The CoC and NCDB are pleased to announce upcoming changes to NCDB quality measures and 2023 compliance requirements for CoC Standard 7.1: Quality Measures.
Updates to NCDB Quality Measures
The CoC under the guidance of the Quality Assurance and Data Committee (QADC) annually reviews, and periodically recommends, clinical changes to the portfolio of quality measures reported in the Rapid Cancer Reporting System (RCRS). The QADC updates the portfolio to ensure all measures are contemporary with current best practices and that maximized measures are retired to make way for new measures.
We are pleased to report that accredited programs have been able to achieve high compliance with four of the measures. Accordingly, the QADC has decided to retire the following measures beginning in January 2023:
- HT: Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or stage IB - III hormone receptor-positive breast cancer
- MASTRT: Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with greater than or equal to four positive regional lymph nodes
- LNoSurg: Surgery is not the first course of treatment for cN2, M0 lung cases
- nBx: Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer
All historical data will be removed from RCRS. However, historical compliance for the measures is available in your facility’s Cancer Quality Improvement (CQIP) report.
Just as select measures with high compliance and changes in practice have led to retirement for some measures, the following measures are scheduled to undergo clinical updates in 2023. Specifics related to these updates will be provided at a later date.
- RECRTCT: Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or Postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is recommended; for patients under the age of 80 receiving resection for rectal cancer
- LCT: Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is recommended for surgically resected cases with pathologic, lymph node-positive (pN1) and (pN2) NSCLC
- G15RLN: At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer
- BCSRT: Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer
Please note: The colon 12 lymph node (12RLN) measure will remain unchanged and will continue to be viewable within RCRS.
Impact on CoC Standard 7.1: Quality Measures
Due to the above transitions planned for 2023 and to allow programs time to adjust to these changes, 2023 program activity for Standard 7.1 will not be rated at future site visits. Additionally, 2023 site visits (which evaluate activity from 2020, 2021, and 2022) will not provide a compliant or non-compliant rating for Standard 7.1. However, site reviewers may discuss previous quality measure compliance and action plans with programs during 2023 site visits.
During calendar year 2023, although programs are not being rated on this activity, they are still expected to review the new and updated measures as they are released and discuss the measures with their cancer committees.
At this time, it is anticipated that 2024 activity for Standard 7.1 compliance will be rated at future site visits. It is strongly recommended that programs keep an eye on the Cancer Program News for updates. More information on 2024 requirements will be provided in late 2023.
Questions on quality measure updates may be submitted to NCDB@facs.org. Questions on Standard 7.1 may be submitted to the CAnswer Forum.
