Download Powerpoint - Association for Pathology Informatics

Establishing Indicators
for Cancer Care:
The Role of the Cancer Registry
and Other Oncology Data Sources
Presented by:
Sharon Winters
Director, Registry Information Services
UPMC Cancer Centers
[email protected]
(412) 647-6390
APIII
October 23, 2008
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

APIII
October 23, 2008
2
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
APIII
3
October 23, 2008
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
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October 23, 2008
4
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/
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October 23, 2008
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http://www.iom.edu/
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
APIII
October 23, 2008
6
The “Cost” of Health Care
Increasing Overall NHE 1960-2006
U.S. National Healthcare Expenditures
http://www.cms.hhs.gov/NationalHealthExpendData/
2.
3
$1 0
,9
73
.3
$2 0
,1
0
5.
50
$2,500.00
,2
.5
$1
90
,1
$1
25
,1
$1
68
,0
$1
16
,0
.2
$1
62
$9
.6
12
$9
49
0
.6
0
81
$7
.0
$7
14
$8
$1,000.00
.0
0
0
0
.5
0
.8
0
.3
0
in Billions
0
65
$1,500.00
.6
$1 0
,3
53
.
6
$1 0
,4
69
.6
$1 0
,6
0
3.
4
$1 0
,7
32
.4
$1 0
,8
5
$2,000.00
4.
$7
$2
7.
50
90
$2
53
.4
0
$500.00
$0.00
1960 1970 1980 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
APIII
October 23, 2008
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The “Cost” of Health Care
Percent by Type of Service 1994 vs. 2004
U.S. National Healthcare Expenditures
% by Type of Service
http://www.cms.hhs.gov/NationalHealthExpendData/
1994
35
2004
34.1
30.4
30
25
21.8
21.3
20
16.9
15.7
%
13
15
12.9
10
10
7
5.6
6.1
2.7
5
2.3
0
Hospital Care
Physician/Clinical
Services
Prescription Drugs
Nursing Home Care
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October 23, 2008
Home Health Care
Other Personal Care
Other Health
Spending
8
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
APIII
October 23, 2008
9
The Organizations
…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)









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


Agency for Healthcare Research and Quality (AHRQ)
Quality Insights of Pennsylvania
Pennsylvania Cancer Control Consortium (PAC3)
Pittsburgh Regional Health Initiative (PRHI)
Disease-specific organizations
….and many others
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October 23, 2008
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Reportable Cases by Insurance Type
2000-2007
UPMC Hospital Based Cancer Cases
by Insurance Type
CY 2000-2007
86% of cancer care is covered by Medicare/Medicaid and Private Insurance
Other Insurance, NOS
or Unknown Status
13%
Medicare
36%
Military/VA,
Indian/Public Health
Service, Tricare
0%
Private
48%
Medicaid
2%
Not Insured, Self Pay
1%
Source: UPMC Network Cancer Registry
Via Hospital billing systems
APIII
October 23, 2008
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Cancer Care Indicators and P4P
“Recent” History

1999: Institute of Medicine report “Ensuring Quality
Cancer Care”



In response, NCI teams up with several agencies to
contract with the National Quality Forum (NQF)





Revealed lack of info on the quality of cancer care
Recommended development of better measures and data to
support evaluation
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
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October 23, 2008
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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
APIII
October 23, 2008
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Pay for Performance Measures
Conditions 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/
APIII
October 23, 2008
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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)
APIII
October 23, 2008
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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
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October 23, 2008
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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 >= 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
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October 23, 2008
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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
APIII
October 23, 2008
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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 >=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
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October 23, 2008
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
APIII
October 23, 2008
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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, howeverAPIII
only facility-specific data is available
21
October 23, 2008
How are we doing?
(2003-2005 data)
Indicator Summary
Hospital 1
Hospital 2
Br1: rad for BCS
939/961
97.7%
165/177
93.2%
Br2: chemo for HR(-)
222/223
99.6%
29/30
96.7%
Br3: hormone for HR(+)
964/989
97.5%
160/168
95.2%
Col1: chemo for Stage III
(CP3R)
NA
99/125
79.2%
Col2: >=12 RLN removed
NA
210/323
65.0%
Rectal: rad for T4, stage
III
NA
62/63
98.4%
Source: eQuIPs and CP3R
APIII
October 23, 2008
Hospital 2 eQuIPs data updated 01/22/08; Hospital 1 updated 01/31/08
22
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……

APIII
October 23, 2008
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Pennsylvania Cancer Control
Consortium (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
APIII
October 23, 2008
24
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.
APIII
October 23, 2008
25
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 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.
APIII
October 23, 2008
26
Percent of All Stage III Colorectal Cancer Patients Who
Did Not Receive Chemotherapy (RX Chemo Code = '00')
PA Cancer Registry Data 2004-2005
60.0%
NQF measure
cut off
at age 80
50.0%
Percent
40.0%
53.6%
31.5%
30.0%
18.4%
20.0%
12.9%
9.4%
10.0%
0.0%
Age 0 to 49
Age 50 to 64
31 / 331
116 / 900
RX Chemo Codes Cases
99
6
88
12
87
2
86
4
85
1
82
1
03
202
02
46
01
26
00
31
Age 65 to 74
173 / 939
RX Chemo Codes Cases
RX Chemo Codes Cases
99
30
99
48
88
43
88
50
87
9
87
24
86
5
86
10
85
2
85
3
82
2
82
6
03
457
03
357
APIII 02
02
177
211
October
23, 2008
01
59
01
57
00
116
00
173
Age 75 to 84
Age 85 and older
347 / 1,100
203 / 379
RX Chemo Codes Cases
99
71
88
55
87
50
86
9
85
9
82
48
03
216
02
261
01
34
00
347
RX Chemo Codes Cases
99
37
88
18
87
17
86
2
85
4
82
39
03
11
27 43
02
01
5
00
203
Percent of Stage III Colorectal Cancer Cases Where Patients Did Not Receive Chemotherapy
With Hospitals With Chemotherapy Services
Pennsylvania Cancer Registry Data (2004 - 2005)
vv
®
®
®
®v
v
Erie
®
v
Warren
Crawford
®
v
v
®
v
®
v
®
McKean
Potter
v
®
v
®
Tioga
®
v
v
®
v
®
Susquehanna
Bradford
®
v
Wyoming
Forest
v
®
v
®
v
®
Mercer
Clarion
®
v
v
®
v
®
Beaver
v
®
v
®
Butler
®
v
v
®
Armstrong
®
v
Jefferson
®
v
Indiana
®
v
® ®
v
v
® ®
Allegheny
vv
®
v v®
®
®
v
v ®
®
®v
v
® v
v
®
v
®
v
®
v
®
v
v
®
v
®
v
®
Clearfield
Centre
v
®
v
®
Blair
v
®
Huntingdon
v
®
®
v
Cumberland
Washington
v
®
Greene
Somerset
v
®
®
v
Bedford
Fulton
v
®
Franklin
Fayette
v
®
Luzerne
®
v
® Carbon
v
v
®
Snyder
Perry
®
v
Schuylkill
Dauphin Lebanon
v®
®
v
v
®
v
®
®
v
®
vv
®
York
Adams
®
v
®
v
®
v
®
v
®Lackawanna
v
Pike
Union
Northumberland
Mifflin
®
v
Juniata
Wayne
®
v
®®
®
vv
®v
v
®
v
MontourColumbia
v
®
v
®
v
®
Cambria
Westmoreland
v
®
v
®
v
®
v
®
v
®
Lycoming
Clinton
v
®
Lawrence
Sullivan
Elk
Venango
v
®
Cameron
v
®
v
®®
v
Monroe
®
v
Northampton
®
v
v
®
Lehigh ®
v
v ®
®
v
®Bucks
v
®
v
v
®
v
®
v
®
v
v ®
®
Montgomery
®
v
®
v
®v
v
®
v
v
®
®
® v
v
v
®® ®
® v
v
®
v
®®
v
v
®
v
®
vv
®
v
®
®v
v
®
v
®
v
®
v
®®v
®Philadelphia
v
®
Chester
vv
®
v
®
®
Delawarev
v
®
Berks
v
v®
®
v
®
Lancaster
v
®
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 APIII
III colorectal cancer cases where there is no valid reason why chemotherapy was28
not
October
administered OR where chemo WAS administered (chemo codes
= '00',23,
'01',2008
'02', or '03').
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.
APIII
October 23, 2008
29
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?

APIII
October 23, 2008
30
Percent of Colon Cancer Cases With Lymph Nodes Found Positive
By Number of Lymph Nodes Examined (Stage 0, I, II, and III),
With Trend Line, Pennsylvania (2004 - 2005)
Percent of Colon Cancer Cases With
Lymph Nodes Found Positive
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
Number of Lymph Nodes Examined
APIII
October 23, 2008
31
30
Percent Staging* of Colon Cancer Cases, By County
Where Lymph Nodes Were Examined Following Surgery
Pennsylvania Cancer Registry Data (2004 - 2005)
Warren
Erie
Susquehanna
McKean
Bradford
Potter
Wayne
Crawford
Tioga
Forest
Wyoming
Elk
Mercer
Venango
Cameron
Clarion
Lackawanna
Sullivan
Luzerne
Clinton
Lycoming
Jefferson
Pike
Monroe
Montour
Clearfield
Columbia
Union
Butler
Armstrong
Lawrence
Carbon
Northumberland
Centre
Beaver
Northampton
Indiana
Lehigh
Mifflin
Schuylkill
Blair
Cambria
Allegheny
Snyder
Lebanon
Juniata
Westmoreland
Huntingdon
Perry
Bucks
Berks
Dauphin
Cumberland
Montgomery
Washington
Lancaster
Fayette
Chester
Fulton
Greene
Philadelphia
Bedford
Somerset
Franklin
York
Delaware
IV
ge
St
a
ge
II I
II
St
a
ge
I
St
a
ge
St
a
St
a
ge
0
Adams
* AJCC Staging Definition
APIII
October 23, 2008
SOURCE: Pennsylvania Department of Health, Bureau of Health Statistics and Research, Pennsylvania Cancer Registry, October, 2007
We can also examine stage
comparisons by county, albeit
some counties have very
32
small overall numbers
Percent of Colon Cancer Cases With Less Than 12 Nodes Examined
Pennsylvania Cancer Registry Data (2004 - 2005)
Erie
80
164
Warren
18
28
McKean
21
38
Crawford
29
55
Forest
2
4
Venango
30
46
Mercer
62
95
Clarion
3
14
Lawrence
54
75
Cameron
1
3
Elk
18
28
Jefferson
27
43
Clearfield
44
68
Butler
75
136
Centre
16
51
Armstrong
37
65
Beaver
63
171
Snyder
18
30
Indiana
34
52
Allegheny
601
1087
Mifflin
34
46
Cambria
79
159
Blair
70
121
Westmoreland
216
392
Washington
135
190
Greene
22
29
Union
18
26
Fayette
88
130
Somerset
34
61
Northumberland
44
68
Dauphin
110
171
Fulton
5
6
Franklin
52
94
Adams
51
69
Lackawanna
131
234
Luzerne
142
316
Columbia
28
45
Montour
13
30
Monroe
43
90
Carbon
26
48
Schuylkill
85
129
Pike
9
22
Northampton
93
222
Lehigh
103
227
Berks
142
372
Lebanon
43
87
Bucks
205
404
Montgomery
247
521
Cumberland
59
104
Bedford
16
28
Wyoming
15
26
Juniata
13
16
Perry
18
30
Huntingdon
20
30
Wayne
29
48
Sullivan
1
4
Lycoming
46
83
Clinton
10
17
Susquehanna
19
40
Bradford
30
45
Tioga
14
33
Potter
4
5
Lancaster
179
330
York
112
266
Chester
120
280
Delaware
217
457
Philadelphia
516
1029
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
APIII in each county.
October 23, 2008
33
Percent of Stage I And Stage II Colon Cancer Cases
With Less Than 12 Lymph Nodes Cumulatively Examined
Pennsylvania Cancer Registry Data (2004 - 2005)
Erie
60
107
McKean
11
17
Warren
Crawford
17
31
Tioga
Potter
Susquehanna
12
23
Bradford
17
25
Wyoming
10
18
Forest
Mercer
32
48
Lawrence
37
52
Elk
11
18
Venango
17
26
Clarion
Butler
40
75
Beaver
25
84
Cameron
Sullivan
Lycoming
22
45
Clinton
Jefferson
11
20
Clearfield
28
42
Centre
11
32
Armstrong
22
37
Snyder
Indiana
20
28
Allegheny
335
619
Washington
67
99
Greene
13
19
Union
Cambria
34
76
Mifflin
25
32
Blair
40
63
Westmoreland
104
215
Columbia
18
Montour
30
Northumberland
25
38
Perry
Dauphin
54
87
Cumberland
36
58
Fayette
48
71
Somerset
19
38
Fulton
Franklin
32
59
Lackawanna
69
126
Luzerne
61
157
Carbon
10
21
Schuylkill
38
62
Adams
27
36
York
54
140
Lebanon
25
51
Lancaster
95
181
Pike
Monroe
29
56
Northampton
36
124
Lehigh
54
133
Juniata
Huntingdon
Bedford
11
18
Wayne
20
31
Berks
54
179
Bucks
103
229
Montgomery
127
276
Chester
66
177
Delaware
141
282
Philadelphia
261
554
Percent
0 - 40.0
40.1 - 55.0
55.1 - 65.0
65.1 - 100
Statistically Unreliable - Less Than 10 Cases
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.
APIII
October 23, 2008
SOURCE: Pennsylvania Department of Health, Bureau of Health Statistics and Research, Pennsylvania Cancer Registry; October, 2007
34
Percent of Stage I And Stage II Right* Colon Cancer Cases
With Less Than 12 Lymph Nodes Cumulatively Examined
Pennsylvania Cancer Registry Data (2004 - 2005)
Erie
27
61
Warren
McKean
Bradford
15
22
Tioga
Potter
Crawford
10
20
Susquehanna
Wayne
Forest
Wyoming
Venango
13
20
Mercer
22
36
Cameron
Lycoming
16
36
Elk
Sullivan
Pike
Luzerne
25
92
Clinton
Clarion
Lackawanna
36
71
Jefferson
Monroe
15
33
Columbia
Lawrence
20
31
Butler
19
43
Beaver
14
48
Clearfield
20
29
Montour
Carbon
Northumberland
14
Snyder
25
Indiana
Allegheny
177
378
Washington
32
50
Greene
Union
Centre
Armstrong
14
25
Cambria
14
46
Blair
24
40
Perry
Dauphin
26
48
Cumberland
16
31
Somerset
Bedford
Fulton
Franklin
20
42
Schuylkill
18
37
Juniata
Huntingdon
Westmoreland
50
129
Fayette
25
45
Mifflin
10
16
Adams
10
17
York
30
90
Northampton
20
82
Lebanon
10
31
Lancaster
48
108
Lehigh
22
70
Berks
20
98
Bucks
55
135
Montgomery
69
177
Chester
37
111
Delaware
77
174
Philadelphia
134
328
Percent
0 - 40.0
40.1 - 55.0
55.1 - 65.0
65.1 - 100
Statistically Unreliable - Less Than 10 Cases
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
APIII
October 23, 2008
SOURCE: Pennsylvania Department of Health, Bureau of Health Statistics and Research, Pennsylvania Cancer Registry; October, 2007
35
Percent of Stage I And Stage II Left* Colon Cancer Cases
With Less Than 12 Lymph Nodes Cumulatively Examined
Pennsylvania Cancer Registry Data (2004 - 2005)
Erie
32
43
Warren
Susquehanna
McKean
Crawford
Bradford
Tioga
Potter
Wayne
11
13
Forest
Wyoming
Cameron
Elk
Venango
Mercer
Sullivan
Lycoming
Jefferson
Monroe
13
22
Columbia
Lawrence
16
19
Montour
Clearfield
Butler
20
29
Union
Centre
Carbon
Northumberland
11
Snyder
13
Armstrong
Beaver
11
35
Indiana
12
14
Allegheny
144
222
Washington
35
46
Greene
Pike
Luzerne
34
63
Clinton
Clarion
Lackawanna
33
54
Cambria
19
29
Blair
15
22
Perry
Dauphin
27
36
Cumberland
20
27
Somerset
Bedford
Fulton
Franklin
11
16
Schuylkill
19
24
Juniata
Huntingdon
Westmoreland
54
85
Fayette
21
23
Mifflin
15
16
Adams
16
18
York
24
49
Northampton
16
40
Lebanon
12
17
Lancaster
46
70
Lehigh
30
59
Berks
31
74
Bucks
45
88
Montgomery
56
93
Chester
29
64
Delaware
61
103
Philadelphia
121
210
Percent
0 - 40.0
40.1 - 55.0
55.1 - 65.0
65.1 - 100
Statistically Unreliable - Less Than 10 Cases
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
APIII
October 23, 2008
SOURCE: Pennsylvania Department of Health, Bureau of Health Statistics and Research, Pennsylvania Cancer Registry; October, 2007
36
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.



Regional LN Removal


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.
“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
APIII
October 23, 2008
37
How are we doing?
2006 data
Facility
Hosp B
Very small
community based;
low socioeconomic
area
Hosp P
Mid sized community
based; high
socioeconomic area
Hosp S1
Teaching hospital;
mixed SE
Hosp S2
small urban facility
Col1:
Chemo for
Stage III
Col1: PCR
Allegheny
County
(2004-2005)
1/5
20%
9/12
75%
66/84
79%
3/5
60%
Col2:
>=12 RLN removed
Col2: PCR
Allegheny
County
(2004-2005)
2/12
16.7%
50-75%
(% having
chemo admin
for Stage
III)
APIII
October 23, 2008
15/40
37.5%
35-45%
(% having
12 or more
LN removed)
122/171
71%
8/16
50%
38
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
APIII
October 23, 2008
39
References
















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/
APIII
October 23, 2008
40