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Michael Gieske, MDDirector Lung Cancer ScreeningSt Elizabeth HealthcareEdgewood, Ky.
September 30, 2020
Our Landscape
•First&onlyhealthcaresysteminKY,OHorINtopassMayoClinic’sreviewprocesstobecomeamemberoftheMayoClinicCareNetwork•CollaborationwithothercommunityhospitalsandtheUniversityofKentuckyaspartoftheUKMarkeyCancerCenterAffiliateNetwork•MemberofKentuckyHealthCollaborative,a10system,60hospitalaffiliationdedicatedtoimprovingthehealthofKentuckians
StElizabethHealthCare- Foundedin1861inCovington,KY
St.ElizabethHealthCare(SEH)operatessevenhospitalfacilities,servingtheNorthernKYTristateRegion,includingKentucky,Ohio,andIndiana
Dearborn County
• Text here.
Our Landscape
Comprehensive Cancer Center - BeginningsAnnounced development of a $140 million cancer center on the Edgewood campus
GROUND BREAKING AUGUST 9, 2018!
Comprehensive Cancer CenterOpen to patients October 2020
140 Million Dollar Center244,000 Square Feet
Atrium and Grand StaircaseFrom Concept to Reality!
Complete IntegrativeMedicine Department
State of Art Tumor Board Auditorium!
“Thousands of families are devastated each year as the disease continues its relentless spread through the state.” Laura Ungar, USA Today
Kentucky also has one of the lowest five-year survival rates after diagnosis: only 17.6 percent of Kentuckians diagnosed with lung cancer live for at least five years after their diagnosis
Heat Map of Cancer Death Rates
Hotbed of Cancer Deaths in Ky,
especially Eastern Ky.
Cancer Deaths in the United States
Hotbed of Cancer Deaths in Ky,
especially Eastern Ky.
The national total of all healthcare costs associated with cancer care is projected to be
$174 Billion in 2020 !
KY 233.6 cancer deaths/100,000
Projections of the Cost of Cancer Care in the U.S.: 2010-2020J Natl Cancer Inst. 2011 Jan
CONFIDENTIAL – FOR INTERNAL USE ONLYUSA, American Cancer Society
= Next 3 Cancers Combined =
142,940
CONFIDENTIAL – FOR INTERNAL USE ONLY
Kentucky, American Cancer Society
= Next 5 Cancers
Combined = 3,040
CONFIDENTIAL – FOR INTERNAL USE ONLY
National Lung Cancer Incidence
Kentucky – 92.6
National Average – 59.6
Utah – 27.1
OHIO – 68.9%
Ind. – 73.2%
Incidence of Lung Cancer by State
Ky. Incidence of Lung Cancer is the highest in the country at 93.5 per 100,000
people
TOBACCO BELT
Smoking Prevalence in the United States
KY 23.4% vs. WV 25.2%
2019 America’s Health Rankings Annual Report
These state-specificLung Cancer rates are directly parallel to USA smokingprevalence rates.
16.1% Adults Smoke
National Lung Cancer Survival
Nov. 13, 2019 Amer. Lung Assoc. State of Lung Cancer Report
Kentucky – 17.6%Five-Year Survival
National Lung Cancer 5-Year Survival
Kentucky – 17.6National Average – 21.7
New York – 26.4
Alabama – 16.8Ohio – 20.0
(Indiana – N/A)
CONFIDENTIAL – FOR INTERNAL USE ONLY
5 Year Survival Rates – 2018 American Cancer Society
The numbers below come from thousands of people from all over the world who were diagnosed with NSCLC between 1999 and 2010. Although the numbers are based on people diagnosed several years ago, they are the most recent rates published for the current AJCC (Am Joint Comm. Ca) staging system.
5 Year Survival RateNon Small Cell Lung Cancer (NSCLC)
Stage IA1 92%
IA2 83%
IA3 77%
IB 68%
IIA 60%
IIB 53%
IIIA 36%
IIIB 26%
IIIC 13%
IVA 10%
IVB < 1%
5 Year Survival RateSmall Cell Lung Cancer (SCLC)
Stage I 31%
II 19%
III 8%
IV 2%The numbers below are relative survival rates calculated from the National Cancer Institute’s SEER database, based on people who were diagnosed with SCLC between 1988 and 2001
These survival rates are based on the TNM staging system in use at the time, which has since been modified slightly for the latest version. Because of this, the survival numbers may be slightly different for the latest staging system.
Stage Matters!
Stage Impact on NSCLC Treatment Patterns
45% surgery alone
66% chemo and/or XRT32% no treatment
CMS Criteria• 55 – 77 yr old (USPSTF 55 – 80 yo)
• 30 pack year smoking history
• Current smoker or quit within the prior 15 years
• Asymptomatic – No current signs or symptoms suggestive of LC
LDCT Lung Cancer Screening
How are we doing?
A total 1.9% of more than 7.6 million current and former heavy smokers in the United States underwent lung cancer screening in 2016 2018 ASCO (Amer Soc Clin Oncol) Annual Meeting
In 2015, among those who met USPSTFcriteria, 4.4% (95% CI=3.0%, 6.6%) Jan. 2019 American Journal of Preventive Medicine
The estimated population meeting USPSTF criteriafor lung cancer screening in 2015 was 8,098,000
JAMA September 2017
3.9% 2015
A total 4.2% in the United States underwent lung cancer screening in 2018, ranging from 0.5% in NV to 12.5% MA (Ky. at 10.3%) Nov. 13, 2019 Amer. Lung Assoc. State of Lung Cancer Report
2014
(Lots of) Room for Improvement
Drop in U.S. Cancer Death Rate
CONFIDENTIAL – FOR INTERNAL USE ONLY
CONFIDENTIAL – FOR INTERNAL USE ONLY
National Lung Cancer Screening Rates
National Lung Cancer Screening Ranking
• St. Elizabeth HealthCare implemented the LDCT Lung Cancer Screening Program, and began to track data in 2013
• Earned Designation as a ‘Lung Cancer Screening Center’ by American College of Radiology (ACR) and a ‘Lung Screening Center of Excellence’ by the Lung Cancer Alliance (now GO2 Foundation) in early 2015
• As of August 2020, over 600 hospitals in the country are SCOEs, spanning 44 states
• In April 2020, we were awarded the GO2 Foundation’s Care Continuum Center of Excellence designation which recognizes centers with patient-focused coordinated, multidisciplinary care led by the expertise of a nurse navigator. (1 of less than 40 centers nationally)
Laying the Foundation
• Investment by St Elizabeth Healthcare to develop Thoracic Oncology as a Lung Center of Excellence, and a key Component of the new Cancer Center
• Collaboration of SEH (St Elizabeth Healthcare) and SEP (St Elizabeth Physicians)
• An integral part of our Health Care System’s goal to make Northern Ky. one of the healthiest communities in the country
• Smoking Cessation has also become a central component of these initiatives, and a collaboration of SEH and SEP, as well
• LDCT Lung Cancer Screening is playing an integral role in this initiative
Executive and Administrative Support
Stuck on the Bottom << 2013 – 2016 >>Sc
ans
per M
onth
Lung-RADS v1.1 Lung-RADS =Lung Imaging Reporting And Data System
• Nodule Review Board (NRB) – critical – meets every Monday 7:00 a.m.o All Cat 4 LCS nodules, and Incidental nodules/masses – ‘Code Lung
Management’o Pulmonologist, Thoracic Surgeon, Radiologist, PC Advocate/LCS Director,
LCS and Thoracic Oncology Nurse Navigatorso Screening Program, Incidental, and Symptomatic results reviewedo Recommendations are forwarded to the PCP, patient, and appropriate
orders are placed for SCP referral, and/or follow-up imaging
Nodule Review Board
The EMR (Epic) WorkflowNudging the provider and lowering barriers
Emphasizing Accuracy of Smoking History
EMR Health Maintenance Prompt
LDCT LCS BPA – Best Practice Alert/Advisory…approved 11/15/17
Other Qualifying Chest CT Codes Accounted
Our Epic SmartSet
Click for Drop-Down Dx List
Choose Diagnosis
Open SmartSet
Yes, by default
Yes, by default
Yes, by default
Yes, by default
Order expires in 1 year
Annual or Baseline
Current or Former Smoker
Epic Progress Note EntryProblem Focused Charting, LDCT SDM Component
Hard-Stop if patient does not meet criteriaCriteria must be met, and smoking history must support and be
up to date
CPT Code – G0296
G0296 - SDM Aides
Ky Cancer Program (KCP)Ky LEADS Collaborative
Flyer/Poster for Exam Rooms
Using Data to Promote Confidence and Buy-in
LCS RegistryLung Cancer Screening Registry - St. Elizabeth HealthCare
2020 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
LDCT LC Screens 346 379 212 13 114 256 430 431 2181
Category 1 Total 204 216 130 6 71 166 266 250 1309
Category 2 Total 108 108 55 5 30 67 118 136 627
Category 3 Total 18 29 18 0 7 16 31 25 144
Follow up screen 28 27 19 8 27 33 21 35 198
Category 4 Total 16 26 9 2 6 7 15 20 0 0 0 0 101
Category 4A 13 17 6 2 4 7 6 15 70
Category 4B 3 9 3 0 1 0 7 5 28
Category 4X 0 0 0 0 1 0 2 0 3
Category S Total 19 23 15 1 6 14 25 29 132
Referrals - screening 0
MultiD - screening 0 2 1 0 0 0 0 1 4
Pulmonary Referral - screening 4 1 1 0 1 1 3 3 14
Thoracic Referral - screening 4 9 3 0 2 3 7 5 33
Total 8 12 5 0 3 4 10 9 0 0 0 0 51
3 month follow up CT rec. 9 9 7 0 4 3 3 9 44
6 month follow up CT rec. 4 4 0 1 0 2 1 0 12
12 month follow up CT rec. 1 0 0 1 0 0 0 2 4
Referrals - Incidental
MultiD clinic - incidental 6 5 0 0 0 0 0 2 13
Pulmonary Referral - incidental 8 8 11 0 5 4 7 6 49
Thoracic Referral - incidental 5 7 6 4 9 14 7 4 56
Total 19 20 17 4 14 18 14 12 0 0 0 0 118
3 month follow up CT rec. 5 5 13 6 5 6 4 7 51
6 month follow up CT rec. 4 1 11 0 1 2 0 7 26
12 month follow up CT rec. 2 1 1 0 3 0 2 1 10
PET/CT (screening) 5 8 2 0 2 1 7 4 29OR (screening) 1 3 2 0 1 0 1 0 8
OR pending 3 2 0 0 2 0 1 1 9
DX Lung Cancer 3 8 1 0 1 1 2 1 17DX Cancer- other 0 1 0 0 0 0 0 0 1Incidental Reviewed 92 97 110 52 94 101 80 111 737
# of scans outside of criteria 11 5 0 0 0 0 0 1 17
Annual Screening Exams 200 193 117 12 81 173 280 300 1356
Baseline Screening Exams 146 186 95 1 33 83 150 131 825
Total 346 379 212 13 114 256 430 431 0 0 0 0 2181
Registry Summary
*NLST - 24.2% Positive Findings - >4mm (18,146 positive scan/75,126 Total LDCTs done)Also positive if effusion, adenopathy, or other abnormalities suspicious for Lung Cancer
***Positive LDCT determined negative for LC/Total Positive LDCT Scans = FALSE DISCOVERY RATENLST - 96.4% False Positive (17,497/18,146), really the false discovery Rate
- the actual FALSE POSITIVE RATE is 23.3% (18,146 - 649/75,126)** - FALSE POSITIVE RATE is false positive scans (positive LDCT scan determined to be negative for LC)/ Total all LDCT scans
Analysis of Positive Scans - St. Elizabeth Healthcare --- 1/1/2015 - 8/31/2020Year 2015 2016 2017 2018 2019 2020 TOTAL % Scans False Positive False Discovery # Scans to
Total LDCT LC Scr. SCANS 252 753 1965 3585 4082 2181 12818 * ** *** find 1 LC
Annual 1815 1356 3171Baseline 2267 825 3092
Cat 1 127 457 1164 2194 2312 1309 7563 59.00%Cat 2 76 201 506 887 1250 627 3547 27.67%Cat 3 (Indeterminate) 22 47 143 240 250 144 846 6.60%Cat 4 (Suspicious) - Total 27 48 152 264 270 101 862 6.72% 4.93% 73.32%
Cat 4A 16 33 108 186 188 70 601 4.69%Cat 4B 11 15 44 78 82 28 258 2.01%Cat 4X 3 3 0.02%
Cat 3 + Cat 4 - Combined 49 95 295 504 520 245 1708 13.33% 11.53% 86.53%Lung Cancer 5 16 37 82 73 17 230 1.79% #LC/per Tot LDCT = 55.7
Quarterly Update for Oncology Team and PCPs
Ranked by site
Quarterly Update for Oncology Team and PCPs
Ranked by PCP
Tracking Our Progress – SEP Attributed Pts. - 2019
Lung Cancer Screening Quality Measure
2019Denominator:
9541
Numerator: 3464
Completed: 36.31 %
2019Denominator:
12851
Numerator: 3835
Completed: 29.84 %
2020 Data – as of 6/15/20
Denominator* 10,627 12,829
Numerator 1,654 1,777
Quarter 1 Completed 1631 1642
Have Ever Completed 7,609 8,720
Percentage Ever Captured (since 2013)
71.6% 67.97%
Data, as of 6/15/20
SEP – Attributed to PCP SEHC - System
Lung Cancer Compendium – 2014 - 2020 YTD
7/28/2020 36 21 20 The tumor cells are positive for CAM 5.2, MOC31, CD56, focally positive for TTF1 (2 clones), synaptophysin, and negative for p40
3/4/2016 64 69
Over 236 Lung Cancers to date
Snapshot – Team-Based Documentation of Program
Overall Lung Cancer Discovery
Stage N %
Stage I 134 56.8%
Stage II 28 11.9%
Stage III 41 17.4%
Stage IV 33 14.0%
Unknown 0 0%
Total 236
Stage I & II 68.6%
Average PY = 57.8
Cancer Stage 2014 – 2020 YTD
Stage per YearYear I II III IV UNK Total % I2014 1 1 0 2 0 4 25.0%
2015 2 2 1 0 0 5 40.0%
2016 12 1 2 1 0 16 75.0%
2017 25 1 6 6 0 38 65.8%
2018 44 11 15 11 0 81 54.3%
2019 36 9 17 11 0 73 49.3%
2020 14 3 0 2 0 19 73.7%
Total 134 28 41 33 0 236 56.8%
68.6% found in early stages
Lung Cancer Screening - Data Generated
Lung Cancer TypeType N %
adenocarc. 98 42.4%squamous 74 32.0%small cell 28 12.1%limited 13
extensive 15
large cell 3 1.3%carcinoid 3 1.3%other 3 1.3%unknown 22 9.5%
231 100%
FemaleMale
49.8%50.2%
100%
116115231
Age N %
<40 0 040 - 44 0 045 - 49 0 050 - 54 0 055 - 59 34 14.7%60 - 64 58 25.1%65 - 69 62 26.8%70 - 77 76 32.9%78 - 80 1 0.4%
>80 0 0TOTAL 23155 - 77 yo 230
Marketing
7 Years of Progress
Trendlines
Making a Difference!
Building Teams – Engaging the PCPBuilding Teams• Primary Care Advocate – catalyst – Became Director Lung Cancer Screening Nov.1, 2019• Started with LDCT Lung Cancer Screening Work Group – met Quarterlyo Oncology, Pulmonology, Radiology, Social Work, Value Based Performance, Quality and
Compliance, Care Management, IT, Report Writers, Process Improvement, Clinical Transformation, Primary Care, Management
• Now have a smaller Lung Cancer Screening Team – meets Weeklyo Director LCS, Director Integrative Oncology, Screening NNs, Thoracic Oncology NN, Quality
Transformation Consultant, Coordinator Strategic Initiatives, Thoracic Oncologist, Research Consultant
• Thoracic Oncology Disease Management Team (TODM) – meets Monthly• Weekly Huddle with Executive Director Oncology, Chief Thoracic Surgeon, Chief Thoracic
Oncologist, Director Oncology Services
Building Teams – Engaging the PCP
• Annual Symposium, 5th to take place Nov. 11, 2020• Presentations to Executive Team, Management, Providers, PC leadership• PCP Site Visits - Thoracic Surgery, Nurse Navigator, Primary Care Advocate• Provider Outreach – Staff Messages, addressing barriers (AAFP – grade ‘I’), gathering
valuable feedback
Education, Primary Care and Specialty Care Outreach
Building Teams (Continued)• Quality Transformation and Patient Outreach Teams - oversight of ordered screens,
annual and subsequent follow-up screens• Research – Clinical Research Institute, Data analysts, Report writers• Continuous Collaboration with Hospital and Physician Group Executives and
Management, Monthly Executive Update
Best Practices – Engaging the PCP
The PATH to TREATMENT• Nodule Review Board (NRB) – critical – every Monday 7:00 a.m.o All Cat 4 LCS nodules, and Incidental nodules/masses – ‘Code Lung Management’o Pulmonologist, Thoracic Surgeon, Radiologist, PC Advocateo Screening Program, Incidental, and Symptomatic results reviewedo Recommendations are forwarded to the PCP, patient, and appropriate orders are placed for
SCP referral, and/or follow-up imaging• Role of Nurse Navigator – the ‘glue’ for the program• Patient and Provider Communication• Getting PCP Buy-in, building confidence and trust, transmitting feedback to PCP Advocate• Programmatic Approach – improved time-efficiency, cost-effectiveness (TCC), reduced risk/harm• Retentiono Follow-up for Annual Screenings with Mailings, MyChart Messages, Care Management Outreach• Intake Coordinator to assure that criteria, and risk determination is met for Retail Group 2 Option
Standardized and Seamless Care of Patient – AFTER THE SCAN
Nodule Review Board & Flow Algorithm
The Lung Cancer Screening Team
1. Ordering provider verifies eligibility and has Shared Decision-Making Discussion with patient and enters lung cancer screening order in EPIC
2. Patient schedules scan through Central Scheduling. Central Scheduling to verify patient meets criteria. (For 7 Pilot offices, Central Scheduling contacts patient to schedule)
3. Patient completes scan and results are forwarded to Lung Cancer Screening Nurse Navigator in-basket
Lung Cancer Screening Workflow
Nurse Navigator Reviews Results, Provides Follow-up Instructions
1. Patient receives letter2. Annual low dose screening recommended
• CAT 1 – No nodules found on scan
• CAT 2 – Probably benign – new nodules less than 4 mm, nodules less than 6 mm, ground glass nodule less than 20 mm, or nodule that is stable for >3 months
1. Patient receives letter2. Annual low dose screening recommended
Nurse Navigator Reviews Results, Provides Follow-up Instructions
1. Patient contacted by Lung Cancer Screening Nurse Navigator regarding results. Ordering MD notified of results.
2. Lung Cancer Screening Nurse Navigator to enter order for follow-up lung cancer screening CT (IMG10913) and will route to ordering MD for co-signature. Lung Screening Nurse Navigator will offer to schedule the follow up scan, or the patient or ordering MD office will need to contact Central Scheduling to set up scan.
3. Patient receives letter, 6 months follow up recommended. If stable at 6 months, 12 months follow up thereafter.
• CAT 3 – Probably benign – Nodules 6-7 mm at baseline, new nodules 4-5 mm, ground glass nodule greater than 20 mm
Nurse Navigator Reviews Results, Provides Follow-up Instructions
• CAT 4 – All cat 4 nodules are automatically reviewed at case conference, Nodule Review Board, including incidentally found nodules and masses: radiology report should end with ‘Code Lung Management’ (that tag means the case will be presented at the next nodule review board, and next steps will be forthcoming)
Nurse Navigator Reviews Results, Provides Follow-up Instructions
4. Nodule Review Board note/recommendations will be sent to ordering MD5. Ordering MD to put in referral for Pulmonology or Thoracic Surgery, if applicable6. Patient will receive letter with recommendations
• CAT 4A – Suspicious finding. Nodules 8mm to 14mm at baseline, new or enlarging nodule 6-7mm endobronchial nodule.
• CAT 4B – Suspicious finding. Solid nodule 15 mm or larger, new or growing nodule 8 mm or larger.
1. Ordering MD will be routed results2. Patient will be reviewed at Nodule Review Board occurring every Monday at 7am3. Patient will be contacted by Lung Cancer Screening Nurse Navigator on Monday or
Tuesday regarding Review Board recommendations.
Role of the Screening Nurse Navigator
• Review LDCT results and convey results to patients and ordering providers
• Compile lists for Nodule Review Board (Screening CAT 4A/4B, Incidental "CODE LUNG MANAGEMENT")
• Attend Nodule Review Board, enter recommendations notes, call patients with results and recommendations
• Enter orders for follow up scans, scheduling and referrals• Track patients to make sure they're getting appropriate and timely
referrals and follow up scans• Provider and patient outreach – office visits, Thoracic Symposium
presentations, health and senior fairs
When will the Nurse Navigator contact my patient
• Incidental findings on LDCT - “S"• CAT 3 LDCT needing a follow up CT• CAT 4A/4B after NRB with recommendations• "Code Lung Follow Up" needing follow up orders and
scheduling• "Code Lung Management" after NRB with recommendations• Any time a provider or patient has questions or requests!
Best Practices – Engaging the PCP and Beyond
Community Outreach – Getting the Good Word Out• Marketing, St Elizabeth Website, FaceBook Live, News Media• Executive Sponsoring and Promotion of Program – Garren Colvin Community and System Addresses,
State of the System • Senior Community Organizations, Edgewood• Senior Fairs, Primewise• Rotary Club• St. Elizabeth Foundation - Fundraisers, Retreat, Fall Fashion Show
Data Assimilation and Analysis• Registry, Epic Lung Module• Lung Cancer Compendium• Quality Control – FP, adverse events, Screen to Dx, Dx to Rx, Screen to Rx• Demonstration of Stage Migration
Determining ROI – Lung Cancer Screening
Prior to Lung Cancer Diagnosis
• Imaging - LDCT (G0297), SDM (G0296), CXR, LDCT F/U, CT chest w and wo contrast, PET (CPT 788150)
• Bronchoscopy – including BAL, EBUS/ENB, ENAV
• Tissue Diagnosis - Mediastinoscopy (CPT 32604), VATS (DRG164), IR – TTNA (CPT 32405)• Pathology to determine diagnosis
• Incidental Findings – imaging, biopsy, surgery, treatment
After Lung Cancer Diagnosis
• Pathology to determine treatment, including special studies, biomarkers• Surgery – VATS, RATS, Open Thoracotomy
• Radiation Oncology - SBRT, IMRT, PCR, Palliative Radiation
• Medical Oncology, including Immuno-Oncology
• In-Patient Utilization, and SCP/PCP Office Visits
Determining ROI – Lung Cancer Screening• LCS Costs to Medicare are $1.02 – 2.22 PMPM;• Total Medicare expenditures for 2012 part A and B benefits = $672 PMPM;
So, 0.3% of MC expenditures d/t LCS (Annals of Translational Medicine 2016; 4(8):155)
• Journal of Clinical Oncology 36, no.15, 6/01/18 – LCS net revenue of $770/case. Advisory Board article on Daffodil Health System – demonstrated $739/case.
• 2019 Est. 4,082 LCSs $3,143,1400 at $770/case• 2019 ROI LCS SEHC $211 net revenue/scan = $861,302• THREE WAYS LCS Benefits System and Drives Value
1. Direct Revenue from scans, reimbursement; marginal return2. Downstream Revenue; a significant contribution3. Cost Savings (Reduction TCC, aka improved health!); highly impactful –
more difficult to measure, but major driver in value-based market
Top 12 Best Practices – Engaging the PCP,…and everyone else!
EMR
1. BPAs2. Health Maintenance Prompts3. Other Qualifying CTs of Chest4. Ordering Smart-Set5. Standardized Progress Note Entry6. G0296 Code for SDM (shared decision making) work
Top 12 Best Practices – Engaging the PCP,…and everyone else!
7. PCP Report – attributed patients• Site and Provider Specific – shared at least quarterly with
providers and management8. System Summary - shared at least quarterly9. Dashboard – updated at least monthly
Performance and Status Reports
Top 12 Best Practices – Engaging the PCP,…and everyone else!
10. Communicate, communicate, communicate11. Educate, educate, educate12. Demonstrate and refine ROI
Other