mcn audit report - woscan.scot.nhs.uk · final published lymphoma qpi mcn audit report v1.0...

The content of this report is © copyright WoSCAN unless otherwise stated.

Audit Report Lymphoma

Quality Performance Indicators

Clinical Audit Data: 01 October 2017 to 30 September 2018

Dr Grant McQuaker Consultant Haematologist MCN Clinical Lead Heather Wotherspoon MCN Manager Julie McMahon Information Officer

West of Scotland Cancer Network Haemato-oncology Managed Clinical Network

West of Scotland Cancer Network Final Published Lymphoma QPI MCN Audit Report v1.0 01/07/2019

2

CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 10

2. BACKGROUND 10

2.1 NATIONAL CONTEXT 10

2.2 WEST OF SCOTLAND CONTEXT 11

3. METHODOLOGY 14

4. RESULTS AND ACTION REQUIRED 14

4.1 DATA QUALITY 14

4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 15

5. CONCLUSIONS 39

ACKNOWLEDGEMENT 41

ABBREVIATIONS 42

REFERENCES 43

APPENDIX 1: NHS BOARD ACTION PLANS 45


3

Executive Summary

Introduction This report contains an assessment of the performance of West of Scotland (WoS) lymphoma services using clinical audit data relating to patients diagnosed with lymphoma in the twelve months between 1st October 2017 and 30th September 2018. Twelve months of data were measured against v3.0 of the Lymphoma Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 October 2016. This was the fifth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Lymphoma QPIs in 2013. Annual comparisons have been made where indicators have remained comparable following formal review. QPIs 12 and 13 are reported on for the first time within this report. Background The Haemato-oncology Managed Clinical Network (MCN) was established in 2002 as a means of delivering equitable, high quality clinical care to all haemato-oncology patients across five NHS Boards; Ayrshire & Arran, Dumfries & Galloway, Forth Valley, Greater Glasgow and Clyde (GGC) and Lanarkshire covering a population of 2.65 million. Audit teams within the WoS recorded 612 new lymphoma cases diagnosed between 1 October 2017 and 30 September 2018. Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 1 October 2017 and 30 September 2018 was downloaded from eCASE on 8 April 2019. Analysis was performed centrally by the West of Scotland Cancer Network (WoSCAN) Information Team.

Results Case ascertainment for lymphoma is high across WoS at 107.7% indicating an excellent level of data capture, however it should be noted that the predicted incidence of all cancer types is based on historic numbers of cases diagnosed and therefore some variation in case ascertainment is expected. Results for each QPI are shown in detail in the main report and illustrate Board performance against each target and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. The following summary of results shows the WoS percentage performance against each QPI target and the range in performance by NHS Board.


Performance Summary Report

QPI Target WoS A&A FV Lan NG SG Clyde D&G

QPI 1(i): Radiological Diagnosis and Staging. Proportion of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

95% 94.5%

<

90.0%

<

96.9%

>

96.6%

<

94.1%

<

92.7%

>

98.0%

>

92.0%

<

327 346 36 40 31 32 57 59 80 85 51 55 49 50 23 25

QPI 1(ii): Radiological Diagnosis and Staging. Proportion of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request.

90% 82.9%

<

83.3%

>

83.9%

<

82.5%

>

83.8%

<

84.3%

<

85.7%

<

69.6%

<

271 327 30 36 26 31 47 57 67 80 43 51 42 49 16 23

QPI 1(iii): Radiological Diagnosis and Staging. Proportion of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment where report is available within 3 weeks of radiology request.

90% 89.0% 86.1% 87.1% 93.0% 88.8% 90.2% 91.8% 78.3%

291 327 31 36 27 31 53 57 71 80 46 51 45 49 18 23

QPI 2: Treatment Response Proportion of patients with DLBCL who are undergoing chemotherapy treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scan at end of chemotherapy treatment.

90%

87.7%

>

100%

>

76.9%

<

96.3%

>

94.1%

<

83.3%

>

80.0%

<

60.0%

<

121 138 10 10 10 13 26 27 32 34 20 24 20 25 3 5

Above Target Result

Below Target Result

> Indicates increase on previous years figure

< Indicates decrease from previous years figure

= Indicates no change from previous year

Indicates no comparable measure from previous year

Lymphoma Performance by Board


5


QPI 3(i): Positron Emission Tomography (PET CT) Staging Proportion of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment.

95% 92.4%

<

88.9%

>

85.7%

<

86.7%

<

100%

=

93.8%

<

100%

=

80.0%

<

73 79 8 9 6 7 13 15 19 19 15 16 8 8 4 5

QPI 3(ii): Positron Emission Tomography (PET CT) Staging Proportion of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment and within 2 weeks of radiology request

95% 90.4%

<

100%

=

100%

=

92.3%

>

89.5%

<

80.0%

<

100%

=

-

66 73 8 8 6 6 12 13 17 19 12 15 8 8 - -

QPI 3(iii): Positron Emission Tomography (PET CT) Staging Proportion of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment and the report is available within 3 weeks of radiology request.

95% 95.9% 100% 100% 92.3% 94.7% 93.3% 100% -

70 73 8 8 6 6 12 13 18 19 14 15 8 8 - -

QPI 4(i): Cytogenic testing Proportion of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy with curative intent who have MYC testing prior to treatment.

60% 75.4%

>

50.0%

<

89.5%

>

48.3%

>

97.3%

>

85.2%

>

92.6%

>

35.7%

<

129 171 9 18 17 19 14 29 36 37 23 27 25 27 5 14

QPI 4(ii): Cytogenic testing Proportion of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy with curative intent who have MYC results reported within 3 weeks of commencing treatment.

85% 94.2%

>

83.3%

>

100%

=

86.2%

<

100%

>

96.3%

>

100%

>

85.7%

<

161 171 15 18 19 19 25 29 37 37 26 27 27 27 12 14

QPI 5: Lymphoma MDT Proportion of patients with lymphoma who are discussed at MDT meeting within 8 weeks of diagnosis.

90% 83.4%

<

91.8%

>

83.3%

<

87.5%

<

65.7%

<

93.4%

>

87.6%

>

94.4%

<

484 580 45 49 50 60 91 104 94 143 85 91 85 97 34 36


6


QPI 6: Treatment for Follicular Lymphoma and DLBCL Proportion of patients with follicular lymphoma and DLBCL who receive chemotherapy in combination with rituximab.

95% 98.1%

<

100%

=

100%

=

97.7%

<

94.3%

<

97.1%

<

100%

=

100%

=

205 209 20 20 24 24 42 43 33 35 34 35 36 36 16 16

*QPI 10: Primary Cutaneous Lymphoma Proportion of patients with PCL who are discussed at a specialist MDT meeting which includes representation from pathology, dermatology, oncology± haemato-oncology.

95% 100%

>

n/a - - - - - -

13 13 0 0 - - - - - - - - - - - -

QPI 11: Hepatitis and HIV Status Proportion of patients with lymphoma undergoing rituximab based treatment who have hepatitis B, C and HIV status checked prior to treatment.

95% 95.9%

>

97.1%

>

100%

=

98.6%

>

94.7%

>

93.4%

<

98.3%

<

84.0%

<

375 391 34 35 44 44 70 71 90 95 57 61 59 60 21 25

QPI 12(i): Treatment Response in Hodgkin Lymphoma Proportion of patients with advanced HL who receive ABVD chemotherapy treatment that have their treatment evaluated with PET CT scan after two cycles of chemotherapy.

80% 80.0% 20.0% 100% 66.7% 100% 87.5% 66.7% -

36 45 1 5 5 5 4 6 12 12 7 8 4 6 - -

QPI 12(ii): Treatment Response in Hodgkin Lymphoma Proportion of patients with advanced HL who receive ABVD chemotherapy treatment that have their treatment evaluated with PET CT scan after two cycles of chemotherapy and where the report is available within 3 days.

80% 61.1% - 40.0% - 83.3% 42.9% - -

22 36 - - 2 5 - - 10 12 3 7 - - - -

QPI 13: Maintenance Therapy for Follicular Lymphoma Proportion of patients with follicular lymphoma undergoing treatment with R-Chemotherapy who receive maintenance treatment with anti-B cell monoclonal antibody therapy.

90% 76.2% - - 77.8% 87.5% 75.0% 44.4% -

32 42 - - - - 7 9 7 8 6 8 4 9 - -

*Small numbers in some Boards - percentage comparisons over a single year should be viewed with caution.


7

QPI Target WoS A&A FV Lan GGC D&G

Clinical Trials - Proportion of patients diagnosed with lymphoma who are consented for a clinical trial / research study in 2018.

15% 12.7% 13.9% 8.8% 7% 15.9% 7.1%

72 568 11 79 5 57 7 100 46 290 3 42


Conclusions and Action Required Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. Following the development of QPIs, this has now become an established national programme to drive continuous improvement and ensure equity of care for patients across Scotland. The results illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement particularly around a number of areas, including: MDT discussion, radiological diagnosis and staging within two weeks of radiological request. It should also be noted that overall percentages are affected by the small numbers of patients meeting the denominator criteria for some of the measures. It is encouraging that case ascertainment and data capture is of a high standard enabling robust assessment of performance against QPIs. Steady improvement has been noted across the WoS for QPIs relating to treatment response (QPI2), cytogenetic testing (QPI4), PCL patients discussed at specialist MDT (QPI10) and virological testing (QPI 11). Where QPI targets were not met, the majority of NHS Boards have provided detailed commentary. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. NHS Boards are encouraged to continue with this proactive approach of reviewing data and addressing issues as necessary, in order to work towards increasingly advanced performance against targets, and demonstration of overall improvement in quality of the care and service provided to patients.

There are a number of actions required as a consequence of this assessment of performance against the agreed criteria. Actions required:

NHS Lanarkshire to review cases with stage not recorded and update the information where possible to ensure complete data is available for future survival analysis and audit.

NHS Ayrshire & Arran to provide assurance that efforts will be made to retrospectively collect data for the 2017/18 cohort.

The MCN to organise an education event for haemato-oncology audit facilitators, to share knowledge and promote consistent data collection across the region/nationally.

QPI 1(i) – Radiological Staging

NHS Ayrshire & Arran to provide detail of action being taken locally to address radiology capacity issues.

NHS Dumfries & Galloway to review and provide further detail on cases not undergoing CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

QPI 1(ii) - Radiological Staging

NHS Dumfries & Galloway to review cases and provide further detail on cases not meeting QPI.

NHSGGC to work with radiology to examine whether imaging can be expedited for patients with lymphoma undergoing curative treatment.

QPI 1(iii) - Radiological Staging


QPI 2 – Treatment Response

NHS Forth Valley to provide further detailed reasons for patients with DLBCL undergoing treatment with curative intent not undergoing CT of chest, abdomen and pelvis or PET CT scan at end of chemotherapy treatment.

NHS Dumfries and Galloway to review all cases not meeting the QPI and provide feedback.


9

QPI 3(i) – PET CT Staging


QPI 4 – Cytogenetic Testing


QPI 5 – Lymphoma MDT

The MCN will initiate an audit to explore further the groups of patients not being discussed at MDT and those being discussed >56 days from diagnosis, with a view to identifying any variance between Boards and any improvement action required.

QPI 11 – Hepatitis and HIV Status


QPI 13 – Maintenance Therapy for Follicular Lymphoma

The MCN will consider if amendments are required to the measurement of this QPI due to the lag time required to capture all relevant data.

A QPI amendment is required to exclude grade 3B follicular lymphoma, and also patients who died before treatment category requires updating. The MCN will feed this in to the national formal review process.

NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a three-yearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012).


10

1. Introduction

This report presents an assessment of performance of West of Scotland (WoS) Lymphoma Services relating to patients diagnosed in the region between 01 October 2017 and 30 September 2018. These audit data underpin much of the regional development/service improvement work of the Managed Clinical Network (MCN) and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. Twelve months of data were measured against v3.0 of the Lymphoma Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 October 2016. This was the fifth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Lymphoma QPIs in 2013. In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland it is critical that the QPIs continue to be clinically relevant and focus on areas which will result in improvements to the quality of patient care. A programme of formal review of all QPIs was implemented whereby all tumour specific QPIs were reviewed following three years of comparative reporting. Formal review of the Lymphoma QPIs was undertaken in May 2017, with the revised QPIs (v3.0) published in October 2017. Future reports will continue to compare clinical audit data in successive years to further illustrate trend analysis.

2. Background

The Haemato-oncology MCN was established in 2002 as a means of delivering equitable, high quality clinical care to all haemato-oncology patients across five NHS Boards; Ayrshire & Arran, Dumfries & Galloway, Forth Valley, Greater Glasgow and Clyde (GGC) and Lanarkshire covering a population of 2.65 million. Membership includes 46 consultant haemato-oncologists, 5 transplant consultants, 1 consultant in young adult and adolescent haematology, 3 clinical oncologists and a number of haemato-pathologists, in addition to other professional groups involved in the multi-disciplinary care of patients with blood cancer (haematological cancer). The Haemato-oncology MCN continues to support and develop the clinical service for approximately 1300 haemato-oncology patients per annum. The effective management of these patients throughout the region continues to rely on co-ordinated delivery of treatment and care that requires close collaboration of professions from a range of specialties. Currently, there are seven local Multi-disciplinary Team (MDTs) meetings held across the West of Scotland (WoS) which complement the function of the Regional Haemato-oncology MDT. Table 1: WoS MDT Configuration

MDT Constituent Hospital

Ayrshire Crosshouse Hospital, Ayr Hospital

Clyde Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven

Dumfries & Galloway Dumfries and Galloway Royal Infirmary

Forth Valley Forth Valley Royal Hospital

Lanarkshire Hairmyres Hospital, Wishaw General Hospital, Monklands and District General Hospital

North Glasgow Beatson West of Scotland Cancer Centre, Transplant Team, Glasgow Royal Infirmary, Stobhill Hospital,

South Glasgow Queen Elizabeth University Hospital, New Victoria Hospital

2.1 National Context Non-Hodgkin Lymphoma (NHL) accounts for 3.2% of all cancers and is the eighth most common cancer type with approximately 1030 cases diagnosed in Scotland each year. The incidence of

NHL has decreased by 5.5% in the past ten years (2007 to 2017)3. NHL accounts for 3.4% of all

cancer diagnoses in men and was the ninth most commonly diagnosed cancer in males in 2017. It was the seventh most common cancer type in females accounting for 3.0% of all female cancer diagnoses3. Overall mortality rates have decreased by 7.9% over the past 10 years (2007 to 2017) and 1-year and 5-year relative survival is noted as being 80% and 69.7% respectively3.


11

Hodgkin Lymphoma (HL) is noted as being the 21st most common cancer with approximately 200 new diagnoses in Scotland each year. The overall incidence of HL has increased by 1.9% over the past 10 years (2007 to 2017), with the female population increasing by 11.5% compared to a decrease of 4.3% in the male population.

2.2 West of Scotland Context

A total of 612 new lymphoma cases were recorded through audit as diagnosed in the WoS between 1 October 2017 and 30 September 2018. The number of patients diagnosed within each Board is presented in Figure 1. As the largest WoS Board, 57% of all new cases of lymphoma were diagnosed in NHSGGC which is in line with population estimates for this Board. Figure 1: Number of patients diagnosed with lymphoma by unit of diagnosis, October 2017 to September 2018

A&A FV Lan NG SG Clyde D&G WoS

Year 2 103 38 93 125 85 82 43 569

Year 3 76 50 95 113 95 101 34 564

Year 4 78 53 103 117 104 88 37 580

Year 5 50 69 106 150 98 101 38 612

A breakdown by cancer subtype is noted below and illustrates that NHL is the most common type of lymphoma and accounts for 80.4% of all lymphomas diagnosed in the WoS in this audit period.

102 HL (16.6%)

493 NHL (80.4%)

13 Primary Cutaneous NHL (2.1%)

4 Other (0.7%)

0102030405060708090

100110120130140150160

A&A FV Lan NG SG Clyde D&G

Nu

mb

er

of

Cas

es

Analysis Group

Year 2 Year 3 Year 4 Year 5


12

Lymphoma Age and Gender Distribution Figure 2 illustrates the distribution of HL and NHL by age and gender. The median age of HL patients was 52 years and the disease continues to be more common in males (56%) than females (44%). In NHL, the median age was 70 years, with 75% of patients aged 60 years or over. The gender distribution illustrates that 51% of patients diagnosed with NHL were female and 49% male. Figure 2: Distribution of Hodgkin lymphoma and non-Hodgkin lymphoma by age and sex in the WoS

Hodgkin Lymphoma Figure 3 illustrates the pathological subtypes of HL. The distribution of HL by clinical stage is presented in Figure 4, which illustrates that 26.5% of patients presented with early stage (I, IIA) disease and 73.5% of patients presented with advanced stage disease (IIB,III,IV).

Figure 3: Hodgkin lymphoma by pathological subtype Figure 4: Hodgkin lymphoma by clinical stage

0

1

2

3

4

5

6

7

8

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

>8

5

No

. of

pa

tie

nts

Age at Diagnosis

Male Female

0

5

10

15

20

25

30

35

40

45

50

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

>8

5

No

. of

Pa

tie

nts

Age at Diagnosis

Male Female

Hodgkin Lymphoma Non Hodgkin Lymphoma

Classical Hodgkin

Lymphoma , 62.7% (n=64)

Lymphocyte-rich Classical

Hodgkin Lymphoma,

2% (n=2)

Mixed CellularityClassical Hodgkin

Lymphoma, 2.9% (n=3)

Nodular Lymphocyte

Predominant Hodgkin

Lymphoma,

8.8% (n=9)

Nodular sclerosis classical Hodgkin

Lymphoma, 23.5% (n=24)

IA, 5.9%(n=6) IIA, 20.6%

(n=21)

IIB, 6.9%(n=7)

IIIA, 12.7%(n=13)IIIB, 14.7%

(n=15)

IVA, 5.9%(n=6)

IVB, 20.6%(n=21)

NR, 9.8%

(n=10)

NA, 2.9%(n=3)


13

Non-Hodgkin Lymphoma Of the 493 cases of NHL diagnosed, DLBCL accounted for 43.2% of the cases, with other B-Cell and follicular NHL accounting for 25.2% and 22.9% of the cases respectively. The remaining 8.7% of cases of NHL recorded were made up of classifications shown in Figure 5. Figure 5: Distribution of Non-Hodgkin lymphoma in the WoS

Figures 6 and 7 display the clinical stage breakdown for both DLBCL and follicular lymphoma. The distribution of DLBCL by clinical stage is presented in Figure 6, which illustrates that 13.6% of patients presented with stage I disease and 72.8% of patients presented with stage II – IV disease. Stage was not recorded in 24 of the 213 patients (11.3%), which is a slight improvement on the 17.1% figure reported in the previous year’s analysis. 16 of the 24 cases with stage NR were from NHS Lanarkshire. Figure 6: DLBCL by clinical stage Figure 7: Follicular lymphoma by clinical stage

Figure 7 illustrates the distribution of follicular lymphoma by clinical stage at presentation. Localised disease may be suitable for involved field radiotherapy (stage I/ some stage II). More

DLBCL, 43.2%(n=213)

Follicular, 22.9%(n=113)

T-Cell, 7.3%(n=36)

Other B-Cell, 25.2%(n=124)

Unclassifiable, 1.4%(n=7)

IA, 11.7%(n=25)

IB, 1.9%(n=4)

IIA, 13.1%(n=28)

IIB, 6.1%(n=13)

IIIA, 6.6%(n=14)

IIIB, 9.4%(n=20)

IVA, 16%(n=34)

IVB, 21.6%(n=46)

NR, 11.3%(n=24)

NA, 2.3%(n=5)

IA, 15%(n=17)

IB, 0.9%(n=1)

IIA, 10.6%(n=12)

IIB, 0.9%(n=1)

IIIA, 35.4%(n=40)

IIIB, 7.1%(n=8)

IVA, 12.4%(n=14)

IVB, 6.2%(n=7)

NR, 11.5%(n=13)

Follicular by clinical stageDLBCL by clinical stage


14

advanced disease will be observed or treated with chemotherapy depending on symptoms. 11.5% of cases did not have clinical stage recorded, with 9 of the 13 patients from NHS Lanarkshire. Action Required:


3. Methodology

The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was recorded manually and entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed with lymphoma between 1 October 2017 and 30 September 2018 was downloaded from eCASE at 2200 hrs on 8 April 2019. Cancer audit is a dynamic process with patient data continually being revised and updated as more information becomes available. This means that apparently comparable reports for the same time period and cancer site may produce slightly different figures if extracted at different times. Analysis was performed centrally for the region by the WoSCAN Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area.

4. Results and Action Required

4.1 Data Quality

Audit data quality can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated by the number of patients identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by ISD, National Services Scotland). Cancer Registry figures used were extracted from ACaDMe (Acute Cancer Deaths and Mental Health) on 9th April 2019 via the standard reports available and are an average of the previous 5 years’ figures to take account of annual fluctuations in incidence within NHS Boards. Case ascertainment figures are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Table 2 presents the case ascertainment for each NHS Board and for WoSCAN as a whole. Table 2: Case ascertainment by NHS Board for patients diagnosed with Lymphoma

Health Board of Diagnosis (01/10/2017- 30/09/2018)

Audit

Cancer Registry 2013-17

Case Ascertainment

Ayrshire & Arran 50 79 63.3%

GGC 349 290 120.3%

Forth Valley 69 57 121.1%

Lanarkshire 106 100 106.0%

Dumfries & Galloway 38 42 90.5%

WoS Total 612 568 107.7%

Table 2 illustrates that case ascertainment was particularly low for NHS Ayrshire & Arran at 63%. The Board has noted resourcing issues over the past twelve months however now has a full complement of staff. The Board has been asked to provide assurance that efforts will be made to


15

retrospectively collect data for the 2017/18 cohort, to ensure complete data is held centrally for any subsequent survival analysis or regional audit projects. Review of cases not meeting the QPI has highlighted some local data recording errors and measurability issues. During the last audit period a number of staff, new to haemato-oncology, have joined local clinical effectiveness teams. The Haemato-oncology MCN Advisory Board has agreed that an education/training event for audit facilitators across the region would be helpful to provide some clinical background to both lymphoma and acute leukaemia and enable discussion on any data issues which have been noted to ensure consistency of practice across the region. Action Required:


The MCN to organise an education event for haemato-oncology audit facilitators.

4.2 Performance against Quality Performance Indicators (QPIs) Results for each QPI are shown in detail in the main report and illustrate Board performance against each target and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this are denoted with a dash (-). Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement.

Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis.


16

QPI 1: Radiological Staging Accurate staging is important to ensure appropriate treatment is delivered and futile interventions avoided. Computed Tomography (CT) of the chest, abdomen and pelvis is recommended as the initial imaging investigation for all patients with lymphoma. CT neck should also be undertaken where clinically appropriate1.

Figure 8: The proportion of patients with lymphoma who undergo CT scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment.

Performance (%) Numerator Denominator Not recorded

numerator Not recorded

numerator (%) Not recorded exclusions

Not recorded exclusions (%)

Not recorded denominator

AA 90.0% 36 40 0 0.0% 0 0.0% 0

FV 96.9% 31 32 0 0.0% 0 0.0% 2

Lan 96.6% 57 59 0 0.0% 0 0.0% 0

NG 94.1% 80 85 2 2.4% 0 0.0% 2

SG 92.7% 51 55 0 0.0% 0 0.0% 0

Clyde 98.0% 49 50 0 0.0% 0 0.0% 0

D&G 92.0% 23 25 0 0.0% 0 0.0% 0

WoS 94.5% 327 346 2 0.6% 0 0.0% 4

Performance across the WoS was 94.5% against the 95% target with 327 of 346 of patients with lymphoma undergoing CT scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment. Three of the seven units achieved the QPI target with performance ranging from 98% in Clyde to 90% in NHS Ayrshire & Arran.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group


Title: (i): Patients with lymphoma should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making.

Numerator: Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

Denominator: All patients with lymphoma undergoing treatment with curative intent. Exclusions: Patients who refuse investigation.

Patients with primary cutaneous lymphoma. Target: 95%


17

NHS Ayrshire & Arran reviewed all cases not meeting the target and provided detailed commentary. Radiology capacity issues were also noted, with local review ongoing. NHSGGC confirmed that, on clinical review, all cases not meeting the QPI had undergone appropriate imaging, however this was not documented in such a way that could be captured by the audit team. Action required:



Figure 9: The proportion of patients with lymphoma who undergo CT scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 4 Year 5

Title: (ii): Patients with lymphoma should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making.

Numerator: Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment and within two weeks of radiology request.

Denominator: All patients with lymphoma undergoing treatment with curative intent who undergo CT of

chest, abdomen and pelvis or PET CT scanning prior to treatment. Exclusions: None Target: 90%


18






AA 83.3% 30 36 0 0.0% 0 0.0% 0

FV 83.9% 26 31 0 0.0% 0 0.0% 2

Lan 82.5% 47 57 0 0.0% 0 0.0% 0

NG 83.8% 67 80 1 1.3% 0 0.0% 3

SG 84.3% 43 51 0 0.0% 0 0.0% 0

Clyde 85.7% 42 49 0 0.0% 0 0.0% 0

D&G 69.6% 16 23 0 0.0% 0 0.0% 0

WoS 82.9% 271 327 1 0.3% 0 0.0% 5

Overall in the WoS 82.9% of patients who underwent CT/PET CT scanning prior to treatment did so within 2 weeks of radiology request, which is below the 90% target. None of the units achieved the QPI target with performance ranging from 69.6% in NHS Dumfries & Galloway to 85.7% in Clyde. All cases not meeting the QPI were clinically reviewed and in the majority of cases appropriate imaging was carried out, however not within the 14 day window specified within the QPI. Boards highlighted that radiology capacity had impacted upon performance for this measure. Some Boards also noted delays when imaging had been requested from other clinical specialties. NHS Lanarkshire continues to monitor this QPI locally, with education in place regarding the 62 day pathway box on TRAK. It has also been incorporated into the FY1 induction programme. The haematology service in NHSGGC will liaise with Radiology and examine whether imaging can be expedited for these patients. Action required:




19

Specification (iii) was added to QPI 1 at formal review to look at patients undergoing PET CT or CT CAP prior to treatment with the report available within 3 weeks of radiology request. As this required new data items, this is the first year results can be reported. Figure 10: The proportion of patients with lymphoma who undergo CT scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment where the report is available within 3 weeks of radiology request.






AA 86.1% 31 36 0 0.0% 0 0.0% 0

FV 87.1% 27 31 0 0.0% 0 0.0% 2

Lan 93.0% 53 57 0 0.0% 0 0.0% 0

NG 88.8% 71 80 1 1.3% 0 0.0% 3

SG 90.2% 46 51 0 0.0% 0 0.0% 0

Clyde 91.8% 45 49 0 0.0% 0 0.0% 0

D&G 78.3% 18 23 0 0.0% 0 0.0% 0

WoS 89.0% 291 327 1 0.3% 0 0.0% 5

Performance across the WoS was 89% against the 90% target with 291 of 327 patients with lymphoma who underwent CT scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment having the report available within 3 weeks of radiology request. Three of the seven units met the target with performance ranging from 93% in NHS Lanarkshire to 78.3% in NHS Dumfries & Galloway. The reasons for not meeting this QPI have already been noted above.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 5

Title: (iii): Patients with lymphoma should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making.

Numerator: Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment where the report is available within 3 weeks of radiology request.

Denominator: All patients with lymphoma undergoing treatment with curative intent who undergo CT of

chest, abdomen and pelvis or PET CT scanning prior to treatment. Exclusions: None Target: 90%


20

The haematology service in NHSGGC will, where possible, indicate when a report is required by on the imaging request, however in some cases a lymphoma diagnosis may not have been confirmed at the time imaging is requested. Action required:-


QPI 2: Treatment response CT scanning is recommended as the most appropriate method of response assessment following chemotherapy for DLBCL as treatment response may not be clinically obvious1. The target for this QPI has been set at 90% and the tolerance within the target is designed to account for the fact that some patients will have a good clinical response to chemotherapy and will therefore not require an end of treatment scan. It also accounts for those patients who may not complete chemotherapy due to factors of fitness. Figure 11: The proportion of patients with DLBCL who are undergoing chemotherapy treatment with curative intent, who have their response to treatment evaluated with CT scan of the chest, abdomen and pelvis or PET CT scan.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group


QPI Title: Patients with DLBCL who are treated with curative intent should have their response to treatment evaluated with appropriate imaging.

Numerator: Number of patients with DLBCL who are undergoing chemotherapy treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scan at end of chemotherapy treatment

Denominator: All patients with DLBCL who are undergoing chemotherapy treatment with curative intent. Exclusions: Patients that died during treatment. Target: 90%


21






AA 100% 10 10 0 0.0% 0 0.0% 0

FV 76.9% 10 13 1 7.70% 0 0.0% 0

Lan 96.3% 26 27 0 0.0% 0 0.0% 0

NG 94.1% 32 34 0 0.0% 0 0.0% 0

SG 83.3% 20 24 0 0.0% 0 0.0% 0

Clyde 80.0% 20 25 1 4.0% 1 4.0% 0

D&G 60.0% 3 5 0 0.0% 0 0.0% 0

WoS 87.7% 121 138 2 1.4% 1 1.4% 0

Of the 138 patients with DLBCL undergoing chemotherapy treatment with curative intent, 121 had their response to treatment evaluated with CT scan of the chest, abdomen and pelvis or PET CT scan. Three of the seven units exceeded the 90% target resulting in an overall performance of 87.7% across the WoS. Whilst this is marginally short of the target, the graph shows there has been a continual improvement in regional performance from Year 3. Small numbers also impacted upon percentages for some Boards. NHS Forth Valley commented that all patients who breached this QPI were reviewed by the clinical lead and were deemed clinically appropriate. Cases not meeting the QPI in South Glasgow and Clyde were reviewed and valid clinical reasons were provided, and in the main related to patient comorbidities. Action required:




22

QPI 3: Positron Emission Tomography (PET CT) Staging Patients with Classical Hodgkin Lymphoma (CHL) should be evaluated with PET CT scanning to detect the extent of disease and guide treatment decision making1. The target for this QPI is 95% and the tolerance within this target is designed to account for situations where patients are not fit enough to undergo all investigations prior to commencing treatment. Figure 12: The proportion of patients with CHL who undergo PET CT scan prior to first treatment.






AA 88.9% 8 9 0 0.0% 0 0.0% 0

FV 85.7% 6 7 0 0.0% 0 0.0% 0

Lan 86.7% 13 15 0 0.0% 0 0.0% 0

NG 100% 19 19 0 0.0% 0 0.0% 0

SG 93.8% 15 16 0 0.0% 0 0.0% 0

Clyde 100% 8 8 0 0.0% 0 0.0% 0

D&G 80.0% 4 5 0 0.0% 0 0.0% 0

WoS 92.4% 73 79 0 0.0% 0 0.0% 0

Performance across the WoS was 92.4% against the 95% QPI target with 73 of 79 patients with CHL undergoing PET CT prior to first treatment. It should however be noted that numbers of patients included within this QPI are low and therefore comparisons should be made with caution. NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire provided valid clinical reasons for cases not meeting the QPI target.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group


QPI Title: Patients with CHL should be evaluated with PET CT scanning to detect the extent of disease and guide treatment decision making.

Numerator: Patients with CHL undergoing treatment with curative intent who undergo PET CT scan

prior to first treatment. Denominator: All patients with CHL undergoing treatment with curative intent. Exclusions: Patients who refuse investigation. Target: 95%


23

Action required:


The second part of the QPI measures those patients with CHL undergoing treatment with curative intent who undergo PET CT scan prior to first treatment and within 2 weeks of radiology request. Figure 13: The proportion of patients with CHL who undergo PET CT scan prior to first treatment and within 2 weeks of radiology request.






AA 100% 8 8 0 0.0% 0 0.0% 0

FV 100% 6 6 0 0.0% 0 0.0% 0

Lan 92.3% 12 13 1 7.7% 0 0.0% 0

NG 89.5% 17 19 0 0.0% 0 0.0% 1

SG 80.0% 12 15 0 0.0% 0 0.0% 0

Clyde 100% 8 8 0 0.0% 0 0.0% 0

D&G - - - 0 0.0% 0 0.0% 0

WoS 90.4% 66 73 1 1.4% 0 0.0% 1

- Data not shown due to small numbers

Again it should be noted that due to small numbers any comparison of proportions should be made with caution. The overall figure in the WoS for patients with CHL undergoing PET CT prior to first

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 4 Year 5



prior to first treatment and within 2 weeks of radiology request Denominator: All patients with CHL undergoing treatment with curative intent who undergo PET CT scan

prior to first treatment. Exclusions: Patients who refuse investigation. Target: 95%


24

treatment and within two weeks of radiology request was 90.4% against the 95% target. Only three of the seven units met the 90% target, NHS Ayrshire & Arran, NHS Forth Valley and Clyde who all achieved 100%. Data is restricted for NHS Dumfries and Galloway due to low numbers. NHS Lanarkshire commented that initially the PET date for the one case not meeting the QPI was unknown; however on review this has now been updated. The case would have met the QPI resulting in a performance of 100%. NHSGGC again noted that delays to imaging result from lack of capacity. A further specification (iii) was added to QPI 3 at formal review to look at the number of patients with CHL undergoing PET CT or CT CAP prior to treatment where the report is available within 3 weeks of radiology request. As this required new data items, this is the first year results can be reported. Figure 14: The proportion of patients with CHL who undergo PET CT scan prior to first treatment where the report is available within 3 weeks of radiology request.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 5



prior to first treatment and the report is available within 3 weeks of radiology request. Denominator: All patients with CHL undergoing treatment with curative intent who undergo PET CT scan

prior to first treatment. Exclusions: Patients who refuse investigation. Target: 95%


25






AA 100% 8 8 0 0.0% 0 0.0% 0

FV 100% 6 6 0 0.0% 0 0.0% 0

Lan 92.3% 12 13 1 7.7% 0 0.0% 0

NG 94.7% 18 19 0 0.0% 0 0.0% 1

SG 93.3% 14 15 0 0.0% 0 0.0% 0

Clyde 100% 8 8 0 0.0% 0 0.0% 0

D&G - - - 0 0.0% 0 0.0% 0

WoS 95.9% 70 73 1 1.4% 0 0.0% 1

- Data not shown due to small numbers

Of the 73 patients with CHL undergoing PET CT scan prior to first treatment, 70 had the report available within 3 weeks of radiology request, resulting in an overall WoS performance of 95.9% against the 95% QPI target. NHS Lanarkshire, North Glasgow and South Glasgow narrowly missed the target however as overall numbers were small this represented one patient in each unit not meeting the target. All cases were reviewed and valid clinical reasons submitted. QPI 4: Cytogenetic Testing Patients with Burkitt lymphoma and DLBCL should have MYC testing as part of diagnostic process, to identify those who may require CNS prophylaxis and alternative treatment 1. Figure 15: The proportion of patients with Burkitt lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported prior to treatment.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group


QPI Title: Patients with Burkitt lymphoma and DLBCL should have MYC testing as part of diagnostic process, to identify those who may require central nervous system (CNS) prophylaxis and alternative treatment.

Numerator: Number of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy

treatment with curative intent who have MYC results reported prior to treatment. Denominator: All patients with Burkitt lymphoma and DLBCL undergoing chemotherapy treatment with

curative intent. Exclusions: No exclusions Target: 60%


26






AA 50.0% 9 18 0 0.0% 0 0.0% 0

FV 89.5% 17 19 0 0.0% 0 0.0% 0

Lan 48.3% 14 29 0 0.0% 0 0.0% 0

NG 97.3% 36 37 0 0.0% 0 0.0% 0

SG 85.2% 23 27 1 3.7% 0 0.0% 0

Clyde 92.6% 25 27 0 0.0% 0 0.0% 0

D&G 35.7% 5 14 0 0.0% 0 0.0% 0

WoS 75.4% 129 171 1 0.6% 0 0.0% 0

WoS performance for patients diagnosed with Burkitt lymphoma or DLBCL undergoing chemotherapy treatment with curative intent having MYC testing prior to treatment was 75.4%; 15.4 percentage points above the 60% target and 20 points above the WoS performance in Year 2 (55.4%). Four of the seven units met the target with performance ranging from 97.3% in North Glasgow to 35.7% in NHS Dumfries & Galloway. NHS Ayrshire & Arran provided feedback on those cases not meeting the QPI, noting that errors in local data recording had impacted upon the result. Due to staff shortages the current audit period was covered by multiple staff hence increased data error rate. An Audit Facilitator has been appointed from 1st May 2019. NHS Lanarkshire achieved 48.3% against the 60% target. Feedback following local review indicated that all cases had MYC testing carried out, however for 15 patients this was not reported prior to treatment being commenced. The Board concluded that in each of these cases there was a clinical need to commence treatment before the MYC results were available. Action required:



27

Figure 16: The proportion of patients with Burkitt lymphoma and DLBCL undergoing chemotherapy with curative intent who have MYC results reported within 3 weeks of commencing treatment






AA 83.3% 15 18 0 0.0% 0 0.0% 0

FV 100% 19 19 0 0.0% 0 0.0% 0

Lan 86.2% 25 29 0 0.0% 0 0.0% 0

NG 100% 37 37 0 0.0% 0 0.0% 0

SG 96.3% 26 27 1 3.7% 0 0.0% 0

Clyde 100% 27 27 0 0.0% 0 0.0% 0

D&G 85.7% 12 14 0 0.0% 0 0.0% 0

WoS 94.2% 161 171 1 0.6% 0 0.0% 0

The second part of the QPI looks at the availability of MYC results within three weeks of commencing chemotherapy. Overall performance for the WoS was 94.2% which exceeds the 85% QPI target by 9.2 percentage points. Five of the six units met the QPI with NHS Forth Valley and Clyde achieving 100%. Previously NHS Ayrshire & Arran reviewed local pathology processes and formalised a diagnostic pathway in collaboration with pathology colleagues in QEUH. It was anticipated that this year’s results would show an improvement against this target, so whilst they were still marginally under

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 4 Year 5

QPI Title: Patients with Burkitt lymphoma and DLBCL should have MYC testing as part of diagnostic process, to identify those who may require CNS prophylaxis and alternative treatment.

Numerator: Number of patients with Burkitt lymphoma and DLBCL undergoing chemotherapy with

curative intent who have MYC results reported within 3 weeks of commencing treatment. Denominator: All patients with Burkitt lymphoma and DLBCL undergoing chemotherapy treatment with

curative intent. Exclusions: No exclusions Target: 85%


28

target at 83.3% the result did demonstrate an improvement of 6.8 percentage points on the previous year’s performance of 76.5%. QPI 5: Lymphoma MDT Effective MDT working is considered integral to provision of high quality cancer care, facilitating a cohesive treatment-planning function and ensuring treatment and care provision is individualised to patient needs. National guidance states that all patients should have a treatment plan discussed at a MDT meeting 5. Figure 17: The proportion of patients with lymphoma who are discussed at MDT meeting within 8 weeks of diagnosis.






AA 91.8% 45 49 0 0.0% 0 0.0% 0

FV 83.3% 50 60 0 0.0% 0 0.0% 0

Lan 87.5% 91 104 0 0.0% 0 0.0% 0

NG 65.7% 94 143 1 0.7% 2 1.4% 0

SG 93.4% 85 91 0 0.0% 0 0.0% 0

Clyde 87.6% 85 97 0 0.0% 0 0.0% 0

D&G 94.4% 34 36 0 0.0% 0 0.0% 0

WoS 83.4% 484 580 1 0.2% 2 0.3% 0

The 90% target for MDT discussion was not achieved in WoS for the fourth consecutive year, with only 83.4% of patients being discussed at the MDT within 8 weeks of diagnosis. Four of the seven units did not meet the 90% QPI target. Although the majority of patients were discussed at MDT,

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group


QPI Title: Patients with lymphoma should be discussed by a MDT following diagnosis.

Numerator: Number of patients with lymphoma discussed at the MDT within 8 weeks of diagnosis.

Denominator: All patients with lymphoma. Exclusions: Patients who died before first treatment.

Patients with primary cutaneous lymphoma.

Target: 90%


29

this was often not within the 8 week timeframe. In many cases these patients were receiving supportive care or watchful waiting and therefore the timeframe for MDT discussion was clinically appropriate. In some cases, patients were referred to haematology via other specialties and this impacted on timelines. A number of local Board improvement actions have been identified: NHS Lanarkshire will continue to emphasise to the clinical team the importance of prompt discussion at MDT; a system is currently being developed/trialled in Clyde for patients managed by haematology to ensure that they will be discussed within the 56 day target; North Glasgow has introduced a check box at the weekly lymphoma meeting to ensure MDT discussion. Action Required:


QPI 6: Treatment for Follicular Lymphoma and DLBCL Patients with symptomatic advanced stage follicular lymphoma and DLBCL should receive rituximab in combination with chemotherapy as this increases response to chemotherapy and provides a progression free, and overall, survival benefit1. As it is difficult to accurately identify those patients with symptomatic advanced follicular lymphoma and DLBCL, the number of patients with follicular lymphoma and DLBCL undergoing chemotherapy is being utilised as a proxy measure for symptomatic advanced disease. Figure 18: The proportion of patients with follicular lymphoma and DLBCL who receive chemotherapy in combination with anti-B cell monoclonal antibody therapy.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group


QPI Title: Patients with symptomatic advanced follicular lymphoma and DLBCL should undergo treatment with anti-B cell monoclonal antibody therapy in combination with chemotherapy.

Numerator: Number of patients with follicular lymphoma and DLBCL who receive chemotherapy in

combination with anti-B cell monoclonal antibody therapy. Denominator: All patients with follicular lymphoma and DLBCL who receive chemotherapy. Exclusions: Patients who refuse chemotherapy.

Patients enrolled in clinical trials.

Target: 95%


30






AA 100% 20 20 0 0.0% 0 0.0% 0

FV 100% 24 24 0 0.0% 0 0.0% 0

Lan 97.7% 42 43 0 0.0% 0 0.0% 0

NG 94.3% 33 35 0 0.0% 0 0.0% 0

SG 97.1% 34 35 0 0.0% 0 0.0% 0

Clyde 100% 36 36 0 0.0% 0 0.0% 0

D&G 100% 16 16 0 0.0% 1 6.3% 0

WoS 98.1% 205 209 0 0.0% 1 0.5% 0

Performance across WoS was 98.1% against the 95% target with 205 of 209 patients diagnosed with follicular lymphoma or DLBCL receiving chemotherapy in combination with anti-B cell monoclonal antibody therapy. Six of the seven units met the QPI with North Glasgow marginally under the 95% target achieving 94.3%. A data error was identified in one of the 2 cases in North Glasgow not meeting the QPI; when corrected, the case would have met the QPI resulting in a performance of 97.1%. QPI 10: Primary Cutaneous Lymphoma A specialist MDT for patients with primary cutaneous lymphoma facilitates clinico-pathological correlation, which is very important in this group of conditions where treatment is multi-faceted. Furthermore it allows for consolidation of expertise in this rare condition which will help develop robust diagnosis and management1.

Figure 19: The proportion of patients with primary cutaneous lymphoma who are discussed at a specialist MDT meeting.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Year

WoS

QPI Title: Patients with primary cutaneous lymphoma should be discussed at a specialist MDT meeting.

Numerator: Number of patients with primary cutaneous lymphoma who are discussed at a specialist

MDT meeting. Denominator: All patients with primary cutaneous lymphoma. Exclusions: No exclusions. Target: 95%


31


Numerator 15 22 17 13

Denominator 15 23 22 13

Performance (%) 100% 95.7% 77.3% 100%

It should be noted that all seven units had denominators of five or less and therefore individual unit results cannot be presented at this time. Overall in the WoS 100% of patients with primary cutaneous lymphoma were discussed at a specialist MDT meeting. This is an increase of 22.7 percentage points from the previous years result, however, the numbers of patients included within this QPI are low and therefore comparisons should be made with caution.

QPI 11: Hepatitis and HIV Status Clinical assessment and virological testing for Human Immunodeficiency Virus (HIV), hepatitis B and C should be undertaken for all patients as part of the diagnostic process and in all patients considered at risk of virus reactivation1. Figure 20: The proportion of patients with lymphoma undergoing SACT who have hepatitis B, hepatitis C and HIV status checked prior to treatment.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group


QPI Title: Virological testing for HIV, hepatitis B and C should be undertaken for patients undergoing SACT.

Numerator: Number of patients with lymphoma undergoing SACT who have hepatitis B, C and HIV

status checked prior to treatment. Denominator: All patients with lymphoma undergoing SACT. Exclusions: No exclusions. Target: 95%


32






AA 97.1% 34 35 0 0.0% 0 0.0% 0

FV 100% 44 44 0 0.0% 0 0.0% 0

Lan 98.6% 70 71 0 0.0% 0 0.0% 0

NG 94.7% 90 95 1 1.1% 0 0.0% 0

SG 93.4% 57 61 0 0.0% 0 0.0% 0

Clyde 98.3% 59 60 0 0.0% 0 0.0% 0

D&G 84.0% 21 25 0 0.0% 0 0.0% 0

WoS 95.9% 375 391 1 0.3% 0 0.0% 0

Figure 20 indicates that 95.9% of patients with lymphoma undergoing SACT had hepatitis B, C and HIV checked prior to treatment. Four of the seven units also achieved the 95% target with many showing an improvement from Year 4 results. In response to a previous action plan, NHS Ayrshire & Arran piloted a new electronic MDT outcome form in early 2018 which included viral screening. It was anticipated that this would lead to further improvement in this QPI result. Figure 19 highlights that performance increased from 85.7% in Year 4 to 97.1% in Year 5.

North Glasgow and South Glasgow narrowly missed the target with performance of 94.7% and 93.4% respectively. All cases were reviewed and reasons included a technical failure in one case in North Glasgow and inclusion of a patient in South Glasgow that should not have been included in the denominator. Action required:


QPI 12: Treatment Response in Hodgkin Lymphoma PET CT demonstrates a higher level of accuracy compared with contrast CT scan and is therefore the most appropriate method of response assessment following chemotherapy in lymphoma patients. Interim PET CT is recommended for patients with advanced Hodgkin Lymphoma undergoing treatment with ABVD chemotherapy as this is an indicator of predicted treatment success when continuing treatment. Evidence suggests that the optimal timing for PET CT to be carried out is following 2 cycles of ABVD chemotherapy. It is important that the PET CT is reported in a timely manner to ensure there is no treatment delay 1.

QPI Title: Patients with advanced Hodgkin Lymphoma who receive treatment with ABVD chemotherapy should have early assessment of response by imaging.

Numerator: Number of patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive

ABVD chemotherapy treatment that undergo PET CT scan after 2 cycles of chemotherapy.

Denominator: All patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD

chemotherapy treatment. Exclusions: No exclusions. Target: 80%


33

Figure 21: The proportion of patients with advanced Hodgkin Lymphoma who receive ABVD chemotherapy treatment, that have their treatment evaluated with PET CT scan after two cycles of chemotherapy.






AA 20.0% 1 5 0 0.0% 0 0.0% 0

FV 100% 5 5 0 0.0% 0 0.0% 0

Lan 66.7% 4 6 0 0.0% 0 0.0% 0

NG 100% 12 12 0 0.0% 0 0.0% 0

SG 87.5% 7 8 0 0.0% 0 0.0% 0

Clyde 66.7% 4 6 0 0.0% 0 0.0% 0

D&G - - - 0 0.0% 0 0.0% 0

WoS 80.0% 36 45 0 0.0% 0 0.0% 0

QPI 12 was added at formal review to look at patients with advanced Hodgkin Lymphoma who receive ABVD chemotherapy treatment, that have their treatment evaluated with PET CT scan after two cycles of chemotherapy. As this required new data items, this is the first year results can be reported. Overall performance in the WoS was noted as 80%. NHS Ayrshire & Arran, NHS Lanarkshire and Clyde failed to meet the 80% target, however denominator numbers are small and therefore impact on percentages. NHS Dumfries & Galloway figures are restricted due to a denominator of less than five. Cases not meeting the target were reviewed locally, with valid clinical reasons and delays at PET centre cited by Boards.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 5


34

The second part of the QPI looks at patients with advanced Hodgkin Lymphoma who receive ABVD chemotherapy treatment, that have their treatment evaluated with PET CT scan after two cycles of chemotherapy where the report is available within 3 days. Figure 22: The proportion of patients with advanced Hodgkin Lymphoma who receive ABVD chemotherapy treatment, that have their treatment evaluated with PET CT scan after two cycles of chemotherapy where the report is available within 3 days.






AA - - - 0 0.0% 0 0.0% 0

FV 40.0% 2 5 0 0.0% 0 0.0% 0

Lan - - - 0 0.0% 0 0.0% 0

NG 83.3% 10 12 0 0.0% 0 0.0% 0

SG 42.9% 3 7 0 0.0% 0 0.0% 0

Clyde - - - 0 0.0% 0 0.0% 0

D&G - - - 0 0.0% 0 0.0% 0

WoS 61.1% 22 36 0 0.0% 0 0.0% 0

In WoS, 22 of 36 patients with advanced Hodgkin Lymphoma who received ABVD chemotherapy treatment and had their treatment evaluated with PET CT scan after two cycles of chemotherapy had the report available within 3 days. This represented 61.1% performance against the 80% QPI target. Only North Glasgow met the QPI, however, the number of patients included in the denominator is low, especially within the smaller units, and this can have a considerable effect on

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 5

QPI Title: Patients with advanced Hodgkin Lymphoma who receive treatment with ABVD chemotherapy should have early assessment of response by imaging.

Numerator: Number of patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive

ABVD chemotherapy treatment that undergo PET CT scan after 2 cycles of chemotherapy where the report is available within 3 days.

Denominator: All patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD

chemotherapy treatment that undergo PET CT scan after 2 cycles of chemotherapy. Exclusions: No exclusions. Target: 80%


35

proportions. Data has been restricted for NHS Ayrshire & Arran, NHS Lanarkshire, Clyde and NHS Dumfries & Galloway due to a denominator of less than five. Boards reviewed all cases not meeting the QPI and in the majority of cases, PET CT was carried out but the report was not available within the 3 days. During analysis a measurability issue was noticed. Patients who received an interim scan after cycle 2 and then escalated for further chemotherapy (not ABVD) were failing the QPI. This has now been amended and future reports will ensure that these cases are correctly assigned. QPI 13: Maintenance Therapy for Follicular Lymphoma It is recommended that patients with follicular lymphoma responding to first line rituximab based chemotherapy should receive rituximab maintenance therapy as this has progression free survival benefits1. Figure 23: The proportion of patients with follicular lymphoma undergoing treatment with R-Chemotherapy who receive maintenance treatment with anti-B cell monoclonal antibody therapy.

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Year 5

QPI Title: Patients with follicular lymphoma undergoing R-Chemotherapy should receive maintenance treatment with anti-B cell monoclonal antibody therapy.

Numerator: Number of patients with follicular lymphoma who undergo treatment with R-Chemotherapy

who receive maintenance therapy with anti-B cell monoclonal antibody therapy. Denominator: All patients with follicular lymphoma who undergo treatment with R-Chemotherapy. Exclusions: Patients enrolled in clinical trials. Target: 90%


36






AA - - - 0 0.0% 0 0.0% 0

FV - - - 0 0.0% 0 0.0% 0

Lan 77.8% 7 9 0 0.0% 0 0.0% 0

NG 87.5% 7 8 0 0.0% 0 0.0% 0

SG 75.0% 6 8 0 0.0% 0 0.0% 0

Clyde 44.4% 4 9 0 0.0% 0 0.0% 0

D&G - - - 0 0.0% 0 0.0% 0

WoS 76.2% 32 42 0 0.0% 0 0.0% 0

Of the 42 patients with follicular lymphoma undergoing treatment with R-Chemotherapy, 32 patients received maintenance treatment with anti-B cell monoclonal antibody therapy resulting in a WoS performance of 76.2% against the 90% QPI target. None of the WoS units met the QPI target, however it should be noted that denominator numbers are small and figures have been restricted for NHS Ayrshire & Arran, NHS Forth Valley and NHS Dumfries & Galloway in line with statistical disclosure control protocols. Following clinical review, Boards concluded that patients were managed appropriately. In some cases maintenance therapy had commenced after the data had been analysed, maintenance therapy was not indicated for some patients (grade 3B follicular lymphoma) or patients were unsuitable for maintenance therapy due to clinical reasons. Action required:-




37

Clinical Trial Access Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Furthermore, evidence suggests improved patient outcomes when hospitals are actively recruiting patients into clinical trials1. Data definitions and measurability criteria to accompany the Clinical Trial QPI are available from the HIS website1. The clinical trials QPI is measured utilising Scottish Cancer Research Network (SCRN) data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and National Cancer Research Institute (NCRI). Utilising SCRN data allows for comparison with CSO published data and ensures capture of all clinical trials recruitment, not solely first line treatment trials, as contained in the clinical audit data. Given that a significant proportion of clinical trials are for relapsed disease this is felt to be particularly important in driving quality improvement. This methodology utilises incidence as a proxy for all patients with cancer. This may slightly over, or underestimate, performance levels, however this is an established approach currently utilised by NHS Scotland1. Figure 24: Proportion of patients diagnosed with lymphoma who are consented* for a clinical trial / research study in 2018.

Consented - QPI Target 15% Recruited

NHS Board of Residence N D % N D %

Ayrshire & Arran 11 79 13.9% 5 79 6.3%

Forth Valley 5 57 8.8% 4 57 7.0%

GGC 46 290 15.9% 32 290 11.0%

Lanarkshire 7 100 7.0% 5 100 5.0%

Dumfries & Galloway 3 42 7.1% 2 42 4.8%

WoS 72 568 12.7% 48 568 8.5%

0

2

4

6

8

10

12

14

16

18

20

A&A FV Lan GGC D&G WoS

Pro

po

rtio

n o

f p

ati

en

ts (

%)

Board of Residence

Consented Entered

QPI Title: All patients should be considered for participation in available clinical trials/research studies wherever eligible.

Numerator: Number of patients diagnosed with lymphoma consented for a clinical trial/research study. Denominator: All patients with diagnosed with lymphoma. Exclusions: No exclusions. Target: 15%


38

Following formal review the Clinical Trials Access QPI was updated to measure the number of patients consented for participation in a clinical trial rather than only those who are enrolled. There are a number of patients who undergo screening but do not proceed to enrolment for various reasons, e.g. they do not have the mutation required for entry on to the trial. It is important to note that the denominator used in the measurement of this QPI is the 5 year average of ISD incidence data for all lymphomas in WoS (2013 -2017). Overall for patients in WoS diagnosed with lymphoma, 72 patients consented for a clinical trial/research study resulting in a WoS performance of 12.7% against the 15% target. Only NHSGGC met the target with unit performance ranging from 15.9% in NHSGGC to 7% in NHS Lanarkshire. There are a number of clinical trials (interventional and non-interventional) open in the WoS for lymphoma. QPI data suggests we have fallen below the 15% target at 12.7%. Almost all of the interventional trials (except the MARIETTA study) were in the relapsed and refractory setting. The cohort of patients who would thus be eligible for participation in these clinical trials are often clinically unwell with rapidly progressive disease which partly explains the "fall off" between the percentage of patients consented and recruited. Importantly, there are very few first-line clinical trials available for lymphoma so the majority of patients with newly diagnosed lymphoma are not recruited into clinical trials. It should be noted that lymphoma is a very heterogeneous disease and most of the clinical trials are specific to the lymphoma disease subtype. Table 3: List of clinical trials and the number of patients with lymphoma consented/entered into each clinical trial in 2018. (N.B. All recruits noted below were resident within WoS).

Project Title Consented Entered

A Phase I trial of AZD3965 in patients with advanced cancer 3 0

CANC - 3341 - E7438 in Advanced Solid Tumours or B-cell Lymphomas 11 1

ARGO 12 9

AVAIL-T - Avelumab in relapsed/refractory T-cell Lymphoma 2 1

BACH 4 4

Cardiac CARE 4 4

HORIZONS: Understanding the impact of cancer diagnosis and treatment 13 7

IELSG 37 1 1

IELSG 42 - Marietta 1 1

INCA 3 2

MaPLe: Molecular profiling for lymphoma 13 13

MCL Biobank Observational Study 2 2

PETReA 1 1

ReBeL Phase II (A HOVON 110FL/GLSG/NCRI study) 2 2

Total 72 48


39

5. Conclusions

Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. Following the development of QPIs, this has now become an established national programme to drive continuous improvement and ensure equity of care for patients across Scotland. The results illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement particularly around a number of areas, including: MDT discussion, radiological diagnosis and staging within two weeks of radiological request. It should also be noted that overall percentages are affected by the small numbers of patients meeting the denominator criteria for some of the measures. It is encouraging that case ascertainment and data capture is of a high standard enabling robust assessment of performance against QPIs. Steady improvement has been noted across the WoS for QPIs relating to treatment response (QPI2), cytogenetic testing (QPI4), PCL patients discussed at specialist MDT (QPI10) and virological testing (QPI 11). Where QPI targets were not met, the majority of NHS Boards have provided detailed commentary. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. NHS Boards are encouraged to continue with this proactive approach of reviewing data and addressing issues as necessary, in order to work towards increasingly advanced performance against targets, and demonstration of overall improvement in quality of the care and service provided to patients.

There are a number of actions required as a consequence of this assessment of performance against the agreed criteria. Actions required:



The MCN to organise an education event for haemato-oncology audit facilitators. QPI 1(i) – Radiological Staging



QPI 1(ii) - Radiological Staging



QPI 1(iii) - Radiological Staging


QPI 2 – Treatment Response




40

QPI 3(i) – PET CT Staging


QPI 4 – Cytogenetic Testing


QPI 5 – Lymphoma MDT


QPI 11 – Hepatitis and HIV Status





Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported to the Regional Cancer Advisory Group (RCAG) annually by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, as part of the regional audit governance process to enable RCAG to review and monitor regional improvement.


41

Acknowledgement

This report has been prepared using clinical audit data provided by the following NHS Boards in the WoSCAN area: NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire NHS Dumfries & Galloway

We would like to thank all members and active participants in the cancer network for their continued support of the MCN, and the many hospitals that are committed to making the audit succeed. We also acknowledge the efforts of the clinical effectiveness staff, nurses, and other service users for their work in ensuring the data are available to enable analysis to take place each year. Without their considerable efforts this level of progress would not be possible.


42

Abbreviations

CAP Chest, Abdominal, Pelvis

CHL Classical Hodgkin Lymphoma

CNS Central Nervous System

CSO Chief Scientist Office

CT Computed Tomography

DLBCL Diffuse Large B Cell Lymphoma

eCASE Electronic Cancer Audit Support Environment

HIS Healthcare Improvement Scotland

HIV Human Immunodeficiency Virus

HL Hodgkin Lymphoma

ISD Information Services Division

MCN Managed Clinical Network

MDT Multidisciplinary Team

NCQSG National Cancer Quality Steering Group

NCRI National Cancer Research Institute

NHL Non Hodgkin Lymphoma

NHSGGC NHS Greater Glasgow and Clyde

NOS Not Otherwise Specified

PET Positron Emission Tomography

QPI Quality Performance Indicator

RCAG Regional Cancer Advisory Group

SCRN Scottish Cancer Research Network

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


43

References

1. http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cance

r_qpis/quality_performance_indicators.aspx

2. http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

3. http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Non-Hodgkins-Lymphoma/

4. http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/

5. http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/

http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/



http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/


44

Copyright


Organisations may copy, quote, publish and broadcast material from this report without payment and without

approval provided they observe the conditions below. Other users may copy or download material for private

research and study without payment and without approval provided they observe the conditions below.

The conditions of the waiver of copyright are that users observe the following conditions:

Quote the source as the West of Scotland Cancer Network (WoSCAN).

Do not use the material in a misleading context or in a derogatory manner.

Where possible, send us the URL.

The following material may not be copied and is excluded from the waiver:

The West of Scotland Cancer Network logo.

Any photographs.

Any other use of copyright material belonging to the West of Scotland Cancer Network requires the formal

permission of the Network.


45

Appendix 1: NHS Board Action Plans

A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix 1. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.


46

Lymphoma Action / Improvement Plan

No Action Required Health Board Action Taken

Timescales Lead Progress/Action Status Status (see key) Start End

Action Detail specific actions that will be taken by the NHS Board.

Insert date

Insert date

Insert name of responsible lead for each specific action.

Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken.

Insert No. from key above

1. The MCN to organise an education event for haemato-oncology audit facilitators.

2.

QPI 5 – Lymphoma MDT The MCN will initiate an audit to explore further the groups of patients not being discussed at MDT and those being discussed >56 days from diagnosis, with a view to identifying any variance between Boards and any improvement action required.



QPI amendment required to exclude grade 3B follicular lymphoma and also patients who died before treatment category requires updating.

Health Board: WoSCAN KEY (Status)

Action Plan Lead: 1 Action fully implemented

Date: 2 Action agreed but not yet implemented

3 No action taken (please state reason)


47





Insert date

Insert date




1.


2.

QPI 1(i) – Radiological Staging NHS Ayrshire & Arran to provide detail of action being taken locally to address radiology capacity issues.

Health Board: NHS Ayrshire & Arran KEY (Status)





48





Insert

date

Insert date




1.

QPI 2 – Treatment Response NHS Forth Valley to provide further detailed reasons for patients with DLBCL undergoing treatment with curative intent not undergoing CT of chest, abdomen and pelvis or PET CT scan at end of chemotherapy treatment.

Health Board: NHS Forth Valley KEY (Status)





49





Insert date

Insert date




1.


Health Board: NHS Lanarkshire KEY (Status)





50





Insert date

Insert date




1.

QPI 1(ii) - Radiological Staging NHSGGC to work with radiology to examine whether imaging can be expedited for patients with lymphoma undergoing curative treatment.

Health Board: NHSGGC KEY (Status)





51





Insert date

Insert date




1.

QPI 1(i) – Radiological Staging NHS Dumfries & Galloway to review and provide further detail on cases not undergoing CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

2.

QPI 1(ii) - Radiological Staging NHS Dumfries & Galloway to review cases and provide further detail on cases not meeting QPI.

3.

QPI 1(iii) - Radiological Staging NHS Dumfries & Galloway to review cases and provide further detail on cases not meeting QPI.

4.

QPI 2 – Treatment Response NHS Dumfries and Galloway to review all cases not meeting the QPI and provide feedback.

5.

QPI 3(i) – PET CT Staging NHS Dumfries and Galloway to review all cases not meeting the QPI and provide feedback.

Health Board: NHS Dumfries & Galloway KEY (Status)





52



6.

QPI 4 – Cytogenetic Testing NHS Dumfries and Galloway to review all cases not meeting the QPI and provide feedback.

7.

QPI 11 – Hepatitis and HIV Status NHS Dumfries and Galloway to review all cases not meeting the QPI and provide feedback.

mcn audit report - woscan.scot.nhs.uk · final published lymphoma qpi mcn audit report v1.0...

Documents