Defining the elements for successful implementation of a small-city radiotherapy department

Defining the elements for successful implementation of a small-city radiotherapy department


P.S. Craighead, MD*, P. Dunscombe, PhD
*Tom Baker Cancer Centre; Cancer Care, Alberta Health Services; and Department of Oncology, University of Calgary, Calgary, AB,
Medical Physics, Tom Baker Cancer Centre, Calgary, AB.

Aims

Distributed delivery models for cancer care have been introduced to bring care closer to home and to provide better access to cancer patients needing radiotherapy. Very little work has been done to demonstrate the elements critical for success in a non-centralized approach. The present study set out to identify the elements that are important for implementing radiotherapy away from large cities.

Methods and Results

This qualitative research project consisted of two separate components. In the first component, structured interviews were conducted with 5 external experts. Input on the expert responses was then sought from internal leaders in medical physics, radiation therapy, and radiation oncology. Those interviews were used to develop a proposed template of the elements needed in a small-city department. We tested the validity of all elements by surveying staff members from the radiation treatment program in Calgary, leading to a definition of the resources needed for the proposed department in Lethbridge. Seventy-five staff members contributed to the survey.

Conclusions

Qualitative research methods allowed us to define important elements for a small-city radiotherapy department and to validate those elements with a large cohort of staff working in a tertiary centre. This work has influenced the planning of a small-city department in Lethbridge, emphasizing the importance of the elements identified to the service planners. We await the completion of the construction project and the opening of the centre so that we can re-evaluate the importance of the identified elements in actual practice. We recommend such an approach to jurisdictions that are considering devolved radiotherapy.

KEYWORDS: Qualitative research, radiotherapy, access

1.INTRODUCTION

Centralized care has been the mainstay of radiotherapy service delivery in Canada for more than four decades 1. “Centralized care” can be defined as a service that is readily accessible only to patients living close to larger cities, but that provides access to all patients willing to travel 2. In practical terms, use of this approach has meant that a significant proportion of cancer patients in countries such as Canada have had to travel for more than 3 hours to reach a city with radiotherapy facilities. Health ministries argue that this model is justified because quality radiotherapy services are not viable outside bigger cities.

In the late 1990s, concerns were expressed about the centralized model because of the poorer outcomes seen in cancer patients living in smaller communities 1,3. Although these poorer outcomes were previously considered to be related mostly to the prevalence of more advanced disease in the smaller communities, data now link poorer outcomes with a lack of appropriate treatment closer to home, probably directly associated with lower utilization of radiotherapy 4. As a result of those findings, several Canadian provinces have expanded services to smaller cities 5,6.

Efforts to decentralize radiotherapy have been made by British Columbia, Nova Scotia, Ontario, Manitoba, and Quebec. In 2005, we evaluated access to radiotherapy in Alberta and found that 28% of cancer patients needing radiotherapy in the province had to travel more than 100 km from home to receive treatment 6. In 2007, the province announced its decision to distribute radiotherapy to 3 small cities, prompting us to ask whether there was clarity about the type of department practical for such cities. We sought opinions from several external experts on the issues that we were considering, and we received input from internal staff on their perspectives about the resources needed for such a department. The present report constitutes our findings from these separate initiatives.

We had at least 3 objectives for this study:

  • To evaluate service-delivery models in radiotherapy

  • To establish the preferred model from a tertiary centre perspective, with input from professionals in radiation medicine in Calgary

  • To use internal and external experts in describing and analyzing the factors that might challenge successful implementation of such a model

2. METHODS

This qualitative study used mixed methods, with a grounded-theory approach 7. Our main objective was to examine and respond to concerns about staffing in small radiotherapy departments. A “small department” was defined as an operation that proposes to function with no more than 2 linear accelerators.

The research group, consisting of a radiation oncologist, a medical physicist, and a radiation therapist, used evidence to formulate elements within draft delivery models for small-city departments. Semi-structured interviews with leaders and external experts were used to define the factors that could assist in implementation of a small-city department. A survey mechanism tested the relevance of those factors to staff in a tertiary-centre radiotherapy department linked to a university. Staff were also made aware of the perspectives of the external experts.

2.1 Evaluation of Alternative Service Delivery Models to Be Considered

We proposed 3 theoretical models of care to illustrate the practical implications of service delivery (Tables i and ii). Certain Canadian centres that approximated those definitions were cited to make the model easier for survey participants to grasp. Using tumour site data from Alberta, we proposed a proportion of patients to consider for treatment in each of the delivery models:

  • Tertiary model (for example, Calgary or Edmonton), with an academic focus, with all technical and professional services for radiotherapy available, and with 100% of patients able to receive treatment locally

  • Basic model (for example, Charlottetown, Prince Edward Island), with palliation as the main focus, but with some radical patients from that region, and with 77% of patients able to receive treatment locally [such a facility could have mobile or permanent equipment to meet patient needs—for example, computed tomography (ct) simulation or linear accelerator]

  • Developed model (for example, Sydney, Nova Scotia), with most radical and palliative treatments being delivered regionally, and with 90%–95% of patients able to receive treatment locally (requires permanent equipment to be stationed at the centre)

TABLE I Service delivery models

 

TABLE II Examples of the service delivery models

 

From census and utilization data, we then developed potential patient numbers for Lethbridge, a city in southwest Alberta that provides medical services to a large area of southern Alberta and eastern British Columbia. This city had already been chosen by the province as the first of the 3 small-city radiotherapy sites. Census, cancer incidence, and registry data for 2005 allowed us to estimate the number of new cancers and the potential radiotherapy workload (total sessions per year).

Workload was calculated using an evidence-based estimate utilization model and average national caseload figures:

We checked the accuracy of this model by comparing the predicted workload with numbers of patients actually treated from the regional counties around Lethbridge in 2005. Based on workload, equipment and staff requirements for the 3 models could then be calculated.

In the basic and developed models, an assumption is made that brachytherapy and stereotactic radiotherapy will continue at tertiary sites. Physical equipment needs for the 2 distributed models were calculated using Alberta ministry of health ratios (1 linear accelerator per 350 new patients treated annually and 1 simulator per 1200 new patients treated annually).

The Canadian national manpower guidelines proposed by Podgorsak in 1999 8 were used to generate a staff table for the basic and developed models. We also calculated staff and equipment needs to retain the centralized model in Calgary rather than to move the service to Lethbridge, which gave staff an opportunity to choose whether they supported the development of basic and developed models, and also allowed for comparisons between the resources needed to establish new departments or to expand existing services.

2.2 Evaluating Staff Perspectives: Survey

Using equipment and staffing tables developed as described earlier, we created a survey tool (Table iii) to evaluate perceptions of the models by staff in the radiation treatment program in Calgary. The survey was distributed to staff members of the radiation services program in Calgary who attended a town hall meeting in 2006. We invited discussion of the merits of a distributed model, and comments were recorded. The major focus of this effort was to evaluate staff perspectives on the personnel requirements for the 3 models. The aim was to assess concurrence with personnel guidelines from the Canadian national society, and whether staff numbers changed with the model type. Staff that completed the survey did so anonymously and placed the completed forms into closed ballot boxes. The results of the survey were collated in an Excel spreadsheet (Microsoft Corporation, Redmond, WA, U.S.A.).

TABLE III Survey conducted May 2006

 

2.3 Defining the Themes that Affect the Operations of a Small-City Radiotherapy Department

Using the survey and comments from the town hall meeting, we held semi-structured focus group discussions with leaders in radiation oncology, medical physics, and radiation therapy in Calgary and Edmonton. Structured interviews also were held with 4 external experts (Table iv), who were asked these questions:

  • Is there sufficient evidence to safely move radiotherapy into small cities?

  • Are there concerns about doing this in Alberta?

  • What are the barriers to such a development?

  • Are there experiences in other provinces or countries from which we could learn?

TABLE IV Names and titles of the external experts consulted

 

Using the outcomes of these discussions, we generated a list of the issues likely to affect a distributed-care initiative in radiotherapy and collated them into themes. We considered themes to be significant if 3 or more of the external experts commented on the particular issue and if the internal leaders had also mentioned it.

2.4 Synthesis Methods

The qualitative answers to the survey were synthesized in an Excel spreadsheet. Descriptive fields were analyzed using the Access database software (Microsoft Corporation). Using the survey results, average and median staffing numbers for medical physics, radiation oncology, radiation therapy, and treatment preparation (simulation and dosimetry) were calculated for each of the 3 models. Standard deviations were calculated, and the Student t-test was used to make statistical comparisons between the survey averages and those found in the national society recommendations.

3. RESULTS

The research team finished the preparatory tables for the survey between May and September 2006. Of the 71 staff members who attended the town hall meeting, 55 (79%) representing 39% of program staff (55 of 140 full-time staff members) completed the survey. The subsequent interviews were held in mid- to late 2007, and the research was collated for synthesis in the fall of 2008 (Tables v and vi).

TABLE V Survey results for the three service delivery models

 

TABLE VI Themes from the discussions with internal leaders and external experts

 

3.1 Comparing Canadian (Podgorsak) Staff Numbers and Estimates

Using cancer registry data, census data, and the Delaney radiotherapy utilization estimate model 9,10, we showed that Lethbridge could treat 77% and 97% of possible local patients in the basic and developed models respectively. Table v shows a concordance between mean personnel estimates from the staff survey and recommended national personnel guidelines for the basic and developed models. For the basic model, the surveys estimated needing 14.9 full-time equivalents (ftes), and the national guidelines, 15.3 ftes; for the developed model, the numbers were 19.5 ftes and 18.9 ftes respectively. There were also no significant differences between the national guidelines and the estimated numbers for each professional subgroup.

Interestingly, the personnel estimate for a tertiary expansion within the staff survey (13.7 ftes) was lower than the number derived from the national guidelines (19.4 ftes, p < 0.01). The survey also showed that research and academic issues were considered less important in a distributed model than in either the basic or the developed option. Comments at the town hall and on the survey made it clear that most staff members supported a distributed model.

3.2 Themes Identified as Important for Developing a Devolved Radiotherapy System

The semi-structured interviews with internal leaders and external experts allowed us to synthesize several overarching themes thought to be critical for successful implementation of a distributed model 1114:

  • The importance of transparent connections between tertiary and smaller centres

  • The essence of balancing complexity of care with access to quality when starting small-city departments (location and size of departments was a driver for this discussion)

  • The relevance of training future staff and retaining current staff

Table vi shows the more common issues that were mentioned within these discussions.

4. DISCUSSION

Until recently, Alberta had used a centralized model for radiotherapy delivery, with tertiary departments in Calgary and Edmonton. The province of Alberta has an overall population of 3.25 million people, with almost 1 million outside the large cities being underserved in radiotherapy services. Moreover, since 2000, the two existing radiotherapy departments have grown considerably to accommodate the increased number of referrals.

It became essential to consider moving radiotherapy services into smaller cities for three reasons. First, the continued concentration of radiotherapy in the two large cities over the next 15 years was impractical; departments would be so large as to be ineffective. Second, we are aware that approximately 30% of the provincial population are placed into significant hardship by living more than 100 km from the facilities in these large cities, a situation that is unlikely to improve with a centralization strategy. As of 2008, the province had 5 linear accelerators per million people; Ontario and British Columbia had 6 per million people, and Newfoundland had 7 per million. Third, we were concerned that distance from treatment facilities often forced patients to choose inferior treatments 15,16.

It was proposed that we increase the proportion of patients receiving radiotherapy closer to home by developing 3 small-city radiotherapy departments (sequentially in Lethbridge, Red Deer, and Grande Prairie) between 2010 and 2013 (Figure 1). This proposal was supported by federal government funds specifically meant to improve wait times, allowing the overall cost of this project to the province to be offset by approximately $62 million.

 


 

FIGURE 1Alberta Health Regions: existing tertiary (filled circles) and proposed small-city (filled triangles) radiotherapy departments as of 2007.

Once that funding was announced, it was important to perform the present study to better understand how departments in those smaller cities would function, so that any barriers to implementation of small-city departments could be removed. The outcomes from the study have allowed us to generate functional plans for Lethbridge and to mitigate potential barriers to recruitment. The Lethbridge centre started treating patients in June 2010. Decisions about caseload, staffing, and required infrastructure have been used to develop a strategic plan for all 3 small departments.

Internal and external discussants all supported the decentralization of radiotherapy—more specifically, they favoured the developed over the basic model. Initial conversations before the survey was conducted indicated that staff were concerned about the potential difficulty of attaining a level of quality and staffing in a small-city department that would be similar to that in the tertiary centres. We believe that support for the developed model demonstrated in the survey was partly a result of our ability to validate successful implementation of similar models in other Canadian jurisdictions. The strong support for a developed model despite the financial benefits of maintaining a centralized model was also interesting.

Our research shows the importance of several drivers thought critical for the successful implementation of small-city radiotherapy departments. Failure to address those drivers is likely to result in failure to maintain quality and safety in cancer care across the province.

4.1 Driver 1: Connectedness to Tertiary Sites and Audit Mechanisms

The interviews, group discussions, and staff surveys all indicated that the link between tertiary and smaller cities is an important element that requires careful attention if radiotherapy is to be safely devolved 15,17. This link is seen to be critical for maintaining quality of care and allowing peripheral departments to feel supported. Several of the external informants expressed viewpoints such as these: “Without links with a tertiary centre, this will not be attractive to younger graduates.” “You will be unable to support a clinical trials agenda without this link.” “You will find that smaller centres take their lead in using provincial guidelines from academics in the larger centres.”

Our interviewees and discussion groups suggested that small departments should have autonomy in service delivery, but that strong interdependence is required between small departments and tertiary centres if quality standards are to be maintained across the province. Furthermore, unless support from tertiary centres is tangible, small departments will find it difficult to retain staff. Finally, such departmental interdependence will foster opportunities for staff to participate in the academic aspects of care and for younger staff to be considered for transfer to a tertiary site when they demonstrate academic prowess. The possibility for advancement encourages the recruitment of quality applicants to positions in small-city departments. In discussing how such a relationship between centres could be secured, we believe that a formal network arrangement is a superior model. That model allows for establishment of, and adherence to, common clinical and technical guidelines. The elements that need to be addressed within such a network include reporting relationships, functional electronic pathways, innovative telehealth, and a transparent audit mechanism.

4.2 Driver 2: Factors Determining the Size and Location of Departments

There are several issues connected with sizing and siting small-city departments 1720. Electronic platforms for health records, transmission of imaging data, and availability of planning systems province-wide are critical concerns. A second broad area needing a clear decision is the importance of defining the acceptable minimum size of a small-city department. An executive decision of this kind seemed to drive the model in a significant way, affecting the overall framework. For example, the Australian and French experiences suggest that single-machine units (smus) are safe and practical, but Canadian provinces are more likely to select departments with more than 1 accelerator.

Participants in Canada suggested that this difference is based on the philosophy that larger departments are associated with greater stability in retention of staff and an ability to offer local treatment to more patients than smus can. Such a model would contain costs relative to the smu, but would force more travel for some patients—which has certainly been the experience in larger provinces such as British Columbia and Ontario.

With that backdrop, we focused on determining whether support existed for a smu approach to service delivery in Alberta 14,18. Most internal respondents felt that having more than 1 unit is always optimal because of greater cost effectiveness, benefits to retention of staff, and mitigation of treatment delays when a single unit has to be taken down for service or repairs. International experts were more likely to support the establishment of smus, but only in the presence of a strong connection with a tertiary facility. The Canadian philosophy of developing larger departments also appears related to previous resistance to devolving care outside large cities in this country. Many mid-sized cities can now easily can support departments with more than 1 accelerator. After radiotherapy is established in more of these mid-sized cities it is likely that smus will be considered again. A trend of this kind is already occurring in Ontario and Quebec.

Our compromise has been to choose a geographic demand model to drive discussion. We found that this approach, and a focus on facilities that already provide chemotherapy to local patients, can increase access to radiotherapy closer to home and justify making departments large enough to be practical to develop. In our decisions of when to develop each department, we included factors such as community acceptance, distance from a tertiary site, and resources required to retain staff in a local community.

Using this model, we believe that Lethbridge, Red Deer, and Grande Prairie will be viable sites for small departments with a minimum of 2 linear accelerators in each centre. There was support from respondents for a ct simulation function rather than a conventional simulator and for a provincially integrated planning approach. Within the realm of modern radiotherapy planning, it is important that this function be networked, to ensure that smaller departments have the ability to offer conformal and intensity-modulated radiotherapy.

4.3 Driver 4: Personnel Issues

Serious concerns have been raised about the ability of our system to attract and retain an appropriate workforce for small departments 8,21. This concern relates partly to Canada’s cancer specialty disciplines not identifying national personnel guidelines for non-academic clinician workloads. In examining the staff survey results, confusion over this issue was apparent. Most guidelines suggest that academic centres require more staff, but our staff survey demonstrated that staffing for academic centres is underestimated. We hypothesize that staff probably recognized that academic institutions have more than one funding source, with university funding of educational and research activities not required in a clinically focused model. We also believe that this finding shows an understanding on the part of staff that establishing any new department requires a baseline staff cohort, with staff-to-patient ratios declining once the baseline is achieved.

Other staffing concerns for devolved radiotherapy services include these:

  • The lack of a consistent national supply of medical physicists and radiation therapists, so that reliance can be placed on that track to provide personnel. We decided to advertise both nationally and internationally, and to develop training positions in our own programs to ensure a sufficient supply of professionals in those domains.

  • The need to have training approaches that attract local students from the communities in Lethbridge, Red Deer, and Grande Prairie to pursue training in the needed disciplines.

  • The importance of selecting sites in which the local community culture is attractive and encourages retention and recruitment to the new centres.

  • The need for adequate support for smaller operations, meaning that tertiary specialists are willing to help out when personnel numbers are compromised.

The selection of the developed model means that we will have to train a significant number of radiation therapists and medical physicists. It remains unclear whether treatment preparation areas require separate training, but we will ensure that radiation therapists and medical physicists in selected small cities have the ability to cover this important function.

5. CONCLUSIONS

This study generated several important qualitative findings that have assisted in our discussions with government about the future model:

  • The environmental scan of opinion leaders gave credibility to the Alberta Cancer Board’s decision to expand radiotherapy services outside Edmonton and Calgary. The strong support for moving radiotherapy services closer to patients, without compromising cost effectiveness, is strong endorsement. That the scan demonstrated successes in other provinces was helpful. The need to expand into other cities is particularly important if we are to achieve a radiotherapy utilization rate of 45%–50% of incident cases in Alberta.

  • Our staff survey findings assisted discussions about staffing in smaller cities. As a result, we can feel confident that the functional planning and budgeting templates could use national guidelines to define equipment and personnel standards in Lethbridge, Red Deer, and Grande Prairie. All those departments will launch (in 2010, 2011, and 2013 respectively) with 1 ct simulator and 2 linear accelerators. They all will be expected to offer state-of-the-art treatment, with linkages to central planning resources in Edmonton and Calgary. The treatment planning system, large equipment, electronic record, and treatment standards will all be consistent throughout the network.

  • Our work also demonstrated the importance of connectedness between the various sites and the need to be proactive about training staff for the new departments. Our centres have already responded to the personnel issues by funding increased training positions for more therapists and medical physicists. We are hiring radiation oncologists both from our own training programs and from across North America to function in clinical roles in the newer departments. Interest in the network concept that allows younger staff to practice high-quality radiotherapy has been tremendous, and because remuneration is salary-based, it has not been an issue for potential recruitment.

Our ultimate vision is to provide cost-effective, optimal care for cancer patients as close to home as possible. We believe that a distributed model will also reduce the size of our tertiary centres so that they can focus on the important role of performing research and establishing provincial standards. We highly recommend such an approach for other jurisdictions, because it allows for local buy-in from staff.

6. CONFLICT OF INTEREST DISCLOSURES

The Alberta Cancer Board provided grant funding to this study. No financial conflicts of interest exist.

7. ACKNOWLEDGMENTS

The authors thank Michael Taylor for his hard work in developing the survey instrument and synthesizing the results, and the four external experts for their input into this study.

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Corresponding author: Peter S. Craighead, Tom Baker Cancer Centre, 1331 29th Street NW, Calgary Alberta T2N 4N2. E-mail: peterch@albertahealthservices.ca

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Current Oncology, VOLUME 18, NUMBER 3, 2011








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