need for comprehensive canadian strategy role of the provincial governments obesity in canada:...
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Need for Comprehensive Canadian Strategy
Role of the Provincial Governments
Obesity in Canada: Prevention to Treatment1st Annual CABPS Conference in Conjunction with OBN & CMAS
Mississauga, OntarioJune 8, 2012
NAMD
Overview
2
Role of Provincial Government in General
- Scope limited to context of program delivery
Case Study: Ontario Bariatric Services Strategy
- Treatment focus (will not include prevention role)
Other Aspects
3
Share and liaise with other provinces
Engage in broader discussion
Policy and Delivery Roadmap
4
Program Cycle
5
Develop evidence-based policy and program design
Allocate resources through provincial priority-setting and
budget process
Engage experts in setting standards and performance
measures
Fund and apply appropriate
accountability mechanisms
Support implementation and make adjustments
Monitor performance and accountability
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Ontario Health Technology Assessment Committee
Expert Consultations
FrameworkEvidence-based FrameworkBariatric Services Strategy
HealthTUGO
LiteratureOther Jurisdictions
Key Recommendations
Provincial ProgramTeam Approach
Centres of Excellence Role for Primary Care
RegistryTelemedicine
Ontario Bariatric Network Clinical Standards
Best Practices
RegistryWait Time ManagementCentral Referral Portal
Patient Outcomes TrackingResearch
Regional Assessment &
Treatment Centres (RATC)
Telemedicine
Education & Outreach
Centres of Excellence
(CofE)
Program Design
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Allocate Resources Out-of-Country and In-Province Surgeries
FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY 20110
500
1000
1500
2000
2500
3000
$0
$10,000,000
$20,000,000
$30,000,000
$40,000,000
$50,000,000
$60,000,000In-Province Services OOC Services OOC Payments
Out-of-Country and In-Province Surgeries
2002 – 2011
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Behind the numbers
DRIVERS SITUATION IMPACT
•↑Rate of obesity •↓Risk (laparoscopic approach)
•↑Knowledge & acceptance of bariatric surgery
• Few Ontario bariatric surgeons
• Limited knowledge among referring physicians
• Applications driven by patients (incl. surgery type)
• Limited Ontario capacity • Inconsistent assessment
• Variable or no long-term follow-up
• Celebrity publicity
• Internet
• Aggressive marketing by US providers
• Walk-in clinic referrals • OOC patients with complications
• Rapidly increasing expenditures OOC and also in-province due to complications
CONTEXT
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Allocate ResourcesBariatric Services Strategy Announcement in July 2008$75 M as part of Ontario Diabetes Strategy
Comprehensive Bariatric Strategy to build capacity in Ontario to: improve patient outcomes; increase patient safety; and reduce the demand for increasing number of referrals for out-of-country (OOC) bariatric procedures.
Short-term Reduce the cost/case for OOC bariatric surgeriesEstablish surgical capacity at two provincial Centres of Excellence
Medium-term
Help reduce patient volume sent OOCImplement provincial waiting list Establish assessment capacity throughout Ontario
Long-term Increase provincial surgical capacity at 6 - 7 Centres of Excellence.
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Standards & Performance MeasuresOntario Bariatric Network in Action
Assessment
Surgery Selection
Pre-op Testing
Mental Health
Registry Implementation
Telemedicine
• Teleconferences • Trouble-shooting• Quick sharing of innovations
Topic-focused Working Groups
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High-Level Bariatric Referral Process
1st Assessment is booked (if patient
agreeable)
1st Assessment is booked (if patient
agreeable)
Confirmation Letter:1st Assessment Appt
sent to Patient & Referring Physician
Confirmation Letter:1st Assessment Appt
sent to Patient & Referring Physician
YPatient Shows
Patient Shows
Patient Shows
Patient Shows
First Assessment
Occurs
First Assessment
Occurs
Subsequent Assessments Booked
Subsequent Assessments Booked
SURGERY Date Booked SURGERY
Date Booked
SURGERY Occurs
SURGERY Occurs
9-month Surgery Goal(1-year Max)
9-month Surgery Goal(1-year Max)
Confirmation Letter: Surgery Date is sent to
Patient & Referring Physician
Confirmation Letter: Surgery Date is sent to
Patient & Referring Physician
Composition of Team differs between Centres.
May include:• Dietitian• Social Worker• Patient Education•
Psychologist/Psychiatrist
• Internist/Endocrinologist
Composition of Team differs between Centres.
May include:• Dietitian• Social Worker• Patient Education•
Psychologist/Psychiatrist
• Internist/Endocrinologist
Confirmation Letter: Orientation Date is sent to Patient &
Referring Physician
Confirmation Letter: Orientation Date is sent to Patient &
Referring Physician
Orientation Session Occurs
Orientation Session Occurs
Patient RespondsPatient
Responds
Physician Faxes Referral Form to the Bariatric
Registry
Physician Faxes Referral Form to the Bariatric
Registry
Referral Data is sent to BCOE/RATC based on
LHIN designation
Referral Data is sent to BCOE/RATC based on
LHIN designation
BCOE/RATC receives Referral Data Information
BCOE/RATC receives Referral Data Information
Orientation Session: within 3-weeks of
Referral received at the centre, patient &
referring physician receives info about the
next Orientation Session
Orientation Session: within 3-weeks of
Referral received at the centre, patient &
referring physician receives info about the
next Orientation Session
Package Received: Patient has 4-weeks to
respond to the BCOE/RATC for their
Orientation Date.
Package Received: Patient has 4-weeks to
respond to the BCOE/RATC for their
Orientation Date.
Y
3-month Goal
3-month Goal
3 month Goal
3 month Goal
Y
3-months1st Assessment to Surgery Date
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Wait Time Paradox
Assumption:
Patients who have the most severe obesity-related co-morbidities should have quicker access to surgery.
Clinical Reality:
Patients who have the most severe obesity-related co-morbidities require several months of assessment and preparation prior to surgery to reduce surgical risk and achieve good outcomes:• Diagnostic tests• Management & stabilization of co-
morbidities
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Funded Programs
Toronto Collaborative
Centres of Excellence
Ottawa Centre of Excellence
Kingston Regional Assessment &
Treatment CentreWindsor Regional
Assessment & Treatment Centre
Sudbury Regional
Assessment & Treatment Centre
Guelph Centre of Excellence
Thunder Bay Regional
Assessment & Treatment Centre
Hamilton Centre of Excellence
Ontario Bariatric Network
Registry
HSCPRATC
CHEO PRATC
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Implementation
2009
436 surgeries in Ontario200+ OOC Approvals / month
2012
Ontario Bariatric NetworkBariatric Registry
2,500+ surgeries in OntarioBariatric Centres across province
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Implementation & AdjustmentsExamples of Innovations & Best Practices
ISSUE SOLUTION BENEFITS
“No shows” & cancellations for appointments
Group Orientation Sessions
Protocol for no shows
Standard intro to bariatric program
Patients return committed to process
Access to step down units for bariatric surgery patients (“bumping”)
Enhanced post-op ward
monitoring (remote O2)Early alert of complications
Fewer pre-op sleep studies required
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Performance & Accountability Ontario Bariatric Registry
Phase II
comprehensive clinical data currently being collected
Phase I
central referral portal, live as of October 8th, 2010
Aim
to improve the care of the obese patient and increase the effectiveness of health care dollars
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Bariatric Registry
AGGREGATE PATIENT DATAAnthropometrics
Laboratory ComorbiditdyMedication
Surgical
PROGRAM DATAType of Surgery
Intra – Operative Complications Post – Operative Complications (Surgical) Post – Operative Complications (Medical)
Care path timelines
Baseline→6-mos→1-yr→2-yr→3-yr→5-yr
Regular Site & Provincial Report Cards
Lessons
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•Forums for both formal and informal discussions at all levels were key to sharing of ramp up lessons and systems response to issues as they arise
Communication
•Mechanisms involving data and health information privacy protection take time
Health Information
•Institutions and clinicians are capable of high levels of collaboration given mandate and supports
Collaboration
