Friday, February 8, 2008

Alberta Bound

Last week, I had the opportunity to present some of our Advanced Access results at a Prostate Cancer conference in Calgary. Alberta has a province-wide initiative to improve prostate cancer care, and the theme of this conference was improving access. While I was pleased to present our experience with a single aspect of improving access (pooled referrals from family physicians), I'm sure that I learned more than I contributed.

Calgary has developed a Rapid Access Clinic (RAC) for men suspected of having prostate cancer. Men sent to the RAC (a somewhat unfortunate acronym) can be assessed and have tests and biopsies completed in under 2 weeks rather than the previous standard of 3 months. Great work!

Another innovative part of RAC (really guys, let's work on that acronym!) is the group information session. When a man's prostate biopsy shows prostate cancer, he and his family need a lot of information about the nature of the disease and treatment options. In my practice, I generally book a 45-minute appointment to discuss this. This week, I've had 4 such sessions. That eats up a lot of office visit capacity.

In Calgary, men are invited to attend a group information session presented by several specialists, including a urologist and radiation oncologist. Offered several times a month, this program is an effective way to present consistent and comprehensive information using a standard curriculum. After this session, men are better prepared for a private discussion with their own urologist.

I particularly enjoyed a demonstration from Kevin Carlson, a Calgary urologist, of a web-based patient education resource called mdconversation. This is a set of online audiovisual presentations about prostate cancer diagnosis and treatment. You can try it out through the Calgary Prostate Cancer Institute website (click on the mdconversation logo). I plan to pass on this link to my patients so they can review the information before our office visit. If they already have the basic information about prostate cancer (viewed as many times as they like, in the comfort of their own home), then I can focus on helping them choose the treatment that suits them best. It might save time at the visit but, more importantly, the time spent will be more productive.

So it looks like Alberta is blowing the doors off poor old Saskatchewan. Ha! Not so! This week, local papers reported Regina's success with improving access to prostate biopsies

The traditional approach to prostate cancer diagnosis is: See your family doctor and have initial testing. If the tests are abnormal, you're referred to a urologist. The urologist decides whether a biopsy is needed. You're referred for a biopsy. A pathologist analyzes the biopsy specimen. The urologist reviews the biopsy results with you.

The seemingly innocuous spaces between the previous sentences represent wait times, sometimes 4-6 weeks between each step.

Regina Qu'Appelle Health Region shortens the wait by cutting the urologist out of the equation. Under many circumstances, the decision to proceed with prostate biopsy is cut and dried. (Some people may be offended if I were to suggest that the decision could be made by a trained monkey, so instead, let's call the process a clinical algorithm.) The urologist may not be contributing much value at the initial stage of diagnosis. If the biopsy shows cancer, the urologist will then become involved. Otherwise, the man may never need to see the urologist.

Allowing family doctors to refer men directly for biopsy (via a clinical algorithm) is incredibly innovative. I think I smell a new project for our group.

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