Authors: Ost DE, Niu J, Elting L, Buchholz TA, Giordano SH
Title: Determinants of Practice Patterns and Quality Gaps in Lung Cancer Staging and Diagnosis.
Journal: Chest :-
Date: 2013 Nov 07
Abstract: BACKGROUND: Guidelines recommend mediastinal lymph node sampling as the first invasive diagnostic procedure in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases. METHODS: Retrospective cohort of 15,316 patients with lung cancer with regional spread without metastatic disease in the SEER or Texas Cancer Registry Medicare-linked databases. Patients were categorized based on the sequencing of invasive diagnostic tests performed: A) Evaluation consistent with guidelines, mediastinal sampling done first; B) Evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling performed but not as part of the first invasive test; C) Evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling never done; and D) Evaluation inconsistent with guidelines, small cell lung cancer. The primary outcome was whether guideline consistent care was delivered. Secondary outcomes included whether patients with NSCLC ever had mediastinal sampling and use of TBNA among pulmonologists. RESULTS: Only 21% of patients had a diagnostic evaluation consistent with guidelines. Only 56% of NSCLC patients had mediastinal sampling prior to treatment. There was significant regional variability in guideline consistent care (range 12%-29%). Guideline consistent care was associated with lower patient age, metropolitan areas, and if the physician ordering or performing the test was male, U.S. trained, had seen more lung cancer patients, and was a pulmonologist or thoracic surgeon who had graduated more recently. More recent pulmonary graduates were also more likely to perform transbronchial needle aspiration (p<0.001). CONCLUSION: Guideline consistent care varied regionally and was associated with physician level factors, suggesting that a lack of effective physician training may be contributing to the quality gaps observed.
Last Modified: 03 Sep 2013