A n n u A l R e p o R t

Transcription

1 2014 Annual Report

2 METHODIST JENNIE EDMUNDSON CANCER CENTER Annual Report These achievements speak volumes about our programs and people as these honors do not come easily. The Cancer Center at Methodist Jennie Edmundson is the only nationally accredited cancer program in southwest Iowa. This accreditation, from the Commission on Cancer of the American College of Surgeons, is testimony to the quality of cancer care available right here at home. Only one-fifth of the nation s cancer centers have achieved this substantial accomplishment. Additional accreditations include accreditation of the Breast Health Center by the National Accreditation Program for Breast Centers (NAPBC), and Mammogram, Breast Ultrasound and Breast Stereotactic Biopsy accreditation by the American College of Radiology. As recipients of a grant from the Susan G. Komen foundation, we are proud to have joined with our community partners to use the funding to assure that women who are uninsured or underinsured are given access to care for breast cancer. These grant dollars support our efforts to educate the community about appropriate screening and provide the needed diagnostic studies and treatments for women with need. These achievements speak volumes about our programs and people as these honors do not come easily. These come only when every member of the team, working together, delivers quality care that puts patients and their families first. Our work to fight cancer and enhance cancer care continues. Thank you for your support of our mission. Donna Hubbell, BSN MHA VP Patient Safety and Quality Cancer Program Administrator 2014 Annual Report 1

3 2013 cases Accessioned 2013 cases Accessioned (continued) Site Group Total CLASS Cases Analytic Non-Analytic Breast Lung/Bronchus - Non Small Cell Colon Lung/Bronchus - Small Cell Bladder Kidney & Renal Pelvis Rectum & Rectosigmoid Leukemia Corpus Uteri Anus, Anal Canal, Anorectum Pancreas Non-Hodgkin s Lymphoma Prostate Thyroid Esophagus Liver Other Nervous System Myeloma Tonsil Stomach Bile Ducts Larynx Other Hematopoietic Melanoma of Skin Vulva Brain Other Endocrine Site Group Total CLASS Cases Analytic Non-Analytic Hodgkin s Disease Unknown or Ill-Defined Lip Nasopharynx Small Intestine Gallbladder Retroperitoneum Peritoneum, Omentum, Mesentery Other Digestive Pleura Uterus Ovary Vagina Testis Ureter ALL SITES

4 Top Ten cancers (All Sites) 2013 AJCC Stage at Diagnosis % % 13% % 15% 15% 0 Breast Lung & Bronchus Colorectal Bladder 12 Kidney & Renal Leukemia Pancreas Non-Hodgkin's Lymphoma Prostate Thyroid Cancer Stage Site Cases % of Cases Breast % Lung & Bronchus % Colorectal % Bladder % Kidney & Renal Pelvis % Leukemia 7 3.3% Pancreas 6 2.8% Non-Hodgkin s Lymphoma 6 2.8% Prostate 5 2.4% Thyroid 5 2.4% Total % Stage Cases % of Cases 0 (In Situ) 19 7% I 75 28% II 35 13% III 41 15% IV 41 15% NA/Unknown 56 21% Total % 4 5

5 patient Age at diagnosis Southwest iowa cancer referrals to mje 40 MONOA CRAWFORD CARROLL 0 0.7% (2) 0.7% (2) Male Female HARRISON 6.6% (8) SHELBY 4.0% (11) AUDOBON 1.1% (3) 10 POTTAWATTAMIE 54.8% (149) CASS 6.6% (4) MILLS 13.2% (36) MONTGOMERY 4.0% (11) ADAMS 1.5% (4) Age at Diagnosis Male % of Male Female % of Females % 2 1% % 3 2% % 12 7% % 33 20% % 46 28% % 38 23% % 26 16% % 3 2% Totals % % OTHER COUNTIES Polk 0.4% (1) Webster 0.4% (1) FREMONT 2.6% (7) PAGE 1.5% (4) TAYLOR 0.4 (1) OUT OF STATE Nebraska 2.6% (7) Colorado 0.4% (1) Kansas 0.7% (2) Missouri 1.1% (3) Oregon 0.4% (1) 6 7

6 2013 mje distribution of major primary sites Acos NCDB CP3R 2013 Measures 30% Oncology Metric MJE Expected Performance Rate 25% 20% 15% 10% 5% MJE ACS - IA ACS - US The ACoS Commission on Cancer has defined nine Cancer Program Practice Profile Reports (CP3R) that must be evaluated in 2014 for accreditation. BCS/RT Radiation therapy is administered within 1 year (365 days) of diagnoses for women under age 70 receiving breast conserving surgery for breast cancer. MAC Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c N0M0 or Stage II or III ERA and PRA negative breast cancer. HT Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c N0M0 or Stage II or III ERA and PRA positive breast cancer. ACT 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. nbx Image or palpation-guided needle biopsy (core or FNA) is performed to establish diagnosis of breast cancer. 100% 100% 90.5% 100% >=90% or upper bound of 95% >=90% or upper bound of 95% >=90% or upper bound of 95% >=90% or upper bound of 95% 96.9% Not yet established 0% Breast (Female) Lung/ Bronchus Colon Bladder Kidney & Renal Pelvis 12RLN At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. BCS Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer. 91.7% >=80% or upper bound of 95% 62% Not yet established Breast (female) Lung/ Bronchus Colon Bladder Kidney & Renal pelvis MJE 26.80% 18.70% 6.00% 5.60% 4.20% ACS - Iowa 13.20% 13.40% 9.40% 4.60% info not available ACS - US 14% 13.70% 6.20% 4.40% 3.90% MASTRT Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with >=4 positive regional lymph nodes. RECRT Radiation therapy is considered or administered within 6 months (180 days) of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer. 0% (no cases qualified) *All measures meet or exceed the defined Confidence Interval, given the number of cases classified for the measures by the NCDB. Not yet established 100% Not yet established 8 9

7 2013 Cancer Screening Summaries 2013 Cancer Screening Summaries Colorectal Screening - March 15 Participants 1 Abnormal Result Abnormal Head & Neck Cancer Screening - April 41 Participants / 14 Abnormal results Abnormal Skin Cancer Screening - June 214 Participants / 70 Abnormal results (5 Basal Cell Carcinomas, 2 Melanomas) Basal Cell Carcinoma Melanoma Other Abnormal Prostate Cancer Screening - September 81 Participants / 10 Abnormal Results (1 Prostate Cancer Diagnosed) Breast/Cervical Cancer Screening - October 103 Participants / 18 Abnormal Results 34 Screening Mammograms 9 Diagnostic Mammograms 9 Ultrasounds Abnormal Breast Cancer Screening Mills County - October 9 Participants / 2 Abnormal Results 6 Screening Mammograms 2 Diagnostic Mammograms 1 Ultrasound Screening Mammogram Diagnostic Mammogram Ultrasound Abnormal Screening Mammogram Prostate Cancer Abnormal Diagnostic Mammogram 1 Ultrasound 10 11

8 2013 cancer program activities 2013 cancer program activities Updated hospital website with current information regarding health screenings, support groups, and available classes. Sponsored and participated in the Winter Fundraiser; Healing Touch Program, Golf Tournament, and Healthy Moves in conjunction with Wings of Hope Cancer Support Center. Sponsored Look Good and Feel Better Classes in conjunction with the American Cancer Society and Heartland Oncology & Hematology. List of Cancer Resources Provided to Patients & Families Available in the MJE Family Resource Center updated. Sponsored and participated in the Women s Health Conference in Glenwood, IA. Continue to promote the American Cancer Society fax referral form & personal health manager packets, developed Collaborative Action Plan & Partnership Update, and participated in Daffodil Days. Introduced to the Clinicians Portal. Sponsored & participated in both the Mills & Pottawattamie county Relay s for Life. Sponsored and participated in A Time to Heal 12 week program to help patients regain physical, emotional, intellectual, psychological, and spiritual health after undergoing treatment for cancer. Participated in the Spirit of Courage weekend benefit to raise money for our cancer patients. Increased employee knowledge & participation in event. Sponsored Women Helping Women with Wings of Hope. Partnered with the VNA Komen Grant to provide resources to breast cancer patients. Participated in the Susan G. Komen Race for the Cure in Des Moines. Standardized Cancer Screening demographic forms for better tracking. Organized and participated in community cancer screening events with particular attention to the underserved populations (Colorectal, Skin, Prostate, Breast & Cervical). Developed a Psychosocial Distress Screening Tool. Participated in various educational and outreach events to promote Breast Cancer Awareness month activities. Participated in an area Ladies Night Out providing educational materials to women. Organized and participated in the Bald and the Brave Challenge which raises funds and awareness for the MJE cancer program. In process of developing Survivorship Care Plans for cancer patients. Handed out breast cancer educational materials at the River City Expo and the Boat, Sport, and Travel Show. Participated in the Great American Smoke-out

9 2013 Cancer Committee Members Rick Blodgett Volunteer Chaplain Becky Bussey Physical Therapist Connie Casson Oncology Nurse John Okerbloom, MD Chairman* Medical Oncologist* Annabel Galva, MD Diagnostic Radiologist* Donna Hubbell Cancer Program Administrator Quality Improvement Coordinator* Tammy Johnson Breast Health Nurse Navigator Becky Goldberg-Kahn, MD Pathologist* Michelle Kaufman Cancer Conference Coordinator* Carol Kroft Cancer Registry Quality Coordinator* Carol Reeder Dietitian Michael Romano, MD Family Practice Melanie Ryan Pharmacist Lyla Schroder Clinical Research Representative* Brent Wakefield, MD Urologist Dee Wicks Psychosocial Services Coordinator* Michael Zlomke, MD Cancer Liaison Physician* Community Outreach Coordinator* *designates individuals or positions that are required by the American College of Surgeons Cancer accreditation program. Barbara Kricsfeld Oncology Nurse / Radiation Oncology 14 mje cancer center

10 2014 Methodist Jennie Edmundson, an affiliate of Methodist Health System.