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Implementing Surgical Quality Improvement in a High Lung Cancer Mortality Region: The Road to an NCI-Funded Regional Dissemination and Implementation Project Ray U. Osarogiagbon, MBBS FACP Multidisciplinary Thoracic Oncology Program, Baptist

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Implementing Surgical Quality Improvement in a High Lung Cancer Mortality Region:

The Road to an NCI-Funded Regional Dissemination and Implementation Project

Ray U. Osarogiagbon, MBBS FACP Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN June 23, 2017

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The Challenge: US Lung Cancer Death Map

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Origins…

Serendipity: MMA-QSR
Every challenge presents an opportunity…

every opportunity re-presents a challenge..

Putting together a study team: rag-tag

volunteer army- residents, fellows, medical students….

Pilot studies- critical insight
Contextualization of data: loop up to national

and international data

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Critical Insight #1

Attainment of NCCN Criteria MMA-QSR

Quality of surgical resection for non-small cell lung cancer in a US metropolitan area. Allen, Farooq, O’Brien, Osarogiagbon. Cancer 2011.

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Nodal Staging: the Key Predictor of Survival

5-year Survival Rate

Clinical Stage Pathologic Stage N0 50 56 N1 39 38 N2 31 22 N3 21 6 Rusch et al. J Thorac Oncol 2007; 2:603

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Critical insight #2:

Contextualizing the quality gap…

How big is this problem?
How widespread?
Are your findings, insights, etc generalizable?

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Pathologic Nodal Staging Quality Gaps

0.00 0.25 0.50 0.75 1.00 2319 1246 690 405 179 36 pn_status = PNX 6795 3359 1675 811 376 94 pn_status = PN1 24200 14854 8685 4801 2268 574 pn_status = PN0 Number at risk 2 4 6 8 10 12 Time(years) PN0 PN1 PNX

Overall Survival (no wedge)

p<.001 0.00 0.25 0.50 0.75 1.00 4638 3435 2626 2152 1241 285 MLN examined 7711 5420 4071 3210 1954 486 No MLN examined Number at risk 2 4 6 8 10 12 Time(years) No MLN examined MLN examined

Mediastinal Lymph Node Examination and Survival

SEER 1998 - 2002 Osarogiagbon and Yu. J Thorac Oncol 2012;7:1798- 1806

pNX survival mirrors pN1, not pN0 SEER 1998 - 2002

Osarogiagbon and Yu. Ann Thorac Surg 2013;96:1178-89.

.4 .6 .8 1 1.2 2 4 6 8 10 12 14 16 18 20 22 24 26 Number of LN examined 95%CI Hazard ratio Smoothed line Lung Cancer Specific Mortality

Hazard Ratio for Death in pN0 in relation to number of lymph nodes examined

‘All animals are equal, but some animals are more equal than others’’

George Orwell, ‘Animal Farm’.

Osarogiagbon, Ogbata, Yu. Ann Thorac Surg 2014;97:385-93.

14% survival difference!

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Solving problems, not another Jeremiad!

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Who’s going to give you twenty nodes?

Number of Lymph Nodes Examined in ‘Node Negative’ Lung Cancer Resections: SEER 1998-2009 Osarogiagbon and Yu. Ann Thorac Surg 2013

OR team: Hilar and mLN; Correct specimen labeling; Secure transfer to path lab Pathology team: Intrapulmonary LN retrieval, thorough examination of all specimens, correct, comprehensive pathology report

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Surgical Intervention

Lymph node specimen collection kit.

Osarogiagbon, Robbins, et al. Ann Thorac Surg, Dec 2013

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Stakeholder Recruitment

High-level hospital administrators
Thoracic surgeons
Pathologist
CV surgery OR staff

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Study Outline

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0.00 0.25 0.50 0.75 1.00 333 66 8 nccn_criteria = 1 1892 782 204 nccn_criteria = 0 Number at risk 50 100 150 Months after surgery Less than four NCCN criteria All four NCCN criteria

Meeting all four NCCN criteria

P<0.001

0.00 0.25 0.50 0.75 1.00 50 100 150 Months after surgery 1 2 3 4

The number of NCCN criteria met

Adjusted hazard ratio of meeting all four criteria: 0.64 (0.50-0.80)

#2190: NCCN Quality Parameters and Survival - Nick Faris, M.Div. #2190: Impact of NCCN Quality Parameters on Patient Survival - Nick Faris, M.Div.

p<0.001

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Critical Insight #3:

Dissecting out the role of pathologists…

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Lobectomy Specimen Before and After Thin Section Dissection Protocol

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Who’s going to give you twenty nodes?

Ramirez RA, et al, J Clin Oncol 2012;30(23):2823-2828. Distribution of non-hilar N1 nodal count: ACOSOG Z0030 Discarded intrapulmonary lymph nodes in lung resection specimens Survival implications: ACOSOG Z0030 Survival implications: MS-QSR Osarogiagbon, Decker, Ballman, Wigle, Allen, Darling. Ann Thorac Surg 2016;102:363-9 Smeltzer, Faris, Yu, et al, Ann Thorac Surg 2016;102:448-53

Lymph nodes …with metastasis

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Building a Multidisciplinary Research

Team

Observation: identify a meaningful challenge.
Iterative reasoning: question everything about it.
Identify stakeholders, identify what’s in it for them,

find a hook.

Collaborate, encourage ownership of the challenge,

engender passion in team members.

Start where you can, start small, let the findings

guide you.

But, keep grand direction/strategy in full view.

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Acknowledgements

R01 CA172253.
Past and present members of ThOR, 2007 – 2016, especially

– Nicholas Faris, M. Div: Overall program manager. – Matthew Smeltzer, PhD: Epidemiologist; head of stats core. – Meredith Ray, PhD: Statistician. – Lisa Klesges, PhD: Implementation Scientist, Psychologist. – Carrie Fehnel, BA – Cheryl Houston-Harris, BS – Wale Akinbobola, BA – Philip Ojeabulu, MBBS – Nibedita Chakraborty, MA – Fujin Lu, MSc – Xinhua Yu, MD PhD: Epidemiologist. – 54 general thoracic, cardiovascular, general surgeons – 36 pathologists and pathology assistants – Hospital administrators in the 14 hospitals in the tri-state MS-QSR