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