CoC-trained consultants on staff Leveraging Your Cancer Registry: A Strategy for Survey Success Toni Hare, RHIT, CTR CoC-trained Consultant Vice President, CHAMPS Oncology November 27, 2012 Georgia s Best and Promising Practices In Quality Cancer Care: Meeting the 2012 Commission on Cancer Standards
Learning Objectives Distinguish how registry data is applied to decisions affecting planning Demonstrate how registry is utilized to validate patient care and outcomes Identify steps to evaluate adherence to multiple accreditations and certifications
The Evolution of Cancer Registry Data in Cancer Control Current: Quality Care Measures & Improvement Strategies Past Present Future Traditional: Data Reporting Future Trends: Information for Financial Incentives, Regulation and Policy
Healthcare Innovators for Quality of Cancer Care Healthcare Providers Government and Federal Agencies National Organizations Access to up-to-date comprehensive quality care close to home Plan, monitor and evaluate programs and services continuously Collect and analyze cancer incidence for a specific population or geographic area Measures progress in cancer prevention and control Explore trends in cancer care Create regional and state benchmarks for participating hospitals Serve as the basis for quality improvement Primary Payers Incentivize programs that monitor performance
Cancer Registry - First Source of Information Develop administrative and marketing plans Support infrastructure decisions Evaluate clinical performance Meet accreditation standards
Administrative & Marketing Plans Enhance oncology service offerings Apply for grants Monitor existing services Establish population trends and referral patterns
Enhance Oncology Services Market Analysis: Building Oncology Center Incidence Primary Cancer Sites Identify physician Referral Patterns Identify Practice Patterns Compare with the State Registry Data Stratify Primary Sites by Zip Code and County Stratify by Managing Physician Stratify by Medical and Radiation Oncology
Enhance Oncology Service Offerings
Monitor Existing Services Incidence all Cancer Sites Stratify by Accession Year Market Analysis: Treatment Trends Trending Referral Patterns Identify Practice Patterns Stratify by Accession Year & Class of Case Stratify by Medical & Radiation Oncology
Class of Case for Trending Reports Initial diagnosis at reporting facility 00 Initial DX at the reporting facility AND all treatment or a decision not to treat was done elsewhere 10 Initial DX at the reporting facility or in a staff physician s office AND part or all of 1st course RX or a decision not to treat was at the reporting facility, NOS 11 Initial DX in staff physician s office AND part of first course treatment was done at the reporting facility 12 Initial DX in staff physician s office AND all 1st RX or a decision not to treat was done at the reporting facility 13 14 Initial DX at the reporting facility AND part of 1st course RX was done at the reporting facility; part of 1st course RX was done elsewhere Initial DX at the reporting facility AND all 1st course treatment or a decision not to treat was done at the reporting facility Initial diagnosis elsewhere 20 Initial DX elsewhere AND all or part of 1st course RX was done at the reporting facility, NOS 21 Initial DX elsewhere AND all 1st course RX or a decision not to treat was done at the reporting facilityrx was done elsewhere 22 Initial DX in staff physician s office AND part of first course treatment was done at the reporting facility Analytic Classes of Case (required by CoC) from FORDS http://www.facs.org/cancer/coc/fordsmanual.html
Diagnosis & Treatment Patterns 400 350 300 250 200 150 362 313 230 234 348 210 315 321-20% 168 170 DX only DX & TX TX Only 100 50 0 36 51 39 26 31 2005 2006 2007 2008 2009
Population Trends & Referral Patterns Market Analysis: Treatment Trends Incidence of Top 5 Cancer Sites Trending Population Patterns Stratify by Class of Case (10-14 & 20-22) Stratify by Zip Code & County Compare with State Data
Population Trends & Referral Patterns
Applying for Funding & Grants Market Analysis: Disparities of Breast Incidence of Breast Cancer Patient Demographics Survival Comparison with NCDB Developed Programs from Grant Funding Stratify by Accession Year (5 yrs) Stratify by Race, Ethnicity, Insurance & Stage at DX Stratify by Stage at Dx B.R.E.A.S.T Program Amigas Unidas MetroHealth Breast Center http://www.metrohealth.org/body.cfm?id=3522&otopid=3522
Support Infrastructure Decisions Recruit physicians Estimate revenue by disease site Analyze costs and utilization of ancillary services Identify staffing needs
Utilization of Ancillary Services Average Number of visits per patient by stage Medical Admissions All I II III IV 2.2 1.2 1.8 2.1 2.9 Inpatient Surgery All I II III IV 1.6 1.0 1.1 1.5 2.7 Outpatient Surgery All I II III IV 2.9 1.7 1.2 3.3 6.9 Radiation Therapy All I II III IV 16.6 2.3 16.3 19.7 22.0 Radiology All I II III IV 14.3 14.5 18.1 13.7 14.4 Laboratory All I II III IV 28.6 25.1 27.6 27.8 43.1
Evaluate Clinical Performance How does your PDCA Plan, Do, Check, Act registry utilize quality improvement methodologies to evaluate Six Sigma Utilizing Quality Improvement Methodology FADE Focus, Analyze, Develop, Execute clinical performance? FMEA Failure mode and effects analysis
Quality Improvement Activities Identify & analyze problem Develop and implement potential solution or improvement Plan Act Do Check How does your registry connect to the quality process in your facility? Implement the improvement Measure effectiveness of improvement
Registry Study Improves Clinical Care Study Topic: (patients identified from cancer registry) Decrease wait time from radiation consult to initial treatment for prostate cancer patients Analysis: (data captured in cancer registry database) Dx date, Consult date (User Defined field), Date Radiation Tx Started Outcome: (quantitative report provided by cancer registry) Average wait time 20% above national benchmark Action: Implement solution Purchased and installed IMRT Additional 1 hour added to RT Clinic schedule Monitor the effectiveness of action plan implemented Improvement - 29 days
Multiple Cancer Program Accreditations & Certifications CoC QOPI Mastering the Juggling Act NAPBC TJC
Commission on Cancer (CoC) CoC-accredited Cancer Programs demonstrate the following services: Comprehensive care with state of the art services and equipment Multidisciplinary team approach to coordinate treatment options Clinical trial information and education Access to patient-centered services: psychosocial distress, navigation Ongoing monitoring and improvement of care Assessment of treatment planning based on evidence-based guidelines Follow-up care including survivorship care plan Cancer information collection (Cancer Registry)
National Accreditation Program for Breast Centers (NAPBC) Centers demonstrate the following services: Multidisciplinary team approach to coordinate the best care and treatment options available Access to breast cancer-related information, education, and support Breast cancer data collection on quality indicators Identifies and references evidence-based guidelines Ongoing monitoring and improvement of care Clinical trials information and new treatment options
The Joint Commission Certification (TJC): Disease-Specific Care Develop a Multidisciplinary Site-specific Advisory Team Compliance with consensus-based national standards which include: Program management Clinical information management Delivering or facilitating care Supporting self-management Measuring and improving performance Effective integration of Clinical Practice Guidelines to manage and optimize care Collects and analyzes performance measure data and drive improvement activities
ASCO: Quality Oncology Practice Initiative (QOPI) Quality assessment and improvement program for US-based outpatient hematology-oncology practices Data analyses on nationally recognized guidelines Practice-specific and aggregate comparison data for data-driven
Strides to Success Is there a shared vision within the cancer services? Is that shared vision supported by senior leadership? Is the Cancer Committee aware of the latest standards? Are there adequate and useful communication tools to promote a successful feedback loop? Is the cancer registry acting as a strategic partner to the cancer care team?
Step # 1: Strategic Plan & Goal Setting Assess Current Internal Resources Available Compare Standards and Guidelines Create Leadership Infrastructure Develop a Communication Tool
Standards Comparison Matrix
Step #2: Form Dedicated Teams Establish subcommittees with diseasespecific focus Identify key stakeholders from cancer committee membership Agree on goals that align with cancer program Reports regularly to the Cancer Committee
Hospital Subcommittee Members Required Member Cancer Committee Breast Program Leadership Lung Cancer Advisory Group Surgeon Pathologist Radiologist Medical Oncologist Radiation Oncologist Navigator Administrator Oncology Nurse Social Worker Quality Improvement Coordinator Data Manager Other members as assigned
Step #3: Create Quality Scorecard Identifies quality indicators Organized by accreditation Track each data set YTD comparison, target, current status, monthly progress Create reporting schedule Assign responsibility
Current NQF Performance Measures Breast BCS/RT- Breast conserving surgery with radiation MAC- Combination Chemo within 120 days Stage II & III ER/PR HT- Tamoxifen w/in 1 year Stage II & III ER/PR+ Colon ACT- Adjuvant chemo w/in 120 days Stage III 12 RLN- 12 lymph nodes removed Rectal ADJ RT- Radiation w/in 180 days Stage III
Breast Cancer Quality Metrics Indicators Benchmark Reference Responsibility Surgery: Mastectomy vs. breast conservation surgery rate - to ensure that women with stage 0-II BC are offered BCT Surgery: Needle biopsy vs open biopsy rate Med Onc: combo chemo given within 120 days of dx for pt <70 with AJCC T1cN0M0, or stage II or III, ER/PR - (CP3R) Med Onc: Tamoxifen or AI tx is initiated within 365 days of dx with AJCC T1cN0M0, or stage II or III, ER/PR + (CP3R) Rad Onc:Is Rad. Tx administered within 365 days of dx for <70 receiving BCT (C3PR) Surgery: Mastectomy vs. breast conservation surgery rate - ensure stage 0-II are offered BCT >50% NAPBC standard 2.3 Cancer Registry >74.2% 100% 97% 98% CoC 2008 NAPBC standard 2.9 NQF #0221 100% for CoC CMS has proposed reporting this quarterly NQF #0559 95% CoC NQF #0220 CMS has proposed reporting 95% CoC NQF #0219 Cancer Registry Cancer Registry Cancer Registry Cancer Registry >50% NAPBC standard 2.3 Cancer Registry
Breast Scorecard for NAPBC & CoC System Metrics Benchmark Report Nov 2012 Report Feb 2013 Report May 2013 Report Aug 2013 Jan-Mar 2012 cases Apr-June 2012 cases July-Sept 2012 cases Oct-Dec 2012 cases Surgery: Breast conservation surgery vs Mastectomy, to ensure that women with stage 0-II breast cancer are offered BCT >50% NAPBC Surgery: needle biopsy vs open biopsy rate >74.2% NAPBC Med Onc: Is combo chemo considered or given within 120 days of dx for women <70 with AJCC T1cN0M0, or stage II or III, ER/PR - (CP3R) 100% COC Med Onc:Tamoxifen or AI tx is considered or initiated within 365 days of dx for women with AJCC T1cN0M0, or stage II or III, ER/PR + (CP3R) 97% CoC Rad Onc:Is Rad. Tx administered within 365 days of dx for <70 receiving BCT for (C3PR) 98% CoC Evaluation of the axilla for patients with early stage breast cancer (I-IIB) via sentinel node biopsy at time of surgery (lumpectomy or mastectomy) 75% Intermountain Timeliness of treatment (screening-path) 8 days (OH) Survival by stage (0, I, II, III, IV), by hospital and OH, compared to NCDB
Lung Cancer Quality Metrics Indicators Benchmark Reference Responsibility Diagnosis by initial stage compared internally by hospital & state and with NCDB Risk adjust morbidity after lobectomy for lung cancer (% of patients undergoing elective lobectomy for lung cancer that have a length of stay > 14 days.) Risk adjusted morbidity & mortality for lung resection (specific list of post-op complications such as need for trach, ARDS, PE and more) % of lung cancer surgeries with >4 mediastinal lymph node stations dissected % of prophylactic cranial irradiation in limited or extensive stage small cell celllung cancer Survival by stage, compared with NCDB and internally by hospital and system 100% NCCN 100% NCCN NQF #0459 (Society for Thoracic Surgeons) NQF #1790 (Society for Thoracic Surgeons) Compare to the National Cancer Database by hospital, by system Cancer Registry Quality Dept. Quality Dept. Cancer Registry Cancer Registry Cancer Registry
Lung Scorecard for TJC: Disease Specific Care System Metrics Benchmark Report Nov 2012 Report Feb 2013 Report May 2013 Report Aug 2013 Jan-Mar 2012 cases Apr-June 2012 cases July-Sept 2012 cases Oct-Dec 2012 cases Diagnosis by initial stage compared internally by hospital & state and with NCDB. NSCLC Only Diagnosis by initial stage compared internally by hospital & state and with NCDB. SCLC Only Risk adjust morbidity (% of pts undergoing elective lobectomy for length of stay > 14 days.) NQF 0459 <6.2% (for 74th percentile) % of surgeries for NSCLC with >4 mediastinal lymph node stations dissected (NCCN) 100% % of prophylactic cranial irradiation given in limited stage small cell (NCCN-adv group set %) 80% Recording of clinical stage prior to resection (% of all surgical patients undergoing treatment procedures for lung cancer that has clinical TNM staging provided) 98.2% (for 75th percentile) Survival by stage compared by hospital and system with NCDB as possible. NSCLC Only Survival by stage compared by hospital and system with NCDB as possible. SCLC Only
Colorectal Cancer Quality Metrics Indicators Benchmark Reference Responsibility Colon/Surgery: At least 12 regional lymph nodes are removed and pathologically examined for resected cancer for staging completeness for stage I, II, III. 81.50% NQF #0225 80% CoC Cancer Registry Colon/Med Onc: Is adjuvant chemotherapy considered or given wtihin 120 days of diagnosis in pts <80 with stage III colon cancer? (CP3R) Rectal/Rad Onc: Radiation therapy given for stage III rectal CA in pts <80, under 6 mths of DX. (C3PR) Rectal: Endorectal ultrasound or pelvic MRI is performed prior to TX for rectal cancer. Colorectal Survival 100% NQF #0223. 100% for CoC CMS has proposed reporting this quarterly Cancer Registry 100% CoC C3PR Cancer Registry 100% NCCN version 3.2012 (colorectal cancer) Cancer Registry Compare to the National Cancer Database by hospital, by system Cancer Registry
Colorectal Scorecard for CoC System Metrics Benchmark Report Nov 2012 Report Feb 2013 Report May 2013 Report Aug 2013 Jan-Mar 2012 cases Apr-June 2012 cases July-Sept 2012 cases Oct-Dec 2012 cases COLON CANCER Colon/Surgery: At least 12 regional lymph nodes are removed and pathologically examined for resected cancer for staging completeness for stage I, II, III. (C3PR) 81.5% Colon/Med Onc: Is adjuvant chemotherapy considered or given wtihin 120 days of diagnosis in pts <80 with stage III colon cancer? (CP3R) 100% RECTAL CANCER Rectal/Rad Onc: Is radiation therapy considered or given for stage III rectal CA in patients <80, under 6 months of diagnosis. (C3PR metric) 100% Rectal/Endorectal ultrasound or pelvic MRI is performed prior to trt for rectal cancer. 100% COLON & RECTAL CANCER Colorectal Survival (separately) - this is 5-year survival, thus the most recent complete year is 2011.
Quality Scorecard for QOPI
Quality Scorecard Sample
Step # 4: Invest in Quality & Informatics Identify Sources of Cancer Information Cancer Registry- First Source Clinical Trial Databases Patient Navigation Databases Utilize IT Support Services AutoMerge from Electronic Health Record Data Warehousing SQL Reporting
Don t Reinvent the Wheel Multidisciplinary Cancer Care Team Data Analytics Standard Guidelines Performance Measures Clinical Practice Guidelines
Thank You! www.champsoncology.com Questions? Contact: Toni Hare, RHIT, CTR CoC-trained Consultant Vice President CHAMPS Oncology toni.hare@chanet.org 216.255.3716