Prostate cancer screening: The debate continues

By Dr. Zachary Klinghoffer, Urologist, Rouge Valley Health System

Early detection of prostate cancer using the prostate-specific antigen (PSA) blood test has remained a controversial topic for several years. The PSA test is often used as a tool to help detect prostate cancer before men develop symptoms, and before the disease has a chance to spread beyond the prostate.

Most groups agree that the decision to screen for prostate cancer with the PSA test should be the result of a detailed discussion between a man, his physician, and any others who may help the decision-making process, such as a spouse, family member or friend. Various decision aid tools are available to help with this process.

The test cannot provide a definite answer as to whether or not a man has prostate cancer.  In general, the higher the number on the PSA test, the higher the chances of having prostate cancer. However, many men with high numbers do not have prostate cancer (this is called a false positive test), while others with low numbers actually do have prostate cancer (this is called a false negative test).

Several large studies released within the past five years have suggested that using the PSA test to screen for prostate cancer can reduce the number of men who die from this disease. However, these benefits do not come without risks. These same studies suggest that, in order to save one man’s life, a very large number would have to be screened.

Furthermore, some men would be diagnosed with, and potentially treated for, less harmful forms of prostate cancer that may never have had any effect on their lifespans. Numerous medical associations in the U.S. and Canada, such as the U.S. Preventative Services Task Force and the Canadian Urological Association, have taken the results of these studies and interpreted them in different ways.

While some take a “men should be screened” or a “men should not be screened” approach, most recognize that the issue is far too complicated to be reduced to a simple “yes” or “no” answer.

As long as a man has been provided with the appropriate information and resources he needs to make a well-informed decision, as well as the time and opportunity to ask questions of his physician, the choice he makes about PSA screening will always be the right one. 

Rouge Valley gets an 'A' in national CBC rating

By Rik Ganderton, President and CEO, RVHS  

The CBC's the fifth estate issued its splash on its hospital survey yesterday. While we have questions about the survey's analytical validity, the old adage of “there is no such thing as bad publicity” comes to mind and in this case the publicity we are receiving is great! 

The CBC's the fifth estate crunched its numbers from the Canadian Hospital Reporting Project by the Canadian Institute for Health Information. The result — both of our Rouge Valley hospital campuses got an "A" ranking! 

We have accepted, made use of and “taken it on the chin” from many reports and studies in the past. Many have been positive, some critical and even harsh on us during the past several years, particularly when we started our efforts of constant improvement and patient focus. So it is great to read and see stuff on TV that the gives all of the staff, physicians and volunteers of Rouge Valley such well-earned accolades this week! 

Our Board of Directors, Chief of Staff Dr. Naresh Mohan and I have thanked and recognized our doctors, staff and volunteers for this remarkable achievement. It is a reflection of their focused efforts to provide the best patient experience every day. Dr. Mohan was interviewed by the CBC Wednesday (April 10). We have received very positive news coverage. More of his interview may run on the fifth estate Friday at 9 p.m. 

But we will not rest on our laurels. We are on a journey of continuous improvement to be the best – a journey that still has a way to go. We have much exciting and challenging work ahead of us to reach our goal of defect-free healthcare. 

Constant improvement is our daily mantra here! 

PS - 

Here are some relevant links about this national news story. 

• CBC news article - http://www.cbc.ca/news/health/ratemyhospital/story/2013/04/08/hospitals-rankings-story.html  
• The fifth estate ratings of each Rouge Valley hospital campus -- 
• RVAP - http://www.cbc.ca/news/health/features/ratemyhospital/profiles/rouge-valley-ajax-and-pickering-rouge-valley-health-system/  
• RVC - http://www.cbc.ca/news/health/features/ratemyhospital/profiles/rouge-valley-centenary-rouge-valley-health-system/  

Next steps: How to organize “the system” for patients and communities – within our means

By Rik Ganderton, President and CEO, RVHS

We are taking the next steps in the evolution of the health care system at Rouge Valley Health System (RVHS) and as with any change process, these first few steps will be among the hardest.

We will be analyzing what services our communities need and how best to meet those health care needs within the constraints of the global and Canadian economy and the financial environment in Ontario. I outlined this context in my blog of Nov. 23, 2012.

The changes we are considering will take analysis, careful thought, creativity, open communication, consultation and expedient action to address the burning question: How do we provide the range of services that meet the greatest needs of the communities at the highest quality and in the most fiscally responsible way within our limited resources? 

We know that highest quality care doesn't always come from hospitals offering a wide array of specialized services.  We know that it costs more to try to do this because we cannot efficiently provide services that we perform only occasionally, and worse still, we cannot deliver these services at acceptable quality levels. This has been a challenge that hospitals have faced, but rarely talked about, for decades.

We know that choosing which specialties to focus our resources on will result in better outcomes, with fewer complications and fewer return visits for our patients. We also know that everyone would much prefer to have everything available in their local hospitals. So this is the balancing act we must achieve – delivering a range of services targeted at the greatest community need at the highest quality within constrained financial resources.

This is our opportunity to focus our resources to address the greatest community needs and grow the critical mass where we choose to specialize. We have already made some of these choices in previous strategic planning exercises, such as cardiac care, high risk maternal/child and advanced paediatrics. The process we will follow will identify those things that we do only occasionally or that we do not do well and we will then have to stop doing those things. 

It's our job, as health care providers, to inform our communities that attempting to be all things to all people is not good for their health, not sustainable and not affordable. In short, we want our communities, our patients, and our team, to know that that there are hard decisions ahead.

* Analysis *
We are seeking objective, expert advice to analyze and strategize on next steps that will allow us to provide an appropriate range of services to our communities.

There are two facts that are driving the analysis:
•    The hospital projects that, during the next three years, we will need to remove an estimated $30 to $45 million from our cost structure. Of this, some $15 million relates to the 2013/14 fiscal year (Year 1).  We have already identified the majority of Year 1 savings, which will include some staff reductions which were recently announced to our employees. Our focus is now on future opportunities in 2014/15 and 2015/16 fiscal years.
•    There is acknowledgement amongst our hospital Board, medical leadership and senior management that we have untapped opportunities for greater collaboration and integration across our hospital sites as well as with our colleagues in the Central East Local Health Integration Network (CE LHIN).

The hospital is seeking expert assistance to develop a plan that will address the following questions:
1.    Which services should we expand, maintain or reduce in order to provide the appropriate quality and access to acute care hospital services that the community needs?
2.    Which site or sites should host which of the hospital’s clinical programs? What are the financial opportunities and implications, if any, that reconfiguration would offer?
3.    What is the impact on health care service access in our community (west Durham and east Toronto)?
4.    What are the financial opportunities, if any, in a reconfiguration of services (what’s offered and where)?
5.    What leadership models would best support the achievement of standardized processes, quality, effectiveness and financial performance (value for our tax dollars) and at the program and service level, including implementation of any recommended changes?
6.    What is the road map for redefining the scope and size of hospital services during the next 18 to 24 months? 

The hospital expects the plan to focus on creating a stronger organization that serves the greatest needs of the east Toronto and west Durham communities, as part of an integrated delivery system within the CE LHIN. 

Specific requirements of the study are:
•    Identification of hospital core and non-core services for each clinical program;
•    Recommendations regarding service profiles and appropriate site or sites for the hospital’s clinical and support programs that will assist the hospital in meeting its operational challenges;
•    Recommendations regarding opportunities for enhancing RVHS competitive positioning under the recent and anticipated provincial funding and service model changes;
•    Recommendations for clearly articulated identities for both hospital campuses that are compelling, respond to community needs and are consistent with directions from the Ministry of Health and Long-Term Care and the Central East LHIN;
•    Recommendations that identify partnership opportunities within the Scarborough and Durham communities and the CE LHIN; 
•    Specific plans, actions and timelines that will allow the hospital to meet its operational challenges in year two and year three.

* Process *
It is the hospital’s expectation that the process used to meet these requirements will be:
•    Built on our existing Strategic Plan;
•    Evidence-based from known and valid sources;
•    Dynamic, engaging and paint a vision that is compelling for all participants;
•    Inclusive, transparent and engage the community in west Durham and east Toronto, our staff, physicians and volunteers.

Our analysis and planning make only a few assumptions, among them that community level birthing and pediatric services as well as emergency services will be maintained at each of our hospital campuses in Ajax and in east Toronto.
We are expecting to have a preliminary report in April and will be sharing this with our communities and partners at that time.

. . . 

As always your thoughts, questions and comments are welcome in this series of blogs discussing how we can provide the best care to patients within available resources.
Please either post your comments to this blog, or email us at communityrelations@rougevalley.ca. 

Why big changes are needed in our health care “system”

By Rik Ganderton, President and CEO, RVHS 

This blog may be considered controversial by some and beyond the purview of a hospital CEO. I am writing it because, as a leader in the system I need to communicate the valid need for change and what is driving that. The need has been there for years. The difference now is the globally-precipitated financial crisis. I am not taking political sides, but am saying the system needs to change.

It has been widely reported in the media that the province has a $14 billion annual operating deficit and accumulated debt of $237 billion. The accumulated debt represents approximately $17,770 for every man, woman and child in Ontario. The province’s annual revenues were $106 billion in 2010/11. (This is all the money the province collects from taxation and user fees, which are the government’s only source of income). So the accumulated debt is 2.25 times the province’s annual revenue.

While there are diverse, if not diametric opinions, on the reason for the deficit and the debt, there is considerable consensus that a major causal factor is the global financial crisis of 2008 and the subsequent anemic economic growth globally. By March 31, 2018, the projected date by which the province has publically said it will balance the annual books, the accumulated debt is expected to be some $275 billion. The Wall Street rating agencies have been to town and have said that if Ontario wants to retain its credit rating it has to get its fiscal house in order. This mandate will apply to any future government, regardless of political stripe.

One of the ways the province is balancing the annual books is by reducing the rate at which health care expenditures are growing. The government is trying to cap that rate to 2.5 per cent a year. That’s no small order. In the last 10 years, health care spending increases amounted to more than six and a half per cent a year.

Currently the province spends $47 billion per year or 42 per cent of its annual revenue on healthcare (hospitals, doctors, homecare, long-term care, community care and drugs). So there really is no need to change very much in the health care system as long as we keep spending more, right?

In my opinion – wrong!

Hidden in the numbers are three important facts that have profound implications for how health care is delivered.

1.     The population of the province will grow by a little more than one per cent a year over the next few years. Every one of these additional people will be entitled to health care.

2.     We are all aging and the impact of this, on health care demand, will result in yet another increase of a little more than one per cent.

3.     We have to deal with inflation factors, such as increasing costs of supplies, drugs and salaries of unionized and non-unionized employees, and billing rates of doctors.

In real terms that 2.5 per cent will be eaten up by growth in demand through aging and population increases. That means every nickel for increased salaries or supply and drug costs, not offset by improved efficiency, will result in real service reductions unless we quickly restructure how we deliver services.

From a hospital perspective the impact is likely to be greater. In Ontario’s Action Plan for Health Care, the government has also said that it intends to shift certain procedures and care from hospitals to community based care – increasing investment and shifting resources to the community by four per cent a year. Since hospitals are the largest component of health care expenditures it is pretty clear that they will be one of the main places from which to take those health care tax dollars. (Physician services are likely to be the other one). This may not necessarily be a bad thing; hospitals are often not the most cost efficient delivery model for many services.

In my opinion there is very little financial wiggle room left to avoid the necessary and needed restructuring of the health care system.

The suits from Wall Street are watching and the debt rating is crucial. If the province’s debt rating decreases, then the province’s cost of borrowing increases. The government’s ability to fund health care is diminished even more by every dollar spent on interest payments. Any future government will have the same problem.

Furthermore, there is ample evidence demonstrating that the current health care system is not really a system. (Ask most patients trying to navigate through it!) It is inefficient, quality is not consistently high, access is confused with geographic proximity and a high quality patient experience is often lacking.

In my view there is currently enough funding in the health care system (with the proposed 2.5 per cent annual budget growth) to meet patient need during the provincial budget balancing cycle. However, the status quo is not an option if we are to achieve this. We have to fundamentally change the delivery model and create a real “system” not a bunch of fragmented silos. 

Here are a few examples of such fundamental changes needed:

• We need to eliminate the fragmented governance and create real integrated delivery organizations that are accountable for quality, access and cost across the continuum of care - this means reducing the number and levels of governance/boards;
• Good quality is more important than proximity to mediocre or poor quality service that is available just around the corner – we must consolidate services to drive quality and cost effectiveness;
• We have too many physical hospitals (particularly in the GTA) – many are aging and are too expensive to maintain – we need to merge and rationalize our physical plant so that we can deliver more and better care more efficiently. (We can pay for much of the upgrades and new facilities from the savings gained by eliminating old plants.)
• We need to understand and accept the research evidence that shows that aggregating services increases quality and efficiency – this means physicians and other clinicians with specialized expertise need to move and work together in hospitals which will focus on services and patients they are trained to serve;
• Hospitals cannot be all things to all people - many procedures can be done outside a hospital more cheaply, safely and with better quality outcomes;
• We have to deliver care using best practices – Medicine is more science than art these days and using best practices and measuring compliance by all care providers is critical.

In the coming electoral campaigns we will hear much in the way of promises from every political party. The provincial financial numbers paint a serious picture, irrespective of which political party occupies Queen’s Park!

There is a danger that we will tax our way out of this need to change. Raising taxes to provide more health care funding would be wrong as we would be wasting more money on an inefficient system and delaying the inevitable – fundamental change that is required.

Health care has to change. The way we are presently organized is a barrier to delivering better quality and better value for our limited tax dollars. We need the political will from every party to support change that is necessary and inevitable. Moreover, we need our citizens, and voters, to fully understand the problem, to contribute to the debate on solutions, and to accept and support the solutions required to create a sustainable health care system.

…

This blog is part of a series we’ve been talking about this year on transforming health care. We will have more to come. In future blogs I will talk about some of the alternatives for the needed restructuring.

I welcome your views on this topic. What options seem realistic to you, or what would you propose?

* Post a comment or email communityrelations@rougevalley.ca.