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Comparative Study
. 2014 Feb;145(2):331-345.
doi: 10.1378/chest.13-1599.

Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis

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Free PMC article
Comparative Study

Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis

David E Ost et al. Chest. .
Free PMC article

Abstract

Background: Guidelines recommend mediastinal lymph node sampling as the first invasive test in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases, but there are no comparative effectiveness studies on how test sequencing affects outcomes. The objective was to compare practice patterns and outcomes of diagnostic strategies in patients with lung cancer.

Methods: The study included a retrospective cohort of 15,316 patients with lung cancer with regional spread without distant metastases in the Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. If the first invasive test involved mediastinal sampling, patients were classified as receiving guideline-consistent care; otherwise, they were classified as receiving guideline-inconsistent care. We used propensity matching to compare the number of tests performed and multivariate logistic regression to compare the frequency of complications.

Results: Twenty-one percent of patients had guideline-consistent diagnostic evaluations. Among patients with non-small cell lung cancer, 44% never had mediastinal sampling. Patients who had guideline-consistent care required fewer tests than those with guideline-inconsistent care (P < .0001), including thoracotomies (49% vs 80%, P < .001) and CT image-guided biopsies (9% vs 63%, P < .001), although they had more transbronchial needle aspirations (37% vs 4%, P < .001). The consequence was that patients with guideline-consistent care had fewer pneumothoraxes (4.8% vs 25.6%, P < .0001), chest tubes (0.7% vs 4.9%, P < .001), hemorrhages (5.4% vs 10.6%, P < .001), and respiratory failure events (5.3% vs 10.5%, P < .001).

Conclusions: Guideline-consistent care with mediastinal sampling first resulted in fewer tests and complications. We found three quality gaps: failure to sample the mediastinum first, failure to sample the mediastinum at all in patients with non-small cell lung cancer, and overuse of thoracotomy.

Figures

Figure 1.
Figure 1.
Study cohort selection results: SEER and Texas Cancer Registry 1995 to 2007. HMO = health maintenance organization; NSCLC = non-small cell lung cancer; SEER = Surveillance, Epidemiology, and End Results.
Figure 2.
Figure 2.
Practice patterns and diagnoses for the entire study cohort of SEER and Texas Cancer Registry patients from 1995 to 2007. See Figure 1 legend for expansion of abbreviation.
Figure 3.
Figure 3.
Number of invasive diagnostic tests performed. Box plots represent median and interquartile range (25th-75th percentile) for the number of invasive tests performed. Patients who had mediastinal sampling as their first test are labeled as first. These patients received guideline-consistent care. Propensity-matched control patients who had mediastinal sampling as a second or later test are labeled as second. Patients who had mediastinal sampling first underwent fewer total tests (P < .0001). The first plot shows the comparison limited to patients with NSCLC given as the final diagnosis. The second plot shows the comparison of patients with NSCLC with patients with small cell lung cancer. See Figure 1 legend for expansion of abbreviation.
Figure 4.
Figure 4.
Practice patterns, diagnoses, stages of disease, and treatment patterns in the SEER database from 2004 to 2007 for which there was detailed T and N stage information. *If surgery was performed without mediastinal lymph node sampling, this was considered as not consistent with guidelines. Similarly, if surgery with lymph node sampling was performed but was not the first test and there was no prior sampling done, then this was classified as not consistent with guidelines. †If a patient received any type of treatment, such as chemotherapy or radiation, without prior lymph node sampling and went on to surgery with lymph node sampling at that time, then this was considered as no lymph node sampling prior to the first treatment. See Figure 1 legend for expansion of abbreviation.
Figure 5.
Figure 5.
Survival in patients with NSCLC according to stage and diagnostic strategy. A, Patients with stage II NSCLC. B, Patients with stage III NSCLC. Diagnostic strategy is shown for each stage as follows: guideline-consistent care with mediastinal sampling performed first (solid line), guideline-inconsistent care with mediastinal sampling performed second or later (long-dashed line), and guideline-inconsistent care with no mediastinal sampling (short-dashed line). Staging was done using the American Joint Commission on Cancer third edition staging guidelines because cases occurring prior to 2004 did not have sufficient detail to use the sixth edition. consist = guideline-consistent care; media = mediastinal sampling. See Figure 1 legend for expansion of other abbreviation.
Figure 6.
Figure 6.
Survival in patients with small cell lung cancer according to diagnostic strategy. Diagnostic strategy is shown as guideline-consistent care with mediastinal sampling first (solid line) vs guideline-inconsistent care (dashed line). non consist = guideline-inconsistent care. See Figure 5 legend for expansion of other abbreviation.

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