2015 Public Outcomes Report Cancer Program Practice Profile Reports 2013 Breast and Colon Cancer

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1 As a Commission on Cancer (CoC)-accredited cancer program, HealthEast ensures that patients with cancer are treated according to nationally accepted measures. Measures for Quality of Cancer Care Each year, CoC-accredited programs are required to review their quality of patient care using the (CP 3 R). The purpose of these reports is to: Evaluate care within and across disciplines Discuss successful processes Evaluate how processes can be improved based on evidence-based practice. The CP 3 R analyzes HealthEast s performance compared to the national standard of care for selected breast and colon cancers. The CP 3 R also provides aggregate feedback for comparison with similar CoC-accredited cancer programs. The CoC partners with internal and external clinical experts to develop quality measures. The HealthEast cancer registry collects the necessary data to assess and monitor concordance with the measures. All measures are designed to assess performance at the hospital or systemslevel, and are not intended for application to individual physician performance. This report focuses on five measures specific to breast cancer and two measures specific to colon cancer. The report includes patients diagnosed in HealthEast meets or exceeds CoC expected performance rates (EPR) for all measures. Commission on Cancer Overview The Commission on Cancer (CoC), a program of the American College of Surgeons (ACoS), recognizes cancer care programs for their commitment to providing comprehensive, highquality, and multidisciplinary patient centered care. The CoC accreditation program is voluntary and encourages hospitals to improve quality of patient care through various cancer-related programs. These programs address the full continuum of cancer from prevention through hospice and end-of-life care, or survivorship and quality of life. HealthEast has maintained accreditation with the Commission on Cancer since 1987.

2 Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer 98% 95% 92% Expected performance rate: 9 Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1c N0 M0, or Stage IB - III hormone receptor positive breast cancer 98% 96% 92% Expected performance rate: 9

3 Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c N0 M0, or Stage IB - III hormone receptor negative breast cancer 95% 96% 93% Expected performance rate: 9 Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with 4 positive regional lymph nodes 93% 88% Expected performance rate: 9

4 Image or palpation-guided needle biopsy (core or FNA) to the primary site is performed to establish diagnosis of breast cancer 97% 93% 91% Expected performance rate: Adjuvant chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for patients under age 80 with AJCC Stage III (lymph node positive) colon cancer 91% 93% 9 Expected performance rate: 9

5 At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer 96% 91% 9 Expected performance rate: 85%

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