Risk-based lung cancer screening performance in a universal healthcare setting

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Moving toward patient-based funding through quality-based procedures (QBPs) for GI endoscopy and colposcopy

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Background: As part of the Ministry’s Health System Funding Reform initiative, Cancer Care Ontario is tasked to develop and implement Quality-Based Procedures (QBPs) for programs such as GI Endoscopy and Colposcopy. QBPs are clusters of patients with clinically related diagnoses or treatments that have been identified by an evidence-based framework as providing opportunity for improving quality outcomes and reducing costs. As stated by the Ministry, the goal is to reimburse providers for the types and numbers of patients treated, using evidence-informed rates associated with the quality of care delivered. Methods: QBPs are multiyear and have four key deliverables: Clinical: developing clinical best practices. Funding: tying best practices to pricing. Capacity Planning: understanding procedure types/volumes for capacity management. Monitoring/Evaluation: measuring the QBP’s impact. Developing the QBPs has involved: Creating Clinical Expert Advisory Groups (CEAG) of clinicians who are recognized for their knowledge and expertise. Tasking the CEAG to define quality and develop best practices informed by literature reviews, jurisdictional scans, and guidelines. Documenting these standards and clinical pathways in a clinical handbook, providing information on the practices that should be implemented to ensure consistent care delivery. The development of best practices is imperative to the foundation of the QBP and spans multiple years. Once best practice development is complete, it will be tied to pricing, where the procedure will be micro-costed based on workload, equipment, supplies, and other administrative costs. Results: The QBPs continue to evolve and aim to: Reduce practice variation. Improve patient outcomes. Improve system accountability. Improve cost-effectiveness of services. Effectiveness will be measured through a performance management framework, including an integrated QBP scorecard measuring appropriateness, access, and efficiency. Conclusions: The underpinning for moving towards an evidence-based, patient-based funding model involves defining quality standards and clincal best practices, and applying these guidelines to determine the cost of quality care.

Involvement of ApoE E4 and H63D in sporadic Alzheimer's disease in a folate-supplemented Ontario population

Dysregulation of iron homeostasis is implicated in Alzheimer's disease (AD). In this pilot study, common variants of the apolipoprotein E (APOE) and HFE genes resulting in the iron overload disorder of hereditary hemochromatosis (C282Y, H63D and S65C) were evaluated as factors in sporadic AD in an Ontario sample in which folic acid fortification has been mandatory since 1998. Laboratory studies also were done to search for genetic effects on blood markers of iron status, red cell folates and serum B12. Participants included 58 healthy volunteers (25 males, 33 females) and 54 patients with probable AD (20 males, 34 females). Statistical analyses were interpreted at the 95% confidence level. Contingency table and odds ratio analyses supported the hypothesis that in females of the given age range, E4 significantly predisposed to AD in the presence but not absence of H63D. In males, E4 significantly predisposed to AD in the absence of H63D, and H63D in the absence of E4 appeared protective against AD. Among E4+ AD patients, H63D was associated with significant lowering of red cell folate concentration, possibly as the result of excessive oxidative stress. However, folate levels in the lowest population quartile did not affect the risk of AD. A model is presented to explain the experimental findings.