Post on 18-Dec-2015
CTOP Retreat 2014
CTOP Retreat
Why Do We Do It?
Bumper cars
• Everyone is going in individual directions
• Varying speeds• Randomly bumping into
others• Sometimes sharing goals• Some are having fun,
others are not
Bumper Cars• At the flip of a switch• Everything stops
CTOP Retreat• Stop• Share knowledge• Prioritize group goals• Set the groundwork for change and
innovation
CTOP Retreat 2012
CTOP Retreat 2014Highlights
• Lung Cancer Screening: Cost Effective Analysis
CTOP Retreat 2014Highlights
• Lung Cancer Screening: Cost Effective Analysis
• Chris Trimble from Tuck School of Business
CTOP Retreat 2014Highlights
• Lung Cancer Screening: Cost Effective Analysis
• Chris Trimble from Tuck School of Business
• Smoking Cessation: e-cigarettes and marijuana
CTOP Retreat 2014New
• 14 hours of CME• Website• Yearly Esophageal
Cancer Patient Reunion
CTOP Retreat 2014Individual Action Plan
• Meet 3 new people• Change one thing
CT Screening for Lung Cancer
DHMC Implementation Plan
NLST Study Design
• Prospective randomized trial
• 53,454 individuals @ high risk
Aberle et al. Radiology 2011; 258(1):243-253
NLST Study Design
• Prospective randomized trial
• 53,454 individuals @ high risk• No symptoms of lung cancer
• Ages 55-74
• >=30 pack-yr history of smoking
• No prior lung cancer
• Medically fit for surgery
Aberle et al. Radiology 2011; 258(1):243-253
NLST Results
• 20% lung cancer mortality reduction• 7% all cause mortality reduction• Cumulative FPR ≈ 37%, 1st CT about 25%• Overdiagnosis ≈ 12%
Aberle et al. N Engl J Med, 2011. 365(5): p. 395-409
USPSTF Recommendation
The USPSTF recommends annual screening for lung
cancer with low-dose computed tomography in
adults ages 55 to 80 years who have a 30 pack-year
smoking history and currently smoke or have quit
within the past 15 years…Grade B recommendation. http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm
Affordable Care Act
Private insurance is mandated to cover the
USPSTF recommendations for preventive
services with a grade of A or B by January 1,
2015 . . .
Centers for Medicare and Medicaid Services(CMS)
• Initiated a National Coverage
Determination (NCD)
• Medicare Evidence Development and
Coverage Advisory Committee (MedCAC)
hearing April 30, 2014
Centers for Medicare and Medicaid Services(CMS)
1. How confident are you that there is adequate evidence
to determine of the benefits outweigh the harms?
2.22/5.0
2. How confident are you that harms will be minimized in
the Medicare population 2.33/5.0
3. How confident are you that evidence gaps remain
4.44/5.0
Explanation?
• "I am concerned that we don’t really have a lot of data in the Medicare population, certainly not in the 75-80 [year-old age group]" said Dr. Rita Redberg, MEDCAC chair and Professor of Medicine at the UCSF
• Screening people for lung cancer carries real risks, including increased radiation exposure and collapsed lungs.
• Some are also concerned that hospitals will offer the tests to lower-risk patients as a way to boost profits.
Oncology Report, USAToday 5/14/14
CMS• CMS will publish their proposed
national coverage decision in November 2014
• Followed by a 30-day comment period
• Final decision and announcement in February of 2014
Two-Tiered System• People aged 55-65 will be covered• People aged 65 and over will not
Action• Letter to CMS from the Senate and the House of
Representatives, May 30, 2014
“National Coverage Determination for LDCT scans for medicare beneficiaries . . . Be completed expeditiously . . . It is essential that seniors on Medicare have access to this screening tool.”
“Americans deserve . . . to have access to potentially life-saving, evidence-based screenings that can prevent further health costs down the road.”
Action• Letter Leads: Senator Feinstein (D-CA) • and Senator Johnny Isakson (R-GA):
• Cosigners • Senator Michael Bennet (D-CO)• Senator Marco Rubio (R-FL)• Senator Saxby Chambliss (R-GA)• Senator Brian Schatz (D-HI)• Senator Mazie Hirono (D-HI) • Senator Charles Grassley (R-IA)• Senator Richard Durbin (D-IL)• Senator Mark Kirk (R-IL)• Senator Jerry Moran (R-KS)• Senator Pat Roberts (R-KS)• Senator Mary Landrieu (D-LA)• Senator Ed Markey (D-MA)• Senator Susan Collins (R-ME)• Senator Richard Burr (R-NC)• Senator Jeanne Shaheen (D-NH)• Senator Kelly Ayotte (R-NH)• Senator Robert Menendez (D-NJ)• Senator Cory Booker (D-NJ) • Senator Martin Heinrich (D-NM)• Senator Dean Heller (R-NV)• Senator Charles Schumer (D-NY)• Senator Kirsten Gillibrand (D-NY)• Senator Sherrod Brown (D-OH)• Senator Maria Cantwell (D-WA)• Senator Jay Rockefeller (D-WV)• Senator Joe Manchin (D-WV)• Senator Michael Enzi (R-WY)
Letter Leads
1. Representative Charles Boustany, MD (R-LA)2. Representative Jim Renacci (R-OH)3. Representative John Barrow (D-GA)4. Representative Richie Neal (D-MA)
Cosigners
5. Representative Spencer Bachus (R-AL)6. Representative Tim Griffin (R-AR)7. Representative Raul Grijalva (D-AZ)8. Representative Devin Nunes (R-CA)9. Representative Ami Bera, MD (D-CA)10. Representative Sam Farr (D-CA)11. Representative Julie Brownley (D-CA)12. Representative Gloria Negrete McLeod (D-CA)13. Representative Lois Capps (D-CA)14. Representative Mike Coffman (R-CO)15. Representative Joe Courtney (D-CT)16. Representative Phil Gingrey, MD (R-GA)17. Representative Tom Price, MD (R-GA)18. Representative David Scott (D-GA)19. Representative Bill Cassidy, MD (R-IA)20. Representative Bruce Braley (D-IA)21. Representative Dave Loebsack (D-IA)22. Representative Mike Simpson (R-ID)23. Representative Aaron Schock (R-IL)24. Representative Adam Kinzinger (R-IL)25. Representative Larry Buschon, MD (R-IN)
26. Representative Lynn Jenkins (R-KS)27. Representative Brett Guthrie (R-KY)28. Representative John Tierney (D-MA)29. Representative Mike Capuano (D-MA)30. Representative Jim McGovern (D-MA)31. Representative Andy Harris, MD (R-MD)32. Representative Gregg Harper (R-MS)33. Representative Carol Shea Porter (D-NH)34. Representative Leonard Lance (R-NJ)35. Representative Bill Pascrell (D-NJ)36. Representative Joe Heck, MD (R-NV)37. Representative Dina Titus (D-NV)38. Representative Chris Gibson (R-NY)39. Representative Eliot Engel (D-NY)40. Representative David Joyce (R-OH)41. Representative Pat Tiberi (R-OH)42. Representative Bob Latta (R-OH)43. Representative Pat Meehan (R-PA)44. Representative Charlie Dent (R-PA)45. Representative Jim Gerlach (R-PA)46. Representative Stephen Fincher (R-TN)47. Representative Diane Black (R-TN)48. Representative Marsha Blackburn (R-TN)49. Representative David “Phil” Roe, MD (R-TN)50. Representative John Duncan (R-TN)51. Representative Scott DesJarlais, MD (R-TN)52. Representative Kenny Marchant (R-TX)53. Representative Gene Green (D-TX)54. Representative Jim Sensenbrenner (R-WI)
Ann Kuster (D-NH)Peter Welch (D-VT)
Patrick Lahey (D-VT)Bernard Sanders (I-VT)
Action
• Senator Jeanne Shaheen (D-NH) http://www.shaheen.senate.gov/
• Senator Kelly Ayotte (R-NH) http://www.ayotte.senate.gov/• Patrick Lahey (D-VT) https://www.leahy.senate.gov/contact/• Bernard Sanders (I-VT)
http://www.sanders.senate.gov/contact/• Carol Shea Porter (D-NH) http://shea-porter.house.gov/• Ann Kuster (D-NH) http://kuster.house.gov/• Peter Welch (D-VT) https://welch.house.gov/email-me
Why lung cancer screening?Why DHMC, Why Now?
DHMC Values DHMC Experience
Responsible leadership and innovation DHMC played leading role in NLST
Disease prevention and early detection Lung cancer is the most lethal cancer,1st time screening has proven to have an impact12,000 lives saved with lung cancer screening76,000 lives with smoking cessationOnly option for former smokers to decrease their chance of dying from lung cancer
Partner with existing community health systems
Groundswell of multidisciplinary supportCoordinating with PCP
Shared decision-making TDI pioneered Shared Decision Making
Quality healthcare practices Value InstituteInformation systems
Lung Cancer Screening Program Timeline
Pilot Lung Cancer
ScreeningTarget DH-Lebanon
Employees
Expand Pilot Target DH-
Lebanon/GCP Provider
Open to Public200 screens 200 screens
Evaluate Process & Systems
Adjust accordingly
Evaluate Process & Systems
Adjust accordingly
Phase 1 Phase 3Phase 2
Lung Cancer Screening at DHMC - Lebanon
Communicate to Providers
Clinical Pathway
Calls to confirm results received & understood.
Quality survey.
Lung Cancer
Screening Program
Confirms:1. Eligibility2. Documents patient received and understands materials3. Smoking cessation counseling arranged for active smokers4. Charges clarified5. Willingness to be contacted for future research
Screening Access
Line
Patient
Provider
CT Performed
Provider
Patient
Create Order
Shared Decision-Making
Inform/Ed
ucate
Inform/Educate
Sent Results
Sent
Res
ults
Schedules CT
Why lung cancer screening?Why DHMC, Why Now?
DHMC Values DHMC Experience
Responsible leadership and innovation DHMC played leading role in NLST
Disease prevention and early detection Lung cancer is the most lethal cancer,1st time screening has proven to have an impact12,000 lives saved with lung cancer screening76,000 lives with smoking cessationOnly option for former smokers to decrease their chance of dying from lung cancer
Partner with existing community health systems
Groundswell of multidisciplinary supportCoordinating with PCP
Shared decision-making TDI pioneered Shared Decision Making
Quality healthcare practices Value InstituteInformation systems
What if we don’t?
What if we don’t
What if we don’t launch a program now?
1. Patients and providers expend energy with inappropriate use of screening and inaccurate orders
2. Regional centers who are looking for our leadership develop their own programs
3. We will not be ready for the influx of patients a. No Shared Decision-Makingb. No coherent follow up plan
Future Planning
• Additional Resource Requirements– Program Director– Clinical Secretary– Program Navigator– Data Manager– Information system and support
Thank You• Questions?
E-DH
Total Patients 116,256
Smoking history recorded 109,909 94%(88% last year)
Former and current smokers 49,532 42%
Current smokers 12,471 10.7
Pack Year Documentation 17,240 34.8%(34% last year)
>30 pack years; ages 55-74 2,783 2.4%
>30 pack years; age outside criteria
2,046 1.8%
Possible eligible former and current smokers with pack years not documented in E-DH
~9,000
Numbers
DH Patient Inquiry DH Provider Outside
Provider
Screening Access Line (SAL)
-Check eligibility-Mail patient materials-Send Provider Note through e-DH-Creates cued order for DH PCP
eDH order created for
Chest CT Lung Cancer Screening
Outside Patient Inquiry
SAL-Check eligibility-Mail patient materials-Send Provider Letter and Provider/Patient Materials-Send Provider Chest CT Lung Cancer Screening order form
Outside Provider faxes order form
eDH order created for
Chest CT Lung Cancer Screening
eDH orderChest CT Lung
Cancer Screening signed by PCP
Outside Provider calls or faxes SAL
SAL -Mails patient and provider materials-Faxes Provider Chest CT Lung Cancer Screening order form
Outside Provider faxes order form
Outside Provider faxes order form
eDH order created for
Chest CT Lung Cancer Screening
How to create a 4556 - Chest CT Lung Cancer
Screening order
SAL checks eDH orders daily
SAL calls patient and reviews Lung Cancer
Screening Note
What happens after a 4556 order received:
Confirms
eligibility
Confirms patient
materials understo
od
Active Smoker
?
Confirms
patient receive
d materia
ls
Refer to Dr. Erkmen/Dr. Black/ Betsy Maislen for
review
SAL notifies patient and provider
Patient Eligible
Future Resear
ch
Mail Patient Materials
Refer patient to PCP or Shared
Decision-Making Center
SAL calls patient
2-3 days after and confirms patient
received material
s
Smoking cessation
arranged w/ Betsy Maislen
SAL calls Radiology to schedule CT
SAL informs patient of
appointment time
Chest radiologist
protocols for Order 4556
CT Performed
CT Read by Thoracic
Radiologist per standard protocol
Patient and Provider sent
results
Navigator contacts patient 7-10 days
after scheduled CT to verify if results were
received & if follow up care is understood. Patient satisfaction survey conducted
NO
YES
NO
NONO
YES YES
YES
YES/NO
YES YES
LUNG CANCER SCREENING NOTE