OSF Moeller Cancer Center - Outcomes
Accountability and Quality Improvement Report - 2016
Annual review of accountability and quality improvement measures performance rates for OSF Saint Anthony’s Cancer Center of Excellence (SAHC) in 2016.
* American College of Surgeons Cancer Programs
| Select Measures | CoC* Std % | SAHC |
|---|---|---|
| Radiation Therapy is administered within 1 year of diagnosis for women less than 70 years of age receiving breast conservation surgery for breast cancer. | 90% | 88% |
| Begin Hormone Therapy within 1 year of diagnois for women with stage IB-III Hormone Receptor positive breast cancer. | 90% | 93% |
| Radiation Therapy within 1 year of diagnosis of breast cancer for women with 4 or more positive regional lymph nodes. | 90% | 100% |
| Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer. | 80% | 92% |
| Combination chemotherapy is recommended or administered within 4 months of diagnosis for women less than 70 years of age with the American Joint Committee on Cancer T1cNO, or stage IB - III Hormone Receptor negative breast cancer. |
90% |
100% |
Quality Studies - 2016
Problem Statement
To ensure palliative radiation for bone metastases follows the ASTRO* guidelines
- Bone metastasis, the most common cause of cancer-related pain, occurs in up to 90% of patients with advanced breast or prostate cancer
- ASTRO* Recommendation: do not routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases
- Part of Affordable Care Act to be reported as performance measure to CMS** beginning January 2016
*American Society for Radiation Oncology
**Centers for Medicare & Medicaid Services
Information Gathering
- Review cases beginning October 2015 (FY 2016)
- No ability for retrospective data due to Electronic Health Record (EPIC) implementation Fall 2015
- Quality Management will pull cases by coding and review based on ASTRO guidelines.
- Report data to Oncology Quality meeting and discuss with Radiation Oncologist
Review Findings
| Timeline for Study | Number Cases | Number of cases falling within the ASTRO guidelines | Number of cases meeting exception |
|---|---|---|---|
|
Nov ‘15 – Oct ‘16 |
7 |
5 |
2 |
|
Summary: There is a low volume of our patients who receive palliative radiation for bone metastases. During the 11 month period of this study 100% of the patients with the diagnosis of bone metastases who received palliative radiation were reviewed using the ASTRO guidelines. Five of the patients received 10 Fractions or less and 2 of the cases reviewed received 14 Fractions. These 2 cases were noted to be spinal treatment and should not be re-treated therefore a slightly higher dosage was used to minimize the chances of returning. Care was deemed appropriate to manage the pain. |
|||
Actions/Improvements
- Care is appropriate
- Continue to review through CMS requirements
- Share results with Radiation Oncologist
- Study is complete