Dataset Information

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

ABSTRACT:

Background

Guidelines recommend mediastinal sampling first for patients with mediastinal lymphadenopathy with suspected lung cancer. The objective of this study was to describe practice patterns and outcomes of diagnostic strategies in patients with lung cancer.

Methods

This study included a retrospective cohort of 15,914 patients with lung cancer with T1-3N1-3M0 disease diagnosed from 2004 to 2013 in the National Cancer Institute's Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. Patients who had mediastinal sampling as their first invasive test were classified as guideline consistent; all others were guideline inconsistent. Propensity matching was used to compare the number of tests performed, and multivariable logistic regression was used to compare the incidence of complications.

Results

Guideline-consistent care increased from 23% to 34% of patients from 2004 to 2013 (P < .001). Use of endobronchial ultrasound-guided transbronchial needle aspiration increased from 0.1% to 25% of all patients (P < .001), and mediastinal sampling increased from 54% to 64% (P < .0001). Guideline-consistent care was associated with fewer thoracotomies (38% vs 71%; P < .001) and CT scan-guided biopsies (10% vs 75%; P < .001) than guideline-inconsistent care but more transbronchial needle aspirations (59% vs 12%; P < .001). Guideline-consistent care was associated with fewer pneumothoraxes (5.1% vs 22%; P < .001), chest tubes (0.9% vs 4.4%; P < .001), hemorrhages (3.5% vs 5.8%; P < .001), and respiratory failure events (2.7% vs 3.7%; P = .047) than guideline-inconsistent care. Bronchoscopic mediastinal sampling was associated with fewer complications than surgical mediastinal sampling.

Conclusions

Guideline-consistent care with mediastinal sampling first was associated with fewer tests and complications. Quality gaps decreased with the introduction of endobronchial ultrasound-guided transbronchial needle aspiration but persist. Gaps include failure to sample the mediastinum first, failure to sample the mediastinum at all, and overuse of thoracotomy.

SUBMITTER: Ost DE

PROVIDER: S-EPMC8173770 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundGuidelines 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.MethodsThe 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.ResultsTwenty-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).ConclusionsGuideline-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.

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