Radiation Treatment Capital Investment Strategy

Transcription

1 Radiation Treatment Capital Investment Strategy April 2012

2 1.0 EXECUTIVE SUMMARY INTRODUCTION AND BACKGROUND RADIATION TREATMENT CAPACITY Planning Parameters Regional Requirements for Capital Investments based on Radiation Treatment Demand SECURE ADDITIONAL FUNDING FOR RADIATION TREATMENT EQUIPMENT REPLACEMENT Impact of Technology on Radiation Treatment Radiation Replacement Funding RECOMMENDATIONS Priorities Risks Conclusion... 24

3 1.0 EXECUTIVE SUMMARY Investments in facilities and technology contribute significantly to the quality of patient care in Ontario and the attendant treatment wait times. To ensure future capital investments for radiation treatment are appropriately timed and strategically placed, Cancer Care Ontario (CCO) has with its provincial partners updated its Radiation Treatment Capital Investment Strategy. This strategy recommends investments in new radiation treatment equipment and related facilities, and identifies the requirements for replacement equipment funding to ensure the existing infrastructure remains reliable and safe. These recommendations guide funding requests in CCO s Annual Business Plan and other provincial capital funding requests by hospitals for radiation treatment services. This strategy makes recommendations on the placement of additional radiation treatment equipment and the development of new or expanded facilities to provide treatment consistent with the Provincial Radiation Treatment Program goals. The plan also aims at maximizing the use of existing equipment and infrastructure investments while ensuring the appropriate tools are in place to provide equitable access to quality care. While investments in equipment and facilities have significantly improved treatment capacity across the province, it is important that we continue to: 1. Improve access to care for cancer patients by ensuring treatment machine capacity matches the demand resulting from increasing cancer incidence rates and we ensure we capture all patients that should be treated with radiation by increasing utilization rates as per the Radiation Treatment Program goals. In order to keep pace with the increasing incidence of cancer with no improvement in radiation therapy utilization rates an annual 3% increase in Radiation Treatment Capacity will be necessary on a yearly basis. 2. Keep pace with advancing technology to ensure the delivery of quality care. This is especially important in Radiation Oncology where the devices for delivering appropriate care are highly specialized and rapidly changing. The radiation 1

4 replacement grant must be adequately funded to keep the current installed equipment modern and safe. 3. Ensure value for investments. To maximize the use of current infrastructure, we reviewed and updated the planning assumptions used to calculate machine capacity and demand. A cost benefit analysis supports longer treatment days as a costeffective strategy. Consequently, we adopted a fundamental change in the revised planning model extending the treatment day for centres with: six or more treatment units extend to 12 hours on 100% of their equipment fewer than six treatment units extend to 12 hours on 50% of their equipment and 10 hours on remaining 50% Extending the treatment day has operating fiscal budget implications which must be adequately addressed if capital equipment utilization is to be maximized, cost benefit analysis supports the longer treatment day as a cost effective strategy. 4. Minimize costs through centralized planning and procurement processes. CCO has established provincial vendor of record arrangements to ensure value for money related to all provincial investments in radiation treatment equipment Under CCO s previous Capital Investment Strategies, investments in new facilities have closed the gap between treatment demand and capacity across the province. There has been a substantial drop in waiting times for treatment (Figure 1) and Ontario has been above the Federal Provincial Territory wait time target of 90% for Ready to Treat to Start of Treatment since August The increased treatment capacity and the improvement in the waiting times have allowed for improved access to radiation therapy for Ontario patients (radiation therapy is an essential element of the curative treatment of many types of localized cancers and is also effective in alleviating the symptoms of many patients with advanced disease). However, the radiation treatment utilization rate (proportion of patients with cancer that receive at least one course of radiation therapy during their lifetime) in Ontario (37%) remains substantially below international norms (50 55%) and below the CCO target of 48%. When facilities under construction in Niagara, Barrie and Kingston are completed there will be 103 units in operation and the potential to equip an additional 16 rooms for a total of 119 machines. Conservative provincial treatment demand 2

5 projections are that by 2020 Ontario will need a minimum of 130 treatment units to achieve a provincial radiation treatment utilization rate of 42%. CCO, through its annual provincial multidisciplinary review process, prioritizes all requests for replacement grant funding based on criteria, which consider: improved access to care quality impacts on operating costs the provincial context Over the past decade, the opening of new treatment centres has increased the number of treatment units providing care to Ontario patients by 50%. During this period there has not been any increase in the annual base funding to replace aging treatment units. These units provide critical treatment capacity to ensure equitable timely access to quality care. It is imperative that they remain reliable and modern. Additional funding for machine replacement must be secured to ensure we can continue to replace old and obsolete equipment and deliver safe, high precision radiation treatment to all Ontario patients who require it. Recommendations 1. Gradually move to 12 hour treatment days in large centres on all equipment and on 50% of equipment in centres operating fewer than six treatment units as required to keep pace with radiation treatment demand 2. Develop alternative approaches to improve radiation grant funding for the replacement of existing radiation treatment equipment 3. Equip constructed rooms in Newmarket, Durham, Grand River and Barrie regions in which additional capacity requirements were identified when construction of these facilities was approved adding six radiation treatment machines. The revised planning model continues to support these investments 4. Equip swing bunkers in 10 locations across the province to provide additional treatment capacity with minimal investment in the construction of new facilities 3

6 5. Work with the Local Health Integration Networks (LHINs) and the Ministry of Health and Long Term Care (MOHLTC) to plan for the construction of new facilities to add radiation treatment capacity in the context of a multidisciplinary treatment setting in three regions of the province Immediate Priorities 1. Maximize the use of existing capital through: 1.1 Gradually moving over the next three years to a 12 hour treatment day in large centres on all equipment and to a 12 hour treatment day on 50% of equipment in centres operating fewer than six treatment units 1.2 Improving the use of existing radiation replacement grant funds 2. Implement funding strategies set out in CCO s annual business plan to: 2.1 Secure additional funding for the radiation replacement grant to ensure the existing infrastructure remains modern and reliable 2.2 Secure new funding to equip existing treatment rooms in regions where rooms are vacant 2.3 Work with regions to develop specific plans for capital expansions where required to provide capacity beyond

7 2.0 INTRODUCTION AND BACKGROUND Cancer care is provided in a variety of settings including teaching hospitals, community hospitals, primary care settings, community based organizations and agencies, and in home. Historically, the need for radiation treatment services drives capital investments in cancer treatment facilities. Projecting radiation needs is simplified because radiation treatment is only delivered in cancer treatment centres while systemic and surgical treatments can occur in a number of different settings. CCO has been very successful in projecting the need for new facilities and investments in equipment based on these methodologies. Further, based on CCO s projections, there is enough current infrastructure to meet the demand for radiation treatment across the province. The need for outpatient systemic and surgical oncology facilities in the ambulatory building were addressed in the past once CCO received approval to develop a Functional Program. The requirement for multidisciplinary care and the increasing frequency of concurrent radiation and systemic care require that facilities planning be based on the projected needs of all treatment modalities. Investments in treatment facilities must be tied to investments in human resources. Improved or expanded facilities can improve human resource opportunities by creating improved working conditions that facilitate recruitment and retention. Provincial facility projections drive decisions on the recruitment of candidates into education and training programs. Previous investments have increased the provincial number of radiation treatment units from 65 in 2000 to 96 in The location and size of these new facilities were determined by: Projected incidence and utilization rates Recommendations in two previous Capital Investment Strategies developed by CCO and accepted by the MOHLTC 5

8 The first strategy resulted in new facilities in Grand River, Peel and Durham. The second strategy resulted in the construction of new facilities in Newmarket, Barrie, Niagara and Algoma and redevelopment of the existing centre in Kingston. Investments in two portable treatment units created flexible treatment spaces one of which will redeploy from Ottawa to Peterborough in 2012 and the Barrie facility which will redeploy in When facilities under construction in Niagara, Barrie and Kingston are completed there will be units in operation and the potential to equip an additional 16 rooms (10 swing rooms and six empty rooms) for a total machine capacity of 119 units. Table 1 Radiation Treatment Machine Potential These new facilities have closed the gap between treatment demand and capacity across the province. There has been a substantial drop in waiting times for treatment (Figure 1) and Ontario has been above the Federal Provincial Territory wait time target since August The increased treatment capacity and improved wait times have allowed for improved access to radiation therapy for Ontario patients who can benefit from this treatment (radiation therapy is an essential element of the curative treatment of many types of localized cancers and is also effective in alleviating the symptoms of many patients with advanced disease). However, the radiation treatment utilization rate (the proportion of patients with cancer who 1 Including portable bunker in Barrie and Ottawa s room relocated to Peterborough 6

9 receive at least one course of radiation therapy during their lifetime) in Ontario (38%) remains substantially lower than international norms (50 55%) and below the CCO target of 48%. Figure 1 Radiation Ready to Treat to Treatment Both regional interdependencies and the timing associated with project implementation influence projected demand/capacity requirements. This capital investment strategy projects requirements for new facilities and equipment to address radiation treatment demand to 2020 and presents the detailed capital investments required over the next five years, building on the three year projections presented in the Ontario Cancer Plan and aligned with CCO s Business Plan priorities. 7

10 Investments in facilities and technology contributed significantly to the quality of care received by Ontario patients and the attendant reduction in treatment wait times. Radiation therapy is a widely used cancer treatment and also used to alleviate symptoms in patients with incurable cancers. Radiation therapy targets radiation at a tumour, using either X ray beams or radioactive compounds, with the goal of destroying the cancer without damaging the surrounding, normal tissues. Approximately half of cancer patients require radiation therapy at least once during the course of their illness. Many will require repeat treatments. Typically, radiation therapy involves the use of X ray machines, known as linear accelerators or linacs, which focus radiation beams on the tumour. Although it has been shown that radiation therapy is a cost effective treatment, it requires high initial capital investment and has high on going operating costs. As a result, radiation has been centralized in regional cancer centres. Traditionally, CCO has focused its capital investments on ensuring there is enough radiation therapy capacity to meet the needs of the population. Of all the services in the cancer care continuum, radiation therapy has the most well developed methodologies to determine the requirements for both radiation machine and human resources. These methodologies previously have been proven accurate in determining the placement and number of investments in facilities and equipment to provide the infrastructure required to treat current volumes of patients. Adding capacity requires the investment of capital resources for the construction or renovation of facilities with significant implementation timelines. This makes accurate and timely capacity planning projections critical to the treatment of cancer patients. 8

11 3.1 Planning Parameters A multidisciplinary provincial expert panel reviewed and revised the planning parameters used to project treatment demand and required capacity. The panel reviewed current practice and benchmarks from other jurisdictions and updated the parameters to ensure the use of current capital infrastructure was maximized to reflect the impact of improved machine utilization as a result of process improvements, investments in new technology, extended work days, and the impact of new and emerging treatment mechanisms. To identify the demand for radiation therapy services to 2020, and to project the resources required to address these demands. We: Assessed current radiation therapy activity Projected the future demand for radiation therapy using growth in cancer incidence and a modest improvement in utilization rates Determined the number of linear accelerators required Assessing Current Radiation Therapy Activity We obtained radiation therapy data for the province from CCO activity level data. Referral rates by county were studied to determine referral patterns. These are presented by region. Projecting the Future Demand for Radiation Therapy Using Growth in Cancer Incidence The demand for radiation therapy in Ontario to 2020 was estimated using the projected growth in cancer incidence based on Ministry of Finance population projections across the province and within each county. Determining the Number of Linear Accelerators Required The number of linacs was based on the radiation treatment required to meet the needs of the provincial population to This calculation included an assessment of six planning parameters: 1. The percentage of cancer patients who need radiation treatment 2. The average number of radiation treatment visits (fractions) per patient 3. The number of radiation treatment visits per hour on a linac 4. The number of hours each linac operates in a day 5. The number of days each linac operates in a year 6. The percentage utilization of the linac 9

12 1. The Percentage of Cancer Patients Who Need Radiation Treatment Radiation cancer patients are distinguished by whether they are receiving: First time treatment Repeat treatment Currently, 38% of new cancer patients in Ontario receive at least one course of radiation. The long term CCO target for the utilization of radiation services is 48%. This is consistent with international standards and reflects current best practice guidelines. Figure 2 Utilization of Radiation Services Across Ontario Many patients will require repeat radiation treatment. Based on trends since 2000, it is assumed that 20% of treated cases each year will have had previous radiation treatments on the same or a different area. The projected utilization rate for radiation treatment services used in this projection model will gradually increase over the next seven years from 38% to 42% by

13 2. The Average Number of Radiation Treatment Visits (Episodes of Care) Per Patient Currently, the number of radiation treatment visits per patient varies across cancer centres. Table 2 Actual Fractions Per Radiation Treated Case However, current Ontario trends suggest an average approaching 20 treatment visits per patient across centres. We used that number for this planning exercise. This estimate is an average only. The number of treatment visits has decreased for some cancers, such as early breast cancer, and increased for others, such as prostate. There also can be varying degrees of complexity and patient mix across regions, which can impact the number of fractions provided. 3. The Number of Radiation Treatment Visits Per Hour On A Linac The number of patients who can be treated per hour on a linac varies according to: The condition of the patient Available technology The complexity of the treatment technique The staffing level on the unit Based on historical Ontario experience and the increasing complexity of treatment delivery including the impact of Intensity Modulated Radiation Treatment (IMRT) the average number of treatment visits per hour is assumed to be 3.4. This number is based on a survey of all radiation therapy managers and on historical radiation data reported to CCO. 11

14 4. The Number of Hours Each Linac Operates In A Day The Expert Panel on Radiation Therapy considered, at length, the issue of operating all linacs 10, 12 and 14 hours a day to maximize the use of currently installed equipment. At present, radiation centres in Ontario operate their equipment an average of 10 hours a day, with some machines operating eight hours and some up to 12 hours a day as required. These variations result from case mix and the technology available. Operating a 10 hour day requires direct treatment services. Support services such as nursing and allied health can be provided through a subsequent visit during regular operating hours by scheduling patients who require less complex techniques, who are unlikely to experience acute side effects requiring immediate intervention, and those without combined modality therapies. Centres with fewer than six machines will be challenged to find the appropriate case mix and related volumes to run all their treatment units longer than 12 hours a day. Operating beyond a 10 hour day requires the availability of support staff outside of direct treatment provision since a higher proportion of patients being treated outside of full service support hours in the centre will not be able to limit direct treatment to those with less complex treatment requirements who are unlikely to experience acute side effects requiring immediate intervention, or combined modality therapies. This is particularly challenging as complex treatment (IMRT/Image Guided Radiation Therapy (IGRT)) becomes the standard of care and combined modality treatment increases. Staffing includes at a minimum nursing staff and physics staff. Alternatives, such as use of emergency departments (ED), are not feasible due to current ED capacity challenges. Laboratory and imaging services are required on an as needed basis to ensure that for patients treated after normal hours, timely laboratory and imaging results are available to manage their care. Funding these indirect hospital costs will be critical to implementing longer day treatment using existing radiation treatment units. Table 3 shows that the total cost per visit is lower when capacity is added through the increased use of current equipment compared with the addition of new space and equipment. Variable operating costs are higher for longer hours of operation due to staff shift and scheduling limitations. 12

15 Table 3 Cost Comparison Based on this analysis and provided additional funding is made available for the indirect costs hospitals incur from managing increased cancer volumes we have projected capacity planning for centres with: Six or more treatment units 12 hours on 100% of their equipment Fewer than six treatment units 12 hours on 50% of their equipment and 10 hours on remaining equipment The challenges in moving to this operational model include managing: Time required for machine maintenance, quality assurance checks, and in some circumstances, clinical research Potential risk that increased use of linacs may result in greater wear, more maintenance over time, increased unexpected downtime and earlier planned replacement. The financial model does not assume a shortened lifespan for equipment as a result of running machines longer The need on the part of hospitals to provide sufficient infrastructure support for 12 hour operations 5. The Number of Days Each Linac Operates in a Year It is assumed that linacs will operate 240 days a year. This planning assumption takes into account staff holidays, weekends and monthly servicing of the machines. 13

16 Consideration has been given to operating routinely on weekends seven rather than five days a week to increase treatment capacity. This currently happens in centres for emergency and some urgent cases. Factors that need to be considered include: Patients cannot be treated for seven consecutive days without a break since the toxicity of treatment has been shown to increase. Thus, the two day break (the weekend) would need to be shifted to use all the treatment slots Since patients treated on weekends could not be selected based on health status and simplicity of management, it would be necessary for the whole, or the majority, of the centre be functioning to support these patients Similarly hospital and community infrastructure supports would need to be in place While operating seven days a week appears to be a way of increasing capacity, the true feasibility needs further exploration. Comparisons with other jurisdictions are difficult since no other cancer system operates based on these parameters. The move to longer workdays Monday to Friday is recommended over moving to a seven day workweek. 6. The Percentage Utilization of the Linac It is assumed that linacs will have 5% downtime. This: Ensures there is sufficient capacity to accommodate variations in patient demand Accounts for unexpected downtime of radiation therapy equipment We have used a 95% occupancy rate to predict capacity. 3.2 Regional Requirements for Capital Investments based on Radiation Treatment Demand Evidence confirms that patients seek healthcare and hospital services within a limited geographic area. 2 A review of CCO s most current referral patterns for radiation treatment services in Ontario confirms that for the most part patients receive care closest to home. 2 Capital Planning and Investment in Ontario s Hospitals, Ontario Hospital Association, November 2003, and CCO review of patients residence and treatment locations. 14

17 Referral rates by region were based on the available county referral patterns from 2010 and adjusted to reflect the introduction of new treatment capacity. The projected regional requirements for treatment capacity were based on the distribution of patients by counties and by treatment centre. Projections regarding required capital investments are made based on regional demand for service and current available regional capacity. While the move to a 12 hour treatment day will be implemented gradually over a three to fiveyear timeframe as demand for treatment warrants and operating funds become available, this projection model assumes that by 2015 treatment units in large centres (six or more units) will provide care to 465 patients annually and smaller centres (fewer than six units) will treat 426 patients annually on all their treatment units. Based on revised planning assumptions and updated cancer incidence projections to the year 2020, the current approved number of treatment units (103) will accommodate the demand for treatment to Table 4 Projected Radiation Treatment Machine Demand by Region Note: Projected demand is driven by the 3% annual increase in the incidence of cancer and a small increase in radiation therapy Utilization (Projected radiation therapy Utilization rate in 2020 of 42% vs. CCO target of 48%) 15

18 Facilities constructed in Durham, Grand River, Newmarket and Barrie contain shielded radiation treatment rooms for which no equipment funding was allocated at the time the project was approved. As demand for treatment capacity warrants, we will seek funding for additional treatment equipment to fill these rooms. Previously, similar funding has been secured for Peel and Durham. Funding requests for this equipment are projected in the CCO Annual Business Plan and have been requested through separate MOHLTC capital project request submissions. In total, six additional treatment machines would be added to the system in these four regions. To facilitate the replacement of radiation treatment units without adversely affecting treatment capacity, we must make earlier investments in cancer treatment facilities, including the construction of swing bunkers. Currently there are rooms without equipment in 10 regions across the province. To maximize the use of these investments and minimize the need for capital investments to construct new facilities, this planning model recommends that these rooms be equipped to provide additional treatment capacity. It takes about one year to get capital funding for operational treatment units. This includes the time associated with procurement, room retrofits, and equipment installation and commissioning. Funding requests outlined in the CCO Business Plan would add a total of 14 treatment units (six in existing unequipped rooms, eight in empty swing bunkers) to existing unequipped treatment rooms across the province bringing the total installed units to 117 by Funding for an additional two units would be requested in 2016 for deployment in 2017 at which time all 119 existing treatment rooms would be equipped. 16

19 Figure 3 Radiation Treatment Machines Proposed Capital Investments When Niagara opens in 2013 there will be 103 equipped rooms and potential to equip six existing empty rooms and 10 swing bunkers. Beyond 2018 additional facilities will be required to house equipment. Flattening of the demand curve between 2013 and 2015 is the result of operating longer hours. Beyond 2017, we will have to realize additional radiation treatment capacity through the construction of new treatment facilities. Detailed planning for these facilities must begin in to ensure that additional treatment capacity in under equipped regions (Table 4) is available by 2018 in: Southwestern Ontario currently served by centres in Windsor and London Western GTA region served by Peel, Grand River, PMH and Sunnybrook North of the GTA served by Barrie, Newmarket, PMH and Sunnybrook Ottawa region Investments in two portable treatment units in Barrie and Ottawa created flexible treatment spaces to address temporary treatment capacity challenges. The treatment capacity from the Ottawa unit s relocation to Peterborough is included in Table 4. The decision on the permanent location for the Barrie unit will be determined when we develop capacity plans for regions that require investments in new or expanded facilities. 17

20 Planning for new or expanded treatment facilities also must consider: Impact of cancer volumes on existing hospital infrastructure Travel distance times for patients Implementation timelines and challenges in the context of other regional initiatives CCO will work closely with LHINs and the MOHLTC to ensure a cost effective, reasonable and achievable plan is developed. 18

21 4.1 Impact of Technology on Radiation Treatment Delivering radiation treatment requires significant upfront technology capital investment. However, given the nine to 10 year lifespan of these treatment devices and the number of patients treated during these timeframes the average capital equipment cost per patient treated is less than $1,000. This is equivalent to the cost of bringing in new drugs to enhance patient treatments. Thus, radiation therapy is cost effective and relatively inexpensive compared with other cancer treatments. Advances in imaging, computer technology and engineering have revolutionized the planning and delivery of radiation therapy. Some of these advances include: Techniques that target radiation on tumours more precisely, while avoiding the surrounding normal tissue (e.g., conformal radiation therapy, IMRT and IGRT). Multiple clinical trials have confirmed that higher doses of radiation can be given with greater tumour control and fewer side effects. Cost effectiveness analyses done by CCO have confirmed the benefits of introducing IMRT to clinical practice Brachytherapy places radioactive sources into or next to a cancer to achieve a very high local dose while minimizing the dose to the surrounding structures Stereotactic Body Radiation Therapy a highly accurate, precise and focused radiation treatment procedure which is now being used in many situations including a potential option for patients with early stage lung cancer who are medically inoperable Biological imaging enables dose sculpting which focuses and shapes radiation exactly where it is needed (e.g., a higher dose is focused on the more active part of the tumour, and a lower dose on the less active part) Genetic markers for cancer are expected to help characterize cancers and may lead to more appropriate selection of patients who would benefit from treatment. Genetic predictors for how tumours will respond to radiation therapy will likely lead to more individualized treatment of patients, and more complex radiation planning and treatment Proton Therapy is a form of radiation treatment that uses beams of protons to deliver more targeted, precise doses than conventional photon beams. Its major benefit is in childhood 19

22 tumours (where it reduces risk of second cancers later in life and decreases normal tissue damage including brain damage in the treatment of brain tumours), and in adult base of skull and ocular cancers. It is currently not available in Canada, and Ontario patients who require this treatment are sent to the United States. The benefits of this approach in childhood malignancies are becoming increasingly evident and it should be noted that in Great Britain the National Health Service (NHS) has mandated that until a proton facility is activated in Great Britain that children with certain malignancies be sent to the U.S. for treatment. CCO will be reviewing the need for this form of treatment to be made available in Ontario The combination of improved access and sophisticated radiation therapy techniques has provided clear benefits to patients in terms of decreased waiting times, better outcomes and reduced toxicity. Access to up to date radiation treatment equipment has numerous benefits for patients and contributes to the provision of exemplary care for individuals requiring radiation treatments. Experience shows that the acquisition of updated equipment can lead to dramatic improvement in patient access as a result of the efficiencies realized through streamlining treatment processes. For instance, the introduction of improved immobilization devices, multileaf collimation for beam shaping, online portal imaging and improved record and verify systems has decreased the treatment time for prostate and breast cancer treatment by up to 50%. 3 These efficiencies translate into increased treatment capacity which results in improved access to radiation treatments for patients and decreased wait times. In addition to improved efficiency, up to date technology improves the quality of radiation treatments provided to patients resulting in fewer side effects and the new opportunity to increase radiation dosage to improve tumour control. IMRT has taken radiation delivery to a higher level of safety and efficacy, and is the standard of care throughout North America for a number of disease sites. Advanced technology has also allowed us to provide treatment in situations where radiation cannot be safely delivered using simpler technology. Capital investments to ensure appropriate technology is available in all cancer centres, the development of disease specific IMRT 3 Glen Bauman London Health Sciences 20

23 guidelines, the availability for coaching and educational courses, and cost effectiveness analysis were all critical factors in the success of the IMRT Implementation Strategy in Ontario. 4.2 Radiation Replacement Funding CCO employs a Radiation Treatment and Related Equipment Replacement Strategy that has been developed to: a) Provide maximum equipment uptime, thus minimizing unforeseen interruptions in patient care due to equipment failure b) Minimize product obsolescence, so patients and staff in Ontario benefit from current technological innovation to improve throughput and patient outcomes CCO through its annual, provincial, multidisciplinary review process prioritizes all requests for replacement grant funding based on criteria, which consider: Improved access to care Quality Impacts on operating costs The provincial context Figure 4 Radiation Replacement Grand Funding Project 21

24 Over the past decade, there has been a 50% increase in the number of treatment units providing care to patients across Ontario. During this period there has not been any increase in base funding to replace treatment units however in 5 of the last ten years the MOHLTC have identified in year funding to augment the replacement grant which has assisted CCO in managing the funding challenges. These units provide critical treatment capacity to ensure equitable timely access to quality care. It is imperative that these installed treatment units remain reliable and modern. Alternative approaches to improve Radiation Replacement Grant funding must be developed to ensure we can keep pace with the requirement to replace old and obsolete equipment. Integrated Cancer Program (ICP) hospitals, through well developed service and maintenance programs, have been very successful in extending the lifespan of treatment units while ensuring their reliability. As a result, these revised planning assumptions do not include any revisions to the machine lifecycles as a result of increasing the operating hours for equipment. These economies mean that in future it will be crucial that equipment replacements occur as scheduled to avoid wait times due to diminished capacity resulting from machine failures. For every week a treatment unit is out of service, 10 patients are added to the wait list. Ultimately, a failure to modernize radiation treatment equipment disadvantages patients, who as a result cannot get good quality treatments. In addition, wait times may increase due to a loss of treatment capacity if recruitment and retention suffers due to inadequate equipment. Finally, failure to renew and enhance our equipment may reduce treatment capacity due to our inability to realize process efficiencies provided through enhanced technology. Continual renewal and expansion of our radiation treatment capabilities carries clear benefits for patients and their families through improved access, decreased wait times and improved techniques that reduce side effects and/or improve tumour control. 22

25 . 5.1 Priorities 1. Gradually move to 12 hour treatment days in large centres on all equipment and on 50% of equipment in centres operating fewer than six treatment units to keep pace with radiation treatment demand 2. Develop alternative approaches to improve radiation grant funding for the replacement of existing radiation treatment equipment 3. Equip already constructed rooms in Newmarket, Durham, Grand River and Barrie, adding six radiation treatment machines to regions where additional capacity requirements were identified when construction of these facilities was approved. The revised planning model continues to support these investments 4. Equip swing bunkers in 10 locations across Ontario to provide additional treatment capacity with minimal investment in new facilities 5. Work with LHINs and the MOHLTC to plan for the construction of new facilities to add radiation treatment capacity in the context of a multidisciplinary treatment setting in three regions of the province. Immediate Priorities 1. Maximize the use of existing capital through: 1.1 Gradually moving over the next three years to 12 hour treatment days in large centres on all equipment and to 12 hour treatment days on 50% of equipment in centres operating fewer than six treatment units. 1.2 Improve use of existing radiation replacement grant funds. 23

26 2. Implement strategies set out in CCO s annual Business Plan for these funding priorities: 2.1 Secure additional funding for the radiation replacement grant to ensure existing infrastructure remains modern and reliable. 2.2 Secure new funding to equip existing treatment rooms in regions where rooms are vacant. 2.3 Work with regions to develop specific plans for capital expansions where required to provide capacity beyond Risks It is imperative that current treatment capacity in the system is reliable. Extending the operating hours and utilization rates for equipment is the most cost effective way to increase capacity. However, this strategy reduces the flexibility to adjust schedules and shift patients across treatment resources when unplanned downtime occurs due to equipment failures. Patient treatment also may be delayed due to equipment failures as equipment becomes old and unreliable due to insufficient replacement funding, thus increasing patient wait times. CCO will work with ICPs to develop tools to monitor equipment performance. 5.3 Conclusion Ontario has significantly improved access to care for radiation patients across Ontario due in large part to the creation of new facilities and funding for radiation treatment equipment. Funding to implement recommendations from previous capital investment strategies has resulted in an equitable distribution of these resources to ensure that patients receive quality care in a suitable environment as close to home as feasible. These achievements must be maintained and additional resources must be committed to ensure the system keeps pace with the growing demand for treatment. 24

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