Progress report on the analysis of cancer care by Rie Fujisawa and Vladimir Stevanovic The OECD HCQI Expert Group Meeting Paris, 3 June 2010 1
Progress to date Nomination of cancer experts in 36 countries Collaboration with CONCORD and EUROCARE Questionnaire development Data collection/validation (through interviews) Preliminary analysis 2
Questionnaires Questionnaire on Cancer Screening Breast, cervical and colorectal cancers. Questionnaire on Systems of Cancer Care Access to cancer care, and governance, effectiveness, costs, and human resources and structure of cancer care. 3
Data collection Questionnaires on screening and systems of cancer care 31 countries (AUS, BEL, CAN, CHL, CYP, CZE, DNK, FIN, FRA, DEU, GRC, HUN, ISL, IRL, ISR, ITA, JPN, KOR, LVA, LUX, MLT, NLD, NOR, POL, PRT, SVN, SWE, CHE, TUR, GBR (ENG and SCT), and USA) Waiting for response from EST, MEX, SLV, and Northern Ireland and Wales 4
Data collection cont. Survival data 21 European countries (including England, Northern Ireland, Scotland, and Wales separately) and the United States participated in EUROCARE-4; and 10 countries (AUS, CAN, HUN, ISR, JPN, KOR, LVA, NZL, SGP and TUR) 5
Access: financial accessibility to care In many countries cancer care is provided free of charge. Most of the other countries offer partial payment exemption for cancer care. Some countries have exemption rules not specific to cancer care but to all care modalities with high medical costs. The level of exemption differs across countries. 6
Access: developmental practices In most countries, breast cancer risk evaluation (BRCA1/BRCA2), HPV vaccination for cervical cancer, and screening for colorectal cancer are available. In about half of the countries, these services are provided free of charge or with partial charges. The majority of countries, which have not introduced these practices, are considering the introduction of breast cancer risk evaluation (BRCA1/BRCA2) and screening for colorectal cancer, but countries are divided in terms of the introduction of HPV vaccination. 7
Access: new and innovative drugs The dates in which they became available to the patients vary across countries. Regarding the selected drugs USA generally authorised them earlier than other countries. Authorisation for certain cancer drugs also came sooner in FRA and SWE. Some drugs were authorised relatively late in JPN, MLT and NOR. In CHL, the time between the authorisation and clinical use was generally longer than in other countries. 8
Access: new and innovative drugs cont. In most countries, these drugs are provided free of charge to patients, but there are some exceptions. In countries including AUS, JPN, KOR and USA, patients pay part of the cost through out-of-pocket. For some specific drugs, patients need to pay full costs in some countries including ISR, KOR, LVA and MLT. 9
Governance: national health policies Most countries have been developing national cancer control strategies and/or national health policies with a focus on cancer care. They were developed rather early in the 1990s in ISR and KOR and even in 1970s in DEU and USA. FIN, GRC, ISL and CHE reported not having introduced specific national strategies or policies for cancer care. 10
Governance: national health policies cont. In a number of countries, cancer control is becoming an increasingly prominent priority on the policy agenda with additional funding; strengthened monitoring mechanism; and improved accountability. Many of the countries set timeframes for specific targets in prevention, early detection, screening, reduced waiting time, and improved diagnosis, treatment and outcomes. 11
Governance: national health policies cont. Many countries have developed national guidelines for breast and cervical cancer screening. For diagnosis, the majority of countries have also developed national guidelines for breast cancer, but about half of the countries do not have guidelines for cervical, colorectal and lung cancers. In many countries physicians have been given freedom to practice based on principles set at their institution or gained through their professional experience. 12
Governance: national health policies cont. Licensing and/or accreditation systems were also established for doctors and institutions specialising in cancer care. Many countries report comparable information on cancer care including clinical outcomes such as survival rates, while the information relating to patient experience is available only in a few countries. 13
Governance: screenings Screening policies have been strengthened across countries. The number of countries with population-based nationwide cancer screening programmes is increasing. Many countries provide breast and cervical cancer screening services for free. 14
Governance: screenings cont. Target age group and screening intervals vary across countries but generally For cervical cancer, the majority of countries have population-based screening for women aged between their 20s and 60s, covering 40 years, every three years. For breast cancer, most countries introduced population-based screening for women in their 50s and 60s, covering 20 years, every two years. 15
Data gaps Data are generally available for Access to and Governance of cancer care But found difficult to compare effectiveness, costs and human resources and structure of cancer care systems across countries. There are a number of significant data gaps in cancer care affecting most participating countries, these include: Referral and waiting time; Compliance; and Expenditure on cancer care. 16
Preliminary findings from the analysis 17
Outcome variables 1-year and 5-year relative survival rates for breast, cervical, colorectal and lung cancers Collected through: - the EUROCARE-4 study - the US SEER (Surveillance, Epidemiology and End Results) program - our own data collection 18
Outcome variables cont. Data have been collected systematically using the EUROCARE-4 study specifications to ensure reliable inter-country comparability: - adult cancer patients 15-99 years - excluding in-situ and DCO (death certificate only) cases - period analysis approach - expected survival by Hakulinen method - age-standardisation by Corazziari s approach Provided survival estimates are as broadly representative for each country as possible 19
Follow-up time (y) Outcome variables cont. The most recently available cancer survival data is for the period 1996-2002, follow-up Dec 2003 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 Calendar Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 DX 2000-2002 DX 1999-2001 DX 1998-2000 DX 1997-1999 DX 1996-1998 20
Independent variables Variables that are likely to explain the relationship between health system characteristics and cancer survival are: - country s income (GDP) - health expenditure - other domains originating from the conceptual model (access, effectiveness, cost, governance, resources) 21
Conceptual framework model CANCER CARE PATH STAYING HEALTHY Managing risk factors GETTING WELL Detection, diagnosis and treatment LIVING WITH CANCER Recidives and methastasis: Regular control. diagnosis and treatment END OF LIFE Palliative care OUTCOME ACCESS TO CANCER CARE EFFECTIVENESS OF CANCER CARE GOVERNANCE OF CANCER CARE COSTS OF CANCER CARE HUMAN RESOURCES AND STRUCTURE Prevalence of life - style risks (many already in HD ie smoking, diet (LIMITED AVAILABLE). Distribution across the population (vulnerable groups) (N O AVAILABLE ) National Specific risks factors prevention policies and agents involved ( LIMITED AVAILABLE ) Prevention and public health expenditure on cancer (LIMITED AVAILABLE) SHA cost of disease) Cancer drugs reimbursement (NO AVAILABLE) Screening and diagnostic tests reimbursement AVAILABLE) Coverage for inpatient, outpatient and home cancer services (NO AVAILABLE) Timeliness/ Waiting tmes for first visists and key procedures (NO AVAILABLE) Screening rates ( length of time series SHOULD BE IMPROVED ) Disease stage at diagnosis Use of Cost - Effective treatments according to disease stage ( AVAILABLE) HD National screening programme ( LIMITED AVAILABLE) Compliance to follow - up guidelines (NO AVAILABLE) (LIMITED (NO AVAILABLE) (NO intensive pain relief treatment in terminal cancer patients (NO AVAILABLE) home care in patients with terminal cancer (NO AVAILABLE) Coordination of care: Cancer disease management schemes including follow - up after screening (NO AVAILABLE) Concentration of cancer services (NO AVAILABLE) In - patient/outpatient balance of services (NO AVAILABLE) ) Providers remuneration structure and pay for performance schemes (NO AVAILABLE) Cancer registry National cancer strategy (limited data available) Inpatient, outpatient, pain relief, home and rehabilitative care expenditure on cancer ( (LIMITED AVAILABLE) SHA cost of disease and PPR for specific surgery, chemotherapy and radiotherapy) Diagnosis and treatment equipment capacity (volume and distribution) (LIMITED AVAILABLE) HD staff capacity (volume and distribution of GPs, oncologists, gynecologists, therapeutic radiologists; (LIMITED AVAILABLE) HD ) Hospital capacity (volume and distribution of acute beds, subacute beds and day care units; (LIMITED HD ) SURVIVAL RATES Available HCQI: Breast, Cervix and Colorectal cancer ( Lung cancer Leukemia (NO AVAILABLE) MORTALITY RATES Available HD Breast cancer Cervix cancer Colorectal cancer Lung cancer Leukemia 22
Independent variables cont. Data at various levels of detail Country s income (GDP) Referral/waiting time perceived as an issue Expenditure on health care Referral/waiting time up to or over 1 month Expenditure on cancer care Referral/waiting time in days 23
Analytical methods Correlation and regression analysis at the cancer site level No attempt to use a cross-sectional structure and time-lags at this stage 24
Health expenditure and resources The following variables were highly correlated with cancer survival: - GDP in US$ per capita and PPP adjusted - TNEH (total national expenditure on health) - number of CT scanners per GDP - number of PET scanners per 1M population - number of oncologists per 1M population - number of cancer treatment centres per 1M pop. - use of innovative cancer drugs Could explain approximately 50-60% of differences in cancer survival 25
Cancer policies Improved health outcomes were likely to be achieved if the following characteristics were incorporated into national cancer policies/national cancer control plan: - setting up cancer-specific objectives or targets - making additional funding available to achieve these - assigning the lead person/organisation to oversee the implementation - introducing regulatory changes required to strengthen national policies - putting quality assurance mechanisms in place for cancer care - coordinating care delivery and developing networks for service delivery - identifying the key milestones and timeframes - monitoring the progress - making someone responsible if objectives or targets are not met Could explain approximately 20-25% of remaining differences in cancer survival 26
Access and effectiveness The following variables were highly correlated with cancer survival: - characteristics of cancer screening programs (interval, target pop, low age, coverage, national rollout, free of charge) - waiting time up to 30 days (from diagnosis to initial treatment) - provision of optimal treatment (combination of surgery, radiotherapy, chemotherapy if diagnosed early) - case management Could explain approximately 20-25% of remaining differences in cancer survival 27
Variation in cancer survival Cancer policies Access and effectiveness Hlth expend and resources 28
Breast cancer Health expenditure and resources - GDP, TNEH - CT, PET scanners - innovative drugs (Herceptin) - oncologists, cancer treatments centres Cancer policies - objectives/targets and timeframes - monitoring and responsibility - quality assurance and coordination - additional funding for implementation Access and effectiveness - characteristics of breast screening program (interval, target population, low age groups, coverage, national rollout, free of charge) - optimal treatment 29
Cervical cancer Health expenditure and resources - GDP - CT scanners Cancer policies - objectives/targets and timeframes - monitoring and responsibility - quality assurance and coordination Access and effectiveness - optimal treatment 30
Colorectal cancer Health expenditure and resources - GDP - CT scanners - oncologists Cancer policies - objectives/targets and timeframes - monitoring and responsibility - quality assurance and coordination Access and effectiveness - waiting time (diagnosis to treatment) - optimal treatment 31
Lung cancer Health expenditure and resources - GDP - CT scanners Cancer policies - timeframes - monitoring Access and effectiveness - waiting time (diagnosis to treatment) 32
Members of the HCQI Expert Group are invited to: Discuss the progress of the work to date; results of the analysis; and future direction for the work. 33