CoC-trained

consultants on staff

Toni Hare, RHIT, CTR CoC-trained Consultant

Vice President, CHAMPS Oncology November 27, 2012

Leveraging Your Cancer Registry: A Strategy for Survey Success

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

Traditional: Data Reporting

Past

Current:

Quality Care Measures & Improvement Strategies

Present Future

Future Trends:

Information for Financial Incentives, Regulation and Policy

Healthcare Innovators for Quality of Cancer Care

•Access to up-to-date comprehensive quality care close to home

•Plan, monitor and evaluate programs and services continuously

Healthcare Providers

•Collect and analyze cancer incidence for a specific population or geographic area

•Measures progress in cancer prevention and control

Government and Federal Agencies

•Explore trends in cancer care

•Create regional and state benchmarks for participating hospitals

•Serve as the basis for quality improvement

National Organizations

• Incentivize programs that monitor performance Primary Payers

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

Monitor existing services

Establish population trends and

referral patterns

Apply for grants

Enhance Oncology Services

Market Analysis: Building Oncology

Center

Incidence Primary Cancer Sites

Stratify Primary Sites by Zip Code

and County

Identify physician Referral Patterns

Stratify by Managing Physician

Identify Practice Patterns

Stratify by Medical and Radiation

Oncology

Compare with the State Registry

Data

Enhance Oncology Service Offerings

Monitor Existing Services

Market Analysis: Treatment Trends

Incidence all Cancer Sites

Stratify by Accession Year

Trending Referral Patterns

Stratify by Accession Year &

Class of Case

Identify Practice Patterns

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 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

14 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

36 51 39

26 31

362

313

348

315 321

230 234 210

168 170

0

50

100

150

200

250

300

350

400

2005 2006 2007 2008 2009

DX only

DX & TX

TX Only

-20%

Population Trends & Referral Patterns

Market Analysis: Treatment

Trends

Incidence of Top 5 Cancer

Sites

Stratify by Class of Case

(10-14 & 20-22)

Trending Population

Patterns

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

Stratify by Accession Year

(5 yrs)

Patient Demographics

Stratify by Race, Ethnicity, Insurance

& Stage at DX

Survival Comparison with

NCDB

Stratify by Stage at Dx

Developed Programs from Grant Funding

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

Identify staffing needs

Recruit physicians

Estimate revenue by disease site

Analyze costs and utilization

of ancillary services

Utilization of Ancillary Services

Radiation Therapy

Radiology

Laboratory

Medical Admissions

Inpatient Surgery

Outpatient Surgery

All I II III IV

16.6 2.3 16.3 19.7 22.0

All I II III IV

14.3 14.5 18.1 13.7 14.4

All I II III IV

28.6 25.1 27.6 27.8 43.1

All I II III IV

2.2 1.2 1.8 2.1 2.9

All I II III IV

1.6 1.0 1.1 1.5 2.7

All I II III IV

2.9 1.7 1.2 3.3 6.9

Average Number of visits per patient by stage

Evaluate Clinical Performance

Utilizing Quality

Improvement Methodology

PDCA Plan, Do,

Check, Act

FADE Focus,

Analyze, Develop, Execute

FMEA Failure mode and effects

analysis

Six Sigma

How does your

registry utilize

quality

improvement

methodologies

to evaluate

clinical

performance?

Quality Improvement Activities

• Measure effectiveness of improvement

• Implement the improvement

• Develop and implement potential solution or improvement

• Identify & analyze problem

Plan Do

Check Act

How does your

registry connect

to the quality

process in your

facility?

Registry Study Improves Clinical Care

• Decrease wait time from radiation consult to initial treatment for prostate cancer patients

Study Topic: (patients identified from cancer registry)

• Dx date, Consult date (User Defined field), Date Radiation Tx Started

Analysis: (data captured in cancer registry database)

• Average wait time – 20% above national benchmark Outcome: (quantitative report provided by cancer registry)

• Purchased and installed IMRT

• Additional 1 hour added to RT Clinic schedule Action: Implement solution

• Improvement - 29 days Monitor the effectiveness of action plan implemented

Multiple Cancer Program Accreditations & Certifications

Mastering the

Juggling Act

CoC

NAPBC

TJC

QOPI

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 disease-specific 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

• 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+

Breast

• ACT- Adjuvant chemo w/in 120 days Stage III

• 12 RLN- 12 lymph nodes removed Colon

• ADJ RT- Radiation w/in 180 days Stage III Rectal

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

>50% NAPBC standard 2.3 Cancer Registry

Surgery: Needle biopsy vs open biopsy rate

>74.2% CoC 2008 NAPBC standard 2.9 NQF #0221

Cancer Registry

Med Onc: combo chemo given within 120 days of dx for pt <70 with AJCC T1cN0M0, or stage II or III, ER/PR - (CP3R)

100%

100% for CoC CMS has proposed reporting this quarterly NQF #0559

Cancer Registry

Med Onc: Tamoxifen or AI tx is initiated within 365 days of dx with AJCC T1cN0M0, or stage II or III, ER/PR + (CP3R)

97% 95% CoC NQF #0220 CMS has proposed reporting

Cancer Registry

Rad Onc:Is Rad. Tx administered within 365 days of dx for <70 receiving BCT (C3PR)

98% 95% CoC NQF #0219

Cancer Registry

Surgery: Mastectomy vs. breast conservation surgery rate - ensure stage 0-II are offered BCT

>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

Cancer Registry

Risk adjust morbidity after lobectomy for lung cancer (% of patients undergoing elective lobectomy for lung cancer that have a length of stay > 14 days.)

NQF #0459 (Society for Thoracic Surgeons)

Quality Dept.

Risk adjusted morbidity & mortality for lung resection (specific list of post-op complications such as need for trach, ARDS, PE and more)

NQF #1790 (Society for Thoracic Surgeons)

Quality Dept.

% of lung cancer surgeries with >4 mediastinal lymph node stations dissected

100% NCCN Cancer Registry

% of prophylactic cranial irradiation in limited or extensive stage small cell celllung cancer

100% NCCN Cancer Registry

Survival by stage, compared with NCDB and internally by hospital and system

Compare to the National Cancer Database by hospital, by system

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)

100%

NQF #0223. 100% for CoC CMS has proposed reporting this quarterly

Cancer Registry

Rectal/Rad Onc: Radiation therapy given for stage III rectal CA in pts <80, under 6 mths of DX. (C3PR)

100% CoC C3PR Cancer Registry

Rectal: Endorectal ultrasound or pelvic MRI is performed prior to TX for rectal cancer.

100% NCCN version 3.2012 (colorectal cancer) Cancer Registry

Colorectal Survival 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

Multi-disciplinary Cancer Care

Team

Standard Guidelines

Clinical Practice

Guidelines

Performance Measures

Data Analytics

Thank You!

• Questions? Contact:

– Toni Hare, RHIT, CTR CoC-trained Consultant Vice President CHAMPS Oncology toni.hare@chanet.org 216.255.3716

www.champsoncology.com