Engaging managing physicians in clinical staging prior to the initiation of cancer treatment

Background: Managing physicians (medical oncologist, radiation oncologist, surgeons) have a responsibility to clinically stage patients prior to the initiation of cancer treatment. Clinical staging not only directs the treatment plan, but identifies appropriate clinical trials and estimates prognosis. We sought to determine whether engagement of managing physicians would result in increased clinical staging for various types of cancer. Methods: Baseline data on clinical staging for breast, colorectal (colon, rectal, anal, rectosigmoid junction)*, thoracic (lung esophageal)†, genitourinary (prostate, penis, testes)‡, and pancreatic primary cancers were obtained. The data were grouped by disease type and sub-specialty of the managing physicians. Based on that data, several performance improvement initiatives were implemented to provide managing physicians the opportunity to clinically stage the cancer patient prior to the initiation of treatment. The initiatives for completing and documenting staging were: a tutorial on use of Problem List in the electronic medical record (EMR); modification of history & physical and consult notes to include a field for staging; sharing among sub-specialties the smart lists within the template to allow for customization of existing templates; and 1:1 review with physicians who had outliers without clinical staging. Results: Clinical staging documented prior to the initiation of cancer treatment significantly increased in all five types of cancers studied (p \u3c .01; Table). Conclusions: Though collaborative efforts by managing physicians continues to evolve, in many cases, use of the electronic medical record through a variety of performance improvement initiatives has facilitated documentation of clinical staging of cancer patients prior to the initiation of treatment. This engagement changed practice patterns, aligned our institution with best practice guidelines and aided in treatment selection for the best possible patient outcomes. Documentation of clinical staging prior to initiation of cancer treatment. Cancer20132014 Breast 89% 93% Colorectal* 74% 94% Thoracic† 71% 95% Genitourinary‡ 67% 84% Pancreatic 59% 95

Implementation of treatment pathways in a large integrated health care system

BACKGROUND: ASCO recently addressed the importance and role of treatment pathways in value based medicine. The 35 medical oncologists at QOPI certified Aurora Cancer Care (ACC) are developing its value-based care model around Via Pathways. VIA’s decision support algorithms are evidence based, and updated quarterly by both academic and community oncologists. Regimens are based on efficacy, then toxicity, and finally cost. When available, a clinical trial is the first recommended option. In the 2 years prior to VIA, over 40 different treatment plans were used for first line treatment for Stage II breast cancer. Our initial goal was to determine if pathways would be accepted by a large, diverse and geographically separated group, decrease the number of treatment algorithms used, increase clinical trial enrollment, and reduce ED utilization. METHODS: Stage IV non-small cell lung and stage II breast cancer patients who received first chemotherapy by ACC were selected for analysis. Patients were split into two cohorts: one diagnosed between 10/1/13 – 4/30/14 (prior to VIA) and another between 12/1/14 – 6/30/15 (post VIA). Data collected include demographics, diagnosis, treatments (pathway selected), and ED visits. The data were integrated together and filtered by disease site and treatment pathway. Protocol selection and ED visit rates for the two populations were analyzed. RESULTS: ACC successfully integrated clinical, financial and quality data from its pathway tool with data from other primary systems and demonstrated reporting capabilities. VIA has been well received with a visit capture rate of 81% and on-pathway protocol selection of 82%. Post VIA, clinical trial participation increased 66%. The table below contains a select description of our initial data set. CONCLUSIONS: Adoption of VIA decision support has been high; the tool was used for 92% of patients in the data set. Although the data set didn’t contain a sufficient number of patients to draw statistically significant conclusions, it will serve as a model for ongoing reporting supporting the development of a value-based care model. Number of patients with an ED visit within 7 days of chemotherapy. Pre VIA:Post VIA: n:PTs w/ ED:%:n:PTs w/ ED:% Lung: 72 18 25% 30 7 23% Breast: 76 13 17% 69 6 9

Getting quality data back to frontline providers

Background: Oncology quality performance metrics may be improved by establishing a coordinated process for getting data back to providers. However, establishing ownership of quality metric data can be a challenge, especially in a large, integrated health system. Methods: Aurora Cancer Care’s team developed quality charters and a coordinated process for its 15-hospital, integrated health system that outlines a course of action for metric selection, data distribution, peer review and development of process improvement plans. A weighted tool was developed and implemented to prioritize measure selection. The weighted tool described and scored each quality measure against its performance improvement opportunity, ease in data collection, national benchmarks, regulatory and reimbursement impact, value to the patient and consideration of the resources required to implement change. The final score was used to prioritize and select measures. The System Multidisciplinary Disease-Specific Quality Subcommittees established quality measures. Abstraction began, outliers were reviewed and results were disseminated to the System Cancer Leadership Council as well as the 15 hospitals via the Regional Cancer Quality Subcommittees (RCQS). The RCQS chairs and quality directors meet quarterly with the system quality liaison to ensure the communication of data back to the front-line providers. Results: We found a rise in the percentages of invasive rectal cancers diagnosed with endorectal ultrasound or magnetic resonance imaging (no stage IV) (2012: 76%, 2013: 84%) and treated with total mesorectal excision (no stage IV) (2012: 72%, 2013: 87%). In addition, increases in the examination of at least 12 regional lymph nodes for invasive colorectal cancer (2012: 93%, 2013: 98%; p\u3c0.05) and partial, rather than total, nephrectomy for renal cancer patients with T1a tumors (2012: 71%, 2013: 95%; p\u3c0.05) were statistically significant. Conclusions: Though our coordinated process to get quality data back to providers continues to evolve, our front-line providers have shown greater enthusiasm for the data, engaged in behavior modification and become more accountable with process improvement plans that are integral to establishing the best patient outcomes

Establishing a Community-Based Lung Cancer Multidisciplinary Clinic As Part of a Large Integrated Health Care System: Aurora Health Care

This Lung Cancer Multidisciplinary Clinic (MDC) included medical and radiation oncologists, a thoracic surgeon, and a pulmonologist and met every third week. Establishment of the clinic resulted in improvements in quality of care, patient satisfaction, and patient retention