|Implemented in this survey?|
One goal of the NSW Cancer Plan 2004-2006 is to ensure that clinical practice is driven by evidence from research. The Standard Cancer Treatment (CI-SCaT) protocols are delivered via a website which provides clinicians, patients and carers with information about chemotherapy cancer protocols, including evidence, cost, drug dose calculation, treatments and side effects.
The purpose of CI-SCaT is to provide clincians with information about chemotherapy cancer protocols, including evidence, cost, drug dose calculation, and patients and carers with detailed information regarding treatments and side effects.
The objectives of CI-SCaT are to ensure that
i) as many cancer clinicians as possible receive up-to-date information about chemotherapy protocols whish are derived from the latest evidence and
ii) that patients and carers have access to the most up-to-date agrred information about alternative treatments for their condition as well as side-effects.
The program has been developed from an idea of a single clinician (Professor Robyn Ward) and the only incentives are related to improving the information available to clinicians and patients, the quality of care and hence outcomes for patients.
cancer clinicians, patients with cancer, carers of patients with cancer
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
We are aware of two other websites, in Canada and the UK, which record and describe clinical practice and make information available about the effectiveness of protocols for cancer therapies. In
Canada, the British Colombia Cancer Agency Systemic Therapy Program have placed summaries of specific treatment protocols on the website. The protocol summaries are those in current use by the
Systemic Therapy Program staff at all regional cancer centres. In the UK, the NHS lists Haematology Chemotherapy Protocols (HCP) which are those approved for use in hospitals across the ASWCS Network
by the Network Drug and Therapeutics Committee.
As it is recognised that healthcare interventions should be based on the best available evidence and that this is the aim of CI-SCaT, there is unlikely to be any controversy associated with the idea. Some internal controversy may surround the approval and display of individual protocols but this is to be expected given the lack of evaluation of many technologies or the fact that evaluation results cannot be generalised across all populations of interest.
Although the outcomes of the program may have profound impacts on individual clinical practice and therefore individual patients, because there is no information provided about the costs relative to the benefits and because the information may be used without regard to a budget constraint, the impact on the health system as a whole is likely to be rather marginal.
The general public is unaware of the program. The program is system neutral as it is not dependent on any particular structural, organisational or funding arrangements.
|Implemented in this survey?|
The CI-SCaT program was originally conceived by Professor Robyn Ward at St Vincent's Hospital in Sydney in 2001. Since 2004 the program has been managed by the Cancer Institute (NSW) with
Prof Ward remaining as Director. Her interest in day-to-day clinical practice as a multi-disciplinary activity led her to instigate the CI-SCaT program and the process of identifying and recording
best practice in cancer care.
The Cancer Institute (NSW) provides the governance structure and support for the program. A core team of project officers as well as two specialist reference groups comprising medical, nursing specialists (rural, metropolitan and interstate representatives) as well as pharmacists and consumers develop detailed treatment protocols. The protocols include information on drug dosing, administration schedules, evidence of clinical effectiveness and comparative toxicities. The information is published on a dedicated website and is available for use by both health professionals and consumers. The system is updated in real time, thus avoiding delays in the release and display of new clinical information.
The approach of the idea is described as:
|Professor Robyn Ward||very supportive||strongly opposed|
|Cancer Institute (NSW||very supportive||strongly opposed|
|cancer clincians||very supportive||strongly opposed|
|Professor Robyn Ward||very strong||none|
|Cancer Institute (NSW||very strong||none|
|cancer clincians||very strong||none|
The Ci-SCaT program is directed at clincians and consumers. Therefore, their involvement in the activities which result in the approval and display of protocols is aimed at ensuring the widest
possible uptake of the information provided by the program. Membership of reference groups is widely advertised and members are asked to review and edit protocols and to attend workshops where the
protocols are discussed and a consensus agreement about what to approve and display is reached.
The obstacles to uptake will be the relative lack of use of web-based protocols by rural-based clinicians, any lack of consensus regarding particular protocols, a lack of information about the impact of adoption on downstream costs and overall budgets (for hospital-based clinicians) and the complexity of the information now available. In addition, the availability of information to both clinicians and consumers may create some conflict about which treatments to adopt and the relative importance of side effects.
Better information about the relative cost-effectiveness of individual protocols and the impact of adoption on downstream costs and overall budgets may facilitate implementation of approved protocols.
There are unlikely to be any opponents to this program of work.
The website is monitored on a monthly basis for the number of hits. It is not possible to distinguish between types of users (eg health care professional or patient) but negotiations are under way
to build into the website the ability to monitor the IP domain of users. In some cases this will enable the identification of individual hospitals whose staff are downloading information from the
site. In addition, it will be possible to monitor the extent of downloads that occur from common IP domains such as Yahoo, BigPond, hotmail etc. It will also be possible to identify which protocols
are being downloaded, enabling better scheduling of reviews (ie the more common the useage of a protocol, the more often it should be reviewed).
In 2006, an 8-week online survey will be conducted amongst users of the site. It will investigate their satisfaction with the design of the site, including ease of use, navagatibility etc. In the longer term, plans are being made to examine the extent to which relevant protocols are being used. This will involve the development of a unique ID system for users of the NSW Cancer Registry to enable them to type in the number of the protocol they are using when they report information about cancer for individual patients.
A national roadshow is planned for 2006 to promote use of the website and to alert users of the website to the current plans for monitoring and evaluation.
The policy will certainly achieve its objectives at least partially. That is, a proportion of clinicans, patients and carers will benefit from the information provided, the quality of care is
likely to be improved for a proportion of patients and their outcomes are likely to be better than they would otherwise be.
The only unexpected or undesirable effects relate to the potential impact of any proposed protocols on the overall budget for cancer or for the health system as a whole. Because there is no information available about the impact on costs downstream and no evaluation of the use to which resources used in implementing recommended protocols may otherwise be put, there is the potential for inefficiency to be increased.
Whilst the impact on quality of care can be expected to increase, there is no evidence about potential impacts on costs, access to care or equity of outcomes.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The quality of care provided to cancer patients could be fundamentally improved if all clinicians adopted the approved protocols. There is no evidence about the impact on equity but given that city-based clincians are most likely to adopt new protocols, the impact, at best, is likely to be neutral. There is no evidence about the impact of the adoption of the approved protocols on the efficiency of health care delivery as no evaluation of this has as yet been undertaken.