Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis.

BACKGROUND Guidelines recommend mediastinal sampling first for patients with mediastinal lymphadenopathy with suspected lung cancer. Our objective was to describe practice patterns and outcomes of diagnostic strategies in patients with lung cancer. METHODS Retrospective cohort of 15,914 lung cancer patients with T1-3/N1-3/M0 disease diagnosed from 2004 to 2013 in the SEER or Texas Cancer Registry Medicare-linked databases. We classified patients who had mediastinal sampling as their first invasive test as guideline-consistent; all others were guideline-inconsistent. We used propensity matching to compare the number of tests performed and multivariable logistic regression to compare incidence of complications. RESULTS Guideline-consistent care increased from 23% to 34% of patients from 2004 to 2013 (p<0.001). EBUS utilization increased from 0.1% to 25% of all patients (p<0.001) while mediastinal sampling increased from 54% to 64% (p<0.0001). Guideline-consistent care was associated with fewer thoracotomies (38% vs. 71%, p<0.001) and CT-guided biopsies (10% vs. 75%, p<001) than guideline-inconsistent care, but more transbronchial needle aspirations (59% vs. 12%, p<0.001). Guideline-consistent care was associated with fewer pneumothoraxes (5.1% vs. 22%, p<0.001), chest tubes (0.9% vs. 4.4%, p<0.001), hemorrhages (3.5% vs. 5.8%, p<0.001) and respiratory failure events (2.7% vs. 3.7%, p=0.047) than guideline-inconsistent care. Bronchoscopic mediastinal sampling was associated with fewer complications than surgical mediastinal sampling. CONCLUSIONS Guideline-consistent care with mediastinal sampling first was associated with fewer tests and complications. Quality gaps decreased with the introduction of EBUS but persist. Gaps include failure to sample the mediastinum first, failure to sample the mediastinum at all, and overuse of thoracotomy.