National Data Report 2017 Prof Conor O’Keane

National Data Report 2017 Prof Conor O’Keane
Histopathology QI Programme Working Group 15 June 2017

Fourth Annual National Data Analysis Report published
Included Round 1 and Round 2 Targets/Recommendations, which will be discussed here Round 3 Targets/Recommendations and data analysis to be discussed during the later Interactive Panel Discussion session Report circulated to all Programme Clinical Leads and Local Operational Managers via To be sent to Hospital Management and Hospital Group Management The National Data Analysis Report should be used as a tool to use to drive reflection on your own local data Decided not to include Round 3 in this year’s National Data Analysis Report for a few reasons, chief being that targets were only announced in June last year with the IT system not being updated until a few months after that. Labs did not have sufficient time to see that their coding was resulting in measurable stats. They will be included in next year’s report and current data will also be discussed in the Panel Discussion session later today (along with their associated data quality issues: e.g coding variation, standardised definitions, etc.) for each Key Quality Area.

Workload Thirty-two public and private hospital laboratories participate in the Histopathology National QI (HQI) Programme and contributed data to the HQI Programme’s 2016 dataset. These thirty-two hospitals comprise all laboratories with a compatible Laboratory Information System (LIS) in Ireland Each of the 32 laboratories record all cases in their local LIS. Information on these cases, including data on quality activities performed, are then extracted from the LIS on a monthly basis and uploaded to the QI Programme’s data collection tool, NQAIS-Histopathology, for local analysis. This dataset gave us 452,036 cases to analyse for This has increased from 435K cases in 2015 and 422K in 2014. In 2016 we have over 750,000 Specimens, almost 1,300,000 blocks, with over 2,850,000 stains across the 5 stain subgroups. There are two labs that were looking to join the QI Programme. The first was Barringtons, Limerick which more recently became part of Bon Secours group, hence the slow down in their onboarding. The test file that I got from the LOM was a Nov 15 file (one month) with 640 cases, which from what I remember was the full months upload. The second was MC Pathology. Staff changes and IT challenges, coupled with they were looking at getting a new LIS to replace their bespoke Socrates one, were the reasons onboarding stalled. The last report that I ran was from Jan to March (inclusive) 2016, and they had 1058 cases for those 3 months.

Workload The majority of cases in 2016 fall into P04 (None Biopsy – Other), with 162,956 cases, or an average of approximately 13,500 per month across the 32 sites. This is followed closely by P02 (GI Endoscopic Biopsy) with 134,319 cases or 11,100 per month. P01 (Small Biopsy) had 94,629 cases or 7,900 per month, P03 (Cancer Resection) had 17,794 cases (1500 per month) and Cytology accounts for 33,309 Cases (approx per month). The December Dip also appears also in 2015, with an average caseload across 12 months as per month, but with a Dec 2015 workload at 31712 Similarly in 2014, the average caseload per month was per month, but with a Dec 2015 workload of

Intradepartmental Consultations

Key to graphs & data report
Anonymised aggregated data – per data bulletin issued & National Data Report available today. Data reports from now on will run Jan – Dec for the prior year CC: Cancer Centre GC – hospital that is not a cancer centre, can include maternity, children’s, general etc. Red horizontal line: target (min. to be achieved) Yellow horizontal line: target (ideal to be achieved) Dark blue plot line: average of all sites uploaded Purple plot line: average of all CC data uploaded Pale blue plot line: average of all GC data uploaded

For the year 2016, 6% (or 26980) of all histology/cytology cases had Intradepartmental Consultations, rising from 6% and 6.5% between January and December, with a dip in July. Cancer centres have a higher percentage of Intradepartmental Consultations than general centres, averaging at 7% with GCs averaging at 5%.

P03 (cancer resections) and P06 (non-gynaecological cytology - FNA) have the most Intradepartmental Consultations (Coded Q006) at over 12% for the year followed by P01 (small biopsy) at 10%, with P04 (non-biopsy – other) at 5%, P07 (non-gynaecological cytology - Exfoliative) at 4.3% and P02 (GI Endoscopic Biopsy) at 3.6% 1.8% of 5800 cases with no Procedure Code also have Q006s.

Intradepartmental Consultations - Histology
The minimum target for Histology Intradepartmental Consultation is 3%, with an achievable target of 5%. Histology Intradepartmental Consultation as a whole is consistently above both the minimum and achievable target. For the year, 6% of Histology Cases Received Intradepartmental Consultations, rising from 6% and 6.4% between January and December, with a dip in July. On a month by month basis, histology is always above the achievable target. Cancer centres have a higher percentage of Intradepartmental Consultations than general centres, averaging at 7% and generally rising throughout the year – from 6.7% to 7.7%, always above target. GCs average at 4.8%, slightly below the achievable target, and are stable around the achievable target for the year - some months above and some just below, decreasing from 5.2% to 4.9% between January and December

Looking at the quarterly trend over the last few years, following a sharp drop and recovery between Q2 and Q3 2014, the national histology Q006 has been very stable over the last 2 years hovering at the 6% mark. The CC trend follows a similar trend with a more gradual recovery with bumps over 4 quarters, then corrects itself and stabilises gradually increasing since Q from 6.6% to 7.6% GC - For the first 2 years of the programme data there has been a steady increase in Q006 percentages from 3.5% to exceeding the achievable target with 5.5% by Q Then there is a sharp drop in Q1 2015, approximately 6 months after a similar drop in cancer centres, where is stabilises at 5% for 6 quarters before dropping below the achievable target for the final 2 quarters of 2016 down to 4.5%, still significantly above the minimum target.

2015 Data for comparison 2016 Data Procedure Code P01, P02, P03, P04 No. of Cases No. Q006 % Q006 CC Cases 200712 13719 6.8% 237388 16363 6.89% CC1 35841 3119 8.7% 40726 3942 9.68% CC2 28497 1301 4.6% 33311 1903 5.71% CC3 26855 1791 6.67% 34161 1619 4.74% CC4 33648 1707 5.1% 37363 1456 3.90% CC5 16671 1049 6.3% 20225 1354 6.69% CC6 24794 1859 7.50% 30779 1993 6.48% CC7 14826 1062 7.2% 17206 1952 11.34% CC8 19580 1831 9.4% 23617 2144 9.08% GC Cases 191248 9504 5.0% 214469 10675 4.97% GC1 899 63 7.0% 877 57 6.50% GC2 6434 412 6.4% 7034 348 4.95% GC3 3062 15 0.5% 3254 26 0.80% GC4 6096 278 6172 280 4.54% GC5 2778 107 3.9% 2897 226 7.80% GC7 18941 777 4.1% 21100 932 4.42% GC8 13547 720 5.3% 15796 788 4.99% GC9 11968 598 4.997% 15206 715 4.70% GC10 14353 665 14206 722 5.08% GC11 7484 1104 14.8% 8382 1368 16.32% GC12 6332 157 2.5% 7475 165 2.21% GC13 7305 373 8649 385 4.45% GC15 7067 405 5.7% 7525 446 5.93% GC16 4576 560 12.2% 4707 513 10.90% GC17 GC19 4419 469 10.6% 4780 7.28% GC20 5742 64 1.1% 6220 76 1.22% GC23 10073 268 2.7% 11209 252 2.25% GC24 22814 496 2.2% 25558 547 2.14% GC25 8979 259 2.9% 10522 341 3.24% GC27 10372 1195 11.5% 10289 1401 13.62% GC28 12242 3.4% 16371 580 3.54% GC29 1303 21 1.6% 1443 71 4.92% GC30 4462 86 1.9% 4797 88 1.83% All Cases 391960 23223 5.9% 451857 27038 5.98% From a site perspective 6 CC sites are above the achievable target. 2 CC sites are below the achievable target, but both of these are above the minimum target. 3 GC and 1 CC sites have in excess of 10% of Histology cases with a Q006. 6 GC sites are below the minimum target. 17 GC sites are above the minimum target, with 7 of these sites also above the achievable target.

Intradepartmental Consultations - for non gynaecological cytology – FNA
The minimum target for non-gynaecological cytology – FNA Intradepartmental Consultation is 7%, with an achievable target of 9%. P06 (non-gynaecological cytology - FNA) Intradepartmental Consultation as a whole is consistently above both the minimum and achievable target. For the year, 12.6% of non-gynaecological cytology - FNA cases received Intradepartmental Consultations, rising from 10.7% and 15.1% between January and December, with a dip in August – but always above the achievable target. CCs average at 10.8%, also above the achievable target, and are stable above the achievable target for all but one month of the year, decreasing from 10.3% to 14.1% between January and December GCs have a higher percentage of Intradepartmental Consultations than cancer centres, averaging at 16.5% and generally rising throughout the year – from 11.8% to 17% - always above the achievable target.

Looking at the quarterly trend over the last four years, Q006 for non-gynaecological cytology – FNA has been steadily increasing from a nadir of 7.8% in Q to 14.1% in Q there is a sharp single decline in Q4 2014, but there is a quick recovery from this. The CC trend over the last four years, again rising steadily from 6.2% (below the minimum target) in Q and generally rising consistently with a sharp increase over Q to 12.6%, well above the achievable target of 9% GC Q006 rates for FNA cytology are significantly higher than CC rates - For the first 18 months of the programme data there has been a steady increase in Q006 percentages from 12% to 17.8%% by Q Then there is a drop in Q (but still always above achievable target), which recovers over 2015, and increases gradually over 2016 up to 17.6% by Q

Q006 P06 2015 2016 No. of Cases No. Q006 % Q006 % Q006 CC cases 7186 726 10.1% 7036 762 10.83% CC1 1802 243 13.5% 237 13.15% CC2 1066 145 13.6% 1144 155 13.55% CC3 1970 90 4.6% 1873 72 3.84% CC4 568 49 8.6% 488 23 4.71% CC5 807 82 10.2% 727 95 13.07% CC6 143 24 16.8% 128 33 25.78% CC7 527 93 17.6% 563 147 26.11% CC8 303 0.0% 311 0.00% GC cases 3186 489 15.3% 3093 510 16.49% GC3 9 1 11.1% 4 GC4 10 10.0% GC5 2 22.2% 22.22% GC7 569 61 10.7% 551 139 25.23% GC8 372 31 8.3% 366 22 6.01% GC9 192 16 235 21 8.94% GC10 476 89 18.7% 460 62 13.48% GC11 125 44 35.2% 117 19.66% GC12 104 3 2.9% 2.11% GC13 69 7 65 8 12.31% GC15 57 13 22.8% 58 11 18.97% GC16 152 40 26.3% 164 36 21.95% GC23 107 7.5% 68 6 8.82% GC24 496 39 7.9% 364 10.99% GC25 211 14 6.6% 267 17 6.37% GC27 114 75 65.8% 94 61.70% GC28 29 24.1% 34 17.65% GC29 84 38 45.2% 103 55.34% GC30 30 10372 1215 11.71% 10129 1272 12.56% From a site perspective 5 CC sites are above the achievable target. 3 CC sites are below the minimum target. One of these sites has recorded 0 IntraDs for 311 P06 cases for the year. The same site also has 0 IntraDs in 2015. 6 GC sites are below the minimum target. All 3 GC sites with 0 IntraDs have 30 P06 cases or less. 2 GC sites have in excess of 50% of P06 cases with a Q006.

Intradepartmental Consultations – non gynaecological cytology – exfoliative
The minimum target for non-gynaecological cytology – exfoliative Intradepartmental Consultation is 3%, with an achievable target of 5%. P07 (non-gynaecological cytology - exfoliative) Intradepartmental Consultation as a whole is consistently above both the minimum and achievable target. For the year, 4.3% of non-gynaecological cytology – exfoliative cases received Intradepartmental Consultations, rising from 3.9% and 5.8% between January and November, with a dip to 4.4% in December – mostly between the minimum and achievable target. CCs average at 4%, also above the minimum target, increasing consistently from 2.5% to 5.4% between January and December GCs have a higher percentage of Intradepartmental Consultations than cancer centres, averaging at 4.9% but is generally slightly decreasing throughout the year – from 6.4% to 5.5% from January to November - mostly above the Achievable target with 2 significant dips in July and December, the latter dipping below the minimum target.

Intradepartmental Consultations non-gynaecological cytology – exfoliative
Looking at the quarterly trend over the last four years, Q006 for non-gynaecological cytology – Exfoliative has been quite stable and mostly increasing since mid 2013Q from just above the minimum target of 3% in 2013 to its highest pint of 5.5% in Q The CC trend began between the minimum and achievable target for 12 months before a dip and sharp rise in 2014 to stabilise at a newer higher level, above the achievable level of 5% for most of the last 2 years. GC Q006 rates for Exfoliative cytology are significantly lower generally than CC rates - For the first 2 years of the programme, GC Q006 was below the minimum target and has risen over the last 2 years to be mostly significantly above the minimum target, rising throughout 2016 to be above the achievable target by Q

Intradepartmental Consultations non-gynaecological cytology – exfoliative
From a site perspective 4 CC sites are above the achievable target. 3 CC sites are below the minimum target. One of these sites has recorded 0 IDCs for 1765 P07 cases for the year. The same site also has 0 IDCs in 2015. 8 GC sites are below the minimum target. 2 GC sites have in excess of 20% of P07 cases with a Q006.

Intradepartmental Consultations - Autopsy
Autopsies (P10,P11) are above the target of 2% IDCs for 5 months of 2016, The dips in November and December may be due to the data being uploaded before autopsies were completed. Cancer centres have a higher level of IDCs than general centres, being above target for 8 of 12 months.

Intradepartmental Consultations - Autopsy
Autopsies were recorded in 2016 in 6 CC hospitals with 4 hospitals recording IDCs on autopsies. These 2 are above the target. 10 GC hospitals recorded autopsies, 3 of these have IDCs and these are the only 3 GC sites that are above target. These hospitals that are above the target are enough to bring the ‘All Sites’, ‘All CC Sites’ and ‘All GC Sites’ close to the target (at 1.93%) for the entire year.

Turn Around Times

Turn Around Times – Small Biopsy
Turnaround Times for P01 (Small Biopsy) has been below target of 80% by Day 5 for 9 of 12 months for 2016, never below 74% and averaging at 77% for the year. CC sites as a whole are below the target of 80% by Day 5 for every month of 2016, averaging at approx 68%. GC sites as a whole are above the target for every month of 2016, averaging at approx 85%.

Over the past 5 years the TAT target of 80% by day 5 has not been met. While hovering just below the target for much of the first 3 years of the programme, there was a drop in Q and has risen again towards the target until Q where there was a slight decline. CC sites have been consistently below the target averaging at 70.2% for the last 4 years, declining slightly from heights of approx. 75% in Q Over the past 5 years, GC sites have been consistently above the target averaging at 85% for the last 4 years

TAT P01 2015 2016 No. of Cases No. completed by day 5 % completed by Day5 All CC Sites 44898 30761 68.5% 45372 30619 67.5% CC1 8941 6515 72.9% 8781 6770 77.1% CC2 6630 5320 80.2% 6879 5048 73.4% CC3 5777 4530 78.4% 6223 4921 79.1% CC4 6254 3542 56.6% 6618 2996 45.3% CC5 4831 3473 71.9% 4806 3445 71.7% CC6 4181 1962 46.9% 4692 1997 42.6% CC7 5210 4393 84.3% 5522 4769 86.4% CC8 3074 1026 33.4% 1851 673 36.4% All GC Sites 49129 42253 86.0% 49256 42415 86.1% GC1 74 70 94.6% 108 101 93.5% GC10 1789 1460 81.6% 1861 1569 GC11 2012 899 44.7% 1896 935 49.3% GC12 1699 1445 85.1% 811 603 74.4% GC13 1798 1795 99.8% 2039 2027 99.4% GC15 2712 2678 98.7% 2449 2394 97.8% GC16 245 217 88.6% 274 259 94.5% GC19 3560 3345 94.0% 3925 3668 GC2 2339 2231 95.4% 2619 2513 96.0% GC20 2028 1921 94.7% 2174 1938 89.1% GC23 1734 1685 97.2% 1142 1001 87.7% GC24 4513 2532 56.1% 4616 2854 61.8% GC25 827 617 74.6% 1013 492 48.6% GC27 2913 69.6% 2580 1993 77.2% GC28 3713 3491 4745 4366 92.0% GC29 230 180 78.3% 234 134 57.3% GC3 410 357 87.1% 392 348 88.8% GC30 804 756 750 652 86.9% GC4 4612 4542 98.5% 4614 4508 97.7% GC5 2045 92.7% 1940 1750 90.2% GC7 5865 5277 90.0% 5902 5615 95.1% GC8 786 568 72.3% 792 607 76.6% GC9 2421 2264 2380 2088 All Sites 94027 73014 77.7% 94628 73034 From a site perspective, ‘All Sites’ are just below target at 77% for Overall 17 sites of 31 with P01s are above the Target for the year. All CC sites are below target at 68%. One CC site is above the target, 7 below target. Of those 4 are above 70%. 3 CC Sites are below 45% of cases completed by Day 5. GC sites are above target at 86%. 16 of 23 sites with P01s are above the target.

Turn Around Times - GI Endoscopic Biopsy
Turnaround Times for P02 (GI Endoscopic Biopsy) has been below target of 80% by Day 5 for all 12 months for 2016, averaging at just over 70% for the 1st 8 months and then dropping to 60% for the last 3 months CC sites as a whole are above the target of 80% by Day 5 for every month of 2016, averaging at approx 55%, only dropping below the 50% mark for the last 4 months of 2016 GC sites as a whole are above the target for 5 of the 1st 8 months of 2016, averaging above the target, averaging at approx 83%, and dropped below the target for the last 4 months of 2016, the average for the whole month being 79.8%

Over the past 5 years the TAT target of 80% by day 5 has not been met. While hovering just below the target for much of the first 2 years of the programme, and exceeding the target by Q1 2015, but has been dropping since then. CC sites have been consistently below the target averaging at 67% for the last 5 years, declining over the past 2 years from heights of approx. 74% in Q Over the past 5 years, GC sites have been consistently above the target averaging at for the last 4 years, but dropped below the Target fro the first time in 3 years in Q

The Workload for P02s has increased over the past year from 122K in 2015, to 134K in 2016, so resourcing could be a possible explanation for the drop in National target attainment. From a site perspective, ‘All Sites’ are below target at 68% for Overall 18 sites of 27 with P02s are above the Target for the year. All CC sites combined are below target at 55%. Three CC sites is above the target, and 5 below (same as 2015). Of those below target, 3 CC Sites have below 35% of cases completed by Day of the CC sites that were below 35% in 2015 were also below 35% in 2015, the 3rd went from 55% in 2015 to 31% in 2016. GC sites just below target at 79.8%. 15 of 19 sites with P02s are above the TAT target of 80% completed by day 5. This is a reduction from 2015 where only 2 GC sites were below target, and the target was met at 86% across GC sites.

Turn Around Times - Non Biopsy Cancer Resection
Turnaround Times for P03 (Non Biopsy Cancer Resection) has been below target of 80% by Day 7 for 9 of 12 months for 2016, never below 73% and averaging at 76% for the year (almost exactly the same percentage as the beginning of the year) CC sites as a whole are below the target of 80% by Day 7 for every month of 2016, averaging at approx 73.5%, beginning the year at 72% and ending the year at 73.5%, with a rise to close to the target for the summer months GC sites as a whole are above the target for every month of 2016, averaging at approx 83%, although reducing slightly (and consistently) in the latter part of the year.

Over the past 5 years the TAT target of 80% completed by day 7 has not been met. While hovering just below and on target for much of the first 2 years of the programme, the % completed by day 7 dropped slightly since 2014 and has stabilised at just below the target – at 77% - for the past 2 years. CC sites have been consistently below the target averaging at 75% for the last 5 years, declining slightly over the past 2 years to (a 73% average) from heights of approx. 79% in Q but always over 70% completed by day 7 over the past 3 years. Over the past 5 years, GC sites have been consistently above the target averaging at for the last 4 years – averaging at 88% completed by day7.

TAT P03 2015 2016 No. of Cases No. completed by day 7 % completed by Day 7 All CC Sites 13490 9825 72.8% 13515 9921 73.4% CC1 2213 1608 72.7% 2229 1732 77.7% CC2 2043 1890 92.5% 2281 2066 90.6% CC3 2126 1646 77.4% 2005 1540 76.8% CC4 3688 2382 64.6% 3079 2000 65.0% CC5 1027 677 65.9% 1138 782 68.7% CC6 612 412 67.3% 793 479 60.4% CC7 1074 946 88.1% 1120 969 86.5% CC8 707 264 37.3% 870 353 40.6% All GC Sites 4918 4281 87.0% 4279 3721 GC1 3 100.0% GC10 1253 1156 92.3% 1017 959 94.3% GC11 383 259 67.6% 308 223 72.4% GC12 192 95 49.5% 231 138 59.7% GC13 159 157 GC15 59 58 98.3% 66 89.4% GC16 76 72 94.7% 35 32 91.4% GC20 1 GC19 GC2 91 87 95.6% 74 73 98.6% GC23 206 202 98.1% 162 142 87.7% GC24 307 195 63.5% 255 203 79.6% GC25 99 92 92.9% 75 51 68.0% GC27 79 63 79.7% 49 40 81.6% GC28 28 24 85.7% 22 91.7% GC29 401 342 85.3% 269 76.2% GC3 7 6 9 77.8% GC30 52 50 96.2% 48 83.3% GC4 38 37 97.4% 21 95.5% GC5 54 34 63.0% 67 56.7% GC7 444 405 91.2% 171 GC8 106 63.2% 120 65.8% GC9 882 876 99.3% 1009 994 98.5% All Sites 18408 14106 76.6% 17794 13642 76.7% The Workload for P03s has decreased over the past year from 18.4K in 2015, to 17.8K in 2016. From a site perspective, ‘All Sites’ are below target at 76.7% for This is a slight increase in % completed by day 7 from 2015 at 76.6%. Overall 15 sites of 29 with P03s are above the Target for the year, 2 less than 2015. All CC sites combined are below target at 73.4%. There is an increase in % completed by day 7 from 2015 – from 72.8% to 73.4%. Two CC sites are above the target, and 6 below (same as 2015). Of those below target, 2 CC Sites are in excess of 75%, just below the target. One site is at 41%, this site was at 37% in 2015. GC sites just below target at 87%, the same as the previous year. 13 of 21 sites with P03s are above the TAT target of 80% completed by day 7. From a hospital perspective, this is a reduction from 2015 where 16 of 22 GC sites were above target.

Turn Around Times – Non Biopsy Other
Turnaround Times for P04 (Non Biopsy Other) has been below target of 80% by Day 7 for all of 12 months for 2016, averaging at 74% for the year. For the 1st part of the year the TAT by Day 7 rises from 74.6% in Jan to a max of 79.9% in July, and then tapers off slowly at 1st before beginning to recover in November 16 and ending the year at 72%. CC sites as a whole are below the target of 80% by Day 7 for every month of 2016, averaging at approx 61%, beginning the year at just above 60% and ending just below 60% with a bubble in the summer reaching a height of 71% in July. GC sites as a whole are above the target for every month of 2016, averaging at approx 89%, although reducing slightly (and consistently) since May 16, which was over 90% TAT by day 7.

Over the past 5 years the TAT target of 80% P04 completed by day 7 has not been met. Starting below target in Q it rose steadily in the 1st two years to exceed the target by Q It decreased slightly after this to just below the target with a more pronounced drop in Q4 2015, to 75% where it stabilised before dropping again in Q – to 69% CC sites have been consistently below the target averaging at 65% for the last 5 years, the large drop in Q seems to be mainly influenced by a Q4 drop to 53.4%. Over the past 5 years, GC sites have been consistently above the target averaging at for the last 4 years – averaging at 90% completed by day 7.

TAT P04 2015 2016 No. of Cases No. completed by day 7 % completed by Day 7 All CC Sites 83013 53953 65.0% 87203 53319 61.1% CC1 14372 11029 76.7% 14082 11062 78.6% CC2 10732 10096 94.1% 10816 8448 78.1% CC3 9753 8687 89.1% 10079 8521 84.5% CC4 14346 5294 36.9% 15355 5725 37.3% CC5 6225 4986 80.1% 6531 4972 76.1% CC6 12815 4933 38.5% 13480 4223 31.3% CC7 4784 4104 85.8% 4888 4192 CC8 9986 4824 48.3% 11972 6176 51.6% All GC Sites 74088 67631 91.3% 75753 67697 89.4% GC1 783 774 98.9% 715 703 98.3% GC10 5236 4910 93.8% 4253 4068 95.7% GC11 2980 1839 61.7% 2947 2083 70.7% GC12 2537 2411 95.0% 2477 2332 GC13 2464 2463 100.0% 2539 2536 99.9% GC15 1722 1648 2125 2049 96.4% GC16 2457 2427 98.8% 2286 2257 98.7% GC19 858 819 95.5% 839 804 95.8% GC2 1736 1707 1721 1683 97.8% GC20 3713 3569 96.1% 3918 3415 87.2% GC23 3761 3691 98.1% 4868 4609 94.7% GC24 7688 6657 86.6% 7220 6413 88.8% GC25 3244 2999 92.4% 2880 1553 53.9% GC27 4915 4509 91.7% 4757 4579 96.3% GC28 3414 3339 3975 3859 97.1% GC29 672 585 87.1% 752 564 75.0% GC3 1757 1613 91.8% 1518 1383 91.1% GC30 2362 2144 90.8% 2534 2181 86.1% GC4 1446 1431 99.0% 1463 1415 96.7% GC5 104 101 93 90 96.8% GC7 7375 7090 7952 7667 GC8 7647 5959 77.9% 7826 6203 79.3% GC9 5217 4946 94.8% 6095 5251 86.2% All Sites 157101 121584 77.4% 162956 121016 74.3% The Workload for P04s has increased over the past year from 157K in 2015, to 163K in 2016. From a site perspective, ‘All Sites’ are below target at 74.3% for This is a decrease in % completed by day 7 from 2015 at 77.4%. Overall 22 sites of 32 with P04s are above the Target for the year, 3 less than 2015. All CC sites combined are below target at 61%. There is an decrease in % completed by day 7 from 2015 – from 65% to 61%. Two CC sites are above the target, and 6 below (there were 4 below in 2015). Of those below target, 3 CC Sites are in excess of 75%, just below the target. But 2 are also below 52%. These 3 sites were also below 50% in 2015. GC sites above target at 89.4%, not too different from the 91.3% the previous year

Turn Around Times - Non Gynaecological Cytology FNA
Turnaround Times for P06 (Non Gynaecological Cytology FNA) has been above target of 80% by Day 5 for all of 12 months for 2016, never below 87% and averaging at 90% for the year. GC sites as a whole are above the target of 80% by Day 5 for all but one (May) month of 2016, averaging at approx 83.4%. CC sites as a whole are above the target for every month of 2016, averaging at approx 92.6%.

Turn Around Times - Non Gynaecological Cytology FNA
From a site perspective, ‘All Sites’ are well above target at 90% for 2016, the same as Overall 22 sites of 28 with P06s are above the Target for the year. This is an improvement from 2015 where 8 sites were below target. Two CC sites are below the target. Of those 2, 1 CC Site is at 19.6% of cases completed by Day 5. This site was at 22% in 2015

Turn Around Times - Non Gynaecological Cytology Exfoliative
Turnaround Times for P07 (Non Gynaecological Cytology Exfoliative) has been above target of 80% by Day 5 for all of 12 months for 2016 averaging at 89% for the year, and reaching a zenith of 93.4% in Dec 16 GC sites as a whole are above the target of 80% by Day 5 for all 12 months of 2016, averaging at approx 91%. CC sites as a whole are also above the target for every month of 2016, averaging at approx 88%.

Turn Around Times - Non Gynaecological Cytology Exfoliative
From a site perspective, ‘All Sites’ are well above target at 88% for 2016, an increase of 1% from 2015’s 87%. Overall 21 sites of 27 with P07s are above the Target for the year. Two CC sites are below the target. Of those 2, 1 CC Site is at 25% of cases completed by Day 5. This site was at 23% in 2015

Frozen Section Correlation and Turn Around Time

Frozen Section Workload
When analysing these statistics it is important to note that Frozen Section case volumes are relatively low. Two cancer centres (CCs) have less than 20 Frozen Section cases in Over One third of all Frozen Section cases nationally (from 24 sites) are done by one cancer centre site. There are a percentage of Frozen Section cases missing a concordance Q-Code. These cases were not included in Frozen Section concordance rate calculations presented on the previous pages. However it should be noted that this is an area for data quality improvement in some laboratories. 5% of cases do not have an FS Correlation Code. Most sites missing a high percentage of codes is due to low actual numbers of FS cases 8.5% of cases do not have an FS TAT Code. Frozen Section TAT is an area in which data quality could be improved. Out of 1398 Frozen Section cases in 2016, 123 (8.5%) cases do not have any Frozen Section TAT code attached, up from 5% the previous year. Five sites have less than 90% of their cases coded with Frozen Section TAT codes. Again this is an area for data quality improvement in certain laboratories.

Frozen Section Concordance
As a whole, the target for Frozen Section concordance is attained for the 2016 year (97.7%), and is up 0.2% from last year. Cancer centres reach the target at 98%, while general centres just miss it at 95.7%. What is also notable is that 2016 is the first year that the target was met for every quarter of the year for both ‘All Sites’ and CCs.

Frozen Section Concordance
As said, All Sites combined have 97.5% compliance. 17 of the 24 sites (71%) with Frozen Section cases met the Frozen Section concordance target for In 2015, seventeen out of 22 sites met this target. CC sites are at 98.1% Concordance (up from 97.4% in 2015) with 6 of 8 sites reaching the target in Two out of eight CC cases did not meet the target of 97% for Both of these are above 90% and are the same two sites that did not make the target the year before. GC Cases FS Concordance rate decreased since 2015 from 98% to 95.7%, however 11 out of 16 GC sites are above target for 2016. One GC site has 80% of their cases concordant, and this is due to their very low figures (four out of five cases concordant). The HQI Programme undertook an audit in mid-2016 of the performance of hospitals against this target. The Working Group of the HQI Programme found that all hospitals were meeting the target or were within expected statistical variation thereof. The analysis of this data over the course of five years ( ) confirms this pervious assessment.

Frozen Section Turn Around Time
Nationally, we did not meet the Turn Around Time target for 2016, averaging at 78.1%. General centres met the target for the year at 85.7% and cancer centres did not meet the target with 76.7%, dropping in the last quarter

Frozen Section Turn Around Time
All sites combined have 78.1% Frozen Section TAT less than 20mins. This has fallen from 2015’s 81.2% rate. Ten of the 24 sites (45.8%) with Frozen Section cases hit the target for 2016. Cancer Centres (CCs) have fallen from 81.2% to 76.7%. All eight CCs did not reach the target. Two cancer centres have less than 30% of cases completed in 20 mins or less. In 2015, two out of eight CCs met the target. Ten of the 16 GCs met the target of 85% completed in 20mis or less. Five of the six GCs that did not reach the target in 2016 have less than ten Frozen Section cases. GCs have increased from 81.5% to 85.7% reaching the target over the last year.

Frozen Section Deferral
As a whole, both cancer centre and general centres surpass the 1% minimum deferral target for the year. The Frozen Section deferral percentage is stable around the 2-3% mark, even though for a number of months it was outside of target. Five cancer centres (CCs) have their deferral numbers outside the target range of 1-5%. This includes eleven sites with zero deferrals - hence 0%. It should be noted that these centres have relatively low numbers of Frozen Section cases, and even if they had one deferral, then they would be over the target – as is the case with GC29. General centres (GCs) have very erratic deferral figures by quarter since This is due to the low volume of Frozen Section cases. Thirteen GCs have their deferral numbers outside the target range. As a whole, 2.8% of GC cases have at least one deferral. However, only five of sixteen GCs (31%) with Frozen Section cases have any deferrals and are in the target range of 1-5%.

Frozen Section Deferral
On a quarterly basis over the last 3 years, bar Q1 2014, FS Deferral has always been within target.

National Data Report 2017 Prof Conor O’Keane

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National Data Report 2017 Prof Conor O’Keane

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