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Quality Assurance Report TTUHSC Breast Center of Excellence January 1, 2011 – December 31, 2011 Compiled by Lynn Day, RN BSN CCM CCRP.

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Presentation on theme: "Quality Assurance Report TTUHSC Breast Center of Excellence January 1, 2011 – December 31, 2011 Compiled by Lynn Day, RN BSN CCM CCRP."— Presentation transcript:

1 Quality Assurance Report TTUHSC Breast Center of Excellence January 1, 2011 – December 31, 2011 Compiled by Lynn Day, RN BSN CCM CCRP

2 Stage Distribution Total Number of Patients = 107 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun12 (22.22%) 22 (40.74%) 11 (20.37%) 4 (7.41%) 0 (0%) 5 (9.26%) 54 (100%) Jul - Dec8 (15.09%) 19 (35.85%) 10 (18.87%) 2 (3.77) 0 (0%) 14 (26.42%) 53 (100%) Jan-Dec20 (18.69%) 41 (38.32%) 21 (19.63%) 6 (5.61%) 0 (0%) 19 (17.76%) 107 (100%) Compiled by Lynn Day, RN BSN CCM CCRP

3 Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Preoperative Core 11 (20.37%) 22 (40.74%) 10 (18.52%) 4 (7.41%) 0 (0%) 5 (9.26%) 52 (96.3%) Jul – Dec Preoperative Core 6 (11.32%) 19 (35.85%) 10 (18.87%) 2 (3.77%) 0 (0%) 13 (24.53%) 50 (94.34%) Jan-Dec Preoperative Core 17 (15.88%) 41 (38.32%) 20 (18.69%) 6 (5.61%) 0 (0%) 18 (16.82%) 102 (95.33%) Mode of Diagnosis Total Number of Patients = 107 95.33% of patients had diagnosis established on preoperative core needle biopsy Exceptions – discordant core biopsy Compiled by Lynn Day, RN BSN CCM CCRP

4 Tumor Board Discussion Total Number of Patients = 107 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Discussed 6/6 (50.0%) 13/22 (59.09%) 9/11 (81.82) 4/4 (100%) 0 (0%) 4/5 (80%) 36/54 (66.67%) Jul – Dec Discussed 4/8 (50.0%) 14/19 (73.68%) 9/10 (90.0%) 2/2 (100%) 0 (0%) 11/14 (78.57%) 40/53 (75.47%) Jan-Dec Discussed 10/20 (50.0%) 27/41 (65.85%) 18/21 (85.71) 6/6 (100%) 0 (0%) 15/19 (78.95%) 76/107 (71.03%) 71.03% of patients were discussed prospectively in the multidisciplinary tumor conference Compiled by Lynn Day, RN BSN CCM CCRP

5 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun MDC seen 8/12 (66.67%) 20/22 (90.91%) 11/11 (100%) 3/4 (75%) 0 (0%) 1/5 (20%) 43/54 (79.63%) Jul – Dec MDC seen 5/8 (62.5%) 14/19 (73.68%) 7/10 (70.0%) 2/2 (100%) 0 (0%) 7/14 (50.0%) 35/53 (66.04%) Jan-Dec MDC seen 13/20 (65.0%) 34/41 (82.93% 18/21 (85.71%) 5/6 (83.33%) 0 (0%) 8/19 (42.11%) 78/107 (72.9%) Multidisciplinary Assessment (Surgical, Medical and Radiation Oncologist) Total Number of Patients = 107 Exceptions29/107 (27.1%) No radiation oncology evaluation (mast./ high-risk)16/29 (55.17%) No documentation in the chart 5/29 (17.24%) Patient non-compliance 5/29 (17.24%) Continuing chemotherapy 3/29 (10.34%) Compiled by Lynn Day, RN BSN CCM CCRP

6 Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Assigned 10/12 (83.33%) 22/22 (100%) 11/11 (100%) 4/4 (100%) 0 (0%) 2/5 (40%) 49/54 (90.74%) Jul – Dec Assigned 7/8 (87.50%) 17/19 (89.47%) 9/10 (90.0%) 2/2 (100%) 0 (0%) 12/14 (85.71%) 47/53 (88.68%) Jan-Dec Assigned 17/20 (85.0%) 39/41 (95.12%) 20/21 (95.24%) 6/6 (100%) 0 (0%) 14/19 (73.68%) 96/107 (89.72%) Nurse Navigation Total Number of Patients = 107 Exceptions11/107 (10.28%) Lateral entry into the system11/11 (100%)* * modifications made to ensure assignment of a nurse navigator for every patient Compiled by Lynn Day, RN BSN CCM CCRP

7 Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Yes 1/12 (8.33%) 22/22 (100%) 9/11 (81.82%) 4/4 (100%) 0 (0%) 0/5 (0%) 36/54 (66.67%) Jul – Dec Yes 0/8 (0%) 18/19 (94.74%) 10/10 (100%) 2/2 (100%) 0 (0%) 0/14 (0%) 30/53 (56.6%) Jan-Dec Yes 1/20 (5%) 40/41 (97.56%) 19/21 (90.48%) 6/6 (100%) 1/2 (50.0%) 0/19 (0%) 66/107 (89.6%) CAP Compliance Total Number of Patients = 107 Exceptions41/107 (38.32%) Progesterone receptor not reported17/41 (41.5%) Complete response, no margins 8/41 (19.5%) Final surgery not done yet (neoadjuvant)14/41 (34.1%) Patient non-compliance, no follow up 2/41 (4.9%) Compiled by Lynn Day, RN BSN CCM CCRP

8 Axillary Staging Total Number of Patients = 107 Total Number of Patients with Invasive Cancer = 87 Number node positive patients on needle biopsy11/87 (12.6%) Number of patients eligible for SLNB76/87 (87.4%) – Number of patients with SLNB54/87 (62.1%) Exceptions12/87 (13.79%) Determined low risk (unlikely to change treatment plan)4/12 (33.3%) Final surgery not done yet 5/12 (41.7%) Patient non-compliance, no follow up2/12 (16.7%) Compiled by Lynn Day, RN BSN CCM CCRP

9 Axillary Dissection Total Number of Patients = 107 Total Number of Patients with Invasive Cancer = 87 Number of Patients with node positive disease 25/87 (28.7%) Number of patients eligible for ALND 25 – Number of patients with ALND 14/25 (56%) Exceptions11/25 (44%) Low risk for non-SLN mets. on MSKCC nomogram7/25 (28%) Final surgery not done yet 3/25 (12%) Patient refused completion ALND1/25 (4%) Compiled by Lynn Day, RN BSN CCM CCRP

10 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Yes 8/12 (66.67%) 19/22 (86.36%) 8/11 (72.73%) 1/4 (25.0%) 0 (0%) 0/5 (0%) 36/54 (66.67%) Jul – Dec Yes 6/8 (75.0%) 12/19 (63.16%) 3/10 (30.0%) 0/2 (0%) 0 (0%) 3/14 (21.43%) 24/53 (45.28%) Jan-Dec Yes 14/20 (70.0%) 31/41 (75.61%) 11/21 (52.38%) 1/6 (16.67%) 0 (0%) 3/19 (15.79%) 60/107 (56.07%) Breast Conservation Total Number of Patients = 107 Number of early stage patients (0, I and II) with breast conservation 56/82 (68.29%) Compiled by Lynn Day, RN BSN CCM CCRP

11 Post-lumpectomy Radiation Total Number of Patients = 107 Number of patients with lumpectomy60/107 (56.1%) Number of patients eligible for Radiation60 – Number of patients radiated50/60 (83.33%) Exceptions10/60 (16.7%) Low risk malignancy age group 75 – 93 years6/10 (60%) severe co morbidities Radiation pending3/10 (30%) Patient non-compliance 1/10 (10%) Number of patients radiated within 12 months48/50 (96%) Compiled by Lynn Day, RN BSN CCM CCRP

12 Post-Mastectomy Radiation Total Number of Patients = 107 Number of patients with mastectomy31/107 (29%) Number eligible for radiation (>T3 or >N2)5/31 (16.1%) – Number of patients radiated3/5 (60%) Exceptions2/5 (40%) - Radiation pending1/5 (20%) - Patient non-compliance 1/5 (20%) Number of patients radiated within 12 months5/5 (100%) Compiled by Lynn Day, RN BSN CCM CCRP

13 Systemic Chemotherapy - I Total Number of Patients = 107  ER negative patients with cancer10/107 (9.35%) Number eligible for chemotherapy(exclude DCIS)7/10 (70%) – Number treated with chemotherapy6/7 (85.7%) Exceptions1/7 (14.29%) Patient refused (1 stage I)1/1 (100%)  Number with chemotherapy within 4 months6/6 (100%) Exceptions0 (none) Patient non-compliance 0 (none) Compiled by Lynn Day, RN BSN CCM CCRP

14 Systemic Chemotherapy - II Total Number of Patients = 107  ER positive patients with cancer94/107 (87.9%) Number eligible for chemotherapy (exclude DCIS)77/94 (81.9%) Number treated with chemotherapy45/77 (58.4%)  Number with chemotherapy within 4 months43/45 (95.5%) Exceptions2/45 (4.4%) Prevented by patient comorbidities (stage III)1/2 (50%) Postop. wound complications (stage I)1/2 (50%) Compiled by Lynn Day, RN BSN CCM CCRP

15 Systemic Endocrine Therapy Total Number of Patients = 107  Number of ER positive patients94/107 (89.7%) Number treated with endocrine therapy69/94 (73.4%) Exceptions25/94 (26.6%) Determined risk > benefit 4/25 (16%) No documentation in the chart 1/25 (4%) Hormonal therapy pending 17/25 (68%) Patient sought treatment elsewhere 1/25 (4%) Patient non-compliance 2/25 (8%)  Number with endocrine therapy within 1 year69/69 (100%) Compiled by Lynn Day, RN BSN CCM CCRP

16 Rehabilitation Total Number of Patients = 107 Number enrolled in CPRP (PT/OT)24/107 (22.43%) Exceptions83/107 (77.6%) Services were available but structured program is pending definitive establishment, whereby every patient gets a baseline arm girth and shoulder range of motion documented; prospective data is maintained with a pre-designed schedule. Improvement over 2009 10.2% Compiled by Lynn Day, RN BSN CCM CCRP

17 Genetic Counseling Total Number of Patients = 107 Number of patients with family history or < 45 years65/107 (60.75%) Number received genetic counseling20/65 (30.77%) – Number tested17/20 (85%) Positive 2/17 (11.76%) Negative15/17 (88.23%) – Number refused testing 3/20 (15%) Exceptions45/65 (69.23%) Did not meet NCCN criteria34/45 (75.5%) No documentation in the chart9/45 (20%) Compiled by Lynn Day, RN BSN CCM CCRP

18 Time Frame Trial / StudyEligible N (%) Participation N (%) Jan – Jun B-SMART18 (38.3%)15 (38.5%) SPOC40 (85.1%)36 (92.3%) ACOSOG Z10717 (14.9%)7 (17.9%) Total 47 (87%)39 (72.2%) Jul - Dec B-SMART13 (27.7%)10 (27%) SPOC37 (78.7%)34 (91.9%) ACOSOG Z1071-- Total 47 (88.68%)37 (69.81%) Trial Participation Total Number of Patients = 107 Total Number of patients enrolled in trials in 2011 94/107 (87.85%) Increase of patients enrolled over the year 200979/15 (526.6%) Compiled by Lynn Day, RN BSN CCM CCRP

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