Monitoring Clinical Stage to Improve Care

Transcription

1 Monitoring Clinical Stage to Improve Care Stephen Dreyer, MD, FACS Cancer Liaison State Chair Nebraska Fremont, NE M. Asa Carter, CTR Manager, Accreditation and Standards American College of Surgeons Chicago, IL New Standard.3 It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change. ~Author unknown Commission on Cancer Mission Statement The Commission on Cancer is: dedicated to reducing cancer morbidity and mortality through education, standard setting, and the monitoring of quality of care 1

2 The Importance of Staging Ensure patient s receive appropriate care Evaluate treatment results and patient outcomes A New Standard With a New Focus The cancer committee, or other appropriate leadership body, develops a process to monitor physician use of stage, site specific prognostic indicators, and evidence-based national treatment guidelines in treatment planning for cancer patients. The findings of the monitoring are presented at least annually to the cancer committee, or other appropriate leadership body, and are documented in minutes. What s Different About the Standard Focuses on care process Defines cancer committee responsibilities Excludes staging mechanics

3 Helpful Definitions - Stage Clinical Stage: Evidence acquired before primary treatment Includes: Physical exam Diagnostic imaging Endoscopy Biopsy Surgical exploration Helpful Definitions - Stage Working Stage: All clinical stage information plus pathologic stage information available at this point Helpful Definitions - Stage Collaborative Stage: A coding system bringing together the AJCC, SEER Summary Stage, and SEER Extent of Disease principles. Can combine clinical and pathologic information Applies to data recorded in the cancer registry data base Not used by physicians 3

4 New Standard.3 Intent Promote physician use of clinical stage to select the most appropriate treatment Extend the benefit of Cancer Conference (.8) to other cancer patients Demonstrate Compliance New Standard.3 Accuracy of clinical stage Evidence in the medical record, or Documentation in other sources Treatment concordant with recognized guidelines Implementing the Process Educate physicians and nurses Identify acceptable locations (in medical record) Select nationally recognized standards Initiate the process Report the findings Improve compliance rates

5 Mutually Accepted Locations for Physician and Registrar Medical/radiation oncology consultation Surgical site verification record Preoperative consultation History/physical EMR line item Operative note description of findings Cancer conference notes Surgical Site Verification Record Current info - physician name, date, procedure Cases with a cancer diagnosis or a suspicion of malignancy - nurse will ask for a clinical stage - record on form or in EMR Create dialog box Cancer Registry Clinical stage date Treatment procedure date Initial treating physician Available for review by data quality coordinator 5

6 Initiate Monitoring Process Start with medical and radiation oncology consultations Select disease sites in which they would provide initial treatment Review records Clinical stage documentation Treatment process Set expected rates of accuracy and compliance Quarterly report to cancer committee Surgical Cases Establish acceptable site in record Review sites in which surgical procedure is the initial course of treatment Clinical stage documentation Treatment process Set expected rates of accuracy and compliance Quarterly report to cancer committee Monitoring Grid MR # site physician Clinical stage accurate Treatment concordant Both accurate and concordant Total Total Total Total Total Percent Percent Percent Percent 6

7 Results of Radiation and Medical Oncology Consultations Sites were selected were: Lung 13 Hematologic malignancies 11 Rectum 3 Esophagus 3 Compliance Rate.3 Clinical stage was noted and accurate 83.3% (5/30) Treatment plan concordant guideline 100% (5/5) Compliance rate 83.3% Noncompliance In the 5 cases not noted hematologic malignancies 1 esophageal carcinoma Hematologic malignancies Prognostic markers Esophageal carcinoma Stage implied by description 7

8 Problems Clinical stage not included in esophageal case discussion of findings, but not noted Solution: Clinical stage will be added to the consultation template reminder Problems Hematologic malignancies CLL, multiple myeloma Utilize prognostic markers that determine tumor burden for treatment planning Modified Rai Staging - CLL Durrie-Salmon Classification multiple myeloma Solution: Include the stage of tumor burden indicated by these guidelines in the consultation Surgical Site Verification Record Review By consensus the Surgical Site Verification Record was selected and this process was begun on Consensus built: Cancer committee Approval patient care review committee Surgery department committee Individual meeting with surgeons 8

9 Case Discovery Perform an operative procedure search of OR log Filter for procedures related to most common sites Prostatectomy Mastectomy-lumpectomy Colectomy Nephrectomy Operating Room Log Data printed Medical record number Preop diagnosis Postop diagnosis Date Procedure Select cases for review Case Review Note the clinical stage listed in the SSVR Review the medical record to verify the accuracy of the clinical stage Evaluate the planned operative procedure for appropriateness 9

10 Quality Improvement Opportunities Adequacy of the staging process Appropriateness of treatment plan Results of Review Site Total Clinical Stage Accurate Concordant Compliant Prostate % Breast % Colon 100% Kidney % Rectum 100% Bladder 1 0 0% Problems Encountered The surgical site verification form requested a clinical stage for cases with a definitive cancer diagnosis Solution: The record has been corrected and the nurse will ask for a clinical stage in any patient with a pre-procedure diagnosis or suspicion of cancer 10

11 Problems Circulating nurse forgot to request the clinical stage Solution: A meeting held with OR nursing staff to review this new documentation procedure and answer any questions Problems The surgical site verification record did not contain a site to record the intended procedure Solution: The signed operative permit will be the source of information for the intended treatment plan Staging methods Problems Confusion regarding terminology T1 needle biopsy considered stage 1 T palpable considered stage Outdated staging system for bladder cancer 11

12 Evolution of Monitoring Process Initially clinical stage review is done as a separate process by a work group To establish benchmark rate Refine clinical staging process After achieve best possible rate of compliance Become a component of annual 10% random review for data quality Ensuring Quality of Care Follow the QI process Plan Do Study (Check) Act Summary Clinical stage is important for understanding initial treatment choices Prognostic factors influence treatment choice Clinical practice guidelines seek to improve care through standardization The cancer committee can use the quality improvement process to monitor and improve the use of stage in treatment planning 1

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