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Diagnostic Assessment Programs for Lung & Esophageal Cancer
Improving the Patient Experience
CSGNA 2014
DR. COLIN SCHIEMANASSOCIATE PROFESSOR – THORACIC SURGERYMCMASTER UNIVERSITY
Overview
• Introduction
– Our Region
– Our Team
• The Diagnostic Assessment Program Concept
• Lung DAP
• Esophageal DAP
LHIN 4
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CHALLENGES FOR LHIN 41.4 M RESIDENTS
• 25% daily/occasional smokers
•27% drink 5 or more drinks (at once) at least 1/month
•32% overweight•19% obese
SJHH Regional Thoracic Program
• One of the largest in Canada
• 750 major thoracic surgeries per year
• 450 Cancer Resections• 400 lung• 50 esophagus
Has highest rates of smoking, heavy drinking and obesity in the province
• Haldimand War Memorial Hospital
• Hamilton Health Sciences (9 sites)
• Hotel Dieu Shaver Health & Rehabilitation Centre
• Joseph Brant Hospital
• Norfolk General Hospital
• West Haldimand General Hospital
• Brantford General Hospital
St. Joseph’s Healthcare Hamilton
Brant Community Healthcare
System
Niagara Health System
(6 hospitals)
THORACIC PROGRAMS
Thoracic Surgery
(Malignant & Non-Malignant)
Respirology (SJHH, NHS, Brantford)
Collaboration & Integration
Integrated Comprehensive
Care (ICC)
Pleural Space & Pulmonary
Nodule Clinics
Screening & Surveillance Clinics
• Brant Community Health System
• Niagara Health System
• Firestone Institute for Respiratory Health
• Juravinski Cancer Centre
• Walker Family Cancer Centre
• Cancer Care Ontario
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Pleural Space & Pulmonary
Nodule Clinics
Screening & Surveillance
Clinics
What is a Diagnostic Assessment Program (DAP)?
A specialized clinic:• Single point of access
• NURSE NAVIGATED• Streamlined scheduling & coordination of tests &
consultations– Follows best practices & evidence
• Comprehensive, Timely, Compassionate Supportfor patients and their families through the early part of their cancer journey
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The DAP Clinics Work!
• CCO has shown through various published pilots that DAP clinics have:
– Simplified referral process
– Improved cancer work-up
– Reduced time from referral to treatment
– Increased patient satisfaction
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CCO CANCER JOURNEY 10
CCO CANCER JOURNEY 11
• Paste map of DAP programs from CCO DAP Map
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Statistics Canada - cancer.ca
• A word about Lung Cancer
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Statistics Canada - cancer.ca15
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Statistics Canada - cancer.ca16
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Statistics Canada - cancer.ca
Need to do better
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HAMILTON LDAP TEAM 19
St. Josephs Hamilton LDAP Team
HAMILTON & BRANTFORD 20
ST CATHARINES TEAM 21Niagara LDAP
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What is the LDAP & How Does it Work?
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• Simplified Intake Process
• 1-800 lung cancer
• 1 form for all locations & all physicians
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The Patient’s Experience
1. Referral sent to the LDAP2. LDAP Nurse Navigator Phones patient
3. Meet the MD4. Diagnostic Tests Planned
5. Review Tests & Plan Treatment
All through one phone number, one nurse, one site as quickly as possible
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25
17
37
49
39
59
72
5355
89
83
63
88
78
100 99
86
96
77
8688
100
113
100
105 106
126
114112 112
83
130
112
117
101 102106
130
0
20
40
60
80
100
120
140
Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13
Lung DAP: Patient Referrals
Total Referrals SJHH NHS Brantford Linear (Total Referrals)
LDAP IN LHIN4
How LDAP Works in LHIN 4:
•~ 140 new LDAP referrals/month
• ~ 20% of all LDAP patients in Ontario
•80% of patients receive a “positive” or “suspected” cancer diagnosis
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LHIN # LHIN NameVolume of Patients
(Jan- Dec 2013)Disease Site
1 Erie St. Clair 292 Lung
2 South West 593Lung
Thoracic
3 Waterloo/Wellington 339 Lung
4 Hamilton Niagara Haldimand Brant 860 Lung
5 / 6 Mississauga Halton/Central West 313 Lung
7Toronto Central North 175 Lung
Toronto Central South 526 Lung
8 Central 691 Lung
9 Central East 737 Thoracic
10 South East 401 Lung
11 Champlain 1,252 Thoracic
12 North Simcoe Muskoka 218 Thoracic
13 North East 302 Lung
14 North West 176 Lung
LDAP Provincial Landscape:
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LHIN # LHIN NameVolume of Patients
(Jan- Dec 2013)Disease Site
1 Erie St. Clair 292 Lung
2 South West 593Lung
Thoracic
3 Waterloo/Wellington 339 Lung
4 Hamilton Niagara Haldimand Brant 860 Lung
5 / 6 Mississauga Halton/Central West 313 Lung
7Toronto Central North 175 Lung
Toronto Central South 526 Lung
8 Central 691 Lung
9 Central East 737 Thoracic
10 South East 401 Lung
11 Champlain 1,252 Thoracic
12 North Simcoe Muskoka 218 Thoracic
13 North East 302 Lung
14 North West 176 Lung
LDAP Provincial Landscape:
> 1300 new patients in LHIN 4 DAP in 2013
Pleural space clinic = 106 EDAP = 137
Nodule clinics= 73
CANCER SURGERIES AT ST JOSEPHS
200230
259
338
398 400
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42
52
69
54 45
0
50
100
150
200
250
300
350
400
450
500
FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14*
CCO Qualifying Cancer Surgeries
Esophageal
Lung
LDAP
SUCCESS
Success of HNHB LDAP program:
•Despite the huge increase in volume, 97% LDAP patients were very satisfied with their care
•Active management of 250-300 patients at a time
•50-75 patient calls/day, addressed within 24 hours
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STRENGTHS
What are the strengths of our LDAP?
•Focus on the patient & their family
•Focus on eliminating unnecessary wait times
•Partnered with DI to prioritize all LDAP testing
•Fostered stronger relationships between respirology, thoracic surgery, oncology & cancer centers
•Stronger Voice at Major Oncology & Planning Meetings
Develop other off-shoot programs in parallel to LDAP
CHALLENGES
What challenges does our LDAP face?
Managing Complex Problems in Complex Health Care Systems with Limited Resources & People, Always Putting the Patients Needs First
CHALLENGES
What challenges does our LDAP face?
•Coordinating 3 different sites
•Distance between sites; differences between data systems and capture; different personnel
•Managing wait times with limited resources
•e.g., CT lung biopsies (3-5 wks), PET scans (1-1.5 wks), EBUS bronchoscopy (1-2 wks)
•Median wait time for testing @ St Joseph’s (2013) ≈ 31 days
•Average time from referral to physician consultation (2013) ≈ 10 days
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A WORD FROM LORRAINE, HAMILTON NURSE NAVIGATOR 34
What we hear from patients is “The waiting is the worst part.”
In Niagara, the collaboration between Respirology & the Thoracic Surgery at St. Joseph’s provides Niagara’s LDAP patients with timely access to the care they require close to home. We have also integrated radiation oncology into the LDAP team quite successfully in Niagara.
- Tara Becevel, LDAP Nurse Navigator for Niagara Health System
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Leveraging The Success of the LDAP model for Esophageal Cancer:
•A highly morbid disease with complicated testing and workup required
•Noticed things were splintered & as result there often delays > 6 months in patients getting to a specialist
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Helen is a 67-year-old retiree from Niagara Falls. She was diagnosed with esophageal cancer and is planned to
undergo chemotherapy, radiation and surgery
Helen’s care will be provided in two different locations:
• Juravinski Cancer Centre (JCC) for chemotherapy and radiation therapy (71 kilometres) &
• St. Joseph’s Healthcare Hamilton (SJHH) for surgery (74 kilometres ).
THE PATIENTS JOURNEY WITH ESOPHAGEAL CANCER 37
Helen’s esophageal cancer care
If there are no complications, her treatment will require at least 66 visits > 9,500km of travel!!!:
– consultations with medical, radiation and surgical oncology for multidisciplinary plan (1 visit to JCC);
– radiology or ancillary service visits (e.g., PET scan, CT scan, endoscopy, echo, PICC line) (5 visits to SJHH);
– simulation for radiation (1 visit to JCC);
– daily radiation treatments (25 visits to JCC);
– chemotherapy (4 visits to JCC);
– radiation oncology (6 visits to JCC);
– medical oncology & dietitian (eight visits to JCC);
– pre-operative visit to surgeon (2 visits to SJHH);
– pre-op clinic (1 visit to SJHH);
– surgery with two-week hospitalization (12 visits by informal/family caregiver to SJHH); and
– post-operative surgeon visit (1 visit to SJHH).
She will also require at least six months of weekly home care services coordinated by her Community Care Access Centre.
THE PATIENTS JOURNEY WITH ESOPHAGEAL CANCER 38
HNHB LUNG DIAGNOSTIC ASSESSMENT PROGRAM
Created the Esophageal Diagnostic Assessment Program:
•Based on success of our LDAP program
•Multi-disciplinary care model
•Nurse navigator provides diagnostic, treatment and care coordination
•First of it’s kind in Canada
“From suspicion of disease until cure or death”
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EDAP COMPREHENSIVE CARE PROGRAM 41
Goals of the EDAP Program
• Reduce the worry and wait – contact within 48 hours• Single Point of Contact
• Rapid Testing & Diagnosis• Longitudinal Care & Support Throughout Journey (until
death or cure)• Improved communication with referring physicians• Improve Outcomes
• Increase multi-disciplinary collaboration between regional sites (JCC, SJHH, NHS, and BGH)
• Education & Research
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• Very Different Problem than Lung Cancer
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Esophageal Cancer Background
• 5 year survival among the lowest of all cancers, < 15%, second only to pancreatic cancer
• BUT of those that are resectable, 5-year survival is 30-40%
• Estimate for LHIN 4: 115-150 new patients/yr
• At SJHH we perform ~ 55 esophagectomies/year, the highest number of cases in ON
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• Piggybacking on the LDAP success & resources
• Simplified Intake
• 1-800 esophageal cancer
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Constructed the EDAP Clinic
• Multiple Stakeholder meetings
• Fundraising (Grants/LHIN support)
• Hired nurse navigator & clerical staff
• Advertised throughout the LHIN
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EDAP TEAM 48
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PHYSICIANS 49
Referrals started trickling in 50
72
7
27
5
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# EDAP Referrals by Region
Hamilton
Brantford
Niagara
Haldimand
Norfolk
Other
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Proportion of symptom occurrence at presentation in EDAP
EDAP Statistics after 1 year:
•176 referrals (April 2013 –March’14)
•Average referrals per week: 3.6
•Average 17 days from referral to decision to treat
•Referral to initial contact by NN: 0.6 Day
•Referral to physician consult : 3 Days
•Referral to completion of testing: 15 Days
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QUESTIONS?
