UMass Memorial Medical Center Cancer Services public reporting of outcomes 2016

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.

7

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

8

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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