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CTOP Retreat 2014

CTOP Retreat 2014. CTOP Retreat. Why Do We Do It?. Bumper cars. Everyone is going in individual directions Varying speeds Randomly bumping into others Sometimes sharing goals Some are having fun, others are not. Bumper Cars. At the flip of a switch Everything stops. CTOP Retreat. Stop

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CTOP Retreat 2014

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  1. CTOP Retreat 2014

  2. CTOP Retreat Why Do We Do It?

  3. Bumper cars Everyone is going in individual directions Varying speeds Randomly bumping into others Sometimes sharing goals Some are having fun, others are not

  4. Bumper Cars • At the flip of a switch • Everything stops

  5. CTOP Retreat • Stop • Share knowledge • Prioritize group goals • Set the groundwork for change and innovation

  6. CTOP Retreat 2012

  7. CTOP Retreat 2014Highlights • Lung Cancer Screening: Cost Effective Analysis

  8. CTOP Retreat 2014Highlights • Lung Cancer Screening: Cost Effective Analysis • Chris Trimble from Tuck School of Business

  9. CTOP Retreat 2014Highlights • Lung Cancer Screening: Cost Effective Analysis • Chris Trimble from Tuck School of Business • Smoking Cessation: e-cigarettes and marijuana

  10. CTOP Retreat 2014New • 14 hours of CME • Website • Yearly Esophageal Cancer Patient Reunion

  11. CTOP Retreat 2014Individual Action Plan • Meet 3 new people • Change one thing

  12. CT Screening for Lung Cancer DHMC Implementation Plan

  13. NLST Study Design • Prospective randomized trial • 53,454 individuals @ high risk Aberle et al. Radiology 2011; 258(1):243-253

  14. NLST Study Design • Prospective randomized trial • 53,454 individuals @ high risk • No symptoms of lung cancer • Ages 55-74 • >=30 pack-yr history of smoking • No prior lung cancer • Medically fit for surgery Aberle et al. Radiology 2011; 258(1):243-253

  15. NLST Results • 20% lung cancer mortality reduction • 7% all cause mortality reduction • Cumulative FPR ≈ 37%, 1st CT about 25% • Overdiagnosis ≈ 12% Aberle et al. N Engl J Med, 2011. 365(5): p. 395-409

  16. USPSTF Recommendation The USPSTF recommends annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years… Grade B recommendation. http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm

  17. Affordable Care Act Private insurance is mandated to cover the USPSTF recommendations for preventive services with a grade of A or B by January 1, 2015 . . .

  18. Centers for Medicare and Medicaid Services(CMS) • Initiated a National Coverage Determination (NCD) • Medicare Evidence Development and Coverage Advisory Committee (MedCAC) hearing April 30, 2014

  19. Centers for Medicare and Medicaid Services(CMS) • How confident are you that there is adequate evidence to determine of the benefits outweigh the harms? 2.22/5.0 • How confident are you that harms will be minimized in the Medicare population 2.33/5.0 • How confident are you that evidence gaps remain 4.44/5.0

  20. Explanation? • "I am concerned that we don’t really have a lot of data in the Medicare population, certainly not in the 75-80 [year-old age group]" said Dr. Rita Redberg, MEDCAC chair and Professor of Medicine at the UCSF • Screening people for lung cancer carries real risks, including increased radiation exposure and collapsed lungs. • Some are also concerned that hospitals will offer the tests to lower-risk patients as a way to boost profits. Oncology Report, USAToday 5/14/14

  21. CMS • CMS will publish their proposed national coverage decision in November 2014 • Followed by a 30-day comment period • Final decision and announcement in February of 2014

  22. Two-Tiered System • People aged 55-65 will be covered • People aged 65 and over will not

  23. Action • Letter to CMS from the Senate and the House of Representatives, May 30, 2014 “National Coverage Determination for LDCT scans for medicare beneficiaries . . . Be completed expeditiously . . . It is essential that seniors on Medicare have access to this screening tool.” “Americans deserve . . . to have access to potentially life-saving, evidence-based screenings that can prevent further health costs down the road.”

  24. Action 26. Representative Lynn Jenkins (R-KS) 27. Representative Brett Guthrie (R-KY) 28. Representative John Tierney (D-MA) 29. Representative Mike Capuano (D-MA) 30. Representative Jim McGovern (D-MA) 31. Representative Andy Harris, MD (R-MD) 32. Representative Gregg Harper (R-MS) 33. Representative Carol Shea Porter (D-NH) 34. Representative Leonard Lance (R-NJ) 35. Representative Bill Pascrell (D-NJ) 36. Representative Joe Heck, MD (R-NV) 37. Representative Dina Titus (D-NV) 38. Representative Chris Gibson (R-NY) 39. Representative Eliot Engel (D-NY) 40. Representative David Joyce (R-OH) 41. Representative Pat Tiberi (R-OH) 42. Representative Bob Latta (R-OH) 43. Representative Pat Meehan (R-PA) 44. Representative Charlie Dent (R-PA) 45. Representative Jim Gerlach (R-PA) 46. Representative Stephen Fincher (R-TN) 47. Representative Diane Black (R-TN) 48. Representative Marsha Blackburn (R-TN) 49. Representative David “Phil” Roe, MD (R-TN) 50. Representative John Duncan (R-TN) 51. Representative Scott DesJarlais, MD (R-TN) 52. Representative Kenny Marchant (R-TX) 53. Representative Gene Green (D-TX) 54. Representative Jim Sensenbrenner (R-WI) Letter Leads 1. Representative Charles Boustany, MD (R-LA) 2. Representative Jim Renacci (R-OH) 3. Representative John Barrow (D-GA) 4. Representative Richie Neal (D-MA) Cosigners 5. Representative Spencer Bachus (R-AL) 6. Representative Tim Griffin (R-AR) 7. Representative Raul Grijalva (D-AZ) 8. Representative Devin Nunes (R-CA) 9. Representative Ami Bera, MD (D-CA) 10. Representative Sam Farr (D-CA) 11. Representative Julie Brownley (D-CA) 12. Representative Gloria Negrete McLeod (D-CA) 13. Representative Lois Capps (D-CA) 14. Representative Mike Coffman (R-CO) 15. Representative Joe Courtney (D-CT) 16. Representative Phil Gingrey, MD (R-GA) 17. Representative Tom Price, MD (R-GA) 18. Representative David Scott (D-GA) 19. Representative Bill Cassidy, MD (R-IA) 20. Representative Bruce Braley (D-IA) Representative Dave Loebsack (D-IA) 22. Representative Mike Simpson (R-ID) 23. Representative Aaron Schock (R-IL) 24. Representative Adam Kinzinger (R-IL) 25. Representative Larry Buschon, MD (R-IN) • Letter Leads: Senator Feinstein (D-CA) • and Senator Johnny Isakson (R-GA): • Cosigners • Senator Michael Bennet (D-CO) • Senator Marco Rubio (R-FL) • Senator Saxby Chambliss (R-GA) • Senator Brian Schatz (D-HI) • Senator MazieHirono (D-HI) • Senator Charles Grassley (R-IA) • Senator Richard Durbin (D-IL) • Senator Mark Kirk (R-IL) • Senator Jerry Moran (R-KS) • Senator Pat Roberts (R-KS) • Senator Mary Landrieu (D-LA) • Senator Ed Markey (D-MA) • Senator Susan Collins (R-ME) • Senator Richard Burr (R-NC) • Senator Jeanne Shaheen (D-NH) • Senator Kelly Ayotte (R-NH) • Senator Robert Menendez (D-NJ) • Senator Cory Booker (D-NJ) • Senator Martin Heinrich (D-NM) • Senator Dean Heller (R-NV) • Senator Charles Schumer (D-NY) • Senator Kirsten Gillibrand (D-NY) • Senator Sherrod Brown (D-OH) • Senator Maria Cantwell (D-WA) • Senator Jay Rockefeller (D-WV) • Senator Joe Manchin (D-WV) • Senator Michael Enzi (R-WY) Ann Kuster (D-NH) Peter Welch (D-VT) Patrick Lahey(D-VT) Bernard Sanders (I-VT)

  25. Action • Senator Jeanne Shaheen (D-NH) http://www.shaheen.senate.gov/ • Senator Kelly Ayotte (R-NH) http://www.ayotte.senate.gov/ • Patrick Lahey(D-VT) https://www.leahy.senate.gov/contact/ • Bernard Sanders (I-VT) http://www.sanders.senate.gov/contact/ • Carol Shea Porter (D-NH) http://shea-porter.house.gov/ • Ann Kuster(D-NH) http://kuster.house.gov/ • Peter Welch (D-VT) https://welch.house.gov/email-me

  26. Why lung cancer screening?Why DHMC, Why Now?

  27. Lung Cancer Screening Program Timeline

  28. Lung Cancer Screening at DHMC - Lebanon Phase 1 Phase 2 Phase 3 Expand Pilot Target DH-Lebanon/GCP Provider Pilot Lung Cancer Screening Target DH-Lebanon Employees Open to Public 200 screens 200 screens Communicate to Providers Evaluate Process & Systems Adjust accordingly Evaluate Process & Systems Adjust accordingly

  29. Clinical Pathway Provider Provider Confirms: 1. Eligibility 2. Documents patient received and understands materials 3. Smoking cessation counseling arranged for active smokers 4. Charges clarified 5. Willingness to be contacted for future research Inform/Educate Create Order Sent Results Lung Cancer Screening Program Screening Access Line Schedules CT Shared Decision-Making CT Performed Sent Results Inform/Educate Patient Patient Calls to confirm results received & understood. Quality survey.

  30. Why lung cancer screening?Why DHMC, Why Now?

  31. What if we don’t?

  32. What if we don’t

  33. What if we don’t launch a program now? • Patients and providers expend energy with inappropriate use of screening and inaccurate orders • Regional centers who are looking for our leadership develop their own programs • We will not be ready for the influx of patients • No Shared Decision-Making • No coherent follow up plan

  34. Future Planning • Additional Resource Requirements • Program Director • Clinical Secretary • Program Navigator • Data Manager • Information system and support

  35. Thank You • Questions?

  36. Numbers

  37. How to create a 4556 - Chest CT Lung Cancer Screening order DH Patient Inquiry Outside Patient Inquiry DH Provider Outside Provider Screening Access Line (SAL) -Check eligibility -Mail patient materials -Send Provider Note through e-DH -Creates cued order for DH PCP SAL -Check eligibility -Mail patient materials -Send Provider Letter and Provider/Patient Materials -Send Provider Chest CT Lung Cancer Screening order form eDH order created for Chest CT Lung Cancer Screening Outside Provider calls or faxes SAL SAL -Mails patient and provider materials -Faxes Provider Chest CT Lung Cancer Screening order form Outside Provider faxes order form eDH order Chest CT Lung Cancer Screening signed by PCP Outside Provider faxes order form Outside Provider faxes order form eDH order created for Chest CT Lung Cancer Screening eDH order created for Chest CT Lung Cancer Screening

  38. What happens after a 4556 order received: SAL checks eDHorders daily SAL calls Radiology to schedule CT SAL calls patient and reviews Lung Cancer Screening Note SAL informs patient of appointment time LUNG CANCER SCREENING NOTE YES/NO Confirms patient materials understood Confirms patient received materials Future Research Confirms eligibility Chest radiologist protocols for Order 4556 Active Smoker? YES YES YES YES CT Performed NO NO NO Smoking cessation arranged w/ Betsy Maislen Refer patient to PCP or Shared Decision-Making Center Refer to Dr. Erkmen/Dr. Black/ Betsy Maislen for review Mail Patient Materials CT Read by Thoracic Radiologist per standard protocol YES YES SAL calls patient 2-3 days after and confirms patient received materials Patient Eligible Patient and Provider sent results NO Navigator contacts patient 7-10 days after scheduled CT to verify if results were received & if follow up care is understood. Patient satisfaction survey conducted SAL notifies patient and provider

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