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

CoC Standards 4.4 and 4.5 Implementation for Surveys in 2015

The Quality Integration Committee has revised expected Estimated Performance Rates (EPR) for accountability and quality measures assessed with Commission on Cancer (CoC)  Standards 4.4 and 4.5.   These standards require performance levels be met annually according to the specified accountability and quality improvement measures defined by the CoC. 

Expected Performance Rates

Each of the following measures listed below will be assessed and rated for 2015 surveys.  The EPRs have changed for some of the measures for 2012 diagnoses.  EPRs remain the same as previously released for cases diagnosed in 2010-2011. 


Measure

Measure
Type

EPR

2010-2011

2012

BREAST

BCSRT - Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer

Accountability

90%

90%

HT - Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage II or stage III hormone receptor positive breast cancer.

Accountability

90%

90%

MAC - Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c, or stage II or III hormone receptor negative breast cancer.

Accountability

90%

90%

MASTRT - Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with >= 4 positive regional lymph nodes.

Accountability

NA

90%

nBx - Image or palpation-guided needle biopsy (core or FNA) is performed to establish diagnosis of breast cancer.

Quality Improvement

NA 

80%

COLON

ACT - Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC stage III (lymph node positive) colon cancer

Accountability

90%

90%

12RLN - At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.

Quality Improvement

80%

85%

Evaluation Criteria of Measures

To be compliant with Standards 4.4 and 4.5, cancer programs must:

1) Meet the above performance rates either with their EPR in CP3R or the upper bound of the 95% confidence interval; or
     If the performance rates are below the EPR, cancer programs must establish and implement an action plan that reviews and addresses improving performance. 

Measures not assessed during 2015 surveys:

Surveillance measures and measures released in the November 2014 CP3R release will not be assessed during 2015 surveys, as listed below   


Breast

BCS - Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer.

Rectum

RECRT - Radiation therapy is considered or administered within 6 months (180 days) of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or stage III receiving surgical resection for rectal cancer.

Gastric

G15RLN- At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer.

Non-Small Cell Lung

10RLN - At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC.

LCT- Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is considered for surgically resected cases with pathologic, lymph node-positive (pN1) and (pN2) NSCLC.

 

How to Interpret Confidence Intervals

The following tables provide examples on how to interpret the 95% Confidence Intervals for compliance with Standards 4.4 and 4.5.


Standard 4.4 Accountability Measures  (Example 1)

Survey
Year

CP3R
Diagnosis 
Year

Measure

EPR

Calculated Performance
Rate (95% CI)

Rating

2015

2012

BCS/RT

90%

94.6 (90-99.2)

1

HT

90%

86.4 (72.1-100)*

MAC

90%

 97.5 (94.1-100)

ACT

90%

 93.8 (82-100)

MASTRT

90%

 85.7 (59.8-100)*

*In the table above, the program's actual performance rate for the HT measure is 86.4%, and the upper bound of the 95% CI is 100%, which is above the 90% EPR.  The program will be assessed as meeting the performance criteria for the HT measure as the CI indicates that the rate is not significantly different from the EPR.  In Example 1, all of the accountability measures meet the evaluation criteria.   


Standard 4.4 Accountability Measures  (Example 2)

Survey
Year

CP3R
Diagnosis 
Year

Measure

EPR

Calculated Performance
Rate (95% CI)

Rating

2015

2012

BCS/RT

90%

80.2 (75-85)**

5
(if no
action
plan in
place)

HT

90%

86.4 (72.1-100)

MAC

90%

 97.5 (94.1-100)

ACT

90%

 93.8 (82-100)

MASTRT

90%

79.6 (73.3-85.9)**

**In the table above the program's calculated performance rate for BCS/RT is 80.2% and the MASTRT is 79.6%.  These performance rates do not meet the 90% EPR; neither do the upper bound of the CI (85% and 85.9% respectively) meet or exceed the 90% EPR. 

For more information on the measures including definitions of Accountability, Quality Improvement and Surveillance measure, please visit the CoC Quality of Care Measures website https://www.facs.org/quality-programs/cancer/ncdb/qualitymeasures.  

If you have any questions on your CP3R rates, please email NCDB at  NCDB@facs.org