Effects of Funding Policy Changes and Health Warnings on the Use of Erythropoiesis-Stimulating Agents [Original Contributions]

Effects of Funding Policy Changes and Health Warnings on the Use of Erythropoiesis-Stimulating Agents [Original Contributions]

Purpose:
To characterize the effects of formulary changes and governmental safety warnings on use of erythropoiesis-stimulating agents (ESAs) in patients with cancer.

Patients and Methods:
We conducted a cross-sectional time-series analysis using health administrative data from Ontario, Canada. From January 1997 to December 2009 we identified all ESA initiations among patients diagnosed with cancer. We explored the effects of two formulary changes that progressively liberalized coverage for ESAs, first by rescinding the requirement for blood transfusion in 2003 and then by removing all restrictions in 2007. We also explored the effect of US Food and Drug Administration and Health Canada warnings issued in the second quarter of 2007. To assess regional variability in ESA use, we determined prescription rates for each of Ontario's 14 regional cancer centers.

Results:
After the first formulary change, the ESA initiation rate increased to 1.66 new users per 1,000 patients with cancer, 374% more than predicted (P < .001). After the second formulary change, the initiation rate increased to 3.97 new users per 1,000 patients with cancer, 73% more than predicted (P < .001). After the safety warnings, this rate declined 81% by study end (P < .001). We found significant regional variation in ESA use.

Conclusion:
Formulary access and safety warnings had significant impacts on the new use of ESA drugs in patients with cancer. This suggests that both are effective means of influencing the use of these drugs. Variable ESA prescription rates across our region may reflect a lack of consensus regarding their utility.

audio/video: Loud and Clear

Loud and Clear

In late fall 2011, The Change Foundation engaged Ontario seniors with chronic health conditions and their informal caregivers about their experiences with transitions in our healthcare system. This report is about their stories, experiences, and ideas.

Loud and Clear: seniors and caregivers speak out about navigating Ontario's healthcare system

Change Foundation engaged Ontario seniors.....

Loud and Clear

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About Loud and Clear

In Loud and Clear: Seniors and caregivers speak out about navigating Ontario’s healthcare system, we explain our rationale for the timing and target of our engagement, describe our methodology, present our findings and how we plan to use them, and share the Foundation’s next steps and how they fit, feed into, and even blaze the way for patient-centred healthcare in Ontario.

Dedication

We dedicate this report to the seniors and their family members and friends across Ontario who shared their experiences and stories with us. They spoke forcefully and thoughtfully, with both emotion and measure, about where the system has failed them and how it could serve them better. They spoke loud and clear.

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“I don’t know what’s happening next, but where do you go to find the answers? Seems like there are roadblocks set up in the system that make it hard.”
Ontario senior 
 

“Our doctor sent us for an appointment with a specialist. We waited five months and never heard anything, so I called and they had no record of the appointment. It would be a good idea if someone from the doctor’s office called the patient once an appointment is made to confirm.”
Ontario senior 

“I’ve never been asked as a caregiver, 'What’s convenient for you?' Or 'How would this work in your family?' instead it’s 'This is what we’re going to do for you.' There's no discussion of collaboration.”
Ontario caregiver

$8.68M in early researcher awards announced in Ontario | Laboratory Product News

$8.68M in early researcher awards announced in Ontario | Laboratory Product News

 UNIVERSITY OF WATERLOO

Project title: Rational design of novel surface active compound for improving non-viral DNA transfection efficiencies. Lead researcher: Dr Shawn Wettig. Gene therapy uses DNA to treat disease. While it shows great promise, creating a delivery system to deliver DNA to specific areas in the body is a challenge. Dr Wettig is working to develop delivery systems, starting with one for ovarian cancer, the leading cause of death among gynecological cancers.

JCO Editorial (re: Ontario/Pritchard et al) [18F]Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography in Breast Cancer: When… and When Not?

[18F]Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography in Breast Cancer: When… and When Not?

"....It has taken a relatively long time to generate the data needed to guide appropriate use of FDG PET/CT for breast cancer for all phases of the disease. The task is still not quite complete but is propelled by studies such as Pritchard et al.⁶ We hope that the approach for directing new imaging procedures into clinical practice will continue to improve and be ready when the next imaging breakthrough emerges."

"Diagnostic imaging plays an important role in the care of patients with breast cancer and is used for breast cancer detection, diagnosis, staging, and therapeutic response evaluation.¹ Advances in imaging technology, especially relatively newer technologies such as magnetic resonance imaging (MRI) and positron emission tomography without or with integrated computed tomography (PET or PET/CT) provide powerful diagnostic tools, but also generate questions and controversy regarding where and when to use these new modalities. Early studies of new imaging approaches most often come from centers that are scientifically invested in the development of the technology. Typically, small and highly selected patient populations are evaluated, and these preliminary studies often indicate excellent diagnostic performance. Later on, when large multicenter trials are performed with more clinically representative patient populations, the new test invariably performs less well. Nevertheless, the excitement surrounding early results from a new imaging technology and the increasing public access to these early results fuel the desire by patients for access to new forms of diagnostic imaging. Physicians and patients share the wish for diagnostic certainty in excluding cancer spread at the time of diagnosis and may reason that a purely diagnostic procedure, even if untested, can do no harm. These factors, combined with the challenge and expense of carrying out larger scale diagnostic imaging trials, can lead to the early adoption of new imaging studies into clinical practice, often before their performance and optimal use have been fully determined. However, ......."

abstract: Prospective Study of 2-[18F]Fluorodeoxyglucose Positron Emission Tomography in the Assessment of Regional Nodal Spread of Disease in Patients With Breast Cancer: An Ontario Clinical Oncology Group Study

Prospective Study of 2-[18F]Fluorodeoxyglucose Positron Emission Tomography in the Assessment of Regional Nodal Spread of Disease in Patients With Breast Cancer: An Ontario Clinical Oncology Group Study

 Purpose 2-[¹⁸F]fluorodeoxyglucose (FDG) positron emission tomography (PET) is potentially useful in assessing lymph nodes and detecting distant metastases in women with primary breast cancer.


Conclusion
FDG-PET is not sufficiently sensitive to detect positive axillary lymph nodes, nor is it sufficiently specific to appropriately identify distant metastases. However, the very high positive predictive value (96%) suggests that PET when positive is indicative of disease in axillary nodes, which may influence surgical care.

Ontario (Canada) ombudsman could hold hospitals to account - thestar.com

Ontario ombudsman could hold hospitals to account - thestar.com

"Ontario is also the only province whose ombudsman cannot investigate hospitals and long-term care facilities."

Evidence-based Guideline Recommendations on the use of Positron Emission Tomography Imaging in Colorectal Cancer (Ontario provincial Gastrointestinal Disease Site Group)

 Blogger's Note: updated to 2010

Evidence-based Guideline Recommendations on the use of Positron Emission Tomography Imaging in Colorectal Cancer

Editorial: The Relationship Between Cost and Quality, No Free Lunch - March 14, 2012 — JAMA + link to original article

The Relationship Between Cost and Quality, March 14, 2012, Joynt and Jha 307 (10): 1082 — JAMA
 Editorial: The Relationship Between Cost and Quality 

No Free Lunch

Since this article does not have an abstract, we have provided the first 150 words of the full text. (Blogger's Note: subscription required to view $$$)

"For the past 30 years, research from investigators at Dartmouth has demonstrated large and persistent variations in costs and quality across the US health care system. Beyond simply showing that cost and quality vary by geography, the Dartmouth Atlas has demonstrated that in many communities, care is so fragmented and ineffective that greater spending on Medicare beneficiaries often leads to worse outcomes^1,2 because some patients receive services that are redundant and low value and that may even have substantial risks. 

However, some US policy makers have misinterpreted the Dartmouth research and in the troves of data have found what they believe to be a free lunch: given the inverse relationship between costs and quality, it follows that it should be possible to simultaneously reduce spending and improve care. Although this notion is attractive, much of the subtlety of the Dartmouth work has been lost in translation. What ....."

[Full Text of this Article] (subscription required to view)

Related article

• Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals  
   JAMA. 2012;307(10):1037-1045.doi:10.1001/jama.2012.265
  • Abstract
  • Full Text
  • Full Text (PDF)
  • eSupplement
  • Author Video/Audio Interview
  • JAMA Report Video

YouTube: Interview with Dr Stukel, Author of Hospital Spending Intensity and Patient Outcomes

Also, planning a comparison study with London School of Economics and Havard

open access: Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario (Canada) Hospitals, March 14, 2012 — JAMA

 Blogger's Note: universal healthcare system, this study included colorectal cancer patients, comparisons between Canadian/U.S. systems, note authors' affiliations

Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals, March 14, 2012

"Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care.......We studied 4 common conditions that have moderate to high incidence and mortality, that can be validly ascertained using health administrative data, and for which treatment follows relatively standard protocols. "

Design Overview

We undertook a longitudinal cohort study of patients hospitalized with selected acute clinical conditions in Ontario, Canada, and assessed the content, quality, and outcomes with respect to “exposure” to the index hospital's medical spending intensity. Medical intensity is defined as the quantity of medical care provided overall to similarly ill patients and is a marker of a hospital's propensity to treat similarly ill patients more (or less) intensively. It reflects the component of spending variation attributable to practice style rather than to differences in illness or price.

Because sicker patients use more services, higher-spending hospitals may appear to have worse outcomes, in part because patients are more severely ill. We used several techniques to remove this potential “reverse causality,” as in previous work.1,2​,3,4

 COMMENT

We found that higher hospital spending intensity was associated with better survival, lower readmission rates, and better quality of care for seriously ill, hospitalized patients in Ontario in a universal health care system with more selective access to medical technology. Higher-spending hospitals were higher-volume teaching or community hospitals with high-volume or specialist attending physicians and having specialized programs, such as regional cancer centers, and specialized services, such as on-site cardiac catheterization, cardiac surgery, and diagnostic imaging facilities. The study also points to plausible mechanisms through which higher spending may be associated with better outcomes. 

Benefits appeared early, suggesting an acute-phase hospital effect. For acute conditions, timely access to preoperative and in-hospital specialist care, skilled nursing staff, rapid response teams, cardiac high-technology services, and regional cancer centers, all found in the higher-spending systems, are related to better outcomes.^{21​,27,34​,35,36​,37,38​,39} These systems also provided consistently, but not strikingly, higher levels of evidence-based care and collaborative ambulatory care, both shown to improve care.^{22​,23,40​} Higher spending on evidence-based services delivered in the acute phase of care for severely ill hospitalized patients—by far the largest component of spending for our cohorts—is indeed likely to be beneficial. 

It would be facile to interpret this study as demonstrating that higher spending is causally related to better outcomes and that providing more money to lower-spending hospitals would necessarily improve their outcomes. Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive. 

To place the study in context, the United States has a 3- to 4-times higher per capita supply of specialized technology, such as computed tomography and magnetic resonance imaging scanners, but a similar supply of acute care beds and nurses.⁴¹ Ontario 2001 population rates of cardiac testing and revascularization lagged behind corresponding 1992 US rates and paralleled the supply of cardiologists and catheterization facilities.^{42​,43,44​} It is therefore possible that Canadian hospitals, with fewer specialized resources, selective access to medical technology, and global budgets, are using these resources more efficiently, especially during the inpatient episode for care-sensitive conditions.^45,46​ Canada's health care expenditures per capita are about 57% of those in the United States.⁴⁷ At this spending level, there might still be a positive association between spending and outcomes. For example, the same-day PCI rate for patients with AMI in low-intensity hospitals in 2008 was 3.5%, leaving room for improvement. This pattern is consistent with studies in the United States showing a positive association between spending and outcomes among low-intensity hospitals or regions but no association at average or higher intensity levels.^5​,6

Strengths of the study include the population-based, longitudinal cohort design; the consistency of findings across cardiac, cancer, medical, and surgical patients; the examination of plausible clinical mechanisms whereby higher intensity may be associated with better outcomes; and the examination of readmissions. The “look-back” (EOL-EI) and “look-forward” (AC-EI) measures of spending intensity were highly correlated and produced similar findings, as in US studies.²

 ^​

Several limitations should be considered. Because the design precludes strong inferences about causation, we cannot know which components of care may have led to better outcomes. In observational studies, comparisons of exposure groups may be biased because of unobserved selection bias.¹³ It is unlikely that the findings are the result of unmeasured case mix, because patients in higher-spending hospitals had similar or higher illness severity at admission, which would, if anything, bias toward finding worse outcomes. We cannot rule out the possibility that higher-intensity hospitals coded more aggressively, but there is less incentive to do so in a system with global hospital budgets. Although admission severity would be determined more accurately using clinical detail from medical charts, previous work has shown high concordance between risk-adjusted hospital outcomes using chart and administrative data.^48​,49 Canadian data distinguish between comorbidities present at admission and complications, leading to improved admission severity coding. The EOL-EI has been critiqued for the purpose of estimating hospital efficiency^50​,51 but is used here simply to distinguish high- and low-intensity hospitals, as in other US studies.^{1​,2,3​,4} The findings may not generalize to chronic conditions, for which avoiding exacerbations of disease that lead to hospitalization through coordinated ambulatory care is key. The findings also may not generalize to jurisdictions in which hospital resources are more abundant and are used in cost-effective as well as cost-ineffective ways, leading to inefficiency.^45​,46

This study shows that in Ontario, a province with global hospital budgets and fewer specialized health care resources than the United States, outcomes following an acute hospitalization are positively associated with higher hospital spending intensity. Higher spending intensity, in turn, is associated with greater use of specialists, better patient care, and more use of advanced procedures. These results suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services. 

pdf file: 

http://jama.ama-assn.org/content/307/10/1037.full.pdf

abstract JCO: Opioid Prescription After Pain Assessment: A Population-Based Cohort of Elderly Patients With Cancer - Sunnybrooke Health Sciences Centre, Toronto, Canada

Opioid Prescription After Pain Assessment: A Population-Based Cohort of Elderly Patients With Cancer

 Abstract

Purpose The purpose of this study was to measure opioid prescription (OP) rates in elderly cancer outpatients around the time of assessment for pain and to evaluate factors associated with receiving OPs for those with severe pain. 

Patients and Methods The cross-sectional cohort includes all patients with cancer in Ontario older than age 65 years who completed a pain assessment as part of a provincial initiative of systematic symptom screening. Patients were assigned to mutually exclusive categories by pain score severity: 0, 1 to 3 (mild), 4 to 6 (moderate), and 7 to 10 (severe). We linked multiple provincial health databases to examine the proportion of patients with an OP within 7 days after or 30 days before the assessment date. We examined factors associated with OPs for patients with pain scores of 7 to 10. 

Results The proportion of patients with an OP increased as pain score severity increased: 10% of those with no pain, 24% of those with mild pain, 45% of those with moderate pain, and 67% of those with severe pain. More specifically, for those with severe pain, 41% filled an OP within 7 days of assessment for pain, and 26% had an OP from the 30 days before assessment for pain, leaving 33% without an OP. In multivariable analysis, factors associated with OPs are younger age, male sex, comorbid illness, cancer type, and assessment at home. 

Conclusion Despite a generous time window for capturing OPs, the proportion of patients without an OP seems high. Further knowledge translation is required to maximize the impact of the symptom screening initiative in Ontario and to optimize management of cancer-related pain.

The POWER Study (Project for an Ontario Women's Health Evidence-based Report) Social Determinants of Health and Populations at Risk chapter

The POWER Study (Project for an Ontario Women's Health Evidence-based Report) Social Determinants of Health and Populations at Risk chapter is now available for download. 
 
 Using a community-engaged research model and integrated KT approach, the POWER Study has examined a comprehensive set of evidence-based indicators bridging population health and health system performance. The Women's Health Equity Report is serving as an evidence-based tool for policy makers, providers and consumers in their efforts to improve health and reduce health inequities in Ontario. POWER has examined gender differences in access to care, as well as quality and outcomes of care for the leading causes of morbidity and mortality in the province and how they differ by gender, socioeconomic status, ethnicity, and geography. 
 
The Social Determinants of Health and Populations at Risk chapter examines the social determinants of health among Ontario's women and men including: low income, low education, indicators of employment, lone-parent families, and food insecurity. We also summarize the POWER Study indicators across all chapters as they relate to low-income populations, providing a synthesis of health functional status, risk factors and prevention, access to health care services, clinical management, and health outcomes of lower-income adults. The final section re-examines and synthesizes the POWER Study findings in relation to immigrant and minority populations, as well as reporting three indicators of immigrant women's health that have not previously been reported in the POWER Study. Based on our analyses, identified opportunities to improve health and health care and reduce inequities, together with broad community consultation and dialogue, we developed the POWER Health Equity Road Map. The 
 aim of the Road Map is to help move us forward to the goal of achieving health equity in Ontario. The time to move forward is now. What is needed is the will and commitment.
 
 To download a copy of the full chapter or the highlights document (which outlines the chapter's key findings and messages): http://powerstudy.ca/the-power-report/the-power-report-volume-2/social-determinants-of-health-and-populations-at-risk
 
The French translation of the Social Determinants of Health and Populations at Risk Highlights document will be available on our website soon.
 
Also available for download from www.powerstudy.ca: Introduction to the POWER Study (Ch 1); The POWER Study Framework (Ch 2); Burden of Illness (Ch 3); Cancer (Ch 4); Depression (Ch 5), Cardiovascular Disease (Ch 6), Access to Health Care Services (Ch 7), Musculoskeletal Conditions (Ch 8), Diabetes (Ch 9), Reproductive and Gynaecological Health (Ch 10), HIV Infection (Ch 11), Older Women's Health Report.
 
The POWER Study's concluding chapter 'Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement' is forthcoming and will be available on our website soon. 
 
Arlene S. Bierman, MD, MS
Echo's Ontario Women's Health Council Chair in Women's Health
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto and
Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital
30 Bond Street (209 Victoria Street, Room 219)
Toronto, ON  M5B 1W8
Phone:  (416) 864-3041
Fax:    (416) 864-5641
 
Web: www.powerstudy.ca 
 
The POWER Study is funded by Echo: Improving Women's Health in Ontario, an agency of the Ministry of Health and Long-Term Care. This report does not necessarily reflect the views of Echo or the Ministry. 
_______________________________________________

abstract: Healthcare Policy - The Use of Registered Nurses to Perform Flexible Sigmoidoscopy Procedures in Ontario: A Cost Minimization Analysis

Reports: ICES - Payments to Ontario Physicians from Ministry of health - period comparisons 1992/3 - 2009/10 (zip file)

Reports

Payments to Ontario Physicians from Ministry of Health and Long-Term Care Sources 1992/93 to 2009/10

Henry DA, Schultz SE, Glazier RH, Bhatia RS, Dhalla IA, Laupacis A. February 2012 In Canada, payments to physicians constitute approximately 20% of provincial health care budgets. This report estimates public payments to Ontario physicians from multiple sources between 1992/93 and 2009/10, and presents these graphically by specialty and specialty group. The report examines variations between specialty groups and considers the impact of changes in the different models of physician payment, including fee for service, capitation and alternate payment plans. [3.3 MB zipped] PDF version [9.9 MB]

Ottawa cancer rates highest in Ontario - Health - but best breast cancer survival ratesCBC News

Cancer Society spends more on fundraising than research - Canada - CBC News

Note: consolidated statement

"An Ontario cancer researcher is concerned that the Canadian Cancer Society has proportionally shifted funding away from research and is spending more of its dollars on fundraising and administration costs.
"Most scientists don’t realize that the budget has been going up and up, and donations have been growing, but the budget for research has been shrinking," said Brian Lichty, a researcher at McMaster University who is looking into treating cancer with viruses that kill tumours. "So they are surprised and disappointed when they find out that this is the case, and the trend."
CBC's Marketplace analyzed the Canadian Cancer Society’s financial reports dating back a dozen years. It discovered that each year, as the society raised more dollars, the proportion of money it spent on research dropped dramatically — from 40.3 per cent in 2000 to under 22 per cent in 2011.........."But when Marketplace scrutinized the financial reports, it found that a greater percentage of funds was not being directed toward support, information and advocacy.........cont'd

LHINs (Ontario, Canada) at Five years – What Now? :: Longwoods.com

Power throttled
On paper, the LHINS are exceedingly powerful, with over $20billion of funding authority and the power to issue integration orders compelling healthcare organizations to alter and even merge services to improve healthcare. In spite of these formidable powers, in 2006, I wrote: “Many fear that LHINs will simply be a funding conduit, perpetuating the status quo; or that they will simply do the Ministry’s bidding and add another layer of unnecessary bureaucracy and contribute further to the inefficiency of the “system”. Sadly, this prediction has largely come true, with LHINs largely reverting to traditional planning exercises, throttled by Ministry directives, and acting much like their predecessor District Health Councils, which were broadly viewed within the Ontario healthcare community as ineffectual......So what went wrong?..........
Leaving Critical Functions Outside
“While the role of the new LHINs is massive, at least on paper, there are significant omissions that may limit their effectiveness in truly improving patient care.  Public health, physician services, ambulance services, laboratories and provincial drug programs are all excluded from the mandate of the new organizations.”  I wrote this five years ago and these omissions continue to hamper an effective integration model today.  Primary care is particularly problematic.  Ontario now has an alphabet soup of primary care models, with Family Health Teams holding the most promise, but with none of them being held publicly accountable for service or performance standards.  It is past time to move to truly integrated care.......

End-of-Life Care for Advanced Lung Cancer Differs Markedly Between U.S. and Ontario

Note: study on lung cancer but pertinent for all cancer patients/families

Even more important, he writes, patient preferences vary from one individual to another and these preferences are often unheard: “Quality in end-of-life care will continue to elude us if we assume that societal average preferences indicate the care individual patients want and need,” he writes.

The Canadian Press: More testing coming for Ontario women at risk of contracting breast cancer