Comprehensive Cancer Care Networking (CCCN) as effective cancer management model: pilot project of the (2014 -> 2017)

Institute of Biostatistics and Analyses , , Czech Republic www.iba.muni.cz Czech cancer care in 2013: many challenges

Opportunistic Population-based cancer screening ?interventions

2013 High and growing Management of cancer incidence ? growing burden

Regional set of cancer centers Equal access to ? high quality care Pilot model of the CCCN -> Main PRINCIPLES adopted

Common information system

Organized structure (multi-tier model)

Implemented cancer management protocols

Multidisciplinary assessment of patients (CCs boards)

Common governance including control (QA/QC indicators)

Quantified and mapped collaboration with neighboring regions

Emphasis on complexity of the system: controlled patient pathways

CC(s) CCCN(s) ? Evolutionary – step by step – transformation ! Pilot CCCN -> Main BARRIERS to overcome

Legislation

allowing data FUNCTIONALE centralization

Representative cancer care model

Support of - stakeholders HEALTH and payers

LEGAL BACKGROUND LEGAL Functional reimbursement mechanisms Pilot CCCN -> IT infrastructure for cancer care networking

Epidemiology Equity of health Population-based care registries Structure of health care Population and treatment burden National Cancer Registry Results of health care

Hospitals Quality of Specialized health care registries REPORTS Hospital information systems Local and national registries Distribution of Monitoring of health care health care EHR Volume of health care Primary care (GPs, gynaecologists) Hospital care Data validation Specialized care and cancer centres Complexity of the CCCN = complexity of its ICT background

SEGMENT VIEW Diagnostics & therapy

Prevention Palliative Primary Follow-up screening care care Supportive care

INDIVIDUAL VIEW

Diagnostics Therapy Supportive care Palliative care Established Pilot CCCN - written agreement - CCCN structure - CCCN territory

Spatially closed, geographically interconnected regions

Fully representative demographic, social and epidemiologic attributes

Sufficient demographic mass of people (patients) Target area of the CCCN

Together, South Moravian Region and the Vysočina Region (target area for CCCN) account for 18% of the total area of the Czech Republic. Although these two regions are geographically next to each other, their remote parts are very different and provide thus representative sample for piloting of CCCN.

SW

South Moravian Region Vysočina Region Both regions Population (as of 31/12/2015) 1 175 025 509 475 1 684 500 Area (km2) 7 195 6 796 13 991 Population density (per km2) 163 75 120 Number of districts 7 5 12 Number of municipalities 673 704 1 377 Total length of roads and motorways (km, estimation) 4 500 5 000 9 500 Total length of railway network (km, estimation) 800 650 1 450 Demography in the CCCN area (2015) – benchmarking

The distribution of age groups in the population

Men Women

South Moravian and Czech Republic South Moravian and Czech republic ]

] Vysocina Regions Vysocina Regions %

% 10 [ [ 10

9 9

8 8

7 7

population population

6 6

the the in in in in 5 5

4 4

3 3

groups groups

2 2

age age 1 1

0 0

Various Various

0 - 4 5 - 9 85 + 0 - 4 5 - 9 85 + 10 - 1415 - 1920 - 2425 - 2930 - 3435 - 3940 - 4445 - 4950 - 5455 - 5960 - 6465 - 6970 - 7475 - 7980 - 84 10 - 1415 - 1920 - 2425 - 2930 - 3435 - 3940 - 4445 - 4950 - 5455 - 5960 - 6465 - 6970 - 7475 - 7980 - 84

Age groups Age groups

Source: The Czech Statistical Office Cancer incidence (2013–2015) – benchmarking

MEN CCCN area Number of reported cancers WOMEN CCCN area Number of reported cancers CR annually per 100,000 men CR annually per 100,000 women 0 100 200 300 0 100 200 300 other malignant neoplasms of skin (C44) 262 other malignant neoplasms of skin (C44) 229 prostate (C61) 133 breast –women (C50) 125 62 colon and rectum (C18–C20) 92 colon and rectum (C18–C20) uterus (C54, C55) 38 trachea, bronchus and lung (C33, C34) 77 trachea, bronchus and lung (C33, C34) 28 kidney (C64) 37 kidney (C64) 21 bladder (C67) 28 ovary (C56) 20 oral cavity and pharynx (C00–C14) 20 pancreas (C25) 18 19 pancreas (C25) cervix uteri (C53) 16 19 malignant melanoma of skin (C43) malignant melanoma of skin (C43) 16 17 stomach (C16) thyroid gland (C73) 14 leukaemias (C91–C95) 16 non-Hodgkin lymphoma (C82–C85, C96) 13 12 non-Hodgkin lymphoma (C82–C85, C96) 15 leukaemias (C91–C95) 11 liver and intrahepatic bile ducts (C22) 11 stomach (C16) 10 9 testis (C62) gallbladder and biliary tract (C23, C24) 8 9 bladder (C67) oesophagus (C15) 7 8 brain and spinal cord (C70–C72) brain and spinal cord (C70–C72) 7 8 oral cavity and pharynx (C00–C14) larynx (C32) 5 6 liver and intrahepatic bile ducts (C22) multiple myeloma (C90) 4 multiple myeloma (C90) 5 3 gallbladder and biliary tract (C23, C24) Hodgkin lymphoma (C81) 4 thyroid gland (C73) connective and soft tissue (C47, C49) 2 3 1 Hodgkin lymphoma (C81) oesophagus (C15) 3 1 connective and soft tissue (C47, C49) larynx (C32) 32 other malignant neoplasms 33 other malignant neoplasms

Source: Czech National Cancer Registry (IHIS CR) Pilot CCCN: South Moravian Region and Vysocina Region – cancer care infrastructure –

Type of health care facility www.onconet.cz Comprehensive Cancer Centre [n=1] Cancer Centres [n=3] CCCN Children’s cancer centres [n=1] Haemato-oncology centres [n=1] Constituent parts of CCCN [n=4] HCF cooperating with CCs [n=20] Mammography screening centres [n=13] Colonoscopy screening centres [n=29] LCTHs and hospices [n=20] All [n=92] Pilot CCCN in institutional view

CCC Masaryk Memorial Cancer Institute www.mou.cz

CC FN Brno CC FNuSA www.fnbrno.cz www.fnusa.cz Institute of Biostatistics Masaryk University and Analyses Faculty of Medicine www.iba.muni.cz www.med.muni.cz

CCCN information system Education – Training ICT background CC Certification Data analyses www.nemji.cz Research

Region Vysocina - coordinating cancer centre -

CCCN collaboration Practical implementation: written agreement

Common governance – given structure –

– multidisciplinary assessment

Common protocols –

– QA/QC standards – common information system Practical implementation: common governance

 Management coordination and leadership  Network managerial board  Network governance, financial management  Involvement of stakeholders, patients Managerial leadership Coordination Independent evaluation team Clinical QA/QC control leadership  Quality and performance evaluation Standards of care  Management of ICT background  QA/QC, reporting, predictions  Cancer care standards and pathways  Standardization of protocols and procedures  Multidisciplinary tumor assessment  Quality control with clinical feedback  Research activities Examples of outcomes I.

ICT background and e-communication tools www.onconet.cz

Comprehensive cancer centers Hospital facilities in general Supportive and palliative centers

Screening centers Primary care specialists www.onconet.cz

Diagrams of cancer care available for each region

PDF download

Regional models of cancer care, presenting professionals and navigating patients

Interactive maps

Access points www.onconet.cz Comprehensive cancer care Regional models of cancer care

Map of facilities involved in comprehensive cancer care

Types and numbers of facilities

Diagram of cancer care

Link to a regional Cancer Centre

Regional news

Detail of a health care facility www.onconet.cz Comprehensive cancer care Cancer Centres On-line

Equipment characteristics

Clinical research

Information systems

…and more Examples of outcomes II.

Data processing and reporting - performance – patients’ flow – equity – QA/QC system

Population level: epidemiology Hospital-based information systems

Predictions of cancer burden Indicators of CCCN functionality CCCN pilot: performance, quality and outcome assessment

Specialized Epidemiological Hospital data registries registries /EHR/ (surveys)

CCCN coverage in Access to CCCN Social & Equity catchment area entry points demographic Performance Volume of care Consumption typology of rates treated patients

(Re)distribution of Pathways: Pathways: specific Patient care primary and therapeutic pathways Inter-regional follow-up care procedures / drugs migration for care

Performance of Time aspects of Standardized No. of patients enrolled tumor diagnostics, protocols Patient flow management staging, follow-up teams

Population-based Hospitalization- Clinical trials Safety, efficacy reference: related safety Adverse events, Outcomes mortality and and outcome Patient’s survival measures satisfaction Examples of reporting generated by the Czech National Cancer Control System: I. Population level Model diagnosis: colorectal cancer – CCCN area

Main trends: Main trends: Clinical stages: primary diagnosis incidence & mortality prevalence TNM 2. TNM 3. TNM 4. TNM 5. TNM 6. TNM 7. 90 600 100% +3,2 % +54,2 % 80 incidence 500 70 mortality 80% 60 400 50 60% 300 40 40% 30 200 -12,0 % 20 100 20% 10 %: trend change 2003–2013 %: trend change 2003–2013

0 Counts per 100 per 100 000 inhabitants Counts

Counts per 100 per 100 000 inhabitants Counts 0 0%

1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 1977197919811983198519871989199119931995199719992001200320052007200920112013 Incidence Mortality Prevalence (31.12.2013) Absolute counts in 2013 1 213 528 Absolute counts 9 176 Stage of the disease Counts per 100 000 in 2013 72,2 31,4 Counts per 100 000 546,5 1 2 3 4 unknown not recorded

Survival of patients in time trends Stochastic predictions Stochastic predictions of incidence and prevalence of therapeutic burden

5yr relative survival Predictions for 2016 Colorectal carcinoma Colorectal carcinoma Newly treated patients Colorectal carcinoma (95% IC) (C18-C20) (C18-C20) in 2016 (C18-C20) Incidence Prevalence 2001–2006 2007–2012 312 3636 Stage I (272; 352) (3498; 3774) Stage I 272 (234; 310) All patients 58.3 (56.3–60.2) 68.2 (66.4–70.0) 282 2817 Stage II (243; 321) (2695; 2939) Stage II 263 (248; 300) stage 1 87.0 (82.4–90.5) 94.2 (89.6–96.8) 329 2575 Stage III (287; 371) (2458; 2692) 267 1308 Stage III 306 (266; 346) stage 2 72.3 (68.3–75.9) 84.2 (80.4–87.3) Stage IV (230; 304) (1225; 1391) 56 526 stage 3 50.6 (46.9–54.2) 66.7 (63.5–69.7) Stage unknown Stage IV – incidence 178 (147; 209) (35; 78) (475; 577) 1246 10862 Disseminated relapses / stage 4 12.0 (9.7–14.6) 15.8 (13.6–18.2) TOTAL 234 (199; 269) (1165; 1327) (10624;11100) progressions TOTAL 1253 (1172; 1334) Examples of reporting: predictive mapping of cancer burden Model diagnosis: colorectal carcinoma

INCIDENCE PREVALENCE CRC (95 % CI) (95 % CI) (C18 – C20) ------Prediction: 2016 ------2050 21 376 Stage I (1903; 2197) (21 136; 21 616) 1951 19 104 Stage II (1844; 2057) (18 877; 19 331) 2117 15 114 Stage III (2010; 2226) (14 912; 15 316) 1631 7083 Stage IV (1359; 1903) (6945; 7221) 8037 65 331 TOTAL (7298; 8777) (64 911; 65 751) Examples of reporting generated by the Czech National Cancer Control System: II. Hospital level Model diagnosis: colorectal carcinoma – CCCN area

Distribution of care among Volume of primary care: Benchmarking of outcome measures: regions/centers capacity of CCCN Survival after given medication vs. EBM trials 2006-2010 N = 54 360 600 1,0 Registr CORECT medián OS - 28,4 měsíce 500 Studie AVF2107g* 0,8 medián OS - 20,3 měsíce Studie NO16966 * 400 medián OS - 21,2 měsíce 0,6 300 Medián OS 0,4 200

0,2 Treated / patients year Treated 100

0 0,0 0 12 24 36 48 60 72 84 96 1 6 11 16 21 26 31 36 41 46 51 Čas (měsíce) Rank of hospitals

Migration of patients Incidence and prevalence of treated CRC Benchmarking of outcome measures: /Example of one CCC/ patients: benchmarking 5yr survival – population comparisons

N = 16 306 350 Incidence 300 Care only in one 250 Average CCC 200 facility . counts Range 150 Migration in primary 100 therapy Cumul 50 0 Migration after primary 150 therapy Prevalence 100 Migration in follow-up

Counts 50 Unknown 0

Rok 2007/032007/072007/112008/032008/072008/112009/032009/072009/112010/032010/072010/11 Example of reporting: clinical outcome assessment Model diagnosis: colorectal carcinoma

Population-based monitoring

CRC: 5-yr relative survival Hospital-based Cohort Cohort Period Period benchmarking 1990–1994 1995–1999 2005–2009 2010–2014

Stage 1 64,9 % 76,2 % 87,6 % 91,8 %

Stage 2 48,4 % 62,9 % 73,7 % 79,4 %

Stage 3 40,0 % 41,8 % 54,5 % 62,2 %

Stage 4 12,0 % 10,7 % 13,9 % 16,2 %

Total 47,9 % 51,7 % 59,4 % 65,4 % Examples of reporting generated by the Czech National Cancer Control System: III. Screening program Model diagnosis: colorectal cancer – CCCN area

CRC screening: regional CRC screening: age-specific FOBT positivity: time trend and coverage coverage regional

Men and women aged over 50 Coverage in Coverage by Men and women aged over 50 10% percents screening Positivity

< 25,0 7,0% One-year Two-year 8% 6,8% 25,0-30,0 interval 5,8% 5,9% 50% interval 30,0-35,0 Muži Ženy 6% 35,0-40,0 > 40,0 40% 4%

2% 30% 0% 2011 2012 2013 2014 20% Year 14% 10% Positivity 12% 10% 0% 8% 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 6% 4% Age group 2% 0%

Region

Coverage in time trend: Share of primary care Primary screening 2013 vs. 2014 specialists Colonoscopy – regional coverage

Men and women aged over 50 Women aged over 50 Men and women aged over 50 Number Difference (%) Year 2011, N = 52 462 examinations Year 2012, N = 53 716 examinations per 10,000 < 3,0 8 (0,01%) other/unknown expertise 29 (0,06%) other/unknown expertise < 10,0 3,0-4,0 10,0-20,0 4,0-5,0 20,0-30,0 5,0-6,0 30,0-40,0 > 40,0 > 6,0 86,5% 13,4% 86,5% 13,5%

Year 2013, N = 57 089 examinations Year 2014, N = 70 415 examinations 8 (0,01%) other/unknown expertise 2 (<0,01%) other/unknown expertise

86,9% 13,0% 88,1% 11,9%

Practitioner Gynecologist SW Moravia CCCN in its web portal

cccn.onconet.cz Examples of the CCCN assessment. I. Coverage of TM teams

Place of treatment of all malignant neoplasms (C00–C97) without C44 from the South-West Moravian region Annual average number of MN Malignant neoplasms (MN) in % in SW Moravia Region of 0% 20% 40% 60% 80% 100% residence: 2006–2007 27 25 46 2 N = 2,152

Vysočina 2011–2012 32 26 39 2 N = 2,194 region

2013 32 28 38 2 N = 2,228

2006–2007 74 1 24 1 N = 4,424

South Moravian 2011–2012 76 1 22 1 N = 4,727 region

2013 76 1 22 1 N = 4,784

CCCN: Vysočina + South 2014–2015 82 1 16 1 N = 6,998 Moravia

treated in the CCCN: period of started collaboration (2014–2015) treated in separated CC in the region (prior to the CCCN establishment) Place of therapy: treated in other CC (out of the region - prior to the CCCN establishment) treated in other hospital in the region treated in other hospital in other region

Data: Czech National Cancer Registry Examples of the CCCN assessment. II. Patient pathways

Patient pathways: I. Vysočina region → South Moravian region II. South Moravian region → Vysočina region III. Vysočina region CCCN healthcare facilities → HJI IV. HJI→ Vysočina region CCCN healthcare facilities IV. V. Distribution among Vysočina healthcare facilities IV. VI. Distribution within cluster of Brno cancer centers III. III. IV. III.

III. IV. V. VI. II.

Healthcare facilities in the CCCN: Jihlava Hospital (HJI) I. 8 574 annually - unique patients hospitalised Hospital in Nové Město na Moravě (HNM) for cancer in 2014/2015 Hospital Havlíčkův Brod (HHB) Hospital Pelhřimov (HPE) Hospital Třebíč (HTR) 60.3% patients with one hospitalisation The University Hospital Brno (UHB) for cancer in 2014/2015 Masaryk Memorial Cancer Institute (MMCI) 39.7% patients with two or more St. Anne’s University Hospital (SAUHB) hospitalisations for cancer in 2014/2015 CONCLUSIONS & FUTURE STEPS

“Export“ of the CCCN model to the whole country -> changes in the National Cancer Control Plan

Promotion of CCCN outcomes Workshops and conferences Revision of the National Cancer Control Plan New norms of the Ministry of Health Lessons learned and future challenges 1. Legislative support for merging different data sources, e-Government rules for assessment of care in chronic diseases.

2. Standardization of cancer management protocols and sharing of clinical experience. Standards for multidisciplinary tumor assessment groups.

3. Management of rising cancer prevalence - optimization of cancer patient pathways in the system, role of different segment of care.

cccn.onconet.cz 4. Financial management of innovative therapies (modes of risk sharing, rare cancer treatment, …) Special thanks to project expert guarantors and clinical leaders

Prof. Jan Žaloudík, MD, PhD Jiří Běhounek, MD Masaryk Memorial Cancer Institute Vysočina Region Director Governor

Prof. Rostislav Vyzula, MD, PhD Lukáš Velev, MD, MHA Masaryk Memorial Cancer Institute Hospital Jihlava Head of Department of Comprehensive Director Cancer Care

Prof. Jiří Mayer, MD, PhD Lubomír Slavíček, MD, PhD University Hospital Brno Hospital Jihlava Head of Department of Internal Head of the Department of Cancer Care Medicine, Haematology and Oncology Dean of Faculty of Medicine, Brno

Prof. Jaroslav Štěrba, MD, PhD Prof. Lucio Luzzatto University Hospital Brno Leader of WP6 CANCON Head of Department of Paediatric Oncology

Prof. Vlastimil Válek, MD, PhD, MBA University Hospital Brno Head of Department of Radiology Thank you very much for your attention