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  O09 - General Thoracic Surgery (ID 100)

  • Event: WCLC 2013
  • Type: Oral Abstract Session
  • Track: Surgery
  • Presentations: 1
  • Moderators:G.E. Darling, W. Weder
  • Coordinates: 10/28/2013, 16:15 - 17:45, Parkside Ballroom B, Level 1

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    O09.03 - Quality Indicators in Thoracic Surgery: The importance of process indicators in lung cancer (ID 2034)

    16:35 - 16:45  |  Author(s): R. McLeod
    • Abstract
    • Presentation
    • Slides

    Background
    Outcome after surgery is the result of many components of the care pathway.. The Thoracic Surgery Community of Practice of Cancer Care Ontario developed quality indicators which reflected processes of care as well as outcomes.

    Methods
    A systematic review of the literature identified potential indicators in the care of lung cancer patients which were relevant to thoracic surgery. These were then evaluated using a modified Delphi process. Seventeen indicators were chosen from seven domains: pre-operative assessment, staging, surgery, pathology, adjuvant therapy, surgical outcomes and miscellaneous based on actionability, validity, usefulness, discriminability, and feasibility. Data obtained from administrative databases is reported for 4 process indicators and 3 outcome indicators.

    Results
    Of the 3242 patients diagnosed with Stage I and Stage II non-small cell lung cancer in 2009 and 2010, 2172 (67%) received a surgical consultation and 1524 (47%) underwent resection within 3 months of diagnosis. For the 1075 Stage I and Stage II patients over age 75 only 634 (59%) received a surgical consultation and 322 ( 32%) underwent resection. Of the 2302 patients resected in total (all stages), only 736 (32%) had invasive mediastinal staging(IMS) prior to resection:15% for sublobar resections; 30% for stage I; and 42% for stage II. Surprisingly only 42% of patients with stage III disease had IMS. IMS was also performed in an additional 23% of patients for whom stage data was unavailable. In a similar cohort of patients resected in 2011-2012, only 28% had ≥10 lymph nodes removed at the time of resection but this did not include nodes assessed by IMS. However, for 20% of patients lymph node resection data was not available or could not be determined. Positive resection margins were reported in 7% of patients, however in a further 7% of patients margins could not be assessed. 30 day mortality for lobectomy was 1.9%, reoperation rate was 2.8% (2.0% for same day as resection).

    Conclusion
    Initial results of 7 quality indicators in thoracic surgery identified some quality gaps in processes of care as well as limitations in databases. Evaluation of process indicators allowed feedback to thoracic surgeons and pathologists who identified quality improvement opportunities. Rate of surgical consultation and resection for stage I and II disease was lower than expected as were rates of invasive mediastinal staging especially for patients with stage III disease for whom cytologic or histologic confirmation is recommended. To address variable intraoperative lymph node assessment, systematic lymph node sampling or complete mediastinal lymphadenectomy was recommended to standardize intraoperative lymph node assessment. Quality improvement opportunities for pathologists also included dissection of intralobar lymph nodes, standardization of pathological processing and margin assessment. Feedback of quality indicator data was important in stimulating quality improvement initiatives by thoracic surgeons and pathologists.

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