Chest. 2020 Nov 13:S0012-3692(20)35134-5. doi: 10.1016/j.chest.2020.10.075. Online ahead of print.
BACKGROUND: Institution-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC.
RESEARCH QUESTION: how do reversible differences in oncologic quality of care contribute to institution-level disparities in early-stage NSCLC survival?
STUDY DESIGN AND METHODS: We retrospectively analyzed patients in the National Cancer Data Base with NSCLC resections from 2004-2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted odds ratios for 6 potentially avoidable poor-quality markers: incomplete resection, non-examination of lymph nodes, non-anatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact.
RESULTS: Of 169,775 patients, 7%, 46%, 10%, 24% and 12% had surgery at Community, Comprehensive Community, Integrated Network, Academic and NCI-Designated Cancer Programs, with 5-year overall survival rates 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI 1.41-1.53), 1.29 (1.25-1.33), 1.18 (1.14-1.23) and 1.20 (1.16-1.24) for Community, Comprehensive Community, Integrated Networks and Academic Cancer Programs to 1.35 (1.28-1.42), 1.22 (1.17-1.26), 1.16 (1.11-1.22), and 1.17 (1.12-1.21), respectively (p<.001 for all comparisons to NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11-25% of the inter-institutional survival disparities.
INTERPRETATION: Targeting 6 readily-identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized in order to eliminate them.