American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

CP3R and RQRS Updates

The NCDB is preparing to release new quality measures and measure updates in its quality reporting systems. As a result from September 8-15:

  • The ability to edit case information will be disabled in CP3R
  • RQRS data submissions will not update the application

Both applications will continue to be available for use by CoC-accredited programs, including the ability to upload RQRS data submissions.

New measures  in CP3R

When full functionality is restored to CP3R on September 15, the system will encompass 20 quality measures covering 8 primary sites: breast, colon, rectum, gastric, non-small cell lung, ovary, endometrium, and cervix. This will include implementation of five new measures and updates to current measures. 

The following 5 surveillance measures will be introduced:  

  • Chemotherapy administered to cervical cancer patients who received radiation for stages IB2-IV cancer (Group 1) or with positive pelvic nodes, positive surgical margin, and/or positive parametrium (Group 2) (CERCT)
  • Chemotherapy and/or radiation administered to patients with Stage IIIC or IV Endometrial cancer (ENDCTRT)
  • Endoscopic or laparoscopic, robotic, or converted to open surgery performed for all Endometrial cancer (excluding sarcoma and lymphoma), for all stages except IV (ENDLRC)
  • Chemotherapy started within 42 days (before or after) the Date of Most Definite Surgery in Stages IA-IV Ovarian, Fallopian Tube, or Peritoneal cancers (OVCT)
  • Salpingo-oophorectomy with omentectomy, debulking/cytoreductive surgery, or pelvic exenteration in Stages I-IIIC Ovarian cancer (OVSAL)

The purpose of surveillance measures is to identify the status quo as well as monitor patterns and trends of care in order to guide decision making and resource allocation. Please note: estimated performance rates (EPRs) for surveillance measures are not assessed in the CoC Standards.  

Measure specification updates in CP3R and RQRS

Users may also notice differences in EPRs for current measures. Updates to the measure specifications and notifications are made based on feedback from CoC programs and the NCDB clinical leadership. Applicable measure specifications will be updated in both CP3R and RQRS.   


Measures Effected

Change

Potential Impact

All Breast (BCSRT, HT, MAC, BCS*, MASRT*, and nBx*)

Exclude rare tumor histologies
·         M8940/3 - Mixed tumor, malignant, NOS
·         M8950/3  - Mullerian mixed tumor
·         M8980/3 - Carcinosarcoma
·         M8981/3 - Carcinosarcoma, embryonal

Decrease in the denominator, EPR may change for some facilities.  

Breast MAC

Exclude 8200 adenoid cystic carcinoma since chemotherapy is not required for this histology

Decrease in the denominator, EPR may change for some facilities.  

Rectum*

Order of assessing adjuvant chemotherapy and radiation therapy receipt has been updated to include all potential cases in the denominator. 
Radiation and chemotherapy receipt required within 6 months of diagnosis. 

Cases previously labeled as incomplete may become non-compliant

Lung LNoSurg*
Cervix CERRT*

Clarification of measure status messages within CP3R case list

No Change in EPR

Gastric G15RLN*

Include behavior 2 in denominator

Increase in the denominator count and EPR may change for some facilities.  

*Measure not reported in RQRS

Additional questions may be directed to NCDB@facs.org  or NCDB_RQRS@facs.org.