PROMEDICA MONROE REGIONAL HOSPITAL Annual Report

Transcription

1 PROMEDICA MONROE REGIONAL HOSPITAL 2015 Annual Report Includes Data Collected Through 2014

2 Welcome from the Cancer Committee Leadership With great pleasure, we present the 2015 ProMedica Monroe Regional Hospital Oncology Program Annual Report. We have the distinct privilege of serving as leaders for our cancer committee. With dedication, hard work and compassion, our teams deliver cancer care to the heart of our program our patients. Joining ProMedica s healthcare system in 2016 has helped Monroe Regional Hospital increase access to superior, convenient healthcare services in southeastern Michigan, Monroe County, and surrounding communities. Patients diagnosed with cancer can be referred to ProMedica Monroe Cancer Center, the area s only integrated facility offering coordinated outpatient radiation therapy and chemotherapy in one convenient location. Accreditations by the American College of Surgeons Commission on Cancer in 2013 (receiving renewal with commendation) and the American College of Radiology in 2014 ensure ProMedica Monroe Regional Hospital s commitment to providing quality oncology services to our patients. Throughout 2015, we have remained committed to providing the highest-quality cancer care and showing our dedication to excellence in clinical quality, patient safety and customer service. Michael J. Charboneau Jr., DO General Surgeon Cancer Committee Chairman Charu Trivedi, MD Medical Oncologist Cancer Committee Liaison Physician 1

3 ProMedica Monroe Regional Hospital Cancer Committee Membership 2015 Physician Members Discipline Michael Charboneau, DO General Surgery Cancer Committee Chairman Charu Trivedi, MD CoC Liaison Physician Celeste Batchev, MD Gehring Sauter, MD Steven Rubin, MD Gary Moorman, DO, FACOEP, FACEP, FAODME Khaled Shahrour, MD Additional Members Donna Booth Megan Coriell, RHIA, CTR Megan Carolin Doreen Cutway Kristin Ferreira, OTRC Gail Gedelian, RT, (R ), (M), (BD) Teressa Hopkins Tammy Knapp Ann Kujawa, MSN, RN, OCN Larry Lyons, M.Div, CBC Teina Melonakos, PharmD Cindy Miller, BS, RTT Debra Osentoski, RN, BSN, OCN, CBCN Brian Paules, BS, CCT Kayla Pugh, RDN.LD Michele Phillips Mary Russ, RN, ACM Pamela Urbanski, MSN, RN Karen Whitmire, RN, OCN Wendy Woelmer, MSN, RN- BC Jeannie Yonkee, LSW Medical Oncology Pathology Radiology Radiation Oncology Senior Vice President, Medical Affairs and Chief Medical Officer Urology Discipline Community Outreach Coordinator Cancer Registry/Coordinator Quality Control of Registry Data American Cancer Society Director, Marketing Communications Director, Rehabilitation Services Radiology Medical Education Program Executive Assistant, Administration Vice President, ProMedica Cancer Institute Pastoral Care Pharmacy Radiology Nurse Navigator Quality Improvement/Coordinator of Quality Improvement Nutrition Physician Recruitment Case Management Vice President, Nursing Oncology Program Coordinator/Clinical Trials Senior Nurse Education Social Work/Coordinator of Psychosocial Services 2

4 Number of New Cancer Diagnoses PROMEDICA MONROE REGIONAL HOSPITAL 2015 Annual Report Overview of 2014 Data In 2014, the ProMedica Monroe Regional Hospital cancer registry accessioned 253 new cases. It now contains more than 2,000 cases since its 2007 reference date. Aggregate data from the cancer registry is routinely analyzed by the cancer committee and is a valuable resource for oncology clinicians and program administrators. In addition to adding new cases annually, the cancer registry is responsible for conducting at least once yearly follow-up on all living patients in the database. The Commission on Cancer sets a standard of a 90% follow-up rate for eligible cases from the last five years and, in 2015, the cancer registry maintained a follow-up rate of 91.3%. The cancer registry has also maintained a 90.8% overall follow-up rate since its 2007 reference date. This exceeds the Commission on Cancer s standard of 80%. Compliance of these standards allows for accurate analysis of survival outcomes and disease recurrence rates as well as for monitoring the development of secondary malignancies. Graph No. 1 illustrates the accession trends from 2007 through Analytic cases include those patients who were diagnosed and/or received initial definitive treatment at ProMedica Monroe Regional Hospital. Analytic cases are followed annually; they are included in all survival, outcome and quality monitored data. Non-analytic cases are those patients who were initially diagnosed and treated elsewhere and then came to ProMedica with progressive or recurrent disease. Overall, the number of annual new cases has hovered around 250 cases Graph #1 - ProMedica Monroe Regional Hospital: Accession Trend Non- Analytic Analytic

5 Table No. 1 illustrates the number of new cases accessioned by primary site as well as the American Joint Committee on Cancer (AJCC) stage at diagnosis for analytic cases. Table #1: ProMedica Monroe: 2015 Primary Site Distribution Total Cases Sex Class of Case *AJCC Stage at Diagnosis M F ANA NA 0 I II III IV N/A UNK Head & Neck Tongue Gum & Other Mouth Tonsil Hypopharynx Larynx DIGESTIVE SYTEM Esophagus Stomach Colon Rectum/Rectosigmoid Liver/Intrahepatic Bile Duct Gallbladder Pancreas RESPIRATORY SYSTEM Lung/Bronchus BREAST FEMALE GENITAL SYSTEM Cervix Uteri Corpus Uteri Ovary MALE GENITAL SYSTEM Prostate Gland URINARY SYSTEM Urinary Bladder Kidney & Renal Pelvis SKIN Melanoma CENTRAL NERVOUS SYSTEM Cranial nerves/other CNS ENDOCRINE SYSTEM Other Endocrine LYMPHOMAS Hodgkin Lymphoma Non Hodgkin Lymphoma HEMATOPOIETIC Leukemia Other Hematopoietic UNKNOWN PRIMARY All Sites Combined *Collection of AJCC Stage is not required nor applicable for the following: Non-analytic cases, myeloma, leuk emias, CNS tumors 4

6 Percent of New 2014 Cases PROMEDICA MONROE REGIONAL HOSPITAL 2015 Annual Report Graph No. 2 demonstrates how Monroe Regional Hospital compares to national and state incidence rates. The hospital reports a much higher incidence of breast and lung cancers as compared to Michigan and national data from the Commission on Cancer s (CoC) National Cancer Database (NCDB). This is attributed to ProMedica s dedicated breast imaging and lung cancer screening programs. 30 Graph # ProMedica Monroe Regional Hospital:Top Site Incidence Comparison 26.6 Monroe Michigan National Breast Lung Prostate Colorectal GYN Bladder CP 3 R (Cancer Program Practice Profile Report) The success of the Commission on Cancer s (CoC) cancer program practice profile (CP 3 R) reports has demonstrated that improvements in data quality and patient care are possible when the entire cancer committee supports system level enhancements to ensure complete and precise documentation. These measures were incorporated into the new CoC 2012 program standards 4.4 and 4.5. These standards require the cancer committee each year to review the quality of patient care using the CP 3 R to evaluate care within and across disciplines, to discuss successful processes and to evaluate how processes can be improved to promote evidenced-based practice. The cancer committee is expected to address performance rates that fall below specific thresholds established by the CoC. 5

7 Below are the CP 3 R measures for beast and colorectal 2013, the most recent data year available. Table #2: ProMedica Monroe: 2013 CP3R Data Measure PMRH Scores Michigan Scores National Scores Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer. Needle biopsy to establish diagnosis of cancer precedes surgical excision/resection. Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with > = 4 positive regional lymph nodes. Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer. Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c, or stage II or III hormone receptor negative breast cancer. Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage II or stage III hormone receptor positive breast cancer No Data 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. At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is recommended; for patients under the age of 80 receiving resection for rectal cancer