title: Determinants of practice patterns and quality gaps in lung cancer staging and diagnosis.
abstract: BACKGROUND
  Guidelines recommend mediastinal lymph node sampling as the fi rst 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 fi rst; (2) evaluation inconsistent with guidelines, non-small cell lung cancer (NSCLC) present, mediastinal sampling performed but not as part of the fi rst 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.
authors.affiliation: Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address: dost@mdanderson.org.
authors.forename: David E
authors.initials: DE
authors.lastname: Ost
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jiangong
authors.initials: J
authors.lastname: Niu
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Linda S
authors.initials: LS
authors.lastname: Elting
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Sharon H
authors.initials: SH
authors.lastname: Giordano
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D044963:Biopsy, Fine-Needle / Q000379:methods*; D001999:Bronchoscopy; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000473:pathology / Q000556:secondary; D003937:Diagnosis, Differential; D019160:Endosonography / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging / Q000473:pathology*; D008175:Lung Neoplasms / Q000175:diagnosis*; D008207:Lymphatic Metastasis; D008297:Male; D008482:Mediastinum / Q000000981:diagnostic imaging / Q000473:pathology; D009367:Neoplasm Staging / Q000379:methods / Q000592:standards*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018426:SEER Program; D055752:Small Cell Lung Carcinoma / Q000175:diagnosis / Q000556:secondary