Audits & Data Quality

The GCR director selects on an “as needed” basis hospitals that will undergo casefinding audits. NPCR Program Standards requires at least once every 5 years, a combination of case-finding and re-abstracting activities are conducted for each hospital-based reporting facility. The purpose of the casefinding audits is to provide reporting facilities with an external assessment of the completeness of their reporting. A hospital also can request an audit be conducted on their facility. To do so, please contact your Regional Coordinator . The following steps are taken when a hospital participates in a casefinding audit:

1. Regional coordinator contacts the facility to schedule an audit.
2. GCR provides the regional coordinator with a list of reported patients for the facility.
3. Regional coordinator identifies all casefinding sources at the hospital.
4. Regional coordinator requests and reviews a disease index for the audit period.
5. Once the screening of hospital records is done, the regional coordinator compares the list of cases reported by the hospital before the audit with the cancers identified during the audit.
6. Regional coordinator provides a list of all patients missed by the hospital to the appropriate hospital personnel.
7. Hospital submits missed cases within 60 days after the end of the casefinding audit.
8. The Casefinding Audit report is completed by the Regional Coordinator and sent to the GCR Director and Director of Registry Operations.

GCR and/or the Regional Coordinator selects hospitals for a re-abstracting audit on an “as needed” basis. The purpose of the re-abstracting audit is to provide facility abstractors with an external assessment of their abstracting quality. A Facility Registry Manager can also request a re-abstracting audit be conducted for their facility. To do so, please contact your Regional Coordinator. Refer to Regional Coordinators to find the regional coordinator in your region. The following steps are taken when a hospital has a re-abstracting audit.

1. Regional Coordinator contacts the facility to schedule an audit.
2. Regional Coordinator establishes primary sites, number of cases, and data items to be re-abstracted.
3. GCCS randomly selects facility cases.
4. Regional coordinator blindly re-abstracts selected data items using Abstract Plus.
5. Regional Coordinator compares re-abstracted data items to facility’s abstract submitted to the GCR.
6. Regional Coordinator provides facility with a final report summarizing abstractor data item discrepancies as well as facility results with any recommendations.
7. The Re-abstraction Audit Summary report is sent to the GCR Director and Director of Registry Operations.

The hospital discharge linkage is another method used by GCR to improve completeness. Each year the Hospital Discharge Reports are sent to the responsible Regional Coordinator for each hospital in their region. The hospital discharge is then reviewed with the tumors reported by that facility. This review is necessary to ensure that all reportable tumors are reported.

1. The GCR Data Manager links the hospital discharge database records to the cancer registry database records with three possible outcomes: positive matches, possible matches and non- matches.
2. The Data Manager sends non-match list to the appropriate Regional Coordinator.
3. The Regional Coordinator and the appropriate hospital review the non-matches and determine case reportability based on guidelines in the appropriate corresponding year SEER Program Coding and Staging Manual and ICD-O-3.2 .
4. Hospitals submit identified missed cases within 30 days to GCR including the appropriate naming and submission of the hospital discharge follow-back records.
5. Hospital Discharge Summary Report is sent to gccs@sph.emory.edu .

An internal review of facility or individual abstractor’s submitted cases will be performed on an as needed basis. Coding issues identified by GCR editors or requests by facility managers may precipitate these reviews.

A detailed data item report is provided to the facility manager. Please contact your Regional Coordinator whenever you would like an assessment.

The GCR links with the Social Security Administration vital status data on a yearly basis. All persons who are alive and do not have an updated follow-up date are sent for linkage. Date of last contact and vital status are updated in the registry with the results from the linkage.

The GCR also links with the National Death Index on a yearly basis. All alive persons in the registry as well as those people whose vital status is dead but there is an unknown cause of death are sent for linkage. Those that link with the National Death Index are dead and have died in a state other than Georgia. Vital status, date of last contact, death state, and primary and secondary causes of death are updated in the registry.

Bi-annually (May and November) a tumor registry follow-up report is sent to cancer registries at the facility level with the most recent date of last contact and cause of death. The available formats for the report are available for software vendors who can then electronically update the facility’s cancer registry database with the incoming information from the central registry. Excel lists as well as Access database are also available to facilities.

Effective January 1, 2014, all abstractors must complete a registration process to obtain a state-assigned Abstractor ID, which is required to be recorded in the Abstracted By data item field (NAACCR Item #570) for abstracts submitted to the state of Georgia.

Once the abstractor has completed the registration process, a unique ID will be assigned. This ID is to be used by the abstractor for abstracting in any facility in Georgia. The registration process allows the registrar to associate any Georgia facility with their name and the assigned ID.

Please contact your Regional Coordinator for any questions you may have during the registration process.

The state database will be linked to the registration ID for each abstractor. Abstracts that are submitted to the state without the unique abstractor ID will not be imported into the State database. An email will be sent to the appropriate supervisor for that facility notifying them of the rejected abstracts.

As a service to our facilities, all new abstractors will have a sampling of 10 cases abstracted early in their employment reviewed for quality assurance (coding and text), and the Regional Coordinator will provide the facility manager with the findings. The facility manager may request an additional review of 10 abstracts should that be required. GCR will assist the facility with recommendations for training as appropriate.

The unique ID for each abstractor will expire once a year and the abstractor will need to re-register before submitting any further abstracts. Advance notices will be automatically sent to the email address of the abstractor and to the abstractor’s facility manager.