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Driving Improvement in Oncofertility Shelby Darland, RN, MSN, CPHQ, Jennifer Eichmeyer, MS, CGC, Kelli Christiaens, RN, Kallie Penchansky, MHS, Michele Betts, LCSW, Dan Zuckerman, M.D., and Thomas M. Beck, M.D. St. Luke’s Mountain States Tumor Institute, Boise, ID Background: In 2006 the American Society of Clinical Oncology (ASCO) recommended that oncologists discuss infertility as a result of cancer treatment with patients of reproductive age and provide referrals to specialists as needed. Despite these guidelines the majority of cancer centers are not in compliance. Mountain States Tumor Institute (MSTI) piloted a process to improve quality of oncofertility preservation (OP) through identification, documentation, and referral to reproductive specialists. Methods: A physician survey in 2010 indicated that perceived barriers to OP discussion were a lack of accessible materials as well as oversight on the part of the provider. Random chart audits of the Quality Oncology Practice Initiative (QOPI) measures (infertility risks discussed prior to treatment and fertility preservation options discussed/referral to a specialist) occurred biannually at that time. To increase awareness of the data chart audits and reporting shifted to quarterly and included all patients that met OP criteria. Additionally, a committee was formed in 2011 to develop patient/provider packets, collaborate with the local reproductive specialists, and create an OP process. The committee established an OP algorithm involving support staff to flag patients of reproductive age at initial medical oncology consultation and utilizing genetic counselors (GC) and social workers (SW) to expedite and facilitate referrals to reproductive specialists. GC/SW were chosen due to sensitivity with psychosocial issues and to share the additional workload. The OP program was launched in October of 2012. Results: Baseline assessment in 2009 revealed MSTI was compliant 6% and 6%. Six months after program initiation the OP measures improved to 47% and 45% respectively. Notably March and April 2013 showed dramatic improvements with 100% and 75% compliance for both OP measures. Conclusions: It is well known that OP has been a challenge for many cancer centers. This multipronged approach is an example of a novel process implementation that demonstrated significant improvement with the QOPI oncofertility measures. Continued work is needed on improving physician documentation and consistency of OP patient identification. New Patient Representative (NPR) assesses “Is patient female age 18-40, male 18-50 with a cancer diagnosis?” NO Nothing further is needed and the Quality checklist (QCL) reminder is deleted YES, NPR flag Baseline Health History (BHH) with yellow dot sticker MD assesses “Does patient require treatment that would affect fertility?” NO MD document patient does not require treatment or is not at risk for infertility •ASCO recommended that infertility as a result of cancer treatment should be discussed •Several studies have demonstrated that patients place high value on fertility discussions •QOPI includes two OP measures 1) infertility risks discussed prior to treatment and 2) fertility preservation options discussed/referral to a specialist •Despite these guidelines the majority of cancer centers are not in compliance •To improve measures and quality MSTI piloted a process that included identification, documentation, and referral to reproductive specialists Methods •In incremental stepwise approach over several years included: •A MSTI physician survey in 2010 suggesting perceived barriers to OP discussion were 1) a lack of accessible materials and 2) lack of oversight on the part of the provider •A shifting of chart audits and reporting to quarterly in 2011 to increase awareness of the data, and in 2012 from quarterly to monthly •Committee formation in 2011 to develop patient/provider packets (Figure 3), collaborate with the local reproductive specialists, and create an OP process (Figure 1) which launched in October 2012 •Infertility Risks Discussed improved from 6.3% (n=16) in 2009 to 47% (n=64) in July 2012June 2013, and most notably to 67% (n=15) in July-August 2013. (Table 1) •Fertility Preservation Options Discussed improved from 6.3% (n=16) in 2009 to 45% (n=64) in July 2012-June 2013, and most notably to 64% (n=14) in July-August 2013. (Table 1) Oncofertility Results YES MD assesses “Does patient want children in the future?” NO 67% 64% 70% MD document patient does not desire children and is aware of risk of infertility YES 38% RN/MD completes referral for Oncofertility consult by: Order on referrals tab Complete the referral document (Figure 2) Document/dictate the fertility risk assessment, discussion of options, and referral Secretary/RN/MD sends “Oncofertility Consult” QCL to Oncofertility location 31% 40% MD informs patient of risk and MD/RN provides oncofertility information packet to patient. Is patient interested in further information or referral? NO MD document patient does not desire further information or Oncofertility consultation Social Work/Genetic Counseling to: Monitor the Oncofertility QCL Confer with Primary RN/MD Follow-up with patient. Is patient interested in referral to Idaho Center for Reproductive Medicine (ICRM)? YES NO, SW/GC to document pt does not desire referral SW/GC will access patient authorization to disclose PHI, coordinate faxing of referral form & medical records to ICRM with HIM, and document Figure 2. St. Luke’s MSTI Referral Form Figure 3. Fertile Hope Provider & Patient Resources 47% 45% 60% 50% YES Background Results Percent Compliance Abstract Figure 1. St. Luke’s MSTI OP algorithm 20% 10% 25% 19% 20% 30% 6% 6% 7% 0% Fall 2009 Fall 2010 Spring 2011 Infertility Risks Discussed Jul 11Jun 12 Jul 12Jun 13 Jul 13Aug 13 Fertility Preservation Options Discussed Table 1 Conclusions •Because OP issues are challenging, cancer centers may need to consider several methods to maximize resources including physician education, written materials, a reminder system, and frequent auditing •Specialties such as GC and SW can be utilized as they have training to address the sensitive needs of OP patients and help facilitate the referrals •Continued work is needed on improving physician documentation and consistency of OP patient identification •This multipronged approach is an example of a novel process implementation that demonstrated improvement with QOPI Oncofertility measures References •The Quality Oncology Practice Initiative (QOPII®) is a physician-led quality improvement program of the American Society of Clinical Oncology for hematology-oncology practices •Lee, S.J., Schover, L.R., Partridge, A.H., Patrizio, P., Wallace, W.H., Hagerty, K., Beck, L.N., Brennan, L.V., Oktay, K. (2006). American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. Journal of Clinical Oncology; 24 (18): 2917-2931. •Fertile Hope (2012) Cancer & Fertility: Fast Facts for Oncology Professionals and Patient Education Booklet, Risk for Amenorrhea, Risk of Azoospermia, Female and Male Reproductive Options. Retrieved from www.fertilehope.org.