CERTAIN’s Lung Cancer Quality Improvement and Research Collaborative was originally developed out of work on the Collaborative to Improve Native Cancer Outcomes (CINCO)—a National Cancer Institute project funded to improve cancer health outcomes and quality of life specifically for American Indian and Alaskan Native patient populations. Fifteen thoracic surgeons, one pulmonologist, and four advanced practice clinicians from five institutions within Washington State convened to work together to improve the quality and value of thoracic oncologic care. These clinicians and hospitals account for over half the state’s volume of lung cancer surgery.

The collaborative has conducted two studies to date.

The first investigation aimed to better understand the landscape of lung cancer surgery across the state’s hospitals. We found that the number of hospitals performing lung cancer surgery decreased over time with a shift in care from low-volume hospitals to medium- and higher-volume hospitals. These findings mirror those from several national studies. Despite this shift in care, there remained considerable variation in outcomes and costs across hospitals. Furthermore, an analysis of outcomes and costs revealed that the value of care also varied across hospitals.

The second study aimed to characterize variability in care. We reported—for the first time—evidence of significant variation in invasive mediastinal staging across hospitals. One remarkably positive finding from the study is that surgeons and pulmonologists successfully sampled lymph node tissue in 93% of individuals undergoing invasive mediastinal staging, a rate substantially higher than the previous national report of only a 47% (Little et. al. Ann Thorac Surg, 2005).

Findings from these two studies demonstrating variability in care delivery, outcomes, and costs motivate a regional quality improvement initiative. We conclude that there are at least two essential components of a regional quality improvement initiative. First, all hospitals should participate in a recognized national quality improvement initiative without attempts to alter standardized definitions, validated risk-adjustment strategies, or vetted outcomes metrics. Clinicians and hospitals in this collaborative all participate in the Society of Thoracic Surgeons General Thoracic Database, and they recommend that hospitals performing lung cancer surgery in Washington State also participate in this database. Participation in this clinical registry allows for comparisons to national benchmarks and efficient use of precious resources for quality improvement initiatives. The second essential component is that quality improvement efforts must occur in the context of a community bound together by common goals, trust, and a willingness to share ideas, experiences, perspectives, and information. Our collaboration is emblematic of what can be achieved across the entire state of Washington.

Finally, an as of yet untapped potential of this collaborative is to conduct multi-center trials in thoracic surgery. We expect ongoing pilot work in lung cancer screening, staging, and surveillance to lead to interventions that can be soon be tested by this collaborative in the form of a rigorous prospective observational cohort study or randomized trial.