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Michael Gieske, MDDirector Lung Cancer ScreeningSt Elizabeth HealthcareEdgewood, Ky.

September 30, 2020

Our Landscape

•First&onlyhealthcaresysteminKY,OHorINtopassMayoClinic’sreviewprocesstobecomeamemberoftheMayoClinicCareNetwork•CollaborationwithothercommunityhospitalsandtheUniversityofKentuckyaspartoftheUKMarkeyCancerCenterAffiliateNetwork•MemberofKentuckyHealthCollaborative,a10system,60hospitalaffiliationdedicatedtoimprovingthehealthofKentuckians

StElizabethHealthCare- Foundedin1861inCovington,KY

St.ElizabethHealthCare(SEH)operatessevenhospitalfacilities,servingtheNorthernKYTristateRegion,includingKentucky,Ohio,andIndiana

Dearborn County

• Text here.

Our Landscape

Comprehensive Cancer Center - BeginningsAnnounced development of a $140 million cancer center on the Edgewood campus

GROUND BREAKING AUGUST 9, 2018!

Comprehensive Cancer CenterOpen to patients October 2020

140 Million Dollar Center244,000 Square Feet

Atrium and Grand StaircaseFrom Concept to Reality!

Complete IntegrativeMedicine Department

State of Art Tumor Board Auditorium!

“Thousands of families are devastated each year as the disease continues its relentless spread through the state.” Laura Ungar, USA Today

Kentucky also has one of the lowest five-year survival rates after diagnosis: only 17.6 percent of Kentuckians diagnosed with lung cancer live for at least five years after their diagnosis

Heat Map of Cancer Death Rates

Hotbed of Cancer Deaths in Ky,

especially Eastern Ky.

Cancer Deaths in the United States

Hotbed of Cancer Deaths in Ky,

especially Eastern Ky.

The national total of all healthcare costs associated with cancer care is projected to be

$174 Billion in 2020 !

KY 233.6 cancer deaths/100,000

Projections of the Cost of Cancer Care in the U.S.: 2010-2020J Natl Cancer Inst. 2011 Jan

CONFIDENTIAL – FOR INTERNAL USE ONLYUSA, American Cancer Society

= Next 3 Cancers Combined =

142,940

CONFIDENTIAL – FOR INTERNAL USE ONLY

Kentucky, American Cancer Society

= Next 5 Cancers

Combined = 3,040

CONFIDENTIAL – FOR INTERNAL USE ONLY

National Lung Cancer Incidence

Kentucky – 92.6

National Average – 59.6

Utah – 27.1

OHIO – 68.9%

Ind. – 73.2%

Incidence of Lung Cancer by State

Ky. Incidence of Lung Cancer is the highest in the country at 93.5 per 100,000

people

TOBACCO BELT

Smoking Prevalence in the United States

KY 23.4% vs. WV 25.2%

2019 America’s Health Rankings Annual Report

These state-specificLung Cancer rates are directly parallel to USA smokingprevalence rates.

16.1% Adults Smoke

National Lung Cancer Survival

Nov. 13, 2019 Amer. Lung Assoc. State of Lung Cancer Report

Kentucky – 17.6%Five-Year Survival

National Lung Cancer 5-Year Survival

Kentucky – 17.6National Average – 21.7

New York – 26.4

Alabama – 16.8Ohio – 20.0

(Indiana – N/A)

CONFIDENTIAL – FOR INTERNAL USE ONLY

5 Year Survival Rates – 2018 American Cancer Society

The numbers below come from thousands of people from all over the world who were diagnosed with NSCLC between 1999 and 2010. Although the numbers are based on people diagnosed several years ago, they are the most recent rates published for the current AJCC (Am Joint Comm. Ca) staging system.

5 Year Survival RateNon Small Cell Lung Cancer (NSCLC)

Stage IA1 92%

IA2 83%

IA3 77%

IB 68%

IIA 60%

IIB 53%

IIIA 36%

IIIB 26%

IIIC 13%

IVA 10%

IVB < 1%

5 Year Survival RateSmall Cell Lung Cancer (SCLC)

Stage I 31%

II 19%

III 8%

IV 2%The numbers below are relative survival rates calculated from the National Cancer Institute’s SEER database, based on people who were diagnosed with SCLC between 1988 and 2001

These survival rates are based on the TNM staging system in use at the time, which has since been modified slightly for the latest version. Because of this, the survival numbers may be slightly different for the latest staging system.

Stage Matters!

Stage Impact on NSCLC Treatment Patterns

45% surgery alone

66% chemo and/or XRT32% no treatment

CMS Criteria• 55 – 77 yr old (USPSTF 55 – 80 yo)

• 30 pack year smoking history

• Current smoker or quit within the prior 15 years

• Asymptomatic – No current signs or symptoms suggestive of LC

LDCT Lung Cancer Screening

How are we doing?

A total 1.9% of more than 7.6 million current and former heavy smokers in the United States underwent lung cancer screening in 2016 2018 ASCO (Amer Soc Clin Oncol) Annual Meeting

In 2015, among those who met USPSTFcriteria, 4.4% (95% CI=3.0%, 6.6%) Jan. 2019 American Journal of Preventive Medicine

The estimated population meeting USPSTF criteriafor lung cancer screening in 2015 was 8,098,000

JAMA September 2017

3.9% 2015

A total 4.2% in the United States underwent lung cancer screening in 2018, ranging from 0.5% in NV to 12.5% MA (Ky. at 10.3%) Nov. 13, 2019 Amer. Lung Assoc. State of Lung Cancer Report

2014

(Lots of) Room for Improvement

Drop in U.S. Cancer Death Rate

CONFIDENTIAL – FOR INTERNAL USE ONLY

CONFIDENTIAL – FOR INTERNAL USE ONLY

National Lung Cancer Screening Rates

National Lung Cancer Screening Ranking

• St. Elizabeth HealthCare implemented the LDCT Lung Cancer Screening Program, and began to track data in 2013

• Earned Designation as a ‘Lung Cancer Screening Center’ by American College of Radiology (ACR) and a ‘Lung Screening Center of Excellence’ by the Lung Cancer Alliance (now GO2 Foundation) in early 2015

• As of August 2020, over 600 hospitals in the country are SCOEs, spanning 44 states

• In April 2020, we were awarded the GO2 Foundation’s Care Continuum Center of Excellence designation which recognizes centers with patient-focused coordinated, multidisciplinary care led by the expertise of a nurse navigator. (1 of less than 40 centers nationally)

Laying the Foundation

• Investment by St Elizabeth Healthcare to develop Thoracic Oncology as a Lung Center of Excellence, and a key Component of the new Cancer Center

• Collaboration of SEH (St Elizabeth Healthcare) and SEP (St Elizabeth Physicians)

• An integral part of our Health Care System’s goal to make Northern Ky. one of the healthiest communities in the country

• Smoking Cessation has also become a central component of these initiatives, and a collaboration of SEH and SEP, as well

• LDCT Lung Cancer Screening is playing an integral role in this initiative

Executive and Administrative Support

Stuck on the Bottom << 2013 – 2016 >>Sc

ans

per M

onth

Lung-RADS v1.1 Lung-RADS =Lung Imaging Reporting And Data System

• Nodule Review Board (NRB) – critical – meets every Monday 7:00 a.m.o All Cat 4 LCS nodules, and Incidental nodules/masses – ‘Code Lung

Management’o Pulmonologist, Thoracic Surgeon, Radiologist, PC Advocate/LCS Director,

LCS and Thoracic Oncology Nurse Navigatorso Screening Program, Incidental, and Symptomatic results reviewedo Recommendations are forwarded to the PCP, patient, and appropriate

orders are placed for SCP referral, and/or follow-up imaging

Nodule Review Board

The EMR (Epic) WorkflowNudging the provider and lowering barriers

Emphasizing Accuracy of Smoking History

EMR Health Maintenance Prompt

LDCT LCS BPA – Best Practice Alert/Advisory…approved 11/15/17

Other Qualifying Chest CT Codes Accounted

Our Epic SmartSet

Click for Drop-Down Dx List

Choose Diagnosis

Open SmartSet

Yes, by default

Yes, by default

Yes, by default

Yes, by default

Order expires in 1 year

Annual or Baseline

Current or Former Smoker

Epic Progress Note EntryProblem Focused Charting, LDCT SDM Component

Hard-Stop if patient does not meet criteriaCriteria must be met, and smoking history must support and be

up to date

CPT Code – G0296

G0296 - SDM Aides

Ky Cancer Program (KCP)Ky LEADS Collaborative

Flyer/Poster for Exam Rooms

Using Data to Promote Confidence and Buy-in

LCS RegistryLung Cancer Screening Registry - St. Elizabeth HealthCare

2020 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

LDCT LC Screens 346 379 212 13 114 256 430 431 2181

Category 1 Total 204 216 130 6 71 166 266 250 1309

Category 2 Total 108 108 55 5 30 67 118 136 627

Category 3 Total 18 29 18 0 7 16 31 25 144

Follow up screen 28 27 19 8 27 33 21 35 198

Category 4 Total 16 26 9 2 6 7 15 20 0 0 0 0 101

Category 4A 13 17 6 2 4 7 6 15 70

Category 4B 3 9 3 0 1 0 7 5 28

Category 4X 0 0 0 0 1 0 2 0 3

Category S Total 19 23 15 1 6 14 25 29 132

Referrals - screening 0

MultiD - screening 0 2 1 0 0 0 0 1 4

Pulmonary Referral - screening 4 1 1 0 1 1 3 3 14

Thoracic Referral - screening 4 9 3 0 2 3 7 5 33

Total 8 12 5 0 3 4 10 9 0 0 0 0 51

3 month follow up CT rec. 9 9 7 0 4 3 3 9 44

6 month follow up CT rec. 4 4 0 1 0 2 1 0 12

12 month follow up CT rec. 1 0 0 1 0 0 0 2 4

Referrals - Incidental

MultiD clinic - incidental 6 5 0 0 0 0 0 2 13

Pulmonary Referral - incidental 8 8 11 0 5 4 7 6 49

Thoracic Referral - incidental 5 7 6 4 9 14 7 4 56

Total 19 20 17 4 14 18 14 12 0 0 0 0 118

3 month follow up CT rec. 5 5 13 6 5 6 4 7 51

6 month follow up CT rec. 4 1 11 0 1 2 0 7 26

12 month follow up CT rec. 2 1 1 0 3 0 2 1 10

PET/CT (screening) 5 8 2 0 2 1 7 4 29OR (screening) 1 3 2 0 1 0 1 0 8

OR pending 3 2 0 0 2 0 1 1 9

DX Lung Cancer 3 8 1 0 1 1 2 1 17DX Cancer- other 0 1 0 0 0 0 0 0 1Incidental Reviewed 92 97 110 52 94 101 80 111 737

# of scans outside of criteria 11 5 0 0 0 0 0 1 17

Annual Screening Exams 200 193 117 12 81 173 280 300 1356

Baseline Screening Exams 146 186 95 1 33 83 150 131 825

Total 346 379 212 13 114 256 430 431 0 0 0 0 2181

Registry Summary

*NLST - 24.2% Positive Findings - >4mm (18,146 positive scan/75,126 Total LDCTs done)Also positive if effusion, adenopathy, or other abnormalities suspicious for Lung Cancer

***Positive LDCT determined negative for LC/Total Positive LDCT Scans = FALSE DISCOVERY RATENLST - 96.4% False Positive (17,497/18,146), really the false discovery Rate

- the actual FALSE POSITIVE RATE is 23.3% (18,146 - 649/75,126)** - FALSE POSITIVE RATE is false positive scans (positive LDCT scan determined to be negative for LC)/ Total all LDCT scans

Analysis of Positive Scans - St. Elizabeth Healthcare --- 1/1/2015 - 8/31/2020Year 2015 2016 2017 2018 2019 2020 TOTAL % Scans False Positive False Discovery # Scans to

Total LDCT LC Scr. SCANS 252 753 1965 3585 4082 2181 12818 * ** *** find 1 LC

Annual 1815 1356 3171Baseline 2267 825 3092

Cat 1 127 457 1164 2194 2312 1309 7563 59.00%Cat 2 76 201 506 887 1250 627 3547 27.67%Cat 3 (Indeterminate) 22 47 143 240 250 144 846 6.60%Cat 4 (Suspicious) - Total 27 48 152 264 270 101 862 6.72% 4.93% 73.32%

Cat 4A 16 33 108 186 188 70 601 4.69%Cat 4B 11 15 44 78 82 28 258 2.01%Cat 4X 3 3 0.02%

Cat 3 + Cat 4 - Combined 49 95 295 504 520 245 1708 13.33% 11.53% 86.53%Lung Cancer 5 16 37 82 73 17 230 1.79% #LC/per Tot LDCT = 55.7

Quarterly Update for Oncology Team and PCPs

Ranked by site

Quarterly Update for Oncology Team and PCPs

Ranked by PCP

Tracking Our Progress – SEP Attributed Pts. - 2019

Lung Cancer Screening Quality Measure

2019Denominator:

9541

Numerator: 3464

Completed: 36.31 %

2019Denominator:

12851

Numerator: 3835

Completed: 29.84 %

2020 Data – as of 6/15/20

Denominator* 10,627 12,829

Numerator 1,654 1,777

Quarter 1 Completed 1631 1642

Have Ever Completed 7,609 8,720

Percentage Ever Captured (since 2013)

71.6% 67.97%

Data, as of 6/15/20

SEP – Attributed to PCP SEHC - System

Lung Cancer Compendium – 2014 - 2020 YTD

7/28/2020 36 21 20 The tumor cells are positive for CAM 5.2, MOC31, CD56, focally positive for TTF1 (2 clones), synaptophysin, and negative for p40

3/4/2016 64 69

Over 236 Lung Cancers to date

Snapshot – Team-Based Documentation of Program

Overall Lung Cancer Discovery

Stage N %

Stage I 134 56.8%

Stage II 28 11.9%

Stage III 41 17.4%

Stage IV 33 14.0%

Unknown 0 0%

Total 236

Stage I & II 68.6%

Average PY = 57.8

Cancer Stage 2014 – 2020 YTD

Stage per YearYear I II III IV UNK Total % I2014 1 1 0 2 0 4 25.0%

2015 2 2 1 0 0 5 40.0%

2016 12 1 2 1 0 16 75.0%

2017 25 1 6 6 0 38 65.8%

2018 44 11 15 11 0 81 54.3%

2019 36 9 17 11 0 73 49.3%

2020 14 3 0 2 0 19 73.7%

Total 134 28 41 33 0 236 56.8%

68.6% found in early stages

Lung Cancer Screening - Data Generated

Lung Cancer TypeType N %

adenocarc. 98 42.4%squamous 74 32.0%small cell 28 12.1%limited 13

extensive 15

large cell 3 1.3%carcinoid 3 1.3%other 3 1.3%unknown 22 9.5%

231 100%

FemaleMale

49.8%50.2%

100%

116115231

Age N %

<40 0 040 - 44 0 045 - 49 0 050 - 54 0 055 - 59 34 14.7%60 - 64 58 25.1%65 - 69 62 26.8%70 - 77 76 32.9%78 - 80 1 0.4%

>80 0 0TOTAL 23155 - 77 yo 230

Marketing

7 Years of Progress

Trendlines

Making a Difference!

Building Teams – Engaging the PCPBuilding Teams• Primary Care Advocate – catalyst – Became Director Lung Cancer Screening Nov.1, 2019• Started with LDCT Lung Cancer Screening Work Group – met Quarterlyo Oncology, Pulmonology, Radiology, Social Work, Value Based Performance, Quality and

Compliance, Care Management, IT, Report Writers, Process Improvement, Clinical Transformation, Primary Care, Management

• Now have a smaller Lung Cancer Screening Team – meets Weeklyo Director LCS, Director Integrative Oncology, Screening NNs, Thoracic Oncology NN, Quality

Transformation Consultant, Coordinator Strategic Initiatives, Thoracic Oncologist, Research Consultant

• Thoracic Oncology Disease Management Team (TODM) – meets Monthly• Weekly Huddle with Executive Director Oncology, Chief Thoracic Surgeon, Chief Thoracic

Oncologist, Director Oncology Services

Building Teams – Engaging the PCP

• Annual Symposium, 5th to take place Nov. 11, 2020• Presentations to Executive Team, Management, Providers, PC leadership• PCP Site Visits - Thoracic Surgery, Nurse Navigator, Primary Care Advocate• Provider Outreach – Staff Messages, addressing barriers (AAFP – grade ‘I’), gathering

valuable feedback

Education, Primary Care and Specialty Care Outreach

Building Teams (Continued)• Quality Transformation and Patient Outreach Teams - oversight of ordered screens,

annual and subsequent follow-up screens• Research – Clinical Research Institute, Data analysts, Report writers• Continuous Collaboration with Hospital and Physician Group Executives and

Management, Monthly Executive Update

Best Practices – Engaging the PCP

The PATH to TREATMENT• Nodule Review Board (NRB) – critical – every Monday 7:00 a.m.o All Cat 4 LCS nodules, and Incidental nodules/masses – ‘Code Lung Management’o Pulmonologist, Thoracic Surgeon, Radiologist, PC Advocateo Screening Program, Incidental, and Symptomatic results reviewedo Recommendations are forwarded to the PCP, patient, and appropriate orders are placed for

SCP referral, and/or follow-up imaging• Role of Nurse Navigator – the ‘glue’ for the program• Patient and Provider Communication• Getting PCP Buy-in, building confidence and trust, transmitting feedback to PCP Advocate• Programmatic Approach – improved time-efficiency, cost-effectiveness (TCC), reduced risk/harm• Retentiono Follow-up for Annual Screenings with Mailings, MyChart Messages, Care Management Outreach• Intake Coordinator to assure that criteria, and risk determination is met for Retail Group 2 Option

Standardized and Seamless Care of Patient – AFTER THE SCAN

Nodule Review Board & Flow Algorithm

The Lung Cancer Screening Team

1. Ordering provider verifies eligibility and has Shared Decision-Making Discussion with patient and enters lung cancer screening order in EPIC

2. Patient schedules scan through Central Scheduling. Central Scheduling to verify patient meets criteria. (For 7 Pilot offices, Central Scheduling contacts patient to schedule)

3. Patient completes scan and results are forwarded to Lung Cancer Screening Nurse Navigator in-basket

Lung Cancer Screening Workflow

Nurse Navigator Reviews Results, Provides Follow-up Instructions

1. Patient receives letter2. Annual low dose screening recommended

• CAT 1 – No nodules found on scan

• CAT 2 – Probably benign – new nodules less than 4 mm, nodules less than 6 mm, ground glass nodule less than 20 mm, or nodule that is stable for >3 months

1. Patient receives letter2. Annual low dose screening recommended

Nurse Navigator Reviews Results, Provides Follow-up Instructions

1. Patient contacted by Lung Cancer Screening Nurse Navigator regarding results. Ordering MD notified of results.

2. Lung Cancer Screening Nurse Navigator to enter order for follow-up lung cancer screening CT (IMG10913) and will route to ordering MD for co-signature. Lung Screening Nurse Navigator will offer to schedule the follow up scan, or the patient or ordering MD office will need to contact Central Scheduling to set up scan.

3. Patient receives letter, 6 months follow up recommended. If stable at 6 months, 12 months follow up thereafter.

• CAT 3 – Probably benign – Nodules 6-7 mm at baseline, new nodules 4-5 mm, ground glass nodule greater than 20 mm

Nurse Navigator Reviews Results, Provides Follow-up Instructions

• CAT 4 – All cat 4 nodules are automatically reviewed at case conference, Nodule Review Board, including incidentally found nodules and masses: radiology report should end with ‘Code Lung Management’ (that tag means the case will be presented at the next nodule review board, and next steps will be forthcoming)

Nurse Navigator Reviews Results, Provides Follow-up Instructions

4. Nodule Review Board note/recommendations will be sent to ordering MD5. Ordering MD to put in referral for Pulmonology or Thoracic Surgery, if applicable6. Patient will receive letter with recommendations

• CAT 4A – Suspicious finding. Nodules 8mm to 14mm at baseline, new or enlarging nodule 6-7mm endobronchial nodule.

• CAT 4B – Suspicious finding. Solid nodule 15 mm or larger, new or growing nodule 8 mm or larger.

1. Ordering MD will be routed results2. Patient will be reviewed at Nodule Review Board occurring every Monday at 7am3. Patient will be contacted by Lung Cancer Screening Nurse Navigator on Monday or

Tuesday regarding Review Board recommendations.

Role of the Screening Nurse Navigator

• Review LDCT results and convey results to patients and ordering providers

• Compile lists for Nodule Review Board (Screening CAT 4A/4B, Incidental "CODE LUNG MANAGEMENT")

• Attend Nodule Review Board, enter recommendations notes, call patients with results and recommendations

• Enter orders for follow up scans, scheduling and referrals• Track patients to make sure they're getting appropriate and timely

referrals and follow up scans• Provider and patient outreach – office visits, Thoracic Symposium

presentations, health and senior fairs

When will the Nurse Navigator contact my patient

• Incidental findings on LDCT - “S"• CAT 3 LDCT needing a follow up CT• CAT 4A/4B after NRB with recommendations• "Code Lung Follow Up" needing follow up orders and

scheduling• "Code Lung Management" after NRB with recommendations• Any time a provider or patient has questions or requests!

Best Practices – Engaging the PCP and Beyond

Community Outreach – Getting the Good Word Out• Marketing, St Elizabeth Website, FaceBook Live, News Media• Executive Sponsoring and Promotion of Program – Garren Colvin Community and System Addresses,

State of the System • Senior Community Organizations, Edgewood• Senior Fairs, Primewise• Rotary Club• St. Elizabeth Foundation - Fundraisers, Retreat, Fall Fashion Show

Data Assimilation and Analysis• Registry, Epic Lung Module• Lung Cancer Compendium• Quality Control – FP, adverse events, Screen to Dx, Dx to Rx, Screen to Rx• Demonstration of Stage Migration

Determining ROI – Lung Cancer Screening

Prior to Lung Cancer Diagnosis

• Imaging - LDCT (G0297), SDM (G0296), CXR, LDCT F/U, CT chest w and wo contrast, PET (CPT 788150)

• Bronchoscopy – including BAL, EBUS/ENB, ENAV

• Tissue Diagnosis - Mediastinoscopy (CPT 32604), VATS (DRG164), IR – TTNA (CPT 32405)• Pathology to determine diagnosis

• Incidental Findings – imaging, biopsy, surgery, treatment

After Lung Cancer Diagnosis

• Pathology to determine treatment, including special studies, biomarkers• Surgery – VATS, RATS, Open Thoracotomy

• Radiation Oncology - SBRT, IMRT, PCR, Palliative Radiation

• Medical Oncology, including Immuno-Oncology

• In-Patient Utilization, and SCP/PCP Office Visits

Determining ROI – Lung Cancer Screening• LCS Costs to Medicare are $1.02 – 2.22 PMPM;• Total Medicare expenditures for 2012 part A and B benefits = $672 PMPM;

So, 0.3% of MC expenditures d/t LCS (Annals of Translational Medicine 2016; 4(8):155)

• Journal of Clinical Oncology 36, no.15, 6/01/18 – LCS net revenue of $770/case. Advisory Board article on Daffodil Health System – demonstrated $739/case.

• 2019 Est. 4,082 LCSs $3,143,1400 at $770/case• 2019 ROI LCS SEHC $211 net revenue/scan = $861,302• THREE WAYS LCS Benefits System and Drives Value

1. Direct Revenue from scans, reimbursement; marginal return2. Downstream Revenue; a significant contribution3. Cost Savings (Reduction TCC, aka improved health!); highly impactful –

more difficult to measure, but major driver in value-based market

Top 12 Best Practices – Engaging the PCP,…and everyone else!

EMR

1. BPAs2. Health Maintenance Prompts3. Other Qualifying CTs of Chest4. Ordering Smart-Set5. Standardized Progress Note Entry6. G0296 Code for SDM (shared decision making) work

Top 12 Best Practices – Engaging the PCP,…and everyone else!

7. PCP Report – attributed patients• Site and Provider Specific – shared at least quarterly with

providers and management8. System Summary - shared at least quarterly9. Dashboard – updated at least monthly

Performance and Status Reports

Top 12 Best Practices – Engaging the PCP,…and everyone else!

10. Communicate, communicate, communicate11. Educate, educate, educate12. Demonstrate and refine ROI

Other