2018 Public Report of Outcomes

At HSHS St. Nicholas Hospital (SNS), we are committed to the design and implementation of quality patient care and treatment services. In this report we highlight our accountability measures used by the Commission on Cancer (CoC) to measure our program outcomes, and present one of the studies we completed to measure the quality of care and outcomes for our cancer patients:

Accountability Measures

National Measures CoC %
Radiation is administered within 1 year (365) days of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer 90.00% 100.00%
Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage IB-III hormone receptor positive breast cancer 90.00% 100.00%
Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer 80.00% 92.60%
Breast conservation surgery rate for women with AJCC clinical stage 0, I or II breast cancer None 45.50%
Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0 or stage IB-III hormone receptor negative breast cancer None 100.00%
The above measures are nationally accepted standards of practice as defined by the CoC. The CoC provides a benchmark comparison for programs to assess performance. As noted in the above table, HSHS St. Nicholas Hospital's cancer program performed higher than the CoC benchmark across all measures. 

Study of Quality

Through feedback from patients, our observations, national and local trends, and other sources, HSHS St. Nicholas Hospital continuously evaluates and improves the quality of care we provide to our patients. This report publically shares outcomes from one of our quality studies completed in 2018.    

Study Topic:
What percent of HSHS St. Nicholas Hospital cancer program patients in calendar year 2017 had an advanced directive in place within three months of a cancer diagnosis?
Identified Problem:
It is perceived that patients diagnosed with cancer do not have follow-up for completing advance directives (or have advance directives in place) during the course of their cancer treatments.
There are several documents that fall under the umbrella of advance directives--living wills and five wishes are two examples. For the purpose of this study, advance directives are defined as documents that have two components: 1) designation of a surrogate decision maker/health care agent; 2) identification of factors and patient preferences that guide decision making (Mahon, 2011).
HSHS-Eastern Wisconsin Division Hospitals (which includes HSHS St. Nicholas Hospital) and Prevea Health use the "Power of Attorney for Health Care" document that includes appointing a health care agent, general authority of the health care agent, and statement of specific desires, special provisions or limitations. The final section requires a patient’s signature, the signature of two witnesses and all signatures need to be signed on the same date. This document meets the above definition.

Methodology - How the Study was Conducted:
A retrospective record review was completed by the cancer program social worker (SW) for all patients diagnosed with cancer in 2017. There were 206 people with a variety of cancer diagnoses. The SW reviewed each patient chart individually and documented whether the patient did or did not have an advance directive, and the date the advance directive was entered into the patient’s electronic medical record.
The SW then used a formula to calculate the difference between the date of diagnosis and the date the advanced directive was entered into the patient’s electronic medical record. The SW did not calculate the days if a patient had an advance directive in place before a diagnosis of cancer.
Of the 206 patients with a cancer diagnosis in 2017, there were 32 patients who were deceased as of Sept. 5, 2018 when the patient chart review was completed. These 32 deceased patients were excluded from this study.
Data Results/Summary of Findings:
There were 174 remaining patients who were diagnosed with cancer in 2017. The chart below shows the comparison or break down of the total patients who did not have an advance directive in their electronic medical record, patients who had an advance directive entered in their chart within 90 days of cancer diagnosis; patients who had an advance directive in their chart either before being diagnosed with cancer or after 90 days of cancer diagnosis; and the total number of patients who currently had an advance directive in their electronic medical record.

  • There were 36 patients or 20.7 percent of patients diagnosed in 2017 that had an advance directive added to their electronic medical record within 90 days of the diagnosis of cancer. 
  • There were 53 or 30.5 percent of patients who had an advance directive in their electronic medical record either prior to the cancer diagnosis or 90+ days after the cancer diagnosis. 
  • In total, 89 patients or 51.1 percent of the patients diagnosed with cancer had advance directives in their electronic medical record.
  • In contrast, there are 85 or 48.9 percent of patients diagnosed with cancer in 2017 who did not have advance directives in their electronic medical record.    
National Benchmarks: 
The HSHS St. Nicholas Hospital Cancer Program study topic specifically examined how many patients completed an advance directive within three months of a cancer diagnosis. While completion of an advance directive before or outside of that timeline is also beneficial, our program desire is to look for additional opportunities to provide our patients with quality services in a timely manner.
A review of professional journal articles did not specifically address a timeframe from diagnosis of cancer and completion of an advance directive. The professional journal articles focused on the overall estimate of how many people have advanced directives and how a diagnosis of cancer can impact the completion of advance directives, which provides a relevant comparison.
Data related to the completion of advance directives in the United States has been characterized as inconsistent and of variable quality. In a review and analysis of 150 studies published in 2011-2016, it is estimated that one in three adults in the United States or 36.7 percent had completed an advance directive (Yadav K. N., 2017). A ten-article literature review focused on patients with cancer over the past ten years, showed 35 to 49 percent had completed advance directives prior to being diagnosed with cancer. The completion of advance directives increased to 88 percent after the diagnosis of cancer in United States patients (Devay de Freitas, 2018).

Discussion/Recommendations for Improvements:
As illustrated in the table above, 51 percent of HSHS St. Nicholas Hospital patients diagnosed with cancer have an advance directive in their medical record as compared with a national benchmark of 88 percent. This represents an opportunity for further education in our community, and with care providers on the benefits of advance directives.
Advance directives are starting to be characterized as a form of preventive medicine where patients can designate a health care agent and make their preferences known in the event they are unable to make their own health care decisions. Often preventive medicine is underutilized; even though advance directives are low- to no-cost to patients, are low-tech, and can be highly effective (Gillick, 2004). Advance directives are a part of the advance care planning process of meaningful communication between patients, family members, and health care providers with the goal of identifying preferences regarding end-of-life care (Scherer, 2015). They are linked to an increased use of palliative care for patients who are nearing/in the end of life, lower medical expenditures at the end of life and a decrease in distress among patients and their family members (Carr, 2017). An advance directive provides a seamless transition from the patient as the decision maker to a designated health care agent verses the time consuming and often expensive court process.
HSHS St. Nicholas Hospital colleagues are able to send a referral directly to the Spiritual Care department when a patient does not have an advance directive in their electronic medical record. Spiritual Care staff follow-up with the patient, but have expressed that the follow-up call can be challenging because patients are not expecting a call to discuss advance directives. We hypothesize that  patients may be more receptive to their oncologist or oncology advanced practice nurse practitioner (APNP) introducing the benefits of advance directives within the first 90 days of a cancer diagnosis, and following that discussion between oncology and the patient, a referral to Spiritual Care is made with the patient’s permission.

Action Items/Quality Improvement:

Currently in place
The ANEW Cancer Survivorship Program facilitator and the manager of Spiritual Care developed an electronic medical records “inbox” referral process for the care team’s use for patients who do not have advance directives in their electronic medical record. HSHS St. Nicholas Hospital Chaplains were educated on the referral process in May, 2018. The medical oncology staff were also educated on the referral process.
Future Quality Improvement Opportunities
Further evaluate opportunities to improve conversations and discussions with patients about their advanced directives. Consider establishing guidelines for which team members should have this conversation with patients and at what point in time after a cancer diagnosis it should occur. This study has given valuable information to the cancer committee and offers great opportunity for a future quality improvement project.

Carr, D. P. (2017). Advance Care Planning: Contemporary Issues and Future Directions. The Gerontological Society of America, 1-9.
Devay de Freitas, E. d. (2018). Advance Directives in Cancer Patients. Hospice & Palliative Medicine International Journal, 84-88.
Gillick, M. R. (2004). Advance Care Planning. The New England Journal of Medicine, 7-8.
Mahon, M. M. (2011). An Advance Directive in Two Questions. Journal of Pain and Symptom Management, 801-807.
Scherer, J. S. (2015). Improving Advance Care Planning and Bereavement Outcomes. American Journal of Kidney Diseases, 735-737.
Yadav, K. N. (2017). Approximately One In Three US Adults Completes Any Type of Advance Directive For End-Of-Life Care. Health Affairs, 1244-1251.
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