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2017 Public Report of Outcomes

 
Through feedback from patients, our observations, national and local trends, and other sources, HSHS St. Vincent Hospital Cancer Centers continuously evaluates and improves the quality of care we provide to our patients. This report publically shares outcomes from one of our endeavors in the past year.    
 
HSHS St. Vincent Hospital Cancer Centers was reaccredited as an Integrated Network Cancer Program in 2015 for a three-year term, with commendation in all applicable standards. 
 
As a result of this excellent program performance, we were also awarded the Commission on Cancer’s Outstanding Achievement Award in 2015.  This award recognizes cancer programs that strive for excellence in demonstrating compliance with the Commission on Cancer Standards and are committed to ensuring high quality cancer care. 
 
The cancer program at HSHS St. Vincent Hospital Cancer Centers provide a broad scope of services from cancer prevention, outreach and education for cancer detection, treatment, palliative care and survivorship. Our program receives guidance and leadership from the HSHS St. Vincent Hospital Cancer Centers’ cancer committee, which convenes regularly to ensure that we are meeting the standards outlined by the American College of Surgeons Commission on Cancer. These standards address education, treatment, clinical research, data collection, performance and quality improvements. 
 
At HSHS St. Vincent Hospital Cancer Centers, we are committed to the design and implementation of quality patient care and treatment services. In this report we highlight one of our quality improvement projects designed to elevate the care provided to our patients with cancer: 
 
Quality Improvement:  Implement process for giving patients with BMI > 25 kg/m 2 information about the impact of BMI on cancer recurrence and specific information about lifestyle modification/weight management
 
Background: 
This 2017 quality improvement was a result of a 2016 study that looked at the Body Mass Index (BMI) of our cancer population. HSHS St. Vincent Hospital Cancer Centers’ Community Needs Assessment reported that 64 percent of Wisconsin adults are either overweight or obese according to the Wisconsin 2010 Behavioral Risk Factor Surveillance System. It was also noted that in April 2014, Gallup research ranked Green Bay in the top 10 most obese cities in the United States with an average BMI of 33 kg/m2. It is known that BMI has a bearing on cancer incidence and recurrence, but our own patient population hadn’t been evaluated. If there is a significant difference in the percentage of our patients who were obese, it was suggested to implement possible strategies around how we educate and or treat our patient population. 
 
The 2016 HSHS St. Vincent Hospital Cancer Centers study was an analysis of the 2014 newly diagnosed cancer cases. An analysis of patient data from the cancer registry was aimed at the top cancer sites associated with obesity, including: endometrium, liver, thyroid, breast, cervical, ovarian, prostate, colorectal, skin, kidney, bladder, lymphoma, head and neck, esophageal/stomach, pancreas, lung and bone marrow.  Compared to the national average BMI of about 26.5 kg/m2, the BMI of HSHS St. Vincent Hospital Cancer Center patients was about 2-10 points higher, across all disease sites within the cancer registry (average BMI of 28-36 kg/m2). Overall, data was consistent with our community needs assessment. Our patients in the study were overweight and it may have contributed to their disease. Regardless of disease site or stage, the average BMI was above national norms and within range of the obesity threshold on the BMI scale.
 

 
These findings were concerning, as we know this can impact cancer occurrence and recurrence. “Being overweight or obese is clearly linked with an increased risk of several types of cancer:  Breast (among women who have gone through menopause), colon and rectum, endometrium (lining of the uterus) esophagus, kidney, and pancreas. Being overweight or obese also likely raises the risk of other cancers such as gallbladder, liver, non-Hodgkin lymphoma, multiple myeloma, cervix, ovary and aggressive forms of prostate cancer.” (Facts & Figures – Healthy Lifestyles and Reducing the Risk of Cancer in Wisconsin, 2016)
 
According to the CDC, the average American adult male has a BMI of 26.6 kg/m2 and the average American adult female is 26.5 kg/m2. A BMI of 25-29.9 kg/m2 is considered overweight, while a BMI greater than 30 kg/m2 is considered obese.
 
There is significant literature available that shows obesity and overweight status is a behavioral risk factor for cancer occurrence and recurrence.  “Approximately one-third of the cancer deaths that occur in the United States each year are associated with poor nutrition and physical inactivity, including excess weight. Aside from not smoking tobacco, eating a healthy diet, being physically active, and maintaining a healthy body weight, are the most important choices the majority of people can make to reduce their cancer risk.” (Facts & Figures – Healthy Lifestyles and Reducing the Risk of Cancer in Wisconsin, 2016) 
 
Based upon the results of this study, the cancer committee determined both the general public and our cancer patients should be further educated on the relationship between overweight/obesity and cancer occurrence and recurrence.  The committee decided to start with educating the breast cancer patient population at HSHS St. Vincent Hospital Cancer Centers. In 2017, a quality improvement project was implemented that focused on breast cancer patients at HSHS St. Vincent Hospital Cancer Centers. 
 
Objective: 
To implement a process within the electronic medical record (EMR) to contact each breast patient with a BMI greater than 25 at the time of their scheduled survivorship care plan visit. A note would be placed within each survivorship care plan which denotes patient BMI and appropriate action based on category of BMI. Information will be given to address the importance of a healthy BMI in terms of cancer recurrence risk and other chronic disease. By addressing this at the time of the survivorship care plan visit, we would be able to address diet/lifestyle risk at an already scheduled clinic visit, without adding resources. 
 
Actions/Interventions:
We sought to find an intervention to educate cancer patients regarding resources for optimal weight control tailored to their BMI. We chose to design a trial for a small group of cancer patients that could be replicated for all cancer patients. The intervention will leverage tools from the EMR to assist in the delivery of the information. Breast cancer cases represent a significant portion of all of the HSHS St. Vincent Hospital Cancer Centers cancer cases. Approximately 100 percent of all breast cancer patients are presented at breast tumor board and BMI is reported on each of them. There is also a high survivorship care plan completion rate for breast cancer patients.
 
The quality improvement project was to implement a process for giving breast cancer patients with BMI greater than 25 information about the impact of BMI on cancer recurrence and specific information about lifestyle modification and weight management. The care team felt it was important to customize this information to the specific patient. The following were steps that were taken to accomplish this improvement:
  • The oncology dietitian created a resource list for weight loss programs within our health system and community to be given to patients. 
  • A workflow was created to alert the oncology dietitian of scheduled survivorship care plan visits for breast cancer patients. 
  • The oncology dietitian created a template of appropriate content to insert into survivorship care plan document within the EPIC electronic medical record.   
  • The oncology dietitian educated nurse practitioners and nurse navigators about how to use this inserted text and how to explain to patients. 
  • A tracking mechanism was established for the oncology dietitian to track the upcoming survivorship care plans so that she could notify the providers of these visits.
  • The team developed a process for tracking these documents, to monitor the progress of the system and evaluate feedback. 
     
Outcome:
This was a significant opportunity to educate patients about how obesity impacts the risk for cancer occurrence and recurrence. Nurse navigators and nurse practitioners have been able to support patients in making lifestyle and behavioral changes that could reduce this risk. 
 
Next steps:
  • Monitor the number of breast cancer patients who receive this information and compare it to the cancer registry data for the number of patients who meet the BMI greater than 25 target. Further evaluate situations where appropriate patients do not receive the information in their survivorship care plans in order to continuously improve the process. 
  • Evaluate and update the list of resources on an ongoing basis.
  • Evaluate ability to receive automated reports and notifications from the electronic medical record.
Phase in implementation of this process to patients who have high BMI with other cancer diagnoses.
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