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2009 Quality Studies
The Cancer Program, following the PeaceHealth commitment to
transparency, publishes its quality reports each year. Using the same
format, there is a summary with a link to the actual study. To compare
the quality of care at SJH to benchmarks, the Cancer Committee utilizes
National Cancer Center Network (NCCN) treatment guidelines. The NCCN is
an organization of the large academic Cancer Centers in the US and they
have review panels that review the medical literature and make
recommended pathways of care for most cancers and stages.
Pathology and Imaging
Review
Year after year, the Pathology and Imaging Departments document
“better than national” standard for oncology related work. This was also
true in this year’s report.
The national accreditation organization for pathologists, the College
of American Pathologists (CAP), requires that cancer related pathology
reports include specific information. Annually, an audit of compliance
is performed. From May 5th through August 4th, there were 414 pathology
reports generated. Of those, 170 cases were appropriate cases for CAP
review. All 170 cases, 100 percent, met all CAP requirements.
Radiology reviews imaging of cases presented at Tumor Board. The
second review ensures quality, and allows an “overread” benefit for
patients. In 2009, 94% of cases were in agreement from initial read to “overread”.
Previous years have reported a range of agreement from 93-97%.
In 2008, 18,928 mammograms were performed. Fifty-seven cancers were
detected in screening mammograms. This is equivalent to three
cancers/1000 screens. The national rate is three to six cancers/ 1000
screens. In addition, the “call back” rate was eight percent with the
national standard set at less than 10%.
Compliance with Tumor
Board Recommendations for Lung Cancer
In a previous study, only 38% of lung cancer cases were in compliance
with NCCN Guidelines. As part of the initiative to improve this
compliance, an effort was made to ensure most, if not all, cases be
presented at Tumor Board. The number of lung cancer cases presented at
Tumor Board rose from 53% in 2007 to 84% in the second half of 2008.
In the second half of 2008, for those cases presented at Tumor Board
and treated at SJH, 80% were treated according to Tumor Board
recommendations.
These two findings demonstrate a strong improvement, but it is
important to recognize that significant staging and treatment often
occurs prior to Tumor Board presentation.
Detailed report
Melanoma Treatment and
Compliance with Surgical Guidelines
Melanoma is a serious disease in Whatcom County with a much
higher-than-expected incidence.
A review of melanoma treatment as it relates to NCCN Guidelines was
undertaken, specifically looking at appropriate surgical margins as well
as the appropriate use of lymph node evaluation. A review article in
American Journal of Hematology and Oncology was used as a “benchmark”.
For all melanoma patients and in all subgroups of patients, SJH
patients received superior treatment when reviewing for appropriate
surgical margins.
When evaluating the appropriate use of lymph node evaluation, SJH
patients were in compliance far better for lymph node evaluation except
for three patients (at par) and patients with ulcerations.
Because melanoma is significantly more frequent in Whatcom County, it
is reassuring to know that patients here receive better than benchmark
care in two critical areas of melanoma therapy.
Detailed report
Squamous Cell Cancer of
Anal Canal Treatment Guidelines
Anal cancer is an uncommon cancer. The Cancer Committee elected to
look at an uncommon cancer to assess the depth of appropriate cancer
care in the community. The appropriate care for anal cancer was compared
to a “benchmark” study in the American Journal of Hematology and
Oncology. Seventeen percent of SJH patients did not receive the NCCN
recommended care, but 23% of the study patients also did not receive
appropriate care. HIV-positive patients and those patients under 75
definitely had superior care, while those over the age of 75 might have
had less than optimal care.
Overall, for a rare tumor, SJH patients had improved survival as
well, when compared to the national study group.
Detailed report
Treatment Options of
Breast Cancer
There was an article published which suggested that community
hospitals had less optimal care for breast cancer patients when compared
to academic centers. This statement resulted in a comparison between
that articles published results and SJH results. The comparison across a
large number of parameters was complicated by the published study having
a much larger number of patients at higher stage and treated with
mastectomies and axillary dissections. There was a suggestion that not
all patients post lumpectomy were receiving radiation, and that local
patients were not receiving appropriate hormonal and chemotherapy
treatments. However, survival, except for Stage 4 patients was
comparable to academic centers.
At the same time, SJH data was reviewed in comparison with the
Commission on Cancer’s 2006 Practice Profile for state and national
compliance with key measures. SJH noticeably surpassed both state and
national numbers in compliance. This study generated a flurry of
comments (available in hard copy), but in review, all affirmed the
excellent care provided in the community.
Detailed report
SJH Cancer Committee
Clinical Indicators
Surgeries for cancer diagnoses from October 1, 2007 through June 30,
2009 have no measurable increased morbidity or mortality compared to ALL
surgeries performed at SJH utilizing the accepted Surgical Outcome data
compiled by the Quality Assurance Department.
Detailed report
2008 QUALITY STUDIES: The reporting of our quality studies is a
reflection of St. Joseph Cancer Committee’s commitment to quality and
transparency. A summary of the studies are presented below, and linked
to the full report.
MELANOMA
A multi-year increased incidence resulted in an
analysis of melanomas in our community. First off, WA state has a
reported higher incidence of Melanoma than most other States probably
due to greater penetration of the SEER Data bank.
With a larger number of young adults than national numbers in the SJH
registry, this might point to an influence of WWU students who would be
entered as cases into the Registry but not in our population pool.
Also, because the SJH Registry is a community based registry rather
than a hospital registry, patients enter our registry who would not be
reported in the other Hospital based registries that we use for
comparison.
Survival for SJH Melanoma patients are at least as good if not better
than national numbers. Detailed report
OUTMIGRATION
The Cancer Program is now considered a Strategic Priority for SJH.
Over the past year or two, SJH has been tracking patients who leave the
community for care. The number or patients who receive all or part of
their care out of the area has remained steady at about 12% since the
data were first evaluated.
SJH tracks patients who leave the community for care as a way of
assessing availability of local cancer programs and patient
satisfaction. The number of outpatients who receive all or part of their
care out of the area has remained steady at about 12% over the last
several years. Inpatient volumes are lower and the outmigration
statistics are higher. Program development is underway to address the
underlying reasons why some patients seek care outside our area.
As has been previously reported, the inpatient outmigration
statistics appear to be higher, but since Oncology is predominantly
outpatient care, the evaluation is difficult.
Detailed report
STAGE 3 NON SMALL CELL LUNG CANCER
As part of a SJH Process improvement a detailed evaluation of the
work up and treatment of Stage 3 Lung Cancer was undertaken. Survival
for Stage 3 patients was on par with national numbers.
However, using NCCN recommendations, staging was often found to be
incomplete prior to initiating treatment, and there was a marked
discrepancy in treatment compared to NCCN Guidelines. This very well may
be due to lack of documentation, but chemotherapy was not reported as
being delivered or even offered according to recommendations.
Based on this study, a set of recommendations have been proposed to
the Lung Cancer Working Group for improvement.
Detailed report
PATHOLOGY AND RADIOLOGY ANNUAL REPORTS
Annually Radiology and Pathology report on the accuracy of Oncology
related diagnoses. In 2007, as in all previous years, the accuracy rates
of diagnosis remain exemplary and at or exceeding national expectations.
Pathology detailed report
and Radiology detailed report
2007 QUALITY STUDIES
CHEMOTHERAPY
The Chemotherapy study was performed to ensure that inpatient
chemotherapy has remained safe even though most chemotherapy is given in
the outpatient setting. The study documented that in-patient
chemotherapy remains extremely safe and error free.
CT GUIDED NEEDLE BIOPSIES OF LUNG NODULES
The CT Lung Biopsy reports that our accuracy and the safety of needle
biopsies in on par with other reporting institutions, even nationally
recognized Cancer Centers. This is attributed to our Radiologist
performing core needle biopsies with a Pathologist present.
Detailed report
ELECTRONIC QUALITY IMPROVEMENT (e-QuIP) FOR BREAST CANCER
The Breast Cancer document was also an ACOS study and CMS indicator.
Its purpose was to assure that Breast cancer patients are at least
offered appropriate postoperative radiation, hormones or chemotherapy.
This study documented that it is often difficult to obtain that
information since some of the care is delivered out of the Hospital
setting. However, once errors in data were corrected, it appears that we
were well within standards at least in postoperative consults being
obtained. Detailed report
LUNG CANCER TIMEFRAME
The Lung Cancer Timeframes study looked at the time between
presenting symptom to the time of diagnosis, and also the time from
diagnosis to treatment. There were no benchmark data to compare to. It
appears that our times were lengthy, and cooperative efforts are being
made to improve this possible issue. The study did document that stage
by stage survival of our Lung Cancer patients are at least equal to the
National survival statistics.
Detailed report
LYMPH NODE COUNTS FROM COLON CANCER RESECTIONS
The Colon cancer report was performed in tandem with the ACOS and is
also one of the CMS Medicare Quality Indicators. The report indicates
that we were falling short of evaluating adequate numbers of lymph nodes
at the time of Surgery. Subsequent Process Improvement by the Pathology
Department has resulted in nearly 100% compliance with the standard as
of Summer 2007. Detailed report
OUTMIGRATION STUDY - PART 2
The Outmigration study documented that in 2005 about 11.6% of all cancer
related activates were performed out of Whatcom County in patients who
had some or all of their care here. About 5.2% of patients received all
of their care out of area. In 2006, this outmigration increased for
surgery but essentially stayed the same for other therapies. The
Hospital Governing Board has committed to a program that will enhance
the patient's care experience.
Detailed report
PATHOLOGY
The Pathology Report assures us that key indicators in Pathology
remain of the highest quality. Accuracy of diagnosis by over reads and
outside confirmation remains exemplary. There was also well over 90%
compliance with the proper cancer reporting system.
Detailed report
RADIOLOGY
The Radiology report reported on the excellent quality of mammograms
and the accuracy of Radiologist impressions based on Tumor Board
over-reads. Detailed report
2006 QUALITY STUDIES
ENDOMETRIAL CANCER:
Because of national recommendations that all Endometrial Cancer
patients be referred to GYN Oncologists for surgery for Endometrial
Cancer, we assessed the local outcomes of patients treated in Whatcom
County for Stage 1 cancer. We had superior 5 year survival compared to
national numbers, and our care (surgery and adjuvant treatments) was
within NCCN* guidelines for the vast majority of our patients. Referral
to GYN Oncologists would have had little impact in survival of our
patients. Detailed
report
GASTRO-ESOPHAGEAL CANCERS:
According to NCCN* Guidelines, 87% of patients received recommended
care. However, our community had less patients receiving combined Rad/Chemo
than NCCN recommendations. This can be explained by patient choice and
by advanced age of those patients.
This was our first NCCN* comparison study to look at Staging. During the
study period we had less patients receiving trans-esophageal ultrasound
and PET scans than recommended. TES is not available in this community,
but PET scans are increasingly available so we expect closer compliance
in the future. Detailed
report
MULTIPLE MYELOMA:
A review of a three year period demonstrated that 100% of Myeloma
patients treated locally were treated in compliance with NCCN*
guidelines. The 5-year survival was equivalent to national data.
Detailed report
ONCOLOGY OUTMIGRATION:
There was concern that there was an increase in the number of local
patient who left the community for oncology care. This concern was based
on an increased % of inpatient admissions occurring out of our area. A
5-year review indicated that there was no increase in patients receiving
diagnosis or treatment for all of their care out of area. This number
has run at round 10% for the past 5 years. A more detailed report is
forthcoming, but it appears that for patients who receive all or part of
their care locally, the number of patient “activities” out of area is
less than 5%.
Detailed report
ANNUAL PATHOLOGY REVIEW:
90% of patients are staged on the Pathology Report. There was a 100%
agreement between initial and “quality review” for all Tumor Board
cases. There was 100% agreement with the locally made diagnosis and a
secondary “outside” review. These findings document the superior quality
of Pathology in local Oncology care.
* - NCCN is a consortium of the major Cancer Centers in North
America. They have “consensus panels” which have developed
recommendations of care for most cancers using evidence-based medicine.
A Community Hospital would not expect to reach 100% compliance with NCCN
recommendations since those patients who are seen at a Cancer Center are
motivated to follow the Center’s recommendations and are usually healthy
enough to have to recommended treatment.
2005 QUALITY STUDIES
In the past year 8 quality studies were performed and reviewed by the Cancer Committee. In summary, they present a glimpse of the level of quality care provided in this community.
One of the Studies performed this year was recommended by the American College of Surgeons, and 4 of the studies were NCCN comparisons.
The NCCN is an organization of the leading Comprehensive Cancer Centers in the US. They had formed “consensus panels” on the management of specific cancers based on “levels of evidence”. Our ambitious goal was to have 75% of our patients meet NCCN Consensus Panel recommendations. Since patients who seek care at a NCCN facility are looking for aggressive “Mecca” care, and are in good enough health to seek it, it is not expected that a community center would be able to reach 100% compliance with their recommendations.
Colon Cancer
This ACOS driven report’s intent was to evaluate whether adjuvant chemotherapy was provided to Stage III colon Cancer. We had more patients receiving the appropriate therapy than our peers and the regional hospitals.
We also learned that we are now doing a better job in getting accurate data with the Registrar traveling to the Medical Oncology office.
For more details, see report.
Malignant Melanoma
We have a large number of Malignant Melanomas diagnosed each year. We attribute this to receiving information from all the non-hospital pathology reports. For example in 2001 only 13 cases were hospital cases and 66 were non-hospital cases.
In addition we assessed if our practice pattern was in line with NCCN for Clark Level 3-4 Melanoma. Because there is no NCCN predetermined adjuvant therapy, all our patients met criteria in that regard. In our study period, 71/72 patients (98.6%) had appropriate excision margins.
For more details, see
report.
Stage III Non-Small Cell Lung Cancer
The management of Non-Small Cell Lung CA has recently incorporated combined chemotherapy and radiation as a standard of care. In 2003 only 50% of our patients were treated within NCCN Guidelines. Of the non-NCCN patients, all of them did not receive the planned chemotherapy. This group of patients had an average age of 73 while the NCCN patients had an average age of 65. All the literature supports withholding concurrent rad/chemo in elderly and poor performance patients. 70% of the non-NCCN patients did not receive NCCN therapy because of “health reasons” and 30% refused the NCCN therapy.
For more details, see
report.
Stage T2N1 Breast Cancer
This stage of Breast Cancer may require a combination of surgery, chemotherapy, hormone therapy and radiation. To assess how our patients were treated, we compared our results to the national pattern of care as determined by NCCN. 73% of patients had recommended care. The majority of these patients did not receive the recommended chemotherapy. Of those, ¾ patients refused what was recommended.
For more details,
see
report.
Pancreas Cancer Treatment
Pancreas Cancer is a highly fatal disease often presenting with advanced cancer. 73% of patients were treated according to the NCCN Guidelines. Of the 6 patients not meeting criteria, 3 of these fell out because they did not have a biopsy because their medical condition was too poor for intervention. In a community setting, a tissue diagnosis is not necessary if no treatment will be given. However our survival data is poor and require further monitoring.
For more details, see
report.
Prostate Cancer Volume and Biopsy
This report was generated by an anecdotal report of minimal cancer seen at biopsy resulting in no cancer seen at Prostatectomy. It looked to see if there were criteria of cancer found at biopsy, which resulted in insignificant cancer. There were multiple definitions of “insignificant cancer” in the literature. Suffice it to say; at least for patients with PSAs over 4.0, even a single core with 1 mm of cancer found could result in a “significant cancer” found at surgery.
In addition the study revealed that 50% more patients in our community were treated with surgery than nationally, and about half the national number were treated with radiation. Only 20% of patients who had surgery had a Radiation Oncology consult before surgery.
For more details, see report.
Radiation Therapy Morbidity
Radiation Therapy can cause acute, or chronic side effects. When a LastWord record lists a radiation complication, it is important to review if the diagnosis is correct and if there could be a better way of delivering radiation in the future. On review, there were no treatment errors, and the side effects listed were the standard expected side effects from curative therapy. This review will be continued on a semi-annual basis.
For more details,
see report.
Post Lumpectomy Radiation
As part of a business plan to explore mammosite HDR treatment, a study of the use of what is the “national standard of care”, whole breast radiation post lumpectomy, was performed. In 2004 the % of patients who received whole breast radiation after lumpectomy was 69%. Among Surgeons, the rate ranged from 100% to 60%. Of those not treated with Radiation at St. Joseph, 2 received their treatment in Seattle, most likely receiving “partial Breast Radiation” which is now the subject of a RTOG Clinical Trial that St. Joseph will participate in.
For more details, see report.
Radiology and pathology department quality studies
Radiology reported that their tumor board driven over read for diagnostic accuracy was 96.2 percent. Pathology reports that their accuracy on over reads for inhouse and outside referral showed no systematic quality problems.
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