251 Background: Lung cancer care is complex, but, for quality improvement, can be simplified into five ‘nodal points’: lesion detection, diagnostic biopsy, radiologic staging, invasive staging, and treatment. We previously demonstrated great heterogeneity in passage through these nodal points in patients who received surgical resection for lung cancer in our healthcare system. However, examining only surgical patients may underestimate the enormity of the opportunity for quality improvement. With the aim of identifying quality gaps in pre-treatment evaluation for lung cancer, we evaluated the flow of care through these nodal points within a community-based healthcare system. Methods: We classified lung cancer care procedures received by all suspected lung cancer patients treated within the Multidisciplinary Thoracic Oncology Program at Baptist Cancer Center, Memphis TN between 2014 and 2019, into five nodal points. We compared the frequency of, and time intervals between, nodal points among patients receiving surgical, nonsurgical (chemotherapy/radiation), or no definitive treatment, using Chi-square or Kruskal Wallis tests, where appropriate. Results: Of 1304 eligible patients: 11% had no pre-treatment diagnostic procedure, 20% no PET/CT, and 39% no invasive staging. 39% of patients underwent surgical resection, 51% received non-surgical treatment, and 10% received no treatment. Patients who had surgery were less likely than those who had non-surgical treatment to get a diagnostic test, radiologic staging, and invasive staging (Table). Patients who had non-surgical treatment were more likely to pass through all five nodal points (50% v 68%, p<0.0001). The median (IQR) duration from initial lesion identification to treatment (n=1126) was 77 days (45-190); 27 days (10-90) from lesion identification to diagnostic biopsy (n=1115); and 38 days (26-63) from diagnostic biopsy to treatment (n=1041). Patients who had surgery received less timely care than those who had non-surgical or no treatment: median 122 v 66 v 68 days from lesion identification to treatment; 40 v 21 v 29 days from lesion identification to diagnostic biopsy; 46 v 38 v 31 days from diagnostic biopsy to treatment (p<0.0001 all comparisons). Conclusions: Quality improvement initiatives within our healthcare system, such as the establishment of a coordinated multidisciplinary program, enhanced care quality over previous benchmarks. Despite improvements, lung cancer patients who had surgery received less frequent and less timely pre-treatment evaluation than those without surgery. Implementing a standardized cancer care pathway from diagnosis to surgery could help to reduce variations in optimal care delivery.[Table: see text]
The Stieltjes string and its associated nodal points
