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Original Research: Lung Cancer |

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

David E. Ost, MD, MPH, FCCP; Jiangong Niu, PhD; Linda S. Elting, DrPH; Thomas A. Buchholz, MD; Sharon H. Giordano, MD
Author and Funding Information

From the Department of Pulmonary Medicine (Dr Ost), Department of Health Services Research (Drs Niu, Elting, and Giordano), and Department of Radiation Oncology (Dr Buchholz), The University of Texas MD Anderson Cancer Center, Houston, TX.

Correspondence to: David E. Ost, MD, MPH, FCCP, Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030; e-mail: dost@mdanderson.org


Portions of these data were presented at the American Thoracic Society International Conference, May 17-22, 2013, Philadelphia, PA.

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.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


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

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