Audit Report. Bladder Cancer Quality Performance Indicators. West of Scotland Cancer Network. Urological Cancer Managed Clinical Network

Transcription

1 Urological Cancer Managed Clinical Network Audit Report Bladder Cancer Quality Performance Indicators Clinical Audit Data: 01 April 2015 to 31 March 2016 Mr Gren Oades MCN Clinical Lead Tom Kane MCN Manager Sandie Ker Information Officer

2 CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION BACKGROUND NATIONAL CONTEXT WEST OF SCOTLAND CONTEXT METHODOLOGY RESULTS AND ACTION REQUIRED DATA QUALITY PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) CONCLUSIONS 35 ACKNOWLEDGEMENT 37 ABBREVIATIONS 38 REFERENCES 39 APPENDIX: NHS BOARD ACTION PLANS 40 Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 2

3 Executive Summary Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed with bladder cancer in the twelve months between 01 April 2015 and 31 March Data are collected for all urological cancers, however data analysed and included within this report relates to cancer of the bladder only and results are measured against the Bladder Cancer Quality Performance Indicators 1 (QPIs) which were implemented for patients diagnosed on or after 01 April The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Bladder Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in April Data definitions and measurability criteria to accompany the Bladder Cancer QPIs are available from the ISD website 2. Twelve months of data were measured against the Bladder Cancer QPIs for the second consecutive year and are presented within this audit report. Following reporting of Year 1 data, a process of baseline review was undertaken to ensure QPIs were fit for purpose and truly driving quality improvement in patient care. This review process resulted in measurability changes to some QPIs and therefore Year 1 data is only presented within this audit report alongside Year 2 data for QPIs where results have remained comparable. Future reports will continue to compare clinical audit data in successive years to further illustrate trends. Background Invasive bladder cancer accounts for 2.6% of all cancers and is the tenth most common cancer type in Scotland 3. There is a notable difference in incidence between the sexes with almost twice as many cases being diagnosed in the male population in (65.9%). Invasive bladder cancer accounts for 3.5% of all cancer diagnoses in men and was the eighth most commonly diagnosed cancer in males in It was the thirteenth most common cancer type in females accounting for 1.8% of all female cancer diagnoses 3. Survival rates for bladder cancer are relatively low compared to other cancer types which are detected more easily, either due to earlier presentation or screening programmes 4. One-year and 5-year relative survival for males diagnosed between 2007 and 2011 is 73.1% and 49.6% respectively, compared to only 58.5% and 34.0% respectively for females 3. The lower survival rates amongst the female population are attributed to delays in diagnosis often due to later presentation or misdiagnosis 5. Although bladder cancer shows a decrease in survival over the past 20 years, this is an artefact of a change in classification whereby some invasive bladder cancers were reclassified as non-invasive and are therefore no longer included in the survival statistics 4. Invasive bladder cancer is the eighth most common cause of death from cancer in Scotland 3 however overall mortality rates have decreased by 6.9% over the past 10 years from 2005 to Four NHS Boards across the WoS serve the 2.47 million population 6. From this population, around 350 new cases of muscle-invasive bladder cancer (MIBC) are diagnosed each year 7. It should be noted that non-muscle-invasive bladder cancers (NMIBC) are also included in audit figures and managed through the Multidisciplinary Teams (MDTs). There were 688 new cases of bladder cancer (MIBC and NMIBC) managed in the WoS between 01 April 2015 and 31 March The configuration of the MDTs in the region is set out below and each MDT convenes on a weekly basis. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 3

4 MDT Constituent Hospitals Ayrshire & Arran (AA) Crosshouse Hospital, Ayr Hospital Greater Glasgow and Clyde (GGC) (i) Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Vale of Leven (ii) Royal Alexandra Hospital, Inverclyde Royal Hospital Forth Valley (FV) Lanarkshire (Lan) Forth Valley Royal Hospital Monklands District General, Wishaw General Hospital, Hairmyres Hospital Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed between 01 April 2015 and 31 March 2016 was downloaded from ecase on 01 February Analysis was performed centrally by the (WoSCAN) Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local NHS Boards to check for inaccuracies or obvious gaps before final analysis was carried out. Final results were disseminated for NHS Board verification in line with the regional audit governance process, to ensure that the data was an accurate representation of service in each area. Results Case ascertainment is an estimate of the proportion of expected patients identified through audit. Case ascertainment for bladder cancer is high across WoS at 93.1% which indicates that the majority of cases have been captured by audit. However, it should be noted that the predicted incidence of all cancer types is based on historic numbers of cases diagnosed and therefore some variation in case ascertainment is expected. Overall data capture is good for Bladder Cancer QPIs with the exception of QPIs 2 and 4. There was significant data missing with regards to the exclusion and/or denominator criteria for these QPIs which may have affected the accuracy of results. Caution should therefore be taken when comparing Year 1 and Year 2 results for these QPIs. The summary of results overpage shows the WoS percentage performance against each QPI target and performance by NHS Board. There were 11 QPIs reported for bladder cancer in Year 2 which were split into 23 sub-qpis. It is evident that Boards found some of the QPI targets challenging to meet. Overall WoS results demonstrate that the target was met for 4 of the 10 reported QPIs (not including QPI 8 Cases per Surgeon) for patients diagnosed in Year 2. This equated to 12 of the 22 sub-qpis being met at a regional level (55%). NHS Ayrshire & Arran has demonstrated above average performance in Year 2 of QPI reporting, exceeding the target for 7 of the 11 reported QPIs. NHSGGC has not yet submitted any comments with regard to this year s QPI performance. Results for each QPI are shown in detail in the main report and illustrate NHS Board performance against each target and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 4

5 BLADDER Quality Performance Indicators 1(i). Multidisciplinary Team Meeting Discussion Proportion of patients who are discussed at MDT before definitive treatment. (i) MIBC Performance by NHS Board QPI target AA FV GGC LAN WoS 95% 96.4% 100% 93.8% 95.5% 95.5% (ii). Multidisciplinary Team Meeting Discussion Proportion of patients who are discussed at MDT following initial TURBT. (ii) NMIBC 2 (i). Quality of TURBT Proportion of patients who undergo TURBT (transurethral resection of bladder tumour) where a bladder diagram has been used at initial resection. 2 (ii). Quality of TURBT Proportion of patients who undergo TURBT where it is documented whether the resection was complete or not at initial resection. 2 (iii). Quality of TURBT Proportion of patients who undergo TURBT where detrusor muscle is included in the specimen at initial resection. 3. Mitomycin C following TURBT Proportion of patients with NMIBC who undergo TURBT who receive a single installation of mitomycin C within 24 hours of resection. 4(i). Early TURBT Proportion of patients with high-risk NMIBC who have undergone TURBT who have a second TURBT or early cystoscopy (+/- biopsy) within 6 weeks of initial resection. 4(ii). Early TURBT Proportion of patients with high-risk NMIBC who have undergone TURBT where detrusor muscle is absent from specimen who have a second TURBT or early cystoscopy (+/- biopsy) within 6 weeks of initial resection. 4(iii). Early TURBT Proportion of patients with high-risk NMIBC who have undergone TURBT where initial resection is incomplete who have a second TURBT or early cystoscopy (+/- biopsy) within 6 weeks of initial resection. 95% 80% 80% 80% 60% 80% 80% 80% 100% 93.8% 95.7% 94.7% 96.0% % 62.0% 36.1% 43.9% 49.2% % 70.4% 93.3% 93.9% 91.3% % 81.7% 78.1% 74.2% 78.1% % < 55.6% < 65.9% < 74.2% > 70.5% < % < 34.8% > 13.0% > 8.6% < 17.6% < % 33.3% 16.7% 18.2% 19.1% % % % (i). Pathology Reporting Proportion of patients who undergo TURBT where the pathology report contains all relevant data. 90% 100% = 97.3% > 94.7% < 80.3% < 92.6% > Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 5

6 BLADDER Quality Performance Indicators Performance by NHS Board QPI target AA FV GGC LAN WoS 5(ii). Pathology Reporting Proportion of patients who undergo cystectomy where the pathology report contains all relevant data. 90% 100% = 90.9% > 100% > 83.3% < 95.7% > Lymph Node Yield Proportion of patients who undergo primary radical cystectomy where 10 lymph nodes are resected and pathologically examined. 7(i). Time to Treatment Proportion of patients with MIBC who undergo radical cystectomy or radiotherapy only within 3 months of diagnosis of MIBC. 7(ii). Time to Treatment Proportion of patients with MIBC who have neoadjuvant chemotherapy who undergo cystectomy or chemoradiation within 8 weeks of initial treatment. 90% 90% 90% 91.7% > 71.4% < 82.9% > 91.7% < 84.8% > % 77.8% 82.5% % 80.0% 42.9% 50.0% 56.4% Volume of cases per surgeon Number of radical cystectomy procedures performed by a surgeon over a 1-year period. 10 per year 6 x Not met 1 x Met 3 x Met 9 x Not met 4 x Not met 4 x Met 19 x Not met 9. Oncological discussion Proportion of patients with MIBC who had radical surgery who met with an oncologist prior to radical cystectomy. 10. Radical Radiotherapy with Chemotherapy Proportion of patients with TCC (transitional cell carcinoma) of the bladder (T2-T4) undergoing radical radiotherapy receiving concomitant chemotherapy. 85% 50% 60.0% < 80.0% > 88.9% > 83.3% > 79.5% > % < 0.0% = 15.2% < (i) 30-day Mortality Patients who die within 30 days of treatment with curative intent. (a) Radical cystectomy < 5% 11(i) 30-day Mortality Patients who die within 30 days of treatment with curative intent. (b) Radiotherapy < 5% 11(i) 30-day Mortality Patients who die within 30 days of treatment with curative intent. (c) Chemotherapy < 5% 0.0% = 0.0% = 2.9% < 0.0% = 1.5% < % = 0.0% = 0.0% = 0.0% = 0.0% = % = 0.0% = 0.0% = 5.6% < 1.8% < Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 6

7 BLADDER Quality Performance Indicators Performance by NHS Board QPI target AA FV GGC LAN WoS 11(ii) 90-day Mortality Patients who die within 90 days of treatment with curative intent. (a) Radical cystectomy < 5% 11(ii) 90-day Mortality Patients who die within 90 days of treatment with curative intent. (b) Radiotherapy < 5% 11(ii) 90-day Mortality Patients who die within 90 days of treatment with curative intent. (c) Chemotherapy < 5% 0.0% = 0.0% = 6.5% < 8.3% < 4.8% < % = 0.0% = 5.3% > 0.0% = 2.6% > % = 0.0% = 0.0% = 5.6% < 1.8% < Meets/exceeds QPI target Figures below percentage performance denote the numerator and denominator values. Does not meet QPI target (-) dash denotes a denominator of less than 5. Figures have been removed to ensure confidentiality. > Indicates increase on previous year s figure < Indicates decrease from previous year s figure = Indicates no change from previous year Indicates no comparable measure from previous year Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 7

8 Conclusions and Action Required Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. With the development of Quality Performance Indicators, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards commitment to the continuous improvement of the quality and completeness of audit data has supported this transition to national reporting. The improvements have provided accurate baseline data for the majority of Bladder Cancer QPIs from which yearly comparisons in the service provision across WoS Boards can be made. Data completeness does however require to be improved for QPIs 2, 4 and 8 to ensure accurate measurement of these performance indicators in the future. Data completeness for the remaining QPIs is of a high standard and therefore results should be an accurate reflection of performance. A number of revisions to the Bladder Cancer QPIs were made following discussion at the National Urological Cancer Meeting and Bladder Cancer QPI Baseline Review and QPIs will undergo formal review after Year 3 of reporting. Overall, with the exception of mortality rates, the Bladder Cancer QPI targets have proved challenging for most NHS Boards to meet. It is encouraging however that improvement on Year 1 performance has been demonstrated for a number of sub-qpis which have remained comparable following baseline review. The audit report has identified actions relating to service provision, including the time from initial to repeat TURBT for patients with high-risk NMIBC, pathology reporting for TURBT and cystectomy procedures and lymph node yield for patients undergoing primary radical cystectomy. The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendix. Action required: Data Quality NHS Forth Valley, NHSGGC and NHS Lanarkshire should review actions implemented following Year 1 analysis with regard to missing data items to assess whether these have been effective and amend where necessary. QPI 2 Quality of Transurethral Resection of Bladder Tumour (TURBT) NHS Forth Valley, NHSGGC and NHS Lanarkshire should complete local six-month review to ensure the introduction of the bladder proforma is improving data collection and accuracy as intended. QPI 4 Early Re-TURBT NHSGGC should review all cases not undergoing repeat TURBT or cystoscopy within 6 weeks of initial TURBT and report findings to MCN, taking appropriate action as necessary. All Boards should undertake local review of waiting times to repeat TURBT or cystoscopy for cases where this treatment is appropriate, and monitor actions which have been implemented to meet the 6-week target. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 8

9 QPI 5 Pathology Reporting NHS Lanarkshire should monitor pathology reporting locally to ensure TURBT and cystectomy procedures are being reported according to RCP guidelines. QPI 6 Lymph Node Yield NHSGGC should review all cases where less than 10 lymph nodes were resected and pathological examined and report back to MCN on findings, implementing action as necessary. QPI 7 Time to Treatment NHSGGC should review cases that did not meet the QPI criteria for QPI 7 and take appropriate action on findings. QPI 8 Volume of Cases per Surgeon All NHS Boards should review SMR01 data in conjunction with local data sources and liaise with coding departments in order to investigate any issues surrounding the accuracy of data. A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendix. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Steering Group and any service or clinical issue which the Steering Group considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a threeyearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012). Final Published Bladder Cancer MCN Audit Report v1.0 01/06/2017 9

10 1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed with bladder cancer in the twelve months between 01 April 2015 and 31 March Regular reporting of activity and performance is a fundamental requirement of a Managed Clinical Network (MCN) to assure the quality of care delivered across the region. Data are collected for all urological cancers, however data analysed and included within this report relates to cancer of the bladder. Results are measured against the Bladder Cancer Quality Performance Indicators 1 (QPIs) which were introduced for patients diagnosed on or after 01 April 2014, and Bladder Cancer QPIs are reported here for the second year of data collection. The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Bladder Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in April Data definitions and measurability criteria to accompany the Bladder Cancer QPIs are available from the ISD website 2. Twelve months of data were measured against the Bladder Cancer QPIs for the second consecutive year and are presented within this audit report. Following reporting of Year 1 data, a process of baseline review was undertaken to ensure QPIs were fit for purpose and truly driving quality improvement in patient care. This review process resulted in measurability changes to some QPIs and therefore Year 1 data is only presented within this audit report alongside Year 2 data for QPIs where results have remained comparable. Future reports will continue to compare clinical audit data in successive years to further illustrate trends. 2. Background Four NHS Boards across the WoS serve the 2.48 million population 6. From this population, around 350 new cases of muscle-invasive bladder cancer (MIBC) are diagnosed each year 7. It should be noted that non-muscle-invasive bladder cancers (NMIBC) are also included in audit figures and managed through the Multidisciplinary Teams (MDTs). There were 688 new cases of bladder cancer (MIBC and NMIBC) managed in the WoS between 01 April 2015 and 31 March The configuration of the MDTs in WoS is set out below and each MDT convenes on a weekly basis. MDT Constituent Hospitals Ayrshire & Arran (AA) Crosshouse Hospital, Ayr Hospital Greater Glasgow and Clyde (GGC) (i) Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Vale of Leven (ii) Royal Alexandra Hospital, Inverclyde Royal Hospital Forth Valley (FV) Lanarkshire (Lan) Forth Valley Royal Hospital Monklands District General, Wishaw General Hospital, Hairmyres Hospital Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

11 2.1 National Context Bladder cancer (MIBC only) accounts for 2.6% of all cancers and is the tenth most common cancer type with approximately 820 cases diagnosed in Scotland each year between 2010 and The age-adjusted incidence of invasive bladder cancer has decreased by 8.8% in the past ten years from 2004 to , the decrease in incidence being significant in the male population (10.8%). There is a notable difference in incidence between the sexes with almost twice as many cases being diagnosed in the male population in Invasive bladder cancer accounts for 3.5% of all cancer diagnoses in men and was the eighth most commonly diagnosed cancer in males in It was the thirteenth most common cancer type in females accounting for only 1.8% of all female cancer diagnoses 3. Survival rates for bladder cancer are relatively low compared to other cancer types which are detected more easily, either due to earlier presentation or screening programmes 4. One-year and 5-year relative survival for males diagnosed between 2007 and 2011 is 73.1% and 49.6% respectively, compared to only 58.5% and 34.0% respectively for females 3. The lower survival rates amongst the female population are attributed to delays in diagnosis often due to later presentation or misdiagnosis 5. Although bladder cancer shows a decrease in survival rates over the past 20 years, this is an artefact of a change in classification whereby some invasive bladder cancers were reclassified as non-invasive and are therefore no longer included in the survival statistics 4. Invasive bladder cancer is the eighth most common cause of death from cancer in Scotland 3 however overall mortality rates have decreased by 6.9% over the past 10 years from 2005 to West of Scotland Context A total of 688 cases of bladder cancer were recorded through audit as diagnosed in the West of Scotland between 01 April 2015 and 31 March The number and percentage of patients diagnosed within each NHS Board is presented in Figure 1. As the largest WoS Board, just over half (50.3%) of all new cases of bladder cancer were diagnosed in NHS Greater Glasgow and Clyde (NHSGGC) which is approximately in line with population estimates for this Board (46.4% of WoS population, 2015 mid-year estimates 6 ). Figure 1: Number and proportion of patients diagnosed with bladder cancer in each NHS Board, Apr 15 to Mar 16. Lan 21.9% AA 14.4% FV 13.4% GGC 50.3% AA FV GGC Lan WoS No. of new diagnoses % of WoS Total 14.4% 13.4% 50.3% 21.9% Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

12 Male cases accounted for almost two thirds of all new WoS bladder cancer diagnoses (64.8%) captured by audit between April 2015 and March The majority of new cases of bladder cancer diagnosed in WoS occurred in people within older age groups with more than three quarters of cases occurring in those over the age of 65 years at time of diagnosis (76.6%). Median age at diagnosis is similar for males and females at 74 years and 73.5 years respectively. Figure 2: Number of patients diagnosed with bladder cancer in WoS within each age group by sex, Apr 15 to Mar 16. Number of new cases Males Females Age group (years) Total Median Male Female Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was recorded manually and entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised webbased database. Data relating to patients diagnosed between 01 April 2015 and 31 March 2016 was downloaded from ecase at 2200 hrs on 01 February Cancer audit is a dynamic process with patient data continually being revised and updated as more information becomes available. This means that apparently comparable reports for the same time period and cancer site may produce slightly different figures if extracted at different times. Analysis was performed centrally for the region by the (WoSCAN) Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local NHS Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

13 4. Results and Action Required 4.1 Data Quality Audit data quality can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated as the number of new cases identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by Information Services Division, National Services Scotland). Cancer Registry figures were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by Information Services Division (ISD). Cancer Registry figures are usually an average of the previous five years figures to take account of annual fluctuations in incidence within NHS Boards; however figures used for bladder cancer are from 2003 to 2007 due to changes in classification. Figure 3: Case ascertainment by NHS Board for patients diagnosed with bladder cancer, Apr 15 to Mar 16. Case ascertainment (%) 110% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC Lan WoS NHS Board of diagnosis AA FV GGC Lan WoS Cases from audit ISD Cases ( average) % Case ascertainment 80.5% 92.9% 92.5% 105.6% 93.1% Overall case ascertainment for WoS is good at 93.1% which indicates that the majority of cases have been captured through audit. Case ascertainment figures however are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Lower or higher figures can also indicate changes in incidence of a particular cancer type within a board or region over time. Case ascertainment for each WoS Board is illustrated in Figure 3. There is variation in percentage case ascertainment across the four NHS Boards ranging from 80.5% in NHS Ayrshire & Arran to 105.6% in NHS Lanarkshire. For the majority of the 11 reported Bladder Cancer QPIs, all the relevant data items had values recorded (i.e. for numerator, denominator or exclusions) and therefore information presented within this report is likely to be of high accuracy. This is with the exception of QPIs 2 and 4 where there was a high proportion of missing data which may have affected the accuracy of QPI reporting. The size of tumour was poorly recorded for QPI 2 and therefore a large number of cases were not recorded for exclusion as tumours less than 5mm should not be included in the analysis. Missing Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

14 fields for QPI 4 included the intent of surgery, whether detrusor muscle was present in the specimen and whether associated carcinoma in situ (CIS) was present, to name a few. QPI 8 utilises General/Acute Inpatient and Day Case data (SMR01) from ISD to report the volume of radical cystectomy procedures performed by each surgeon. The accuracy of these reports should be assessed by each NHS Board in conjunction with their local coding departments however, as there is question over the number of individual surgeons being reported as carrying out these procedures. Actions were identified in last year s audit report with regard to data collection and Boards should reassess the completion of these fields and carry forward any actions which have not resulted in improved data recording. As there is often a time lag between analysis, reporting and the implementation of actions, it may be that improvements are not yet apparent and Boards should assess this locally and amend any actions if required. Of note, NHS Ayrshire & Arran did not have any not-recorded values for the second consecutive year. Action required: NHS Forth Valley, NHSGGC and NHS Lanarkshire should review actions implemented following Year 1 analysis with regard to missing data items to assess whether these have been effective and amend where necessary. 4.2 Performance against Quality Performance Indicators (QPIs) Results of the analysis of Bladder Cancer Quality Performance Indicators (QPIs 1 11) are set out in the following sections. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Data (both graphically and in tabular format) are presented by location of diagnosis, location of treatment, or by operating surgeon, with some criteria given as an overall West of Scotland representation. Specific NHS-Board actions have been identified to address issues highlighted through the data analysis. It should be noted that commentary for this year s QPI analysis has not yet been received from NHSGGC and therefore is not included in this report. Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this are denoted with a dash (-). Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement. An asterisk (*) is applied to indicate a denominator of zero and to distinguish between this and a 0% performance. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

15 QPI 1: Multidisciplinary Team Meeting Discussion Evidence suggests that patients with cancer managed by a multidisciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care 1. Discussion prior to definitive treatment decisions being made provides reassurance that patients are being managed appropriately 1. Following baseline review, QPI 1 was split into two parts as it is appropriate for patients with nonmuscle-invasive bladder cancer (NMIBC) to be discussed following initial transurethral resection of bladder tumour (TURBT). (i) Muscle-invasive Bladder Cancer (MIBC) Description: Numerator: Denominator: Proportion of patients with MIBC who are discussed at the MDT before definitive treatment. Number of patients with MIBC discussed at the MDT before definitive treatment (this includes: neoadjuvant SACT, radical cystectomy, radiotherapy and supportive care only). All patients with MIBC. Exclusions: Patients who died before first treatment. Target: 95% (ii) Non-muscle-invasive Bladder Cancer (NMIBC) Description: Proportion of patients with NMIBC who are discussed at the MDT following initial TURBT. Numerator: Number of patients with NMIBC discussed at the MDT following initial TURBT. Denominator: All patients with NMIBC. Exclusions: No exclusions. Target: 95% Figure 4: The proportion of patients with (i) muscle-invasive and (ii) non-muscle invasive bladder cancer who are discussed at MDT meeting. Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target - 95% QPI 1 (i) QPI 1 (ii) QPI 1 (i) and (ii) AA FV GGC Lan WoS NHS Board of diagnosis Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

16 QPI 1(i) Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 96.4% % 0 0.0% 0 FV 100.0% % 0 0.0% 0 GGC 93.8% % 0 0.0% 0 Lan 95.5% % 0 0.0% 0 WoS 95.5% % 0 0.0% 0 QPI 1(ii) AA 100.0% % 0 0.0% 0 FV 93.8% % 0 0.0% 0 GGC 95.7% % 0 0.0% 2 Lan 94.7% % 0 0.0% 1 WoS 96.0% % 0 0.0% 3 QPI 1 (i) and (ii) AA 99.0% % 0 0.0% 0 FV 96.2% % 0 0.0% 0 GGC 95.1% % 0 0.0% 2 Lan 95.0% % 0 0.0% 1 WoS 95.8% % 0 0.0% 3 There were 198 cases in the WoS defined as MIBC and 189 of these patients were discussed at MDT meeting prior to definitive treatment, resulting in an overall WoS performance of 95.5% against the 95% target for QPI 1 (i). Similarly, for NMIBC cases, 96.0% of cases met the QPI with 405 of 422 cases diagnosed with NMIBC in WoS discussed at MDT following initial TURBT (QPI 1 (ii)). Collectively, part (i) and (ii) of QPI 1 was met at a regional level and NHS-Board level for all WoS Boards with an overall WoS performance of 95.8% and Board performance ranging from 95.0% in NHS Lanarkshire to 99.0% in NHS Ayrshire & Arran. However, performance was slightly short of the target at Board level in some instances when broken into component parts (MIBC and NMIBC). It should however be noted that by splitting the QPI at baseline review, there are now a number of patients not included for measurement in the MDT QPI. This is a result of defining muscle-invasive or non-muscle-invasive in the denominators for parts (i) and (ii) as there are 68 patients for whom this is not defined by the data fields used. Regional WoS performance based on the original measurability was also 95.8% in Year 2 however this included all patients diagnosed with bladder cancer with 659 of 688 discussed at MDT. The measurability of this QPI should be discussed at Formal Review. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

17 QPI 2: Quality of Transurethral Resection of Bladder Tumour Recording Transurethral resection of bladder tumour (TURBT) procedures undertaken should be of good quality. TURBT is considered to be the gold standard initial treatment of non-muscle-invasive bladder cancer (NMIBC), with the aim of completely removing all macroscopic tumours and obtaining tissue for essential pathological evaluation 1. It is recommended that a TURBT is performed in a systematic manner; a complete resection with detrusor muscle in the sample is the ultimate aim. Adequate documentation (use of a bladder diagram) with a conclusion regarding radicality or residual tumour is recommended 1. Following baseline review, QPI 2 was divided into three core elements to illustrate how Boards are performing for each TURBT recommendation. Performance against part (i), (ii) and (iii) is illustrated in Figure 5 for Year 2 analysis. Figure 6 illustrates the proportion of patients who have met all three core elements of good-quality TURBT for Year 1 and Year 2 of analysis. Description: Numerator: Denominator: Proportion of patients with bladder cancer who undergo good quality TURBT where the following have been undertaken at initial resection: (i) Use of a bladder diagram with documentation of tumour location, size, number and appearance; (ii) Documented whether complete resection or not; and (iii) Detrusor muscle included in the specimen. Number of patients with bladder cancer who undergo good quality TURBT where the following have been undertaken at initial resection: (i) Use of a bladder diagram with documentation of tumour location, size, number and appearance; (ii) Documented whether complete resection or not; and (iii) Detrusor muscle included in the specimen. All patients with bladder cancer who undergo TURBT. Exclusions: Patients undergoing palliative resection. Patients with very small tumours ( 5 mm). Target: 80% Figure 5: The proportion of patients with bladder cancer who underwent good-quality TURBT in Year 2. The QPI measures whether (i) a bladder diagram was used (ii) it was recorded whether resection is complete (iii) detrusor muscle was included in the specimen. Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target - 80% QPI 2 (i) QPI 2 (ii) QPI 2 (iii) AA FV GGC Lan WoS NHS Board of surgery Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

18 Performance (%) Numerator Denominator QPI 2(i) Bladder diagram numerator numerator (%) exclusions exclusions (%) denominator AA 98.5% % 0 0.0% 0 FV 62.0% % % 0 GGC 36.1% % % 0 Lan 43.9% % % 0 WoS 49.2% % % 0 QPI 2(ii) Resection AA 100.0% % 0 0.0% 0 FV 70.4% % % 0 GGC 93.3% % % 0 Lan 93.9% % % 0 WoS 91.3% % % 0 QPI 2 (iii) Detrusor muscle AA 82.1% % 0 0.0% 0 FV 81.7% % % 0 GGC 78.1% % % 0 Lan 74.2% % % 0 WoS 78.1% % % 0 Figure 6: The proportion of patients with bladder cancer who underwent TURBT in Year 1 and Year 2 where all three core elements of good-quality TURBT were met and recorded. Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target - 80% Combined QPI 2 results: Year 1 Year 2 AA FV GGC Lan WoS NHS Board of surgery Of the 539 patients diagnosed with bladder cancer in WoS undergoing TURBT, a bladder diagram was used for 269 patients (49.2%), resection was recorded as complete or not for 492 patients (91.3%) and detrusor muscle was present in the specimen for 421 patients (78.1%). Overall this resulted in 195 patients (36.2%) having all three recommendations complete at initial TURBT in Year 2 which is higher than Year 1 performance of 24.3%. NHS Ayrshire & Arran was the only Board to meet the 80% target for all three criteria individually and as a combined result, with 80.6% of patients having met all three core elements. As in Year 1, NHS Ayrshire & Arran did not have any not-recorded values for Year 2 data. Figure 5 illustrates that the remaining three NHS Boards would need to improve the use of a bladder diagram at initial TURBT in order to maximise improvement of overall results. NHSGGC and NHS Lanarkshire did show improvement in the final quarter of Year 2, with performance of 54.2% and 75.8% respectively with regards to the use of bladder diagram. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

19 There was a high proportion of not-recorded values for the exclusion criteria in NHS Forth Valley, NHSGGC and NHS Lanarkshire (range 35.6% to 60.6%) and it is possible that some of these patients should have been excluded from the denominator. Data fields which were not recorded for exclusion relate to tumour size in NHSGGC and Lanarkshire and tumour size and/or treatment intent for TURBT in NHS Forth Valley. It was agreed at baseline review that the use of a proforma is key to ensure accurate recording and reporting of this QPI. NHS Lanarkshire has commented that a bladder proforma was introduced in April 2016 which should help in collecting accurate data. It has already been noted that introduction of the proforma has improved the accurate recording of whether detrusor muscle is present or not and NHS Lanarkshire has stated that progress will be monitored on all aspects of data collection with early local reporting. NHS Forth Valley has commented that results have improved greatly since implementation of a proforma (as evidenced in Figure 6) and continued effort will be made to capture all the information required. Action required: NHS Forth Valley, NHSGGC and NHS Lanarkshire should complete local six-month review to ensure the introduction of the bladder proforma is improving data collection and accuracy as intended. QPI 3: Mitomycin C Following Transurethral Resection of Bladder Tumour (TURBT) Patients with non-muscle-invasive bladder cancer (NMIBC) who undergo TURBT should receive a single instillation of mitomycin C within 24 hours of resection, unless contraindicated. The recurrence rate in NMIBC is as high as 70% 1. Tumour features (number, size, grade and stage) and quality of TURBT determine overall recurrence rates. However, TURBT causes tumour cells to be dispersed within the bladder during the procedure and these could be re-implanted in the bladder mucosa, subsequently being detected as recurrence 1. By destroying floating cancer cells and those that have been implanted on the resection site, a single instillation of intravesical chemotherapy confers an absolute reduction in tumour recurrence of 12% 1. Previous definitions excluded those cases with a confirmed perforation but not others in whom the risk of extravasation is thought to be excessive as the dataset cannot currently identify these cases. At baseline review the difficulty in recording the exclusion criteria for QPI 3 was discussed along with the challenges associated with the measurement of other clinically appropriate exclusions (e.g. risk of extravasation) and it was agreed that the exclusions should be removed and the target lowered accordingly to 60%. Description: Numerator: Denominator: Proportion of patients with NMIBC who undergo TURBT who receive a single instillation of mitomycin C within 24 hours of resection. Number of patients with NMIBC who undergo TURBT who receive a single instillation of mitomycin C within 24 hours of resection. All patients with NMIBC who undergo initial TURBT. Exclusions: No exclusions Target: 60% Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

20 Figure 7: The proportion of patients with NMIBC who undergo TURBT who receive a single instillation of mitomycin C within 24 hours of resection, Year 1 and Year 2. Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target - 60% Year 1 Year 2 AA FV GGC Lan WoS NHS Board of diagnosis QPI 3 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 90.4% % 0 0.0% 0 FV 55.6% % 0 0.0% 0 GGC 65.9% % 0 0.0% 5 LAN 74.2% % 0 0.0% 2 WoS 70.5% % 0 0.0% 7 Of the 447 patients diagnosed in WoS with NMIBC that underwent TURBT, 315 patients are recorded as having received a single instillation of mitomycin C within 24 hours of resection resulting in a WoS performance of 70.5% against the 60% QPI target. Performance is broadly similar to Year 1 when 319 of 447 patients received mitomycin C (71.4%). Three of the four NHS Boards exceeded the 60% target, with NHS Ayrshire & Arran, NHS Lanarkshire and NHSGGC achieving 90.4%, 74.5% and 65.9% respectively. NHS Lanarkshire demonstrated significant improvement on Year 1 performance from 50.4% (54/107) to 74.2% (72/97) in Year 2. NHS Lanarkshire had previously commented that an additional mechanism for data collection had been identified which audit staff could access. NHS Forth Valley completed a review of all cases that did not meet the QPI criteria and found that, of the 24 patients that did not receive mitomycin C, its administration was inappropriate in 21 of these cases; two of which it was unclear whether the tumour was superficial or invasive. There were 3 cases where the reason was not recorded. Following discussion between the three regional networks and cancer lead clinicians, it has been proposed that QPI 3 (and QPI 5 Pathology reporting) should be reported by NHS Board of surgery in the next reporting period. Three years of comparable analysis will be undertaken for verification. QPI 4: Early Re-Transurethral Resection of Bladder Tumour (TURBT). A second resection should be carried out within 6 weeks of initial TURBT in patients with high-risk non-muscle-invasive bladder cancer (NMIBC), when detrusor muscle is absent or when initial resection is incomplete, unless contraindicated. Evidence suggests that re-turbt should be performed if the primary resection was not radical, e.g. if there is no detrusor muscle in the sample and/or where the initial specimen shows a high grade Ta/T1 tumour 1. A second TURBT in high-risk NMIBC improves the recurrence-free survival 1. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

21 Description: Numerator: Denominator: Proportion of patients who have undergone TURBT with high-risk NMIBC, where detrusor muscle is absent from specimen or initial resection is incomplete, who have a second resection or cystoscopy (± biopsy) within 6 weeks of initial TURBT. Number of patients with high-risk NMIBC who have undergone TURBT who have a second TURBT or early cystoscopy (± biopsy) within 6 weeks of initial resection. All patients with high-risk NMIBC who have undergone TURBT. (i) high-risk NMIBC, (ii) high-risk NMIBC and detrusor muscle absent from specimen, (iii) high-risk NMIBC and initial resection incomplete. Exclusions: Patients where TURBT has been carried out for palliation. Target: 80% Figure 8: The proportion of patients who have undergone TURBT with (i) high-risk NMIBC (ii) high-risk NMIBC and detrusor muscle absent (iii) high-risk NMIBC and incomplete resection, who have a second TURBT or early cystoscopy (± biopsy) within 6 weeks of initial TURBT. Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Performance (%) Numerator Denominator QPI 4(i) High-risk NMIBC numerator QPI target - 80% QPI 4 (i) QPI 4 (ii) QPI 4 (iii) - - AA FV GGC Lan WoS NHS Board of surgery numerator (%) exclusions exclusions (%) denominator AA 28.9% % 0 0.0% 0 FV 34.8% % % 0 GGC 13.0% % 0 0.0% 6 Lan 8.6% % 0 0.0% 2 WoS 17.6% % % 8 QPI 4(ii) High-risk NMIBC and detrusor muscle absent AA 16.7% % 0 0.0% 0 FV 33.3% % % 0 GGC 16.7% % 0 0.0% 7 Lan 18.2% % 0 0.0% 2 WoS 19.1% % 2 4.3% 9 QPI 4 (iii) High-risk NMIBC and incomplete initial resection AA 20.0% % 0 0.0% 0 FV % % 8 GGC 13.3% % 0 0.0% 10 Lan % 0 0.0% 1 WoS 19.2% % 1 3.8% 19 Final Published Bladder Cancer MCN Audit Report v1.0 01/06/

22 Figure 9: The proportion of patients with (i) high-risk NMIBC who have undergone TURBT who have a second TURBT (or cystoscopy ± biopsy in Year 2) within 6 weeks of initial TURBT, Year 1 and Year 2. Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target - 80% Year 1 Year 2 AA FV GGC Lan WoS NHS Board of surgery Of the 204 patients who were diagnosed with high-risk non-muscle-invasive bladder cancer who underwent TURBT, 36 patients underwent a second TURBT or cystoscopy within 6 weeks of the initial resection. This resulted in a WoS performance of 17.6% against the 80% QPI target in Year 2 which is a decrease of 8.0 percentage points on Year 1 performance. None of the four NHS Boards met the target for this QPI and performance varied across the Boards from 8.6% in NHS Lanarkshire to 34.8% in NHS Forth Valley. Following analysis of Year 1 data, a number of comments received from WoS Boards stated that some patients had undergone an alternative treatment. Performing cystoscopy, with or without biopsy, was considered appropriate treatment in a number of cases and therefore this was added to the numerator criteria following discussion at baseline review. It should also be noted that both NHS Ayrshire & Arran and NHS Forth Valley have commented below that it was not appropriate to perform re-resection in over 40% of their respective Year 2 cohorts, and this may suggest that the 80% target is unrealistic. NHS Ayrshire & Arran commented that 11 patients did not meet the QPI due to capacity issues and a further 16 patients were not fit for repeat TURBT or refused further surgery (42.1% of denominator). NHS Ayrshire & Arran have stated that management are aware of the recent capacity issues and there have been discussions within the Urology Department as to whether there should be subspecialisation with two or three consultants taking on the TURBT workload. NHS Forth Valley has commented that it was inappropriate to perform a repeat TURBT in 10 cases (43.5% of denominator). The remaining patients that did not meet the QPI did undergo repeat procedures however this was outwith the 6-week timeframe, with timescales ranging from 8 weeks to 36 weeks. Reasons cited for delay included; hospital or patient-induced delays and patients undergoing longer courses of mitomycin therapy. No actions were identified. NHS Lanarkshire stated that 5 cases did have re-resection but outwith the 6-week timeframe. For these cases, timeframes ranged from 6.5 to 14 weeks. The majority of cases went on to have BCG or mitomycin therapy, followed by a check scope. A few cases went directly for cystectomy or cystoprostatectomy procedures. NHS Lanarkshire has commented that a change in practice has been implemented whereby the operating surgeon carrying out the initial TURBT is responsible for booking appropriate patients for re-resection. Discussion at MDT will identify the 42-day timeframe and this will be recorded on the MDT proforma. The new process will be monitored with local reporting. Final Published Bladder Cancer MCN Audit Report v1.0 01/06/