Activity Report March 2012 February 2013

Transcription

1 Upper Gastro-intestinal Cancer Managed Clinical Network Activity Report March 2012 February 2013 Mr Colin K MacKay Consultant Surgeon MCN Clinical Lead Margaret Welsh Network Service Manager

2 CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 4 2. MCN WORKPLAN AND ACTIVITIES (REPORTING PERIOD 03/2012 TO 02/2013) CORE OBJECTIVES INDIVIDUAL MCN OBJECTIVES OTHER MCN ACTIVITIES 6 3. QUALITY ASSURANCE / SERVICE DEVELOPMENT AND IMPROVEMENT 7 4. KEY PRIORITY AREAS FOR THE MCN IN THE NEXT 12 MONTHS 9 5. CONCLUSION 9 ACKNOWLEDGEMENT 10 REFERENCES 11 2

3 Executive Summary Introduction The purpose of this document is to report the upper gastro-intestinal (GI) cancer Managed Clinical Network (MCN) activities in respect of: Performance against agreed objectives; Outcomes achieved; and Challenges encountered and actions taken to remedy defined issues. This activity report covers March 2012 to February It also reports on key audit findings and resultant actions from the 2011 clinical audit, as well as looking forward from March 2013 to February MCN Objectives The upper GI cancer MCN has made progress and delivered a number of key objectives which include: Multi-disciplinary Team Working: The regional priority is to ensure all cancer patients are efficiently managed by a multi-disciplinary team (MDT). The four upper GI cancer MDTs are well established with good representation from multiple disciplines and administrative groups. Implementation of Regional Follow Up Consensus Guideline: Following MCN wide engagement, the future model for follow up was presented to and ratified by the Regional Cancer Clinical Leads Group and the Regional Cancer Advisory Group in April Implementation is currently being assessed across the partner Boards. Regional Clinical Audit: The 2011 clinical audit data report published in October 2012 is available on the (WoSCAN) website and the action plans are monitored on a regular basis at the Advisory Board. Quality Performance Indicator (QPI) development: MCN members were well represented in this national programme and following publication of the upper GI cancer QPIs in late 2012 the Advisory Board is undertaking an exercise to benchmark performance of how close we are to the specified quality measures. Curative Major Resectional Service Model: NHS Forth Valley has now transferred radical curative surgery to Glasgow, given the low case volume being performed locally. Agreement on an appropriate clinical pathway has been reached and patients requiring major upper GI resection from Forth Valley now have their surgery in Glasgow Royal Infirmary. Clinical Management Guideline (CMG) Review: The review process for both the oesophageal and gastric cancer CMGs has been completed in line with the agreed governance framework. Key Priority Areas for the MCN in the next 12 months The MCN work plan has been developed with an emphasis on identifying outcomes that improve the quality of patient care and overall efficiency. Below are the objectives to be progressed in the coming year: In preparation for QPI reporting and achievement of the specified quality measures, review data capture issues with the four MDTs; Continue to support the regional clinical audit programme and effectively utilise audit findings to inform and drive service improvement; Participate in the national transforming care after treatment programme and its related workstreams as they apply to the post treatment care of upper GI cancer patients; Assess the potential to apply enhanced recovery techniques and improve the nutritional status of patients who receive neo-adjuvant chemotherapy prior to surgery; and Explore the feasibility of extending the NHS Forth Valley model of early disease surveillance. 3

4 1. Introduction The upper gastro-intestinal (GI) cancer managed clinical network (MCN) was established in 2004 as a means of delivering equitable high quality clinical care to all upper GI cancer patients across the constituent NHS Boards that comprise the West of Scotland (WoS) region; Ayrshire & Arran, Forth Valley, Greater Glasgow and Clyde (GGC) and Lanarkshire. The upper GI cancer MCN continues to support the service for patients with oesophago-gastric cancer and at present there are four upper GI cancer clinics held across the region. The 2011 West of Scotland Cancer Network (WoSCAN) audit data indicates that there were 396 and 284 new cases of oesophageal and gastric cancer respectively diagnosed in the WoS. Oesophago-gastric cancers are more common in men than women with almost two thirds of those managed in WoSCAN in 2011 occurring in males. The disease occurs mostly in older people with more than 80% of cancers occurring in individuals 60 years old and over. The vast majority of treatment is non-curative and the majority of patients present with advanced disease. Surgical resection carries a high risk of morbidity and mortality meaning that surgery is not always possible due to patient fitness, even when disease appears early. This results in only a fifth of patients undergoing curative treatment 1. The purpose of this document is to report the upper GI cancer MCN activities in respect of: Performance against agreed objectives; Outcomes achieved; Challenges encountered and actions taken to remedy defined issues; and Update on progress of actions identified from the Audit Report. MCN Governance The Advisory Board meets three times per annum with representation from each of the partner NHS Boards and all relevant specialities involved in the management of oesophago-gastric cancer. The Advisory Board is consulted between meetings as required by the lead and manager. Mr Colin MacKay has now led the MCN for over four years and is in the final year as clinical lead of the MCN, after which he will demit office. MCN members will be contacted in late summer 2013, requesting that applications are made for this important regional role. The terms of reference and membership of the Advisory Board will be refreshed in early 2014, when a new clinical lead is appointed. 2. MCN Workplan and Activities (reporting period 03/2012 to 02/2013) 2.1 Core Objectives Multi-disciplinary Team (MDT) Working It is recognised nationally and internationally that all cancer patients are efficiently managed by an MDT, and each MDT requires safe and effective governance arrangements to be in place. The four upper GI cancer MDTs are well established, generally well structured and organised across the WoS. The main clinical specialities involved in the management of upper GI cancer are well represented at all MDT review meetings. Administrative groups are represented at MDT meetings providing a resource for audit, clerical and overall co-ordination functions. Particularly encouraging is that the high proportion of patients discussed at an MDT meeting has remained fairly static from 2009 to

5 Implementation of Regional Follow Up Consensus Guideline Following MCN wide engagement, the future model for follow up was presented to and ratified by the Regional Cancer Clinical Leads Group (RCCLG) and the Regional Cancer Advisory Group (RCAG) in April The Follow Up Regional Consensus Guideline was formally issued to the WoS NHS Boards for detailed impact assessment and planning for implementation. No barriers to implementation have been identified and in support of implementation, follow up is discussed at Advisory Board meetings with members indicating that the guideline is being utilised. Regional Clinical Audit Programme A key area of work for the upper GI cancer MCN was to effectively utilise audit findings to inform and drive service improvement. The 2011 audit report and progress with action plans are being discussed on a regular basis at the Advisory Board. Data quality has improved in recent years however in a number of areas there is still consistently poor quality data and the Advisory Board has been reviewing: performance status, dietetic input, neoadjuvant chemotherapy and staging data; as it is important to distinguish if issues relate to coding errors rather than issues with clinical care. Application of Enhanced Recovery Techniques There has been discussion amongst the Advisory Board members on potential opportunities to apply enhanced recovery techniques. It is recognised that the benefit is with pre-operative/pre-intervention optimisation of patients and managing patient/carer expectations with good communication and an example of this is improving the nutritional status for patients on three months of neo-adjuvant chemotherapy who then proceed to surgery. MCN members work closely with colleagues providing care to patients with pancreatic cancer and there are protocols that can be shared and adapted. This work will carry forward into the work plan for 2013/ Individual MCN Objectives National Quality Performance Indicator Development Programme The Scottish Cancer Taskforce Quality Subgroup is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. MCN members were well represented in the group tasked with developing the QPIs for upper gastro-intestinal cancer with WoS representation from audit, management, nursing, oncology, pathology, radiology and surgery. The upper GI cancer QPIs were published in December 2012 and have been implemented for all patients diagnosed with upper GI cancer on, or after, 1st January A revised upper GI cancer dataset and measurability specification was developed as part of the QPI development process to facilitate consistent measurement and comparative reporting of QPIs across Scotland. Every three years regional comparative analysis results will be submitted by the WoSCAN Information Team to the Information Services Division (ISD) to be incorporated into a national comparative report in line with the national QPI governance process. Upper GI survival analysis will be reported and analysed on a 3 yearly basis by ISD. In support of implementation and in preparation for reporting against the upper GI cancer QPIs the MCN initiated a desktop exercise in late January with Advisory Board members to assess how close are we to the QPI targets and each Board Lead is currently undertaking an exercise to benchmark performance and will report back in late May. In addition to raising awareness, the anticipated outcome is that regional actions may be identified that will ensure progress towards the specified quality measures. 5

6 Review of Oesophageal and Gastric Clinical Management Guidelines (CMGs) CMGs ensure the safe and equitable management of patients across the WoSCAN area whilst optimising the effectiveness of treatment and care. The review of the 2010 oesophageal and gastric cancer CMGs was led by oncologists Professor Jeff Evans and Dr Vivienne MacLaren. The review process progressed well with input from dietetic, nursing, oncology, pharmacy, radiology and surgical colleagues. The oesophageal CMG had minor changes and received Prescribing Advisory Sub Group (PASG) chair s approval. The gastric CMG has systemic anti cancer therapy changes to reflect latest Scottish Medicine Consortium (SMC) guidance and was formally submitted to the January 24th PASG for review and will proceed to the WoS Area Drug and Therapeutic Committees for approval. Following this approval process the 2013 CMGs are published on the WoSCAN intranet site. 2.3 Other MCN Activities Curative Major Resectional Service Model NHS Forth Valley has now transferred radical curative surgery to NHSGGC, given the low case volume being performed locally. Agreement on an appropriate clinical pathway has been reached and from November 2011, patients requiring major upper GI resection from Forth Valley now have their surgery in Glasgow Royal Infirmary. The Forth Valley surgeons are responsible for the local diagnosis, staging and follow up and are involved with the surgical resection in Glasgow. Further work will be undertaken regionally to determine the extent and timing of any further change that may be required. The scope of this work and approach to be taken requires to be agreed by RCAG. Data Sharing Request Following receipt of an approved data sharing agreement work is underway in collaboration with the West of Scotland Cancer Surveillance Unit to provide the upper GI cancer MCN with information on determinants of survival and hospital readmissions of their patients during the period from January 2006 to December The timescale for completing this work is around 12 months and when the initial results are available and prior to publication, a meeting will be arranged with the four Board Leads to review the findings. Education A national education event, hosted by North of Scotland Cancer Network (NOSCAN), was held in Aberdeen in November 2012, the event was well attended by a variety of professions from South East Scotland Cancer Network (SCAN), NOSCAN and WoSCAN and feedback received on the event was favourable. The 2011 WoSCAN oesophago-gastric cancer audit data was presented in the first session and although there was no direct comparative analysis audit data were also presented by NOSCAN and SCAN. The focus in the afternoon session was on early disease. Topics presented and discussed included: Development and co-ordination of a Barrett s service: a Forth Valley experience; Radio-frequency ablation for Barrett s oesophagus and management of early lesions; Oesophago-gastric anastomotic techniques; and COG Trial: Addressing the need for 2nd Line therapy in Oesophageal Cancer. The focus on Barrett s and the work presented by Stuart Paterson, Consultant Gastroenterologist from NHS Forth Valley was well received; this presents an opportunity for shared learning and the MCN recognises the potential to adopt the Forth Valley model. This will be considered for the forthcoming year s work plan. Upper GI cancer survival analysis will be reported and analysed by ISD every 3 years and NOSCAN is hosting the national meeting for

7 Positron Emission Tomography/Computed Tomography (PET/CT) Scanner Use This national project is currently underway and will evaluate the use of PET/CT scanners across Scotland. Six cancers groups for which there are nationally agreed clinical protocols and indications for PET/CT scanning are being evaluated and this includes oesophageal or oesophagogastric junctional cancers. MCN clinical audit data is included in the methodology and members are participating as and when required to provide information on clinical practice and there is an awareness that management plans do change as a result of a patient undergoing a PET/CT scan. Service Mapping A pilot exercise is nearing completion in the development of a regional service map which details the points of upper GI cancer service delivery and the connections between them. This high level summary information will be utilised as an internal planning resource. 3. Quality Assurance / Service Development and Improvement The primary function of the MCN is to facilitate continuous clinical service improvement, supporting delivery of high-quality, equitable, treatment and care to patients with oesophago-gastric cancer in the WoS. The MCN prospective clinical audit programme underpins much of the regional service development and improvement work of the MCN and supports quality assurance (QA) by providing the means for regular assessment and reporting against recognised and agreed measures of service performance and quality. The annual regional quality assurance of service provision utilises fourteen regionally agreed criteria and the latest report of audit data is based on 680 new diagnoses of oesophago-gastric cancer presenting in 2011, set against results obtained from the previous report. The MCN QA process requires local multi-disciplinary teams to critically review and verify their own results before being collated to provide a regional comparative report of performance against agreed measures and variance between MDTs. The report of the 2011 clinical audit data was published in October 2012 and can be found in the WoSCAN internet site. Regional Audit and Governance Process In accordance with agreed governance procedures, Boards were asked to produce Action/Improvement Plans, in response to audit findings, to take forward recommendations set out in the Audit Report; the expectation thereafter is that these actions will be progressed and monitored via local governance structures. Plans are expected to be submitted to the Regional Information Manager within two months of publication of the report. An Action/Improvement Plan template is provided to ensure consistency and standardisation across the region. The MCN Manager/Clinical Lead have been reviewing Board Action Plans to identify priorities for co-ordinated regional action and these, along with progress against specific Board actions are monitored throughout the year by the Advisory Board under the standing MCN Work Plan agenda item. Action Plan Progression Recommended actions on the basis of the key findings of the audit report were directed to Boards requesting that local plans are developed to address areas of deficiency identified. All of the Boards have produced Action/Improvement plans and outlined below is a high level summary of progress: All Boards have reviewed their local processes to ensure capture of dietetic information at MDTs. Actions taken vary by Board and include: developing proforma, preparation of biannual patient lists and establishing regular meetings between dietitians and audit staff. 7

8 NHS Lanarkshire has plans in place for a clinical nurse specialist (CNS) to undertake a casenote review for patients not discussed at the MDT, the reason will be identified and actioned accordingly. All Boards have reviewed their local processes to ensure improved availability of data. Actions taken vary by Board and include: CNSs and audit staff meeting up on a regular basis normally after the MDT, review of liaison and co-operation between staff and development of a local database which will be updated by the CNS. Both NHS Greater Glasgow and Clyde and NHS Lanarkshire are planning to undertake a review of individual cases reported as not being seen by CNS. If data issue identified there will be a review of process for data collection. If not due to a data issue, there will be a review of the cause for the decrease. Three of the four Boards have reported that TNM data is recorded at MDT and NHS Lanarkshire will develop a proforma to ensure staging data is captured accurately. NHS Forth Valley has reviewed audit process and for patients who have surgery in Glasgow processes have been put in place to ensure there is an exchange of information; thus ensuring capture of surgical data for all patients to facilitate robust measurement of surgical outcomes. In terms of chemotherapy and radiotherapy mortality, NHS Forth Valley has reviewed completion of death data and the small numbers of cases has a major impact on percentages; mortality figures include those patients who have oncology with palliative intent. The oncologists have agreed to send the audit team copies of all oncology letters to assist in the collection of chemotherapy/radiotherapy information as they currently rely on electronic downloads from the Beatson information systems. In terms of chemotherapy and radiotherapy mortality, NHS Lanarkshire has reviewed completion of death data and the clinical quality team will perform an end of year survival check via TrakCare system to ascertain appropriate death dates as required. All Boards have reviewed the issue relating to the accurate capture of data relating to intent of chemotherapy. Actions taken vary by Board and include: recording data in Chemocare, oncologist sharing copies of clinical letters with audit staff, review of cases to identify if intent is miscoded and if coding issue exists then review processes of collection of this data item with audit staff. Advisory Board members have had discussions on the issue relating to capture of accurate chemotherapy data and are promoting with colleagues the importance of improving data quality to facilitate ability for robust assessment of outcomes following neo-adjuvant chemotherapy. Across all Boards all the actions identified in the Board-specific action/improvement plans have been reviewed and a progress/action status provided in line with the governance framework; the majority of actions are described as complete and for those that remain ongoing a further update will be requested for the next Advisory Board meeting in May as the expectation is that all actions would be addressed prior to the onset of the next audit reporting schedule with sign off of the 2012 clinical audit data completed in the summer. Escalation Process Any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the Regional Lead Cancer Clinician and relevant Territorial NHS Board Cancer Clinical Lead by the MCN Clinical Lead. 8

9 4. Key Priority Areas for the MCN in the next 12 months The MCN work plan is currently being developed with an emphasis on identifying outcomes that improve the quality of patient care and overall efficiency. Below are the objectives to be progressed in the coming year, subject to additional objectives agreed at the regional cancer planning workshop in February 2013: In preparation for QPI reporting and achievement of the specified quality measures, review data capture issues with the four MDTs; Continue to support the regional clinical audit programme and effectively utilise audit findings to inform and drive service improvement; Participate in the national transforming care after treatment programme and its related workstreams as they apply to the post treatment care of upper GI cancer patients; Assess the potential to apply enhanced recovery techniques and improve the nutritional status of patients who receive neo-adjuvant chemotherapy prior to surgery; and Explore the feasibility of extending the NHS Forth Valley model of early disease surveillance. A further update will be available when the MCN Clinical Lead and Manager attend RCAG in April to present the MCN s annual update report after which the work plan is expected to be published by mid May Conclusion This has been a productive year and the continued support of the Advisory Board is essential in order for the MCN to achieve their work plan objectives. Over the last 12 months, the MCN has continued to work closely with local and regional clinical and management teams across the region to support the MDTs. The MCN has just completed the review of the oesophageal and gastric cancer CMG. The MCN has regularly reviewed the implementation of the regional consensus guideline for follow up of upper GI cancer, which indicates that the guideline has been accepted and utilised. These developments will continue to drive consistency of practice and provide improved care for patients with oesophago-gastric cancer in the WoS. Looking ahead the membership welcomes the opportunity to focus on the management of early disease; improve the degree and reporting of dietetic involvement in patient care; assess the probable implications of the QPI process and continue to support and improve the effective patient journey around services that can be provided locally and those that require centralised care. 9

10 Acknowledgement This report represents the achievements and challenges progressed across the four partner NHS Boards of the : NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire We would like to thank all members and active participants in the cancer network for their continued support of the Managed Clinical Network, without their efforts this level of progress would not be possible. 10

11 References 1. WoSCAN Annual Upper GI Cancer Audit Data. 11