Of 633 new patient cases of lung cancer identified over the study period, 587 met inclusion criteria (), and 222 (37.8%) were judged to have missed opportunities after consensus agreements. Before consensus, both reviewers independently agreed on the presence of at least one missed opportunity in 184 patients and on the absence of any missed opportunities in 284 patients (overall κ = 0.69).43
The median time elapsed from first appearance of a diagnostic clue to final pathologic diagnosis was 132.0 days (range, 15 to 2,445 days) in patients with at least one missed opportunity compared with 19.0 days (range, 0 to 870 days) in patients with no identified missed opportunities (P
< .001). The outliers in the latter group included patients that required serial imaging and were appropriately followed up. The Venn diagram at the bottom of shows the distribution of provider-related, system-related, and patient-related factors in the 222 patients with at least one missed opportunity.
Study flowchart. IQR, interquartile range.
Type I missed opportunities were judged to occur in 148 (25.2%) of 587 included patients; among these, the median time to pathologic diagnosis was 168 days (range, 15 to 2,445 days; interquartile range, 290 days). Type II missed opportunities occurred in 121 patients (20.6%); in these patients, the median time to pathologic diagnosis was 141.5 days (range, 38 to 2,445 days; interquartile range, 224 days).
We compared baseline characteristics of patients with and without at least one missed opportunity for subsequent inclusion in adjusted predictor models. At the 0.10 level of significance, three comorbidities were more frequent in patients with missed opportunities: hypertension, chronic obstructive pulmonary disease (COPD), and antisocial personality disorder (). However, only COPD remained statistically significant in subsequent logistic regression models.
Baseline Characteristics of Patients With and Without Missed Opportunities
Provider characteristics () were associated with patients with one or more missed opportunities. In the final adjusted multivariable model, trainees were less likely to be associated with patients with missed opportunities (odds ratio [OR], 0.41; 95% CI, 0.27 to 0.62; referent, staff physician). Whereas emergency medicine providers were relatively unlikely to be associated with missed opportunities (OR, 0.52; 95% CI, 0.28 to 0.96), oncology and pulmonary specialists were overrepresented in patients with missed opportunities (OR, 18.72; 95% CI, 2.30 to 152.46 and OR, 2.35; 95% CI, 1.36 to 4.08, respectively; referent, primary care). For both oncologists and pulmonologists, type I missed opportunities were more frequent. Patient factors were associated with more than half of missed opportunities associated with pulmonary (20 [54%] of 37), but were associated with only two (2 [20%] of 10) missed opportunities related to oncology. Sample sizes were insufficient to test whether these relationships differed between sites.
Characteristics of Providers in Patients With and Without Any Missed Opportunities
comparisons of diagnostic clues in patients with type I missed opportunities and no missed opportunities. Median times to clue recognition for missed clues is also listed. An abnormal chest x-ray was the most frequently missed clue, followed by abnormal chest computed tomography scan, and new or worsening persistent cough > 8 weeks. When we relaxed the criterion for recognition from 7 days to 14 days, the total number of patients with type I missed opportunities decreased from 148 to 127. Only recurrent bronchitis was associated with type I missed opportunities in unadjusted and adjusted logistic regression models (adjusted OR, 3.31; 95% CI, 1.20 to 9.10; referent, no recurrent bronchitis). We further assessed whether nonsmokers experienced longer delays from type I missed opportunities (data not shown). We found that of 19 outlier patients,44
11 were smokers, seven were past smokers, and one had never smoked. Smoking history was not associated with outlier status.
Diagnostic Clues and Associated Median Time to Clue Recognition in Lung Cancer Patients With and Without Missed Opportunities
compares the proportions of requested actions (procedures, consultations, or follow-up actions on clues) in patients with type II missed opportunities and no missed opportunities. For missed opportunities, median times to action completion are also listed. Patient factors were strongly associated with type II missed opportunities: completion of needle biopsies (15 [62.5%] of 24), completion of bronchoscopies (15 [100%] of 15), follow-up of abnormal chest x-rays (28 [38.9%] of 72), pulmonary consults (17 [65.4%] of 26), and follow-up of abnormal chest computed tomography scans (11 [61.1%] of 18). Follow-up of abnormal chest x-ray, completion of first needle biopsy, and follow-up of recurrent bronchitis were significant predictors of type II missed opportunities in the unadjusted logistic regression model. In the adjusted model, which controlled for the presence of COPD, only follow-up action on abnormal chest x-ray (OR, 2.07; 95% CI, 1.04 to 4.13; referent, no abnormal chest x-ray) and completion of first needle biopsy (OR, 3.02; 95% CI, 1.76 to 5.18; referent, no needle biopsy) were associated with type II missed opportunities. Appendix Table A1 summarizes logistic regression results for missed opportunities.
Requested Actions and Associated Median Time to Completion in Patients With and Without Missed Opportunities