QUALITY of CARE AMONG PATIENTS with EARLY STAGE NON-SMALL-CELL Lung CANCER (NSCLC)

OBJECTIVE: To assess quality of care by comparing patterns of diagnosis and treatment for patients with initial primary, early stage (TNM I-IIB) NSCLC to National Comprehensive Cancer Network (NCCN) clinical practice guidelines (Version 1.2000). Both overuse and underuse were assessed. Although studies have documented lower rates of surgical resection among black and older patients with NSCLC, other disparities in receipt of guideline-recommended care have not been well studied. METHODS: The primary data source, the 2001 American College of Surgeons Commission on Cancer Patient Care Evaluation (PCE) study database, contains demographic and clinical cancer patient data as well as facility-level data from 729 hospitals that voluntarily participated. Characteristics of patients receiving guideline-recommended care were compared to characteristics of patients who did not. Facility-level characteristics associated with less than optimal care were also examined. Generalized estimating equations were used to control for clustering by facility. RESULTS: Of 11,266 patients meeting inclusion criteria, guideline adherence during clinical staging (four required tests) was low (45%) due to infrequent liver function test (LFT) use. Excluding LFTs, guideline adherence for history and physical, chest radiography, and computed chest tomography (CT) was high (89-95%) and varied by area-level income, region, comorbidities, facility type, facility volume, and safety net burden. Among 8,879 patients with negative mediastinal CT results, pre-treatment guideline compliance was low (55%) due to infrequent utilization of mediastinoscopy (21% overall; 25% for TNM stage II). Adherence for bronchoscopy alone was higher (62%). Pre-treatment evaluation varied by region, facility type, and volume. Of patients not undergoing mediastinoscopy, 43% underwent fine needle aspiration biopsy, though not recommended. Among 4773 patients with definitive pre-treatment evaluation results, 42% (N=1990) with negative results were surgical resection candidates. Patients were less likely to undergo resection if older than 69, non-white, Medicare-insured, resided in the Midwest or South or in areas with few high school graduates or low incomes, and treated at low volume community hospitals. Among 1497 patients with pathologic early stage NSCLC and negative margins, 95% met adjuvant treatment guidelines. Patients less likely to meet guidelines were younger than 60 and non-Medicare insured. CONCLUSION: Disparities in guideline-recommended care exist in staging and pre-treatment evaluation as well as in surgical treatment and adjuvant therapy. Both patient and facility level factors impact adherence to guidelines. Though important, physician characteristics were not available for analysis. The relationship between non-adherence and both complications and survival is currently under analysis.