Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, Tennessee.
School of Public Health, University of Memphis, Memphis, Tennessee.
J Thorac Oncol. 2023 Jul;18(7):858-868. doi: 10.1016/j.jtho.2023.03.002. Epub 2023 Mar 15.
Lung cancer surgery with a lymph node kit improves patient-level outcomes, but institution-level impact is unproven.
Using an institutional stepped-wedge implementation study design, we compared lung cancer resection quality between institutions in preimplementation and postimplementation phases of kit deployment and, within implementing institutions, resections without versus with the kit. Benchmarks included rates of nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and attainment of American College of Surgeons Operative Standard 5.8. We report institution-level adjusted ORs (aORs) for attaining quality benchmarks.
From 2009 to 2020, three preimplementing hospitals had 953 resections; 11 implementing hospitals had 4013 resections, 58% without and 42% with the kit. Quality was better in implementing institutions and with kit cases. Compared with preimplementing institutions, the aOR for nonexamination of lymph nodes was 0.62 (0.49-0.8, p = 0.002), nonexamination of mediastinal lymph nodes was 0.56 (0.47-0.68, p < 0.0001), and attainment of Operative Standard 5.8 was 7.3 (5.6-9.4, p < 0.0001); aORs for kit cases were 0.01 (0.001-0.06), 0.08 (0.06-0.11), and 11.6 (9.9-13.7), respectively (p < 0.0001 for all). Surgical quality was persistently poor in preimplementing institutions but sequentially improved in implementing institutions in parallel with kit adoption. In implementing institutions, resections with the kit had a uniformly high level of quality, whereas nonkit cases had a low level of quality, approximating that of preimplementing institutions. Within implementing institutions, 5-year overall survival was 61% versus 51% after surgery with versus without the kit (p < 0.001).
Surgery with a lymph node specimen collection kit improved institution-level quality of curative-intent lung cancer resection.
肺癌手术使用淋巴结试剂盒可改善患者层面的预后，但机构层面的影响尚未得到证实。
采用机构级别的逐步楔形实施研究设计，我们比较了试剂盒实施前和实施后各机构的肺癌切除术质量，并在实施机构内比较了有试剂盒和无试剂盒的切除术。基准包括淋巴结检查率、纵隔淋巴结检查率和达到美国外科医师学院手术标准 5.8 的情况。我们报告了达到质量基准的机构水平调整后的比值比（aOR）。
2009 年至 2020 年，3 家实施前的医院进行了 953 例切除术；11 家实施中的医院进行了 4013 例切除术，其中 58%没有使用试剂盒，42%使用了试剂盒。实施机构和使用试剂盒的病例质量更好。与实施前的机构相比，淋巴结检查率的 aOR 为 0.62（0.49-0.8，p=0.002），纵隔淋巴结检查率的 aOR 为 0.56（0.47-0.68，p<0.0001），达到手术标准 5.8 的 aOR 为 7.3（5.6-9.4，p<0.0001）；试剂盒病例的 aOR 分别为 0.01（0.001-0.06）、0.08（0.06-0.11）和 11.6（9.9-13.7）（p<0.0001 均）。实施前的机构手术质量一直较差，但随着试剂盒的采用，实施中的机构质量逐渐提高。在实施机构中，使用试剂盒的切除术质量普遍较高，而非试剂盒病例的质量较低，接近实施前机构的水平。在实施机构内，手术后 5 年的总生存率为 61%，而使用试剂盒和不使用试剂盒的生存率分别为 51%（p<0.001）。
使用淋巴结标本采集试剂盒可提高机构层面根治性肺癌切除术的质量。
