The New CP 3 R Application And Revisions To Standard 4.6 Integration Of The NCDB With The Accreditation Process

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1 The New CP 3 R Application And Revisions To Standard 4.6 Integration Of The NCDB With The Accreditation Process Wednesday, April 29, 2009 at 11 AM Central M. Asa Carter, CTR Manager, Approvals and Standards Commission on Cancer Andrew K. Stewart, MA Senior Manager, National Cancer Data Base Commission on Cancer 1

2 What s on the Agenda? Background and development of the CoC Quality Reporting Tools CP 3 R (version 2) How is it different How to navigate Integration into the CoC Program Standards Standard 4.6 for surveys How CP 3 R and Standard 4.6 integrate 2

3 Commission on Cancer Mission Statement The Commission on Cancer is a consortium of professional organizations dedicated to reducing the morbidity and mortality of cancer through education, standard setting, and the monitoring of quality of care. 3

4 What Is The NCDB? The NCDB was founded in 1989 as a joint project of the American Cancer Society and the American College of Surgeons (ACoS). The National Cancer Data Base Data (NCDB) is a nationwide oncology database for close to 1,460 hospitals in 49 states. The NCDB collects information on about 70% of all newly diagnosed malignant cases of cancer nationwide annually. 4

5 CoC Cancer Program Quality Tools Cancer Program Practice Profile Reports (CP 3 R) Web-based application providing local providers comparative information to assess local adherence to standards of care. Hospital Comparison Benchmark Reports Web-based reports permit analysis of your cancer program relative to 59 different cancers by demographics, insurance status, stage, 1 st course of treatment, 1 st course surgery type, radiation therapy, systemic therapy, histology, and behavior Hospital Comparison Survival Reports Web-based reports permit analysis of survival for 59 different cancers by cancer program type, census division, state, and AJCC stage. 5

6 How You Can Use the CoC Quality Tools Provide feedback on performance through Web reports Cancer Program Practice Profile Reports (CP 3 Rs) Benchmark Reports Survival Data Promote quality improvement activities that can assist facilities in the fulfillment of the CoC Accreditation Standards requirements: 2.11: for analysis of diagnostic and treatment modalities; 8.1 : to complete and document studies that measure quality and outcomes; 8.2 : to document implementation of two improvements that directly affect cancer patient care. Assist Cancer Liaison Physicians and State Chairs Use of data and Web-reports to improve quality at the local and state level 6

7 Rolling Out Cancer Diagnosis & Treatment Performance Measures Development Endorsement ASCO/ NCCN Implementation ACoS/ CoC National Quality Forum Hospitals & Physicians 3 Breast Measures 2 Colon Measures 1 Rectal Measure QCCC Fed Partners 1,400 CoC- Accredited Hospitals 7

8 CP 3 R: Data Reconciliation Periodic Rate Adjustment Facility Specific Data Comparison Data e-quip: Data Reconciliation Immediate Rate Adjustment Facility Specific Data 8

9 CP 3 R (v1): Chemo for Stage III Colon Cancer by Annual Hospital Case Volume for 1,270 CoC Programs Change in Performance Rates, January January Bottom 50% Top 25% Top 10% 9

10 Slipping and Sliding: Relative Shift in CP 3 R(v1) Performance Rates Bottom 25% 10

11 CP 3 R (v2): What s New! Brings All 6 Measures into Complete Alignment with the NQF Specifications Data Reconciliation Facility Specific Data Immediate Adjustment for Facility Rates Comparison Data Overnight Adjustment on Comparison Rates Reports Rates for Diagnoses 11

12 Bringing the Breast Measures into Alignment Patients receiving breast conserving surgery who are under age 70 should receive radiation therapy. Patients with Stage I (tumor size > 1cm and N0) or Stage II/III (any tumor size and N+), with ER/PRtumors and who are under age 70 should receive or be considered for combination chemotherapy. Patients with Stage I (tumor size > 1cm and N0) or Stage II/III (any tumor size and N+), with ER+ or PR+ tumors should receive or be considered for hormone therapy (Tamoxifen or third generation Aromatase Inhibitor). Patients receiving breast conserving surgery who are under age 70 should receive radiation therapy within 365 days of Dx. Patients with Stage I (tumor size > 1cm and N0) or Stage II/III (any tumor size and N+), with ER/PRtumors and who are under age 70 should receive or be considered for combination chemotherapy within 120 days of Dx. Patients with Stage I (tumor size > 1cm and N0) or Stage II/III (any tumor size and N+), with ER+ or PR+ tumors should receive or be considered for hormone therapy (Tamoxifen or third generation Aromatase Inhibitor) within 365 days of Dx. 12

13 Bringing the Colorectal Measures into Alignment Resected colon specimen should have at least 12 regional lymph nodes pathologically examined. Adjuvant chemotherapy is considered or administered for patients with AJCC Stage III (lymph node positive) colon cancer. Resected colon specimen should have at least 12 regional lymph nodes pathologically examined. Adjuvant chemotherapy is considered or administered within 120 days of Dx for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. Radiation therapy is considered or administered for clinical or pathologic AJCC T4N0M0 or Stage III surgically resected rectal cancer. Radiation therapy is considered or administered within 180 days of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer. 13

14 CP 3 R Case Eligibility - Breast Women only Adults - patients >=18 at time of diagnosis First or only cancer diagnosis: Sequence codes 00 or 01; Primary tumors of the breast - ICD-O-3 Primary site codes: C50.0 C50.6, C C50.9; Epithelial tumors required to be staged by AJCC: , , 8010, 8012, 8013, 8020, 8021, 8032, , 8050, 8070, , , , , 8230, , , 8490, 8510, 8560, , ; Invasive tumors only: ICD-O-3 behavior code 3; No reported clinical or pathological evidence of metastatic disease; All or part of first course of treatment was performed at the reporting facility. 14

15 CP 3 R Case Eligibility - Colorectal Adults - patients >=18 at time of diagnosis; First or only cancer diagnosis: Sequence codes 00 or 01; Primary tumors of the colon or rectum - ICD-O-3 Primary site codes: C18.0, , 20.9; Epithelial tumors required to be staged by AJCC: 8010, 8020, 8070, 8140, , 8211, 8480, , 8510, 8520, 8522, 8530, , 8543, 8980, 9020; Invasive tumors only: ICD-O-3 behavior code 3; No reported clinical or pathological evidence of metastatic disease; All or part of first course of treatment was performed at the reporting facility. 15

16 CP 3 R: Computing Measure Concordance Using Cancer Registry Coding Standards Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. Conditions Assessment Numerator Regional Treatment Modality=20-98; and Date Radiation Started <=365 days following the Date of Diagnosis Concordant Denominator Age at Diagnosis<70 AND Surgery of the Primary Site = Age at Diagnosis >=70 OR AJCC Stage= 0 or IV; OR Surgery of the Primary Site >= 30 OR Vital Status=0 and Date of Death <=365 days following the Date of Diagnosis All other combinations Not Applicable Non-Concordant 16

17 CP 3 R: Computing Measure Concordance Using Cancer Registry Coding Standards Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. Conditions Assessment Numerator Denominator Chemotherapy = OR Chemotherapy =1,2, or 3; and Date Chemotherapy Started <=120 days following the Date of Diagnosis Age at Diagnosis<80 AND Surgery of the Primary Site = AND Number of Regional Lymph Nodes Positive = 1-90, 95, 97 Concordant Surgery of the Primary Site <=29 OR Number of Regional Lymph Nodes Examined = 0, 98 OR Age at Diagnosis>=80 OR Vital Status=0 and Date of Death <=120 days following the Date of Diagnosis All other combinations Not applicable Non-Concordant 17

18 CP 3 R (v2) Case review and on-line reconciliation: Just like e-quip Comparisons: Just like CP 3 R 18

19 CP 3 R (v2) 19

20 CP 3 R (v2) 20

21 CP 3 R (v2) 21

22 Benefits of CP 3 R Emphasizes the importance of the entire cancer program s role in the survey process Highlights collaborative, multidisciplinary efforts Moves responsibility beyond registry staff Links all departments of the cancer program Call to action for cooperation within cancer program and between cancer programs for data capture and follow-up Uses past performance as a means to foster quality improvement for cancer cases today 22

23 Cancer Program Standard 4.6 Patient Guidelines Introduced in 2004 Initial step to focus on quality of care Standardization of pathology report content through use of CAP protocols Commendation recognized importance of guidelines 23

24 Percentage Compliance with Standard 4.6 (Patient Guidelines) Deficiencies and Commendations Surveys Percent Deficiencies Commendations

25 New Standard 4.6 New requirements introduced for 1/1/2009 Retains and strengthens pathology report component New Commendation measure established Establishes new component focused on quality of care Cancer committee activity Surveyor activity during on-site visit 25

26 Standard 4.6 Quality of Care Component The cancer committee will: Review the quality of patient care using CoC quality reporting tools Report and discuss findings at meetings at least annually Address performance rates that fall below the established levels Document activity in cancer committee minutes Include the CoC quality reporting tools discussed, actions taken, and follow-up if relevant 26

27 Surveyor Evaluation of Compliance with the Quality of Care Portion of Standard 4.6 Surveyor will be provided with documentation demonstrating monitoring of the quality of patient by the cancer committee, or other appropriate leadership body, using the CoC quality reporting tools. Surveyor will confirm compliance with the standard of care by reviewing abstracts and medical records for not more than 25 analytic cases related to the measure identified by the CoC. 27

28 History of Active Monitoring Reported in the SAR: verify through review of minutes 28

29 Quality of Patient Care: Case Review List Posted 3 Weeks Prior to Survey Date Hospital Name: Your Medical Center Registries get PDF of SAR displayed case list Surveyors get PDF with case-specific review directives 29

30 Program PDF: Case List and Preparation Instructions 30

31 In Summary NCDB provides a variety of tools for data quality and data use, including CP 3 R, Survival and Benchmarking reports; QI projects using NCDB quality tools can objectively improve quality of cancer care; Tools are for use by the CoC-accredited Cancer Programs and their Cancer Chair, Liaison Physician, Administrator, and Registrar to champion ongoing quality improvement; NCDB is evolving more timely and interactive quality measurement tools to improve quality cancer care at the local level. 31