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Simultaneously Diagnosing and Staging Lung CancerDiagnosing and Staging Lung Cancer Simultaneously: A Win-Win for the Patient and the Health-Care System FREE TO VIEW

Nichole T. Tanner, MD, MSCR; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina.

Correspondence to: Gerard A. Silvestri, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 96 Jonathan Lucas St, Ste 812 CSB, Charleston, SC 29425; e-mail: silvestri@musc.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2013;144(6):1747-1748. doi:10.1378/chest.13-1353
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In the 1950s, US Secretary of Defense Charles Wilson coined the phrase getting a “bigger bang for the buck.” The meaning is simple: When presented with a variety of options, choose the one that will provide the best value. This is true for physicians when faced with a diagnostic dilemma and a myriad of options from which to choose. The best first test for a patient often requires the physician to choose the one that provides maximal information with minimal risk. For common diseases, there often are evidence-based clinical practice guidelines (CPGs) that can provide direction for physicians. They are created by content area experts in collaboration with formally trained methodologists. Ultimately, however, they are only as good as the paper they are written on unless they can be widely disseminated and broadly implemented. But what happens when adherence to guideline-directed care is lacking? In this issue of CHEST (see page 1776), Almeida and colleagues1 provide a clear answer: Patients suffer.

In a retrospective analysis of a single academic center, only one in five patients with suspected lung cancer and adenopathy received guideline-consistent care. The 2007 American College of Chest Physicians (ACCP) evidence-based CPGs on lung cancer recommends sampling the mediastinum first.2 The 2013 ACCP-CPGs go one step further by recommending minimally invasive needle techniques (ie, endobronchial ultrasound with fine needle aspiration, esophageal ultrasound with fine needle aspiration) as the first test of choice.3 The rationale is in-line with the bigger-bang-for-the-buck premise because it allows for both diagnosis and staging in a single, minimally invasive, low-risk, outpatient procedure. The findings of the study by Almeida and colleagues1 provide further support for the recommendation because patients with guideline-inconsistent care underwent twice the number of invasive procedures than those who had mediastinal staging first. The majority of those who diverged from the guideline did so because they performed either a CT image-guided needle biopsy of the lung lesion or standard bronchoscopy as the initial diagnostic test. This resulted in a significantly higher complication rate (17%) in patients receiving guideline-inconsistent care, mainly because of CT image-guided biopsy. The finding that two-thirds of the complications could have been eliminated simply by changing the testing sequence further highlights the importance of following guideline-directed care.

So why do physicians not follow published guidelines? There are at least four possibilities: (1) They do not know about them, (2) they do not believe that they are useful, (3) there are financial incentives for doing something else, or (4) there is a barrier to implementation (ie, equipment/diagnostic test is not readily available). Regardless of the reason, overuse of testing with resultant complications suggests that there is room for improvement in compliance with these guidelines.

The use of quality indicators is one way of improving compliance with guideline-based recommendations for commonly encountered clinical scenarios where variation in care is common and can be detrimental to the patient. Quality metrics allow for benchmarking between providers within a single institution and comparison across institutions and can be made transparent to the public. Quality indicators for other disease states in medicine have been used to improve outcomes. For example, although evidence and guidelines support the use of angiotensin-converting enzyme inhibitors and β-blockers as part of standard care in patients with congestive heart failure, previous studies demonstrated that only 60% of eligible hospitalized patients with heart failure receive these therapies.4,5 A number of studies have since demonstrated that implementation of standardized order sets that include quality indicators for heart failure result in a reduction in inpatient and 30-day mortality, readmission rates, and overall health-care costs.6 This is also true for diabetes management, where the use of quality indicators reduce ED and inpatient visits and cost of care and improve patient outcomes.7 For patients undergoing surgery, adherence to blood product conservation during and after cardiac procedures improves postoperative morbidity, mortality, and resource utilization.8

Quality indicators are increasingly becoming part of the medical landscape, and if we fail to create them for ourselves, someone else will do it for us. Should this happen, there is the risk that the wrong indicators will be imposed on our profession based on poor reasoning, evidence, or both. For example, ventilator-associated pneumonia rate is one such quality indicator. Initially, the subjective definition of what constitutes an accurate diagnosis of ventilator-associated pneumonia made reported rates difficult to interpret and compare both internally and externally.9 One can imagine a scenario where hospitals and providers could be penalized for a quality measure that is meaningless.

To develop meaningful quality indicators in lung cancer, the Thoracic Oncology Network of the ACCP has nearly completed a project to develop quality indicators for the pretreatment evaluation of patients with lung cancer (P. Mazzone, MD, FCCP, personal communication, June 10, 2013). The committee reviewed all available evidence-based guidelines to provide a basis for the indicators. From this review, seven indicators were chosen according to their validity (connection to improved outcomes), feasibility (ability to obtain information from the medical records related to the indicator), and relevance (potential for poor or variable performance of the indicators). Not surprising, one of them is mediastinal staging as the first invasive test in suspected lung cancer. Objectively measuring compliance and reporting outcomes would provide a concrete context for increasing physician effort to improve staging practices.

In the current reimbursement model, there is a perverse incentive to do multiple procedures in the workup of patients with lung cancer (ie, separate biopsy specimens of the primary tumor and mediastinal adenopathy). In this example, the losers are the patients (unnecessary procedures with inherent risk and associated anxiety) and the health-care system that has to absorb the cost. An alternative model might be to incentivize quality adherence through a pay-for-performance structure. One example from the psychiatric literature demonstrated that a pay-for-performance program where payment was tied to key quality indicators in patients with severe depression resulted in reception of timely follow-up and a faster rate of depression improvement.10 Accountable care organizations, another potential health-care model, would realign incentives to ensure timely care while preventing the unnecessary duplication of services. All components of the system for delivery of care (eg, hospitals, physicians) are jointly held accountable for reaching measured quality indicators and reducing costs while sharing in a portion of the savings.11,12

Although there is an entire science focused on quality indicator development, guideline-based mediastinal staging in patients with suspected lung cancer is ready made: It minimizes the number of procedures and complications and the cost. The emphasis must move from diagnose followed by stage to simultaneously stage and diagnose to get the best bang for the buck. Our patients deserve no less.

References

Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782.
 
Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer: ACCP evidence-based clinical practice guidelines (2nd ed). Chest. 2007;132(2_suppl):178S-201S.
 
Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e211S-e250S.
 
Fonarow GC, Yancy CW, Heywood JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Intern Med. 2005;165(13):1469-1477. [CrossRef] [PubMed]
 
Fonarow GC. The role of in-hospital initiation of cardioprotective therapies to improve treatment rates and clinical outcomes. Rev Cardiovasc Med. 2002;3(suppl 3):S2-S10. [CrossRef] [PubMed]
 
Ballard DJ, Ogola G, Fleming NS, et al. Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care. Int J Qual Health Care. 2010;22(6):437-444. [CrossRef] [PubMed]
 
Pinsky B, Harnett J, Paulose-Ram R, Mardekian J, Samant N, Nair KV. Impact of treatment by NCQA-certified physicans on diabetes-related outcomes. Am Health Drug Benefits. 2011;4(7):429-438.
 
LaPar DJ, Crosby IK, Ailawadi G, et al; Investigators for the Virginia Cardiac Surgery Quality Initiative. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg. 2013;145(3):796-803.
 
Klompas M, Platt R. Ventilator-associated pneumonia—the wrong quality measure for benchmarking. Ann Intern Med. 2007;147(11):803-805. [CrossRef] [PubMed]
 
Unützer J, Chan YF, Hafer E, et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. Am J Public Health. 2012;102(6):e41-e45. [CrossRef] [PubMed]
 
McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Aff (Millwood). 2010;29(5):982-990. [CrossRef] [PubMed]
 
Fisher ES, Shortell SM. Accountable care organizations: accountable for what, to whom, and how. JAMA. 2010;304(15):1715-1716. [CrossRef] [PubMed]
 

Figures

Tables

References

Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782.
 
Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer: ACCP evidence-based clinical practice guidelines (2nd ed). Chest. 2007;132(2_suppl):178S-201S.
 
Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e211S-e250S.
 
Fonarow GC, Yancy CW, Heywood JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Intern Med. 2005;165(13):1469-1477. [CrossRef] [PubMed]
 
Fonarow GC. The role of in-hospital initiation of cardioprotective therapies to improve treatment rates and clinical outcomes. Rev Cardiovasc Med. 2002;3(suppl 3):S2-S10. [CrossRef] [PubMed]
 
Ballard DJ, Ogola G, Fleming NS, et al. Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care. Int J Qual Health Care. 2010;22(6):437-444. [CrossRef] [PubMed]
 
Pinsky B, Harnett J, Paulose-Ram R, Mardekian J, Samant N, Nair KV. Impact of treatment by NCQA-certified physicans on diabetes-related outcomes. Am Health Drug Benefits. 2011;4(7):429-438.
 
LaPar DJ, Crosby IK, Ailawadi G, et al; Investigators for the Virginia Cardiac Surgery Quality Initiative. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg. 2013;145(3):796-803.
 
Klompas M, Platt R. Ventilator-associated pneumonia—the wrong quality measure for benchmarking. Ann Intern Med. 2007;147(11):803-805. [CrossRef] [PubMed]
 
Unützer J, Chan YF, Hafer E, et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. Am J Public Health. 2012;102(6):e41-e45. [CrossRef] [PubMed]
 
McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Aff (Millwood). 2010;29(5):982-990. [CrossRef] [PubMed]
 
Fisher ES, Shortell SM. Accountable care organizations: accountable for what, to whom, and how. JAMA. 2010;304(15):1715-1716. [CrossRef] [PubMed]
 
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