Defining Quality of Care in Lung Cancer

定义肺癌护理质量

• 批准号: 10048126
• 负责人: Varun Puri
• 金额: --
• 依托单位: ST. LOUIS VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-10-01 至 2023-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10048126
• 关键词: Address; Adherence; Adjuvant; Age; American; American College of Surgeons; Benchmarking; Cancer Etiology; Cancer Patient; Caring; Cessation of life; Chest; Clinical; Colon Carcinoma; Consensus; Data; Data Set; Databases; Diagnosis; Disease; Early treatment; Excision; Expert Opinion; Future; General Population; Geography; Goals; Gold; Guidelines; Health Policy; High Prevalence; Incidence; Individual; Intervention; Knowledge; Lead; Link; Lung; Malignant Neoplasms; Malignant neoplasm of lung; Malignant neoplasm of prostate; Measures; Mediastinal lymph node group; Methodology; Modeling; Morbidity - disease rate; National Comprehensive Cancer Network; Neoplasm Metastasis; Nodal; Non-Small-Cell Lung Carcinoma; Operative Surgical Procedures; Outcome; Pathologic; Patients; Physicians; Policies; Postoperative Complications; Process; Public Health; Quality of Care; Race; Sample Size; Sampling; Socioeconomic Status; Systemic Therapy; Testing; Time; United States Department of Veterans Affairs; Validation; Variant; Veterans; Veterans Health Administration; base; cancer diagnosis; care costs; college; comorbidity; computed tomography screening; cost estimate; evidence base; health care quality; implementation science; improved; innovation; lung cancer screening; meetings; military veteran; model development; mortality; novel; operation; optimal treatments; prospective; rural patients; screening; screening program; smoking prevalence; tumor

Background: Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related mortality in Veterans. With the implementation of computed tomography screening, the incidence of Stage I lung cancer (tumors less than 5 cm with no metastases) is increasing exponentially in Veterans. Stage I NSCLC is potentially curable with surgery as the recognized gold standard of therapy. Wide variations exist in the care of Veterans with lung cancer. These inconsistencies in care are directly linked to suboptimal short- and long-term outcomes. Lack of clear guidelines is an important determinant of variable care. A number of national organizations have proposed quality measures (QMs) for surgery in lung cancer. However, these measures have largely been developed based upon retrospective institutional studies or expert opinion. A lack of evidence-based, validated QMs remains a critical unmet need. To address this crucial gap in knowledge, we will use the large, prospectively maintained Veterans Health Administration (VHA) database. The goal of this proposal is to develop a model to define high-quality surgical care for lung cancer and understand factors impacting quality of surgery. Significance: By creating a model of high-quality surgery for lung cancer, relevant to Veterans and the general population, our proposal directly addresses the Department of Veterans Affairs (VA) priorities of quality of care and transforming VA data into a national treasure. The recently launched VA-Partnership to increase Access to Lung Screening aims to detect 80% of all lung cancers at a curable stage. Our study focuses on optimal therapy for early-stage lung cancer, a current and, even more importantly, future imperative for the Veteran population. Innovation: Our proposal is innovative both conceptually and technically. The conceptual innovation relates to the holistic consideration of modifiable variables to define and impact high quality healthcare. The technical innovation relates to the implementation of a unique approach utilizing a prospectively maintained dataset for model development and validation. Specific Aims: Aim 1. To identify model-based quality measures for surgery in lung cancer and determine which have the greatest impact on short, and long-term outcomes. We hypothesize that among the candidate QMs, our models will identify key measures that are associated with improved short-term outcomes (operative morbidity and mortality) and long-term survival. Aim 2. To evaluate adherence to quality measures for surgery and understand the contribution of geographic, patient-, disease-, and treatment-related factors in adherence to quality measures for surgery in lung cancer. We hypothesize that younger, white patients, with smaller tumors, treated at urban facilities will be associated with meeting QMs for surgery in lung cancer. Methodology: In Aim 1, utilizing the VHA database, we will examine the relationship between adherence to previously proposed (e.g. type of operation, extent of nodal sampling) as well as novel (e.g. delay in surgery) QMs for surgery and short-term outcomes (postoperative complications, 30-day mortality) and long-term survival using regression models. The relative importance of the QMs will be assessed by rank ordering. In Aim 2, we will develop a weighted, validated QM adherence score ranging from 0 (no adherence to QMs) to 100 (complete adherence to QMs) for lung cancer operations. We will evaluate geographic (e.g. urban versus rural), patient (race, comorbidities), disease (e.g. tumor size), and treatment (e.g. facility size) factors associated with adherence to QMs. Next Steps/Implementation: Our study will define “what constitutes a high-quality lung cancer operation”. For the next logical step of “how to optimize the likelihood of a high-quality operation”, we will propose interventions addressing important QMs with input from the results of our study and the advisory board, which represents expertise in lung cancer, health policy, and implementation science. These interventions will be refined and pilot- tested in our VISN 15 in a future study before being nominated for policy change at the national level.

背景：非小细胞肺癌（NSCLC）是退伍军人癌症相关死亡的主要原因。 随着计算机断层扫描筛查的实施，I期肺癌（肿瘤较少）的发病率 超过5厘米，没有转移）是指数增加退伍军人。I期NSCLC可通过以下方法治愈： 手术作为公认的治疗金标准。退伍军人肺部疾病的护理存在很大差异 癌护理中的这些不一致与次优的短期和长期结果直接相关。缺乏 明确的指导方针是可变护理的一个重要决定因素。一些国家组织建议， 肺癌手术的质量措施（QM）。然而，这些措施主要是在 基于回顾性机构研究或专家意见。缺乏循证、经验证的质量管理体系 仍然是一个未得到满足的关键需求。为了解决这一关键的知识差距，我们将使用大型，前瞻性 维护退伍军人健康管理局（VHA）数据库。本提案的目标是开发一个模型， 定义高质量的肺癌手术护理，了解影响手术质量的因素。 意义：通过创建一个高质量的肺癌手术模型，与退伍军人和一般 人口，我们的建议直接解决退伍军人事务部（VA）的护理质量的优先事项 并将退伍军人事务部的数据转化为国家财富最近发起的脆弱性评估伙伴关系， 肺癌筛查旨在检测80%处于可治愈阶段的所有肺癌。我们的研究集中在最佳治疗 对于早期肺癌，这是退伍军人群体当前以及更重要的是未来的当务之急。 创新：我们的建议在概念和技术上都是创新的。概念创新涉及到 全面考虑可修改的变量，以定义和影响高质量的医疗保健。技术 本发明涉及一种独特方法的实现，该方法利用前瞻性维护的数据集， 模型开发和验证。 具体目标：目标1。识别肺癌手术的基于模型的质量指标，并确定 对短期和长期的结果有最大的影响。我们假设在候选QM中， 我们的模型将确定与改善短期结果（手术）相关的关键措施 发病率和死亡率）和长期生存率。目标2.评价对手术质量措施的依从性 并了解地理、患者、疾病和治疗相关因素对依从性的影响， 肺癌手术的质量措施。我们假设年轻的白色患者，肿瘤较小， 在城市机构接受治疗将与满足肺癌手术的QM相关。 方法：在目标1中，利用VHA数据库，我们将研究依从性与 先前提出的（例如手术类型、淋巴结采样范围）以及新的（例如手术延迟） 手术和短期结局（术后并发症、30天死亡率）和长期生存率的QM 使用回归模型。质量管理体系的相对重要性将通过等级排序进行评估。 在目标2中，我们将制定一个加权的、经过验证的QM依从性评分，范围从0（不依从QM）到 100（完全遵守QM）用于肺癌手术。我们将评估地理位置（例如，城市与 农村）、患者（种族、合并症）、疾病（例如肿瘤大小）和治疗（例如设施大小）相关因素 坚持qm。 下一步/实施：我们的研究将定义“什么是高质量的肺癌手术”。为 下一个合乎逻辑的步骤是"如何优化高质量操作的可能性"，我们将提出干预措施 根据我们的研究结果和咨询委员会的意见处理重要的质量管理问题， 肺癌、卫生政策和实施科学方面的专业知识。这些干预措施将得到完善和试点- 在未来的研究中，在我们的VISN 15中进行测试，然后被提名为国家层面的政策变化。