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Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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ACS
Cancer Programs

ACS Terms of Use and Conditions regarding Public Reporting of NCDB Reports and Tools

November 14th, 2022

Background

The National Cancer Database (NCDB), under the guidance of the Commission on Cancer (CoC) leadership and committees, develops and disseminates aggregate and individual institutional reports for CoC-accredited programs. These NCDB reports have permissible and non-permissible uses that are predicated on the methodologies employed to generate the reports. Public reporting at the present time is not supported due to the absence of rigorous risk adjustment and audit validation against original records.

Purpose

This document describes guiding principles and permissible and non-permissible uses of the NCDB reports.

This document only pertains to the following NCDB reports:

  • NCDB Hospital Comparison Benchmark Reports (HCBR)
  • NCDB Survival Reports
  • Cancer Quality Improvement Program (CQIP) Reports
  • NCDB Rapid Cancer Reporting System (RCRS)
  • Site by Stage Distribution Reports
  • NCDB Completeness Reports

Other ACS documents describe the terms and conditions specific to the use of Participant User Files.

This document does not pertain to the use of data that is generated by the institution and not analyzed or reported by the NCDB staff.

Guiding principle regarding internal uses of NCDB reports

NCDB reports are primarily intended for internal use within CoC-accredited cancer programs and intended to be used for the purpose of evaluating and/or improving the cancer care that is delivered to patients at the institutional level. Individual program reports and aggregate reports and benchmarks are intended to be used for a variety of internal purposes including, but not limited to, advising improvements in practice management, multidisciplinary coordination of care and quality of care. These reports are also intended to be used as part of quality improvement, research and knowledge generation.

Guiding principle regarding external reporting of NCDB reports

New knowledge that is generated as a result of quality improvement and/or research activities using NCDB reports may be considered appropriate for sharing outside the institution when it is being communicated in order to enhance the general knowledge and understanding of cancer and/or facilitate adoption of improved practices and outcomes. In such cases, it is imperative that the methodologies and specifics of the quality improvement interventions and/or research hypotheses be provided as part of the external sharing.  NCDB reports are not to be publicly reported or shared outside the CoC accredited program for purposes of marketing or branding.

Permissible Use of All CoC/NCDB Reports:

  • Measuring, monitoring and improving cancer practices
    • Identifying and reporting the need for cancer prevention programs
    • Identifying areas for cancer screening programs
    • Improving multidisciplinary coordination and timeliness of care
    • Meeting standards
  • Meeting and maintaining compliance with the Standards for CoC accreditation
  • Quality improvement and assurance initiatives involving the cancer program and hospital (i.e. reporting on results of interventions)
  • General education supporting cancer advocacy, medical education, and patient care
  • Generating new knowledge through research
    • Materials to support grant funding
    • Reports on interventions
    • Abstracts, articles, or chapters of scientific meetings, medical journals or books that utilize or present NCDB data
  • Other reports derived from the tools to be distributed to internal staff and patients, including annual reports, public websites, community outreach brochures, and announcements of CoC-accreditation

Non-Permissible Use of All CoC/NCDB Tools:

  • Local, state, or federal public reporting
  • Benchmarking performance of one institution relative to national experience for promotional purposes and without documentation of methods and approach to data.
  • Reporting of any data obtained from the NCDB Quality Reporting Tools for specific marketing purposes
  • Reporting of any outcomes data including unadjusted and risk-adjusted survival and operative mortality rates calculated and reported by the NCDB.
NCDB Hospital Comparison Benchmark Reports (HCBR) - Public

Cell sizes less than 10

Not permissible

My hospital only report

Permissible

Aggregate Report

Permissible

Comparison report

Not permissible

Days to first treatment

Permissible

Report image

Permissible

Report table

Permissible

Public Reporting

Not permissible

NCDB Survival Reports

Any part of the report

Not permissible

Cancer Quality Improvement Program (CQIP)

Cell sizes less than 10

Not permissible

Cancer Program Administrative Reports (My Program Only)

Permissible

Quality Measure Reports (My Program Only, excluding caterpillar plots)

Permissible 

Volume and unadjusted 30, 90 day mortality

Not permissible

Unadjusted survival

Not permissible

Risk adjusted survival

Not permissible

Additional Reports:

 - Stage distribution (My Program Only)

 - In/Out migration (My Program Only)

 - Insurance status (My Program Only)

 - Distance traveled (My Program Only)

 - First course treatment (My Program Only)

 - Days to first treatment (My Program Only)

 - Heat map

Permissible

  Permissible

  Permissible

  Permissible

  Permissible

  Permissible

  Permissible

  Not permissible

Commission on Cancer background/informational slides

Permissible

Public reporting (any part of the report)

Not permissible

NCDB Rapid Cancer Reporting System (RCRS)

Cell sizes less than 10

Not permissible

Dashboard (home page):

 - CoC accreditation measures for site reviewer

 - Alert summary

 - Notifications

 - Most recent quality measure data available

 

Permissible

Permissible

Not permissible

Permissible

Upload

Not permissible

Submission history report

Not permissible

Submission detail report:

 - Records by

 - Edit summary

 - Records list

 

  Not permissible

  Not permissible

  Not permissible

Notifications

Not Permissible

Alerts report:

 - Total alerts

 - Case list

 - Alert summary by primary site

 - Edit errors

 

 

  Permissible

  Not permissible

  Permissible

  Not permissible

 

Case log report:

 - Case list

 - Case-level alerts

 - Case-level edit errors

 

  Not permissible

  Not permissible

  Not permissible

Quality Measure Report:

 - Summary panel

 - Details panel – case status

 - Case list

 

  Permissible

  Permissible

  Not permissible

Comparisons Report:

 - Performance rate comparisons

 - Performance rate comparison by

 - Details by … with case counts

 

  Not permissible

  Not permissible

  Not permissible

Report image

Not permissible

Report table

Not permissible

Public reporting (any part of the report)

Not permissible

Site by Stage Distribution Report

Cell sizes less than 10

Not permissible

Counts by primary site

Permissible

Counts by primary site and stage

Permissible

Case level detail

Not permissible

Report image

Permissible

Report table

Permissible

Public reporting (any part of the report)

Not permissible

NCDB Completeness Reports

Cell sizes less than 10

Not permissible

Benchmark percent

Permissible

Hospital percent

Permissible

Report image

Permissible

Report table

Permissible

Public reporting (any part of the report)

Not permissible

Reporting Conditions:

  • You agree to include a credit line stating the information was derived from the ACS’ NCDB in all publications and disseminated materials
  • When confidence intervals or statistical significance levels are applicable, they must be included in the report.
  • The tools, content, and data are owned by ACS
  • The ACS holds copyrights for all text, tables, figures, and data generated by or featured within the NCDB Quality Reporting Tools
  • Permission is granted on a limited, non-exclusive basis for both print and electronic use
  • The ACS and the CoC will not verify the changes and are not responsible for conclusions drawn from any modification of data obtained from the reporting tools

For any questions about the reporting policies or the information above, please direct all questions to ncdb@facs.org.