APIII October 23, 2008 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 (412)

APIII October 23, 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, 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 October 23, 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

APIII October 23, 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.

APIII October 23, 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

APIII October 23, The “Cost” of Health Care Increasing Overall NHE

APIII October 23, The “Cost” of Health Care Percent by Type of Service 1994 vs. 2004

APIII October 23, 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, 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) 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  ….and many others

APIII October 23, Reportable Cases by Insurance Type % of cancer care is covered by Medicare/Medicaid and Private Insurance Source: UPMC Network Cancer Registry Via Hospital billing systems

APIII October 23, 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

APIII October 23, 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, 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

APIII October 23, 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 = 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, 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 = 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

APIII October 23, NQF, ASCO/NCCN and CoC Adopted Indicators: Breast Cancer #3  Tamoxifen or 3 rd 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

APIII October 23, 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 = 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, 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

APIII October 23, 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, 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 (CP 3 R) – 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

APIII October 23, How are we doing? ( data) Indicator SummaryHospital 1Hospital 2 Br1: rad for BCS939/ % 165/ % Br2: chemo for HR(-)222/ % 29/ % Br3: hormone for HR(+)964/ % 160/ % Col1: chemo for Stage III (CP 3 R) NA99/ % Col2: >=12 RLN removedNA210/ % Rectal: rad for T4, stage III NA62/ % Source: eQuIPs and CP 3 R Hospital 2 eQuIPs data updated 01/22/08; Hospital 1 updated 01/31/08

APIII October 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……

APIII October 23, 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, PAC3: Why Focus On Colorectal Cancer Treatment?  In 2004, colorectal cancer had the 3rd highest number of new cases for men and 3 rd 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, 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, / / / 1, / / 331 NQF measure cut off at age 80

APIII October 23,

APIII October 23, 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, 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,

APIII October 23, We can also examine stage comparisons by county, albeit some counties have very small overall numbers

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APIII October 23, 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

APIII October 23, How are we doing? 2006 data FacilityCol1: Chemo for Stage III Col1: PCR Allegheny County ( ) Col2: >=12 RLN removed Col2: PCR Allegheny County ( ) Hosp B Very small community based; low socioeconomic area 1/5 20% 50-75% (% having chemo admin for Stage III) 2/ % 35-45% (% having 12 or more LN removed) Hosp P Mid sized community based; high socioeconomic area 9/12 75% 15/ % Hosp S1 Teaching hospital; mixed SE 66/84 79% 122/171 71% Hosp S2 small urban facility 3/5 60% 8/16 50%

APIII October 23, 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, References                