title: Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes.
abstract: BACKGROUND
  Evidence-based guidelines recommend mediastinal sampling as the first invasive test in patients with suspected lung cancer and mediastinal adenopathy. The goal of this study was to assess practice patterns and outcomes of diagnostic strategies in this patient population.
  
  
  METHODS
  We conducted a retrospective analysis of all patients in 2009 who had mediastinal adenopathy without distant metastatic disease to determine whether guideline-consistent care was delivered. Guideline-consistent care was defined as mediastinal lymph node sampling being performed as part of the first invasive procedure.
  
  
  RESULTS
  One hundred thirty-seven patients were included. Guideline-consistent care was provided in 30 cases (22%). Patients receiving guideline-consistent care had fewer invasive tests than patients with guideline-inconsistent care (1.3 ± 0.5 tests/patient vs 2.3 ± 0.5 tests/patient, respectively; P &lt; .0001) and fewer complications (0 of 30, 0% vs 18 of 108, 17%; P = .01). Most of the complications (16 of 18) were related to CT image-guided needle biopsy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was sufficient to guide treatment decisions without any other invasive tests in 88 patients (64%). Although not all the complications and costs due to CT image-guided biopsies could have been avoided, roughly two-thirds could have been eliminated by just changing the testing sequence.
  
  
  CONCLUSIONS
  Quality gaps in lung cancer staging in patients with mediastinal adenopathy are common and lead to unnecessary testing and increased complications. In patients with suspected lung cancer without distant metastatic disease with mediastinal adenopathy, EBUS-TBNA should be the first test.
authors.affiliation: Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, OH.
authors.forename: Francisco A
authors.initials: FA
authors.lastname: Almeida
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX.
authors.forename: Roberto F
authors.initials: RF
authors.lastname: Casal
authors.affiliation: Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Jimenez
authors.affiliation: Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: George A
authors.initials: GA
authors.lastname: Eapen
authors.affiliation: The Department of Pulmonary Medicine, Our Lady of Lourdes and Beaumont Hospitals, Dublin, Ireland.
authors.forename: Mateen
authors.initials: M
authors.lastname: Uzbeck
authors.affiliation: Department of Anesthesia, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Mona
authors.initials: M
authors.lastname: Sarkiss
authors.affiliation: Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address: dost@mdanderson.org.
authors.forename: David
authors.initials: D
authors.lastname: Rice
authors.affiliation: Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Rodolfo C
authors.initials: RC
authors.lastname: Morice
authors.affiliation: Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: David E
authors.initials: DE
authors.lastname: Ost
mesh_terms: D000368:Aged; D044963:Biopsy, Fine-Needle; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging / Q000473:pathology; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000628:therapy*; D008198:Lymph Nodes / Q000000981:diagnostic imaging / Q000473:pathology; D008297:Male; D008481:Mediastinoscopy; D008875:Middle Aged; D009367:Neoplasm Staging; D011787:Quality of Health Care / Q000592:standards*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014463:Ultrasonography