quality assurance report ttuhsc breast center of excellence january 1, 2011 – december 31, 2011...

Quality Assurance ReportTTUHSC Breast Center of Excellence

January 1, 2011 – December 31, 2011

Compiled by Lynn Day, RN BSN CCM CCRP

Stage DistributionTotal Number of Patients = 107

Time Frame

Stage 0 Stage I Stage II Stage III Stage IV Stage Unassigned

Total

Jan – Jun 12(22.22%)

22(40.74%)

11(20.37%)

4(7.41%)

0(0%)

5(9.26%)

54(100%)

Jul - Dec 8(15.09%)

19(35.85%)

10(18.87%)

2(3.77)

0(0%)

14(26.42%)

53(100%)

Jan-Dec 20(18.69%)

41(38.32%)

21(19.63%)

6(5.61%)

0(0%)

19(17.76%)

107(100%)


Time Frame Stage 0 Stage I Stage II Stage III Stage IV Stage Unassigned

Total

Jan – JunPreoperativeCore

11(20.37%)

22(40.74%)

10(18.52%)

4(7.41%)

0(0%)

5(9.26%)

52(96.3%)

Jul – DecPreoperativeCore

6(11.32%)

19(35.85%)

10(18.87%)

2(3.77%)

0(0%)

13(24.53%)

50(94.34%)

Jan-DecPreoperativeCore

17(15.88%)

41(38.32%)

20(18.69%)

6(5.61%)

0(0%)

18(16.82%)

102(95.33%)

Mode of DiagnosisTotal Number of Patients = 107

95.33% of patients had diagnosis established on preoperative core needle biopsy

Exceptions – discordant core biopsy


Tumor Board DiscussionTotal Number of Patients = 107

Time Frame


Total

Jan – JunDiscussed

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 – DecDiscussed

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-DecDiscussed

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


Time Frame


Total

Jan – JunMDC 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 – DecMDC 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-DecMDC 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

Exceptions 29/107 (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%)



Total

Jan – JunAssigned

10/12(83.33%)

22/22(100%)

11/11(100%)

4/4(100%)

0(0%)

2/5(40%)

49/54(90.74%)

Jul – DecAssigned

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-DecAssigned

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 NavigationTotal Number of Patients = 107

Exceptions 11/107 (10.28%)

•Lateral entry into the system 11/11 (100%)*

* modifications made to ensure assignment of a nurse navigator for every patient



Total

Jan – JunYes

1/12(8.33%)

22/22(100%)

9/11(81.82%)

4/4(100%)

0(0%)

0/5(0%)

36/54(66.67%)

Jul – DecYes

0/8(0%)

18/19(94.74%)

10/10(100%)

2/2(100%)

0(0%)

0/14(0%)

30/53(56.6%)

Jan-DecYes

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 ComplianceTotal Number of Patients = 107

Exceptions 41/107 (38.32%)

•Progesterone receptor not reported 17/41 (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%)


Axillary StagingTotal Number of Patients = 107

Total Number of Patients with Invasive Cancer = 87

• Number node positive patients on needle biopsy 11/87 (12.6%)

• Number of patients eligible for SLNB 76/87 (87.4%)– Number of patients with SLNB 54/87

(62.1%)

• Exceptions 12/87 (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 up 2/12 (16.7%)


Axillary DissectionTotal 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%)

• Exceptions 11/25 (44%) Low risk for non-SLN mets. on MSKCC nomogram 7/25 (28%)

Final surgery not done yet 3/25 (12%) Patient refused completion ALND 1/25 (4%)


Time Frame


Total

Jan – JunYes

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 – DecYes

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-DecYes

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 ConservationTotal Number of Patients = 107

Number of early stage patients (0, I and II) with breast conservation 56/82 (68.29%)


Post-lumpectomy RadiationTotal Number of Patients = 107

• Number of patients with lumpectomy 60/107 (56.1%)• Number of patients eligible for Radiation 60

– Number of patients radiated 50/60 (83.33%)

• Exceptions 10/60 (16.7%) Low risk malignancy age group 75 – 93 years 6/10 (60%)

severe co morbiditiesRadiation pending 3/10 (30%)Patient non-compliance 1/10 (10%)

• Number of patients radiated within 12 months 48/50 (96%)


Post-Mastectomy RadiationTotal Number of Patients = 107

• Number of patients with mastectomy 31/107 (29%)• Number eligible for radiation (>T3 or >N2) 5/31 (16.1%)

– Number of patients radiated 3/5 (60%)

• Exceptions 2/5 (40%) - Radiation pending 1/5 (20%) - Patient non-compliance 1/5 (20%)

• Number of patients radiated within 12 months 5/5 (100%)


Systemic Chemotherapy - ITotal Number of Patients = 107

ER negative patients with cancer 10/107 (9.35%)• Number eligible for chemotherapy (exclude DCIS) 7/10 (70%)

– Number treated with chemotherapy 6/7 (85.7%)

• Exceptions 1/7 (14.29%) Patient refused (1 stage I) 1/1 (100%)

Number with chemotherapy within 4 months 6/6 (100%)

• Exceptions 0 (none) Patient non-compliance 0 (none)


Systemic Chemotherapy - IITotal Number of Patients = 107

ER positive patients with cancer 94/107 (87.9%)• Number eligible for chemotherapy (exclude DCIS) 77/94 (81.9%)• Number treated with chemotherapy 45/77 (58.4%)

Number with chemotherapy within 4 months 43/45 (95.5%)

• Exceptions 2/45 (4.4%) Prevented by patient comorbidities (stage III) 1/2 (50%) Postop. wound complications (stage I) 1/2 (50%)


Systemic Endocrine TherapyTotal Number of Patients = 107

Number of ER positive patients 94/107 (89.7%)• Number treated with endocrine therapy 69/94 (73.4%)

• Exceptions 25/94 (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 year 69/69 (100%)


RehabilitationTotal Number of Patients = 107

• Number enrolled in CPRP (PT/OT) 24/107 (22.43%)

• Exceptions 83/107 (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%


Genetic CounselingTotal Number of Patients = 107

• Number of patients with family history or < 45 years 65/107 (60.75%)

• Number received genetic counseling 20/65 (30.77%)– Number tested 17/20 (85%)

• Positive 2/17 (11.76%)• Negative 15/17 (88.23%)

– Number refused testing 3/20 (15%)

• Exceptions 45/65 (69.23%) Did not meet NCCN criteria 34/45 (75.5%) No documentation in the chart 9/45 (20%)


Trial ParticipationTotal Number of Patients = 107

Total Number of patients enrolled in trials in 2011 94/107 (87.85%) Increase of patients enrolled over the year 2009 79/15 (526.6%)


quality assurance report ttuhsc breast center of excellence january 1, 2011 – december 31, 2011...

Documents

lynn day

rn bsn ccm ccrptime

rn bsn ccm ccrpcompiled

patient noncompliance

decmdc seen5862

decmdc seen132065

progesterone receptor

complete response