APIII

1
Establishing Indicators for Cancer CareThe
Role of the Cancer Registry and Other Oncology
Data Sources

• Presented by
• Sharon Winters
• Director, Registry Information Services
• UPMC Cancer Centers
• winterssb_at_upmc.edu
• [phone]

2
Session 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 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 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 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
Whats 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.p
df
7
The Cost of Health CareIncreasing Overall NHE
1960-2006
8
The Cost of Health CarePercent by Type of
Service 1994 vs. 2004
9
Pay for Performance (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 Organizationsor 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

11
Reportable Cases by Insurance Type2000-2007
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 P4P 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 and P4P 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 MeasuresConditions 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 Adopted Indicators
Breast Cancer 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 Adopted Indicators
Breast Cancer 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 Adopted Indicators
Breast Cancer 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 gt 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 Adopted Indicators Colon
Cancer 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 Adopted Indicators Colon
Cancer 2

• At least 12 regional lymph nodes are removed and
  pathologically examined for resected colon
  cancer. Denominator includes
• Age gt18 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 Indicators Rectal 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 Indicators

• 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? (2003-2005 data)
Source eQuIPs and CP3R
Hospital 2 eQuIPs data updated 01/22/08 Hospital
1 updated 01/31/08
23
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 Control Consortium (PAC3)

• In 2001 an unprecedented partnership was
  initiated in Pennsylvania by the Pennsylvania
  Department of Health to develop the
  Commonwealths first-ever comprehensive cancer
  control plan in response to the Centers for
  Disease Control and Preventions 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 Colorectal Cancer 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 Chemotherapy 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 Institutes (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
NQF measure cut off at age 80
203 / 379
173 / 939
347 / 1,100
116 / 900
31 / 331
28
(No Transcript)
29
PAC3 Colon Cancer and Lymph Node Examination
Background

• 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 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
(No Transcript)
32
We can also examine stage comparisons by county,
albeit some counties have very small overall
numbers
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
Data 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? 2006 data
39
Discussion 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
References

• www.cms.hhs.gov/apps/media/press/release.asp?Count
  er1343
• http//www.kff.org/insurance/7031/print-sec1.cfm
• http//outcomes.cancer.gov/survey/test_report
• http//www.ahrq.gov/qual/nhqr07/Chap2.htmcancer
• 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/