From the Journals

Defining quality in lung cancer surgery

 

Key clinical point: Quality and value initiatives in lung cancer surgery are complex and multifaceted.

Major finding: Expert opinion identifies quality and value strategies for the preoperative, intraoperative, and postoperative stages.

Data source: Review of elements of quality and value for lung cancer surgery, including the Donabedian classification of structure, process and outcomes.

Disclosures: Dr. Brandt and co-authors reported having no financial disclosures. The National Institutes of Health/National Cancer Center provided grant support.

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Consider two more metrics

Whitney S. Brandt, MD, and her coauthors pointed out the difficulty of finding a comprehensive quality metric because of the multitude of contributing indicators, said Alessandro Brunelli, MD, of St. James University Hospital in Leeds, England, in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:1404-5). But he added that two nonclinical indicators needed further consideration: patient perspectives and costs.

“Satisfaction with care depends on multiple subjective factors and is affected by different socioeconomic and cultural backgrounds,” Dr. Brunelli said. “There have been very few attempts to use patient satisfaction scales as a measure of quality in our specialty.” Residual quality of life after surgery is another key measure of patient perspective. “Long-term survival in fact cannot be assessed in isolation and without taking into consideration the actual quality of life of the cancer survivors,” he said. That information would help inform surgical decision-making.

To be meaningful as a quality metric, cost requires clinical risk adjustment, Dr. Brunelli wrote, and surgeons should take the lead here “to prevent misleading evaluations by third parties.” He added, “There have been few studies reporting on financial risk models in our specialty, and more research is needed in this field.”

Dr. Brunelli reported having no financial disclosures.


 

FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY

Implementing quality initiatives and creating reporting mechanisms for lung cancer patients can lead to better outcomes, including overall survival. While barriers exist – namely the conflicting perspectives of providers, payers, hospitals, and patients – thoracic oncologic surgeons should seize the opportunity to establish robust quality and value metrics for lung cancer programs, said Whitney S. Brandt, MD, and her coauthors in an expert opinion in the Journal of Thoracic and Cardiovascular Surgery (2017;154:1397-403).

Dr. Brandt, a surgeon at Memorial Sloan Kettering Cancer Center in New York, and her coauthors examined the key elements of quality and value initiatives, categorizing them into preoperative, intraoperative, and postoperative components and primarily focusing on early stage lung cancer. The National Institutes of Health/National Cancer Center provided a grant for the authors’ work.

The preoperative evaluation should at least include CT imaging of the tumor and, for smokers, smoking cessation, said Dr. Brandt and her coauthors. All candidates for pulmonary lung resection should have spirometry and diffusion capacity tests; furthermore, both predicted postoperative forced expiratory volume in 1 second and diffusing capacity of the lungs for CO should be calculated. “Patients with a predicted postoperative value less than 40% for either measurement should be considered high risk for lobectomy and should be offered either sublobar resection or nonsurgical therapy,” they recommended.

Dr. Brandt and her colleagues also clarified preoperative management of patients with cardiac disease. Only patients with significant cardiac disease risk factors need to undergo cardiac testing before lung surgery, and patients with stable cardiac disease do not require revascularization beforehand.

For preoperative staging, the most comprehensive clinical guidelines come from the National Comprehensive Cancer Network, they stated. The guidelines recommend that all patients with a small cell lung cancer or stage II to IV non–small cell lung cancer (NSCLC) receive a brain MRI or – if that’s not available – a head CT with contrast to assess for brain metastasis.

Intraoperative quality measures take into account the surgical approach, including cost, resection and margins, and lymph node evaluation. With regard to surgical approach, trials have shown traditional video-assisted surgery (VATS) lobectomy results in shorter hospital stays and thereby lower costs, as well as fewer complications and deaths, than thoracotomy, said Dr. Brandt and her coauthors. But that cost advantage has not yet carried over to robotic-assisted VATS. That said, “robotic-assisted VATS remains a relatively new technology, and with time and increased robotic platform competition, costs will likely decrease.”

Dr. Brandt and her coauthors also noted that clinical trials support resection margins of 2 cm in patients having surgery for NSCLC and that adequate lymph node evaluation is a critical component of a lung cancer quality initiative. “Regardless of whether lymph nodes are sampled or dissected, we believe that systematic acquisition of mediastinal nodal tissue based on nodal station(s) is a useful quality metric, and, therefore, we recommend each program adopt a preferred approach and track adherence,” they said.

As for postoperative quality metrics, the most obvious are morbidity and mortality. “A quality program should track 30-day or in-hospital mortality, as well as 90-day mortality, following lung cancer resection.” Such metrics can serve as “starting points” for quality improvement initiatives. Length of stay has also emerged as an important metric because it is a surrogate of other metrics, such as patient comorbidities, age, and socioeconomic status. “Length-of-stay metrics likely need to be risk-stratified on the basis of these and other variables to be meaningful to a practicing surgeon,” Dr. Brandt and her coauthors said, adding that: “Studying the effectiveness of enhanced recovery after surgery programs in thoracic surgical oncology poses an opportunity for a well-designed trial.”

Two other key quality metrics for lung cancer programs that need further development were pointed out in the paper: hospital readmissions and tracking of adjuvant therapies. “Programmatic oncologic quality metrics to track appropriate and inappropriate referrals for adjuvant therapy and the number of patients who complete such therapy are important,” they said.

Another step programs should take: Participating in a national or regional database, as recommended by the Society of Thoracic Surgeons, and taking advantage of the “clear benefits to benchmarking your program to others.”

Dr. Brandt and her coauthors reported having no financial disclosures. The National Institutes of Health/National Cancer Center provided grant support.