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Legislative Assembly of Ontario |
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Assemblée législative de l'Ontario |
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STANDING
COMMITTEE ON
PUBLIC ACCOUNTS
CANCER
SCREENING PROGRAMS
(Section 4.01, 2014 Annual Report of the Auditor General
of Ontario)
1st
Session, 41st Parliament
64 Elizabeth II
ISBN 978-1-4606-6884-9 (Print)
ISBN 978-1-4606-6886-3 [English] (PDF)
ISBN 978-1-4606-6888-7 [French] (PDF)
ISBN 978-1-4606-6885-6 [English] (HTML)
ISBN 978-1-4606-6887-0 [French] (HTML)
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Legislative Assembly of Ontario |
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Assemblée législative de l'Ontario |
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The Honourable Dave Levac, MPP
Speaker of the Legislative Assembly
Sir,
Your Standing Committee on Public Accounts has the honour to present its Report and commends it to the House.
Ernie Hardeman, MPP
Chair of the Committee
Queen's Park
November 2015
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Comité permanent des comptes publics
Toronto, Ontario M7A 1A2
STANDING COMMITTEE ON
PUBLIC ACCOUNTS
MEMBERSHIP
LIST
1st Session, 41st
Parliament
ERNIE HARDEMAN
Chair
LISA MACLEOD
Vice-Chair
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Han dong |
JOHN FRASER |
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PERCY HATFIELD |
HARINDER MALHI |
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JULIA MUNRO |
ARTHUR POTTS |
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LOU RINALDI |
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FRANCE GÉLINAS regularly served as a substitute member of the Committee.
Valerie Quioc Lim
Clerk of the Committee
Ian Morris
Research Officer
Contents
Status of Actions Taken on Auditor's Recommendations: Summary 2
Issues Raised in the 2014 Follow-up and Before the Committee 3
Cancer Screening for People with No Primary Care Providers 6
Monitoring for Quality of Services 7
Consolidated List of Committee Recommendations 11
Preamble
On September 16, 2015, the Standing Committee on Public Accounts (the Committee) held public hearings on the follow-up on Cancer Screening Programs, Section 4.01 of the 2014 Annual Report of the Auditor General of Ontario (the Auditor). Senior officials from the Ministry of Health and Long-Term Care (the Ministry) and Cancer Care Ontario (CCO) participated in the hearings. (For a transcript of the Committee proceedings, please see Committee Hansard, September 16, 2015.)
The Committee endorses the Auditor's findings and recommendations and presents its own findings, views, and recommendations in this report. The Committee requests that the Ministry and the CCO provide the Committee Clerk with written responses to the recommendations within 120 calendar days of the tabling of this report with the Speaker of the Legislative Assembly, unless otherwise specified in a recommendation.
Acknowledgments
The Committee extends its appreciation to officials from the Ministry of Health and Long-Term Care and Cancer Care Ontario for their attendance at the hearings. The Committee also acknowledges the assistance provided during the hearings and report writing deliberations by the Auditor, the Clerk of the Committee, and staff in the Legislative Research Service.
Background
The original value-for-money audit of cancer screening programs was contained in the Auditor's 2012 Annual Report. The 2012 audit assessed whether Cancer Care Ontario (CCO) used established clinical evidence to decide what types of cancer warrant formal screening programs, and how effective the CCO was in achieving high screening participation rates.
Audit staff visited sites in the following regions and Local Health Integration Networks (LHINs): the Greater Toronto Area, Hamilton Niagara Haldimand Brant, South West (London), Champlain (Ottawa), and North East (Sudbury), and spoke to various stakeholders, such as the Canadian Cancer Society, the Institute of Clinical Evaluative Sciences, and the Cancer Quality Council of Ontario. A follow-up to the audit was published in the 2014 Annual Report.
Cancer Care Ontario
Cancer Care Ontario (CCO) is responsible for overseeing cancer services in Ontario. It works with the LHINs to address local needs and advises government on cancer-related matters. The CCO directs cancer care funding to hospitals and other care providers and is responsible for implementing cancer prevention and screening programs. The CCO has 13 Regional Cancer Programs across the province. The regional programs are required to ensure that service providers meet the requirements and targets set out in their partnership agreements with the CCO. Regional cancer centres are responsible for cancer screening and treatment services. In 2011/12 the CCO had total expenditures of $887 million, $92 million of which were spent on cancer screening programs.
The CCO has implemented cancer screening programs for breast, colorectal, and cervical cancers. The key objective for each of the three cancer screening programs is to reduce the number of deaths from cancer through early detection and treatment. The mortality rates from these three types of cancer have fallen in Ontario over the past two decades and are similar to the Canadian averages.
The Committee acknowledges the excellent work of the CCO and its dedication to saving lives in communities across Ontario. The CCO is an organization of excellence with a full range of high-quality patient services and a leader in the quality of cancer care across the province.
2014 Follow-up
Status of Actions Taken on Auditor's Recommendations: Summary
The CCO is in the process of implementing the Auditor's recommendations, with most (70%) of the recommendations already fully implemented and significant progress made on others. A summary of the status of the three screening programs is as follows:
· Breast cancer screening: The CCO is monitoring wait times for breast cancer screening through monthly performance reports and quarterly performance reviews with Regional Cancer Programs.
· Colon cancer screening: The CCO is working to increase participation in colon cancer screening and to improve its colon cancer screening efforts by replacing the guaiac-based Fecal Occult Blood Test (gFOBT) with the more sensitive fecal immunochemical test (FIT). FIT also has a better rate of detecting cancer and advanced pre-cancerous lesions. The CCO has completed a pilot project that reviewed the colonoscopies conducted in independent health facilities to determine the colonoscopy activity in these facilities, to assess the impact that increased capacity for conducting colonoscopies had on quality of care, and to assess the level of engagement of the facilities to their Regional Cancer Programs.
· Cervical cancer screening: The CCO has hired six regional cervical screening/colposcopy leads to monitor wait times for achievement of performance standards and to assess performance management, including colposcopy access, wait times, and quality management in the cervical cancer screening program. Work is still needed to increase the participation of people who do not have primary care providers in screening programs; and to obtain screening data to enable the CCO to assess the work of cancer screening service providers and to measure the results against appropriate quality assurance standards.
Issues Raised in the 2014 Follow-up and Before the Committee
Breast Cancer Screening
The Auditor recommended the CCO take measures to increase its capacity to expedite genetic assessments for women who have been referred to the high-risk program by their doctors. Also, it was found that mammography screening wait times for women with average risk for breast cancer ranged from just over two weeks to 10½ months.
As an update to the 2014 follow-up, CCO representatives informed the Committee that it has conducted an evaluation of the Ontario Breast Screening Program (OBSP) High Risk Screening Program after one year of operations. One of the recommendations of this evaluation was to identify measures to increase capacity to expedite genetic assessments.
In 2013 the CCO worked with the Ministry to update the OBSP High Risk Screening Program funding model. The new funding model, implemented in 2014/15, is expected to better support the high-risk sites in meeting program demands.
Changes were made to the funding model for genetic assessments and OBSP High Risk Screening Program navigators. According to the CCO, the revised funding rate for genetic assessments more accurately reflects the cost of providing the service, which will help ensure its operational sustainability. Also, the revised funding model for navigators is better aligned with expected workload and allows facilities to recruit and retain these staff.
Enhancements were also made to key OBSP High Risk Screening Program clinic processes, the referral form, and genetic assessment forms to support improvements in the appropriateness of referrals and in program capacity.
As part of the CCO's annual business planning process with Regional Cancer Programs, volume allocations have increased each year since the program's inception.
Taken together, the revised funding model, enhanced clinic processes and tools, as well as the growth in volume allocations are increasing the capacity to expedite genetic assessments in the OBSP High Risk Screening Program. The volume of women who completed a genetic assessment increased from 6,679 assessments in 2013/14 to 7,378 in 2014/15.
It was noted that the CCO's 2015 Cancer System Quality Index (CSQI) provides data from 2013–2014 despite data being collected on a quarterly basis.
In its response, the CCO noted that the more recent information is the basis of regular calls with the regional cancer screening team in each of the LHINs and is reported annually.
Committee Recommendations
The Standing Committee on Public Accounts recommends that:
1. Cancer Care Ontario provide the Committee with the range of wait times for mammography screening and genetic assessments, and compare to the benchmark and explain any material variances.
2. Cancer Care Ontario ensure that its CSQI website is regularly updated with the most recent data available.
Colorectal Cancer Screening
The Auditor recommended the CCO examine and work to address the concerns doctors have with the effectiveness of the Fecal Occult Blood Test (FOBT) as a screening tool.
The CCO reviewed evidence on the fecal immunochemical test (FIT) and concluded that the FIT is a better test than the FOBT. The CCO testified to the Committee that "[w]ith respect to the fecal occult blood test, we are working towards replacing that with another stool test called the fecal immunochemical test, or FIT, which is a superior test." According to the CCO, the FIT is a more sensitive test for colorectal neoplasia because it detects both cancers and advanced adenomas (pre-cancerous lesions). As a result, the CCO plans to implement FIT as the screening test for people without a family history of colorectal cancer (average-risk) in the ColonCancerCheck (CCC) program.
The CCO conducted a pilot study in 2012 and 2013 to evaluate implementation considerations for FIT in Ontario. Detailed planning for a provincial implementation of the transition to FIT is currently underway. This work is planned to begin in 2016 and be completed within fiscal year 2017/18.
Also, the CCO is updating its colorectal cancer screening recommendations for the CCC program. These recommendations will be based on a rigorous evidence-based review of the effectiveness of various colorectal cancer screening tests (expected fall 2015). The recommendations will also consider factors such as cost-effectiveness, feasibility, and impact on participation. These recommendations are expected by March 31, 2016 and will be used to help educate physicians regarding the benefits of FIT.
As part of the transition to FIT, the CCO is developing a comprehensive change management plan to educate primary care providers and endoscopists about the benefits of FIT and to address concerns regarding the efficacy of stool-based screening tests.
The CCO expects to see increased participation in the CCC program following the implementation of FIT. This expectation is derived from greater acceptance by primary care providers, and the improved test accuracy and patient-friendly attributes of FIT, coupled with the planned provider/public education and change management campaigns.
For colorectal screening, the Auditor's review of hospital records found instances where wait times for follow-up colonoscopies were as long as 72 weeks for people with family histories of colon cancer and 17 weeks for those with positive fecal occult blood test results.
Committee Recommendations
The Standing Committee on Public Accounts recommends that:
3. Cancer Care Ontario report back to the Committee on the expected implementation date of the FIT for use in colon cancer screening.
4. Cancer Care Ontario provide the Committee with the range of wait times for follow-up colonoscopies, and compare to the benchmark and explain any material variances.
Cervical Cancer Screening
The Auditor recommended the CCO target promotional and educational efforts to increase participation and rescreening rates among older women.
As an update to the 2014 follow-up, the CCO provided details about its developments with respect to its promotional and educational efforts:
· In 2012 the CCO updated its cervical cancer screening guidelines to clarify the age at which to start screening and the time interval between screens. The CCO ran media and social media campaigns targeted at the public to raise awareness of the new cervical cancer screening guidelines and encourage Ontarians to have a conversation about cancer screening with their healthcare provider.
· The CCO launched targeted promotional and educational initiatives to educate women about the new cervical cancer screening guidelines, including older women. In 2014/15 the CCO created a customizable press release for Regional Cancer Programs, focused on the importance of screening in older women.
· The CCO created a frequently asked questions (FAQs) sheet to educate cervical screening participants on the mobile coaches in Hamilton and Thunder Bay about Pap tests and how to get their screening results.
· In 2013 the CCO implemented the Ontario Cervical Screening Program (OCSP) correspondence campaign by mailing invitation letters to eligible women in Ontario between the ages of 30 and 69 years of age and mailing recall letters to eligible women between the ages of 21 and 69 who were due for screening. The CCO evaluated the effectiveness of this correspondence campaign and found that women who were mailed an invitation letter were 1.7 to 1.8 times more likely to have a Pap smear test. The effectiveness of this correspondence campaign was independent of age and other factors meaning that it was effective at improving participation for all eligible women, including older women.
· In 2016 cervical cancer will be the special focus of the Cancer System Quality Index (CSQI). In this report a detailed examination of cervical cancer services performance will be highlighted, including age and screening participation. The purpose of this reporting is to provide the public with information on Ontario's cancer system performance and to serve as a call to action for cancer system stakeholders.
The Committee welcomes the promotional and educational efforts made by the CCO to increase participation and rescreening rates among individuals and hopes to see this progress tracked and published regularly with the most current data available.
Committee Recommendation
The Standing Committee on Public Accounts recommends that:
5. Cancer Care Ontario provide the Committee with the range of wait times for follow-up colposcopies, and compare to the benchmark and explain any material variances.
Cancer Screening for People with No Primary Care Providers
The Auditor recommended the Ministry monitor and assess current CCO initiatives designed to improve participation in screening programs among people without family physicians.
As an update to the 2014 follow-up, the CCO informed the Committee that it has implemented five initiatives to address this recommendation:
· Correspondence: Cancer Screening sends mail correspondence to eligible Ontarians to promote participation in cancer screening. Aligned with internationally accepted practices for organized screening programs, this correspondence includes sending invitations to begin screening, sending reminders when it's time to be screened again, as well as sending screening test results. Correspondence is sent to Ontarians regardless of whether or not they have a primary care provider. As of May 2015 the correspondence program has been fully implemented for the ColonCancerCheck (CCC), the Ontario Cervical Screening Program (OCSP), and the Ontario Breast Screening Program (OBSP).
· Health Care Connect (HCC): Between its launch in February, 2009 and July, 2015, the HCC has registered 435,451 patients, with 89% (386,223) of those registered having been referred to a primary health care provider within their local community. The Ministry has implemented a process for tracking future enrolments of unattached patient participants in cancer screening programs through the HCC.
· Internal Operational Procedures: The CCO Contact Centre encourages participants to contact the HCC to find and enrol with a primary care provider within their community for ongoing primary care. To augment the HCC process, the Contact Centre also maintains a list of primary care providers-LHIN by LHIN or region by region-to facilitate primary care provider attachment for Ontarians where appropriate, and a follow-up is performed to ensure this takes place.
· Public Awareness: The CCO develops and implements interventions to increase public awareness of cancer screening and to inform and direct Ontarians to appropriate screening services.
· MyCancerIQ: In February 2015 the CCO publicly launched MyCancerIQ, an online tool accessible by both the public and providers to help Ontarians determine their risk of developing certain cancers (breast, colorectal, cervical and lung). Participants answer several questions (habits, environmental factors, screening and family history, among other things) and, based on the results, MyCancerIQ provides personalized recommendations and access to resources with more information. The Personal Action Plan encourages individuals to be screened and provides a link to additional cancer screening information which includes where and when to get screened.
In addition, as part of the ColonCancerCheck program, the Ontario Public Drug Programs continues to fund pharmacists for distributing the FOBT kit to Ontarians who do not have a primary care provider.
Committee Recommendation
The Standing Committee on Public Accounts recommends that:
6. Cancer Care Ontario work with the Ministry to provide the Committee with the results, LHIN by LHIN, of the percentage of attachments made via Health Care Connect and the CCO's Contact Centre.
Monitoring for Quality of Services
The Auditor recommended the CCO work with the Ministry to establish monitoring procedures to ensure quality assurance requirements are met for screening, regardless of where they are provided.
The CCO representatives updated the Committee on the status of its quality assurance measures since the 2014 follow-up. The CCO noted that under the Independent Health Facilities Act, the Ministry and the College of Physicians and Surgeons of Ontario (CPSO) are responsible for managing a quality assurance program for Independent Health Facilities in Ontario. The Ministry and the CCO are currently engaged in discussions to ensure alignment of the quality assurance programs set out in the Act and those required by the CCO's OBSP and any future funding agreements entered into between the CCO and colonoscopy providers.
The CCO provided the following updates in terms of quality assurance practices for its screening programs:
· Breast Screening (Monitoring): The CCO is working with the Ministry to expand the OBSP to include all eligible breast screening in Ontario. Once these initiatives are implemented, the following quality assurance monitoring practices, currently in place for OBSP sites, will be in place for all facilities that provide screening mammography services in Ontario:
· Requirement to complete and comply with the Canadian Association of Radiologists Mammography Accreditation Program (CAR-MAP): Facilities will be required to show proof of this accreditation to the CCO. This quality standard is already in place for Independent Health Facilities (IHFs) providing screening mammography services.
· Requirement to conduct regular physics inspections of mammography machines in accordance with OBSP standards: Evidence of the physics inspections will be required by the CCO. This quality standard is already in place for the IHFs providing screening mammography services.
· Periodic reviews of Medical Radiation Technologists (MRTs) screening mammogram image quality: These reviews are conducted by regional MRT leads that are funded by the CCO. This quality standard is already in place for the IHFs providing screening mammography services.
According to the CCO, expansion of the OBSP and implementation of the above quality assurance monitoring practices are expected to be complete by 2016/17. Performance monitoring of radiologists, facilities and regions currently occurs as part of the OBSP. This includes the Radiologist Outcome Report that provides individual performance data to radiologists within the OBSP.
The CCO is working with the Ministry and the College of Physicians and Surgeons of Ontario (CPSO) to implement a provincial quality management program for all mammography services. Once implemented, the existing performance monitoring functions will be expanded to include all radiologists and facilities that provide mammography services through the expansion of the OBSP and implementation of the mammography provincial quality management program. In addition, more robust oversight, monitoring, and escalation processes will be implemented. The planning has begun and full implementation will require data submitted to the CCO from all facilities that provide mammography services.
· Breast Screening (Data Collection): As a result of the expansion of the OBSP and implementation of the mammography provincial quality management program, the CCO will collect data from all facilities that perform mammography services in Ontario. Specifically, the CCO will collect the following data:
· The Integrated Client Management System (ICMS), the database that provides an integrated set of data for each client screened in the OBSP for the purposes of program administration, management, and evaluation, will be redesigned and deployed to all sites that provide breast screening by the end of 2016/17.
· Data on diagnostic mammography will be collected from all sites through the implementation of the mammography provincial quality management program. The CCO is in the initial planning stages of this work.
· Colorectal Screening (Monitoring): The CCO is working with the Ministry to implement the Gastrointestinal Endoscopy Quality Based Procedure (GI Endo QBP) and a provincial colonoscopy quality management program. Once these initiatives are implemented, all facilities that provide colonoscopy services in Ontario will be required to adhere to provincial standards (e.g., equipment, staffing, and infection control practices) and there will be regular performance monitoring at the primary care provider, facility, regional, and provincial levels. Implementation of the GI Endo QBP began in 2014/15 for hospitals. Planning is underway for further refinements to the GI Endo QBP and implementation of the provincial colonoscopy quality management program.
The CCO is also working with the Institute for Quality Management in Healthcare (IQMH) and the Ministry to implement a laboratory quality assurance program for the fecal occult blood test (FOBT) that includes laboratory proficiency testing and peer assessment components. This program will be fully operational in 2015/16. The CCO will receive regular reports from the IQMH regarding laboratory performance.
· Colorectal Screening (Data Collection): As part of the implementation of the GI Endo QBP and the provincial colonoscopy quality management program, data will be required to be submitted to the CCO from all facilities that provide colonoscopy services in Ontario to enable quality monitoring at the physician, facility, regional and provincial levels. Pending Ministry approval, the CCO will begin collecting data from all facilities by the end of 2016/17.
· Cervical Screening (Monitoring): The CCO is working with the Ministry to implement the Colposcopy Quality Based Procedure (Colposcopy QBP). Once this initiative is implemented, provincial standards for colposcopy will be established and regular performance monitoring tied to facility funding will be in place. The first phase of the Colposcopy QBP is focused on activity occurring in hospital. Year one of the Colposcopy QBP in hospitals will be implemented in 2016/17 with further refinements in subsequent years. The second phase of the Colposcopy QBP is focused on activity occurring out of hospitals in physician offices.
· Cervical Screening (Data Collection): To support quality monitoring, the CCO is in the process of developing a cervical screening data collection strategy that will include collecting and reporting on all Pap test and colposcopy procedures in Ontario. The timelines (shown in parentheses) for this initiative include
· identifying the performance indicators and developing a minimum data set (completed);
· developing a data collection strategy for missing data (March 31, 2016);
· capturing data on all Pap tests in Ontario (2016/17); and
· capturing data on all colposcopy procedures in Ontario (2017/18).
It was noted that, according to CCO guidelines, endoscopists are required to perform at least 200 colonoscopies annually to achieve or maintain competency, and colposcopists are required to complete 100 colposcopies per year to maintain their competency level.
In defense of the above requirements, the CCO stated that "[w]e're going to be reporting publicly, region by region, on the proportion of colonoscopies that are done by someone, an endoscopist, who's doing at least 200 a year. So there's good evidence to support the 200."
It was noted that 5% of individuals in the target age group-50 to 74-for the ColonCancerCheck program do not have a family physician.
Committee Recommendation
The Standing Committee on Public Accounts recommends that:
7. Cancer Care Ontario provide the Committee with international or external evidence to support its volume-based competency standards for endoscopists and colposcopists.
8. The Ministry provide the Committee with details of its strategy for increasing access to
· cancer screening services for individuals in rural and remote communities; and
· primary care providers for individuals without one.
9. Cancer Care Ontario provide the Committee with details on how it will support endoscopists and colposcopists who do not meet its volume-based annual standards.
Consolidated List of Committee Recommendations
The Standing Committee on Public Accounts recommends that:
1. Cancer Care Ontario provide the Committee with the range of wait times for mammography screening and genetic assessments, and compare to the benchmark and explain any material variances.
2. Cancer Care Ontario ensure that its CSQI website is regularly updated with the most recent data available.
3. Cancer Care Ontario report back to the Committee on the expected implementation date of the FIT for use in colon cancer screening.
4. Cancer Care Ontario provide the Committee with the range of wait times for follow-up colonoscopies, and compare to the benchmark and explain any material variances.
5. Cancer Care Ontario provide the Committee with the range of wait times for follow-up colposcopies, and compare to the benchmark and explain any material variances.
6. Cancer Care Ontario work with the Ministry to provide the Committee with the results, LHIN by LHIN, of the percentage of attachments made via Health Care Connect and the CCO's Contact Centre.
7. Cancer Care Ontario provide the Committee with international or external evidence to support its volume-based competency standards for endoscopists and colposcopists.
8. the Ministry provide the Committee with details of its strategy for increasing access to
· cancer screening services for individuals in rural and remote communities; and
· primary care providers for individuals without one.
9. Cancer Care Ontario provide the Committee with details on how it will support endoscopists and colposcopists who do not meet its volume-based annual standards.