title: Completing the audit cycle improves surgical standards in lung cancer. Why do some patients still not receive the best care?
abstract: BACKGROUND
  Intraoperative gold standards in the management of lung cancer include performing anatomical resection and mediastinal lymphadenectomy). Our aim was to measure improvement in quality of surgery by reauditing anatomical resection and lymph node excision in patients undergoing lung cancer surgery as per gold standards.
  
  
  METHODS
  A complete audit cycle was performed-an initial retrospective analysis of 100 consecutive patients with primary lung cancer operated on by a single surgeon (July 2009-October 2010), followed by a prospective reaudit of 102 patients (November 2010-October 2011). Clinical and pathological data were collected from clinical notes, surgical database, and histopathology reports. Univariate and multivariate analyses were performed to identify further areas of potential improvement.
  
  
  RESULTS
  The number of nonanatomical resections dropped from 12% to 6% (p = not significant). The rate of performing excision of at least 1, 2, and 3 mediastinal (N2) lymph node stations improved from 86% to 91%, 63% to 77%, and 40% to 63%, respectively (p = 0.003). On multivariate analysis, failure to perform anatomical resection was related to use of video assisted thoracic surgery (VATS) techniques, previous malignancy, and high-predicted surgical risk by European Society Objective Score .01. Less complete intraoperative lymph node excision was associated with cases performed by VATS and in octogenarians.
  
  
  CONCLUSIONS
  There is continued adherence to the guidelines, when considering cases in terms of anatomical resections, and marked improvement in complying with the gold standards for lymph node excision. The use of the audit tool has contributed to improved quality of surgical care in patients operated for lung cancer.
authors.affiliation: Department of Thoracic Surgery, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Marissa E
authors.initials: ME
authors.lastname: Hagan
authors.forename: Sophie T
authors.initials: ST
authors.lastname: Williams
authors.forename: Laura
authors.initials: L
authors.lastname: Socci
authors.forename: Munib
authors.initials: M
authors.lastname: Malik
authors.forename: Eveline
authors.initials: E
authors.lastname: Internullo
authors.forename: Antonio Eduardo
authors.initials: AE
authors.lastname: Martin-Ucar
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018287:Carcinoma, Large Cell / Q000473:pathology / Q000601:surgery*; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology / Q000601:surgery*; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology / Q000601:surgery*; D008197:Lymph Node Excision / Q000592:standards*; D008297:Male; D008482:Mediastinum / Q000473:pathology / Q000601:surgery; D008485:Medical Audit; D008875:Middle Aged; D009367:Neoplasm Staging; D018802:Patient-Centered Care; D011013:Pneumonectomy / Q000592:standards*; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies