A pilot quality improvement initiative for lymph node dissection during lung cancer surgery

Objectives: To evaluate the impact of a quality improvement initiative on intraoperative lymph node (LN) dissection adequacy.

Methods: A single-centre cohort of 781 naïve patients who underwent resection of non-small cell lung cancer with pathological LN involvement and survived beyond 90 days was reviewed. LN dissection metrics were compared before and after the implementation of a quality improvement initiative. Quality metrics (QM) were: QM1 (≥10 LN examined), QM2 (≥3 intrapulmonary and hilar LN, ≥ 3 mediastinal stations, including station 7 in all cases), and QM3 (combination of QM1 and QM2).

Results: The proportion of patients meeting QM1 did not differ significantly between the pre- (87.8%) and post-implementation (89.1%) periods. However, meeting QM2 and QM3 significantly improved from 79.5% to 88.6% (P = 0.001), and 76.2% to 84.4% (P = 0.007), respectively. Cox proportional hazard regression model for disease-free survival showed that patients operated on after the implementation of the quality improvement initiative exhibited better disease-free survival compared to those operated on before [adjusted hazard ratio (aHR): 0.73; 95% confidence interval (CI) 0.59-0.90; P = 0.003]. Nevertheless, none of these quality metrics influenced long-term outcomes. In contrast, adjuvant chemotherapy (aHR: 0.55; 95% CI 0.43-0.71; P < 0.001) was associated with improved disease-free survival. In case of metastatic progression, immunotherapy improved overall survival (hazard ratio: 0.54; 95% CI 0.37-0.77; P = 0.0003).

Conclusions: Utilizing transparent data and collaborative feedback were effective to enhance the quality of nodal assessment in lung cancer surgery. Overall, long-term outcomes for patients with lymph node involvement was primarily associated with disease burden, adjuvant chemotherapy, and rescue immunotherapy.

Irb approval number: CERC-SFCTCV-2024-04-30_34750 on 30 April 2024.