Endometrial Cancer. Measurability of Quality Performance Indicators Version 2.0

Transcription

1 Endometrial Cancer Measurability of Quality Performance Indicators Version 2.0 To be read in conjunction with: Endometrial Cancer QPIs Final Publication v2 Endometrial QPI Dataset (latest published version)

2 Measurability of Quality Performance Indicators for Endometrial Cancer Document control: This Version Title Endometrial Cancer Measurability of QPIs Version/Issue Number 2.0 Effective From October 2015 Author Jane Garrett, ISD Document Type Guidance Document status Final For Publication Document Purpose Final For Publication Summary of changes Revision History Version Date Status Summary of Changes QPI (s) 0.1 Feb 2014 Draft First draft All 0.2 Mar 2014 Draft Changes following comments from KC All 0.3 May 2014 Draft Changes following public engagement All 0.4 June 2014 Draft Further changes following public engagement All 0.5 Sept 2014 Draft Changes following Board Review All 2.0 July 2015 Final Changes agreed at 9mth Review 2 Updates from Previous Version QPI Summary of changes (excluding formatting changes) 2 Num change to [MDTDATE <> 10/10/1010] AND ([MDTDATE DEFTREATDATE] OR [DEFTREATDATE = 10/10/1010])

3 QPI 1 Radiological Staging Patients with endometrial cancer should have their stage of disease assessed by Magnetic Resonance Imaging (MRI) and/or Computed Tomography (CT) prior to first treatment. Proportion of patients with endometrial cancer who have an MRI and/or CT scan of the abdomen and pelvis performed prior to first treatment. Number of patients with endometrial cancer having a CT scan and/or MRI of the abdomen and pelvis carried out prior to first treatment. Date Imaging Completed (Pre-Treatment) not coded as Not Recorded and coded as less than Date of First Cancer Treatment. ( [SINVESTDATE <> 10/10/1010] AND [SINVESTDATE < FIRSTTREATDATE] ) All patients with endometrial cancer (Excluding patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy, and patients with atypical hyperplasia on pre-operative biopsy). Date of Diagnosis [DIAGDATE] in range specified for comparative analysis; and Tumour Grade Pre-Operative Biopsy {Endometrial Cancer} not coded as Grade 1 and Morphology of Tumour Pre-Operative Biopsy not coded as Endometriod or Mucinous Carcinoma; or Morphology of Tumour Pre-Operative Biopsy not coded as Atypical Hyperplasia. ( [BIOTGRADE <> G1] AND [BIOMORPHOL <> 8140/3 OR 8262/3 OR 8380/3 OR 8382/3 OR 8383/3 OR 8480/3 OR 8481/3 OR 8570/3] ) AND [BIOMORPHOL <> 7777/7] exclusion [SINVESTDATE = 09/09/0909] OR [FIRSTTREATDATE = 09/09/0909] [BIOTGRADE = 99] OR [BIOMORPHOL = 9999/9]

4 QPI 2 Multidisciplinary Team Meeting (MDT) Patients with endometrial cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment. Proportion of patients with endometrial cancer who are discussed at a MDT meeting before definitive treatment. Number of patients with endometrial cancer discussed at the MDT prior to definitive treatment. Date Discussed by Care Team (MDT) not coded as not applicable; AND Date Discussed by Care Team (MDT) is before or equal to Date of Definitive Treatment OR Date of Definitive Treatment is equal to not applicable. [MDTDATE <> 10/10/1010] AND ([MDTDATE DEFTREATDATE] OR [DEFTREATDATE = 10/10/1010]) All patients with endometrial cancer. (Excluding patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy, and patients with atypical hyperplasia on pre-operative biopsy). Date of Diagnosis [DIAGDATE] in range specified for comparative analysis; and Tumour Grade Pre-Operative Biopsy {Endometrial Cancer} not coded as Grade 1 and Morphology of Tumour Pre-Operative Biopsy not coded as Endometriod or Mucinous Carcinoma; and Morphology of Tumour Pre-Operative Biopsy not coded as Atypical Hyperplasia. ( [BIOTGRADE <> G1] AND [BIOMORPHOL <> 8140/3 OR 8262/3 OR 8380/3 OR 8382/3 OR 8383/3 OR 8480/3 OR 8481/3 OR 8570/3] ) AND [BIOMORPHOL <> 7777/7] [MDTDATE = 09/09/0909] OR [DEFTREATDATE = 09/09/0909] exclusion [BIOTGRADE = 99] OR [BIOMORPHOL = 9999/9]

5 QPI 3 Total Hysterectomy and Bilateral Salpingo-Oophorectomy Patients with endometrial cancer should undergo total hysterectomy (TH) and bilateral salpingo-oophorectomy (BSO). Proportion of patients with endometrial cancer who undergo TH/BSO. Number of patients with endometrial cancer who undergo TH/ BSO. Surgery Performed coded as Total hysterectomy and bilateral salpingo-oophorectomy or Total hysterectomy, bilateral salpingooophorectomy and lymphadenectomy [SURG = 01 OR 02] All patients with endometrial cancer. (Excluding patients with FIGO Stage IV disease, patients who decline surgical treatment and patients having neo-adjuvant chemotherapy). Date of Diagnosis [DIAGDATE] in range specified for comparative analysis; and Final FIGO Stage {Endometrial Cancer} not coded at Stage IV; and Surgery Performed not coded as Patient refused treatment; and Type of Systemic Anti-Cancer Therapy (SACT) 1 not coded as Neoadjuvant. [FIGO <> IVa OR IVb] AND [SURG <> 95] AND [CHEMTYPE1 <> 01] [SURG = 99] exclusion [FIGO = 99] OR [SURG = 99] OR [CHEMTYPE1 = 99]

6 QPI 4 Laparoscopic Surgery Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate. Proportion of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery. Number of patients with endometrial cancer undergoing definitive surgery who have laparoscopic surgery. Surgical Approach coded as Laparoscopic or Laparoscopic converted to Open. [SURGAPPR = 02A OR 02B] All patients with endometrial cancer undergoing definitive surgery. Date of Diagnosis [DIAGDATE] in range specified for comparative analysis; and Date of Surgery not coded as Not Applicable. [SURGDATE <>10/10/1010] exclusion [SURGAPPR = 99] [SURGDATE = 09/09/0909]

7 QPI 5 Adjuvant Vaginal Brachytherapy Patients with intermediate risk (stage IB, grade 1 or 2; or stage IA, grade 3 endometrioid or mucinous) endometrial cancer should be considered for adjuvant vaginal brachytherapy. Proportion of patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer having adjuvant vaginal brachytherapy. Number of patients with stage IB, grade 1 or 2 or stage IA, grade 3 endometrioid or mucinous endometrial cancer receiving vaginal vault brachytherapy. Vaginal Vault Brachytherapy {Endometrial Cancer} coded as Yes [BRACHY = 01] All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer. (Excluding patients who decline brachytherapy). Date of Diagnosis [DIAGDATE] in range specified for comparative analysis; and Final FIGO Stage {Endometrial Cancer} coded as Stage IB and Tumour Grade Post Operative {Endometrial Cancer} coded as Grade 1 or 2; or Final FIGO Stage {Endometrial Cancer} coded as Stage IA and Tumour Grade Post Operative {Endometrial Cancer} coded as Grade 3; and Morphology of Treatment Post Operative coded as Endometriod or Mucinous Endometrial Cancer; and Vaginal Vault Brachytherapy {Endometrial Cancer} not coded as Patient refused treatment. ( [FIGO = IB] AND [TGRADE = G1 OR G2] ) OR ( [FIGO = IA] AND [TGRADE = G3] ) AND [MORPHOL = 8140/3 OR 8262/3 OR 8380/3 OR 8382/3 OR 8383/3 OR 8480/3 OR 8481/3 OR 8570/3] AND [BRACHY <> 95] [BRACHY = 99] exclusion [BRACHY = 99] [FIGO = 99] OR [TGRADE = 99] OR [MORPHOL = 9999/9]

8 QPI 6 Chemotherapy Patients with stage IV endometrial cancer should have chemotherapy. Proportion of patients with stage IV endometrial cancer receiving chemotherapy. Number of patients with stage IV endometrial cancer receiving chemotherapy. Type of Systemic Anti-Cancer Therapy 1-2 coded as Neoadjuvant, Adjuvant, Palliative or Chemoradiotherapy. [CHEMTYPE1 OR CHEMTYPE2 = 01 OR 02 OR 04 OR 05] All patients with stage IV endometrial cancer. (No exclusions). Date of Diagnosis [DIAGDATE] in range specified for comparative analysis; and Final FIGO Stage {Endometrial Cancer} coded as Stage IV. [FIGO = IVA or IVB] exclusion [CHEMTYPE1 OR CHEMTYPE2 = 99] [FIGO = 99]