[show abstract][hide abstract] ABSTRACT: Our aim was to systematically determine how features of patients and hospitals influence access to chemotherapy and survival for people with small-cell lung cancer in England.
We linked the National Lung Cancer Audit and Hospital Episode Statistics and used multiple logistic and Cox regression analyses to assess the influence of patient and hospital features on small-cell lung cancer outcomes.
There were 7845 patients with histologically proven small-cell lung cancer. Sixty-one percent (4820) of the patients received chemotherapy. Increasing age, worsening performance status, extensive stage and greater comorbidity all reduced the likelihood of receiving chemotherapy. There was wide variation in access to chemotherapy between hospitals in general and patients first seen in centres with a strong interest in clinical trials had a higher odds of receiving chemotherapy (adjusted odds ratio 1.42, 95% confidence interval (CI) 1.06, 1.90). Chemotherapy was associated with a lower mortality rate (adjusted hazard ratio 0.51, 95% CI 0.46, 0.56).
Patients first seen at a hospital with a keen interest in clinical trials are more likely to receive chemotherapy, and chemotherapy was associated with improved survival.
British Journal of Cancer 08/2011; 105(6):746-52. · 5.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: The treatment given to patients with lung cancer and survival vary between and within countries. The National Lung Cancer Audit (NLCA) linked to Hospital Episode Statistics was used to quantify the extent to which these outcomes are influenced by patient features and/or hospital facilities and performance indicators.
All patients with a histological diagnosis of non-small cell lung cancer (NSCLC) were included. Logistic regression was used to quantify the independent influence of features of both patients and hospitals on the likelihood of having surgery and Cox regression was used for survival analyses.
There were 34,513 patients with NSCLC in our dataset. After adjusting for age, sex, performance status, stage and Charlson Index of comorbidity, patients with NSCLC first seen in thoracic surgical centres (27% of the cohort) were 51% more likely to have surgery than those seen in non-surgical centres (adjusted OR 1.51, 95% CI 1.16 to 1.97). Resection rates varied from 13% to 17% between non-surgical and thoracic surgical centres. Surgery was the most powerful determinant of overall survival (adjusted HR 0.41, 95% CI 0.39 to 0.44).
A minority of patients with NSCLC first seen in a thoracic surgical centre are more likely to have surgery and to benefit from the survival advantage this confers. This finding suggests that there is an opportunity to improve the outcome for patients with lung cancer in England by optimising access to thoracic surgeons in non-surgical centres.
[show abstract][hide abstract] ABSTRACT: Our aims were to determine whether the information in the National Lung Cancer Audit database (LUCADA) is influenced by the completeness of reporting and to describe the current socio-demographics and survival of people with lung cancer in England.
Using national registry data as a gold standard we stratified NHS Trusts into quartiles on the basis of their patient ascertainment. We assessed the distribution of patient features across these quartiles using Cox and logistic regression. We then examined overall survival and access to treatment.
We analysed data for 60,059 patients whose data were entered between 2004 and 2008. There was little variation in key patient features, treatment and median survival across quartiles of data completeness. Socio-economic disadvantage did not influence survival or access to surgery but was related to a decreased use of chemotherapy.
Our findings suggest that LUCADA accurately describes people in England who are diagnosed with lung cancer and can therefore be used to drive health care improvements. Individual patient socio-economic status does not affect survival and has only a limited impact on access to treatment and so NHS Trust level factors should be studied to explain the previously published regional variations in these outcomes.
Lung cancer (Amsterdam, Netherlands) 04/2011; 72(1):16-22. · 3.14 Impact Factor
[show abstract][hide abstract] ABSTRACT: Initial studies on the use of ultrasound in the detection and sampling of supraclavicular lymph nodes in patients with suspected lung cancer show this to be a promising technique, giving both a cytological diagnosis and pathological N3 (pN3) stage. Leicester published its initial experience in 2005 and the aim of this study was to establish if this had been embedded into the diagnostic pathway, and further to examine the use of ultrasound in diagnosing and staging lung cancer by imaging other areas including pleural effusions, chest wall, bone and liver lesions.
All patients diagnosed with lung cancer, registered on the Leicester lung cancer database over a two year period between January 2007 and December 2008, had their imaging and pathology retrospectively reviewed; 996 primary lung cancer patients were identified (n=996). Of these, 318 patients underwent an ultrasound examination (n=318), consisting of ultrasound of the neck, pleural cavity, and metastatic lesions potentially amenable to ultrasound guided aspiration/biopsy.
The overall malignant yield was 45% of patients scanned (95% CI 39.5% to 50.4%) and 81.3% of patients sampled (95% CI 75.5% to 87%). Of the 996 patients, 14.4% (n=143) had a positive ultrasound guided cytological diagnosis (95% CI 12.2% to 16.5%). Of all the pathological diagnoses (n=765), 18.7% were ultrasound guided (95% CI 15.9% to 21.5%). In particular, 32.2% of patients with CT detected neck or mediastinal nodes had a diagnosis and stage achieved by neck ultrasound.
The use of ultrasound gives a rapid and less invasive method of diagnosing and staging lung cancer and has become embedded into the diagnostic pathway. We advocate its increased use and availability in patients with lung cancer.
[show abstract][hide abstract] ABSTRACT: Medical thoracoscopy (MT) is indicated for the investigation of unexplained pleural exudates. Not all MT units create artificial pneumothoraces because of time. Difficult pleural space access and thick fibrous adhesions may prevent MT and pleurodesis, respectively. The potential role of thoracic ultrasound (TUS) pre-MT has not been fully evaluated. We hypothesized TUS would reduce failure to access the pleural space and enable detection of thick fibrous adhesions.
Thirty patients underwent single port MT consecutively for investigation of pleural exudates without pre-MT TUS over a 6-month period. Over the following 6 months, 30 consecutive patients underwent TUS immediately prior to MT. Pleural access rate and thick fibrous adhesion detection at both MT and TUS were recorded.
In the non-TUS cohort, pleural space access failure occurred in 16.7% (leading to five extra procedures), versus no failures in the TUS cohort (P = 0.0522). There were no differences in prevalence of MT fibrous adhesions between cohorts. TUS identified all cases of fibrous septation versus only 12.5% identified by CT in the non-TUS cohort (P = 0.001). All identified cases of thick fibrous septation on TUS did not receive pleurodesis at MT. TUS detected useful ancillary features in 43% of cases.
A strong trend to reduction in single port MT pleural access failure was noted with pre-MT TUS thus reducing extra procedures and the need for artificial pneumothoraces. Pre-MT TUS also reliably detects thick fibrous adhesions at MT. TUS may also detect useful ancillary features. This study provides a rationale for ultrasound-guided single port MT if a pneumothorax is not created.
[show abstract][hide abstract] ABSTRACT: Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional pulmonologists. It allows diagnosis of unexplained effusion, while at the same time allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse interstitial disease or associated peripheral lung abnormality in the presence of effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or chronic pancreatic pain. This article reviews the technical aspects and range of applications of MP.
Clinics in chest medicine 03/2010; 31(1):165-72, Table of Contents. · 2.51 Impact Factor
[show abstract][hide abstract] ABSTRACT: Staging for non-small cell lung cancer (NSCLC) requires accurate assessment of the mediastinal lymph nodes which determines treatment and outcome. As radiological staging is limited by its specificity and sensitivity, it is necessary to sample the mediastinal nodes. Traditionally, mediastinoscopy has been used for evaluation of the mediastinum especially when radical treatment is contemplated, although conventional transbronchial needle aspiration (TBNA) has also been used in other situations for staging and diagnostic purposes. Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) offers a minimally invasive alternative to mediastinoscopy with additional access to the hilar nodes, a better safety profile, and it removes the costs and hazards of theatre time and general anaesthesia with comparable sensitivity, although the negative predictive value of mediastinoscopy (and sample size) is greater. EBUS-TBNA also obtains larger samples than conventional TBNA, has superior performance and theoretically is safer, allowing real-time sampling under direct vision. It can also have predictive value both in sonographic appearance of the nodes and histological characteristics. EBUS-TBNA is therefore indicated for NSCLC staging, diagnosis of lung cancer when there is no endobronchial lesion, and diagnosis of both benign (especially tuberculosis and sarcoidosis) and malignant mediastinal lesions. The procedure is different than for flexible bronchoscopy, takes longer, and requires more training. EBUS-TBNA is more expensive than conventional TBNA but can save costs by reducing the number of more costly mediastinoscopies. Revenue based tariff systems have been slow to reflect the innovation of techniques such as EBUS-TBNA. In the future, endobronchial ultrasound may have applications in airways disease and pulmonary vascular disease.
Postgraduate medical journal 02/2010; 86(1012):106-15. · 1.38 Impact Factor
[show abstract][hide abstract] ABSTRACT: Conventional transbronchial needle aspiration (TBNA) is a cheap, minimally invasive tool for lung cancer staging and diagnosis. Endobronchial ultrasound-guided TBNA (EBUS-TBNA) is more sensitive but is more expensive and less widely available. We describe a prospective analysis of TBNA diagnostic, staging and cost utility in a centre in the UK. Objectives: To illustrate the potential diagnostic, staging and cost utility of a low cost conventional TBNA service.
A prospective analysis of 79 TBNA procedures over a 2-year period was performed looking at performance and cost utility in a 'mixed' cohort with variable pre-test probability of malignancy (year 1) followed by a high probability cohort (year 2).
TBNA avoided mediastinoscopy in 25% of the cases overall (37% in high probability vs. 13% in the 'mixed' cohort, p = 0.03). The overall prevalence of malignancy was 84%, sensitivity 79%, negative predictive value 58% and accuracy 85%. Diagnostic utility varied with pre-test probability and nodal station. TBNA down-staged 8% of lung cancer patients to receive surgery and confirmed the pre-treatment stage (inoperability) in 74%. TBNA led to theoretical cost savings of GBP 560 per patient.
TBNA can achieve a high diagnostic sensitivity for cancer in high probability patients and stage the majority appropriately, thereby avoiding unnecessary mediastinoscopies and reducing costs. It may also down-stage a minority to have surgery. TBNA is cheap, routinely available and learnable. As EBUS-TBNA will take time to develop due to its costs, all respiratory centres should perform TBNA at flexible bronchoscopy in suspected lung cancer with accessible mediastinal adenopathy.
[show abstract][hide abstract] ABSTRACT: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) offers a minimally invasive option for staging the mediastinum in suspect lung cancer but also in the diagnosis of mediastinal lesions accessible from the airway. This review is aimed at centres considering establishing an EBUS service that may not be so familiar with the technique. It focuses primarily on technical aspects of EBUS-TBNA, training issues, cost considerations, indications, advantages and disadvantages compared with other mediastinal sampling techniques as well as some reference to its performance in clinical studies. In summary, EBUS-TBNA is primarily used for staging non-small cell lung cancer, especially for bulky mediastinal disease and discrete N2 or N3 disease on CT, but also used for the diagnosis of unexplained mediastinal lymphadenopathy. For radical treatment staging, mediastinoscopy is still used at many centres and negative EBUS-TBNA results should be corroborated by mediastinoscopy. In the future, EBUS-TBNA may be used for staging the radiologically normal mediastinum and in re-staging. It is a procedure that can be taught with ease by an experienced operator, has numerous advantages over mediastinoscopy and is potentially cost saving by reducing the number of mediastinoscopies and associated peri-operative support required.
[show abstract][hide abstract] ABSTRACT: Interventional pulmonology, lung cancer staging, and diagnostic algorithms are evolving. Endoscopic needle aspiration techniques (endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration [EUS]) have a key role to play in staging the mediastinum and offer potential advantages over surgical staging. They are less invasive, avoid hospital admission, and save costs. However, a negative endobronchial ultrasound-guided transbronchial needle aspiration or EUS result should still be clarified by surgical staging. EUS also offers the ability to diagnose M1 disease.
Neck ultrasound-guided fine needle aspiration offers a minimally invasive method of diagnosing N3 or M1 disease, potentially avoiding endoscopic needle aspiration techniques as well as surgical staging in patients with suspected N2 or N3 disease or extrapulmonary inaccessible metastases.
Local anesthetic video-assisted thoracoscopy offers a minimally invasive method to diagnose malignant pleural metastases more effectively than by traditional closed pleural biopsy techniques. It also allows drainage of the effusion and pleurodesis in one combined procedure while avoiding more invasive surgical thoracoscopy.
Interventional pulmonology will continue to expand in the future and offer further benefits to patients with suspected lung cancer as well as potential cost savings to health care systems.
Clinical Pulmonary Medicine 10/2009; 16(6):328-336.
[show abstract][hide abstract] ABSTRACT: New innovative techniques can improve patient care but may not be appropriately funded. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) offers a minimally invasive mediastinal staging and diagnostic method for suspected lung cancer.
We report the performance and cost analysis of a newly established EBUS service in a prospective real world cohort of patients to assess the impact of Payment by Results (PbR).
Prospective cohort study.
Fifty-four patients between June 2008 and April 2009 underwent EBUS for evaluation of unexplained mediastinal lymphadenopathy on CT. Cost analysis was performed from local Trust financial data and 2008-09 tariffs.
EBUS had an 89% sensitivity, 75% negative predictive value and 92% accuracy for malignancy. EBUS coding was inaccurate in 15.6% of cases. The actual cost of an EBUS is 1252-1433 pounds but is coded as a standard bronchoscopy (561 pounds). EBUS reduces health community costs by 107824 pounds/year, as a result of a Primary Care Trust cost saving of 113968 pounds/year and a Trust cost deficit of 6144 pounds/year. Coding inaccuracies further alter the Primary Care Trust costs.
Medical innovation is fundamental to improved patient care. EBUS can potentially reduce morbidity for lung cancer patients and save health community costs. However, with PbR the service provider delivers this at a loss as the tariffs do not reflect innovation and because of coding inaccuracies. We suggest tariffs for innovative procedures need to reflect the true cost.
QJM: monthly journal of the Association of Physicians 09/2009; 102(12):859-64. · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative.
EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses.
Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.
Current opinion in pulmonary medicine 05/2009; 15(4):334-42. · 3.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: Local anaesthetic video-assisted thoracoscopy (LAVAT) is a safe, reliable and therapeutic procedure used by respiratory physicians in the management of pleural disease, especially pleural malignancy. We describe a prospective analysis of a UK LAVAT service set up in a tertiary respiratory centre to complement an existing large surgical video-assisted thoracic surgery (VATS) service.
A prospective analysis of 125 LAVAT procedures over a 34-month period was performed looking at a variety of quality control endpoints comparing them to national thoracic surgical VATS standards.
Talc pleurodesis was effective in over 86% of cases and this did not significantly lengthen bed stay (median 4.5 days). Bed stay was also unchanged between the ages of 60-89 years. Over 77% of the 48 patients with proven metastatic pleural lung malignancy or mesothelioma received either surgical decortication or oncological treatment (palliative chemotherapy in 57%). In only 6% were biopsies not possible because of technical factors. LAVAT biopsies had a diagnostic accuracy of 97.4%, sensitivity 95.4%, specificity 100%, positive predictive value 100%, and negative predictive value 94.7%. Our complication rate was 4% and mortality rate 0.8%.
Our LAVAT service meets surgical VATS standards for diagnosis and safety with a good pleurodesis efficacy rate. It complements our surgical VATS service, offering a pleural diagnostic service for patients with non-complex pleural exudates or too frail for VATS. Our data demonstrate there is a demand and potential for respiratory physicians dealing with pleural malignancy to develop LAVAT and enhance their local lung cancer and pleural diagnostic pathway.
Lung cancer (Amsterdam, Netherlands) 04/2009; 66(3):355-8. · 3.14 Impact Factor
[show abstract][hide abstract] ABSTRACT: Correct service costing is essential but may not always be done accurately.
To assess the accuracy of Healthcare Resource Group (HRG) coding allocation for patients undergoing local anaesthetic video-assisted thoracoscopy (LAVAT) against predicted codes under Payment by Results (PbR).
Single centre retrospective study. Tertiary respiratory centre in Leicestershire.
One hundred twenty-five patients undergoing LAVAT from July 2005 to July 2008.
Predicted and actual revenue per LAVAT episode based on predicted and actual HRG codes allocated.
Among 125 patients undergoing LAVAT, the actual HRG code matched the predicted code in only 39 cases (31.2%), odds ratio (OR) 0.002, 95% confidence intervals (CIs) 0.0001-0.03, P < 0.0001. In 51 cases (40.8%), this resulted in a median (interquartile range) excess of PbR revenue of 574 pounds (574-1366) per episode; a total estimated overspend of 29,274 pounds. In 35 cases (28.0%), this resulted in a median underspend of --1093 pounds (-1285 to -851) per episode; a total estimated underspend of 38,529 pounds, with a total estimated financial error of 67,529 pounds. The net median (interquartile range) difference for PbR-related revenue was 0 pounds (-89 to + 574). Factors associated with coding discrepancy were longer length of stay (OR = 2.52, 95% CIs = 1.09-5.81, P = 0.03) and talc pleurodesis (OR = 2.25, 95% CI = 1.01-4.99, P = 0.06).
HRG coding allocation errors occur frequently. The potential financial implications of this are significant for providers and commissioners. Future strategies are required at multiple levels (NHS Trust, Primary Care Trust and Department of Health) to minimize future discrepancies and financial error.
QJM: monthly journal of the Association of Physicians 02/2009; 102(5):329-33. · 2.36 Impact Factor