Surgical Quality Metric Adherence Substantially Improves Outcomes in Early NSCLC

Overall survival and recurrence-free survival showed substantial improvement when physicians more closely followed quality recommendations for non–small cell lung cancer (NSCLC).

Adherence to intraoperative quality metrics leads to a substantial improvement in the outcomes of patients with early stage non–small cell lung cancer (NSCLC) following curative-intent resection, according to a new study published in JAMA Surgery.

The report found patients receiving care through the Veterans Health Administration (VHA) whose physicians followed most of the 13 intraoperative quality metrics had a median overall survival (OS) more than double that of patients whose physicians followed 5 or fewer metrics.

The preferred treatment for fit patients with early-stage NSCLC is surgical resection, and most guidelines for surgery recommend following a set of modifiable, process-based quality metrics, wrote the study authors.

“These metrics include timely surgery, receipt of anatomic resection, a minimally invasive approach, negative surgical margin, and adequate lymph node sampling,” the authors wrote.

Still, despite evidence that following these metrics improves patient outcomes, widespread adoption of the guidelines has been insufficient, they noted.

“Standardization of lung cancer treatment quality within the VHA may therefore have a disproportionate impact on early-stage NSCLC outcomes among veterans and provide a road map for implementation in the general US population,” they wrote.

To demonstrate the effects of following quality metrics, the authors turned to the VHA, which they said has similar patterns of lung cancer care and outcomes as those of the general population. They then developed a scoring system to see how closely providers were following the quality metrics, and compared those scores with patient outcomes.

The investigators retrospectively compiled a cohort of 9628 veterans who underwent resection for clinical stage I NSCLC between 2006 and 2016. The patients had a mean age of 67.6 years, and most (96.4%) were males. More than half (58.4%) reported being smokers at the time of their treatment.

The analysis showed varying rates of adherence to quality measures. For instance, negative surgical margins were used in most cases (96.7%), but adequate lymph node sampling was performed in just 1 in 3 cases (34.0%).

Using their scoring system, in which 0 points were awarded in cases where no quality metrics were met and 13 points were awarded when all quality metrics were met, the study investigators found stark differences in patient outcomes.

The median OS was 7.0 years when 12 or 13 quality metric points were earned, but just 2.6 years when 0 to 5 points were earned. A risk-adjusted HR calculation showed the adjusted HR for recurrence-free survival between 12 to 13 points and 0 to 5 points was 0.39 (95% CI, 0.31-0.49).

The investigators then used a data set of more than 107,000 nonveteran patients from the National Cancer Database (NCDB) and found a similar benefit to using quality metrics. They noted that although the VHA is often perceived as providing lower-quality care, their rates of quality-metric adherence were similar to those in the NCDB, despite having higher rates of comorbidities than the general population. They said these data show the VHA is already performing well.

“Nonetheless, both the VHA and NCDB data sets suggest that [quality metric] adherence is variable, presenting an opportunity for significant quality improvement efforts in both practice settings,” they wrote.

Although adherence to quality metrics has improved over time, the authors said further policy efforts are needed to ensure the metrics become more fully ingrained in everyday practice.


Heiden BT, Eaton DB Jr, Chang SH, et al. Association between surgical quality metric adherence and overall survival among US veterans with early-stage non-small cell lung cancer. JAMA Surg. Published online January 18, 2023. doi:10.1001/jamasurg.2022.6826

Related Videos
Rachel Dalthorp, MD
dr jennifer vidrine
dr brian koffman
Amy Shapiro, MD, medical director, Indiana Hemophilia and Thrombosis Center
dr thomas hall
RAvin Ratan, MD, MEd, MD Anderson
Amy Shapiro, MD
Ali Khawar
Binod Dhakal, MD
Related Content
CH LogoCenter for Biosimilars Logo