Insights into colorectal cancer care pathways in Ontario and Quebec

Introduction

The Conference Board of Canada is examining colorectal cancer care (CRC) pathways in Ontario and Quebec to understand how to align provincial guidelines, existing pathways for patient care, and a value-based model of healthcare for these patients. Patient care pathways are multidisciplinary stepped-care plans founded on evidence-based clinical guidelines and expert consensus.

The Challenge

Colorectal cancer (CRC) is the second-leading cause of mortality due to cancer in Canada,¹ despite being preventable, treatable, and, often, curable.²
While CRC incidence and mortality rates are falling, new challenges are emerging. These include rising rates of CRC in young adults and making innovative treatments easier to access.³

The Opportunity

Transitioning to value-based healthcare offers a path to improved cancer care outcomes and costs. Value-based healthcare is where value is assessed in terms of patient-derived health benefits per healthcare dollar spent.
But Canada lacks the infrastructure needed to standardize how patient-reported outcomes are measured and tracked. Health IT systems need to interact with each other to enable data collection and sharing within and between organizations and regions. Infrastructure that enables this would support integrated models of care, and would also help link outcomes to care costs to support continuous quality improvements.
Integrating and coordinating the various steps of patient care pathways presents another opportunity.⁴ Care pathways represent a value-based approach that can support continuity of care between healthcare providers and healthcare settings.

The Insights

Different pathways

Colorectal cancer care guidelines and standard CRC care pathways are publicly accessible. In Ontario, doctors and patients can find pathways through Cancer Care Ontario. In Quebec, through the Institut national d’excellence en santé et services sociaux (specifically for colorectal and rectum cancers). These pathways are based on best practices and expert consensus; they span the entire disease trajectory, from prevention to recovery and end-of-life care.
We have identified 15 major public cancer care delivery organizations in Ontario and 12 in the province of Quebec. Our survey data (from 4 Ontario-based and 7 Quebec-based organizations) indicate that most organizations (10/11) are implementing care pathways for both colon and rectal cancers.
The elements and implementation of colorectal care pathways vary across institutions. As does the care patients receive. There are also inconsistencies in care between institutions based on geography (rural versus urban, regional centre versus community hospital) and academic affiliation (e.g., teaching hospital versus not).

Are pathways value-based?

The care pathways are mainly a tool for healthcare providers and institutions and are reportedly not patient-centred. The care trajectory is not communicated well to patients. This leads to knowledge gaps around the pathway concept or the steps involved.
Standardizing CRC care pathways could help all patients access best practices at every step. These practices include access to a multidisciplinary team of healthcare professionals and to innovative treatments, both of which can improve patient outcomes. However, standardization requires a broader strategy to address inherent challenges, such as insufficient outcomes data and healthcare funding based on patient volumes.
Institutions are inconsistent in measuring patient-reported outcomes and linking them to costs of care per patient. Two-thirds of the surveyed institutions collect patient-reported outcome data (e.g., symptoms of distress) from CRC patients. Less than a third collect or measure per-patient cost data. And no institution monitors costs of care in relation to health outcomes. Barriers include health human resources, workflow, and technology.

Looking ahead

The COVID-19 pandemic interrupted CRC care pathways. The pandemic forced a quick shift to virtual care, which made it difficult for patients to access care such as screening and treatment. While virtual care cannot replace all aspects of in-person care, there is an opportunity to realize greater value for both patients and health systems. Virtual care is expected to continue to be important beyond the pandemic.

Conclusion

While provincial CRC care pathways exist, they are not consistently implemented. There are significant gaps in institutions’ abilities to measure patient-reported outcomes and link them to costs of care per patient—current practices do not align with value-based healthcare principles. Integrated models of care are also underdeveloped due to a lack of infrastructure.

The current shift to virtual care represents an unprecedented opportunity to achieve deeper value. It may help healthcare systems transition to value-based oncology care. To achieve this, various stakeholders and provincial policy-makers will need to work together.

The next phase of this research will examine how the value-based healthcare model can be used to standardize CRC care pathways in select cancer care delivery organizations in the province of Quebec.

Acknowledgements

This research was made possible through the financial support of Amgen Canada.

¹ Brenner, D., and others, “National Trends in Colorectal Cancer Incidence Among Older and Younger Adults in Canada,” JAMA Network Open 2, no. 7 (July 2019): e198090.
² Colorectal Cancer Canada, “Screening,” accessed December 10, 2020.
³ Colorectal Cancer Canada, “Current Initiatives,” accessed December 9, 2020.
⁴ M. Slovinec and I. Moroz, “Through the Lens of Value-Based Healthcare: Oncology Care,” The Hill Times, February 3, 2020.