TY - JOUR
T1 - Quality gaps and comparative effectiveness in lung cancer staging and diagnosis
AU - Ost, David E.
AU - Niu, Jiangong
AU - Elting, Linda S.
AU - Buchholz, Thomas A.
AU - Giordano, Sharon H.
N1 - Funding Information:
Funding/Support: This work was supported in part by Comparative Effectiveness Research on Cancer in Texas, a multiuniversity consortium funded by the Cancer Prevention and Research Institute of Texas [Grant RP101207 by 2P30 CA016672]. Dr Giordano is also supported by a grant from the American Cancer Society [RSG-09-149-01-CPHPS]. The collection of cancer incidence used in this study was supported by the Texas Department of State Health Services and Cancer Prevention Research Institute of Texas, as part of the statewide cancer reporting program, and the Centers for Disease Control and Prevention National Program of Cancer Registries Cooperative Agreement #5U58/DP000824-05.
PY - 2014/2
Y1 - 2014/2
N2 - Background: Guidelines recommend mediastinal lymph node sampling as the fi rst 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 fi rst invasive test involved mediastinal sampling, patients were classifi ed as receiving guideline-consistent care; otherwise, they were classifi ed 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 fi rst resulted in fewer tests and complications. We found three quality gaps: failure to sample the mediastinum fi rst, failure to sample the mediastinum at all in patients with non-small cell lung cancer, and overuse of thoracotomy.
AB - Background: Guidelines recommend mediastinal lymph node sampling as the fi rst 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 fi rst invasive test involved mediastinal sampling, patients were classifi ed as receiving guideline-consistent care; otherwise, they were classifi ed 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 fi rst resulted in fewer tests and complications. We found three quality gaps: failure to sample the mediastinum fi rst, failure to sample the mediastinum at all in patients with non-small cell lung cancer, and overuse of thoracotomy.
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U2 - 10.1378/chest.13-1599
DO - 10.1378/chest.13-1599
M3 - Article
C2 - 24091637
AN - SCOPUS:84893705318
SN - 0012-3692
VL - 145
SP - 331
EP - 345
JO - Chest
JF - Chest
IS - 2
ER -