2017 Public Report of Outcomes

Through feedback from patients, our own observations, national and local trends and other sources, the HSHS St. Nicholas Hospital cancer program continuously evaluates and improves the quality of care we provide to our patients. This report publically shares outcomes from two of our endeavors from the past year.
HSHS St. Nicholas Hospital cancer program has been accredited by the American College of Surgeons Commission on Cancer for more than 25 years and was most recently surveyed in 2016 as a Community Cancer Program. 
The cancer program at HSHS St. Nicholas Hospital provides a broad scope of services from cancer prevention, outreach and education to cancer detection, treatment, palliative care and survivorship. Our program receives guidance and leadership from the HSHS St. Nicholas Hospital cancer committee, which convenes regularly to ensure we are meeting the standards outlined by the Commission on Cancer. These standards address education, treatment, clinical research, data collection, performance and quality improvement data. 
At HSHS St. Nicholas Hospital we are committed to the design and implementation of quality patient care and treatment services. In this report, we highlight one study that measures quality of care and outcomes for our cancer patients, and one quality improvement project that we implemented because of a study that was completed in 2016: 
Study of Quality:  The Uncertainty of Cancer Survivors
Identified Problem / Study Topic: 
Uncertainty was rated moderate to severe by 28.5 percent of respondents in our 2015 Survivorship Needs Assessment.  The source of uncertainty, however, was not identified in that survey. This led to the cancer committee’s desire to ask the question, “What are the leading sources of uncertainty for our local cancer survivors?”
In collaboration with Prevea Behavioral Care, a sub-committee of the cancer committee developed a survey to identify the sources of uncertainty for our cancer patients. The survey included three main sources of uncertainty (medical, personal and social) with identified contributors in each category. The survey was distributed to and completed by a core group of local cancer survivors at our 2017 National Cancer Survivors Day celebration in Sheboygan. Once the surveys were collected, the data was tabulated and the results were presented with potential next steps. 
National Benchmarks: 
There are few national benchmarks that evaluate uncertainty in cancer survivors. However, one qualitative study1 was identified which investigated the experience of uncertainty. It concluded that uncertainty is not limited to the time of diagnosis and treatment of cancer, but extends throughout cancer survivorship and can present challenges, even for those without evidence of disease.

1. Miller, L. (2012). Sources of uncertainty in cancer survivorship. Journal of Cancer Survivorship, 6(4), 431-440.


Results of the Study:
  • 45 surveys were completed
    • Age:  Mean – 67 years  Range – 36 – 90 years
    • Gender:  Male – 13 (29 percent)  Female – 32 (71 percent)
  • Year of cancer diagnosis:
    • Mean – 2009
    • Range – 1987 – 2017
  • 9 survivors reported being in treatment (20 percent)
  • 7 survivors reported having a cancer recurrence (16 percent)
  • Top three topics which create uncertainty for cancer survivors: 
    • Side effects (56 percent of survivors) 
    • Physical changes (42 percent of survivors) 
    • Insurance (40 percent of survivors)
  • Many survivors identified numerous concerns (not just three as requested) and/or wrote open-ended comments.
  • Like the national benchmark, survivors identified uncertainty even when having no evidence of disease and throughout survivorship.
This data triggered significant discussion about the many aspects of uncertainty patients experience after a cancer diagnosis and treatment.  Further discussion included:
  • Does the phase of treatment at the time of the survey make a difference to the level of uncertainty?   20 percent were in treatment and 16 percent were in some phase after a recurrence.
  • Would better education relieve uncertainty around these issues?
  • Education and resources available to patients are actionable ways of providing assistance to patients that may relieve uncertainty.
  • The dual screening tool (that patients complete every 30 days) helps our care team determine some stressors of patients currently in treatment.
  • Uncertainty extends throughout a patient’s entire lifetime after being diagnosed with cancer.
  • Survivorship care plans are now provided to patients and may assist in providing information to relieve their uncertainty.
Action Items:
With better understanding regarding the source and degree of uncertainty that cancer survivors experience, there is an opportunity to improve and/or increase the connection of patients to available survivorship services.   The cancer committee recommended we pursue one of the following in 2018:
  1. Repeat the study again for patients diagnosed in the past two years. Another study would allow us to capture information from patients who received survivorship care plans. We would be able to evaluate if the care plans, and the information in them, has a positive impact on patients’ uncertainty after a cancer diagnosis. Uncertainty cannot be eliminated so patients need tools to cope.  The survivorship care plans offer information and some coping tools. 
  2. Focus a quality improvement effort on providing patients with specific education related to the top three areas of uncertainty that were identified by this study. 
Quality Improvement Project:  Education of Survivors about the Impact of Obesity on Cancer Occurrence and Recurrence
This quality improvement was a result of a 2016 study that looked at the Body Mass Index (BMI) of our cancer population. There is significant literature available showing that obesity and overweight status is a behavioral risk factor for cancer occurrence and recurrence. “Approximately one-third of the cancer deaths that occur in the United States each year are associated with poor nutrition and physical inactivity, including excess weight.  Aside from not smoking tobacco, eating a healthy diet, being physically active, and maintaining a healthy body weight- are the most important choices the majority of people can make to reduce their cancer risk.” (Facts & Figures – Healthy Lifestyles and Reducing the Risk of Cancer in Wisconsin, 2016)  
The 2016 HSHS St. Nicholas Hospital study was an analysis of the 2015 newly diagnosed cancer cases.   This study looked at the percent of these patients with a BMI greater than 25. Being overweight is defined as a BMI of 25.0-29.9.9 kg/m2, and obesity is defined as a BMI equal to or greater than 30 kg/m2. This analysis showed that 76 percent of the HSHS St. Nicholas Hospital cancer patients diagnosed in 2015 had a BMI of 25 or higher.  This is concerning as we know this can impact cancer occurrence and recurrence. “Being overweight or obese is clearly linked with an increased risk of several types of cancer: Breast (among women who have gone through menopause), colon and rectum, endometrium (lining of the uterus), esophagus, kidney and pancreas. Being overweight or obese also likely raises the risk of other cancers such as gallbladder, liver, non-Hodgkin lymphoma, multiple myeloma, cervix, ovary and aggressive forms of prostate cancer.” (Facts & Figures – Healthy Lifestyles and Reducing the Risk of Cancer in Wisconsin, 2016)
Summary of Findings for patients with documented BMI 

National Benchmark or Guidelines: Population categorized as overweight or with a BMI of greater than 25
  • In 2014, Sheboygan County = 67 percent
  • In 2014, Wisconsin = 67 percent
  • In 2014, US = 65 percent
Because of the results from this 2016 study, the cancer committee decided that we should educate both the general public and our cancer patients on the impact that being overweight can have on cancer occurrence and or recurrence. So, the committee decided to start with educating the breast cancer patient population at HSHS St. Nicholas Hospital. This led to a Quality Improvement project for 2017. 
Quality Improvement
The quality improvement project was to implement a process for giving breast cancer patients with BMI greater than 25 information about the impact of BMI on cancer recurrence and specific information about lifestyle modification and weight management. 
The following process was implemented:
  • The nurse navigator identifies all breast cancer patients with a BMI greater than 25. 
  • The nurse navigator puts the following text in the patient’s survivorship care plan and reviews it with him/her at the time of survivorship visit.  
Survivorship care plan text:
According to the American Cancer Society, about 20 percent of cancer diagnoses are attributed to factors that are within your control such as nutrition, physical activity, smoking and alcohol use. We have made a commitment to your continued wellness as you transition into survivorship! Nutritional health and maintaining a healthy weight are a few of the many important parts of your recovery. You have already received tools to encourage healthy habits from our staff, and we want you to feel confident with your wellness decisions in the future. 
Body Mass Index or BMI is one way to determine if a person’s weight places them at risk for chronic disease such as diabetes, heart disease and cancer.
  • Below 18.5-underweight
  • 18.5-24.9-normal or healthy weight
  • 25-29.9-overweight
  • 30-39.9-obese
  • 40 and above-morbidly obese
If your BMI falls between 25 and 29.9, here are a few ways you can aim for a healthier weight and reduce your chronic disease risk:
  • Wearable devices (pedometer, Fitbit®)
  • Tablet/smart phone apps such as MyFitnessPal or Lose It!
  • HSHS St. Nicholas Hospital Bridge to Wellness® Survivorship Classes or Livestrong® at the YMCA. 
If your BMI is over 30, here are a few ways you can aim for a healthier weight and reduce your chronic disease risk:
  • Wearable devices (pedometer, Fitbit®)
  • Tablet/smart phone apps such as MyFitnessPal or Lose It!
  • HSHS St. Nicholas Hospital Bridge to Wellness® Survivorship Classes or Livestrong® at the YMCA
  • HSHS St. Vincent Hospital Cancer Centers registered dietitian
  • Weight Watchers®
  • Local fitness facility
  • Prevea Health’s Ideal Weigh Program
  • Bariatric surgery*
*eligibility based on individual consult
This has been a significant opportunity to educate patients about how obesity impacts the risk for cancer occurrence and recurrence. As well, the nurse navigator provides support to patients in making lifestyle and behavioral changes that could reduce this risk. 
Notice of Nondiscrimination:  English

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