Timely care for patients with lung cancer (LC) is associated with improved clinical outcomes. In Southeastern Ontario, Canada, we identified delays in the diagnostic process for patients undergoing evaluation for suspected LC through a rapid assessment clinic. We developed improvement initiatives with an aim of reducing the time from referral to diagnosis. A Standardized Triage Process (STP) was implemented for patients referred with suspected LC, including routine interdisciplinary triage, standardized pathways with preordered staging tests, and a new Small Nodule Clinic. We retrospectively analyzed all patients referred pre-STP (January to April 2018) and prospectively for improvement (May 2018 to March 2019). Process measures included STP compliance and time to completion of staging investigations (positron emission tomography [PET] and computed tomography/magnetic resonance imaging of brain). Data are reported as means; significance was determined by special-cause variation using Statistical Process Control charts; unpaired t tests were compared between groups. We reviewed 833 referrals (207 baseline and 626 post-STP). STP compliance improved monthly to 99.4%. Post-STP, time from referral to PET decreased (from 38.5 to 15.7 days), time from referral to brain imaging decreased (from 33.4 to 13.1 days), and time from referral to diagnosis decreased (from 38.0 to 22.7 days), all demonstrating special-cause variation. Patients completing preordered staging tests experienced significantly faster care than those without preordered tests, including time to PET (23.0 v 35.9 days), computed tomography/magnetic resonance imaging of brain (16.2 v 29.9 days), and diagnosis (39.9 v 28.1 days), all P < .001. An STP significantly improved timeliness of diagnosis and staging for patients with suspected LC undergoing evaluation in a rapid assessment clinic.

Background: Lung cancer (LC) is the leading cause of cancer-related mortality. In Ontario, Canada, there are significant survival differences for patients with newly diagnosed LC across the 14 provincial regions. Methods: A population-based retrospective cohort study using ICES databases from 01/2007–12/2017 identified patients with newly diagnosed LC through the Ontario Cancer Registry and those with LC as the cause of death. Descriptive data included patient, disease, and system characteristics. The primary outcome was 5-year survival by region. Results: 178,202 patient records were identified; 101,263 met inclusion criteria. LC incidence varied by region (5.6–14.6/10,000), as did histologic subtype (adenocarcinoma: 27.3–46.1%). Five-year cancer-specific survival was impacted by age, rurality, pathologic subtype, stage at diagnosis, and income quintile. Timely care was inversely related to survival (fastest quintile: HR 3.22, p < 0.0001). Adjusted 5-year cancer-specific survival varied across regions (24.1%, HR 1.12; 34.0%, HR 0.89, p < 0.001). Conclusions: When adjusting for confounders, differences in survival by health region persisted, suggesting a complex interplay between patient, disease, and system factors. A single approach to improving patient care is likely to be ineffective across different systems. Quality improvement initiatives to improve patient outcomes require different approaches amongst health regions to address local disparities in care.

Background: Interstitial lung abnormalities (ILAs) are common incidental findings in lung cancer screening (LCS). However, challenges remain in identifying clinically relevant ILAs as highlighted in a joint statement by a European multidisciplinary task force led by the European Respiratory Society (ERS). To address these challenges, we analysed ILAs identified in one of Europe’s largest LCS studies. Methods: Of 11 635 LCS individuals, 417 screen-detected ILAs were evaluated using a new visual classification system focused on traction bronchiolectasis: non-fibrotic ILA (no traction bronchiolectasis), fibrotic ILA (traction bronchiolectasis in ≤2 lobes); undiagnosed interstitial lung disease (traction bronchiolectasis in >2 lobes). Observer agreement was compared with Fleischner Society ILA classification using Cohen’s Kappa. An age, sex and smoking history-matched control group allowed the examination of associations between baseline ILA/UILD and comorbidities, forced vital capacity (FVC), hospitalisations (Student’s t-tests) and mortality (univariable and multivariable Cox proportional hazards models). Findings: Our visual ILA classification showed superior interobserver agreement (K=0.76) versus the Fleischner ILA classification (K=0.64). ILA/UILD subjects had more prevalent comorbidities, increasing (vs controls) approximately 10 years prior to ILA/UILD diagnosis. Compared with controls, mortality rates were 6-fold higher for UILD participants and 3-fold higher for fibrotic and non-fibrotic ILA subtypes. On multivariable Cox regression analysis, ILA/UILD presence (HR=4.90, 95% CI =2.36 to 10.10, p<0.001) showed stronger independent associations with mortality than baseline FVC (HR=0.98, 95% CI =0.96 to 1.00, p=0.04). Conclusion: We demonstrate a new reproducible classification of clinically important ILA/UILDs in LCS populations. We highlight that FVC shows limited associations with mortality in ILA/UILD subjects. Increased multiorgan comorbidity in ILA/UILD subjects highlights a need for comprehensive early multisystem evaluation.

Introduction: Lung cancer is the leading cause of cancer-related death worldwide. Low-dose CT (LDCT) screening improves outcomes by detecting early-stage cancers as pulmonary nodules. As most are benign, diagnosing these nodules is challenging and often requires surveillance imaging. The aim of this study is to assess the frequency of cancer progression in a lung cancer screening study as measured by tumour stage (T-stage). Methods: SUMMIT is a prospective cohort study assessing implementation of lung cancer screening with LDCT in a high-risk population. Screen-detected lung cancers with clinical tumour stage cT1a–c at time of referral were included. Upstaging was defined as an increase in T-stage from referral to treatment. The date of death was obtained from the National Cancer Registration and Analysis Service. Cox proportional hazards analysis with adjustment for age, sex, Charlson Comorbidity Index and pack years was used to assess mortality between groups. Results: 390 screen-detected cancers were stage cT1a–c at time of referral. Upstaging occurred more frequently in cT1a (n=48, 56%) compared with cT1b (n=83, 38%) or cT1c (n=34, 40%), p=0.01. The proportion of part-solid nodules was similar between groups (upstaged-N=47, 27%, vs not upstaged-N=45, 21%, p=0.19). 43% of tumours increased T-stage from referral to first treatment (n=165). In participants upstaged, time from referral to treatment was longer (upstaged: 84 days, 46–298 vs not upstaged: 72 days, 43–211, p=0.04). Adjusted overall survival analyses showed an association between upstaging and mortality (HR 1.68, 95% CI 1.13 to 2.51, p=0.01). Conclusion: Tumour upstaging occurred in nearly half of early-stage cases in a lung cancer screening population. Tumour upstaging was associated with longer time to treatment and poorer outcomes in this population. Trial registration number: NCT03934866 .

This study sought to identify opportunities for improvement of an Internal Medicine (IM) resident quality improvement (QI)/patient safety (PS) program at an academic teaching hospital. The authors conducted semi-structured interviews with 15 residents and 6 attending physicians, which were analyzed from an inductive and thematic lens using NVivo software. Ethics was approved by the institution’s Research Ethics Board (File #: 6026140). Four themes emerged from this analysis. Residents and attending physicians agreed on (i) integrating QI/PS knowledge and skills into practice using active learning approaches. However, there was concern that requiring QI project completion through (ii) standardization of QI/PS education could create a barrier to clinical research required for sub-specialization. There was agreement that the (iii) QI/PS culture within the IM program was supportive and that a lack of safe reporting efficiency within the hospital, along with interprofessional discord, could cause (iv) external barriers to QI/PS training. By integrating these findings, evidence-informed and low-resource solutions could be incorporated into the QI/PS curriculum that uses minimal preparation requirements, and fulsome conversation-based exploration of QI/PS techniques within real-world clinical cases.