public reporting of outcomes 2014 annual report · pi quality improvement rep** denise dunn, ......

Public Reporting of Outcomes 2014 Annual Report

BaptistHealthMadisonville.com 2

Baptist Health Madisonville’s Merle M. Mahr Cancer Center

continues to offer the best possible cancer care to the

communities that we serve. Our approach to cancer care is based

on a team approach, not just a group of medical providers, but a

united team that includes the patient. Our caregivers understand

that the healing process is not just a physical journey, but it is also

an emotional one. We strive to show our patients the compassion

they deserve and to equip them with the knowledge they need to

be an active member of their care team.

The 2014 Merle M. Mahr Cancer Center’s Annual Report showcases our high quality program and

our commitment to our communities. From early detection programs, advanced diagnostic testing,

multidisciplinary treatment teams, and support programs the Merle M. Mahr Cancer Center truly

provides comprehensive care right here at home.

Our cancer program is deeply committed to not only treating cancer, but also increasing awareness

and prevention by making available educational programs, early detection screenings, community

partnerships, and improving access to medical care.

The 2014 Annual Report provides a comprehensive review of the current state of cancer care, survival

rates, and compares our local expertise to state and national standards.

Baptist Health Madisonville is committed to offering high quality, compassionate care in our community.

The resources available from the Merle M. Mahr Cancer Center allow our patients to know that we are

supporting them on their journey to wellness.

Mike BaumgartnerPresident, Baptist Health Madisonville


About the Cancer Program at Baptist Health

As a member of the Baptist

Health Oncology Network, we

continue to provide high quality

care to residents of Western

Kentucky both locally and as a

region partnering with Baptist

Health Paducah. From early

detection programs, advanced diagnostic testing, multidisciplinary

surgical, chemotherapy and radiation therapy treatment options

to support programs, the Cancer Program truly provides

comprehensive care close to home.

The cancer program has been continuously accredited by the

American College of Surgeon’s Commission on Cancer since 1976.

Since 80% of all cancer patients are diagnosed and treated at ACoS

CoC accredited programs, this participation allows our cancer

program to compare our experiences and trends with that of the

nation through the data submissions to the National Cancer Data

Base(NCDB) and participation in the Cancer Program Practice

Profile Reports (CP3R).

Baptist Health Madisonville is part of the Baptist Health Cancer Network delivering high quality cancer care across Kentucky.

Our VisionThe vision of Baptist

Health Cancer Network of Kentucky is to be the

leader among cancer programs offering the most comprehensive, integrated,

quality driven, and patient-centered care in

community-based settings.

Justin Sedlak, MDChairman/Pathologist

Darren Chapman, MD, FACSGeneral Surgery/ Cancer Liaison Physician

Diana Jackson, MSN, RN, OCNCancer Program Administrator


Baptist Health Madisonville2014 Cancer Committee Members

Chairman/Pathologist* Justin Sedlak, MD***

Diagnostic Radiologist* Neal Rosner, MD William Tagg, MD - Designee

General Surgery/ Cancer Liaison Physician* Darren Chapman, MD, FACS***

Radiation Oncologist* Satish Shah, MD

Medical Oncologist* Ali Kanbar, MD

ENT Surgeon William A. Logan, MD, FACS

Pathology* Richard Bauer, MD

Cancer Program Administrator** Diana Jackson, MSN, RN, OCN Director, Oncology Services/Nurse Navigator

Oncology Nurse (Inpatient)** Penny Levill BSN, RNAngie Bland, RN - Designee

Oncology Nurse Practitioner Tracy Hagan, RN, MSN, AONP

Oncology Nurse Navigator Heather Tow, RN, OCN

Clinical Social Worker** Judy Blue, CSW

Cancer Registry** Stacy Littlepage, CTR, Registry Coordinator Teresa Ruddell, CTR - Designee

PI Quality Improvement Rep** Denise Dunn, BSN, RN Lisa Boone, RN - Designee

Clinical Trial Research Associate** Jenifer Miller, RN, OCN

Radiation Oncology Shari Walker, RT(T), Lead Therapist

Chaplain Rev. Bill McCann

Pharmacy Margo Ashby, PharmD Director Cynthia Workman - Designee

Reg. Coordinator Ky. Cancer Program Joan Lang, MBA

ACS Representative Ellen Schroeder

Hospice Care Michelle Byrd, BSN, RN, Hospice Mgr

Rehabilitation Care Kevin Moser, MBA, MS, ATC

Oncology Dietician Sheila Baker, RD

Cancer Registry Dianna Wiles, CTR

Ad Hoc MembersCardiothoracic Surgery T. Mark Stanfield, MD, FACS

Family Practice Residency Faculty William Crump, MD

West Area Health Education Ashley Poore

Medical Library Teresa Ruddell, CTR

* Required Physician Members

** Required Non-Physician Members

*** Registry Advisors


Multidisciplinary Cancer ConferencesGiven our commitment to Commission on Cancer Accreditation and our growing focus patient satisfaction and cancer out-comes, tumor board meets the 1st and 3rd Wednesdays of each month. These multidisciplinary conferences involve surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, nurses, clinical research staff and ancillary support staff. The conferences are certified as continuing medical education for physicians and nurses.

These conferences bring cancer care specialists together to share ideas, discuss management, and review national treatment guidelines and the latest research findings in order to create the best treatment plan or management plan for individual pa-tients.

2013 Cancer Registry Summary The Cancer Registry at Baptist Health Madisonville collects and maintains data on all patients diagnosed and/or treated with cancer at our facility. Essential information is provided to local, state and national cancer registries to assist cancer programs to accurately determine cancer patient populations, measure outcomes of treatment and survival, and formulate plans for improvement.

The cancer registry is part of the Kentucky Cancer Registry’s Cancer Patient Data Management System (CPDMS.net) using a modern data encryption sys-tem with patient confidentiality and data security a top priority. This system is a computerized data center, which provides a broad range of demographic, diag-nostic, therapeutic and lifetime follow-up information about cancer patients at Baptist Health Madisonville, Merle M. Mahr Cancer Center, and Baptist Health Medical Associates. Data from the registry enables the medical staff, as well as other health care professionals, to analyze the results of their efforts.

In 2013, approximately 362 new cancer cases were accessioned into the cancer registry database.

The cancer registry staff is continually following an average of 6950 patients on an annual basis with a success rate of 94%. Our cancer registry continually exceeds all expectations of data quality as evidenced by audits performed by the state, the Surveil-lance, Epidemiology, and End Results (SEER) Program and NCDB.

For questions concerning Cancer Registry, please contact Stacy Littlepage, Cancer Registry Coordinator at (270) 825-5820 or by e-mail at [email protected]

2013 New Cancer Cases at Baptist Health Madisonville

143

57

23

371214

71

Breast Head & NeckProstate LungColon OtherBladder


Quality of Care-Cancer Program Practice Profile Reports (CP3R)

The Cancer Committee ensures and monitors that patients treated at Baptist Health receive care according to nationally accept-ed measures. The Commission on Cancer measures compliance with current CoC quality reporting tools—the Cancer Program Practice Profile Reports. Below is the summary CP3R performance grid that reports 2007-2011 cases diagnosed at Baptist Health Madisonville. We are proud that our program is exceeding or meeting the required performance expectations of the Commis-sion on Cancer.

CP3R Measure2007 2008 2009 2010 2011Radiation therapy is administered within 1 year (365 days) of diagnosis for

women under age 70 receiving breast conserving surgery for breast cancer. [BCS/RT]

Baptist Health Madisonville 100.0% 100.0% 100.0% 100.0% 100.0%

Kentucky 92.0% 93.7% 93.0% 93.0% 95.1%

All CoC Approved Programs 87.1% 89.0% 89.7% 90.6% 91.2%

CP3R Measure2007 2008 2009 2010 2011Combination chemotherapy is considered or administered within 4 months (120

days) of diagnosis for women under 70 with AJCC T1c NO MO, or Stage II or III ERA and PRA negative breast cancer. [MAC]

Baptist Health Madisonville 100.0% 100.0% 100.0% N/A N/A

Kentucky 90.6% 94.3% 94.0% 93.8% 96.9%


CP3R Measure2007 2008 2009 2010 2011Tamoxifen or third generation aromatase inhibitor is considered or administered

within 1 year (365 days) of diagnosis for women with AJCC T1c NO MO, or Stage II or III ERA and/or PRA positive breast cancer. [HT]


Kentucky 89.3% 89.8% 90.5% 94.1% 94.2%


CP3R Measure2007 2008 2009 2010 2011Adjuvant chemotherapy is considered or administered within 4 months (120

days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. [ACT]


Kentucky 87.0% 90.0% 89.5% 94.8% 92.3%


CP3R Measure2007 2008 2009 2010 2011At least 12 regional lymph nodes are removed and pathologically examined for

resected colon cancer. [12RLN]


Kentucky 74.6% 84.6% 86.6% 87.9% 86.0%


CP3R Measure2007 2008 2009 2010 2011Radiation therapy is considered or administered within 6 months (180 days) of

diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4NOMO or Stage III receiving surgical resection for rectal cancer. [AdjRT]

Baptist Health Madisonville 100.0% N/A 100.0% 100.0% 100.0%

Kentucky 85.0% 89.3% 98.9% 95.5% 94.6%



Quality Studies The Baptist Health Cancer Committee commissioned a physician led study focused on lung can-cer. The following are the identified measures, results, and implications reviewed by the Cancer Committee:

Stage II and III Non-Small Cell Lung Cancer

PurposeValidation of timely treatment, and adherence to National Comprehensive Cancer Network (NCCN) guidelines for patients diagnosed with Non-Small Cell Lung Cancer .

Introduction A study of patients diagnosed with Stage II or III non-small cell lung cancer was completed to review timeliness of treatment and compliance with NCCN guidelines, specifically looking at time of oncology appointment to time of treatment average number of days. Cancer Registry data was used to complete the study.

Method 35 patients were studied from January 2012 thru March 2014

Lung cancer is the second most common cancer in the US and the leading cause of cancer-related death. Unfortunately, 75 per-cent of patients with lung cancer present with symptoms due to advanced local or metastatic disease that is not curable.

Treatment of lung cancer has evolved significantly over the last 25 years. Small cell lung cancers are mostly treated with chemo-therapy with or without radiation, with virtually no role for surgery. On the other hand, Non-Small Cell Lung cancers are treated based on the stage at presentation.

Stage I and II NSCLC are usually treated with surgical resection for patients who can tolerate it. Radiation can be considered for patients who are not good candidates for surgery. In some patients, depending on tumor characteristics, chemotherapy may be offered following surgery. Treatment for Stage III NSCLC is more complex. It depends on the size and location of the tumor, the status of lymph nodes, and whether surgery has been done or not. In general, chemotherapy and radiation are offered for stage III patients who can tolerate it. Patients with Stage IV NSCLC (Metastatic disease) are generally non-curable and surgery usually is not offered. Chemotherapy, molecular targeted therapy, and radiation therapy are all options to palliate patients’ symptoms and prolong their lives. It has been well documented that 40% of patients with stage I, 60% of stage II, and more than 70% of stage III NSCLC patients will eventually recur and die of their disease.

The following graphs describe Non-Small Cell Lung cancer diagnosed at Baptist Health Madisonville compared to all National Cancer Data Base hospitals.

Ali Kanbar, MDMedical Oncologist


Age Group of Lung, Bronchus Non-Small Cell Carcinoma Cancer Diagnosed in 2000 to 2012

Baptist Health Madisonville - Madisonville, KY vs. All Types Hospitals in All StatesAll Diagnosed Cases - Data from 1,593 Hospitals

Stage of Lung, Bronchus Non-Small Cell Carcinoma Cancer Diagnosed in 2000 to 2012


35%

30%

25%

20%

15%

10%

5%

0%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Ages 20–29

Ages 30–39

Ages 40–49

Ages 50–59

Ages 60–69

Ages 70–79

Ages 80–89

Age 90& Over UnknownUnder

Age 20

Stage 0 Stage I Stage II Stage III Stage Iv OC NA UNK

0% 0% 0%1% 1%

6%

1% 1%

5%

18%

30%

34%

12%

16%

30%

33%

14%

17%

8%

30%

35%

9%

0%

25%

8%

23%

36%

8%

0%0% 0%

Baptist Health Madisonville


All Other Hospitals Reporting to NCDB



Gender of Lung, Bronchus Non-Small Cell Carcinoma Cancer Diagnosed in 2000 to 2012


Diagnosis Year of Lung, Bronchus Non-Small Cell Carcinoma Cancer Diagnosed in 2000 to 2012


60%

50%

40%

30%

20%

10%

0%

10%

8%

6%

4%

2%

0%

60% 55%40% 45%

Male Female

8%

9%

8% 8%

10%

8% 8% 8% 8% 8% 8% 8% 8%

6% 6% 6%

7% 7% 7% 7% 7% 7%

9% 9%

7%

6%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20122000






In the current study, we reviewed thirty five lung cancer cases over the course of the last two years to monitor our adherence to National treatment guidelines.

Surgery was offered to all patients who were thought to be good candidates for resection (six patients). Concurrent chemo-therapy and Radiation was offered to sixteen patients. Thirteen patients were not offered any treatment at Baptist Health, either because they decided to go to a different facility or because they were too weak to be able to tolerate chemotherapy (poor performance status). Three patients refused treatment altogether.

ConclusionAll treatments offered conformed to the guidelines set by the National Comprehensive Cancer Network (NCCN). Similarly, sur-vival seen among our patients is consistent with the reported survival rates of stage II and III NSCLC patients.

Baptist Health Madisonville Stage II and III Non-Small Cell Lung Cancer

Concurrent Chemo/Radiation, then surgeryNo Tx @ BHM

Surgery>concurrent chemo/radiationConcurrent Chemo/RadiationRefused TxPoor performance status, no tx.

Palliative radiation onlyTx @ other facilityNo Tx Radiation for Brain Mets, then chemoPalliative Chemo OnlySurgery, then chemo

Stag

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Stag

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A S

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Stag

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B Sq

uam

ous

4

3

2

1

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Stag

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Stag

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A A

deno

Stag

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B A

deno


Lung Cancer ScreeningUnfortunately, Kentucky has the highest rate of lung cancer in the nation. Early detection of lung cancer is crucial and, if found early there is a better chance the cancer could be removed before it spreads to other areas of the body. Results of the National Lung Screening Trial (NLST) have shown a 20% reduction in mortality from lung cancer with low-dose CT’s as compared to stan-dard chest X-ray in high-risk patients.

CT lung screening is a noninvasive, painless procedure that uses low dose x-ray to screen the lungs for cancer. This allows for earlier detection of small tumors in the lung and also may show non-cancerous abnormalities. National guidelines have now been implemented by the American Cancer Society.

The Lung Cancer Screening Program at Baptist Health is designed to identify potential issues before they become problematic. The Lung Cancer Screening program is coordinated through the Nurse Navigators at the Merle M. Mahr Cancer Center.

To qualify for a low dose CT screening the following guidelines are followed and must be met:

l Ages 55-74

l Current smoker with at least a 30 pack year history

l Former smoker with at least a 30 pack year history, who has stopped smoking within the last 15 years

l No current signs or symptoms of cancer

l No previous history of lung cancer

l No previous history of an abnormal CT of the chest

If a positive finding is noted on a screening CT, the referring physician and Nurse Navigator are notified. The Nurse Navigator will play an essential role in supporting patients through the transitions and phases of care. If the referring provider chooses, our Pulmonary/Cardiovascular team here at Baptist Health will evaluate the case and direct care.

Patient NavigationCancer treatment can be complicated and overwhelming for newly diagnosed cancer patients. But now there’s someone to help if you have breast, colon, lung, head or neck or cancer of the female organs. The navigation concept is designed to enhance timely treatment and reduce barriers to care. Our nurse navigators provide patients with a number of services that include:

l Guidance through the medical maze, including help in understanding diagnosis and treatment options

l Consultations with you and your family members to assess medical and emotional needs

l Help in accessing educational and support services

l Continued contact throughout the cancer experience


All services can help enhance your care and quality of life during treatment as well as assist your loved ones during this challenging time. Patients and physicians throughout the counties we serve have access to these dedicated Nurse Navigators.

This year we have expanded services and Heather Tow, RN, OCN has been added to the Patient Navigation team.

SurvivorshipIn 2005, the Institutes of Medicine (IOM) and National Research Council report, From Cancer Pa-tient to Cancer Survivor: Lost in Transition, recommended patients with cancer who are complet-ing the first course of treatment be provided a comprehensive care summary and follow up plan. This year, the cancer committee developed a policy and plan to provide these comprehensive care summaries and follow up plans for a subset of cancer survi-vors. This plan will be implemented in January 2015 and continuously monitored and evaluated for effectiveness by the Cancer Committee. The Nurse Navigators and physicians will work together to design specific plans for patients to meet their survivor-ship needs.

Heather Tow, RN, OCNPatient Navigation Team

270.825.5800 800.295.6247

900 Hospital Drive l Madisonville, KY

BaptistHealthMadisonville.com

public reporting of outcomes 2014 annual report · pi quality improvement rep** denise dunn, ......

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