Transcript Document
2014 Cancer Program Performance Outcomes Introduction • • • • Saint Agnes Medical Center has proudly maintained a American College of Surgeons’ Commission on Cancer (CoC) approved cancer program since 1986, providing service to our community, cancer patients and their families as well as physicians, researchers and the State of California Cancer Registry. As part of our CoC accredited status we also participate in the National Cancer Data Base (NCDB) which offers us the opportunity to compare our cancer program’s performance to nationally recognized standards of care. The Commission on Cancer accountability and quality improvement measures include the following: Breast measures: – BCS (surveillance measure rating not included): Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer. – BCSRT: Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. – MASTRT: Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer with =/> 4 positive regional lymph nodes. – MAC: Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under age 70 with AJCC T1cN0M0, or stage IB – III hormone receptor negative breast cancer. – HT: Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or stage IB - III hormone receptor positive breast cancer. – nBx: Image or palpation guided needle biopsy (core of FNA) is performed to establish the diagnosis of breast cancer. Colon measures – ACT: Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under age of 80 with AJCC Stage III (lymph node positive) colon cancer. – 12RLN: At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. • • • Rectum measure: – RECRT (surveillance measure rating not included): Radiation therapy is considered or administered within 6 months (180 days) of diagnosis for patients under age 80 with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer. Gastric measure: – G15RLN: At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer. Non-Small Cell Lung measures: – 10RLN (surveillance measure rating not included): At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC. – LCT: Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is considered for surgically resected cases with pathologic, lymph node-positive (pN1) and (pN2) NSCLC. Through our unrelenting pursuit of excellence Saint Agnes Medical Center continuously evaluates our performance to insures that we provide the highest quality patient care. As a result, since the inception of NCDB Cancer Program Performance Ratings (CP3R) our designated Comprehensive Community Cancer Program (CCCP) has met and/or exceeded compliance for each of these important quality measures. For your inspection, the following slide display our CoC performance ratings. Saint Agnes Medical Center’s Cancer Program Performance Ratings COMPLIANCE ACHIEVED ALL YEARS All ratings within 95% Confidence Interval Range & Comparable to CoC program type CCCP CoC Measure 2010 2011 2012 Rating all years MASTRT 91% 75% 86% 86.36% BCSRT 93% 100% 90% 95.29% MAC 91% 89% 100% 92.59% HT 98% 95% 100% 97.5% nBx 83% 87% 85% 85.02% ACT 100% 86% 67% 84.21% 12RLN 84% 83% 82% 82.95% G15RLN 60% 100% no data 71.43% LCT 100% 100% 100% 100% COMPLIANCE