Original Article|Articles in Press

Institution-Level Evolution of Lung Cancer Resection Quality with Implementation of a Lymph Node Specimen Collection Kit.

Published:March 15, 2023DOI:
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      Lung cancer surgery with a lymph node kit improves patient-level outcomes, but institution-level impact is unproven.


      Using an institutional stepped-wedge implementation study design, we compared lung cancer resection quality between institutions in pre- and post-implementation phases of kit deployment and, within implementing institutions, resections without versus with the kit. Benchmarks included rates of non-examination of lymph nodes (pNX), non-examination of mediastinal lymph nodes and attainment of American College of Surgeons Operative Standard 5.8. We report institution-level adjusted odds ratios (aOR) for attaining quality benchmarks.


      From 2009-2020, three pre-implementing hospitals had 953 resections; 11 implementing hospitals had 4,013 resections, 58% without and 42% with the kit. Quality was better in implementing institutions, and with kit cases. Compared to pre-implementing institutions, the aOR for pNX was 0.62 (0.49-0.8, P=0.002), non-examination of mediastinal lymph nodes 0.56 (0.47-0.68, P<0.0001), attainment of Operative Standard 5.8 7.3 (5.6-9.4, P<0.0001); aOR for kit cases were 0.01 (0.001-0.06), 0.08 (0.06-0.11) and 11.6 (9.9-13.7), respectively, P<0.0001 for all.
      Surgical quality was persistently poor in pre-implementing institutions, but sequentially improved in implementing institutions in parallel with kit adoption. In implementing institutions, resections with the kit had a uniformly high level of quality, whereas non-kit cases had a low level of quality, approximating that of pre-implementing institutions. Within implementing institutions, 5-year overall survival was 61% versus 51% after surgery with versus without the kit (p<0.001).


      Surgery with a lymph node specimen collection kit improved institution-level quality of curative-intent lung cancer resection.

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