RIO DE JANEIRO NOV 2016

FUNDACION ARTURO LOPEZ PEREZ torzsok@falp.org

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Briefly

• What is FALP • The New RT challenge • Modelization of the project • Productivity issues and quantum leap • Relation to medical outcomes • The importance of a global cancer

management system

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Time lapse 1954-2016

• FALP is a NGO, NPO founded 62 years ago • Acting as a stand alone “cancer only social

security” system in Chile • Covering for 20 Eu/month/family cancer

specialities: surgery, chemotherapy, RT • 500.000 suscribers of Falp cancer insurance • Due to local factors, RT was historically

poorly reimbursed in Chile thus inhibiting new investments in the field

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Un modelo integrado y solidario de salud MEDICINA ONCOLOGICA PERSONALIZADA: RADIOTERAPIA AVANZADA –CIRUGIA COMPLEJA -ONCOGENOMICA

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• Create an RT activity with high added value • Of recognized quality and patient centered • Offer a wide range of therapeutic tools • Competitive solutions in terms of tecnology,

quality control and pricing • Quantum leap: show how more advanced is less

complicated and efficient gap bridging • Create a comprehensive cancer center on the

existing bases started 60 years ago

The vision: new state of the art RT

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Modelization: Time lapse 2013-2015

• Preparation of the de radiation shielding project

before the arquitectural plans (Q2-2013) • High complexity due to the fact that it had to be

build below an existing building • Need of a highly collaborative setup in the area

design • Choice of equipment • Choice of wide range of QA tools • Modelizacion of Mosaiq paperless management

system • HL7 external systems interfaces

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First project 08-2013

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Flaws in RT management in general

• Buy machines but not foresee:

– radiotherapy solutions and workflow implications

• the importance of organizational factors

– Team building

• Training issues

– Learning to work together – Quick and easy response to IGRT and SBRT treatments team work – Solve any possible communication problems through careful department

planning • Generalized and centralized data access in order to tackle: medical,

technical and administrative records plus all the department resource mangement

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Time consuming workflows los tiempos indicados en la tabla son por paciente y por caso simple

Aplicar factor de complejidad para cualquiera de las tecnicas POR PACIENTE Simple : los tiempos indicados en la tabla

mediano : x 2 los tiempos indicados en la tabla complejo: x 3 los tiempos indicados en la tabla

HITOS PRINCIPALES STAFF 3D Varian 3D ELEKTA TOMOTHERAPY VMAT CYBERKNIFE

key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff

1. Evaluacion clinica Comité Multidisciplinar MD residentes 9 horas semanales en promedio por medico

decision terapeutica e etapificacion recepcion 0.5h de cordinacion para recepcion

2. 1ra Consulta y prescripcion RT Seleccion del protocolo de tratamiento MD residentes 1 hora en promedio por medico

Prescripcion: volumenes y fraccionamiento

3. appointment management escaneo de documentacion pacientes, confeccion de agendas, tarjetas de seguridad recepcion TENS 20 minutos por paciente por recepcion o TENS

x2 si cordinaciones con QT, internas externas, convenios con requisitos

4. CT, PET SCAN e inmobilization optimizar aditamentos, adquisicion de escaneos 1 TM MD, M. Phys. 30 minutos por paciente por TM y TENS

1 TENS

5. determinacion de volumenes volumenes Target MD 1h 1h 2h 2h 3h

Organos a riesgo TM MD 1h SN 1h SN 2h SN 2h SN 3h SN

preparacion estudio global si fusion TM M. Phys. SN SN SN SN SN

6. Planificacion de tratamiento construccion y calculo del plan de tratamiento TM M. Phys. 1h SN 1h SN NA 1h NA 1h 4h 4h

7. Fabricacion de protecciones en Cerrobend TENS TM 0.5h NA NA NA NA

8.exportacion a RV documentacion de parameteros de tto TM M. Phys. 1h 0.5h 1h 0.5h NA 0.2h 1h 0.5h 1h 1h

preparcaion estudios de firma IP, CBCT, TOMOSCAN, tracking

9. Patient QA M. Phys. NA NA 1H 1H 1H

10. Tratamiento firma Ok inicio de tratamiento TM, MD M. Phys. 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN

tratamientos diarios 2 TM M. Phys. 2 x 0.25h SN 2 x 0.25h SN 2 x 0.5h SN 2 x 0.25h SN 2 x 1h SN

fraccionamientos por tecnica 5 a 6 semanas 5 a 6 semanas 3 semanas 3 a 4 semanas 1 semana

11. evaluacion paciente durante el tto consulta semanal MD, residente Reception 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.5h *una semana tto

Recepcion: informes, peticiones y licencias varias

12. revision semanal expediente y citas clinico administrativa TM TENS 0.5h 0.1h 0.5h 0.1h 0.1h 0.1h 0.5h 0.1h 0.5h NA

Imagenes MD TM 0.1h 0.1h 0.1h 0.1h NA NA NA NA NA NA

13. Fin de tratamiento reporte, epicrisis e archivo papel MD reception 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h

14. facturacion facturacion y reporting reception M. Phys. 1h SN 1h SN 1h SN 1h SN 1h SN

15. consultas de seguimiento post tratamiento consulta de seguimiento : evaluacion tratamiento y complicaciones MD residents SN 0.3h SN 0.3h 0.3h SN SN 0.3h 0.5h NA

QA Diario ACTIVIDAD TRANSVERSAL TM M. Phys. 3.75h 0.5h 3.75h 0.5h 3.75h 0.5h 3.75h 0.5h 3.75h 0.5h

QA mensual semestral annual promediado M. Phys. M. Phys. 4h 4h 4h 8h 12h 9

Final project 08-2014 Improved WORKFLOW through gaining 90m2 of open space for collaborative spaces

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Workflow optimizing

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2D 1970

3D 1980

IMRT 1999

IGRT 2006

VMAT IORT Tomotherapy Cyberknife 2010

Proton / IMPT

Carbon ion

RT ADAPTAVE…. FALP OCTOBER 2015

How to make up for the lost decades?

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RT in 50 years

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what is the (level 1) evidence? the budgetary impact? the cost? the value for money?

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Methods of economical analisis in healthcare

Cost minimizing Allegedly all the benefits of competing treatments in terms of survival and y quality of life are the same. only the cost of a new treatment vs. Standard treatment is considered. The treatment of choice is the cheapest ! Value expressed in : U$

Cost effectivity The cost of an intervention is related to its impact on clínically relevant end point ("effectiveness”)… like: global survival Incremental Cost-effectivity Ratio (ICER) is the incremental cost, divided by the incremental benefit of a new intervención relatively to the STANDARD one. Value expressed in : U$ per year of saved life or U$ per QALYs US $ 50.000 / year of saved life

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extra cost extra effect

new treatment

cost per life year gained (LYG) = incremental cost-effectiveness ratio

cost per quality-adjusted life year (QALY) = incremental cost-utility ratio

= ICER

cost effect

standard treatment

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more effective less costly

cost

effectiveness

less effective more costly

more effective

more costly

less effective less costly

ICER 30-40.000€

per (quality adjusted) life year

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Ploquin and Dunscombe, R&O 2008

historical evolution of the cost of radiation therapy over 20 years corrected for inflation and exchange rates

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more complex treatments more time more resources capital investments

sophisticated equipment buildings QA

human resources treatment maintenance QA

more costly

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El costo de la aplicacion de las nuevas tecnologias

materiales costo salarial

Ploquin and Dunscombe, Radiother Oncol 2008

Tramientos mas complejos: • mas tiempo de preparacion • mas recursos humanos y

materiales

Lievens Y, IJROBP 2003 20

Multidisciplinary cordination

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Perrier et al. R&O 2013

IGRT, prostate

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Van de Werf et al. R&O 2012 23

more complex treatments contain costs without impact on quality?

1. limit cost of resources

2. optimize use of resources

3. decrease total treatment time 4. (time per fraction X number of fractions)

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Unique range of solutions in South America • Cyberknife

• Tomotherapy • Elekta VMAT • LIAC (IORT) • Mosaiq Paperless

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Lievens Y. The Breast 2010

hypofractionation, breast resource costs

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“It’s always too early until, unfortunately, it’s suddenly too late!” (Buxton)

exte

nt c

linic

al u

se

time development Phase I-II

use in selected centres

RCT unethical? belief / widespread use still avoidable?

premarket emerging diffusing established obsolete cost calculation

finan

cing

finan

cing

>

>

effectiveness

cost effectiveness

uncertainty

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Bonastre et al. Bull cancer 2006

Impact of training and previous experience

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25 SUB-PROJECTS IN ORDER TO GO LIVE in 2015

1 Tomotherapy HD WORK FLOWS ARQUITECTURA ERGONOMETRICA INTERFACES CON SICI

2015: PET-CT big bore RADIOTERAPIA

1 Acelerador VMAT

IORT /HDR

- CENTRO PAPER LESS MOSAIQ 30 LICENCIAS

- CONECTIVIDAD 100% SICI Y RCC

3 XIO 2 MONACO 8 FOCAL

Neuro-Radiocirugía

1 CYBERKNIFE M6

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The booster: Elekta Consulting services

• 100% paperless since day 1 means all your processes and interfaces with other services are 100% operational and optimized

• Centralized document fast scanning • Workflow modeling • Workflow automation with IQ Script • ESI :

– ADT (in and out) – SIU (agendas in and out) – DOC export (comite requests) – DOC Import (comite results)

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THE MANAGEMENT SYSTEM IS KEY

MOSAIQ paperless in 2015 MOSAIQ big data in 2016

ESI+ IQ SCRIPT

MICRO-MANAGEMENT

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MANAGING THE CHANGE= NEW STREAMLINED ORGANIZATION 1. NEW MD AGENDA ALLOWING TO CONTROL

1. PATIENTS WORKFLOW 2. QUALITY OF PET CT IMAGING 3. QUALITY OF CONTOURING 4. QUALITY OF TREATMENT PLANS REVIEWS AND SIGNATURE 5. PATIENT TREATMENT QA 6. MACHINE QA 7. OPTIMIZATION OF RESOURCE USAGE (TECHNICIANS, RADIOGRAPHERS ETC..} 8. WAIT LIST REMOVAL 9. ALL RT TASKS UNDER CONTROL 10. ALL TASKS MANAGED THROUGH MOSAIQ QCL

2. NEW JOB DESCRIPTIONS FOR ALL THE PERSONNEL INVOLVED IN RT 3. DOCUMENT ALL SOP (STANDARD OPERATION PROCEDURES) OF NEW TECHNIQUES

EMPLOYED, FROM END TO END 1. CONSULTATION 2. SCAN 3. CONTOURING 4. PRESCRIPCION 5. TREATMENT PLAN REVIEW 6. PATIENT SETUP AND IGRT 7. END OF TREATMENT EVALUATION 8 FOLLOW UP SCHEMES

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The booster: Elekta Consulting services

• Build a procedure code nomenclature • Configure MOSAIQ with the procedure code

nomenclature • Develop charge capture quality control

reporting • Implement charge capture process and

controls for quote process and billing process • Validate account and charge exchange process

with CISI (FALP billing system)

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Out of scope

Treatment cost

DIRECTINDIRECT

Personnel MaterialEquipment

RT patient related activities RT support act.

Intake consultation

Medical review …

APBI -brachytherapy

SBRT – lung –5 fractions …

Overhead

OtherEquipment Maint. & QA

Material

Time driven

Activity consumption Per fraction

Non-RT, care

activities

Non- care activities

RT patient related

RT support

Mark-up % on treatment cost

80% fraction20% patient

56.6%

Hulstaert et al, Rapport 198 KCE 2013

The booster: Elekta Consulting services, reducing overheads and operations costs through automated interfaces

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Time consuming workflows los tiempos indicados en la tabla son por paciente y por caso simple

Aplicar factor de complejidad para cualquiera de las tecnicas POR PACIENTE Simple : los tiempos indicados en la tabla

mediano : x 2 los tiempos indicados en la tabla complejo: x 3 los tiempos indicados en la tabla

HITOS PRINCIPALES STAFF 3D Varian 3D ELEKTA TOMOTHERAPY VMAT CYBERKNIFE

key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff

1. Evaluacion clinica Comité Multidisciplinar MD residentes 9 horas semanales en promedio por medico

decision terapeutica e etapificacion recepcion 0.5h de cordinacion para recepcion

2. 1ra Consulta y prescripcion RT Seleccion del protocolo de tratamiento MD residentes 1 hora en promedio por medico

Prescripcion: volumenes y fraccionamiento

3. appointment management escaneo de documentacion pacientes, confeccion de agendas, tarjetas de seguridad recepcion TENS 20 minutos por paciente por recepcion o TENS

x2 si cordinaciones con QT, internas externas, convenios con requisitos

4. CT, PET SCAN e inmobilization optimizar aditamentos, adquisicion de escaneos 1 TM MD, M. Phys. 30 minutos por paciente por TM y TENS

1 TENS

5. determinacion de volumenes volumenes Target MD 1h 1h 2h 2h 3h

Organos a riesgo TM MD 1h SN 1h SN 2h SN 2h SN 3h SN

preparacion estudio global si fusion TM M. Phys. SN SN SN SN SN

6. Planificacion de tratamiento construccion y calculo del plan de tratamiento TM M. Phys. 1h SN 1h SN NA 1h NA 1h 4h 4h

7. Fabricacion de protecciones en Cerrobend TENS TM 0.5h NA NA NA NA

8.exportacion a RV documentacion de parameteros de tto TM M. Phys. 1h 0.5h 1h 0.5h NA 0.2h 1h 0.5h 1h 1h

preparcaion estudios de firma IP, CBCT, TOMOSCAN, tracking

9. Patient QA M. Phys. NA NA 1H 1H 1H

10. Tratamiento firma Ok inicio de tratamiento TM, MD M. Phys. 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN

tratamientos diarios 2 TM M. Phys. 2 x 0.25h SN 2 x 0.25h SN 2 x 0.5h SN 2 x 0.25h SN 2 x 1h SN

fraccionamientos por tecnica 5 a 6 semanas 5 a 6 semanas 3 semanas 3 a 4 semanas 1 semana

11. evaluacion paciente durante el tto consulta semanal MD, residente Reception 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.5h *una semana tto

Recepcion: informes, peticiones y licencias varias

12. revision semanal expediente y citas clinico administrativa TM TENS 0.5h 0.1h 0.5h 0.1h 0.1h 0.1h 0.5h 0.1h 0.5h NA

Imagenes MD TM 0.1h 0.1h 0.1h 0.1h NA NA NA NA NA NA

13. Fin de tratamiento reporte, epicrisis e archivo papel MD reception 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h

14. facturacion facturacion y reporting reception M. Phys. 1h SN 1h SN 1h SN 1h SN 1h SN

15. consultas de seguimiento post tratamiento consulta de seguimiento : evaluacion tratamiento y complicaciones MD residents SN 0.3h SN 0.3h 0.3h SN SN 0.3h 0.5h NA

QA Diario ACTIVIDAD TRANSVERSAL TM M. Phys. 3.75h 0.5h 3.75h 0.5h 3.75h 0.5h 3.75h 0.5h 3.75h 0.5h

QA mensual semestral annual promediado M. Phys. M. Phys. 4h 4h 4h 8h 12h 35

Objetivos del control de calidad • Ni errores aleatorios (puesta del paciente, reproductibilidad

entre fracciones) • Ni errores sistemáticos (TPS, equipo mal calibrado,

contención defectuosa) • radioterapia es un multi-proceso complejo, de alta

tecnicidad, que requiere reflexión profunda sobre la seguridad de todas las etapas: SISTEMA DE CALIDAD

• Valorar constantemente la practica y organización de un servicio : implantar la CULTURA DE LA SEGURIDAD

• Cultura de la transparencia y declaración de los fallos • Fiabilisacion et automatización

– Peer review et CQE antes 1er tratamiento – Doble calculo independiente – Verify & Record avanzado – In vivo – Protocolos de Imágenes Portales/ IGRT – CQI (leyes y responsabilidades Físicos) – CQE (organismos de control, APAVE, ASN, etc..)

IMPLEMENTACION FALP: SQL DB MYQA (IBA)

AUDITORIA EXTERNA Y CERTIFICACION FALP: EQUAL ESTRO

• UN TEST POR CONO • TEST PREVIOS CON CC01 • IMPRESCINDIBLE

Safety basics

If you think safety is expensive, think about an accident (Epinal) or a

plane crash.

TOMOTHERAPY HD

• RT EN 360°

• IMRT-IGRT con Tomo View (megavoltaje).

• Varias localizaciones únicas, simultáneas o voluminosas.

• Tumores pediátricos.

• Tratamientos hipofraccionados.

SYNERGY AGILITY VMAT

• RT en hemi-arcos.

• IMRT – IGRT cone beam CT (kilovoltaje)

• Tumores con fraccionamiento convencional.

CENTRO DE RADIOTERAPIA AVANZADA RADIOTERAPIA DE INTENSIDAD MODULADA-GUIADA POR IMÁGENES

PARA QUÉ UN PLAN DE CALIDAD

• Para mejorar la supervivencia con la máxima calidad vital de los pacientes oncológicos

• Para evitar accidentes. • Para optimizar los recursos sanitarios • Para optimizar el uso racional de las radiaciones

ionizantes. • Para prevenir demandas legales.

Curso de Actualización para Tecnólogos en Radioterapia. ARCAL RLA6/058 Tema 22 : Garantía de Calidad J. M. Delgado 32 2008-10

Increasing health care expenses force us to consider the value for money of novel treatments.

Shorter treatment times compensate for the higher cost of complexity.

Hypofractionation has the potential of being “economically dominant”.

Coverage with Evidence Development can facilitate the early introduction of promising new technologies.

Convince with figures through careful big data planning,,, being the pioneer

Conclusions

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FALP GRACIAS…. 45