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From Abstract to Audit and Back Again

From Abstract to Audit and Back Again. Nancy Rold Missouri Cancer Registry MoSTRA Annual Meeting 2010.

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From Abstract to Audit and Back Again

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  1. From Abstract to Audit and Back Again Nancy Rold Missouri Cancer Registry MoSTRA Annual Meeting 2010 This project was supported in part by a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Missouri Department of Health and Senior Services (DHSS) (#U58/DP000820-04) and a Surveillance Contract between DHSS and the University of Missouri.

  2. To see ourselves as others see us, would from many a blunder free us. -Robert Burns

  3. Outline • Review Results • National NPCR audit • NPCR audit of MCR data • MCR audits of hospital data • Strategies to Use • Field specific recommendations to avoid occasional traps and pitfalls

  4. National NPCR Audit • Compared select abstract data fields to source documents for all sites from 28 states • Cases diagnosed 2004-2006 • Overall accuracy by state was 90-98% - Excellent!

  5. National NPCR Audit CS Elements Errors by Diagnosis Year Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis

  6. National NPCR Audit Surgery Errors by Diagnosis Year Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis

  7. NPCR Audit of MCR Data • In 2008, with the help of 9 Missouri hospitals of varying size - Thank you!! • NPCR re-abstracted 297 MCR cases diagnosed in 2005 for Quality in 20 critical data fields • Casefinding was also audited to assess data for Completeness

  8. NPCR Audit of MCR Data Overall data accuracy for Missouri was 95% Overall completeness was 96.7%

  9. NPCR Audit of MCR Data Accuracy Rates for Tumor-Specific Elements Source: NPCR Data Completeness and Quality Audit of Missouri Cancer Registry – Diagnosis Year 2005

  10. NPCR Audit of MCR Data Sites with the highest error rates • Lung 20% • Breast 19% • GI & Urinary15%

  11. MCR Audits of Hospital Data • MCR tries to audit every hospital within a 5 year cycle • Audits may include casefinding and/or re-abstraction/re-coding • Again, Thank You for participating!

  12. MCR Re-Abstraction - Sources • 2007 Hospital Data • Abstracts From Recent Transmittal(s) • Text - Source Document

  13. MCR Re-Abstraction - Outcomes Primary Sites Breast - Highest Incidence of Errors (10%) Colorectal (8%) Lung (6%)

  14. MCR Re-Abstraction - Outcomes Field Coding Errors • CS Extension Highest Incidence of Errors (11%) • Grade, CS LNs, Rx Surgery Summary (10% Respectively) • Primary Site/Subsite, Dx Date (9% Respectively)

  15. MCR Re-Abstraction - Recommendations • Enter Supporting Text Into the Abstract First Then Code the Data Items • Review Codes and Text Carefully to Ensure Each Substantiates the Other • Be Specific When Assigning Codes • Look Twice Before Assigning 9’s

  16. MCR Re-Abstraction - Conclusion • Text to Code Auditing will be one of MCR’s standard audit methods • Keep in mind Supporting Text is required as explained in previously published MCR guidelines and now in the MCR Manual

  17. MCR Casefinding Audit - Purpose • Affirm Case Completeness of Electronic Reporting Facilities – 2007 data • Special Emphasis on Evaluation of New Multiple Primary rules • Evaluate Hospital Casefinding Procedures, Patterns • Provide Education

  18. MCR Casefinding Audit - Sources • Twenty Facilities Reviewed - High, Medium, Low Categories • 2007 MRDI Provided By Facility • 2007 MCR Extract File Of Hospital Data

  19. MCR Casefinding Audit - Outcomes • Overall Results Were Very Good 95-100% • Fifteen Hospitals Met the Standard • 1 Hospital Was 100% Complete!! • 2 Hospitals Missed Only One Case!

  20. MCR Casefinding Audit - Findings

  21. Casefinding – Types of Missed Cases • Clinically Diagnosed cases • Cases Diagnosed On Imaging • Cases Diagnosed on Biopsy • Encounters for XRT, Chemotherapy, Hormonal Therapy • Majority Outpatient Cases

  22. Casefinding - Reasons for Missed Cases • Pathology Reports / OP Treatment Summaries Not Routed to Registry • No MRDI Review • Inadequate MRDI Review • Incomplete ICD-9 and Service Codes on MRDI

  23. Casefinding - Recommendations • Do Not Limit Casefinding to Pathology Reports or Treatment Summary Referrals • Develop a Medical Record Disease Index • Run Separate MRDI’s To Capture Benign Brain/CNS Cases and Op Rx Cases

  24. Casefinding - Recommendations • Be cognizant of timeliness/completeness reminders • Notify MCR of late file submissions • Encourage electronic casefinding enhancements when feasible

  25. CS Extension - Colon Path: MD adenocarcinoma extending through the subserosa into the pericolic fat Code: 450 – Extension to pericolic fat Not: 400 – Subserosal fat invaded or 420 – Fat, NOS Source: CS Colon Schema

  26. CS Extension - Bladder Path: Transitional cell carcinoma, non-invasive Code: 010- stated non-invasive Not 300 - localized, NOS

  27. CS Extension - Prostate H&P: PSA elevated, DRE unremarkable, biopsy recommended & done, stated cT1 Code: 150 – tumor identified by needle biopsy, e.g. for elevated PSA, clinically inapparent Not 999 – extension unknown See CS schema notes – registrar should not infer whether tumor is apparent

  28. CS – SSF 3 - Prostate • Code based on first course prostatectomy or autopsy findings, not the clinical findings coded in CS Extn • 970 – no prostatectomy (RT consult notes may confirm this) • 960 – unknown if prostatectomy done • Avoid use of 030 – Localized, NOS when a more specific code applies (230 - both lobes)

  29. CS – SSF 3 - Prostate Path: Gleason 7 adenocarcinoma with extracapsular extension and positive margins Code: 480 – extracapsular extension and positive margins Not: 420 – unilateral extracapsular extension

  30. CS Extension - Lung Radiologic evidence of Pleural Effusion was not properly coded as CS Extn 72 in several findings in the NPCR audit of MCR 2005 data. NOTE: in 2010 pleural effusion is coded in CS Mets at DX (codes 15-18) for lung primaries and in SSF1 for Pleura primaries. Read the CS coding notes carefully relative to your case.

  31. CS Extension - Thyroid Path: two areas of papillary carcinoma in left thyroid lobe Code: 200 - Multiple foci confined to thyroid Not: 300 – local, NOS

  32. CS Extension vs. Mets Op Note/Path: Lung cancer with direct extension into adjacent rib Med Onc note: surgeon found rib mets • Code: CS Extn 730 – Adjacent rib • Not: Mets at Dx 40 Text, Text, Text – to support

  33. CS Lymph Nodes – Lung CT scan: mediastinal mass suspicious for LN involvement Code : 200 – Mediastinal, NOS Not: 999 - Unknown • For other terms that constitute clinical diagnosis of LN, see CS Manual, part 1section 1, pg 23.

  34. CS Mets • 999 – Unknown may be an over-used code • 000 should be used if the cancer is stated to be early stage and tx is for such Example: Localized lung cancer treated with surgery alone.

  35. CS Mets For standard treatments by stage see: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp

  36. Site - Meninges MRI of brain – probable meningioma Site Code: C70.0 cerebral meninges Not: C71.0 cerebrum

  37. Subsite - Breast On the NPCR audit of MCR data, breast accounted for 60% of the subsite discrepancies.

  38. Subsite - Breast Used by permission: April Fritz, A Fritz and Associates, LLC

  39. Subsite - Breast C50.8 Single tumor Overlaps contiguous subsites Point of origin unknown C50.9 Multiple tumors Origins in different subsites of one breast, or NOS Source: FORDS p. 107, ICD-O-3 p. 25

  40. Subsite - Breast Use of C50.9 - NOS may be a result of the lack of availability in the medical record. Source: MCR data extract, Use of C50.9 by class of case in abstracts 2004-2008 as % of total breast sites.

  41. C50.9 - MCR Data

  42. Histology – Colon Polyps Path: adenocarcinoma within a tubulovillous adenoma Code: 8263 – Adenocarcinoma in a tubulovillous adenoma Not: 8140 – Adenocarcinoma, NOS

  43. Histology - Colon Polyps

  44. Histology - Thyroid Path for thyroid surgery: papillary carcinoma Code: 8260 – papillary carcinoma (C73.9) Not: 8050 – papillary carcinoma, NOS

  45. Grade – Bladder (historic) Path: papillary urothelial carcinoma, low grade Code: 2 – moderately differentiated Not: 1 – well differentiated Similarly high grade was coded to 04 undifferentiated BUT….

  46. Grade – Bladder – NEW! August I&R question 48073: For Urothelial Bladder Primaries, stated high or low grade: SSF 1 – records the grade (010 low, 020 high) Grade (6TH digit) is coded 9 Grade Path System and Value = blank FORDS p. 115 bullet 4, other sections to be clarified in next update

  47. Grade - Prostate Path: adenocarcinoma, Gleason 6 Code: 2- moderately differentiated Not: 9 – unknown Source: FORDS p. 12 WD Gleason 2,3,4 MD Gleason 5,6 PD Gleason 7-10

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