UMass Memorial Medical Center PUBLIC REPORTING OF OUTCOMES OF THE CANCER COMMITTEE • 2014 Quality Improvement Measures • 2016 Prevention Program: The HPV Vaccine and Cancer Prevention
2014 Quality Measures Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer (Surveillance)
Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer (Surveillance)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
74%
68.4-80.4
203
1
My ACS Division
75%
74-76
7444
101
My Census Region
75%
74-76
7444
101
My CoC Program Type
64%
63-64
38712
233
My State
78%
76.8-79.8
3059
42
All CoC Approved Programs
65%
64.2-64.8
122262
1375
Tamoxifen or third generation aromotase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women withwAJCC T1c Tamoxifen or third generation aromotase inhibitor is considered or administered ithin 1 year (365 or stage IB-III days) of diagnosis f or w omen w ith A JCC T 1c o r s tage I B-‐III h ormone r eceptor p ositive b reast c ancer hormone receptor positive breast cancer (Accountability) (Accountability)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
100%
100-100
147
1
My ACS Division
95%
94.5-95.7
4441
101
My Census Region
95%
94.5-95.7
4441
101
My CoC Program Type
91%
90.9-91.7
24299
233
My State
95%
93.9-95.9
1826
42
All CoC Approved Programs
91%
90.6-91
76199
1375
1
2014 Quality Measures Radiation therapy is considered or administered following any mastectomy Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of within yearcancer (365 days) diagnosis of lbreast cancer for women with diagnosis o1 f breast for w omen wof ith >= 4 positive regional ymph nodes (Accountability) ≥ 4 positive regional lymph nodes (Accountability)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
100%
100-100
14
1
My ACS Division
92%
88.6-94.8
313
101
My Census Region
92%
88.6-94.8
313
101
My CoC Program Type
86%
84.8-87.6
2249
233
My State
88%
82.8-93.6
136
42
All CoC Approved Programs
85%
84.4-86
6823
1375
Radiation is administered within 1 year (365 days) of diagnosis Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 for women under the age of 70 receiving breast conservation surgery receiving breast conservation surgery for breast cancer (Accountability) for breast cancer (Accountability)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
99%
97.9-100
141
1
My ACS Division
93%
92.6-94.2
4114
101
My Census Region
93%
92.6-94.2
4114
101
My CoC Program Type
91%
90.9-91.7
18459
233
My State
93%
91.8-94.2
1819
42
All CoC Approved Programs
91%
91-91.4
55731
1375
2
2014 Quality Measures Combination chemotherapy is considered ois r administered within or 4 months (120 days) of diagnosis for 4 months Combination chemotherapy considered administered within women under 70 with AJCC T1cN0, or stage IB -‐ III hormone receptor negative breast cancer (120 days) of diagnosis for women under 70 with AJCC T1cN0, or stage (Accountability) IB - III hormone receptor negative breast cancer (Accountability)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
94%
82-100
16
1
My ACS Division
94%
91.7-95.5
670
101
My Census Region
94%
91.7-95.5
670
101
My CoC Program Type
92%
90.9-92.5
4232
233
My State
91%
88.2-94.6
290
42
All CoC Approved Programs
92%
91.5-92.5
12264
1375
Adjuvant chemotherapy is considered or administered within 4 months Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for (120 days) of diagnosis for patients under the age of 80 with AJCC patients under the age of 80 with AJCC stage III (lymph node positive) colon cancer (Accountability) stage III (lymph node positive) colon cancer (Accountability)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
100%
100-100
9
1
My ACS Division
93%
90.4-95
505
101
My Census Region
93%
90.4-95
505
101
My CoC Program Type
88%
86.5-88.9
2902
233
My State
92%
88.6-95.2
260
42
All CoC Approved Programs
88%
87.2-88.4
9962
1375
3
2014 Quality Measures Image or palpation-guided needle biopsy (core or FNA) of the primary site is performed to establish diagnosis of breast cancer (Quality Improvement)
Image or palpation-‐guided needle biopsy (core or FNA) of the primary site is performed to establish diagnosis of breast cancer (Quality Improvement)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
100%
100-100
223
1
My ACS Division
92%
91.6-92.8
8698
101
My Census Region
92%
91.6-92.8
8698
101
My CoC Program Type
92%
91.3-91.9
36337
233
My State
90%
88.5-90.5
3545
42
All CoC Approved Programs
91%
90.6-91
130256
1375
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality Improvement)
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality Improvement)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
100%
100-100
58
1
My ACS Division
93%
91.8-94
2146
101
My Census Region
93%
91.8-94
2146
101
My CoC Program Type
93%
92.6-93.6
10633
233
My State
94%
92-95
1018
42
All CoC Approved Programs
91%
90.8-91.4
40033
1375
4
2014 Quality Measures
Surgery is not the first course of treatment for cN2, M0 lung cases (Quality Improvement)
Surgery is not the first course of treatment for cN2, M0 lung cases (Quality Improvement)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
100%
100-100
15
1
My ACS Division
93%
91.2-95.4
550
101
My Census Region
93%
91.2-95.4
550
101
My CoC Program Type
91%
90.2-92.2
3041
233
My State
91%
87.5-94.7
237
42
All CoC Approved Programs
92%
91.5-92.5
9512
1375
Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is considered for surgically resected cases with pathologic lymph node-positive (pN1) and (pN2) NSCLC (Quality Improvement)
Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is considered for surgically resected cases with pathologic lymph node-‐ positive (pN1) and (pN2) NSCLC (Quality Improvement)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
100%
100-100
6
1
My ACS Division
93.5%
90.6-96.4
277
101
My Census Region
93.5%
90.6-96.4
277
101
My CoC Program Type
90.2%
88.8-91.6
1665
233
My State
95.1%
91.3-98.9
123
42
All CoC Approved Programs
90.2%
89.3-91.1
4320
1375
5
2014 Quality Measures Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or Postoperative chemo and radiation are within 180AJCC days diagnosis for clinical Preoperative chemo and administered radiation are administered for clinical T3N0, of T4N0, or Stage III; or Postoperative and radiation administered within 180 days of diagnosis for clinical JCC T1-‐ III; AJCCchemo T1-2N0 withare pathologic AJCC T3N0, T4N0, or AStage 2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is considered; for patients under the or treatment is considered for patients under the age of age of 80 receiving resection for rectal cancer (Quality Improvement) 80 receiving resection for rectal cancer (Quality Improvement)
Comparison to
EPR%
95% CI
# Cases
# Facilities
My Cancer Program
94%
82.9-100
17
1
My ACS Division
89%
85.9-92.5
333
99
My Census Region
89%
85.9-92.5
333
99
My CoC Program Type
87%
85.3-88.1
2380
231
My State
87%
82.1-92.7
151
41
All CoC Approved Programs
87%
85.9-87.5
6229
1354
6
UMass Memorial Health Care HPV Vaccine and Cancer Prevention Marketing Campaign Summary Presented to the Cancer Committee November 18, 2016 Project Summary: A comprehensive awareness and educational campaign executed by the UMass Memorial Health Care Marketing and Communications Department to educate multiple audiences about the importance and effectiveness of the HPV vaccine as a cancer prevention measure. Time Frame: February 2016 to present Audiences: •
Physicians, including pediatricians, primary care physicians, and family medicine specialists, and when possible nursing and office staff
•
Parents of boys and girls, especially those between the ages of 9 and 16 years old
•
Patients/young adults ages 18 to 26
•
UMass Memorial Health Care employees
Medical Experts: •
Richard Moriarty, MD, FAAP, Professor of Clinical Pediatrics, UMass Medical School; Co-Chair, MA Chapter of American Academy of Pediatric Immunization Initiative
•
Sarah Hughes, MD, Ob-Gyn, Gynecologic Oncology, UMass Memorial Medical Center; Assistant Professor, UMass Medical School
Marketing Message: Message to All Audiences: The HPV vaccine should be administered to boys and girls, beginning at age 11 or 12, as an important cancer prevention measure. Message to Physicians: The vaccine should be given as part of an immunization platform that includes the Tdap and meningococcal vaccines. Also, vaccine rates for boys in particular are lagging and a more concerted effort must be taken. Message to Parents, Young Adults and Employees: Expanded to stress that the vaccine is safe and effective, and the importance of receiving all three doses. Adjustment to Message: Midway through the campaign, new dosing guidelines were released (two vaccines instead of three for children in specific age brackets), and the campaign message was adjusted to reflect the new recommendations.
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Summary of Marketing Tactics & Metrics AUDIENCE
ACTIVITY
METRICS
Physicians
GroupTalk Article
Group Talk article emailed to 1,200 employed physicians
POD Meeting
Thirty in attendance (primary care); materials and contact information electronically distributed to employed primary care physicians
Letter from Mary Lee, MD
Emailed to 1,600 physicians (1,200 pediatricians, 400 family medicine physicians)
Links to handouts (CDC, Massachusetts DPH, AAP, all with UMass Memorial logo/ branding)
Distributed to primary care, pediatricians, family medicine physicians (Note: distributed through multiple channels) Also included with Group Talk article distributed to 1,200 employed physicians
Physician Outreach
Employed, managed care and private physicians No fixed number
Simply Well Blog (October 2016)
9,000 readers (2,000 direct via email; 7,000 via MailChimp)
Facebook Posts
Multiple boosted posts. September webinar post: 12,767 people reached, 189 reactions, comments and shares; 269 post clicks
Twitter Feeds
Multiple boosted tweets; audience reach ranges from 7,328 to 9,534; engagements range from 150 to 209
Health Watch Video
Video shared through Facebook post on November 1. Post metrics: 8,495 people reached, 63 reactions, comments and shares, 259 post clicks
Webinar (live web event)
One-hour web event focused at parents of teens and pre-teens; 37 total registrants with a 46 percent conversion rate, double industry standard. Twenty-five questions were fielded during the Q&A segment, with 100 percent post-event survey responders agreeing that the presentation provided enough information to make an educated decision about the vaccine.
Cancer Walk
Handout distributed at hospital’s table in the Wellness Tent to event participants; approximately 12,000 participants in attendance
News & Views
Multiple posts sent between August 2016 and October 2016 about tactics including blog posts and webinar. Read rates average 4,800 to 5,700 per week
OurNet blog posts
Multiple posts sent between August 2016 and October 2016, about blog posts and webinar. No fixed number of blog reads
Wallpaper and Screensavers
Information shared on hospitals wallpaper and screensavers, which is distributed on all employee computers; no fixed number on viewing. Approximately 11,000 employees
Parents of Patients Young Adults/Patients (Ages 18 to 26)
Employees
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Patients and families trust UMass Memorial Medical Center as the region’s leading academic medical center, committed to improving the health of our communities in Central Massachusetts. With our partner, the University of Massachusetts Medical School, we are committed to excellence in primary and specialty care, community service, teaching and research. The Medical Center offers advanced technology and support services for patients and families, providing the region with specialists renowned for their expertise in caring for adults and children. Visit www.umassmemorial.org. General information: 508-334-1000
UMass Memorial Health Care is the largest not-for-profit health care system in Central Massachusetts with more than 12,000 employees and 1,600 physicians, many of whom are members of UMass Memorial Medical Group. Our member hospitals and entities include UMass Memorial – Clinton Hospital, UMass Memorial – HealthAlliance Hospital, UMass Memorial – Marlborough Hospital, UMass Memorial Medical Center and UMass Memorial – Community Healthlink, our behavioral health agency. With our teaching and research partner, the University of Massachusetts Medical School, our extensive primary care network and our cancer, diabetes, heart and vascular, orthopedic and surgery programs, UMass Memorial delivers safe, high-quality and compassionate care. Visit www.umassmemorialhealthcare.org. To find a physician in your community, call 855-UMASS-MD (855-862-7763).
UMass Memorial Medical Center - University Campus 55 Lake Avenue North, Worcester, MA 01655
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