Cancer Program Practice Profile Reports (CP3R) Version 3

Cancer Program Practice Profile Reports (CP3R) Version 3

Cancer Program Practice Profile Reports (CP3R) Version 3 User Guide 1 Updated November 2019 Cancer Program Practice Profile Reports The CP3R (v3) provides feedback to Commission on Cancer (CoC) accredited cancer programs to: Improve the quality of data across several disease sites Foster preemptive awareness of the importance of charting and coding accuracy Improve clinical management and coordination of patient care in the multidisciplinary setting 2 Navigating CP3R v3 To enter CP3R, select your facility from the facility

list. Educational documents are found on the left tool bar of the CP3R homepage. The following pages provide information on how to navigate and interpret information presented in CP3R (v3). 3 CP3R CP3R allows users to assess facility level compliance and comparisons through Facility Measures and Measure Comparisons. Facility Measures: Reports estimated performance rates (EPRs) for your cancer program. By clicking on Case Review you may assess individual case compliance. Measure Comparisons: Reports the difference between your programs EPR and the average for all CoC programs. By clicking on Review you may compare your EPRs to other CoC accredited programs based on program type and geography. This report also provides the 95% confidence intervals for EPRS. The following pages describe how to navigate the CP3R application and

information found on the site. 4 CP3R Basic Navigation The header of all screens in CP3R provides navigation throughout the site. Facility Selection: Brings you back to select a facility to view in CP3R Facility Measures: Allows programs to view their estimated performance rates (EPR) and drill down into individual case information. Measures Comparison: Allows programs to view the difference between their EPR and all CoC accredited programs and view their EPRs and 95% confidence intervals compared to CoC accredited facilities in similar geography and program type. Interpreting This Report: describes the information presented for the screen you are currently viewing Primary site list: You may navigate to your primary site of interest by selecting Breast, Cervix, Colon, Gastric, Lung or Rectum Save to Excel: Will download the results of the page you are viewing to Microsoft Excel 5 Main Page Facility Measures

The Facility Measures page provides: Measure description Measure abbreviation If the measure is currently applicable to the CoC standards, The Estimated Performance Rates (EPRs) for the last three years and The ability to review more detailed information about the rates. EPRs are updated based on edits made to cases within CP3R within 5 minutes after the screen is refreshed. If you click on the icon under the Review column you will be brought to the Facility Measures Review page. 6 Facility Measures Review The Facility Measures Review page allows programs to review case counts and individual cases used to determine EPRs. For many of the CoC Quality of Care measures, cases are concordant if treatment is administered or considered and not received for a specific reason captured by the cancer registry. To allow CoC-accredited cancer program to assess cases receiving and not receiving these therapies, concordant cases have been stratified into cases in which treatment has been administered and cases in which treatment was considered but not administered. Users may click on the hyperlinked numbers in any row to view cases included in the strata. This allows users to focus their attention on cases to review by measure status. This page is updated based on edits made to cases within CP 3R within 5 minutes after the screen is refreshed

7 Facility Measure Case List In the Facility Measures Case List, users are able to view specific case information for cases assessed for each measure. Scroll bars are located on the bottom and right sides of the screen for ease of navigation. Users designated as registrars and co-hospital registrars in CoC Datalinks are able to edit elements of the record based on updated treatment or case information using FORDS eligible codes. 8 Facility Measure Case List Within the Facility Measures Case List users are able to modify the information viewed: By clicking on the down arrow next to any column you can sort your cases Select Column to select the columns you would like to view (this information is NOT saved for future sessions) Filter to filter for select cases or case criteria. 9 Facility Case Review cont.

To update a modifiable value, click on the box and select your valid code from the available drop down list. If you need to edit a date please enter in the correct date manually. Press Update to process your changes. Please note: Editing capabilities are limited to users designated as hospital registrar and co-registrar. 10 Modifiable Values Variables in CP3R users can edit information to determine case eligibility and measure status. Variable Names AGE DATE CHEMO TX START PATH M REG LN EXAMINED BEHAVIOR DATE HORM TX START

PATH N REG LN POSITIVE CHEMO TX DATE MOST DEFIN SURG PATH T SEX CLASS OF CASE DATE OF INITIAL DIAGNOSIS PATH STG GROUP SURG OF PRIMARY SITE AT THIS FACILITY

CLIN M DATE RAD TX START PRA SURG PRIM SITE AT ANY FACILITY INCL YOURS CLIN N ERA PRIMARY SITE VITAL STATUS CLIN T HISTOLOGY

RAD TX MODALITY CLIN STG GROUP HORMONE TX RAD TX VOLUME DATE 1ST SURGERY LAST CONTACT DATE REASON FOR NO RAD TX 11 Breast nBx Exclusions The following manual exclusions are allowed for cases in the breast needle biopsy measure: Code

Measure Definition 12 nBx Patient medically unable to hold position for image guided biopsy 13 nBx Patient requires sub areolar excision for nipple discharge 14 nBx Lesion too superficial

15 nBx Breast too small 16 nBx Lesion inaccessible by needle biopsy 17 nBx Cancer found in prophylactic mastectomy or through an elective procedure 18

nBx Benign, high risk lesions diagnosed by needle biopsy, requiring excisional biopsy 19 nBx Discordant biopsy results compared to suspicious imaging 20 nBx Patient presents with co-morbid conditions that directly impact the delivery of the standard of care 21 nBx

Diagnosed via cytology FNA only 90 nBx Patient refusal Note: These exclusions are only for the breast needle biopsy measure. Once exclusions are entered the case will update automatically and the estimated performance rates will update within 5 minutes after the screen is refreshed. 12 Measure Exclusions The following manual exclusions are allowed for cases based on the specific measure: Code Primary site: Measure(s) Definition

80 Breast: BCSRT, HT, MAC, BCS, MASTRT, Colon: ACT, Rectum: RECRTCT, Lung: LCT, LNoSurg, Cervix: CERCT, CBRRT, CERRT, Endometrium: ENDCTRT, ENDLRC, Ovary: OVSAL Patient enrolled in a clinical trial that directly impacts delivery of the standard of care 90 Breast: BCS, nBx Patient refusal

41 Colon 12RLN Perforation of the primary site 42 Colon 12RLN Acute obstruction 43 Colon 12RLN Positive FNA; nodes removed surgically were negative due to neo-adjuvant chemo Note: Exclusions are measure specific. Once exclusions are entered the case will update automatically and the estimated performance rates will update within 5 minutes after the

screen is refreshed. 13 Exclusions cont. To code a manual exclusion, in the case review: Scroll to the last column Hover over the exclusions column to determine the accurate code for your exclusion. Select the appropriate code Click Update Note: These exclusions are measure specific. All additional edits to cases should be made to the NAACCR codes. 14 CP3R Measures Comparison This page reports the difference between your cancer programs reported EPR and the reported EPR for all CoC- accredited cancer programs. A positive number highlighted green indicates that your EPR is higher than the national average (lower 95% confidence interval above the mean). A negative number highlighted red indicates your EPR is lower than that in all CoC- accredited cancer programs (upper 95% confidence interval below the mean). None highlighted cells indicate non-significant differences or surveillance measures. Please review the information in the Review tab for the comparison EPR and confidence intervals. Check your Case List for your programs programs individual case information to ensure that the EPRs are accurate.

15 CP3R Measures Comparison Review In the Measure Comparison Review users can review EPRs with 95% confidence intervals, and compare EPRs by geography and program type. Aggregate rates are updated nightly. Comparisons are only available for a group if there are at least 30 cases reported from five or more programs. The 95% confidence intervals are used for assessment of Standards 7.1. If the upper limit of the confidence interval is above the set benchmark, your EPR is compliant with the standard. 16 CP3R Case Processing Cases reported in CP3R are derived from a cancer programs annual NCDB data

submission and from any changes previously made to a case utilizing the edits features in CP3R. Processing of each years annual call for data includes a de-duplication process. This is used when cases are entered into CP3R. If a case has been updated in CP3R additional changes submitted via the call for data will not appear in the CP3R application and will need to be updated manually. Duplicate cases may appear in CP3R if an update to one of the main identifiers (facility ID, accession number, sequence number) for a previously manually updated case is submitted to the NCDB during a subsequent call for data. If this occurs please contact [email protected] for assistance. 17 CP3R Questions For questions regarding CP3R, please contact [email protected] 18

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