The Center for Cancer Prevention and Treatment Public Reporting of Outcomes

Transcription

1 The Center for Cancer Prevention and Treatment 2013 Public Reporting of Outcomes

2 The Center for Cancer Prevention and Treatment at St. Joseph Hospital of Orange 2013 Public Reporting of Outcomes Review of Venous Thromboembolism (VTE) in cancer patients for care improvement opportunities. Pulmonary embolism (PE) and deep vein thrombosis (DVT) are both types of VTE. Description and Reason for the Study A review of VTE incidence and prophylaxis of hospitalized patients was initiated as a result of the Centers for Medicare and Medicaid Services (CMS) core measure regarding VTE prophylaxis for hospitalized patients and the Patient Safety Indicator (PSI) of postoperative PE/DVT. St. Joseph Health (SJH) conducted a quality study on VTE at all SJH facilities within the system. The result of the SJH review demonstrated that St. Joseph Hospital s (SJO) VTE incidence was the lowest of all the facilities. However, the final results were general to all patient diagnoses and not specific to cancer patients. Criteria for Evaluation Cancer patients are at high risk for VTE. The risk of VTE increases with central lines, and there are fewer prophylaxis options for patients with a low platelet count, as is often the case with cancer patients. Study Method Quality Management staff reviewed cases daily for appropriate VTE prophylaxis for all SJO inpatients admitted the previous day. The general physician admission order requires a VTE risk assessment and appropriate treatment or a contraindication to treatment for all patients. All postoperative orders also include the same VTE risk assessment. There are four categories in the risk assessment and points ranging from 1 to 4 are assigned. Some, but not all of the factors assessed include age, weight, status, presence of a central venous line, high risk diagnosis or recent major surgery, and mobility status. After a total point value is assigned a risk score is calculated. The risk stratification categories are: Low (0-1): No prophylaxis is required Moderate (2-4): physicians order EITHER mechanical compression devices or pharmacologic prophylaxis Very high (> 5): physicians order both mechanical compression devices and pharmacological prophylaxis If VTE prophylaxis is contraindicated, a reason is selected by the physician directly on the orders. The patient record is reviewed by Quality Management staff, and a daily is generated by Quality Management and sent to nursing managers and nurse practitioners identifying patients requiring interventions to demonstrate that appropriate VTE prophylaxis has taken place.

3 Quality Management reviews all VTE as they are identified, determining if the appropriate prophylaxis took place prior to the patient having developed this condition. This report is provided to the Board of Trustees, Executive Management Team, Medical Executive Team, and Nursing Leadership Team (NLT) on a monthly basis. Additionally, the VTE Evidence Based Care Clinical Excellence Report, reviewing randomly sampled patients, is also provided to NLT monthly. Data St. Joseph Hospital uses the Agency for Healthcare Research & Quality (AHRQ) Patient Safety Indicator (PSI) definition utilized by the Centers for Medicare and Medicaid Services (CMS). The definition is as follows: Perioperative pulmonary embolism or deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis for pulmonary embolism or deep vein thrombosis; cases with secondary diagnosis for pulmonary embolism or deep vein thrombosis present on admission; cases in which interruption of vena cava is the only operating room procedure or in which interruption of vena cava occurs before or on the same day as the first operating room procedure; and obstetric discharges. Reports are run identifying surgical discharges age 18 and older with any ICD-9-CM code for an operating room procedure (except Inferior Vena Cava Filter placement and emergent intubation) with a secondary ICD-9-CM diagnosis code for either deep vein thrombosis or pulmonary embolism. The aforementioned ICD-9CM codes are as follows: , , 451.2, , 451.9, , , , 453.8, 453.9, 415.1, , and Data for patients who developed VTE (PSI definition)

4 There were 12 patients who met the PSI-90 definition as previously described. Two patients had oncologic diagnoses. One patient was a very high bleeding risk as well as a high risk for VTE and had an Inferior Vena Cava Filter placed prior to the VTE occurring. The second patient refused mechanical prophylaxis. Designing and Initiating Action Plans Based on the Evaluation of the Data Despite the low incidence of VTE in the cancer patient population at SJO, a strong emphasis is placed on assessment of risk and appropriate prophylaxis. The oncologists, surgeons, hospitalists, intensivists, and oncology nurses maintain a heightened watch on all cancer patients to assure platelet monitoring is in place, compression devices are ordered and are on all VTE at risk patients at all times. If the patient is high risk, anticoagulation is considered and ordered as appropriate on an individual patient basis with documentation of contraindications to pharmacologic prophylaxis as needed. Patient and family education is a priority since patient compliance is a major success factor. In the event a patient or family refuses compression devices, informed education includes the risk of death, increased length of hospital stay and the potential for long-term sequelae. Follow-Up Steps to Monitor the Actions Implemented: Continue monitoring all cancer patients Report the VTE Core Measure data in cancer patient population Monthly Clinical Excellence Team meeting to report results and promote appropriate prophylaxis Quality Management report VTE Core Measure results monthly to NLT Weekly meeting with Oncology Leadership Team to detail specifics on cancer patient VTE assessment and prophylaxis Respectfully submitted, Trish Cruz, RN, BSN, PHN Hisham El-Bayar, MD

5 MRI-INITIATED BREAST BIOPSY: A BURDEN OF CARE ANALYSIS* Kamelia D. Cohen, BS, and Lawrence D. Wagman, MD, FACS Introduction The NCCN Guidelines for the use of MRI in breast cancer are 2B (lower level evidence). This reflects disagreement amongst experts and the lack of randomized clinical trials. This study was undertaken to evaluate the burden of care and results for women who had MRI-initiated and underwent MRI breast biopsies in a community hospital cancer program that utilizes NCCN Guidelines. Objective To determine how breast lesions are identified and subsequently biopsied by MRI contributed to the time and complexity of patient care. Methods Medical records of all patients who underwent MRI-guided biopsy between 10/2010 and 2/2013 were reviewed. The following data was collected: date of birth, initial mammogram (M) and/or ultrasound (USG), diagnostic MRI findings (positive, negative, known malignancy) and pathologic diagnosis for each tissue acquisition by MRI, M and USG-guided biopsy. IRB approval was obtained. Results 63 patients with an average age of 54.3 y (25-85) who underwent 69 MRI-guided biopsy were evaluated. The average time between initial M/ USG and MRI biopsy was 49.4d (13-124). There were a total of 238 individual MRI findings: 65 (27%) negative, 39 (16%) index malignancy, and 134 (56%) positive findings. Of the 134 positive findings, 21 were benign and biopsy was not recommended. Of the remaining actionable 113, 77 (68%) had MRI biopsy, 18 (16%) were biopsied but not by MRI, 6 were not biopsied due to technical failure (e.g. inaccessible location, vasovagal episode), and 12(11%) were of uncertain clinical significance and not biopsied. For the 77 MRI biopsies, 52 (68%) were benign, 3 (4%) ILC, 4 (5%) IDC, 14 (18%) DCIS and 4 (5%) DCIS/IDC. Of the 18 non-mri biopsies, 1 DCIS, 7 INV, 10 benign. A total of 27/63 (43%) patients had cancer diagnoses. The majority of MRI lesions were less than 10 mm. Conclusions For positive findings identified and biopsied by MRI, 68% were benign and 32% were malignant. A significant number (36/113) of MRI identified lesions did not undergo MRI biopsy. The average delay related to MRI biopsies was 6 weeks. The clinical significance of the large percentage of cancers identified and biopsied by MRI is uncertain. *Presented at the2014 Southern California Chapter American College of Surgeons Annual Scientific Meeting.

6 STANDARD PREVENTION PROGRAMS Smoking Cessation Program January March 2013 Program Description From January through March 2013, St. Joseph Hospital provided tobacco cessation services to the community in English. These services adhered to the U.S. Department of Health and Human Services Clinical Practice Guidelines for Treating Tobacco Use and Dependence. The guideline was established through evidence-based outcomes that combine nicotine replacement therapy and behavioral counseling. The class was taught by a registered nurse, with certification in tobacco treatment counseling from the Mayo Clinic. An initial one-on-one assessment with the tobacco treatment counselor followed by five consecutive sessions of education and support were included. Class Sessions January 2013 February participants 7 participants Evidence-Based Intervention The U.S. Department of Health and Human Services Clinical Practice Guidelines for Treating Tobacco Use and Dependence are used as a guideline for our Smoking Cessation Program. Evaluation Qualitative input from participants.

7 Smoking Cessation Program March December 2013 Program Description In March 2013, St. Joseph Hospital initiated a partnership with the Orange County Health Care Agency Tobacco Use Prevention Program (TUPP) to provide free tobacco cessation services to the community in English, Spanish, and Vietnamese. The Tobacco Cessation Program uses combination therapy that is comprised of a five-session series, which focuses on behavior modification and nicotine replacement therapy, via nicotine patches. Classes are taught by a Tobacco Cessation Specialist, who has been trained in tobacco treatment counseling by the Orange County Health Care Agency. Each class meets for one hour each week for five consecutive weeks and highlights how participants can identify their tobacco triggers, develop personalized coping strategies, manage stress, avoid relapse, and maintain a tobacco-free lifestyle. A six-week supply of nicotine patches is provided to aid participants in their quitting process and lessen the burden of withdrawal symptoms. Class Sessions March 2013 May 2013 July 2013 October Participants 10 Participants 12 Participants 12 Participants Evidence-Based Intervention Cessation curriculum is based on clinical practice guidelines from Treating Tobacco Use and Dependence (U.S. Department of Health and Human Services, 2008). These guidelines have been established through evidence-based outcomes that combine nicotine replacement therapy and behavioral counseling. Evaluation Evaluation for the cessation program is conducted at 30 days, 90 days and 180 days after the completion of the first cessation class. The 180- day quit rate for the Tobacco Cessation Program is 53%. Participant satisfaction with the cessation program is very high, with 92% responding very satisfied or satisfied. Participants who need additional support after completion of their cessation class can call the tobacco cessation hotline (1-866-NEW-LUNG). The following evaluation tools are used: Intake form collects demographics on participants and their tobacco use 30-day follow-up form 90-day follow-up form 180-day follow-up form Adult satisfaction survey (English and Spanish) Youth satisfaction survey

8 The Cancer Lottery: Really Understanding a Woman s Risk May 15, 2013 Program Description A free community education event focused on education and awareness on how a woman can more accurately manage her risk of developing cancer. Participants were educated cancer risk assessment, family history of cancer, and how weight management and exercise can impact the risk of cancer. There were a total of 37 attendees. Moderator Michele Carpenter, MD Program Director, Breast Program The Inside Story on the HPV Virus: What It Is and What To Do Leslie Randall, MD Gynecologic Oncologist Putting Family History Into Perspective Sandra Brown, MS, LCGC Manager, Cancer Genetic Program Weight Management, Exercise and Cancer Kathy Berger, PT, MT Director, Physical Rehabilitation Services and Wound Care Center Evidence-Based Intervention Qualitative Input from Participants Evaluation (based on 26 surveys collected) Overall Event 88% Excellent, 12% Good, 0% Poor Venue 92% Excellent, 4% Good, 4% Poor Format/Length of Event 96% Excellent, 4% Good, 0% Poor Comments From Attendees Enjoyed genetic counseling discussion Excellent information Very important topics because there is a lot of cancer history in my family Speakers were very knowledgeable and presented in a simple way Speakers had great statistics to prove their points. Great prevention strategies

9 STANDARD 4.2 SCREENING PROGRAMS 2013 CT Lung Screening Program Program Description In 2011, there were 1,280 new cases of lung cancer in Orange County (California Cancer Registry). According to the American Cancer Society, there will be an estimated 159,480 deaths due to lung cancer in Lung cancer can be insidious and oftentimes symptoms do not appear until the disease is advanced. Unfortunately, this is often in the later stages of lung cancer, when the chances of a five-year survival rate drop to 2-4%. However, if lung cancer is diagnosed in its earliest stages the cancer is potentially treatable and curable. With the advent of low dose CT scan the landscape of lung cancer screening was altered with studies indicating that low dose CT scan detects many tumors at early stages. The screening is open to high risk individuals in Orange County. High risk individuals are defined as: years of age Over a 30 pack year history, including former and current smokers Former smokers who quit within the previous 15 years CT Lung Screening Results Number of Screenings 69 Number of Abnormal Findings 53 Number of Abnormal Findings that were non-pulmonary 7 Follow Up Following the CT lung screening, all patients receive written correspondence advising them of the results. An abnormality could be lung related or other findings such as coronary artery calcifications or other suspicious malignancies. If an abnormality is indicated, the patient is advised to see their primary care physician. Each physician receives a copy of the CT scan report and the recommendation for follow up. Patients whose initial scan requires immediate evaluation are presented to the Thoracic Oncology Program multidisciplinary cancer conference, where the patient s CT scans and history are reviewed. Recommendations are communicated to the patient s physician directly either by the nurse navigator or by written communication. Evidence-Based Intervention International Early Lung Cancer Action Project (I-ELCAP) The National Lung Screening Trial (NLST) National Comprehensive Cancer Network (NCCN) Guidelines

10 In 2013, there were 1,959 cases accessioned to the St. Joseph Hospital Cancer Registery. The total number of cases includes 1,640 analytic cases, meaning that these cases were diagnosed and/or treated at St. Joseph Hospital. Site Group Total Cases Class Sex Stage Analytic NonAn Other M F Other Stage 0 Stage I Stage II Stage III Stage IV Not Applicable Unknown ALL SITES BREAS T PROSTATE LUNG/BRONCHUS-NON SM CELL COLON/RECTUM/ANUS THYROID NON-HODGKIN'S LYMPHOMA KIDNEY AND RENAL PELVIS MELANOMA OF SKIN BLADDER CORPUS UTERI LEUKEMIA P ANCREAS S TOMACH BRAIN OVARY LIVER OTHER HEMATOPOIETIC MYELOMA CERVIX UTERI OTHER NERVOUS SYSTEM SOFT TISSUE UNKNOWN OR ILL-DEFINED HODGKIN'S DISEASE ESOPHAGUS OTHER ENDOCRINE LUNG/BRONCHUS-SMALL CELL TESTIS TONGUE SALIVARY GLANDS, MAJOR SMALL INTESTINE BILE DUCTS VULVA GALLBLADDER OTHER SKIN CA P LEURA BONE UTERUS NOS VAGINA OTHER FEMALE GENITAL MOUTH, OTHER & NOS TONSIL OTHER DIGESTIVE NASAL CAVITY,SINUS,EAR LARYNX GUM P ERITONEUM,OMENTUM,MES ENT P ENIS FLOOR OF MOUTH OROPHARYNX NASOPHARYNX RETROPERITONEUM EYE

11 The Center for Cancer Prevention and Treatment at St. Joseph Hospital of Orange 1000 W. La Veta Avenue Orange, CA (714) sjo.org/cancer