Quality Measures in Clinical Stage I Non-Small Cell Lung Cancer: Improved Performance Is Associated With Improved Survival.
BACKGROUND
National organizations have recommended quality measures for operations in early-stage non-small cell lung cancer (NSCLC). The outcomes of adherence to these guidelines are unknown.


METHODS
Information about patients who underwent an operation for clinical stage I NSCLC was abstracted from the National Cancer Database. After reviewing current guidelines, the following quality measures were selected: anatomic resection, operation within 8 weeks of diagnosis, achievement of negative surgical margins, and sampling of 10 or more lymph nodes. Multivariate models identified variables independently associated with receiving quality measures and a Cox model created to evaluate overall survival.


RESULTS
Between 2004 and 2013, 133,026 of 133,366 (99.7%), 126,598 of 133,366 (94.9%), 91,472 of 133,366 (68.6%), and 30,041 of 133,366 (22.5%) patients met one, two, three, or four measures. Income of at least $38,000/year (odds ratio [OR] 1.20, 95% CI: 1.15 to 1.24), insurance type (private insurance: OR 1.22, 95% CI: 1.09 to 1.36; Medicare: OR 1.16, 95% CI:1.04 to 1.30), centers with at least 38 cases/year (OR 1.18, 95% CI: 1.14 to 1.22), academic institutions (OR 1.31, 95% CI: 1.27 to 1.35), and clinical stage IB patients (OR 1.50, 95% CI: 1.40 to 1.60) were more likely to meet all four measures; whereas increasing age (OR 0.99, 95% CI: 0.99 to 0.99), women (OR 0.93, 95% CI: 0.91 to 0.96), non-Caucasian race (OR 0.83, 95% CI: 0.79 to 0.87), and increasing Charlson/Deyo comorbidity score (1: OR 0.90, 95% CI: 0.87 to 0.93; ≥2: OR 0.82, 95% CI: 0.79 to 0.86) were associated with lower likelihood. Pathologic upstaging (hazard ratio [HR] 1.84, 95% CI: 1.78 to 1.89) and meeting all four measures (HR 0.39, 95% CI: 0.31 to 0.48) were most powerfully associated with overall survival.


CONCLUSIONS
National adherence to quality measures in stage I NSCLC resection is suboptimal. Guideline compliance is strongly associated with survival, and vigorous efforts should be instituted by national societies to improve adherence.
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Pamela
P
Samson
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Traves
T
Crabtree
Division of Cardiothoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Stephen
S
Broderick
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Daniel
D
Kreisel
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
A Sasha
AS
Krupnick
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
G Alexander
GA
Patterson
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
Bryan
B
Meyers
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri. Electronic address: puriv@wudosis.wustl.edu.
Varun
V
Puri
D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D008297:Male; D009367:Neoplasm Staging / Q000592:standards*; D011013:Pneumonectomy / Q000379:methods*; D058996:Quality Improvement; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
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