F C D S A N N U A L C O N F E R E N C EB O C A R A T O N , F L O R I D A

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S T E V E N P E A C E , C T R

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2015-2016 QC Activities Summary

Presentation Outline2

FCDS Data Quality Program

FCDS 2015 Submission Summary

FCDS QC Review Sample Summary

FCDS QC Review Summary Reports

2016 FCDS DQIR (2014 Data)

2016 NPCR Data Evaluation Reports

Surgery, NOS Codes

Sex Coding Errors – Again!

FCDS Data Quality Program - Goals3

Establish, perform, manage Quality Improvement/Quality Control projects

Apply national and internal standards for data collection, aggregation, etc

Systematically measure performance against those standards

Assess outcomes and performance measures

Develop measurement and evaluation tools

Develop quality enhancement strategies

Assess registry needs and satisfaction

Monitor completeness, quality and timeliness

Provide education and training to improve data quality

FCDS Data Quality Program - Methods4

FCDS Policy FCDS Abstractor Code Requirement FCDS EDITS Requirement Text Documentation Requirement Deadlines and IT Security

FCDS Procedures FCDS IDEA – Communication/Transmission FCDS Internal Data Processing Monitoring FORCES/CORRECTIONS/DELETIONS Patient and Tumor Linkage & Consolidation

FCDS Monitoring / Audits Audits for Completeness Audits for Timeliness Audits for Accuracy

FCDS Data Quality Reports Quarterly/Annual Status Reports QC Review Summary Ad Hoc Reports Audit Results

Submission Summary & QC Review Sample5

Description # Cases % of TotalTotal Cases Submitted to FCDS 1/1/2015-12/31/2015 – All Sources 224,356 100%Total Cases – NO CHANGE – Pass ALL Edits – No Visual Review by FC or QC 210,574 93.9%

Total Cases – FC Visual Review (FC Review to assess case for possible FORCE) 13,708 6.1%• FORCED (EDIT Override Confirmed and FORCE was set - NOT an error) 4,598 2.0%• CORRECTED (1 or more corrections made based on text – NOT a FORCE) 6,750 3.0%• DELETED (duplicate case, not a reportable neoplasm, not a new primary) 2,360 1.1%

Total Cases – Every 25th Case QC Review Sample/Visual Editing

10,308 4.6%• Sample includes 4% of analytic hospital, radiation, surgery center cases• Sample includes ALL male breast and ALL pediatric cases • Sample does not include dermatology or other physician office cases

Total Cases Visually Edited by FCDS in 2014 (combined FC and/or QC Review) 24,016 10.7%

QC Review Sample / Visual Editing - Summary6

Description # Cases % of TotalTotal Cases – Every 25th Case QC Review Sample/Visual Editing 10,308 4.6% of All Cases

Total Cases – NO CHANGE on QC Review 7,118 69.1% of QC SampleTotal Cases Sent to Facility with Correction or Inquiry 3,190 30.9% of QC Sample

Total Cases Sent to Facility with Correction or Inquiry 3,190 30.9% of QC Sample• NO CHANGE after Follow-Back to Facility 794 24.9%• FORCED (EDIT Override Confirmed - NOT an error) 46 1.4%• CORRECTED (1 or more corrections made – NOT a FORCE) 2,309 72.4%• DELETED (duplicate case, not a reportable neoplasm, not a new primary) 41 2.3%

AHCA In-Patient: Follow-Back Analysis7

AHCA Ambi: Follow-Back Analysis8

QC Review Summary Report9

QC Review Summary Reports10

QC Review Summary Reports11

2016 FCDS DQIR (2014 Analytic Cases)12

Sample Report

2016 Call for Data – NPCR DER Report13

2016 Call for Data – NPCR DER Report14

2016 Call for Data – NPCR DER Report15

2016 Call for Data – NPCR DER Report16

Overuse of Surgery NOS Codes17

Sex Coding Errors18

Unusual first names

Increase over past 5 Years

Registrars still not checking

Edit Failures will be checked and validated.

Easy for Reproductive Cancers but not Colon, Lung, etc.

FCDS is borrowing methodology from New York and Alaska that will validate common first names by decade.

Questions19