Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis.

Chest

PubMedID: 24091637

Ost DE, Niu J, S Elting L, Buchholz TA, Giordano SH. Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis. Chest. 2014;145(2):331-45.
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 impacts outcomes. Our objective was to compare practice patterns and outcomes of diagnostic strategies in patients with lung cancer.

METHODS
Retrospective cohort of 15,316 lung cancer patients with regional spread without distant metastases in the SEER or Texas Cancer Registry Medicare-linked databases. If the first invasive test involved mediastinal sampling patients were classified as guideline consistent, otherwise they were classified as inconsistent. We used propensity matching to compare the number of tests performed and multivariate logistic regression to compare the frequency of complications.

RESULTS
21% of patients had guideline consistent diagnostic evaluations. Among patients with NSCLC, 44% never had mediastinal sampling. Patients that had guideline consistent care required fewer tests than patients with guideline inconsistent care (p<0.0001), including thoracotomies (49% vs. 80%, p<0.001) and CT-guided biopsies (9% vs. 63%, p<0.001), although they had more transbronchial needle aspirations (37% vs. 4%, p<0.001). The consequence was that patients with guideline consistent care had fewer pneumothoraxes (4.8% vs. 25.6%, p<0.0001), chest tubes (0.7% vs. 4.9%, p<0.001), hemorrhages (5.4% vs. 10.6%, p<0.001) and respiratory failure events (5.3% vs. 10.5%, p<0.001).

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 NSCLC patients, and overuse of thoracotomy.