APIII October 23, 2008 Establishing Indicators for Cancer Care: The Role of the Cancer Registry and Other Oncology Data Sources Presented by: Sharon Winters

APIIIOctober 23, 2008

Establishing Indicators Establishing Indicators for Cancer Care:for Cancer Care:

The Role of the Cancer Registry The Role of the Cancer Registry and Other Oncology Data and Other Oncology Data

SourcesSources

Presented by:

Sharon WintersDirector, Registry Information Services

UPMC Cancer [email protected]

(412) 647-6390


2

Session ObjectivesSession Objectives Understand the history of Pay for

Performance initiatives Identify organizations dedicated to the

evaluation of quality of care indicators Identify electronic medical data sources

being used to evaluate these indicators Create an open forum for discussion of

how pathology, cancer registry and other clinical applications can continue to play key roles


3

Session OutlineSession Outline Identify the difference between Quality of Care

vs. Pay for Performance Brief review of Healthcare expenditures Identify organizations dedicated to the evaluation

of quality care indicators Specific focus on oncology care

Understand the history of Pay for Performance initiatives

Identify indicators accepted by the National Quality Forum and CMS

Identify electronic medical data sources being used to evaluate these indicators

Discussion


4

Quality ManagementQuality Management A method for ensuring that all activities

necessary to design, develop and implement a product or service are effective with respect to the system and its performance.

Three main components: Quality Control Quality Assurance Quality Improvement

http://en.wikipedia.org/wiki/Quality_improvement


5

What is meant by “Quality What is meant by “Quality of Care”?of Care”? The degree to which health services for individuals and

populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. U.S. Institutes of Medicine (IOM)

Each individual consumer should receive the best possible health care available every time services are needed.

Health care providers should provide care that meets the needs of each individual patient, including the use of appropriate advances in medical technology.

Healthcare should also be non-discriminatory, providing the same quality of service regardless of race, ethnicity, age, sex or health status. http://www.medicareadvocacy.org/

http://www.iom.edu/


6

What’s in a Name?What’s in a Name? Quality Management Quality Assurance Continuous Process Improvement Total Quality Improvement Clinical Indicators of Care Quality Indicators of Care Clinical Pathways

Incorporating multidisciplinary approach to surgical oncology, medical oncology, radiation oncology and clinical therapeutic trials

http://www.oncbiz.com/documents/OBRJA07_Pathways.pdf


7

The “Cost” of Health CareThe “Cost” of Health CareIncreasing Overall NHE 1960-2006Increasing Overall NHE 1960-2006

U.S. National Healthcare Expenditures

$0.00

$500.00

$1,000.00

$1,500.00

$2,000.00

$2,500.00

1960 1970 1980 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

in B

illi

on

s

http://www.cms.hhs.gov/NationalHealthExpendData/


8

The “Cost” of Health CareThe “Cost” of Health CarePercent by Type of Service 1994 Percent by Type of Service 1994 vs. 2004vs. 2004

34.1

30.4

21.821.3

5.6

10

76.1

2.7 2.3

13 12.9

15.716.9

0

5

10

15

20

25

30

35

%

Hospital Care Physician/ClinicalServices

Prescription Drugs Nursing Home Care Home Health Care Other Personal Care Other HealthSpending

U.S. National Healthcare Expenditures % by Type of Service

1994 2004

http://www.cms.hhs.gov/NationalHealthExpendData/


9

Pay for Performance Pay for Performance (P4P)(P4P) Insurance companies, large corporations

providing health benefits to their employees, Medicare, and other healthcare purchasers are looking to improve the quality of healthcare and control costs by changing the way they pay for healthcare paying doctors, hospitals, and other providers

more for high quality care, and less for poor quality care


10

The OrganizationsThe Organizations…or shall we say, the acronyms?…or shall we say, the acronyms? Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Centers for Medicare and Medicaid Services (CMS) National Quality Forum (NQF) US Department of Health and Human Services (USDHHS)

Agency for Healthcare Research and Quality (AHRQ) National Comprehensive Cancer Network (NCCN) American Society of Clinical Oncology (ASCO) American College of Surgeons Commission on Cancer (ACoS CoC) Centers for Disease Control and Prevention (CDC) American Medical Association (AMA) College of American Pathologists (CAP) American Cancer Society (ACS) Center for Health Care Strategies (CHCS)

Insurance Companies State Specific Initiatives

Quality Insights of Pennsylvania Pennsylvania Cancer Control Consortium (PAC3) Pittsburgh Regional Health Initiative (PRHI)

Disease-specific organizations ….and many others


11

Reportable Cases by Reportable Cases by Insurance TypeInsurance Type2000-20072000-2007

UPMC Hospital Based Cancer Cases by Insurance Type

CY 2000-2007

Medicare36%

Military/VA, Indian/Public Health

Service, Tricare0%

Medicaid2%

Not Insured, Self Pay1%

Private48%

Other Insurance, NOS or Unknown Status

13%

86% of cancer care is covered by Medicare/Medicaid and Private Insurance

Source: UPMC Network Cancer Registry Via Hospital billing systems


12

Cancer Care Indicators and Cancer Care Indicators and P4PP4P“Recent” History“Recent” History 1999: Institute of Medicine report “Ensuring Quality

Cancer Care” Revealed lack of info on the quality of cancer care Recommended development of better measures and data to

support evaluation In response, NCI teams up with several agencies to contract

with the National Quality Forum (NQF) Agency for Health Care Research and Quality (AHRQ) Centers for Disease Control (CDC) Centers for Medicare and Medicaid Services (CMS)

2004: American College of Surgeons supports use of NCCN and ASCO benchmark guidelines for breast and colorectal cancers

2004 and 2005: NQF announces call for breast and colorectal measures NQF contracts with the American College of Surgeons

Commission on Cancer


13

Cancer Care Indicators Cancer Care Indicators and P4Pand P4P “Recent” History (Continued)“Recent” History (Continued) January 2005: Medicare (CMS) releases “Pay for

Performance” Initiatives (P4P) – this is working its way into cancer care… Linking level of payment to reporting of quality measures Some initiatives also provide for ‘bonus’ payments

2% above standard DRG payment for facilities scoring in the top 10% of “highest quality”

1% above standard DRG payment for next highest 10% April 2007: NQF Endorses American College of Surgeons

Commission on Cancer (CoC) Measures for Cancer Care of Breast and Colorectal Cancers Out of 8 measures proposed by the CoC, 5 measures met the

requirements of the NQF Steering Committee 3 for breast cancer 2 for colon cancers


14

Pay for Performance Pay for Performance MeasuresMeasuresConditions for ConsiderationConditions for Consideration Be in a public domain or have a signed

intellectual property (IP) agreement to make open source

Have an identified responsible entity and process to maintain and update the measure

Be intended for both public reporting and quality improvement

Be fully developed and tested so that all evaluation criteria have been addressed and information needed to evaluate the measure is provided

http://www.qualityforum.org/


15

NQF, ASCO/NCCN and CoC NQF, ASCO/NCCN and CoC Adopted Indicators: Breast Adopted Indicators: Breast Cancer #1Cancer #1 Radiation therapy is administered within 1 year

(365 days) of initial diagnosis for women under the age of 70 receiving breast conserving surgery for breast cancer. Denominator includes: Gender = women Age at dx = 18-69 at time of diagnosis Known or assumed first or only cancer diagnosis Primary breast tumors Epithelial invasive tumors AJCC stage = I, II or III BC Surgery = excision less than mastectomy All or part of the first course of tx performed at reporting

facility Known to be alive within 1 year (365 days of dx)


16

NQF, ASCO/NCCN and CoC NQF, ASCO/NCCN and CoC Adopted Indicators: Breast Adopted Indicators: Breast Cancer #2Cancer #2 Chemotherapy is considered or administered

within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0 or Stage II/III hormone receptor negative breast cancer. Denominator includes: Gender = women Age at dx = 18-69 at time of diagnosis Known or assumed first or only cancer diagnosis Primary breast tumors Epithelial invasive tumors AJCC stage = T1cN0M0 or stage II/III ER neg (-) and PR neg (-) All or part of the first course of tx performed at reporting

facility Known to be alive within 4 months (120 days) of diagnosis


17

NQF, ASCO/NCCN and CoC NQF, ASCO/NCCN and CoC Adopted Indicators: Breast Adopted Indicators: Breast Cancer #3Cancer #3 Tamoxifen or 3rd generation aromatase

inhibitor is considered or administered within 1 year (365 days) of diagnosis for AJCC T1cN0M0 or Stage II/III hormone receptor positive breast cancer. Denominator includes: Gender = women Age at dx >= 18 at time of diagnosis Known or assumed first or only cancer diagnosis Primary breast tumors Epithelial invasive tumors AJCC stage = T1cN0M0 or stage II/III ER positive (+) or PR positive (+) All or part of the first course of tx performed at reporting

facility Known to be alive within 1 year (365 days) of diagnosis


18

NQF, ASCO/NCCN and CoC NQF, ASCO/NCCN and CoC Adopted Indicators: Colon Adopted Indicators: Colon Cancer #1Cancer #1 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. Denominator includes: Age = 18-79 at time of initial diagnosis Known or presumed to be the first or only cancer

diagnosis Primary tumors of the colon Epithelial invasive malignancies only AJCC Stage III All or part of the first course of treatment performed at

reporting facility Known to be alive within 4 months (120 days) of diagnosis


19

NQF, ASCO/NCCN and CoC NQF, ASCO/NCCN and CoC Adopted Indicators: Colon Adopted Indicators: Colon Cancer #2Cancer #2 At least 12 regional lymph nodes are

removed and pathologically examined for resected colon cancer. Denominator includes: Age >=18 at time of initial diagnosis Known or presumed to be the first or only cancer

diagnosis Primary tumors of the colon Epithelial invasive malignancies only AJCC Stage I, II or III Surgical resection performed at reporting facility


20

ASCO and CoC Adopted ASCO and CoC Adopted Indicators: Indicators: Rectal CancerRectal Cancer Radiation therapy is considered or administered

within 6 months (180 days) of diagnosis for patients under the age of 80 with clinical or pathological AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer. Denominator includes: Age =18-79 at time of initial diagnosis Known or presumed to be the first or only cancer

diagnosis Primary tumors of the rectum Epithelial invasive malignancies only AJCC clinical or pathologic Stage T4N0M0 or Stage

III All or part of the first course of treatment performed at

reporting facility Known to be alive within 6 months (180 days) of diagnosis


21

Data Collection to Support Data Collection to Support IndicatorsIndicators American College of Surgeons Commission on

Cancer National Cancer DataBase (NCDB) 75% of all newly dx cancer cases in U.S. annually Over 20 million cases reported since 1985 – from data

collected/reported by cancer registries in approved facilities Jointly supported by CoC and American Cancer Society Several “SubReports” available

Public Benchmark Reports Survival Reports Hospital Comparison Benchmark Reports Cancer Program Practice Profile Reports (CP3R) – focused

on adjuvant chemo admin for Stage III cancer of the colon (colon indicator #1): comparative data available

Electronic Quality Improvement Packets (e-QuIP) – focused on the 3 breast indicators and colon indicator #1 and rectal indicator, however only facility-specific data is available


22

How are we doing?How are we doing? (2003-2005 data)(2003-2005 data)

Indicator Summary Hospital 1 Hospital 2Br1: rad for BCS 939/961

97.7%165/17793.2%

Br2: chemo for HR(-) 222/22399.6%

29/3096.7%

Br3: hormone for HR(+) 964/98997.5%

160/16895.2%

Col1: chemo for Stage III(CP3R)

NA 99/12579.2%

Col2: >=12 RLN removed NA 210/32365.0%

Rectal: rad for T4, stage III NA 62/6398.4%

Source: eQuIPs and CP3R

Hospital 2 eQuIPs data updated 01/22/08; Hospital 1 updated 01/31/08


23

What happens next?What happens next? With the NQF endorsement of breast and

colon cancer indicators, and the Centers for Medicare and Medicaid Services (CMS) exploring precursors to P4P, the CoC programs are well positioned to understand needed areas for improvement and should be acting on deficiencies.

Additional indicators will be recommended, evaluated for top sites/rare cancers

Even if your facilities does NOT have a CoC approved cancer program……


24

Pennsylvania Cancer Pennsylvania Cancer Control Consortium Control Consortium (PAC3)(PAC3) In 2001 an unprecedented partnership was initiated in

Pennsylvania by the Pennsylvania Department of Health to develop the Commonwealth’s first-ever comprehensive cancer control plan in response to the Centers for Disease Control and Prevention’s very ambitious challenge – to eliminate suffering and death due to cancer by the year 2015

PAC3 Priority Indicators Chemotherapy is recommended/administered for Stage III

(regional LN positive) colon cancer At least 12 regional lymph nodes are removed for Stage I-III

colon cancer Using PA Cancer Registry data obtained from facility based

registries and pathology labs Preliminary data reported at October 2007 PAC3 meeting

and ongoing evaluation/manuscript in progress see next slides


25

PAC3: Why Focus On PAC3: Why Focus On Colorectal Cancer Colorectal Cancer Treatment?Treatment? In 2004, colorectal cancer had the 3rd highest number of

new cases for men and 3rd highest for women.

However, in 2004 and 2005, colorectal cancer mortality was ranked 2nd behind bronchus and lung cancer for both men and women.

Colorectal cancer is highly treatable and recent research and clinical trials have shown that there is a correlation between adjuvant chemotherapy following surgery and the number of lymph nodes tested to cancer recurrence and mortality of patients.


26

PAC3: Colon Cancer and PAC3: Colon Cancer and Chemotherapy BackgroundChemotherapy Background Clinical trials conducted in the 1980s established that

postoperative chemotherapy treatment for stage III colon cancer patients reduces the risk of recurrence and mortality by as much as 30 percent (1,2).

The National Institutes of Health (NIH) released a consensus statement in 1990, which has led to adjuvant chemotherapy being the standard of care for stage III colon cancer patients after surgery (3).

An analysis from the Mayo Clinic (4) showed that the benefits of chemotherapy on older patients (over age 70) decreases only slightly with increased age.

The National Cancer Institute’s (NCI) webpage for Colon Cancer: Treatment states that recurrence of colorectal cancer after surgery is a major problem and is often the ultimate cause of death.


27

Percent of All Stage III Colorectal Cancer Patients Who Did Not Receive Chemotherapy (RX Chemo Code = '00')

PA Cancer Registry Data 2004-2005

9.4%12.9%

18.4%

31.5%

53.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Age 0 to 49 Age 50 to 64 Age 65 to 74 Age 75 to 84 Age 85 and older

Perc

en

t

203 / 379173 / 939

RX Chemo Codes Cases99 3788 1887 1786 285 482 3903 1102 4301 500 203

347 / 1,100



116 / 90031 / 331



NQF measure cut off

at age 80


28

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Elk

York

Centre

Berks

Pike

Butler

Lycoming

Bedford

Clinton

Clearfield

Indiana

Somerset

Blair

Luzerne

Fayette

Perry

Lancaster

Mercer

Bucks

Chester

Franklin

Clarion

Cambria

Monroe

Greene

Schuylkill

Venango

Huntingdon

Adams

Washington

Westmoreland

Jefferson

Fulton

Mifflin

Dauphin

Beaver

Armstrong

Sullivan

Union Carbon

Lehigh

Snyder

Tioga

Erie

PotterBradfordWarren McKean

CrawfordWayne

Allegheny

Forest

Susquehanna

Juniata

Columbia

Cumberland

CameronWyoming

Lebanon

Montgomery

Lawrence

Lackawanna

NorthumberlandNorthampton

Delaware

Montour

Philadelphia

Percent of Stage III Colorectal Cancer Cases Where Patients Did Not Receive ChemotherapyWith Hospitals With Chemotherapy Services

Pennsylvania Cancer Registry Data (2004 - 2005)

Percent

0.0 % 0.1% - 25.0% 25.1% - 50.0% 50.1% - 75.0% 75.1% - 100.0%

NOTE: The color shading and percentages are based on the ratio of the number of stage III (AJCC staging definition) colorectal cancer cases where chemotherapy was not received (chemo code = '00') and the total number of stage III colorectal cancer cases where there is no valid reason why chemotherapy was not administered OR where chemo WAS administered (chemo codes = '00', '01', '02', or '03').


29

PAC3: Colon Cancer and PAC3: Colon Cancer and Lymph Node Examination Lymph Node Examination BackgroundBackground The American Joint Committee on Cancer and a NCI panel

recommended that at least 12 lymph nodes be examined in colon cancer patients to confirm the absence of nodal involvement by tumor.

Recent PCR numbers show that more than 60% of patients do not have the recommended 12+ nodes examined.

Screenings for colon cancer are recommended to become routine for adults age 50 or older; however, PCR numbers show that 6% of colon cancer cases leading to surgery were in patients under the age of 50.

Studies have shown that an increased number of lymph nodes examined have led to an increased survival rate, especially in earlier staged cancer.


30

PAC3: QuestionsPAC3: Questions How many lymph nodes are really needed,

and what is the cut-off? Who should decide how many nodes to

examine, the surgeon or the pathologist? Are patients being staged properly? Does the location of the cancer in the

colon have an effect? Does age, race, or sex play a role in how

many nodes should be examined?


31

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Number of Lymph Nodes Examined

Per

cent

of C

olon

Can

cer

Cas

es W

ithL

ymph

Nod

es F

ound

Pos

itive

Percent of Colon Cancer Cases With Lymph Nodes Found PositiveBy Number of Lymph Nodes Examined (Stage 0, I, II, and III),

With Trend Line, Pennsylvania (2004 - 2005)


32

Elk

York

Centre

Berks

Lycoming

Bedford

Butler

Somerset

Pike

Clinton

Clearfield

Luzerne

Fayette

Indiana

Lancaster

Bucks

Blair

Chester

Perry

Franklin

Venango

Schuylkill

Greene

Clarion

Monroe

Cambria

Huntingdon

Allegheny

Washington

Adams

Jefferson

Fulton

Dauphin

Beaver

Armstrong

Montgomery

Lawrence

Tioga

Erie

PotterBradfordMcKeanWarren

Wayne

Crawford

Mercer

Westmoreland

Forest

Susquehanna

Mifflin

Sullivan

Juniata

Columbia

Union

Carbon

LehighSnyder

Cumberland

Cameron

Wyoming

Lebanon

Lackawanna

Northumberland

Northampton

Delaware

Montour

Philadelphia

Percent Staging* of Colon Cancer Cases, By CountyWhere Lymph Nodes Were Examined Following Surgery


SOURCE: Pennsylvania Department of Health, Bureau of Health Statistics and Research, Pennsylvania Cancer Registry, October, 2007

* AJCC Staging Definition

We can also examine stage comparisons by county, albeit

some counties have very small overall numbers


33

Elk1828

York112266

Centre1651

Berks142372

Lycoming4683

Bedford1628

Butler75136

Clearfield4468

Clinton1017

Pike922

Somerset3461

Luzerne142316

Indiana3452

Fayette88130

Lancaster179330

Blair70121

Chester120280

Mercer6295

Perry1830

Franklin5294

Bucks205404

Cambria79159

Clarion314

Schuylkill85129

Monroe4390

Huntingdon2030

Venango3046

Greene2229

Westmoreland216392

Allegheny6011087

Washington135190

Adams5169

Jefferson2743

Dauphin110171

Fulton56

Armstrong3765

Beaver63171

Columbia2845

Carbon2648

Union1826

Cumberland59104

Snyder1830

Lebanon4387

Lawrence5475

Tioga1433

Erie80164

Potter45

Bradford3045

Warren1828

McKean2138

Crawford2955

Wayne2948

Forest24

Susquehanna1940

Mifflin3446

Sullivan14

Juniata1316

Lehigh103227

Cameron13

Wyoming1526

Montgomery247521

Lackawanna131234

Northumberland4468

Northampton93222

Delaware217457

Montour1330

Philadelphia5161029

Percent of Colon Cancer Cases With Less Than 12 Nodes ExaminedPennsylvania Cancer Registry Data (2004 - 2005)

Percent

00.0% - 35% 35.1% - 45% 45.1% - 55% 55.1% - 65% 65.1% - 75% 75.1% - 100%

NOTE: The top number under the county name represents the number of stage 0, I, II, and III (AJCC Staging definition) colon cancer cases where less than 12 lymph nodes were examined. The bottom number represents the total number of colon cancer cases with lymph nodes being examined by a pathologist. The color shading and percentages are based on the ratio of the two numbers in each county.


34

TiogaPotter

Pike

Clinton

Warren

Perry

Elk1118

Clarion

Huntingdon

York54140

Erie60

107

Forest

Centre1132

Berks54179

Sullivan

Juniata

Lycoming2245

Union

Bradford1725

Bedford1118

Butler4075

Somerset1938

Clearfield2842

Snyder

McKean1117

Cameron

Luzerne61157

Wayne2031

Crawford1731

Fayette4871

Indiana2028

Lancaster95181

Bucks103229

Blair4063

Chester66177

Mercer3248

Franklin3259

Venango1726

Schuylkill3862

Greene1319

Monroe2956

Cambria3476

Allegheny335619

Westmoreland104215Washington

6799

Adams2736

Jefferson1120

Susquehanna1223

Dauphin5487

Beaver2584

Armstrong2237

Wyoming1018

Lawrence3752

Fulton

Mifflin2532

Columbia1830 Carbon

1021

Lehigh54

133

Cumberland3658

Lebanon2551

Montgomery127276

Montour

Lackawanna69126

Northumberland2538

Northampton36124

Delaware141282

Philadelphia261554

Percent of Stage I And Stage II Colon Cancer CasesWith Less Than 12 Lymph Nodes Cumulatively Examined


Percent

0 - 40.0 40.1 - 55.0 55.1 - 65.0 65.1 - 100 Statistically Unreliable - Less Than 10 Cases

SOURCE: Pennsylvania Department of Health, Bureau of Health Statistics and Research, Pennsylvania Cancer Registry; October, 2007

NOTES: The top number under the county name is the number of stage I and stage II (AJCC Staging definition) colon cancer cases where less than 12 lymph nodes were examined following surgery. The bottom number is the total number of stage I and stage II colon cancer cases with lymph nodes being examined by a pathologist following surgery. The percentages are based on the ratio of the two numbers in each county where there were at least 10 cases with less than 12 lymph nodes being examined following surgery. County names/numbers that appear in red indicate significantly higher rates than the PA rate. Blue county names/numbers indicate significantly lower rates.


35

Elk

Centre

BedfordSomerset

Pike

Clinton

Indiana

Perry

Greene

Clarion

Huntingdon

Jefferson

York3090

Erie2761

Fulton

Sullivan

Juniata

Lycoming1636

Columbia

UnionCarbon

Bradford1522

Snyder

Luzerne2592

Crawford1020

Fayette2545

Lancaster48108

Chester37111

Franklin2042

Venango1320

Westmoreland50129

Washington3250

Adams1017

TiogaPotter

McKeanWarren

Wayne

Forest

Susquehanna

Berks2098

Butler1943

Clearfield2029

Cameron

Wyoming

Bucks55135

Blair2440

Mercer2236

Schuylkill1837

Monroe1533

Cambria1446

Allegheny177378

Dauphin2648

Beaver1448

Armstrong1425

Mifflin1016

Lehigh2270

Cumberland1631

Lebanon1031

Montgomery69

177

Lawrence2031

Montour

Lackawanna3671

Northumberland1425

Northampton2082

Delaware77

174

Philadelphia134328

Percent of Stage I And Stage II Right* Colon Cancer CasesWith Less Than 12 Lymph Nodes Cumulatively Examined


Percent



NOTES: The top number under the county name is the number of stage I and stage II (AJCC Staging definition) right colon cancer cases where less than 12 lymph nodes were examined following surgery. The bottom number is the total number of right colon cancer cases with lymph nodes being examined by a pathologist following surgery. The percentages are based on the ratio of the two numbers in each county where there were at least 10 cases with less than 12 lymph nodes being examined following surgery. County names/numbers that appear in red indicate significantly higher rates than the PA rate. Blue county names/numbers indicate significantly lower rates.

* Right colon cancer refers to ICD-O-3 sites C18.0 - C18.4


36

Elk

Centre

Lycoming

BedfordSomerset

Pike

Clinton

Clearfield

Perry

MercerVenango

Greene

Clarion

Huntingdon

Jefferson

York2449

Erie3243

Fulton

Armstrong

Sullivan

Juniata

Columbia

UnionCarbon

Snyder

Luzerne3463

Wayne1113

Fayette2123

Lancaster4670

Chester2964

Franklin1116

Westmoreland5485

Washington3546

Adams1618

TiogaPotter

BradfordMcKeanWarren

Crawford

Forest

Susquehanna

Berks3174

Butler2029

Cameron

Wyoming

Indiana1214

Bucks4588

Blair1522

Schuylkill1924

Monroe1322

Cambria1929

Allegheny144222

Dauphin2736

Beaver1135

Mifflin1516

Lehigh3059

Cumberland2027

Lebanon1217

Montgomery5693

Lawrence1619

Montour

Lackawanna3354

Northumberland1113

Northampton1640

Delaware61

103

Philadelphia121210

Percent of Stage I And Stage II Left* Colon Cancer CasesWith Less Than 12 Lymph Nodes Cumulatively Examined


Percent



NOTES: The top number under the county name is the number of stage I and stage II (AJCC Staging definition) left colon cancer cases where less than 12 lymph nodes were examined following surgery. The bottom number is the total number of left colon cancer cases with lymph nodes being examined by a pathologist following surgery. The percentages are based on the ratio of the two numbers in each county where there were at least 10 cases with less than 12 lymph nodes being examined following surgery. County names/numbers that appear in red indicate significantly higher rates than the PA rate. Blue county names/numbers indicate significantly lower rates.

* Left colon cancer refers to ICD-O-3 sites C18.5 - C18.7


37

Data Quality ConcernsData Quality Concerns Chemotherapy Admin for Stage III

CS was new effective 2004; AJCC Stage Group derived for these cases – level of review?

Collection of treatment data started in ~2000 for non-ACOS COC hospitals reporting to the PCR, this is the first time they are looking at treatment specific benchmark.

Documentation of chemotherapy administration for many community facilities may be lacking – level of review / follow back?

Documentation of recommendation/administration in any “hospital-based” record is of concern. With chemo being administered in outpatient environments, UPMC has an optimal environment to assist with evaluation.

Regional LN Removal “It is what it is” – a reflection of surgical removal, pathologic

findings and registrar documentation Data evaluation process now underway – UPMC involved

with modeling project PCR staff evaluating how PA registrars document

chemotherapy administration


38

How are we doing? How are we doing? 2006 data2006 dataFacility Col1:

Chemo for Stage III

Col1: PCRAllegheny

County(2004-2005)

Col2: >=12 RLN removed

Col2: PCRAllegheny

County(2004-2005)

Hosp BVery small community based; low socioeconomic area

1/520%

50-75%(% having

chemo admin for Stage III)

2/1216.7%

35-45%(% having 12 or more LN removed)

Hosp PMid sized community based; high socioeconomic area

9/1275%

15/4037.5%

Hosp S1Teaching hospital; mixed SE

66/8479%

122/17171%

Hosp S2small urban facility

3/560%

8/1650%


39

Discussion PointsDiscussion Points Familiarize yourself with the indicators Data Sources

Cancer registry – public health reporting Pathology – synoptics, diagnosis, staging Radiology Pharmacy Labs – screening, recurrence

Issues with standards and measurable criteria


40

ReferencesReferences www.cms.hhs.gov/apps/media/press/release.asp?Counter=1343 http://www.kff.org/insurance/7031/print-sec1.cfm http://outcomes.cancer.gov/survey/test_report http://www.ahrq.gov/qual/nhqr07/Chap2.htm#cancer http://www.qualitymeasures.ahrq.gov/ http://www.qualityforum.org/ www.nccn.org http://www.nccn.org/professionals/physician_gls/f_guidelines.asp http://www.guideline.gov/ www.facs.org/cancer/qualitymeasures.html www.facs.org/cancer/coc/ncdboverview.html www.pac3.org http://www.ncqa.org/ http://www.qipa.org/pa/ http://www.paehi.org/ http://www.prhi.org/

Documents

APIII October 23, 2008 Establishing Indicators for Cancer Care: The Role of the Cancer Registry and Other Oncology Data Sources Presented by: Sharon Winters