Download Slide 1

Driving Improvement in Oncofertility
Shelby Darland, RN, MSN, CPHQ, Jennifer Eichmeyer, MS, CGC, Kelli Christiaens, RN, Kallie Penchansky, MHS,
Michele Betts, LCSW, Dan Zuckerman, M.D., and Thomas M. Beck, M.D.
St. Luke’s Mountain States Tumor Institute, Boise, ID
Background: In 2006 the American Society of Clinical Oncology (ASCO) recommended that oncologists discuss
infertility as a result of cancer treatment with patients of reproductive age and provide referrals to specialists as
needed. Despite these guidelines the majority of cancer centers are not in compliance. Mountain States Tumor
Institute (MSTI) piloted a process to improve quality of oncofertility preservation (OP) through identification,
documentation, and referral to reproductive specialists. Methods: A physician survey in 2010 indicated that
perceived barriers to OP discussion were a lack of accessible materials as well as oversight on the part of the
provider. Random chart audits of the Quality Oncology Practice Initiative (QOPI) measures (infertility risks discussed
prior to treatment and fertility preservation options discussed/referral to a specialist) occurred biannually at that time.
To increase awareness of the data chart audits and reporting shifted to quarterly and included all patients that met
OP criteria. Additionally, a committee was formed in 2011 to develop patient/provider packets, collaborate with the
local reproductive specialists, and create an OP process. The committee established an OP algorithm involving
support staff to flag patients of reproductive age at initial medical oncology consultation and utilizing genetic
counselors (GC) and social workers (SW) to expedite and facilitate referrals to reproductive specialists. GC/SW
were chosen due to sensitivity with psychosocial issues and to share the additional workload. The OP program was
launched in October of 2012. Results: Baseline assessment in 2009 revealed MSTI was compliant 6% and 6%. Six
months after program initiation the OP measures improved to 47% and 45% respectively. Notably March and April
2013 showed dramatic improvements with 100% and 75% compliance for both OP measures. Conclusions: It is
well known that OP has been a challenge for many cancer centers. This multipronged approach is an example of a
novel process implementation that demonstrated significant improvement with the QOPI oncofertility measures.
Continued work is needed on improving physician documentation and consistency of OP patient identification.
New Patient Representative (NPR) assesses “Is patient
female age 18-40, male 18-50 with a cancer diagnosis?”
NO
Nothing further is needed and the Quality
checklist (QCL) reminder is deleted
YES, NPR flag Baseline Health History (BHH) with yellow dot
sticker
MD assesses “Does patient require treatment that would
affect fertility?”
NO
MD document patient does not require
treatment or is not at risk for infertility
•ASCO recommended that infertility as a result of cancer treatment should be discussed
•Several studies have demonstrated that patients place high value on fertility discussions
•QOPI includes two OP measures 1) infertility risks discussed prior to treatment and 2)
fertility preservation options discussed/referral to a specialist
•Despite these guidelines the majority of cancer centers are not in compliance
•To improve measures and quality MSTI piloted a process that included identification,
documentation, and referral to reproductive specialists
Methods
•In incremental stepwise approach over several years included:
•A MSTI physician survey in 2010 suggesting perceived barriers to OP discussion were
1) a lack of accessible materials and 2) lack of oversight on the part of the provider
•A shifting of chart audits and reporting to quarterly in 2011 to increase awareness of
the data, and in 2012 from quarterly to monthly
•Committee formation in 2011 to develop patient/provider packets (Figure 3),
collaborate with the local reproductive specialists, and create an OP process (Figure 1)
which launched in October 2012
•Infertility Risks Discussed improved from 6.3% (n=16) in 2009 to 47% (n=64) in July 2012June 2013, and most notably to 67% (n=15) in July-August 2013. (Table 1)
•Fertility Preservation Options Discussed improved from 6.3% (n=16) in 2009 to 45% (n=64)
in July 2012-June 2013, and most notably to 64% (n=14) in July-August 2013. (Table 1)
Oncofertility Results
YES
MD assesses “Does patient want children in the future?”
NO
67% 64%
70%
MD document patient does not desire
children and is aware of risk of infertility
YES
38%
RN/MD completes referral for Oncofertility consult
by:
Order on referrals tab
Complete the referral document (Figure 2)
Document/dictate the fertility risk
assessment, discussion of options, and
referral
Secretary/RN/MD sends “Oncofertility Consult”
QCL to Oncofertility location
31%
40%
MD informs patient of risk and MD/RN provides
oncofertility information packet to patient. Is patient
interested in further information or referral?
NO
MD document patient does not desire
further information or Oncofertility
consultation
Social Work/Genetic Counseling to:
Monitor the Oncofertility QCL
Confer with Primary RN/MD
Follow-up with patient.
Is patient interested in referral to Idaho
Center for Reproductive Medicine (ICRM)?
YES
NO,
SW/GC to
document pt
does not
desire referral
SW/GC will access patient authorization to
disclose PHI, coordinate faxing of referral form &
medical records to ICRM with HIM, and document
Figure 2. St. Luke’s MSTI Referral Form
Figure 3. Fertile Hope Provider & Patient
Resources
47%
45%
60%
50%
YES
Background
Results
Percent Compliance
Abstract
Figure 1. St. Luke’s MSTI OP algorithm
20%
10%
25%
19%
20%
30%
6% 6%
7%
0%
Fall
2009
Fall
2010
Spring
2011
Infertility Risks Discussed
Jul 11Jun 12
Jul 12Jun 13
Jul 13Aug 13
Fertility Preservation Options Discussed
Table 1
Conclusions
•Because OP issues are challenging, cancer centers may need to consider several methods
to maximize resources including physician education, written materials, a reminder system,
and frequent auditing
•Specialties such as GC and SW can be utilized as they have training to address the
sensitive needs of OP patients and help facilitate the referrals
•Continued work is needed on improving physician documentation and consistency of OP
patient identification
•This multipronged approach is an example of a novel process implementation that
demonstrated improvement with QOPI Oncofertility measures
References
•The Quality Oncology Practice Initiative (QOPII®) is a physician-led quality improvement program of the American Society of Clinical Oncology for hematology-oncology practices
•Lee, S.J., Schover, L.R., Partridge, A.H., Patrizio, P., Wallace, W.H., Hagerty, K., Beck, L.N., Brennan, L.V., Oktay, K. (2006). American Society of Clinical Oncology
recommendations on fertility preservation in cancer patients. Journal of Clinical Oncology; 24 (18): 2917-2931.
•Fertile Hope (2012) Cancer & Fertility: Fast Facts for Oncology Professionals and Patient Education Booklet, Risk for Amenorrhea, Risk of Azoospermia, Female and Male
Reproductive Options. Retrieved from www.fertilehope.org.