Transcript Lifting all Boats: Quality Improvement as a Means to Reducing

LIFTING ALL BOATS:
Quality Improvement as a Means to Reducing Racial Health
Disparities
Anne Marie Murphy, PhD1, Danielle Dupuy, MPH 2, Garth Rauscher, PhD 3, Terry Macarol, RT(R)(M)(QM)C-BPN-IC 4,
, Ryan Alvarez, MS 2. (1) Chicago Breast Cancer Quality Consortium, Metropolitan Chicago Breast Cancer Task Force, 1645 W. Jackson
Blvd., Suite 450, Chicago, IL 60612. (2) Chicago Breast Cancer Quality Consortium, The Metropolitan Chicago Breast Cancer Task Force,
1645 W. Jackson Blvd., Suite 450, Chicago, IL 60612. (3) School of Public Health, University of Illinois at Chicago, Division of Epid/Bios
(M/C 923), 1603 West Taylor Street, Chicago, IL 60612. (4) Advocate Health Care, 2025 Windor Dr, Oak Brook, IL, 60523.
Presented by:
Terry Macarol RT,(R)(M)(QM)C-BPN-IC
The Response
1st Symposium:
In response to the evidence, a ‘Call to Action’ Summit was held that brought together clinicians, researchers, breast cancer survivors and other interested community
members. Three areas were hypothesized to be at the root cause of the disparity: Access to Mammography, Quality of Mammography and Quality of Treatment. From the
Call to Action Summit, a report was released in October 2007 detailing 37 recommendations to Chicago on how to improve breast cancer outcomes for all women in the city.
One recommendation was to develop a Consortium of Chicago area health care institutions that would review quality data and implement quality improvement
interventions around breast cancer screening and treatment.
Based on the high level of participation and the energy around this project, the
Consortium teamed up with Med-IQ and the Illinois Hospital Association to put on its
first symposium: “Improving Quality and Reducing Disparities in Breast Cancer Care
and Outcomes”. Representatives from over 60 institutions attended the event.
Multi-disciplinary teams in breast care from participating hospitals discussed the
significance of the data and the challenges they deal with in their attempts to deliver
high quality breast care.
The Chicago Breast Cancer Quality Consortium
The Consortium far exceeded it’s initial goal of bringing 10 institutions on board. This important quality endeavor has solicited participation from 53 institutions representing
over 70% of mammography in Metropolitan Chicago. We credit this high level of participation not only to our diverse and involved board but also to the fact that the
Consortium is the first Patient Safety Organization (PSO) dedicated exclusively to breast health. This federal designation as a PSO provides protection around the data that is
collected assigning it’s use strictly for the purpose of quality improvement.
Data Collection
(Cycle 1)
100
60
40
20
Meets
Standard
Not Shown
to Meet
Standard
60
40
20
0
Proportion Minimal Cancers=
# of cancers, DCIS or ≤ 1 cm )/ # of cancers found
ACR benchmark: 2-10 cancers/ 1000
Our benchmark: 4-9 cancers/ 1000
ACR Benchmark: > 30%
Our Benchmark: > 30%
Percent Disparity
50%
41%
10%
0%
New York City
U.S.
Chicago
Prepared by the Sinai Urban Health Institute
20
ACR Benchmark: None
Our Benchmark: < 20%
Hormone Receptor Testing
80
60
40
20
Not Shown
to Meet
Standard
Timely Treatment=
Patients receiving treatment within 30 days of
diagnosis/ All patients receiving treatment
60
40
20
Meets
Standard
Not Shown
to Meet
Standard
Not Shown
to Meet
Standard
Follow-up Imaging=
Abnormal Mammograms with no follow-up
imaging)/ Total abnormal mammograms
80
Meets
Standard
Meets
Standard
Meets
Standard
60
40
20
Not Shown
to Meet
Standard
0
0
80
70
60
50
40
30
20
10
0
White
67
57
56
21
Digital mammography
avaliable
50
23
All mammography
read by breast
specialists
Face-to-face on same
day as exam
0
80
Our benchmark: ≥ 80%
27%
40
100
0
62%
60
100
70%
60%
80
100
Facilities
All Treatment Measures:
- % Received Radiation Therapy after
breast conserving surgery
- % Tested for Hormone Receptors
- % ER/PR + that received hormonal
therapy
- % Tested for HER-2
- % HER-2 + that were recommended
for herceptin
%
Black and White Breast Cancer Mortality Disparity (3-year
averages) New York City, U.S. & Chicago, 2005-2007
20%
Not Shown
to Meet
Standard
Cancer Detection Rate=
cancers found/1000 screening mammograms
% Facilities
Hospitals with American College of
Surgeons approved Cancer Programs
30%
Meets
Standard
80
QUALITY OF TREATMENT (Sample of Results)
Radiation After Breast
Conserving Surgery (BCS)
Timely Treatment
Hospitals with American College of
Surgeons Approved Cancer Programs
40%
100
% Facilities
Non African American Communities
Non- African American Community
Areas.
Follow-up for Imaging
% Facilities
80
% Facilities
% Facilities
All Screening Measures:
- Recall Rate
- Loss to Follow up Imaging
- Loss to Follow up Biopsy
- Cancer Detection Rate
- Proportion of minimal cancers
- Proportion of early stage cancers
Characteristics of Mammography Services Offered, by
Race, to Women Living in Chicago (2007)
Black
100
0
Predominately African American
Predominately African
American Community Areas.
Communities
It is known that access and quality of care can vary by race. In the city of Chicago it
is likely that such differences play a major role in the mortality disparity.
The first round of data collection resulted in submissions from a total of 40 sites . Institutions could submit on screening data , treatment data or
both and by race where possible. Specifically we asked for data pertaining to screening and treatment measures for a patient population screened for
or diagnosed with breast cancer in calendar year 2006.
QUALITY OF SCREENING (Sample of Results)
Proportion of Minimal
Cancer Detection Rate
Cancers
Chicago Community Areas with the Highest 2000 -2005 Average
Annual Breast Cancer Mortality Rates
Continuing the Fight for High Quality Breast Cancer Care
Percent
The City of Chicago:
In 2007, research was published that demonstrated a large and growing disparity in
breast cancer mortality between Black and White women in Chicago. In 1980, the rates
were roughly similar. Between 2005-2007 however, the mortality rate from breast
cancer among Black women in Chicago was 62% higher than the White rate looking
across a 3 year average. Findings suggest that this disparity is a result of both access
and system issues. When looking at access to care, the location of American College
of Surgeons approved Cancer Programs were largely absent in communities of color
where breast cancer mortality rates were the highest . When thinking about Chicago
as opposed to other urban areas, Chicago’s breast cancer mortality disparity is one of
the highest in the nation, higher than New York City or the U.S. as a whole. This data
suggests that there are system of care issues that need to be addressed.
Radiation after BCS=
Patients receiving radiation after BCS/ All
patients who had BCS
Hormone Receptor Testing=
Patients who were tested for hormone
receptors/ All patients diagnosed with cancer
Our benchmark: ≥ 80%
Our benchmark: ≥ 80%
In working to address the disparities through quality improvement, the
Consortium does not just gather data. We are dedicated to helping institutions
acquire the resources they need to implement quality improvement
interventions. We have received a second Komen grant to:
1. Take a deeper look into the results of our first cycle of data collection, and
the processes in breast care that are integral to quality
2. Determine appropriate interventions and provide resources to institutions
to implement them.
Next Steps (in short):
• Begin Cycle 2 of data collection in January, 2011 to gather information on
patients screened with mammography or diagnosed with breast cancer in
calendar year 2009
• Begin to look into the role of the primary care provider
• Begin to look at quality of survivorship care
• Implement the 2nd Komen Grant
A BIG JOB AHEAD
As of October 18, 2010 the state of Illinois announced the
implementation of SB 1174: the Reducing Breast Cancer
Disparities Act. As part of the implementation of the bill, the
state will be requiring all Illinois hospitals to report quality
data to the Chicago Breast Cancer Quality Consortium: an
amazing demonstration of the states’ commitment to
quality health care.
We will continue to work with all hospitals to help assess
quality and implement improvement interventions.