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Multidisciplinary team (MDT) input into cancer treatment aims to provide coordinated care to patients and improve their oncological outcomes as a result.[[1]] MDT meetings are a standard of care for lung cancer management in many regions around the world.[[1]] In New Zealand between 2014 and 2017, 9,093 patients were diagnosed with lung and tracheal malignancy.[[2]] At a regional level, the Southern District Health Board (SDHB) has a catchment of over 350,000 patients, covering the Otago and Southland regions. With the most recent data available, between 2014–2017, the SDHB treated a total of 603 public patients diagnosed with lung cancer.[[3–6]] Lung cancer MDT meetings are conducted once a week at Dunedin Public Hospital for all patients within the SDHB. Thoracic surgery is one of the key components of multidisciplinary care of lung cancer patients.[[7]] In the SDHB, Dunedin Public Hospital is the centre that performs thoracic surgery for those with thoracic malignancy. Both diagnostic biopsies and curative treatment of suspected or proven malignancy are offered.

Clinical quality indicators (CQIs) can be used to assess the effectiveness of multidisciplinary teams, and to analyse important outcomes in the oncological management of patients based on recommended standards.[[8]] CQIs have the capacity to drive quality improvement and can highlight steps in the patient’s lung cancer treatment that could be enhanced. In 2012, the New Zealand Ministry of Health Faster Cancer treatment (NZMHFCT) indicators were implemented into the regional district health boards to ensure thorough collection of data pertaining to oncological management.[[9]] For patients with a confirmed cancer diagnosis, one indicator is whether they have their first cancer treatment within 31 days of the decision to treat.[[9]] Another recommendation is that those patients with a high suspicion of malignancy should be referred to hospital services and have their first treatment within 62 days of the referral being received by the hospital.[[9]] The NZMHFCT indicators are generic guidelines for all cancer treatment.[[9]]

More specific for lung cancer is the Standards of Service Provision for Lung Cancer Patients in New Zealand (SSPLCPNZ) document.[[7]] The second edition of SSPLCPNZ (2016) outlines goals for MDT management. These include all patients (target of ≥95% of patients) seeing a respiratory medicine specialist within 14 days of referral from a general practitioner (GP) or other specialist, and all patients (target ≥95% of patients) commencing lung cancer treatment within 62 days of hospitals receiving a referral. The standard states that all patients should have prompt availability of computed tomography (CT) guided biopsy and endobronchial ultrasound (EBUS) services within seven days of referral (both target ≥95% of patients). All patients with suspected or confirmed small cell and non-small cell lung cancer who are potentially curative should undergo positron emission tomography (PET) scanning (target 100% of patients). The SSPLCPNZ references international guidelines including the British Thoracic Society (BTS) and Society for Cardiothoracic Surgery in Great Britain and Ireland Guidelines on the Radical Management of Patients with Lung Cancer 2010.[[7]]

Although the NZMHFCT and SSPLCPNZ documents give some guidance regarding timeframes for various steps in the lung cancer diagnostic and treatment pathways in New Zealand, they are not comprehensive. As a result, guidelines from the BTS can provide other benchmarks, as these have also been referred to in the SSPLCPNZ document.[[7]]

The purpose of this study was to use existing CQIs to evaluate lung cancer management in thoracic surgical patients in the Southern Health District.

Methods

Medical records for all patients who underwent curative intent oncological lung surgery consisting of wedge resection, lobectomy and pneumonectomy at Dunedin Public Hospital between 2014–2020 were obtained. Curative intent patients included those patients deemed to have radiologically staged disease of I or II with Eastern Cooperative Oncology Group (ECOG) performance status between 0–2. There were no exclusion criteria. Demographic data collected included age, sex, ethnicity, place of residence and New Zealand Index of Deprivation (NZDep) (reflecting socio-economic disparity).[[10]] Place of residence was categorised as either Dunedin and Greater Dunedin or outside of Dunedin, which included other large towns such as Invercargill. Oncological data included PET utilisation, CT biopsy and EBUS referral intervals, radiological staging, pathological staging and histology. Patients were discussed at the weekly lung cancer MDT meeting to decide on proposed investigation and treatment. MDT participants included respiratory physicians, cardiothoracic surgeons, radiation and medical oncologists, a radiologist specialising in lung pathology, a pathologist and a respiratory clinical nurse specialist.

The CQIs for this study included time from referral to first specialist appointment, time from referral to surgery, time from first respiratory specialist appointment to surgery, time from discussion at lung cancer MDT to surgery, timing of CT biopsy or EBUS if these were performed, and inclusion of PET staging. Time from referral to surgery included all referrals from both primary care and secondary care medical practitioners who were non-respiratory specialists. Concordance of radiological and pathological stage was also investigated. These CQIs were based on the SSPLCPNZ, NZMHFCT indicators and BTS Lung Cancer Guideline.[[7,9,11]] Justification for the inclusion of these particular CQIs are included in Table 1.

Statistics

The percentage of patients that met the prescribed timeframes for CQI 1–5 for each year was calculated. Mean days for each timeframe along the lung cancer pathway were also derived from cumulative patient data for each year studied. The rate of PET uptake was described as a percentage of surgical patients undergoing PET scanning in a certain year (CQI 6). IBM SPSS statistical software was used for analysis.

This study was exempt from review by the Southern Health and Disability Ethics Committee.

Results

A total of 108 patients underwent oncological thoracic surgery between 2014–2020 at Dunedin Public Hospital, with a mean age of 70.5 years and a relatively equal proportion of males and females (Table 2). In terms of ethnicity, 91 patients identified as New Zealand European (84.3%); 11 as Māori (10.2%); three as European (2.8%); one as Samoan (0.9%); one as Asian (0.9%); and one as Middle Eastern (0.9%). Seventy-one patients (65.7%) were from outside the greater Dunedin area (defined as up to one hours’ drive away from Dunedin). Eight Māori patients (7.4% of all patients) lived outside Dunedin. Regarding the NZDep Index, indices of 1–2 demonstrate low levels of deprivation and indices of 9–10 the highest levels of deprivation.[[10]] Fifty-three patients (49.1%) had a NZDep Index of 7–10, highlighting high levels of deprivation in the cohort.

The majority of procedures performed were lobectomies (80.6%). Fifty-eight patients (53.7%) did not have a histological diagnosis before their operation. In terms of final surgical histopathology, 66 patients (61.1%) had adenocarcinoma, 38 patients (35.2%) had squamous cell carcinoma, three patients (2.8%) had mixed adenosquamous histology, and one patient (0.9%) had small cell carcinoma. Final pathological staging showed that most patients who were operated on had carcinoma in situ, Stage I and II disease (n=81, 75%). Māori patients had similar frequencies of certain tumour pathologies as non-Māori. Twenty-six patients (24.1% of all patients) had a final staging of incurable disease (Stage IIIA and greater), with five Māori patients (45.5% of Stage IIIA and greater) with incurable disease.

A further breakdown of demographics is found in Table 2.

View Tables 1–2.

The clinical quality indicator for timing of referral to first contact with a respiratory medicine specialist was met, in regards to mean days between these two timepoints in all years studied (Figure 1). In all years bars for 2014 and 2017, the standard for time from referral date to surgery was met based on mean days. In 2017, the mean time to surgery was only longer than this standard by one day. The mean days between respiratory specialist review and surgery was less than 56 days in all years, except for 2014. Based on mean days, 2018 was the only year in which patients were operated on within 31 days of discussion at the Lung cancer MDT. CT guided biopsies and EBUS were only performed within a mean of seven days in two years (2015 and 2017) out of the seven years of data. In no years did 100% of patients receive PETs pre-operatively, with the highest percentage of PETs performed being 88.2% in 2019 (Figure 1).

Figure 1: Six CQIs used to assess the surgical lung cancer management in the SDHB.

Standard demonstrated on graph is as follows (as per Table 1): referral date to respiratory outpatient department (OPD) – 14 days; referral date to OT – 62 days; respiratory OPD to OT – 56 days; lung cancer MDT to OT – 31 days; request date to EBUS/CT biopsy – seven days; PET performed – 100%.

Māori patients accounted for four out of the 17 patients (23.5%) who were classified as NZDep 9–10. Eight Māori patients (72.7% of Māori patients) lived outside of Dunedin. Forty-five-point-five percent of Māori patients had incurable disease at final staging compared to 24.1% of the total cohort. Regarding the ≥95% (90% for CQI 2, 100% for CQI6) percentage compliance targets, five patients (45.5% of all Māori patients) took more than 14 days from referral to first respiratory specialist appointment. From referral to surgery, six patients (54.5%) exceeded the proposed 62 days’ timeframe. Regarding the time from first respiratory specialist appointment to surgery, again six patients (54.5%) were above the proposed 56-day interval. Six patients (54.5%) took longer than 31 days from the time of discussion at the lung cancer MDT to surgery. Thus, no CQI met the standard proposed for Māori patients. However, when Māori patients were excluded from the dataset, non-Māori patients also did not meet CQI targets in any years, except for CQI 1 in 2015 and 2016. For Māori patients, the mean number of days from referral to first respiratory specialist appointment was 30.3 days, from referral to surgery was 79.6 days, from first respiratory specialist appointment to surgery was 78.5 days, from discussion at lung cancer MDT to surgery was 47.6 days and from referral to CT biopsy or EBUS 8.7 days. When comparing to non-Māori patients, Māori patients had longer timeframes for all outcomes except for time from referral to CT biopsy or EBUS. Out of the six patients who had CT biopsies performed, it took four patients (66.7%) over one week for this to occur from referral. Six patients (54.5%) had PET scans performed pre-operatively, with a target of 100%.

In terms of patients with the highest deprivation indices (NZDep 9–10; 20 patients over all years), four patients (10% of all NZDep 9–10) took more than 14 days from referral to first respiratory specialist appointment and eight patients (40%) took longer than 62 days from referral to surgery. Regarding time from first respiratory specialist appointment to surgery, seven patients (35%) exceeded 56 days. Discussion at lung cancer MDT to surgery was longer than 31 days in 13 patients (65%). This is compared to those who had the lowest deprivation indices (NZDep 1–2; 15 patients over all years) who had values of 17% (of all NZDep 1–2 patients), 13%, 17% and 47%, respectively, for the same CQIs. Cumulatively over all years, these patients’ treatment did not meet the standards for referral date to surgery (mean 67.9 days vs 59.7 days for NZDep 1–2), first respiratory specialist appointment to surgery (mean 61.2 days versus 49.6 days for NZDep 1–2), lung cancer MDT to surgery (mean 45.4 days versus 40.5 days for NZDep 1–2) or request date to EBUS or CT biopsy (mean 11 days versus 4.8 days for NZDep 1–2). However, the mean days from referral to respiratory specialist appointment was 7.3 days (better than for the least deprived patients who had a mean of 10.1 days). Five patients (25%) had longer than one week between referral for CT biopsy and this being performed. The rate of PET scanning pre-operatively was 70% (compared to 80% for NZDep 1–2).

Overall, Māori patients and those with the highest deprivation indices were found to meet CQIs less frequently than the total cohort; however, due to the small number of patients making up these groups, a level of statistical significance cannot be calculated.

Comparison of radiological versus pathological staging in patients who underwent oncological surgery showed upstaging was more frequent than downstaging, with 21 patients (19.4%) over the seven-year study period being upstaged and 16 downstaged (14.8%). Fifteen (71.4%) patients who were upstaged had PETs performed pre-operatively. In hindsight, a total of nine patients (8.3%) with final N2 disease should not have been offered surgery within the seven-year study period. Of the patients who were upstaged, ten patients were upstaged on the basis of nodal status, but only eight patients received preoperative PET staging (80%).

Discussion

The purpose of this study was to determine whether the Southern DHB is meeting national standards for surgical lung cancer management. The six CQIs investigated were primarily derived from the SSPLCPNZ document, NZMHFCT indicators and the BTS Lung Cancer Guideline.[[7,9,11]] Both the BTS guideline and the SSPLCPNZ document are based on the National Institute for Health and Care Excellence (NICE), Welsh and Scottish National guidelines and the American National Cancer Care Network guideline. Thus, these standards allow comparison to other developed health care systems around the world.[[7]]

To summarise, except for CQI 1 in 2015 and 2016, no CQIs over any years reached the target of ≥95% (90% for CQI 2, 100% for CQI 6) of patients meeting SSPLCPNZ, NZMHFCT or BTS standards. The CQI for referral to first contact with a respiratory medicine specialist met the SSPLCPNZ standard in all years studied in terms of mean days; however, 31-, 56- and 62-day timeframes were not met in terms of mean days for all years. 2015 and 2017 were the only years in which CT guided biopsy and EBUS were performed within seven days of referral based on mean days. The target of all patients with curative small or non-small cell lung cancer pre-operatively receiving a PET was not reached in any year. Upstaging was more frequent than downstaging post-operatively (19.4% vs 14.8%), with 71.4% who were upstaged receiving a PET scan pre-operatively. Two patients did not have PET scans before their surgery, which may have ultimately changed their clinical course if this had demonstrated N2 disease.

Māori patients and those living outside Dunedin did not regularly meet SSPLCPNZ, NZMHFCT or BTS standards. There is no nationwide standard for provision of lung cancer treatment specific to Māori patients.

Previous research has demonstrated mortality rates up to 3.5 times higher in Māori patients with lung cancer compared to non-Māori patients.[[17,18]] Deficits in secondary care and diagnosis at late stage due to reduced access to general practitioners may have contributed to this disparity.[[18]] Māori patients accounted for four out of the 17 NZDep indices of 9 and 10 (23.5%), which is disproportionate to their ethnic proportion of 11% in this study. A high proportion (72.7%) of Māori patients in this study lived outside Dunedin which may have also contributed to poor continuity of care and to later referrals to secondary services. Stevens et al found that Māori patients had a significantly longer time from diagnosis to treatment.[[17]] The current study has confirmed this finding with 54.5% of Māori patients exceeding the 56-day interval, as opposed to 29.4% for all patients over all years. Additionally, 54.5% of Māori patients exceeded the 31-day interval, again compared to 46.7% of all patients over all years.

Most patients were from outside of Dunedin in the current study, so this did not have a significant influence on outcomes. However, 18.5% of patients had the highest levels of deprivation based on NZ Deprivation scoring (9–10) and these patients had the longest waits from referral to surgery with a mean of 67.9 days. For example, 13 patients (65% of NZ Dep 9–10 patients) had more than 31 days between discussion at lung cancer MDT and surgery, showing that deprivation may be a barrier to expedited cancer care.

Clinical quality indicators are tools for local institutions to benchmark their lung cancer management against national and international standards.[[8]] As this study is the first New Zealand study of this type, the results can only be compared to international research.

Comparable statistics from other sources include those from two large audits. The UK National Lung Cancer Audit (NLCA) 2019/2020 found that for all patients undergoing lung cancer treatment (both surgical and nonsurgical), the median time to treatment was 28 days (2019) and 27 days (2020) nationally.[[19]] The Victorian Lung Cancer Registry Annual Report for 2019 has numerous equivalent clinical quality indicators.[[20]] The mean rate of PET uptake in patients undergoing resection of was 96% in this report, far higher than the current study. The proportion of patients with non-small cell lung cancer who underwent surgical resection and whose clinical stage was in agreement with pathological stage was 83%.[[20]] In the current study, 19.4% of patients were upstaged and 14.8% downstaged (total 34.2%), with agreement of staging in only 65.8% of cases.

Furthermore, the Queensland Lung Quality Index 2011–2016 noted a median time from diagnosis to surgery of 30 days, with 46% of all patients having surgery within this time period.[[21]] This was benchmarked against a standard of 42 days as per the Cancer Council Australia’s Optimal Care Pathway for lung cancer patients.[[22]] A surrogate marker in this study for diagnosis to surgery could be discussion at the lung cancer MDT to surgery, with a standard of 31 days. In this case, results ranged from 23.1–57.1% of patients reaching this target of the seven years, not dissimilar to the Queensland statistics. In terms of rural patients and those at socio-economic disadvantage, the Queensland data found that patients living outside a major city did not receive different care but those who were socio-economically disadvantaged did.[[21]] This mirrors the result of the current study. The Danish National Indicator Project has highlighted certain clinical quality indicators for lung cancer management.[[23]] Comparable to the current study is the time from referral to diagnosis of 28 days with the target of 85% of patients achieving this standard. Similarly, the waiting time for surgery (presumed from referral) should be 14 days, with a target of 85% of patients reaching this. In 2006, 69% of patients met the referral to diagnostic standard and 83% of patients met the waiting time until surgery standard with both results under the 85% standard.[[23]] This data demonstrates considerably better achievements of standards than the current study.

The West of Scotland Cancer Network Audit Report for Lung Quality Performance Indicators for 2019 included reviewing whether non-small cell lung cancer patients were undergoing pre-treatment PETs, with a target of 95% of patients receiving this.[[24]] They found that all districts achieved this target and thus far greater rates of PET scanning compared to the Southern DHB.[[24]] Similarly, other UK studies have mostly achieved critical timeframes along the treatment pathway based on BTS guidelines. A 2007 study from the South Manchester University Hospital had a mean of 3.8 days for GP referral to first respiratory specialist appointment (standard of 14 days).[[25]] Additionally, a mean of 53.8 days from GP referral to decision to treat (a surrogate for lung cancer MDT; standard of 31 days) and a mean of 75.5 days from GP referral to definitive treatment (standard of 62 days) were demonstrated.[[25]] A 2002 study, again comparing to BTS guidelines, found that the median days from respiratory review to decision to operate (again a surrogate for Lung cancer MDT) was 14 and from lung cancer MDT to operation was 17 days.[[26]] The median timeframe between first respiratory physician review and surgery was 24 days.[[24]]

The goal of CQIs is to identify areas that require improvement or further investigation. Apart from time from referral to respiratory physician review, all CQIs have improved since 2014; however, benchmarks were not always met. The time between respiratory specialist review and surgery has been standardised at 56 days in the BTS guideline.[[11]] This was met in the most recent years of the study (2015–2020). This is interesting considering that this is not part of the New Zealand guideline, but that improvement has occurred despite this.

There have been multiple quality improvement strategies implemented by Southern DHB regarding lung cancer investigation and management.

The first engagement the patient has with the hospital healthcare system is the Fast Track respiratory clinic at Dunedin Hospital, which allows streamlined management for patients with suspected lung cancer. Respiratory physician assessment and bronchoscopy with potential for tissue biopsy is performed on the same day. The clinic relieves some of the responsibility of general practitioners to commence what can be a complex investigatory pathway for lung cancer. It appears that this Fast Track clinic is facilitating timely review of patients as seen in the outcomes from 2014–2020.

The longer than 31-day interval between the lung cancer MDT meeting and surgery was potentially impacted by only having a fortnightly thoracic operating list at Dunedin Hospital. Additionally, the need for patient assessment in the Cardiothoracic Surgery outpatient clinic to quantify surgical risk and optimise the patient’s condition prior to surgery may have lengthened this interval. In order to improve this outcome, in the last three years there has been more extensive evaluation via the Fast Track clinic (including full spirometric workup) before the patient’s presentation at the lung cancer MDT meeting. Another quality improvement measure has been for patients who are on the surgical waiting list but are likely to breach the 31-day standard to be brought forward for surgery on lists that are usually used for cardiac surgery patients. This clinical reprioritisation had significantly reduced the thoracic oncological waiting list. Reassessment of this CQI should occur with data from 2021 onwards, to ensure that these measures have resulted in an ongoing improvement.

Accessing diagnostic services may have impacted the timeliness of management. This includes EBUS and PET scanning, which is only available at Christchurch Hospital for any public patients in the SDHB catchment. In 2020, the lengthening of time from referral to PET and CT guided biopsy dates was likely affected by the COVID-19 pandemic. Currently, PET scans are also being referred to the private sector to ensure there is adequate staging for all patients with curative potential and until more public PET facilities are available to the SDHB catchment.

As of 2021, a quality assurance committee has finally been established for patients undergoing lung cancer treatment under the Southern DHB. It is aimed at ensuring patients are receiving care in concordance with New Zealand Standards of Service Provision for lung cancer, including reduced timeframes between key points in their management. In order to address the issue of access to timely EBUS services, a business case has been developed to commence EBUS at Dunedin Hospital.

This study has limitations. There are relatively few cases that were analysed in this study—only 108 cases over seven years. Surgical resection is most likely to result in cure for patients with early-stage non-small cell cancer compared to other treatment modalities.[[7]] The low surgical treatment numbers in this study may be a reflection of cautious patient selection based on Lung cancer MDT discussion where patients with higher ECOG scores may have been deemed as not surgically suitable. It has been shown that rates of surgical resection of non-small cell lung cancer in New Zealand is 14.1%, which is lower than other countries, including Australia (for example, the rate of resection in Victoria is 19.1%).[[20]] Quality of patient records is also likely to have impacted on the accuracy of this study, particularly regarding correct documentation of radiological staging. It must be noted that the clinical quality indicators are developed for all lung cancer patients, many of whom will not undergo surgery. Patients with early-stage lung cancer and those who were referred for surgery but subsequently were not operated on are not included in this study, and thus the results should be interpreted in this context. Finally, analysis of outcomes for Māori patients and those with socio-economic deprivation is challenging due to their small proportion of the studied cohort.

Conclusion

Between 2014–2020, the standards for lung cancer management in SDHB surgical patients was frequently achieved in terms of mean days. However, a target of ≥95% (90% for CQI 2; 100% for CQI 6) of patients receiving care at the standard was rarely met. Timing of CT biopsy and EBUS was consistently longer than recommended and pre-operative PET utilisation was less than 100%. Māori patients and those patients who were the most socio-economically deprived appear to have inequity of care compared to non-Māori patients and those who are not socio-economically deprived. Thus, there is still potential for improvement.

Guaranteeing equity of resource in regards to PET scans and EBUS will be important in the future. This is particularly true in Otago and Southland regions, as these regions have a greater proportion of patients over 60 years of age than the rest of New Zealand.[[27]] It is hoped that this important step in many patients’ lung cancer management can be provided at a local level.

Summary

Abstract

Aim

Multidisciplinary team (MDT) meetings are a standard of care for lung cancer management in many regions around the world. Clinical quality indicators (CQIs) can be used to assess the proficiency of these multidisciplinary teams and compare their performance against those recommended by local and international guidelines. The effectiveness of the lung cancer MDT meeting at Dunedin Public Hospital has been evaluated using CQIs with a focus on the timeliness of surgical management.

Method

Medical records for all 108 patients who underwent curative intent oncological lung surgery at Dunedin Public Hospital between 2014–2020 were obtained. All patients were discussed at the lung cancer MDT meeting. Performance in six CQIs were evaluated as per the results below.

Results

The CQI for timing of referral to first contact with a respiratory medicine specialist was met in all years studied by mean days. In all years bars for 2014 and 2017, the standard for time by mean days from referral date to surgery was met. In 2017, the mean time to surgery exceeded this standard by only one day. The mean time between respiratory specialist review and surgery was less than 56 days in all years except for 2014. By mean days, 2018 was the only year that surgery was performed within 31 days of discussion at the lung cancer MDT. Computed tomography (CT) guided biopsies and endobronchial ultrasound (EBUS) were only performed within a mean of seven days in only two years (2015 and 2017) out of the seven years of data. The target of all patients with curative small or non-small cell lung cancer receiving a positron emission tomography (PET) scan was not achieved in any year. Post-operative upstaging was more frequent than downstaging (19.4% vs 14.8%), and 71.4% of those upstaged received a PET scan pre-operatively. Māori patients and those with significant socio-economic deprivation were less likely to meet standards of lung cancer care.

Conclusion

Between 2014–2020, the standards for lung cancer management in surgical patients were frequently achieved as measured by mean days. However, a target of ≥95% (90% for CQI 2; 100% for CQI 6) of patients receiving care at the standard was rarely met. Timing of CT biopsy and EBUS was consistently longer than recommended, and pre-operative PET utilisation was less than 100%. Thus, there is still room for improvement in surgical lung cancer management in the Southern Health District.

Author Information

Sally Harrison: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Public Hospital, Dunedin, Otago. Michelle Kim: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Public Hospital, Dunedin, Otago.

Acknowledgements

Correspondence

Sally Harrison: Department of Cardiothoracic Surgery, Dunedin Public Hospital, 201 Great King Street Dunedin 9016 Otago New Zealand. +64226444409

Correspondence Email

sally_harrison@hotmail.com

Competing Interests

Nil.

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7) National Lung Cancer Working Group 2016. Standards of Service Provision for Lung Cancer Patients in New Zealand (2nd edn). Wellington: Ministry of Health.

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Multidisciplinary team (MDT) input into cancer treatment aims to provide coordinated care to patients and improve their oncological outcomes as a result.[[1]] MDT meetings are a standard of care for lung cancer management in many regions around the world.[[1]] In New Zealand between 2014 and 2017, 9,093 patients were diagnosed with lung and tracheal malignancy.[[2]] At a regional level, the Southern District Health Board (SDHB) has a catchment of over 350,000 patients, covering the Otago and Southland regions. With the most recent data available, between 2014–2017, the SDHB treated a total of 603 public patients diagnosed with lung cancer.[[3–6]] Lung cancer MDT meetings are conducted once a week at Dunedin Public Hospital for all patients within the SDHB. Thoracic surgery is one of the key components of multidisciplinary care of lung cancer patients.[[7]] In the SDHB, Dunedin Public Hospital is the centre that performs thoracic surgery for those with thoracic malignancy. Both diagnostic biopsies and curative treatment of suspected or proven malignancy are offered.

Clinical quality indicators (CQIs) can be used to assess the effectiveness of multidisciplinary teams, and to analyse important outcomes in the oncological management of patients based on recommended standards.[[8]] CQIs have the capacity to drive quality improvement and can highlight steps in the patient’s lung cancer treatment that could be enhanced. In 2012, the New Zealand Ministry of Health Faster Cancer treatment (NZMHFCT) indicators were implemented into the regional district health boards to ensure thorough collection of data pertaining to oncological management.[[9]] For patients with a confirmed cancer diagnosis, one indicator is whether they have their first cancer treatment within 31 days of the decision to treat.[[9]] Another recommendation is that those patients with a high suspicion of malignancy should be referred to hospital services and have their first treatment within 62 days of the referral being received by the hospital.[[9]] The NZMHFCT indicators are generic guidelines for all cancer treatment.[[9]]

More specific for lung cancer is the Standards of Service Provision for Lung Cancer Patients in New Zealand (SSPLCPNZ) document.[[7]] The second edition of SSPLCPNZ (2016) outlines goals for MDT management. These include all patients (target of ≥95% of patients) seeing a respiratory medicine specialist within 14 days of referral from a general practitioner (GP) or other specialist, and all patients (target ≥95% of patients) commencing lung cancer treatment within 62 days of hospitals receiving a referral. The standard states that all patients should have prompt availability of computed tomography (CT) guided biopsy and endobronchial ultrasound (EBUS) services within seven days of referral (both target ≥95% of patients). All patients with suspected or confirmed small cell and non-small cell lung cancer who are potentially curative should undergo positron emission tomography (PET) scanning (target 100% of patients). The SSPLCPNZ references international guidelines including the British Thoracic Society (BTS) and Society for Cardiothoracic Surgery in Great Britain and Ireland Guidelines on the Radical Management of Patients with Lung Cancer 2010.[[7]]

Although the NZMHFCT and SSPLCPNZ documents give some guidance regarding timeframes for various steps in the lung cancer diagnostic and treatment pathways in New Zealand, they are not comprehensive. As a result, guidelines from the BTS can provide other benchmarks, as these have also been referred to in the SSPLCPNZ document.[[7]]

The purpose of this study was to use existing CQIs to evaluate lung cancer management in thoracic surgical patients in the Southern Health District.

Methods

Medical records for all patients who underwent curative intent oncological lung surgery consisting of wedge resection, lobectomy and pneumonectomy at Dunedin Public Hospital between 2014–2020 were obtained. Curative intent patients included those patients deemed to have radiologically staged disease of I or II with Eastern Cooperative Oncology Group (ECOG) performance status between 0–2. There were no exclusion criteria. Demographic data collected included age, sex, ethnicity, place of residence and New Zealand Index of Deprivation (NZDep) (reflecting socio-economic disparity).[[10]] Place of residence was categorised as either Dunedin and Greater Dunedin or outside of Dunedin, which included other large towns such as Invercargill. Oncological data included PET utilisation, CT biopsy and EBUS referral intervals, radiological staging, pathological staging and histology. Patients were discussed at the weekly lung cancer MDT meeting to decide on proposed investigation and treatment. MDT participants included respiratory physicians, cardiothoracic surgeons, radiation and medical oncologists, a radiologist specialising in lung pathology, a pathologist and a respiratory clinical nurse specialist.

The CQIs for this study included time from referral to first specialist appointment, time from referral to surgery, time from first respiratory specialist appointment to surgery, time from discussion at lung cancer MDT to surgery, timing of CT biopsy or EBUS if these were performed, and inclusion of PET staging. Time from referral to surgery included all referrals from both primary care and secondary care medical practitioners who were non-respiratory specialists. Concordance of radiological and pathological stage was also investigated. These CQIs were based on the SSPLCPNZ, NZMHFCT indicators and BTS Lung Cancer Guideline.[[7,9,11]] Justification for the inclusion of these particular CQIs are included in Table 1.

Statistics

The percentage of patients that met the prescribed timeframes for CQI 1–5 for each year was calculated. Mean days for each timeframe along the lung cancer pathway were also derived from cumulative patient data for each year studied. The rate of PET uptake was described as a percentage of surgical patients undergoing PET scanning in a certain year (CQI 6). IBM SPSS statistical software was used for analysis.

This study was exempt from review by the Southern Health and Disability Ethics Committee.

Results

A total of 108 patients underwent oncological thoracic surgery between 2014–2020 at Dunedin Public Hospital, with a mean age of 70.5 years and a relatively equal proportion of males and females (Table 2). In terms of ethnicity, 91 patients identified as New Zealand European (84.3%); 11 as Māori (10.2%); three as European (2.8%); one as Samoan (0.9%); one as Asian (0.9%); and one as Middle Eastern (0.9%). Seventy-one patients (65.7%) were from outside the greater Dunedin area (defined as up to one hours’ drive away from Dunedin). Eight Māori patients (7.4% of all patients) lived outside Dunedin. Regarding the NZDep Index, indices of 1–2 demonstrate low levels of deprivation and indices of 9–10 the highest levels of deprivation.[[10]] Fifty-three patients (49.1%) had a NZDep Index of 7–10, highlighting high levels of deprivation in the cohort.

The majority of procedures performed were lobectomies (80.6%). Fifty-eight patients (53.7%) did not have a histological diagnosis before their operation. In terms of final surgical histopathology, 66 patients (61.1%) had adenocarcinoma, 38 patients (35.2%) had squamous cell carcinoma, three patients (2.8%) had mixed adenosquamous histology, and one patient (0.9%) had small cell carcinoma. Final pathological staging showed that most patients who were operated on had carcinoma in situ, Stage I and II disease (n=81, 75%). Māori patients had similar frequencies of certain tumour pathologies as non-Māori. Twenty-six patients (24.1% of all patients) had a final staging of incurable disease (Stage IIIA and greater), with five Māori patients (45.5% of Stage IIIA and greater) with incurable disease.

A further breakdown of demographics is found in Table 2.

View Tables 1–2.

The clinical quality indicator for timing of referral to first contact with a respiratory medicine specialist was met, in regards to mean days between these two timepoints in all years studied (Figure 1). In all years bars for 2014 and 2017, the standard for time from referral date to surgery was met based on mean days. In 2017, the mean time to surgery was only longer than this standard by one day. The mean days between respiratory specialist review and surgery was less than 56 days in all years, except for 2014. Based on mean days, 2018 was the only year in which patients were operated on within 31 days of discussion at the Lung cancer MDT. CT guided biopsies and EBUS were only performed within a mean of seven days in two years (2015 and 2017) out of the seven years of data. In no years did 100% of patients receive PETs pre-operatively, with the highest percentage of PETs performed being 88.2% in 2019 (Figure 1).

Figure 1: Six CQIs used to assess the surgical lung cancer management in the SDHB.

Standard demonstrated on graph is as follows (as per Table 1): referral date to respiratory outpatient department (OPD) – 14 days; referral date to OT – 62 days; respiratory OPD to OT – 56 days; lung cancer MDT to OT – 31 days; request date to EBUS/CT biopsy – seven days; PET performed – 100%.

Māori patients accounted for four out of the 17 patients (23.5%) who were classified as NZDep 9–10. Eight Māori patients (72.7% of Māori patients) lived outside of Dunedin. Forty-five-point-five percent of Māori patients had incurable disease at final staging compared to 24.1% of the total cohort. Regarding the ≥95% (90% for CQI 2, 100% for CQI6) percentage compliance targets, five patients (45.5% of all Māori patients) took more than 14 days from referral to first respiratory specialist appointment. From referral to surgery, six patients (54.5%) exceeded the proposed 62 days’ timeframe. Regarding the time from first respiratory specialist appointment to surgery, again six patients (54.5%) were above the proposed 56-day interval. Six patients (54.5%) took longer than 31 days from the time of discussion at the lung cancer MDT to surgery. Thus, no CQI met the standard proposed for Māori patients. However, when Māori patients were excluded from the dataset, non-Māori patients also did not meet CQI targets in any years, except for CQI 1 in 2015 and 2016. For Māori patients, the mean number of days from referral to first respiratory specialist appointment was 30.3 days, from referral to surgery was 79.6 days, from first respiratory specialist appointment to surgery was 78.5 days, from discussion at lung cancer MDT to surgery was 47.6 days and from referral to CT biopsy or EBUS 8.7 days. When comparing to non-Māori patients, Māori patients had longer timeframes for all outcomes except for time from referral to CT biopsy or EBUS. Out of the six patients who had CT biopsies performed, it took four patients (66.7%) over one week for this to occur from referral. Six patients (54.5%) had PET scans performed pre-operatively, with a target of 100%.

In terms of patients with the highest deprivation indices (NZDep 9–10; 20 patients over all years), four patients (10% of all NZDep 9–10) took more than 14 days from referral to first respiratory specialist appointment and eight patients (40%) took longer than 62 days from referral to surgery. Regarding time from first respiratory specialist appointment to surgery, seven patients (35%) exceeded 56 days. Discussion at lung cancer MDT to surgery was longer than 31 days in 13 patients (65%). This is compared to those who had the lowest deprivation indices (NZDep 1–2; 15 patients over all years) who had values of 17% (of all NZDep 1–2 patients), 13%, 17% and 47%, respectively, for the same CQIs. Cumulatively over all years, these patients’ treatment did not meet the standards for referral date to surgery (mean 67.9 days vs 59.7 days for NZDep 1–2), first respiratory specialist appointment to surgery (mean 61.2 days versus 49.6 days for NZDep 1–2), lung cancer MDT to surgery (mean 45.4 days versus 40.5 days for NZDep 1–2) or request date to EBUS or CT biopsy (mean 11 days versus 4.8 days for NZDep 1–2). However, the mean days from referral to respiratory specialist appointment was 7.3 days (better than for the least deprived patients who had a mean of 10.1 days). Five patients (25%) had longer than one week between referral for CT biopsy and this being performed. The rate of PET scanning pre-operatively was 70% (compared to 80% for NZDep 1–2).

Overall, Māori patients and those with the highest deprivation indices were found to meet CQIs less frequently than the total cohort; however, due to the small number of patients making up these groups, a level of statistical significance cannot be calculated.

Comparison of radiological versus pathological staging in patients who underwent oncological surgery showed upstaging was more frequent than downstaging, with 21 patients (19.4%) over the seven-year study period being upstaged and 16 downstaged (14.8%). Fifteen (71.4%) patients who were upstaged had PETs performed pre-operatively. In hindsight, a total of nine patients (8.3%) with final N2 disease should not have been offered surgery within the seven-year study period. Of the patients who were upstaged, ten patients were upstaged on the basis of nodal status, but only eight patients received preoperative PET staging (80%).

Discussion

The purpose of this study was to determine whether the Southern DHB is meeting national standards for surgical lung cancer management. The six CQIs investigated were primarily derived from the SSPLCPNZ document, NZMHFCT indicators and the BTS Lung Cancer Guideline.[[7,9,11]] Both the BTS guideline and the SSPLCPNZ document are based on the National Institute for Health and Care Excellence (NICE), Welsh and Scottish National guidelines and the American National Cancer Care Network guideline. Thus, these standards allow comparison to other developed health care systems around the world.[[7]]

To summarise, except for CQI 1 in 2015 and 2016, no CQIs over any years reached the target of ≥95% (90% for CQI 2, 100% for CQI 6) of patients meeting SSPLCPNZ, NZMHFCT or BTS standards. The CQI for referral to first contact with a respiratory medicine specialist met the SSPLCPNZ standard in all years studied in terms of mean days; however, 31-, 56- and 62-day timeframes were not met in terms of mean days for all years. 2015 and 2017 were the only years in which CT guided biopsy and EBUS were performed within seven days of referral based on mean days. The target of all patients with curative small or non-small cell lung cancer pre-operatively receiving a PET was not reached in any year. Upstaging was more frequent than downstaging post-operatively (19.4% vs 14.8%), with 71.4% who were upstaged receiving a PET scan pre-operatively. Two patients did not have PET scans before their surgery, which may have ultimately changed their clinical course if this had demonstrated N2 disease.

Māori patients and those living outside Dunedin did not regularly meet SSPLCPNZ, NZMHFCT or BTS standards. There is no nationwide standard for provision of lung cancer treatment specific to Māori patients.

Previous research has demonstrated mortality rates up to 3.5 times higher in Māori patients with lung cancer compared to non-Māori patients.[[17,18]] Deficits in secondary care and diagnosis at late stage due to reduced access to general practitioners may have contributed to this disparity.[[18]] Māori patients accounted for four out of the 17 NZDep indices of 9 and 10 (23.5%), which is disproportionate to their ethnic proportion of 11% in this study. A high proportion (72.7%) of Māori patients in this study lived outside Dunedin which may have also contributed to poor continuity of care and to later referrals to secondary services. Stevens et al found that Māori patients had a significantly longer time from diagnosis to treatment.[[17]] The current study has confirmed this finding with 54.5% of Māori patients exceeding the 56-day interval, as opposed to 29.4% for all patients over all years. Additionally, 54.5% of Māori patients exceeded the 31-day interval, again compared to 46.7% of all patients over all years.

Most patients were from outside of Dunedin in the current study, so this did not have a significant influence on outcomes. However, 18.5% of patients had the highest levels of deprivation based on NZ Deprivation scoring (9–10) and these patients had the longest waits from referral to surgery with a mean of 67.9 days. For example, 13 patients (65% of NZ Dep 9–10 patients) had more than 31 days between discussion at lung cancer MDT and surgery, showing that deprivation may be a barrier to expedited cancer care.

Clinical quality indicators are tools for local institutions to benchmark their lung cancer management against national and international standards.[[8]] As this study is the first New Zealand study of this type, the results can only be compared to international research.

Comparable statistics from other sources include those from two large audits. The UK National Lung Cancer Audit (NLCA) 2019/2020 found that for all patients undergoing lung cancer treatment (both surgical and nonsurgical), the median time to treatment was 28 days (2019) and 27 days (2020) nationally.[[19]] The Victorian Lung Cancer Registry Annual Report for 2019 has numerous equivalent clinical quality indicators.[[20]] The mean rate of PET uptake in patients undergoing resection of was 96% in this report, far higher than the current study. The proportion of patients with non-small cell lung cancer who underwent surgical resection and whose clinical stage was in agreement with pathological stage was 83%.[[20]] In the current study, 19.4% of patients were upstaged and 14.8% downstaged (total 34.2%), with agreement of staging in only 65.8% of cases.

Furthermore, the Queensland Lung Quality Index 2011–2016 noted a median time from diagnosis to surgery of 30 days, with 46% of all patients having surgery within this time period.[[21]] This was benchmarked against a standard of 42 days as per the Cancer Council Australia’s Optimal Care Pathway for lung cancer patients.[[22]] A surrogate marker in this study for diagnosis to surgery could be discussion at the lung cancer MDT to surgery, with a standard of 31 days. In this case, results ranged from 23.1–57.1% of patients reaching this target of the seven years, not dissimilar to the Queensland statistics. In terms of rural patients and those at socio-economic disadvantage, the Queensland data found that patients living outside a major city did not receive different care but those who were socio-economically disadvantaged did.[[21]] This mirrors the result of the current study. The Danish National Indicator Project has highlighted certain clinical quality indicators for lung cancer management.[[23]] Comparable to the current study is the time from referral to diagnosis of 28 days with the target of 85% of patients achieving this standard. Similarly, the waiting time for surgery (presumed from referral) should be 14 days, with a target of 85% of patients reaching this. In 2006, 69% of patients met the referral to diagnostic standard and 83% of patients met the waiting time until surgery standard with both results under the 85% standard.[[23]] This data demonstrates considerably better achievements of standards than the current study.

The West of Scotland Cancer Network Audit Report for Lung Quality Performance Indicators for 2019 included reviewing whether non-small cell lung cancer patients were undergoing pre-treatment PETs, with a target of 95% of patients receiving this.[[24]] They found that all districts achieved this target and thus far greater rates of PET scanning compared to the Southern DHB.[[24]] Similarly, other UK studies have mostly achieved critical timeframes along the treatment pathway based on BTS guidelines. A 2007 study from the South Manchester University Hospital had a mean of 3.8 days for GP referral to first respiratory specialist appointment (standard of 14 days).[[25]] Additionally, a mean of 53.8 days from GP referral to decision to treat (a surrogate for lung cancer MDT; standard of 31 days) and a mean of 75.5 days from GP referral to definitive treatment (standard of 62 days) were demonstrated.[[25]] A 2002 study, again comparing to BTS guidelines, found that the median days from respiratory review to decision to operate (again a surrogate for Lung cancer MDT) was 14 and from lung cancer MDT to operation was 17 days.[[26]] The median timeframe between first respiratory physician review and surgery was 24 days.[[24]]

The goal of CQIs is to identify areas that require improvement or further investigation. Apart from time from referral to respiratory physician review, all CQIs have improved since 2014; however, benchmarks were not always met. The time between respiratory specialist review and surgery has been standardised at 56 days in the BTS guideline.[[11]] This was met in the most recent years of the study (2015–2020). This is interesting considering that this is not part of the New Zealand guideline, but that improvement has occurred despite this.

There have been multiple quality improvement strategies implemented by Southern DHB regarding lung cancer investigation and management.

The first engagement the patient has with the hospital healthcare system is the Fast Track respiratory clinic at Dunedin Hospital, which allows streamlined management for patients with suspected lung cancer. Respiratory physician assessment and bronchoscopy with potential for tissue biopsy is performed on the same day. The clinic relieves some of the responsibility of general practitioners to commence what can be a complex investigatory pathway for lung cancer. It appears that this Fast Track clinic is facilitating timely review of patients as seen in the outcomes from 2014–2020.

The longer than 31-day interval between the lung cancer MDT meeting and surgery was potentially impacted by only having a fortnightly thoracic operating list at Dunedin Hospital. Additionally, the need for patient assessment in the Cardiothoracic Surgery outpatient clinic to quantify surgical risk and optimise the patient’s condition prior to surgery may have lengthened this interval. In order to improve this outcome, in the last three years there has been more extensive evaluation via the Fast Track clinic (including full spirometric workup) before the patient’s presentation at the lung cancer MDT meeting. Another quality improvement measure has been for patients who are on the surgical waiting list but are likely to breach the 31-day standard to be brought forward for surgery on lists that are usually used for cardiac surgery patients. This clinical reprioritisation had significantly reduced the thoracic oncological waiting list. Reassessment of this CQI should occur with data from 2021 onwards, to ensure that these measures have resulted in an ongoing improvement.

Accessing diagnostic services may have impacted the timeliness of management. This includes EBUS and PET scanning, which is only available at Christchurch Hospital for any public patients in the SDHB catchment. In 2020, the lengthening of time from referral to PET and CT guided biopsy dates was likely affected by the COVID-19 pandemic. Currently, PET scans are also being referred to the private sector to ensure there is adequate staging for all patients with curative potential and until more public PET facilities are available to the SDHB catchment.

As of 2021, a quality assurance committee has finally been established for patients undergoing lung cancer treatment under the Southern DHB. It is aimed at ensuring patients are receiving care in concordance with New Zealand Standards of Service Provision for lung cancer, including reduced timeframes between key points in their management. In order to address the issue of access to timely EBUS services, a business case has been developed to commence EBUS at Dunedin Hospital.

This study has limitations. There are relatively few cases that were analysed in this study—only 108 cases over seven years. Surgical resection is most likely to result in cure for patients with early-stage non-small cell cancer compared to other treatment modalities.[[7]] The low surgical treatment numbers in this study may be a reflection of cautious patient selection based on Lung cancer MDT discussion where patients with higher ECOG scores may have been deemed as not surgically suitable. It has been shown that rates of surgical resection of non-small cell lung cancer in New Zealand is 14.1%, which is lower than other countries, including Australia (for example, the rate of resection in Victoria is 19.1%).[[20]] Quality of patient records is also likely to have impacted on the accuracy of this study, particularly regarding correct documentation of radiological staging. It must be noted that the clinical quality indicators are developed for all lung cancer patients, many of whom will not undergo surgery. Patients with early-stage lung cancer and those who were referred for surgery but subsequently were not operated on are not included in this study, and thus the results should be interpreted in this context. Finally, analysis of outcomes for Māori patients and those with socio-economic deprivation is challenging due to their small proportion of the studied cohort.

Conclusion

Between 2014–2020, the standards for lung cancer management in SDHB surgical patients was frequently achieved in terms of mean days. However, a target of ≥95% (90% for CQI 2; 100% for CQI 6) of patients receiving care at the standard was rarely met. Timing of CT biopsy and EBUS was consistently longer than recommended and pre-operative PET utilisation was less than 100%. Māori patients and those patients who were the most socio-economically deprived appear to have inequity of care compared to non-Māori patients and those who are not socio-economically deprived. Thus, there is still potential for improvement.

Guaranteeing equity of resource in regards to PET scans and EBUS will be important in the future. This is particularly true in Otago and Southland regions, as these regions have a greater proportion of patients over 60 years of age than the rest of New Zealand.[[27]] It is hoped that this important step in many patients’ lung cancer management can be provided at a local level.

Summary

Abstract

Aim

Multidisciplinary team (MDT) meetings are a standard of care for lung cancer management in many regions around the world. Clinical quality indicators (CQIs) can be used to assess the proficiency of these multidisciplinary teams and compare their performance against those recommended by local and international guidelines. The effectiveness of the lung cancer MDT meeting at Dunedin Public Hospital has been evaluated using CQIs with a focus on the timeliness of surgical management.

Method

Medical records for all 108 patients who underwent curative intent oncological lung surgery at Dunedin Public Hospital between 2014–2020 were obtained. All patients were discussed at the lung cancer MDT meeting. Performance in six CQIs were evaluated as per the results below.

Results

The CQI for timing of referral to first contact with a respiratory medicine specialist was met in all years studied by mean days. In all years bars for 2014 and 2017, the standard for time by mean days from referral date to surgery was met. In 2017, the mean time to surgery exceeded this standard by only one day. The mean time between respiratory specialist review and surgery was less than 56 days in all years except for 2014. By mean days, 2018 was the only year that surgery was performed within 31 days of discussion at the lung cancer MDT. Computed tomography (CT) guided biopsies and endobronchial ultrasound (EBUS) were only performed within a mean of seven days in only two years (2015 and 2017) out of the seven years of data. The target of all patients with curative small or non-small cell lung cancer receiving a positron emission tomography (PET) scan was not achieved in any year. Post-operative upstaging was more frequent than downstaging (19.4% vs 14.8%), and 71.4% of those upstaged received a PET scan pre-operatively. Māori patients and those with significant socio-economic deprivation were less likely to meet standards of lung cancer care.

Conclusion

Between 2014–2020, the standards for lung cancer management in surgical patients were frequently achieved as measured by mean days. However, a target of ≥95% (90% for CQI 2; 100% for CQI 6) of patients receiving care at the standard was rarely met. Timing of CT biopsy and EBUS was consistently longer than recommended, and pre-operative PET utilisation was less than 100%. Thus, there is still room for improvement in surgical lung cancer management in the Southern Health District.

Author Information

Sally Harrison: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Public Hospital, Dunedin, Otago. Michelle Kim: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Public Hospital, Dunedin, Otago.

Acknowledgements

Correspondence

Sally Harrison: Department of Cardiothoracic Surgery, Dunedin Public Hospital, 201 Great King Street Dunedin 9016 Otago New Zealand. +64226444409

Correspondence Email

sally_harrison@hotmail.com

Competing Interests

Nil.

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2) Ministry of Health 2019. Cancer: Historical summary 1948-2017. Wellington: Ministry of Health. New Zealand Cancer Registry.

3) Ministry of Health 2016. New cancer registrations 2014. Wellington: Ministry of Health. New Zealand Cancer Registry.

4) Ministry of Health 2017. New cancer registrations 2015. Wellington: Ministry of Health. New Zealand Cancer Registry.

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6) Ministry of Health 2020. New cancer registrations 2017. Wellington: Ministry of Health. New Zealand Cancer Registry.

7) National Lung Cancer Working Group 2016. Standards of Service Provision for Lung Cancer Patients in New Zealand (2nd edn). Wellington: Ministry of Health.

8) Campbell SM, Braspenning J, Hutchinson A, Marshall MN. Research methods used in developing and applying quality indicators in primary care. BMJ. 2003;326:816‐19.

9) Ministry of Health. 2013. National Cancer Programme: Work Plan 2012/13. Wellington: Ministry of Health. New Zealand Cancer Registry.

10) Atkinson J, Salmond C, Crampton P. NZDep2018 Index of Deprivation, Final Research Report, December 2020. Wellington: University of Otago.

11) BTS recommendations to respiratory physicians for organising the care of patients with lung cancer. The Lung Cancer Working Party of the British Thoracic Society Standards of Care Committee. Thorax. 1998;53:S1-8.

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Multidisciplinary team (MDT) input into cancer treatment aims to provide coordinated care to patients and improve their oncological outcomes as a result.[[1]] MDT meetings are a standard of care for lung cancer management in many regions around the world.[[1]] In New Zealand between 2014 and 2017, 9,093 patients were diagnosed with lung and tracheal malignancy.[[2]] At a regional level, the Southern District Health Board (SDHB) has a catchment of over 350,000 patients, covering the Otago and Southland regions. With the most recent data available, between 2014–2017, the SDHB treated a total of 603 public patients diagnosed with lung cancer.[[3–6]] Lung cancer MDT meetings are conducted once a week at Dunedin Public Hospital for all patients within the SDHB. Thoracic surgery is one of the key components of multidisciplinary care of lung cancer patients.[[7]] In the SDHB, Dunedin Public Hospital is the centre that performs thoracic surgery for those with thoracic malignancy. Both diagnostic biopsies and curative treatment of suspected or proven malignancy are offered.

Clinical quality indicators (CQIs) can be used to assess the effectiveness of multidisciplinary teams, and to analyse important outcomes in the oncological management of patients based on recommended standards.[[8]] CQIs have the capacity to drive quality improvement and can highlight steps in the patient’s lung cancer treatment that could be enhanced. In 2012, the New Zealand Ministry of Health Faster Cancer treatment (NZMHFCT) indicators were implemented into the regional district health boards to ensure thorough collection of data pertaining to oncological management.[[9]] For patients with a confirmed cancer diagnosis, one indicator is whether they have their first cancer treatment within 31 days of the decision to treat.[[9]] Another recommendation is that those patients with a high suspicion of malignancy should be referred to hospital services and have their first treatment within 62 days of the referral being received by the hospital.[[9]] The NZMHFCT indicators are generic guidelines for all cancer treatment.[[9]]

More specific for lung cancer is the Standards of Service Provision for Lung Cancer Patients in New Zealand (SSPLCPNZ) document.[[7]] The second edition of SSPLCPNZ (2016) outlines goals for MDT management. These include all patients (target of ≥95% of patients) seeing a respiratory medicine specialist within 14 days of referral from a general practitioner (GP) or other specialist, and all patients (target ≥95% of patients) commencing lung cancer treatment within 62 days of hospitals receiving a referral. The standard states that all patients should have prompt availability of computed tomography (CT) guided biopsy and endobronchial ultrasound (EBUS) services within seven days of referral (both target ≥95% of patients). All patients with suspected or confirmed small cell and non-small cell lung cancer who are potentially curative should undergo positron emission tomography (PET) scanning (target 100% of patients). The SSPLCPNZ references international guidelines including the British Thoracic Society (BTS) and Society for Cardiothoracic Surgery in Great Britain and Ireland Guidelines on the Radical Management of Patients with Lung Cancer 2010.[[7]]

Although the NZMHFCT and SSPLCPNZ documents give some guidance regarding timeframes for various steps in the lung cancer diagnostic and treatment pathways in New Zealand, they are not comprehensive. As a result, guidelines from the BTS can provide other benchmarks, as these have also been referred to in the SSPLCPNZ document.[[7]]

The purpose of this study was to use existing CQIs to evaluate lung cancer management in thoracic surgical patients in the Southern Health District.

Methods

Medical records for all patients who underwent curative intent oncological lung surgery consisting of wedge resection, lobectomy and pneumonectomy at Dunedin Public Hospital between 2014–2020 were obtained. Curative intent patients included those patients deemed to have radiologically staged disease of I or II with Eastern Cooperative Oncology Group (ECOG) performance status between 0–2. There were no exclusion criteria. Demographic data collected included age, sex, ethnicity, place of residence and New Zealand Index of Deprivation (NZDep) (reflecting socio-economic disparity).[[10]] Place of residence was categorised as either Dunedin and Greater Dunedin or outside of Dunedin, which included other large towns such as Invercargill. Oncological data included PET utilisation, CT biopsy and EBUS referral intervals, radiological staging, pathological staging and histology. Patients were discussed at the weekly lung cancer MDT meeting to decide on proposed investigation and treatment. MDT participants included respiratory physicians, cardiothoracic surgeons, radiation and medical oncologists, a radiologist specialising in lung pathology, a pathologist and a respiratory clinical nurse specialist.

The CQIs for this study included time from referral to first specialist appointment, time from referral to surgery, time from first respiratory specialist appointment to surgery, time from discussion at lung cancer MDT to surgery, timing of CT biopsy or EBUS if these were performed, and inclusion of PET staging. Time from referral to surgery included all referrals from both primary care and secondary care medical practitioners who were non-respiratory specialists. Concordance of radiological and pathological stage was also investigated. These CQIs were based on the SSPLCPNZ, NZMHFCT indicators and BTS Lung Cancer Guideline.[[7,9,11]] Justification for the inclusion of these particular CQIs are included in Table 1.

Statistics

The percentage of patients that met the prescribed timeframes for CQI 1–5 for each year was calculated. Mean days for each timeframe along the lung cancer pathway were also derived from cumulative patient data for each year studied. The rate of PET uptake was described as a percentage of surgical patients undergoing PET scanning in a certain year (CQI 6). IBM SPSS statistical software was used for analysis.

This study was exempt from review by the Southern Health and Disability Ethics Committee.

Results

A total of 108 patients underwent oncological thoracic surgery between 2014–2020 at Dunedin Public Hospital, with a mean age of 70.5 years and a relatively equal proportion of males and females (Table 2). In terms of ethnicity, 91 patients identified as New Zealand European (84.3%); 11 as Māori (10.2%); three as European (2.8%); one as Samoan (0.9%); one as Asian (0.9%); and one as Middle Eastern (0.9%). Seventy-one patients (65.7%) were from outside the greater Dunedin area (defined as up to one hours’ drive away from Dunedin). Eight Māori patients (7.4% of all patients) lived outside Dunedin. Regarding the NZDep Index, indices of 1–2 demonstrate low levels of deprivation and indices of 9–10 the highest levels of deprivation.[[10]] Fifty-three patients (49.1%) had a NZDep Index of 7–10, highlighting high levels of deprivation in the cohort.

The majority of procedures performed were lobectomies (80.6%). Fifty-eight patients (53.7%) did not have a histological diagnosis before their operation. In terms of final surgical histopathology, 66 patients (61.1%) had adenocarcinoma, 38 patients (35.2%) had squamous cell carcinoma, three patients (2.8%) had mixed adenosquamous histology, and one patient (0.9%) had small cell carcinoma. Final pathological staging showed that most patients who were operated on had carcinoma in situ, Stage I and II disease (n=81, 75%). Māori patients had similar frequencies of certain tumour pathologies as non-Māori. Twenty-six patients (24.1% of all patients) had a final staging of incurable disease (Stage IIIA and greater), with five Māori patients (45.5% of Stage IIIA and greater) with incurable disease.

A further breakdown of demographics is found in Table 2.

View Tables 1–2.

The clinical quality indicator for timing of referral to first contact with a respiratory medicine specialist was met, in regards to mean days between these two timepoints in all years studied (Figure 1). In all years bars for 2014 and 2017, the standard for time from referral date to surgery was met based on mean days. In 2017, the mean time to surgery was only longer than this standard by one day. The mean days between respiratory specialist review and surgery was less than 56 days in all years, except for 2014. Based on mean days, 2018 was the only year in which patients were operated on within 31 days of discussion at the Lung cancer MDT. CT guided biopsies and EBUS were only performed within a mean of seven days in two years (2015 and 2017) out of the seven years of data. In no years did 100% of patients receive PETs pre-operatively, with the highest percentage of PETs performed being 88.2% in 2019 (Figure 1).

Figure 1: Six CQIs used to assess the surgical lung cancer management in the SDHB.

Standard demonstrated on graph is as follows (as per Table 1): referral date to respiratory outpatient department (OPD) – 14 days; referral date to OT – 62 days; respiratory OPD to OT – 56 days; lung cancer MDT to OT – 31 days; request date to EBUS/CT biopsy – seven days; PET performed – 100%.

Māori patients accounted for four out of the 17 patients (23.5%) who were classified as NZDep 9–10. Eight Māori patients (72.7% of Māori patients) lived outside of Dunedin. Forty-five-point-five percent of Māori patients had incurable disease at final staging compared to 24.1% of the total cohort. Regarding the ≥95% (90% for CQI 2, 100% for CQI6) percentage compliance targets, five patients (45.5% of all Māori patients) took more than 14 days from referral to first respiratory specialist appointment. From referral to surgery, six patients (54.5%) exceeded the proposed 62 days’ timeframe. Regarding the time from first respiratory specialist appointment to surgery, again six patients (54.5%) were above the proposed 56-day interval. Six patients (54.5%) took longer than 31 days from the time of discussion at the lung cancer MDT to surgery. Thus, no CQI met the standard proposed for Māori patients. However, when Māori patients were excluded from the dataset, non-Māori patients also did not meet CQI targets in any years, except for CQI 1 in 2015 and 2016. For Māori patients, the mean number of days from referral to first respiratory specialist appointment was 30.3 days, from referral to surgery was 79.6 days, from first respiratory specialist appointment to surgery was 78.5 days, from discussion at lung cancer MDT to surgery was 47.6 days and from referral to CT biopsy or EBUS 8.7 days. When comparing to non-Māori patients, Māori patients had longer timeframes for all outcomes except for time from referral to CT biopsy or EBUS. Out of the six patients who had CT biopsies performed, it took four patients (66.7%) over one week for this to occur from referral. Six patients (54.5%) had PET scans performed pre-operatively, with a target of 100%.

In terms of patients with the highest deprivation indices (NZDep 9–10; 20 patients over all years), four patients (10% of all NZDep 9–10) took more than 14 days from referral to first respiratory specialist appointment and eight patients (40%) took longer than 62 days from referral to surgery. Regarding time from first respiratory specialist appointment to surgery, seven patients (35%) exceeded 56 days. Discussion at lung cancer MDT to surgery was longer than 31 days in 13 patients (65%). This is compared to those who had the lowest deprivation indices (NZDep 1–2; 15 patients over all years) who had values of 17% (of all NZDep 1–2 patients), 13%, 17% and 47%, respectively, for the same CQIs. Cumulatively over all years, these patients’ treatment did not meet the standards for referral date to surgery (mean 67.9 days vs 59.7 days for NZDep 1–2), first respiratory specialist appointment to surgery (mean 61.2 days versus 49.6 days for NZDep 1–2), lung cancer MDT to surgery (mean 45.4 days versus 40.5 days for NZDep 1–2) or request date to EBUS or CT biopsy (mean 11 days versus 4.8 days for NZDep 1–2). However, the mean days from referral to respiratory specialist appointment was 7.3 days (better than for the least deprived patients who had a mean of 10.1 days). Five patients (25%) had longer than one week between referral for CT biopsy and this being performed. The rate of PET scanning pre-operatively was 70% (compared to 80% for NZDep 1–2).

Overall, Māori patients and those with the highest deprivation indices were found to meet CQIs less frequently than the total cohort; however, due to the small number of patients making up these groups, a level of statistical significance cannot be calculated.

Comparison of radiological versus pathological staging in patients who underwent oncological surgery showed upstaging was more frequent than downstaging, with 21 patients (19.4%) over the seven-year study period being upstaged and 16 downstaged (14.8%). Fifteen (71.4%) patients who were upstaged had PETs performed pre-operatively. In hindsight, a total of nine patients (8.3%) with final N2 disease should not have been offered surgery within the seven-year study period. Of the patients who were upstaged, ten patients were upstaged on the basis of nodal status, but only eight patients received preoperative PET staging (80%).

Discussion

The purpose of this study was to determine whether the Southern DHB is meeting national standards for surgical lung cancer management. The six CQIs investigated were primarily derived from the SSPLCPNZ document, NZMHFCT indicators and the BTS Lung Cancer Guideline.[[7,9,11]] Both the BTS guideline and the SSPLCPNZ document are based on the National Institute for Health and Care Excellence (NICE), Welsh and Scottish National guidelines and the American National Cancer Care Network guideline. Thus, these standards allow comparison to other developed health care systems around the world.[[7]]

To summarise, except for CQI 1 in 2015 and 2016, no CQIs over any years reached the target of ≥95% (90% for CQI 2, 100% for CQI 6) of patients meeting SSPLCPNZ, NZMHFCT or BTS standards. The CQI for referral to first contact with a respiratory medicine specialist met the SSPLCPNZ standard in all years studied in terms of mean days; however, 31-, 56- and 62-day timeframes were not met in terms of mean days for all years. 2015 and 2017 were the only years in which CT guided biopsy and EBUS were performed within seven days of referral based on mean days. The target of all patients with curative small or non-small cell lung cancer pre-operatively receiving a PET was not reached in any year. Upstaging was more frequent than downstaging post-operatively (19.4% vs 14.8%), with 71.4% who were upstaged receiving a PET scan pre-operatively. Two patients did not have PET scans before their surgery, which may have ultimately changed their clinical course if this had demonstrated N2 disease.

Māori patients and those living outside Dunedin did not regularly meet SSPLCPNZ, NZMHFCT or BTS standards. There is no nationwide standard for provision of lung cancer treatment specific to Māori patients.

Previous research has demonstrated mortality rates up to 3.5 times higher in Māori patients with lung cancer compared to non-Māori patients.[[17,18]] Deficits in secondary care and diagnosis at late stage due to reduced access to general practitioners may have contributed to this disparity.[[18]] Māori patients accounted for four out of the 17 NZDep indices of 9 and 10 (23.5%), which is disproportionate to their ethnic proportion of 11% in this study. A high proportion (72.7%) of Māori patients in this study lived outside Dunedin which may have also contributed to poor continuity of care and to later referrals to secondary services. Stevens et al found that Māori patients had a significantly longer time from diagnosis to treatment.[[17]] The current study has confirmed this finding with 54.5% of Māori patients exceeding the 56-day interval, as opposed to 29.4% for all patients over all years. Additionally, 54.5% of Māori patients exceeded the 31-day interval, again compared to 46.7% of all patients over all years.

Most patients were from outside of Dunedin in the current study, so this did not have a significant influence on outcomes. However, 18.5% of patients had the highest levels of deprivation based on NZ Deprivation scoring (9–10) and these patients had the longest waits from referral to surgery with a mean of 67.9 days. For example, 13 patients (65% of NZ Dep 9–10 patients) had more than 31 days between discussion at lung cancer MDT and surgery, showing that deprivation may be a barrier to expedited cancer care.

Clinical quality indicators are tools for local institutions to benchmark their lung cancer management against national and international standards.[[8]] As this study is the first New Zealand study of this type, the results can only be compared to international research.

Comparable statistics from other sources include those from two large audits. The UK National Lung Cancer Audit (NLCA) 2019/2020 found that for all patients undergoing lung cancer treatment (both surgical and nonsurgical), the median time to treatment was 28 days (2019) and 27 days (2020) nationally.[[19]] The Victorian Lung Cancer Registry Annual Report for 2019 has numerous equivalent clinical quality indicators.[[20]] The mean rate of PET uptake in patients undergoing resection of was 96% in this report, far higher than the current study. The proportion of patients with non-small cell lung cancer who underwent surgical resection and whose clinical stage was in agreement with pathological stage was 83%.[[20]] In the current study, 19.4% of patients were upstaged and 14.8% downstaged (total 34.2%), with agreement of staging in only 65.8% of cases.

Furthermore, the Queensland Lung Quality Index 2011–2016 noted a median time from diagnosis to surgery of 30 days, with 46% of all patients having surgery within this time period.[[21]] This was benchmarked against a standard of 42 days as per the Cancer Council Australia’s Optimal Care Pathway for lung cancer patients.[[22]] A surrogate marker in this study for diagnosis to surgery could be discussion at the lung cancer MDT to surgery, with a standard of 31 days. In this case, results ranged from 23.1–57.1% of patients reaching this target of the seven years, not dissimilar to the Queensland statistics. In terms of rural patients and those at socio-economic disadvantage, the Queensland data found that patients living outside a major city did not receive different care but those who were socio-economically disadvantaged did.[[21]] This mirrors the result of the current study. The Danish National Indicator Project has highlighted certain clinical quality indicators for lung cancer management.[[23]] Comparable to the current study is the time from referral to diagnosis of 28 days with the target of 85% of patients achieving this standard. Similarly, the waiting time for surgery (presumed from referral) should be 14 days, with a target of 85% of patients reaching this. In 2006, 69% of patients met the referral to diagnostic standard and 83% of patients met the waiting time until surgery standard with both results under the 85% standard.[[23]] This data demonstrates considerably better achievements of standards than the current study.

The West of Scotland Cancer Network Audit Report for Lung Quality Performance Indicators for 2019 included reviewing whether non-small cell lung cancer patients were undergoing pre-treatment PETs, with a target of 95% of patients receiving this.[[24]] They found that all districts achieved this target and thus far greater rates of PET scanning compared to the Southern DHB.[[24]] Similarly, other UK studies have mostly achieved critical timeframes along the treatment pathway based on BTS guidelines. A 2007 study from the South Manchester University Hospital had a mean of 3.8 days for GP referral to first respiratory specialist appointment (standard of 14 days).[[25]] Additionally, a mean of 53.8 days from GP referral to decision to treat (a surrogate for lung cancer MDT; standard of 31 days) and a mean of 75.5 days from GP referral to definitive treatment (standard of 62 days) were demonstrated.[[25]] A 2002 study, again comparing to BTS guidelines, found that the median days from respiratory review to decision to operate (again a surrogate for Lung cancer MDT) was 14 and from lung cancer MDT to operation was 17 days.[[26]] The median timeframe between first respiratory physician review and surgery was 24 days.[[24]]

The goal of CQIs is to identify areas that require improvement or further investigation. Apart from time from referral to respiratory physician review, all CQIs have improved since 2014; however, benchmarks were not always met. The time between respiratory specialist review and surgery has been standardised at 56 days in the BTS guideline.[[11]] This was met in the most recent years of the study (2015–2020). This is interesting considering that this is not part of the New Zealand guideline, but that improvement has occurred despite this.

There have been multiple quality improvement strategies implemented by Southern DHB regarding lung cancer investigation and management.

The first engagement the patient has with the hospital healthcare system is the Fast Track respiratory clinic at Dunedin Hospital, which allows streamlined management for patients with suspected lung cancer. Respiratory physician assessment and bronchoscopy with potential for tissue biopsy is performed on the same day. The clinic relieves some of the responsibility of general practitioners to commence what can be a complex investigatory pathway for lung cancer. It appears that this Fast Track clinic is facilitating timely review of patients as seen in the outcomes from 2014–2020.

The longer than 31-day interval between the lung cancer MDT meeting and surgery was potentially impacted by only having a fortnightly thoracic operating list at Dunedin Hospital. Additionally, the need for patient assessment in the Cardiothoracic Surgery outpatient clinic to quantify surgical risk and optimise the patient’s condition prior to surgery may have lengthened this interval. In order to improve this outcome, in the last three years there has been more extensive evaluation via the Fast Track clinic (including full spirometric workup) before the patient’s presentation at the lung cancer MDT meeting. Another quality improvement measure has been for patients who are on the surgical waiting list but are likely to breach the 31-day standard to be brought forward for surgery on lists that are usually used for cardiac surgery patients. This clinical reprioritisation had significantly reduced the thoracic oncological waiting list. Reassessment of this CQI should occur with data from 2021 onwards, to ensure that these measures have resulted in an ongoing improvement.

Accessing diagnostic services may have impacted the timeliness of management. This includes EBUS and PET scanning, which is only available at Christchurch Hospital for any public patients in the SDHB catchment. In 2020, the lengthening of time from referral to PET and CT guided biopsy dates was likely affected by the COVID-19 pandemic. Currently, PET scans are also being referred to the private sector to ensure there is adequate staging for all patients with curative potential and until more public PET facilities are available to the SDHB catchment.

As of 2021, a quality assurance committee has finally been established for patients undergoing lung cancer treatment under the Southern DHB. It is aimed at ensuring patients are receiving care in concordance with New Zealand Standards of Service Provision for lung cancer, including reduced timeframes between key points in their management. In order to address the issue of access to timely EBUS services, a business case has been developed to commence EBUS at Dunedin Hospital.

This study has limitations. There are relatively few cases that were analysed in this study—only 108 cases over seven years. Surgical resection is most likely to result in cure for patients with early-stage non-small cell cancer compared to other treatment modalities.[[7]] The low surgical treatment numbers in this study may be a reflection of cautious patient selection based on Lung cancer MDT discussion where patients with higher ECOG scores may have been deemed as not surgically suitable. It has been shown that rates of surgical resection of non-small cell lung cancer in New Zealand is 14.1%, which is lower than other countries, including Australia (for example, the rate of resection in Victoria is 19.1%).[[20]] Quality of patient records is also likely to have impacted on the accuracy of this study, particularly regarding correct documentation of radiological staging. It must be noted that the clinical quality indicators are developed for all lung cancer patients, many of whom will not undergo surgery. Patients with early-stage lung cancer and those who were referred for surgery but subsequently were not operated on are not included in this study, and thus the results should be interpreted in this context. Finally, analysis of outcomes for Māori patients and those with socio-economic deprivation is challenging due to their small proportion of the studied cohort.

Conclusion

Between 2014–2020, the standards for lung cancer management in SDHB surgical patients was frequently achieved in terms of mean days. However, a target of ≥95% (90% for CQI 2; 100% for CQI 6) of patients receiving care at the standard was rarely met. Timing of CT biopsy and EBUS was consistently longer than recommended and pre-operative PET utilisation was less than 100%. Māori patients and those patients who were the most socio-economically deprived appear to have inequity of care compared to non-Māori patients and those who are not socio-economically deprived. Thus, there is still potential for improvement.

Guaranteeing equity of resource in regards to PET scans and EBUS will be important in the future. This is particularly true in Otago and Southland regions, as these regions have a greater proportion of patients over 60 years of age than the rest of New Zealand.[[27]] It is hoped that this important step in many patients’ lung cancer management can be provided at a local level.

Summary

Abstract

Aim

Multidisciplinary team (MDT) meetings are a standard of care for lung cancer management in many regions around the world. Clinical quality indicators (CQIs) can be used to assess the proficiency of these multidisciplinary teams and compare their performance against those recommended by local and international guidelines. The effectiveness of the lung cancer MDT meeting at Dunedin Public Hospital has been evaluated using CQIs with a focus on the timeliness of surgical management.

Method

Medical records for all 108 patients who underwent curative intent oncological lung surgery at Dunedin Public Hospital between 2014–2020 were obtained. All patients were discussed at the lung cancer MDT meeting. Performance in six CQIs were evaluated as per the results below.

Results

The CQI for timing of referral to first contact with a respiratory medicine specialist was met in all years studied by mean days. In all years bars for 2014 and 2017, the standard for time by mean days from referral date to surgery was met. In 2017, the mean time to surgery exceeded this standard by only one day. The mean time between respiratory specialist review and surgery was less than 56 days in all years except for 2014. By mean days, 2018 was the only year that surgery was performed within 31 days of discussion at the lung cancer MDT. Computed tomography (CT) guided biopsies and endobronchial ultrasound (EBUS) were only performed within a mean of seven days in only two years (2015 and 2017) out of the seven years of data. The target of all patients with curative small or non-small cell lung cancer receiving a positron emission tomography (PET) scan was not achieved in any year. Post-operative upstaging was more frequent than downstaging (19.4% vs 14.8%), and 71.4% of those upstaged received a PET scan pre-operatively. Māori patients and those with significant socio-economic deprivation were less likely to meet standards of lung cancer care.

Conclusion

Between 2014–2020, the standards for lung cancer management in surgical patients were frequently achieved as measured by mean days. However, a target of ≥95% (90% for CQI 2; 100% for CQI 6) of patients receiving care at the standard was rarely met. Timing of CT biopsy and EBUS was consistently longer than recommended, and pre-operative PET utilisation was less than 100%. Thus, there is still room for improvement in surgical lung cancer management in the Southern Health District.

Author Information

Sally Harrison: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Public Hospital, Dunedin, Otago. Michelle Kim: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Public Hospital, Dunedin, Otago.

Acknowledgements

Correspondence

Sally Harrison: Department of Cardiothoracic Surgery, Dunedin Public Hospital, 201 Great King Street Dunedin 9016 Otago New Zealand. +64226444409

Correspondence Email

sally_harrison@hotmail.com

Competing Interests

Nil.

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