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Original Research: Lung Cancer |

Determinants of Practice Patterns and Quality Gaps in Lung Cancer Staging and DiagnosisLung Cancer Staging Practice Patterns and Quality

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

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


Funding/Support: This work was supported in part by the Center for Comparative Effectiveness Research on Cancer in Texas (CERCIT), a multi-university consortium funded by the Cancer Prevention and Research Institute of Texas [Grant RP101207 by 2P30 CA016672]. Dr Giordano is also supported by the American Cancer Society [Grant RSG-09-149-01-CPHPS]. The collection of cancer incidence data 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’s 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(5):1097-1113. doi:10.1378/chest.13-1628
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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:  Patients were a retrospective cohort of 15,316 patients with lung cancer with regional spread without metastatic disease in the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) or Texas Cancer Registry Medicare-linked databases. Patients were categorized based on the sequencing of invasive diagnostic tests performed: (1) evaluation consistent with guidelines, mediastinal sampling done first; (2) evaluation inconsistent with guidelines, non-small cell lung cancer (NSCLC) present, mediastinal sampling performed but not as part of the first invasive test; (3) evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling never done; and (4) 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 transbronchial needle aspiration (TBNA) among pulmonologists.

Results:  Only 21% of patients had a diagnostic evaluation consistent with guidelines. Only 56% of patients with NSCLC 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, trained in the United States, had seen more patients with lung cancer, and was a pulmonologist or thoracic surgeon who had graduated more recently. More recent pulmonary graduates were also more likely to perform TBNA (P < .001).

Conclusions:  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.

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