDIX I: ADDITIONAL DEMAND PROJECTION INFORMATION Demand Projections by Service for each LHA and Period Demand Projections by Service for each Site and Period Prepared by INSITE Consultancy Inc Page vii

11 APPENDIX II: PRELIMINARY EQUIPMENT REPLACEMENT PLAN APPENDIX III: METHODOLOGY DETAILS Population Adjustment Due to Increased Workforce Appointment Data and Exam Counts Projection Assumptions Adjusted Scenario Aggregated Demand Projections by Step APPENDIX IV. STAKEHOLDERS CONSULTED IN THE PLANNING PROCESS APPENDIX V. FACILITY SERVICE LEVELS Page viii Prepared by INSITE Consultancy Inc. 2014

12 Introduction Northern Health (NH), one of the 5 regional health authorities in British Columbia (BC), provides health services to 300,000 people over an area of 600,000 square kilometers. Services include acute care (hospitals), mental health and addictions, public health, and home and community care. More than 7,000 people work in the multiple facilities within NH, including over two dozen hospitals, 14 long term care residences, and many public health units and specialized offices. Similar to the rest of BC, and Canada in general, the population of NH is growing and aging. These two factors, especially the latter, have a deep impact on the demand for health care services and the associated resources. In addition, the BC government has recently announced a range of new industry projects that will have a profound effect on the region. In particular, the Liquefied Natural Gas (LNG) Strategy is expected to bring a boom of construction that will attract a large workforce to areas of NH. This will further increase the demand for health care services into the future. Within health care services, Medical Imaging (MI) is an important component. The business of MI is a support service to other core clinical specialties. Referring physicians require the assistance of various modes of imaging technology and expertise to assist with diagnosis and clinical management of their patients. The efficiency and effectiveness of the diagnostic process has a significant impact on treatment decisions, cost and clinical outcomes of patients. It is generally understood that early accurate diagnosis provides a significant opportunity to reduce the length, complexity, anxiety and cost of the entire clinical journey in a large number of disease processes. Typically, excellence in MI services is defined in terms of the quality and timeliness of diagnostic information being presented to referring physicians. To achieve high performance the specialty relies on a range of high-technology imaging equipment and information systems that are used according to the specific diagnostic situation. MI comprises several different modalities: Radiology and Fluoroscopy, Interventional Radiology, Ultrasound, Bone Density, Nuclear Medicine, Mammography, Computerized Tomography and Magnetic Resonance Imaging. All services combined, NH provided about 293,000 MI exams in the 2012/13 Fiscal Year. Services are provided across the entire region in facilities ranging from large referral hospitals providing all services, to small diagnostic and treatment centres offering core services only. Given the extent and complexity of MI service delivery, and considering the anticipated growth and aging of NH s population, it became imperative to look into the future, estimate future demand, and develop service models that efficiently meet the needs of the population. The MI Strategic Plan presented in this report is a critical review of current and future state for Medical Imaging across Northern Health over the next 10 years. This Strategic Plan focusses on MI services to 2025 and encompasses the following objectives: 1. Assess / leverage the present state of MI services and the extent to which they meet the health needs of the catchment populations 2. Describe the future state MI service need and mix 3. Propose a blue print for MI equipment in each HSDA for the year Make recommendations for best practice in: a. Information Management b. Organizational Best Practice Prepared by INSITE Consultancy Inc Page 1

13 REPORT ORGANIZATION The MI Strategic Plan starts with a brief Introduction to set the context of the report. Next, the Methodology section presents a high-level description of the planning process, the services and sites, and the approach used throughout the current and future state analysis and report preparation. Supplementary information is provided in Appendix III: Methodology Details. The Present State Analysis provides a look at the population today and into the future, summarizes current service utilization across the region, and evaluates access to services. The Future Need section presents demand projections by service from both a population and a facility perspective, under two planning scenarios. More detailed projections are provided in Appendix I: Additional Demand Projection Information. The Service Specific Review section looks at each service in more detail, describing its present state, future trends and recommendations. Finally, the Conclusions and Recommendations summarizes findings from the entire planning process and presents recommendations for MI service delivery and equipment planning. A draft plan for equipment replacement is shown in Appendix II: Preliminary Equipment Replacement Plan. Page 2 Prepared by INSITE Consultancy Inc. 2014

14 Methodology Medical Imaging Strategic Plan 2014 ENGAGEMENT AND PLANNING PROCESS The MI Strategic Plan is the result of a comprehensive consultation process and detailed analytical study of the current and future demand for services. The consultation process 3 included: A MI Conference and Workshop with over 30 participants from different regions and areas of work in NH, including physicians, administrators and technicians. The workshop took place on April 10th 2014 at the Prince George Civic Centre. Face to face meetings held by the MI Leadership across NH to engage over 35 local service providers and gather input for planning the future of service delivery. Consultation with specialists in the field. Open communication between NH s staff and MI Leadership. The analytical study was a data-intensive process to: 1. Review NH s population, the current delivery and utilization of MI services, the geographic access across the region and the impact of the recently announce Industrial Provincial Projects taking place in the territory. 2. Develop demand projections for each modality into the future. Additional information on the specific methodologies used in each part of the analysis follows. MEDICAL IMAGING SERVICES MI services comprise 8 major modalities and the supporting technology platform: Radiology and Fluoroscopy (XR) Interventional Radiology (IR) Ultrasound (US) Bone Density (BD) Nuclear Medicine (NM) Mammography (MA). Computerized Tomography (CT) Magnetic Resonance Imaging (MR) PACS and RIS Information Systems SERVICE LOCATIONS Currently, there are 26 locations across Northern Health providing medical imaging services to different extents. These range from large referral hospitals providing the full range of services and extended hours, to Diagnostic and Treatment Centres where only core services are available. Table 1 shows all the sites, organized by the region where they are located, and the services provided in each of them. 3 Appendix IV includes a list of stakeholders engaged in the planning process Prepared by INSITE Consultancy Inc Page 3

15 Northeast Northern Interior Northwest Current Availability of Services by Site HSDA / LHA Site Peer Group MR CT NM US BD IR XR MA Peace River South DCDH Dawson Creek & District Hospital Medium Hospital CGH Chetwynd General Hospital Very Small Hospital TRDT Tumbler Ridge D&T Centre D&T Centre Peace River North FSJH Fort St. John Hospital Medium Hospital HHHC Hudson'S Hope D&T Centre D&T Centre Fort Nelson FNGH Fort Nelson General Hospital Very Small Hospital Quesnel GRB GR Baker Memorial Hospital (Quesnel) Medium Hospital Burns Lake LDH Lakes District Hospital (Burns Lake) Very Small Hospital Nechako VSJH St. John Hospital (Vanderhoof) Very Small Hospital FLDT Fraser Lake D&T Centre D&T Centre SLH Stuart Lake Hospital (Fort St James) Very Small Hospital Prince George UHNBC University Hospital Of Northern BC (PGRH) Large Hospital VLDT Valemount Health Centre D&T Centre VIC Victoria Medical Centre X-Ray Centre MBDH Mcbride & District Hospital Very Small Hospital MKDH Mackenzie & District Hospital Very Small Hospital Queen Charlotte QCIH Queen Charlotte Islands Hospital Very Small Hospital NHGH Northern Haida Gwaii Hospital (Masset) Very Small Hospital Snow Country SHC Stewart Health Centre D&T Centre Prince Rupert PRRH Prince Rupert Regional Hospital Medium Hospital Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) Very Small Hospital Smithers BVDH Bulkley Valley District Hospital (Smithers) Small Hospital HHC Houston D&T Centre D&T Centre Kitimat KGH Kitimat Hospital And Health Centre Small Hospital Stikine STC Stikine Health Centre (Dease Lake) D&T Centre Terrace MMH Mills Memorial Hospital (Terrace) Medium Hospital Nisga'a - Telegraph Creek - Table 1: Medical imaging sites and current provision of services. POPULATION ANALYSIS The population within NH is organized into 17 Local Health Areas (LHAs), grouped in three Health Service Delivery Areas (HSDAs): Northeast, Northern Interior and Northwest. The LHAs form the basis of analysis for population and service utilization. The most recent population projections for NH from BC Stats PEOPLE 2013 were used. These are the latest release and provide information at very detailed levels (yearly counts by individual years of age and gender for each LHA). To account for specific large-scale industry projects anticipated in the region, population projections from BC Stats were adjusted based on expected workforce increase. Information on additional labour (considering direct, indirect and induced employment) for LNG facilities was taken from the Employment Impact Review commissioned by the BC Government in February 2013 to Grant Thornton LLP. The projected addition in workforce spans over a 9-year period, from 2013 to 2020, as shown in Table 2. Estimates for each year were equally distributed across the 5 regions where the industry projects are expected to have a stronger impact considering extraction plants, pipelines and shipping facilities: Fort Nelson, Peace River South (Dawson Creek), Prince George, Kitimat and Prince Rupert. To account for both young trade construction workers and senior professionals (architects, engineers, etc.), the additional population was assumed to be concentrated among the 20 to 55 age groups (both genders), and distributed proportionally to current estimates within each group. The original population estimates from BC Stats and the adjusted projections including the workforce increase are shown in more detail in Table 41 on Appendix III: Methodology Details. Page 4 Prepared by INSITE Consultancy Inc. 2014

16 LNG represents a temporary increase in population. Influx of LNG workforce will peak in 2016/17 then decline towards end of the project. Construction Total Employment Direct 1,600 1,600 6,900 21,600 21,600 18,500 14,700 11,000 5, ,500 Indirect 3,000 3,000 13,400 41,900 41,900 35,900 28,600 21,300 9, ,700 Induced ,500 11,200 11,200 9,600 7,600 5,700 2,600 53,000 Total 5,400 5,400 23,800 74,700 74,700 64,000 50,900 38,000 17, ,200 Table 2: Annual Construction Employment for LNG projects over Nine-Year Construction Period DEMAND ANALYSIS Record-level workload data for each MI appointment booked in a NH facility was obtained from the Cerner Hospital Information System (HIS). Each record included the service and exam, site where provided, age and gender of patient, place of residence, and other relevant fields. Information was obtained for multiple years, with the analysis focused on the most recent complete fiscal year available: 2012/13. Workload associated with NH residents receiving MI services in other health authorities was not available. Obtaining such information is recommended for future planning. For each medical imaging modality a process of enquiry was used to determine the projected demand in 2020 and These questions examined: Key drivers for MI demand Base utilization rate (historical, benchmark) Population changes: growth, age/gender composition Clinical practice Clinical indications (used by clinical services) Availability (and waitlists) Overutilization Repeat imaging (unnecessary duplication) Technological advances To more accurately capture the effects of the aging population in NH, utilization rates for each modality were calculated by gender and age group. As an example, Figure 1 shows the utilization profile for CT, with a typical pattern of increasing rates for older age groups. Prepared by INSITE Consultancy Inc Page 5

17 F M NHA Exam Rate for CT 2013 A change to the over 60 population will have a large impact on CT demand 350 Exams per 1,000 Population Age Group Figure 1: Sample utilization rate profile by gender and age group for CT services. (2013 calendar year, exams for NHA residents within NHA facilities only) REFERRAL PATTERNS AND CATCHMENT AREAS Besides looking at each service category, MI demand was analyzed both from a population and facility levels. This means that exam workload was summarized based on place of residence of the patient (the LHAs, where the demand is generated) and where the service was provided (the sites). To understand the dynamics of demand and supply of services, referral patterns between each LHA and site were analyzed. This allows us to understand, for each service, where patients go to receive treatment (referral patterns), and conversely, which communities are served by each site (catchment areas). Referral patterns capture the fact that although a facility may be located in one community, depending on the service, that site may serve a much larger population, beyond the local boundaries. This is creates an inflow of patients from other communities. That is especially the case for services with limited availability, such as MR and CT. In these cases, the catchment areas for each site include population from multiple LHAs (or all of them for MR). Additionally, referral patterns reflect that, even if available, not all the residents receive services in their home community. A combination of service accessibility, clinical practice, and convenience and preference for the patient, generates an outflow of local patients that seek care elsewhere. This outflow is common in smaller communities, where patients go to larger hospitals/communities to receive MI services. Figure 2 shows a sample referral pattern for Ultrasound. Patient residence is shown to the left, including residents of other Health Authorities and out-of-province patients that received services (ultrasound exams in this case) at a NH Facility (shown as columns). The total number of exams for residents of each area is shown in the final column (farthest to the right), and the percent of those exams delivered at the different sites is shown in the middle cells, color-coded by intensity. It should be noted that this referral pattern only captures services delivered within NH facilities, and for residents of other Health Authorities this outflow to NH is only a small portion of their total volume of services. Page 6 Prepared by INSITE Consultancy Inc. 2014

18 49% of Queen Charlotte patients received an U/S scan at PRRH 16% of the VIHA residents inflow to NH received an U/S scan at UHNBC 96% of PG residents receive an U/S scan at UHNBC Patient Residence SERVICE HA HSDA LHA QCIH NHGH SHC PRRH WMH BVDH HHC KGH MMH GRB LDH VSJH SLH FLDT UHNBC MBDH MKDH VLDT DCDH CGH TRDT FSJH HHHC FNGH Total Peace River South 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3% 0% 0% 0% 95% 0% 0% 2% 0% 0% 4959 Peace River North 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0% 5% 0% 0% 93% 0% 0% 6787 Fort Nelson 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 4% 0% 0% 0% 10% 0% 0% 30% 0% 56% 643 Quesnel 0% 0% 0% 0% 0% 0% 0% 0% 0% 97% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 7377 Burns Lake 0% 0% 0% 0% 0% 51% 0% 0% 1% 1% 0% 2% 0% 8% 36% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1167 Nechako 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 43% 0% 9% 46% 0% 0% 0% 0% 0% 0% 0% 0% 0% 2509 Prince George 0% 0% 0% 0% 0% 0% 0% 0% 0% 2% 0% 0% 0% 0% 96% 0% 0% 0% 0% 0% 0% 0% 0% 0% Queen Charlotte 0% 44% 0% 49% 0% 0% 0% 0% 5% 0% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 848 NHA Snow Country 0% 0% 0% 4% 1% 7% 0% 1% 81% 0% 0% 0% 0% 0% 6% 0% 0% 0% 0% 0% 0% 0% 0% 0% 104 Prince Rupert 0% 0% 0% 98% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3859 US Upper Skeena 0% 0% 0% 1% 71% 10% 0% 1% 14% 0% 0% 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1073 Smithers 0% 0% 0% 1% 1% 93% 0% 0% 2% 0% 0% 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 4587 Kitimat 0% 0% 0% 6% 0% 1% 0% 54% 37% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 2409 Stikine 0% 0% 0% 5% 0% 9% 0% 0% 78% 0% 0% 0% 0% 0% 4% 0% 0% 0% 2% 0% 0% 0% 0% 2% 64 Terrace 0% 0% 0% 2% 2% 1% 0% 2% 91% 0% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 4429 Nisga'a 0% 0% 0% 3% 0% 2% 0% 2% 92% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 385 Telegraph Creek 0% 0% 0% 6% 0% 4% 0% 2% 81% 0% 0% 0% 0% 0% 5% 0% 0% 0% 2% 0% 0% 0% 0% 0% 97 FHA 0% 0% 0% 6% 6% 4% 0% 3% 9% 13% 0% 1% 0% 0% 28% 0% 0% 0% 12% 0% 0% 18% 0% 0% 80 IHA 0% 0% 0% 1% 0% 2% 0% 0% 1% 89% 0% 0% 0% 0% 4% 0% 0% 0% 2% 0% 0% 1% 0% 0% 1408 VCHA 0% 0% 0% 11% 0% 6% 0% 1% 6% 54% 0% 0% 0% 0% 9% 0% 0% 0% 6% 0% 0% 6% 0% 1% 82 VIHA 0% 0% 0% 16% 0% 9% 0% 4% 7% 7% 0% 0% 0% 0% 16% 0% 0% 0% 18% 0% 0% 23% 0% 0% 66 Unknown / Out of Province 0% 0% 0% 8% 1% 3% 0% 3% 7% 12% 0% 0% 0% 0% 13% 0% 0% 0% 34% 0% 0% 16% 0% 2% 998 Northeast Northern Interior Northwest Figure 2: Illustrative Referral Pattern for Ultrasound Services in 2013 DEMAND PROJECTIONS Projections are calculated for individual services at the population level, meaning that demand is estimated for the residents of each LHA based on the rates of utilization by specific age/gender groups. The calculation of utilization rates by age group in combination with population projections at the same level allow to not only account for the increased workload due to population growth, but also accurately capture the impact of future population structure (aging) to the demand for service (Figure 3). These are the baseline projections where current rates and population factors are taken into consideration. Figure 3: Illustrative Baseline Projections Methodology Building on the baseline projections, additional considerations based on expert opinion, historical trends, emerging technologies and other factors are reflected into the projections (Figure 4). The adjusted projections are, therefore, based on both population factors and the input from stakeholders with knowledge and insight into emerging trends in medical practice, technology and future practice. Prepared by INSITE Consultancy Inc Page 7

19 Once demand is projected at the individual LHAs level, referral patterns are applied to allocate the future demand to the different sites providing services. This provides exam volumes for each service at every site. clinical considerations Clinical indications Available technology Clinical practice Levels of care Critical mass Models of practice Service standards demographic considerations Structure: age / gender / ethnicity Epidemiology: incidence / prevalence / mortality geographic considerations Population density / urban-rural-remote locations Existing facilities / catchment areas / referral patterns Transportation network / distance & travel-time service demand Period Period t Period t+1 Patients Appointments Space Resources Figure 4: Framework for Trend Adjusted Projections ACCESS ANALYSIS The objective of this component of analysis is to measure geographic access to MI services. In doing so the driving distance from place of residence to the destination health facility can be used as a proxy for access measurement. Access is measured at the LHA level using a customized quantitative approach based on driving distance to the closest site within NH providing the service. The approach taken can be summarised as follows: Service-specific access was calculated (e.g. MRI, CT, US, etc.) Access is calculated at an aggregate-level using Local Health Areas (LHA) for both patient residence and health facility delivering the service It is assumed that patients will be served by the closest site with service Figure 5 below illustrates how driving distance is incorporated into the analysis of access. For each service, the driving distance to each location providing the service (green points) is calculated using specialized mapping software, and then closest location is selected. Although distance is important on its own, it is not sufficient to determine the largest impact on population. To assess the effective impact, the relative population of each LHA is considered through population or demand weighting to the driving distances, resulting in a Relative Access Impact metric. This metric is expressed as the percentage of total person-kilometers for each LHA out of the total for the entire health authority. It is calculated, for each LHA and service, as the driving distance to the closest site with service multiplied by the population (or demand) of the LHA, and divided by the total population of NH times the average driving distance for the corresponding service. Page 8 Prepared by INSITE Consultancy Inc. 2014

20 Measure distance to locations offering service For each LHA w/o service Select closest location Site providing service Site NOT providing service Figure 5: Analysis of driving distance to service locations To further illustrate the importance of weighted distance as a measure of relative access to services, Table 3 below shows an example for CT services. It shows the population for each LHA, the distance to service, and the relative access impact (weighted distance x population). Looking at the distance, communities like Stikine and Telegraph Creek show poor access at over 400 Km from the closest service location. But when looking at the relative impact, which considers both the distance and the size of the population subject to that distance, it is actually communities like Fort Nelson and Smithers that have the lowest access. Distance (Km) Impact Factor HSDA LHA Population Closest Site 059 Peace River South 29,147 10% DCDH 0 0% Northeast 060 Peace River North 37,612 13% FSJH 0 0% 081 Fort Nelson 6,552 2% FSJH % 028 Quesnel 24,113 8% GRB 0 0% Northern Interior 055 Burns Lake 7,952 3% UHNBC % 056 Nechako 15,284 5% UHNBC 99 12% 057 Prince George 98,480 33% UHNBC 0 0% 050 Queen Charlotte 4,578 2% PRRH 203 7% 051 Snow Country 540 0% MMH 311 1% 052 Prince Rupert 14,384 5% PRRH 0 0% 053 Upper Skeena 5,452 2% MMH 143 6% Northwest 054 Smithers 16,315 6% MMH % 080 Kitimat 10,081 3% MMH 64 5% 087 Stikine 984 0% MMH 582 4% 088 Terrace 20,935 7% MMH 0 0% 092 Nisga'a 1,959 1% MMH 102 2% 094 Telegraph Creek 715 0% MMH 693 4% NHA Weighted Average 295, Largest impact (distance x pop.) Worst access (longest distance) Table 3: Geographic Access to Service Illustration Prepared by INSITE Consultancy Inc Page 9

21 PLANNING TOOLS To achieve the flexibility and responsiveness that Executives need, two planning tools have been developed to support two of the main drivers for this work: 1. The Northern Health MI Access Tool (Access Tool) Objectives: Quantitative assessment of geographic access to MI services across NH Service configuration planning tool Features: Data-driven, population-based approach Dynamic service mix per site Determines access from each community to closest site with service Easy scenario planning of service configuration and access implications 2. The Northern Health MI Capital Equipment Planning Tool (Capital Tool) Objectives: Repository of MI equipment inventory Decision support tool for capital investment and replacement planning Features: Individual list of equipment by site and modality, with replacement costs Tracks equipment age, expected life, remaining years Multi-year planning horizon Easy scenario planning of capital investment and replacement per year, modality, site and region These tools are user-driven, Excel-based applications with automated calculation routines, reports and charts. They allow the user to alter the present state parameters as equipment or services are developed or deleted, and create scenarios to support decision-making. Data collected to support the tools is from the NH Cerner Hospital Information System and, although NH was not able to provide record level data in all circumstances, the data sets used are representative of the present state. In the event NH is able to obtain the required record level data we recommend it be incorporated into the decision-support tools. These tools were used to support the scenario analysis and preparation of this report. Page 10 Prepared by INSITE Consultancy Inc. 2014

22 Present State Analysis Medical Imaging Strategic Plan 2014 POPULATION ESTIMATES AND EXPECTED GROWTH AND AGING The population in NH is estimated at just over 300,000 in 2013, with the Northern Interior HSDA accounting for about half of the total population and the Northeast and Northwest about a quarter each. The largest population centre is the Prince George LHA, with almost one third of NH s total residents. Considering the population projections adjusted for major industry projects in the region, NH s population is anticipated to grow from the current 300,000 to about 314,200 by 2025, a 4.6% increase. However, it is in during this period where a peak in population is expected due to the LNG construction boom. Besides population growth, and perhaps more importantly for healthcare services in general, NH s population is aging. The compounded effect of both growth and aging will result in higher demand for services, and it is important to accurately capture how, where and when that will happen. Table 4 shows the projected population by LHA between 2013 and Communities in the Northeast, are expected to grow significantly, while other areas will see more moderate or no increase in population. Adjusted Population Projection % Growth % Growth Region Northeast 75,471 85,258 96,602 85, % 13.3% Fort Nelson 7,632 11,415 14,468 7, % -7.0% Peace River North 37,612 39,107 42,820 45, % 22.2% Peace River South 30,227 34,736 39,314 32, % 7.3% Northern Interior 146, , , , % 2.3% Burns Lake 7,952 7,937 7,832 7, % -3.7% Nechako 15,284 15,466 15,659 15, % 2.8% Prince George 99, , , , % 2.7% Quesnel 24,113 24,213 24,452 24, % 2.4% Northwest 78,103 85,751 92,663 78, % 0.3% Kitimat 11,161 14,906 17,818 10, % -7.8% Nisga'a 1,959 1,973 2,002 2, % 3.8% Prince Rupert 15,464 19,339 22,632 15, % -0.6% Queen Charlotte 4,578 4,612 4,668 4, % 1.6% Smithers 16,315 16,516 16,956 17, % 5.9% Snow Country % -0.9% Stikine % -3.8% Telegraph Creek % 2.0% Terrace 20,935 20,688 20,797 20, % 0.1% Upper Skeena 5,452 5,489 5,550 5, % 2.0% NHA 300, , , , % 4.6% Table 4: Adjusted Population Projections for Northern Health. The effect of an aging population is better appreciated in the unadjusted population projections shown in Figure 6. Progressive aging can be clearly seen for the and age groups in 2013 as they transform into the and groups by Because of their significantly higher service utilization, the growth in the 65+ population is of special interest and will result in greater demand for services. Prepared by INSITE Consultancy Inc Page 11

23 30,000 25,000 Unadjusted Population Higher utilization population Population 20,000 15,000 10,000 5, Age Group Figure 6: Unadjusted Population Projections by Age Group, The temporary increase in population due to the additional workforce modifies the distribution of people by age, resulting in an important increase in the number of people between 20 and 54 years of age (Figure 7). 30,000 25,000 Adjusted Population Additional workforce 2025 Adjusted 2020 Adjusted 2015 Adjusted 2013 Adjusted 20,000 Population 15,000 10,000 5, Age Group Figure 7: Adjusted Population Projections by Age Group, Page 12 Prepared by INSITE Consultancy Inc. 2014

24 M EDICAL I MAGING EXAM VOLUMES AND UTILIZATION Northern Health provided a total of 293,766 Medical Imaging exams during the 2012/13 Fiscal Year (Table 5). The vast majority of exams were General Radiology (X-Ray) at 186,003, followed by Ultrasound at 55,830. University Hospital of Northern BC delivered the largest number of exams (95,824 exams, one third of the total volume) out of the 26 locations across Northern Health. Northwest Northern Interior Northeast Actual Exam Volume /13 HSDA / LHA Site MR CT NM US BD IR XR MA Total Peace River South DCDH Dawson Creek & District Hospital - 3,030-5, ,430 1,136 24,447 CGH Chetwynd General Hospital ,188-4,188 TRDT Tumbler Ridge D&T Centre ,711-1,711 Peace River North FSJH Fort St. John Hospital - 2, , ,661 1,302 29,904 HHHC Hudson'S Hope D&T Centre Fort Nelson FNGH Fort Nelson General Hospital ,178-4,567 Quesnel GRB GR Baker Memorial Hospital (Quesnel) - 2,613-8, ,665 1,799 29,332 Burns Lake LDH Lakes District Hospital (Burns Lake) ,733-4,733 Nechako VSJH St. John Hospital (Vanderhoof) , ,205-7,338 FLDT Fraser Lake D&T Centre ,311-1,651 SLH Stuart Lake Hospital (Fort St James) ,905-1,905 Prince George UHNBC University Hospital Of Northern BC (PGRH) 5,273 13,215 3,735 14,053 1, , ,824 VLDT Valemount Health Centre ,141-1,141 VIC Victoria Medical Centre MBDH Mcbride & District Hospital MKDH Mackenzie & District Hospital ,281-2,281 Queen Charlotte QCIH Queen Charlotte Islands Hospital ,365-1,365 NHGH Northern Haida Gwaii Hospital (Masset) ,391-1,775 Snow Country SHC Stewart Health Centre Prince Rupert PRRH Prince Rupert Regional Hospital - 1,161-4, , ,902 Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) ,387-4,314 Smithers BVDH Bulkley Valley District Hospital (Smithers) , ,760 1,113 16,068 HHC Houston D&T Centre ,403-1,403 Kitimat KGH Kitimat Hospital And Health Centre , , ,380 Stikine STC Stikine Health Centre (Dease Lake) Terrace MMH Mills Memorial Hospital (Terrace) - 5,649 1,680 5, ,365 1,598 29,257 Nisga'a Telegraph Creek Total All Sites 5,273 27,917 6,156 55,830 2, ,503 8, ,766 Table 5: Utilization rate per medical imaging service for each LHA, 2012/13. While looking at services provided at each site is very important, it is also relevant to determine who the users of those services are. Current utilization of services varies significantly across communities in Northern Health. Table 6 below shows crude utilization rates (exams per 1,000 population) per service for each LHA. An important driver of service utilization is availability. In areas where services are not provided in the sites nearby, utilization is lower as patients have reduced access, and will need to travel farther to get access to the services. Readers are cautioned that these are crude rates, calculated using the total number of exams and population in each LHA. LHAs differ in their population structure (e.g. some LHAs may have a younger population than others), which produce different aggregate utilization levels. Comparisons among communities should be done over standardized rates that remove the effect of It is important to consider that the exam volumes shown in this report correspond to services provided only in Northern Health locations. Some areas may be closer or have better access to facilities from other health providers, such as hospitals in Alberta or Interior Health. Without knowing the volume of services provided elsewhere, it may seem that residents of those regions have a much lower utilization than in reality. Prepared by INSITE Consultancy Inc Page 13

25 different population structures. The calculation of standardized rates was outside the scope of this report. Exam Utilization Rates (per 1,000 Population) /13 Region MR CT NM US BD IR XR MA Total Northeast Fort Nelson Peace River North Peace River South Northern Interior Burns Lake Nechako ,081.9 Prince George Quesnel ,246.0 Northwest ,115.4 Kitimat ,170.2 Nisga'a ,112.4 Prince Rupert ,139.5 Queen Charlotte Smithers ,233.6 Snow Country ,036.2 Stikine Telegraph Creek Terrace ,096.1 Upper Skeena NHA Table 6: Crude utilization rate per LHA for each medical imaging service, 2012/13. To more accurately capture the effects of the aging population in Northern Health, utilization rates for all MI services combined and each modality were calculated by gender and age group (Figure 8). The utilization profiles differ significantly by service, although they consistently show higher utilization rates for the older age groups. For all MI services combined, females show a higher rate than males, across all age groups. Within individual services, the differences in utilization by gender are most noticeable for Ultrasound (higher use for women in fertile age), Bone Density (post-menopausal women screening for osteoporosis) and Mammography (cancer screening for women aged 40 to 79). Page 14 Prepared by INSITE Consultancy Inc. 2014

26 NHA Exam Rate for All MI 2013 NHA Exam Rate for XR 2013 NHA Exam Rate for IR F M F M F M Exams per 1,000 Population Exams per 1,000 Population Age Group Age Group NHA Exam Rate for US 2013 NHA Exam Rate for BD 2013 NHA Exam Rate for NM F M F M F M Exams per 1,000 Population Exams per 1,000 Population Exams per 1,000 Population Age Group Age Group Age Group NHA Exam Rate for MA 2013 NHA Exam Rate for CT 2013 NHA Exam Rate for MR F M F M F M Exams per 1,000 Population Exams per 1,000 Population Exams per 1,000 Population Age Group Exams per 1,000 Population Age Group Age Group Age Group Figure 8: Utilization rate profiles by age group and gender for MI services (2013) 4 GEOGRAPHIC ACCESS Access to services was analyzed using the Access Tool developed during this planning process. The Tool allows estimating the geographic access to services for each community using a quantitative approach. Table 7 below shows the present state geographic access for all MI services by LHA. Each cell represents the driving distance (in kilometers) between each LHA and service. Results for each service are color-coded based on access: red (longer distance, worse access), orange (medium) and green (shorter distance, better access). From this table it is clear that, at an aggregated Health Authority level, accessing MRI services has the largest distance at 286 Km on average, which is consistent with MRI services being centralized at UHNBC in Prince George. Conversely, access to X-Ray is the best with almost all the LHAs having X-Ray services locally. Within each service, the LHAs with longer distances are highlighted in red. Telegraph Creek, with no MI services provided locally, is consistently the community with the lowest absolute access, while Prince George, with all MI services available within the LHA, is the community with best absolute access. 4 Source: Cerner data for 2013 calendar year. Prepared by INSITE Consultancy Inc Page 15

27 HSDA 51 Northwest 52 Northern Interior 53 Northeast Distance (Km) to MI Services LHA MRI CT NM US BD IR XR MA 050 Queen Charlotte Snow Country Prince Rupert Upper Skeena Smithers Kitimat Stikine Terrace Nisga'a Telegraph Creek 1, Quesnel Burns Lake Nechako Prince George Peace River South Peace River North Fort Nelson NHA Average Table 7: Closest Distance to Service by LHA, 2013 (original BC Stats population projections used to estimate NH average). A complementary view of the access analysis is the corresponding definition of catchment areas for each site providing the services. Table 8 below shows which communities are served by each site, based on closest distance to service. HSDA 51 Northwest 52 Northern Interior 53 Northeast Closest Site Providing Access to MI Services LHA MRI CT NM US BD IR XR MA 050 Queen Charlotte UHNBC PRRH MMH QCIH PRRH PRRH QCIH PRRH 051 Snow Country UHNBC MMH MMH WMH KGH PRRH SHC MMH 052 Prince Rupert UHNBC PRRH MMH PRRH PRRH PRRH PRRH PRRH 053 Upper Skeena UHNBC MMH MMH WMH KGH PRRH WMH BVDH 054 Smithers UHNBC MMH MMH BVDH KGH PRRH BVDH BVDH 080 Kitimat UHNBC MMH MMH KGH KGH PRRH KGH KGH 087 Stikine UHNBC MMH MMH WMH KGH PRRH STC MMH 088 Terrace UHNBC MMH MMH MMH KGH PRRH MMH MMH 092 Nisga'a UHNBC MMH MMH MMH KGH PRRH MMH MMH 094 Telegraph Creek UHNBC MMH MMH WMH KGH PRRH STC MMH 028 Quesnel UHNBC GRB UHNBC GRB GRB GRB GRB GRB 055 Burns Lake UHNBC UHNBC UHNBC VSJH UHNBC UHNBC LDH BVDH 056 Nechako UHNBC UHNBC UHNBC VSJH UHNBC UHNBC VSJH UHNBC 057 Prince George UHNBC UHNBC UHNBC UHNBC UHNBC UHNBC UHNBC UHNBC 059 Peace River South UHNBC DCDH FSJH DCDH DCDH DCDH DCDH DCDH 060 Peace River North UHNBC FSJH FSJH FSJH FSJH DCDH FSJH FSJH 081 Fort Nelson UHNBC FSJH FSJH FNGH FSJH DCDH FNGH FSJH Table 8: Estimated Site of Service by LHA Based on Closest Distance, However, it is important to factor in the analysis the size of the population that is affected by the calculated distance to services. To this end, the calculated driving distances are weighted by the estimated population (or demand) in each LHA, resulting in a Relative Access Impact metric, as shown in Table 9. For each service, the relative access impact percentage represents the proportion of the total person-km in Northern Health attributable to each LHA. Page 16 Prepared by INSITE Consultancy Inc. 2014

28 HSDA 51 Northwest 52 Northern Interior 53 Northeast Relative Access Impact (% of Population x Distance) LHA MRI CT NM US BD IR XR MA 050 Queen Charlotte 5% 7% 8% 0% 6% 4% 0% 12% 051 Snow Country 0% 1% 1% 6% 1% 1% 0% 2% 052 Prince Rupert 12% 0% 10% 0% 0% 0% 0% 0% 053 Upper Skeena 3% 6% 4% 0% 7% 6% 0% 5% 054 Smithers 7% 26% 16% 0% 28% 23% 0% 0% 080 Kitimat 8% 5% 3% 0% 0% 9% 0% 0% 087 Stikine 1% 4% 3% 22% 4% 3% 0% 7% 088 Terrace 14% 0% 0% 0% 9% 12% 0% 0% 092 Nisga'a 1% 2% 1% 9% 2% 2% 71% 3% 094 Telegraph Creek 1% 4% 2% 20% 4% 2% 29% 6% 028 Quesnel 3% 0% 14% 0% 0% 0% 0% 0% 055 Burns Lake 2% 14% 9% 44% 12% 7% 0% 14% 056 Nechako 2% 12% 7% 0% 10% 6% 0% 19% 057 Prince George 0% 0% 0% 0% 0% 0% 0% 0% 059 Peace River South 14% 0% 11% 0% 0% 0% 0% 0% 060 Peace River North 20% 0% 0% 0% 0% 12% 0% 0% 081 Fort Nelson 6% 19% 12% 0% 16% 12% 0% 31% Table 9: Relative access impact metric for each service by LHA, 2013 (original BC Stats population projections used to estimate relative impact). This revised access indicator provides a better picture of where services are needed most, as it considers the population need together with access to services. From the results in this table, the communities with poor access to service can be identified, and considered as candidates for future provision of service. Table 10 summarizes the communities with poor access. Service Lowest Access Other communities Community with low access MRI Peace River North Terrace, Peace River South, Prince Rupert CT Smithers Fort Nelson, Burns Lake, Nechako NM Smithers Quesnel, Fort Nelson, Peace River South US Burns Lake Stikine, Telegraph Creek BD Smithers Fort Nelson, Burns Lake, Nechako IR Smithers Terrace, Fort Nelson, Peace River North XR Nisga a Telegraph Creek MA Fort Nelson Nechako, Burns Lake, Queen Charlotte Table 10: Communities with Lowest Access (Larger Distance) to Services, Access Scenario Analysis 1 The same methodology to evaluate access to services can be applied to a future state of the system, with a different configuration of services. Multiple scenarios can be defined and analyzed using the Geographic Access Analysis Tool developed by INSITE Consultancy for Northern Health. As an illustration, consider a future state scenario where services are now provided in the communities previously identified with the current lowest access for each service (Table 10). The results are shown in Table 11. Comparing the absolute distance to service between the present state (Table 7) and this hypothetical scenario shows that the implementation of services in the communities with lowest access yields significant improvement, reducing the current average driving distance to between 54% and 68% of current values for MRI, CT, US, BD, IR and MA, 78% for NM, and 28% for XR. Prepared by INSITE Consultancy Inc Page 17

29 Similarly, the access analysis can now be performed over this new service configuration for the system. The relative access impact metric can now be used to identify the next round of communities with poor access and prioritize the implementation of new service locations. Distance (Km) to MI Services - Future State Relative Access Impact - Future State HSDA LHA MRI CT NM US BD IR XR MA MRI CT NM US BD IR XR MA 050 Queen Charlotte % 11% 10% 0% 10% 5% 0% 17% 051 Snow Country % 2% 1% 10% 2% 1% 0% 3% 052 Prince Rupert % 0% 13% 0% 0% 0% 0% 0% 053 Upper Skeena % 5% 2% 0% 4% 2% 0% 8% 51 Northwest 054 Smithers % 0% 0% 0% 0% 0% 0% 0% 080 Kitimat % 7% 4% 0% 0% 12% 0% 0% 087 Stikine % 6% 3% 39% 6% 3% 0% 10% 088 Terrace % 0% 0% 0% 14% 18% 0% 0% 092 Nisga'a % 2% 1% 15% 3% 3% 0% 4% 094 Telegraph Creek 1, % 6% 3% 35% 5% 3% 100% 9% 028 Quesnel % 0% 17% 0% 0% 0% 0% 0% Burns Lake % 13% 7% 0% 12% 6% 0% 21% Northern Interior 056 Nechako % 18% 9% 0% 16% 9% 0% 28% 057 Prince George % 0% 0% 0% 0% 0% 0% 0% 059 Peace River South % 0% 14% 0% 0% 0% 0% 0% 53 Northeast 060 Peace River North % 0% 0% 0% 0% 19% 0% 0% 081 Fort Nelson % 30% 15% 0% 27% 18% 0% 0% NHA Average Table 11: Illustrative scenario Future state scenario with services added in communities with highest relative access impact in present state (original BC Stats population projections used to estimate NH average and relative impact). Access Scenario Analysis 2 As an example of iterative analysis, consider the following case for MRI (Table 12): Current state access analysis shows that Peace River North, Terrace and Peace River South are the communities with highest relative access impact, at 19.5%, 14.2% and 14.0%, respectively. Step 1 is a future state scenario where MRI services are now implemented in Peace River North (highest impact). Access then improves significantly for both Peace River North and Piece River South, and relative access impact becomes now highest for Terrace (21.2%). Step 2 would then consider implementing MRI services in Terrace, which will make Smithers the community with highest relative impact. These results are consistent with current considerations to implement a mobile MRI service rotating between Fort Saint John Hospital (Peace River North) and Mills Memorial Hospital (Terrace). It should be noted that these access analysis scenarios are only an illustration of potential future states and limited to geographic implications only. Further consideration of many other factors, including critical mass volumes to sustain practice, availability of other services, staffing, cost and others, is required before any formal recommendations can be made. Page 18 Prepared by INSITE Consultancy Inc. 2014

30 HSDA 51 Northwest 52 Northern Interior 53 Northeast Distance (Km) to MRI Relative Access Impact LHA Current Step 1 Step 2 Current Step 1 Step Queen Charlotte % 7.6% 7.6% 051 Snow Country % 0.7% 0.8% 052 Prince Rupert % 18.7% 10.2% 053 Upper Skeena % 4.4% 3.7% 054 Smithers % 11.0% 16.1% 080 Kitimat % 11.4% 3.0% 087 Stikine % 1.7% 2.6% 088 Terrace % 21.2% 0.0% 092 Nisga'a % 2.2% 0.9% 094 Telegraph Creek 1,079 1, % 1.4% 2.3% 028 Quesnel % 5.2% 13.8% 055 Burns Lake % 3.2% 8.3% 056 Nechako % 2.7% 7.2% 057 Prince George % 0.0% 0.0% 059 Peace River South % 4.1% 11.2% 060 Peace River North % 0.0% 0.0% 081 Fort Nelson % 4.5% 12.2% NHA Average Table 12: Illustrative scenario Iterative changes in system with MRI services added in communities with highest relative access impact in present state (original BC Stats population projections used). Prepared by INSITE Consultancy Inc Page 19

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32 Future Need Medical Imaging Strategic Plan 2014 DEMAND PROJECTIONS Two main projection scenarios were considered: 1. Baseline: current utilization rates + projected changes in population (growth + aging) 2. Adjusted: baseline + additional service delivery assumptions 5 (from process input) Table 13 below summarizes exam volumes for both scenarios for every modality and period. Actual and Projected Exam Volume by Service and Period Scenario/Period MR CT NM US BD IR XR MA Total Growth from /13 5,273 27,917 6,156 55,830 2, ,503 8, ,766 Baseline ,107 35,595 7,961 70,134 3,096 1, ,352 11, ,859 25% ,950 35,942 8,282 66,832 3,304 1, ,405 10, ,736 22% Adjusted ,676 33,815 7,961 70,134 3,406 1, ,999 12, ,988 28% ,822 34,145 8,282 66,832 3,634 1, ,933 12, ,971 25% Table 13: Projected exam volume by scenario for each service and period. Both scenarios consider significant growth in demand due to population growth, population aging, additional people due to increase workforce (LNG projects) and other service-specific assumptions made by NH experts throughout the planning process. Depending on the scenario, growth of about 25%-28% and 22%-25% from current (2012/13) levels is expected for 2020 and 2025, respectively. It becomes evident from the projected exam volumes that higher volume is anticipated by 2020 instead of This is a direct result of the temporary effect expected from the construction boom associated with the LNG projects, which is predicted to peak by and end by 2012 as shown earlier in Table 2. Under the baseline scenario, all services but MR show similar growth. This is the result of disproportionally lower utilization rates for MR outside the Northern Interior HSDA. Conversely, in the adjusted scenario MR now becomes the service with the largest proportional growth as a result of adopting the provincial average utilization rate across each LHA in NH. As additional reference, summarized volumes for all services by LHA of patient residence and projection period are shown in Table 14, and by site of service delivery and projection period on Table 15. Additional details on demand projections for both scenarios are provided on Appendix I: Additional Demand Projection Information. The LHAs with the highest projected growth in exam volume are Fort Nelson, Kitimat and Prince Rupert, with 135%, 79% and 63% growth from current volumes by This is again the direct effect of the anticipated increase in workforce in those regions due to LNG projects. A similar effect is also observable, although to a lesser degree due to the larger population size, in the other communities with LNG projects: Peace River South and Prince George, with 40% and 21% growth by Specific assumptions for each service are described on Appendix II: Methodology Prepared by INSITE Consultancy Inc Page 21

33 Actual and Projected Exam Volume by LHA Baseline Adjusted Region 2012/ Northeast 61,196 85,732 80,738 89,445 84,100 Fort Nelson 5,057 11,874 6,399 12,415 6,671 Peace River North 29,276 36,154 40,616 37,800 42,409 Peace River South 26,864 37,704 33,723 39,230 35, Northern Interior 135, , , , ,286 Burns Lake 7,931 8,744 9,050 8,814 9,118 Nechako 16,464 18,460 19,449 18,586 19,564 Prince George 81,070 98, ,039 98, ,060 Quesnel 29,825 32,443 33,904 33,066 34, Northwest 83, ,550 99, , ,475 Kitimat 11,740 20,970 14,191 21,698 14,651 Nisga'a 2,173 2,462 2,572 2,527 2,639 Prince Rupert 16,279 26,602 19,906 27,516 20,568 Queen Charlotte 4,121 4,748 4,981 4,936 5,172 Smithers 20,003 22,809 24,372 23,233 24,810 Snow Country Stikine Telegraph Creek Terrace 22,653 24,605 25,982 25,313 26,707 Upper Skeena 5,441 6,119 6,470 6,260 6, Non-NHA 13,267 14,889 15,822 15,162 16,111 Rest of BC 7,768 8,711 9,217 8,854 9,368 Out of Province 5,498 6,177 6,604 6,307 6, NHA 293, , , , ,971 Table 14: Projected exam volume by scenario for all services combined by LHA and period. A similar effect of the LNG projects is observed from a facility perspective. Fort Nelson General Hospital, Kitimat Hospital and Health Centre and Prince Ruper Regional Hospital show the highest growth in MI exam volume by 2020, at 113%, 65% and 57% increase from 2012/13, respectively. The sites located in the Peace River South LHA (Dawson Creek & District Hospital, Chetwynd General Hospital and Tumbler Ridge D&T Centre) also show significant projected increase in exam volume by 2020, at about 36%-38%. Page 22 Prepared by INSITE Consultancy Inc. 2014

34 Northeast Northern Interior Northwest Actual and Projected Exam Volume by LHA Baseline Adjusted HSDA / LHA Site 2012/ Peace River South DCDH Dawson Creek & District Hospital 24,447 33,715 30,796 34,118 31,169 CGH Chetwynd General Hospital 4,188 5,717 5,215 5,831 5,320 TRDT Tumbler Ridge D&T Centre 1,711 2,319 2,123 2,366 2,165 Peace River North FSJH Fort St. John Hospital 29,904 37,724 40,905 38,242 41,483 HHHC Hudson'S Hope D&T Centre Fort Nelson FNGH Fort Nelson General Hospital 4,567 9,746 5,684 9,923 5,788 Quesnel GRB GR Baker Memorial Hospital (Quesnel) 29,332 32,143 33,623 32,617 34,112 Burns Lake LDH Lakes District Hospital (Burns Lake) 4,733 5,209 5,389 5,313 5,497 Nechako VSJH St. John Hospital (Vanderhoof) 7,338 8,195 8,588 8,334 8,733 FLDT Fraser Lake D&T Centre 1,651 1,839 1,928 1,869 1,958 SLH Stuart Lake Hospital (Fort St James) 1,905 2,130 2,237 2,172 2,281 Prince George UHNBC University Hospital Of Northern BC (PGRH) 95, , , , ,064 VLDT Valemount Health Centre 1,141 1,352 1,381 1,379 1,408 VIC Victoria Medical Centre MBDH Mcbride & District Hospital 889 1,055 1,078 1,076 1,099 MKDH Mackenzie & District Hospital 2,281 2,724 2,766 2,778 2,821 Queen Charlotte QCIH Queen Charlotte Islands Hospital 1,365 1,581 1,656 1,613 1,689 NHGH Northern Haida Gwaii Hospital (Masset) 1,775 2,047 2,128 2,080 2,162 Snow Country SHC Stewart Health Centre Prince Rupert PRRH Prince Rupert Regional Hospital 17,902 28,148 21,753 28,607 22,106 Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) 4,314 4,849 5,102 4,925 5,183 Smithers BVDH Bulkley Valley District Hospital (Smithers) 16,068 18,215 19,328 18,593 19,730 HHC Houston D&T Centre 1,403 1,592 1,695 1,624 1,729 Kitimat KGH Kitimat Hospital And Health Centre 10,380 17,107 12,498 17,562 12,842 Stikine STC Stikine Health Centre (Dease Lake) Terrace MMH Mills Memorial Hospital (Terrace) 29,257 34,446 34,306 34,630 34,504 Nisga'a Telegraph Creek Total All Sites 293, , , , ,472 Table 15: Projected exam volume by scenario for all services combined by site and period. Prepared by INSITE Consultancy Inc Page 23

35 OPERATING CAPACITY To estimate staffing needs, projected exam volumes need to be translated into operating hours at each site. This is done using the following reference volumes and utilization rates obtained from CAMRT/CAR Lifecycle Guidance of Medical Imaging Equipment in Canada (2013) report: Service MR CT NM US BD IR XR MA Annual volume 4,000 7,500 3,000 2,000 5,000 2,000 10,000 3,500 per shift 6 Utilization rate 7 75% 75% 75% 75% 75% 75% 75% 75% Table 16: Reference exam volume and service utilization for different medical imaging modalities. Using these reference values, operating capacity expressed in number of hours per day for each service and site is estimated (Table 17) based on the following formula: Operating Capacity [hrs] = Projected Exam Volume / [Reference Volume x Utilization Rate] Operating Hours per Day (5 days/week) Service Location 2012/ Baseline Adjusted Baseline Adjusted MRI UHNBC DCDH FSJH CT GRB UHNBC PRRH MMH FSJH NM UHNBC MMH DCDH FSJH FNGH GRB VSJH FLDT US UHNBC NHGH PRRH WMH BVDH KGH MMH DCDH FSJH BD GRB UHNB PRRH KGH Refers to typical exam volume achievable in an 8-hours 5 days/week shift configuration. 7 Target utilization rate for the service (relative to a fully operating unit). Page 24 Prepared by INSITE Consultancy Inc. 2014

36 Operating Hours per Day (5 days/week) Medical Imaging Strategic Plan 2014 Service Location 2012/ Baseline Adjusted Baseline Adjusted DCDH IR UHNB PRRH DCDH CGH TRDT FSJH HHHC FNGH GRB LDH VSJH FLDT SLH UHNBC XR VLDT VIC - MBDH MKDH QCIH NHGH SHC PRRH WMH BVDH HHC KGH STC MMH DCDH FSJH GRB MA UHNBC PRRH BVDH KGH MMH Table 17: Calculated operating hours based on projected volumes and reference workload & utilization per service. From the calculated operating hours above, the following can be observed: MRI at UHNBC currently requires two 8-hour shifts/day and could increase to three shifts/day depending on the scenario considered o This model does not take into account any additional MRI services in NH CT services require about half an 8-hour shift at most locations except UHNBC (2 to 3 shifts/day) and MMH (1 to 1.5 shifts/day) NM at FSJH requires about half an 8-hour shift/day, while UHNBC needs two shifts/day and MMH 1 shift/day US is in high demand across many sites, requiring multiple teams operating 8-hours or longer. The exception are FNGH, FLDT and NHGH where less than half an 8-hour shift/day is required Prepared by INSITE Consultancy Inc Page 25

37 BD requires less than one hour per day of service at all locations except UHNBC where it could be up to half an 8-hour shift/day IR also shows low operating capacity except at UHNBC (about half an 8-hour shift/day) XR is a service requiring operating capacity across all sites, although smaller sites need only a few hours a day of staffed capacity MA requires between half and one 8-hours shift/day at most sites Based on required operating capacity and similarities in service delivery between modalities, combined service delivery and cross-education of staff can be planned at each site. Page 26 Prepared by INSITE Consultancy Inc. 2014

38 Service Specific Review Medical Imaging Strategic Plan 2014 RADIOLOGY AND FLUOROSCOPY General radiography is the conventional use of x-rays to image the human anatomy for diagnostic purposes. In 2012 NH converted the last of its film based sites to Computerized Radiography (CR), which utilizes digital cassettes together with conventional analog X-Ray machines. CR enables the transition from film to digital imaging without replacing existing x-ray units, offering a low cost solution for entry into a Picture Archiving and Communication System (PACS) environment. Digital Radiography (DR) is the final step in digital imaging where images are generated on a digital receptor without the need for handling cassettes. DR effectively automates part of the imaging process by obviating the need for cassettes and in so doing improves throughput but at an increased capital cost. The business case for DR requires high demand. And consideration of the following: DR is approximately three times the cost of comparable analog machines. Service costs are 8-12% cost of equipment. DR can process a higher number of patients than traditional CR rooms, decision to replace equipment should include utilization of existing equipment. Dose reduction to the population needs to be considered in the context of the population size and the radiation dose reduction benefit. Fluoroscopy is a real-time procedure that allows medical staff to see tissues and organs in motion, as well as capture them on still film. In almost all cases, fluoroscopy is done at sites where a radiologist is present or in the OR (using a C-Arm) with an orthopedic surgeon. In recent years there has been a gradual reduction in the use of fixed fluoroscopy equipment and as a result many of the existing machines are underutilized. Mobile fluoroscopy (C-Arms) continues to be required to support orthopedic and some other surgical procedures. General Radiography services exist at each of the 25 NH sites. General radiography (x-ray) continues to be a basic component of diagnostic imaging portfolio and in many communities is the sole modality available. Within NH there are 8 : 40 X-ray units (mix of X-ray, X-ray/fluoroscopy and IR machines) 26 portable X-ray units 8 C-arm X-ray units 7 film printers 33 CR units Trends Recent trends in radiography include: Lowest growth (2%) modality in BC 9 The move to complete digital imaging (DR), eliminating the need for cassettes Radiation dose reduction with the implementation of DR. Implementation of PACS and the associated workflow Full integration of PACS with the NH HIS/RIS Annual general radiography demand grew by an average of 2% provincially in the last five years and accounts for approximately 60% of all medical imaging in BC. While fluoroscopy is necessary for some procedures, there is considerable movement toward the use of CT scan for abdominal procedures (bowel studies) and angiography. It is conceivable that NH will not be 8 SOURCE: NH Biomedical Engineering Medical Imaging Inventory (August 2013) 9 BC Health Enterprise Architecture Program. Medical Imaging Pilot Vision. May 18, V0.6 Prepared by INSITE Consultancy Inc Page 27

39 replacing several fluoroscopic units when they come to the end of their life expectancy. This will result in several significant impacts: Fluoroscopic procedures are done in conjunction with a radiologist or other trained medical staff (i.e. Orthopedic Surgeon). Fewer fluoroscopic procedures may result in decreased capital expenditures for fluoroscopic equipment based on service delivery models. Increased CT scanner usage (for provision of alternate/similar type studies) may impact the delivery of CT services. Fluoroscopic equipment will still be required for speech pathology group, which depends on the equipment for modified barium swallow studies. Decreased utilization of fluoroscopic equipment for abdominal studies/angiography may mean more time available for speech pathology s swallow studies; a decreased waitlist for these studies is anticipated. Recommendations 1. Of the 7 printers in use, few are ever used. We recommend eliminating all film printers as part of a filmless strategy. Downtime and service continuity plans need to be developed that are independent of hard copy images. 2. All DR purchasing decisions must be subject to a business case that considers a threshold volume that justifies DR over CR. 3. Multi-purpose rooms need to be considered in place of dedicated fluoroscopy equipment replacement. 4. Review the number of CR readers available in all CR sites; one CR reader can support 2 rooms provided there is one additional reader for redundancy (regional spare). INTERVENTIONAL RADIOLOGY Interventional Radiology is the name given to many procedures that are minimally invasive and use imaging as a guide. Interventional radiology can be used for diagnosis and for treatment. A list of procedures includes: Angioplasty and Vascular Stenting Needle Biopsy of Lung (Chest) Nodules Catheter Angiography Permacath Insertion Catheter Embolization Radiofrequency Ablation of Liver Tumours Chemoembolization Thrombolysis Computed Tomography Angiography Transjugular Intrahepatic Portosystemic Shunt (TIPS) Page 28 Prepared by INSITE Consultancy Inc Cryotherapy Ultrasound-guided Breast Biopsy Detachable Coil Embolization Uterine Fibroid Embolization Endovenous Ablation of Varicose Veins Vascular Access Procedures Magnetic Resonance (MR) Angiography Vertebroplasty Magnetic Resonance (MR) Breast Biopsy X-Ray Guided Breast Biopsy Interventional Radiology is a specialized field and few Radiologists are trained in the discipline. Advances in technology are resulting in an increased amount of interventional patient care within Medical Imaging departments, performed by radiologists instead of in operating rooms by surgeons. Interventional procedures decrease demand for operating room time. Typically interventional procedures are performed quicker, are less invasive, and require less recovery time than the same procedure if performed in the operating room. Currently interventional procedures are performed only at Dawson Creek, UHNBC and Prince Rupert. In general, the medium sized sites perform a limited scope of these exams whereas UHNBC provides a more complete array of Interventional work.

40 Recommendations 1. Continue monitoring volumes to assess utilization and capacity needs. Medical Imaging Strategic Plan 2014 ULTRASOUND Ultrasound is a modality that uses high frequency sound waves displayed and recorded in real time on a monitor. Ultrasound is a valuable modality because it provides dynamic imaging without the use of ionizing radiation (as is used in CT and general X-ray) to obtain the image. It is the modality of choice in a wide range of anatomical sites and conditions, including: Abdomen especially liver Heart (echo) Veins (Deep Vein Thrombosis) Female pelvic organs Breast follow up Soft tissues Fetus-standard for prenatal care & assessment of fetal development & wellbeing 10 Annual Ultrasound demand grew by an average of 4% provincially in the last five years and accounts for approximately 17% of all medical imaging in BC. Arteries (carotids) Thyroid Prostate Scrotum Ultrasonography is a valuable component of patient care that provides physicians with the information they require to determine diagnoses and develop treatment plans. Many Interventional procedures such as Biopsies and Drainages are performed in the MI Ultrasound department replacing the need for a surgical suite, surgeon and OR staff. There is considerably less risk and discomfort to the patient and faster recovery times as general anaesthetic is not required. The numbers and types of interventional procedures provided under Ultrasound guidance within Imaging Departments are increasing. Ultrasound services are provided at 13 NH sites in different capacity and predominantly to outpatients, with payment for services by the provincial medical services plan. Ultrasound services typically generate revenue for NH in excess of the cost of providing the service. Consequently, the provision of ultrasound services is sometimes seen as a business opportunity by clinicians and by facility administrators. Ultrasound services generate more MSP income than their operating costs, resulting in a net revenue generate service. NH waitlist data is collected regularly and does not project any immediate changes in trends. The current wait times are listed below. Ultrasound Wait Times Community Wait Times (days) OB NON OB Prince George Prince Rupert Terrace Dawson Creek 5 12 Kitimat 8 8 Smithers 8 11 Hazelton Vanderhoof Quesnel Fort St. John Fort Nelson Table 18: Ultrasound wait times (July 2013). 10 Society of Obstetricians and Gynecologists national clinical guidelines: SOGC CPG 187; Recommendation 1; Feb FSJ extended wait times due to US staffing shortages Prepared by INSITE Consultancy Inc Page 29

41 Ultrasound in the North is an increasingly demanded service that meets a variety of physician and patient needs. US exam utilization continues to grow in all HSDA s. Factors driving growth include: Increasing population Replacing Fluoroscopy and OR procedures with Ultrasound (biopsies, drainages, injections) Increase in shoulder and MSK ultrasound exams due to lack of MRI resources and long MRI wait times In nearly every British Columbia Health Authority, sonographers, are the least available medical imaging staff. According to a survey conducted by the Provincial Imaging Council (July 2013) there is currently vacant FTE s comprising 102 vacant positions in Health Authorities of BC. This data shows that the human resource shortage related to Ultrasonography services is significant. Staffing is the major issue facing the delivery of Ultrasound service in NH. It is geographically and financially challenging for rural NH residents to attend formal education in the lower mainland. NH currently has 7.8 vacant FTE ultrasound positions. It is anticipated this number will rise with the increase in US workload, aging staff, population, and staff repetitive strain injuries. A proposal has been drafted to address the chronic shortage of Ultrasound Technologists in Northern BC and was to be submitted for approval December The Sonography Training At Rural Sites (STARS 12 ) proposal is designed to train currently employed Medical Imaging technologists in the skills of sonography to a level where they are prepared to write national certification exams in general ultrasound. This 18-month process can be delivered through the community hospitals in Northern BC currently offering ultrasound and thus, train and retain staff at a local level. The shortage of ultrasonographers is the most significant issue facing the NH ultrasound service. Northern Health Shortage 12 In relation to the specific challenges encounter by NH, a current snapshot of our ultrasound vacancies is listed below: Site FTE Positions FTE Vacancy Comments Fort Nelson Locum service when available Fort St John One vacancy is a term Dawson Creek (+new Mat leave vacancy March FTE) Prince George One vacancy is a term Quesnel Vanderhoof Terrace Locum service Kitimat Locum service Prince Rupert Chief technologist jointly holds the ultrasound position (1 FTE), retiring in June 2014 Smithers/ Hazelton FTE shared between the sites Total % vacancy rate Table 19: Current ultrasound vacancies. There are also growing service needs that support the ability to have ultrasound services in smaller communities outside of centers where there is not a sonographer. The presence of a sonographer and on-site radiologist is the preferred standard of care. However, tele-ultrasound services are being provided in communities throughout Canada where the shortage of sonographers prevents establishment of a resident or visiting service and the alternative is no study at all. 12 Northern Health Sonography Training At Rural Sites-October 11, 2013 Page 30 Prepared by INSITE Consultancy Inc. 2014

42 Some physicians and surgeons are acquiring small portable US units to perform quick bedside scans in OR, ER and on the patient wards. These exams are not supported by the Medical Imaging departments or by the onsite Radiologists and is not an MSP billable service. The quality of these services are not known, however it is reasonable to question diagnostic quality if such modalities are used by minimally trained personnel. Obstetrical Ultrasound in smaller communities Many smaller communities would benefit from having a local ultrasound service, especially those sites where travel in and out of the community is difficult. An ultrasound service would be beneficial in monitoring maternity patients as ultrasound fetal assessment is part of the clinical practice guidelines for prenatal care of the Society of Obstetricians and Gynecologists of Canada. Being able to perform an ultrasound examination requires a great deal of skill and may only be performed by staff having the appropriate certification. The challenge is in finding sufficient qualified Sonographers to accommodate these sites. Accreditation standards require that ultrasound services be provided under the supervision of a physician recognized by the College of Physicians and Surgeons to monitor and interpret ultrasound examinations. Normally this is a Radiologist. However, there is at least one Obstetrician in Northern BC who is also certified to interpret obstetrical ultrasound images. The potential ultrasound workload in smaller communities would not support a resident sonographer. An option for communities where there are less than 150 ultrasound scans each month is to seek remote status from the Diagnostic Accreditation Program. Having that status allows a radiologist to provide supervision from a distance. Echocardiography Echocardiography examinations are advanced ultrasound procedures that are used to examine the heart. Echocardiography allows clinicians to see the heart visually and to measure the velocity of blood and cardiac tissue. This information equips clinicians in making informed decisions around treatment for heart conditions. Echocardiography is performed at fewer sites than general ultrasound. In Northern Health, echocardiography exams are subject to technologist training and staffing limitations. Technologists who wish to perform echocardiograms are required to complete the specialized Echocardiography training program. The scarcity of sonographers naturally translates to a shortage of echo techs as well. Terrace is currently training 2 of its radiology staff to perform dedicated echocardiography exams. NH has reduced the echocardiography waitlist times significantly from 2006 to 2013: Echocardiogram Wait List Community 2006 Waitlist July 2013 Waitlist Prince Rupert Quesnel Prince George Dawson Creek Fort St John Terrace 21 Smithers 17 Table 20: Echocardiogram wait list, 2006 and This reduction in wait times in due significantly to the hiring of an external echocardiography solution service, Canadian Cardiac Solutions. With the ongoing shortage of ultrasound technologists, 7 of the 8 NH sites performing cardiac ultrasounds, have contracted this company to perform echocardiography while utilizing their NH ultrasound technologists to perform general ultrasound exams. Some centers have been utilizing this service for the last 5 years to alleviate their staff shortages and echo waitlists. 11% of the total workload exams at PGRH and 14% of the total workload exams at Mills Prepared by INSITE Consultancy Inc Page 31

43 Memorial in were performed by Canadian Cardiac Solutions. There is a substantial risk to service at these sites while dependent on an external company to provide such a large portion of the workload. The recognized acceptable wait time for an outpatient echocardiogram is within 28 days. Due to the nature of the test, waitlists of this length are unacceptable and often render the examination unnecessary, as physicians are forced to treat patient symptoms without the information from the echo. The physician may be choosing other tests of less diagnostic value. Equipment Northern Health s ability to replace the ultrasound units as they become outdated is a concern. Northern Health has 38 ultrasound units accounted for: 2 dedicated echo 30 general ultrasound 5 portables 1 Interventional Five of these units are designated to the departments of Maternity, Emergency, Oncology & OR. The replacement costs spanning 2014/ /22 for these 38 units total $ 5.3M. The rapidly changing technology in this area has prompted other Health Authorities to implement an ultrasound purchase replacement strategy of every 5 or 6 years. Ultrasound capital equipment purchase considerations: Ultrasound equipment in Northern Health is well-utilized. Trained staff is the limiting factor to increasing the number of examinations performed. The accepted life expectancy for an ultrasound machine is 8-12 years depending on utilization. US machines not designated to MI departments should be purchased and expensed to the individual department utilizing the machine. Trends Future trends in ultrasound include: Continued growth in demand as a versatile and relatively low cost modality. Improved PACS viewer capabilities for echo that will enable improved remote access to specialists. Increased computer power and, therefore image quality and capability. Greater capability in small, hand-held or portable devices. Increased adoption and use of 3DUS and 4DUS, especially in areas of volume imaging and functional imaging. Real-time transmission of images across networks for remote supervision (Tele-ultrasound). Recommendations 1. All ultrasound purchases to be subject to a business case. 2. Develop a business case for remote ultrasound and echocardiography in under-served communities: a. Initiate a program to cross-educate medical imaging technologists, or other suitably qualified staff, to obtain their ultrasound and echo diplomas. b. Continue to engage BCIT or a similar institution as a partner to resolve the staff shortage in ultrasound and echo in the North of BC. c. Approval of STARS program. d. Continual advertising and recruitment of applicants to STARS program. 3. Apply to the DAP for remote status in ultrasound. 4. Support use of Canadian Cardiac Solutions until such time that NH can service the ultrasound workload internally. Page 32 Prepared by INSITE Consultancy Inc. 2014

44 BONE DENSITOMETRY Medical Imaging Strategic Plan 2014 Bone Density is a radiologic procedure that uses X-Rays to measure the density of bones to assess the patient for osteoporosis. Currently Bond Density services are provided on a part-time basis at 6 NH sites, 2 in each HSDA: Northeast: services are provided in Fort St John and Dawson Creek. The Dawson Creek service is a long standing program with the Fort St John program launched in Northern Interior: services are provided in Prince George and Quesnel. Unlike other centers, the Prince George bone density is operated out of the Nuclear Medicine Department. Northwest: services are provided in Kitimat and Prince Rupert. The Kitimat service is a long standing program with the Prince Rupert program launched in Equipment Bone Density capital equipment purchase considerations: Scanner lifespan is generally accepted to be 10 years. Although there have been limited changes in the hardware aspects of bone density, software and computer processing continues to improve at a high rate. NH replacements (based on 10 year cycle)at approximately $120,000 per unit is as follows: o Kitimat: 2016/17 o UHNBC: 2017/18 o Dawson Creek: 2020/21 o Quesnel: 2021/22 o Fort. St John.: 2021/22 o Prince Rupert: 2022/23 Trends Bone Density exams have decreased significantly over the past 5 years and although an aging population could marginally increase the demand, the impact would likely be minimal. Recent changes to the MSP reimbursement schedule have changed the frequency of insurable scans from a 2 to 3 year cycle appear to have negatively impacted the utilization of this exam. In 2005/06 NH was operating 4 scanners providing approximately 2,800 exams annually, in 2012/13 there are 6 scanners providing 1,940 exams. Wait list data is not being tracked for this modality Bone Density Activity by HSDA HSDA 2012/ / / / /09 5 YEAR Bone Density equipment is significantly underutilised and the utilisation trend is declining. AVG ANNUAL CHANGE CHANGE Northeast % 3.5% Northern Interior % -11.0% Northwest % -11.2% TOTAL % -10.7% Table 21: Bone density activity by HSDA 13. Recommendations 1. Review utilization rates at each site and alter the service delivery model from fixed units to a mobile service. 2. Use the equipment planning and the access to service tools provided to determine the optimal solution and rotation frequency to maintain current utilization rates in each HSDA. 13 Source: Northern Health Imaging Volumes- March 2013 Prepared by INSITE Consultancy Inc Page 33

45 NUCLEAR MEDICINE Nuclear Medicine Imaging involves injecting a radioactive isotope into a patient. As the isotope decays, gamma rays are emitted and detected by a gamma camera to produce an image. Nuclear medicine is used to detect cancer, as well as a number of cardiovascular, neurological and physiological abnormalities. In addition to diagnostic assessments, Nuclear Medicine provides therapeutic procedures for thyroid cancer, hyperthyroidism and occasional palliative therapies for metastatic bone cancer. Nuclear Medicine is provided in three NH sites, one in each HSDA: Fort St. John (Northeast), UHNBC (Northern Interior) and Terrace (Northwest). Northeast: Nuclear Medicine services in the NEHSDA were interrupted in 2013 with the departure of the sole technologist from Fort St John. A replacement was recruited and the service has resumed however the lack of relief staff limits the delivery of service to the NE. Nuclear imaging is done using a GE Hawkeye (2005) SPECT/CT Gamma camera (non-diagnostic CT tube for attenuation correction). Medical interpretive services are provided by a part-time onsite radiologist and/or select radiologists located in Prince George. Northern Interior: Nuclear Medicine services in the NIHSDA are well established and provided by a 2 camera department in Prince George. Nuclear imaging is done using a GE Hawkeye (2007) (non-diagnostic CT tube for attenuation correction) which is the newest SPECT/CT Gamma camera in NH and a Skylight Gamma Camera (2003). Medical interpretive services are provided by full-time onsite radiologists. Northwest: Nuclear Medicine services in the NWHSDA are well established and provided by a single camera department using a Skylight Gamma Camera (2003). Medical interpretive services are provided by nuclear medicine radiologists located in Prince George. Equipment Gamma Camera lifespan is generally accepted to be 10 years. Gamma Camera configurations and approximate costs are as follows: Basic SPECT unit $500,000 No significant renovations required SPECT/CT non-diagnostic $700,000 Possible limited renovations required SPECT/CT diagnostic 8 slice) $800,000 Renovations required; can be used as backup CT scanner or secondary scanner SPECT/CT diagnostic 16 slice $900,000 Renovations required A foundation project is currently underway to replace the UHNBC Skylight. From 2015/16 through 2017/18 Northern Health will be faced with annual Gamma Camera replacements expenditures (based on a 10 year lifespan) of approximately $1,000,000. Trends Nuclear Medicine is a low volume, labor intensive service that, apart for myocardial perfusion imaging, shows little signs of significant growth. Provincially, the volume of nuclear medicine scans reduced by 3%over the past five years. Recent isotope shortages have resulted in service delivery issues and although the current supply is stable, there are concerns that without significant changes, future shortages may reoccur. Other trends in Nuclear Medicine include: The development of Positron Emission Tomography (PET) as valuable diagnostic tool. Note: PET scanning is generally limited to sites that are near the cyclotrons that produce the isotopes used in PET imaging. The development of SPECT/CT cameras where concurrent Nuclear Medicine and CT imaging is done improves the clinical accuracy of some Nuclear Medicine procedures. PET/CT is specialized hybrid technology that enables one test to provide both functional (PET) and structural (CT) images which can significantly enhance the effectiveness of diagnosis. A cyclotron unit is required to manufacture the radioactive compound. There is currently only one PET/CT in BC located at the BCCA site in Vancouver. Page 34 Prepared by INSITE Consultancy Inc. 2014

46 Potential for high speed multi slice CT scanners or cardiac MRI to replace a proportion of the nuclear medicine cardiac imaging. Increasing cost and uncertain supply of isotopes. Northern Cancer Center may increase the demand for nuclear medicine procedures across the Health Authority. There is an overall decline in the number of Nuclear Medicine exams in Northern Health, partially the result of staffing issues. Recommendations 1. Closely monitor volumes and referral patterns using data from the Cerner system. Influences such as a shift of referral to alternate modalities like CT and MRI need to be reviewed at least annually. MAMMOGRAPHY Mammography services are divided into two distinct streams of activity, screening mammography and diagnostic mammography. Screening mammography is administered through a provincial program, the Screening Mammography Program of BC (SMPBC), under the BC Cancer Agency. The SMPBC contracts with health authorities and community clinics to provide an annual quota of screens for the target population. The current service delivery locations are shown in Figure 9. The SMPBC closely monitors screening volumes by region and site on a reporting period basis. The screening statistics are provided in the following chart current to Period 7, 2013/14. Site Annual Target YTD Actual YTD Assigned YTD Variance % Variance Wait Time (Weeks) Prince Rupert (89) -22.5% 3.5 Kitimat (91) -27.1% 0.5 Terrace 1, (103) -16.7% 2.0 Smithers (49) -11.3% 0.5 Prince George 6,000 3,228 3,312 (84) -2.5% 2.0 Community Clinic Quesnel 1, (4) -0.5% 0.5 Dawson Creek (138) -30.6% 3.5 Fort St John 1, (62) -11.1% 6.5 Table 22: Period 7, 2013 /14 Screening Mammography Status Report Prepared by INSITE Consultancy Inc Page 35

47 Screening Services Diagnostic Services Capacity and Exam Mix Figure 9: Current Mammography Services in Northern Health A review of mammography exam procedures was completed for all northern sites doing screening and diagnostic procedures. NH data was crossed referenced with SMPBC data to ensure data accuracy (Table 23. Observations: The annual screening volume target for northern BC is 14,500 exams / year. The annual screening volume on the digital mobile unit is targeted for 14,500 exams / year. There are very small volumes of both screening and diagnostic procedures being performed across the north. Page 36 Prepared by INSITE Consultancy Inc. 2014

48 Mammography reading in small centers provides insufficient volume to meet expertise levels 14 There is a large amount of over capacity from an equipment perspective across the north. Concentration of diagnostic mammography volume at the HSDA level could generate sufficient volume to justify EUSOME 15 - based health center(s) of excellence. Vernon has one film based mammography unit with a higher throughput of screens and diagnostic procedures. Exam volumes do not warrant two digital mammography units in Prince George. Site Diagnostic Procedures Fine Wire Localizations Stereotactic Core Biopsies/ FWL Total Diagnostic Exam Mix Total Screening Target Total Exams per Unit Prince Rupert Kitimat Terrace ,100 1,603 Smithers ,156 Prince George (UHNBC) Prince George (CIC) 17 3, ,000 6,000 9,000 Quesnel ,300 1,788 Dawson Creek ,331 Fort St. John ,000 1,454 Comparative Site Data Vernon (1 FFDM unit) 3, ,613 6,075 9,688 Table 23: Summary of mammography volumes by site (Public and Private). Source: SMPBC Database Digital versus Analogue Mammography Technology Full Field Digital Mammography (FFDM) has led to improved throughput, lower radiation dose and improved image quality in breast imaging. The target productivity volume per technologist proposed by SMPBC is 5000 mammograms per year. The equipment utilization target is 17,500 mammograms per FFDM unit per year in order to justify the additional technology cost. In NH there are no locations that can justify having a dedicated, fixed FFDM unit based on the SMPBC recommendation. The combination of FFDM and PACS, with mammography software, presents a great opportunity to manage breast imaging services with increased efficiency and effectiveness. Remote reading can be concentrated on fewer sub-specialized radiologists, thus increasing the expertise of the reading radiologist. Software to automate the detection of abnormalities in digital mammograms is becoming increasingly advanced. Computer Aided Diagnosis (CAD) represents both an efficiency opportunity as well as a potential quality improvement opportunity when used appropriately. Capital Equipment Maintenance (per year) Equipment Maintenance (per screen) Figure 10: FFDM Equipment and Digital Image Display Analog $ 191,154 $ 14,173 $ 2.12 Digital $ 448,182 $ 37,750 $ 5.66 Table 24: Comparative Costs of Digital and Analogue Mammography equipment 14 BCCA recommends min 1000 reads per radiologist/year. Eusoma recommends 5000 reads per radiologist /year 15 European Society of Mastology 16 The mammography volume shown at UHNBC is mainly associated with stereotactic biopsies 17 The mammography volume at this Community Imaging Clinic is not part of Northern Health volume Prepared by INSITE Consultancy Inc Page 37

49 Improve quality by consolidating digital mammography into a mobile service with dedicated reading radiologists reading 1000 per year. Site Estimated Digital Conversion Costs Annual Service Contract 10 year Amortization Exam Volume Targets (2013/14) Average Cost per Exam Prince Rupert $700,000 $36,000 $106, $ Kitimat $700,000 $36,000 $106, $ Terrace $850,000 $66,205 $151,205 1,100 $ Smithers $700,000 $36,000 $106, $ Prince George $850,000 $66,205 $151,205 6,000 $25.20 (UHNBC) 18 Prince George $700,000 $36,000 $106,000 6,000 $17.67 (CIC) 19 Quesnel $700,000 $36,000 $106,000 1,300 $81.54 Dawson Creek $700,000 $36,000 $106, $ Fort St John 20 $850,000 $73,705 $158,705 1,000 $ Estimated Conversion Costs for all NH sites $6,750,000 $422,115 $1,097,115 12,270 $89.41 Table 25: Conversion costs for Mammography services for all existing Northern Health sites. Site Cost Comments Terrace $850,000 Screening and diagnostic procedures Prince George $850,000 Screening and diagnostic procedures Fort St John already converted Screening and diagnostic procedures SMPBC Digital Mobile planned for 2015 Screening procedures Table 26: Summary of Digital Mammography Conversion Costs SMPBC proposed approach. The transition from film based mammography to full field digital mammography technology has provided the following benefits: Significantly improved image quality Continuity of reporting and patient record Increased productivity for the reading radiologist via PACS Increased productivity for the technologist Elimination of physical record storage requirements Although there are many noted benefits to digital mammography, the capital costs and operating costs require a substantial volume per machine to justify the investment. Breast Health Centers The time from suspicion of breast cancer to diagnosis and start of treatment can make the difference between life and death for this patient group. In a 2008 study at Fraser Health (FH) by INSITE Consultancy the longest time to diagnosis was over six months and the average was three months. With process re-engineering the 18 The UHNBC mammography unit is currently used for diagnostic work only, however it could be replaced with a digital unit capable of screening and diagnostic work 19 SMPBC currently contracts with the Community Imaging Clinic to offering screening services in Prince George 20 Fort St John was converted to digital mammography through external funding in conjunction with the new hospital building. Fort St. John service costs are based on actuals Page 38 Prepared by INSITE Consultancy Inc. 2014

50 maximum time to diagnosis can be reduced to 15 working days and FH have been able to achieve that performance in a large number of cases. The model, known as the EOSOMA model is well understood and represents an opportunity for NH to deliver such a service for its residents and, we commitment from all clinical specialties and management can consistently achieve the EUSOMA performance standards. Figure 11: Diagram representing the BCCA model for Breast Health in BC BCCA has adapted the EUSOMA model in a provincial breast health strategy that is summarized in the diagram above (Figure 11). The Hubs are coterminous with EUSOMA breast health clinics with operational process and clinical specialties (pathology, radiology, surgery and oncology) arranged in a one-stop clinic model. The service providers are arranged around the patient instead of the traditional model which revolves around the constraints of the service (Figure 12). Prepared by INSITE Consultancy Inc Page 39

51 Figure 12: Patient Centred Breast Health Clinic (Hub) Regulatory Standards In October 2013, Health Canada released new federal safety standards entitled Radiation Protection and Quality Standards in Mammography: Safety Code 36. These standards have the goal of providing optimal mammographic image quality, while ensuring the personnel working within the department and the general public are safe. These federal standards contain the quality control requirements for mammography departments. The quality control requirements and quality assurance practices of the Diagnostic Accreditation Program of BC, and the Mammography certification of the Canadian Association of Radiologists are requirements for all SMPBC screening sites. Fulfilling the increasing regulatory standards is a factor in the decision of where to locate mammography services. Delivery Options Delivery of mammography services should be aligned with the developed Provincial Breast Health Strategy, which is focused on improving patient navigation, improving screening rates, and decreasing time to diagnosis. A delivery model that provides consistency of service, independent of local staff availability, would be one factor in improving over-all screening rates in the north. Currently many sites have very few mammography certified technologists, and availability of staff becomes the limiting factor in providing effective mammography screening. Available technical staff Digital equipment Integrated electronic reporting Hubs of Excellence for diagnostic procedures Available radiologist support Cost effective Page 40 Prepared by INSITE Consultancy Inc. 2014

52 Recommendations Medical Imaging Strategic Plan Align the digital mammography strategy for the North with the Provincial strategy for the roll out of the digital mobile screening unit operated by SMPBC. 2. Adopt the Provincial Breast Health Strategy and actively work towards the development of one EUSOMA-based breast health hub with future expansion to one hub per HSDA. 3. Transition to digital mammography, screening and diagnostic (shared unit) using a mobile mammography service. a. Develop a business case to define the service and justify the capital and operating costs. 4. Consolidate mammography reading on fewer radiologists to achieve the BCCA minimum mammography reads per radiologist per year. COMPUTERIZED TOMOGRAPHY Computerized Tomography (CT) scanning is considered the modality of choice in clinical identification of many diseases and conditions; the modality is increasingly being utilized for screening purposes such as for colorectal cancer. Modern CT scanners are capable of acquiring multiple cross-sectional images in a single revolution of the x-ray tube, thus collecting a volume of image data that can be processed and displayed as cross sectional slices or as 3-D images of the anatomy. Advances in CT technology in the past five years have focused on faster scanning times, decreased radiation dose to the patient and advanced imaging procedures such as coronary CT angiography, CT colonoscopy and similar advanced imaging techniques. Access to CT is critical to the treatment decisions of suspected stroke victims. If a cerebral hemorrhage can be ruled out in less than four and a half hours (4.5) of onset 21, thrombolytic therapy can be given and long term brain damage can be avoided. There are presently seven CT Scanners situated across six NH facilities, all of comparative age and technological capacity. In response to the region s large geographic catchment area, CT services were supplemented with the purchase of a second scanner at UHNBC (2008) and a new scanner in Fort St John (2009) and are spread out across the health authority (two in the NW, three in the NI, and two in the NE). Jurisdiction Number of CT Exams per 1000 Population Number of Exams per CT Scanner per Year Northeast ,639 Northern Interior ,273 Northwest ,405 NH Average ,988 British Columbia (2009) 106 9,452 Alberta ,739 P.E.I 104 7,291 New Brunswick ,199 Nova Scotia ,025 Canada 121 9,387 USA 228 5,298 OECD Table 27: Utilization rates per 1,000 population for CT and exams per CT scanner NICE technology appraisal guidance 264.Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122) Issued: September 2012 Prepared by INSITE Consultancy Inc Page 41

53 CT utilization rates are below the Provincial average (Table 27), with the Northeast HSDA showing the lowest rate. Observations from the above table: Overall the NH region is under-utilizing CT relative to other Canadian jurisdictions based on population. The Northeast and Northwest HSDAs have the lowest utilization rate for CT. CT wait times are very low and for practical purposes there is no meaningful wait time at any site in NH. CT wait times (Table 28) are significantly lower than the average for BC (4 weeks) and other jurisdictions. This is in part the result of the considerable capacity available across Northern Health and the low utilization of the CT scanners. CT Wait Times Community Wait Times (days) Comments Prince George 1 days Dec Quesnel 2 days Dec Terrace 14 days Dec Prince Rupert 9 days Dec Dawson Creek 1 days Dec Fort St. John 7 days Dec Jurisdiction British Columbia 4 weeks 2012 Alberta 2.9 weeks 2013 Manitoba 4 weeks 2013 Ontario 35 days 2013 Table 28: Wait times for CT 23. CT Services Site Summary Prince Rupert Regional Hospital: A 64-slice Toshiba Aquilion CT scanner was purchased in This is the newest scanner in Northern Health and utilizes the latest in dose reduction software, allowing scans to be performed at dose levels 30-50% less than on older 64 slice models. CT coronary angiography services are not performed at this site however CT Colonography is provided. The scanner is capable of serving patients per day and is currently processing approximately 6. Mills Memorial Hospital (Terrace): A 64-slice Toshiba Aquilion CT scanner was installed in 2006, making it one of the oldest scanners in Northern Health. The scanner is capable of serving patients per day and is currently processing approximately 21. The cardiac imaging function of the scanner is currently not being used. This Aquilion 64 is not upgradable to the latest dose reduction software. G.R. Baker Memorial Hospital (Quesnel): A 32-slice Aquilion CT scanner was installed in 2006, making it one of the oldest scanners in Northern Health. The scanner is capable of serving patients per day and is currently processing approximately 9. CT coronary angiography services are not performed at this site. This Aquilion 32 is not upgradable to the latest dose reduction software. University Hospital of Northern British Columbia (Prince George): UHNBC has 2 CT scanners (2008) in operation, a 320 slice Toshiba Aquilion ONE and a 64 slice Toshiba Aquilion. Each scanner is capable of serving patients per day and are currently processing approximately 28. CT coronary angiography 22 Figures reflect year of latest available information (2013 calendar year for NH and 2008/09 for national and OECD data). Regionally the number of CT exams per 1000 population has increased by 13% since 2008/ Sources: Northern Health Wait Time Reports July 2013; Fraser Institute Waiting your Turn 2012; Page 42 Prepared by INSITE Consultancy Inc. 2014

54 services are performed at this site. The Aquilion ONE was recently upgraded to the latest version of dose reduction software and the Aquilion 64 is upgradable. Dawson Creek District Hospital: A 64-slice Toshiba Aquilion CT scanner was installed in The scanner is capable of serving patients per day and is currently processing approximately 9. CT coronary angiography services are not performed at this site. This Aquilion 64 is upgradable to the latest dose reduction software. Fort St. John Hospital and Health Centre: A 64-slice Toshiba Aquilion CT scanner was installed in The scanner is capable of serving patients per day and is currently processing approximately 8. CT coronary angiography services are not performed at this site. This Aquilion 64 is upgradable to the latest dose reduction software. Equipment Scanner lifespan is generally accepted to be 10 years. 64 slice scanners will likely phase out of production in 2-3 years, CT technology changes in recent years have focused on the following areas: From 2015/16 through Northern Health will be faced with annual CT replacements that (based on a 10 year lifespan) will result in a yearly capital expenditure of approximately $1,000,000. The NH region currently has excess CT capacity. The population weighted access limitation for Smithers is the greatest in NH. CT utilisation will increase during the LNG project period. Trends The provincial CT volume increased by an average of 5% per annum over the past five years 24 and is the second greatest growth modality behind MRI. Factors driving growth include new and emerging applications for CT and the growing and ageing population in the Province. Examples of the enhanced application of CT are listed below: Coronary angiography (or diagnostic cardiac catheterization) is the reference standard for the diagnosis of coronary artery disease. CT continues to develop as an acceptable way to noninvasively image and detect coronary artery disease. Continued broadening of the clinical criteria for Cardiac CT could result in significant volume increases in facilities with the proper CT technology. Advances in CT software and data processing technologies have proven to significantly reduce the radiation dose from CT procedures. As dose reduction improves this may increase the demand for CT services. Colonoscopy is considered to be the gold standard for the diagnosis of colorectal cancer. CT Colonography (Virtual Colonoscopy) is a minimally invasive procedure that provides a viable alternative to traditional colonoscopy in the diagnosis of colorectal cancer. The Canadian Association of Radiologists (CAR) has developed standards which define best practices in developing this service 25. CT could replace as much as 80% of barium enema procedures for colonoscopy, much of which is done on an outpatient basis. In regions without MRI, physicians continue to utilize CT as a best available alternative. As the abilities of CT continue to increase, coupled with dose reduction CT will provide a larger component of the overall number of diagnostic procedures. The literature supports the projection that the use of CT will only increase and will be a consideration when traditional x-ray units are due for replacement. 24 BC Health Enterprise Architecture Program. Medical Imaging Pilot Vision. May 18, V Source: CAR-CT Colonography Standards Prepared by INSITE Consultancy Inc Page 43

55 As dose reduction technologies become available, a screening program for lung cancer using Low Dose Chest CT could be developed, increasing the use of CT. Age profile data shows CT utilization increases sharply as patients approach middle aged and peak for the segment of population between years of age. As Northern Health s population ages it can be expected there will be continued growth in the number of CT scans. Demand for CT could be reduced significantly with the implementation of new MRI service locations, as in many cases it is clinically preferable to use MRI instead of CT and avoid the exposure to radiation. Recommendations The following recommendations are influenced by three factors: Northern Health has excess CT capacity and, effectively, no wait lists. Access to CT and thrombolytic therapy in less than 4.5 hours for stroke patients is recommended. The utilization trend is increasing with the age of the population and will be affected by the LNG development. Having made the investment in CT it is not pragmatic to propose decommissioning such assets. Recommended strategies for CT are, therefore: 1. In sites with under-utilized CT scanners, increase utilization through a combination of reduced operating hours and reallocation of workload to patient choice. 2. Require all CT scanner replacement (particularly Quesnel in 2015 and Terrace in 2016) to undergo a business case process that considers access to service, mobile options and radiation risk. 3. Using the Capital Planning Tool provided, adjust the equipment replacement plan for CT to avoid replacing or investing in additional CT scanners unless there is sufficient demand within the HSDA. MAGNETIC RESONANCE IMAGING Magnetic Resonance Imaging (MRI) is a radiology technique that uses a powerful magnet, radio waves, and a computer to produce cross sectional images of human anatomy. The patient is placed on a moveable table that is inserted into the center of the magnetic field. The strong magnetic field aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins (excitation) the targeted protons at an angle away from the original alignment direction until they gradually return to the magnetically aligned direction. In the re-alignment phase (relaxation) the protons release energy that is characteristic of the tissues within they are bound. The relaxation energy is detected by receiver coils that is then amplified and processed into an image. The images produced by MRI able to demonstrate clear differences in tissue composition which is highly valuable in diagnosing wide range of pathological conditions without the use of ionizing radiation. For some procedures, contrast agents, such as gadolinium, are used to help differentiate different tissue types or pathological conditions Patients with cardiac pacemakers, some metal implants or foreign cannot be scanned with MRI because of the effect of the strong magnetic field. High field strength magnets (3 Tesla and above) are known to increase the heating effect in some tissues / materials and need to be used with increase caution. The present mode of delivery of MRI services in Northern Health is a centralized model with one unit at the University Hospital of Northern BC (UHNBC) in Prince George. This unit has reasonably high utilization but could achieve a higher level with operational improvements and increased hours of operation. However, challenges that would make this difficult include; the age and condition of the scanner and the desire to perform specialized procedures such as cardiac imaging, breast imaging, angiography, etc. These specialized procedures cannot be performed with the current equipment. Image quality is a serious concern of radiologists that have cited cases where lesions have not been visible on the current scanner but clearly identifiable on newer units. Page 44 Prepared by INSITE Consultancy Inc. 2014

56 This UHNBC MRI serves patients from the entire Health Authority. Northern Health is large and sparsely populated, which makes access to MRI services difficult for people in remote areas. People in the Northwest often find it easier to go to Vancouver for their MRI, while those in the North East have easier access to Alberta than Prince George. In 2012/13, a total of 5,273 MRI exams were provided at UHNBC. This translates to an average of 17.6 exams per 1,000 population, which is the lowest rate among all the BC Health Authorities (Figure 13). The provincial average of 27.4 scans per 1,000 of population is the target for Northern Health and within each of the HSDAs. MRI Exams per 1,000 Population 34.4 Gap = 33% of BC rate GA NHA IHA FHA BC VIHA VCHA Figure 13: MRI utilization rates per 1,000 population 26. Service utilization across different areas within Northern Health varies significantly, as shown in Table 5 in the following sections of this report. The Northern Interior HSDA with 49% of the population used the service 86.1% of the time. In contrast, the Northwest and Northeast have 26% and 24% of the population and used the service 16% and 2.8% of the time, respectively. The result is that many patients in the NE and NW go outside the NHA for MRI exams or do not receive an MRI at all. Equipment The UHNBC MRI scanner is 10 years old and is at or close to the end of its useful life. The estimated replacement cost of the UHNBC MRI is $2,500,000. Trends The constrained availability of MRI in Northern Health, with a single service location, is the single most relevant factor limiting its use by the population. The addition of new service locations would allow appropriate access to MRI, increasing demand and utilization to Provincial standards. 26 Source: OASIS/HAMIS April 24, 2013 Ministry of Health, Management Information Branch.BC Stats Population Estimates, Prepared by INSITE Consultancy Inc Page 45