Audit Report Lymphoma Quality Performance Indicators

Transcription

1 West of Scotland Cancer Network Haemato-oncology Managed Clinical Network Audit Report Lymphoma Quality Performance Indicators Clinical Audit Data: 01 October 2016 to 30 September 2017 Dr Grant McQuaker Consultant Haematologist MCN Clinical Lead Heather Wotherspoon MCN Manager Julie McMahon Information Officer The content of this report is copyright WoSCAN unless otherwise stated.

2 CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 7 2. BACKGROUND NATIONAL CONTEXT WEST OF SCOTLAND CONTEXT 8 3. METHODOLOGY RESULTS AND ACTION REQUIRED DATA QUALITY PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 12 ACKNOWLEDGEMENT 33 ABBREVIATIONS 34 REFERENCES 35 APPENDIX 1: NHS BOARD ACTION PLANS 37 2

3 Executive Summary Introduction This report contains an assessment of the performance of West of Scotland (WoS) lymphoma services using clinical audit data relating to patients diagnosed with lymphoma in the twelve months between 1 st October 2016 and 30 th September Twelve months of data were measured against v3.0 of the Lymphoma Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 October This was the fourth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Lymphoma QPIs in In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland, a process of formal review was carried out after Year 3 of comparative reporting with tumour-specific Regional Clinical Leads undertaking a key role in determining the extent of the review required for each tumour type. The revised Lymphoma QPIs 1 were published in October 2017 and, as stated above, are valid for patients diagnosed on or after 01 October Background The Haemato-oncology Managed Clinical Network (MCN) was established in 2002 as a means of delivering equitable, high quality clinical care to all haemato-oncology patients across five NHS Boards; Ayrshire & Arran, Dumfries & Galloway, Forth Valley, Greater Glasgow and Clyde (GGC) and Lanarkshire covering a population of 2.6 million. Audit teams within the WoS recorded 580 new lymphoma cases diagnosed between 1 October 2016 and 30 September 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 1 October 2016 and 30 September 2017 was downloaded from ecase on 28 March Analysis was performed centrally by the West of Scotland Cancer Network (WoSCAN) Information Team. Results Case ascertainment for lymphoma is high across WoS at 101.9% indicating an excellent level of data capture, 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. Results for each QPI are shown in detail in the main report and illustrate 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. The following summary of results shows the WoS percentage performance against each QPI target and the range in performance by NHS Board. 3

4 Performance Summary Report Above Target Result Below Target Result > Indicates increase on previous years figure < Indicates decrease from previous years figure = Indicates no change from previous year Indicates no comparable measure from previous year Lymphoma Performance by Board QPI Target WoS A&A FV Lan NG SG Clyde D&G QPI 1(i): Radiological Diagnosis and Staging. Proportion of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment. QPI 1(ii): Radiological Diagnosis and Staging. Proportion of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request. QPI 2: Treatment Response Proportion of patients with DLBCL who are undergoing chemotherapy treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scan at end of chemotherapy treatment. QPI 3(i): Positron Emission Tomography (PET CT) Staging Proportion of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment. *QPI 3(ii): Positron Emission Tomography (PET CT) Staging Proportion of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment and within 2 weeks of radiology request 95% 95.4% 94.8% 96.6% 97.2% 97.1% > < < > > 89.8% 94.7% 100% > > > % 85.5% 81.8% 96.4% 78.3% 86.6% 96.2% 86.5% 73.9% % 85.6% > 75.0% > 100% = 87.0% > 100% > 71.4% < 93.3% > 83.3% < % 98.3% 85.7% 100% 100% 100% 100% - - > < = > > > % 94.7% 100% 100% 75.0% 91.7% 100%

5 QPI Target WoS A&A FV Lan NG SG Clyde D&G QPI 4(i): Cytogenetic testing Proportion of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy with curative intent who have MYC testing prior to treatment. QPI 4(ii): Cytogenetic testing Proportion of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy with curative intent who have MYC results reported within 3 weeks of commencing treatment. QPI 5: Lymphoma MDT Proportion of patients with lymphoma who are discussed at MDT meeting within 8 weeks of diagnosis. QPI 6: Treatment for Follicular Lymphoma and DLBCL Proportion of patients with follicular lymphoma and DLBCL who receive chemotherapy in combination with rituximab. *QPI 10: Primary Cutaneous Lymphoma Proportion of patients with PCL who are discussed at a specialist MDT meeting which includes representation from pathology, dermatology, oncology± haematooncology. 60% 68.5% 64.7% 83.3% 46.7% 76.7% < > > < > 75.0% 85.0% 60.0% < < > % 89.1% 76.5% 100% 86.7% 93.3% 91.7% 95.0% 93.3% % 84.3% > 83.6% > 89.8% > 90.4% > 70.3% > 91.0% > 79.7% > 100% > % 100% 100% 100% 100% 100% > > = > > 100% 100% 100% > = = % 77.3% % > < QPI 11: Hepatitis and HIV Status Proportion of patients with lymphoma undergoing rituximab based treatment who have hepatitis B, C and HIV status checked prior to treatment. Clinical Trials Proportion of patients with lymphoma consented for a clinical trial/research study. 95% 94.4% 85.7% 100% 98.3% 92.1% < < = > < 93.8% 100% 95.7% < > < % 9.8% 7.3% 11.3% 8.0% GGC 4.6% 11.7% *Small numbers in some Boards - percentage comparisons over a single year should be viewed with caution. 5

6 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 QPIs, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland. Overall results from the fourth year of Lymphoma QPI reporting are encouraging; case ascertainment and data capture is of a high standard. Targets relating to PET CT staging in Hodgkin Lymphoma (HL), cytogenetic testing and treatment for follicular lymphoma and Diffuse Large B Cell Lymphoma (DLBCL) were met by the majority of Boards. However, some of the QPI targets set have been challenging for NHS Boards to achieve. There remains room for further service improvement around a number of areas, including: Multidisciplinary Team (MDT) discussion, treatment response following chemotherapy and radiological diagnosis and staging within two weeks of radiological request. Where QPI targets were not met, the majority of NHS Boards have provided detailed commentary. In the main these indicate valid clinical reasons or that, in some cases, patient choice or comorbidities have influenced patient management. There are a number of actions required as a consequence of this assessment of performance against the agreed criteria. Actions required: QPI 1(ii):- Radiological Staging NHS Ayrshire & Arran to provide detail of action being taken locally to address radiology capacity issues. NHSGGC to provide further detailed feedback on all patients not undergoing CT of chest, abdomen, pelvis or PET CT prior to treatment and within two weeks of radiology request. NHS Lanarkshire to report back to MCN outcomes of discussion with the cancer management team and radiology. QPI 2: Treatment response NHS Ayrshire & Arran and NHS Dumfries & Galloway to provide further detailed feedback on all patients not undergoing CT of the chest, abdomen or pelvis or PET CT at the end of chemotherapy treatment QPI 5: Lymphoma MDT NHS Ayrshire & Arran to report back to MCN outcomes of discussion with the new Clinical Director in radiology regarding MDT cover. NHSGGC to investigate delays in MDT discussion in North Glasgow and feedback detailed reasons to MCN. QPI 11: Hepatitis and HIV Status NHS Ayrshire & Arran should report the outcome of the pilot of the new electronic MDT outcome form to the MCN advisory board. NHSGGC to provide detailed feedback on all cases that did not have hepatitis B, C and HIV status checked prior to treatment. NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

7 Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board 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). 1. Introduction This report presents an assessment of performance of West of Scotland (WoS) Lymphoma Services relating to patients diagnosed in the region between 01 October 2016 and 30 September These audit data underpin much of the regional development/service improvement work of the Managed Clinical Network (MCN) and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. Twelve months of data were measured against v3.0 of the Lymphoma Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 October This was the fourth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Lymphoma QPIs in This was part of a programme of work led by the National Cancer Quality Steering Group (NCQSG) to develop national measures in the form of QPIs for all cancer types, in collaboration with the three Regional Cancer Networks and Information Services Division (ISD). In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland, a process of formal review was carried out after Year 3 of comparative reporting with tumour-specific Regional Clinical Leads undertaking a key role in determining the extent of the review required for each tumour type. The revised Lymphoma QPIs 1 were published in October 2017 and, as stated above, are valid for patients diagnosed on or after 01 October Annual comparisons have been made where indicators remain comparable following this formal review. Any new QPIs which were developed requiring new data items will be reported in Year 5 once data becomes available for these new measures. Future reports will continue to compare clinical audit data in successive years to illustrate trends. 2. Background The Haemato-oncology MCN was established in 2002 as a means of delivering equitable, high quality clinical care to all haemato-oncology patients across five NHS Boards; Ayrshire & Arran, Dumfries & Galloway, Forth Valley, Greater Glasgow and Clyde (GGC) and Lanarkshire covering a population of 2.6 million. Membership includes 48 consultant haemato-oncologists, 3 clinical oncologists and a number of haemato-pathologists, in addition to other professional groups involved in the multi-disciplinary care of patients with blood cancer (haematological cancer). The Haemato-oncology MCN continues to support and develop the clinical service for approximately 1200 haemato-oncology patients per annum. The effective management of these patients throughout the region continues to rely on co-ordinated delivery of treatment and care that requires close collaboration of professions from a range of specialties. Currently, there are seven local Multi-disciplinary Team (MDTs) meetings held across the West of Scotland (WoS) which complement the function of the Regional Haemato-oncology MDT. 7

8 Number of Cases Table 1: WoS MDT Configuration MDT Constituent Hospital Ayrshire Crosshouse Hospital, Ayr Hospital Clyde Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven Dumfries & Galloway Dumfries and Galloway Royal Infirmary Forth Valley Forth Valley Royal Hospital Lanarkshire Hairmyres Hospital, Wishaw General Hospital, Monklands and District General Hospital North Glasgow Beatson West of Scotland Cancer Centre, Transplant Team, Glasgow Royal Infirmary, Stobhill Hospital, South Glasgow Queen Elizabeth University Hospital, New Victoria Hospital 2.1 National Context Non-Hodgkin Lymphoma (NHL) accounts for 3.1% of all cancers and is the eighth most common cancer type with approximately 985 cases diagnosed in Scotland each year. The incidence of NHL has decreased by 2.7% in the past ten years (2005 to 2015) 3. NHL accounts for 3.3% of all cancer diagnoses in men and was the ninth most commonly diagnosed cancer in males in It was the seventh most common cancer type in females accounting for 2.9% of all female cancer diagnoses 3. Overall mortality rates have decreased by 10.2% over the past 10 years (2006 to 2016) and 1-year and 5-year relative survival is noted as being 80% and 69.7% respectively 3. Hodgkin Lymphoma (HL) is noted as being the 24 th most common cancer with approximately 150 new diagnoses in Scotland each year. The incidence of HL has increased by 3.1% over the past 10 years (2005 to 2015), the increase in incidence being more significant in the female population (12.3%). Overall HL mortality rates have decreased by 9% over the past 10 years (2006 to 2016) and 1-year and 5-year relative survival is noted as being 90.6% and 84.1% respectively West of Scotland Context A total of 580 new lymphoma cases were recorded through audit as diagnosed in the WoS between 1 October 2016 and 30 September The number of patients diagnosed within each Board is presented in Figure 1. As the largest WoS Board, 53% of all new cases of lymphoma were diagnosed in NHSGGC which is in line with population estimates for this Board. Figure 1: Number of patients diagnosed with lymphoma by unit of diagnosis, October 2016 to September Year 2 Year 3 Year 4 A&A FV Lan NG SG Clyde D&G Analysis Group A&A FV Lan NG SG Clyde D&G WoS Year Year Year

9 > >85 No. of patients No. of Patients A breakdown by cancer subtype is noted below and illustrates that NHL is the most common type of lymphoma and accounts for 82.8% of all lymphomas diagnosed in the WoS in this audit period. 77 HL (13.3%) 480 NHL (82.8%) 22 Primary Cutaneous NHL (3.8%) 1 Malignant Lymphoma not otherwise specified (NOS) (0.2%) Lymphoma Age and Gender Distribution Figure 2 illustrates the distribution of HL and NHL by age and gender. The median age of HL patients was 51 years and the disease continues to be more common in males (58%) than females (42%). In NHL, the median age was 70 years, with 73% of patients aged 60 years or over. The gender distribution illustrates that 56% of patients diagnosed with NHL were male and 44% female. Figure 2: Distribution of Hodgkin lymphoma and non-hodgkin lymphoma by age and sex in the WoS Hodgkin Lymphoma Non Hodgkin Lymphoma 8 Male Female 50 Male Female Age at Diagnosis Age at Diagnosis 9

10 Hodgkin Lymphoma Figure 3 illustrates the pathological subtypes of HL. The distribution of HL by clinical stage is presented in Figure 4, which illustrates that 28.6% of patients presented with early stage (I, IIA) disease and 67.5% of patients presented with advanced stage disease (IIB,III,IV). Figure 3: Hodgkin lymphoma by pathological subtype Figure 4: Hodgkin lymphoma by clinical stage Lymphocytedepleted Classical HL, 1.3% (n=1) Lymphocyterich Classical HL, 1.3% (n=1) Mixed Cellularity Classical HL, 9.1%(n=7) Nodular Lymphocyte Predominant HL,11.7% (n=9) IVB, 23.4% (n=18) NR, 3.9% (n=3) IA, 6.5% (n=5) IIA, 22.1% (n=17) IVA, 10.4% (n=8) Classical HL 53.2% (n=41) Nodular sclerosis classical HL, 23.4%(n=18) IIIB, 5.2% (n=4) IIIA, 15.6% (n=12) IIB, 13% (n=10) Non-Hodgkin Lymphoma Of the 480 cases of NHL diagnosed, 41.5% (n=199) were Diffuse Large B Cell Lymphoma (DLBCL), 25.8% (n=124) follicular lymphoma and 32.7% (n=157) were classed as other. Figures 5 and 6 display the clinical stage breakdown for both DLBCL and follicular lymphoma. Figure 5: DLBCL by clinical stage DLBCL by clinical stage Figure 6: Follicular lymphoma by clinical stage Follicular by clinical stage NR, 17.1%, (n=34) NA,1.0%, (n=2) IA, 16.1%, (n=32) IB, 2.5%, (n=5) IIA, 9.0%, (n=18) NR, 10.5%, (n=13) IVB, 8.9% (n=11) IA, 15.3% (n=19) IB, 0.8% (n=1) IIA, 9.7% (n=12) IVB, 18.6%, (n=37) IIB, 6.5%, (n=13) IIB, 1.6% (n=2) IVA, 13.6%, (n=27) IIIB, 7.5%, (n=15) IIIA, 8.0%, (n=16) IVA, 30.6% (n=38) IIIB, 4.8% (n=6) IIIA, 17.7% (n=22) 10

11 3. 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 web-based database. Data relating to patients diagnosed with lymphoma between 1 October 2016 and 30 September 2017 was downloaded from ecase at 2200 hrs on 28 March 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 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. 4. Results and Action Required 4.1 Data Quality Quality of audit data can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated by the number of patients identified as diagnosed in a NHS Board through audit as a percentage of the incidence of cancer diagnosed in that NHS Board from Cancer Registry. Cancer Registry information is available some time after the year of interest as collection and verification of data is time intensive. For this reason, audit data cannot be compared directly to Cancer Registry data for the same year. The number of patients diagnosed each year will naturally vary. Cancer Registry figures used were extracted from Cancer Registry Scotland, a system provided by ISD via the standard reports available. Cancer Registry figures are an average of 2012 to 2016 figures to take account of annual fluctuations in incidence within NHS Boards. Table 2 presents the case ascertainment for each NHS Board and for WoSCAN as a whole. Table 2: Case ascertainment by NHS Board for patients diagnosed with Lymphoma Health Board of Diagnosis (01/10/ /09/2017) Audit Cancer Registry Case Ascertainment Ayrshire & Arran % GGC % Forth Valley % Lanarkshire % Dumfries & Galloway % WoS Total % 11

12 4.2 Performance against Quality Performance Indicators (QPIs) Results for each QPI are shown in detail in the main report and illustrate 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. 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. Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis. 12

13 Proportion of patients (%) QPI 1: Radiological Staging Accurate staging is important to ensure appropriate treatment is delivered and futile interventions avoided. Computed Tomography (CT) of the chest, abdomen and pelvis is recommended as the initial imaging investigation for all patients with lymphoma. CT neck should also be undertaken where clinically appropriate 1. Title: Numerator: (i): Patients with lymphoma should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making. Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment. Denominator: All patients with lymphoma undergoing treatment with curative intent. Exclusions: Patients who refuse investigation. Patients with primary cutaneous lymphoma. Target: 95% Figure 7: The proportion of patients with lymphoma who undergo CT scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment Year 2 Year 3 Year A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 94.8% % 0 0.0% 0 FV 96.6% % 0 0.0% 0 Lan 97.2% % 0 0.0% 0 NG 97.1% % 0 0.0% 1 SG 89.8% % 0 0.0% 0 Clyde 94.7% % 0 0.0% 1 D&G 100% % 0 0.0% 0 WoS 95.4% % 0 0.0% 2 Following formal review the QPI target was increased from 90% to 95%. In the WoS, 95.4% of patients with lymphoma underwent CT of chest, abdomen and pelvis or PET CT scanning prior to treatment with curative intent which exceeds the 95% target. Performance ranged from 100% in NHS Dumfries & Galloway to 89.8% in South Glasgow. 13

14 Proportion of patients (%) NHS Ayrshire & Arran stated that the three cases not meeting the QPI had been reviewed. Two cases had incomplete staging at time of urgent treatment but staging was completed soon afterwards. The remaining case did not have staging completed. NHSGGC reviewed cases and commented that in one patient in Clyde was managed by another discipline and was never seen by Haematology. In South Glasgow data errors were noted; if corrected the QPI target would have been met in both South Glasgow and NHSGGC as a whole. Title: Numerator: (ii): Patients with lymphoma should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making. Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment and within two weeks of radiology request. Denominator: All patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment. Exclusions: None Target: 90% Figure 8: The proportion of patients with lymphoma who undergo CT scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request. 100 Year A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 81.8% % 0 0.0% 0 FV 96.4% % 0 0.0% 0 Lan 78.3% % 0 0.0% 1 NG 86.6% % 0 0.0% 1 SG 96.2% % 0 0.0% 1 Clyde 86.5% % 0 0.0% 1 D&G 73.9% % 0 0.0% 0 WoS 85.5% % 0 0.0% 4 Following formal review, it was agreed that this QPI would focus only on those patients who have undergone CT/PET CT prior to treatment i.e. met QPI 1 part (i). The tolerance statement was also 14

15 updated to account for situations where imaging may be delayed due to factors of patient fitness or patient choice. Overall WoS results show that 85.5% of patients who underwent CT/PET CT scanning prior to treatment did so within 2 weeks of radiology request which is below the 95% target. NHS Forth Valley and South Glasgow achieved the QPI target with performance of 96.4% and 96.2% respectively. Performance in the other NHS Boards ranged from 73.9% in NHS Dumfries & Galloway to 86.6% in North Glasgow. NHS Ayrshire & Arran commented that all ten cases not meeting the QPI waited more than fourteen days for CT, due to capacity issues. NHS Ayrshire & Arran added that radiology pressures were under review. This remains an ongoing issue as radiology service pressures in NHS Ayrshire & Arran have been highlighted in the previous three audit reports. NHS Lanarkshire reviewed the cases not meeting the QPI target and reported that thirteen cases had received a CT scan but not within two weeks of request and two cases PET scan request date was unknown. NHS Lanarkshire added that this will be discussed locally at the cancer management team meeting to formulate a plan in conjunction with radiology. This issue was also raised as an action in last year s audit report. It is anticipated that the appointment of a new clinical lead for radiology in 2018 will address this issue. NHSGGC stated that in North Glasgow occasionally patients were waiting between 2-3 weeks but this was not a recurrent problem. NHS D&G identified data collection issues which should be addressed with the planned implementation of an electronic booking system system within radiology. Local pressures within the radiology department have also been identified. Action required: NHS Ayrshire & Arran to provide detail of action being taken locally to address radiology capacity issues. NHSGGC to provide further detailed feedback on patients not meeting QPI. NHS Lanarkshire to report back to MCN outcomes of discussion with the cancer management team and radiology. A further specification (iii) was added to QPI 1 at formal review to look at patients undergoing PET CT or CT CAP prior to treatment with the report available within 3 weeks of radiology request. As this required new data items, results will be reported in Year 5 once data becomes available. 15

16 Proportion of patients (%) QPI 2: Treatment response CT scanning is recommended as the most appropriate method of response assessment following chemotherapy for DLBCL as treatment response may not be clinically obvious 1. The target for this QPI has been set at 90% and the tolerance within the target is designed to account for the fact that some patients will have a good clinical response to chemotherapy and will therefore not require an end of treatment scan. It also accounts for those patients who may not complete chemotherapy due to factors of fitness. QPI Title: Patients with DLBCL who are treated with curative intent should have their response to treatment evaluated with appropriate imaging. Numerator: Number of patients with DLBCL who are undergoing chemotherapy treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scan at end of chemotherapy treatment Denominator: All patients with DLBCL who are undergoing chemotherapy treatment with curative intent. Exclusions: Patients that died during treatment. Target: 90% Figure 9: The proportion of patients with DLBCL who are undergoing chemotherapy treatment with curative intent, who have their response to treatment evaluated with CT scan of the chest, abdomen and pelvis or PET CT scan. 100 Year 2 Year 3 Year A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 75.0% % 3 9.4% 0 FV 100.0% % 0 0.0% 0 Lan 87.0% % 1 4.3% 0 NG 100.0% % 0 0.0% 0 SG 71.4% % 0 0.0% 0 Clyde 93.3% % 0 0.0% 0 D&G 83.3% % 0 0.0% 0 WoS 85.6% % 4 2.9% 0 The 90% target for QPI 2 was not achieved in WoS for patients diagnosed with DLBCL in Year 4, with 119 of 139 patients undergoing chemotherapy treatment with curative intent receiving CT of chest, abdomen and pelvis or PET CT scan at the end of chemotherapy treatment (85.6%). NHS Forth Valley, North Glasgow and Clyde were the only units to meet the 90% target. However, 16

17 Proportion of patients (%) improved performance from Year 3 results is evident across the majority of units and the overall WoS performance has risen by 17.3 percentage points from the previous year. NHS Ayrshire & Arran and NHS Lanarkshire reviewed cases not meeting the target and provided detailed clinical reasons including patients who did not complete planned treatment or died prior to CT assessment. NHSGGC reviewed all cases not meeting the QPI target and reported that in South Glasgow four cases not meeting the target were for valid clinical reasons. Data errors were noted for the remaining two cases; once corrected NHSGGC performance would change to 91.5%, above the target level. NHS D&G stated that two cases did not have full CT post treatment; in both cases this was considered. Full discussion will be held with the clinical team. Action required: NHS Ayrshire & Arran and NHS Dumfries & Galloway to provide further detailed feedback on all patients not meeting QPI. QPI 3: Positron Emission Tomography (PET CT) Staging Patients with Classical Hodgkin Lymphoma (CHL) should be evaluated with PET CT scanning to detect the extent of disease and guide treatment decision making 1. The target for this QPI is 95% and the tolerance within this target is designed to account for situations where patients are not fit enough to undergo all investigations prior to commencing treatment. QPI Title: Numerator: Patients with CHL should be evaluated with PET CT scanning to detect the extent of disease and guide treatment decision making. Patients with CHL undergoing treatment with curative intent who undergo PET CT scan prior to first treatment; Denominator: All patients with CHL undergoing treatment with curative intent. Exclusions: Patients who refuse investigation. Target: 95% Figure 10: The proportion of patients with CHL who undergo PET CT scan prior to first treatment A&A FV Lan NG SG Clyde D&G WoS Analysis Group 17

18 Proportion of patients (%) Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 85.7% % 0 0.0% 0 FV 100% % 0 0.0% 0 Lan 100% % 0 0.0% 0 NG 100% % 0 0.0% 0 SG 100% % 0 0.0% 0 Clyde % 0 0.0% 1 D&G % 0 0.0% 0 WoS 98.3% % 0 0.0% 1 - Data not shown due to small numbers Overall in WoS in Year 4, 98.3% of patients with CHL received a PET CT scan prior to treatment with curative intent which exceeds the QPI target of 95%. This is an improvement on the previous years performance of 88.2%. It should however be noted that numbers of patients included within this QPI are low and therefore comparisons should be made with caution. NHS Ayrshire & Arran reviewed and submitted a valid clinical reason for the one case not meeting the QPI target. The second part of the QPI measures those patients with CHL undergoing treatment with curative intent who undergo PET CT scan prior to first treatment and within 2 weeks of radiology request. QPI Title: Numerator: Patients with CHL should be evaluated with PET CT scanning to detect the extent of disease and guide treatment decision making. Patients with CHL undergoing treatment with curative intent who undergo PET CT scan prior to first treatment and within 2 weeks of radiology request Denominator: All patients with CHL undergoing treatment with curative intent who undergo PET CT scan prior to first treatment. Exclusions: Patients who refuse investigation. Target: 95% Figure 6: The proportion of patients with CHL who undergo PET CT scan prior to first treatment and within 2 weeks of radiology request A&A FV Lan NG SG Clyde D&G WoS Analysis Group 18

19 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100% % 0 0.0% 0 FV 100% % 0 0.0% 0 Lan 75.0% % 0 0.0% 0 NG 91.7% % 0 0.0% 0 SG 100% % 0 0.0% 0 Clyde % 0 0.0% 0 D&G % 0 0.0% 0 WoS 94.7% % 0 0.0% 0 - Data not shown due to small numbers Following formal review, it was agreed that this QPI would focus only on those patients who have undergone PET CT prior to treatment i.e. met part QPI 3(i); therefore Year 4 results are not comparable to previous years results. In WoS, 54 of 57 patients with CHL undergoing treatment with curative intent underwent a PET CT scan prior to first treatment and within 2 weeks of radiology request. This represented 94.7% performance against the 95% QPI target. All boards met the QPI with the exception of NHS Lanarkshire and North Glasgow who achieved 75% and 91.7% respectively, however, the number of patients included in the denominator is low, especially within the smaller WoS Boards, and this can have a considerable effect on proportions. NHS Lanarkshire reviewed cases not meeting the QPI target and commented that in both cases the PET request date was unknown. NHSGGC commented that the target was missed in NG by a single case. A further specification (iii) was added to QPI 3 at formal review to look at the number of patients with CHL undergoing PET CT or CT CAP prior to treatment where the report is available within 3 weeks of radiology request. As this required new data items results will be reported in Year 5 once data becomes available 19

20 Proportion of patients (%) QPI 4: Cytogenetic Testing Patients with Burkitt lymphoma and DLBCL should have MYC testing as part of diagnostic process, to identify those who may require CNS prophylaxis and alternative treatment 1. QPI Title: Numerator: Patients with Burkitt lymphoma and DLBCL should have MYC testing as part of diagnostic process, to identify those who may require central nervous system (CNS) prophylaxis and alternative treatment. Number of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported prior to treatment. Denominator: All patients with Burkitt lymphoma and DLBCL undergoing chemotherapy treatment with curative intent. Exclusions: No exclusions Target: 60% Figure 11: The proportion of patients with Burkitt lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported prior to treatment A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 64.7% % 0 0.0% 0 FV 83.3% % 0 0.0% 0 Lan 46.7% % 0 0.0% 0 NG 76.7% % 0 0.0% 0 SG 75.0% % 0 0.0% 0 Clyde 85.0% % 0 0.0% 0 D&G 60.0% % 0 0.0% 0 WoS 68.5% % 0 0.0% 0 In the WoS 68.5% of patients with Burkitt lymphoma and DLBCL undergoing chemotherapy with curative intent had MYC testing results reported prior to treatment which exceeds the 60% QPI target. All units with the exception of NHS Lanarkshire achieved the target with performance ranging from 46.7% in NHS Lanarkshire to 85% in Clyde. For a proportion of the audit period, NHS Lanarkshire were using a different pathway for MYC testing which may have contributed to poorer performance against part 1 of this QPI. Treatment was started appropriately, pending MYC results, based on clinical need. The pathway has now been reviewed and adjusted. 20

21 Proportion of patients (%) At formal review, a second specification was added to QPI 4 to focus on the availability of MYC results within three weeks of chemotherapy start date and a more challenging target of 85% was applied. QPI Title: Numerator: Patients with Burkitt lymphoma and DLBCL should have MYC testing as part of diagnostic process, to identify those who may require CNS prophylaxis and alternative treatment. Number of patients with Burkitt lymphoma and DLBCL undergoing chemotherapy with curative intent who have MYC results reported within 3 weeks of commencing treatment. Denominator: All patients with Burkitt lymphoma and DLBCL undergoing chemotherapy treatment with curative intent. Exclusions: No exclusions Target: 85% Figure 12: The proportion of patients with Burkitt lymphoma and DLBCL undergoing chemotherapy with curative intent who have MYC results reported within 3 weeks of commencing treatment A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 76.5% % 0 0.0% 0 FV 100% % 0 0.0% 0 Lan 86.7% % 0 0.0% 0 NG 93.3% % 0 0.0% 0 SG 91.7% % 0 0.0% 0 Clyde 95.0% % 0 0.0% 0 D&G 93.3% % 0 0.0% 0 WoS 89.1% % 0 0.0% 0 Overall in WoS, of the 165 patients with Burkitt lymphoma and DLBCL undergoing chemotherapy treatment with curative intent, 147 received intensive chemotherapy, resulting in a performance of 89.1% which exceeds the 85% QPI target. NHS Ayrshire & Arran were the only Board not to meet the target with a performance of 76.5%. NHS Ayrshire and Arran stated that review of cases indentified clinical reasons or specimen quality as the reason for delays to testing. In response to last year s action plan, NHS Ayrshire & Arran reviewed local pathology processes and formalised a diagnostic pathway in collaboration with pathology colleagues in QEUH. It is anticipated that next year s results should show an improvement against this target. 21

22 Proportion of patients (%) QPI 5: Lymphoma MDT Effective MDT working is considered integral to provision of high quality cancer care, facilitating a cohesive treatment-planning function and ensuring treatment and care provision is individualised to patient needs. National guidance states that all patients should have a treatment plan discussed at a MDT meeting 5. QPI Title: Numerator: Patients with lymphoma should be discussed by a MDT following diagnosis. Number of patients with lymphoma discussed at the MDT within 8 weeks of diagnosis. Denominator: All patients with lymphoma. Exclusions: Patients who died before first treatment. Patients with primary cutaneous lymphoma. Target: 90% Figure 13: The proportion of patients with lymphoma who are discussed at MDT meeting within 8 weeks of diagnosis A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 83.6% % 0 0.0% 0 FV 89.8% % 0 0.0% 0 Lan 90.4% % 1 1.1% 0 NG 70.3% % 0 0.0% 0 SG 91.0% % 0 0.0% 0 Clyde 79.7% % 0 0.0% 0 D&G 100% % 0 0.0% 0 WoS 84.3% % 1 0.2% 0 At the lymphoma QPI formal review, it was agreed that the time from diagnosis to discussion at MDT would be changed from within 6 weeks to within 8 weeks of diagnosis. The QPI target was also increased from 85% to 90%. The 90% target for QPI 5 was not achieved in WoS for patients diagnosed with lymphoma in Year 4, with 84.3% of patients being discussed at MDT meeting within 8 weeks of diagnosis. Four of the seven units met the QPI target (NHS Forth Valley, NHS Lanarkshire, South Glasgow and NHS Dumfries & Galloway). 22

23 NHS Ayrshire & Arran reviewed cases and commented that the majority of cases did present to the MDT but not within the eight week timescale. Most had low grade disease and did not require active treatment. Two cases were not discussed at the local MDT, one of which had been discussed at a neurosurgical MDT. In last year s audit report NHS Ayrshire & Arran had an action to address delays in MDT discussion. In January 2018, NHS Ayrshire & Arran noted that radiology MDT cover would be discussed with the new Clinical Director in Radiology. The MCN will seek an updated position regarding this action. NHSGGC commented that in Clyde the majority of cases were discussed but outwith the timescale. A MDT co-ordinator was appointed half way through the year which has tightened up MDT discussion. The full effect should be demonstrated in next year s report and is expected to show a more favourable result. In North Glasgow patients are discussed when all results are available to allow a final treatment plan to be made. All new patients are discussed at a weekly lymphoma meeting, with treatment discussed and started as appropriate. MDT discussion is for final management plan with all information available. Action required: NHS Ayrshire & Arran to report back to MCN outcomes of discussion with the new Clinical Director in radiology. NHSGGC to investigate delays in MDT discussion in North Glasgow and feedback detailed reasons to MCN. QPI 6: Treatment for Follicular Lymphoma and DLBCL Patients with symptomatic advanced stage follicular lymphoma and DLBCL should receive rituximab in combination with chemotherapy as this increases response to chemotherapy and provides a progression free, and overall, survival benefit 1. As it is difficult to accurately identify those patients with symptomatic advanced follicular lymphoma and DLBCL, the number of patients with follicular lymphoma and DLBCL undergoing chemotherapy is being utilised as a proxy measure for symptomatic advanced disease. QPI Title: Numerator: Patients with symptomatic advanced follicular lymphoma and DLBCL should undergo treatment with anti-b cell monoclonal antibody therapy in combination with chemotherapy. Number of patients with follicular lymphoma and DLBCL who receive chemotherapy in combination with anti-b cell monoclonal antibody therapy. Denominator: All patients with follicular lymphoma and DLBCL who receive chemotherapy. Exclusions: Patients who refuse chemotherapy. Patients enrolled in clinical trials. Target: 95% 23

24 Proportion of patients (%) Figure 14: The proportion of patients with follicular lymphoma and DLBCL who receive chemotherapy in combination with anti-b cell monoclonal antibody therapy Year 2 Year 3 Year A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100% % 0 0.0% 0 FV 100% % 0 0.0% 0 Lan 100% % 0 0.0% 0 NG 100% % 0 0.0% 0 SG 100% % 0 0.0% 0 Clyde 100% % 0 0.0% 0 D&G 100% % 0 0.0% 0 WoS 100% % 0 0.0% 0 As demonstrated in Figure 13, all NHS Boards achieved the QPI target with 100% of patients in the WoS with follicular lymphoma or DLBCL receiving chemotherapy in combination with anti-b cell monoclonal antibody therapy. All Boards have consistently met the target over the last 3 years. QPI 10: Primary Cutaneous Lymphoma A specialist MDT for patients with primary cutaneous lymphoma facilitates clinico-pathological correlation, which is very important in this group of conditions where treatment is multi-faceted. Furthermore it allows for consolidation of expertise in this rare condition which will help develop robust diagnosis and management 1. QPI Title: Numerator: Patients with primary cutaneous lymphoma should be discussed at a specialist MDT meeting. Number of patients with primary cutaneous lymphoma who are discussed at a specialist MDT meeting. Denominator: All patients with primary cutaneous lymphoma. Exclusions: No exclusions. Target: 95% 24

25 Proportion of patients (%) Figure 15: The proportion of patients with primary cutaneous lymphoma who are discussed at a specialist MDT meeting. WoS Year 2 Year 3 Year 4 Analysis Year Year 2 Year 3 Year 4 Numerator Denominator Performance (%) 100% 95.7% 77.3% It should be noted that all seven units had denominators of five or less and therefore individual unit results cannot be presented at this time. Overall in the WoS 77.3% of patients with primary cutaneous lymphoma were discussed at a specialist MDT meeting. This is a decrease of 18.4 percentage points from the previous years result, however, the numbers of patients included within this QPI are low and therefore comparisons should be made with caution. All cases not meeting the QPI target were reviewed and all Boards provided valid clinical reasons for cases not meeting the QPI target, for example some cases were discussed at the Regional Haemato-oncology MDT rather than the skin lymphoma specific MDT. QPI 11: Hepatitis and HIV Status Clinical assessment and virological testing for Human Immunodeficiency Virus (HIV), hepatitis B and C should be undertaken for all patients as part of the diagnostic process and in all patients considered at risk of virus reactivation 1. QPI Title: Numerator: Virological testing for HIV, hepatitis B and C should be undertaken for patients undergoing SACT. Number of patients with lymphoma undergoing SACT who have hepatitis B, C and HIV status checked prior to treatment. Denominator: All patients with lymphoma undergoing SACT. Exclusions: No exclusions. Target: 95% 25

26 Proportion of patients (%) Figure 16: The proportion of patients with lymphoma undergoing SACT who have hepatitis B, hepatitis C and HIV status checked prior to treatment Year 2 Year 3 Year A&A FV Lan NG SG Clyde D&G WoS Analysis Group Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 85.7% % 0 0.0% 0 FV 100% % 0 0.0% 0 Lan 98.3% % 0 0.0% 0 NG 92.1% % 0 0.0% 0 SG 93.8% % 0 0.0% 0 Clyde 100% % 0 0.0% 1 D&G 95.7% % 0 0.0% 0 WoS 94.4% % 0 0.0% 1 Following formal review QPI 11 was revised to focus only on patients undergoing SACT and the QPI target was lowered from 100% to 95%. Overall in the WoS 94.4% of patients with lymphoma undergoing SACT had their hepatitis B, C and HIV status checked prior to treatment which is marginally below the 95% QPI target. Four of the seven units met the target with performance ranging from 85.7% in NHS Ayrshire & Arran to 100% in NHS Forth Valley and Clyde. NHS Ayrshire & Arran reviewed all cases not meeting the target and reasons provided included four cases where only Hepatitis B status was checked and three cases that had no virology testing carried out prior to commencing treatment. Compliance with this QPI has been raised in the previous three annual audit reports. In response to last year s action plan, NHS Ayrshire & Arran advised that a new electronic MDT outcome form which includes viral screening would be piloted early NHSGGC carried out a preliminary review, however it is requested that further detail is provided to the MCN. Action Required: NHS Ayrshire & Arran should report the outcome of the pilot to the MCN Advisory Board. NHSGGC to provide detailed feedback on the nine cases not meeting the QPI. 26

27 Proportion of patients (%) Clinical Trial Access Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Furthermore, evidence suggests improved patient outcomes when hospitals are actively recruiting patients into clinical trials 1. Data definitions and measurability criteria to accompany the Clinical Trial QPI are available from the HIS website 1. The clinical trials QPI will be measured utilising Scottish Cancer Research Network (SCRN) data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and National Cancer Research Institute (NCRI). Utilising SCRN data allows for comparison with CSO published data and ensures capture of all clinical trials recruitment, not solely first line treatment trials, as contained in the clinical audit data. Given that a significant proportion of clinical trials are for relapsed disease this is felt to be particularly important in driving quality improvement. This methodology utilises incidence as a proxy for all patients with cancer. This may slightly over, or underestimate, performance levels, however this is an established approach currently utilised by NHS Scotland 1. QPI Title: Numerator: All patients should be considered for participation in available clinical trials/research studies wherever eligible. Number of patients diagnosed with lymphoma consented for a clinical trial/research study. Denominator: All patients with diagnosed with lymphoma. Exclusions: No exclusions. Target: 15% Figure 17: Proportion of patients diagnosed with lymphoma who are consented* for a clinical trial / research study in Consented Entered A&A FV Lan GGC D&G WoS Analysis Group Consented - QPI Target 15% Entered Trial N D % N D % AA % % FV % % Lan % % GGC % % D&G % % WoS Total % % 27