COMMISSION ON CANCER 2013 Cancer Program Practice Profile Reports (CP 3 R)

Transcription

1 COMMISSION ON CANCER 2013 Cancer Program Practice Profile Reports (CP 3 R) Women often choose to have a mastectomy with breast reconstruction surgery instead of breast conservation following a breast cancer diagnosis. Women are offered the added benefit of our highly skilled and widely recognized breast cancer surgeons working hand-inhand with our breast reconstruction team who offer surgical expertise and advanced procedures and techniques. (pictured l to r Neil B. Friedman, M.D., Director, The Hoffberger Breast Center, Gauri Bedi, M.D., Associate Director, and Jennifer Joh, M.D., Bernard Chang, M.D., Director, Plastic and Reconstructive Surgery, and Brendan Collins, M.D.) The Institute for Cancer Care at Mercy is committed to providing high-quality care to our patients and their families. We are especially proud that the care, an instrumental element to our Commission on Cancer (CoC) of cancer program. the American College of Surgeons awarded our Cancer Program As a CoC accredited cancer Accreditation with Commendation program, Mercy is able to gather Gold Status. This accreditation information from the CoC s Cancer acknowledges Mercy s commitment Program Practice Profile Reports to offering the highest standard of (CP 3 R) to examine outcomes data from other local providers and hospitals to compare to standard of care therapies for major cancers. This provides an arena which to further improve upon quality of patient care locally as well as share in how other hospitals care for patients. Additionally, allowing all CoC programs to recognize issues in caring for and delivering and applying best practices that will help eliminate any discrepancies in care throughout CoC accredited cancer programs.

2 Commission on Cancer Program Practice Profile continued CP 3 R measures: accountability, quality improvement, and surveillance. Accountability: High level of evidence supports the measure, including multiple randomized control trials. These measures can be used for such purposes as public reporting, payment incentive program, and the selection of provides by consumers, health plans, or purchasers. Debra A. Vachon, M.D., Surgical Director for The Center for Inflammatory Bowel and Colorectal Diseases, part of The Melissa L. Posner Institute for Digestive Health & Liver Disease at Mercy, is a recognized surgical specialist in the diagnosis and treatment of inflammatory bowel and colorectal diseases. She is committed to helping her patients learn how to manage their illness. The CP 3 R provides feedback to Commission on Cancer (CoC) accredited cancer programs to: Report compliance with CoC approved quality measures Improve the quality of data across several disease sites Foster preemptive awareness of the importance of charting and coding accuracy Improve clinical management and coordination of patient care in the multidisciplinary setting Each year, CoC standards require Cancer Committees to review the quality of patient care using the CP 3 R tool to evaluate care within and across disciplines, to discuss successful processes, and to evaluate how procedures that can be improved to promote evidencedbased practice. The Cancer Committee is expected to address performance rates that fall below specific thresholds established by the CoC as well as document findings. There are three types of Quality Improvement: Evidence from experimental studies, not randomized control trials supports the measure. These are intended for internal monitoring of performance within an organization. Surveillance: Limited evidence exist that supports the measure or the measure is used for informative purposes to accredited programs. These measures can be used to identify the status quo as well as monitor patterns and trends of care in order to guide decisionmaking and resource allocation. Note: This page and all content are a Copyright 2013 by the NCDB and American College of Surgeons, Chicago, IL

3 BCS Measure nbx Measure BCS Breast conservation surgery rate for women with AJCC Clinical Stage 0, I, or II breast cancer (Measure: Surveillance) There is no specific performance rate that must be met to comply with the CoC requirement for this measure. Mercy s breast conservation rate is lower than the other groups; however, many times women choose to have a mastectomy with reconstruction rather than breast conservation. nbx Image or palpation-guided needle biopsy (core or FNA) of the primary site is performed to establish diagnosis of breast cancer (Measure: Quality Improvement)) The CoC requires an 80% performance rate, which Mercy far exceeds. HT Measure HT Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or Stage IB-III hormone receptor positive breast cancer The CoC requires a 90% performance rate to comply with this measure. Mercy has a 95.1% performance rate, which exceeds all the other groups.

4 MASTRT Measure BCSRT Measure MASTRT 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. Mercy has a performance rate of 100% for this measure, which exceeds the requirement of 90% by the CoC and far exceeds the other comparison groups. BCSRT Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer The CoC requires a performance rate of 90% for this measure. Mercy exceeds this requirement and exceeds the comparative groups as well. MAC Measure MAC Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0, or Stage IB-III hormone receptor negative breast cancer Mercy exceeds the 90% performance rate required by the CoC and exceeds the other comparative group percentages as well.

5 ACT Measure 12RLN Measure ACT Adjuvant chemotherapy is recommended within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer Mercy has a performance rate of 100%, which far exceeds the other comparative groups as well as the 90% requirement by the CoC for this measure. BCSRT At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Measure: Quality Improvement) The CoC requirement for 12RLN measure is an 85% performance rate. As indicated in the chart above, Mercy far exceeds this requirement as well as the other comparative groups displayed. Quality Results Exceed Standards Based on the CoC 2013 data, Mercy Medical Center met and/or exceeded the required performance rates for all measures. Our outcome measures support Mercy s commitment to provide high-quality cancer care services. The Institute for Cancer Care 227 St. Paul Place Baltimore, Maryland MDMercy.com