ASCOs Quality Training Program Project Title: Integrated Post-Surgical Colon Cancer Care Planning at the Rutgers Cancer Institute of New Jersey and the Robert Wood Johnson University Hospital Presenters Name: Nell Maloney Patel Institution: Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School Date: October 8th, 2015 1 Institutional Overview Rutgers Cancer Institute of New Jersey (CINJ) is the states only NCI-designated Cancer Center. CINJ is affiliated with Robert Wood Johnson University Hospital (RWJUH) and the Rutgers Robert Wood Johnson Medical School (RWJMS). The hospital is staffed by full-time faculty in every department, along with a large group of private faculty, and serves as the clinical campus of RWJMS. There are numerous faculty, private and general surgeons with privileges at RWJUH who may be performing colon cancer surgeries. 10 colorectal surgeons unaffiliated with CINJ 1 unaffiliated Surgical Oncologists 8 General Surgeons/ACS surgeons who do colon surgery There are almost 20 medical oncologists with privileges at the hospital who are not affiliated with CINJ. Pathology services are unified in one RWJMS department. 2
Problem Statement The time to adjuvant chemotherapy (TTAC) in stage III colon cancer has been shown to have an effect on overall and disease-free survival. At present, there is no integrated post-surgical colon cancer care planning for patients who have surgery at RWJUH. Poor understanding on the part of patients and ancillary providers regarding appropriate follow up may cause delay in TTAC. 3 Team Members Team Leaders: Rebecca Moss, MD GI Oncologist Nell Maloney Patel, MD Colorectal Surgeon Team Members: Teresa Brown, DO Medicine Resident Sondra Patella, APN, Oncology NP Kristen Donohue, MD Surgical Resident Neil Newman, Medical Student Improvement Coach: David Bivens Statistician Viktor Dombrovskiy,PhD Project Sponsor: Howard Kaufman, MD, Professor of Surgery,
Associate Director of Clinical Sciences 4 Surgery Patient Adjuvant Chemo post-op recovery Call Med Onc inpatient? Surgeon Oncologist understands need for chemo cultural/ language Communicate Path results inpatient? Refer to Med
Onc as outpatient Availability for outpatient visits Availability inpatient Identify patients as needing Med Onc ASAP Intake Office Institution Post op surgery visit/ Path results? calls for Med Onc appt Obtains records
MD availability Insurance/ referral Path report turnaround time Clinic space for IPV Insurance precert for chemo Labs/CT scan done Port done Treatment space Cause & Effect Diagram Surgeon/Surgery Delay in consulting Med Onc Timing of Post Op visit Having patient make own appointment SAR
Data Dela in pathology report Data availability Tumor markers Technical Issues Post operative complications Nutritional evaluation Delay in time to Chemotherapy initiation Failure to follow up Printed Information Transportation Insurance Printed Info Mental well being Improper referral Educational understanding Language Incorrect contact info Patient 6 Port placement Additional workup
5 0 7 20.00% 10.00% 0.00% frequency cumulative % Aim Statement To decrease the wait time to Time to Adjuvant Chemotherapy (TTAC) to 6 weeks for 80% of patients within a 2 year time period 8 Measures Measure: TTAC Patient population: Stage 3 colon cancer patients who have surgery at RWJUH Calculation methodology: time from surgery to first dose chemotherapy Data source: Tumor Registry and chart review Data collection frequency: monthly Data quality (any limitations): limited access to private medical oncology practices
9 Baseline Data TTAC prior to intervention over time 140 120 D a y s t o C h e m o 100 80 60 40 20 0 x
10 x-bar date of surgery LCL UCL Results: time from surgery to Variable N Mean Std Dev Minimum Maximum Median Lower quartile Chemo 79 49.6
40 16.7 8 96 39 29 Outpatient 38 Med Onc apt 30 15 -7 74 27 18 11 Effect of variables on time to chemotherapy
variable Intraop postop Surg onc vs Surg onc vs complications complications colorectal general surgeon Colorectal vs general surgeon inpatient medical oncology consult Academic vs private practice Med Onc T-TEST 0.059 0.0155 0.45
0.86 0.67 0.64 0.27 Pr>ChiSquare 0.21 0.007 0.38 0.61 0.93 0.49 0.212 12 Histogram with outliers Histogram: TTAC - Days (not incl. the 1169 day outlier) 25
0 39 0 41 14 Prioritized List of Changes (Priority/Pay-Off Matrix) Nursing education Inpatient Med Onc consult Impact High Patient education Passport with timeline Path results prior to d/c Early post-op Surgery visit Hire another oncologist Make more space in clinic Low Easy Difficult Ease of Implementation
14 PDSA Plan (Tests of Change) Date of PDSA cycle 15 Description of intervention Results 9/1/15 Creation of Pamphlet Pamphlet printed 9/21/15 Focus Group meeting with nursing staff and leadership to begin to use clinical setting Education with staff nurses completed 11/1/15
Go live with pamphlet. Hand out POD 2, review prior to D/C by residents or APN. Will measure monthly through tumor board. 4/2016 Revise Pamphlet and translate to Spanish 1/2016 IRB approval for Private Practice Oncology Group Action steps Present to Hospital committees for final approval Pending approvals. Pending approvals Passport to Colon Cancer Care 16 Passport to Colon Cancer Care
17 Challenges to Implementation Site Specific Team structure changes IRB 18 Conclusions TTAC is an area for quality improvement Engaging the patient may help decrease TTAC 19 Next Steps/Plan for Sustainability Roll out Patient Passport in Hospital Setting Work on Education with Physicians and supporting staff 20
Evidence informed policy…. an approach which 'helps people make well informed decisions about policies, programs and projects by putting the best available evidence at the heart of policy development and implementation' (Davies 1999 in Gough et al, 2011).
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