OSF Saint Anthony's Health Center

Alton, Illinois

Accountability and Quality Improvement 2016

Annual review of accountability and quality improvement measures performance rates for OSF HealthCare 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