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IIR 05-101 – HSR&D Study

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IIR 05-101
Quality of Practices for Lung Cancer Diagnosis and Staging
David H. Au MD MS
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: October 2006 - September 2010

BACKGROUND/RATIONALE:
VA lung cancer registry data suggest that VA cares for approximately 10,000 cases of lung cancer per year, which is nearly 6% of all lung cancers diagnosed within the US annually. Lung cancer is highly fatal, with nearly 85% of all patients dying within 5 years of diagnosis. Receiving appropriate care is dependent on timely diagnosis and appropriate staging of disease. Little is known about the quality of lung cancer evaluation within VA.

OBJECTIVE(S):
Supplementing data collected from the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium, the objectives of this project were to examine the timeliness of care and practices for lung cancer diagnosis and staging among both veterans and non-veterans with lung cancer. Specifically, the aims were:

1) Describe variation in time to diagnosis and treatment (wait times) in veterans with lung cancer, and identify patient-related and institutional barriers to timely diagnosis and treatment.
2) Examine the effect of wait times on pre-treatment resource utilization, stage distribution and survival.
3) Characterize variation in use of imaging tests and invasive mediastinal biopsy procedures for lung cancer staging, and identify factors associated with the use of tests for staging.
4) Determine the effect of imaging tests and invasive mediastinal biopsy procedures on pre-treatment resource utilization, survival and the rate of thoracotomy without cure.

Additional objectives were to assess (i) the proportion of patients who had adequate lung function but did not undergo surgical resection, and (ii) the effect of lung function, age and comorbid illnesses on 30-day post operative mortality, mechanical ventilation days, length of ICU and hospital stay, and location of discharge.

METHODS:
Prospective observational cohort study of Veterans and non-Veterans diagnosed with lung cancer. Primary explanatory variables included socio-demographic characteristics, disease characteristics, use of specific invasive or non-invasive staging tests, pulmonary function testing, and hospital or facility characteristics. We examined several outcomes, including measures of timeliness, survival, rate of lung resection, the rate of thoracotomy without cure, and resource utilization.

FINDINGS/RESULTS:
We identified 3,638 veteran and non-veteran patients with non-small cell lung cancer (NSCLC). There was significant variability in the receipt of mediastinal imaging using positron emission tomography (PET). Patients who had lower educational achievement, those who used Medicare as their primary insurance, and those patients who received care from VA and integrated health systems had lower use of PET scans. There were significant racial disparities in PET use that were not mediated by other markers of socio-economic characteristics. Among VA CanCORS sites, there was significant variability in the use of non-invasive and invasive mediastinal staging procedures. There was a non-statistically significant higher rate of downstaging at VA centers with high frequency use of PET scans, and a non-statistically significant higher rate of futile thoracotomy at low use centers. Frequency of PET use was not associated with survival. We also found significant variation and predictors of evaluation times for patients with lung cancer. Surprisingly, centers with a dedicated clinic or clinical staff did not have shorter evaluation times, nor did patients who live a greater distance have longer evaluation times. Variation times were longer than recommended by professional societies.

IMPACT:
Lung cancer is a common and fatal condition among Veterans. We have found significant variability in the evaluation process and timeliness for patients with lung cancer. The results suggest a need for quality initiatives that reduce heterogeneity in lung cancer staging.

PUBLICATIONS:

Journal Articles

  1. Gould MK, Schultz EM, Wagner TH, Xu X, Ghaus SJ, Wallace RB, Provenzale D, Au DH. Disparities in lung cancer staging with positron emission tomography in the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Journal of Thoracic Oncology. 2011 May 1; 6(5):875-83.
  2. Slatore CG, Au DH, Gould MK, American Thoracic Society Disparities in Healthcare Group. An official American Thoracic Society systematic review: insurance status and disparities in lung cancer practices and outcomes. American journal of respiratory and critical care medicine. 2010 Nov 1; 182(9):1195-205.
Conference Presentations

  1. Greene CC, Williams EC, Bradley KA, Au DH. The Association between Alcohol Misuse and Health Status among Veterans with COPD. Poster session presented at: American Thoracic Society Annual International Conference; 2011 May 15; Denver, CO.
  2. Gould MK, Schultz EM, Wagner TH, Xu X, Ghaus SJ, Wallace RB, Provenzale D, Au DH. Racial and ethnic disparities in the use of positron emission tomography for patients with non-small cell lung cancer. Presented at: American Thoracic Society Annual International Conference; 2010 May 18; New Orleans, LA.
  3. Gould MK, Schultz EM, Wagner TH, Xu X, Ghaus SJ, Wallace RB, Provenzale D, Au DH. Differential use of positron emission tomography and survival in veterans with non-small cell lung cancer. Presented at: American Thoracic Society Annual International Conference; 2010 May 18; New Orleans, LA.
  4. Gould MK, Schultz EM, Wagner TH, Xu X, Ghaus SJ, Wallace RB, Provenzale D, Au DH. Differential use of positron emission tomography and the risk of futile thoracotomy in veterans with non-small cell lung cancer. Presented at: American Thoracic Society Annual International Conference; 2010 May 18; New Orleans, LA.
  5. Slatore CG, Au DH, Gould MK. Insurance Status and Disparities of Outcomes of Lung Cancer Care: A Systematic Review. Presented at: American Thoracic Society Annual International Conference; 2009 May 18; San Diego, CA.


DRA: Substance Abuse and Addiction, Health Systems
DRE: Epidemiology, Diagnosis, Prevention
Keywords: Decision support, Research method, Risk adjustment
MeSH Terms: none

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