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Improving quality and access in Ontario’s privately owned colonoscopy clinics


Five years ago, researchers in Ontario raised concerns about access and quality in privately owned clinics that performed colonoscopy, suggesting that the quality in these clinics was significantly below the standard of care in public hospitals. Privately owned clinics can be either for-profit or not-for-profit. Medical services provided at these private clinics are paid for publicly.

Since that time, the College of Physicians and Surgeons of Ontario has begun regulating and inspecting these clinics.

In the last five years, quality in private colonoscopy clinics appears to have improved, and for the first time, Cancer Care Ontario (CCO) is exploring expanding its provincial colon cancer screening program into these clinics.

Quality and access concerns

Concerns about quality in privately owned colonoscopy clinics began in 2007, with the release of several research papers.  This research showed that roughly 13% of colonoscopies in Ontario between 1999 and 2003 were not completed (the scope did not make it all the way through the colon), and that a leading risk factor for an incomplete procedure was having the colonoscopy performed in a private clinic. In addition, the research suggested that there were more missed cancers in private clinics than in hospitals. The researchers concluded that “colonoscopy practice in office settings may be suboptimal.”

Other research raised concerns that private colonoscopy clinics were more likely to screen patients more frequently than recomended by guidelines.

Around the same time, concerns were growing that some private colonoscopy clinics were charging patients user fees, in violation of the Canada Health ActData collected in Toronto in 2009 suggested that about a third of patients receiving colonoscopy in private clinics were being charged to access the services. This led to criticism from groups such as Canadian Doctors for Medicare, who argued these fees were against the law in Ontario.

Low funding and no regulation

One of the main contributors to quality and access problems within private colonoscopy clinics was less generous per case funding than is provided to hospitals.  When a colonoscopy is performed in a hospital, the doctor performing the procedure is paid by the Ontario Health Insurance Plan (OHIP) for providing the service and the hospital’s expenses are covered through its global budget. In some high volume hospitals there is additional program funding associated with Cancer Care Ontario’s provincial colon cancer screening program.

When a colonoscopy is performed in a private clinic, the doctor is paid by OHIP, but the clinic itself receives no money from the government and no funding from CCO.  Therefore, the clinic must find other ways of covering operating expenses (including purchasing equipment, sterilization procedures, staff, etc.).

This lack of funding made it difficult for private clinics to maintain the same quality standards as hospitals. In order to remain profitable, some private clinics may have rushed procedures, leading to incomplete colonoscopies. Others did not maintain the highest standards of sterilization. Some private clinics turned to various forms of alternative financing, such as charging patients for anesthetic or mandatory counseling with a dietitian.

Sherif Hanna, head of surgical oncology at Sunnybrook Hospital and former director of the Kensington Clinic, a private clinic identified by several experts as having high quality standards, says “when a clinic is only billing OHIP, [high quality] is not feasible.” At Kensington, he explains “we were operating at a loss – the only reason we were able to stay afloat was the Kensington Foundation,” a charitable foundation that helps fund the clinic.

The other main contributor to quality and access concerns in private clinics was a lack of regulation. Prior to 2010, the College of Physicians and Surgeons of Ontario (CPSO), the organization responsible for regulating Ontario’s doctors, did not have jurisdiction over private colonoscopy clinics.  As a result, there was no organization responsible for establishing and enforcing quality standards for these clinics.

Without an independent organization to establish and enforce quality standards, there was no mechanism in place to ensure quality of care in private clinics was at the same standard as the care provided in hospitals.

At the same time, without oversight from the College, regulations prohibiting user fees were not enforced consistently, creating potential barriers to access for patients.

CPSO regulation

In recognition that surgical services and other medical procedures were moving outside of hospitals, the CPSO and the Ontario government moved to create a regulatory framework for community-based clinics that would be providing these services.

“The goal,” explains CPSO registrar Rocco Gerace, “was to get a single standard of care for the entire province, regardless of where a procedure is performed.”

In 2010, the CPSO was granted jurisdiction over procedures performed at a range of Out-of-Hospital Premises (OHP), which included private colonoscopy clinics. The CPSO established quality standards for all OHPs, and initiated an inspection program for these clinics.

The CPSO also developed a specialized guide for colonoscopy clinics, which advised each clinic to form a quality assurance committee to establish standards, monitor activity and improve performance. These committees are mandated to ensure that clinic care is appropriate to the volume and scope of service provided.

The CPSO also inspects private clinics on a five year cycle. Clinics are evaluated on the basis of premises, staff requirements, patient admission requirements, procedure standards, infections control standards, and quality assurance activities.

In 2011, the CPSO completed 104 assessments of out-of-hospital premises, of which roughly 50 were private colonoscopy clinics.  54% of the facilities received a full pass, 43% passed with conditions and 3% failed.  Doctors working at facilities that failed inspection were barred from performing any procedures at these facilities.

There appears to be wide agreement in the medical profession that the CPSO’s enforcement activities have had a dramatic effect on quality in these private clinics.  According to Dr. Michael Gould, a gastroenterologist and Medical Director and President of the Vaughan Endoscopy Clinic, “the quality has elevated enormously.” He thinks that there remains room for improvement with the process, “but that’s always the case with a first process… The College started in the right place and it will continue to improve over time,” he says.

Integrating private clinics into the provincial screening program

Linda Rabeneck, Vice President of Prevention and Cancer Control at Cancer Care Ontario, explains that until now CCO has declined to inlcude private clinics within its provincial colon cancer screening program, because of concerns that they were unregulated and the evidence that their quality was inferior. As a result, CCO has contracted exclusively with hospitals, which are both more expensive and have longer wait time than private clinics. CCO believes, however, that the time is right to test whether private clinics are ready to become a part of the provincial screening program.

After the CPSO began to regulate private clinics, CCO invited these clinics to participate in a pilot where they would report on their activities (volumes, indications, quality measures, etc.) through the same electronic system used by hospitals to send data to CCO.  While some clinics refused to participate, many others have begun reporting to CCO. This reporting infrastructure has provided CCO with the ability to monitor quality across the province, and compare the performance of participating clinics and hospitals.

This October, CCO invited facilities who have passed CPSO inspection and use their reporting infrastructure to contract with CCO to provide a set number of colonoscopies under its provincial screening program.

Doctors at private clinics will continue to bill OHIP for their services, but CCO will provide some additional funding for contracted procedures to the clinics to cover operating expenses.

According to Rabeneck, ongoing funding for private clinics will depend on clinics continuing to pass CPSO inspections and report their data to CCO. CCO will also require every private facility it contracts with to have back-up hospital arrangements with doctors who have hospital admitting privileges.

Rabeneck believes the funding from CCO should reduce the incentive for colonoscopy clinics to charge their patients for access to services. These funds also will cover the necessary costs of running a colonoscopy clinic in the community, which will make it considerably easier for private clinics to maintain the same high standards as hospitals.

Gould believes this pilot program will benefit everyone. “This is the right way forward,” he says. “It makes no sense to keep colonoscopies in hospitals when they can be done for half the cost in the community.” He predicts that the program will not only save the health care system money, but also free up hospital resources to focus on more acute care.

Hanna agrees, and believes the additional funding available from CCO will provide a powerful incentive for private clinics to ensure the highest quality in order to qualify for the program. “A rising tide raises all boats,” he says, “clinics will either raise their standards to compete, or they will close.”

A thoughtful focus on quality

Five years ago, the quality of care provided by Ontario’s private colonoscopy clinics was extremely uneven. Today, these problems appear to have been largely addressed through regulation, and these clinics are on the verge of being integrated into the provincial colon cancer screening system.  For Rabeneck, “it’s a nice example of what can be accomplished with a thoughtful focus on quality.”

For more coverage of access problems in privately owned clinics, see our partner article in the Toronto Star.

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10 comments

  1. Anthony Miller

    The article does not clarify whether CCO funding will be restricted to diagnostic colonoscopy in private clinics, or whether colonoscopy for screening will also be supported. The comment that colonoscopies should be done only on low risk patients seems to provide no room at all for these clinics to perform supported colonoscopy, as there is no justification for screening colonoscopy in low risk patients.

  2. Terry Sullivan

    Tony fair question for clarification. While this is, as I understand still under discussion, I believe the indications for initial screening with colonoscopy are limited within the colon cancer screening program to individuals with first order relatives with family histories of colon cancer who have good performance status. The other indication is diagnostic investigation following a positive FOBT. There is an expectation that patients who have multiple comorbidities, or more serious pre-xisting gastrointestinal disease would not be supported for colonscopy outside of hospital.
    Terry Sullivan

  3. Jeremy Petch

    This article originally made reference to private clinics screening for low risk patients, while hospitals would screen for high risk patients. This was based on a misunderstanding on our part and has been removed from the article.

  4. Jeff Axler

    anyone know what the false positive and false negative rates are for the FOBT test in Ontario?
    anyone know what the colon cancer rates are ie % of patients with colon cancer that are under the age of 50?
    interesting that CCO does not disclose this important information for Ontario citizens…to help them make important decisons.

    • Terry Sullivan

      Jeff, thanks for chiming in. The cancer rates by age group and type are easily known by any citizen in Canada who is interested in newly incidence cases,rates and. mortality by age. They are disclosed every year in the spring by Canadian Cancer Statistics which compiles these from provincial registries including Ontario’s. These data can be found and downloaded at

      https://www.cancer.ca/Canada-wide/About%20cancer/Cancer%20statistics.aspx?sc_lang=EN

      The program can also provide you with the test characteristics of guiac testing in Ontario.

      Terry Sullivan

    • Jeff Axler

      just got some of the data from CCO
      rather shocking…
      Colon Cancer rates in males Ontario 2009:those under 50: 8.8% of all cases are under age 50
      rates for men: 8.8%
      rates for women: 8.14%
      combined rates for men and women 8.5%

      so…before CCO even starts theri screening at age 50, they have missed 8.5% of patients, and these are the YOUNGEST of the group.
      and they suggest screening with a test that misses half of the cases, ie false negative rates, ie miss rate of 50%

  5. Michael Gould

    Low risk relates to patients health status/ASA classification not indication for endoscopy.

  6. Dr Ken Woolfson

    there will be great variability in quality. We opened a non profit private endoscopy suite 5 years ago when our wait times for colonoscopy were close to 1 year. With no help from the government whatsoever the wait times for endoscopy have improved dramatically for many patients in the Oshawa area. We have several certified GI specialists and surgeons performing endoscopy here. All but one maintain full hospital priveledges. Our surgeons include surgical oncologists (2) and colorectal specialists as well (2). We have had our college review and the one ‘deficiency ‘ we had was that we lacked a portable generator. We purchased one. We have upheld the highest standards in cleansing the endoscopes and quality of endoscopy. We pay 50% overhead that pays for equipment, rent and the best staff we can find (RN’s). We continue performing this as we sincerely want to keep our wait list short. We are allowed to request a ‘block fee’ but patients are not under any obligation to pay it whatsoever. They are explicitly told this.Sometimes half do, sometimes more than that.
    Frankly, I would suggest that the college should not only look at independant clinics but should review every center , including hospitals. This would be prudent.

  7. Michael A P Smith

    Regarding a recent article in the Star in November 2012, which states that Out of Hospital Clinics refused to take part in the stage 2 CCO (Cancer Care Ontario) trial? I tried to join this present trial examining colonoscopies in Ontario; I was refused access because I do not have hospital privileges. In order to be granted access to this CCO trial, 80 % of colonoscopies in Out of Hospital Clinics must be done by doctors who have hospital privileges. I no longer have hospital privileges by personal choice. I did participate in the stage 1 trial. Presently 9 Clinics have been selected to receive funding for this trial. Why would any clinic refuse participation in a trial which entails benefit from extra fundng? The present selection of clinics to participate in the Stage 2 trial leads me to have uneasy concerns about selection processes in CCO.

    Secondly, when will someone explain what a Not for Profit Clinic is. The much lauded Kensington Clinic has doctors who perform procedures including colonoscopy, do you believe that they do this unpaid and for charity? Of course they get paid for their services. In fact they are paid the full colonoscopy fee. On the other hand I receive the same colonoscopy fee but out of that run a busy colonoscopy clinic employing 5 staff and performing almost 4000 procedures a year .Could someone finally put this Not for Profit phrase where it belongs, in the garbage Finally It is my belief that the CCO has an agenda, part of which is to eliminate certain clinics and have out of hospital colonoscopy managed by hospital doctors. With regards to being admissible for CCO funding, I am expected to provide CCO with detailed statistics from my clinic. In the first trial I was able to employ someone to perform relevant documentation as I received funding from CCO. Now however I must take one nurse out of circulation in order to provide CCO with their required data. This reduced availability would affect my efficiency and the safety level. This is a catch 22 situation. Failure to provide reports gratis results in no funding. Reports to CCO involve less nursing availability and less safety or more expenses to cover yet more staff. I would need to employ someone to manage the documentation required by CCO. I already have 6 employees and there is a limit to how much a single handed clinic can spend on staffing. This is discrimination. Finally I would ask of CCO, what is their agenda and where is it available and is their written agenda only part of their proposed plans for the future of out of hospital colonoscopy

    Dr Michael A P Smith

  8. MICHAEL A P SMITH MISSISSAUGA COLONOSCOPY CENTRE

    WHY WOULD A CLINIC HAVE TO HAVE A DOCTOR IN IT WHO HAS HOSPTIAL PRIVILEGES.

    if A PATIENT COMES TO ME FORM Richmond hILL, HE OR SHE WONT COME TO A MISSISSAUGA HOSPITAL FOR COMPLICACTIONS.
    IF A GASTROENTEROLOGIST HAS A COMPLICATION THEYU WONT BE INVOLCED IN THE SURGICAL MANAGMENT OF COMKPLICATIONS.

    CCO IS DELUDED AND RIDICULOUS I HAVE CLOSE TIES TO THE SURGEONS AT THE LOCAL HOSPITAL, THATS ALL THAT IS NEEDED

    CCO AND THE STAR WHICH SEEMS TO RUN THE CPSO NEED SOME PEOPLE WITH COMMON SENSE.
    IN TRYING TO KEEP DOWN COSTS HOW HAS THE USE OF ANAESTHETISTS BEEN ALLOWED TO FLOURISH. THIS INCREASES S COSTS AND ALLOWS LESSER TRAINED ENDOSCOPISTS TO TO BREED.

    CCO IS DISCRIMINATORY AND THE OMA SHOULD TAKE LEGAL ACTION BEFORE CCO FORCES ITS NON BUDDIES TO CLOSE CLINIC

    DR MIKE SMITH MISSISSAUGA COLONOCSOPY CENTRE
    .

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