Pan-Birmingham Cancer Network

NCATCommissioning

Exemplar

Breast Cancer Surgery

4th November 2010

Approach• Initial scoping was cross-referenced to established

guidelines (NICE, NSSG, Map of Medicine)• Taken the PbR datasets that are already readily

available to NHS Commissioners• Analysed and tested outputs with clinicians in the

know• Refined the data and information and retested with

clinicians – Key Issues emerged• Production of a Commissioner’s Guidance Note• Aim is to inform the discussions between

commissioners and hospital providers

Project Phases• Phase 1 - Project Scoping (Established guidelines

and listening to clinicians)• Phase 2 – Data Crunch 1 & Clinical Networking to

Identify the Issues

• Phase 3 – Data Crunch 2 & Addressing the Issues• Phase 4 – Expanding the Scope – The Wider Clinical

Pathway

• Phase 5 – Bringing it all Together

ICD-10 Diagnosis Codes•C50 – Breast Neoplasms

•D05 – Ductal Carcinoma in Situ (DCIS)

2008/09 Dataset

Apr 08 Apr 09

2009/10 Dataset

Apr 10

Dec 09

9 mths Mastectomy / BCS cases Further Ops in next12 mths

The PbR Data-Set

849 ~ £2m 214 ~ £430k

An extended dataset for the 21-month period April 2008 to December 2009 was used to identify 849 patients who had either a mastectomy or breast conserving surgery in the 9-month period April to

December 2008.

It was then possible to undertake a detailed analysis of the 214 follow-up operations needed by the cohort during the course of the following year.

Key Issues that Emerged

• Ratio of Mastectomies .v. BCS• Rate of Sentinal Node Biopsy• Conversion of SNB to Full Axillary Clearance• The need for further surgery after BCS• Cases planned and achieved as 23hr/daycase• Reconstruction• Consultant Caseload

Presenting a Data Summary

Dashboard Created

A Separate Dashboard for each of the main

pan-Birmingham Hospitals

Proportion of patients requiring only a single operation

Conserving the Axillary Lymph Node Tissue

Ratio of Mastectomies to Breast Conserving Surgery

The Need for Additional Surgery

Simultaneous Reconstruction

Payment by Results Tariff Details ££

Conserving Breast Tissue

Number of Initial BCS & Mastectomies

Delving Deeper into the Data to Address the Key Issues

Low Number of Second Operations

High Proportion of Breast Conserving

Surgery

Low Number of Second Operations

Low Proportion of Breast Conserving

Surgery

High Number of Second Operations

High Proportion of Breast Conserving

Surgery

High Number of Second Operations

Low Proportion of Breast Conserving

Surgery

Can anything be done to reduce

the number of second operations

Sentinel Node BiopsyBreast Conserving

Surgery+ Sentinel Node Biopsy

HRG JA07 a,b or cPbR £2,053 to £2,764

Axillary ClearanceHRG JA06

PbR £2,760

Histology

Breast Conserving Surgery+ Sentinel Node Biopsy

Histology in Theatre and proceed to Axillary Clearance if needed

HRG JA06 / JA07 a,b or cPbR £2,053 to £2,764

£4,813 to £5,524 £2,053 to 2,764

•List planning / Theatre Time / Equipment•£400/case extra

Sentinel Node Biopsy

Total Ops

Apr'08 to Dec'08 Partial

Mastectomy

Axilla

NIL Sample SNB Clearance

Ops % Ops % Ops % Ops %124 HEFT 25 20% 2 2% 66 53% 31 25%

160 SWBH 38 24% 4 3% 98 67% 20 13%109 UHB 27 25% 1 1% 54 47% 27 25%70 Walsall 10 14% 43 61% 15 21% 2 3%23 Other Hospitals 4 17% 4 17% 10 48% 5 22%

486 All Hospitals 104 21% 54 11% 243 49% 85 17%

£ PbR ExpenditureAxilla

NIL Sample SNB Clearance

£ total£ average £ total

£ average £ total

£ average £ total

£ average

£223,772 HEFT £42,611 £1,686 £3,512 £1,756£122,00

5 £1,848 £55,644 £1,798

£291,416 SWBH £65,870 £1,733 £6,794 £1,699£179,94

0 £1,836 £38,812 £1,941

£201,971 UHB £50,522 £1,829 £1,907 £1,907£100,77

1 £1,866 £48,771 £1,824£123,708 Walsall £15,034 £1,503 £78,377 £1,823 £26,634 £1,776 £3,663 £1,857£43,665 Other Hospitals £7,024 £1,781 £9,999 £2,500 £17,862 £1,489 £8,780 £1,463

£884,532 All Hospitals£181,06

1 £1,725£100,58

9 £1,863£447,21

2 £1,825£155,67

0 £1,818

Using the Data to Quantify the

Key Issues

SNB to Full Ax ClearanceTotal Ax

Clearances % of snbSNB converting to Axillary

Clearance

at Time of Further MastectomyNone Partial Full

Ops % Ops % Ops %

4 6% HEFT 2 50% 2 50%

17 17% SWBH 953%

318%

529%

6 11% UHB 3 50% 3 50%

1 7% Walsall 1 100%

3 30% Other Hospitals 1 33% 2 67%

31 13% All Hospitals 13 42% 8 26% 10 32%

£ Expenditure

at Time of Further MastectomyNone Partial Full

£ total£ average £ total

£ average £ total

£ average

£10,330 HEFT £4,456 £2,228 £5,874 £2,937

£42,920 SWBH £22,364 £2,485 £7,081 £2,360 £13,473 £2,695

£15,037 UHB £7,647 £2,549 £7,390 £2,463

£2,937 Walsall £2,937 £2,937

£9,903 Other Hospitals £2,549 £2,549 £7,354 £3,677

£81,127 All Hospitals £32,560 £2,505 £18,927 £2,366 £29,638 £2,964

Sentinel Node BiopsyBreast Conserving

Surgery+ Sentinel Node Biopsy

HRG JA07 a, b or cPbR £2,053 to £2,764

Axillary ClearanceHRG JA06

PbR £2,760

Histology

Breast Conserving Surgery

+ Sentinel Node BiopsyHistology in Theatre

and proceed to Axillary Clearance if needed

HRG JA06PbR £2,760

£4,813 to £5,524 £2,760

•List plannning•£400/case extra

City Hosp x £400 =

£39,200

City Hosp x £2,760 =

£46,920

98

17

Sentinel Node BiopsyBreast Conserving

Surgery+ Sentinel Node Biopsy

HRG JA07 a, b or cPbR £2,053 to £2,764

Axillary ClearanceHRG JA06

PbR £2,760

Histology

Breast Conserving Surgery

+ Sentinel Node BiopsyHistology in Theatre

and proceed to Axillary Clearance if needed

HRG JA06PbR £2,760

£4,813 to £5,524 £2,760

•List plannning•£400/case extra

City Hosp98 x £400 = £39,200

City Hosp17 x £2,760 = £46,920

Invest £39,200 to Save £46,920

Only 1 operation for patient instead of 2

• Should we be petitioning for Best Practice Tariff ?

•CQUIN ?

•Commissioners and Providers now have something

to talk about that is evidence based

•Leverage for Better Care