Zimolzak Andrew J, Kapadia Paarth, Upadhyay Divvy K, Korukonda Saritha, Murugaesh Rekha Riyaa, Mushtaq Umair, Mir Usman, Murphy Daniel R, Offner Alexis, Mounce Luke T A, Abel Gary A, Lyratzopoulos Georgios, Singh Hardeep
Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas.
Department of Medicine, Baylor College of Medicine, Houston, Texas.
JAMA Intern Med. 2025 Jul 21. doi: 10.1001/jamainternmed.2025.2875.
Missed and delayed cancer diagnoses worsen patient outcomes. Overlooking cancer-related diagnostic signals may result in advanced-stage presentations.
To develop and implement a digital quality measure of the proportion of advanced-stage cancer diagnoses in the US and assess the rate of missed diagnostic opportunities.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used electronic health records and a cancer registry of patients with cancer diagnosed from 2016 to 2020 at 2 integrated health care systems, Department of Veterans Affairs (VA) health system and Geisinger Health System. Patients with incident colorectal cancer (CRC) or non-small cell lung cancer, with at least 1 primary care visit in the 2 years before cancer diagnosis, were included. A random sample of 100 advanced-stage cases per cancer type and health system was manually reviewed using a 2-year look-back period. Data were analyzed from January 27 to June 9, 2025.
The primary outcome was a digital quality measure for advanced stage cancer and a descriptive analysis (by health system and cancer type) of the rate of missed opportunities in diagnosis, dates of investigation initiation and completion, and factors associated with missed opportunities.
There were 37 691 patients from the VA health system and 2914 patients from Geisinger with lung cancer, and there were 14 674 patients from the VA health system and 627 patients from Geisinger with CRC. For lung cancer, the advanced stage comprised 45.9% at the VA health system and 58.3% at Geisinger. Advanced CRC stage was 33.2% at the VA health system and 36.2% at Geisinger. Notably, 58.9% (95% CI, 48.6%-68.5%) of patients from the VA health system and 77.8% (95% CI, 68.6%-84.8%) of patients from Geisinger with advanced-stage lung cancer had missed opportunities in diagnosis. For CRC, 66.3% (95% CI, 56.3%-75.0%) of patients at the VA health system and 69.7% (95% CI, 60.0%-77.9%) of patients at Geisinger had missed opportunities. Patients with missed opportunities had notable delays in diagnosis (eg, the median time from diagnostic signal to workup completion ranged from 1 to 20 months). Lack of screening was associated with 6.1% to 16.7% of late-stage cancers across health systems and cancer types. For lung cancer, missed opportunities were associated with problems in patient-clinician encounters and performing and interpreting diagnostic tests. For CRC, missed opportunities were primarily associated with patient-related factors and problems performing and interpreting diagnostic tests.
This study found high rates of missed diagnostic opportunities among patients with advanced-stage cancer. By using advanced stage as a digital quality measure, health systems, payers, and other stakeholders can better identify care gaps and track initiatives to reduce preventable delays in cancer diagnosis.
癌症诊断的遗漏和延迟会使患者的治疗结果恶化。忽视与癌症相关的诊断信号可能导致癌症晚期确诊。
制定并实施一项关于美国癌症晚期诊断比例的数字质量指标，并评估诊断机会遗漏率。
设计、背景和参与者：这项队列研究使用了电子健康记录以及退伍军人事务部（VA）医疗系统和盖辛格医疗系统这两个综合医疗系统中2016年至2020年被诊断为癌症的患者的癌症登记信息。纳入了在癌症诊断前两年内至少有一次初级保健就诊记录的新发结直肠癌（CRC）或非小细胞肺癌患者。对每个癌症类型和医疗系统随机抽取的100例晚期病例进行为期两年的回顾性人工审查。于2025年1月27日至6月9日对数据进行分析。
主要结局是癌症晚期的数字质量指标，以及对诊断机会遗漏率、调查开始和完成日期以及与诊断机会遗漏相关因素的描述性分析（按医疗系统和癌症类型）。
VA医疗系统中有37691例肺癌患者，盖辛格医疗系统中有2914例；VA医疗系统中有14674例CRC患者，盖辛格医疗系统中有627例。对于肺癌，VA医疗系统的晚期比例为45.9%，盖辛格医疗系统为58.3%。VA医疗系统中晚期CRC比例为33.2%，盖辛格医疗系统为36.2%。值得注意的是，VA医疗系统中58.9%（95%CI，48.6%-68.5%）的晚期肺癌患者和盖辛格医疗系统中77.8%（95%CI，68.6%-84.8%）的晚期肺癌患者存在诊断机会遗漏。对于CRC，VA医疗系统中66.3%（95%CI，56.3%-75.0%）的患者和盖辛格医疗系统中69.7%（95%CI，60.0%-77.9%）的患者存在诊断机会遗漏。存在诊断机会遗漏的患者诊断明显延迟（例如，从诊断信号到检查完成的中位时间为1至20个月）。在各个医疗系统和癌症类型中，缺乏筛查与6.1%至16.7%的晚期癌症相关。对于肺癌，诊断机会遗漏与医患接触以及进行和解释诊断检查方面的问题有关。对于CRC，诊断机会遗漏主要与患者相关因素以及进行和解释诊断检查方面的问题有关。
本研究发现晚期癌症患者中诊断机会遗漏率很高。通过将晚期作为数字质量指标，医疗系统、支付方和其他利益相关者可以更好地识别护理差距，并跟踪旨在减少可预防的癌症诊断延迟的举措。
