Surgeon Quality Metrics and Survival After Curative-Intent Surgery for NSCLC

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In a study reported in the Journal of Clinical Oncology, Ray et al found that higher surgeon quality (determined by intermediate outcome metrics) was associated with improved overall survival among patients undergoing curative resection for non–small cell lung cancer (NSCLC). The investigators concluded that adoption of quality metrics by surgeons and associated targeting of processes for improvement could reduce disparity in outcomes.

Study Details

The study involved data from The Mid-South Quality of Surgical Resection Consortium, consisting of 12 hospitals located in Eastern Arkansas, North Mississippi, and Western Tennessee. Surgeon-level cutpoints for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections were derived from a baseline surgical resection cohort. The cutpoints were applied to a subsequent cohort from the same population-based dataset, with surgeons assigned into three performance categories for each metric: 1 (< 25th percentile), 2 (25th–75th percentile), and 3 (> 75th percentile). The sums of performance scores were divided into three surgeon quality tiers: 1 (4–6, low), 2 (7–9, intermediate), and 3 (10–12, high).

Key Findings

From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among the 31 subsequent cohort surgeons, 5 were classified as tier 1, 5 as tier 2, and 21 as tier 3 (highest quality). Tier 3 surgeons were associated with significantly better overall survival for patients vs tier 1 surgeons (hazard ratio [HR] = 1.37, 95% confidence interval [CI] = 1.10–1.72) and vs tier 2 surgeons (HR = 1.19, 95% CI = 1.00–1.43).

After analysis adjusting for clinical stage, patient age, number of comorbidities, sex, race, insurance, histology, proportion of resections in which lymph node collection kits were used, use of positron emission tomography-computed tomography, and nonexamination of lymph nodes at surgery, there were no longer significant differences in overall survival for tier 3 surgeons vs tier 1 surgeons (adjusted HR = 1.02, 95% CI = 0.8–1.3) or vs tier 2 surgeons (adjusted HR = 0.93, 95% CI = 0.7–1.25).  

The investigators concluded, “Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.”

Raymond U. Osarogiagbon, MBBS, FACP, of the Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, is the corresponding author for the Journal of Clinical Oncology article.

Disclosure: The study was supported by a grant from the National Cancer Institute. For full disclosures of the study authors, visit

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